Retrieval of the retracted flexor tendons for long fingers: New tip

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Surgery technical

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Retrieval of the retracted flexor tendons for long fingers: New tip

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Récupération des tendons fléchisseurs rétractés des doigts longs : nouvelle astuce

4 Q1

K. Ahed

a,

* , M. Moujtahid

^b

, M. Nechad

^b

5 ^aServicedechirurgieorthopédiqueettraumatologie(A4),centrehospitalieruniversitaireIbn-Rochd,El-Haddaoui3,rue33,n^o37,

6 Ain-Chok,20460Casablanca,Maroc

7 ^bServicedechirurgieorthopédiqueettraumatologie(A4),centrehospitalieruniversitaireIbn-Rochd,Casablanca,Maroc 8 Received2March2014;receivedinrevisedform22April2014;accepted20May2014

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10 Abstract

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Zone II flexor tendon injuries continue to be a challenge for hand surgeons. During the injury event, the tendon ends may retract towards the

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palm. Retrieval of these lacerated ends can be problematic because the tendon sheath is unstretchable. This demanding surgery requires a precise

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repair technique where the tendon stumps are handled in an atraumatic manner. Microtrauma to the tendon sheath must be avoided as this can

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induce adhesions and lead to poor functional outcomes. Several retrieval methods for retracted tendon ends have been described in published

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studies. In this technical note, we will describe a technical variation that streamlines the surgical procedure and uses commonly available materials.

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This simple trick makes the procedure easier and avoids having to suture the tendon to the tubing.

17 #

2014 Elsevier Masson SAS. All rights reserved.

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19 Keywords:Flexortendon;ZoneIIinjuries;Retractedflexortendon;Tendonretrieval;Flexortendonretrieval

20 Résumé

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Les lésions des tendons fléchisseurs de la main, situées au niveau de la zone II, constituent un réel challenge pour les chirurgiens. Au cours de

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ces lésions, les extrémités tendineuses peuvent se rétracter vers la région palmaire, nécessitant leur récupération à travers un canal digital

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inextensible. Cette chirurgie difficile est exigeante et demande de la minutie de la part du chirurgien afin d’être le plus atraumatique possible et de

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respecter les extrémités tendineuses et le canal digital évitant les microtraumatismes sources d’adhérences et donc de mauvais résultats

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fonctionnels. Plusieurs techniques de récupération de ces extrémités tendineuses rétractées ont été décrites dans la littérature. Nous décrivons ici

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une variante technique qui nous a facilité le geste chirurgical, utilisant un matériel rapidement disponible. Simple et facile à exécuter, elle apporte

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un artifice supplémentaire pouvant faciliter le déroulement de cette chirurgie en permettant d’éviter le recours à des sutures du tendon à la tubulure.

28 #

2014 Elsevier Masson SAS. Tous droits réservés.

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30 Motsclés: Tendonfléchisseur;LésionsenzoneII;Rétractiontendonfléchisseur;Récupérationdutendon;Récupérateurdetendon

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1. Introduction

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Zone II flexor tendon injuries continue to be a challenge for

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hand surgeons. During the injury event, the tendon ends may

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retract towards the palm. Retrieval of these lacerated ends can

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be problematic because the tendon sheath is unstretchable [1].

This demanding surgery requires a precise repair technique

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where the tendon stumps are handled in an atraumatic manner.

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Microtrauma to the tendon sheath must be avoided as this can

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induce adhesions and lead to poor functional outcomes [2–4].

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Several retrieval methods for retracted tendon ends have been

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described in published studies [5–19].

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This article describes a simple but reproducible alternative

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to the usual techniques. The inexpensive materials that are

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required are available in all operating rooms.

44 Availableonlineat

ScienceDirect

www.sciencedirect.com

Chirurgiedelamainxxx(2014)xxx–xxx

*Correspondingauthor.

E-mailaddresses:ahed-karim@hotmail.com,karimahed1@gmail.com (K.Ahed).

