Primary Repair of Flexor Tendons - The Journal of Bone & Joint ...

Primary Repair of Flexor Tendons 

BY CLAUDE E. VERDAN, M.D., LAUSANNE, sw’ITzERLAND 

Among some of the difficult problems still to be solved mi hand surgery, 

repair of flexor tendons in the digital sheath is not the least. 

It is generally agreed that inn a single fresh cut of the flexor profundus between 

the distal imisertion and the middle third of the middle phalanx, primary 

suture can give good results (Figs. 1-A through 2-C). It. is quite differemit, however, 

whemi the w’ound is located more proximally and both tendons are cut. Most 

authors say it is wise not to undertake immediate tendon repair when both flexor 

tendomis are divided in Bunnell’s no man’s land. Treatment. is limited to closing 

FIG. 1-A Flo. 1-B 

Result of I)rinn:try’ suture of the flexor l)OlliciS bingos, severed in the interphalanigeal fold. 

the w’ound, preceded by ecomnomnical excision of the wound edges, it the’ are 

contused. Secondary tendomi repair is postponed for two or three w’eeks. After 

this interval, excision of the sublimnis is recommemided, followed by a long tendon 

graft of the profundus, extemiding from the distal attachmemnt of this temidoni up to 

the proximal half of the palm (Figs. 3-A and 3-B). 

According to my ow’n experiemice, this operation is not only one of the niost 

difficult undertakimigs inn reparative surgery but also omie which gives the most uncertain 

results. It is known that these results depemnd on the select.iomn of cases 

for the operatiomi. A badly performed or unsuccessful primary repair can, of 

course, jeopardize the success of a secondary graft; but it must also be recalled 

that division of the two neurovascular bundles of a finger will cause trophic disorders, 

amid these make secomidary repair very difficult. 

Skill, patience, and painstakimig attention to details are required of the 

surgeomi. 

The good results obtained by Boyes’ amid Pulvertaft8 (70 to 80 per cent 

success) are not. always attained. I, personally, durimig the past seven years have 

performed about sixty temidon-grafting procedures. I must admit, however, that 

niy percentage of good reults is miot so high. 

Without giving details comicermnimng the technical difficulties that may impair 

the final result, I would say that, at present, a temidomi graft is still the exclusive 

job of the specialist or, at least, the specially trained surgeon. Usually tinese 

* Read at the Annual Meeting of the American Society for Surgery of the IIanl(l, Chicago, 

illinois, January 23, 1959. 

VOl.. 42-A, NO. 4. JUNE 1960 617

648 (‘. E. VERDAN 

}I(. 2-C 

Figs. 2-A, 2-B, Lli(I 2-C : The flexor l)rofumidus 

alone severed in the IUi(Idl(’ thir(l of the 

middli’ phalanx of the iln(1eX finger. Omily 

PrimarY tefl(lOIi r(’pair Was l)(m’fornn(’(I (no 

tUIiol\’Sis). 

Figs. 3-. an(1 3-13 : (‘mit of both, flexor t(’n(lonls 

in mo mami’s lanid of the little finger. Photographs 

show the result five months aft’r ten(lomi-graf ting. 

JoImtNAL OF BONE ANI) JOINT sI’IWERY

VOl.. 42-., NO. 4. JUNm: 1960 

I’RlM;mv REPAIR OF FLEXOR TENI)ONS 649 

FIG. 4-A Fmo. 4-B 

Figs. 4-A, 4-B, amid 4-C: Cit of both flexor 

t(nldonis imi the index fimnger, of the flexor lrofmndus 

and one-half of the subliiiiis in the long 

finger, an(l of one-half the profimnidus in the ring 

finnger. Only l)riniarY repair was l)erforlned ; the 

Patient. (li(l not wishi a secomRlarv t.(’flolVSiS. 

sum’geonns a.re not. tine onnes who see the 

Ptttiemnts inn the eniergemi(’y m’oomii. It is, 

minost. fiequeiit ly, tine gemienal pm’a(’t itionel’ 

or the imnt.em’ni. l.mi(lem these cii’- 

(‘umiistannces, it is justified ali(l wise riot 

to pem’foi’ni pm’innary repan’. 

