HAND/PERIPHERAL NERVE

Flexor Tendon Repair, Rehabilitation,

and Reconstruction
Downloaded from https://journals.lww.com/plasreconsurg by Rs1PdakgPaCP5ALAgwkYgrA0P/mlFjFCRuo0fZ4uwZFInQETZFxCSxW/4R90i4z2qrCE3fQXVWnDm6DNNLIFVDQPXZGQOnO9dIAljq4xWeJ3IvsMcXkuB8K3iljJYADh6pspLJ44Crn2PImc3k05KnRS25fuK6+k on 04/27/2020

Brinkley K. Sandvall, M.D.

Kate Kuhlman-Wood, M.D.
Carol Recor, O.T.R./L.,
C.H.T.
Jeffrey B. Friedrich, M.D.
Seattle, Wash.
Background: Flexor tendon injury is a common problem that plastic surgeons
are called on to treat. Despite their common nature, they present a challenge,
not necessarily in the surgical treatment per se but in the ability to achieve a
“normal” finger as the end result. Because of the difficulty in attaining good
outcomes, much continues to be studied and written about flexor tendon injury.
Methods: The current literature on flexor tendon repair, rehabilitation, and
reconstruction is reviewed.
Results: Aspects reviewed include type of anesthesia, suture material and
configuration, repairs in the different flexor tendon zones, types of tendon
rehabilitation, complications of flexor tendon surgery, and flexor tendon
reconstruction.
Conclusion: This review provides an update on the current standards in the
treatment of flexor tendon injury.  (Plast. Reconstr. Surg. 132: 1493, 2013.)

PREOPERATIVE ASSESSMENT adults has been described.4 However, with time,

A detailed history, including age, sex, hand
dominance, occupation, functional status, mech-
anism of injury, time elapsed, hand position at
time of injury, and level of contamination, is
helpful not only in operative planning but also
in discussing patient desires, risks, benefits, likely
outcomes, and alternative treatments. Systematic
examination of each digit is crucial and should
be performed before local anesthesia or seda-
tion. Location of injury and resting position of
digits give clues to injury location and severity
(Table 1).1 Flexor tendons to each digit should be
examined in isolation, as injury results in loss of
active flexion. Partial laceration may cause click-
ing or catching. Complete examination should
assess for accompanying injuries such as fractures,
nerve lacerations, and vessel injuries. Ultrasound
and magnetic resonance imaging may be helpful
for locating tendon ends preoperatively and thus
helping plan surgical exposure; however, they are
not routinely recommended.2,3
tendon ends become distorted, tendon sheaths
fibrose, muscle-tendon units shorten, and adhe-
sions form, making repair more difficult.5 An isch-
emic digit or limb clearly increases the urgency of
an operation.
Indications and Contraindications
Indications for primary repair are clean-cut
wounds and limited crush injuries.5 Relative con-
traindications are severe contamination, infec-
tion, associated unstable fractures, and lengthy
tendon defect. A series of borderline indications
require thoughtful consideration and possibly a
delay in tendon repair or reconstruction—local-
ized soft-tissue injury, associated stable fracture,
rupture of a repaired tendon, delayed repairs,
and massive soft-tissue damage.5 If partial tendon
laceration causes triggering or catching, it should
be repaired or trimmed, or the impinging pulley
should be released; in general, if greater than 50
percent, primary repair is indicated.6–11

Timing of Repair ANESTHESIA

Flexor tendon repair in a vascularized hand
is not an emergency, and delay up to 3 weeks in
From the Division of Plastic Surgery and the Univer-
sity of Washington Medicine Hand Center, University of
­Washington.
Received for publication February 1, 2013; accepted August
18, 2013.
Copyright © 2013 by the American Society of Plastic Surgeons
DOI: 10.1097/01.prs.0000434411.78335.63
Wide-Awake
Wide-awake flexor tendon repair (with no
tourniquet and no sedation) has been described.12
Disclosure: None of the authors has a finan-
cial interest in any of the products, devices, or
drugs mentioned in this article.