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CHIMAI8841–4

Please cite this article in press as: Ahed K, et al. Retrieval of the retracted flexor tendons for long fingers: New tip. Chir Main (2014), http://

dx.doi.org/10.1016/j.main.2014.05.003

http://dx.doi.org/10.1016/j.main.2014.05.003

1297-3203/#2014ElsevierMassonSAS.Allrightsreserved.

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2. Surgical technique

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The proximal tendon ends are typically retrieved with small

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forceps inserted through an opening in the sheath, in

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combination with proximal to distal ‘‘milking’’ of the

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antebrachial anterior compartment or by applying the reversed

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Esmarch tourniquet technique [5].

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The technique described here to retrieve tendon ends that are

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retracted into the palm is simple and does not require any

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specialized materials. It only requires a 15-cm long piece of

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tubing from an IV infusion set available in all operating rooms

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(Fig. 1) and 3-0 Prolene

¹

type suture.

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The sequence for this technique is described below.

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The piece of tubing is inserted in a retrograde manner

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through the sheath laceration along the digital canal.

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A counterincision is made at the distal palmar crease, in line

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with the injured finger. Once dissection is complete, the

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lacerated tendon ends can be exposed.

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The proximal ends of the lacerated tendons and the tubing

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segment are externalized through this counterincision. These

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two elements must be retrieved proximal to the palmar

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aponeurosis pulley A0.

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A shark’s nose cut is made in the proximal end of the tubing,

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along with two lateral eyelets (Fig. 1).

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After verifying the anatomical relationship of the tendons

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relative to each other (deep/superficial), a horizontal mattress

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suture is placed through the two tendon ends with 3-0

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Prolene

¹

; the needle is subsequently removed (Fig. 2).

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The free suture ends are passed through the corresponding

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eyelet on each side of the tubing (Fig. 3A). By pulling on the

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suture, the tendon ends are seated into the two slits in the

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tubing.

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While holding light but constant proximal traction on the

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suture (the suture will bend 1808 at the eyelets) (red arrow on

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Fig. 3B), pull the tubing out by its distal end (green arrow on

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Fig. 3B). This will slide the tendon-tubing unit through the

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digital canal.

With the proximal ends now externalized through the

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laceration opening, the surgery can continue as usual by

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suturing the corresponding tendon ends.

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In some cases, only the flexor digitorum profundus (FDP) is

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retracted, while one or more of the flexor digitorum

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superficialis (FDS) slips remain intact. The goal here is not

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only to retrieve the FDP, but also to restore its normal

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anatomical relationships, especially with both the division of

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FDS and its chiasma tendinum (Camper’s chiasma), and its

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spatial orientation. Our technique can also be used to achieve

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these objectives.

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Fig.2. Tendonends(rightside):horizontalmattressstitchplacedthroughthe tendonends(FDSandFDP).Tubing(leftside):scissorsareusedtocuttwo lateraleyelets(*)andtwoanterior(blackarrow)andposterior(greenarrow) slitsintheshapeofashark’snoseattheproximalendofthetubing.(T:tubing;

FDS:flexordigitorumsuperficialis;FDP:flexordigitorumprofundus).

Fig.1. Leftphoto:IVinfusionset.Rightphoto:cutsinthetubingsegment(whitearrow:sharknose;blackarrow:lateraleyelets).

K.Ahedetal./Chirurgiedelamainxxx(2014)xxx–xxx 2

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Please cite this article in press as: Ahed K, et al. Retrieval of the retracted flexor tendons for long fingers: New tip. Chir Main (2014), http://

dx.doi.org/10.1016/j.main.2014.05.003

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A bevel cut can be made at the end of the tubing to help it

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pass through the tendinous chiasma of the flexor tendons

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(Fig. 4). Once at the counterincision, make sure the tubing is

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posterior to the FDS.