Iiowe\’eI, I would like to show that 

the surgeomi is’ho is trainne(l to perfoi’nn a 

successful giaft of the flexom temidomis is 

also cttpal)le of perfom’nnimig a su(’(’essful 

PI’imnial’y 

fresh an(i 

tendon 

cleanly 

m’epaim’-if 

cut-without 

the vounicl 

crushing 

is 

FIG. 4-C 

the tissues, if he applies somne sound techmiical mules. 

Iii miny 1)00k Chirurgie R#{233}paratrice et Fonctionnelle (ICS Tendons (IC La ibm 

\Vlii(’li I wrote inn 1951, I t’anne to tine conclusiomi, after givimig all the I’easonis fon’ 

amn(l agaimns’t it, that priniam’y iepaii’ of the flexor temidomis is nnot on1’ ad’isable 

lilt also possible, riot omily imi the al-eas kmiowmi to be favorable for lnimiian’’ m’epaim-, 

l)Ut. also in the osteofibm’ou.s tunnel of the tingem’. Ilowevem’, this l)m’imiiamy m’epaim’ minust 

sol’e the miie(’hamii(’al amid physiological pn’oblemii of glidimng. 

I (l(SCmil)(!(l iii ny 1)00k a miew t.ecliniique I applied \\‘hi(’hi utilizes staimilesssteel 

tm’annstixion pins to hold the ends of the lacem’ated tenidoni inn (‘omita(’t witin 

omit’ lmiOtliem’ mi ii part of the sheath that is imnta(’t, without pla(’imig amiy sutures iii 

the tenidonn ends. 

Although somnie good m’esults have beemi obtainie(l with this mniethod (Figs. 4- 

A, 4-13, ami(l 4-C), I have now (le(’ided that this is not the 1)est possible solution to 

the difficult l)m’Ol)lemii \Vhii(’hi Buniniell, i\Iasoni a.mi(I Allen, loch, rimnd others have 

tm’ie(l to solve. 

I ha\e miov nnnodified this (inst te(’hnii(luc amid hna\’ use(l SVSt(’miiaticahlV a 

se(’om i(l niet 110(1 of I )Io(’ ked simt times, vhi i(’h i ni ci t1(leS m’ese(’t i( )n i (if t Inc shieat In ann (1 

gi’eatem’ l)1’((’i5)1i in the aligminiemit of tine (‘lit emitis. 

(‘tually, mi the first nietliod, the enids of the flexor i)n’0tlmmidLIS \vcn’e sonii(’- 

I iiiies too loose iniside the sheath fn’oni \vhi(’hi the sui)himiiis had b)e(’ni m’emnoved. 

\Vithini the inittt(’t sheath the tendon emids could have sonic l)laY amid thins, durimig 

hiealimng, a bm’iish of iegenierat.imng “umnsa.t.isfied’’ fibers was for-nied. Since tine sheath

650 C. E. VERDAN 

participates imi the healing of the tendomi, the healed tendon did not glide as 

well as one might. hope for. 

Therefore, I miow resect about omie inch of the sheath at the site of the suture, 

as Mason did, amid suture the emids of the tenndomn together very accurately w’ith 

four small epitendimious stitches at the four cardimial poimnt.s, usimig fimne 000000 

arterial silk, as is’ domie for a nerve suture. 

This ac(’urate but fragile repair will mnot resist the tractioni of the muscles. 

however, protectiomi is achieved by imnimnobilizing the tendon with two stainless- 

steel pimis, a procedure which is much easier than Bunnell’s “sut.um’e at a dist.amnce”, 

usimng a pull-out. nn’ire. 

The pimi,s that. pass through the skin, the sheath, amid the tendon are placed 

t.ramisverselv ; one distal and omie proximal to the suture. 

FIG. 5 

Technique of Primary blocked suture of the flexor profundus when both flexor temidons are 

severed in no man’s land; resection of the flexor suI)limis and the digital sheath. 

TECHNIQUE 

After ecomnomical excisioni of the margimis of the transverse w’ound caused by 

the accident, the incision for the repair of the tendon is made, usimig a classic 

mid-lateral opemnimig, without much regard for the woumid produced by the trauma. 

