520277 research-article2014
JHS0010.1177/1753193413520277The Journal of Hand SurgeryCavadas et al.
JHS(E)
Full length article
Single-stage reconstruction of flexor tendons with vascularized tendon transfers
The Journal of Hand Surgery (European Volume) 2015, Vol. 40E(3) 259–268 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193413520277 jhs.sagepub.com
P. C. Cavadas, A. Pérez-García, A. Thione and C. Lorca-García Abstract The reconstruction of finger flexor tendons with vascularized flexor digitorum superficialis (FDS) tendon grafts (flaps) based on the ulnar vessels as a single stage is not a popular technique. We reviewed 40 flexor tendon reconstructions (four flexor pollicis longus and 36 finger flexors) with vascularized FDS tendon grafts in 38 consecutive patients. The donor tendons were transferred based on the ulnar vessels as a single-stage procedure (37 pedicled flaps, three free flaps). Four patients required composite tendon and skin island transfer. Minimum follow-up was 12 months, and functional results were evaluated using a total active range of motion score. Multiple linear regression analysis was performed to evaluate the factors that could be associated with the postoperative total active range of motion. The average postoperative total active range of motion (excluding the thumbs) was 178.05° (SD 50°). The total active range of motion was significantly lower for patients who were reconstructed with free flaps and for those who required composite tendon and skin island flap. Age, right or left hand, donor/motor tendon and pulley reconstruction had no linear effect on total active range of motion. Overall results were comparable with a published series on staged tendon grafting but with a lower complication rate. Vascularized pedicled tendon grafts/flaps are useful in the reconstruction of defects of finger flexor tendons in a single stage, although its role in the reconstructive armamentarium remains to be clearly established. Keywords Tendon injuries, tendon transfer, surgical flaps Date received: 4th August 2013; revised: 15th September 2013; accepted: 29th November 2013
Introduction Secondary reconstruction of the flexor tendon defects of the digits is a demanding procedure for the surgeon, therapist and patients as well. Despite often protracted and complex treatments, suboptimal functional results are not uncommon. Although single-stage tendon grafts may have some indications, staged reconstruction using a silicone spacer is the preferred technique in most cases (Strickland, 2005). Gliding of the tendons relative to the surrounding tissues is the sine-qua-non for finger flexion. Functional arcs of motion after tendon surgery depend on the paradox of inducing a dense, strong scar at the repair sites, while inhibiting the formation of this same dense scar tissue around the tendon. Immediate postoperative mobilization, through different protocols, is the most (if not the only) effective way of inhibiting dense scar and adhesion formation around the tendon. Attempts at avoiding tendon adhesions through chemical or physical means have
resulted in some success, although its use has not been widespread (Zhao et al., 2009; Riccio et al., 2010). Free gliding of the tendons within the digital canal depends on lubrication and relative lack of physical connections between the tendon and its sheath, whereas at the carpal tunnel and palm levels it depends on specialized lax connective tissue whose nomenclature varies in the literature. According to Guimberteau et al. (1993) the tendon and its surrounding lax connective tissue can be transferred as a composite vascularized gliding unit, based on branches of the ulnar vessels, for finger flexor single-stage reconstruction. Reconstructive Surgery, Hospital de Manises, Valencia, Spain Corresponding author: A. Pérez-García, Reconstructive Surgery, Clinica Cavadas, Hospital de Manises, Paseo Facultades 1, 46021 Valencia, Spain. Email: [email protected]
Downloaded from jhs.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 10, 2015
260
The Journal of Hand Surgery (Eur) 40(3)
The technical complexity and the sacrifice of the distal ulnar artery has prevented wide acceptance of the technique. There has not been any reported series on this technique from other groups, to the best of our knowledge. The aim of the present article is to report on the experience of the authors in a series of reconstructions of chronic flexor tendon defects, with singlestage pedicled vascularized tendon grafts/flaps, with a minimum follow-up of 12 months, in order to assess its efficacy and reproducibility.
