SURGICAL TECHNIQUE

Zone I Flexor Digitorum Profundus

Repair: A Surgical Technique
Elizabeth M. Polfer, MD,*† Jennifer M. Sabino, MD,† Ryan D. Katz, MD†

We present an all-inside technique for zone I flexor tendon repair that combines suture anchor
fixation with buried back-up fixation. The back-up fixation uses transosseous tunnels and a
dorsal counterincision to allow a suture tied dorsal to the distal phalanx and buried. This
technique is strong and permits early active range of motion. The dorsal tie-over does not
require a suture button and, therefore, does not imperil the nail matrix. The surgical technique
is herein described including the proposed anesthesia (wide awake), the incisions (midlateral),
the exposures, and the repair itself. (J Hand Surg Am. 2018;-(-):1.e1-e5. Copyright Ó 2018
by the American Society for Surgery of the Hand. All rights reserved.)
Key words Flexor profundus, jersey finger, pull-out suture, tendon rupture, wide awake.

A
VULSION INJURY OF THE FLEXOR digitorum pro-
fundus (FDP) is a relatively common injury.1
In a recent study, the incidence of acute
traumatic tendon injuries in the hand and wrist was
33.2 per 100,000 person-years with 4% of these be-
ing zone I flexor tendon injuries.1 The injury often
occurs as the result of forcible hyperextension of the
distal interphalangeal (DIP) joint while the FDP is
maximally contracted.2 This is commonly seen in
sports when 1 player grabs onto an opponent’s jersey
while the other player pulls away, hence, the name
jersey finger.2 The injury itself has been described
for over a century, and the treatments have evolved
with time. The original treatment described by Bun-
nell in 19483 included use of a suture pull-out button.
Historic treatments for acutely diagnosed injuries
From the *Walter Reed National Military Medical Center, Bethesda; and the †Curtis
National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
Received for publication May 10, 2018; accepted in revised form August 24, 2018.
No benefits in any form have been received or will be received related directly or
indirectly to the subject of this article.
The views expressed in this article are those of the author(s) and do not reflect the
official policy of the Department of Army, Department of Defense, or U.S. Government.
Corresponding author: Ryan D. Katz, MD, care of Anne Mattson, The Curtis National
Hand Center, MedStar Union Memorial Hospital, 3333 North Calvert St., Baltimore,
MD 21218; e-mail: anne.mattson@medstar.net.
0363-5023/18/---0001$36.00/0
https://doi.org/10.1016/j.jhsa.2018.08.015
consisted of either no treatment, suturing the tendon
into the adjacent periosteum, or pull-out button
technique.4,5 However, if there was a delay in diag-
nosis, no treatment,2 a free flexor tendon graft as a
single-stage or 2-stage procedure,6 tenodesis, or
fusion of the DIP joint at a later date might be
recommended.2
More recently, treatment has included the use of
the pull-out button with varying suture configurations
and button locations, the use of suture anchors, the
use of anchors and a suture button, and repair to the
volar plate.4,5,7,8 Disadvantages of the pull-out button
include failure of the suture, damage to the germinal
or sterile matrix leading to a nail plate deformity,
infection, discomfort until the button is removed, and
lack of adequate healing by the time the button is
removed. Suture anchor failure at the anchor-bone
interface or from suture material failure is also a
noteworthy concern.9,10 As a result, we present an
alternative repair configuration that eliminates the
concerns associated with the pull-out button and
provides back-up fixation in the event of suture an-
chor pull-out.
INDICATIONS AND CONTRAINDICATIONS
This procedure is indicated in patients with acute
(10e14 days), subacute (14 dayse6 weeks), or
chronic (> 6 weeks) FDP avulsion that is amenable

Ó 2018 ASSH r Published by Elsevier, Inc. All rights reserved. r 1.e1

1.e2 ZONE I FLEXOR DIGITORUM PROFUNDUS REPAIR

FIGURE 1: Preoperative images of the finger in A extension and B flexion demonstrate zone I injury to the left middle finger. With the
patient awake during surgery, we were able to have him flex and extend actively.