The approach to the sheath goes dorsal to the neurovascular pedicle ; the nerve, if 

severed, is repaired only at the emid of the operatiomi. 

First the sublimis is resected. For this procedure, the lesion of the tendon 

sheath caused by the accidemit generally is too small. This opemnimig is therefore 

enlarged amid used for the extractiomi amid resection of the two small distal slips. 

The proxinial emid of the flexor sublimis tendon, which has retracted into the 

palm, is located through a short transverse incision inn the distal palmar crease. 

It is divided as far proximally as possible. Only the profumidus is replaced iii 

the sheath amid l)Ilsiie(1 innto the (ligital (‘amial. 

At t.hnLs timne it. is inniportanit to place tine fInger mi the proper semniflexed 

1)OsitiOni inn nvhichi it will he immniohiilized rtmi(1 inn which the pins will be inserted 

before tine tenidomi iss’utured. In doing this one lutist look for tine ‘‘position of rest’’, 

which cinamiges \n.ith:flexionior extenision of tine wrist. With the finnger in this positiomi 

the lacerated ends of the tenidomi will proh)ably have no relationrt,o the acci- 

THE JOURNAL. OF OONE AND JOINT SURGERY

FIG. 6-A FIG. 6-B 

Figs. 6-A, 6-B, amid 6-C: Both flexor tendomns 

were severed in no mamn’s land of the long 

finger. mi the index finger, there was a cut of 

the flexor l)rofufldus between the proximal and 

nniiddle thirds of the middle phalanx. Figs. 6-B 

atiti 6-C show the result seven months after 

Primar)’ repair. 

Figs. 7-A 1.fl(l 7-B : Both flexor tenidons wt’r(’ 

severed iii the middle thuird of the proximal 

l)halalix of the ring finger. The photographs 

show the result after primary suture of the 

l)rofumidmms and omne collateral mierve. 

VOL. 42-A, NO. 4, JUNE 1960 

PRIMARY REPAIR OF FLEXOR TENDONS 651 

FIG. 6-C 

FIG. 7-A Fmo. 7-B 

dental openimig in the sheath. Conisequemitly, this opemning in the sheath is disregarded 

from this point on. 

Over the juncture of the two ends of the tendomi, the sheath is opemned or the 

existing openimig is enlarged so that the sheath is excised over a distance of about 

onie inch. This is dome misuch a way that the futuie scar at tine site of tendomi repair 

will slide freely inn both directions without contacting the sheath. The amount of


FIG. S-. 

Fa;. 8-C 

Figs. 8-A, 8-B, :01(1 8-C: Cut of both flexors in the distal third of the first. Phalanx of the ring 

finger. Primary l)lo(’k(’d suture of tine flexor profimmndims was l)(’rformnn(’d. Figs. S-B anid 8-C show the 

functional result. at follow-up t no ‘‘ars after operation. 

sheath resected is detem’niiimied by estimniat.inig the physiologica.l glidimng amplitude 

at this level (Fig. 5). 

This nieamns that niost frequemitly the suture line will not be at the same location 

as the origimial lesiomn. If the finger i’as extended at the time of injury-a 

very rare occ’um’i’enice-tiie suture limie will be proximal to the site of injury. If, on 

the comit.ram’y, the fimngem- was flexed at the tinie of imnjury-which quite frequently 

happens i)eeause of au imnstimictive protective m’eflex which comes into play at the 

tinie of injum’y-t.he sutiim’e limie n’ill lie mneai’ the distal emid of the huddle phalanx. 

This is very iminportant because if the temidomi scar does becoiiie fixed to the middle 

phalamix, the poimnt of attachment. will be so far distal that the tendomn will preserve 

enough excumsiomn within the fimiger to pi-oduce flexiomi of the proximal int.erphalan- 

geal joint-a inotiomi of capital imiipoi-tance fon’ fumiction of the digit.. 