Patients and methods A total of 40 finger flexor tendons were reconstructed in 38 consecutive patients between 2002 and 2011 (Table 1). There were 37 males and one female, with ages between 18 and 65 years (mean 39 years). Two cases were secondary to bacterial tenosynovitis. The rest of the injuries were of traumatic origin. The technique used was similar to that described by Guimberteau et al. (1993), and is described here briefly with minor modifications.
Surgical technique After an Allen’s test showing a patent palmar arch, the distal third of the forearm, the wrist and the involved digit were incised in a zig-zag fashion. The remnants of the flexor tendons and the non-usable pulleys within the digit were excised down to the periosteal plane. A pedicled flap usually containing the ring finger FDS tendon (middle finger FDS as second choice) and the common carpal synovial sheath, in continuity with the gliding tissue around the tendon in the palm, was elevated based on branches off the ulnar vessels. The branch described by Guimberteau et al. (1993) immediately proximal to the flexor carpal retinaculum, or another constant more proximal branch was used. When present, the median artery can also be used. The vascularized gliding tissue around the tendon was carefully preserved (Figures 1 and 2). The tendons were harvested from distal forearm to the A1 pulley. The ulnar vessels were divided proximal to the selected branch and the distally based flap was transposed. When the flexor pollicis longus (FPL) was reconstructed, the vascularized ring FDS can be transposed after mobilization of the ulnar vessels without dividing them. The FDS tendon was anchored to the distal phalanx distally with a trans-osseus pullout suture and to a suitable motor at the carpal tunnel level using Pulvertaft weaving and moderate hyperflexion of the digit. The missing A2 and/or A4 pulleys were reconstructed with local tendon grafts around the proximal and/or middle
phallanges. When the native A2 pulley was intact, the tendon and vascularized paratenon fit well inside. Occasionally the native A4 pulley required minimal venting to accommodate the tendon-paratenon complex. In the cases when the tendon was transferred as a free flap, a segment of the ulnar artery was taken with the flap and interposed in the palmar arch, and the ulnar artery was re-anastomosed (Cavadas and Mir, 2006) All patients received oral vitamin A at a dose of 50.000 U/12 h for two months, based on its ability to increase the tensile strength of repaired tendons in experimental models (Greenwald et al., 1991), and the author’s unpublished clinical experience with shorter healing times. Passive range of motion exercises were performed for 2 weeks starting on postoperative day (POD) 1, with the wrist in neutral and metacarpophalangeal joint in 80° flexion. No dynamic splints or place-and-hold exercises were performed. From POD 15 active finger flexion exercises were progressively performed, with a dorsal wrist splint in neutral. Unrestricted use of the hand was allowed after 2 months. Our Institutional review board approved this study and informed consent was obtained from each patient.
Assessment Evaluation of the functional results was performed using the total active range of motion (TAM) score of the American Society for Surgery of the Hand for the digits (Kleinert and Verdan, 1983), and the AROM of the IP joint in FPL reconstructions, as a percentage of the 75° normal active range of motion (AROM) of the IP joint (Unglaub et al., 2006). Descriptive results are presented as mean values and percentages. Multiple linear regression analysis was performed to evaluate the factors that could be associated with the postoperative TAM (which was the dependant variable). Six independent variables were selected: age of the patient, involvement of left or right hand, pulleys reconstruction, association with soft tissue reconstruction, reconstruction with pedicled or free flap and motor tendon flexor digitorum profundus (FDP/FDS). Gender was not analysed because there was only one woman in the study. Reconstructed FPL tendons were excluded from the analysis.
