646521

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JHS0010.1177/1753193416646521Journal of Hand Surgery (European Volume)Moriya et al.

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JHS(E)
The Journal of Hand Surgery

Clinical results of releasing the entire (European Volume)

XXE(X) 1­–7
© The Author(s) 2016
A2 pulley after flexor tendon repair Reprints and permissions:
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in zone 2C DOI: 10.1177/1753193416646521

jhs.sagepub.com

K. Moriya, T. Yoshizu, N. Tsubokawa, H. Narisawa,

K. Hara and Y. Maki

Abstract
We report the results of complete release of the entire A2 pulley after zone 2C flexor tendon repair followed by
early postoperative active mobilization in seven fingers and their comparisons with 33 fingers with partial A2
pulley release. In seven fingers, release of the entire A2 pulley was necessary to allow free gliding of the repairs
in five fingers and complete release of both the A2 and C1 pulleys was necessary in two. No bowstringing was
clinically evident in any finger. Two fingers required tenolysis. Using Tang’s criteria, the function of two digits
was ranked as excellent, four good and one fair; there was no failure. The functional return in these seven
fingers was similar with that in 33 fingers with partial A2 pulley release; in these patients only one finger
required tenolysis. Our results support the suggestion that release of the entire A2 pulley together with the
adjacent C1 pulley does not clinically affect finger motion or cause tendon bowstringing, provided that the
other pulleys are left intact.

Level of evidence: IV

Keywords
A2 pulley, early active mobilization, flexor tendon injury, release, six-strand technique, zone 2C

Date received: 9 February 2016; revised: 23 March 2016; accepted: 23 March 2016

Introduction
Flexor tendon repair in zone 2 is technically more
demanding than the repair in other zones of the hand.
Tang and Shi (1992) divided this complicated area into
four subdivisions by reference to biomechanical and
structural differences between each segment of the
tendon. Of the four subdivisions, the area covered by
the A2 pulley was defined as zone 2c. When repairing
the flexor digitorum profundus (FDP) tendon in zone
2c, pulley release occasionally needs to be extended
to a large proportion of the A2 pulley to improve digi-
tal function after primary tendon repair. In cadaveric
models, release of the A2 pulley by up to 50% of its
entire length does not cause substantial tendon bow-
stringing or reduce the excursion efficiency of the
FDP tendon (Tomaino et al., 1998). There are different
considerations and recommendations about suitabil-
ity of release of the major pulleys, i.e. the A2 or A4
pulleys (Elliot, 2002; Moriya et al., 2016; Tang, 2014a;
Tolerton et al., 2014). More recently, several studies
have found that there is no absolute need to preserve
the A2 pulley completely, when the majority of the
other pulleys are intact (Lu et al., 2015; Mitsionis
et al., 1999; Savage, 1990; Tang et al., 2001).
In the past 23 years, we have had to release the
entire A2 pulley in some patients during primary
repair in zone 2. The aim of this study was to evaluate
the effects of release of the entire A2 pulley on clini-
cal outcomes following primary or delayed primary
flexor tendon repair in zone 2c.
Niigata Hand Surgery Foundation, Niigata, Japan
Corresponding author:
K. Moriya, Niigata Hand Surgery Foundation, Suwayama 997,
Seiro-machi, Niigata 957-0117, Japan.
Email: kmoriya@k8.dion.ne.jp

