Dr. Gavinash Rao presented on the history and techniques of tendon reconstruction. The history of tendon repair before 1960 primarily involved single-stage free tendon grafting. In the 1960s, two-stage reconstruction using silicone implants was developed. Currently, the Hunter technique uses a silicone rod implant in the first stage followed by tendon grafting in the second stage. Primary tendon repair is preferred if possible, while reconstruction uses tendon grafts from the palmaris longus, plantaris, or toe extensors. Complications can include adhesions, implant failure, and joint contractures.

1. PRESENTOR – DR G AVINASH RAO
2ND YEAR FELLOW
MODERATOR – DR MIR YASIR
ASSISTANT PROF.
Tendon Reconstruction

2. HISTORY – Before 1960’s
 In the tenth century, Avicenna, an Arabian surgeon, was credited with
performing the first tendon repair surgery.
 In Europe, Galen teachings resulted in infrequent tendon repair. Galen did
not differentiate between nerves and tendons.
 Historically, one of the first experiments on flexor tendon reconstruction -
described in 1910 by Lange - strengthened the transplanted tendon with
strands of silk impregnated with paraffin - did not have favourable results-
post-operative adhesions.

3.  In 1936, Carl Henze and Leo Mayer - a novel technique for the restoration of the
digital sheath using celloidin tubes -mto provide a gliding.
 Until the 1960s, tendon lacerations in zone 2, or “no man’s land,” - treated with
removal of the tendon with grafting of new tendons.(Sterling Bunnell teachings)

4. HISTORY – After 1960’s
 Single-stage free tendon grafting - Pulvertaft, Graham, Littler, Boyes, and
Stark
 In 1963, Bassett and Carroll first described - two-stage flexor tendon
reconstruction using a silicone implant.
 In 1965, Hunter first published - tendon implants for tendon reconstruction.
 He further refined his work in 1970s using Hunter silicone rod - staged
tendon reconstruction technique - currently used.

5.  Paneva-Holevich in 1969, sutured the proximal cut end of the FDS to
the proximal cut end of the FDP in the palm.
 At the second stage, the FDS tendon was severed proximal and this
end was brought out to be inserted at the distal phalanx as a pedicle
graft.
 In 1982, Paneva-Holevich - secondary repair of 324 flexor tendon
injuries using pedicle FDS tendon grafting.

6. Anatomy

7. ANATOMY

8. Anatomy

11. Tendon Surgery
•Early
•Delayed
Primary Repair
•Early
•Late
Secondary
repair /
Reconstruction

12. • Primary repair
12-24 hrs
• Delayed primary
repair
1 - 14 days
• Early secondary repair
14days to 4-5weeks
• Late secondary repair
> 4-5 weeks

13. Primary / Delayed PrimaryTendon repair
 Absolute Indications :-
1. Clean-cut” wounds
2. Limited crush injuries with no soft tissue / joint defects

15. Primary Tendon repair
 Contraindications :-
1. Severe contamination with suspicion of wound infection,
2. Long defects of the tendons,
3. Extensive destruction of pulleys.
4. Serious crush injuries, extensive loss of soft tissues,
5. Fractures involving multiple bones, particularly at different levels.
6. Fractures which cannot be stabilized adequately by internal fixation,
7. Bony injuries involving joint components.

17. Reconstructive ladder

18. Primary tendon graft reconstruction (BUNNELL)
 The outcomes are inferior to primary flexor tendon repair.
 Prerequisites -
1. Well healed, stable, mobile soft tissue cover without extensive scarring.
2. With an adequate pulley system.
3. Passive movements are full, or nearly full.
4. At least one intact digital nerve

19. Indications
1. Injuries with segmental tendon loss.
2. Severe peritendinous tissue injuries at initial presentation.
3. Delay in repair > 3 to 6 weeks.
4. Suspicion of wound infection - percluding primary repair
5. Delayed presentation of closed FDP avulsion from the insertion with
significant retraction.
6. Closed rupture in zone 1 to zone 3, with retraction of the proximal
tendon that does not permit a direct end-to-end repair.
Primary tendon graft reconstruction (BUNNELL)

20. Contraindications
 Extensive scarring, pulley incompetence, or joint
contracture.
Primary tendon graft reconstruction (BUNNELL)

21. The best indication for single-stage free tendon graft for flexor tendon injury is
the grade 1 hand according to Boyes classification or according to Merle and
Dautel’s classification For grade 2 or 3 hands and above staged tendon
grafting is preferred.