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The retracted FDP tendon end is externalized through the

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counterincision. Gently pull on the tendon to make sure it is not

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twisted. Pass a suture through the FDP to place it into the

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‘‘shark’s nose’’ slit as described previously. Since the two

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anchoring suture ends pass through the corresponding eyelets,

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the tendon is immobilized in the tubing, which controls its

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orientation when sliding and retrieving it through the laceration

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opening.

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3. Discussion

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Several varied techniques have been described to retrieve

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flexor tendons that are retracted in the palm area. One option is

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to introduce a skin hook inside the digital canal [6]. However,

this hook may get caught up, which would cause additional

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trauma to an already inflamed canal, along with the risk of

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tendon fraying. Another option involves inserting a curved

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aneurysm needle into the tendon sheath to retrieve an anchoring

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suture that has been placed in the tendon [7]. Use of wire

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cerclage has been described by several groups as another means

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to retrieve the anchoring sutures [8,9]. In our experience, we

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find it tedious to retrieve the tendon ends by pulling on the

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tendon stumps, as their edges bump into the digital canal

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entrance, stopping it from gliding smoothly.

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Sourmelis and McGrouther described end-to-side suturing

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with a plastic catheter [10]. This simple prop concept was then

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adopted by several teams. Most of the proposed variations

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revolve around the type of tubing used (Seldinger catheter [20],

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newborn feeding tube [11], Silastic tube [12], rubber catheter

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[13], and silicon catheter [20]) but there are also differences in

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where the tendon to tubing suture is located (end-to-end [11],

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end-to-side [11,14] or intra-luminal [12,13]). Suturing the

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tendon directly to the tubing often results in a bulky mass,

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making it harder to pass this construct through pulleys, further

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injuring the tendon and its sheath and increasing the surgical

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time.

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Thornton and Miller [15] described how they used the tip of

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a surgical glove to cover the tendon end and held it in place with

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sutures. The tendon is retrieved distally by pulling and twisting

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the glove tip. We have not tried this method, but it appears to be

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difficult to perform and not harmless: the risk of glove plication

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can increase the diameter of the construct and prevent it from

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passing through the digital canal, the twisting action can change

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the tendon’s spatial orientation, and there is a risk of glove

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fragments being left behind!

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Some authors have described,using a very thin, flexible

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endoscope (ureteroscope) with optical and instrument portals to

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retrieve retracted tendons without performing a proximal skin

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incision [16,17]. This technique is interesting, especially in

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cases of lacerations with retraction of the flexor pollicis longus,

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which often requires relatively significant proximal extension.

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But the equipment needed to perform this technique is not

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available in every operating room. Conversely, our technique

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uses inexpensive, ubiquitous materials.

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Our technique resembles two fairly recently published

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techniques. However, in these techniques, the tendon is

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sutured to the end of the catheter [18] or Silastic tubing [19].

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The trick that we are proposing is less traumatic to the tendon

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because less suturing is needed, thereby also reducing the

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surgery time.

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4. Conclusion

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The surgical technique described here to retrieve retracted

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flexor tendons has the advantage of being simple, easy to carry

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out and only requires a piece of tubing, which is easily available

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in any operating room. It is a clever trick that avoids having to

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suture the tendon to the tubing. This makes a complex and

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difficult surgery much easier, although the digital canal and

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tendon ends must still be preserved meticulously.

161 Fig.3. Tendon-tubefixation(A).Tendon-tubeunitslidingthroughthedigital

canal(B).

Fig.4. Tubingplacementandorientationincasesofisolatedflexordigitorum profundusretraction(FDS:flexordigitorumsuperficialis;T:tubing;P:pulley;

*:distalendoflaceratedflexordigitalisprofundus).

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Please cite this article in press as: Ahed K, et al. Retrieval of the retracted flexor tendons for long fingers: New tip. Chir Main (2014), http://

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Disclosure of interest

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The authors declare that they have no conflicts of interest

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concerning this article.

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