Phẫu Thuật Gân Bàn Tay (Tendon Surgery of the Hand)

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Section 3:  Secondary Flexor Tendon Surgery
A
B
C
D
E
F
G
Figure 27-2  A, Exploration of the thumb of a 45-year-
old man after primary repair of the FPL ruptured through
infection, with the arrows showing a considerable length
of the tendon replaced by scar. B, The arrow on the
thumb indicates the position of the distal end of the FPL
tendon when pulled distally. C, Showing the additional
length achieved by one Le Viet cut of the tendon in
muscle. D, Tendon suture indicates that the tendon is still
too short. E, Two Le Viet cuts still not providing sufficient
tendon lengthening. F, Further advance of the tendon by
Z lengthening at the wrist. G, Achieving adequate position
of the IP joint.

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Chapter 27:  Secondary Reconstruction of the Flexor Pollicis Longus Tendon
grafting or tendon transfer reconstruction, presumably
because the excursion of the new tendon is largely
taken up by movement of the MCP and the segment
of new tendon beyond the MCP moves little during
rehabilitation. I have tried passing a K-wire across
the MCP for 4 to 6 weeks to prevent this failure to
achieve IP joint flexion,19 but with no greater success, as
the patients reverted to MCP flexion on removal of the
K-wire. Tubiana (1988) warns that satisfactory flexion
of the distal phalanx will only be achieved by grafting
in the absence of hyperextension of the MCP joint.20 I
have no experience of this alternative problem of MCP
extension hypermobility affecting FPL surgery.
THE IDEAL OF INTERPHALANGEAL MOTION
With these exceptions, it is generally advisable in respect
of best function of the thumb to try to achieve some
after very distal division is frequently mentioned in the
literature. This can be considered as a means of dealing
with a gap in the tendon, albeit one created by the
surgeon by removing the distal segment of the FPL. A
warning is often given that such an advancement can
only be done without significant flexion contracture of
the IP joint if the division is within 1 cm of the inser­
tion. I believe this practice to be unwise and likely to
give rise to IP flexion contracture if an advancement of
even 1 cm is carried out. When the distal part of the
tendon is 34 to 1 cm in length, it is quite possible to
insert a core suture into the distal end of the tendon.
With divisions closer to the insertion than 34 cm, it is
possible to leave the distal segment of tendon in place
and anchor the suture into the distal phalanx by one of
the various described techniques, after passage of the
sutures through the distal segment of the tendon. While
the small attached segment of tendon could be excised
and any IP contracture subsequent to advancement of
the proximal tendon corrected by lengthening of the
proximal tendon, this seems a complicated way of
achieving the same end.
NO FPL REPAIR
In respect of patients presenting after significant delay,
management by doing nothing, particularly if the car­
pometacarpal (CMC) and metacarpophalangeal (MCP)
joints are functioning normally, is generally only sug­
gested as suitable for the elderly.12 It has been my experi­
ence with several younger-than-elderly patients who
have presented late with inability to flex the IP joint that
they have been quite happy with the function of the
thumb for their needs and, when the option of a com­
plicated operation and a lengthy rehabilitation period
is explained as the logical treatment of their problem,
have declined any treatment (Figure 27-3). Doing
nothing or a (relatively simple) distal fixation procedure
to prevent hyperextension of the IP joint, if this is
causing problems of pinching, is definitely an option to
be discussed with all patients. As the variable hyperex­
tension of this joint commonly seen, particularly in
supple hands, appears to have no useful function,18 such
fixation causes no obvious deficit of thumb function.
When fixation of the IP joint is necessary, general obser­
vation suggests that plastic surgeons prefer distal tendon
tenodesis and orthopedic surgeons prefer joint fusions.
Either, performed correctly, works well, but both require
1 to 2 months of protection before being used for force­
ful pinching. A small but definite group of patients who
may be best advised to choose this option of manage­
ment are patients with very mobile MCP joints who
routinely flex the MCP joint through 40° to 50° degrees
when pinching. This variation of thumb flexion can be
ascertained by examining the contralateral thumb. In
my experience, these patients will continue to flex the
MCP joint alone, with no, or little, IP flexion after either
Figure 27-3  A 50-year-old woman who presented several
months after division of the FPL and declined surgery as she
thought that her disability was minimal. A, Full thumb
extension. B, Pinch to the index. C, Pinch to the little finger.
A
B
C

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Section 3:  Secondary Flexor Tendon Surgery
21 of 35 tendons.11 Matev (1983) warned that the FPL
muscle was particularly liable to lose its contractile
qualities quickly after tendon division at the wrist,
giving poor results from grafting.6 He recommended
that another motor be used more readily after tendon
division at this level. This observation in itself appears
inexplicable until considered in the light of Pulvertaft’s
observations as mentioned earlier. Of all FPL divisions,
those at the wrist are the most likely to suffer complete
retraction of the proximal tendon and muscle as there
is little to hold the tendon to length, or partial length,
and complete retraction probably occurs immediately
after tendon division.
Pulvertaft usually found the tendon and sheath distal
to the division to be in good condition but warned that,
in children, there was no stimulus to develop and the
tendon and sheath remained as they had been at the
time of injury, necessitating reconstruction of an entirely
new set of pulleys to retain any tendon graft.1 Once in
situ and working, the graft grows with the child’s hand
and late contracture due to relative shortening of the
graft is not seen.
There is no way of determining the quality of
the muscle before exposing the proximal tendon, so
the possible need for another motor should always be
explained before surgery to the patient. The FPL has a
functional amplitude of excursion of 5.5 to 6 cm23: if the
amplitude of excursion of the cut end of the proximal
tendon is far short of this, then it is unlikely that using
it as a motor for reconstruction will achieve much in
respect of IP joint flexion. Matev provided a useful rule
of thumb in this respect: if the passive stretch of the
muscle fibers, measured at the wrist, is 3 to 4 cm, full
restoration of function may be expected.6 Even with 1.0
to 1.5 cm of passive stretch, the result is likely to be ade­
quate. If less than this, he advised using another motor.
TENDON GRAFTING—BRIDGE GRAFTS
Although some authors recommend and illustrate inter­
position of short segments of graft to bridge gaps,20,24 I
believe that it is more logical in most situations to use
long grafts that take the suture lines to the wrist and the
distal insertion of the FPL tendon, as short segment
grafting most commonly creates a suture line within the
narrow confines of the digital sheath or in the thenar
muscles, or both. Because of the other tendon, artery,
and nerve injuries, it is rare for a division of the FPL
tendon at the wrist not to be repaired primarily. Where
it is not, a short segment of graft will reestablish contact
between the distal tendon and the retracted proximal
tendon and can be used, provided the muscle has not
lost its contractility early, as discussed above. Care is
necessary to avoid impingement of the distal suture line
on the proximal edge of the carpal ligament on full
thumb extension and this part of the ligament may have
to be resected.
movement of the thumb IP joint. Our experience of
primary repair of the extensor pollicis longus tendon18
identified a group of patients who developed extensor
tendon adherence by scar tissue to the underlying bone
and overlying skin, with loss of IP joint movement that
caused functional problems. In this study, eight patients
complained of difficulties with fine pinch functions
such as the handling small screws, when the IP joint of
the thumb has to flick back and forth rapidly over a
small range of motion within its flexion range. This is
most likely to be a problem to those in whom fine
degrees of movement of this joint are critical, such as
musicians, surgeons, craftsmen, mechanics, and electri­
cians. The same problem arises if the FPL is not intact,
or the IP joint imperfect, and it is the loss of rapid move­
ment over a small range, rather than the loss of the fuller
range of motion of this joint, that we record with a
goniometer, which is the problem. The stated goal of a
previous generation of surgeons of achieving only 30°
to 40° of IP movement to provide good function of the
thumb is in keeping with the above observations.1,2
TENDON GRAFTING—THE FPL MUSCLE
Where there is a delay of presentation and a significant
gap between the tendon ends, it is usually recommended
that a tendon graft be interposed. A sine qua non for
this to be successful is that the FPL muscle is still func­
tional and has not fibrosed after shortening. This is a
particular concern after a delay of years between tendon
division and reconstruction. Pulvertaft (1988) addressed
this subject by examination of 77 tendon grafts per­
formed more than 2 years after tendon division, of
which 11 were divisions of the FPL.1 This study recorded
an average joint range of the IP joint of the thumb of
64° in a population of patients of average age of 18
years at operation, after an average delay of 512 years.
This study showed that muscle shortening does not
occur as often, or as severely, as might be expected.
Tendons retract only as far as natural structures attached
to them permit, provided these do not rupture at the
time of injury, or immediately after. The FPL only very
rarely has a lumbrical.21 The distal vinculum brevis is
present in 90% of thumbs and is strong.22 If intact after
injury at the level of the IP joint, it may transmit some
amount of flexion of the IP joint and it will retain the
FPL within the thumb. The existence of a true vinculum
longus is debated.10 Pulvertaft thought that local adhe­
sions played a part in maintaining the tendon in the
thumb. A partial division of a tendon that ruptures later
may have the same effect, as a result of edema in the
tendon preventing retraction (see Figure 27-1). There­
fore, the muscle may still be functional, albeit partially,
and its integrity preserved, after a considerable period
of time. More recently, Urbaniak and Goldner (1973)
recorded retraction of the proximal tendon to the thenar
area or wrist after laceration distal to the MCP joint in

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Chapter 27:  Secondary Reconstruction of the Flexor Pollicis Longus Tendon
the tension of the graft is set by placing the hand flat on
the table with the thumb in a position of slightly
increased flexion over its normal resting position, then
using the wrist tenodesis action to check that the IP joint
of the thumb is fully extended when the wrist is held in
full flexion and is partially flexed and opposed when the
wrist is extended to the functional position.24 Schneider
(1999) detailed a more precise setting of the wrist at 0°,
the thumb abducted in front of the index finger meta­
carpal, and the IP joint of the thumb in 30° of flexion.12
Matev suggested the IP joint be set at 20° to 30°.6 All
of these recommendations are very similar in practice
and can all be used in combination. In general, the
tension should be a little greater than normal, allowing
for the fact that the contracted muscle will extend
slightly towards normal with subsequent use.1 A graft
TENDON GRAFTING—WRIST–TO–DISTAL
PHALANX GRAFTS
A length of tendon graft of 13 to 14 cm is sufficient to
replace the FPL from the wrist to the distal phalanx.
Palmaris longus (PL) is usually of suitable length, always
of suitable diameter and conveniently near to hand. It
is also present in a very high percentage of the popula­
tion. Plantaris is probably the next choice although it is
often very thin and difficulty to suture well with convic­
tion. It remains a matter of wonder to me that it usually
retains its distal attachment throughout rehabilitation.
My third option is the extensor indicis tendon as this
tendon is of adequate length, is sufficiently thick as to
be easy to sew, is near to hand, can be harvested through
small dorsal incisions, is almost always present, and is
seldom missed, as we know from our various other
uses of it.
TENDON GRAFTING—DISTAL AND
PROXIMAL ATTACHMENT
Grafting of the FPL is generally carried out using various
techniques of distal attachment to the distal phalanx of
the thumb and a Pulvertaft weave proximally. I routinely
suture the Pulvertaft weave with a continuous 4-0
Prolene suture (Figure 27-4), which starts at one end of
the weave and returns to the same end to be knotted
with a single knot. I prefer this technique to leaving
multiple knots along the weave, which are more likely
to snag. It is seldom that the passage of the needle cuts
a previous pass of the suture. Even if it does and a
second knot is required, this technique is still faster and
neater than the conventional use of multiple suture and
knots.
TENDON GRAFTING—THE THENAR TUNNEL
The most difficult technical activity in secondary recon­
struction of the FPL is passing the new tendon, or the
silicon rod if a two-stage procedure is carried out,
through the thenar muscles, particularly if the tunnel is
scarred and closed. Good exposure of the entry to the
tunnel at the base of the thenar muscles includes fully
opening the carpal tunnel and identifying the motor
branch of the median nerve and the sensory branches
to the thumb more distally. Where the tunnel is present,
the tendon can be pulled through to the base of the
thumb with a fine tendon passer or attached by a suture
to a small-bore stiff plastic tube. Where necessary, the
tunnel is recreated with McKindoe scissors and, mostly,
blunt dissection. Under these circumstances, we would
use a two-stage tendon graft reconstruction.
TENDON GRAFTING—THE TENSION
OF SETTING IN THE GRAFT
The tension at which the graft is set is important. Camp­
bell Reid and McGrouther (1986) recommended that
Figure 27-4  A 48-year-old man who ruptured a primary
repair of the FPL. Reconstruction at immediate exploration
with a one-stage PL graft from the wrist to the distal
phalanx of the thumb. A, The technique of suturing the
Pulvertaft weave at the wrist using a single continuous
suture is illustrated in close-up (B).
A
B

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Section 3:  Secondary Flexor Tendon Surgery
entirely without supplement by a tendon graft. This
transfer also needs little re-education. Little has been
written in recent years about this transfer but what has
been written is favorable.25,26
While some authors suggest transfer of the FDS
tendon of the ring finger as an alternative to grafting of
the FPL,27 I do not agree with this for various reasons.
Use of this tendon transfer introduces a further com­
plexity to the situation. Weakening the ring finger may
have little functional significance, but it has been my
experience, even with a very experienced and large
therapy department looking after these patients after
surgery, that the subsequent mobility of the ring finger
is not always normal. In particular, in a white popula­
tion, loss of extension of the proximal interphalangeal
(PIP) joint as a result of palmar plate contracture is
possible. Those with more mobile joints are more
likely to suffer swan-necking unless the distal end of the
FDS tendon is carefully sutured to the sheath or A2
pulley proximal to the PIP joint. More significant inter­
ference with normal flexion and extension movements
that is too tight is more likely to gain extension than
one that is too slack to regain flexion.
TENDON TRANSFER
Where there is doubt as to the function of the FPL
muscle at exploration (Figure 27-5), it is necessary to
use a tendon transfer to provide another motor for
thumb flexion. While the flexor digitorum superficialis
of the ring finger, the PL, the brachioradialis, and the
flexor carpi radialis have all been suggested as suitable
for this transfer, the first is that normally used. The PL
is an antagonist to the FPL, making re-education more
difficult. Dissection of the brachioradialis is unnecessar­
ily extensive, compared with that necessary to harvest
the flexor digitorum superficialis (FDS) of the ring
finger, and leaves a long and visible forearm scar to no
particular advantage. The FDS of the ring finger can be
harvested without difficulty through small incisions that
fade to be inconspicuous at the base of the finger and
in the palm, if a palmar incision is needed. The length
of the tendon is such that it will always replace the FPL
A
B
C
Figure 27-5  Exploration of a nonfunctioning FPL in a
48-year-old woman 4 months after removal of a plate
elsewhere that had been used to treat a radial fracture 5
years earlier. The plate was perceived to be the cause of
difficulties of finger and thumb movement. A, View after
extensive tenoneurolysis (with the appearance of the
median nerve as an indicator of the degree of scarring
prior to tenoneurolysis). The FPL muscle was completely
bound in scar tissue and nonfunctional. B, The FPL
tendon had snapped or been divided at removal of the
plate, with the distal end resting at the MCP level of the
thumb. C, Insertion of a silicone rod with a view to
performing a secondary FDS tendon transfer from the
ring finger.

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Chapter 27:  Secondary Reconstruction of the Flexor Pollicis Longus Tendon
recent reports33,34 of two-stage FPL grafting achieved the
30° to 40° of IP motion required for fine pinch func­
tion but their results are disappointing compared to the
extraordinary results mentioned earlier of Pulvertaft1 in
patients presenting after long delays. However, many
hidden factors may be at play here, not the least being
the difference between the average age of Pulvertaft’s
group of 18 years and that of the patients in these
studies. I also believe that the delay between the stages
in one study34 of 8 weeks is too short.
The presence of an annular pulley at the base of the
thumb is essential to FPL function. In most circum­
stances where pulleys need to be reconstructed, the
clinical situation includes a need for secondary recon­
struction of the FPL tendon and we prefer to reconstruct
the pulleys over a silicone rod at a first stage and recon­
struct the flexor tendon later (see Figure 27-5). This
allows the use of a pulley reconstruction in which the
of the remaining flexor tendon may occasionally arise
as a result of adhesion formation. Ebelin et al also
reported problems with this reconstruction, including a
problem of cortical integration in two cases.16 Therefore,
I believe this transfer, although a relatively simple pro­
cedure, should only be used if the FPL muscle is not
functional or has been badly damaged in a complex
forearm injury. This view is supported by most previous
authors. Without knowledge of the mentioned possible
problems, many patients also see this as an unneces­
sarily complex alternative to reconnecting the original
system.
TWO-STAGE TENDON GRAFTING
Most authors recommend single stage reconstruction of
the FPL and this would seem reasonable where the
suture lines are placed at the wrist and the distal phalanx
and not within the digital tendon sheath or the thenar
muscles. However, there are circumstances in which two
stage reconstruction28-32 can be useful, or advisable,
whether the actual reconstruction is by grafting or
tendon transfer. Some cases in my unit requiring sec­
ondary FPL reconstruction have already had a primary
repair that has stuck and is found at tenolysis to have a
gapped tendon. Removal of the tendon may leave a
badly scarred sheath (see Figure 27-5) and/or damage
of the pulleys (Figure 27-6) to an extent that reconstruc­
tion of new pulleys is necessary. A few more primary
repairs rupture and, for a variety of reasons (see Chapter
19), cannot be re-repaired, although they generally
re-present to us early. In all of these cases, we insert a
silicone rod, with reconstruction of new pulleys over the
rod if need be. This is a convenient means of both creat­
ing a better tendon “tunnel” and recreating pulleys that
will not be expected to withstand the forces of a func­
tioning tendon for a few months. Many of these failures
of primary surgery are known better to us and our thera­
pists than cases presenting acutely; a human factor also
comes into our choice of two-stage grafting. These
patients have already had primary surgery fail, so they
may be at least as likely to have secondary surgery fail
for reasons as diverse as that they are noncompliant
with therapy, they live too far away to attend therapy,
other home circumstances militate against their attend­
ing therapy, they have a very low pain tolerance, the
initial injury was more severe and likely to have laid
down considerable scar in the thumb, etc. Under such
circumstances, we believe that the two-stage process
gives them the best chance of avoiding adherence of the
tendon and further tenolysis surgery. In other circum­
stances, where presentation is delayed and the sheath is
found to be badly scarred, such as after tendon sheath
infection, or complex thumb injuries that include major
loss of the palmar surface soft tissues, including the
palmar face of the sheath and/or the pulleys, two-stage
secondary reconstruction has the same benefits. Two
Figure 27-6  Immediate exploration of the FPL in a
32-year-old woman after rupture of a primary repair.
A, Pulley reconstruction using the discarded distal FPL over
a tendon rod as the first stage of a two-stage reconstruction.
B, The completed pulleys.
A
B