FIGURE 2: The skin incision described as A midsagittal to the DIP joint flexion crease, horizontal at the DIP joint, and vertical distal to
the DIP joint, and B again with the skin retracted.

to primary repair.11 Contraindications include active
infection, loss of bone integrity that would prevent
placement of a suture anchor or ability for the
pull-out suture to be tied over the bone, and
chronic ruptures that do not have adequate tendon
excursion to allow for primary repair. The latter can
only be determined during surgery but should be
suspected for purely tendinous injuries greater than
8 weeks old.
SURGICAL ANATOMY
The FDP inserts on the palmar aspect of the distal
phalanx with its insertion covering 18% to 21% of the
distal phalanx with an insertion footprint of 5.1 to 7.0
mm in length and 6.9 to 8.4 mm in width centered
approximately 3.1 to 3.9 mm from the proximal edge
of the distal phalanx.12 Clinical and experimental
studies have demonstrated that the weakest point of
the muscle tendon unit is at the insertion of the
tendon at the bone-tendon interface and the most
common finger to sustain an avulsion is the ring
finger.
SURGICAL TECHNIQUE
Prior to surgery, the patient is met in the preoperative
holding area where a wrist/digital block is performed
using 2% lidocaine with epinephrine. This is done
such that there is time for the block to set up and the
epinephrine to take effect prior to skin incision. The
patient is placed supine on the operating room table
with the arm extended on a hand table. We prefer to
perform the surgery in a wide-awake fashion to allow
for interrogation of tension after completion of the
operation by having the patient actively flex and
extend prior to skin closure (Fig. 1). We do not use a
tourniquet. The wide-awake patient is able to better