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2 The Journal of Hand Surgery (Eur)
Methods
Patients
We identified 88 patients (102 fingers) with isolated
zone 2 flexor tendon injuries, with or without con-
comitant flexor digitorum superficialis (FDS) tendon
lacerations, repaired at our institution between 1993
and 2015. We excluded patients with extensor tendon
injuries, fractures, joint injuries or skin defects.
Using Tang’s subdivisions of zone 2 injuries, 28 fin-
gers had zone 2a injuries (from the distal margin of
the insertion of the FDS tendon to the proximal mar-
gin of the insertion), 53 fingers zone 2b injuries (in
regions from the proximal margin of the FDS inser-
tion to the distal edge of the A2 pulley), 15 fingers
zone 2c injuries and six fingers zone 2d injuries (in
the region from the proximal margin of the A2 pulley
to the proximal reflection of the synovial sheath). The
A2 pulley was partially released in 33 fingers (23 zone
2b, eight zone 2c and two with zone 2d injuries).
Of these 102 fingers, seven fingers (in six men and
one woman) with zone 2c tendon injuries required
complete release of the A2 pulley. The size and loca-
tion of the excised pulley were determined based on
a simple sketch of the hand and an operative note
(Figure 1). The patients had a mean age of 34 years
(range 13 to 59) with injuries to three index, three
middle and one little finger. Primary repair (i.e. end-
to-end repair performed within 24 hours of injury)
was performed in four fingers and delayed primary
repair (from 1 to 5 days after primary skin closure) in
three fingers. Six fingers had relatively clean injuries,
one had a blunt cut caused by machinery.
Surgical methods
Via a standard approach we repaired the FDS (six
cases; excision in one case) and all FDP tendons. The
injured A2 and adjacent pulleys were opened to expose
the cut tendon when the lacerated FDP tendon was
difficult to pass under these pulleys. We usually
released a pulley for about 18 mm, centred on the cut
end, to perform an adequate tendon repair (Figure 2).
The FDS tendons were repaired with 4-0 or 5-0 mono-
filament nylon utilizing figure-of-eight or Tsuge
sutures, together with a simple running peripheral
epitendinous sutures using 6-0 monofilament nylon.
The FDP tendon was repaired using the six-strand
suture of 4-0 looped nylon and double threads with
two needles (Bear Medic Corp., Ichikawa, Japan)
attached to 4-0 monofilament nylon described in the
Yoshizu #1 technique (Moriya et al., 2015; Yoshizu,
1996), accompanied by a simple running peripheral
epitendinous suture of 6-0 monofilament nylon. We
performed the extension–flexion test (Tang, 2013) to
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verify tension across the repair site and strength of
the repair. The repaired digit was fully extended pas-
sively to ensure no gapping between tendon ends.
Next the digit was flexed to determine whether the
tendon gliding was smooth and finally the digit was
markedly flexed to ensure the repair site did not catch
against the pulley. Then, the A2 pulley was released a
further 8–11 mm proximally, to eliminate the danger
of tendon overloading when the tendon glides against
the pulley rim (Figure 2). In five fingers the entire A2
pulley was released without other pulleys being
released; in two fingers we had to release both the A2
and C1 pulleys. The pulleys were released by cutting
them through a lateral longitudinal incision (Figure 3).
The pulleys were not repaired or reconstructed. All
other annular pulleys were intact.
Our indications for complete surgical release of
the entire A2 pulley were: (1) it was difficult to pass
the ends of the lacerated FDP tendon under the A2
pulley; (2) the A2 pulley had to be opened to achieve
adequate core suture purchase (about 18 mm in the
Yoshizu #1 technique); or, (3) the repair could not
pass easily through the residual part of the pulley.
Digital nerves (if damaged) were repaired with either
9-0 or 8-0 nylon under an operative microscope, after
the tendon repairs were complete. According to
Tang’s levels of surgical expertise (Tang, 2009a;
2013), all repairs were performed by one expert (level
5 expertise) who pioneered the Yoshizu #1 technique,
and four highly experienced specialists (level 4 exper-
tise). Post-operative rehabilitation of the digits
started on the first postoperative day with the previ-
ously described controlled active mobilization regime
(Moriya et al., 2015). In 33 fingers with partial release
of the A2 pulley the operations were the same, but
the A2 pulleys were only partially released.
Follow-up and evaluation
The mean follow-up period for the seven patients
was 9 months (range 6–12). At the final visit, we asked
the patients whether they noticed tendon bowstring-
ing or not. Additionally, tendon bowstringing was
objectively determined when the finger was flexed
against resistance (Figure 1). Active digit motion was
measured with a goniometer at the three finger joints
at the time of final evaluation by a surgeon or thera-
pist who had been part of the treatment team. The
clinical results were evaluated by reference to the
total active motion (TAM) of the proximal interphalan-
geal (PIP) and distal interphalangeal (DIP) joints of
the fingers using the criteria of Strickland and
Glogovac (1980) and Tang (2007a, 2013). The Tang cri-
teria are more stringent in terms of recognition of an
‘excellent’ outcome than are those of Strickland and
Moriya et al. 3