294
Section 3:  Secondary Flexor Tendon Surgery
which leaves a prominent scar on the dorsum of the
wrist.
Many secondary reconstructions of the FPL tendon
will be carried out within a few weeks of the primary
injury and the need to consider use of the techniques
of tendon reconnection described in this chapter only
become apparent at surgery, when it is seen that a simple
primary repair cannot be carried out. Other cases will be
undertaken as a one-stage reconstruction after a greater
delay, or will undergo a two-stage reconstruction. In
these cases, where there has been an injury but no imme­
diate surgery or a first stage tendon operation, it is advis­
able to delay the second operation and have the patient
undertake preoperative therapy with passive forced
flexion exercises and ultrasound to mobilize the extensor
tendon. The thumb is no stranger to tethering of the long
extensor tendon and tightening of the dorsal capsules of
the MCP and IP joints with loss of passive flexion of
these joints.18,35 The result of the subsequent FPL recon­
struction can only be as good as the maximum passive
flexion of these joints. I agree with Pulvertaft’s policy of
allowing a minimum of 6 months between injury and
new pulley, typically made from discarded tendon,
which has been split longitudinally, is simply sutured
to the remnants of the sheath on either side of the sili­
cone rod. By the time of replacing the rod with a func­
tioning tendon, the bond of the pulley at its lateral
margins is strong. This reconstruction also avoids enter­
ing the extensor space of the thumb, with the inherent
risk of extensor adhesion and loss of passive flexion of
the thumb joints. However, the situation does arise
where the patient presents with an intact FPL with bow­
stringing from previous loss of the A1 and oblique
pulleys alone (see Figure 27-6). The need to re-create a
pulley at the base of the thumb, which must immedi­
ately withstand the forces of a functional FPL, also arises
if a decision is made to reconstruct both the pulley and
the FPL at a single stage (Figure 27-7). These cases
require a new pulley with immediate strength. Invasion
of the extensor space with the risk of extensor tethering
is surrendered here to achieve strength.35 We prefer to
reconstruct the pulley by use of a tendon, as described
in 1944 by Bunnell,36 rather than using the extensor
retinaculum, as described by Lister,37 the harvesting of
Figure 27-7  A, Six-year bowstringing in a 44-year-old woman. B–D Reconstruction of a pulley at the base of the thumb
over an intact FPL tendon using PL tendon passed around the phalanx and under EPL.
A
B
C
D

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Chapter 27:  Secondary Reconstruction of the Flexor Pollicis Longus Tendon
strong, but the other two problems, particularly those
on the dorsal surface of the thumb, are common enough
that full free and fast movements of the IP joint, which
are the long-term goals of FPL surgery, are often less
than perfect, even if better than preoperatively. Patients
should be advised of this accordingly and consideration
given seriously to the option described regarding no FPL
repair, even if only to delay the secondary surgery for
sufficient time for the patient to assess whether recon­
struction is necessary.
CONCLUSION
In writing this paragraph, I make no apology for repeat­
ing the opinions of some of the experts of old in this
field so freely. My generation of surgeons were brought
up to carry out primary flexor tendon repairs for most
patients, as witness the 215 patients with primary repair
of divisions of the FPL over the 20 years of my consul­
tant practice who are the basis of the research described
in Chapter 16. This leaves only a few who got through
the primary catchment net during this period, or failed
to complete rehabilitation, and required secondary
reconstruction, subsequently. I perform these secondary
reconstructions of the flexor pollicis longus now much
less than primary repairs. By comparison, the authors of
the past carried out many more secondary reconstruc­
tions. Given that the techniques of reconstruction are
entirely unchanged, their experience is invaluable for us
and it is my impression that the uses to which they were
put by the masters of an earlier era were well thought
out, logical, and improved on the preoperative thumb
function.
reconstruction whenever possible, particularly as the
lack of an FPL tendon does not negate use of the thumb.1
We use a similar gap in time between the stages of a
two-stage procedure. This advice applies to the Northern
European hand, and hands of Northern European origin,
and may not be necessary in other parts of the world.
TENDON GRAFTING—REHABILITATION
Our splinting regimen and rehabilitation after all sec­
ondary FPL reconstructions are exactly as for primary
repair of this tendon, i.e., early active mobilization in a
protective dorsal splint (see Chapter 16), although one
could argue reasonably for a more relaxed regimen as
the both tendon sutures are much stronger than an end-
to-end primary repair. It is necessary to include a dorsal
splint behind the fingers as well as behind the thumb
and prevent finger gripping activities, as these are fol­
lowed by movement of the thumb into tight flexion over
the dorsum of the index finger, which may rupture any
suture of the FPL.
OUTCOMES AND PROGNOSIS
It is my impression, from accumulated experience of
these secondary operations over twenty years, that the
results of the various procedure in which the FPL tendon
is reconstructed secondarily are mostly functionally
better than before reconstruction, although they are
subjected to the same problems as all flexor tendon
surgery, namely loss of IP joint flexion as a result of
extensor tendon tethering and joint dorsal capsule tight­
ening, repair rupture, and flexor tendon tethering.
Rupture is uncommon as the repair techniques are
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Section 3:  Secondary Flexor Tendon Surgery
28. Bassett AL, Carroll RE: Formation of tendon sheaths by sili­
cone rod implants. In Proceeding of the American Society for
Surgery of the Hand, J Bone Joint Surg (Am) 45:884, 1963.
29. Hunter JM: Artificial tendons: Early development and
application, Am J Surg 109:325–338, 1965.
30. Hunter JM: Staged flexor tendon reconstruction, J Hand Surg
8:789–793, 1983.
31. Hunter JM, Salisbury RE: Flexor tendon reconstruction in
severely damaged hands. A two stage procedure using a sili­
cone Dacron reinforced gliding prosthesis prior to tendon
grafting, J Bone Joint Surg (Am) 53:829–858, 1971.
32. Mayer L, Ransohoff N: Reconstruction of the digital tendon
sheath: a contribution to the physiological method of repair
of damaged finger tendons, J Bone Joint Surg (Am) 18:607–
616, 1936.
33. Frakking TG, Depuydt KP, Kon M, et al: Retrospective outcome
analysis of staged flexor tendon reconstruction, J Hand Surg
(Br) 25:168–174, 2000.
34. Unglaub F, Bultmann C, Reiter A, et al: Two-staged recon­
struction of the flexor pollicis longus tendon, J Hand Surg (Br)
31:432–435, 2006.
35. Kulkarni M, Harris SB, Elliot D: The significance of extensor
tendon tethering and dorsal joint capsule tightening after
injury to the hand, J Hand Surg (Br) 31:52–60, 2006.
36. Bunnell S: Surgery of the Hand, Philadelphia, 1944, Lippin­
cott, p 315.
37. Lister GD: Reconstruction of pulleys employing extensor reti­
naculum, J Hand Surg (Am) 4:461–464, 1979.
18. Khandwala AR, Blair J, Harris SB, et al: Immediate repair and
early mobilisation of the extensor pollicis longus tendon in
zones 1-4, J Hand Surg (Br) 29:250–258, 2004.
19. Brown CP, McGrouther DA: The excursion of the tendon of
flexor pollicis longus and its relation to dynamic splintage,
J Hand Surg (Am) 9:787–791, 1984.
20. Tubiana R: Flexor tendon grafts in the hand. In Tubiana R,
editor: The Hand, Vol 3, Philadelphia, 1988, WB Saunders,
p 237.
21. Hollinshead WH: Back and limbs. In Anatomy for Surgeons,
Vol 3, ed 2, New York, 1969, Harper, p 410.
22. Armenta E, Fisher J: Anatomy of flexor pollicis longus vincu­
lum system, J Hand Surg (Am) 9:210–212, 1984.
23. Kaplan EB: Functional and Surgical Anatomy of the Hand, ed 2,
Philadelphia, 1965, Lippincott, p 12.
24. Campbell Reid DA, McGrouther DA: Surgery of the Thumb,
London, 1986, Butterworth, pp 30–36.
25. Posner MA: Flexor superficialis tendon transfers to the
thumb—an alternative to the free tendon graft for treatment
of chronic injuries within the digital sheath, J Hand Surg
8:876–881, 1983.
26. Schneider LH, Wiltshire D: Restoration of flexor pollicis
longus by flexor digitorum superficialis transfer, J Hand Surg
(Am) 8:98–101, 1983.
27. Razemon JP, El Hassar S, Meresse B: Les réparations
secondaires du long fléchisseur du pouce par transposition
du fléchisseur superficial du IV, Lille Chir 26:198–205,
1971.

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CHAPTER
28 
STAGED TENDON GRAFTS AND
SOFT TISSUE COVERAGE
David Elliot, MA, FRCS, BM, BCh
graft with fingers that simply need a graft instead of a
primary repair to reconnect the tendons.
Wherever one practices, the patients included in the
group “secondary flexor tendon surgery” will include
some of your “worst” injuries and “worst” patients.
These cases are more likely to do badly whatever one
does and may do no better after secondary surgery than
they did the first time, if they have already undergone
primary surgery. Unfortunately, conventional one-stage
secondary flexor tendon surgery is not always followed
by satisfactory return of flexor function. Two-stage flexor
tendon grafting was introduced with the intention of
achieving better results under circumstances where the
likelihood of poor results can be identified. The per­
ceived advantage over single-stage grafting is that mobi­
lization of the tendon graft following the second
operation is started with the graft moving in a smooth-
walled pseudo-sheath, created by the silicone rod over
several months after insertion at a first operation, and
in a less traumatized, less painful, and more supple
hand. Despite a very small incidence of reaction to sili­
cone rods and a small incidence of infection and/or
extrusion of the rods, the two-stage procedure appears
at least to reduce the influence of the “scarring” factors
on the result.
The primary, and most significant, problem of flexor
tendon surgery is the formation of adhesions between
injured tendons and their surrounds, particularly the
tendon sheath within the digits and distal palm. Over­
coming adhesion of repairs to the sheath has been
the driving force for most research in this field over the
past 100 years. Mayer and Ransohoff (1936), writing in
the era when delayed flexor tendon grafting was the
routine,2 described how “these adhesions extend from
the point of division of the tendons down to the distal
end of the digital theca (tendon sheath)… . It is obvious
that the normal gliding mechanism of the tendon has
been completely destroyed and that, consequently, the
conditions for re-establishing free gliding of a trans­
planted tendon are so unfavorable that only in excep­
tional instances can an implanted tendon perform its
normal function.” Mayer was the first surgeon to try to
OUTLINE
The following quotation clearly identifies the intended
benefit of two-stage tendon grafting. The evolution of
the technique is recorded and its benefits discussed,
including the use of the technique to deal with
problems requiring pulley and skin reconstruction
simultaneously with reconstituting the flexor tendon
system.
The objective of the two-staged flexor tendon method is
to improve the predictability of final results in difficult
problems dealing with tendon reconstruction.
Hunter, 19901
The ideal treatment of flexor tendon injuries under
almost every circumstance is primary repair. I believe
this to be true whether the injury is a simple laceration
of the finger or a replantation, as it is easier to rehabili­
tate a finger over the several months following injury
with the finger flexing actively than being flexed pas­
sively. However, this is not always possible. A percentage
of primary repairs may also either become adherent to
their surrounds, gap, and become secondarily adherent
to their surrounds, or rupture. All of these circumstances
may lead to “secondary flexor tendon surgery,” which is
a broad description of a variety of procedures, including
tenolysis, tendon grafting, pulley reconstruction, and
skin replacement over the tendons. Although tendon
grafting may give comparable results to primary flexor
tendon repair in the hands of some experts, general
opinion would support the view that primary repair is
less difficult for most surgeons and more likely to be
more successful, even if this has never been proved by
comparative trial. For most of us, tendon grafting is
more difficult, therapy is more vital to success and the
results are usually less near to normal. The reported
results of secondary flexor tendon surgery are generally
worse than those of primary surgery. Undoubtedly, this
relates, not only to surgical technique, but also to the
fact that we collect and report all secondary flexor
surgery cases together. We are bundling together the
complex cases who also, and incidentally, need a tendon

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Section 3:  Secondary Flexor Tendon Surgery
CHOICE BETWEEN SINGLE-STAGE AND
TWO-STAGE GRAFTING
Although much of the flexor tendon surgery performed
in western Europe is primary surgery, we do have to
undertake a surprising amount of secondary flexor
surgery, some of which is because of delayed presenta­
tion and some of which is because the flexor tendon
injury quite frequently does not come as an isolated and
simple one but rather in association with injuries to
other tissues. Nevertheless, secondary surgery for us is
mostly that of the complications of primary repair,
namely ruptured and adherent primary repairs, as the
results of the initial surgery are not universally good. In
the best units, the failures constitute about 10% of all
primary repairs, not a small number and something of
an indictment of our present techniques of primary
flexor tendon surgery. The cases that come to secondary
surgery are mostly either the result of more severe inju­
ries or have occurred in patients who make excessive
amounts of scar tissue or have not cooperated with
therapy because of low pain thresholds, social circum­
stances, or lack of judgment.12 Therefore, the cases
needing secondary surgery can be considered under the
headings of either “bad injuries” or “bad patients.” Else­
where in the world, many patients will only get to an
appropriate surgeon at a time when secondary repair of
the tendon using grafts is the only option because of
proximal tendon retraction. This, by definition, becomes
“secondary flexor surgery,” although the problem is
simply an extended finger with good passive but no
active flexion but now no longer amenable to direct
repair. However, among the patients presenting after
delay, and also defined as undergoing “secondary flexor
surgery,” are a group with much more complicated
problems, sometimes as a result of injuries to the other
structures of the digits and, sometimes, as a result of the
unaided healing process within a digit in the presence
of an inactive flexor system. The problems in these cases
are not simply those of being unable to get the tendon
ends together. So, in terms of the pathologies in the
digits themselves, the problems we all face in the rather
heterogeneous mix of cases that we call “secondary
flexor tendon surgery” are not so different—namely,
flexor tendons that are not intact and flexor tendons that
are stuck in scar tissue, variably associated with divided
pulleys, skin deficit on the flexor aspect of palm and
digits, stiff fingers, and injuries to other, adjacent struc­
tures in the fingers, hand, or forearm.
Whether we should be carrying out single-stage or
two-stage tendon grafting, or a mixture of both, depend­
ing on the individual case, is a matter of opinion with
little hard fact to support either side of the debate. It is,
perhaps, worth remembering that the two-stage graft
was introduced because of dissatisfaction with the
results of the one-stage procedure, albeit in North
reestablish the milieu required for free gliding of the
tendon within the sheath by insertion of an inert rod,
then, at a later stage, replace this with a tendon graft.
He used celloidin tubes but had to abandon his experi­
ment to create a “pseudo-synovial” sheath as these were
too rigid. Twenty-five years later, Bassett and Carroll
(1963) repeated the work using silicone rods.3 James
Hunter carried this work forward through the 1960s and
1970s to establish the technique clinically.1,4-10 The suc­
cessors to the rods of woven Dacron covered by silicon
developed by him for use in staged flexor tendon graft­
ing are known to us all today simply as “Hunter” rods.
Curiously, Hunter’s first use of a silicone rod was to
replace an extensor tendon. The rod was sutured to the
extensor tendon with fine wire. It became clear that the
rod was being stretched and acting as an elastic band to
pull the flexed finger back into extension when the
flexor tendon relaxed. Had the wire suture not pro­
truded through the skin, there would have been no
second stage. On exploration of the protruding wire, it
was clear to Hunter that a shiny mesothelium-lined
membrane had formed around the rod. The rod was
replaced by a tendon graft and the finger went through
rehabilitation to achieve acceptable function. Hunter’s
initial intention was to design an artificial tendon for
permanent use and he pursued both the concept of the
pseudo-sheath and the idea of a permanent artificial
tendon replacement in his research. While the former
has become part of the armamentarium of most hand
surgeons, a permanent artificial tendon remains “experi­
mental,” largely because of the problems of achieving a
permanent bond between the rod and the biological
tissues to which it must be attached proximally and
distally.
THE PSEUDO-SHEATH
After implantation, the silicone rod holds the adjacent
tissues apart. Microscopic studies show that the pseudo-
sheath is not simply a tube of scar.11 The tissues adjacent
to the rod organize over a few days into a mesothelium-
like layer. In the chicken experiments described by
Salisbury and his colleagues, this intima consisted pre­
dominantly of one layer of flattened fibroblasts with
a surface made irregular by pleats and pores, whereas
the normal tendon sheath has an intima of several
layers of thicker, cuboidal cells. The intima also con­
tained macrophages, intermediate cells, mast cells, and
Schwann cells. By 4 to 6 weeks, the deeper tissues have
formed a second layer of loose, well-vascularized con­
nective tissue and the pseudo-sheath has a basic appear­
ance similar to normal synovial sheath. The collagen in
the outer layer was of variable thickness and contained
collagen, reticulum, and elastic and unmyelinated nerve
fibers. The collagen was orientated along the axis of the
implant much as it is orientated along the lines of stress
in a tendon sheath.