Furtherniom’e, by excising the sheath inn an imitact zone, the tendon scam’ 

vil1 be surrounide(l by sul)cutaneous fat and not by a fibrous tunnel of fixed diam- 

THE JOURNAL OF BONE AND JOINT SURGERY

Vol.. 42-A. NO. .1, Jt’NE 1960 

I’1tIM.RY IIEI’.i.IiI OF FLEXOR TENDONS 653 

FIG. 9-A Fli;.0-B 

Figs. 9-A. 9-B, amid 9-C: Tennolysis. (ut of 

hoth flexors at the level of the l)roXinial inter- 

)halamigea1 joimit of tin(’ in(l(’N finger. Because 

t lie priniary r(’pair failed, t(’mnolysis was p’rfon’nii(’(l 

t\v() ami(l onie-hialf nionthis laten’. 

(‘icr. The m’enflriimi(ler of this sheath 

suffices to pm’evemnt dislocation of the 

tenidomi, j tist. as it does inn the t.echmiique 

of tendoni-graftinig, inn which mesN’tiomn 

of the sheath is still mimic extemisive. 

The finigem’ is iminniol)ilized mi a rest- 

inig l)Ositioni i)y a pad(Ied doi’sal sphimit. 

If tine flexon tenndomi of the thnimnil) is 

l)eing repaim-ed a (‘Iist should be used. 

I have 

‘ - 

com’tieoids 

not V(t. \‘emntllm’e(l to 

. 

aftem Ol)eratiomi. 

use 

Fr;. 9-C 

After a iinaximiiunn of thnmee weeks, the splint amid tine hiockimig l)ilis are re- 

nniove(l. Svst.emniatie active exem(’ises, inicludimig )lmshimng oni the palnmam’ side of the 

l)halallx, rime them stamted cautiously amid imn(’m’eased gl-a(lually to niobihize the terndomi. 

Somnietinnes, gentle passive mnioi)ihizatiomi dum’inng the foum’t.h iveek aft.en opera- 

tiomn w’ill m’upt time fm’eshn rulhnesiomis, amid this mnnay imnipmove tine enid n-esiilt (‘omisi(ler- 

InI)ly. 

Eight to ten (lays aft.em’ tine begiiimiimig of mnobihizat.iomi of tine digit. the patiemit 

is pernuit.ted to resume pai-t.ially his former activities. 

rfiius, tine timine of inmnnoi)ihizatiomi amid the pem’iO(l of eim’ly m’ehabilitat.iomi anniounit. 

to fioiii foui to five weeks of disability (Figs. 6-A t.hi’oughn 8-C). 

Ten ol!Jsis after Un s uccessful Pri?nar!J “ mire 

It will lie niec’essan’v to j)(’mfoi’mii a secondam’y temnolysis : ( 1 ) if after three inionithis 

t.h(’n’e has beemi ho funictiomial imiipmo\’emiiemit amid tine active nnotiomn n.emnLti!is mnniichn 

less than the l)assiVe mniovememnt inn tine joimits of the involved fimiger : (2) if th( 

l)ati9it. thimnks the result. is not. suffieiemnt. for the mieeds of his professionial task 

on- (3) if thiel(’ is (‘omnplete a(lhnesiomn of the temi(Ion , as o(’cIini’e(l inn 25 to 30 Pel’ (‘emit 

of the pat.iennts. 

‘1ii openat.iomn i’e(ltiim’es niot only tine fneeing of adinesiomis i)l.it. oftemi a ri’- 

sectiomi of tiie temi(lofl -heatin, amid of tue mnom’mnial pulleys as vehl, inn (higits inn winicin 

adhesionns of’ tine tendomi (‘over a lomig dist.anice. As mi the f’mi-st stel) of a temndoni 

graft, only a shomt fibrous m-imig is left as a pulley on each phalanx. Hemiio’al of 

the sheath is (‘onltinnue(l umntil traction on the flexor profumndus at tine tipper inalf 

of tine pain causes complete, effortless flexion of the fimnger. Elastic i)anidages


FIG. 10-C 

an umisuecessful temndonn graft if 

the graft.. For prinnary repair of 

sufficiennt (Figs. 9-A tinrough 10-C). 

