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Flexor Tendon Injury and Repair – A Freely Sliding Tendon Capable of Restoring Good Function
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Flexor Tendon Injury and Repair – A Freely Sliding Tendon Capable of Restoring Good Function
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Segment:0 .
JEFF YAO: All right. So I want to welcome everybody back to the Hand Fellowship Virtual Debate. This has been, for those that have joined us in the past, this has been my opening slide. A little bit of a boxing match between the Fellows for 2020-2021. We're going to be easing into it. So instead of a traditional virtual debate format, we have a webinar with some gurus and some sages from across the country.
JEFF YAO: And we actually have Dr. Lalonde from Canada joining us today. So this has been, for the most part, it's been a face off or sometimes a cage match between Fellows from different institutions, sometimes two, three or four different Fellows going at it. For week one, I think we had a great Wrist arthroscopy webinar with the professors, with Dr. Osterman, Goldfarb and Kakar giving us a kind of a whirlwind tour through wrist arthroscopy, some of the key pearls and tips for success, and also what they should try and learn during fellowship.
JEFF YAO: And starting next month, we're going to be going back to the traditional format, doing a virtual debate between Fellows that will be facing off. So Scutters could be the third Thursday of every single month starting October. And we're trying to really recruit Fellows and faculty from across the country so certainly for any of the Fellows or faculty who are on the webinar today, if you're interested, please reach out to myself and Dr.
JEFF YAO: Hammert if you want to be involved in the process. So looking forward to a few little matches coming up. So save the date. So we're looking at Distal Radius fractures for October 15. November 19 is going to be looking at Thumb Tip Reconstruction, looking at toe transfer versus local flap coverage versus osteoplasty and then Dupuytren's contracture release for December 17. So we're looking at a kind of a once a month format for this.
JEFF YAO: So again, it'll be following the format of having the Fellows present in a lively debate and followed by a moderator with faculty panel for Q&A afterwards. I'm really excited. We have a phenomenal piano faculty educators who are going to share their wisdom on Flexor Tendon Repairs.
JEFF YAO: We have Dr. Leversedge, Dr. Lalonde, Dr. Seiler and Dr. Osei. I'm going to leave a more formal introduction to Dr. Leversedge in a few minutes here, but really want to thank all four of you for joining us on the faculty today, for joining us out of your busy schedule. So again, really thank you for your time. And again, I'm going to leave the formal introduction to Dr. Leversedge, but the theme
JEFF YAO: today is Freely Sliding Super Flexor Tendon capable of restoring the function. So the four lectures are as listed here.
FRASER LEVERSEDGE: Great well, thanks, Jerry and Warren, again, for this is a tremendous series and we've all learned and benefited from your work and so it's a fun part of both debating, but also in this part of the series it's a great way of reaching out and working together with colleagues.
FRASER LEVERSEDGE: And so our topic is flexor tendon injury and repair and I have the privilege of working with Dr. John Seiler, who's at Georgia Hand and Shoulder and Elbow. Don Leland, who I think everyone knows, is up in Canada. As a Canadian, I was allowed to bring one Canadian into this debate, Dr. Dan Osei, who's at the Hospital for Special Surgery.
FRASER LEVERSEDGE: And the format of this presentation is really to try to review in the short period of time, some of the pearls and pitfalls and the basic concepts of flexor tendon repair and rehabilitation. You'll see our agenda here, and we'll start out with a small case presentation to give you a sense as to what's important about flexor tendon injuries. Dr. Seiler is going to talk about zone 2 repair methods, concepts that have influence outcomes.
FRASER LEVERSEDGE: Dr. Leland is going to talk to us about wide awake repair methods that actually let him sleep at night. And then Dr. Osei is going to talk about distal repairs that don't keep him wide awake at night. So hopefully at the end, we'll have 15 minutes or so to go through a few cases just to have the faculty discuss some of the concepts in more of a clinical format. As you may have noticed from the topic title, this is actually a, I think, an important observation that Guy Pulvertaft had many years ago, some 80 years ago almost.
FRASER LEVERSEDGE: And he said it's not difficult to suture tendons and prepare the ground for sound union, i.e. putting in the sutures but the real problem is to obtain a freely sliding tendon capable of restoring good function. And I think for the Fellows who are here and the residents, if you have done a flexor tendon repair, the downside is you probably haven't been a part of the follow up care afterwards to see the struggles that we see following a flexor tendon repair, particularly in no man's land.
FRASER LEVERSEDGE: And so these types of injuries are real clinical challenges, not only because of associated injuries, but just getting the normal gliding, the normal sliding tendon back together again and to keep it sliding without peri tenderness, adhesion formation and without failure. So really the key points that our faculty is going to point out to highlight the anatomy, the biology of tendon healing is unique to this area of injury, the surgical techniques that will hopefully give us success
FRASER LEVERSEDGE: and importantly, again, just as importantly, if not more importantly, the post-operative rehabilitation. So I want you to think about this case as the faculty are talking and if you can think about going to see a patient in therapy and this is a patient three weeks after a zone two flexor tendon repair, who in therapy all of a sudden notes this unusual phenomenon that the finger is he tries to flex to make a composite digital fist.
FRASER LEVERSEDGE: The finger actually extends and he's worried that you've hooked things up in an incorrect manner. And I want, I hope everyone has maybe seen this or at least understood it to the point of understanding the anatomy of why this occurs, because it does present a little bit of a clinical challenge. So here's the anatomy. Remember that your flexor tendon injury somewhere along the line, you've got a disruption and there's a disruption in terms of the force through your proximal muscle to the distal fingertip, the target.
FRASER LEVERSEDGE: And if that is not allowed to transmit this force from to the fingertip, remember your lumbrical origin at the FTP and as your patient is trying to actively flex because there is no force going through the tendon, it's now bypassing the tendon and passing through your lumbar goal. And as you all know, the lumbrical goes, inserts through your extensor hood, through the oblique fibers of your extensor hood, through the conjoined lateral bands
FRASER LEVERSEDGE: and so the effect of the proximal traction against the FTP tendon is now your extending the interphalangeal joints of your finger. And so that's your paradoxical digital extension so why does this occur? Well, there's no gliding tendon, so it's either that your repair has ruptured, your repair site is too bulky to pass through the fibrosis digital tunnel that the tendon needs to pass through, whether it's at a pulley, whether it's too large of a repair or where you've got some peri tendon adhesions, the tendon is no longer gliding.
FRASER LEVERSEDGE: So those are the three things that we think about potentially amongst others but when you have a patient early on in your repair, you have to try to figure out why is the tendon not gliding as it should? So Dr. Seiler will lead things off with zone two. Remember this is a unique environment interest synovial tendon. Dr. Dr. Leland is going to talk to us about trying to avoid this catastrophic failure of a repair, particularly with some intraoperative techniques that allow us to visualize the tendon as we prepared it.
FRASER LEVERSEDGE: And then Dr. Osei is going to talk to us about what may not look at first glance importance of getting from here to here but we all know that when our patients can't actively flex the digit to create a composite digital fist, that it really does reduce functional activities. So without further ado, I will pass this along to Dr. Seiler.
JOHN SEILER: And I wanted to start a little bit with some of Don's concepts around what kind of a patient are we working with, Because I think the kind of patient you have really depends on the kind of suture you may want to place and certainly the aftercare.
JOHN SEILER: And then in our institution, we always have a big checklist of things that we need to run through in terms of our ability to do the case. We try to be pretty meticulous about that. I generally prefer mid lateral incisions Do Bruner incisions when it's possible, but I like to incorporate the existing laceration into the approach for surgical exposure. And then I do like to preserve as much of the A2 and A4 pulleys as possible, but agree with Don that really over the last 10 years, one of the big changes in how you approach the pulley system is you need to make sure that you have good tendon excursion in the OR because it's clear that you'll never get it if you don't have it at the time you start the case.
JOHN SEILER: So here's just a quick example of an exposure. You can see a modified Bruner kind of approach. The annular pulleys have been preserved. There's a flap of flexor sheath has been raised, which you can repair to the ever present rim. There's one slip of the FTS and the digital nerves are intact, and I won't spend much time on McGrath's technique of tendon retrieval because I think that's going to be the focus of additional discussion.
JOHN SEILER: Sometimes I'll use this technique, sometimes I like to use, I'll just retrieve the tendons proximally, place my core suture, pass it distally, and then just be ready to sew. One of the biggest problems I have seen over the years is with people not correctly orienting the tendons back in the middle of zone 2. And there is just, it's good to spend
JOHN SEILER: just a minute thinking back on the anatomy in that area where the flexor digitorum superficialis is rolling around the profundus and as it comes underneath it and cradles it, 50% of those fibers cross and then the insertion runs out. And I think that's something that's really important to OR to get that as precise as you can get it, because that is a common source of complication when I see patients and referral. This simple anatomical principle hasn't been observed.
JOHN SEILER: One of the things when we teach flexor tendon repair, after we establish the tendons into the wound, I like to do the FDS first through the FTP back wall and then stabilization of the tendon becomes much easier. You can put a needle or a 25 gauge needle through it. I prefer a 25 gauge needle, but that technique of doing the FDS first and the back wall first really simplifies the procedure so that you can teach the core suture method that you want to teach.
JOHN SEILER: And there's just the distal stump. So once you have everything in the wound, again from a strategic standpoint, I always get the FDS stabilized first because that helps me plan and perform the repair of the FTP and I think if you do a backup wall first, every tendon and stitch on your FTP, that sets things up for success with your core suture. It just makes everything easier to do and you feel like you're running downhill.
JOHN SEILER: When you think about core suture methods, remember that stronger techniques may be associated with more bulk. You may have to pay more attention to your tendon sheath to make sure that they glide appropriately and generally speaking, they're more technically difficult to place. And reproducibility is important in my view here. I think there's a lot of different materials that are appropriate for flexor tendon repair.
JOHN SEILER: I still am a fan of the looped Keppra lactam suture because I can put in a four strand repair more quickly and easily with less handling of the tendon. I think that's a nice strategy for doing it, but certainly there's plenty of articles that show other suture types as being effective here. When I think of suture methods, I like to simply divide them up into two types. Two strand suture methods or Kessler or modified Kessler pajamas methods, Tsuge method.
JOHN SEILER: These are generally not going to be strong enough for early active motion, but they're appropriate for early passive mobilization programs. And there's still plenty of cases that we see where that's an appropriate strategy for rehabilitation. The repairs I think everybody prefers are the multi strand, multi grass repairs. And one of the really interesting things about these repairs is when they're studied in vivo, in animal models, you don't see a lot of repair side strength softening here.
