THE DIRECT MIDLATERAL APPROACH WITH LATERAL

ENLARGEMENT OF THE PULLEY SYSTEM FOR REPAIR OF

FLEXOR TENDONS IN FINGERS

A. MESSINA and J. C. MESSINA

From the Traumatologic and Orthopaedic Hospital, Torino and the First Orthopaedic Clinic, University of Milano, Milano, Italy
The direct midlateral approach and the lateral enlarging procedure of the pulley system have
been utilized in our service since 1972. The incision runs directly behind the neurovascular
pedicle, which is !eft in the palmar skin flap of the anterior compartment of the finger, in order
to ensure its blood supply and sensibility. The transverse digital lamina of Landsmeer's skin
anchoring system and Cleland's ligament are preserved and are used to perform a lateral
enlargement of the pulleys after tendon repair. The technique allows wide surgical exposure of
the digital fibro-osseous tunnel, enlargement and reconstruction of the pulley system and tendon
sheath, flexor tendon repair (using the technique of choice) and reduces postoperative impingement
in zone 2.
Journal of Hand Surgery (British and European Vohtme, 1996) 2lB." 4." 463-468

Various authors underline the importance of closure of
the tendon sheath to allow nutrition and the physiologi-
cal gliding of repaired flexor tendons (Lister, 1983;
Verdan, 1972; Lundborg, 1976). Moreover reconstruc-
tion of the pulley system is of primary importance in
obtaining full strength of the hand. These structures are
almost always damaged in traumatic flexor tendon
lesions.
It is always difficult to suture the digital sheath and
the pulley system completely after flexor tendon repair,
because the pulleys are closely applied to the underlying
tendons. Impingement on the annular edge of the severed
pulleys or a difficult gliding area during postoperative
swelling may aggravate this situation. Hence, different
techniques are described to reconstruct these structures
after flexor tendon suture (Lister, 1983; Kapandji, 1983;
Verdan, 1972).
Two commonly used approaches are the midlateral
and the midaxial approach (Tubiana et al, 1990). The
midlateral approach does not preserve the vascularity
and sensibility of the palmar flap of the anterior com-
partment of the finger, but does preserve the transverse
digital lamina. The midaxial approach preserves the
palmar flap vascularity and sensibility but not the trans-
verse digital lamina of Landsmeer's skin anchoring
system and Cleland's ligament, as it goes through them.
A direct midlateral approach and a lateral enlarging
procedure of the pulley system by the transverse digital
lamina have been used at the Hand Surgery Centre in
Torino since 1972 (Figs 1 and 2).
MATERIALS AND METHODS
Surgical technique
A midlateral skin incision is performed. The deep
incision lies posterior to the neurovascular bundle of
the finger, but just anterior to the transverse digital
lamina and Cleland's ligament (Figs 1 and 3). In this
463
way a palmar skin flap, which includes the neurovascular
bundle (to ensure its vascularity and sensibility) and
Grayson's ligament, is turned over to display the anterior
compartment of the finger and the fibro-osseous flexor
tendon tunnel (Doyle, 1988).
From our anatomical and surgical observations on
flexor tendon exposure, the bony attachment of the
pulley on each side of the phalanx corresponds to the
insertion of the transverse digital lamina (Landsmeer,
1976). The common insertion can be detached from the
bone while the fibrous structures (the pulley and the
lamina insertions) remain united. In this way a lateral
fibrous enlargement of the pulley is obtained using the
strong transverse fibrous lamina (Fig 3). The detach-
ment of the common insertion is performed through the
traumatic sheath laceration or through a transverse
incision in the sheath; one blade of a pair of strong
triangular-shaped scissors is placed inside and the other
blade outside the flexor sheath at the insertion of the
sheath itself and of the transverse digital lamina.
Detachment may also be performed with a scalpel
(Fig 4). This enlarged flap (transverse digital lamina) is
then cut longitudinally 2 mm from its skin insertion
parallel to the skin surface, and transversely proximal
and distal to the tendon lesion (point F in Fig 1; Fig 3).
The flap is turned over and held in place with two
stitches to facilitate the tendon repair. The tendon repair
is performed using the technique of choice. We use in
most cases the "double armed suture" (Messina, 1973;
1988; 1992). After repair of the tendon, the edge of the
transverse digital lamina detached from the skin inser-
tion is sutured to the palmar rim of the posterior digital
fascia or to the fibrous tissue near the phalangeal shaft,
and the pulley enlargement is completed (Figs 5, 6, and
7). The transverse edges of the enlarged pulley are
sutured with a running suture or interrupted stitches to
the proximal and distal pulleys using 6/0 monofilament
nylon (Fig 7). The delicate retinacular portion of the
digital sheath (C1, A3, C2 and C3, A5) at the joint level
464
C E
.4
27 1
lateral direction from the lateral surface of the phalanx to the
midaxial skin. It is reinforced anteriorly by the oblique fibres
of Cleland's ligament. (C) Enlarged annular pulley using the
transverse digital lamina. (D) Phalangeal common insertion
point of the transverse digital lamina and A2 or A4 pulleys.
(E) The periosteal common insertion of the transverse digital
lamina and the pulleys A2 and A4 are disinserted together in
order to obtain a laterally enlarged fibrous flap. (F) The
transverse digital lamina is divided 2 mm from the skin
longitudinally and parallel to the skin and taken off to enlarge
the pulley (F) becomes C).
is thin and demands gentle handling; its disinsertion
and closure can be performed more easily under
magnification.
We use early active mobilization postoperatively.
Clinical features and indications
The direct midlateral approach and the lateral enlarge-
ment of the pulley system have been used in different
