FLEXOR TENDON

AND SHEATH:
ANATOMY INJURY
AND HEALING

Christian Dumontier, MD, PhD

Guadeloupe Hand Center
 FLEXOR TENDON INJURY
• Rare (5 / 100,000)

• Severe injuries (associated lesions

including nerves, arteries, bones)

• A major challenge to all hand surgeons:

• Tendon ruptures (3-9%) within

10-12 post days up to 6 weeks

• At the site of the repair

 INTRA-SYNOVIAL (FLEXOR) TENDONS CAN HEAL ?

• Yes (Lundborg, late

70’s)

• Intrinsic healing

• Extrinsic healing =
Adhesion

• Extrinsic healing
starts 1st !
ANATOMY OF THE FLEXOR TENDONS

• Extra-cellular matrix
contained mainly collagen
type 1 (resists compression)

• Collagen bers arranged in

a longitudinal fashion to
form the tendon unit

• Relatively avascular
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 FLEXOR TENDON VASCULARISATION

• In zone 2, vascularisation
comes through the vincula
(sing: vinculum)

• Each tendon has 2: a brevis

and a longus

• Relative avascular zone

under A2 and A4 pulleys
 FLEXOR TENDON SHEATH

• Annular pulleys =
mechanical role

• A2 & A4 are the most

important to lessen the
moment arm

• Cruciate pulleys: Nutrition

 TENDON HEALING

• 3 phases

• In ammation (1 week)

• Proliferative (Weeks)

• Remodeling (Months)

Tital AL et al. Flexor Tendon: Development, Healing, Adhesion Formation, and Contributing Growth Factors. Plast Reconstr Surg. 2019 ; 144(4):
639e–647e.
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 TENDON HEALING: INFLAMMATORY PHASE =
1 WEEK

• Haematoma activates a cascade of

vasodilators and proin ammatory
mediators

• Increased vascular permeability

promotes the venue of

• In ammatory cells, platelets that

release factors stimulating
angiogenesis and tenocytes
proliferation

• Tendon repair is reliant on the

suture strength +++
Zhao C, Amadio PC, Paillard P, et al. Digital resistance and tendon strength during the rst week after exor digitorum
profundus tendon repair in a canine model in vivo. J Bone Joint Surg Am 2004;86:320–7.
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 TENDON HEALING: PROLIFERATIVE
PHASE (1-3 WEEKS)

• Fibroblasts proliferation

• Immature collagen (type III)

• Production of ECM

• Scar formation within the

tendon ➘ strength

• Risk of rupture is major at

10-12 days
 TENDON HEALING: REMODELING PHASE
(> 6 WEEKS)

• Type I collagen bers are re-

oriented in a longitudinal matter

• Collagen brils begin cross-linking

➚ strength

• Adhesions are more apparent

• Tendons never regain their

previous resistance +++
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 PATIENT INTRINSIC FACTORS
• Age

• Sex (Males > females)

• Health status

• Malnutrition

• Smoking

• Steroid use

• Poor compliance
 PATIENT EXTRINSIC FACTORS

• Wound localisation

• Type of injury

• Extent of injury

• Associated lesions (fracture,

nerves, arteries,…)

• Late presentation
 ➚ INTRINSIC
• Timing for surgery
• Limit soft-tissues trauma
during exposure
• Solid xation (purchase,
number of core sutures,
epitendinous sutures,…)

• Preserve the pulleys • Close the sheath

• Protect the tendon • Timing for rehabilitation

(retrieval, grasping,
xation…) • Active mobilisation
➘
EXTRINSIC
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 TIMING FOR SURGERY

• Equal or better results in delayed (> 1 week) repair

• Avoid immediate repair by inexperienced surgeons

Lalonde DH. An evidence-based approach to exor tendon laceration repair. Plast Reconstr Surg 2011;127:885–90
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 LIMIT SOFT-TISSUES TRAUMA
• Good exposure (concomitant
injuries)

• Incisions should allow tendon

end retrieval

• Usually Bruner type 1,5-2 cm

long

Wu YF, Tang JB. Tendon Healing, Edema, and Resistance to Flexor Tendon Gliding: Clinical Implications. Hand Clin 29 (2013) 167–178
 PRESERVE PULLEYS (1)
• Tendon repair is up to
300% larger than native
tendon

• Try to protect A2 > A4 >

A3…

Hwang MD, Pettrone S, Trumble TE. Work of exion related to different suture materials after exor digitorum profundus and exor digitorum
super cialis tendon repair in zone II: a biomechanical study. J Hand Surg Am 2009;34:700–4.
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 PRESERVE PULLEYS (2)
• If sutures cannot glide, venting
of the pulley may be a solution
(< 2/3 of A2, complete A4) -
unless other pulleys are intact

• Or decrease size of tendons

(FDS slip removal)

Kwai Ben I, Elliot D. “Venting” or partial lateral release of the A2 and A4 pulleys after repair of zone 2 exor tendon injuries. J Hand Surg Br
1998;23:649–54.
Mitsionis G, Fischer KJ, Bastidas JA, et al. Feasi- bility of partial A2 and A4 pulley excision: residual pulley strength. J Hand Surg Br 2000;25:90–4.
Savage R. The mechanical effect of partial resection of the digital brous exor sheath. J Hand Surg Br 1990;15:435–42.
Tang JB. The double sheath system and tendon gliding in zone 2C. J Hand Surg Br 1995;20:281–5.
Tomaino M, Mitsionis G, Basitidas J, et al. The effect of partial excision of the A2 and A4 pulleys on the biomechanics of nger exion. J Hand
Surg Br 1998;23:50–2.
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PROTECT THE TENDON ENDS

• Protect the vincula

• Avoid clamps on the

tendon ends (retrieval
tricks)