22. Donor Tendons
 Ipsilateral palmaris longus or plantaris tendons remain the most common
choices. (extrasynovial tendons)
 Toe extensors from beneath the ankle retinaculum within the sheath and
Toe flexors are also intrasynovial; but their sheaths tend to be much
shorter than those of the fingers.
 Vascularized tendon grafts have been described - rarely used and little is
written in literature.

23. Palmaris longus
 Present in about 75-85% of population.
 Lister said that it was absent unilaterally in 14% and bilaterally in
16% subjects.
 PL agenesis differs according to race, sex, and to the right and left
side.
 There is a wide variation in the incidence of PL ranging from 0% to
63% with an overall 16% unilateral and 9% bilateral absence
described in the literature.

25. Mishra test 1

26. Mishra test 2

27. Pushpakumar 2 finger test

29. Plantaris tendon
 When multiple grafts / one long distal forearm-to-fingertip graft needed,
 The presence cant predicted clinically, ultrasound or MRI can,
 It is said to be absent in only 7% of cadavers,
 Harvey and associates - tendon was present in only 80% of limbs.
 Unusable sometimes because of variations in its girth / attachments to
the triceps surae, which make removal impossible.

31. Long Toe Extensor Tendon
 Presence is never in doubt, and diameter is adequate
 Three long tendon grafts - second, third, and fourth toes
 Individual tendons may fuse distal to the ankle.
 Large longitudinal incision / Tendon stripper / multiple transverse incisions
 Other options – EIP , FDL of foot can also be used

33. Biology of Tendon graft
Incorporation
 Intrasynovial donor tendons seem adapted to survive transplantation
to the digital sheath and can incorporate without the formation of
peritendinous adhesions - surface is designed to allow for synovial
fluid imbibition , promote nutrition and cellular survival.
 Extrasynovial donor tendons undergo - peritendinous necrosis - with
the formation of dense peritendinous adhesions during tendon graft
incorporation - new vessels growing through adhesion formation and
the tendon junctures

34. Distal tendon juncture

37. Proximal Juncture

40.  In cases of disruption of both the FDP and FDS tendons, general
surgical principles for this procedure include:
1. Place only one graft in each finger.
2. Use a graft of a suitable caliber to fit into the finger.
3. Place the proximal junction outside the tendon sheath.
4. Avoid damage to the fingernail or fingertip, in making the distal
junction.
5. Ensure adequate graft tension.
Primary tendon graft reconstruction (BUNNELL)

41.  In cases with an intact or functioning FDS tendon, the following
additional principles apply:
1. FDS-only fingers may have sufficient function without using free tendon
grafting to reconstruct the FDP tendon.
2. Never sacrifice an intact FDS or damage the surface of the FDS tendon
during surgery.
3. In young patients – Consider FDP grafting – After explaining risk of
worsening function.
4. Options – Tenodesis / Arthrodesis in Manual Labours & elderly.
5. Prefer in RF, LF @ Power Grip.
Primary tendon graft reconstruction (BUNNELL)

42. Post op Rehabilitation
 Accelerated rehabilitation protocols.
 Early active motion protocol is used for compliant patients.
 Postoperative splint - static dorsal blocking splint, with the wrist in
neutral, the MP joints in 45 degrees of flexion, and the IP joints in
neutral worn for 6 weeks after surgery.

43. Two stage - Reconstruction
Indications - Considered in severe trauma
 with extensive destruction of flexor pulleys,
 with crushing injuries with extensive soft tissue damage and underlying
fractures,
 with extensive scarring of the flexor tendon bed and Overlying skin.
 Inadequate passive range of digital motion.