Results Forty digits in 38 patients underwent reconstruction with vascularized tendon transfer. There were 37 males and one female. There were 27 left-hand injuries and 11 right-hand injuries. The most frequently
Downloaded from jhs.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 10, 2015
Gender, age
M 27
M 24
M 37
M 49
M 29
M 37
M 31
M 26
M 28
M 37
M 47
M 30
M 24
M 27
Case
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10
Case 11
Case 12
Case 13
Case 14
7 years 9 months 7 years 5 months 7 years 5 months 7 years 2 months
8 years
9 years 4 months 9 years 1 months 9 years 1 months 8 years 11 months 8 years 2 months 8 years 1 months 8 years 1 months 8 years
9 years 5 months
Follow-up
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Flexor tendon and skin defect 5th left. Previous regional flap
Chronic avulsion FDP 4th finger left
FPL defect left
Flexor tendon defect 3rd right
Ruptured repair of FPL left
Flexor tendon defect 2nd left
Multidigital injury. Flexor tendon defect 5th finger left Multidigital zone II replant Flexor tendon defect 4th finger right Flexor tendon defect 2nd right
Ruptured repair flexors 5th finger left. Skin necrosis Chronic composite defect flexor tendons and skin 3rd finger left Neglected avulsion FDP 5th finger left Tendon rupture after suppurative synovitis 2nd finger right Flexor tendon defect 4th finger right
Injury
Tendon and skin. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Free. Ulnar artery Tendon. Free. Ulnar artery Tendon. Free Ulnar artery Tendon and skin. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon and skin. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery
Tendon and skin. Pedicled. Ulnar artery
Tissue transferred. Remarks
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th. Contralateral FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
Donor tendon
Table 1. Summary table of a total of 40 finger flexor tendons reconstructed in 38 patients between 2002 and 2011.
FDP 5th
FDP 4th
FPL
FDS 3rd
FPL
FDS 2nd
FDS 2nd
FDS 4th
FDP 5th
FDP 4th
FDS 2nd
FDP 5th
FDP 3rd
FDP 5th
Motor tendon
A2, A4
A2, A4
Oblique
A4
Oblique
A2
A2, A4
A2, A4
A2
A2, A4
None
A4
A2, A4
A4
Reconstructed pulleys
(Continued)
130° Fair 220° Good 100° Poor 145° Fair 110° Poor 65° Poor 90° Poor 205° Good 30° Active IP motion 190° Good 30° Active IP motion 260° Excellent 130° Fair
170° Fair
TAM
Cavadas et al. 261
M 18
M 56
M 65
M 55
M 37
M 25
M 53
F 39
M 34
M 48
Case 18
Case 19
Case 20
Case 21
Case 22
Case 23
Case 24
Case 25
Case 26
Case 27
M 54
Case 16
M 45
M 30
Case 15
Case 17
Gender, age
Case
Table 1. (Continued)
4 years 7 months 4 years 6 months 4 years 4 months 4 years 2 months 3 years 9 months
4 years 11 months 4 years 9 months 4 years 8 months
6 years 8 months 6 years 8 months 6 years 2 months 5 years 4 months 5 years 1 months
Follow-up
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Defect flexors 2nd finger right
Defect flexors 2nd finger right
Defect FPL left
Flexor tendons defect 5th finger right Flexor tendons defect 5th finger left
Flexor tendon defect 3rd finger left. replanted
Rupture flexors 4th finger left
Rupture flexors 4th finger left
Rupture FPL and Flexors of the 2nd finger left
Chronic avulsion FDP 4th left
Flexor defect right 3rd finger after suppurative synovitis Flexor tendon defect 5th finger left
Chronic avulsion FDP 4th left
Injury
Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery
Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery
Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Median artery Tendon. Pedicled. Ulnar artery Tendons. Pedicled. Ulnar artery
Tissue transferred. Remarks
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 5th
FDS 3rd
FDS 3rd
FDS 2nd and 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
Donor tendon
FDS 2nd
FDP 2nd
FPL
FDP 5th
FDP 5th
FDS 3rd
FDS 4th
FDS 4th
FDP 2nd, FPL
FDP 4th
FDP 5th
FDS 3rd
FDP 4th
Motor tendon
A2
A2, A4
Oblique
A2
A4
A2
A2
A2
A4, oblique
None
A4
None
A4
Reconstructed pulleys
220° Good 195° Good 100° Poor 220° Good 40° active thumb IP motion 150° (Fair) 145° Fair 150° Fair 170° Fair. Superficialis finger 270° Excellent 230° Good 45° active IP motion 200° Good 170° Fair
TAM
262 The Journal of Hand Surgery (Eur) 40(3)
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M 60
M 32
M 43
M 33
M 25
M 59
M 41
M 54
M 35
M 52
M 31
Case 28
Case 29
Case 30
Case 31
Case 32
Case 33
Case 34
Case 35
Case 36
Case 37
Case 38
2 years 11 months 2 years 10 months 2 years 7 months 2 years 6 months 2 years 5 months 2 years 4 months 1 years 8 months 1 years 5 months 1 years
3 years
3 years 6 months
Follow-up
Defect flexors 2nd finger right
Rupture flexors 4th finger left
Defect flexors 2nd finger left
Rupture flexors 2nd finger left
Defect flexors 5th finger left
Defect flexors 2nd left
Defect flexors 2nd left
Defect flexors 4th finger right
Rupture flexors 3rd finger left
Rupture flexors 5th left
Defect flexors 2nd and 3rd fingers left
Injury
Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery
Tendon. Pedicled. median artery.
