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Secondary Flexor Tendon Reconstruction, A Review

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 REVIEW ARTICLE
Secondary Flexor Tendon Reconstruction,
A Review
Aaron M. Freilich, MD, A. Bobby Chhabra, MD

From the University of Virginia, Department of Orthopaedics; and the University of Virginia Hand Center,
Charlottesville, VA.

As techniques have improved, primary repair of flexor tendon lacerations, including zone II
injuries, have become more common. Secondary reconstruction, whether in 1 or 2 stages,
remains an important and useful technique for the treatment of these injuries. Current indications
and methods, including delayed treatment and 1-stage and 2-stage reconstruction, are reviewed.
Future directions of tendon reconstruction are also discussed. (J Hand Surg 2007;32A:
1436 –1442. Copyright © 2007 by the American Society for Surgery of the Hand.)
Key words: Flexor tendon, secondary reconstruction, zone II, tendon graft, Hunter rod.

lexor tendon injuries account for less than 1% bilitation may be contraindications for primary

F of all hand injuries1; however, their effect on

function for both the patient and society should
not be underestimated.2 Primary or delayed primary
repair of flexor tendon injuries, with changes in tech-
nique, rehabilitation, and technology, has moved to
the forefront of treatment options. Secondary recon-
struction, however, long the mainstay of treatment
for these injuries, remains an important technique in
the care of certain injuries.
Secondary reconstruction of tendon injuries in
zone II (also known as “no man’s land”) using a
silicone implant was first described by Bassett and
Carroll in 1963 and refined by Hunter in 1971.3,4
Until the late 1970s, this type of 2-stage reconstruc-
tion was the standard for treatment of flexor tendon
injuries in the finger. The use of a locally pedicled
intrasynovial graft, flexor digitorum superficialis
(FDS), instead of a more remote tendon has also been
described.5,6 As results with primary tendon repair
have improved, secondary reconstruction is mainly
reserved for complicated injuries (Boyes grades 2–5,
Table 1), or those that have failed primary repair.
Delayed Repair
In certain cases, primary repair can still be accom-
plished after a delayed presentation. This includes
patients with missed injuries or those with associated
medical conditions that have delayed surgical treat-
ment. Substantial soft tissue or crush injury, infec-
tion, or soft tissue defects that may delay early reha-
repair.7 Leddy type I avulsions involve retraction of
the flexor digitorum profundus (FDP) tendon into the
palm, with severe injury to the vascularity of the
tendon and formation of a hematoma in the tendon
sheath.8 These injuries are best treated early, before
myostatic shortening occurs. In cases in which a
delay is unavoidable, several options are possible.
The tendon can be reconstructed as will be discussed
later, the distal interphalangeal joint can be fused, or
if functional, the finger can be left alone. In patients
with Leddy type II or III avulsion injuries of the FDP
in which retraction and myostatic shortening does not
occur, primary repair can be delayed past 6 weeks.9
Ultrasound or magnetic resonance imaging, in addi-
tion to clinical examination, can be used to identify
retraction of the tendon stump.
One Versus Two Stages; Making the Decision
in Zone II
Patients who present either in a delayed fashion or who
have segmental tendon loss are unable to be adequately
treated with primary repair. In these patients, the deci-
sion needs to be made whether to reconstruct the flexor
tendons in a single setting or to perform a 2-stage repair.
In a single-stage reconstruction, the injured portions of
tendon are removed and replaced with an appropriately
harvested free tendon graft.
Both preoperative and intraoperative assessment is
necessary for a successful outcome. Indications for a
single-stage grafting procedure have been described
by Pulvertaft and others.10 These include beginning

1436 The Journal of Hand Surgery

 Freilich and Chhabra / Secondary Flexor Tendon Reconstruction 1437

Table 1. Boyes Classification

Grade Condition
1 Good. Minimal scar
2 Cicatrix. Deep scarring due to injury or prior surgery or infection. Loss of motion due
to scar rather than joint injury
3 Injury to the joint resulting in loss of motion
4 Injury to the digital nerves
5 Multiple combined problems involving multiple digits, including one or more of the
above categories
From Boyes JH. Flexor tendon grafts in the fingers and thumb: An evaluation of end results. J Bone Joint Surg 1950;32A:489-9.