www.PRSJournal.com 1493
 Plastic and Reconstructive Surgery • December 2013
Table 1.  Zones of Flexor Tendon Injury, Excluding
the Thumb
Zone Description
I Distal to FDS insertion
II Between A1 pulley and FDS insertion
III Distal edge of transverse carpal ligament to A1 pulley
IV Within carpal tunnel
V Proximal forearm to proximal edge of transverse
carpal ligament
FDS, flexor digitorum superficialis; A1, first annular.
Safety of epinephrine in digits makes it possible,
and epinephrine-induced vasoconstriction obvi-
ates the need for a tourniquet and cautery.13–17
Intraoperatively, patients follow directions and
perform active range of motion, allowing the sur-
geon to check for bunching, gapping, and trigger-
ing. This also provides an opportunity to revise the
repair and vent (partially open) annular pulleys
before closure. Improved compliance with post-
operative therapy is also reported after patients
visualize the repair in real time and gain a better
understanding of limitations and expectations.
Contraindications include very young patients,
those who are mentally impaired, and complex
trauma.12,18
Regional
Brachial plexus blocks using supraclavicular,
infraclavicular, or axillary approaches are stan-
dard.19 The intravenous regional (Bier) block is
another common anesthetic technique, and its
use in flexor tendon repairs has been described.20
Tourniquet pain can limit the duration of surgery.
Recommended duration of cuff inflation varies.
To avoid complications related to systemic anes-
thetic toxicity, 30 minutes is considered the mini-
mum inflation time.21 Serial cuff deflations with a
double-lumen tourniquet can extend overall tour-
niquet time.22,23
General
Complex or multisystem injuries are best
repaired in an operating room under general
anesthesia.
SURGICAL TREATMENT PLAN
Incisions
Exposure should preserve flap vascularity,
avoid creation of flexion contracture, and provide
adequate exposure. Frequently used incisions are
the Bruner, midlateral, and palm zigzag; exist-
ing lacerations are incorporated into these. The
Bruner incision avoids the digital neurovascular
1494
bundle, whereas the midlateral incision avoids
volar sensory changes.24 When the proximal ten-
don end has retracted, retrieval is possible by
“milking” the tendon, flexing the wrist, or making
an additional proximal incision.24,25
Pulleys
Pulley handling and preservation are essen-
tial.26 The digital pulley system consists of five
annular (A) and three cruciate pulleys. The pal-
mar aponeurosis and carpal tunnel also act as
pulleys for flexor tendons. Annular pulleys, spe-
cifically A2 and A4, are critical to hold flexor ten-
dons close to bone, thereby decreasing work of
flexion.27–30
Partially opening an adjacent pulley by vent-
ing diminishes constriction on a fresh repair site.5
Conventional wisdom holds that if more than
50 percent of the A2 or A4 pulley is disrupted,
it should be reconstructed to avoid painful grip,
weakened flexion, and contracture deformity
from bowstringing.27,28 However, there are reports
of dividing these pulleys without meaningful
clinical consequences, challenging the premise
that the A2 and A4 pulleys need to be preserved
entirely.5,29,30
Core Suture Technique
Generally, increasing core strand number, cal-
iber, and purchase length increases the strength
of the tendon repair.31–35 However, there is no
high-level evidence identifying the optimal num-
ber of core strands, nor is there consensus on
the optimal suture configuration. A core suture
purchase of 7 to 10 mm is recommended, as it
increases gap resistance and strength.36–40 Locking
core suture configuration, in which the transverse
component passes volar to the longitudinal com-
ponent, allows tightening around bundles of ten-
don fibers and provides greater tensile strength
than grasping sutures.41–43 Multiple configurations
of the locking loop exist, and additional locking
components may result in improved grip when
suture materials with higher tensile strength are
used.44 The decision of where to place suture
knots—either within the repair site (temporarily
weakening tensile strength) or outside the repair
site (which increases gliding resistance and work
of flexion)—depends largely on preference.45–48
Peripheral Suture Technique
The peripheral circumferential suture not
only smoothens the repair site but also signifi-
cantly increases strength when placed deeper than
2 mm.49 Other in vivo studies have corroborated
Volume 132, Number 6 • Flexor Tendon Repair
the utility of epitendinous suture use in flexor
tendon repair.50,51 Core and peripheral sutures are
typically used together.
Suture Material
Trail et al. suggested that the ideal suture for
flexor tendon repairs would have high tensile
strength, knot easily, resist gapping, have mini-
