The 

operation of a flexor tendon graft 

is a very commonly done procedure.

The reason is that injuries to the flexor 

tendons in this area of the 

palm.

Between the distal crease 

here and the middle flexion 

crease of the fingers is an 

area that has been called no man's land.

Now in this area we have to flexor 

tendons held in place by a 

thick fibrous surrounding sheath,

sometimes called a pulley,

and when the damage occurs to the tendons in this 

area,

if they're injured by laceration or 

scarring from an operation of a 

repair,

then flexion of the finger is impaired.

Now,

in order to reproduce a flexor 

mechanism in the finger,

it's necessary to substitute for the whole 

tendon.

In other words,

a tendon from the lumber ical origin in the palm to the 

insertion.

So we must remove all of the old 

tendons,

the scarred area as well as the remaining parts of the 

tendon as well.

Likewise,

the synovial sheath that covers this tendon.

Now the pulleys should be repaired if 

necessary,

or reconstructed.

The principle of this operation is based on the work of banel 

and consists of the full length tendon graft 

going from the lumberjack large in in the palm 

through the finger to insert into the bone of the 

terminal phalanx.

Now at the same time that this graft is inserted,

we reconstruct pulleys and also repair 

the nerves if they're damaged.

The usual incision is mid lateral in the finger.

In other words it's dorsal to the flexion creases of 

the finger and a curved incision in the 

palm paralleling the flexor creases here.

Now in the following scenes you will 

see an operation of a tendon graft into a finger.

Dr.

Stark will do the operating procedure and while 

he's doing it I will try to point out the important steps 

in the operation.

This is the hand of a patient who severed both flexor 

tendons in the right middle finger.

You'll notice that she can flex the 

metacarpal financial joint for the intrinsic muscles 

are still functioning but she cannot flex the middle 

and distal joints of the fingers.

Both flexor tendons have been severed in the proximal 

segment,

passive motions are normal.

The joints are completely limber.

She has a palmer's longest in the forearm which we will use 

for the grass.

Operations of this type are not done until 

the tissues are soft and supple and the joints are 

completely mobile.

Here you see a full range of passive motion 

of the digits.

Incisions in the finger are made mid lateral.

Here you see the dorsal points of the 

flexor creases.

The incision should be dorsal to this.

If it is made anterior you're apt to develop a 

flexion contracture.

All the operations are done under the ischemia of a tourniquet and the 

arm is first wound with a rubber bandage 

and then the cuff is inflated on the upper arm.

The mid lateral incision is made the full length of the finger 

and by undermining the skin carefully at the level of the middle 

joint.

Small retractors can be placed and the finger 

held firmly for the rest of the 

dissection.

The deeper part of the incision here now goes through a layer of 

fashion which may be part of Cleveland's ligament 

or part of the transfers 

retina macular system.

This is divided carefully and we will place 

sutures in this layer of tissue.

Later 

is the incision is deepened,

the flexor tendons and the sheep come into view 

and on the volar flap the neurovascular bundle 

remains here.

You will see some adhesions between the subcutaneous 

tissues and the sheath and here 

carefully towards the tip of the finger.

We make sure that we do not damage the 

digital nerve which tends to go a little more 

dorsal.

In this area of the hand 

there's also a deep layer of fashion at the level of the distal joint.

Similar to that at the middle joint.

And this is divided but not necessarily 

sutured as a separate layer.

Later when we 

expose the flexor tendons now in the finger.

MS.

Buller flap containing the 

neurovascular bundle is held out of 

the way and we have a complete exposure 

of the contents of the finger,

we could even repair a digital nerve on the opposite side.

We want to save these pulleys these national 

bands which hold the tendons in place.

But we want to remove all the remaining 

she and scar and tendons 

here we're removing the tenant and its insertion dividing 

the vehicle.

Um But being very careful to not damage the 

volar plate.

For if any scar occurs here,

the tendon will become adherent will not glide 

and we will have difficulty in getting a good range of 

motion.

It's not necessary to preserve the entire 

pulley.

This pulley in the middle segment has been narrowed,

but it is necessary to save some 

pulley in both the middle and the proximal segments of 

the finger.

The supplements 10ant is removed.

Clear out to its insertion.

We do not believe that you should leave the decolonization of 

the fibers or the chasm of camper as 

it is called.

But should remove the tendon completely here,

you will notice that the proximal pulley is being 

opened in a portion of it being removed.

If the pulleys are so badly damaged and scarred 

that they have to be removed,

then we believe that reconstruction of the pulley by free graphs 

should be carried out at the same time as the flexor 

tendon graft 

all of the scar tissue was divided with sharp 

dissection 

and the entire contents of this area removed 

all excessive sheath and scar,

leaving only these pulleys here a little strand of 

tissue at the middle joint has been left 

Notice that the 10ant is now fairly free 

as far as the finger is concerned.