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Chapter 28:  Staged Tendon Grafts and Soft Tissue Coverage
infection and those who re-rupture the re-repair will
present at a later stage for tendon grafting but also may
be unsuitable for single-stage grafting, for a variety of
reasons, including those grouped together above under
“bad injury” and “bad patient.”
A small group of patients presenting with severe and/
or contaminated injuries, sometimes with missing seg­
ments of the flexor tendons, are deemed unsuitable for
primary repair. This subject is discussed in Chapter 9 by
Professor Tang. While we endeavor to carry out primary
repairs now in most of these patients while carrying out
the other procedures necessary to their overall hand
reconstruction, then mobilize them as early as possible,
there are some cases where primary repair is impossible.
Whenever possible in such cases, we insert tendon rods
into the flexor sheaths to maintain these until the flexor
tendons can be reconstituted at a later date.
Most other situations in which the surgeon has to
consider the need to graft arise in clinic in preparation
for exploration of digits with various deficits of move­
ment on elective surgical lists, whether after delayed
presentation or after problems following primary
surgery. In clinic, the latter group of patients have to be
told that the surgeon cannot predict whether the need
at surgery will simply be to free the (intact) tendon from
scarring and then move it as early as possible to prevent
readhesion, with 2 to 4 weeks off work, or the tendon
will be found to have gapped or be so scarred that
releasing it intact from the scarring will prove impossi­
ble. If grafted immediately, this will require a 2- to
3-month period without use of this hand while the graft
heals fully at each end. The dilemma for the patient,
given this information and, often, having just had a long
period off work, is that he or she cannot tell his, or her,
employer how long the period off work after surgery will
be until after the event. Under these circumstances,
many, if given the option of staged grafting, will prefer
to have a rod inserted, buddy strap the finger to the
adjacent one for use for a few months, and choose
an opportune time from the point of view of his or
her employment to have a graft inserted and the subse­
quent 2 to 3 months of one-handed life. The second
stage can be carried out at any time after the hand has
become supple, giving the patient a wide choice of the
timing of the second operation. That the second stage
is inevitably being planned with a minimum of 3 to 4
months’ notice is often convenient to the work situation
in Europe.
Where it is obvious in clinic that there is either a pulley
or skin deficit on the palmar aspect of the finger, or both,
I also advise two-stage grafting because (1) I believe it is
easier to deal with the deficit(s) surgically without having
the reconstructions of pulleys and/or skin mobilized
aggressively in the early postoperative period, as is neces­
sary to maintain movement of a tendon graft, and (2) it
is easier to rehabilitate the tendon graft after the second
America, which has a largely white population of
Northern European origin. When the scar tissue between
the tendon and sheath is fine and diaphanous, we talk
of “adhesions” and two-stage grafting seems to be
overkill. When the scar is more dense, we talk not of
adhesions but of scarring! This is an inconsistency of
surgical thought as either can prevent movement and,
perhaps, it might be better to stage the grafting in all
cases, because a failure of secondary flexor tendon
surgery is usually a handicap for life and can even lead
the patient to demand amputation.
I almost always use two-stage grafting as I was brought
up at a time and place where this was believed to give
the best results. Sometimes, it seems that this is overkill,
particularly when the sheath is not badly scarred.
However, most of my cases for tendon grafting are
patients for whom primary surgery failed and, as a
group, are “bad patients,” as defined earlier. Although
not the reason for doing two-stage grafting when I
started, I have come to realize that this technique may,
particularly, suit these cases and my practice. More gen­
erally, it is also the case that no one has worked out how
to identify the “bad patient,” whether in northern
Europe, or elsewhere.
Two-stage graft surgery can be unrealistic to the eco­
nomic needs of many patients in many parts of the
world and the circumstances of hand practice elsewhere
push surgeons more toward single-stage grafting. Prag­
matism in this respect, and one’s early teaching and
experience, is probably the major determinant of the
preferences of different surgeons for single or two-stage
grafting! Despite the preference for single-stage grafting
of many senior surgeons, who may have great skill in
this, and the supportive feeling that the particular sup­
pleness of the hands of certain peoples, compared to the
hand of those of northern European origin, allows
single-stage grafting to be effective more often, there will
be circumstances where this expedient may be so
unlikely to give a good result that the two-stage graft
should be considered by even the most ardent supporter
of the one-stage graft.
Previously unemphasized reasons for staging grafting
have become evident in my practice over the past 20
years. Some patients present with ruptures of primary
repairs and undergo immediate exploration with a view
to re-repair.13 If it is found at surgery that re-repair is not
possible, we routinely put a tendon rod into the finger,
with the rod being replaced by a graft when the finger
has settled. At this point in time, the finger is often
unsuited to a single-stage tendon graft procedure
because of its swollen condition, this being the third
traumatic episode for this finger (exploration of the
rupture following after the causative incident and the
primary repair) in a short period of time. Others who
rupture a primary repair and cannot undergo immediate
re-repair for reasons such as skin breakdown and

300
Section 3:  Secondary Flexor Tendon Surgery
intact tendons and intact pulleys after surgical dissec­
tion is impossible (Figure 28-1). The second is finding
a gapped tendon with scar in the tendon gap after a
previous primary repair. The tendon is now several mil­
limeters too long, and tenolysis is likely to be followed
by re-adhesion as the tendon will be moving less than
optimally during rehabilitation. It is usually the case
that these tendons are considerably scarred within the
tendon sheath, possibly because the gapped tendon has
moved inadequately for most of period of rehabilitation
after the primary surgery.
If a tendon is so frayed after tenolysis that I do not
think it will survive rehabilitation, I replace it with a
rod, with a view to two-stage tendon grafting. In this
circumstance, I do not use special regimens, such as the
Strickland frayed tendon regimen, as this places thera­
pists in the uncomfortable position of using a regimen
with which they are less familiar with tendons that may
snap under their care. This may make their rehabilita­
tion too cautious in a group of patients in whom this is
likely to be counterproductive and lead to further stuck
tendons.
Under all three of these circumstances, I insert a
tendon rod. The distal end of the tendon of the FDS or
flexor digitorum profundus (FDP) that will motor the
graft is held to physiological length by suturing it, with
a nonabsorbable 2-0 or 3-0 suture, to either the deep
transverse ligament in the palm or the ligamentous
structures of the flexor aspect of the wrist. My preference
is to use the palmaris longus whenever possible as the
graft, as it is easier to suture than the smaller plantaris,
and to graft from the distal phalanx back to the palm,
as this only requires harvest of the palmaris tendon in
its extramuscular part. Only occasionally have I found
it necessary to graft back to the wrist. A silicone rod of
approximately the diameter of one of the patient’s flexor
tendons is passed through the sheath from the distal
end of the proximal motor tendon to the distal phalanx.
These rods are manufactured in round and oval shape:
either works equally well. We use sizes 3 or 4 most com­
monly. A new and useful alternative is the “Universal
Tendon Spacer,” which is a flexible silicon rod whose
diameter changes along its length. This rod is moved
through the tendon sheath until the part of appropriate
diameter fits comfortably within the sheath; then the
two ends are cut off (Figure 28-2). The distal end of
the rod is cut obliquely and passed behind the FDP
stump distally, to maintain a pocket to aid attachment
of the distal end of the tendon graft to the distal phalanx
at the second operation. The rod is then sutured with
4-0 nylon to the FDP stump, and to the A4 pulley if
suture to the FDP stump is thought to be too weak
to hold the rod in position during subsequent finger
movements until the second stage. The free proximal
end of the rod is not sutured and should reach slightly
proximal to the sutured distal end of the motor tendon
operation without restrictions to protect reconstructions
of pulley and/or skin deficiencies.
THE CLINICAL PRINCIPLES OF TWO-STAGE
TENDON GRAFTING
Detail of the First Stage
This often begins as the exploration of a digit with a
deficit(s) of movement on an elective surgical list.
Simple statements, such as “tenolysis” and “tendon
graft” that we put on our operating lists are often a gross
simplification of the surgery needed and reinforce an
underestimation of the problem. Whether secondary
surgery is being carried out after delayed primary pre­
sentation or for failed primary surgery, all of the tissues
on the palmar side of the finger may be scarred to some
degree and each layer may require treatment. In respect
of the management of the sheath and tendon, the sepa­
ration of sheath and tendons by surgical dissection
requires meticulous technique, time, and considerable
concentration, and can be tediously slow. Great care is
required to try to achieve an end point of intact tendons
and intact pulleys whenever possible. Where this dissec­
tion ends otherwise, both tendons are usually removed
in preparation for tendon grafting. If the flexor digito­
rum superficialis (FDS) tendon is intact and functional,
this is normally left in situ with a view to replacing
the profundus tendon with a graft passed through the
chiasma of the FDS, or a decision is made to leave the
finger with proximal interphalangeal (PIP) flexion only,
in which case a hyperextending distal interphalangeal
(DIP) joint may need distal flexor tendon tenodesis or
joint fusion.
Two situations will make tendon grafting inevitable.
The first is where the tendon is found to be so severely
scarred to the sheath that achieving an end point of
Figure 28-1  A flexor tenolysis showing such dense
scarring that excision of the flexor tendons leaving a
functional pulley system is impossible.

301
Chapter 28:  Staged Tendon Grafts and Soft Tissue Coverage
Figure 28-2  A Universal Tendon Spacer passed through
the tendon sheath until the part of appropriate diameter fits
comfortably within the sheath, then the two ends will be
cut off.
Figure 28-3  The undersurface of the skin and
subcutaneous fat of a typical case of flexor tenolysis,
showing the scarring of the subcutaneous fat which causes
a longitudinal skin deficiency.
Subcutaneous scarring
Sheath scarring
Figure 28-4  A, Marking of the typical skin excisions used
by the author for secondary exploration of the digital flexors.
These include distal palmar V incisions. B, These allow
advancement of the distal palmar skin into the digits to
counter the typical skin shortage due to the subcutaneous
scarring shown in Figure 28-3, with the palmar wounds
being allowed to heal by secondary intention under moist
antiseptic dressings during early postoperative mobilization.
A
B
in the palm or wrist. The hand is then closed. The first
stage of a staged tendon graft procedure requires no
protection postoperatively. The hand is mobilized early
without protective splinting and the patient usually
returns to work within 2 to 3 weeks. Adjunctive proce­
dures, such as pulley reconstructions and skin replace­
ment, are also carried out at this stage (see later).
Usually between 3 and 6 months is an adequate
delay before carrying out the second-stage tendon graft­
ing procedure. Impatience to complete the second stage
by the patient or the surgeon is counterproductive as the
final result is generally much better if the healing process
of the first, and larger, operation is completely over.
Correction of Skin Deficiencies at the
First Stage
Scarring of the skin and subcutaneous soft tissues at the
time of primary injury may cause longitudinal skin
shortening in the finger or thumb. In fact, during dis­
section of the digit to reach the tendon sheath, if one
examines the undersurface of the subcutaneous fat, one
will see that this almost never escapes some scar deposi­
tion with resultant tightening of the overlying skin
(Figure 28-3). I routinely open these cases using a mid-
lateral incision to allow this incision to be extended
into the distal palm as a V (Figure 28-4). This allows
one to advance the V of skin from the palm into the
finger to compensate for the subcutaneous scarring
in the finger. We first reported use of this technique
for reconstruction of skin deficits of the palmar aspect
of the fingers.14 This advancement of palmar skin is
usually sufficient to deal with skin shortage where the
skin injury has been a simple cut. We usually do not
close the V as a Y but allow it to epithelialize under a
moist antiseptic dressing done twice daily by the patient
during the first few postoperative weeks of mobilization

302
Section 3:  Secondary Flexor Tendon Surgery
of skin deficiency. The finger is opened through a mid-
lateral incision on the same side as the intended donor
finger for the cross finger flap (Figure 28-5B). The mobi­
lized skin is split at the PIP level, and a cross finger flap
is incorporated into the gap (Figure 28-5C–E).
Cases with greater skin deficiency need more exten­
sive flap reconstruction. There are many options of free
and distant pedicled flaps available. Most will swell sig­
nificantly and require secondary thinning of the flap
in the manner described after the McCash open palm
technique in Dupuytren’s surgery. Preoperatively, it is
usually obvious from the nature of the primary injury
and/or the appearance of the finger whether more sig­
nificant skin shortage is present and more skin will have
to be incorporated onto the palmar aspect of the finger
to achieve full extension (Figure 28-5A). Use of a cross
finger flap is a simple way of incorporating more skin
onto the palmar aspect of the finger for moderate cases
A
B
C
D
E
Figure 28-5  A, A case with more extensive shortage of
skin, for which the palmar V incision is inadequate. B, The
same incision was made initially, then the flap was split
at the PIP joint level (shown by the white line). C, A cross
finger flap was inset into the split. D and E, The finger
was mobilized normally postoperatively after the cross
finger flap pedicle was divided.

303
Chapter 28:  Staged Tendon Grafts and Soft Tissue Coverage
technique,19-21 or using fascial flaps with skin graft, or
fascial flaps carrying a skin island vascularized by the
underlying fascia.22-24 These reconstructions may be
based on either the radial or the ulnar artery in the distal
forearm.
later. Guimberteau (2001) described a simple means of
resurfacing the whole palmar aspect of a finger using a
distal ulnar artery pedicled fasciocutaneous flap from
the distal part of the ulnar aspect of the flexor surface
of the forearm.15 Unlike distally based radial artery–
based forearm flaps, the ulnar artery can be dissected
free into the middle of the palm, so the flap reaches the
tip of the finger comfortably.
Skin deficit in the palm with flexor tendon exposure
can often be reconstructed using local flaps, which have
the advantage of avoiding the swelling and subsequent
unnatural wobbling mobility which is common after
distant flap reconstruction of the palm. A longitudinal
exposure of a flexor tendon in the palm can be closed
quickly and simply using local bipedicled flaps. We first
reported this technique as a means of closing the gap in
the palm after harvesting a Zancolli reverse digital artery
flap for finger tip reconstruction.16 Two bipedicle flaps
are designed, one on either side of the defect (Figure
28-6A). The common digital neurovascular structures
are retained in the flaps by dissecting under the skin
bridges at a deep level, immediately adjacent to the
tendons and their sheaths. At the lateral margin of each
palmar flap, only the skin is incised and the fibers in
the subcutaneous fat broken by blunt scissor dissection
to create a much more superficial wound. The palmar
flaps then slide in to close the deep defect (Figure
28-6B) and the superficial lateral wounds epithelialize
under moist antiseptic dressings done by the patient
during the first few postoperative weeks of mobiliza­
tion, as in the McCash Open Palm Technique for
Dupuytren’s surgery (Figure 28-6C). We have used the
same principle to close longitudinal skin defects on the
palmar surface of the fingers exposing the flexor tendons
and their sheath.17
For round, or near-round, defects of the palm, large
triangular flaps are useful. This technique was first
described by Mathes and his colleagues in 1988 for
closure of defects on the sole of the foot.18 One, or more,
skin triangles are designed and incised adjacent to the
defect (Figure 28-7A). The fibers immediately below
the skin incisions are released by pressing down on the
subcutaneous fat with a scalpel, then the deeper fat is
mobilized by blunt scissor dissection. The blood supply
of each flap is from small arterial branches coming up
through the underlying pulp from the underlying neu­
rovascular bundles. While a very small flap may have
insufficient blood supply beneath the triangle of skin,
big flaps are entirely safe. These flaps will slide freely in
any direction after being released in this way (Figure
28-7B). Several flaps may be designed, each sliding in a
different direction, or a very big one right across the
palm may be used.
Skin deficiency exposing flexor tendons in zone 5
can be easily reconstructed in most cases with local
flaps from the forearm, using the V-Y fasciocutaneous
Figure 28-6  A, A patient presenting for secondary flexor
surgery with a longitudinal defect of the palm and exposure
of the flexor tendons in the mid-palm. The poor quality
palmar skin has been excised. B, Bipedicle flaps have been
advanced centrally to close the mid-palmar defect. C, Late
view showing excellent healing of the palm with palmar skin.
This case also illustrates multiple pulley reconstructions over
a silicone rod.
A
4 pulley reconstructions
over a rod
Design of two
bipedicle flaps
Excision of unstable skin
(recurrent breakdown)
B
C

304
Section 3:  Secondary Flexor Tendon Surgery
space but leaves concerns in respect of their strength,
unless elaborate bone fixation techniques are used. We
mostly have a need for pulley reconstruction when we
explore a flexor secondarily and come across a severe
“mess” of scarring (see Figure 28-1). Sometimes, the
last cut of the tenolysis, or the removal of a completely
welded-in flexor, destroys what was left of a weakened
pulley and, sometimes, it is simply impossible to undo
the scar tissue. For us, this is a situation that demands
use of a two-stage tendon graft. The tendons being
removed from the finger or, if these are too poor, the
more proximal part of the tendon of the muscle not
intended for use later as the motor for the graft can be
used to reconstruct the pulleys. The tendon is split lon­
gitudinally and opened out, then turned through 90°
(Figure 28-8A). This provides enough material to make
as many pulleys as one wants (Figure 28-8B). Because
there will be no force on them for 3 to 6 months, the
new pulleys can be simply sutured to the remnant edges
of the sheath, to which they will be strongly bound by
the time they have to hold a tendon against the skele­
ton. This technique avoids harvesting of tendons that
may be required for the second stage or the use of exten­
sor retinaculum, which leaves an obvious scar on the
very visible dorsum of the wrist.
Correction of Joint Deficiencies at
the First Stage
The deepest problems at exploration of these fingers,
and the most likely to give rise to a recurrence of loss
Correction of Pulley Deficiencies at the
First Stage
Single-stage tendon grafting in conjunction with pulley
reconstruction requires that the pulleys be strong
enough to resist the tendon forces when mobilization
is started immediately. The most important pulley defi­
cits requiring reconstruction are those of the A2 at the
base of the finger and the A1 at the base of the thumb.
By careful preservation of the sheath in the middle part
of the digit to avoid distal digital bowstringing, it is
usually unnecessary to reconstruct an A4 pulley (see
Chapter 10 regarding distal bowstringing). Commonly,
palmaris longus tendon, the proximal tendon of which­
ever of the flexor muscles will not be used to motor the
tendon graft, or the extensor retinaculum, is used as the
new pulley at the base of the digit. Whichever material
is used, it is passed around the repaired flexor tendons,
or flexor tendon graft, and the proximal phalanx, and
under the extensor tendon two or three times, then
sutured to itself. Bearing in mind that many cases under­
going flexor surgery have poor results because the exten­
sor tendons, bathed in fibrin in the edema of the injury,
tether to the underlying skeleton and overlying skin to
a greater degree than do the flexor tendons in their
sheaths, and are restricting even passive finger flexion,25
I have reservations about use of techniques of pulley
reconstruction that require passage of tendon, or exten­
sor retinaculum, around the phalanges and through the
extensor compartment. Attachment of new pulleys to
the sides of the phalanx avoids invading the extensor
Figure 28-7  A, A patient presenting for secondary flexor surgery with a near-round skin deficiency in the distal palm. A
palmar triangle flap has been designed and dissected prior to movement laterally into the defect. B, Late view showing
excellent healing of the palm with palmar skin.
A
B

305
Chapter 28:  Staged Tendon Grafts and Soft Tissue Coverage
to the distal phalanx, it is advisable to pass a temporary
suture through the proximal end of the graft and attach
it to the tissues in the palmar, or wrist, incision to prevent
the tendon graft being pulled out of the sheath repeat­
edly during the distal suturing activities. Numerous
methods of attachment of the distal end of the graft to
the distal phalanx have been described: we mostly use
the technique we described in 1996, which dispenses
with the use of a button on the nail of the digit26 and is
simple, effective, and cheap. The proximal end of the
graft is woven into the tendon of the motor using Pul­
vertaft’s technique, with the tension of the new muscu­
lotendinous unit being set in the conventional manner
by reference to the finger cascade when the hand is
resting on the operating table with the wrist in the neutral
position. After the second stage, the graft is mobilized
by the modification of the early active mobilization
technique we use for primary flexor tendon repairs.27,28
We use exactly the same regimen of immediate mobi­
lization after tendon grafting as we do after primary
repair (see Chapter 13B, Box 13[B]-1), which simplifies
things for everyone in the unit. Mobilization is started
the day after the second stage and continues for the
same period, although it could be argued that this
regimen could be relaxed as the suture techniques are
stronger than those of primary flexor tendon surgery.
OUTCOMES AND PROGNOSIS
It is my impression, after using two-stage tendon graft­
ing for many years, that the results are better than previ­
ously with a one-stage procedure. The inclusion of the
extra step of insertion of the rod converts the situation
normally found in secondary surgery in respect of
moving a repair in a scarred environment to one that is
more like that found in primary flexor tendon surgery,
as intended by the pioneers of this technique. Conse­
quently, these cases are assessed by us using the more
rigorous methods of assessing primary flexor tendon
surgery, rather than those of earlier times, which accepted
a much poorer expectation from secondary surgery. It is
my belief that all flexor tendon grafting should now be
assessed in this way to identify any difference from
primary surgery and emphasize the disparity, should
such exist. Where disparity exists, it should be inter­
preted as a need to improve on surgery and rehabilita­
tion and not an acceptance, as in the past, that the cases
are more “difficult.”
Failure of staged flexor tendon grafting may occur at
either of the two stages. Protrusion of the rod, always
through the skin of the distal part of the finger and
not the palm, where it is better covered, is a very rare
experience in our practice, except where there has been
an infection, which has also been a rare occurrence,
perhaps because all are given 5 days of antibiotic cover­
age after insertion of the rod. More common, but also
uncommon, has been movement of the rod from the
of extension, are the ligaments of the underlying joints.
In general, this has little bearing on whether one grafts
in a single stage or two stages, except that the degree of
dissection of the interphalangeal joints usually reflects
the degree of general scarring of the fingers. A consider­
able dissection of the PIP joint, particularly, will also
give rise to more inflammation and scarring in the post­
operative period and increase the likelihood of failure
of the one-stage procedure.
Details of the Second Stage
At the second operation, it is only necessary to expose
the rod at its two ends through small skin incisions to
allow removal of the 4-0 nylon sutures attaching the rod
to the stump of the profundus tendon distally, then
remove the rod and attach the graft distally and proxi­
mally. The harvested tendon graft is sutured to the proxi­
mal end of the rod and pulled distally through the new
pseudo-sheath. Before working distally to attach the graft
Figure 28-8  A, A pulley reconstruction over a silicone rod
using the proximal (FDS) tendon, which will not be the
eventual motor of the tendon graft. B, Another case using
the same material to entirely replace the pulley system of a
finger.
A
Rod under
preserved
A3 and A4
pulleys
Split FDS
New pulley
B