Tissue transferred. Remarks
FDS 4th
FDS 3rd
FDS 4th
FDS 5th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 2nd and 3rd
Donor tendon
FDS 2nd
FDS 4th
FDP 2nd
FDS 2nd
FDP 5th
FDS 2nd
FDS 2nd
FDP 4th
FDS 3rd
FDP 5th
FDP 2nd and 3rd
Motor tendon
A2, A4
A2, A4
A2, A4
A2, A4
A2
A2, A4
A2, A4
A2, A4
A2
A4
A2 2nd and 3rd
Reconstructed pulleys
FDP: flexor digitorum profundus; FDS: flexor digitorum superficialis; FPL: flexor pollicis longus; IP: interphalangeal; TAM: total active range of motion. TAM
JHS0010.1177/1753193413520277The Journal of Hand SurgeryCavadas et al.
JHS(E)
Full length article
Single-stage reconstruction of flexor tendons with vascularized tendon transfers
The Journal of Hand Surgery (European Volume) 2015, Vol. 40E(3) 259–268 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1753193413520277 jhs.sagepub.com
P. C. Cavadas, A. Pérez-García, A. Thione and C. Lorca-García Abstract The reconstruction of finger flexor tendons with vascularized flexor digitorum superficialis (FDS) tendon grafts (flaps) based on the ulnar vessels as a single stage is not a popular technique. We reviewed 40 flexor tendon reconstructions (four flexor pollicis longus and 36 finger flexors) with vascularized FDS tendon grafts in 38 consecutive patients. The donor tendons were transferred based on the ulnar vessels as a single-stage procedure (37 pedicled flaps, three free flaps). Four patients required composite tendon and skin island transfer. Minimum follow-up was 12 months, and functional results were evaluated using a total active range of motion score. Multiple linear regression analysis was performed to evaluate the factors that could be associated with the postoperative total active range of motion. The average postoperative total active range of motion (excluding the thumbs) was 178.05° (SD 50°). The total active range of motion was significantly lower for patients who were reconstructed with free flaps and for those who required composite tendon and skin island flap. Age, right or left hand, donor/motor tendon and pulley reconstruction had no linear effect on total active range of motion. Overall results were comparable with a published series on staged tendon grafting but with a lower complication rate. Vascularized pedicled tendon grafts/flaps are useful in the reconstruction of defects of finger flexor tendons in a single stage, although its role in the reconstructive armamentarium remains to be clearly established. Keywords Tendon injuries, tendon transfer, surgical flaps Date received: 4th August 2013; revised: 15th September 2013; accepted: 29th November 2013
Introduction Secondary reconstruction of the flexor tendon defects of the digits is a demanding procedure for the surgeon, therapist and patients as well. Despite often protracted and complex treatments, suboptimal functional results are not uncommon. Although single-stage tendon grafts may have some indications, staged reconstruction using a silicone spacer is the preferred technique in most cases (Strickland, 2005). Gliding of the tendons relative to the surrounding tissues is the sine-qua-non for finger flexion. Functional arcs of motion after tendon surgery depend on the paradox of inducing a dense, strong scar at the repair sites, while inhibiting the formation of this same dense scar tissue around the tendon. Immediate postoperative mobilization, through different protocols, is the most (if not the only) effective way of inhibiting dense scar and adhesion formation around the tendon. Attempts at avoiding tendon adhesions through chemical or physical means have
resulted in some success, although its use has not been widespread (Zhao et al., 2009; Riccio et al., 2010). Free gliding of the tendons within the digital canal depends on lubrication and relative lack of physical connections between the tendon and its sheath, whereas at the carpal tunnel and palm levels it depends on specialized lax connective tissue whose nomenclature varies in the literature. According to Guimberteau et al. (1993) the tendon and its surrounding lax connective tissue can be transferred as a composite vascularized gliding unit, based on branches of the ulnar vessels, for finger flexor single-stage reconstruction. Reconstructive Surgery, Hospital de Manises, Valencia, Spain Corresponding author: A. Pérez-García, Reconstructive Surgery, Clinica Cavadas, Hospital de Manises, Paseo Facultades 1, 46021 Valencia, Spain. Email: [email protected]