groups of patients:
Group 1:70 flexor tendons as primary, delayed pri-
mary and secondary repair using the double armed
THE JOURNAL OF HAND SURGERY VOL. 21B No. 4 AUGUST 1996
a
c
Fig 2 (a) Anatomical drawing of a cross section of the finger.
(b) Classical midlateral approach used today. (c) Classical
midaxial approach used today.
suture technique (Messina, 1992) and early active
mobilisation
Group 2 : 2 0 flexor tendons repaired using other tech-
niques (Kessler, Kleinert)
Group 3: six cases of tenolysis
Group 4: ten flexor tendon grafts.
In six acute cases the traumatic skin wound was used
and lengthened by the Bruner surgical approach and
enlargement of the pulley was performed, but in the
majority of cases we used the direct midlateral approach.
The maximum follow-up was 20 years, minimum 5 years.
Indications for the technique were primary and sec-
ondary flexor tendon injuries in the digital tunnel,
adhesion or impingement of flexor tendons from pre-
vious trauma or inflammatory diseases, tendon grafts,
and severe injuries to tendon sheaths or pulleys in the
finger (Messina, 1973; 1988; 1992).
FLEXOR TENDON REPAIR
, ~ i-~ ~. A
(a)
(d)
Fig 3 (a) Direct midlateral approach. (b) The palmar skin flap is turned over in order to display the anterior compartment of the finger and
the fibro-osseous flexor tendon tunnel. (c) The transverse digital lamina is divided from the skin insertion longitudinally. (d) The
common insertion of the pulley and lamina is disinserted but the two structures remain united. (e) The pulley is enlarged using the
transverse digital lamina. (f) The enlarged pulley is sutured to the posterior digital fascia and the new pulley is closed. For labels A, B,
C, E, F, see Fig 1.
RESULTS
No surgical complications related to the enlarged pulleys
or skin healing were observed. The results of the enlarge-
ment of the pulleys and the tendons repair using the
double armed suture technique (group 1) were:
Excellent 10%. These digits have regained full active
and passive motion.
Good 80%. These digits show a variable degree of
functional limitation in flexion and extension of an
interphalangeal joint. Digits were rated good if they met
the following criteria: complete passive mobility of the
involved joints; active DIP joint mobility of at least 5°
to t0°; active PIP joint mobility of at least 30 ° to 45°;
the pulp of the digit could actively touch the palm and
the patient was satisfied and functioned well at work
and leisure.
Poor 10%. Joint stiffness was present, adhesions pre-
vented motion, there was no active joint mobility, the
pulp of the digit could not touch the palm or the patient
was dissatisfied. Using the TAM (Total Active Motion)
465
F
/
(b) (c)
¢"~'
'~J C
:0 B
..../F
(e) (f)
evaluation, the results were 10% excellent, 60% good,
20% fair, 10% poor (Messina, 1992).
The results obtained in the other groups of patients
were generally satisfactory but were not analysed in
detail. Up to now, the small number of treated cases
renders them statistically not significant.
DISCUSSION
The direct midlateral incision runs directly behind the
neurovascular bundle, which is left in the palmar skin
flap of the anterior compartment of the finger, in order
to ensure its vascularity and sensibility. In contrast, with
the classical midlateral incision the neurovascular pedicle
is left dorsally and the palmar skin flap receives its
vascularity and sensibility only from the opposite side
of the finger, posing a risk in severe and in simple
wounds (Tubiana, 1990; Fig 2).
Our midlateral direct exposure preserves the trans-
verse digital lamina and Cleland's ligament, which are
generally cut in the traditional mid-axial exposure
(Fig 2). Consequently this exposure allows us to perform
a lateral enlargement of the pulley system.
We have shown that there is a common bony insertion
466
° 2,;?
Fig 4 Lateral pulley enlargement (C1, A3, C3) A4 (C3, A5) in delayed flexor tendon repair. Through the traumatic sheath lesion, or through
a transverse incision of the sheath by means of a scalpel or strong triangular shaped scissors, we disinsert the common periosteal
insertion of the pulley and the transverse digital lamina from the phalangeal shaft•
The transverse digital lamina is detached from its skin insertion
Fig 5
to enlarge the pulley. The enlarged flap is held with three
sutures and clips.
of the pulley and the transverse digital lamina of
Landsmeer's skin anchoring system at the side of the
phalanx. This important anatomical structure allows us
to enlarge the digital pulley and the flexor tendon
sheath laterally. In this way, the lateral suture of the
pulley enlargement does not correspond to the line of
THE JOURNAL OF HAND SURGERY VOL. 21B No. 4 AUGUST 1996
the flexion force of the finger as it would using
other methods of enlargement, leaving the pulley
stronger.
The need for sheath enlargement and closure in
tendon repair is widely acknowledged (Lundborg, 1976;
Manske and Lesker, 1982; Matthews and Richards,
1976); different procedures of pulley enlargement have
been described (Lister, 1983; Kapandji, 1983). However,
many of these techniques are performed with numerous
triangular flaps and oblique sutures on the anterior
gliding surface of the tendons that can create adhesions,
and do not always allow satisfactory sheath closure.
Lateral enlargement of the pulley allows complete clos-
ure of the synovial sheath and ensures a wide and safe
anterior gliding surface for the repaired flexor tendons,
reducing impingement.
The technique may consequently improve the synovial
nutrient pathway into the enlarged gliding area. The
strong fibrous lateral flap (the enlarged new part)
guarantees a good anterior resistance to flexor tendon
tension, particularly during early active mobilization
(Landsmeer, 1976; B in Fig 1).
Finally, with the direct midlateral approach the critical
fibro-osseous segment of the middle and proximal phal-
anges can be widely exposed to facilitate all tendon
repair techniques.
FLEXOR TENDON REPAIR 467