JOHN SEILER: So, to Don's point earlier, you're in a good motion in the OR, that repair site is probably not going to soften in the first 14 to 21 days. It's going to continue to build strength and over that period of time, an active rehabilitation method is probably going to work out nicely for you. So the factors that influence the strength or the gauge of the suture, the number of strands in the suture, geometry, the material, and then the biologic response to the injury and repair I think is important.
JOHN SEILER: So some patients with very complicated injuries, I may choose a simpler tendon repair strategy, knowing I'm going to alter my aftercare and I still think that's a fair thing to do. If you if you get a lot of industrial injuries, and there are multiple fingers, you might change the repair side strategy because you know that your aftercare strategy is going to have to be different.
JOHN SEILER: So for me, this is still an optimal type of core suture. I want sturdy coaptation of the ends, I like a low profile appearance of the suture. I want it to be strong enough to allow active digital mobilization, and I want it to be pretty easy to put in. So here's one way. Again, I'm going to show this with a single strand because it shows up better on the slides.
JOHN SEILER: But we use a, we use a loop suture because it makes it a little easier. So we're going to use a modified Kessler type strategy where the tendon, the knot will be internal to the repair site and this is an easy way to get a four strand suture. You can add a mattress over the top, as Dr. Strickland used to recommend, to get to another couple of strands
JOHN SEILER: and then we finish it with a deep EPI tendon and the suture. Ed Diashio [?] showed that this definitely increases not only the gap strength, it smooths the edges, but it adds a little bit of strength to the repair site as well. So I think it's a useful, useful strategy. But the principal advantage of these sutures is they allow early active mobilization. You can look for increased tendon excursion or a lot of nice new rehab programs.
JOHN SEILER: Don's partial fist is a good example of that. And there's some biological evidence that you might even accelerate intrinsic tendon repair. But certainly these can be done safely, you're not going to have post-operative gap formation and you're going to have a very low rate of tendon rupture. For the distal FTS repair, there's a lot of different strategies that are useful. A modified Becker is a nice strategy, but a lot of times this is a very short piece of tendon and so you may be stuck with a mattress or a mattress and a figure 8 to get that together.
JOHN SEILER: And again, I choose the suture caliber. These are based on tendon size so that it can be done effectively. And here's just an example of a modified Becker type strategy. Sometimes you only have enough tendon to work with, but this is a nice one. It's very durable if you like it. So here, here's a child's hand laceration where we've retrieved the FTP through a repaired, now repaired FDS, and you can see, it fits in there nicely.
JOHN SEILER: We've preserved the pulleys, and you can finish that repair off and it's going to be a nice, smooth repair and you can see we invented a little more sheath there, just as Don had alluded to, to make sure there's good gliding there. What about sheath repair? The sheath repair is really something that there's no clear clinical evidence
JOHN SEILER: that it improves outcomes
JOHN SEILER: so I think it's useful only when it improves the gliding of the repair site. The operative endgame for me here is always the same thing. We've got to check the tenant excursion because if it won't go smoothly in the OR on day one, it will never go. And then I venture recess pulleys just to make sure that I can get full gliding and then look at sheath repair only in the context of how it might facilitate repair site gliding.
JOHN SEILER: I like it to be nice and dry when I'm done because I don't want to fight through hematoma and other things that create increased work or deflection, as Don alluded to and as Don also pointed out after care here is really important. And our goal is the same. As Don pointed out, we want to safely allow differential tenant excursion.
JOHN SEILER: So that they can get to a full fist. And we prefer, when possible, the active, early active aftercare methods. Dr. Gelberman and colleagues showed us that this is really important. He showed a nice cause and effect for more therapy, causing improved digital motion in the end of care and so there's good rationale for this for both passive and active programs.
JOHN SEILER: And I'll just show just a couple of quick cases. This is a guy that had a hand laceration that we fixed with a two strand repair. He took off his splint, never came back to clinic until he needed some paperwork figured out. And he had early active motion. And this is the case that sort of spurred my interest. But these multi strand, multi grass repairs allow you to get the much improved motion for me relative to two strand repairs and passive mobilization
JOHN SEILER: tactics. You see these work out? We have a very low rupture rate now with this strategy. And here's one that's a kiddo that came in about three months, two three months out and she had a complete FDS, FTP. You wonder if you could even repair it, and even in a child that's compliant, you can work an early active program and get a good outcome. And that's supported in the literature with a prospective randomized trial that shows improved outcomes for patients that had multi strand, multi graft, suture method repairs and active, early active rehabilitation.
JOHN SEILER: And our poor results there, we're really just smokers and crushing injuries. All right, Fraser, I think I'm going to stop there. Is that OK?
FRASER LEVERSEDGE: That's, that is great. Thank you, John.
DON LALONDE: OK can you hear me? You see my screen? Perfect. All right, we're on.
DON LALONDE: John, I think if you hit home there, you're going to get it.
JOHN SEILER: OK I'll try. I don't know what was happening there.
DON LALONDE: Thanks, you'll figure it out. So there is a book, but I'm not making any money on it. That's my disclosure. There is a website, which is also very helpful and I'm not making any money on that either, but they're good sources of information.
DON LALONDE: So I have to tell you that my results in flexor tendon repair used to suck terribly when I was a young surgeon, and they still occasionally suck but most of the time in most good patients, I'm now getting good results. And I'm not having to do a lot of tenolysis anymore and I'm not having a lot of rupture anymore. And I think the two biggest reasons are doing them awake and also true active movement post op instead of full fist place in the hold.
DON LALONDE: And I'm going to go through some of that stuff. I'm going to talk to you about what I think are the most important things and it's not just wide awake surgery. I think these bulky repairs like Fraser talked about are really, really good repairs and if you haven't read this paper by Jin Boateng from 2017, you should. I think it's almost as important as Harold Kleiner.
DON LALONDE: It's 1967 paper on early movement. 300 tendons, young surgeons, almost all of them got good results and only one rupture. And they all had these bulky repairs and I'm doing this six strand repair now, but I think for way too many years, we focused on the sutures, it's not about the suture. It's about a good, damn solid repair.
DON LALONDE: That's what it is. You need a good solid repair. And the problem with a bulky repair is that we used to think it had to fit through those damned A2 and A4 pulleys and I used those, that word appropriately damned the A2 and A4 pulleys. They caused us 50 years of unnecessary rupture and tenolysis because we prayed to the altar of you, we can't sacrifice those things.
DON LALONDE: And this is on the right. That's a grandma kiss repair. I actually published that drawing and I'm embarrassed about it because it's a poor repair, but I used to think it was a good repair because I needed to get underneath those damn A2 and A4 pulleys. And it's called a grandma kiss repair because the ends of the tendon are just touching just like when you kiss your grandmother on the cheek, you know, like [smacks lips].
DON LALONDE: Right and here's a grandma kiss repair. I mean, they look beautiful. This, this patient's awake on her belly. It's an easier way to do the thumb. But watch what happens when she starts to stress it with active movement. It starts to gap and you're thinking, oh, that's going to be great. Bullshit. It's not good at all.
DON LALONDE: And we all know that the gap turns to rupture, and we know that happens about 7% of the time. But if they're awake, you can fix it. So if they get a gap with an active movement because your tendon repairs not tight enough, and one of the biggest reasons that I used to get ruptures and that a lot of us get ruptures is our freaking repair is not tight enough. It's so make it bulky, like make it like it counts.
DON LALONDE: And then you're going to be able to vent the pulleys so your bulky repair fits, that's the whole deal. And we know it happens 7% of the time because of this series of over 100 patients that I published with Mike Bell from Ottawa, where 7% of the time, these grandma kiss repairs came apart when we watched them with wide awake repairs and we were able to fix the problem.
DON LALONDE: But if you're still doing them asleep or with a motor block, you don't know that's going on. And so, you know, a few weeks later, your repair comes apart. And so what you want to do is a bulky repair that's not going to gap and that's going to fit through vented pulleys. That's the new deal, is venting these blasted pulleys. So this patient has A4 vented, A3 intact, and there's no clinically significant bolstering on the table and there's no clinically significant bolstering after surgery.
DON LALONDE: And I use the word clinically significant because a little bit of bolstering never killed anybody, but a stiff finger is useless so I'll take a little bit of bolstering any day. This one has venting A3 and A4 with no clinically significant bolstering during or after the surgery. And I could show you dozens of these.
DON LALONDE: And this one is one that I. Sorry we're going to go back there. This one is one that I did. [VOICEOVER] 2.5 centimeters of tendon sheath. You have to bring them in all the way. Fantastic and straighten out all the way. OK you're not getting stuck. We're in good shape and flex again.
DON LALONDE: And straight. Now we are three weeks after tendon repair. Let's just have a look. Yeah beautiful because now I'm seeing that DIP joint move. Good show. Yeah beautiful. And straighten out. We're now five weeks after tendon repair. Oh, that's lovely.
DON LALONDE: Look at that PIP extension. I like that. And do it again. Flex again, wrist extended a little more. There we go. Great, fantastic. And then put your hand on the table here, like that. There we go. And flex and extend.
DON LALONDE: Flex and extend. Great let's take the Koband off. So you don't just whack out the pulleys, you incrementally divide just as much as what you need so that your fat repair fits through without getting stuck. So here I got my first core suture in. This was before I was doing Jin Bo Tang's sixth strand, and I see that I need to divide a little more cruciate pulley.
DON LALONDE: I can leave my A3 intact in this case because it's not getting in the way, and so you just take out as much pulley as what you need. You don't just go whacking everything out, but you've got to take out whatever you have to so that the end of the case, they're getting a full range, and they're not gapping. And so she had a four vented, no clinically significant bolstering in during or after the case.
DON LALONDE: And the new rule, forget the old A2 A4 business. The new rule is up to 1 and 1/2 to 2 centimeters of pulley venting, because if you do that, you're never going to vent both A2 and A4. And the case that I just showed you where I had to vent A1 and A2, I still had A3 and A4. And yeah, there's probably a little bit of bolstering, but at 5 weeks he almost had a full range. I'm going to see tomorrow.
DON LALONDE: And he said, my therapist tells me he's got a full range now, but this rule is in Jim Bo Tang's 2017 paper, the one I said that all Fellows ought to read because you really should. I think it's critical, but I think probably the most important thing about wide awake repairs is that after you're done and you do full fist flexion and extension testing, you know that there's no gap. And if there's no gap with a full fist today, then there's not going to be a gap with a half a fist four or five days from now.