306
Section 3:  Secondary Flexor Tendon Surgery
ranges of movement due to extensor tendon tethering
and joint dorsal capsule tightening, (2) rupture of the
repairs (which is rare as they are stronger than those
after primary surgery), and (3) adhesion of the graft to
its surrounds, which is not common but more likely
than rupture of one of the two repairs. The management
of each of these crises is exactly as after their occurrence
following primary surgery or one-stage grafting, except
that the patient may be influenced to choose options of
treatment more accepting of the disability and less
inclined to further surgery because of the passage of
time with adaptation of the hand to his, or her, needs
and the repeated failure of one’s surgery.
finger proximally into the forearm. This has occurred in
three patients, each of whom required secondary flexor
tendon grafting after rupture of a primary repair. All
three patients were of slightly “manic” personality, with
the fault of overactivity rather than underactivity in the
pursuit of their rehabilitation. One presumes that, in
pursuit of either their daily activities or their therapy,
the rod was, in some way, pulled proximally and the
suture attachment distally in the finger gave way. Why
all three rods were coiled in the forearm and the mecha­
nism of this occurring are mysteries.
Failures after the second stage are exactly like failure
of one-stage flexor tendon grafting and include (1) poor
References
1. Hunter JM, Singer DI, Macklin EJ: Staged flexor tendon recon­
struction using passive and active tendon implants. In Hunter
JM, Schneider LH, Mackin EJ, et al, editors: Rehabilitation of
the Hand: Surgery and Therapy, ed 3, St Louis, 1990, CY Mosby,
Ch 34:427.
2. Mayer L, Ransohoff N: Reconstruction of the digital tendon
sheath: A contribution to the physiological method of repair
of damaged finger tendons, J Bone Joint Surg (Am) 18:607–
616, 1936.
3. Bassett CAL, Carroll RE: Formation of a tendon sheath by
silicone-rod implants, J Bone Joint Surg (Am) 45:884–885,
1963.
4. Hunter JM: Artificial tendons. Early development and appli­
cation, Am J Surg 109:325–338, 1965.
5. Hunter JM, Aulicino PL: Salvage of the scarred tendon systems
utilizing the Hunter tendon implant. In Flynn JE, editor:
Tendon Surgery in the Hand, ed 3, Baltimore, 1981, Williams
and Wilkins.
6. Hunter JM, Blackmore S, Callahan AD: Flexor tendon salvage
and functional redemption using the Hunter tendon implant
and the superficialis finger operation, J Hand Ther 2:107–113,
1989.
7. Hunter JM, Jaeger SH: Tendon implants. In AAOS Symposium
on Tendon Surgery of the Hand, St Louis, 1975, CV Mosby.
8. Hunter JM, Jaeger SH: Tendon implants: primary and second­
ary usage, Orthop Clin North Am 8:473–489, 1977.
9. Hunter JM, Jaeger SH: Flexor tendon implants and prosthe­
ses. In Rubin LR, editor: Biomaterials in Reconstructive Surgery,
St Louis, 1983, CV Mosby.
10. Hunter JM, Jaeger SH, Singer DI, et al: Tendon reconstruction
with implants. In Tubiana R, editor: The Hand, Vol 3,
Philadelphia, 1988, WB Saunders, pp 255–279.
11. Salisbury RE, Levine NS, McKeel DW, et al: Tendon sheath
reconstruction with artificial implants: A study of ultrastruc­
ture. In Hunter JM, Schneider LH, editors: AAOS Symposium
in Tendon Surgery in the Hand, St Louis, 1975, CV Mosby,
Chapter 6:59–65.
12. Harris SB, Harris D, Foster AJ, et al: The aetiology of acute
rupture of flexor tendon repairs in zones 1 and 2 of the fingers
during early mobilization, J Hand Surg (Br) 24:275–280,
1999.
13. Dowd MB, Figus A, Harris SB, et al: The results of immediate
re-repair of zone 1 and 2 primary flexor tendon repairs which
rupture, J Hand Surg (Br) 31:507–513, 2006.
14. Moiemen NS, Elliot D: Palmar V-Y reconstruction of proxi­
mal defects of the volar aspect of the digits, Br J Plast Surg
47:35–41, 1994.
15. Guimberteau JC: New Ideas in Hand Flexor Tendon Surgery,
Aquitaine, 2001, Domaine Forestier, pp 135–143.
16. Moiemen NS, Elliot D: A modification of the Zancolli reverse
digital artery flap, J Hand Surg (Br) 19:142–146, 1994.
17. Yii NW, Elliot D: Bipedicle flap reconstruction of longitudinal
palmar skin and soft tissue defects of the digits, J Hand Surg
(Br) 27:122–128, 2002.
18. Colen LB, Replogle SL, Mathes SJ: The V-Y plantar flap for
reconstruction of the forefoot, Plast Reconstr Surg 81:220–228,
1988.
19. Bardsley AF, Soutar DS, Elliot D, et al: Reducing morbidity in
the radial forearm flap donor site, Plast Reconstr Surg 86:287–
292, 1990.
20. Elliot D, Bainbridge LC: Ulnar fasciocutaneous flap of the
wrist, J Hand Surg (Br) 13:311–312, 1988.
21. Elliot D, Bardsley AF, Batchelor AG, et al: Direct closure of
the radial forearm flap donor defect, Br J Plast Surg 41:358–
360, 1988.
22. Becker C, Gilbert A: Le lambeau cubital, Ann Chir Main
7:136–142, 1988.
23. Elliot D, Lloyd M, Hazari A, et al: Relief of the pain of
neuromas-in-continuity and scarred median and ulnar nerves
in the distal forearm and wrist by neurolysis, wrapping in
vascularized forearm fascial flaps and adjunctive procedures,
J Hand Surg (Br) 35:575–582, 2010.
24. Yii NW, Niranjan NS: Fascial flaps based on perforators for
reconstruction of defects in the distal forearm, Br J Plast Surg
52:534–540, 1999.
25. Kulkarni M, Harris SB, Elliot D: The significance of extensor
tendon tethering and dorsal joint capsule tightening after
injury to the hand, J Hand Surg (Br) 31:52–60, 2006.
26. Sood MK, Elliot D: A new technique of attachment of flexor
tendons to the distal phalanx without a button tie-over,
J Hand Surg (Br) 21:629–632, 1996.
27. Elliot D, Moiemen NC, Flemming AFS, et al: The rupture
rate of acute flexor tendon repairs mobilised by a controlled
active motion regimen, J Hand Surg (Br) 19:607–612,
1994.
28. Elliot D: Primary flexor tendon repair: operative repair, pulley
management and rehabilitation, J Hand Surg (Br) 27:507–
513, 2002.

307
CHAPTER
29 
TWO-STAGE RECONSTRUCTION
WITH THE MODIFIED
PANEVA-HOLEVICH TECHNIQUE
Alexandros E. Beris, MD, Marios G. Lykissas, MD, and
Ioannis Kostas-Agnantis, MD
In 1972, Kessler4 reported a combination of these
techniques using the pedicle tendon transfer to replace
the rod. This method was later known as “modified
Paneva-Holevich method.” This combination presents
several technical advantages and resolves some prob­
lems emerging from the Hunter technique.11 The graft
used (FDS) is an intrasynovial donor tendon and has
better morphological, functional, and healing character­
istics than extrasynovial tendons.12-14 In the past two
decades, we used modified Paneva-Holevich method in
the patients who were indicated for staged tendon
reconstruction in the digits. We found that this tech­
nique has some unique advantages. The size of the FDS
is similar to the silicone rod that is used in the first stage
for stimulation of pseudo-sheath formation. In addi­
tion, during the second stage we found it very easy to
locate the loop between FDP and FDS that is usually
situated at the level of the lumbrical muscles. There have
been no donor site morbidity. This operation is associ­
ated with a lower rate of post-reconstruction tendon
ruptures, because there is only one suture site at the
second stage instead of two for a free tendon graft as
with the Hunter technique.
INDICATIONS
The indications for the modified Paneva-Holevich are
the same as for the Hunter technique. Candidates
for a modified Paneva-Holevich technique must have
suffered injuries of both flexor tendons to the affected
digit with serious scarring and a nonfunctional flexor
apparatus. More specifically, indications include (1)
flexor tendon reconstruction in Boyes 2 to 5 injuries
in zone 2 with considerable scarring of the tendon
bed; (2) finger replantation with damage to the fibro­
osseous canal; and (3) failed previous flexor tendon
reconstruction.11
In cases where FDS of the injured finger is intact this
technique cannot be used, since a distal interphalangeal
OUTLINE
Flexor tendon reconstruction in zone 2 with the
Hunter technique is an established approach to restore
digital flexion and to overcome adhesions in the fibro-
osseous canal. Paneva-Holevich modification of the
Hunter technique refers to forming a pseudo-sheath
around a silicone rod and a loop between the flexor
digitorum profundus and the flexor digitorum super­
ficialis in the first stage, and the use of the formed
pedicle graft through the pseudo-sheath in the second
stage. This combination presents several technical
advantages and resolves problems emerging from the
Hunter technique. We describe the indications, opera­
tive technique, postoperative care, outcomes, and
complications of this method for the flexor tendon
reconstruction in zone 2 based on our clinical experi­
ence over the past decades.
In 1965, Paneva-Holevich1 published a small series of
flexor tendon injuries in which the proximal part of the
flexor digitorum superficialis (FDS) was used as a pedicle
graft for flexor digitorum profundus (FDP) tendon
reconstruction. In 1969, Paneva-Holevich reported two-
stage tendon reconstruction using this method in 34
digits.2 She called her new method “two-stage teno­
plasty.” This surgery was later known as the “Paneva-
Holevich procedure.” James Hunter,3 the pioneer of
staged tendon reconstruction, first described the use of
a silicone rod as a “space saver” followed by free tendon
grafting for the management of patients with poor prog­
nosis (Boyes grades 2 to 5) in 1971. The philosophy was
simple: a flexible silicone-Dacron–reinforced gliding
implant for the formation of a pseudo-sheath as the first
stage of profundus tendon reconstruction, followed by
grafting an autogenous tendon into the pseudo-sheath
in the second stage. This method was used rather popu­
larly in later years.5-9

308
Section 3:  Secondary Flexor Tendon Surgery
is chosen corresponding to the diameter of the FDS
tendon (usually No. 3 to 5). The implant is inserted
and its distal insertion is secured with direct sutures to
the profundus stump and is reinforced with pull-out
suture to the distal phalanx. The proximal part of
the silicone rod is cut to the lumbrical level and is left
free underneath the FDS-FDP loop after checking its
free motion.
We usually reconstruct at least A1, A2, and A4 pulleys
using pieces of the removed tendons (see Figure 29-2).
The technique used for pulley reconstruction is suturing
these pieces of flexors to the lateral sides of the fibro-
osseous canal. Pulley reconstruction should follow
silicone rod insertion in order to accurately match the
selected implant. Any necessary secondary procedures,
such as nerve repair, interphalangeal (IP) or metacarpo­
phalangeal (MCP) joint arthrolysis, and web space
plasty, are performed at this point, and the skin is closed
without tension.
Stage 2
The stage 2 surgery is done after an interval of 3 months
and consists of three steps: (1) a mid-palmar inverted L
incision for loop retrieval; (2) an antebrachial incision
for transsection of the FDS at the musculotendinous
junction; and (3) an angular incision over the DIP joint
for graft retraction and anchoring the graft (FDS) to the
distal phalanx (Figures 29-3 to 29-5).
(DIP) tenodesis or arthrodesis is the treatment of
choice.11 A relative contraindication is scarring in the
palm that may compromise the anatomic integrity of
the FDS.
This procedure greatly facilitates staged flexor tendon
reconstruction in children with minor modifications in
the rehabilitation program.15 Indications and contrain­
dications of a modified Paneva-Holevich in children are
the same as in adults.
OPERATIVE TECHNIQUE
The surgical technique includes two stages with a
minimum of a 3-month time interval.11 In both stages,
the use of magnifying loupes is mandatory.
Stage 1
The flexor tendons are exposed through a Bruner inci­
sion, which gives excellent access. Complete removal of
the cicatrix follows and special care is taken to preserve
as many pulleys as possible. The injured FDP tendon is
excised proximally at the level of the lumbrical muscles.
Distally, a 1-cm FDP stump at the base of the distal
phalanx is preserved for anchoring of the silicone rod
during the first stage and the tendon graft during the
second stage.
A second incision is made in the palm (inverted L)
and is center near thenar for index and middle finger
and near hypothenar for the ring and small finger
(Figure 29-1). The FDS and FDP tendon ends of the
injured finger are retrieved, freed of adhesions, and
sutured together with a loop at the lumbrical level in
an end-to-end fashion (Figure 29-2). A silicone rod
Figure 29-1  A Bruner incision in the digit and an L incision
in the palm for the FDS-FDP loop junction.
Figure 29-2  Formation of a loop between FDS and FDP
tendon, reconstruction of A1, A2, and A4 pulleys, and
silicone rod placement in stage 1.
Silicone rod
Reconstructed
A1, A2, and A4
pulleys
Flexor
digitorum
profundus
(FDP)
Flexor
digitorum
superficialis
(FDS)

309
Chapter 29:  Two-Stage Reconstruction With the Modified Paneva-Holevich Technique
Figure 29-3  An L incision in the palm for retrieval of
the loop and rod. A longitudinal incision is made in the
antebrachium for proximal transection of the FDS, and an
angular incision made at the DIP joint level for rod removal
and advancement of the grafted FDS tendon.
Figure 29-4  The loop site between FDS and FDP has
healed. The distal end of the FDS tendon is sutured to the
distal stump of the FDP tendon.
Flexor
digitorum
superficialis
(FDS)
Flexor
digitorum
profundus
(FDP)
Figure 29-5  The FDS tendon is retrieved from the wrist.
The area of the healed FDS-FDP junction is indicated with an
arrow.
A mid-palmar incision is used to identify the proxi­
mal end of the silicone rod and to retrieve the FDS-FDP
loop. The loop is identified easily because of its volume.
Trimming of the loop may be necessary in rare cases.
A longitudinal antebrachial incision is used to iden­
tify the FDS tendon to the same finger. The tendon is
cut at the musculotendinous junction after a measure­
ment is done for the needed length. The cut FDS is then
pulled out to the palmar incision through the carpal
tunnel (see Figure 29-5). The FDS stump is sutured to
the proximal end of the silicone rod.
A third angular incision is made over the DIP joint
and the silicone rod with the graft sutured to its end is
gently retracted through the pseudo-sheath (Figure
29-6). The silicone rod is then discharged and the
tension of the graft is estimated by temporary stabiliza­
tion with a hypodermic needle through the skin of the
distal phalanx. The desired tension is adjusted so that
the reconstructed finger is kept in slightly more flexion
than the adjacent fingers in flexion and extension of the
wrist. Then, the graft is secured to the profundus stump
in the distal phalanx with three or four interrupted 3-0
nonabsorbable sutures. To avoid nail deformities, pull-
out sutures should exit proximal to the nail matrix on
the dorsum of the phalanx. In the recent years, we used

310
Section 3:  Secondary Flexor Tendon Surgery
OUTCOMES
Between 1992 and 2011, we treated 46 patients (55
digits) with zone 2 injuries using modified Paneva-
Holevich reconstruction. Between 1992 and 2000, we
had 20 patients (22 digits); they were followed for at least
1 year. The mean age of the patients was 24 years (range,
3 to 54 years). The mean total active motion recorded
was 189° of 219° of total passive motion (71% of the
contralateral respective finger) (Figure 29-7).11 Accord­
ing to the Buck-Gramcko scale, overall, an excellent
score was achieved in 50%, good in 32%, fair in 9%, and
poor in 9% of the digits. Using the revised Strickland
scale, 73% of the digits had good or excellent results.
Complications included pulley rupture in 4, nail defor­
mity in 8 (cosmetically unacceptable in one only), trig­
gering at the MCP joint in one, sensitive scar in one, and
deep infection in 2 digits in stage 1. These results are
slightly better than those achieved by Wehbe and others8
with the Hunter method of reconstruction. They reported
a total active range of digital motion of 176°. Superior
results were also noted when our findings were com­
pared with those of the two of the largest series using the
Hunter method.9,10 The good and excellent results in
these reports were 40% and 42% (La Salle-Strickland
scale), respectively, for zone 2 injuries, compared with
72% in our series (revised Strickland scale).
Since 1970s, many authors have reported good and
excellent results in the majority of their patients by
using the modified Paneva-Holevich technique (Table
29-1). Kessler4 had good and excellent results in 83%
of his patients by using the Strickland scale. Winspur
and colleagues17 obtained good and excellent results in
80% of their patients, by using the Buck-Gramcko scale.
Similarly, in our patients, good and excellent results
were recorded in 82% of the digits after surgery using
the Buck-Gramcko scale and 73% using the modified
Strickland scale.11
We used the modified Paneva-Holevich technique in
9 children (nine digits) with zone 2 injuries between
1992 and 2005 and recorded good and excellent results
in 8 children (89%) after a mean follow-up of 40
months.15 The mean total active motion achieved was
196° (75% of the contralateral finger) of 237° of total
passive motion.
COMPLICATIONS
The staged flexor tendon reconstruction is a demanding
technique with risks and complications. The complica­
tions can appear in both stages of surgery.25
In stage 1 of the two-stage flexor tendon reconstruc­
tion, complications include (1) rod buckling, (2) necro­
sis of the skin, (3) rod migration, (4) rupture of the distal
end of silicone rod, (5) synovitis, and (6) infection.
At the second stage, the following complications can
be noticed: (1) bowstringing, (2) impingement of the
a small anchor inserted in the palmar aspect of the distal
phalanx, securing the distal part of the graft.
POSTOPERATIVE CARE
A part of the preoperative passive physiotherapy program
to overcome stiffness and achieve maximum joint
motion, a postoperative rehabilitation program is also
of paramount importance to maintain maximum finger
joint flexion. Intensive postoperative physiotherapy
should follow both stages.
Stage 1
At the end of the first stage, the hand should be immo­
bilized with a bulky dressing for 48 hours. An intensive
rehabilitation program consisting of passive MCP and
IP joints flexion is initiated 3 days after surgery. The goal
is to achieve and preserve full passive joint flexion and
extension of the reconstructed finger until the second
stage is undertaken.
Stage 2
After the second stage operation, a dorsal splint is
applied to hold the wrist in 30° flexion, the MCP joint
in 70° flexion, and the IP joints in a slightly flexed posi­
tion. An early controlled motion program comprising
passive flexion and active extension is started at day 3.16
The splint is removed by 5 weeks and active motion
and blocking exercises are initiated to avoid flexion
contractures.
Figure 29-6  An angular incision is made over DIP joint and
the silicone rod with the FDS graft sutured to its distal end is
retracted through this incision.