Downloaded from jhs.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 10, 2015
260
The Journal of Hand Surgery (Eur) 40(3)
The technical complexity and the sacrifice of the distal ulnar artery has prevented wide acceptance of the technique. There has not been any reported series on this technique from other groups, to the best of our knowledge. The aim of the present article is to report on the experience of the authors in a series of reconstructions of chronic flexor tendon defects, with singlestage pedicled vascularized tendon grafts/flaps, with a minimum follow-up of 12 months, in order to assess its efficacy and reproducibility.
Patients and methods A total of 40 finger flexor tendons were reconstructed in 38 consecutive patients between 2002 and 2011 (Table 1). There were 37 males and one female, with ages between 18 and 65 years (mean 39 years). Two cases were secondary to bacterial tenosynovitis. The rest of the injuries were of traumatic origin. The technique used was similar to that described by Guimberteau et al. (1993), and is described here briefly with minor modifications.
Surgical technique After an Allen’s test showing a patent palmar arch, the distal third of the forearm, the wrist and the involved digit were incised in a zig-zag fashion. The remnants of the flexor tendons and the non-usable pulleys within the digit were excised down to the periosteal plane. A pedicled flap usually containing the ring finger FDS tendon (middle finger FDS as second choice) and the common carpal synovial sheath, in continuity with the gliding tissue around the tendon in the palm, was elevated based on branches off the ulnar vessels. The branch described by Guimberteau et al. (1993) immediately proximal to the flexor carpal retinaculum, or another constant more proximal branch was used. When present, the median artery can also be used. The vascularized gliding tissue around the tendon was carefully preserved (Figures 1 and 2). The tendons were harvested from distal forearm to the A1 pulley. The ulnar vessels were divided proximal to the selected branch and the distally based flap was transposed. When the flexor pollicis longus (FPL) was reconstructed, the vascularized ring FDS can be transposed after mobilization of the ulnar vessels without dividing them. The FDS tendon was anchored to the distal phalanx distally with a trans-osseus pullout suture and to a suitable motor at the carpal tunnel level using Pulvertaft weaving and moderate hyperflexion of the digit. The missing A2 and/or A4 pulleys were reconstructed with local tendon grafts around the proximal and/or middle
phallanges. When the native A2 pulley was intact, the tendon and vascularized paratenon fit well inside. Occasionally the native A4 pulley required minimal venting to accommodate the tendon-paratenon complex. In the cases when the tendon was transferred as a free flap, a segment of the ulnar artery was taken with the flap and interposed in the palmar arch, and the ulnar artery was re-anastomosed (Cavadas and Mir, 2006) All patients received oral vitamin A at a dose of 50.000 U/12 h for two months, based on its ability to increase the tensile strength of repaired tendons in experimental models (Greenwald et al., 1991), and the author’s unpublished clinical experience with shorter healing times. Passive range of motion exercises were performed for 2 weeks starting on postoperative day (POD) 1, with the wrist in neutral and metacarpophalangeal joint in 80° flexion. No dynamic splints or place-and-hold exercises were performed. From POD 15 active finger flexion exercises were progressively performed, with a dorsal wrist splint in neutral. Unrestricted use of the hand was allowed after 2 months. Our Institutional review board approved this study and informed consent was obtained from each patient.