J Hand Surg Am. r Vol. -, - 2018

 ZONE I FLEXOR DIGITORUM PROFUNDUS REPAIR
FIGURE 3: The 4-0 looped suture with the 2 tails to be brought
through the distal phalanx.
FIGURE 4: Passing the sutures through the distal phalanx with
straight needles.
tolerate the procedure without a tourniquet and
adequate hemostasis can be achieved using local
anesthetic with epinephrine. If preferred, the pro-
cedure can be performed under general anesthesia.
A midlateral incision on the nonborder surface of
the digit extending from the metacarpophalangeal
flexion crease to the DIP flexion crease is per-
formed. At the level of the DIP flexion crease, the
incision is oriented transversely along the crease to
the midpoint of the digit. The incision is extended
distally longitudinally to the midpoint of the swirl
on the pulp of the digit (Fig. 2). Dissection is car-
ried out through the subcutaneous tissue, allowing
identification of the neurovascular bundle. Once the
bundle is identified, the blade can then be used
directly volar to the bundle to lift a skin flap. The
J Hand Surg Am.
1.e3
FIGURE 5: The suture anchor (see cartoon representation) is
placed in the distal phalanx and used to secure the tendon to the
bone with a horizontal mattress stitch.
dissection is carried proximally and distally with
care taken to protect the terminal branches of
the digital nerve. The skin flap is held back with a
4-0 nylon suture.
After the flexor tendon sheath is fully exposed, a
fullness may be identified within the sheath that re-
veals the location of the proximal end of the ruptured
FDP tendon. If the tendon cannot be identified from
external examination of the sheath, a small incision
in the tendon sheath is made at the level of the A3
pulley. Once the proximal end of the ruptured FDP is
identified, it is atraumatically pulled out to length
using a tendon grasper or hemostat. At this point, the
patient is asked to flex the finger to ensure adequate
tendon excursion.
The tendon is then secured using a 4-0 looped
nonabsorbable suture in a running grasping fashion
(Fig. 3). The needle is removed from the loop and the
suture cut such that there are 2 free suture tails exiting
the distal portion of the tendon stump. Using the free
suture ends, the tendon is passed through the fibro-
osseous sheath in the proximal-to-distal direction. It
is important to take care in maintaining as much of
the fibro-osseous sheath as possible. If necessary to
facilitate passage of the tendon, the sheath can
be vented at the level of the A4 pulley. Next, a
bioabsorbable suture anchor is placed in the distal
phalanx distal to the joint line. The sutures from the
anchor are left free at this point. A transverse incision
is made on the dorsum of the finger, proximal to the
germinal matrix and distal to the DIP joint extension
r Vol. -, - 2018
1.e4 ZONE I FLEXOR DIGITORUM PROFUNDUS REPAIR
FIGURE 6: The end result prior to closure having the patient A make a fist, B extend his finger, and C make a fist again. Having the
patient awake and able to perform active motion allows for appropriate tension.
crease. The tissue is dissected to the level of the
extensor tendon with care being taken not to disrupt
the extensor tendon. Two straight free needles are
drilled in a volar-to-dorsal direction through the distal
phalanx on either side of the suture anchor, exiting
the distal phalanx through the previously made dorsal
incision (Fig. 4). Each needle is used to pass 1 limb of
the suture from the tendon end. Tension on the 2
limbs of the suture allows for excellent bone-to-
tendon coaptation. While tension is held, the suture
from the anchor is passed through the tendon and
tied down in a horizontal mattress configuration to
secure the tendon down to the bone (Fig. 5). The free
suture ends are then tied over the terminal extensor
tendon.
The sutures are cut short, and the wounds are
irrigated. The patient is then asked to flex and extend
the digit to ensure full active range of motion (Fig. 6;
and Videos 1, 2, available on the Journal’s Web site
at www.jhandsurg.org). The wound is then closed
with 4-0 simple interrupted chromic sutures. The
patient is placed in a dorsal blocking orthosis.
The postoperative dressing is removed within the first
postoperative week and the patient is started in an
early active motion protocol with therapy.
PEARLS AND PITFALLS
It is important to ensure the neurovascular bundles
are protected during the case. We prefer to leave the
bundle on the side of the access incision dorsal to the
skin flap during flap elevation.
A longitudinal incision through the central pulp of
the digit provides excellent exposure to the distal
phalanx and can be made safely because it resides
J Hand Surg Am.
within the internervous plane between the radial and
the ulnar neurovascular bundles. This incision can be
included as an extension of the midlateral approach
rather than the traditional oblique incision (Fig. 2).
Care must be taken when making the dorsal inci-
sion to injure neither the terminal tendon nor the
germinal matrix. The dorsal incision should be made
prior to passing the tie-over suture to ensure that the
suture is not accidentally cut while making the
incision.
COMPLICATIONS
Although the suture is pulled through dorsally and
tied over the distal phalanx under the skin, there is the
possibility that the suture knot will become bother-
some given that a nonabsorbable suture is used. If it
becomes problematic, the suture knot can be removed
in the clinic with local anesthetic 3 months after
surgery.
In a digit with an intact flexor digitorum super-
ficialis, repairing the FDP could place the patient at
risk of pain, stiffness, and interphalangeal joint flexion
contractures. Therefore, a thorough risk-benefit
assessment and discussion should occur prior to pro-
ceeding with surgery. As with any surgery, there is
always the risk of infection.
DISCUSSION
The ultimate strength of the repair depends on mul-
tiple factors. Factors related to the surgery include the
type of suture used (both for the pull-out button
method and the suture anchor method), the suture
configuration, and the method of fixation to bone.
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 ZONE I FLEXOR DIGITORUM PROFUNDUS REPAIR
There is no one method that has been definitively
proven to provide a better functional outcome than
another, although certain trends in repair strength
emerge from the literature. From a review of the
literature, discussed below, the surgeon can surmise
that, all things being equal: (1) braided suture allows
a stronger repair than that of monofilament, (2)
locking configurations add strength to the repair, (3)
2 methods of repair (fixation and back-up) provide
for a stronger repair than 1.
Biomechanical studies in human cadavers have
demonstrated gap formation at the bone-tendon
interface when using a monofilament suture7 as
well as greater gap formation when compared directly
with a nonabsorbable braided suture.10 Studies have
also shown the average yield strength of the pull-out
button method to be between 30 N and 47 N,7,10
which, though greater than the force required for
active digital flexion, is much less than the uninjured
anatomical value of 118.6  12.8 N. The pull-out
button also underperforms (in mean strength) when
compared with a suture anchor, which is often cited
as having failure loads between 28.5 N and 69.6 N.10
When comparing the pull-out suture button, the
suture anchor, and the pull-out button with the suture
anchor, the ultimate load-to-failure was highest (115
N) and the gapping was the lowest (0.02 mm) with the
suture button using a locking Krakow stitch and a
suture anchor.5 The difficulty with this method comes
when it is time to remove the button. In McCallister
et al,4 the only significant difference in outcomes be-
tween a suture anchor repair and a pull-out button was
a quicker return to work in the suture anchor group.
The benefit of this all-inside technique is dual
fixation, which eliminates the concerns associated
J Hand Surg Am.
1.e5
with the pull-out button and provides back-up fixa-
tion in the event of suture anchor pull-out.
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