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25th Anniversary Presentation

Development of Flexor Tendon
Surgery: Twenty-Five Years
of Progress
James W. Strickland, MD, Indianapolis, IN

Regaining satisfactory digital function after flexor
tendon laceration and repair within the digit has long
been one of the most difficult problems in hand
surgery. Until the 1960s it was universally recommended that tendons divided in the digit (then referred to as “no man’s land”) should not be repaired.
Bunnell taught that “it is better to remove the tendons
entirely from the finger and graft in new tendons
smooth throughout its length.”1 That dictum remained sacrosanct until the 1960s when reports by
Verdan,2,3 Kleinert et al,4 and Kessler and Nissim5
challenged the concept that flexor tendons should not
be repaired primarily. These investigators noted that
when done correctly, immediate tendon suture would
outperform secondary free tendon grafting. Armed
by those encouraging reports, there was a gradual
and cautious development of the concept and practice of primary flexor tendon repair. Initially, primary
tendon repair was often combined with anecdotal
protocols by Duran et al,6 Lister et al,7 and Strickland and Glogovac8 for applying varying amounts of
early post-repair motion to the repaired tendons.
As often happens with advances in medicine, the
efforts to improve the performance of flexor tendon
repairs were based almost entirely on individual exFrom the Indiana Hand Center, Indianapolis, IN.
Received for publication October 25, 1999; accepted in revised form
December 6, 1999.
No benefits in any form have been received or will be received from
a commercial party related directly or indirectly to the subject of this
Reprint requests: James W. Strickland, MD, Indiana Hand Center,
8501 Harcourt Rd, Indianapolis, IN 46280.
Copyright © 2000 by the American Society for Surgery of the Hand

214 The Journal of Hand Surgery

perience and clinical experimentation with little or
no scientific support. The last 25 years, however,
have heralded an enormous amount of basic research
designed to improve our knowledge of the structure
of tendons, including the kinesiology, the biomechanics of their action on the joints they move, their
biologic response to injury and repair, the mechanical characteristics of various tendon suture constructs, and the effect of post-repair motion stress on
tendon strength and healing. These investigative efforts have given rise to improved methods of tendon
repair, a greater emphasis on flexor sheath preservation and restoration, and protocols for the early application of passive and active wrist and digital motion as a means to more rapidly increase the strength
and gliding of repaired tendons. The following sections will provide a concise review of some of the
most important of these reports.

Basic Science of Flexor Tendon Surgery
Flexor Tendon Morphology
Many recent studies have investigated biology,
histology, innervation, lymphatic drainage, ultrastructure, biochemical composition, physical characteristics, energy storage, and response to loading of
the normal and injured animal and human tendon and
tendon sheath. Much of this work has been summarized by Gelberman et al,9 and this body of laboratory information has proven to be extremely valuable
to the clinician’s efforts to improve results.
In summary, tendons are composed of approximately 70% molecules made up of peptide chains in
a triple helix configuration (tropocollagen). Tendon
fascicles consist of long, narrow, spiraling bundles of

The Journal of Hand Surgery / Vol. 25A No. 2 March 2000 215

Figure 1. Lateral (top) and palmar (bottom) views of a finger depict the components of the digital flexor sheath. The sturdy
annular pulleys (A1, A2, A3, A4, and A5) are important biomechanically in keeping the tendons closely applied to the
phalanges. The thin, pliable cruciate pulleys (C1, C2, and C3) collapse to allow full digital flexion. A recently described
addition is the palmar aponeurosis pulley (PA), which adds to the biomechanical efficiency of the sheath system.

mature fibroblasts (tenocytes) and type I collagen
fibers. The surface of the individual bundles of collagen is covered by the endotenon; externally, the
septa of the endotenon join together to form a fine
fibrous outer layer, the epitenon, that covers the
surface of the tendon. In the hand, the flexor tendon
fascicles are covered by a thin visceral and parietal
adventitia, the paratenon, that is associated with a
fluid environment similar to synovial fluid.

Flexor Tendon Anatomy
While historic anatomic descriptions of flexor
muscle tendon anatomy have largely stood the test of
time, recent investigations have added greatly to our
understanding of the restraint system within the digit.
Flexor tendon sheaths, with their predictable annular
pulley arrangement (Fig. 1), serve not only as a
protective housing for the tendons, but also provide a
smooth gliding surface by virtue of their synovial
lining and an efficient mechanism to hold the tendons
close to the digital bone and joint. Although there is
some controversy about the exact anatomy and nomenclature of the elements of the flexor tendon
sheath, the original descriptions of Doyle and

Blythe10 –14 as supplemented by the findings of
Hunter15 and Manske and Lesker16 (aponeurosis pulley) remain the accepted “working” system for most
hand surgeons.