DON LALONDE: And you always elevate an immobilized 3 to 5 days, let the swelling come down, let the work of flexion come down, let the bleeding stop and let them get off painkillers so they can do pain guided healing. And you always know this way that you vented just enough pulley that you're not going to have to do tenolysis. You know, it's like testing blood flow after a vascular anastomosis. You don't just do your repair and hope it works.
DON LALONDE: You let your clamps down to make sure it doesn't work. And when you simulate full fist place and hold, so there's true active movement OK, and that's what we're recommending. Up to half a fist of true active movement. Here's what happens when you simulate full fist, place and hold. See halfway? It stops moving.
DON LALONDE: It's buckling. It is not passively moving. And when you say hold it, watch it. Jerk, right there. I want to show you that again. It stops moving about halfway. And then you say to the patient, hold it, and there you go with full fist place and hold.
DON LALONDE: Jerk, right there. So we call that buckle and jerk. And so this is what we do now up to half a fist of true active movement. So there's three fingers with cut tendons. There we are at 4 days doing up to half a fist, but really want to get the DIP flexing. It's not about MP flexing, it's about the hook fist push the hook.
DON LALONDE: And Jin Bo Tang takes some right out of splint for exercises, and we're doing that more and more. So here's what I think is one of the most important things, and that's talking to the patient, and I told you, I still get the occasional result that sucks and this is one that I remember very badly because I spent my whole case educating the resident on how to repair the tendon, and I totally didn't talk to the most important person in the room who was the patient.
DON LALONDE: And I missed the fact that he was a drug addict and he went and shoveled snow the day after surgery for drug money. Now, he probably would have done that anyway, but at least if I'd have talked to him, I might have picked it up. Instead, I ignored him. And so let me explain the theory of the movement that we're going to do when I'm at the start. See, moving on Friday.
DON LALONDE: The goal is to move it just a little bit so it doesn't get stuck, but not to move it too much so that it rips apart. It doesn't take much to rip this apart because the stitches are only about 1/10 as strong as your tendon. You're not going to use it at all. You're just going to move it just enough to keep it moving so it doesn't get stuck.
DON LALONDE: What's the most important rule when we get you to start moving it and you can move it, but I can't use it. Well, when you start moving it off right, I can move it, but I can't use it. So it's Monday morning. You've got no Advil, no Tylenol on board more than three days after the flexor tendon repair. What's the most important rule?
DON LALONDE: And we let you move it today. But I can't use it. You know, a flexor tendon repair really changes somebody's life. And so my favorite question is, so what were you planning to do this week? Because almost inevitably that person has to change the plan of their life. And there's nothing like during the surgery when you have their uninterrupted attention and their sedated brain listening to you to go through a possible new plan that's actually going to work
DON LALONDE: so they don't screw up your result. And more importantly, they don't screw up their hand. And relative motion splinting has been really, really valuable to improve extensor leg. This is a fifth finger repair and after two weeks he gained 20 degrees of active extension because they exercise while they're living and instead of hyperextending their fifth finger, they're extending their PIP joint.
DON LALONDE: And this a relative motion extension splint when your patients are stuck in scar because that happens a lot. They come in, you do your ultrasound, by the way, a real hand surgeon today has an ultrasound probe in his clinic around his neck, just like a cardiologist used to have a stethoscope around his neck.
DON LALONDE: So if you've got an ultrasound probe in your clinic, you check the tendon, make sure that it's not ruptured, it's just stuck in scar, that's great. You put them in a relative motion extension splint, which helps differentiate the glide between the profundus and the superficialis and they exercise while they're living and you're going to avoid a lot of tenolysis if you use these splints and your ultrasound.
DON LALONDE: So in summary, I think the seven most important things to consistently get good results with clean cut repairs in reasonable patients is at least a four strand, very solid repair with one centimeter bite's, bulky, judiciously venting up to 1 and 1/2 to 2 centimeters of total pulley, intraoperative active full fist flexion and extension testing to make sure that your repair fits through the pulleys and you've vented them well enough and make sure that they're not gapping. Teaching your patient during the surgery
DON LALONDE: instead of talking to the nurses about the weather or the anesthetist about his new sailboat and up to half a fist of true active movement post-op and relative motion splinting to improve flexor and extensor leg. Thanks very much.
DAN OSEI: I've been trying to take a few things out of the talk as we've been speaking. These these talks have been fantastic
DAN OSEI: and hopefully give the Fellows and residents on the call a good sense of some of the newest and most important tactics, as well as important aspects to what is a very technical challenge for most hand surgeons. Even now in 2020, I don't know that we've kind of solved this problem, although we're clearly getting better by the work of a lot of the folks that have talked today. So I've been tasked to talk a little bit about zone 1 repairs, and there are certainly many similarities to what has been talked about with zone 2 tendons.
DAN OSEI: But I do think it's worth reviewing a little bit about some of the differences. So recall that zone 2 is really the intra synovial tendon and once you start to get out of that area and have injuries where the tendon is inserting into the distal phalanx, some of the biology is quite different and I would say that much of what we know about the vascular anatomy of the FTP insertion comes from the work of Dr. Leversedge, who's been moderating this session today.
DAN OSEI: And he described this interosseus blood supply coming from the palmar surface of the distal phalanx, as well as from a leash of blood vessels exiting radially and ulnarly from the distal phalanx into the distal FTP tendon and then more proximally he also described that the FTP tendon gets direct blood supply from the vincular brevis profundus. And there is a little bit of this watershed area which is relative hypo vascular zone, which can play a role in terms of the biology and particularly may play a role in terms of the repairs, similar to what we see in some of the zone
DAN OSEI: 2 injuries with hypo vascular zones. However, one of the things that Dr. Leversedge also described in one of his cadaveric studies is the neovascularization that occurs at the distal tendon stump of the FDP over time, certainly by 21 days, but even as early as two weeks. And that is sort of demonstrated by this clinical picture here where you see the extra almost erythema, which corresponds to a picture from one of his papers.
DAN OSEI: And so this is one of the reasons that in certain circumstances that we'll discuss further. It's possible to fix distal FTP evulsions at a later time from injury than we typically associate with zone 2 injuries, where it's often paramount to get the patient into the OR within the first week. So when we think a little bit about this issue, one of the other reasons to address these injuries that we're able rather to address some of these injuries later relates to how they present clinically.
DAN OSEI: And so I think most of the residents and Fellows on the call are familiar with Leddy classification, which describes the different types of FTP avulsions with type 1 being the most severe, which is actually different than most of our classifications, usually getting more severe with increasing number, with type one, again, corresponding to avulsions proximally with both the FLP and FBP being avulsed. So their extrinsic blood supply being avulsed. 3 is the least severe as the tendon gets trapped usually under the A4 pulley with no disruption of the vinculers system.
DAN OSEI: And then you have the type 4 and 5 injuries, which really correspond to bony distal phalanx convulsions. Number one, in association with the retracted tendon, that's type IV and then with a comminuted, usually intra articular fracture of the distal phalanx, which is type 5. So as we see essentially depending on how much of the extrinsic blood supply is disrupted, that tends to correspond with how quickly we need to fix some of these repairs.
DAN OSEI: So I that's an important concept, particularly for the trainees where type I injuries as well as the 4 and 5 injuries really need to be fixed quickly based on, number one, the amount of blood supply disruption as well as the bony injuries, whereas the type 2 and 3 injuries with preserved blood supply and being trapped closer to its insertion on the FTP, typically we have up to three weeks has been described, they still try to fix these a little bit sooner, but certainly it is possible to fix these later than we typically associate with flexor tendon injuries.
DAN OSEI: I'm not going to perseverate on this. One of the things that we talked about discussing is how do you actually do your tendon repairs? And one of the things that hasn't been talked about that much is tendon retrieval. And there are lots of described techniques. Certainly as a fellow in Saint Louis at Wash U, Richard Gilman was very fond of this technique of familias where you basically use an iced pediatric feeding tube and you feed it through the sheath with suture attached, and then you're able to drag the tendon through.
DAN OSEI: And that works both for zone 2 as well as zone 1 injuries. There are a lot of other techniques. Certainly we'll try to keep this talk free of commercial influence. There are certainly commercially available tendon retrieval tools as well as what was one of the more inventive techniques using a reverse Esmarch to essentially milk the tendon from proximal back distal. Now fortunately, with a lot of the FTP avulsion injuries that we're talking about here with zone 1 injuries, the possibility of flexor tendons all the way in the forearm is less than with zone 2.
DAN OSEI: But certainly knowing these techniques can be helpful regardless of the type of injury that you are facing in the operating room. So talking a little bit about repair techniques, this is certainly an area that things start to go away from what we were talking about with zone 2 injuries and there's a lot of information in our orthopedic literature. Now one of the biggest controversies relates to whether you use the historical pull out technique where typically a key needle or drill is taken through the FTP tendon after a repair has been done to the distal stump and it's brought through the sterile matrix and then tied over a suture button
DAN OSEI: and this is in comparison to suture button techniques, of which there are many. And when you look at the literature, it's actually a bit mixed. This study from Gil Ramin and Matt Silva, looking at some of the mechanical properties, demonstrated that the pull out suture technique was actually stronger with regard to ultimate tensile force required to disrupt the injury.
DAN OSEI: But in terms of displacement of the repair, it was actually the weakest, meaning that when you have 20 Newtons of force placed on the repair site, that is the displacement of the bone to tendon interval was greatest with the pull out suture technique as opposed to any of the suture anchor techniques. And so this was one of the studies that started to caution the use of suture means a lot.
DAN OSEI: When you look at other studies, one of the ones that I've certainly found useful is this one by Steve Lee when he was at NYU. And he looked at a variety of different techniques, and this was useful to me. He basically said that when you look at different configurations, a configuration using a pull out technique with suture anchors is actually the strongest with regards to holding displacement against cyclical loading as well as ultimate load to failure
DAN OSEI: and so certainly the combination is something that you should consider. In terms of what matters, I think a lot of what was been talked about, certainly by Dr. Lalonde's talk is the same. I think that although we've spent a lot of time and a lot of literature, a lot of words written down talking about suture size, suture caliber technique, doing a good solid repair is ultimately the most important thing. I do like super mid much like Dr. Seiler was talking about, I do like a looped suture giving us more strands across the repair site, but I don't think that it's as important as doing a good solid repair.