Figs. 10-A, 10-B, and 10-C: Tenolysis. Both flexor 

tendons of the long finger were severed at the metacarpophalangeal 

fold. Failure of primary simtmmre of the 

profundus and resection of the sublimis was followed by 

complete adhesions of the tendons. Normal ftmnct.ion was 

regained after tenolysis. 

are applied after operation , amid nioi)ilizat ionn 

is begun as soomi as the postoperative painn 

ns’ill allow’. 

Myfriend, .Jacques Michomi, fromin Xamncy, 

amid I demomnst.rated that seconidary tennolysis, 

the indications of w’hich are many , (‘am be 

particularly useful after au unsuccessful primary 

suture as well as after am unsuccessful 

tendomi graft. However, it is advisable to w’ait 

six months before performing a tenolysis for 

one w’ishes to avoid spomitaneous rupture of 

flexor tendons a delay of three niomiths seemnis 

RESULTS 

Lesions of tine flexor temndomns in no main’s land are relatively rare. Although 

the hand surgeonn is seldom called on to repair fresh lacerations, he is vemy often 

requested to perform grafts on patients sent to him from all over the country. 

These Se(’omnd operatiomns, of course, must be performed accordimig to the prescribed 

prograni for t enndomn-graft.ing. 

Since 1952, end results after primary suture of flexor t.endomis inn nio mann’s 

laud, perfornied accordimng to the technique described, are available for five thumb 

flexor temndons amid fourteen flexor tendons in the four other digits, a total of nineteem 

cases. The results’ obtainied iii three other patiemits nn’hose digits are still umnder 

tm’eatnient are too re(’enit. to be considered. 

Imi tine t.hunibs tine aniplitude of active nnotiomi, measure(l at. tine innteipinalani- 

geal joint, m’aniged fn’onn 45 to 80 degrees. 

mi the lesser digits, temn of fourt.eemi Iinngem’s have a ramige of ru’tive mniotiomi 

betweenn 20 and 95 degrees foi’ tine proximnial interphalangeal joinit, amn(1 betweeni 

10 amnd 30 (legrees for the distal initerphalamngeal joint.. None of these t.emn fingers 

required additional intervention. 

There were three failures due to complete adhesions of the tendon and one 

THI JOURNAL OF BONE AND JOINT SURGERY


partial failure due to flexion contracture of the proximal interphalangeal joint; 

these fingers required reoperation. In one of these fingers a temndomn graft was a 

failure. The other three were treated with temnolysis, resulting iii a functiomnal 

recovery which was almost normal in one amid perfect in amnother. In the third, 

complete flexion w’as regained but a new progressive linnitatiomn of extemnsioii was 

produced by flexion contracture of the proximal interphalangeal joint. 

I recently reoperated on this last-mentioned finger, resectimng the retracted 

mew sheath amid the volar ligament of the proximal interphalangeal joimit. Luckily, 

the final result, at the time of writing, is good, the patient having worn an elastic 

dorsal splint. 

Gemierally, results, as in the case of grafts, seem to depemid omi the trophic 

state of the finger, and, therefore, on the presence of concomitant laceration of the 

digital mierves. Possibly, the results also depend, to sonic extemnt, omi the integrity 

of the periosteal covering of the phalanx. 

It is worthy of note that even a poor result in the imidex finger can give useful 

fumnction since pinch between the thumb and index finger will be possible. The 

absemice of complete flexion is a less severe handicap in the index finger than in the 

other three fingers, as was pointed out by Pulvertaft in connection with temndomn 

grafts. The same argument is applicable for primary sutures. 

Multiple Sections 

I believe that w’hemi the flexors of several fingers have been cut simultaneously, 

repair by a secondary graft becomes particularly difficult. To perform multiple 

tendon grafts at one operation is a very long and detailed procedure. 

The time required for the functional re-education will be longer, adhesions 

of grafts will be more difficult to liberate, and the patient’s period of incapacity 

will be longer. 

When the flexor tendons of several fingers have been severed, primary repair 

-a relatively short operation-seems all the more justified. Inn the hands of a 

specially trained surgeon primary repair does not endanger the future of the hanid 

and offers the possibility of restoring adequate function by performing omnly a 

secondary localized tenolysis on one or more fingers or, if need be, a complete 

tenolysis. Moreover, after primary repair the possibility of doing a later graft still 

exists. 

