A Simple Tendon T r a n s / e r / o r the Isolated Division of the Flexor Digitorum Pro[undus - - B r u c e M. Rigg
A SIMPLE T E N D O N T R A N S F E R FOR THE I S O L A T E D DIVISION OF T H E F L E X O R D I G I T O R U M P R O F U N D U S
BRUCE M. RIGG, Peterborough, Canada SUMMARY
A tendon transfer of one slip of the superficialis, to repair a cut profundns. Either some active flexion or a stable tenodesis can be achieved. INTRODUCTION
Delayed management of the divided profundus tendon with an intact superficialis may be broadly considered in two groups. The first group consists of immobilisation procedures such as tenodesis or arthrodesis. The second comprises attempts to achieve some degree of dynamic activity, such as tendon transfer, tendon advancement, or tendon grafts. The advantage of the former is the stability achieved and the lack of interference with a normally-functioning superflcialis tendon. Most dynamic procedures run such a high risk of loss of superflcialis function that they have largely fallen into disrepute. The duration of immobilisation is an important factor in stabilisation procedures. These injuries are commonly seen in working people for whom lengthy immobilisation presents a major problem. The tendon transfer described in this paper is basically an attempt to combine some of the advantages of both approaches: that is to say, an attempt to achieve some stability as with the tenodesis effect, combined with the possibility of gaining some dynamic flexion at the distal interphalangeal level. The tendon transfer is effected by the suture of one mobilised slip of the superficialis to the distal stump of the injured profundus tendon (Fig. 1).. OPERATIVE TECHNIQUE
Routine exposure of the flexor tendons is made (Fig. 2). Either the radial or ulnar slip of the superficialis may be used. This is divided flush from its attachment to the edge of the middle phalanx (Fig. 3), and then directly sutured to the distal stump of the profundus tendon. The repair is done producing slight tension and a small degree of buckling of the other intact superficialis slip. The adjustment of the tension is critical to this procedure (Fig. 4).
Fig. 1. Schematic representation of the transfer of the superficialis slip to the profundus tendon. 246
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1975
A Simple Tendon Transfer for the Isolated Division of the Flexor Digitorum Profundus --Bruce M. Rigg
Fig. 2. Exposure of the superficialis slip and the stump of the profundus tendon. Fig. 3. Division of one slip of the superficialis. Fig. 4. Direct suture of the superficialis slip to the distal stump of the profundus.
At operation, traction on the superficialis tendon proximally demonstrates the effect by producing some distal interphalangeal flexion (Figs. 5 and 6). RESULTS
This procedure has been performed in ten patients who have been followedup for from three to twenty-five months (Table 2). The results, in summary, have shown that in about three-quarters of the cases an average of fifteen degrees of active distal interphalangeal joint movement may be anticipated (Table II). This compares favourably with those of Kahn's tendon sling procedure, which showed ranges of movement from five to twenty degrees of active flexion. The majority of patients did achieve a small but worthwhile degree of activity, and those patients who gained no active movement achieved a stable tenodesis effect without interference with the superficialis function (Figs. 8, 9, 10). TABLE 1 TENDON TRANSFER--FLEXOR DIGITORUM PROFUNDUS
Patient
B.P. T. McN. S.C. J.N. H.D. H.F.. M. McD. T.F. P.G. L..A.
Side
Digit
Follow-up
(R) (R) (R) (R) (L) (R) (R) (L) (L) (R)
Index Little Index Middle Index Index Middle Little Index Middle
5 months 18 months 29 months 16 months 17 months 12 months 21 months 22 months 3 months Lost to Follow-up
The I-land--Vol. 7
No. 3
1975
Active Movement
Active Range
150 165 140/150 160/160 135/155 140/155 165/16.5 135/150 144/155 135/150
15 ° 10 ° 0o 20 ° 15 ° 0o 15 ° 10 ° 15 °
247
A Simple Tendon Transfer for the Isolated Division of the Flexor Digitorum Profundus --Bruce M. Rigg
Fig. 5. Digit position after tendon transfer. Fig. 6. Proximal traction of the superficialis demonstrating distal joint flexion from tendon transfer. Fig. 7. A small tendon graft has been used to bridge a larger defect between one slip of the superficialis and the distal stump of the profundus tendon. TABLE 2 T E N D O N T R A N S F E R - - F L E X O R DIG I T O R U M P R O F U N D U S T E N D O N T R A N S F E R RESULTS
Approximately 15 degrees of active D.I.P. Joint flexion ......... 0 degrees of D.I.P. Joint movement . . . . . . . . . . . . . . . . . . Lost to follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 2 1
As with Kahn's operation, a loss of full extension at the distal interphalangeal joint must be expected. Here, the average loss of extension was approximately twenty-five degrees.. DISCUSSION