But we will see later there are still some 

adhesions in the pond.

Now the attachment is made for the tendon to the 

distal phalanx.

Here we turn up an osteoporosis,

osteo flat distal to the joint 

so that there's a good angle of approach of the tendon to 

provide flexion of this terminal segment.

A drill is passed through the nail 

to exit in this hole in the phalanx,

and this will provide us with the channel through which a wire can 

be passed,

and later on the tendon suture itself 

drawn through this area,

This enables us to bring the tendon right into 

the raw bony surface.

This guide wire is a simple loop of wire 

to facilitate the later passage of the tendon suture 

itself.

Here again are the three pulleys,

essential mechanical feature so 

that the tendon will flex the finger completely.

Now we're ready to expose the tendons in the palm 

incisions here are made paralleling the flexor creases 

and make them of adequate size to gain 

exposure and do a careful excision of 

scar as well as an adequate repair 

of the tendon and the graft in this area.

We expect to make our tendon suture 

at this level as far proximal as possible,

so that the lum brickell origin will cover the 

point of the junction between the graft and the 

tendons.

We usually excise a small portion of the palmer upon 

neurosis and very carefully remove all of 

the thickened sheath and perry tenderness tissues 

here in the palm,

you will notice now as these tendons are exposed 

that there is a thin filmy layer of 

scar surrounding them and though they 

appear to be fairly free,

they are adherent at the level of the metacarpal 

pulley.

Once this is freed the tendons and he 

lifted up notice the little adhesions holding 

one to the other and to the deeper structures.

The point of greatest adherence of the tenant is in this 

metacarpal pulley.

And here we are careful to excise all of the thick and 

surrounding sheet.

The supplements and the profundis tenants are separated 

here so that later we can withdraw this supplements 

in the forearm and cut it off at the muscular tendon.

This junction.

This will also enable us to free the profundis in the 

palm,

removing all of this thickened carotene in this tissue 

in the film of scar which lies over the 

lumber ical muscle,

the lumber ical here is being freed so that our junction can 

be made as far proximal as possible,

notice the full amplitude of motion that is now present.

We have found we can use the profundis as the motor 

even many years after the original injury,

a short incision just above the wrist will expose the 

palmer as long as tendon.

And also enable us to take out the proximal 

portion of the supplements.

Years ago we thought if we attached the proximal supplements 

to the profundity of the same finger that had added to the strength 

of grip,

we have found it since that this 

causes more problems than it tends to solve.

So now we simply divide the tendon as far 

approximate as possible and allow the end to retract 

the palmer's longest is to be removed through two 

incisions,

this one at the wrist and another higher in the forearm.

It's not necessary to make a longitudinal incision 

and remove the so called parity non along with the 

palmer's longest.

Perhaps if the finger was badly scarred,

this might add something to the 

result.

But we have found that in most cases it is best to 

remove the tendons,

simply just avoiding damage 

to its surface,

not making any attempt to remove any surrounding tissue 

with it in the proximal 

portion of the form.

The tendon lies deep to the fashion of course,

and that the fashion must be opened in order to 

isolate the tendon.

The palmer's longest is used by preference as a graft.

If it is not present,

we could use the proximal portion of the suppleness of the 

same digit or we could use one of the toe 

extensive.

We feel that the planned terrorist tendon is too small in 

diameter.

Suture has now passed through the distal end of the palmer as long 

as tendon.

This is the panel pull a wire suture.

It's number 34.

Wire Woven back and forth through the Tendon 

with a pullout loop to enable it to be 

withdrawn later At the end of three 

weeks.

When the future is no longer necessary.

It's well to avoid any kinks in the wire when it's being 

placed for a kink in the wire will weaken it 

and may cause it to rupture later 

under some stress.

Now these two ends of the wire which have been brought out the end of 

the tendon,

will be passed through the terminal phalanx,

utilizing the guide wire that we placed before 

and by traction on this wire.

We draw the raw end of the tendon into the 

opening and the bone.

We have tendon to bone attachment,

not tending to scar,

not tending to tendon or tending to 

curiosity.

We feel that this method gives adequate 

fixation,

and if the tenant is held in place for three weeks,

healing will be sufficient to withstand the 

pull of the tendon.

The wire after being passed through the fingernail is tied over a 

button and then the proximal loop,

the pullout loop is brought out the finger on the volar 

surface in line with the opening in the bone 

traction on this later will withdraw the suture material.

Now the 10ant has passed through the police and will 

be placed in the palm and then making 

traction on it.