If the patiemit can start working soon after the primary suture, dystrophic 

changes in the injured hand will be minimized. These chamiges are so frequemnt amid 

sometimes so serious after the flexor tendons of several fingers have been severed, 

that one often hesitates to undertake the risk of a secondary tendon graft. In the 

meantime, the tendon sheaths contract and become obliterated, the articulatiomns 

become stiff, and success is jeopardized. 

CONCLUSIONS 

Although my series of nineteen cases of primary sutures and sixty tendomi 

grafts is a modest one, I believe, nonetheless, that it entitles me to state that 

primary repair of the flexor tendons in no man’s land, performed according to 

certain technical rules, is a valid operation for fresh, cleanly cut wounds. 

Results of primary repair appear to me, as far as quality is concerned, the 

same as, if not superior to, those obtained by tendon grafts. 

Regarding fresh simultaneous lacerations of the tendons of several digits, my 

preference for primary suture becomes imperative. 

SUMMARY 

The rule hitherto adopted that tendon grafts should be performed in preference 

to primary repair of tendons cut in Bunnell’s no man’s land is too rigorous. 

Delayed tendon-grafting is only justified for those physicians having no experience 

in hand surgery or when general or local conditions do not allow innmediate 

repair. 

VOL. 42-A, NO. 4, JUNE 1960

656 c. E. VERDAN 

For cleanly cut, fresh w’ounds, specialists capai)le of performinng temndomn grafts 

correctly, are a fortiori qualified to effect successful primary sutures. ‘rhe tech- 

mii(lue proposed comisists un excisimng the sublimis, suturing the profumndus accum’ateiy 

with fine epitendinous stitches, resecting the sheath inn the regiomi of the 

repair, amid immobilizing the emids of the tendon with two transverse stainlesssteel 

pius to prevemnt tensiomn omi the delicate suture himne, w’hich is (‘oniparal)le to 

that in a nerve suture. 

Should adhesions hinder gliding, a secondary temnolysis will pi-oduce functional 

results often better thami those obtained by tendon grafts. 

For multiple simultaneous flexor-temidomi lacerations iii several digits, primary 

repair is evemn more justified thamn for a tendon laceration imi one digit. 

REFERENCES 

1. BOYES, J. H. : Flexor-Tendon Grafts in the Fingers and Thumb. Ann Evaluatiomi of Lmnd Results. 

J. Bone and Joint Surg., 32-A: 489-499, July 1950. 

2. BOYES, J. H. : 1)iscussion. Le Sixi#{232}me Congr#{232}s Intenmnational de la Soci#{233}t#{233} Int.ernationale (1(’ 

Chirurgie Orthop#{233}dique et de Traumatologie, Berne, Switzerland, 1954. Bruxelles, lmnnprimnerie 

Lichens, 1955. 

3. BUNNELL, STERLING: Surgery of the Hand. Ed. 3. Philadelphia, J. B. Lippincott Co., 1956. 

4. KOCH, S. L. : 1)ivisiomn of the Flexor Tendons withimn the 1)igital Sheath. Surg., (iymiec., amid 

Obstet., 78: 9-22, 1944. 

5. IASox, M. L. : Primary amid Secondary Tenndon Suture. A 1)iscussion of the Sigmnificamice 

of Technique in Tendon Surgery. Sung., Gynec., and Obstet., 70: 392-402, 1940. 

6. MASON, M. L., and ALLEN, H. S. : The Rate of Healing of Tendons. Ami Expenimelntal Study of 

Tensile Strength. Ann. Sung., 113: 424-459, 1941. 

7. MASON, M. L., and SHEARON, C. G. : The Process of Temndomn Repair. An 1’x1)eninn(’nital Study 

of Tendon Suture and Tendon Graft. Arch. Sung., 25: 615-692, 1932. 

8. IULVERTAF’F, H. G. : Repair of Tendonn Injuries in the Hand. Annn. Roy. CoIl. Sung. Emigland, 

3: 3-14, 1948. 

9. PULVERTAFT, R. G. : Repair of Tendomi Injuries inn the Hamnd, with Special Reference to Flexor 

Tendomns. Postgrad. Med., 8: 81-87, 1950. 

