Mateusz Gładysz FESSH prep

FESSH prep Tendon injuries Prognostic factors in staged reconstruction, its commonest complication, the Paneva Holevich pedicled graft, expected results of flexor tenolysis, quadriga effect from graft over tension

Flexor tendon reconstruction: staged grafting and tenolysis

Last reviewed v1.0

FESSH-083Tendon injuries●●● advanced

Regarding secondary flexor tendon reconstruction by staged grafting, and flexor tenolysis:

  1. 1.After staged flexor tendon reconstruction, Amadio and colleagues found injury in zone I or II to be a factor associated with a poor result.

  2. 2.In large series of two-stage flexor tendon reconstruction, flexion contracture of the finger was the most common complication.

  3. 3.In the Paneva-Holevich technique, the second stage uses a free tendon graft, such as palmaris longus, passed through the pseudosheath.

  4. 4.In a systematic review of flexor tenolysis, about two-thirds of results graded with the Strickland criteria were good or excellent.

  5. 5.Excessive tension in a flexor digitorum profundus graft to the ring finger can reduce active flexion in neighbouring fingers.

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Question ID
FESSH-083
First published
Last reviewed
Version
v1.0
Answer key and explanations — open after answering

  1. 1. After staged flexor tendon reconstruction, Amadio and colleagues found injury in zone I or II to be a factor associated with a poor result.

    True

    Amadio and colleagues evaluated 117 fingers after two-stage tendon grafting; 65% of patients were in the Boyes salvage group before surgery. Zone I or II injury was associated with a poor result, and zone IV or V injury and therapy supervised by the treating surgeon with a better one. Sixteen per cent of patients needed tenolysis after stage II.

    • Amadio PC, Wood MB, Cooney WP, Bogard SD. Staged flexor tendon reconstruction in the fingers and hand. J Hand Surg Am. 1988;13(4):559-62. PMID 3418059

  2. 2. In large series of two-stage flexor tendon reconstruction, flexion contracture of the finger was the most common complication.

    True

    In Wehbé and colleagues' 10-year experience of 150 fingers, flexion contracture of varying degree affected 41% of fingers, especially when a contracture was present before surgery; graft rupture occurred in 14% and infection in 4%. Soucacos and colleagues' review of 109 digits also found flexion deformity of the interphalangeal joints to be the commonest complication.

    • Wehbé MA, Mawr B, Hunter JM, Schneider LH, Goodwyn BL. Two-stage flexor-tendon reconstruction. Ten-year experience. J Bone Joint Surg Am. 1986;68(5):752-63. PMID 3722234
    • Soucacos PN, Beris AE, Malizos KN, Xenakis T, Touliatos A, Soucacos PK. Two-stage treatment of flexor tendon ruptures. Silicon rod complications analyzed in 109 digits. Acta Orthop Scand Suppl. 1997;275:48-51. PMID 9385266

  3. 3. In the Paneva-Holevich technique, the second stage uses a free tendon graft, such as palmaris longus, passed through the pseudosheath.

    False

    Paneva-Holevich described a two-stage tenoplasty with a pedicled graft. In the modified technique the first stage places a silicone rod and joins the flexor digitorum profundus and superficialis in a loop; at the second stage the superficialis is reflected as a pedicled graft through the pseudosheath formed around the rod, so no donor tendon is harvested elsewhere. Beris and colleagues reported 82% good or excellent results on the Buck-Gramcko scale in 22 digits.

    • Beris AE, Darlis NA, Korompilias AV, Vekris MD, Mitsionis GI, Soucacos PN. Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft. J Hand Surg Am. 2003;28(4):652-60. PMID 12877856
    • Paneva-Holevich E. Two-stage reconstruction of the flexor tendons. Int Orthop. 1982;6(2):133-8. PMID 7152747

  4. 4. In a systematic review of flexor tenolysis, about two-thirds of results graded with the Strickland criteria were good or excellent.

    True

    Van Carlen and colleagues reviewed 14 observational studies (556 digits). In the studies using the Strickland criteria an average of 68% of results were good or excellent, with a range of 45–91%. A separate review of isolated digital tenolysis reported a complication rate of 15.3%, so the procedure suits well-selected patients after a detailed discussion.

    • VAN Carlen M, Plonczak A, VAN J, Mishra A, Breahna AN. A Systematic Review of the Outcomes of Flexor Tenolysis in Zones 2-5. J Hand Surg Asian Pac Vol. 2022;27(4):607-614. PMID 35965368
    • Kher S, Graham DJ, Symes M, Lawson R, Sivakumar BS. Outcomes of Isolated Digital Flexor Tenolysis: A Systematic Review. J Hand Surg Asian Pac Vol. 2021;26(4):580-587. PMID 34789105

  5. 5. Excessive tension in a flexor digitorum profundus graft to the ring finger can reduce active flexion in neighbouring fingers.

    True

    The profundus tendons of the middle, ring and small fingers have coupled excursion. Shortening or over-tensioning one tendon can limit excursion of the others, producing a quadriga effect.

    • Schannen A, Cohen-Tanugi S, Konigsberg M, Noback P, Strauch RJ. A Novel Cadaveric Model of the Quadriga Effect. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews. 2017;1(8):e062. PMID 30211370
    • Schreuders TAR. The quadriga phenomenon: a review and clinical relevance. The Journal of hand surgery, European volume. 2012;37(6):513-22. PMID 22170246