Kahn (1973) has eloquently expounded upon the problems of both static and dynamic procedures in this particular problem. His tendon sling technique is a more complex procedure which produces a similar mechanical situation to the simple tendon transfer described here. This tendon transfer is not much affected by the problem of tendon lengthening which is frequently noted in tenodesis procedures. The immobilisation period is the same as for any tendon repair and significantly less than that for tenodesis or arthrodesis. F r o m the technical aspect, the degree of tension at which the superficialis slip and the profundus are sutured, is critical. A small degree of tension is required to produce independent distal joint movement. However, excessive 248
The Hand--Vol. 7
No. 3
1975
A Simple Tendon Transfer/or the Isolated Division of the Flexor Digitorum Profundus --Bruce M. Rigg
Fig. 8. Post-operative extension. Fig. 9. Post-operative extension. Fig. 10. Post-operative flexion of 20 °. tension may produce loss of free proximal interphalangeal joint extension. Disparity of diameter between the superficialis slip and the profundus stump has not proved to be a major technical problem. The range of tendon excursion to produce movement in the distal interphalangeal joint is approximately five millimetres (Boyes, 1972) and thus only a minimal superficialis advancement is required to provide the potential for active movement. If the advancement for transfer is much greater than approximately ½ cm then a small bridge tendon graft may need to be added (Fig. 7). CONCLUSION
The tendon transfer described has been performed on ten patients and seven of these have gained a worthwhile degree of active movement at the distal joint level. This simple transfer has been proposed for secondary management of the isolated flexor digitorum profundus tendon division. It has been found possible to effect this transfer even in the more distal divisions of the profundus tendon. However, in one case, a small tendon graft was required to bridge a larger defect. The results have shown that, at worst, a tenodesis is achieved which has not stretched, and at best, produces a situation from which some dynamic activity at the distal joint may be achieved without risk to the superficialis function. This technique should be considered as another method for managing the isolated division of the flexor digitorum profundus tendon. REFERENCES
BOYES, J. H. (1964) Bunnell's Surgery of the Hand, 4th Edition. Philadelphia and Montreal, J. B. Lippincott Company, p. 14. KAHN, S. (1973) A Dynamic Tenodesis of the Distal Interphalangeal Joint, for Use after Severance of the Profundus Alone. Plastic and Reconstructive Surgery, 51: 536-540.
The Hand--Vol. 7
No. 3
1975
249
A SIMPLE T E N D O N T R A N S F E R FOR THE I S O L A T E D DIVISION OF T H E F L E X O R D I G I T O R U M P R O F U N D U S
BRUCE M. RIGG, Peterborough, Canada SUMMARY
A tendon transfer of one slip of the superficialis, to repair a cut profundns. Either some active flexion or a stable tenodesis can be achieved. INTRODUCTION
Delayed management of the divided profundus tendon with an intact superficialis may be broadly considered in two groups. The first group consists of immobilisation procedures such as tenodesis or arthrodesis. The second comprises attempts to achieve some degree of dynamic activity, such as tendon transfer, tendon advancement, or tendon grafts. The advantage of the former is the stability achieved and the lack of interference with a normally-functioning superflcialis tendon. Most dynamic procedures run such a high risk of loss of superflcialis function that they have largely fallen into disrepute. The duration of immobilisation is an important factor in stabilisation procedures. These injuries are commonly seen in working people for whom lengthy immobilisation presents a major problem. The tendon transfer described in this paper is basically an attempt to combine some of the advantages of both approaches: that is to say, an attempt to achieve some stability as with the tenodesis effect, combined with the possibility of gaining some dynamic flexion at the distal interphalangeal level. The tendon transfer is effected by the suture of one mobilised slip of the superficialis to the distal stump of the injured profundus tendon (Fig. 1).. OPERATIVE TECHNIQUE
Routine exposure of the flexor tendons is made (Fig. 2). Either the radial or ulnar slip of the superficialis may be used. This is divided flush from its attachment to the edge of the middle phalanx (Fig. 3), and then directly sutured to the distal stump of the profundus tendon. The repair is done producing slight tension and a small degree of buckling of the other intact superficialis slip. The adjustment of the tension is critical to this procedure (Fig. 4).
Fig. 1. Schematic representation of the transfer of the superficialis slip to the profundus tendon. 246
The H a n d - - V o l . 7
No. 3
1975
A Simple Tendon Transfer for the Isolated Division of the Flexor Digitorum Profundus --Bruce M. Rigg
Fig. 2. Exposure of the superficialis slip and the stump of the profundus tendon. Fig. 3. Division of one slip of the superficialis. Fig. 4. Direct suture of the superficialis slip to the distal stump of the profundus.