DAN OSEI: So whether you use the pullout technique, whether you use suture anchors or combination, whether you use a Kessler or modified Kessler style suture or a modified Becker, which is commonly used with the FTP insertion, I think making sure that you've prepared the distal phalanx appropriately, that the tensioning is appropriate and that your suture security is solid. Those are the things that are going to make for the best repair and cut down on complications.
DAN OSEI: One thing that is worth noting again for the residents and Fellows is that the manner in which you place an anchor, if you were going to use one, matters greatly. So this paper looked at a couple of different configurations, whether the suture anchor is placed antegrade, meaning going from more proximal to distal in direction, perpendicular to the distal phalanx or going retrograde. And what they found is that both with regard to displacement, to cyclical loading, as well as ultimate load to failure, the retrograde typically at a 45 degree angle is the best
DAN OSEI: and most optimal suture anchor placement configuration. So certainly if you're going to use the anchor, make sure that you do it in this manner. In terms of A4 management, I won't belabor this. I do think it's particularly important at the distal FTP insertion site, particularly as you're trying to go about 1 centimeter back in terms of your repair. Many people, as we've talked about, are very comfortable venting the entire pulley.
DAN OSEI: It's been talked about at meetings. It's been talked about in this conference. I think at this point, as long as you're preserving the pulleys proximally to Dr. Lalonde's pulley, not venting more than 1 and 1/2 to 2 centimeters it's perfectly acceptable to vent the entire a-4 pulley with FTP distal FTP repair. In terms of stunt management, something that Dr. Leversedge thought that we should talk about.
DAN OSEI: I think this is a common dilemma. Oftentimes you'll see that it isn't a clean avulsion of the entire FTP tendon from the distal phalanx and so you have to decide what to do. For call that if you have enough tendon and you resect it all the way down to the base of the distal phalanx, you may end up with quadriga, which is almost impossible to rehab your way out of
DAN OSEI: so you have to be careful. I called this level 6 evidence. This is just sort of my gestalt and how I manage this. If I have enough tendons, so 7 to 10 millimeters to do a good repair and again, I typically use a Becker style repair. I do use tendon to tendon repair even with these zone 1 injuries. If less than 4 to 5 millimeters more of a true avulsion, I would do direct tendon to bone repair.
DAN OSEI: There are times that there's enough tendon that I think I can almost do a hybrid where I'll do my repair directly to bone whether I use the pull out or anchor, and then I'll repair some of the stump on top of the repair to augment and perhaps strengthen the repair. Make sure that you vent your a-4 pulley if you do this, because it's certainly going to add to the bulk of the repair and to the point made by both Dr. Seiler and Dr. Lalonde, you're going to have difficulty having FTP excursion across the DIP if you don't vent when you do this technique.
DAN OSEI: In terms of complications, there are many and this is one of the things that I think it's important to know and be aware of. There can be some horrible complications with FTP repair at the distal phalanx. This paper highlighted many. I mean, you can get horrible osteomyelitis, CRPS. I think that this report was probably a little too cautionary with 15 complications reported after 23 repairs over about a 10 year period.
DAN OSEI: But certainly technique matters, making sure that sterility is kept throughout the environment, despite the fact that blood supply distally is quite good and usually will lead to a lack of infection but certainly lots can happen, be careful with your technique. So in terms of my approach, I still, despite some of the evidence against the pull out suture, have really liked it.
DAN OSEI: I will at times augment with a suture anchor. I usually don't use two suture anchors when I do the pull out technique and so I'll do similar to Steve Lee's, a hybrid one anchor, and then the pull out suture through the sterile matrix over a button. I find that to be a reliable technique. I generally have not been as good as some in terms of doing wide awake surgery, although I have with increased frequency over the last couple of years used that technique for all the reasons highlighted in this conference.
DAN OSEI: And certainly if you're not going to do it, I will say that I'll do some tenodesis to get a sense of the excursion. Again, the point I made about Quadriga and making sure that you've tensioned your repair, particularly distally, is quite important and so this is your chance to make sure that you get it right. I think that if you can't do a little bit of tenodesis on the operating room table without having gapping, to Dr. Lalonde's point, you probably have to do a stronger repair and it's probably worth doing it again.
DAN OSEI: So that's typically my approach for that. So with that, I know we're running over. I'll turn it back to Fraser and if there is any time left, we can answer any questions.
FRASER LEVERSEDGE: And we'll play this case here and so, this is a patient comes in two months after zone 2 flexor tendon repairs and for our faculty, I'm curious as to your sense of timing and your sense of strategy.
FRASER LEVERSEDGE: So the patient's able to flex a digit, but only to roughly about a DPC of 2 centimeters , 3 centimeters. There's full passive flexion and there's an intact active FTP function with distal P2 blocking. Passive extension is to approximately 20 degrees at the PIP joint. Dan, Don and John, a quick 1 minute just to explain your strategy for obviously possible tenolysis and what is your sense of timing for this type of a patient who's two months from surgery?
FRASER LEVERSEDGE: John Seiler, do you want to take a go at this?
JOHN SEILER: Sure. You know, for me, at two months, I would still be optimistic he would gain some additional improvement in therapy. So I would keep working with therapy. I would probably increase the frequency of his therapy, make sure he's on a good anti-inflammatory medicine and follow him closely and try and keep him moving forward with his rehab.
JOHN SEILER: For me, the window for tenolysis usually starts between four and six months. And then at that point, if he had full passive, limited, active motion, which is the scenario that looks to be developing here, you know, at that point, he may be up to around 90% of his total active motion so I would go ahead and offer him a tenolysis at that point but that would be my approach in this early, early phase.
FRASER LEVERSEDGE: Don Lalonde, any thoughts?
DON LALONDE: Yeah, I think that two months is too early for tenolysis and I think one of the, I'm in with John that I don't like to do them before six months. And even then I think that's often too early. And I think a relative motion flexion splint here might improve your DIP, your PIP extension sorry, I don't know what his MP hyperextension looks like, but certainly that can be a helpful strategy here.
DON LALONDE: I think if I'm going to do a tinolysis, I want the skin and subcutaneous fat to be soft if that when I palpate it and move it around because that's a reflection of what the peri tendonis adhesions are like. Like if you go in and the skin is hard as rock and stuck to everything, everything inside is going to be concrete so you've got to wait for that to soften up before you're going to have a shot at that.
DON LALONDE: And in my experience and view, if you don't want to have decent passive movement, you're not going to win with tenolysis. And so I think you're going to go from a stiff finger to a stiff finger if you do tenolysis in this person at two months.
FRASER LEVERSEDGE: Great. Dan?
DAN OSEI: All great thoughts and I think I share a lot of similar sentiments about this.
DAN OSEI: I generally don't do tenolysis earlier than four months. I've actually had a patient rupture following tenolysis at six months, so I think the longer I go, the more I wait. There's a few things here. It's funny, I was just talking to my fellow about this kind of situation with stiffness, so full passive flexion. So, you know, there's nothing going on the extensor side tethering you,
DAN OSEI: so there's some issue with the flexor and yes, with FDS/FDP, you're worried about the lack of differential glide. I'd also worry potentially, depending on how you did the repair, that perhaps there is some pulley insufficiency here that's playing a role. And so some of the time I may, although two months would be too early, consider getting ultrasound again to Don's point, making sure that I have a good understanding of the issue, whether it's true adhesions between FDS and FTP, or whether there's a mechanical issue with some bone stream that's leading to the increased DPC, or whether perhaps there's even some gapping going on, which could be a sentinel warning that the patient hasn't been able to make a full composite fist.
DAN OSEI: And with increasing efforts, which oftentimes happens with therapy, you're on your way to a rupture. So those would be some of the things that I'd want to rule out. But in general, probably adhesions and I would wait as long as possible. I do like a relative motion splint to Don's point with this patient population as well, and I found that to be helpful.
FRASER LEVERSEDGE: Those are always those are all great points. And I too believe that two months is too soon. I think just the biology of your repair if you are relying on some extrinsic peritoneum, tenderness, adhesion formation can actually help with your vascular supply to your tendon, you do run the risk of a rupture if you're aggressively tenolysing the digit too early. I think one of the nice guides here, if you look at this picture, it's one of the signs that we learn in medical school of rubor and sort of as you flex the finger here, you just see this sign.
FRASER LEVERSEDGE: You have to have, you have to give it an extra little bit of push to Don Lalonde's point, that the skin is still hard here, you get that relative redness or rubor along the digit as you try to squeeze it down into flexion. And it just suggests that the wound is not mature. I think that the keys to the tenolysis have been discussed. I think when you stop making progress, I like to tell our patients that progress is our good measure as to when to decide to embark on a tenolysis for me again, it's probably somewhere closer to four to six months erring closer to five or six months.
FRASER LEVERSEDGE: And this is just being prepared and lenolysis knives are certainly nice tools to have in your toolbox. They're more meals designed but that you can cut the pulleys as you do this. So you have to be somewhat familiar with them. And at the same time, you want to restore this freely sort of sliding pulley beneath your pulleys that you want to preserve along the way where you can to prevent tendon bolstering.
FRASER LEVERSEDGE: So I know we're a little short on time and I just wanted to sort of sum up here, we've had some wonderful talks by our faculty and thank you to Dr. Seiler, Leland and Osei for their wisdom. These are challenging subjects and is as somebody who did some repairs and fellowship with lots of canine repairs, it was always amazing to me that no matter how well staged and standardized your repair, you still ended up with ruptures
FRASER LEVERSEDGE: and I think our goals of trying to advance our technical abilities, whether it's by the numbers of sutures we put in to the way that we vent our pulleys to making sure that we've got a good sliding pulley at the time of our repair without gapping is really critical. And I think Don's introduction to many of us for WALANT been very helpful. So for this particular unique zone, recognize the pertinent anatomy, really respect the biology of the repair
FRASER LEVERSEDGE: and every time you grasp your gliding surface of the tendon, if you remember Dr. Osei's pictures from the vascular studies, think of each time you're grasping the tendon is disrupting those small peritoneum related vessels and then consider associated injuries in terms of your post repair rehabilitation protocol. That's really critical to individualize treatment and communicate this with your therapists and that's really, really the key.
FRASER LEVERSEDGE: You don't want to send somebody out with a two strand repair that follows a cookbook repair for early active motion because they're going to end up with a rupture. And don't burn bridges, don't start your tendon reconstruction with an immature wound or something that you're going to have to come back to and ultimately may cause you to fail your reconstruction. So thanks to the staff and the faculty, Thanks to Warren and to Jerry for a fantastic series and thanks for your attention tonight.