Figure 1.  Clinical photographs of a 46-year-old male who sustained a zone 2c flexor tendon injury to the middle finger of
the left hand. (a) The laceration traversed the entire depth of the A2 pulley. (b) The pulley was opened to a length of about
18 mm (centred on the cut end) to provide an operative field for tendon repair. (c) The remainder of the proximal portion of
the A2 pulley was completely released to allow the repaired tendon to easily glide against the pulley rim. (d) Simple sketch
used to delineate pertinent findings of the operation, including the size and location of the excised pulley. (e) Postoperative
extension and flexion 7 months after surgery. (f) No bowstringing of the middle finger was evident at the final visit.
FDP: flexor digitorum profundus; FDS: flexor digitorum superficialis.

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4 The Journal of Hand Surgery (Eur)
Figure 2.  Incisions of pulleys in patients with zone 2c flexor
tendon injuries. (a) First, the injured A2 and adjacent pul-
leys are opened to lengths of about 18 mm, centred on the
cut end, and core suturing is performed. (b) Next, the pul-
leys are proximally released for an additional 8–11 mm,
depending on the extent of flexor tendon excursion at the
proximal phalanx.
Figure 3.  Our method of A2 pulley release. The remaining
A2 pulley, which disturbs excursion of the repaired FDP
tendon, is released by cutting it longitudinally through a
lateral incision with scissors in addition to partial excision
of the A2 pulley for the performance of the Yoshizu #1 tech-
nique.
Glogovac (1980). In addition, the Tang criteria sepa-
rately grades the fingers that fail to achieve 30%
return to active range of motion of the PIP and DIP
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joints as failures. The results classified by the Tang
criteria are excellent (90%–100% of normal motion of
the PIP and DIP joints), good (70%–89% of normal),
fair (50%–69% of normal), poor (30%–49% of normal)
or failure (<30% of normal).
Results
Tendon rupture or bowstringing
No tendon rupture occurred; no wound complication
or infection was noted. No patient exhibited subjec-
tive or objective tendon bowstringing at the final visit.
Two patients had inadequate active finger excursion
(the TAM of the PIP and DIP joints of 75° and 130°)
(Table 1). They were treated with tenolysis at a mean
of 5 months (range 4–6) after primary repair. The
results reported below are endpoint evaluation after
tenolysis.
Range of active digital motion
The mean TAM of the metacarpophalangeal, PIP and
DIP joints was 231° (range 190°–262°) and the TAM of
the PIP and DIP joints 148° (range 108°–180°); the
range of motion of the DIP joint was a mean of 60°
(range 30°–75°) at the final evaluation (Table 1).
According to Strickland’s criteria, four fingers were
ranked excellent, two good and one fair. Using Tang’s
criteria, two fingers were ranked excellent, four good
and one fair. No repair failed.
The distributions of the injuries of the 33 fingers
with partial release of the A2 pulley are shown in
Table 2. The mean TAM of the metacarpophalangeal,
PIP and DIP joints was 229° (range 160°–286°) and of
the PIP and DIP joints 147° (range 80°–203°); the
range of motion of the DIP joint was a mean of 66°
(range 15°–95°). Patients with a partial release of the
A2 pulley in zone 2c showed worse TAM and poorer
evaluations according to Strickland’s and Tang’s cri-
teria; however, the number of fingers with complete
A2 pulley releases were not large enough to allow
statistical analysis with sufficient power.
Analysis of fingers requiring tenolysis
Two (29%) of seven fingers with release of the entire
A2 pulley needed tenolysis. We performed the tenoly-
sis when a patient had a poor range of motion (com-
bined PIP and DIP range of motion less than 90°)
more than 3 months after operation or requested
near normal function even if digital function was
already reasonable (Table 1). In the 33 fingers with
only partial release of the A2 pulley, only one (3%) fin-
ger required tenolysis, performed at 4 months after
primary repair. In this patient, the TAM of the PIP and
Moriya et al. 5

Table 1.  The patient data of the seven cases with release of entire A2 pulleys.

