Originl Article Silicone Foley s ctheter s n effective lterntive to Hunter s rod in stged flexor tendon reconstruction of the hnd Twheed Ahmd, Sheikh Adil Bshir, Mohmmd Inm Zroo, Adil Hfeez Wni, Sim Rshid, Summir Jn Deprtment of Plstic nd Reconstructive Surgery, Sher I Kshmir Institute of Medicl Sciences, Sringr, Jmmu nd Kshmir, Indi Address for correspondence: Dr. Twheed Ahmd, Deprtment of Plstic nd Reconstructive Surgery, Sher I Kshmir Institute of Medicl Sciences, Sringr, Jmmu nd Kshmir, Indi. E mil: drtwheedhmd@yhoo.com ABSTRACT Context: Stged flexor tendon reconstruction is most suitle tretment method for extensive zone II tendon injuries. The Hunter s rod used in this procedure is costly nd not esily ville, which dds to the miseries of oth ptients s well s treting surgeon. Aims: The im of this study is to evlute the results of stged zone II flexor tendon repir using silicone Foley s ctheter s cheper nd redily ville lterntive to Hunter s rod. Settings nd Design: This ws prospective study. Mterils nd Methods: Seventy digits in 35 ptients were treted y the stged flexor tendon reconstruction using silicone Foley s ctheter in plce of Hunter s rod, nd the ptients were followed for n verge period of 18 months. Erly controlled motion exercise protocol ws instituted in ll cses. Results: As per the Stricklnd scle, totl ctive motion otined ws excellent in 70%, good in 20%, fir in 7.1% nd poor in 2.9% of ptients. Conclusions: Silicone Foley s ctheter is cheper, esily ville nd n effective lterntive to Hunter s rod in stged flexor tendon reconstruction procedure, yielding high rtes of excellent nd good results with fewer complictions. KEY WORDS Hnd flexor tendon injury; Hunter s rod; silicone ctheter; stged tendon reconstruction; tendon grft INTRODUCTION The reconstruction of the scrred flexor tendon system in zone II of the hnd remins chllenge for the hnd surgeon ecuse the heling tendon tends to dhere to its firo osseous tunnel. It ws termed Quick Response Code: Access this rticle online Wesite: www.ijps.org DOI: 10.4103/0970-0358.197232 No Mn s Lnd y Bunnell ecuse of the poor outcome in rnge of motion following tendon repir in this zone. The outcome is worse in cse of neglected old tendon injuries. [1] This is n open ccess rticle distriuted under the terms of the Cretive Commons Attriution NonCommercil ShreAlike 3.0 License, which llows others to remix, twek, nd uild upon the work non commercilly, s long s the uthor is credited nd the new cretions re licensed under the identicl terms. For reprints contct: reprints@medknow.com How to cite this rticle: Ahmd T, Bshir SA, Zroo MI, Wni AH, Rshid S, Jn S. Silicone Foley s ctheter s n effective lterntive to Hunter s rod in stged flexor tendon reconstruction of the hnd. Indin J Plst Surg 2016;49:322-8. 2016 Indin Journl of Plstic Surgery Pulished y Wolters Kluwer Medknow 322
Ahmd, et l.: Silicone ctheter s lterntive to Hunter s rod in Tendon The stged flexor tendon reconstruction using silicone rod in the first stge nd free tendon grft through the pseudosheth formed round the silicone rod in the second stge, s descried in 1971 y Hunter nd Slisury, [2] is the most widely ccepted tretment for poor prognosis flexor tendon injuries (Boyes grde 2 5). [3] However, the Hunter s rod used in stged tendon reconstruction is costly nd mostly unville, especilly in developing countries. [4] Atik et l. replced Hunter s rod with Foley s silicone ctheter, which is redily ville t every centre nd 50 times less costly thn the former. [5] Our this study ws designed to evlute the results of stged zone II flexor tendon reconstruction using silicone Foley s ctheter s replcement of Hunter s