with a hand or finger that has adequate passive mo-
tion of all joints, a well healed wound without ex-
cessive scarring, and a neurovascularly intact digit.
Some loss of passive motion can be addressed with
preoperative therapy. The patient must also be able to
cooperate with a complex rehabilitation program.
This precludes performing the procedure on children
under the age of 3 years.11 The procedure may also
have to be abandoned in favor of 2-stage reconstruc-
tion when intraoperative assessment demonstrates an
inordinate amount of scarring in the surgical bed or
an inadequate pulley system.
fixation. Proximally, the graft may be fixed to the FDP
tendon in the palm, just distal to the lumbrical insertion,
if there is no scarring present. This is usually accom-
plished with a tendon weave (Fig. 2). The original
tendon end should be prepared to remove any scarred,
bulbous, or frayed tissue. As always, care must be taken
to tension the graft appropriately. The profundus tendon
can be grafted in cases of an intact and functioning

Single-Stage Reconstruction
As described by Bunnell, strict surgical technique
must be followed to obtain satisfactory results.12
This includes aseptic, bloodless technique and the
preservation of the pulley system. The decision of
whether to use a midlateral or zigzag (Bruner) ap-
proach is based partly on surgeon preference and
partly on the presence of preexisting surgical or
traumatic scar location.13 Some authors have sug-
gested that using a midlateral incision keeps the scar
from sitting directly on the tendon sheath. Care
should be taken to ensure the preservation of as much
of the tendon sheath and pulley system as possible.
Originally it was recommended that only portions of
the annular pulleys be retained, but current recom-
mendations include preserving as much of the sheath
as possible.14,15
Donor tendons can be chosen from a variety of
sources. This choice will be discussed in detail later;
however, the most commonly used are ipsilateral
palmaris longus tendon or plantaris. The use of plan-
taris tendon has the added benefit of additional length
if needed.
Distally, the tendon is fixed to bone at the FDP
insertion using standard techniques that have been well
described (Fig. 1). If the stump of the FDP is long
enough, the graft can be woven through for added Figure 1. The modified Bunnell distal juncture technique.
1438 The Journal of Hand Surgery / Vol. 32A No. 9 November 2007
Figure 2. The proximal and distal junctures of the tendon
graft are seen after placement through the sheath and pulleys.
FDS. Careful preoperative patient selection and discus-
sion is necessary to ensure that the functional outcome
after grafting is not worse than before surgery. Many
patients do very well without a profundus tendon in the
setting of a well-functioning FDS.16 Others have shown
good outcomes with grafting through an intact FDS.
Indications generally include skilled technicians or mu-
sicians, especially aged 10 to 21 years.17 A thin graft,
such as plantaris, should be passed either through the
FDS decussation or around it if too tight. An intact FDS
should not be taken down in order to pass the graft.
With appropriate surgical technique and in a pa-
tient with the correct indications, single-stage graft-
ing for flexor tendon injuries can result in excellent
functional outcome. In cases with inadequate soft
tissue coverage, dense scarring, or insufficient pulley
systems, 2-stage flexor tendon reconstruction repre-
sents a better option.
Two-Stage Reconstruction
Once the decision to proceed with a staged recon-
struction has been made, the soft tissues must be
prepared for the eventual implantation of a final
tendon graft. This involves several steps, including
reconstruction of the pulley and sheath system,
placement of a temporary implant, and guided reha-
bilitation to regain maximum flexibility prior to the
second stage reimplantation. This method of flexor
tendon reconstruction was first demonstrated by
Hunter in 1965 and later refined in 1971.4
Frequently a 2-stage reconstruction is selected be-
cause of inadequacy of the soft tissues, sheath, and
pulley system. An adequate and functional pulley sys-
tem is needed prior to implant of the temporary silicone
graft. As was first described by Doyle and Blythe in
1975, the flexor tendon pulley system consists of annu-
lar pulleys A1 to A5 and cruciate pulleys C1 to C3.18,19
The most important pulleys, especially in reconstruc-
tion, are A2, located over the proximal phalanx, and
A4, over the middle phalanx. At a minimum, A2 and
A4 must be present or reconstructed to have a func-
tional pulley system.20 The pulleys function to maxi-
mally convert tendon excursion efficiently into joint
motion by preventing volar translation.
Several techniques are available for reconstruction
of the pulleys. Intact but constricted pulleys can be
dilated. Damaged but structurally sound pulleys can
be directly repaired. The ideal graft for reconstruc-
tion of the pulley system would have an intrasynovial
lining on the tendon gliding side. The reconstructed
pulley must also be tensioned appropriately to per-
form its function properly while still allowing unim-
peded tendon gliding. A free tendon graft can be used
with a variety of suture techniques. The simplest is to
use a remnant of free tendon graft. This encircles the
phalanx and can be placed deep to the extensor
mechanism.21 Originally, Bunnell described placing
the graft deep to the extensors for reconstruction of
A2 and superficial to the mechanism at A4; however,
Taras and Kaufmann recommend placing the graft
deep at all levels7,22 (Figs. 3A and B). Other more
complex techniques include the Kleinert, Weibly,
triple loop, Karev, and Lister techniques.
Figure 3. (A) Pulley reconstruction with placement of graft
encircling the phalanx. (B) The graft for pulley reconstruction
is sutured to the original pulley rim.
 Freilich and Chhabra / Secondary Flexor Tendon Reconstruction 1439