Flexor Tendon Nutrition
Studies during the last 25 years have added to
some existing understanding of the nutrition of flexor
tendons. Studies by Armenta and colleagues,17,18
Azar et al,19 Caplan et al,20 Chaplin,21 Hooper et
al,22 Hunter,15 Lundborg and colleagues,23–27 Manske and colleagues,28 –31 Ochiai et al,32 Peterson et
al,33 Weber,34,35 and Zbrodowski et al,36 among others, have established an understanding that tendons
receive nutrition from both vascular and synovial
sources. The vascular perfusion of flexor tendons is
provided by longitudinal vessels that enter in the
palm and extend down intratendinous channels, vessels that enter at the level of the proximal synovial
fold in the palm, segmental branches from the paired
digital arteries that enter in the tendon sheaths by
means of the long and short vincula, and vessels that
enter the flexor digitorum superficialis (FDS) and
flexor digitorum profundus (FDP) tendons at their

216 James W. Strickland / Development of Flexor Tendon Surgery

Figure 2. The blood supply to the flexor tendons within the digital sheath. The segmental vascular supply to the flexor
tendons is by means of long and short vincular connections. The vinculum brevis superficialis (VBS) and the vinculum
brevis profundus (VBP) consist of small triangular mesenteries near the insertion of the FDS and FDP tendons,
respectively. The vinculum longum to the superficialis tendon (VLS) arises from the floor of the digital sheath of the
proximal phalanx. The vinculum longum to the profundus tendon (VLP) arises from the superficialis at the level of the
proximal interphalangeal joint. The cutaway view depicts the relative avascularity of the palmar side of the flexor tendons
in zones I and II compared with the richer blood supply on the dorsal side, which connects with the vincula.

osseous insertions. Both tendons have relatively
avascular segments over the proximal phalanx; the
profundus has an additional short avascular zone
over the middle phalanx (Fig. 2).
Synovial fluid diffusion provides an effective alternative nutritional and lubricating pathway for
flexor tendons. The rapid delivery of nutrients is
apparently accomplished by a pumping mechanism
known as imbibition in which fluid is forced into the
interstices of the tendon through small conduits in
the tendon surface as the digit is flexed and extended.
The clinical importance of these nutrition studies
relates to an appreciation that the biologic response
to injury and the healing of repaired flexor tendons
may be substantially affected by injury to the vascular and tissue fluid nutritional systems.36 – 42 Because
these nutritional sources are vital to rapid tendon
healing and the restoration of gliding, it is imperative
that the surgeon respect their integrity during all
reparative efforts.

Biomechanical Properties of Flexor Tendons
In recent years much has been done to study the
normal and injury-altered mechanics of the human

flexor tendon system. In particular, the work of Amadio et al,43 Brand and colleagues,44 – 47 Doyle and
Blythe,10 –14 Hume et al,48 Idler,49 Lin et al,50,51
Mitsionis et al,52 Peterson et al,53 Phillips and
Mass,54 Pring et al,55 Thompson and Giurintano,56
Walbeehm and McGrouther,57 and Zissimos et al58
has made us appreciate the importance of preserving
and restoring the normal anatomy and function of the
flexor tendon system.
The greater the distance a tendon is from the axis
of joint rotation, the greater the moment arm and the
less motion that a given muscle contraction will
generate at that joint. Conversely, a shorter moment
arm will result in more joint rotation from the same
tendon excursion. The moment arm, excursion, and
joint rotation produced by the flexor tendons is governed by the constraint of the pulley system. Loss of
portions of the digital pulleys may significantly alter
the normal integrated balance between the flexor,
intrinsic, and extensor tendons. The A2 and the A4
pulleys are the most biomechanically important; the
loss of a substantial portion of either may diminish
digital motion and power and lead to flexion contractures of interphalangeal joints (Fig. 3).

The Journal of Hand Surgery / Vol. 25A No. 2 March 2000 217

Figure 3. The function of the finger flexor tendon pulley
system. (Top) Arrangement of the annular (A1, A2, A3,
A4, and A5) and cruciate within the intact fibro-osseous
canal and the normal moment arm (MA) and FDP tendon
excursion as the proximal interphalangeal joint is flexed
90°. (Bottom) Biomechanical alteration that results from
excision of the distal half of the A2 pulley; the C1, A3, and
C2 pulleys; and the proximal portion of the A4 pulley. The
distance between the distal edge of the A2 pulley and the
proximal edge of the A4 pulley is the intra-annular pulley
distance (IAPD). The moment arm is increased and a
greater FDP tendon excursion is required to produce 90°
flexion because of the bowstringing that results from the
loss of pulley support.

Flexor tendon excursion studies by Horibe et
al,59 McGrouther and Ahmed,60 and Wehbe and
Hunter61,62 indicate that as much as 9 cm of flexor
tendon excursion may be required to produce composite wrist and digital flexion, while only approxi-

mately 2.5 cm is required for full digital flexion with
the wrist stabilized at neutral (Fig. 4).
The pressure between the normal digital pulleys
and the flexor tendon may be considerable during
active flexion according to experimental measurements reported by Lin et al50,51 and Manske and
Lesker.63 In addition, the frictional forces existing
between normal and sutured gliding tendons have
been reported by An et al,64 Coert et al,65 and
Uchiyama et al.66
From studies conducted by Bright and Urbaniak,67
Evans and Thompson,68 Greenwald et al,69 and
Schuind et al,70 it appears that during unresisted
passive flexion, flexor tendons are subjected to 2 to 4
N of force. Active flexion with mild resistance may
result in up to 10 N of force, moderate resisted
flexion in up to 17 N, and strong composite grasp in
up to 70 N; firm tip pinch can apparently generate as
much as 120 N of tensile load on the index FDP.
Schuind et al70 have demonstrated that the forces
produced by the FDS tendon are less than those
produced by the FDP during grasp and pinch. The
forces required to produce full excursion and the
work (force ⫻ distance) of flexion are increased
significantly after flexor tendon repair according to
study results reported by Aoki et al,71–73 Halikis et
al,74 and Lane et al.75 The information from these
studies can help generate force estimates that can be
plotted against strength estimates of various flexor
tendon repairs to determine the relative safety of
post-repair motion protocols during the healing process.