44.  Hunter - is credited for his work with a goal of creating a new flexor
tendon bed allowing for gliding of the implanted tendon graft and
recreate a sufficient and functional pulley system.
 Options exists for pulley reconstruction, include - Extensor retinaculum,
remnant of free tendon, FDS tendon, Volar plate or synthetic materials
like Dacron arterial graft, silicone rubber sheeting, xenograft materials,
polytetrafluoroethylene, woven nylon and fascia lata, and porcine
collagen and peritoneum.

45.  The first stage includes reconstruction of the pulley and sheath system,
and the placement of the silicone rod as a temporary implant in the
tendon bed.
 This is followed by a strict rehabilitation protocol to restore digital flexion
before secondary reconstruction 3–6 months afterwards.
 The placement of the silicone rods (8, 10, 12,14 F – Corresponding to
diameter of FDS) leads to the development of a pseudosheath
(mesothelium) around the implant.
 This allows for replacement of silicone implant with - tendon graft in a
functional bed - that prevents scar formation and soft tissue adhesions.

46.  The pulleys should be carefully evaluated and prepared in order to
receive the graft.
 When the pulleys are intact they can be dilated to allow tendon graft
gliding.
 In cases with complete damage, the pulleys can be repaired,
reconstructed and tensioned.
 The ideal tendon graft for the second stage reconstruction - should
have intrasynovial lining on the tendon gliding side.

50.  In the second stage the tendon graft is fixed to the distal end of the
previously implanted rod and pulled proximally through the
pseudosheath.
 Then the implant is removed and discarded and the tendon graft is finally
sutured to the proximal intact flexor stump with correct tensioning.

52. Complications of Tendon Reconstruction
 Adhesion formation
 Mechanical failure of implant
 Graft rupture
 Pulley Disruption
 Quadrigia Syndrome
 Lumbrical plus finger
 Swan neck deformity
 Infection
 Synovitis
 Late flexion deformity

53. Post operative
 A short-arm posterior molded plaster splint from - fingertips to below the
elbow.
 The wrist is maintained in neutral, the MP joints in 40 to 50 degrees of
flexion, and the IP joints in neutral.
 Controlled active range of motion exercises under supervision of hand
therapist

54. Tendon Prosthesis - Hunter rod
 Made of woven polyester core covered with barium impregnated silicone
elastomer.
 This device is developed by Dr. James M. Hunter for the reconstruction
of flexor and extensor tendons.
 Residual antecedent infection is a contraindication for the use of this
device.
 Rod portion of the device is 4 mm wide and 2 mm thick and varies in
length, The cords extend 15 cm beyond the ends of the rod

55.  Passive - distal end of the implant is fixed to bone or tendon & proximal
end glides freely in the proximal palm or forearm.
 Active – Fixed both proximally and distally.
 2 passive tendon implants available - differ only in their distal juncture.
 One has a stainless steel distal metal end plate that is attached to the
distal phalanx by a screw.
 Other has a screw-fixation terminal device is held in place with a 4-0
nonabsorbable suture to distal FDP stump.

56. Hunter rod
Passive
tendon device
Passive
tendon
implant
Active tendon
device
BC (bi-
cordal)
DC(distal
cord)
PC(proximal
cord)

57.  Indications for an active tendon rather than a passive tendon:
(1) Patient with proper motivation & good compliance with rehabilitation
protocol,
(2) An extensor system that functions well enough to balance the
flexion,

58. Soft tissue and joint deficiencies
/scarring
 Management - Individualized to each case.
 Two staged procedure –
1. First stage – Soft tissue + joint deficiencies + pulley reconstruction + silicon
rod.placement.
2. Second Stage – Tendon grafting.
3. Might extend to third stage
 Keep proximal stump away from the scarred / injured area. – Preffered at
Wrist Level.