At operation, traction on the superficialis tendon proximally demonstrates the effect by producing some distal interphalangeal flexion (Figs. 5 and 6). RESULTS
This procedure has been performed in ten patients who have been followedup for from three to twenty-five months (Table 2). The results, in summary, have shown that in about three-quarters of the cases an average of fifteen degrees of active distal interphalangeal joint movement may be anticipated (Table II). This compares favourably with those of Kahn's tendon sling procedure, which showed ranges of movement from five to twenty degrees of active flexion. The majority of patients did achieve a small but worthwhile degree of activity, and those patients who gained no active movement achieved a stable tenodesis effect without interference with the superficialis function (Figs. 8, 9, 10). TABLE 1 TENDON TRANSFER--FLEXOR DIGITORUM PROFUNDUS
Patient
B.P. T. McN. S.C. J.N. H.D. H.F.. M. McD. T.F. P.G. L..A.
Side
Digit
Follow-up
(R) (R) (R) (R) (L) (R) (R) (L) (L) (R)
Index Little Index Middle Index Index Middle Little Index Middle
5 months 18 months 29 months 16 months 17 months 12 months 21 months 22 months 3 months Lost to Follow-up
The I-land--Vol. 7
No. 3
1975
Active Movement
Active Range
150 165 140/150 160/160 135/155 140/155 165/16.5 135/150 144/155 135/150
15 ° 10 ° 0o 20 ° 15 ° 0o 15 ° 10 ° 15 °
247
A Simple Tendon Transfer for the Isolated Division of the Flexor Digitorum Profundus --Bruce M. Rigg
Fig. 5. Digit position after tendon transfer. Fig. 6. Proximal traction of the superficialis demonstrating distal joint flexion from tendon transfer. Fig. 7. A small tendon graft has been used to bridge a larger defect between one slip of the superficialis and the distal stump of the profundus tendon. TABLE 2 T E N D O N T R A N S F E R - - F L E X O R DIG I T O R U M P R O F U N D U S T E N D O N T R A N S F E R RESULTS
Approximately 15 degrees of active D.I.P. Joint flexion ......... 0 degrees of D.I.P. Joint movement . . . . . . . . . . . . . . . . . . Lost to follow-up . . . . . . . . . . . . . . . . . . . . . . . . . . .
7 2 1
As with Kahn's operation, a loss of full extension at the distal interphalangeal joint must be expected. Here, the average loss of extension was approximately twenty-five degrees.. DISCUSSION
Kahn (1973) has eloquently expounded upon the problems of both static and dynamic procedures in this particular problem. His tendon sling technique is a more complex procedure which produces a similar mechanical situation to the simple tendon transfer described here. This tendon transfer is not much affected by the problem of tendon lengthening which is frequently noted in tenodesis procedures. The immobilisation period is the same as for any tendon repair and significantly less than that for tenodesis or arthrodesis. F r o m the technical aspect, the degree of tension at which the superficialis slip and the profundus are sutured, is critical. A small degree of tension is required to produce independent distal joint movement. However, excessive 248
The Hand--Vol. 7
No. 3
1975
A Simple Tendon Transfer/or the Isolated Division of the Flexor Digitorum Profundus --Bruce M. Rigg
Fig. 8. Post-operative extension. Fig. 9. Post-operative extension. Fig. 10. Post-operative flexion of 20 °. tension may produce loss of free proximal interphalangeal joint extension. Disparity of diameter between the superficialis slip and the profundus stump has not proved to be a major technical problem. The range of tendon excursion to produce movement in the distal interphalangeal joint is approximately five millimetres (Boyes, 1972) and thus only a minimal superficialis advancement is required to provide the potential for active movement. If the advancement for transfer is much greater than approximately ½ cm then a small bridge tendon graft may need to be added (Fig. 7). CONCLUSION
The tendon transfer described has been performed on ten patients and seven of these have gained a worthwhile degree of active movement at the distal joint level. This simple transfer has been proposed for secondary management of the isolated flexor digitorum profundus tendon division. It has been found possible to effect this transfer even in the more distal divisions of the profundus tendon. However, in one case, a small tendon graft was required to bridge a larger defect. The results have shown that, at worst, a tenodesis is achieved which has not stretched, and at best, produces a situation from which some dynamic activity at the distal joint may be achieved without risk to the superficialis function. This technique should be considered as another method for managing the isolated division of the flexor digitorum profundus tendon. REFERENCES
BOYES, J. H. (1964) Bunnell's Surgery of the Hand, 4th Edition. Philadelphia and Montreal, J. B. Lippincott Company, p. 14. KAHN, S. (1973) A Dynamic Tenodesis of the Distal Interphalangeal Joint, for Use after Severance of the Profundus Alone. Plastic and Reconstructive Surgery, 51: 536-540.
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No. 3
1975
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