Tendon Healing
In the last 3 decades there have been an enormous
number of published investigations dealing with the
biology of the tendon healing process. Convincing
studies by Becker et al,76 Garner et al,77 Gelberman
et al,78,79 Lundborg and Rank,80 Manske et al,81– 84
Mass and Tuel,85,86 Matthews and Richards,87,88 McDowell and Snyder,89 and Umeda90 have dispelled
the previous concept that tendons lacked the intrinsic
biologic capability to participate in their own healing. Almost all students of tendon healing now believe that tendons have both an intrinsic and an
extrinsic capability to heal and that the relative contribution of each will depend on factors that relate to
the injury and the surgical repair.
In the clinical setting it is impossible to isolate the
2 types of healing and the cellular events are similar
for all flexor tendons (Fig. 5). Tendon healing involves an inflammatory phase from 48 to 72 hours

218 James W. Strickland / Development of Flexor Tendon Surgery

Figure 4. Approximate flexor tendon excursion (measured in mm) necessary to produce full flexion of digital joints at the
forearm, wrist, hand, and digital levels. P, FDP; S, FDS.

after repair, a fibroblastic- or collagen-producing
phase from 5 days to 4 weeks, and a remodeling
phase that continues until approximately 112 days.
During the inflammatory phase of tendon healing the
strength of the repair is almost entirely that which is
imparted by the suture itself with a modest contribution from the fibrin clot between the tendon ends.
Strength increases rapidly during the fibroblastic collagen-producing phase when granulation tissue is
formed in the defect. When extrinsic healing predominates, adhesions between the tendon and its
surrounding tissues are inevitable while healing that
is largely based on intrinsic cellular activity will
result in fewer, less-dense adhesions.
A large amount of research is currently being
conducted in an effort to understand the influence
that soluble polypeptides, including growth factors,
hormones, and chemotatic factors such as fibronectin, exert on the cellular sequence of tendon healing.91–100 These factors play a role in both normal
and pathologic processes, and their clinical manipulation may greatly improve the outcome of tendon
repair and rehabilitation.
Externally applied modalities have been used in an
attempt to favorably alter flexor tendon healing. Gan
et al101 and Roberts et al102 studied the effects of
ultrasound, Fujita et al103 evaluated constant direct
electrical current, and Greenough104 used pulsed
electromagnetic fields. Although these methods have
promise, none has yet found its way into the postrepair armamentarium of most hand surgeons.
In a series of outstanding laboratory experiments

and reviews, Gelberman and colleagues9,105–109
demonstrated that the application of early passive
motion stress to repaired canine tendons led to a
more rapid recovery of tensile strength, fewer adhesions, improved excursion, better nutrition, and minimum repair site deformation compared with immobilized tendons. These investigators concluded that
passive mobilization enhances healing by stimulating
maturation of the tendon wound simultaneously with
the remodeling of tendon scar. Hitchcock et al110 and
Aoki et al71–73 have added to these studies with their
findings that active (in contrast to passive) mobilization applies stress to the sutured tendon, enhances the
strength of the repair and the biologic response, and
obviates the loss of tensile strength during the first 3
weeks of healing. From these reports it has been
clinically accepted that the most effective method of
returning strength and excursion to repaired tendons
involves the use of a strong, gap-resistant suture
technique followed by the application of early postrepair controlled motion stress.

Adhesion Formation and Control
Factors that influence the formation of excursionrestricting adhesions around repaired flexor tendons
include trauma to the tendon and sheath from the
initial injury and the reparative surgery, tendon ischemia, tendon immobilization, gapping at the repair
site, and excision of components of the tendon
sheath. In 1964 Potenza111 described the quantitative
formation of adhesions in proportion to the amount
of tissue crushing and the number of surface injuries

The Journal of Hand Surgery / Vol. 25A No. 2 March 2000 219

Figure 5. The biologic sequence of tendon healing. (Top left) At 1 week an inflammatory response predominates and the
laceration site is filled with cells that originate from the extrinsic peritendinous tissue, epitenon, and endotenon. The cells
proliferate; their function is largely phagocytosis and the synthesis of new collagen. (Top right) At 3 weeks there is marked
fibroblastic proliferation from the endotenon and epitenon, and these fibroblasts participate in both synthesis and resorption
of collagen. The fibroblasts and collagen are in a plane perpendicular to the long axis of the tendon and revascularization
increases at the repair site, including penetration of the former avascular zones by a new vessel. (Bottom) At 8 weeks the
collagen is mature and realigned in linear fashion. Adhesions are stimulated both by the initial trauma to the tendon and
sheath and by immobilization.