62. Modified Paneva - Holevich Technique
 Prerequisite-
 Injury to both FDP, FDS with serious scarring and a nonfunctional flexor
apparatus.
 Indications
(1) Flexor tendon reconstruction in Boyes 2 to 5 injuries in zone 2 with
considerable scarring of the tendonbed;
(2) Finger replantation with damage to the fibroosseous canal;
(3) Failed previous flexor tendon reconstruction.

63. Stage 1

64. Stage 2

66. Advantages over Hunter
technique
 (1) No need of identify motor during the first stage;
 (2) The FDS-FDP loop - identified easily in palm - during the second
stage;
 (3) There is no donor site morbidity (no free grafts)
 (4) Performed easily in children;
 (5) Pedicled tendon graft with a strong proximal junction - already healed
before second stage ;
 (6) Uses FDS as graft that is consistent. (palmaris longus, plantaris,
which are reported to be absent in few)

67.  (7) The FDS tendon graft is three times larger than conventional grafts
used in the Hunter technique – need thicker Silicone rod.
 (8) FDS - intrasynovial graft – better graft incorporation than
extrasynovial grafts.

68. Disadvantages
 The difficulty in tensioning the graft at the distal anchoring site of the
graft. The proximal tendon junction healed by this time.
 The FDS of the little finger sometimes is thin in the wrist 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.

69. Complications
 Flexion contracture of the DIP joint (most common) - treated with night
extension splints.
 In First stage complications include (1) rod buckling, (2) necrosis of the
skin, (3) rod migration, (4) rupture of the distal end of silicone rod, (5)
synovitis, and (6) infection.
 In second stage complications can be (1) bowstringing, (2) impingement
of the proximal suture in the fibro-osseous canal, (3) tendon grafts loose
or tight, (4) disruption at the distal or proximal junctions, (5) flexion
deformity of the proximal interphalangeal (PIP) and/or DIP joints, and (6)
infection.

70. Flexor tendon injuries in
children
 In delayed cases - parents should be informed of the possibility for
grafting of the flexor tendon.
 Immobilize with above elbow plaster cast for 1 month in <7 yrs
children – followed by active motion exercises
 Defer Reconstruction (not repair) in < 7 years.
 Bruners incision vs Midlateral incision (Absorbable sutures)
 Bunnell pull out suture – avoid physeal damage.
 Repair both FDP and FDS.
 Avoid Plantaris as graft.

71. Tendon Reconstructions - FPL

72. FPL reconstruction
 Direct repair - possible - 3 to 4 weeks after injury but, there is sufficient
shortening of the muscle within a few days – Extended primary repair
with proximal tendon lengthening.
 Delay of the repair beyond 3 to 4 weeks may cause myostatic shortening
of the muscle–tendon unit.
 Primary repair in zone 3 is difficult – Matev (1983) – Tendon graft from
wrist – reconstruct FPL primarily in single stage.
 Distal tendon dissection – Requires careful attention to digital NVB.
 Zone 4 injury – immobilize wrist in neutral to slight extension – after
repairing sphagetti wrist and releasing Carpal tunnel. (Jin bo Tang).

73. FPL reconstruction
 Indicated in failed repairs and Neglected injuries.
 Prerequisite for grafting in stage 1 is adequate excursion on table
and intact Oblique pulley.
 Incompetent pulley system and extensively scarrred bed with
adequate excursion – Two staged reconstruction.
 No adequate excursion on table – Tendon transfer.

76.  The distal vinculum brevis is present in 90% of thumbs and is strong.
 If intact after injury at the level of the IP joint, it will retain the FPL within
the thumb.
 Pulvertaft thought that local adhesions played a part in maintaining the
tendon in the thumb.
 The FPL has a functional amplitude of excursion of 5.5 to 6 cm:
 If the amplitude of excursion of the cut end of the proximal tendon is far
short - using it as a motor for reconstruction will not achieve IP joint
flexion.