311
Chapter 29:  Two-Stage Reconstruction With the Modified Paneva-Holevich Technique
Flexion contracture of the DIP joint is one of the most
commonly described complications that can be treated
with night extension splints.10,11,15,17-24 Silicone rod
rupture, bowstringing, and rupture of the distal graft
suture are other common complications.
In stage 1, rod buckling can be prevented by avoiding
suturing the pulleys under tension, so that silicone rod
moves freely. Skin necrosis can be avoided by using a
Bruner incision with angles no less than 45°. We could
prevent rupture of the distal end of the silicone rod by
suturing the rod to the distal stump of the FDP and a
pull-out suture of the silicone rod. In case of rupture of
the silicone rod, the volar aspect of the distal phalanx
is opened and the implant is fished out with a retriever.
Silicone rod synovitis can be treated effectively with
antibiotics and splinting. In stage 2, bowstringing can
be prevented by meticulous and secure reconstructions
of A1, A2, and A4 pulleys in stage 1. If the distal graft
junction is disrupted, the graft should be reattached
methods are same for silicone rod rupture. Flexion
deformity of the DIP joint can be prevented by placing
less tension of the graft during surgery and dynamic
night splints after stage 2.
Infection is an uncommon complication but can be
a serious one that may affect considerably the outcome.
The percentage of infection varies from 2.3% to 25.6%
in both stage 1 and 2.8,9,15,25-28 Inadequate treatment may
require removal of the rod and reoperation with the
two-stage technique after 5 months. Infection is more
common in stage 1 than in stage 2; this fact may be
attributed to extensive surgical exposure of the digit and
silicone rod synovitis or both. In our series infection was
recorded in 2 digits (9%) during stage 1.29 In one
case infection was resolved by closed irrigation and
proximal suture in the fibro-osseous canal, (3) tendon
grafts loose or tight, (4) disruption at the distal or proxi­
mal junctions, (5) flexion deformity of the proximal
interphalangeal (PIP) and/or DIP joints, which is con­
sidered to be the most common complication at this
stage, and (6) infection.
Complications after the modified Paneva-Holevich
technique occur in 0% to 27% of the digits.10,11,15,17-24
Figure 29-7  Flexion (A) and extension
(B) of a ring finger 3.5 years after tendon
reconstruction with the modified
Paneva-Holevich method.
A
B
Table 29-1  Outcomes of the Modified Paneva-
Holevich Technique
Authors
Digits
Criteria* and
Good-Excellent Rate
Kessler et al4
6
83%†, Strickland
Winspur et al17
10
80%†
Brug et al18
27
52%
Chuinard et al19
16
62.5%, Boyes (modified)
Paneva-Holevich
et al20
39
56%, Boyes (modified)
Alnot et al21
19
73%, total active motion
Naam22
21
52.4%, Strickland
Brug et al23
76
55%
Beris et al11
22
82%
Darlis et al15
9
89%
Abdul-Kader and
Amir24
12
75%
*Buck-Gramcko method was used unless specified.
†Calculated based on data provided in the articles.

312
Section 3:  Secondary Flexor Tendon Surgery
because it has already healed by stage 2; and (2) the FDS
of the little finger sometimes is thin in the wrist area
and cannot be used. This problem can be overcome by
reinforcement of the tendon with a PL graft or by using
the FDS of an adjacent finger.18
We started using the modified Paneva-Holevich tech­
nique from 1992. Since 1999, this method has been
used for all patients who required staged tendon recon­
struction. The modified technique has several advan­
tages over the Hunter’s staged reconstruction and is now
more familiar to us. Some modifications regarding the
methods of tendon junction have been described in the
literature, where a Kessler suture or a fish-mouth tech­
nique was used for the loop junction between the FDS
and the FDP in stage 1 operation,22,23 but three or four
simple sutures are considered more than enough for the
loop. The lumbrical muscle belly can be folded over the
FDS-FDP loop, but this may increase the risk for a lum­
brical plus finger.18,23 Pulley reconstruction can be
achieved by using the excised tendon material and not
using the PL19 or extensor retinaculum.21
Many authors recommended that the distal anchor of
the graft during stage 2 should include attachment to
both the FDP tendon stump and a pull-out suture. Addi­
tional strength can be achieved by passing the graft
through an osseous tunnel in the distal phalanx.3,5 We
currently prefer to pass the graft underneath the distal end
of the profundus stump and suture to it with transverse
sutures on both sides and an additional suture through
an absorbable anchor to the distal phalanx without a
pull-out suture through the nail. If the A5 pulley has been
preserved, the proximal end of the profundus stump can
also be sutured to the distal edge of the A5 pulley.37
In most cases, the proximal part of the FDP to the
injured finger is used as a motor. When power of this
FDP muscle is absent or questionable, the FDS of the
same or adjacent finger can be used as a motor.8 During
operation, care should be taken to making proper judge­
ment about which proximal motor tendon is the best
motor, and either a FDP or a FDS tendon can be the
motor source.18
Two-stage flexor tendon reconstruction with combi­
nation of a silicone rod and a pedicle FDS tendon graft
is an efficient method of restoration of function of the
flexor tendons in zone 2. The combination presents
several technical advantages and resolves some prob­
lems emerging from the Hunter technique.
intravenous antibiotics, while in another case rod
removal was necessary.
DISCUSSION
In 1971, Hunter and Salisbury2 presented the prelimi­
nary results after two-stage flexor tendon reconstruction
addressing the problem of functional compromise after
flexor tendon injuries in zone 2. Since then, two-stage
flexor tendon reconstruction has been widely accepted,
presenting different rates of success and complica­
tions.26,30,31 In the first stage, the silicone rod is inserted
to stimulate pseudo-sheath formation with a smooth
and gliding surface that allows the passage of a free
tendon graft through it at a second stage.32,33 In further
studies Hunter showed that the fibroosseous canal
reconstruction in zone 2 allows an unrestricted gliding
without adhesions formation.34
In 1982, Paneva-Holevich reported 324 digital flexor
tendon reconstruction with her method of pedicle FDS
tendon grafting, among which in 39 digits with exten­
sive scar, she combined her technique (loop between
the FDP and the FDS in the first stage and the use
of the formed pedicle graft in the second stage) with
the Hunter silicone rod technique.20 Compared to
the Hunter technique, the modified Paneva-Holevich
method is advantageous because (1) there is no need of
identifying the motor during the first stage; (2) the
FDS-FDP loop can be identified easily in the palm
during the second stage; (3) there is no donor site mor­
bidity, since no free grafts are harvested; (4) it can be
performed easily in children15; (5) it comprises a pedi­
cled tendon graft with a strong proximal junction that
has already healed by stage 2; (6) it uses a tendon graft
(FDS) that is consistent compared with palmaris longus
(PL) and plantaris, which are reported to be absent in
20% and 25% of healthy individuals, respectively35; (7)
the FDS tendon graft is three times larger than conven­
tional grafts used in the Hunter technique (mean cross-
sectional area of 10.6 mm compared with the 3.1 mm,
1.6 mm, and 3.2 mm of PL, plantaris, and toe extensors,
respectively)3,36; and (8) it uses an intrasynovial graft,
which has better morphological, functional, and healing
characteristics than extrasynovial grafts.12-14
We have found only two disadvantages with the
Paneva-Holevich technique: (1) the difficulty in ten­
sioning the graft at the distal anchoring site of the graft.
The proximal tendon junction presents no problem
References
1. Paneva-Holevich E: Two stage plasty in flexor tendon injuries
of the fingers within digital synovial sheath, Acta Chir Plast
7:112–124, 1965.
2. Paneva-Holevich E: Two-stage tenoplasty in injury of the flexor
tendons of the hand, J Bone Joint Surg (Am) 51:21–32, 1969.
3. Hunter JM, Salisbury RE: Flexor-tendon reconstruction in
severely damaged hands. A two-stage procedure using a
silicone-Dacron reinforced gliding prosthesis prior to tendon
grafting, J Bone Joint Surg (Am) 53:829–858, 1971.
4. Kessler FB: Use of a pedicled tendon transfer with a silicone
rod in complicated secondary flexor tendon repairs, Plast
Reconstr Surg 49:439–443, 1972.
5. Schneider LH: Flexor tendons-late reconstruction. In Green
DP, Hotchkiss RN, Pederson WC, editors: Green’s Operative

313
Chapter 29:  Two-Stage Reconstruction With the Modified Paneva-Holevich Technique
21. Alnot JY, Mouton P, Bisson P: Longstanding flexor tendon
lesions treated by two-stage tendon graft, Ann Chir Main
Memb Super 15:25–35, 1996.
22. Naam NH: Staged flexor tendon reconstruction using pedi­
cled tendon graft from the flexor digitorum superficialis,
J Hand Surg (Am) 22:323–327, 1997.
23. Brug E, Wetterkamp D, Neuber M, et al: Secondary recon­
struction of flexor tendon function of the fingers, Unfallchirurg
101:415–425, 1998.
24. Abdul-Kader MH, Amin MA: Two-stage reconstruction for
flexor tendon injuries in zone II using a silicone rod and ped­
icled sublimis tendon graft, Indian J Plast Surg 43:14–20, 2010.
25. Soucacos PN, Beris AE, Malizos KN, et al: Two-stage treatment
of flexor tendon ruptures: Silicone rod complications analyzed
in 109 digits, Acta Orthop Scand (Suppl) 275:48–51, 1997.
26. Weinstein SL, Sprague BL, Flatt AE: Evaluation of the two-
stage flexor-tendon reconstruction in severely damaged digits,
J Bone Joint Surg (Am) 58:786–791, 1976.
27. Frakking TG, Depuydt KP, Kon M, et al: Retrospective outcome
analysis of staged flexor tendon reconstruction, J Hand Surg
(Br) 25:168–174, 2000.
28. Finsen V: Two-stage grafting of digital flexor tendons: A
review of 43 patients after 3 to 15 years, Scand J Plast Reconstr
Surg Hand Surg 37:159–162, 2003.
29. Beris AE, Korompilias AV, Lykissas MG, et al: Management
of infection in 2-stage flexor tendon reconstruction. In
Malizos KN, Soucacos PN, editors: Infections of the Hand and
Upper Limb, Athens, 2007, Paschalidis Medical Publications,
pp 271–276.
30. Honner R, Meares A: A review of 100 flexor tendon recon­
structions with prosthesis, Hand 9:226–231, 1977.
31. Reill P: Die zweizeitige beugesehnentransplantation, Hand­
chirurgie 10:215–221, 1978.
32. Schneider LH: Staged tendon reconstruction, Hand Clin
1:109–120, 1985.
33. Schneider LH: Complications in tendon injury and surgery,
Hand Clin 2:361–371, 1986.
34. Hunter JM: Staged flexor tendon reconstruction. In Hunter
JM, Schneider LH, Mackin EJ, et al, editors: Rehabilitation of
the Hand, St Louis, 1984, CV Mosby, pp 288–313.
35. Wehbé MA: Tendon graft anatomy and harvesting, Orthop Rev
23:253–256, 1994.
36. Carlson GD, Botte MJ, Josephs MS, et al: Morphologic and
biomechanical comparison of tendons used as free grafts,
J Hand Surg (Am) 18:76–82, 1993.
37. Viegas SF: A new modification of two-stage flexor tendon
reconstruction, Tech Hand Up Extrem Surg 10:177–180, 2006.
Hand Surgery, ed 4, New York, 1999, Churchill Livingstone,
pp 1898–1941.
6. Soucacos PN: Two-stage flexor tendon reconstruction using
silicone rods. In Vastamaki M, editor: Current Trends in Hand
Surgery, Amsterdam, 1995, Elsevier, pp 353–357.
7. Soucacos PN: Secondary flexor tendon reconstruction. In
Duparc S, editor: Textbook on Techniques in Orthopaedic Surgery
and Traumatology, Paris, 2000, Elsevier SAS, pp 55–340.
8. Wehbé MA, Mawr B, Hunter JM, et al: Two stage flexor-tendon
reconstruction, Ten-year experience. J Bone Joint Surg (Am)
68:752–763, 1986.
9. LaSalle WB, Strickland JW: An evaluation of the two-stage
flexor tendon reconstruction technique, J Hand Surg (Am)
8:263–267, 1983.
10. Amadio PC, Wood MB, Cooney WP 3rd, et al: Staged flexor
tendon reconstruction in the fingers and hand, J Hand Surg
(Am) 13:559–562, 1988.
11. Beris AE, Darlis NA, Korompilias AV, et al: Two-stage flexor
tendon reconstruction in zone II using a silicone rod and a
pedicled intrasynovial graft, J Hand Surg (Am) 28:652–660,
2003.
12. Abrahamsson SO, Gelberman RH, Lohmander SL: Variations
in cellular proliferation and matrix synthesis in intrasynovial
and extrasynovial tendons: An in vitro study in dogs, J Hand
Surg (Am) 19:259–265, 1994.
13. Seiler JG 3rd, Chu CR, Amiel D, et al: Autogenous flexor
tendon grafts. Biologic mechanisms for incorporation, Clin
Orthop Relat Res 345:239–247, 1997.
14. Leversedge FJ, Zelouf D, Williams C, et al: Flexor tendon
grafting to the hand: An assessment of the intrasynovial
donor tendon—a preliminary single-cohort study, J Hand
Surg (Am) 25:721–730, 2000.
15. Darlis NA, Beris AE, Korompilias AV, et al: Two-stage flexor
tendon reconstruction in zone 2 of the hand in children,
J Pediatr Orthop 25:382–386, 2005.
16. Kleinert HE, Kutz JE, Atasoy E, et al: Primary repair of flexor
tendons, Orthop Clin North Am 4:865–876, 1973.
17. Winspur I, Phelps DB, Boswick JA Jr: Staged reconstruction
of flexor tendons with a silicone rod and a “pedicled” subli­
mis transfer, Plast Reconstr Surg 61:756–761, 1978.
18. Brug E, Stedtfeld HW: Experience with a two-staged pedicled
flexor tendon graft, Hand 11:198–205, 1979.
19. Chuinard RG, Dabezies EJ, Mathews RE: Two-stage superficia­
lis tendon reconstruction in severely damaged fingers, J Hand
Surg (Am) 5:135–143, 1980.
20. Paneva-Holevich E: Two-stage reconstruction of the flexor
tendons, Int Orthop 6:133–138, 1982.

314
CHAPTER
30 
OUTCOMES OF THE MODIFIED
PANEVA-HOLEVICH
PROCEDURES AND
EARLY POSTOPERATIVE
MOBILIZATION
Nash H. Naam, MD, FACS, and Lori Niemerg, OTR/L, CHT
In 1965, Paneva-Holevich suggested the use of pedi­
cled flexor digitorum superficialis (FDS) tendon as a
graft by creating a loop of the flexor digitorum profun­
dus (FDP) and flexor digitorum superficialis (FDS) then
reflecting the latter in the second stage as a pedicled
tendon graft.1,2 In 1971, Hunter and Salisbury intro­
duced the concept of using a silicone-Dacron reinforced
tendon rod to stimulate formation of a new tendon
sheath before tendon grafting.3 This transforms the
scarred tendon bed into a gliding pliable functional
system. In 1972, Kessler reported on the combined use
of Hunter rod and pedicled FDS for staged flexor tendon
reconstruction.4 Since then, several reports of the com­
bined method have been published.5-9
We started performing this procedure in 1983. In
1997, we published our experience with the use of this
technique in 33 patients.8 Up to 2009, we applied this
technique in 116 patients. Candidates for this type of
tendon reconstruction included patients who did not
have their flexor tendon repaired or those who had their
repairs failed secondary to rupture or adhesions (Figure
30-1). Most of these procedures are performed in
patients with zone 2 flexor tendon injuries. However,
zone 1 injuries are also amenable to this type of recon­
struction. Zone 3 and 4 injures can usually be treated
with conventional single-stage interposition tendon
grafts unless there is a concomitant damage to the flexor
tendon sheath in zone 2. This procedure is particularly
useful in tendon injuries associated with severe crushing
injuries when there are associated fractures, nerve inju­
ries, and skin defects.5,7,8
This technique has become our standard technique
for flexor tendon reconstruction when the tendon bed
does not allow one-stage flexor tendon grafting. A dis­
tinct advantage of this procedure is to allow earlier
active range of motion (AROM), since the proximal
repair should be completely healed by the time the
OUTLINE
Patients with severe flexor tendon injuries associated
with scarred digital tendon sheath may require tendon
grafting. Single-stage flexor tendon reconstruction may
be unfeasible because of the scarred tendon bed; there­
fore, staged flexor tendon reconstruction is recom­
mended. The Paneva-Holevich technique uses the
pedicled flexor digitorum superficialis (FDS) as the
donor graft thereby avoiding harvesting a free tendon
graft. The modified technique incorporates the use of
a Silastic rod in the first stage to promote the formation
of a new tendon sheath and the use of a pedicled FDS
as the tendon graft in the second stage. This technique
combines the benefits of the Hunter rod and the use
of a pedicled intrasynovial tendon, which may create
less adhesion than extrasynovial tendons. This modi­
fied technique is ideal for the implementation of an
early active range of motion (AROM) program since
the proximal repair is already healed by the time the
second stage is performed, but the distal graft repair
to the bony distal phalanx should be strong enough
to withstand the stresses of the AROM program. The
incorporation of an early AROM program with this
technique provides a significant advantage in improv­
ing the ultimate outcome of the procedure.
Flexor tendon reconstruction in the presence of a
damaged flexor tendon sheath with destruction of
majority of pulley system or serious scar formation is
very challenging to the hand surgeon. The fibrotic
tendon gliding bed does not allow smooth excursion of
the tendon graft, which results in significant adhesions
and limited range of motion. In these circumstances
single-stage flexor tendon reconstruction would not be
appropriate and staged tendon reconstruction should
be considered.