to the tendon, giving further support to the timehonored advice of Bunnell1,112 that a meticulous
surgical technique must be used for flexor tendon
surgery. Pennington42 and Amadio et al43 have
shown that disruption of the vincula also has been
associated with a decrease in the recovery of tendon
excursion and Gelberman et al,9,109 Lister,113,114 Oei
et al,115 Peterson and colleagues,33,116,117 Saldana et
al,118 Tang and colleagues,119,120 and Tonkin and
Lister121 have provided studies and commentary regarding the pros and cons of repairing the tendon
Various biochemical agents have been studied in
an attempt to modify adhesion formation around
tendon repairs. Douglas et al122 and Lindsay and
Walker123 studied the effect of antihistamines and
the potential benefits of various steroid preparations

was reported by Ketchum.124 Nonsteroidal anti-inflammatory drugs have been subject to the most
recent laboratory investigations. Kulick and colleagues125,126 have provided laboratory and clinical
evidence that ibuprofen was beneficial and Carstedt
et al127,128 and Szabo and Younger129 have demonstrated the possibility of improving tendon excursion
by blocking prostaglandin synthesis through the inhibition of the enzyme cyclooxygenase at the cell
level. Peacock et al130,131 attempted to create controlled lathyrism with oral or topically applied betaaminoproprionitrile with varying degrees of success.
Amiel et al,132 Frykman et al,133 Hagberg and Gerdin,134,135 Porat et al,136 Salti et al,137 and St Onge et
al138 have evaluated various forms of hyaluronate
(sodium hyaluronate or hyaluronic acid), topically
enriched collagen solutions, and fibrin sealants;

220 James W. Strickland / Development of Flexor Tendon Surgery

while some of these compounds have demonstrated
laboratory or clinical usefulness, none have found
their way into widespread clinical usage. Efforts to
mechanically block adhesion connections to repaired
flexor tendons also have been described. The fact
that none of these methods have made their way into
recognized hand surgery publications testifies to their

Flexor Tendon Repair
In recent years there have been a large number of
published reports that describe new and allegedly
better methods of flexor tendon repair and post-repair
motion protocols. These investigations stem from the
consensus that the greater the increments of repair
site stress and tendon excursion, the quicker the
tendon will achieve normal tensile strength with
fewer motion-restricting adhesions. Interpreting
these reports and comparing them with other studies
is difficult because they use different laboratory
models, in vivo versus in vitro investigations, different testing methods, and diverse definitions of failure. Nevertheless, there have been major advances in
the strength and gap resistance of tendon suture
techniques, permitting more vigorous post-repair
motion protocols and a global improvement in results.
Armed with substantial advances in the basic science of flexor tendons and the results of studies
evaluating different methods of tendon suture and
rehabilitation, many widely held concepts have been
clinically abandoned. Primary repair of flexor tendons severed in the digital sheath has universally
replaced the “no man’s land” concept, which favored
secondary grafting. The concept that flexor tendon
repair should be considered a surgical emergency
also has been effectively dispelled by studies by
Arons,139 Gainor,140 Green and Niebauer,141 Honner,142 Madsen,143 Matev et al,144 Salvi,145 Schneider et al,146 among others, which demonstrate that
equal or better results usually can be achieved by
delayed primary flexor tendon suture. Bolton,147
Brown,148 Fetrow,149 Jensen and Weilby,150 Kleinert
et al,151 Strickland,152 and others also have effectively shown that it is better to repair both the FDP
and FDS tendons rather than the FDP alone, as once
was thought to be the wiser option. Flexor digitorum
profundus advancement, which was once advocated
for distal zone I injuries, has now been largely dis-

carded in favor of direct suture, which better maintains the normal digital balance of the injured and
adjacent digits.

Flexor Tendon Retrieval
An appreciation for the need to protect the delicate
synovial lining of the flexor tendon sheath and the
potential for motion-restricting adhesions to be propagated by repeated efforts to retrieve a retracted
tendon end has given rise to several creative methods
of facilitating tendon capture and repositioning.
Kleinert et al153 recommended proximal-to-distal
milking of the tendons toward the repair site and
Rice and Yanni154 described the use of a reversed
Esmarch tourniquet technique. Morris and Martin155
used skin hooks passed down the sheath to engage
the tendon stumps, while Pennington156 used a suction catheter. The use of various catheters and silicone rods has been described by Kilgore et al,157
Sourmelis and McGrouther,158 and Titley.159

Flexor Tendon Suture Techniques
Core sutures. Strickland160 listed the characteristics of an ideal primary flexor tendon repair:

Sutures easily placed in the tendon
Secure suture knots
Smooth juncture of tendon ends
Minimal gapping at the repair site
Minimal interference with tendon vascularity
Sufficient strength throughout healing to permit the
application of early motion stress to the tendon