mal tissue response, and be easily manipulated.52
Biomechanical properties of suture materials
have been evaluated extensively.52,53 Braided poly-
ester, monofilament nylon, and monofilament
polypropylene are commonly used; nylon is the
weakest.52–54 Although nonabsorbable sutures
are more commonly used, evidence suggests that
both absorbable and nonabsorbable sutures can
be used with early active rehabilitation, achieving
similar functional outcomes and rupture rates.55
Level I evidence supports use of the Teno Fix
(Ortheon Medical, Columbus, Ohio), a stainless-
steel tendon-repair device which, when compared
with a four-strand cruciate repair in the flexor
digitorum profundus, had fewer ruptures (0 per-
cent versus 18 percent) and similar functional out-
comes.56 Mechanical profile and recommended
loading parameters are still being investigated.57
Use requires training in its implementation.
Bidirectional barbed suture (Quill SRS;
Angiotech, Inc., Vancouver, British Columbia,
Canada) is a knotless option with similar strength
but smaller cross-sectional area than standard
techniques. Several biomechanical ex vivo studies
have demonstrated adequate strength; however, it
has not yet been analyzed clinically.58,59
Core-jacketed suture (FiberWire; Arthrex,
Inc., Naples, Fla.) and Monofilament stainless
steel (Core Essence Orthopaedics, Fort Washing-
ton, Pa.) have increased strength and stiffness
compared with other materials.53 There are cadav-
eric studies investigating optimal configuration,
tensile strength, and mode of failure in flexor ten-
don repairs but none in live humans.40,53,60–63
Zones
In zone I, the flexor digitorum profundus is
often either repaired primarily or reattached to
the distal phalanx. The long-term goal is a func-
tional distal interphalangeal joint with 30 to 40
degrees of motion and minimal bowstringing.64
Vincula often prevent significant tendon retrac-
tion. Two common methods of bony attachment
are the pullout button and suture anchor. With
a pullout button, repair is commonly with 3-0
Prolene (Ethicon, Inc., Somerville, N.J.) and a
Keith needle, externalized distal to the lunula on
the nail bed, then tied over a button.24 A benefit of
the suture anchor is that no material is exposed.
In one series, there was no significant difference
in clinical outcome of pullout button and suture
anchor techniques; however, there was improved
patient satisfaction, quicker return to work, and
decreased morbidity in the suture anchor group.65
Zone II has a tenuous blood supply, and
repairs are more difficult because of pulleys,
Camper chiasm, the close relationship of flexor
digitorum superficialis and flexor digitorum pro-
fundus, the tendency for adhesion formation, and
a narrow fibro-osseous tunnel; each contributes to
increased friction and restricted tendon gliding
(Fig. 1). In combined flexor digitorum superficia-
lis/flexor digitorum profundus transections, both
are often repaired; however, to minimize bulk and
work of flexion, one may resect one slip of flexor
digitorum superficialis and repair the other slip
or perhaps not repair the flexor digitorum super-
ficialis at all.18,66–69 In a flexor digitorum superfi-
cialis–only digit, arthrodesis of the joint can be
performed or the flexor digitorum profundus dis-
tal stump can be tenodesed to the A4 pulley.
In zone III, the surrounding palmar fascia,
A1 pulley, and part of the transverse carpal liga-
ment may be resected to reduce the likelihood
of adhesions or retrieve proximal tendon.64,70,71
In zone IV, if the median nerve and tendons are
not constricted, one may leave part of the trans-
verse carpel tunnel ligament intact to minimize
bowstringing.64
Difficulties encountered in zone V are attrib-
utable to concomitant injuries to the flexor digito-
rum superficialis and flexor digitorum profundus,
retraction of tendons into the forearm, and dif-
ficulty obtaining suture purchase at the musculo-
tendinous junction (Fig. 2).64
Pediatric Tendon Injuries
Thinner tendons and decreased ability to
cooperate with postoperative protocols present
unique challenges in children. Zone I injuries
tend to fare better than zone II injuries; how-
ever, those with concomitant nerve injury tend
to have worse outcomes.72,73 In children, patient
age and rehabilitation protocol do not seem to
have a significant impact on outcome, provided
that the length of immobilization is less than 4
weeks (Fig. 3).72,73 The ability to achieve a strong
repair with fewer core sutures is supported.72,74–76
However, studies with relatively small sample sizes
make detecting significant differences in rupture
rates between two-strand and multistrand repairs
difficult.77,78 A recent series using a six-strand
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 Plastic and Reconstructive Surgery • December 2013