rod. SUBJECTS AND METHODS This study ws conducted from August 2011 to July 2016, nd during this period, 35 ptients with delyed presenttion of zone II flexor tendon injuries underwent two stge tendon reconstruction using silicone Foley s ctheter. These included 21 mles nd 14 femles, with men ge of 23 yers (rnging from 14 to 50 yers). In totl 70 digits, 12 index fingers, 22 middle fingers, 22 ring fingers, 12 little fingers nd 2 thums were operted. Pre opertively, injury of ptients ws grded using Wehe modifiction of Boyes nd Strk clssifiction system [Tle 1]. The first stge of reconstruction ws performed t men intervl of 5½ months (rnge: 2 24 months) fter injury, nd the men durtion etween two stges ws 4 months (rnge: 3 8 months). Written informed consent ws otined from ll ptients, nd the study ws pproved y our hospitl sed ethics committee. All ptients followed the sme surgicl nd post opertive procedure. Tle 1: Wehe et l. modifiction of Boyes nd Strk clssifiction Grde of Fetures injury Grde 1 Tendon injury only, good soft tissue, supple joints nd no significnt scrring Grde 2 Injury to tendon nd soft tissue, deep cictrix from injury or previous surgery Grde 3 Injury to tendon nd contrcture of >10 t ny joint Grde 4 Injury to tendon nd one or oth neurovsculr undles Grde 5 More thn one of the forementioned injuries nd in ddition involvement of the plm or more thn one finger injured Opertive procedure The surgicl procedure included two stges. All surgeries were performed under generl nesthesi nd tourniquet control. Ptients underwent ggressive physiotherpy efore the first stge to overcome stiffness nd chieve mximum pssive motion [Figures 1 nd 2]. Stge I Bruner s plmer zigzg incisions were mde to provide wide exposure of the flexor tendon from the mid plm to the centre of distl phlnx. [6] The injured tendons nd scr tissues were excised [Figures 3 nd 4]. Aout 1 cm of the distl flexor digitorum profundus (FDP) stump ws preserved. Silicone Foley s ctheter (s replcement for Hunter s rod) ws inserted into the rudimentl sheths. The size of Foley s ctheters used is given in Tle 2. The injured pulleys (A2 nd A4) were reconstructed over the implnt using excised flexor digitorum superficilis (FDS) tendon. The distl end of the implnt ws sutured to the distl stump of FDP, nd the proximl end of the implnt ws fixed to the proximl stump of respective FDP tendon in the plm [Figures 5 nd 6]. As oth ends of the silicone ctheter were ttched with proximl nd distl stumps of flexor digitorum tendon, respectively, hence there ws no scr tissue ingrowth within its lumen. Pssive motion exercises were strted 1 week fter the surgery. The gol ws to chieve full pssive flexion t metcrpophlngel nd interphlngel joints. Stge II The distl portion of the previous incision t the distl phlnx ws used to retrieve the distl stump of the FDP, nd n incision t mid of the plm ws mde to retrieve the proximl junction of the implnt nd FDP [Figures 7 nd 8]. Plmris longus tendon or plntris tendon of proper length ws procured [Figure 9]. Distl end of the tendon grft ws sutured to the distl stump of FDP using modified Kessler s tendon suturing technique y 4 0 prolene suture mteril. The proximl end of tendon grft ws sutured temporrily to the distl end of the silicone ctheter nd pulled proximlly through the pseudosheth formed round the implnt [Figure 10]. The proximl end of the tendon grft ws sutured with proximl stump of the respective FDP tendon using the Pulvertft weve 323 Indin Journl of Plstic Surgery Septemer-Decemer 2016 Vol 49 Issue 3
