4 Flexor Tendon Repair (Zone 2)



10.1055/b-0040-177419

4 Flexor Tendon Repair (Zone 2)

David W. Lee, Stephen Ros, and Christopher Doumas


Abstract


Zone 2 flexor tendon lacerations are notoriously difficult injuries to manage and have historically led to poor outcomes after attempted repair. Even with excellent tendon repair, complications such as adhesion formation, rupture, and stiffness remain possible. Thus, a thorough understanding of surgical anatomy and technique is required. The goal of repair is accurate coaptation of the tendon ends with sufficient strength to allow early postoperative rehabilitation; a strong and smooth surgical repair will also reduce the likelihood of adhesion formation. Because of the importance of postoperative therapy, patient selection, compliance, and education must not be overlooked.




4.1 Description


Zone 2 flexor tendon injuries occur between the A1 pulley proximally and the flexor digitorum superficialis insertion distally (► Fig. 4.1). In this region, the flexor digitorum superficialis and profundus tendons lie within a tight fibro-osseous sheath with a series of pulleys that prevent bowstringing (► Fig. 4.2). Within this sheath, the two tendons are covered by fibrous epitenon. Together, the fibro-osseous sheath and epitenon play a critical role in the smooth gliding of the tendon. The superficialis is split by the profundus and its two slips turn sideways and insert on the middle phalanx in an upside-down manner.

Fig. 4.1 Diagram of flexor tendon zones within the hand and wrist. (Data from Kleinert HE, Schepel S, Gill T. Flexor tendon injuries. Surg Clin North Am 1981; 61:267–286.)
Fig. 4.2 Flexor tendon sheath of a finger (Lateral aspect). (1) Palmar ligament (volar plate). (2) Deep transverse metacarpal ligament (resection site). (3) Tendon of the flexor digitorum superficialis. (4) Tendon of the flexor digitorum profundus. (5) Radial collateral ligament. (6) Accessory radial collateral ligament. (7) Phalangoglenoidal ligament. (8) Check rein ligament. [A1-A5] Annular parts of flexor tendon sheath [A1-A5 pulleys]. (C1) Cruciform part of flexor tendon sheath [C1 pulley]. (Reproduced with permission from Pechlaner S, Hussl, H, Kerschbaumer. F, 1st eds. Atlas of Hand Surgery. New York, NY: Thieme; 2000.)

Zone 2 was historically named “no man’s land” because injuries here invariably led to adhesion formation and poor outcomes. However, in the 1960s, Kleinert and others first reported good outcomes after primary repair, stressing the importance of meticulous atraumatic surgical technique and early postoperative rehabilitation. 1 Subsequent advancements in suture technique, design, and postoperative therapy have drastically improved outcomes. 2 , 3 , 4 , 5


As described by Strickland, core sutures should have the following characteristics: easy placement, secured knots, smooth juncture at tendon ends, minimal gapping, minimal interference with vascularity, and sufficient strength to permit early motion. 6 Although there are many core suture techniques, it is known that multiple suture strands (> 4) provide superior load to gapping and failure. 7 Classic suture techniques such as the Kirchmayr and modified Kessler are still common; however, newer techniques such as the Strickland, Cruciate, Becker, and Winters-Gelberman are becoming more common due to increased repair site strength 7 (► Fig. 4.3). A peripheral epitendinous suture is recommended to increase repair site strength and reduce gapping. 8

Fig. 4.3 Common suture techniques. (a) Cruciate. (b) Strickland. (c) Winters-Gelberman. (Reproduced with permission from Germann G, Levin LS, Sherman R, eds. Reconstructive Surgery of the Hand and Upper Extremity. © Thieme; 2018.)

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Aug 26, 2020 | Posted by in Hand surgery | Comments Off on 4 Flexor Tendon Repair (Zone 2)

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