Fig. 1. Knife injury to middle, ring, and small fingers in zone II. On the lateral view, note the abnormal
tenodesis effect of the ring finger.

core suture and immediate active mobilization
achieved good results without rupture, although
only flexor digitorum profundus was repaired and
bowstringing from pulley venting was noted.67
Flexor Tendon Reconstruction
Reconstruction may be indicated when
injury presents late and tendon is significantly
retracted, when there is segmental tendon loss,
or when primary repair fails to glide sufficiently
(Fig. 4).79,80 Either a single-stage or a two-stage
procedure is performed, depending on the
degree of scarring and pulley disruption, level
of tendon laceration, degree of passive motion,
neurovascular status, amount of soft-tissue cover-
age, patient desires, and ability to comply with

Fig. 2. (Left) Glass injury to zone V in the forearm. (Second from left) Sutures placed in ruptured flexor tendons at the musculoten-
dinous junction. Note the difficulty in achieving a smooth and tidy repair at this location because of the poor ability of muscle to
hold suture. (Second from right and right) Patient demonstrating good range of motion at approximately 6 weeks, likely in part
because of the lack of flexor tendon sheath at this anatomical level.

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Volume 132, Number 6 • Flexor Tendon Repair

Fig. 3. (Above, left) Ring finger flexor tendon injury presenting several weeks after laceration in
the palm at the base of the ring finger. Many pediatric flexor tendon injuries present in delayed
fashion because of the inability to adequately assess flexor tendons at the time of initial injury.
(Above, right) Postoperative splinting of the injury. Note long arm splint with forearm supinated
(which is not a position in which a child can do much with the hand) and the palm open so that
some active flexion of the digit is possible. (Below) Postoperative range of motion at 6 weeks.

rehabilitation.79,81 In a two-stage procedure, the
first operation consists of pulley reconstruction
and silicone rod insertion. The second, approxi-
mately 3 months later, after sufficient healing
and passive range of motion, is tendon harvest
and insertion.82 Reconstruction is a large com-
mitment, and patients should also be counseled
about the options of no operation, arthrodesis,
or amputation.
Future Directions
Tissue-engineered flexor tendon grafts have not
yet been used in a human clinical trial, but much
research supports its potential.83 Biochemical modi-
fication and use of growth factors to potentially
decrease adhesion formation are still experimental.83
POSTOPERATIVE REHABILITATION
Postoperative care greatly influences the
outcome of a properly conducted flexor tendon
repair. Hand therapists consider several variables
when designing postoperative regimens—force
that the repair can withstand, work of flex-
ion, tendon excursion, and the time course of
tendon healing.

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 Plastic and Reconstructive Surgery • December 2013

Fig. 4. (Left) Zone I laceration of the small finger (flexor digitorum profundus alone injured). This patient developed adhesions
limiting active flexion of the digit. At the time of tenolysis, it was noted that the flexor tendon repair had gapped and repair of this
was not possible, so a silicone spacer was placed after tendon excision. (Center and right) Range of motion following tendon graft
placement and subsequent rehabilitation