Assessment Evaluation of the functional results was performed using the total active range of motion (TAM) score of the American Society for Surgery of the Hand for the digits (Kleinert and Verdan, 1983), and the AROM of the IP joint in FPL reconstructions, as a percentage of the 75° normal active range of motion (AROM) of the IP joint (Unglaub et al., 2006). Descriptive results are presented as mean values and percentages. Multiple linear regression analysis was performed to evaluate the factors that could be associated with the postoperative TAM (which was the dependant variable). Six independent variables were selected: age of the patient, involvement of left or right hand, pulleys reconstruction, association with soft tissue reconstruction, reconstruction with pedicled or free flap and motor tendon flexor digitorum profundus (FDP/FDS). Gender was not analysed because there was only one woman in the study. Reconstructed FPL tendons were excluded from the analysis.
Results Forty digits in 38 patients underwent reconstruction with vascularized tendon transfer. There were 37 males and one female. There were 27 left-hand injuries and 11 right-hand injuries. The most frequently
Downloaded from jhs.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 10, 2015
Gender, age
M 27
M 24
M 37
M 49
M 29
M 37
M 31
M 26
M 28
M 37
M 47
M 30
M 24
M 27
Case
Case 1
Case 2
Case 3
Case 4
Case 5
Case 6
Case 7
Case 8
Case 9
Case 10
Case 11
Case 12
Case 13
Case 14
7 years 9 months 7 years 5 months 7 years 5 months 7 years 2 months
8 years
9 years 4 months 9 years 1 months 9 years 1 months 8 years 11 months 8 years 2 months 8 years 1 months 8 years 1 months 8 years
9 years 5 months
Follow-up
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Flexor tendon and skin defect 5th left. Previous regional flap
Chronic avulsion FDP 4th finger left
FPL defect left
Flexor tendon defect 3rd right
Ruptured repair of FPL left
Flexor tendon defect 2nd left
Multidigital injury. Flexor tendon defect 5th finger left Multidigital zone II replant Flexor tendon defect 4th finger right Flexor tendon defect 2nd right
Ruptured repair flexors 5th finger left. Skin necrosis Chronic composite defect flexor tendons and skin 3rd finger left Neglected avulsion FDP 5th finger left Tendon rupture after suppurative synovitis 2nd finger right Flexor tendon defect 4th finger right
Injury
Tendon and skin. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Free. Ulnar artery Tendon. Free. Ulnar artery Tendon. Free Ulnar artery Tendon and skin. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon and skin. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery
Tendon and skin. Pedicled. Ulnar artery
Tissue transferred. Remarks
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th. Contralateral FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
Donor tendon
Table 1. Summary table of a total of 40 finger flexor tendons reconstructed in 38 patients between 2002 and 2011.