FRASER LEVERSEDGE: And I hope everyone has a good night.
Segment:0 .
JEFF YAO: All right. So I want to welcome everybody back to the Hand Fellowship Virtual Debate. This has been, for those that have joined us in the past, this has been my opening slide. A little bit of a boxing match between the Fellows for 2020-2021. We're going to be easing into it. So instead of a traditional virtual debate format, we have a webinar with some gurus and some sages from across the country.
JEFF YAO: And we actually have Dr. Lalonde from Canada joining us today. So this has been, for the most part, it's been a face off or sometimes a cage match between Fellows from different institutions, sometimes two, three or four different Fellows going at it. For week one, I think we had a great Wrist arthroscopy webinar with the professors, with Dr. Osterman, Goldfarb and Kakar giving us a kind of a whirlwind tour through wrist arthroscopy, some of the key pearls and tips for success, and also what they should try and learn during fellowship.
JEFF YAO: And starting next month, we're going to be going back to the traditional format, doing a virtual debate between Fellows that will be facing off. So Scutters could be the third Thursday of every single month starting October. And we're trying to really recruit Fellows and faculty from across the country so certainly for any of the Fellows or faculty who are on the webinar today, if you're interested, please reach out to myself and Dr.
JEFF YAO: Hammert if you want to be involved in the process. So looking forward to a few little matches coming up. So save the date. So we're looking at Distal Radius fractures for October 15. November 19 is going to be looking at Thumb Tip Reconstruction, looking at toe transfer versus local flap coverage versus osteoplasty and then Dupuytren's contracture release for December 17. So we're looking at a kind of a once a month format for this.
JEFF YAO: So again, it'll be following the format of having the Fellows present in a lively debate and followed by a moderator with faculty panel for Q&A afterwards. I'm really excited. We have a phenomenal piano faculty educators who are going to share their wisdom on Flexor Tendon Repairs.
JEFF YAO: We have Dr. Leversedge, Dr. Lalonde, Dr. Seiler and Dr. Osei. I'm going to leave a more formal introduction to Dr. Leversedge in a few minutes here, but really want to thank all four of you for joining us on the faculty today, for joining us out of your busy schedule. So again, really thank you for your time. And again, I'm going to leave the formal introduction to Dr. Leversedge, but the theme
JEFF YAO: today is Freely Sliding Super Flexor Tendon capable of restoring the function. So the four lectures are as listed here.
FRASER LEVERSEDGE: Great well, thanks, Jerry and Warren, again, for this is a tremendous series and we've all learned and benefited from your work and so it's a fun part of both debating, but also in this part of the series it's a great way of reaching out and working together with colleagues.
FRASER LEVERSEDGE: And so our topic is flexor tendon injury and repair and I have the privilege of working with Dr. John Seiler, who's at Georgia Hand and Shoulder and Elbow. Don Leland, who I think everyone knows, is up in Canada. As a Canadian, I was allowed to bring one Canadian into this debate, Dr. Dan Osei, who's at the Hospital for Special Surgery.
FRASER LEVERSEDGE: And the format of this presentation is really to try to review in the short period of time, some of the pearls and pitfalls and the basic concepts of flexor tendon repair and rehabilitation. You'll see our agenda here, and we'll start out with a small case presentation to give you a sense as to what's important about flexor tendon injuries. Dr. Seiler is going to talk about zone 2 repair methods, concepts that have influence outcomes.
FRASER LEVERSEDGE: Dr. Leland is going to talk to us about wide awake repair methods that actually let him sleep at night. And then Dr. Osei is going to talk about distal repairs that don't keep him wide awake at night. So hopefully at the end, we'll have 15 minutes or so to go through a few cases just to have the faculty discuss some of the concepts in more of a clinical format. As you may have noticed from the topic title, this is actually a, I think, an important observation that Guy Pulvertaft had many years ago, some 80 years ago almost.
FRASER LEVERSEDGE: And he said it's not difficult to suture tendons and prepare the ground for sound union, i.e. putting in the sutures but the real problem is to obtain a freely sliding tendon capable of restoring good function. And I think for the Fellows who are here and the residents, if you have done a flexor tendon repair, the downside is you probably haven't been a part of the follow up care afterwards to see the struggles that we see following a flexor tendon repair, particularly in no man's land.
FRASER LEVERSEDGE: And so these types of injuries are real clinical challenges, not only because of associated injuries, but just getting the normal gliding, the normal sliding tendon back together again and to keep it sliding without peri tenderness, adhesion formation and without failure. So really the key points that our faculty is going to point out to highlight the anatomy, the biology of tendon healing is unique to this area of injury, the surgical techniques that will hopefully give us success
FRASER LEVERSEDGE: and importantly, again, just as importantly, if not more importantly, the post-operative rehabilitation. So I want you to think about this case as the faculty are talking and if you can think about going to see a patient in therapy and this is a patient three weeks after a zone two flexor tendon repair, who in therapy all of a sudden notes this unusual phenomenon that the finger is he tries to flex to make a composite digital fist.
FRASER LEVERSEDGE: The finger actually extends and he's worried that you've hooked things up in an incorrect manner. And I want, I hope everyone has maybe seen this or at least understood it to the point of understanding the anatomy of why this occurs, because it does present a little bit of a clinical challenge. So here's the anatomy. Remember that your flexor tendon injury somewhere along the line, you've got a disruption and there's a disruption in terms of the force through your proximal muscle to the distal fingertip, the target.
FRASER LEVERSEDGE: And if that is not allowed to transmit this force from to the fingertip, remember your lumbrical origin at the FTP and as your patient is trying to actively flex because there is no force going through the tendon, it's now bypassing the tendon and passing through your lumbar goal. And as you all know, the lumbrical goes, inserts through your extensor hood, through the oblique fibers of your extensor hood, through the conjoined lateral bands
FRASER LEVERSEDGE: and so the effect of the proximal traction against the FTP tendon is now your extending the interphalangeal joints of your finger. And so that's your paradoxical digital extension so why does this occur? Well, there's no gliding tendon, so it's either that your repair has ruptured, your repair site is too bulky to pass through the fibrosis digital tunnel that the tendon needs to pass through, whether it's at a pulley, whether it's too large of a repair or where you've got some peri tendon adhesions, the tendon is no longer gliding.
FRASER LEVERSEDGE: So those are the three things that we think about potentially amongst others but when you have a patient early on in your repair, you have to try to figure out why is the tendon not gliding as it should? So Dr. Seiler will lead things off with zone two. Remember this is a unique environment interest synovial tendon. Dr. Dr. Leland is going to talk to us about trying to avoid this catastrophic failure of a repair, particularly with some intraoperative techniques that allow us to visualize the tendon as we prepared it.
FRASER LEVERSEDGE: And then Dr. Osei is going to talk to us about what may not look at first glance importance of getting from here to here but we all know that when our patients can't actively flex the digit to create a composite digital fist, that it really does reduce functional activities. So without further ado, I will pass this along to Dr. Seiler.
JOHN SEILER: And I wanted to start a little bit with some of Don's concepts around what kind of a patient are we working with, Because I think the kind of patient you have really depends on the kind of suture you may want to place and certainly the aftercare.
JOHN SEILER: And then in our institution, we always have a big checklist of things that we need to run through in terms of our ability to do the case. We try to be pretty meticulous about that. I generally prefer mid lateral incisions Do Bruner incisions when it's possible, but I like to incorporate the existing laceration into the approach for surgical exposure. And then I do like to preserve as much of the A2 and A4 pulleys as possible, but agree with Don that really over the last 10 years, one of the big changes in how you approach the pulley system is you need to make sure that you have good tendon excursion in the OR because it's clear that you'll never get it if you don't have it at the time you start the case.
JOHN SEILER: So here's just a quick example of an exposure. You can see a modified Bruner kind of approach. The annular pulleys have been preserved. There's a flap of flexor sheath has been raised, which you can repair to the ever present rim. There's one slip of the FTS and the digital nerves are intact, and I won't spend much time on McGrath's technique of tendon retrieval because I think that's going to be the focus of additional discussion.
JOHN SEILER: Sometimes I'll use this technique, sometimes I like to use, I'll just retrieve the tendons proximally, place my core suture, pass it distally, and then just be ready to sew. One of the biggest problems I have seen over the years is with people not correctly orienting the tendons back in the middle of zone 2. And there is just, it's good to spend
JOHN SEILER: just a minute thinking back on the anatomy in that area where the flexor digitorum superficialis is rolling around the profundus and as it comes underneath it and cradles it, 50% of those fibers cross and then the insertion runs out. And I think that's something that's really important to OR to get that as precise as you can get it, because that is a common source of complication when I see patients and referral. This simple anatomical principle hasn't been observed.
JOHN SEILER: One of the things when we teach flexor tendon repair, after we establish the tendons into the wound, I like to do the FDS first through the FTP back wall and then stabilization of the tendon becomes much easier. You can put a needle or a 25 gauge needle through it. I prefer a 25 gauge needle, but that technique of doing the FDS first and the back wall first really simplifies the procedure so that you can teach the core suture method that you want to teach.
JOHN SEILER: And there's just the distal stump. So once you have everything in the wound, again from a strategic standpoint, I always get the FDS stabilized first because that helps me plan and perform the repair of the FTP and I think if you do a backup wall first, every tendon and stitch on your FTP, that sets things up for success with your core suture. It just makes everything easier to do and you feel like you're running downhill.
JOHN SEILER: When you think about core suture methods, remember that stronger techniques may be associated with more bulk. You may have to pay more attention to your tendon sheath to make sure that they glide appropriately and generally speaking, they're more technically difficult to place. And reproducibility is important in my view here. I think there's a lot of different materials that are appropriate for flexor tendon repair.
JOHN SEILER: I still am a fan of the looped Keppra lactam suture because I can put in a four strand repair more quickly and easily with less handling of the tendon. I think that's a nice strategy for doing it, but certainly there's plenty of articles that show other suture types as being effective here. When I think of suture methods, I like to simply divide them up into two types. Two strand suture methods or Kessler or modified Kessler pajamas methods, Tsuge method.
JOHN SEILER: These are generally not going to be strong enough for early active motion, but they're appropriate for early passive mobilization programs. And there's still plenty of cases that we see where that's an appropriate strategy for rehabilitation. The repairs I think everybody prefers are the multi strand, multi grass repairs. And one of the really interesting things about these repairs is when they're studied in vivo, in animal models, you don't see a lot of repair side strength softening here.