Cases Age Injury Timing of repair Pulleys Follow-up TAMa Strickland Tang
released (months) gradingb gradingb
Before tenolysis At final evaluation
(degrees) (degrees)
1 21 Sharp Primary A2 6 152 Excellent Good
2 35 Sharp Primary A2 12 130 135 Good Good
3 13 Sharp Delayed primary A2 + C1 8 171 Excellent Excellent
4 59 Sharp Delayed primary A2 9 148 Excellent Good
5 21 Sharp Primary A2 8 180 Excellent Excellent
6 42 Sharp Delayed primary A2 + C1 10  75 108 Fair Fair
7 46 Blunt Primary A2 8 145 Good Good
aThe sum of total active motion of the PIP and DIP joints.
bForthe two fingers needing tenolysis, the outcomes noted here after tenolysis.
The grade of outcomes before tenolysis was good for case 2, and poor for case 6 according to both Strickland and Tang grading.
TAM: total active motion.

DIP joints improved from 140° before tenolysis to
180° after tenolysis. Two out of these 33 fingers suf-
fered tendon ruptures (Table 2).
Discussion
Although the importance of any given pulley can be
debated, the A2 pulley has traditionally been consid-
ered to play a major role in preventing bowstringing.
In the past, most hand surgeons kept the A2 pulley
intact during flexor tendon repair, or repaired and
reconstructed a released A2 pulley with a retinacu-
lar or fascial graft, because reconstruction of the A2
pulley was considered important, not only to ensure
mechanical efficiency of the flexor system, but also
to restore intrathecal circulation of the synovial fluid
(Elliot and Giesen, 2013; Saito, 1989). Today, some
hand surgeons still consider it important to leave
the A2 pulley intact or to close the pulley as much as
possible (Tang et al., 2014b). In an in vivo chicken
model, Wu et al. (2012) noted that preservation of A2
pulley integrity significantly increased the resist-
ance to movement of the repaired flexor tendon;
Tang et al. (2009b) reported that A2 pulley release
significantly reduced the force required for flexion
after flexor tendon repair. Various studies have
emphasized that the A2 pulley can be partially
excised without any significant effect on the digital
range of motion (Lu et al., 2015; Mitsionis et al.,
1999; Tomaino et al., 1998). Currently, up to 75% of
the A2 pulley is often released to facilitate tendon
gliding, provided that the other pulleys are intact
(Tang et al., 2014b). Tanaka et al. (2004) concluded
that partial excision of the A2 pulley was feasible
with little risk of rupture and little increase in glid-
ing resistance. This result was obtained through a
cadaveric model in which the remaining tendon
sheath except the A2 pulley was excised. Because
the size and location of the remaining pulley affects
gliding resistance after pulley excision, their study
may not have reproduced in vivo biomechanics.
Previous studies have reported that complete
release of the A2 pulley creates obvious bowstringing
across the proximal phalanx and reduced the total
range motion by 1.6%–10% (Lowrie and Lees, 2014;
Tang, 1995). In a cadaveric study, entire release of the
A2 pulley did not cause bowstringing at the PIP or
metacarpophalangeal joints, but did cause bow-
stringing over the concave palmar shaft of the proxi-
mal phalanx (bony bowstringing) (Tang, 1995). Savage
(1990) reported that the maximal changes associated
with incision of the entire A2 pulley were small in
terms of any effect on FDP functionality, such as ten-
don excursion, flexion force and bowstringing. The
effects of complete A2 release on flexor tendon integ-
rity were not deleterious to FDP tendon function in a
live chicken model (Tang, 2007b). In addition, even
entire incision of the A2 pulley may be acceptable
based on findings in a cadaveric study (Tang, 1995). In
this study, our data indicate that release of the entire
A2 pulley together with the adjacent C1 pulley does
not clinically affect finger function, provided that the
other pulleys are intact. The muscle appears to adapt
to take the extra load required to control normal digi-
tal function when the A2 pulley is completely released.
Clinically bowstringing is not evident. Two fingers
required flexor tenolysis, although the A2 pulley was
released completely. The percentage of fingers
requiring tenolysis was much higher after release of
the entire A2 pulley (two out of seven fingers, 29%)
than after partial release of the A2 pulley (one out of
33 fingers, 3%). We are not sure whether this rate of
tenolysis relates to the release of the entire A2 pulley,
or severity or location (zone 2c) of the injury. However,
we believe that complete release of the A2 pulley
could prevent the compression of the edematous

