Flexor tendon repair requires protecting the tendon repair while allowing early controlled motion to minimize adhesions. This involves splinting the fingers in flexion after primary repair or tendon grafting, followed by progressive range of motion exercises. Complications can include infection, scarring and joint contractures, but good outcomes are achieved with protocols emphasizing early motion like Duran or Kleinert methods.

1. FLEXOR TENDON REPAIR

2. Flexor tendon function depends on
• tendon excursion,
• intact pulley system,
• joint motion,
• presence of lubricating synovial fluid

5. If bowstringing is present, to close fingertip
greater amplitude of muscle contraction and
greater amount of tendon excursion

7. •Digital flexor tendons receive
nutrition:-
1.intrinsic
longitudinal vessels
entering the palm in the
endotendinous channel,
vessels that enter at the
osseous insertion,
vincula (two short and
two long).
2.extrinsic
synovial fluid

9. Incidence
• 33.2 per 100,000:- hand & wrist injuries
• <1% of all hand injuries:- Flexor tendon
injuries

10. Systematic Examination
Integument Examination.
• The integrity of the skin on the volar
• and dorsal aspects

11. Musculoskeletal Examination.
• angular or rotational deformity of the digit
• Realignment of a fracture
• Reduction of a dislocation
• Tenodesis effect
• Partial tendon injuries: pain on resisted flexion

13. Neurologic Examination
• light touch and
• static two-point discrimination

14. Vascular Examination.
• Capillary refill of the volar digital pulp and the
nail bed
• digital Allen test

15. Diagnostic Imaging
• Plain radiographs
• Diagnostic ultrasound for flexor tendon
• MRI
• Intraoperative fluoroscopic images

16. Boye’s grading of flexor tendon injuries

17. Verdan's classification:
• based upon chances of adhesion formation

19. Historically
recommendations of Sterling Bunnel in 1922 for
the treatment of cut flexor tendon injuries:
• 1. Close the skin,
• 2. Wait for the wound to heal,
• 3. Perform secondary procedures:
– (a) Excise both the flexor tendon.
– (b) Undertake tendon grafting of the flexor
digitorum profundus tendon only

20. Surgical exposure
• The standard midlateral incision or Bruner's
zigzag incision
• no study comparing the two methods of
surgical exposures

23. • midlateral incision
– prevents scar formation directly over the tendon,
– is less likely to breakdown during physiotherapy
– but requires surgical dissection directly over the
neurovascular bundle.
• Bruner's zigzag incision
– provides excellent surgical exposure
– scar formation directly over the tendon and may
break in case of infection thereby affecting the
physiotherapy

25. Surgical repair
If digital perfusion is compromised
Urgent exploration and tendon repair with
microvascular digital artery and nerve repair
• Done promptly after injury, the wound is
easier to manage and the tendon ends are
fresh for the repair

26. zone 1 injuries (Gersey finger injury).
Flexor Digitorum
Profundis (FDP)
retracts to the
palm
Leddy type 1 the tendon must
be repaired
within 2 weeks.
retracted to the
PIP joint
Type 2 the repair must
be performed
within 6 weeks
When caught at
A4 pulley
Type 3 the repair can be
performed at any
time

28. • patient presents
too late and the
FDS is intact can be
considered
• more than 1 cm of
FDP stump is
available
• stump is less than 1
cm long,
distal
interphalangeal joint
arthrodesis
primary tenorrhaphy
FDP tendon advancement and
primary repair to bone

29. tendon-to bone repair
• traditional pull-out suture methods
• internal suture methods
• “pull-out suture” removed approximately 6
weeks after the procedure

31. Zone 2 repair
• important to preserve the critical A2 and A4
pulleys
• repair of both prevents hyperextension of the
PIP joint.

32. • Different options of treatment:
1. repair of the FDP tendon only with debridement
of the FDS stump;
2. repair of both tendons; or
3. repair of FDP with repair of one slip of FDS
tendon.
• Repair of both tendons in zone 2 is ideal
• Most hand surgeons prefer to repair the FDP
and one slip of FDS

34. • number of core strands that cross the repair
site will increase the strength of the repair
• Increasing the number of strands to >4 leads
to more tissue handling, increase in the
surgical time.