77.  Matev - Rule of thumb : FPL Reconstruction.
 If the passive stretch of the muscle fibers, measured at the wrist, is 3 to
4 cm, full restoration of function may be expected.
 Even with 1.0 to 1.5 cm of passive stretch, the result is likely to be
adequate. If less than this, he advised using another motor.

78. Tendon grafting in FPL
Reconstruction
 Bridge grafts from Wrist to distal phalynx planned / Thenar tunneling /
Distal attachment / proximal attachment
 Tension adjustment – Schneider (1999) detailed a more precise setting
of the wrist at 0°, the thumb abducted in front of IF metacarpal, and IP
joint of thumb in 30° of flexion.
 Matev suggested the IP joint be set at 20° to 30°.
 Tendon Transfer – FDS of RF (most common), BR, PL, FCR.
 The presence of an oblique pulley of the thumb is essential
to FPL function.

79.  When pulleys need to be reconstructed, Excessive scarring bed & Joint
Instabilities - secondary reconstruction of the FPL tendon - prefer to
reconstruct the pulleys over a silicone rod at a first stage and reconstruct
the flexor tendon later.
 Aim at - 30-40 degrees of IP joint motion postop - to have fine pinch
function Good Result
 Pulvertaft’s policy - allowing a minimum of 6 months between injury and
reconstruction and between the stages of a two-stage procedure –
recommended.

81. Tenolysi
s -
 On Examination - wide discrepancy between active and passive range of digital
motion,
 Flexor tenolysis is indicated - digital flexion is reduced due adhesions in a bed of
scar tissue - restricts tendon gliding & active ROM,
 Before planning - the patient should be well motivated for prolonged rehabilitation.
 Goal - Independent and wide active motion of FDS & FDP – after surgery.
 Oral ibuprofen administration limited adhesion formation after FDP repair.
 Tenolysis is attempted –
1. After an interval of 3–6 months of primary tendon repair / tendon grafting.
2. After good fracture healing

82. Carbodiimide-derivatized hyaluronic acid, 5-fluorouracil and gelatin-
modified intrasynovial allografts reduced gliding resistance of repair in
animal models.

83. Extensor tendon reconstruction

85. Chronic mallet injuries with or without Swan
neck deformity
 Doyle - > 4 weeks
 Splint / Direct tendon repair / Skin imbrications (or both).
 > 6 months
 Tendon rebalancing with a central slip tenotomy (Fowler tenotomy),
 SORL reconstruction using a lateral band or tendon graft.
 Arthrodesis is a salvage procedure - Arthritic changes.
 Tendon grafting - Tendon-bone construct harvested from the ECRB–
third metacarpal junction.

87.  Distal Bouviers test

91. Boutonniere deformity

92. Pseudo boutonniere deformity

93.  Elsons test

94. Central Slip Reconstruction Using Local Tissue
 1. Snow’s Technique
 2. Aiche’s Technique
 3. Littler and Eaton’s Technique
 4. Matev’s Technique

95. Acute with tendon loss – Snow
Procedure

97. Burton classified chronic boutonnière deformity
into three stages:
 Stage I: Supple, passively correctable deformity
 Stage II: Fixed contracture, contracted lateral bands
 Stage III: Fixed contracture, joint fibrosis, collateral ligament and
palmar plate contractures
 Stage IV: stage III plus PIP joint arthritis.

98. Distal fowler / Dolphin tenotomy

99. Littler tendon grafting

100. Curtis staged Reconstruction

102. Saggital band reconstruction

103. Chronic Zone 6 injuries
 Side-to-side transfer
 Tendon grafts – TFL / PL / Plantaris etc
 In severe tendon loss - a two-stage reconstruction with silicone
rods (in literature)
 Composite Vascularized tissue transfers – Dorsalis pedis
cutaneotendinous free flap / Radial artery or ulnar artery based
island flap with vascularized tendon,

105. Chronic Zone 7 injuries
 EIP to EPL Transfer

106. Zone 8 - 9
 Tendon Transfers after adequate soft tissue
cover.

107. Vascularized tendon Grafts