Flexor tendon

Flexor tendon repair HuynhThi Linh Thu, MD Hospital for Traumatology & Orthopaedics Upper Limb Surgery Department Anatomy zones of flexor tendon injury      Zone I: only FDP tendon (insertion of the FDP → insertion of the FDS tendon) Zone II ("no man's land”): insertion of the FDS tendon → proximal end of A1 pulley) Zone III: the zone of lumbrical origin Zone IV: the carpal tunnel Zone V: proximal to the carpal tunnel in the forearm Tendon nutrition  Avascular zones    FDS (over proximal phalanx FDP (over middle phalanx) Nutrition vital for rapid healing, minimization of adhesion and restoration of gliding Tendon nutrition sources: intrinsic and extrinsic  Intrinsic nutrition through vascular perfusion of the tendon     Longitudinal vessels that enter the palm and extend down the intertendinous channels Vessels entering at the level of the proximal synovial fold in the palm Vincula (2 short and long) harboring segmental branches from the digital arteries Osseous insertions Tendon nutrition   Extrinsic nutrition is provided by synovial fluid, pumped into the tendon fibers during flexion and extension of the fingers Vascular supply mainly on the dorsal of the tendons Anatomy Preop: cascade of fingers lost Postop: cascade of fingers restored Flexor tendon repair Flexor tendon repair tendon healing mechanism  Intrinsic: proliferation of epitenon endotenon tenocytes  Intrinsic healing results in better biomechanics and fewer complication tendon healing   Extrinsic healing, scar tissue results in adhesion Disruption of synovial sheath (injury/surgery) allows granulation tissue and tenocytes from surrounding tissue to invade the repair site Flexor Tendon Repair Rehabilitation  6-week Program:   weeks: active extension & passive flexion Flexor Tendon Repair Rehabilitation  6-week Program:  Since 4th week: Rubber band cut  Place-hold exercise  Flexor Tendon Repair Rehabilitation  7weeks :    Weeks    Discontinue DBS Exercise-Light Activities of Daily Living Digit-Tendon Blocking Exercises Mild Resistive Activities 12 Weeks  Heavy Resistance/Return to Work Activities Results Case  P.V.Anh-Female-16yrs student Knife cut  Finger II (Zone I)  3-month postop Results Case    NVChinh-1982-1725CT/08 Cushing injury Finger II: open fx of phalanx 2+ flexor tendon cut (I-II) 3-month postop Results Case    T.V.Song-male-22 yrs old-worker-456CT/08 Knife cut Finger IV (Zone II) 2-month postop Results Case   P.X.Thuy-male-23 yrs old-worker-899CT/08 Finger II: metacarpal fractured+ flexor tendon cut (Zone II-III ) 3-month postop Results Case    N.X.Hung-18 yrs old-2756CT/08 Stabbing Lesions:   Fracture of metacarpal Flexor tendons I→V + Median nerve (Zone IV) 3-month postop 4- month postop Results Case    NHVu-male- 23 yrs old- worker5032T/08 Work accident Lesions:   Communited distal radius fracture Flexor tendons III, IV cut (zone V) 3-week postop Results Case   DCTrieu-male-23 yrs old-worker1243CT/08 Crush injury week postop 11-week postop Results   Old lesion Knife cut 4-week postop Tendon repair Complication: adhesions at the repair site Suture (even inert material)  Sheath resection  Immobilization  →The more factors the more serious adhesion Results A case of revision  Difficult operation  Tiring period of physical therapy  Partial functional recovery!!! Conclusion  Flexor tendon repair:  Strong suture  stable fixation (fracture) → early postoperative mobilization → good result  Education+supervision!!! Thank you ...Anatomy zones of flexor tendon injury      Zone I: only FDP tendon (insertion of the FDP → insertion of the FDS tendon) Zone II ("no man''s land”): insertion of the FDS tendon → proximal... Anatomy Preop: cascade of fingers lost Postop: cascade of fingers restored Flexor tendon repair Flexor tendon repair tendon healing mechanism  Intrinsic: proliferation of epitenon endotenon tenocytes... 6th week)   increasing strength of the tendon repair The collagen fibers reorientate→ parallel with the noninjured tendon fibers Postop splint Flexor Tendon Repair Rehabilitation (Passive flexion