35. Line diagram showing (a) conventional two strand suture
techniques (b) conventional four strand suture techniques

36. • Different suture techniques
• two-strand Kessler core with a simple
peripheral suture remains the most popular
flexor tendon suture technique

38. Modified Becker 4 strand

39. The MGH flexor tendon repair (modified Becker) technique

42. • Single knotted core suture techniques (e.g.,
Cruciate) have been shown to be
biomechanically superior to double-knotted
techniques (e.g., Double Kessler, modified
Becker, Tsuge)

43. cruciate repairs (Adelaide
technique)

44. Winters-Gelberman
Strickland
Cruciate

45. Suture material for core suture
• nonabsorbable, 3/0 or 4/0 braided or
monofilament material.
• 4-0 Fibre Wire (Anthrex, Naples, FL)

46. For peripheral epitendinous suture
• 6/0 nonabsorbable suture
• contributes to the strength of the repair upto
50%
• makes repair neat (smoothes tendon and
decreases bulk)

51. • Tendons with repair site gaps less than 3 mm
acquire strength during the fourth to sixth
week postoperatively.
• ibuprofen at antiinflammatory doses (2400
mg/day) decrease peritendinous adhesions
following zone 2 flexor tendon repairs

52. Vitamin C
• antioxidant
• improved gliding resistance,
• Reduced fibrotic size,
• fewer histologic peritendinous adhesions

53. Zone 3, 4, 5 repair
• repair of flexor tendon injuries proximal to the
A1 pulley are similar to injuries in zone 2
• improved prognosis

54. For the forearm
• arterial repairs first,
• tendon repairs second, and
• nerve repairs last.
Tendon repairs started from the deepest tendon
and then superficially

55. On exploration,
• if injury >60% of the tendon in diameter, it
should be repaired.
• If injury <60%, free edges are debrided to
prevent catching on the pulleys

57. Postoperative dressing
• wrist in flexion (20 to 30 degrees),
• the MP joints in flexion (50 to 70 degrees),
• PIP and DIP joints at zero or slight flexion

58. Secondary flexor tendon
reconstruction
• Carroll first described the use of silicone rod
for use in two stage flexor tendon
reconstruction in 1963.
• The technique was modified by Hunter in
1970 and has been used extensively since
then with satisfactory results

59. indications:
1. failed primary repair,
2. neglected injuries,
3. segmental tendon loss and
4. complicated injuries (Boyes grade 2-5)

60. single stage reconstruction
Prerequisites:
1. supple joints,
2. wounds healed without contracture or much
scarring,
3. intact neurovascular structure,
4. willingness and understanding to participate
in rehabilitation programmes

61. • If excessive scarring is found in the tendon bed or
pulleys are contracted leading to constriction of the
graft; then two stage tendon reconstruction.

62. two stage tendon reconstruction
• Debridement of the cut tendons done
• silicone rod is placed with suturing the distal
end to the distal phalanx and the proximal end
is left free in the distal forearm
• pulleys are reconstructed over the silicone rod

63. • Materials for pulley:
1. Sheath of extensor retinaculam (advantage of
synovial lining leading to fewer chances of
adhesions)
2. Debrided tendons
3. Palmaris longus or Plantaris

64. Different surgical techniques.
• Making a double loop beneath the extensor
tendon encircling the proximal phalanx in its
proximal one third for reconstruction of the
A2 pulley.
• A4 Pulley is also reconstructed over the
middle phalanx by encircling around the
extensor apparatus.
• Using the remnants of the pulley

67. • Use of volar plate as the pulley by Karev; he
makes incisions distal and proximal in the
volar plate, and the tendon is passed through
it. Due to nonelasticity of the volar plate, the
tendon glide is impaired
• reconstruct the pulley as third stage
procedure under LA. Ensures proper tightness

68. • If nerve repair is indicated it is done at this
stage.
• The joints are mobilised in the postoperative
period.
• The mobilisation is started depending upon
the repair of the nerves. It may be started
immediately or after two weeks.