315
Chapter 30:  Outcomes of the Modified Paneva-Holevich Procedures and Early Postoperative Mobilization
should be performed at this stage utilizing pieces of the
excised flexor tendons. Any nerve grafting or flexion
contracture release can be done at this stage. The largest
possible Hunter rod is then inserted. The Hunter rod
should not touch the gloves as this may produce inflam­
matory reaction secondary to the contact with the talc
powder. The distal end of the rod is sutured to the distal
stump of the FDP with horizontal mattress sutures of
4-0 Prolene or 4-0 fiberwire. It is important to be sure
that the sutures include the Dacron tape within the
Hunter rod since the silicone alone has very little
holding power. The proximal stump of the rod is left
free in the palm. The FDS and FDP tendons of the
injured finger are exposed at the mid palm level. Their
ends are freshened to healthy margins and then sutured
to each other with an end-to-end method (Figures 30-5
and 30-6).
In making the end-to-end suture, the dorsal epiten­
dinous layer is performed first with a running interlock­
ing 6-0 Prolene suture followed by core suture of 4-0
Figure 30-1  Loss of active flexion of the index finger after
an old injury of both flexor tendons.
Figure 30-2  Stage 1: severely scarred flexor tendon
sheath. Some of the pulleys are still intact.
Figure 30-3  The FDS and FDP tendons are seen at the
base of the finger. Note the scarring of the flexor tendon
sheath.
Figure 30-4  The flexor tendons remnants have been
excised. Note the proximal ends of FDS and FDP tendon are
ready for the repair.
second stage is performed if a tendon graft, instead of
tendon transfer, is used. A strong distal repair, preferably
attaching the tendon to the bony distal phalanx, would
allow the graft to withstand the forces of early AROM
without fears of rupture. Actually, Paneva-Holevich rec­
ommended starting active motion of the involved digit
in the first postoperative week and reported no increase
in the incidence of rupture in her early report of second­
ary reconstruction of the FDP tendon by FDS transfer
from the same finger.7
SURGICAL TECHNIQUE
Stage 1
Through a Bruner zigzag incision, the flexor tendon
sheath is exposed. The remnants of the flexor tendons
are excised (Figures 30-2 to 30-4). Special care should
be taken to preserve all the normal pulleys as much as
possible. If the important pulleys or majority of the
flexor pulley system are destroyed, pulley reconstruction

316
Section 3:  Secondary Flexor Tendon Surgery
Patients are started on passive range of motion
(PROM) of the operated digits 3 to 5 days postopera­
tively, which lasts as long as required to ensure adequate
passive range of finger motion. PROM is performed to
keep the joints flexible. The patient is instructed to
perform PROM of each joint of the involved digit for 10
repetitions 6 to 8 times a day. Unrestricted active motion
exercises of the uninvolved digits are emphasized as well
(Box 30-1).
Stage 2
We recommend allowing at least 12 weeks before pro­
ceeding with the second stage. The scar should be
supple. Excellent PROM is a prerequisite before pro­
ceeding to stage 2. Through a zigzag incision in the
palm, the site of FDS-to-FDP tenorrhaphy in the palm
is exposed and freed of the scar tissue (Figure 30-7). A
zigzag incision is made over the distal forearm and the
FDS tendon of the involved digit is isolated. The tendon
is divided at the musculotendinous junction and then
retrieved in the palm incision as a pedicled graft (Figures
30-8 and 30-9). The Hunter rod is exposed and the new
sheath is opened at its proximal end in the palm.
Figure 30-5  The proximal ends of the FDS and FDP
tendons have been repaired end-to-end.
Figure 30-6  A Hunter rod has been inserted. The A2 pulley
has been reconstructed using part of the excised flexor
tendons.
Figure 30-7  Stage 2: the site of FDS and FDP tendon
repair and the proximal end of the Hunter rod are exposed in
the palm.
Prolene or 4-0 fiberwire in a modified Kessler technique.
The volar epitendinous layer is then completed using
the 6-0 Prolene. The Prolene suture is left long to facili­
tate easier identification of the site of the tendon repair
during the second stage. The wounds are closed and the
patient is put in a dorsal splint with the wrist flexed 45°.
This technique is used mostly for flexor tendon inju­
ries in zones 1 and 2. If the tendon laceration is in zone
3 or 4 and the digital sheath is compromised, because
of either a concomitant injury or extension of scarring
that limits tendon excursion, this technique can be used
as well. This will require placing the end-to-end suturing
of the FDS and FDP either distal to the carpal tunnel in
zone 3 injuries or proximal to the carpal tunnel in zone
4 injuries. The FDS tendon may be divided proximal to
the musculotendinous junction and stripped of any
muscle tissue.
 Flexor tendon remnants are excised.
 Pulleys are preserved or reconstructed using the excised
flexor tendons.
 The proximal ends of the FDS and FDP are repaired end-
to-end in the palm.
 Leave the Prolene suture long to facilitate identification
in stage 2.
 The largest possible Hunter rod is inserted. The distal
end is repaired to the FDP stump and the proximal end
is left free in the palm.
 PROM is started 3 to 5 days postoperatively.
Box 30-1
Clinical Pearls—Stage 1

317
Chapter 30:  Outcomes of the Modified Paneva-Holevich Procedures and Early Postoperative Mobilization
Figure 30-8  The FDS tendon is exposed at the distal
forearm and divided at the musculotendinous junction.
Figure 30-9  The FDS tendon is retrieved in the palm
incision.
Figure 30-10  The end of the FDS is guided by the Hunter
rod through the new sheath.
Figure 30-11  The FDS pedicled graft has been delivered to
the distal attachment site guided by the Hunter rod.
Figure 30-12  The position of the digit after repair of
the distal end of the graft to the distal phalanx with a
pullout wire.
A distal incision is made at the level of the distal
interphalangeal (DIP) joint. The distal end of the new
sheath is opened and the Hunter rod is exposed and
freed. The proximal end of the rod is sutured to the
proximal end of the FDS graft (Figure 30-10). As the
rod is pulled distally, it guides the FDS graft through
the new sheath (Figure 30-11). After the distal end of
the FDS tendon is pulled beyond the fingertip, tension
of the graft is adjusted. Optimal tension on the graft is
set to allow extension of the finger with the wrist flexed
and flexion of the finger with wrist extension. The
tension should flex the finger should be slightly more
than the normal flexion cascade. The distal end of
the graft is anchored to the volar aspect of the base
of the distal phalanx using 4-0 stainless steel pullout
wire that is tied over a button (Figure 30-12). Extra
horizontal mattress sutures of 4-0 Prolene are inserted
attaching the graft to the distal stump of the FDP.

318
Section 3:  Secondary Flexor Tendon Surgery
by the hand therapist to be of an immense value. Patients
tended to understand the details of the program better
and their compliance with the therapy program to be
also better. Patients are seen preoperatively by our certi­
fied hand therapist. The therapist discusses with the
patient the postoperative rehabilitation program to
allow the patient to participate in understanding the
importance of this rehabilitation program and its impact
on the eventual result of the staged flexor tendon recon­
struction. Sometimes splints are prefabricated preopera­
tively to decrease the time and the difficulty of making
custom splints postoperatively. Since virtually all these
patients are scheduled on an elective basis, preoperative
teaching by the therapist can be easily incorporated in
the protocol.
At the first postoperative visit, 3 to 5 days postopera­
tively, the compression dressing is removed and a light
compression dressing is applied along with fingersocks
or 1-inch Coban. A dorsal blocking splint is applied.
The wrist is kept in neutral or 20° flexion and the meta­
carpophalangeal joints (MP) in 60° flexion with the IP
joints kept extended. Patients are taught first the place-
and-hold exercise program as well as wrist tenodesis
exercises. The patient is advanced gradually to AROM
exercises within the middle arc of motion and within
the restraints of the dorsal blocking splint. The extremes
of the arc of motion in extension and flexion are to be
avoided in this early phase. Exercises are performed 4
times a day.
At 2 weeks, scar mobilization is started. Scar mobili­
zation is a manual therapeutic technique that uses
massage to break down scar tissue. It is performed 4
times a day by applying gentle firm pressure over the
scar and massaging it in a horizontal, vertical and circu­
lar motion. A self adhesive Silicone gel sheet is used at
night. The sheet is cut appropriate to the size of the scar
and applied directly over the scar. It may be wrapped
with Coban or stockinet. It helps to reduce, flatten, and
smooth the scar.
At 2 weeks, the AROM is increased. Gentle blocking
exercises may be started. Exercises are repeated 6 to 8
times a day. Sometimes ultrasound is used if adhesions
are excessive.
At 4 to 5 weeks, the dorsal blocking splint is dis­
continued. A clamshell splint is fabricated supporting
the MP joint at 0°, allowing full AROM of the PIP and
the DIP joints to promote excursion of the flexor
tendons. The splint is a hand-based, volar/dorsal splint
maintained with Velcro straps on the ulnar and radial
aspects of the hand (Figure 30-13). All the fingers are
included in the splint, but the thumb is excluded to
allow full range of motion of the thumb. The splint
may be used all the time or just during exercises. Neu­
romuscular electrical stimulation may be used. The
patient is advised to avoid any lifting or heavy use of
the hand.
Postoperatively, the patients are instructed to perform
early AROM exercise 3 to 5 days after surgery, as detailed
in the paragraphs that follow (Box 30-2).
EARLY MOBILIZATION
In the past four decades, significant advances in basic
and clinical research have improved our understanding
of tendon function, physiology, and tendon healing.10-13
These advancements triggered an evolution in the post­
operative rehabilitation after flexor tendon repairs. Suc­
cessful rehabilitation after flexor tendon repairs has to
provide both protection of the repair and prevention of
adhesions from limiting the tendon excursion. Studies
have documented improved tendon function with early
controlled mobilization as the forces applied to flexor
tendon repairs provide more rapid recovery of tensile
strength with improved tendon excursion and fewer
adhesions.14,15 Several studies have documented the
superior results of early AROM following flexor tendon
repair and reconstruction.13,16-20
This technique of flexor tendon reconstruction using
the pedicled FDS is ideal for implementation of an
AROM program. The site of the proximal repair is
already healed by the time the second-stage procedure
is performed. The strong bony fixation of the graft to the
bony distal phalanx provides a strong construct allowing
AROM. In our experience we have found that the results
of the more recent procedures were significantly better
than the older ones essentially because of the AROM
program that we adopted in the last 15 years. Smith and
colleagues17 used early AROM following staged flexor
tendon reconstruction. In 26 digits in 22 patients, 20
digits (77%) achieved good to excellent results.
Our Protocol
Early AROM requires a cooperative, focused, and under­
standing patient. We found that preoperative teaching
 Allow at least 12 weeks before proceeding with the
second stage.
 The second stage should not be performed unless the
patient gains excellent passive range of motion.
 The site of the tenorrhaphy is exposed in the palm.
 An incision is made at the distal forearm and the FDS
of the involved digit is isolated and divided at the
musculotendinous junction.
 The tendon graft is retrieved in the palm.
 The tendon graft is threaded through the new sheath
guided by the Hunter rod.
 Optimum tension should be adjusted then the tendon
graft is anchored to the bony distal phalanx with 4-0
stainless steel wire. Extra sutures of 4-0 Prolene can be
placed between the FDP and the tendon graft.
 Early active motion starts 3 to 5 days postoperatively.
Box 30-2
Clinical Pearls—Stage 2

319
Chapter 30:  Outcomes of the Modified Paneva-Holevich Procedures and Early Postoperative Mobilization
classification.21,22 There were no patients in grade 1; 32
patients in grade 2; 14 patients in grade 3; 19 patients
in grade 4; and 29 patients in grade 5. Sixty-six patients
had previous surgery: 36 patients had tendon repairs;
25 were primary and 11 were secondary repairs. Eleven
patients had single staged flexor tendon grafts and 19
had flexor tenolysis.
During the first stage of the tendon reconstruction,
42 patients underwent pulley reconstruction. Pulley
reconstruction was performed using Kleinert and
Bennett’s method in which the tendon graft is sutured
to the remaining rim of tissue at the site of the pulley.23
Twelve patients had nerve grafting, 5 patients had nerve
conduits using polyglycolic acid neurotubes, and 26
patients had release of flexion contractures of the PIP
joint by excision of the check-rein ligaments.
At 8 weeks, progressive strengthening exercises with
the use of putty and/or hand gripper are started. Patients
are gradually weaned from the clamshell splint after
obtaining satisfactory AROM. Unrestricted activities are
allowed at 8 weeks (Figure 30-14).
PERSONAL EXPERIENCE AND OUTCOMES
From 1983 to 2009, we treated 116 patients with this
technique; 94 patients were available for review. The 68
male and 26 female patients ranged in age from 14 to
71 years with an average of 34 years. The index finger
was involved in 21 patients; long finger in 37; ring finger
in 17; and little finger in 19 patients. Twelve patients
had injuries in zone 1; 63 patients in zone 2; 13 patients
in zone 3; and 6 patients in zone 4. Preoperatively,
patients were evaluated according to modified Boyes
Figure 30-13  Clamshell splint.
Figure 30-14  Postoperative function at 1 year after surgery. A, Flexion. B, Extension.
A
B

320
Section 3:  Secondary Flexor Tendon Surgery
CHOICE OF PROCEDURE
Whenever the FDS is available, this technique has proved
to be simple and reliable, and the results are reproduc­
ible. This technique avoids harvesting a donor graft,
thereby reducing the morbidity of the site of the donor
graft. The FDS being an intrasynovial tendon has advan­
tages over the use of an extrasynovial tendon. There have
been several studies that found improved function in
animal models following tendon grafting using an
intrasynovial tendon such as the FDS compared to
extrasynovial tendons such as the palmaris longus or
plantaris.25-28 Gelberman and colleagues25 compared the
morphological and functional characteristics of intrasy­
novial tendons with the extrasynovial tendon grafts in
dogs. They found that the intrasynovial tendon grafts
heal with minimal adhesions with normal cellularity
and collagen organization. This provided a smooth
gliding surface. The extrasynovial grafts, on the other
hand, healed with ingrowth of connective tissue from
the digital sheath that obliterated the gliding surface
and occupied the space between the tendon surface and
surrounding tissues. They concluded that intrasynovial
tendon grafts had significantly improved morphological
and functional characteristics compared with the extra­
synovial tendon grafts.
An added advantage of this technique is proximity of
the size of the FDS tendon to that of the FDP compared
The postoperative follow-up ranged from 2 to 27
years with an average of 9.5 years. The results were
evaluated using the grading system reported by Strick­
land and Glogovac.24 This method measures the active
degree of PIP and DIP joint flexion minus any extension
lag. Patients who have more than 150° are rated as
excellent, 125° to 149° as good, 90° to 124° as fair,
and less than 90° as poor. According to this evaluation,
27 of our patients were rated as excellent, 43 as good,
11 as fair, and 13 as poor. The results by zone of injury
are listed in Table 30-1. The results according to the
preoperative status of the finger according to the modi­
fied Boyes grading system are listed in Table 30-2.
Patient satisfaction was very high; 78% of the patients
were satisfied or very satisfied with the procedure. Of the
94 patients, 64 were manual laborers; 59 of them
returned to their original work activities, 3 retired, and
2 had to change their job.
Persistent flexion contractures of the PIP or the
DIP joints or both were present in 57 patients. The
flexion contracture ranged from 5° to 57° with an
average of 14°.
There were no infections or tendon ruptures in this
group of patients. Fourteen patients required tenolysis;
10 improved, but 4 did not improve and 2 of them
underwent arthrodesis of the PIP joint because of per­
sistent flexion deformities.
Table 30-1  Results According to Zone of Injury
Zone
No. of Patients
Functional Recovery
Excellent + Good, %
Excellent
Good
Fair
Poor
1
12
2
9
0
1
92
2
63
20
24
10
9
70
3
13
3
8
0
2
85
4
6
2
2
1
1
67
Total
94
27
43
11
13
74
Table 30-2  Results According to Preoperative Status With the Modified Boyes Grading Method
Grade
No. of Patients
Functional Recovery
Excellent + Good, %
Excellent
Good
Fair
Poor
II
32
9
16
4
3
78
III
14
4
7
1
2
79
IV
19
6
9
2
2
79
V
29
8
11
4
6
66

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Chapter 30:  Outcomes of the Modified Paneva-Holevich Procedures and Early Postoperative Mobilization
FDS-to-FDP repair in the second stage is much easier
than trying to isolate the profundus tendon of that digit.
The addition of a long Prolene suture at the site of the
repair actually makes identification of the repair site
much easier. The use of the largest possible size of
Hunter rod takes away the uncertainty of whether the
FDS tendon graft will fit in the new tendon sheath. We
have not had any difficulty with passing the FDS in the
tendon sheath. This combined approach of using Hunter
rod to stimulate the production of a new sheath and the
use of the pedicled FDS as a graft takes advantage of the
benefits of the two techniques. This method of flexor
tendon reconstruction provides certain advantages over
the classic use of Hunter rod and an extrasynovial
tendon graft such as the palmaris longus, plantaris, or
toe extensors.30-33
with the size of the palmaris longus or plantaris, which
is much smaller. Carlson and colleagues29 studied the
morphological and biomechanical characteristics of the
free tendon grafts, comparing palmaris longus, plan­
taris, and extensor digitorum longus of the toe with the
FDP. They found that the average cross-sectional area of
the FDP was 10.6 mm2 and the cross-sectional areas of
the palmaris longus, plantaris, and the toe extensors
were 3.1 mm2, 1.6 mm2, and 3.2 mm2, respectively.29
The FDS tendon has a cross-sectional area much closer
to the FDP tendon. That is why we recommend using
the largest possible size of Hunter rods during the first
stage. We used size 6 Hunter rods in 76%, size 5 in 14%,
and size 4 in 10% of the patients.
From the technical standpoint this procedure is
straightforward. Even identification of the site of the
References
1. Paneva-Holevich E: Two-stage plasty in flexor tendon injuries
of fingers within the digital synovial sheath, Acta Chir Plast
7:112–124, 1965.
2. Paneva-Holevich E: Two-stage tenoplasty in injury of the
flexor tendons of the hand, J Bone Joint Surg (Am) 51:21–32,
1969.
3. Hunter JM, Salisbury RE: Flexor tendon reconstruction in
severely damaged hands: a two-stage procedure using a
silicone-Dacron reinforced gliding prosthesis prior to tendon
grafting, J Bone Joint Surg (Am) 53:829–858, 1971.
4. Kessler FB: Use of a pedicled tendon transfer with a silicone
rod in complicated secondary flexor tendon repairs, Plast
Reconstr Surg 49:439–443, 1972.
5. Chong JK, Cramer LM, Culf NK: Combined two-stage teno­
plasty with silicone rods for multiple flexor tendon injuries
in “no-man’s land,” J Trauma 12:104–121, 1972.
6. Winspur I, Phelps DB, Boswick JA: Staged reconstruction of
flexor tendons with a silicone rod and a “pedicled” sublimis
transfer, Plast Reconstr Surg 61:756–761, 1978.
7. Paneva-Holevich E: Two-stage tenoplasty: results. In Hunter
JM, Schneider LH, Mackin EJ, editors: Tendon Surgery in the
Hand, St Louis, 1987, CV Mosby, pp 272–281.
8. Naam NH: Staged flexor tendon reconstruction using pedi­
cled tendon graft from the flexor digitorum superficialis,
J Hand Surg (Am) 22:323–327, 1997.
9. Beris AE, Darlis NA, Korompilias AV, et al: Two-stage flexor
tendon reconstruction in zone II using a silicone rod and a
pedicled intrasynovial graft, J Hand Surg (Am) 28:652–660,
2003.
10. Lundborg G: Experimental flexor tendon healing without
adhesion formation—a new concept of tendon nutrition and
intrinsic healing mechanisms. A preliminary report, Hand
8:235–238, 1976.
11. Gelberman RH, Vande Berg JS, Lundborg GN, et al: Flexor
tendon healing and restoration of the gliding surface: An
ultrastructural study in dogs, J Bone Joint Surg (Am) 65:70–80,
1983.
12. Boyer MI, Strickland JW, Engles D, et al: Flexor tendon repair
and rehabilitation: state of the art in 2002, Instr Course Lect
52:137–161, 2003.
13. Tang JB: Indications, methods, postoperative motion and
outcome evaluation of primary flexor tendon repairs in Zone
2, J Hand Surg (Eur) 32:118–129, 2007.
14. Chesney A, Chauhan A, Kattan A, et al: Systematic review of
flexor tendon rehabilitation protocols in zone II of the hand,
Plast Reconstr Surg 127:1583–1592, 2011.
15. Gelberman RH, Woo SL, Lothringer K, et al: Effects of early
intermittent passive mobilization on healing canine flexor
tendons, J Hand Surg (Am) 7:170–175, 1982.
16. Khan K, Riaz M, Murison MS, et al: Early active mobilization
after second stage flexor tendon grafts, J Hand Surg (Br)
22:372–374, 1997.
17. Smith P, Jones M, Grobbelaar A: Two-stage grafting of flexor
tendons: results after mobilization by controlled early active
movement, Scand J Plast Reconstr Surg Hand Surg 38:220–227,
2004.
18. Braga-Silva J, Kuyven CR: Early active mobilization after
flexor tendon repairs in zone two, Chir Main 24:165–168,
2005.
19. Pettengill KM: The evolution of early mobilization of the
repaired flexor tendon, J Hand Ther 18:157–168, 2005.
20. Yamazaki H, Kato H, Uchiyama S, et al: Long term results of
early active extension and passive flexion mobilization fol­
lowing one-stage tendon grafting for neglected injuries of the
flexor digitorum profundus in children, J Hand Surg (Eur)
36:303–307, 2011.
21. Boyes JH: Flexor tendon grafts in the fingers and thumb: an
evaluation of end results, J Bone Joint Surg (Am) 32:489–499,
1950.
22. Boyes JH, Stark HH: Flexor tendon grafts in the fingers and
thumb: a study of factors influencing results in 1000 cases,
J Bone Joint Surg (Am) 53:1332–1342, 1971.
23. Kleinert HE, Bennett JB: Digital pulley reconstruction employ­
ing the always present rim of the previous pulley, J Hand Surg
(Am) 3:297–298, 1978.
24. Strickland JW, Glogovac SV: Digital function following flexor
tendon repair in Zone II: A comparison of immobilization
and controlled passive motion techniques, J Hand Surg (Am)
5:537–543, 1980.
25. Gelberman RH, Seiler JG III, Rosenberg AE, et al: Intercalary
flexor tendon grafts: A morphological study of intrasynovial
and extrasynovial donor tendons, Scand J Plast Reconstr Surg
Hand Surg 26:257–264, 1992.
26. Seiler JG III, Gelberman RH, Williams CS, et al: Autogenous
flexor-tendon grafts: A biomechanical and morphological
study in dogs, J Bone Joint Surg (Am) 75:1004–1014, 1993.