Some authors have suggested that the simple sin-

gle-loop technique is too narrow to provide an ade-
quate pulley.23 Okutusu’s triple-loop technique uses
3 passes of the graft around the phalanx and sutures.
Kleinert’s technique was to weave a tendon graft
through the old pulley rim.24 Karev’s “belt-loop”
technique uses a portion of the volar plate as the
pulley. Incisions are made distal and proximal in the
volar plate, and the tendon is passed through.25 The
inherent stiffness of the volar plate increases friction
and inhibits gliding.26 Lister used a portion of exten-
sor retinaculum, passing it around the phalanx. This
provides an excellent surface for gliding at the ex-
pense of a second incision.27 Artificial materials have
been used, including silicone sheet, Dacron graft, and
polytetrafluoroethylene, but there is usually enough
graft material to make the need for synthetics rare. In
those cases in which artificial material is needed,
polytetrafluoroethylene has been shown to be most
attractive, as it is incorporated without foreign body
reaction or adhesions.28
Once the pulley system is reconstructed, the Da-
cron-reinforced silicone graft is passed. Distally, the Figure 4. Removal of the silicone implant with placement of
implant is sutured below the FDP stump. Proximally the tendon graft through proximal and distal incisions.
no suture anastomosis is performed, allowing unim-
peded gliding in the forearm or palm. Most important
detached from the distal stump, and the graft is
is ensuring that the implant glides smoothly and does
sutured to the implant proximally, allowing it to be
not buckle with passive flexion.
pulled through the proximal end of the sheath. The
After stage 1 of a flexor tendon reconstruction, it is
implant is removed and is passed within the sheath in
vitally important to maintain or obtain full passive
a proximal to distal direction. The technique for
range of all joints. During rehabilitation, the goal is fixing the graft distally is similar to that used in a
maximal passive motion and correction of contrac- single-stage reconstruction. Proximally, an inter-
tures. Initially a dorsal blocking splint can be used weave technique is used, ensuring appropriate ten-
with passive motion. Dynamic splinting can be used sioning of the graft.
in cases of contracture release. Care must be taken in
cases where nerve or vessel repair was performed, Rehabilitation
and postoperative rehabilitation will need to be ad- Guided rehabilitation after both stage 1 and stage 2 in
justed accordingly. After allowing the scar to mature flexor tendon reconstruction is crucial to obtaining
and wounds to heal, the second stage can be per- the best possible outcome. Over the last 20 years,
formed. Three months is generally agreed on as ad- early motion protocols have been developed. Several
equate time for the formation of a suitable gliding studies have demonstrated the efficacy of early mo-
sheath around the implant. tion on tendon gliding and healing of the repair.29 As
The second stage involves the replacement of the suture techniques have improved, therapy protocols
silicone implant with a suitable tendon graft. Ideally, have become more aggressive. Rehabilitation after
the pseudosheath is left intact, and small distal and stage 1 involves mainly passive motion, attempting
proximal incisions are used to pass and secure the to gain maximum passive joint motion and improve
graft (Fig. 4). Depending on which portions of the contractures.30 This is typically begun several days
hand are scarred or involved, the graft can be fixed after surgery. After stage 2, similar therapy is insti-
either in the palm or further proximal in the forearm. tuted. At rest, the hand is protected in a flexed posi-
A motor unit must also be selected, and usually the tion via splinting, and a passive motion protocol is
adjacent profundus will suffice. If that is not suitable, begun. Others have recommended early active mo-
the superficialis can also be used. The implant is tion programs beginning as early as 2 weeks.15
1440 The Journal of Hand Surgery / Vol. 32A No. 9 November 2007
Choosing a Graft
A variety of options are available as suitable graft
choices for the second stage of the reconstruction.
The most obvious and easily available is the palmaris
longus. This can be harvested from the ipsilateral
forearm, if present, avoiding additional morbidity. In
most cases where a tip to forearm graft is needed, the
palmaris will be too short. Most frequently used in
this instance is the plantaris. This of course requires
access to the posterior medial heel for harvest. The
plantaris tendon provides a graft long and thin
enough for use in tip to forearm grafting. This tendon
is present in approximately 80% of patients.31 Other.