Published investigations of the characteristics and
performance of differing flexor tendon repairs have
added greatly to our understanding of the best way to
suture a tendon in preparation for the application
of motion stress. Urbaniak et al,161 Komanduri et
al,162 Savage and Risitano,163,164 Silfverskio¨ld and
Andersson,165 Shaieb and Singer,166 and Strickland,167–170 have shown that the strength of a flexor
tendon repair is roughly proportional to the number
of suture strands that cross the repair site. Trail et
al171,172 demonstrated that flexor tendon repairs usually rupture at the suture knots. Mashadi and Amis173
studied the effect of locking loops on repair strength
and concluded that they contributed modestly to
strength but could collapse and lead to gapping at
moderate loads. Hatanaka and Manske174 studied the
effect of the cross-sectional area of locking loops and
concluded that an increase of 10% to 50% resulted in
a proportionate increase in the ultimate tensile

The Journal of Hand Surgery / Vol. 25A No. 2 March 2000 221

strength of the repair. Hotokezaka and Manske175
observed that the locking loop suture configuration
tightened around tendon fibers and increased tensile
strength compared with grasping loops, which pulled
through tendon fibers when tensile forces were applied. Increasing the number of grasping loops increased the propensity for tendon gapping. Taras176
confirmed that larger-caliber sutures significantly increase repair strength.
Ketchum et al177,178 found that a polyfilament ensheathed by caprolactan (Supramid, S. Jackson, Inc,
Alexandria, VA) was the best tendon suture material;
this is currently one of only a few sutures that are
available with 2 strands per needle. Absorbable sutures have been developed for tendon repair and
seem advantageous because of low long-term foreign
body tissue reaction and reduction of stress shielding
effects of the host tissue. Unfortunately, the optimal
rates of material absorption and strength reduction
are yet to be determined. Trail et al171 suggested that
3– 0 or 4 – 0 braided sutures were clinically practical
for flexor tendon repair because of their ease of
placement, adequate strength, and minimum extension at time of failure.
Aoki et al179 and Pruitt et al180 indicated that the
fewer the suture knots located in the tendon junction
site the better, and that whenever possible it was best
to locate knots outside the repair despite the potential
for increased frictional drag on the tendon. Soejima
et al,181 Komanduri et al,162 and Aoki et al72 have
also convincingly showed that there are significant
strength and biomechanical advantages to dorsal
rather that palmar placement of core sutures. Finally,
Trail et al172 have pointed out the importance of
having equal tension across all suture strands to
prevent differential loading and a consequent weakening of the repair.
The observation that the number of suture strands
crossing the repair strongly influences the strength of
the repair has initiated a departure from the 2-strand
core sutures that were clinically dominant until the
last 10 years. A number of 4-strand, 6-strand, and
even 8-strand methods or their strength equivalents
have been described in recent hand surgery literature
and some are now in clinical use. Lee,182,183 Robertson and Al-Quattan,184 and Strickland167,168,170 have
described 4-strand methods that are roughly twice as
strong as 2-strand core techniques. Singer et al185
used a new method of analysis to show that an
augmented repair described by Becker and Davidoff186 was the most optimum tendon suture. A cruciate 4-strand flexor repair described by McLarney et

al187 appears to come closest to the ideal suture
technique. It is easy to place, stronger than most
other 4-strand methods, and eliminates knots from
the junction site. Savage and Risitano,163,164 Lim and
Tsai,188 Sandow and McMahon,189 Kusano et al,190
Wagner et al,191 and Thurman et al192 have introduced or evaluated 6-strand tendon repairs, which
are approximately 3 times stronger than 2-strand
techniques. An 8-strand method has been recently
designed by Silva et al193 and is now being clinically
evaluated. It appears that the more suture strands that
cross the repair site, the more difficult the technique
and the more likely the method is to damage the
tendon excessively or compromise its nutrition or
ability to heal. Various 4- and 6-strand flexor tendon
repairs are depicted in Figure 6.
Circumferential sutures. Ejeskar and Irstam,194
Kulick et al,195 Lin et al,196 Lindsay et al,197 Pruitt
and colleagues,198,199 Seradge,200 and Silfverskio¨ld
et al201,202 have indicated that gapping at the repair
site becomes the weakest part of the tendon, unfavorably alters tendon mechanics, and may attract
adhesions resulting in decreased tendon excursion.
The importance of the use of a peripheral circumferential suture at the completion of a tendon repair has
been demonstrated by the findings of Diao et al,203
Silfverskio¨ld and colleagues,165,201,202,204 and Wade
and colleagues205,206 that such sutures may provide a
10% to 50% increase in flexor tendon repair strength
and a significant reduction in gapping between the
tendon ends. These benefits have been further confirmed by Pruitt and colleagues198,199 and Williams
and Amis,207 who applied cyclic loads to the tendon
repair. The running lock loop stitch described by Lin
et al,196 a horizontal mattress intrafiber method introduced by Mashadi and Amis,208 a Halsted continuous horizontal mattress suture recommended by
Wade et al,206 and a cross-stitch technique reported
by Silfverskio¨ld and colleagues165,201,202,204,209 have
been shown to be the strongest of the peripheral
epitendinous suture methods (Fig. 7). The gap-retarding quality of these peripheral sutures is particularly important in light of the finding by Seradge200
that gapping of marked flexor tendon repairs is associated with poorer clinical results. McAuliffe,210
Papandrea et al,211 and Sanders212 advocate completing the circumferential suture before any core sutures
are added as the best method of creating a smooth
tendon junction site.
Based on data from a number of studies and adjusting for friction, edema, and the effect of early
repair stress, Strickland160,169 created rough esti-

222 James W. Strickland / Development of Flexor Tendon Surgery

Figure 6. Techniques for end-to-end flexor tendon repair.

mates and working numbers that allow the preparation of a reasonable strength versus force graph (Fig.
8). The safety of any 4-strand core suture combined
with a running lock or horizontal mattress circumferential suture can be appreciated and should permit
light composite grip during the entire healing period.