JOHN SEILER: So, to Don's point earlier, you're in a good motion in the OR, that repair site is probably not going to soften in the first 14 to 21 days. It's going to continue to build strength and over that period of time, an active rehabilitation method is probably going to work out nicely for you. So the factors that influence the strength or the gauge of the suture, the number of strands in the suture, geometry, the material, and then the biologic response to the injury and repair I think is important.
JOHN SEILER: So some patients with very complicated injuries, I may choose a simpler tendon repair strategy, knowing I'm going to alter my aftercare and I still think that's a fair thing to do. If you if you get a lot of industrial injuries, and there are multiple fingers, you might change the repair side strategy because you know that your aftercare strategy is going to have to be different.
JOHN SEILER: So for me, this is still an optimal type of core suture. I want sturdy coaptation of the ends, I like a low profile appearance of the suture. I want it to be strong enough to allow active digital mobilization, and I want it to be pretty easy to put in. So here's one way. Again, I'm going to show this with a single strand because it shows up better on the slides.
JOHN SEILER: But we use a, we use a loop suture because it makes it a little easier. So we're going to use a modified Kessler type strategy where the tendon, the knot will be internal to the repair site and this is an easy way to get a four strand suture. You can add a mattress over the top, as Dr. Strickland used to recommend, to get to another couple of strands
JOHN SEILER: and then we finish it with a deep EPI tendon and the suture. Ed Diashio [?] showed that this definitely increases not only the gap strength, it smooths the edges, but it adds a little bit of strength to the repair site as well. So I think it's a useful, useful strategy. But the principal advantage of these sutures is they allow early active mobilization. You can look for increased tendon excursion or a lot of nice new rehab programs.
JOHN SEILER: Don's partial fist is a good example of that. And there's some biological evidence that you might even accelerate intrinsic tendon repair. But certainly these can be done safely, you're not going to have post-operative gap formation and you're going to have a very low rate of tendon rupture. For the distal FTS repair, there's a lot of different strategies that are useful. A modified Becker is a nice strategy, but a lot of times this is a very short piece of tendon and so you may be stuck with a mattress or a mattress and a figure 8 to get that together.
JOHN SEILER: And again, I choose the suture caliber. These are based on tendon size so that it can be done effectively. And here's just an example of a modified Becker type strategy. Sometimes you only have enough tendon to work with, but this is a nice one. It's very durable if you like it. So here, here's a child's hand laceration where we've retrieved the FTP through a repaired, now repaired FDS, and you can see, it fits in there nicely.
JOHN SEILER: We've preserved the pulleys, and you can finish that repair off and it's going to be a nice, smooth repair and you can see we invented a little more sheath there, just as Don had alluded to, to make sure there's good gliding there. What about sheath repair? The sheath repair is really something that there's no clear clinical evidence
JOHN SEILER: that it improves outcomes
JOHN SEILER: so I think it's useful only when it improves the gliding of the repair site. The operative endgame for me here is always the same thing. We've got to check the tenant excursion because if it won't go smoothly in the OR on day one, it will never go. And then I venture recess pulleys just to make sure that I can get full gliding and then look at sheath repair only in the context of how it might facilitate repair site gliding.
JOHN SEILER: I like it to be nice and dry when I'm done because I don't want to fight through hematoma and other things that create increased work or deflection, as Don alluded to and as Don also pointed out after care here is really important. And our goal is the same. As Don pointed out, we want to safely allow differential tenant excursion.
JOHN SEILER: So that they can get to a full fist. And we prefer, when possible, the active, early active aftercare methods. Dr. Gelberman and colleagues showed us that this is really important. He showed a nice cause and effect for more therapy, causing improved digital motion in the end of care and so there's good rationale for this for both passive and active programs.
JOHN SEILER: And I'll just show just a couple of quick cases. This is a guy that had a hand laceration that we fixed with a two strand repair. He took off his splint, never came back to clinic until he needed some paperwork figured out. And he had early active motion. And this is the case that sort of spurred my interest. But these multi strand, multi grass repairs allow you to get the much improved motion for me relative to two strand repairs and passive mobilization
JOHN SEILER: tactics. You see these work out? We have a very low rupture rate now with this strategy. And here's one that's a kiddo that came in about three months, two three months out and she had a complete FDS, FTP. You wonder if you could even repair it, and even in a child that's compliant, you can work an early active program and get a good outcome. And that's supported in the literature with a prospective randomized trial that shows improved outcomes for patients that had multi strand, multi graft, suture method repairs and active, early active rehabilitation.
JOHN SEILER: And our poor results there, we're really just smokers and crushing injuries. All right, Fraser, I think I'm going to stop there. Is that OK?
FRASER LEVERSEDGE: That's, that is great. Thank you, John.
DON LALONDE: OK can you hear me? You see my screen? Perfect. All right, we're on.
DON LALONDE: John, I think if you hit home there, you're going to get it.
JOHN SEILER: OK I'll try. I don't know what was happening there.
DON LALONDE: Thanks, you'll figure it out. So there is a book, but I'm not making any money on it. That's my disclosure. There is a website, which is also very helpful and I'm not making any money on that either, but they're good sources of information.
DON LALONDE: So I have to tell you that my results in flexor tendon repair used to suck terribly when I was a young surgeon, and they still occasionally suck but most of the time in most good patients, I'm now getting good results. And I'm not having to do a lot of tenolysis anymore and I'm not having a lot of rupture anymore. And I think the two biggest reasons are doing them awake and also true active movement post op instead of full fist place in the hold.
DON LALONDE: And I'm going to go through some of that stuff. I'm going to talk to you about what I think are the most important things and it's not just wide awake surgery. I think these bulky repairs like Fraser talked about are really, really good repairs and if you haven't read this paper by Jin Boateng from 2017, you should. I think it's almost as important as Harold Kleiner.
DON LALONDE: It's 1967 paper on early movement. 300 tendons, young surgeons, almost all of them got good results and only one rupture. And they all had these bulky repairs and I'm doing this six strand repair now, but I think for way too many years, we focused on the sutures, it's not about the suture. It's about a good, damn solid repair.
DON LALONDE: That's what it is. You need a good solid repair. And the problem with a bulky repair is that we used to think it had to fit through those damned A2 and A4 pulleys and I used those, that word appropriately damned the A2 and A4 pulleys. They caused us 50 years of unnecessary rupture and tenolysis because we prayed to the altar of you, we can't sacrifice those things.
DON LALONDE: And this is on the right. That's a grandma kiss repair. I actually published that drawing and I'm embarrassed about it because it's a poor repair, but I used to think it was a good repair because I needed to get underneath those damn A2 and A4 pulleys. And it's called a grandma kiss repair because the ends of the tendon are just touching just like when you kiss your grandmother on the cheek, you know, like [smacks lips].
DON LALONDE: Right and here's a grandma kiss repair. I mean, they look beautiful. This, this patient's awake on her belly. It's an easier way to do the thumb. But watch what happens when she starts to stress it with active movement. It starts to gap and you're thinking, oh, that's going to be great. Bullshit. It's not good at all.
DON LALONDE: And we all know that the gap turns to rupture, and we know that happens about 7% of the time. But if they're awake, you can fix it. So if they get a gap with an active movement because your tendon repairs not tight enough, and one of the biggest reasons that I used to get ruptures and that a lot of us get ruptures is our freaking repair is not tight enough. It's so make it bulky, like make it like it counts.
DON LALONDE: And then you're going to be able to vent the pulleys so your bulky repair fits, that's the whole deal. And we know it happens 7% of the time because of this series of over 100 patients that I published with Mike Bell from Ottawa, where 7% of the time, these grandma kiss repairs came apart when we watched them with wide awake repairs and we were able to fix the problem.
DON LALONDE: But if you're still doing them asleep or with a motor block, you don't know that's going on. And so, you know, a few weeks later, your repair comes apart. And so what you want to do is a bulky repair that's not going to gap and that's going to fit through vented pulleys. That's the new deal, is venting these blasted pulleys. So this patient has A4 vented, A3 intact, and there's no clinically significant bolstering on the table and there's no clinically significant bolstering after surgery.
DON LALONDE: And I use the word clinically significant because a little bit of bolstering never killed anybody, but a stiff finger is useless so I'll take a little bit of bolstering any day. This one has venting A3 and A4 with no clinically significant bolstering during or after the surgery. And I could show you dozens of these.
DON LALONDE: And this one is one that I. Sorry we're going to go back there. This one is one that I did. [VOICEOVER] 2.5 centimeters of tendon sheath. You have to bring them in all the way. Fantastic and straighten out all the way. OK you're not getting stuck. We're in good shape and flex again.
DON LALONDE: And straight. Now we are three weeks after tendon repair. Let's just have a look. Yeah beautiful because now I'm seeing that DIP joint move. Good show. Yeah beautiful. And straighten out. We're now five weeks after tendon repair. Oh, that's lovely.
DON LALONDE: Look at that PIP extension. I like that. And do it again. Flex again, wrist extended a little more. There we go. Great, fantastic. And then put your hand on the table here, like that. There we go. And flex and extend.
DON LALONDE: Flex and extend. Great let's take the Koband off. So you don't just whack out the pulleys, you incrementally divide just as much as what you need so that your fat repair fits through without getting stuck. So here I got my first core suture in. This was before I was doing Jin Bo Tang's sixth strand, and I see that I need to divide a little more cruciate pulley.
DON LALONDE: I can leave my A3 intact in this case because it's not getting in the way, and so you just take out as much pulley as what you need. You don't just go whacking everything out, but you've got to take out whatever you have to so that the end of the case, they're getting a full range, and they're not gapping. And so she had a four vented, no clinically significant bolstering in during or after the case.
DON LALONDE: And the new rule, forget the old A2 A4 business. The new rule is up to 1 and 1/2 to 2 centimeters of pulley venting, because if you do that, you're never going to vent both A2 and A4. And the case that I just showed you where I had to vent A1 and A2, I still had A3 and A4. And yeah, there's probably a little bit of bolstering, but at 5 weeks he almost had a full range. I'm going to see tomorrow.
DON LALONDE: And he said, my therapist tells me he's got a full range now, but this rule is in Jim Bo Tang's 2017 paper, the one I said that all Fellows ought to read because you really should. I think it's critical, but I think probably the most important thing about wide awake repairs is that after you're done and you do full fist flexion and extension testing, you know that there's no gap. And if there's no gap with a full fist today, then there's not going to be a gap with a half a fist four or five days from now.