less common sources may be used. These include
harvest of toe flexors or long extensors, extensor
indicis proprius and extensor digiti minimi. Up to 3
grafts may be obtained using the long toe extensors
from the middle 3 toes. This graft is long enough for
a complete graft but is usually larger than plantaris or
palmaris,32 which can create problems in fitting
through the pseudosheath. The toe flexors to the
second through fifth toes are intrasynovial grafts,
potentially healing with fewer adhesions. These can
be used in similar fashion to the toe extensors.33
Additionally, the extensor digiti minimi or extensor
indicis proprius may be used. Either of these pro-
vides adequate length for palm to tip graft.
Zones III, IV, and V
Injuries involving the flexor tendons proximal to the
tendon sheath may frequently be treated with primary
repair. Reconstruction of a sheath and pulley system
is not necessary in these zones. Patients with associ-
ated soft tissue defect, infection, or segmental loss
may necessitate a more delayed form of reconstruc-
tion. In injuries involving zones III, IV, and V, sev-
eral techniques have been used. This includes cases
where the injury or repair is just underneath the A1
pulley and all or part of this pulley can be sacrificed.
In delayed treatment where direct end-to-end repair
is not possible, an interposition graft can be used as
discussed earlier. Another option is end-to-side FDP
transfer. The distal stump is sutured to an adjacent,
intact FDP tendon. Also possible is the transfer of an
adjacent FDS to the distal stump of the injured FDP.
Addressing Complications
Although it is a solution to a complex problem,
staged reconstruction can be fraught with postoper-
ative complications. Adhesions are the most common
of complications. They can occur at graft junction
sites or along the surface of the graft.34 A good
postoperative therapy program helps to limit the for-
mation of adhesions and can mobilize through some
adhesions. If a plateau is reached despite appropriate
therapy, tenolysis can be used to provide additional
motion.35 This is especially true if passive motion is
greater than active motion. Authors have suggested
waiting at least 3 to 6 months following reconstruc-
tion before returning for tenolysis.35,36 Proper surgi-
cal technique will limit the formation of adhesions.
Although less common, a reconstructed pulley may
fail. This may be noted by decreased range of motion
or bowstringing of the tendon. Either excessively
aggressive rehabilitation or poor surgical technique
may result in graft rupture. This can occur at both the
distal and proximal junctures.37 Once again, strict
adherence to appropriate surgical technique can limit
this occurrence. If caught early, the graft may be
salvaged by treating the rupture like an acute flexor
tendon injury with early reoperation. As a salvage, an
FDS finger can be created.38 The ultimate result with
this treatment is a finger motored by a single FDS
tendon with its insertion at the middle phalanx. The
distal interphalangeal joint may need to be fused if
unstable. Quadregia may also occur as a complica-
tion of improper tensioning or adhesions limiting
excursion. Flexion of the adjacent digits will be lim-
ited as a result of sharing a common muscle belly
when the repaired finger has reached maximal flex-
ion. On the other extreme, a graft tensioned too
loosely will result in a lumbrical-plus finger.39 Ten-
sion on the lumbrical muscle will cause a hyperex-
tension deformity of the interphalangeal joints. Hy-
perextension of the proximal interphalangeal joint
may occur in hyper-lax patients who are missing an
FDS tendon. Tenodesis of a slip of FDS may help
prevent this complication. Complications may also
occur after the first stage. Infection during this stage
may ultimately necessitate removal of the silicone
implant. Also possible is failure of the temporary
implant. Leaving the proximal end free will limit the
resulting proximal juncture failure and scarring40; if
it does not rupture at the proximal end, a distal
rupture may ultimately result. Joint contractures may
be noted early or late, and during rehabilitation after
either the first or second stages. If caught early, a
program of dynamic splinting can be initiated to
achieve adequate motion.37 If this approach ulti-
mately fails, surgical release can be performed. Sy-
novitis is a problem that may also occur in patients
after stage 1 reconstruction. This may result in im-
paired rehabilitation and a less optimized sheath for
stage 2.7,41 Tight pulleys, poor implant gliding, or
ruptures of the juncture of the implant may be pos-
 Freilich and Chhabra / Secondary Flexor Tendon Reconstruction
sible causes. Ultimately, using appropriate surgical
technique to ensure unimpeded implant motion and