Sheath Repair
In recent years many surgeons have advocated repair
of the flexor tendon sheath after tendon suture. Gelber-

man et al,105 Lister,113,213,214 Peterson et al,116,215 Saldana et al,118 Tang and colleagues,119,120,216 and
Tonkin and Lister121 studied the advantages and disadvantages to sheath repair; their cumulative work fails to
give the clinician clear direction. The advantages of
sheath repair are that it serves as a barrier to the formation of extrinsic adhesions, provides a quicker return
of synovial nutrition, acts as a mold for the remodeling
tendon, and results in better tendon–sheath biomechanics. The disadvantages to sheath repair are that it is

The Journal of Hand Surgery / Vol. 25A No. 2 March 2000 223

Figure 7. Peripheral (epitendinous) tendon suture techniques.

often technically difficult and that the repaired sheath
may narrow and restrict tendon gliding. These studies
also provide conflicting laboratory and clinical information regarding the biologic and biomechanical ben-

efits of sheath repair. No clear-cut benefit has been
A number of autogenous and synthetic materials
have been used to restore tendon sheath continuity.
Deffino et al,217 Doyle,12 Kleinert and Bennett,218
Okutsu et al,219 and Strickland220 preferred tendon
grafts. Kessler et al221 and Liu and Lu222 used fascia
and Lister213 used extensor retinaculum. Oei et al115
restored the synovial– cruciate sheath with peritenon
while Eiken et al223 used tendon sheath; Dunlap et
al224 and Hanff and Abrahamsson225 demonstrated
that polytetrafluoroethylene worked well in the laboratory setting. Nishida et al226 reported that of all
the sheath restoration methods they studied, extensor
retinaculum creates the least resistance to tendon

Partial Tendon Lacerations

Figure 8. A strength-versus-force graph showing 2-, 4-,
and 6-strand repairs plotted against passive, light active
flexion and strong grip. The data are adjusted for friction,
edema, and stress.

Wray et al227,228 created considerable controversy
by recommending that partial flexor tendon lacerations should not be repaired. After those reports
considerable debate ensued regarding the appropriate
management of partial tendon lacerations. Chow and
Yu,229 Bishop et al,230 and McGeorge and Stilwell231
demonstrated that partial lacerations of 50% or less
do not need to be sutured but that those greater than

224 James W. Strickland / Development of Flexor Tendon Surgery

50% should be repaired. Grewal et al232 recently
confirmed that nonrepaired partial lacerations had a
significantly higher ultimate load and stiffness than
those that were repaired. The possibility of entrapment, rupture, and triggering of unrepaired partial
severances also has been reported by Schlenker et

Post-Flexor Tendon Repair Rehabilitation
Rationale for Early Post-Repair Motion Stress
The traditional immobilization of repaired flexor
tendons for 3 or more weeks has been almost universally abandoned. Recent hand surgery literature is
replete with laboratory confirmation of the beneficial
effects of applying early controlled forces to healing
tissues, and descriptions of an assortment of posttendon repair motion protocols speak to the clinical
use of this biologic knowledge. Buckwalter,234
Evans and Thompson,68 Feehan and Beauchene,235
Gelberman and colleagues,105–109,236 Mass et al,237
Pruitt and colleagues,198,199 Tanaka et al,238 Woo et
al,239 Wray et al,240 Kubota et al,241 and Aoki et al,71
in particular, have provided biologic verification that
imparting early post-repair motion stress to repaired
flexor tendon repairs provides a more rapid recovery
of tensile strength, less adhesions, improved tendon
excursion, and less repair site deformation.
Brown and McGrouther,242 Gelberman et al,105
Greenwald et al,69 Hagberg and Selvik,243 Horibe et
al,59 and McGrouther and Ahmed60 conducted studies in an effort to determine the normal amount of
flexor tendon excursion resulting from increments of
digital joint motion, the gliding of repaired tendons,
and the amount of excursion that may occur in the
various post-tendon repair splints that are commonly
used. It has been observed that passive metacarpophalangeal joint movement produces no relative motion of the flexor tendons. Distal interphalangeal
joint motion produces excursion of the FDP of 1 to 2
mm per 10° of joint flexion while each 10° of proximal interphalangeal joint flexion results in excursion
of both the FDP and the FDS of approximately 1.5
mm. Silfverskio¨ld et al,244 who measured the excursion of marked flexor tendon repairs, demonstrated
that there is a substantial decrease in the normal
movement of the profundus to an average of 0.3 mm
per 10° of distal interphalangeal flexion (36%) while
proximal interphalangeal motion retained approximately 1.3 mm (90%) of FDS and FDP excursion per
10° flexion.
The amount of tendon excursion that should occur