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:a .°4~

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... i'+, :, +" ' ~ x,:'~-<~ 4?

!,:,,

Fig 6 Lateral closure of the pulley by running suture and some interrupted stitches of monofilament nylon 6/0. This procedure ensures an
improved nutrient pathway (as the pulley is completely closed), and an enlarged gliding area. This is important, either in this case where
a retracted or closed pulley in delayed flexor tendon repair can be found or when vascular tendon troubles are observed.

Fig 7 Careful closure of the laterally enlarged A1 and A2 pulley of a tittle finger after tendon repair. The direct midlateral approach is wide
in order to perform all kinds of tendon sutures without specific difficulties.
468
References
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system. Journal of H a n d Surgery, 13A: 473-484.
K A P A N D J I I A (1983). Plastie d'agrandissement des poulies m6tacarpiennes.
Annales de Chirurgie de la Main, 2: 281-282.
L A N D S M E E R J M F Atlas of' anatomy of the hand, 1st Edn. Edinburgh,
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LISTER G D (1983). Incision and closure of the flexor sheath during primary
tendon repair. The Hand, 15: 123-135.
L U N D B O R G G (1976). Experimental flexor tendon healing without adhesion
f o r m a t i o n - - a new concept of tendon nutrition and intrinsic healing mechan-
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M A N S K E P R and LESKER P A (1982). Nutrient pathways of fiexor tendons
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MESSINA A (1973). La "double armed suture": nuovo metodo di riparazione,
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MESSINA A (1992). The double armed suture: tendon repair with immediate
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TUBIANA R, M c C U L L O U G H C J and M A S Q U E L E T A C. An atlas of surgi-
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Accepted after revision: 8 January 1996
Dr A. Messina, via Monte Rosa 20, 10098 Rivoli (Torino), Italy.
© 1996 The British Society for Surgery of the Hand