adequate distal fixation, as well as avoiding irritants
such as talc, will help limit this complication. If the
inflammatory cycle does begin, early treatment with
temporary rest and splinting can assist in improving
outcomes.
Difference in the Treatment of the Pediatric
Population
Children with tendon lacerations pose a different
clinical problem. While the tendons, sheath, and pul-
leys are structurally similar to those of adults, they
are far more delicate. Pediatric patients are also dif-
ficult to examine. Up to 25% of patients may be
undiagnosed at initial presentation.42 Primary repair
in some cases can still be performed in children up to
2 months after injury with good results.43 In cases
where primary repair is no longer feasible, grafting
can be performed. This requires an intact sheath and
pulley system and adequate proximal muscle excur-
sion.44 Perhaps the biggest difference is in rehabili-
tation. This important phase of treatment requires the
ability to actively understand and participate with the
protocols as well as comply with treatment. As this is
difficult to achieve in younger children, immobiliza-
tion is used for 4 weeks. In older, more active chil-
dren, a removable dorsal blocking splint can be used
to prevent reinjury during daytime play. Two-stage
reconstructions in children have been reported. Dar-
lis et al used a modified Paneva-Holevich technique
in 9 children with mostly good and excellent re-
sults.45 This involves a 2-stage reconstruction in
which the FDS is sutured to the FDP proximal stump
and then, in the second stage, is severed proximally
and rotated as a pedicled graft.5 It is also important to
keep in mind that excessive dissection around growth
plates, transosseous tunnels and pulley reconstruc-
tions may result in growth disturbances.
Salvage
As mentioned previously, an FDS finger can be created,
together with arthrodesis of the adjacent unstable joint,
to provide an adequate functional result. Providing a
finger with proximal interphalangeal motion alone mo-
tored by a single FDS tendon may be advisable when
the distal interphalangeal joint is unstable or unrecon-
structable. It may also be used as a salvage when distal
pulleys are unable to be reconstructed or in cases of
distal graft rupture after reconstruction. The staged re-
construction of flexor tendons in a badly injured ex-
tremity cannot be treated in an isolated manner without
careful consideration given to the neurovascular status
1441
of the hand or finger. In many cases, amputation may
give a better functional outcome rather than attempted
replant or reconstruction. Indications for amputation or
replantation are beyond the scope of this article but are
nevertheless important in considering possible recon-
struction.
Conclusions and the Future
Early repair of flexor tendon injuries, including those in
zone II, has become a mainstay of treatment in these
injuries. Delayed 2-stage reconstruction remains an ex-
cellent alternative to provide a functional digit in cases
of failed early repair or when early repair simply is not
an option. Strict adherence to surgical principles that
have been established and access to appropriate hand
therapy specialists can result in good outcomes for these
patients. The last 30 years have seen tremendous strides
in the understanding of the tendon biology of healing
and repair.46 This has resulted in stronger repair tech-
niques and improved therapy regimens with early mo-
tion protocols. Research, however, continues to attempt
to find ways of improving healing and limiting adhe-
sions and scarring. Current studies involve modifying
healing at the cellular, molecular, and genetic levels.46
This includes the use of mesenchymal stem cells to
speed or improve tendon healing or to provide tendon
graft material.47 Work also continues on the use of
molecular growth factors such as TGF-beta, PDGF,
IGF, and BMPs to limit adhesion formation while pro-
moting earlier healing.48 Similarly, research is looking
at ways to use gene therapy to affect local mediator
expression. None of these advances has made its way
into current widespread clinical practice, but advance-
ments in biologics may provide answers to today’s
difficulties following flexor tendon reconstruction.
Received for publication March 4, 2007; accepted August 22, 2007.
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
article.
Corresponding author: A. Bobby Chhabra, MD, University of Vir-
ginia, Department of Orthopaedic Surgery, 400 Ray C. Hunt Drive, Suite
330, Charlottesville, VA 22903; e-mail: ac2h@virginia.edu.
Copyright © 2007 by the American Society for Surgery of the Hand
0363-5023/07/32A09-0018$32.00/0
doi:10.1016/j.jhsa.2007.08.018
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