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6 The Journal of Hand Surgery (Eur)

Table 2.  Comparison of the patient data and outcomes between the fingers with partial or entire A2 pulley release.
Areas Number Age Repair Tenolysis TAMa Strickland criteriab Tang criteriab
of fingers (range) rupture (range)
Excellent Good Fair Poor Excellent Good Fair Poor Failure

With partial A2 release

Zone 2b 23 33 years 2 1 152° 13 5 3 2 10 8 3 0 2
(9–82) (88°–203°)
Zone 2c 8 45 years 0 0 126° 4 0 3 1 1 3 3 1 0
(21–63) (80°–170°)
Zone 2d 2 29 years 0 0 177° 2 0 0 0 2 0 0 0 0
(25–33) (164°–190°)
Total 33 36 years 2 1 147º 19 5 6 3 13 11 6 1 2
(9–82) (80º–203º) (58%) (15%) (18%) (9%) (40%) (33%) (18%) (3%) (6%)
With complete A2 release
Zone 2c 7 34 years 0 2 148° 4 2 1 0 2 4 1 0 0
(13–59) (108°–180°) (57%) (29%) (14%) (29%) (57%) (14%)

aThesum of total active motion of the PIP and DIP joints.

bForthose fingers needing tenolysis, the outcomes shown here are after tenolysis.
TAM: total active motion.

tendon by the pulley, but not adhesions caused by Funding

bleeding from the cutting edge of the A2 pulley.
Resection of the FDS tendon also reduces the
gliding resistance imposed on the FDP tendon
(Hwang et al., 2009; Paillard et al., 2002; Tang et al.,
2007b; Wu and Tang, 2013, 2014; Zhao et al., 2002);
however, FDS excision compromises the clinical out-
come of flexor tendon repair because the total exten-
sion deficit increases (Moriya et al., 2015).
Functionally, FDP gliding is affected by the FDS ten-
don, which acts as an additional sheath for the FDP.
Thus, a double-sheath system, consisting of the A2
pulley and the FDS tendon, is found in zone 2c (Tang,
1995). We prefer to perform partial or complete
release of the A2 pulley rather than resect the FDS
tendon when we repair flexor tendons in zone 2c. We
believe that the good clinical outcomes (including no
obvious bowstringing) seen in our present study may
be attributable to our careful repair of the FDS ten-
don, which was possible in all but one case.
There are weaknesses in this study: it is retro-
spective; the sample size is small and heterogene-
ous; and we did not assess bowstringing with
ultrasound, which may have shown bowstringing not
evident clinically (Bouyer et al., 2016).
Based on the clinical follow-up of the seven fingers
requiring release of the entire A2 pulleys of our patients
over years, we believe that release of the entire A2 pul-
ley does not necessarily influence the clinical outcome
of digital flexion, provided that the other pulleys remain
intact.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of
this article.
The authors received no financial support for the research,
authorship, and/or publication of this article.
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