We can duplicate the motion of the finger 

and show that there are no adhesions and no 

limitations in the joints and that the tendon 

will be enabled to flex the finger completely 

notice the great amplitude that is necessary and a 

flexor tendon to fully flex a 

digit.

Here is the suture in the fashion at the level of the middle 

joint which we talked about before 

this suture is placed before the proximal suture line in the 

tendon because we want to put the finger in a few degrees of 

flexion,

and if we made our proximal tendon attachment we 

would no longer have control in this position.

Now the problem,

how do you determine the tension or the length of the 

graft?

In other words,

we feel that if the risk is put in a neutral position 

and you look at the hand,

the normal fingers will be in semi flexion.

If we adjust the tension or the length of the graft 

so that the involved digit is in slightly more 

flexion than the others.

This will be the approximate correct position.

Once this has been determined the remaining portions of the 

tendons are excised,

making sure that the junction will be as far approximate as 

possible.

And then these two Tendon ends will be united with the 

number 34 buried wire suture 

placed again according to the method 

that was described by Banel.

The future is woven in and out of the tendon,

avoiding any kinks in the wire 

and the tendons approximated end to end.

We feel this is possible even though there is a slight difference in 

the size of the graft and the profundis tendon.

It is only if there is a large difference in 

diameter that one need go to other 

methods of approximations such as poverty.

Simple end to end suture provides adequate healing,

adequate strength and will withstand the 

full pull of the muscles at a later date.

Now the future has been placed in the proximal end in the 

profundity,

and here it will be placed in the ground.

Notice how the future has passed through the cut end of the tendon 

first,

and then out through the tendon more distantly.

The damaged portion in the clamp,

it's been cut off.

The tenant ends are approximated,

they are actually over approximated.

There's an accordion like effect here.

The ruins of the wire are pressed down into the tendon,

and you will notice that our junction is now almost 

automatically covered with alum brickell 

muscle.

There's no objection to placing a few fine sutures in 

the american muscle,

but if you do this you must pull the lum 

brickell distillate before it's attached on the 

tendon.

Otherwise you will interrupt and interfere 

with the smooth functioning of the finger later 

here,

one or two fine sutures are simply placed to hold the 

lumber ical around the proximal junction.

At this point the tourniquet is removed.

Bleeding points are litigated after maintaining pressure for 

several minutes,

and the hand is covered with fluff.

Cause stocking it,

some sheet wadding and a posterior plaster 

bandage.

Now we want to split this hand with the wrist and palm 

reflection,

and we want to prevent extension of the finger,

but we do not want anything on the volar surface of 

that finger that will impair its flexion.

If the patient should unconsciously or 

involuntarily flex this finger,

we do not want any of this flexion to be 

against resistance because this means 

tension on our fresh suture line,

so the splint is posterior,

but the entire volar surface of the finger 

remains free.

We want to be able to see the tip of the finger,

see that the circulation is maintained and be sure 

that there is nothing here that the finger will flex 

against in case of involuntary motion.

This position of the hand with the wrist and palm 

reflection will be maintained for the first three 

weeks.

Then the pull out wire is removed 

now the hand will still be 

kept in the wrist and palm reflection,

but the patient will be allowed to remove the splint 

carefully protecting this position,

wash the hand with luke warm,

soapy water and to start gentle 

active motion.

It is important that the joints have a full range of 

motion and may be necessary to 

help him buy some passive manipulation.

We maintain the protection by not 

Dorsey flexing the wrist Until the end of 

the 4th week.

Now,

at about the end of the fourth week or the early in the fifth 

week there are two maneuvers that are 

important and it may help to provide a 

better range of motion in the tendon.

First of all,

if the finger is held with the metacarpal financial 

joint in full extension and the 

patient asked to flex voluntarily 

all of the forces now being placed upon the 

tendon to slip it through the finger.

The second maneuver is to passively flex the 

metacarpal financial joint and the 

interface Langil joint,

and then to passively 

hyper extend the distal joint and then 

gradually extend the middle joint of the finger.

This tends to slip the tendon through the 

finger and thus break up a few 

adhesions.

Now,

at the 5th week we can also advise 

a little stronger active flexion,

But this should be guarded until the 6th week.

At least.

We would prefer that a man not do any type of heavy 

work until after the sixth week and 

perhaps even the eighth week would be even better.

Now.

Now the results of a tendon graft will depend 

upon many factors.

First of all,

the proper choice of patients.

Age makes a great difference.

The type of the tissue,

the amount of scarring,

the length of time sits injury.

Perhaps another factor,

but the proper choice of procedure 

and the necessary proper technique in 

carrying it out.

Then adequate postoperative 

care and follow up.

And finally a patient who is 

willing to undergo a certain amount of 

discomfort and exercise in order 

to obtain the most desired results.

Mm.

Hmm.