10. PL’LVERTAFT, H. G. : Experiences in Secondary Flexor Temidon Grafting in the Hand. Acta 

Orthop. Belgica, :Z4 (Supplementum 3): 62-74, 1958. 

1 1. RoBINS, R. H. C. : The Primary Reconstruction of the Imnjured Hand. Ann. Roy. CoIl. Sung. 

England, 14: 355-370, 1954. 

12. VERDAN, C. F:. : Chirurgie R#{233}paratnice ct Fomictionnelle des Tendomns (he itu Main. Paris, L’Expansion 

Scientifique Fran#{231}aisc, 1952. 

13. VERDAN, C. E. : La nparation immediate des tendons fl6chisseuns darns Ic canal digital. Acta 

Orthop. Belgica, 24 (Supplementum 3): 15-23, 1958. 

14. VERDAN, C. B., and MIcH0N, JACQUES: T#{233}nolyse des tcmndons flchisseurs (1(’s doigts. Animi. 

Chin. Plastiquc, 4: 283-296, 1956. 

1)ISCUSSION 

DR. MICIIAEL L. MASON, CuIcAGo, ILLINOIS: The only area of the hand where there is nnajor 

disagreement concerning primary tendon repair is in what has been euphemistically called mo man’s 

land, and I should like to confimne my few remarks to that phase of the problem. It was not too 

many years ago that the grafting of tendons in this area of the hand seemed to be am insurmountable 

problem and was undertaken with little assurance of success. In fact, the solution for the problem 

of a motionless fimiger was often amputation. Even today, temidon-grafting in the digits is undentaken 

omily when conditions are satisfactory and by surgeons well trained in the technique. Even 

so, tendon grafts in the digits are by no means 100 per cent successful and many iingenious measurennents 

are made to gauge the degree of return of function. No one suggests, however, that tendongrafting 

should be abandoned ; but, simply, that before it is undertaken the surgeon should have 

mastered its technique. 

By technique one does not necessarily mean the various steps in the operative i)rOcedure, 

since these are easily learned and have beemn very adequately illustrated. Technique implies much 

more than that: it connotes the manner in which the surgeon handles the tissues. It took many 

years for the surgeon to realize the significance of Listen’s antiseptic system, which as it developed 

emphasized two points. These were: first, to prevent the access of infectious organisms to a wound, 

and, second, to do as little harm as possible to the tissues, since they could cope with only minimum 

contamination. It has taken less time for us to realize what Halsted taught, namely, the need for 

gentle, meticulous handling of tissues, careful hemostasis, and the use of fine, non-absorbable 

sutures. The general surgeon has, perhaps, been somewhat slow to adopt the Halsted technique. 

However, two surgical specialties developed to their present degree of perfection to a great extent 

because Halsted’s teachings enabled the surgeon to carry out procedures previously thought 

impossible to accomplish. These specialties are neurosurgery and plastic surgery. There is no doubt 

but that vascular surgery, likewise, owes such of its success to the careful techniques inaugurated 

by Halsted. 

THE JOURNAL OF BONE AND JOINT SURGERY


\(‘rdan has given ms sOflie en(’ouragement ill the pursuit of this prohlem amid his method of 

l)rinnarN repair 1)3’ relaxation of tine sutured tendon by transfixion through ann area away from the 

site of repair, careful appositiomi of the tendon ends with a few fine sutures, and unroofing of the 

lil)rOlms canal over the area poimnt up the essentials of tendon repair; adequate relaxation of the site 

of repair, minimum disttmrhamnce of the tendon by suture and handling, and provision for the site 

of r(’pair to lie in soft areolar and fatty tissue from which the initial elements of healing and blood 

Stm1)l)l’ must come. This is the same goal that Bunnell attempted to reach with his pull-out wires. 

More recently, an Austrian surgeon, Bsteh, has developed a techniqume along the same principles. 

This surgeon hnimngs the divided tendoni ends together by tractiomn on the proximal stumps in the 

palm well away from the site of divisiomi and themn transfixes them with a stainless-steel hypodermic 

needle which is 1)rished into the peniosteum of the metacarpal. Only one or two fine sutures are 

1)lac(’d in the peritenoneum of the site of division. The fibrous temidoin sheath at the site of injury is 

relaxed by lateral incisions. 