DON LALONDE: And you always elevate an immobilized 3 to 5 days, let the swelling come down, let the work of flexion come down, let the bleeding stop and let them get off painkillers so they can do pain guided healing. And you always know this way that you vented just enough pulley that you're not going to have to do tenolysis. You know, it's like testing blood flow after a vascular anastomosis. You don't just do your repair and hope it works.
DON LALONDE: You let your clamps down to make sure it doesn't work. And when you simulate full fist place and hold, so there's true active movement OK, and that's what we're recommending. Up to half a fist of true active movement. Here's what happens when you simulate full fist, place and hold. See halfway? It stops moving.
DON LALONDE: It's buckling. It is not passively moving. And when you say hold it, watch it. Jerk, right there. I want to show you that again. It stops moving about halfway. And then you say to the patient, hold it, and there you go with full fist place and hold.
DON LALONDE: Jerk, right there. So we call that buckle and jerk. And so this is what we do now up to half a fist of true active movement. So there's three fingers with cut tendons. There we are at 4 days doing up to half a fist, but really want to get the DIP flexing. It's not about MP flexing, it's about the hook fist push the hook.
DON LALONDE: And Jin Bo Tang takes some right out of splint for exercises, and we're doing that more and more. So here's what I think is one of the most important things, and that's talking to the patient, and I told you, I still get the occasional result that sucks and this is one that I remember very badly because I spent my whole case educating the resident on how to repair the tendon, and I totally didn't talk to the most important person in the room who was the patient.
DON LALONDE: And I missed the fact that he was a drug addict and he went and shoveled snow the day after surgery for drug money. Now, he probably would have done that anyway, but at least if I'd have talked to him, I might have picked it up. Instead, I ignored him. And so let me explain the theory of the movement that we're going to do when I'm at the start. See, moving on Friday.
DON LALONDE: The goal is to move it just a little bit so it doesn't get stuck, but not to move it too much so that it rips apart. It doesn't take much to rip this apart because the stitches are only about 1/10 as strong as your tendon. You're not going to use it at all. You're just going to move it just enough to keep it moving so it doesn't get stuck.
DON LALONDE: What's the most important rule when we get you to start moving it and you can move it, but I can't use it. Well, when you start moving it off right, I can move it, but I can't use it. So it's Monday morning. You've got no Advil, no Tylenol on board more than three days after the flexor tendon repair. What's the most important rule?
DON LALONDE: And we let you move it today. But I can't use it. You know, a flexor tendon repair really changes somebody's life. And so my favorite question is, so what were you planning to do this week? Because almost inevitably that person has to change the plan of their life. And there's nothing like during the surgery when you have their uninterrupted attention and their sedated brain listening to you to go through a possible new plan that's actually going to work
DON LALONDE: so they don't screw up your result. And more importantly, they don't screw up their hand. And relative motion splinting has been really, really valuable to improve extensor leg. This is a fifth finger repair and after two weeks he gained 20 degrees of active extension because they exercise while they're living and instead of hyperextending their fifth finger, they're extending their PIP joint.
DON LALONDE: And this a relative motion extension splint when your patients are stuck in scar because that happens a lot. They come in, you do your ultrasound, by the way, a real hand surgeon today has an ultrasound probe in his clinic around his neck, just like a cardiologist used to have a stethoscope around his neck.
DON LALONDE: So if you've got an ultrasound probe in your clinic, you check the tendon, make sure that it's not ruptured, it's just stuck in scar, that's great. You put them in a relative motion extension splint, which helps differentiate the glide between the profundus and the superficialis and they exercise while they're living and you're going to avoid a lot of tenolysis if you use these splints and your ultrasound.
DON LALONDE: So in summary, I think the seven most important things to consistently get good results with clean cut repairs in reasonable patients is at least a four strand, very solid repair with one centimeter bite's, bulky, judiciously venting up to 1 and 1/2 to 2 centimeters of total pulley, intraoperative active full fist flexion and extension testing to make sure that your repair fits through the pulleys and you've vented them well enough and make sure that they're not gapping. Teaching your patient during the surgery
DON LALONDE: instead of talking to the nurses about the weather or the anesthetist about his new sailboat and up to half a fist of true active movement post-op and relative motion splinting to improve flexor and extensor leg. Thanks very much.
DAN OSEI: I've been trying to take a few things out of the talk as we've been speaking. These these talks have been fantastic
DAN OSEI: and hopefully give the Fellows and residents on the call a good sense of some of the newest and most important tactics, as well as important aspects to what is a very technical challenge for most hand surgeons. Even now in 2020, I don't know that we've kind of solved this problem, although we're clearly getting better by the work of a lot of the folks that have talked today. So I've been tasked to talk a little bit about zone 1 repairs, and there are certainly many similarities to what has been talked about with zone 2 tendons.
DAN OSEI: But I do think it's worth reviewing a little bit about some of the differences. So recall that zone 2 is really the intra synovial tendon and once you start to get out of that area and have injuries where the tendon is inserting into the distal phalanx, some of the biology is quite different and I would say that much of what we know about the vascular anatomy of the FTP insertion comes from the work of Dr. Leversedge, who's been moderating this session today.
DAN OSEI: And he described this interosseus blood supply coming from the palmar surface of the distal phalanx, as well as from a leash of blood vessels exiting radially and ulnarly from the distal phalanx into the distal FTP tendon and then more proximally he also described that the FTP tendon gets direct blood supply from the vincular brevis profundus. And there is a little bit of this watershed area which is relative hypo vascular zone, which can play a role in terms of the biology and particularly may play a role in terms of the repairs, similar to what we see in some of the zone
DAN OSEI: 2 injuries with hypo vascular zones. However, one of the things that Dr. Leversedge also described in one of his cadaveric studies is the neovascularization that occurs at the distal tendon stump of the FDP over time, certainly by 21 days, but even as early as two weeks. And that is sort of demonstrated by this clinical picture here where you see the extra almost erythema, which corresponds to a picture from one of his papers.
DAN OSEI: And so this is one of the reasons that in certain circumstances that we'll discuss further. It's possible to fix distal FTP evulsions at a later time from injury than we typically associate with zone 2 injuries, where it's often paramount to get the patient into the OR within the first week. So when we think a little bit about this issue, one of the other reasons to address these injuries that we're able rather to address some of these injuries later relates to how they present clinically.
DAN OSEI: And so I think most of the residents and Fellows on the call are familiar with Leddy classification, which describes the different types of FTP avulsions with type 1 being the most severe, which is actually different than most of our classifications, usually getting more severe with increasing number, with type one, again, corresponding to avulsions proximally with both the FLP and FBP being avulsed. So their extrinsic blood supply being avulsed. 3 is the least severe as the tendon gets trapped usually under the A4 pulley with no disruption of the vinculers system.
DAN OSEI: And then you have the type 4 and 5 injuries, which really correspond to bony distal phalanx convulsions. Number one, in association with the retracted tendon, that's type IV and then with a comminuted, usually intra articular fracture of the distal phalanx, which is type 5. So as we see essentially depending on how much of the extrinsic blood supply is disrupted, that tends to correspond with how quickly we need to fix some of these repairs.
DAN OSEI: So I that's an important concept, particularly for the trainees where type I injuries as well as the 4 and 5 injuries really need to be fixed quickly based on, number one, the amount of blood supply disruption as well as the bony injuries, whereas the type 2 and 3 injuries with preserved blood supply and being trapped closer to its insertion on the FTP, typically we have up to three weeks has been described, they still try to fix these a little bit sooner, but certainly it is possible to fix these later than we typically associate with flexor tendon injuries.
DAN OSEI: I'm not going to perseverate on this. One of the things that we talked about discussing is how do you actually do your tendon repairs? And one of the things that hasn't been talked about that much is tendon retrieval. And there are lots of described techniques. Certainly as a fellow in Saint Louis at Wash U, Richard Gilman was very fond of this technique of familias where you basically use an iced pediatric feeding tube and you feed it through the sheath with suture attached, and then you're able to drag the tendon through.
DAN OSEI: And that works both for zone 2 as well as zone 1 injuries. There are a lot of other techniques. Certainly we'll try to keep this talk free of commercial influence. There are certainly commercially available tendon retrieval tools as well as what was one of the more inventive techniques using a reverse Esmarch to essentially milk the tendon from proximal back distal. Now fortunately, with a lot of the FTP avulsion injuries that we're talking about here with zone 1 injuries, the possibility of flexor tendons all the way in the forearm is less than with zone 2.
DAN OSEI: But certainly knowing these techniques can be helpful regardless of the type of injury that you are facing in the operating room. So talking a little bit about repair techniques, this is certainly an area that things start to go away from what we were talking about with zone 2 injuries and there's a lot of information in our orthopedic literature. Now one of the biggest controversies relates to whether you use the historical pull out technique where typically a key needle or drill is taken through the FTP tendon after a repair has been done to the distal stump and it's brought through the sterile matrix and then tied over a suture button
DAN OSEI: and this is in comparison to suture button techniques, of which there are many. And when you look at the literature, it's actually a bit mixed. This study from Gil Ramin and Matt Silva, looking at some of the mechanical properties, demonstrated that the pull out suture technique was actually stronger with regard to ultimate tensile force required to disrupt the injury.
DAN OSEI: But in terms of displacement of the repair, it was actually the weakest, meaning that when you have 20 Newtons of force placed on the repair site, that is the displacement of the bone to tendon interval was greatest with the pull out suture technique as opposed to any of the suture anchor techniques. And so this was one of the studies that started to caution the use of suture means a lot.
DAN OSEI: When you look at other studies, one of the ones that I've certainly found useful is this one by Steve Lee when he was at NYU. And he looked at a variety of different techniques, and this was useful to me. He basically said that when you look at different configurations, a configuration using a pull out technique with suture anchors is actually the strongest with regards to holding displacement against cyclical loading as well as ultimate load to failure
DAN OSEI: and so certainly the combination is something that you should consider. In terms of what matters, I think a lot of what was been talked about, certainly by Dr. Lalonde's talk is the same. I think that although we've spent a lot of time and a lot of literature, a lot of words written down talking about suture size, suture caliber technique, doing a good solid repair is ultimately the most important thing. I do like super mid much like Dr. Seiler was talking about, I do like a looped suture giving us more strands across the repair site, but I don't think that it's as important as doing a good solid repair.