69. • second stage: replacement of the silicone rod
with the tendon graft
• A pseudosheath must be formed before
replacing the silicone rod with a graft.
• performed after 3 months as during this
period the scars mature and a suitable gliding
sheath forms around the implant

70. (a) Well placed silicone rod at zone 2 along with the reconstructed
pulleys (b) Silicone rod brought into proximal forearm (c) Silicone rod
is replaced by a free tendon using two minimal incisions and rail-road
technique

71. • proximal end of the graft is tied (with an
interweave fish mouth suture) to the adjacent
FDP tendon, if that is not suitable then the FDS is
selected.
• The graft is pulled through the pseudosheath by
stitching to the silicone rod at the proximal site
and pulling the rod at the distal end.
• The graft is stitched distally first with a Bunnel's
pull through suture over a button or with anchor
sutures

74. Tendon grafts:
• Palmaris longus (most commonly used graft).
absent in 25% of the population. useable length
is 16cm
• Plantaris (2nd most common). absent in 20%,
usable length is 35 cm. thin- can be passed
easily through the newly constructed tendon
sheath.
• The long extensors of foot (middle three
extensors). Very thick

75. • flexor digitorum longus of second toe. is the
only intrasynovial tendon. The chances of
adhesions are expected to be lower than
extrasynovial tendons. 12-13 cm long
• Extensor indicis proprius

76. Rehabilitation
Controversy:
• early/late mobilisation,
• position and type of the splint and
• mobilisation protocols (controlled passive
motion, active extension/passive flexion or
controlled active motion)
• old concept of 2-3 weeks of immobilisation in
splint and then starting the mobilisation has
been abandoned

77. • start mobilisation by the 3-5th postoperative
day
• no general consensus at present
• In original Duran and associates protocol, 3 to
5 mm of tendon excursion was sufficient to
prevent restrictive adhesions after repair

78. EARLY ACTIVE MOTION PROTOCOL
Day l
• Dorsal blocking splint with wrist neutral, MCPJ 70°,
and IPJ straight
• Digits strapped to splint
• Modified Duran passive flexion with active extension
to splint
• Place and hold exercises passively flex digits and
allow patient to actively contract muscles to hold
digits in fist, composite, and differential.

79. • hourly home exercise program that consists
initially of passive positioning of the fingers in
a fist for 3 minutes
• Therapist monitor the patient’s compliance,
attend therapy at least two times a week for
the first 6 to 8 weeks

80. Controlled passive motion method

81. In controlled passive motion regimen of Duran and
Houser
• dorsal splint to keep the PIP and DIP joints in
extension with no elastic band for passive flexion,
• Patient uses another hand to move the PIP, DIP,
and MCP joints passively
• active extension is also done by the patient.
• associated with a poor capacity for differential
gliding between the superficialis and profundus
tendons, particularly in Zone II

82. • Kleinert's classical description of controlled active
extension with passive flexion utilizing elastic
band traction has been used by most hand
surgeons who are proponents of immediate
controlled mobilization
• Strickland introduced an early active motion
protocol (Indiana Hand Centre) for a four-strand
repair with an epitendinous suture for which
good patient motivation and comprehension are
required

83. 3wk
• Gentle tenodesis exercises out of splint
• No active composite flexion
• Continue place and hold exercises

85. 4wk
• Active composite flexion exercises out of splint
• Differential tendon gliding exercises
• No passive extension, no blocking
• Continue dorsal blocking splint between
exercises

86. 5wk
• Initiate blocking exercises
• Splint at night and for protection only during
the day

87. 6wk
• Discontinue splint
• Initiate passive extension
7wk
• Start composite passive extension

88. 8wk
• May start light strengthening (putty)
12wk
• Normal activities

89. “high” physiologic response
• Accelerated wound healing, edema, and
dense scar resulting in the formation of
peritendinous adhesions
• significant loss of flexor tendon excursion.
• Hence are progressed through the pyramid of
exercises quickly to promote force and
prevent further adhesions

90. “low” physiologic response
• slower wound healing, limited edema, and
minimal discrepancy between the patient’s
active and passive finger flexion
measurements.
• have improved flexor tendon excursion
• less risk is required in therapy to maintain the
range of motion.

91. Complications
• Infection,
• Skin flap necrosis,
• tendon repair rupture, and
• tendon adherence
• Interphalangeal joint contracture

92. Outcomes
Boyes outcome scale that judged results based
on finger tip flexion measurement from palm
• poor being >6 cm,
• fair 4 to 6 cm,
• Good 2.S to 4 cm, and
• excellent 0 to 2.5 cm.

93. Strickland Modified outcome assessment scale
• poor is 0% to 24% motion (<44°).
• fair is 25% to 49% motion (44° to 87°)
• good is 50% to 74% motion (88° to 131°), and
• excellent is 7S% to 100% motion (>131°)