A method described some years ago has proved successful in a number of instances and it, 

too, follows these principles : relaxatiomn by sutures placed some distance from the site of division, 

accurate appositiomn of tendon emids with a few fine sutures, and excision of fibrous sheath to leave 

a window over the area of healing. This method is not perfect because it entails perhaps more 

handling of the tendon than necessary. \\‘hen it. fails, the failure is 1)rObablY dime to tendon irritation 

at tine site of repair. 

The plea I should like to make is that we do mnot take a completely pessimistic or defeatist 

attitunde toward primary n’pair in this critical zone. It is a most. frequent site for temidon division 

:01(1 where suitable cases present themselves, it would be most advantageous to the patient if 

PrimarY repair could be carried mit with reasomiable assurance of success. However, only by constamitlv 

striving to better our tcchmiique, by following the example of the plastic surgeon, and by 

observing the 1)nilicih)les of tendon repair can we obtain this end. 

a. BSTEH, 0. : Schnentransfixation bei Sehnenidurcht.rennungen . Chirurgische Praxis, 3: 

317-320, 1958. 

I )R. J. \‘SILLIAII LITTLER, NEw \ORK, N. V. : It is obvious that I)r. Verdan has developed 

a techiliiqlie of great. value for this difficult problem. 1)espite a limited experience with primary 

tendomi repair ni’ frequent encounters with the secomndary problem make me appreciate his contrihimtiomn 

all tine more. With his technique more early tendon repairs can be performed with more 

optimism than heretofore. 

A better understanding of the retimnaculan system of a1m amid digits is needed in ten(lomi 

surg(’ry. A full-length fibrous sheath is not required for good tendomn function. Two strategically 

J)laced pu1le’s fulfill the mechanical demand and prevent tendomn prolapse at the metacarpo- 

J)halaligeal Itri(i interphalangeal levels. These need be no wider than one-fourth of an imnch and 

should, if 1)ossible, be left at the base of the proximal phalanx and at the center of the middle 

phalanx. The remainder of the fibrous sheath may be discarded. This is especially important at the 

site of injury amid repair. However, in I )m . Verdan’s repair enough of the fibrous sheath must be 

left. for l)roximal t.ransfixion of the temndomn. 

IRt. us hope, thnat with more attenit.ion to l)r. Verdan’s refimned linethiOd more of us can ap- 

Proach his results. 

1)R. JOSEPH H. BOYES, Los ANGELES, CALIFORNIA: This paper poimits out somethimng that Dr. 

Michael Mason brought out some years ago : the importance of excision of the sheath at the point 

of primary repair. It is commonly believed that a flexor tendon must have a tendon sheath in order 

to function, but this is not necessarily true. There are many tendons in the body that do not have 

sheaths. Excision of the sheath allows a blood supply to be provided. The same thing is true of 

tendon grafts. If a tendon graft in the finger is to survive, it must have a blood supply. If a tendon 

is 1)ut through the sheath it will die. Gonzalez showed that by putting polyethylene around the 

tendon the blood supply was cut off. I h)eheve that the blood supply for a repaired tendon comes 

from the comntiguous soft tissues and I make it a point to excise all the sheath except at the two 

sites mentioned by Dr. Littler. I am not convinced that relaxation of the tendon is obtained 

by transfixion. In about twenty primary repairs done with simple suture amid with mno transfixion 

I believe we have had only one or two complete failures. Our percentage of secondary tenolyses 

was not quite so high as Dr. Verdan’s. 

l)R. VERDAN (closing): I am very happy that I found a positive echo in the discussions of 

1)r. Mason, I)r. Littler, and Dr. Boyes. I should like to insist on what I said at the beginning of 

my paper: one who is capable of making a graft of a flexor tendon is also capable of making a 

primary repair. You can say the same thing in a negative way : one who is not capable of making 

a tendon graft will not be capable of making a primary repair. I think we have to be very prudent 

in doing this primary repair. 

VOL. 42-A. NO. 4, JUNE 1960

Primary Repair of Flexor Tendons - The Journal of Bone & Joint ...

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