Figure 9. Estimated tendon excursion (measured in mm)
with 3 types of mobilization splints: the Kleinert splint (no
palmar bar, 䊐), the Brooke Army splint (with a palmar bar
pulley, 1), and the Mayo Clinic synergistic dynamic
tenodesis splint, which permits wrist extension (■). (Data
from Cooney et al.245)

for uninjured tendons in the original Kleinert-type
splint, modifications of the Kleinert splint with a
palmar bar pulley (Brooke Army Splint), and an
experimental synergistic dynamic tenodesis splint
that permits wrist extension (Mayo Clinic) have also
been studied by Cooney et al,245 who demonstrated
that improved excursion can be expected from the
use of a palmar bar and that even greater excursion
can be expected if wrist extension is added (Fig. 9).
Differential excursion between the 2 digital flexors
was also increased dramatically by the synergistic
splint. Savage246 also has shown that a position of
wrist extension and metacarpophalangeal joint flexion produces the least tension on a repaired flexor
tendon during active digital flexion.

Early Motion Stress Post-Rehabilitation
Following flexor tendon repair in zones I or II,
there are several options for the application of motion stress to the repaired tendon to facilitate healing
and maximize gliding. The once widely used rubber
band technique popularized by Kleinert and colleagues151,153,247,248 and Lister et al7 in the 1960s,
1970s, and early 1980s has largely given way to
modifications of that method and to passive and
active motion protocols. McGrouther and Ahmed60

The Journal of Hand Surgery / Vol. 25A No. 2 March 2000 225

and Phillips et al249 concluded that the original
Kleinert splint was a poor mobilizer of the distal
interphalangeal joint and that cross-union between
the tendons should be expected to be a problem. In
recent years modifications of the original Kleinert
method have been tendered by Becker and Hardy,250
J. A. Chow et al,251 S. P. Chow et al,252 Citron and
Forster,253 Edinburg et al,254 Knight,255 Reis,256
Slattery and McGrouther,257,258 and Werntz et al.259
These splints have used a variety of changes designed to create more complete composite digital
The controlled passive motion method originally
recommended by Duran and Houser260 was shown to
outperform immobilized flexor repairs by Strickland
and Glogovac,8 and a retrospective study by Stone et
al261 demonstrated that early passive motion was
associated with improved total active motion for
isolated FDP injuries. Proponents of the controlled
passive motion protocols contend that it is less likely
to result in flexion contractures than the rubber band
flexion/active extension method and that the involved digit may be better protected between periods
of exercise. Despite the enthusiasm for these and
other passive tendon repair mobilization programs,
Manske41 has expressed skepticism as to how much
movement is actually realized at the repair site in the
absence of muscle contraction to mobilize the tendon, particularly during the 1- to 3-week post-repair
period. Additionally, Gault262 reported a series of
repairs managed by a passive motion protocol that
had less than ideal results.
Although Peck et al263 indicated that there may be
little difference between the results of active and
passive mobilization of flexor tendon repairs, there
has been a growing trend toward the use of some
increment of active digital motion in an attempt to
obtain better functional recovery after flexor tendon
repair. It has been demonstrated that 4- and 6-strand
flexor tendon repair methods combined with strong
circumferential sutures should be sufficiently strong
to withstand light active forces throughout the healing period (see Fig. 8). While post-repair motion
protocols vary somewhat, many follow the sequence
recommended by Strickland167–170 in which the wrist
is immobilized in modest flexion, the metacarpophalangeal joints in near full flexion, and the interphalangeal joints in extension when the hand is at rest.
The motion program is initiated by passively flexing
the injured finger, after which the wrist is extended
and the patient is asked to actively maintain the
flexed position of the digit (Fig. 10). Advocates of

controlled active digital motion believe that this technique generates greater gliding of the healing tendon,
less adhesions, and the ability to more rapidly
achieve tendon strength than passive motion protocols.
In 1979 Becker et al264 reported the results of early
active motion following the use of a strong beveled
technique of tendon repair. Subsequent active motion
protocols and the results of the clinical use of those
programs have been described by Chow et al,251,265
Cullen et al,266 Elliot et al,267 Gratton,268 Lee,183
Sandow and McMahon,189 Savage and Risitano,164
Schenck and Lenhart,269 Silfverskio¨ld et al,201,204
Small et al,270 Strickland,167,169 and Taras et al.271
Several of these programs have used a strong
4-strand repair or its equivalent with a running lock
loop, horizontal mattress, or intrafiber circumferential repair combined with early protected passive and
active motion. The results are clearly better than with
previous, more conservative techniques. It is interesting that the results of the use of early post-repair
active motion have shown that the rupture rates are
no greater than those for passive motion regimens.