FDP 5th
FDP 4th
FPL
FDS 3rd
FPL
FDS 2nd
FDS 2nd
FDS 4th
FDP 5th
FDP 4th
FDS 2nd
FDP 5th
FDP 3rd
FDP 5th
Motor tendon
A2, A4
A2, A4
Oblique
A4
Oblique
A2
A2, A4
A2, A4
A2
A2, A4
None
A4
A2, A4
A4
Reconstructed pulleys
(Continued)
130° Fair 220° Good 100° Poor 145° Fair 110° Poor 65° Poor 90° Poor 205° Good 30° Active IP motion 190° Good 30° Active IP motion 260° Excellent 130° Fair
170° Fair
TAM
Cavadas et al. 261
M 18
M 56
M 65
M 55
M 37
M 25
M 53
F 39
M 34
M 48
Case 18
Case 19
Case 20
Case 21
Case 22
Case 23
Case 24
Case 25
Case 26
Case 27
M 54
Case 16
M 45
M 30
Case 15
Case 17
Gender, age
Case
Table 1. (Continued)
4 years 7 months 4 years 6 months 4 years 4 months 4 years 2 months 3 years 9 months
4 years 11 months 4 years 9 months 4 years 8 months
6 years 8 months 6 years 8 months 6 years 2 months 5 years 4 months 5 years 1 months
Follow-up
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Defect flexors 2nd finger right
Defect flexors 2nd finger right
Defect FPL left
Flexor tendons defect 5th finger right Flexor tendons defect 5th finger left
Flexor tendon defect 3rd finger left. replanted
Rupture flexors 4th finger left
Rupture flexors 4th finger left
Rupture FPL and Flexors of the 2nd finger left
Chronic avulsion FDP 4th left
Flexor defect right 3rd finger after suppurative synovitis Flexor tendon defect 5th finger left
Chronic avulsion FDP 4th left
Injury
Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery
Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery
Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Median artery Tendon. Pedicled. Ulnar artery Tendons. Pedicled. Ulnar artery
Tissue transferred. Remarks
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 5th
FDS 3rd
FDS 3rd
FDS 2nd and 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
Donor tendon
FDS 2nd
FDP 2nd
FPL
FDP 5th
FDP 5th
FDS 3rd
FDS 4th
FDS 4th
FDP 2nd, FPL
FDP 4th
FDP 5th
FDS 3rd
FDP 4th
Motor tendon
A2
A2, A4
Oblique
A2
A4
A2
A2
A2
A4, oblique
None
A4
None
A4
Reconstructed pulleys
220° Good 195° Good 100° Poor 220° Good 40° active thumb IP motion 150° (Fair) 145° Fair 150° Fair 170° Fair. Superficialis finger 270° Excellent 230° Good 45° active IP motion 200° Good 170° Fair
TAM
262 The Journal of Hand Surgery (Eur) 40(3)
Downloaded from jhs.sagepub.com at HOWARD UNIV UNDERGRAD LIBRARY on March 10, 2015
M 60
M 32
M 43
M 33
M 25
M 59
M 41
M 54
M 35
M 52
M 31
Case 28
Case 29
Case 30
Case 31
Case 32
Case 33
Case 34
Case 35
Case 36
Case 37
Case 38
2 years 11 months 2 years 10 months 2 years 7 months 2 years 6 months 2 years 5 months 2 years 4 months 1 years 8 months 1 years 5 months 1 years
3 years
3 years 6 months
Follow-up
Defect flexors 2nd finger right
Rupture flexors 4th finger left
Defect flexors 2nd finger left
Rupture flexors 2nd finger left
Defect flexors 5th finger left
Defect flexors 2nd left
Defect flexors 2nd left
Defect flexors 4th finger right
Rupture flexors 3rd finger left
Rupture flexors 5th left
Defect flexors 2nd and 3rd fingers left
Injury
Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery Tendon. Pedicled. Ulnar artery
Tendon. Pedicled. median artery.
Tissue transferred. Remarks
FDS 4th
FDS 3rd
FDS 4th
FDS 5th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 4th
FDS 2nd and 3rd
Donor tendon
FDS 2nd
FDS 4th
FDP 2nd
FDS 2nd
FDP 5th
FDS 2nd
FDS 2nd
FDP 4th
FDS 3rd
FDP 5th
FDP 2nd and 3rd
Motor tendon
A2, A4
A2, A4
A2, A4
A2, A4
A2
A2, A4
A2, A4
A2, A4
A2
A4
A2 2nd and 3rd
Reconstructed pulleys
FDP: flexor digitorum profundus; FDS: flexor digitorum superficialis; FPL: flexor pollicis longus; IP: interphalangeal; TAM: total active range of motion. TAM