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27. Abrahamsson SO, Gelberman RH, Lohmander SL: Variations
in cellular proliferation and matrix synthesis in intrasynovial
and extrasynovial tendons: An in vitro study in dogs, J Hand
Surg (Am) 19:259–265, 1994.
28. Leversedge FJ, Zelouf D, Williams C, et al: Flexor tendon
grafting to the hand: an assessment of the intrasynovial donor
tendon: A preliminary single-cohort study, J Hand Surg (Am)
25:721–730, 2000.
29. Carlson GD, Botte MJ, Josephs MS, et al: Morphologic and
biomechanical comparison of tendons used as free grafts,
J Hand Surg (Am) 18:76–82, 1993.
30. Brug E, Stedtfeld HW: Experience with a two-stage pedicled
flexor tendon graft, Hand 11:198–205, 1979.
31. LaSalle WB, Strickland JW: An evaluation of the two-stage
flexor tendon reconstruction technique, J Hand Surg (Am)
8:263–267, 1983.
32. Amadio PC, Wood MB, Cooney WP 3rd, et al: Staged flexor
tendon reconstruction in the fingers and hand, J Hand Surg
(Am) 13:559–562, 1988.
33. Wehbe MA, Mawr B, Hunter JM, et al: Two-stage flexor-
tendon reconstruction. Ten-year experience, J Bone Joint Surg
(Am) 68:752–763, 1986.

323
CHAPTER
31 
VASCULARIZED TENDON
TRANSFERS FOR
RECONSTRUCTION
Jean Claude Guimberteau, MD
A
Tendon Vascularity and
Gliding, Island and Free
Vascularized Transfers
be insufficient collagen production. Instead, vascular
connections develop through adhesion between the
tendon and peripheral tissues. The adhesion diminishes
the sliding capacity of the tendons and limits functional
recovery of the tendon.
Potenza introduced the essential roles of adhesions
for tendon healing in early 1960s.1 Since then, investiga­
tors sought to lessen functional impact of adhesion
formation and optimize the sliding capacities of the
tendon. Few attempts were made to understand why
tendons need vascular or pseudo-vascular connections.
Indeed, some researchers tended to minimize the role
of vascularization. The efforts have led to less research
aimed at providing vascular supplies to the tendon for
many years because it seemed pointless to carry out
research on this subject if tendons are very slightly vas­
cularized and receive sufficient nourishment from the
synovial fluid.2
Major past effort was done to diminish adhesion by
limiting the contact between the grafted tendon and the
recipient site. Catgut, polyester, and silicone interposi­
tions were introduced and showed their efficacy but to
the detriment of tendon solidity; rupture due to insuf­
ficient healing or necrosis is a major complication. The
fact that some damaged tendons need adhesions in
order to heal was acknowledged, as was its detrimental
effect on sliding and functional outcome. For decades,
research was aimed at decreasing the adhesion. Yet two
antagonistic aspects have to be reconciled: healing with
poor sliding and with the risk of rupture.
Different avascular tendon grafts, such as the pal­
maris longus, the plantaris, and others, have been used
thus far.3 The two-stage techniques became popular to
OUTLINE
This chapter presents several new approaches to flexor
tendon reconstruction for salvage tendon surgery. The
use of an island tendon, vascularized by the mesoten­
don, with all its gliding surfaces intact, provides new
methods to deal with adhesions and has the added
merit of being a one-stage procedure. The procedure
can be done as a local pedicled flap, as a free vascular­
ized composite tissue transfer from the foot, or as a
vascularized transplant from a cadaver donor. These
types of vascularized tendon, or tendon and flap, trans­
fers had multiple applications; the author achieved
rather favorable functional results in the patients.
These procedures are expected to offer reconstructive
options for the cases involving damages to multiple
structures together with flexor tendons.
From the outset, surgical principles concerning the
reconstruction of finger flexor tendons have centered on
the tendon as a simple force transmission belt connect­
ing the muscular structure. Muscles create the forces that
move articulated structures of bones, and the tendon is
bent by this force around the joints during motion of
the extremities. Consequently, this very mechanical
concept led to the development of techniques mainly
aiming at rebuilding this “transmission belt” as solidly
as possible. The tendon is considered as mostly avascu­
lar; mechanically, the tendon simulates a transmission
belt.
From the 1940s, many researchers have accumulated
evidence of poor tendon healing capacity. The major
reason for poor tendon healing is believed to

324
Section 3:  Secondary Flexor Tendon Surgery
the subcutaneous tissues and led to new concepts and
to new surgical procedures.10
ANATOMICAL STUDIES AND SURGICAL BASIS
Microvideo Observations of Tendon
Structures in Zones 3, 4, and 5
We have performed 95 video observations in vivo with
functional analysis, either directly under the skin or
close to tendons, muscle, and nerve sheaths during
human surgical dissection using light microscopy (at
magnification ×25).
This gliding or sliding tissue structure, traditionally
called “connective,” “areolar,” or “loose tissue and
paratenon around the tendons,” has for long been con­
sidered to be packing tissue that fills spaces. In fact, this
tissue plays a mechanical role, allowing movements
between the structures it connects, preserving mobility
and independence between organs, in particular,
between tendons and skin. This tissue is important
for the nutrition of the structures embedded in it
and acts as a frame for blood and lymph vessels
(Figure 31[A]-1).
Mechanically, it diminishes friction while facilitating
deformability and adaptability. The fibrous tissue,
known as the paratendon, surrounds the tendon. It is
composed of multidirectional filaments, intertwining
and creating partitions that enclose microvacuolar
shapes (Figure 31[A]-2). We term this the Multimicro­
vacuolar Collagenous Dynamic Absorbing System
(MVCAS) to emphasize its function. This system is situ­
ated between the tendon and its neighboring tissue and
favors optimal sliding. The tendon is able to travel far
and fast without any hindrance, and without inducing
movement in any other neighboring tissue, thus account­
ing for the absence of any dynamic repercussions of
movement on the skin surface. When the flexor tendon
moves, its movement is barely discernible in the palm.
In the light of above new information obtained, the
time has come to confirm some anatomical truths
about this tissue. The notion of multilayered sliding
between completely anatomically separate tissues—
sliding thanks to what many believe to be an elastic
process—is likely to be revised in the light of these
observations. Continuous matter and microvacuolar
framework should be noted between the tendon and
surrounding structures.11,12 Scanning electron micro­
scopy demolished the existence of different super­
imposed layers because they were never observed.
Furthermore, the elementary laws of mechanics and rhe­
ology presented the problem in terms of global dynam­
ics where continuous matter composed of millions of
vacuoles, each measuring a few microns to a few milli­
meters in size, is organized in dispersed branching
fractal patterns (Figure 31[A]-3). The sides of the vacu­
oles, which are intertwined, are composed of collagen
treat the cases with serious scar during secondary
repairs or reconstruction. Two-stage tenoplasty by James
Hunter4 and Paneva Holevitch5 needs to be completed
with multiple operations. In these operations, a silicone
rod capable of recreating the conditions of a synovial
sheath is inserted first. A tendon is then grafted or trans­
ferred in a second stage. Despite all the precautions,
functional results were sometimes mediocre because,
apart from Hunter’s series, which found 80% good
results, other teams only approached 50% success rates.
A good skin condition is required before surgery. The
two-stage technique necessitates at least 6 months, thus
discouraging patients and surgeons owing to the time
factor and to the difficulty in obtaining good functional
result. Moreover, in the mid to long term, the outcome
becomes even less satisfactory sometimes, with some
fingers in flexion deformities.
In fact, these techniques obey a certain mechanical
logic. The tendon acts as a force transmission cord; its
motion should require optimization of smooth gliding
surface in the first stage of the operation. An attempt
was made to solve the biological problem by trying to
create sliding conditions with a synovial pseudo-sheath.
Although this principle may represent enormous prog­
ress compared to the past, the biological realities and
requirements are not respected. The results of the pro­
cedures and the difficulties encountered led some sur­
geons to question very foundations of avascular nature
and believed mechanical role of the tendon.
In the staged tendon reconstruction, the tendon is
not vascularized and placed in a more or less sclerotic
recipient site. It is not always possible to achieve both
healing and gliding of the repaired tendon at the same
time. Past investigations demonstrated that the tendon
is a vascularized structure and has vascularity distribut­
ing both inside and outside the tendon, as well as
having a very specific lymphatic drainage system.6-9 The
current techniques remain completely alien to these
biological realities and ignore, or at least exclude, neces­
sity of vascular supplies to the grafted tendon during
surgical reconstruction. Therefore, better knowledge of
the intricate physiology of the tendon and the condi­
tions favoring optimum function are necessary to obtain
better outcome of the surgery.
For many decades, terms such as hierarchical tissue
distribution, stratification, and virtual space between struc­
tures have been taken for granted, yet the real basis for
them needs to be questioned. Their scientific under­
pinnings were limited to the notion of virtual space
or the existence of loose connective tissue, but their
biomechanical foundations were more than vague. In
the past 50 years, research focused on the microscopic
findings of these structures while the global concept of
the structures has not been addressed. As we have exam­
ined these tissues more closely, new hypotheses and
findings have emerged concerning the organization of

325
Chapter 31A:  Tendon Vascularity and Gliding, Island and Free Vascularized Transfers
fibers. This approach to tendon physiology also sup­
poses a completely different way of perceiving the
problem of reconstruction. These observations demon­
strating the real histological continuity between the
paratenon, the common carpal sheath, and the flexor
tendons illustrate the perfect vascularization of this
functional ensemble. The observations introduce a new
concept: the sliding unit, composed of the tendon and
its surrounding sheaths. Further functional detail of this
sliding unit includes (1) a tendon only has optimal
functional value when it is surrounded by its original
sliding sheath and its vascular heritage; (2) a tendon is
adherent only when it is artificially separated from its
own sliding sheath, or when the harmony between the
tendon and the sheath has been interrupted; and (3) a
tendon is only one of the elements involved in the
transmission of force through the sliding unit.
Figure 31(A)-1  A, Traction on the paratenon that shows
tendon surface and fibrous tissue. B, Fiber networks inside
the sliding system between the tendons.
A
B
Figure 31(A)-2  Histological and collagenous continuity
between the epitenon and sliding system.
Figure 31(A)-3  Multifibrillar framework, microvacuoles
inside the sliding system. Illustrates the microvacuole filled
with components (e.g., glycosaminoglycan and framed by
collagen types I and III).
A
B

326
Section 3:  Secondary Flexor Tendon Surgery
of elastic traction (grade 3) and those with all possible
complicating factors such as major soft-tissue damage,
joint stiffness, poor vascularization, and trophic changes
(grade 4).
The theoretical bases for this technique are that the
tendon can be conceived as vascularized and that the
tendon is an element of a highly complex sliding and
functional unit in association with its surrounding
sheaths (Figure 31[A]-4).
In developing this technique, the author sought to
answer following basic questions: (1) Which sliding
structures should be used to replace zone 1 and 2
tendons? The mesotendon and its vascular branches
provide good vascularization of the flexor tendon and
the sliding carpal sheath both extrinsically and intrinsi­
cally. The structure thus transferred is a real sliding struc­
ture which already exists naturally in zones 3, 4, and 5.
(2) How will the replacement flexion structure be vas­
cularized? Vascularization is ensured by a preretinacular
mesotendon with branches arising from the ulnar artery.
At the inferior third of the wrist, just before the flexor
retinaculum or the annular ligament, the latter has
two or three branches of around 1 mm in diameter.
For zones 3, 4, and 5, the author set out to define a
different role for the tendon in the production and
transmission of a force. The tendon is not purely a
transmission belt acting in the carpal sheath surrounded
by a virtual space, nor is it a tissue that is avascular or
only very slightly vascularized. The tendon is nourished
by its own vascular system. Due to existence of the
MVCAS, the tendon is extensively linked to its sur­
rounding structures in these areas, including sheath in
zone 4. The MVCAS lies above the tendon and exerts a
major role of tendon vascularization with peritendinous
tissues.
Basic Principles for Our Methods
of Tendon Reconstruction
The idea is to transfer en bloc a digital flexion unit
composed of the flexor tendon with the sheaths from
zones 3, 4, and 5 to zones 1 and 2 at a single stage. The
author uses this technique for the reconstruction of
finger flexor tendons with Boyes grade 3 and 4 presenta­
tions.13,14 These patients include those with restricted
passive motion in the proximal interphalangeal (PIP)
or distal interphalangeal (DIP) joints even after a period
Figure 31(A)-4  A and B, Sliding unit composed of flexor tendon, common carpal sheath (zone 3), and mesotendon
(branches of the ulnar artery inside). C and D, Movement of the MCVAS during tendon gliding.
A
B
C
D

327
Chapter 31A:  Tendon Vascularity and Gliding, Island and Free Vascularized Transfers
These branches pass through the common carpal sheath
toward the superficial flexor tendons, especially those
of the middle, the ring, and the little fingers, through a
fine transparent mesotendon acting as a mesentery con­
necting the tendons. This vascular supply to the flexor
system and the common carpal sheath is distal to the
tendon–muscle junction, thus allowing harvesting of
retrograde island transfers of purely tendinous struc­
tures without muscles. (3) How will the sliding unit be
positioned in zone 2? For reversed vascularized tendon
transfer, only the ulnar artery–based pedicle is suitable
owing to its distally based palmar point of rotation and
to its branch transmission at the level of the tendon.
Since there are many clinical circumstances and forms
of tissue destruction, this surgical technique has been
developed over time to include a wide range of variants
(Figure 31[A]-5).
Anatomical Features of the Ulnar
Artery–Based Pedicle Flap
In the distal forearm, the ulnar artery runs parallel to
the nerve between the flexor carpi ulnaris (FCU) tendon
laterally and the flexor digitorum superficialis (FDS)
tendons of the fourth and fifth fingers medially. Covered
only by skin, subcutaneous fat, and the superficial fascia,
this artery is relatively superficial in the lower and
middle compartments. However, in the upper compart­
ment, the cutaneovascular relationships are less clear
and the raising of a reverse island flap is thus more
problematic. Cutaneous vascularization is ensured by a
series of two to four small pedicles linked to the main
pedicle through the fascia. The vessels are about 1 cm
long and 1 to 3 mm in diameter. Since the small pedi­
cles lie 15 to 25 mm apart, each flap usually contains at
least two pedicles of good quality. In all our patients,
the anatomic presentation was constant, both topo­
graphically and with regard to vascular distribution
(Figure 31[A]-6). The anterior compartment of the
forearm is drained by two venous systems, the venae
comitantes of the ulnar artery and the superficial system,
whose veins are of larger diameter. Both systems have
abundant anastomotic networks, which make it easy to
raise both free and pedicle flaps.
OPERATIVE PROCEDURES
Vascularized FDS Tendon Graft Based on the
Ulnar Artery: Essential Procedures
The basic procedure consists of the transfer of the FDS
tendon of the ring finger to repair tendon defects of the
other fingers. Preoperative evaluation includes Allen and
Doppler tests to ascertain that the radial artery provides
adequate blood supply to the hand. Angiography of the
arm is also advisable. A bayonet-shaped incision is first
traced and then made on the medial side of the forearm,
the axis of the incision overlying the lateral border of
the FCU tendon. The ulnar artery is dissected, and all
its branches are carefully separated and divided. First,
the cutaneous branches between the ulnar artery and the
skin are carefully isolated. The branches emerge from
the volar aspect of the pedicle and are major compo­
nents of the ulnar forearm flap. These branches should
be divided only when skin transfer is not required. The
ulnar pedicle is then separated from the ulnar nerve on
its dorsal aspect along its whole length from the lower
third of the forearm to Guyon’s canal. On the posterior
aspect of the artery, the branches to the ulna are then
identified. The branches on the anterolateral side emerg­
ing just proximal to the Guyon’s canal are those supply­
ing the common carpal sheath and the flexor sliding
system. These small branches emerge from the ulnar
artery and go into the common carpal sheath and the
multi-microvacuolar absorbing system. The vascular
branches and fibrous tissues act as a mesentery, i.e.,
mesotendon, a mobile structure 2 cm long.
A mesotendinous structure composed of the FDS
tendon of the ring finger is then raised with the carpal
sheath and its vascular connections from the ulnar
artery (Figure 31[A]-7). These connections, usually
comprising two or three small branches on the antero­
lateral side and measuring on average 0.2 to 0.5 mm
in diameter, are found just proximal to the proximal
edge of the flexor retinaculum. At the level of the A1
pulley, the FDS tendon is transected proximal to the
decussation after forceful traction on the tendon, avoid­
ing laceration of the vinculum longum of the flexor
digitorum profundus (FDP) tendon. The ulnar artery is
then ligated proximally. All the other branches of the
ulnar artery to the deep arch division are ligated to
obtain a rotation point at the level of the deep branch.
The MVCAS surrounding the tendon is kept in place,
thus ensuring a real vascular connective link around the
tendon. A composite mesotendinous unit of 20 cm long
is then raised.
The sliding unit is transferred to the distal part of the
hand to provide a complete flexor tendon unit from the
finger tip to the wrist. The transferred tendon unit is laid
into the zone 2 and is passed under the A2 and A3
pulleys. These pulleys must be carefully preserved or
reconstructed if necessary, since the tendon transfer
exposes them to much greater force than a simple
tendon graft does. The pulley system often presents a
difficult problem. We prefer to use the remaining parts
of pulleys. Sometimes, the preserved pulleys are too
narrow and require careful dilatation. It is better to
rebuild a pulley than to keep one if the transfer and its
blood supply are compromised.
The distal junction of the grafted tendon is achieved
by inserting the graft tendon into the distal phalanx
with a “barbed wire” suture. The proximal junction with
the distal stump of the relevant FDP tendon is per­
formed using Pulvertaft repair. The tension on the suture