DAN OSEI: So whether you use the pullout technique, whether you use suture anchors or combination, whether you use a Kessler or modified Kessler style suture or a modified Becker, which is commonly used with the FTP insertion, I think making sure that you've prepared the distal phalanx appropriately, that the tensioning is appropriate and that your suture security is solid. Those are the things that are going to make for the best repair and cut down on complications.
DAN OSEI: One thing that is worth noting again for the residents and Fellows is that the manner in which you place an anchor, if you were going to use one, matters greatly. So this paper looked at a couple of different configurations, whether the suture anchor is placed antegrade, meaning going from more proximal to distal in direction, perpendicular to the distal phalanx or going retrograde. And what they found is that both with regard to displacement, to cyclical loading, as well as ultimate load to failure, the retrograde typically at a 45 degree angle is the best
DAN OSEI: and most optimal suture anchor placement configuration. So certainly if you're going to use the anchor, make sure that you do it in this manner. In terms of A4 management, I won't belabor this. I do think it's particularly important at the distal FTP insertion site, particularly as you're trying to go about 1 centimeter back in terms of your repair. Many people, as we've talked about, are very comfortable venting the entire pulley.
DAN OSEI: It's been talked about at meetings. It's been talked about in this conference. I think at this point, as long as you're preserving the pulleys proximally to Dr. Lalonde's pulley, not venting more than 1 and 1/2 to 2 centimeters it's perfectly acceptable to vent the entire a-4 pulley with FTP distal FTP repair. In terms of stunt management, something that Dr. Leversedge thought that we should talk about.
DAN OSEI: I think this is a common dilemma. Oftentimes you'll see that it isn't a clean avulsion of the entire FTP tendon from the distal phalanx and so you have to decide what to do. For call that if you have enough tendon and you resect it all the way down to the base of the distal phalanx, you may end up with quadriga, which is almost impossible to rehab your way out of
DAN OSEI: so you have to be careful. I called this level 6 evidence. This is just sort of my gestalt and how I manage this. If I have enough tendons, so 7 to 10 millimeters to do a good repair and again, I typically use a Becker style repair. I do use tendon to tendon repair even with these zone 1 injuries. If less than 4 to 5 millimeters more of a true avulsion, I would do direct tendon to bone repair.
DAN OSEI: There are times that there's enough tendon that I think I can almost do a hybrid where I'll do my repair directly to bone whether I use the pull out or anchor, and then I'll repair some of the stump on top of the repair to augment and perhaps strengthen the repair. Make sure that you vent your a-4 pulley if you do this, because it's certainly going to add to the bulk of the repair and to the point made by both Dr. Seiler and Dr. Lalonde, you're going to have difficulty having FTP excursion across the DIP if you don't vent when you do this technique.
DAN OSEI: In terms of complications, there are many and this is one of the things that I think it's important to know and be aware of. There can be some horrible complications with FTP repair at the distal phalanx. This paper highlighted many. I mean, you can get horrible osteomyelitis, CRPS. I think that this report was probably a little too cautionary with 15 complications reported after 23 repairs over about a 10 year period.
DAN OSEI: But certainly technique matters, making sure that sterility is kept throughout the environment, despite the fact that blood supply distally is quite good and usually will lead to a lack of infection but certainly lots can happen, be careful with your technique. So in terms of my approach, I still, despite some of the evidence against the pull out suture, have really liked it.
DAN OSEI: I will at times augment with a suture anchor. I usually don't use two suture anchors when I do the pull out technique and so I'll do similar to Steve Lee's, a hybrid one anchor, and then the pull out suture through the sterile matrix over a button. I find that to be a reliable technique. I generally have not been as good as some in terms of doing wide awake surgery, although I have with increased frequency over the last couple of years used that technique for all the reasons highlighted in this conference.
DAN OSEI: And certainly if you're not going to do it, I will say that I'll do some tenodesis to get a sense of the excursion. Again, the point I made about Quadriga and making sure that you've tensioned your repair, particularly distally, is quite important and so this is your chance to make sure that you get it right. I think that if you can't do a little bit of tenodesis on the operating room table without having gapping, to Dr. Lalonde's point, you probably have to do a stronger repair and it's probably worth doing it again.
DAN OSEI: So that's typically my approach for that. So with that, I know we're running over. I'll turn it back to Fraser and if there is any time left, we can answer any questions.
FRASER LEVERSEDGE: And we'll play this case here and so, this is a patient comes in two months after zone 2 flexor tendon repairs and for our faculty, I'm curious as to your sense of timing and your sense of strategy.
FRASER LEVERSEDGE: So the patient's able to flex a digit, but only to roughly about a DPC of 2 centimeters , 3 centimeters. There's full passive flexion and there's an intact active FTP function with distal P2 blocking. Passive extension is to approximately 20 degrees at the PIP joint. Dan, Don and John, a quick 1 minute just to explain your strategy for obviously possible tenolysis and what is your sense of timing for this type of a patient who's two months from surgery?
FRASER LEVERSEDGE: John Seiler, do you want to take a go at this?
JOHN SEILER: Sure. You know, for me, at two months, I would still be optimistic he would gain some additional improvement in therapy. So I would keep working with therapy. I would probably increase the frequency of his therapy, make sure he's on a good anti-inflammatory medicine and follow him closely and try and keep him moving forward with his rehab.
JOHN SEILER: For me, the window for tenolysis usually starts between four and six months. And then at that point, if he had full passive, limited, active motion, which is the scenario that looks to be developing here, you know, at that point, he may be up to around 90% of his total active motion so I would go ahead and offer him a tenolysis at that point but that would be my approach in this early, early phase.
FRASER LEVERSEDGE: Don Lalonde, any thoughts?
DON LALONDE: Yeah, I think that two months is too early for tenolysis and I think one of the, I'm in with John that I don't like to do them before six months. And even then I think that's often too early. And I think a relative motion flexion splint here might improve your DIP, your PIP extension sorry, I don't know what his MP hyperextension looks like, but certainly that can be a helpful strategy here.
DON LALONDE: I think if I'm going to do a tinolysis, I want the skin and subcutaneous fat to be soft if that when I palpate it and move it around because that's a reflection of what the peri tendonis adhesions are like. Like if you go in and the skin is hard as rock and stuck to everything, everything inside is going to be concrete so you've got to wait for that to soften up before you're going to have a shot at that.
DON LALONDE: And in my experience and view, if you don't want to have decent passive movement, you're not going to win with tenolysis. And so I think you're going to go from a stiff finger to a stiff finger if you do tenolysis in this person at two months.
FRASER LEVERSEDGE: Great. Dan?
DAN OSEI: All great thoughts and I think I share a lot of similar sentiments about this.
DAN OSEI: I generally don't do tenolysis earlier than four months. I've actually had a patient rupture following tenolysis at six months, so I think the longer I go, the more I wait. There's a few things here. It's funny, I was just talking to my fellow about this kind of situation with stiffness, so full passive flexion. So, you know, there's nothing going on the extensor side tethering you,
DAN OSEI: so there's some issue with the flexor and yes, with FDS/FDP, you're worried about the lack of differential glide. I'd also worry potentially, depending on how you did the repair, that perhaps there is some pulley insufficiency here that's playing a role. And so some of the time I may, although two months would be too early, consider getting ultrasound again to Don's point, making sure that I have a good understanding of the issue, whether it's true adhesions between FDS and FTP, or whether there's a mechanical issue with some bone stream that's leading to the increased DPC, or whether perhaps there's even some gapping going on, which could be a sentinel warning that the patient hasn't been able to make a full composite fist.
DAN OSEI: And with increasing efforts, which oftentimes happens with therapy, you're on your way to a rupture. So those would be some of the things that I'd want to rule out. But in general, probably adhesions and I would wait as long as possible. I do like a relative motion splint to Don's point with this patient population as well, and I found that to be helpful.
FRASER LEVERSEDGE: Those are always those are all great points. And I too believe that two months is too soon. I think just the biology of your repair if you are relying on some extrinsic peritoneum, tenderness, adhesion formation can actually help with your vascular supply to your tendon, you do run the risk of a rupture if you're aggressively tenolysing the digit too early. I think one of the nice guides here, if you look at this picture, it's one of the signs that we learn in medical school of rubor and sort of as you flex the finger here, you just see this sign.
FRASER LEVERSEDGE: You have to have, you have to give it an extra little bit of push to Don Lalonde's point, that the skin is still hard here, you get that relative redness or rubor along the digit as you try to squeeze it down into flexion. And it just suggests that the wound is not mature. I think that the keys to the tenolysis have been discussed. I think when you stop making progress, I like to tell our patients that progress is our good measure as to when to decide to embark on a tenolysis for me again, it's probably somewhere closer to four to six months erring closer to five or six months.
FRASER LEVERSEDGE: And this is just being prepared and lenolysis knives are certainly nice tools to have in your toolbox. They're more meals designed but that you can cut the pulleys as you do this. So you have to be somewhat familiar with them. And at the same time, you want to restore this freely sort of sliding pulley beneath your pulleys that you want to preserve along the way where you can to prevent tendon bolstering.
FRASER LEVERSEDGE: So I know we're a little short on time and I just wanted to sort of sum up here, we've had some wonderful talks by our faculty and thank you to Dr. Seiler, Leland and Osei for their wisdom. These are challenging subjects and is as somebody who did some repairs and fellowship with lots of canine repairs, it was always amazing to me that no matter how well staged and standardized your repair, you still ended up with ruptures
FRASER LEVERSEDGE: and I think our goals of trying to advance our technical abilities, whether it's by the numbers of sutures we put in to the way that we vent our pulleys to making sure that we've got a good sliding pulley at the time of our repair without gapping is really critical. And I think Don's introduction to many of us for WALANT been very helpful. So for this particular unique zone, recognize the pertinent anatomy, really respect the biology of the repair
FRASER LEVERSEDGE: and every time you grasp your gliding surface of the tendon, if you remember Dr. Osei's pictures from the vascular studies, think of each time you're grasping the tendon is disrupting those small peritoneum related vessels and then consider associated injuries in terms of your post repair rehabilitation protocol. That's really critical to individualize treatment and communicate this with your therapists and that's really, really the key.
FRASER LEVERSEDGE: You don't want to send somebody out with a two strand repair that follows a cookbook repair for early active motion because they're going to end up with a rupture. And don't burn bridges, don't start your tendon reconstruction with an immature wound or something that you're going to have to come back to and ultimately may cause you to fail your reconstruction. So thanks to the staff and the faculty, Thanks to Warren and to Jerry for a fantastic series and thanks for your attention tonight.
FRASER LEVERSEDGE: And I hope everyone has a good night.
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