Late Restoration of Flexor
Tendon Function
Conventional free-tendon grafting after flexor division in a digit remains one of the most eloquent
procedures in the hand surgeon’s armamentarium.
The best descriptions of the techniques are found in
the writings of Bunnell, Pulvertaft, Boyes, and Littler. While few advances in tendon grafting have
occurred in recent years, Boyes and Stark,272 McClinton et al,273 and Stark et al274 have reported
notable reviews of large clinical series and that good
results have been obtained by grafting through an
intact FDS for isolated FDP loss.
Tenolysis of adherent flexor tendon repairs or
grafts remains an excellent salvage procedure in appropriate circumstances. Recent technical descriptions, rehabilitation methods, and results analyses by
Baker et al,275 Fetrow,276 Foucher et al,277 Hunter et
al,278 McCarthy et al,279 Schneider,280 Strickland,281
and Whitaker et al282 have contributed to previous
information regarding this subject.
In the last 4 decades there have been significant
advances in the ability to restore flexor tendon function to badly scarred digits. Staged reconstruction
uses passive or active tendon implants, followed
secondarily by a replacement graft. The implant and
method that currently enjoy the most popularity have

226 James W. Strickland / Development of Flexor Tendon Surgery

Figure 10. Controlled active motion post-flexor tendon repair protocol. (Top left) Following removal of the surgical
bandage, a traditional dorsal blocking splint that positions the wrist in 20° flexion, the metacarpophalangeal joints in 50°
flexion, and the interphalangeal joints in extension is applied. (Top right) A tenodesis splint with a wrist hinge is fabricated
to allow for full wrist flexion, wrist extension of 30°, and maintenance of metacarpophalangeal flexion of at least 60°.
(Bottom left) Following composite passive digital flexion, the wrist is extended and passive flexion is maintained. (Bottom
right) The patient actively maintains digital flexion and holds that position for approximately 5 seconds. Patients are
instructed to use the lightest muscle power necessary to maintain digital flexion.

largely resulted from the work of Hunter and colleagues283–290; subsequent investigators291,292 have
reported results using this method. Hunter et al293–295
also pursued the development and clinical use of a
permanent tendon implant; in some instances, the
results of the use of these prostheses have been
encouraging. Asencio et al296 have demonstrated reasonable results from the use of human composite
flexor tendon allografts for difficult salvage situations.

Flexor Digitorum Profundus Avulsion
The clinical presentation, pathomechanics, classification, and treatment of avulsion injuries of the
FDP have been reported in the recent hand surgery
literature. In particular, the reports of Leddy and
colleagues297–300 and Manske and Lesker301 have
been helpful to our understanding of the condition.
Figure 11 depicts the classification of profundus
avulsions provided by Leddy and Packer.300

Evaluating the Results of Flexor
Tendon Repair
Students of flexor tendon surgery have been historically frustrated by the many variations in the
methods of measurement and classification of the
results reported in the literature. In recent years the
historic method of measuring the distance between
the pulp of the distal phalanx and the distal palmar
skin crease has been replaced by more scientifically
reliable and comparable methods that measure the
angular motion of the digital joints adjusted for any
extension deficit. A critical analysis of 5 methods of
evaluating the results of flexor tendon repair by So et
al302 concluded that the method of Buck-Gramcko et
al303 was the most reliable. A simpler system devised
by Strickland and Glogovac8 that uses the combined
flexion of the proximal and distal interphalangeal
joints (while making a full composite fist) minus the
extensor lag has enjoyed the most popularity in recent reports, probably because of its simplicity. The

The Journal of Hand Surgery / Vol. 25A No. 2 March 2000 227

Figure 11. The management of FDP avulsion. (Top) Direct repair of the avulsed tendon into the base of the distal
phalanx by drill holes and sutures through the terminal
tendon. The sutures are taken dorsally and secured through
a button over the nail. (Bottom) Repositioning of the
avulsed distal phalangeal fragment using K-wires.

results, expressed as a percentage of normal, can then
be classified by the system reported by Kleinert and
Verdan.304 Similar systems for the evaluation of
staged tendon reconstruction and tenolysis also have
been described by Whitaker et al282 and Strickland.305
In the last 30 years there has been a steady improvement in the reported results of flexor tendon
surgery. Recovery of good or excellent function can
now be expected in 80% or more of most strong
tendon repair followed by early post-repair motion
protocols. In a multivariate prospective analysis of
factors affecting results after flexor tendon repair in
zone II, Silfverskio¨ld et al306 stated that a large part
of the variance in all the outcomes was probably
related to the psychological and biologic characteristics of the patient. Harris et al307 confirmed that
impression when investigating the etiology of acute
rupture of flexor repairs during early mobilization
with their finding that “in approximately half of these
patients, tendon rupture followed acts of stupidity.”
The amount of scientific and clinical information
that has been published regarding injuries to the
flexor tendon in recent decades probably exceeds the
total of all previous reports and comprises a tremendous and highly meaningful body of work. It has

unquestionably resulted in markedly improved results for the management of these conditions, and
one can rest assured that an equally impressive body
of new information and even better clinical results
will occur in this new millennium.
Any review of the important scientific contributions to the overall understanding of flexor tendons
during the last few decades immediately creates a
profound appreciation for both the enormity and the
quality of the publications of two investigators: Paul
R. Manske and Richard H. Gelberman. With their
associates, they have produced a tremendous body of
meaningful work and the elegance of their experimental models, their dedication to scientific validity,
the simplicity and clarity of their writings, and the
clinical relevance of their laboratory studies are renowned throughout the hand surgery world. The
spectrum and diversity of their investigations and the
sheer volume of their combined publications are
truly overwhelming. It is particularly impressive that
these two colleagues have provided so much toward
a strong scientific basis for flexor tendon surgery.
Hand surgeons and patients worldwide owe them a
great debt of appreciation.

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