Chapter 30 Outcomes of the Modified Paneva-Holevich Procedures and Early Postoperative Mobilization

Nash H. Naam, MD, FACS, Lori Niemerg, OTR/L, CHT

Outline

Patients with severe flexor tendon injuries associated with scarred digital tendon sheath may require tendon grafting. Single-stage flexor tendon reconstruction may be unfeasible because of the scarred tendon bed; therefore, staged flexor tendon reconstruction is recommended. The Paneva-Holevich technique uses the pedicled flexor digitorum superficialis (FDS) as the donor graft thereby avoiding harvesting a free tendon graft. The modified technique incorporates the use of a Silastic rod in the first stage to promote the formation of a new tendon sheath and the use of a pedicled FDS as the tendon graft in the second stage. This technique combines the benefits of the Hunter rod and the use of a pedicled intrasynovial tendon, which may create less adhesion than extrasynovial tendons. This modified technique is ideal for the implementation of an early active range of motion (AROM) program since the proximal repair is already healed by the time the second stage is performed, but the distal graft repair to the bony distal phalanx should be strong enough to withstand the stresses of the AROM program. The incorporation of an early AROM program with this technique provides a significant advantage in improving the ultimate outcome of the procedure.

Flexor tendon reconstruction in the presence of a damaged flexor tendon sheath with destruction of majority of pulley system or serious scar formation is very challenging to the hand surgeon. The fibrotic tendon gliding bed does not allow smooth excursion of the tendon graft, which results in significant adhesions and limited range of motion. In these circumstances single-stage flexor tendon reconstruction would not be appropriate and staged tendon reconstruction should be considered.

In 1965, Paneva-Holevich suggested the use of pedicled flexor digitorum superficialis (FDS) tendon as a graft by creating a loop of the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) then reflecting the latter in the second stage as a pedicled tendon graft.^1,² In 1971, Hunter and Salisbury introduced the concept of using a silicone-Dacron reinforced tendon rod to stimulate formation of a new tendon sheath before tendon grafting.³ This transforms the scarred tendon bed into a gliding pliable functional system. In 1972, Kessler reported on the combined use of Hunter rod and pedicled FDS for staged flexor tendon reconstruction.⁴ Since then, several reports of the combined method have been published.⁵^–⁹

We started performing this procedure in 1983. In 1997, we published our experience with the use of this technique in 33 patients.⁸ Up to 2009, we applied this technique in 116 patients. Candidates for this type of tendon reconstruction included patients who did not have their flexor tendon repaired or those who had their repairs failed secondary to rupture or adhesions (Figure 30-1). Most of these procedures are performed in patients with zone 2 flexor tendon injuries. However, zone 1 injuries are also amenable to this type of reconstruction. Zone 3 and 4 injures can usually be treated with conventional single-stage interposition tendon grafts unless there is a concomitant damage to the flexor tendon sheath in zone 2. This procedure is particularly useful in tendon injuries associated with severe crushing injuries when there are associated fractures, nerve injuries, and skin defects.^5,^7,⁸

Figure 30-1 Loss of active flexion of the index finger after an old injury of both flexor tendons.

This technique has become our standard technique for flexor tendon reconstruction when the tendon bed does not allow one-stage flexor tendon grafting. A distinct advantage of this procedure is to allow earlier active range of motion (AROM), since the proximal repair should be completely healed by the time the second stage is performed if a tendon graft, instead of tendon transfer, is used. A strong distal repair, preferably attaching the tendon to the bony distal phalanx, would allow the graft to withstand the forces of early AROM without fears of rupture. Actually, Paneva-Holevich recommended starting active motion of the involved digit in the first postoperative week and reported no increase in the incidence of rupture in her early report of secondary reconstruction of the FDP tendon by FDS transfer from the same finger.⁷

Surgical Technique

Stage 1

Through a Bruner zigzag incision, the flexor tendon sheath is exposed. The remnants of the flexor tendons are excised (Figures 30-2 to 30-4). Special care should be taken to preserve all the normal pulleys as much as possible. If the important pulleys or majority of the flexor pulley system are destroyed, pulley reconstruction should be performed at this stage utilizing pieces of the excised flexor tendons. Any nerve grafting or flexion contracture release can be done at this stage. The largest possible Hunter rod is then inserted. The Hunter rod should not touch the gloves as this may produce inflammatory reaction secondary to the contact with the talc powder. The distal end of the rod is sutured to the distal stump of the FDP with horizontal mattress sutures of 4-0 Prolene or 4-0 fiberwire. It is important to be sure that the sutures include the Dacron tape within the Hunter rod since the silicone alone has very little holding power. The proximal stump of the rod is left free in the palm. The FDS and FDP tendons of the injured finger are exposed at the mid palm level. Their ends are freshened to healthy margins and then sutured to each other with an end-to-end method (Figures 30-5 and 30-6).