Tendon Healing 30 degrees of flexion and a hinged splint allows

Tendons heal by both intrinsic and extrinsic 30 degrees of wrist extension. The hinged splint
mechanisms and transition through inflammatory, is used only during the exercise program, and the
fibroblastic, and remodeling phases.69 Strength patient returns to the static dorsal blocking splint
decreases initially and then increases steadily.84,85 the remainder of the time. These exercises exploit
Mobilized tendons heal faster and stronger.86–92 the tenodesis pattern of movement (in which wrist
extension essentially causes passive flexion of the
Protocols digits), preventing excessive tension on the repair
Zone II rehabilitation protocols are gener- site (Fig. 7).
ally classified as early passive motion (Duran A pyramid of progressive exercises program
and/or Houser), dynamic flexion (Kleinert), has been described and is a modification of
and early active motion (synergistic). The Duran early motion protocols that use individual tissue
and Houser protocol is a passive flexion and pas- response to determine when to advance ther-
sive extension protocol. A dorsal blocking splint apy.95,96 It is based not on a strict timeline but
holds the wrist at 20 to 30 degrees of flexion, the on adhesions, tensile strength of the repair, and
metacarpophalangeal joints at 40 to 60 degrees
of flexion, and the interphalangeal joints neu-
tral (Fig. 5). From postoperative weeks 0 to
3, passive digit flexion and active digit exten-
sion within limits of the dorsal blocking splint
are performed.
The Kleinert protocol is a passive flexion and
active extension protocol (Fig. 6).93,94 Dynamic
traction is applied to fingernails and active digit
extension is permitted within splint constraints.
Modifications include the distal interphalangeal
joint in dynamic traction by using a palmar pul-
ley or cuff. In an effort to minimize proximal
interphalangeal joint flexion contractures from
constant dynamic traction, fingers are strapped in
extension at night. Fig. 5. Duran protocol dorsal blocking splint demonstrating
The original synergistic protocol uses two wrist neutral and metacarpophalangeal and interphalangeal
splints—a dorsal blocking splint keeps the wrist at joints in flexion.

