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Flexor Tendon Repair


- Anatomy:
      - on volar aspect of finger, FDP passes through FDS to insert on distal phalanx;
      - both long flexor tendons are tightly enclosed in common tendon sheath which corresponds to zone II;
      - anatomical proximity explains the development of adhesions between FDS & FDP tendons & digital
               fibrous sheaths following injury;
      - excursion of tendons
      - tendon sheath anatomy

- Partial Laceration of Flexor Tendons

- Primary Tendon Repair:
     - tendon injuries are usually repair primarily, esp in clean wounds;
     - surgical approach and statedgy are dependent on location of tear:
             - FDS Laceration
             - FDP Laceration  (FDP avulsion)
             - Zone I Injuries
             - Zone II injuries
             - Zone III injuries
             - Zone IV and Zone V
     - Tendon Repair Technique:
             - core suture techniques
             - optimizing tension in flexor tendon repair:

- Primary Flexor Tendon Grafting
- Staged Flexor Tendon Repair:
     - optimizing tension in flexor tendon repair
     - prosthetic Grafts
     - pulley reconstruction
     - complications:
            - delayed primary repair is complicated by enlargement of proximal tendon end, which contracts into palm and thus cannot be
                      passed back through narrow digital sheath;
            - adhesions will also restrict tendon from entering the tendon sheath;
            - if these conditions are encountered then consider a tendon graft;

- Pulley Reconstruction:
    - Tendon Sheath Anatomy

- Post Operative Care

- Complications:
    - tendon rupture
    - adhesion formation: (see: flexor tenolysis)
           - adhesions form if part is immobilized because the wound in sheath and wound in the tendon grow together;
                  - if part is kept mobile, they heal separately, and function is more likely to be restored;
                  - collagen tensile strength across the repair is not sufficient to permit active loading for 4-5 weeks
           - on exam, patient will demonstrate loss of active flexion, but relative maintenance of active extension and maintenance of
                  passive flexion;
           - severe adhesion formation is managed with tenolysis
           - ref: Effects of Nonsteroidal Anti-Inflammatory Drugs on Flexor Tendon Adhesion 
    - flexion contracture:
           - may occur in up to 20%;
           - distinguish between true flexion contracture (loss of both active and passive ROM) and flexor tendon adhesions (loss of active
                   ROM only);      
           - occurs as a result of holding finger in the flexed position;
    - swan neck deformity:
           - especially likely to happen, in pts w/ hyperextensible PIP joint;
           - can occur after primary repair of FDP or free tendon grafting;
           - may result from complete excision of FDS;
                  - see: swan neck deformity following FDS harvest;
                  - when FDS is exised at its insertion, the vinculum is also excised, which damages the checkrein of PIP allowing to fall into
                  - as extensor apparatus becomes lengthened from PIP hyperextension, the terminal phalanx will sag into flexion;
                  - lateral bands displace dorsally;
           - to prevent swan neck deformities:
                  - avoid excision of FDS farther distally than neck of middle phalanx or just proximal to the vinculum
    - references:    
           - Treatment of unfavourable results of flexor tendon surgery: Ruptured repairs, tethered repairs and pulley incompetence.


Bridge flexor tendon grafts.

Angiogenesis in healing autogenous flexor-tendon grafts.

Autogenous flexor-tendon grafts. A biomechanical and morphological study in dogs.

Work of flexion after flexor tendon repair according to the placement of sutures.

Practice patterns in flexor tendon repair.

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