• Use 25G needles to hold

the stumps
 SOLID FIXATION

• Strength relies on the

sutures the 1st week

• Gapping at the suture site

increased adhesions

Tang JB. Flexor Tendon Injuries. Clin Plastic Surg 46 (2019) 295–306
 STRONG SUTURES

Lee C. Tendon physiology and Repair. Orthopaedics and Trauma 2021; 35(5):274-281
Myer C, Fowler JR. Flexor Tendon Repair Healing, Biomechanics, and Suture Con gurations. Orthop Clin N Am 47 (2016) 219–226
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 • Core placement • Locking vs grasping
(dorsal vs volar) sutures

• Core size • Type of sutures

• Tendon purchase • Knot placement

(7-12 mm)
• Epitendinous
• Asymetry sutures

Hotokezaka S, Manske PR. Differences between locking loops and grasping loops: effects on 2-strand core suture. J Hand Surg Am 1997;22: 995–1003
Taras JS, Raphael JS, Marczyk SC, et al. Evaluation of suture caliber in exor tendon repair. J Hand Surg Am 2001;26:1100–4
Soejima O, Diao E, Lotz JC, et al. Comparative mechanical analysis of dorsal versus palmar placement of core suture for exor tendon repairs. J Hand Surg
Am 1995;20:801–7.
Barrie KA, Tomak SL, Cholewicki J, et al. Effect of suture locking and suture caliber on fatigue strength of exor tendon repairs. J Hand Surg Am 2001;26:
340–6.
Cao Y, Zhu B, Xie RG, et al. In uence of core suture purchase length on strength of four-strand tendon repairs. J Hand Surg Am 2006;31(1):107–12.
Tang JB, Zhang Y, Cao Y, et al. Core suture purchase affects strength of tendon repairs. J Hand Surg Am 2005;30:1262–6.
Wu YF, Tang JB. The effect of asymmetric core suture purchase on gap resistance of tendon repair in linear cyclic loading. J Hand Surg Am 2014; 39(5):910–8
Lee SK, Goldstein RY, Zingman A, et al. The effects of core suture purchase on the biomechanical characteristics of a multistrand locking exor tendon
repair: a cadaveric study. J Hand Surg Am 2010; 35:1165–71.
Lee SK. Modern tendon repair techniques. Hand Clin 2012;28:565–70.
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 ADDITIONAL MEDICATION

• Many trials with

pharmacological agents,
growth factors,…

• Mechanical barriers

• Useless clinical evidence

Chang J. Studies in exor tendon reconstruction: biomolecular modulation of tendon repair and tissue engineering. J Hand Surg Am 2012;37:
552–61.
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 SHEATH CLOSURE
• Theoretical advantages :

• Serve as a barrier to the formation of

extrinsic adhesions,

• Provide a quicker return of synovial

nutrition,

• Act as a mold for the remodeling tendon,

• Disadvantages: technically dif cult and may

narrow and restrict tendon gliding.

• No clear-cut bene t to sheath repair has yet

been established.
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 REHABILITATION

• Usefulness ?

• When to start ?

• Active or passive ?

• Wrist immobilisation ?

Cao Y, Tang JB. Resistance to motion of exor tendons and digital edema: an in vivo study in a chicken model. J Hand Surg Am 2006;31:1645–
51.
Peters SE, Jha B, Ross M. Rehabilitation following surgery for exor tendon injuries of the hand. Cochrane Database of Systematic Reviews,
2021 (1), art. no. CD012479.
Trumble TE, Vedder NB, Seiler JG 3rd, et al. Zone-II exor tendon repair: a randomized prospective trial of active place-and-hold therapy
compared with passive motion therapy. J Bone Joint Surg Am 2010;92:1381–9.
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 CONCLUSION
• Delicate balance to avoid both tendon rupture and adhesion

• Understanding of the healing process will help the surgeon

to adapt his/her surgical technique to:

• The patient

• The injury

• The (availability) physiotherapist

 • Core placement (dorsal vs volar)

• Core size

• Tendon purchase (7-12 mm)

• Asymetry

• Locking vs grasping sutures

• Type of sutures
Hotokezaka S, Manske PR. Differences between locking loops and grasping loops: effects on 2-strand core suture. J Hand Surg Am 1997;22:
• Knot placement 995–1003
Taras JS, Raphael JS, Marczyk SC, et al. Evaluation of suture caliber in exor tendon repair. J Hand Surg Am 2001;26:1100–4
Soejima O, Diao E, Lotz JC, et al. Comparative mechanical analysis of dorsal versus palmar placement of core suture for exor tendon repairs. J
• Epitendinous sutures Hand Surg Am 1995;20:801–7.
Barrie KA, Tomak SL, Cholewicki J, et al. Effect of suture locking and suture caliber on fatigue strength of exor tendon repairs. J Hand Surg Am
2001;26: 340–6.
Cao Y, Zhu B, Xie RG, et al. In uence of core suture purchase length on strength of four-strand tendon repairs. J Hand Surg Am
2006;31(1):107–12.
Tang JB, Zhang Y, Cao Y, et al. Core suture purchase affects strength of tendon repairs. J Hand Surg Am 2005;30:1262–6.
Wu YF, Tang JB. The effect of asymmetric core suture purchase on gap resistance of tendon repair in linear cyclic loading. J Hand Surg Am 2014;
39(5):910–8
Lee SK, Goldstein RY, Zingman A, et al. The effects of core suture purchase on the biomechanical characteristics of a multistrand locking exor
tendon repair: a cadaveric study. J Hand Surg Am 2010; 35:1165–71.
Lee SK. Modern tendon repair techniques. Hand Clin 2012;28:565–70.
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