328
Section 3:  Secondary Flexor Tendon Surgery
Figure 31(A)-5  Transfer of a sliding flexion unit composed of a flexor tendon and surrounding sheath as a reverse island
pedicle graft. A, Identification of mesotendon around the FDS tendon of the ring finger. B, Section of FDS tendon of the ring
finger and ulnar artery. C, Insertion of the grafted tendon into the middle finger. D, Completion of the transfer and tendon
junction placed outside zone 2.
Ulnar
artery
Flexor digitorum
superficialis (FDS)
of the ring finger
A
D
B
Ulnar
artery
Ulnar
artery
Flexor digitorum
superficialis (FDS)
tendon
Flexor
digitorum
superficialis
(FDS)
tendon
Middle
Ring
C

329
Chapter 31A:  Tendon Vascularity and Gliding, Island and Free Vascularized Transfers
Delay between injury and reconstruction seems to cause
progressive narrowing of the pulleys. The pulleys may
be widened by mechanical manipulations, avoiding
rupture, but this maneuver is not easy. Otherwise, surgi­
cal pulley reconstruction is mandatory. Our functional
results obtained to date have been good and very often
excellent. Under good patient conditions, the results are
much better than with a tenodesis or an arthrodesis.
Combined Island FDS Tendon and Palmaris
Longus Tendon Transfer for Tendon and
Pulley Reconstruction
For a long time we used the Weilby procedure for pulley
reconstruction. However, the idea arose of using the
palmaris longus as another vascularized tendon on the
same mesotendon as the FDS. The palmaris longus is
transferred together with the FDS. Like the Weilby pro­
cedure, we use this method with a periosteum wedge
suture as cross lacing from A1 to A4 pulleys. Before
suturing, the smooth sliding of the transferred tendon
has to be checked.
should be slightly overcorrected in comparison with the
other fingers. The whole procedure takes about 3 hours:
1 hour for finger dissection and preparation, 1 hour
for raising the transfer and 1 hour for insertion and
closure.
On completion of the procedure, a dynamic Kleinert
splint is applied to allow early movement, which is
indicated in the cases with flexor tendons or pulleys
reconstruction but without skin problems and where
mobilization can intervene early.
FDS Tendon Transfer to Reconstruct the FDP
Tendon With an Intact FDS in Another Finger
This procedure was first attempted after much reflection
and with good experience of the basic procedure
obtained in 30 cases. There is no fundamental difference
in the dissection and the donor elevation. The most
difficult part is to respect the FDS tendon in the recipi­
ent site and the chiasma of Camper. Because the two
tendons are squeezed together, the presence of the A1
and A2 pulleys sometimes make the procedure difficult.
Figure 31(A)-6  A, Various vascular branches emerging from the ulnar artery proximal to entrance to Guyon’s canal. B, The
ulnar artery forearm flap has a very distal rotation point, the graft can be used to repair the distal part of the hand. Radial
forearm flap does not have a distal rotation point, not fitting distal finger repair. C, Vascular branches running from the ulnar
artery to the FDS tendon. D, Mesotendon and its vascular connections to the ulnar artery act as a mesentery.
Flexor digitorum
superficialis
A
Ulnar
artery
Ulna
Skin
6 cm
B
Radial rotation
point
Ulnar rotation
point
Ulnar straight
line continuity
C
D

330
Section 3:  Secondary Flexor Tendon Surgery
flap can be rotated for 180° and positioned on the
digital surface, but the tendon can be placed at its physi­
ological orientation due to flexibility of mesotendon.
The skin is closed tension free, providing good healing
without skin disunion or necrosis. This is of fundamen­
tal importance for achieving a good functional result.
Based on author’s experience, the operation is reli­
able, with almost complete absence of complications.
The anatomy of ulnar artery is constant, with at least
one good-sized artery found in all the patients. The flap
has 360° mobility around a rotation point in the palm,
which makes the entire skin surface of the hand acces­
sible. This is not the case with the radial forearm flap.
Tissue quality is excellent, being fine, fat free, and virtu­
ally hairless. There are no serious consequences at the
donor site. The scar on the forearm is usually very fine
and not hypertrophic. The technique allows for further
developments such as sensory innervation by means of
the medial cutaneous branches of the ulnar nerve.
Composite Flexor Tendon and Skin
Flap Transfer
Combined transfer of vascularized flexor tendon and
skin flap allows surgeons to treat skin problem and to
reconstruct the tendon at the same time (Figure 31[A]-
8). In the lower third of the forearm, the ulnar artery
sends branches not only to the FDS tendons but also to
the skin. These branches are easily identified, being
close to the mesotendon branches and constantly of
excellent caliber, allowing simultaneous composite
transfer of the skin and tendon.13-15 Slight upward trac­
tion on the internal edge of the flap reveals the small
vertical vessels arising from the ulnar artery to the skin.
After identifying the skin flap pedicle, the flap is dis­
sected (Figure 31[A]-9).
The second step is dissection of the ulnar artery and
identifying the mesotendon branches. Generally, the
skin flap lies proximal to the mesotendon. However,
thanks to the flexibility of these cutaneous branches, the
Figure 31(A)-7  A, The mesotendon and branches of the ulnar artery to the FDS tendon and sectioning the FDS proximal to
the Camper’s chiasma. B, After tendinomuscular section and before ulnar artery section. C, The flexion sliding unit is created.
D, The unit is moved distally and the sliding unit is grafted to the recipient finger.
A
C
B
D

331
Chapter 31A:  Tendon Vascularity and Gliding, Island and Free Vascularized Transfers
underneath and achieve early motion. Skin of this sort
inevitably breaks down or necroses, compromising
the functional result, so it should be replaced (Figure
31[A]-10). The solution is to perform a safe skin flap
transfer together with tendon reconstruction, thereby
making early motion possible.
This procedure is indicated in cases with significant
contracture of the skin on the palmar aspect of the digits
after multiple surgical procedures. A plain skin graft
cannot solve this problem. In some cases where the
overlying skin is extremely scarred and of poor quality,
it would be impossible to replace the flexor tendon
Figure 31(A)-8  Transfer of a sliding flexion unit composed of a flexor tendon and a skin flap. A, Mesotendon and skin
branches identification. B, Section of FDS tendon to the ring finger and ulnar artery. The tendon and ulnar artery flap are
isolated. C, Tendon junction outside of the zone 2 and digital skin coverage with the flap.
A
B
C

332
Section 3:  Secondary Flexor Tendon Surgery
This statement remains true. The influences of aspects
of the patient’s life such as their psychological profile,
smoking, socioeconomic status, and desire for future
employability have an impact on functional outcome.
All of these factors must be taken into consideration in
determining the aim of reconstruction, in choosing
these procedures and result evaluation.
Many systems of evaluation have been proposed. We
use the modified Strickland’s criteria.17 Nevertheless,
the arithmetical addition of degrees between extension
and flexion compared with the hypothetical maximum
amplitude, while not distinguishing between metacar­
pophalangeal (MCP) joint and PIP or DIP joints, would
seem debatable for this sort of salvage situation. A
significant alteration of MCP joint movement only
rarely occurs. Clearly in such cases, the principal aim
is to restore effective and useful function, including
grip, and especially to achieve recovery of good PIP
joint movement. For heavily damaged fingers, too many
unfavorable factors are present and it is not possible
achieve a full recovery. The patient should be informed
of incapability of full recovery preoperatively. More
The wide variety of composite flap transfer is made
possible by the ulnar artery at the lower third of the
forearm, which offer a solution to a large number of
clinical cases and meet varied surgical reconstructive
requirements. For example, it is possible to perform a
double skin flap with one or two flexor tendon transfers,
or a skin flap with a flexor tendon for reconstruction
and a palmaris longus as an island transfer for pulley
repair. It is also possible to add a bone transfer at the
same time (Figure 31[A]-11).
RESULTS AND DISCUSSION
It is almost impossible to evaluate the results of tendon
reconstruction operations by any statistical method. There
are so many variables; e.g., the type and extent of the
injury, the age of the patient, the accompanying injuries
of nerves and vascular structures and the procedures
used—that only general conceptions, based on experience,
can be used. Tendons in the fingers are the most difficult
to repair.
Joseph H. Boyes16
Figure 31(A)-9  Rising of the composite flexor tendon and skin flap island transfer for tendon repair and digital palmar
resurfacing. A, Outline of the skin flap incision based on the lateral edge of the FCU tendon. B, Identification of the fascia
connection to the tendon before cutting the ulnar pedicle. C, Owing to plasticity and distal rotation point of the ulnar pedicle,
the graft can be easily placed to the finger. D, Skin resurfacing is completed in the same time of the tendon reconstruction.
A
B
C
D

333
Chapter 31A:  Tendon Vascularity and Gliding, Island and Free Vascularized Transfers
mobilization inducing pain and inflammation and
requiring dressing. We now prefer to add a skin flap in
order to reinforce cicatrization, even if slight revision
under local anesthesia may be required several months
later.
Group 2
We began to have this group of patient 10 years after
group 1. With the experience gained, the technique was
extended, to be indicated in young subjects, such as
rugby players. Nevertheless, the technique is extremely
intricate and is indicated only in young subjects capable
of following stringent rehabilitation. We had 17 cases:
7 excellent (41%), 7 good (41%) and 3 poor, including
2 who preferred not to have joint arthrodesis after inter­
vention. A useful range of motion was obtained in 80%
of cases (Figure 31[A]-13).
Four cases (23. 5%) required tenolysis, which revealed
the excellent state of the transferred tendon. Any adher­
ences found were always located around the tendinous
anastomoses. After tenolysis, 4 fingers obtained 2 excel­
lent and 2 good results.
Group 3
Forty patients were analyzed. There were 1 excellent
(2.5%), 26 good (65%), 5 fair (12.5%), and 8 poor
importance should also be given to preoperative skin
condition.
We treated 75 patients with Boyes grade 3 and 4
injuries, all previously operated on at least twice. Our
strategy was determined by the skin quality primarily.
Since mobilization is early (3 days postoperatively), it
is mandatory to avoid skin dehiscence or necrosis. In
these circumstances, we use a composite skin and flexor
tendon transfer.
Our patients were divided into three groups: (1) 18
patients, including 13 grade 3 and 5 grade 4 patients in
whom FDS tendon transfers were used; (2) 17 patients
in whom only the FDP tendon was injured with intact
FDS tendon were repaired by islanded FDS transfer; and
(3) 40 grade 4 patients, needing flap transfers due to
either major skin retraction, due to presence of a skin
defect or skin stiffness together with vascular or nerve
problems.
Group 1
There were 5 excellent (4 grade 3, 1 grade 4, 27.8%); 7
good (6 grade 3, 1 grade 4, 38.9%); 4 medium (2 grade
3, 2 grade 4, 22.3%); and 2 poor (1 grade 3, 1 grade 4,
11.1%) results (Figure 31[A]-12). Improvement was
achieved in 66.5% of patients. The fair and poor results
were mainly due to healing problems during early
Figure 31(A)-10  A and C, Results of two cases of palmar skin contracture and loss of flexor tendon function. B and D, Skin
resurfacing with a composite flexor transfer and skin flap.
A
B
C
D

334
Section 3:  Secondary Flexor Tendon Surgery
Overall, 42 patients (66.6%) achieved an excellent,
good result compared to an average of 55% in series
where similar cases are operated using the two-stage
procedure with or without a silicone rod. However, in
this particular field, precise evaluation of results is a real
challenge, and in many previous publications results
(20%) results (Figure 31[A]-14). The results show that
67.5% of these extreme salvage flexor tendon situations
were greatly improved. The technique also produces
favorable trophic changes. Finger skin becomes more
supple and sensitive, joints are less stiff and are mechan­
ically active, and flexion is improved.
Figure 31(A)-11  Several types of combined
transfers of multiple tissues. A, Transfer of multiple
flexor tendons. B, Transfer of double flexor tendons
and double skin flaps. C, Combined skin flap,
island FDS tendon transfer, and grafting palmaris
longus (PL) tendon for flexor pulley reconstruction.
D, Composite skin flap, flexor tendon, and bone
transfer. We called above types of combined transfer
as “ulnar trail.”
A
B
C
D
Two flexor tendons
Flexor digitorum
superficialis (FDS)
tendon
Palmaris
longus (PL)
tendon
Skin flap
Skin flap
Skin flap
Bone

335
Chapter 31A:  Tendon Vascularity and Gliding, Island and Free Vascularized Transfers
Figure 31(A)-12  Functional results of the flexion system transfer.
GROUP 1: 18 CASES
Fair
22.25%
Poor
11.1%
Excellent
27.75%
B
A
Good
38.9%
Figure 31(A)-13  Results of the flexion system transfers for cases of the FDP tendon disruption with an intact FDS.
GROUP 2: 17 CASES
Poor
18%
Excellent
41%
B
A
Good
41%
Figure 31(A)-14  Results of combined flexor tendon–pulley and skin flap transfer.
GROUP 3: 40 CASES
Poor
20%
Fair
12.5%
Excellent
2.5%
B
A
Good
65%

336
Section 3:  Secondary Flexor Tendon Surgery
the patient’s own will and the skills of the therapist.
Smoking appeared to be a major factor to worsen the
outcomes.
Regrettably, in the earlier years, we did not perform
vascularized flexor tendon grafting during a tenolysis,
when the tendons were found continuous but of poor
quality. Some tendons ruptured one day after surgery.
It is also regrettable that such procedures were not
performed in patients with poor tendon conditions
such as dehiscence. From 1996, the author changed
the approach, and now performs composite skin and
tendon transfers more often. It led to good results. The
composite skin flap allows surgery to be done under
good conditions and facilitates immediate rehabilita­
tion, which is a major advantage. Sometimes a later
tenolysis may still be required. However, the psychologi­
cal impact is very positive in our patients. Rehabilitation
can be begun immediately after surgery.
FUTURE CHALLENGES: PROCEDURES
USING OTHER GRAFT SOURCES
Our experience in the more recent years using vascular­
ized flexor tendon autotransplants from the toes and
homotransplants (allografts) suggests some applicable
procedures. In the author’s unit, the transfer of flexor
mechanism of the second toe was performed in six patients
to repair the digital flexor tendons, sheath, and palmar
plates in a single operation. On the donor site, the
tendon is approached through a plantar incision from
the medial side of the second toe to the mid plantar
area. The plantar fat is retracted and the plantar aponeu­
rosis is transected, exposing the second toe flexor system
and its vascular network. Attention should be paid to
several anatomical points: (1) The flexor sheath of the
second toe is shorter than the second, third and fourth
digital flexor sheaths in the hand by 15% on average,
while it is longer than the fifth digital flexor sheath (by
5%); (2) the metatarsophalangeal (MTP) plate is wider
and thicker than the MCP joint plate; and (3) the A3
pulley is more developed in the toe flexor sheath.
The vascular type is identified and the composite
tendon flap is harvested from distal to proximal. The
vascular supply of the toe flexor system depends on the
medial collateral digital artery, which is a terminal
branch of the first common plantar digital artery, a
branch of the medial plantar artery. Venous drainage is
from its comitantes veins.
There are two different anatomic types. In type I,
which is present in 50% of the cases, the second toe
medial collateral artery arises directly from the first
common plantar digital artery, giving a long vascular
pedicle. In type II (i.e., the other 50% of cases), the
second toe medial collateral artery arises from the
medial branch of the medial plantar artery beneath
the big toe flexor tendon and has a short vascular
pedicle. Dissection is performed under the periosteum,
have been evaluated by different methods, rendering
true comparison difficult, if not misleading. What is
sure is this new technique seems to give better func­
tional performance and reduces time lost from work.
The new technique using a mesovascular tendon
transfer unit, which is now our standard procedure for
Boyes grade 3 or 4 cases, is likely to set the trend for
flexor tendon surgery because the requisite tendon
reconstruction can be carried out in one operation.
Compared with other techniques, the advantages of this
technique are as follows. It makes use of a living tendon
islanded on a thin mesotendon with vascular branches,
providing a perfect blood supply to all areas both extrin­
sic and intrinsic. It thus avoids adhesions and improves
the vascularity of the surrounding tissues. Since the graft
is a vascularized flexor tendon, rather than a simple
avascular graft, it retains its flexibility, pliability, and
resistance and allows the correct tension to be achieved.
The MVCAS and the carpal sheath retain the unrestricted
gliding movement of the tendon. The grafted tendon is
approximately 18 to 20 cm, which can be used to recon­
struct flexor tendon defect from the pulp to the carpal
area. All the damaged pulleys have to be reconstructed
because the traction exerted by this type of tendon is
greater. The vascular supplies to the tendon are anatomi­
cally constant. Because of the very distal rotation point
and the plasticity and versatility of the mesotendon, the
flap transfer is performed in the same way as a classic
reverse-flow radial or ulnar forearm flap.
It should be noted that the radial forearm flap does
not allow transfer of the common carpal sheath and the
flexor tendon because the radial artery supplies them
only at the myotendinous level and its point of rotation
is too proximal. The composite flap and tendon transfer
described here are confined to the ulnar vascular system.
The main disadvantage is the need to transect the
ulnar artery. However, in our experience of 629 cases of
a variety of ulnar artery–based flaps, no serious long-
term effects such as paresthesia or functional deficits
have been encountered.
These procedures described in this chapter have now
become routine practice in the author’s unit. Our experi­
ence indicates that they are safe, technically feasible, and
above all provide practical solutions to problems that
often led to amputations or arthrodesis in the past. Only
one patient requested an amputation since he was
unable to carry plasterboard panels owing to a problem
with his index finger.
Nevertheless, the functional outcome of our patients
has not improved in the past 15 years. The good or
excellent rates are still the same as they were then.
Factors influencing the outcome go far beyond the
purely technical or surgical. Such concerns exist as to
skin tissue quality of the patient, whether pain or edema
is present, and the duration of the postoperative edema­
tous phase. Other factors affecting the outcomes are