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Volume 132, Number 6 • Flexor Tendon Repair
Fig. 6. Kleinert protocol dynamic flexion splint demonstrating (left) digit flexed by means of a rubber band and (right) digit
actively extended against the dorsal blocking splint.
forces required for specific exercises. This more
aggressive protocol has the goal of full active
motion within the first 2 weeks. Initially, with
the wrist protected with a dorsal blocking splint,
passive protected extension begins. Place-and-
hold exercises are introduced, followed by active
composite fist/hook and straight fist. Next, the
wrist is transitioned to an unprotected state and
motion is increased in isolated joints. Then, the
splint is discontinued and resistive composite fist
and resisted hook are started, followed by straight
fist. The last exercise introduced is resisted iso-
lated joint motion. Advancing from one “step” in
the pyramid to the next is determined by tissue
response to each exercise.
No single therapy protocol has been consis-
tently demonstrated to be optimal.94,97 In a system-
atic review of the literature, early active motion
protocols seemed to have the best intersection of
low rupture rates and improved range of motion.94
OUTCOMES
Early Complications
Infection
In general, there is conflicting data on periop-
erative antibiotic use in hand surgery.98–107 Level
I evidence exists for withholding prophylactic
antibiotics in clean hand injuries, simple hand
lacerations, and elective hand cases less than 2
hours.98–103 However, level I evidence supports pro-
phylactic antibiotics in elective hand cases more
than 2 hours, dirty hand wounds, and complex
reconstructive hand surgery.98,104–107 In a retrospec-
tive chart review analyzing the role of perioperative
antibiotics in simple open flexor tendon injuries,
there was no benefit.108 A large, randomized,
double-blind study evaluating antibiotics in hand
surgery revealed no significant decrease in infec-
tion rates in patients who received prophylactic
antibiotics, regardless of type, depth, length, or
timing of surgery.109
Postoperative Rupture
A recent meta-analysis estimates rupture rates
of 4 percent both before and after 2000, similar
to previously reported rupture rates; core suture
technique or use of an epitendinous suture did
not influence rupture rate.94,110,111 Rupture is most
likely to occur at approximately day 10 (between
days 6 and 18), when the repair site is weakest,
although later ruptures have been reported.112
Causes include repair-site weakness (because of
inadequate suture strength, gapping, catching on
a pulley, or infection), overly aggressive therapy,
and patient noncompliance.39,113–115 The opportu-
nity to redo the repair during wide-awake repairs
resulted in decreased rupture rates in one study.114
The small finger is more likely to rupture (46 per-
cent) and rerupture (20 percent) and have fewer
good results than other digits.116,117 Proposed rea-
sons for this include slim profile of the tendons
and sheath and its location as a border digit.116
Late Complications
Adhesions
A recent meta-analysis suggests the rate of clin-
ically important adhesion formation is 4 percent,
lower than that of prior studies suggesting 10 or 20
percent.84,110,111 Tendon trauma (both from initial
injury and from intraoperative handling), a bulky
repair site, and postoperative immobilization
each contribute to adhesion formation. Adhe-
sions are likely proportional to degree of crush
injury and number of surfaces disrupted.69 Thus,
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 Plastic and Reconstructive Surgery • December 2013
Fig. 7. Synergistic (early active motion) protocol demonstrating
(above) passive wrist extension with the other hand, allowing
tenodesis to flex digits; (center) digits held in flexed position
after releasing passive wrist extension; and (below) extension of
digits following wrist flexion, again using the tenodesis effect.
one should handle tendon and sheath delicately
to minimize iatrogenic scarring. When compared
with a combination of techniques in a meta-analy-
sis, adhesion formation was 57 percent lower with
the modified Kessler technique.110 In reviewing
tendon adhesion prevention (specifically, modifi-
cations in surgical technique and pharmacologic
adjuvants), Khanna et al. conclude that the only
factor clinically justified in adhesion prevention is
the use of postoperative mobilization, recognizing
that the optimal regimen is still controversial.118
1500
Tenolysis
A meta-analysis revealed reoperation (tenolysis
or rerepair) rates to be 6 percent and unchanged
since 2000.110 A retrospective review of one state’s
database showed 91 percent of reoperations were
within the first year of repair; in addition, patients
who were older or had workers’ compensation
were more likely to undergo reoperation, whereas
those with concomitant nerve injury were less
likely.119 Tenolysis is indicated when passive range
of motion is nearly normal and greater than active
range of motion, tissues are supple, and fractures
healed—approximately 6 months after primary
repair.120–122 Tenolysis is a complex procedure and
should be performed carefully and deliberately.
Established scarring makes tenolysis difficult and
may result in rerupture of the tendon. Dissec-
tion should be performed sharply, with either a
scalpel or specialized tenolysis knives. Before the
procedure, patients should be informed that the
tendon and/or pulleys could be densely scarred
and/or have swollen and frayed ends, and that if
this is the case, tenolysis will likely not be helpful.
In these instances, one must be prepared to move
ahead with flexor tendon reconstruction.24
Joint Contracture
Common causes are decreased motion, splint-
ing position, volar plate scarring, bowstringing,
adhesions, skin contracture, and ligament con-
tracture.113,115 Early recognition and continued
follow-up with a hand therapist for splint adjust-
ment are crucial to halting establishment of con-
tracture. Release should proceed systematically,
sequentially releasing contracted structures until
full extension is reached.113 In a retrospective
review comparing index to small finger flexor ten-
don injuries in zones I and II, the small finger was
significantly worse only in zone I injury flexion
contracture.123 Potential reasons are relative weak-
ness of the extensor mechanism compared with
the flexor and gliding constraints of a narrower
tendon sheath.123,124
Bowstringing
Loss of the A2 or A4 pulley may result in bow-
stringing, leading to weaker flexion, decreased
range of motion, and flexion contracture.24 If the
A2 or A4 pulley is significantly damaged, pulley
reconstruction and enlargement is possible with a
palmaris longus autograft, a portion of flexor digi-
torum superficialis, or plantaris.28,113,125 One can
also use part of the extensor retinaculum secured
either with suture or suture anchor to the edges of
the A2 or A4 pulley.28
Volume 132, Number 6 • Flexor Tendon Repair
Quadriga
Because of a common muscle belly, func-
18. Lalonde DH. An evidence-based approach to flexor tendon
tional shortening of the flexor digitorum profun-
dus to the small, ring, or middle finger results in
restricted flexion of all profundus tendons and
weakened grip. Treatment depends on the root
cause—adhesions, joint contracture, or improper
tendon tensioning.114,126–128
Jeffrey B. Friedrich, M.D.
325 9th Avenue, Box 359796
Seattle, Wash. 98104
jfriedri@uw.edu
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