Ahmd, et l.: Silicone ctheter s lterntive to Hunter s rod in Tendon Figure 1: Ptient with post trumtic scr in zone II of the left hnd Figure 2: Ptient with flexor digitorum superficilis nd flexor digitorum profundus injury in zone II of middle, ring nd little finger of the left hnd Figure 3: Brunner incision mrked suturing method. The tension ws djusted so tht the finger ws rested in position pproximtely the sme s the djcent ulnr digit, nd in the fifth finger, position of flexion ws djusted somewht greter thn tht of the fifth finger in the opposite hnd [Figure 11]. At the end of surgery, it ws ensured tht proximl tendon juncture should glide freely on extension of respective digit. Those ptients in whom tendon reconstruction ws done in ll four fingers, tension in the tendon grft ws djusted using the wrist tenodesis effect (on extension of wrist joint, fingers ttin flexion posture). Post opertive cre In the immedite post opertive period, Kleinert s splint ws pplied with wrist in 30 flexion, metcrpophlngel joint in 40 flexion nd interphlngel joints kept in extension. After 24 h Kleinert s erly ctive motion, protocol ws strted, with ptient doing ctive extension nd pssive flexion using ruer nd trction, repeting exercise 10 times every hour [Figure 12]. During sleep Figure 4: Exposure of scrred zone II through Brunner s incision Tle 2: Size of silicone ctheters used Size (French) n (%) 8 5 (7.1) 12 30 (42.9) 14 35 (50) Totl 70 hours, interphlngel joints were splinted in extension to the prevent development of flexion contrctures. Four weeks postopertively, ctive flexion ws strted without resistnce, nd dorsl locking splint ws discontinued during dytime ut continued for night time splintge. Six weeks postopertively, the splint ws discontinued during sleep hours s well, nd ctive flexion with progressive resistnce exercises ws strted. RESULTS Ptients were followed for men durtion of 18 months (rnging from 6 to 24 months). The results Indin Journl of Plstic Surgery Septemer-Decemer 2016 Vol 49 Issue 3 324
Ahmd, et l.: Silicone ctheter s lterntive to Hunter s rod in Tendon Figure 5: Silicone ctheter kept in plce s n ctive implnt Figure 6: Incisions closed ck Figure 7: Ptient tken for stge II surgery Figure 8: In stge II of surgery, proximl end of silicone ctheter exposed through mid plmr incision Figure 9: Plmris longus tendon grft hrvested Figure 10: Silicone ctheters replced y tendon grft in stge II surgery were mesured 6 months fter the stge II surgery. No ptient with <6 months of follow up ws included in the 325 study. Assessment of our cses ws mde sed on the totl ctive motion system of evlution. Indin Journl of Plstic Surgery Septemer-Decemer 2016 Vol 49 Issue 3
Ahmd, et l.: Silicone ctheter s lterntive to Hunter s rod in Tendon Figure 11: Tendon grft kept in plce nd incision closed ck Figure 12: Post opertive Kleinert splint nd exercise %Ageof norml totlctivemotion ( PIPflexion+DIPflexion) ( Extensionof deficit of PIPndDIP) = 100 175 PIP = Proximl interphlngel joint; DIP = Distl interphlngel joint. Four grdes s per the Stricklnd scle: Excellent = 85% 100% Good = 70% 84% Fir = 50% 69% Poor = 0% 49%. Of the 70 digits operted, excellent results were seen in 70% (49 digits), good in 20% (14 digits), fir in 7.1% (5 digits) nd poor in 2.9% (2 digits) [Tle 3 nd Figures 13 17]. Infection ws oserved in two ptients fter stge I surgery. In one ptient, Stphylococcus ureus ws cultured, nd in other ptient, pseudomons ws cultured. In the first ptient, the silicone rod ws removed, nd in the other ptient, the infection responded well to conservtive tretment [Figure 18]. Silicone rod got exposed in two ptients, in one ptient exposed rod ws slvged y cross finger flp while in nother ptient exposed rod hd to e removed. None of our ptients hd ny skin necrosis, rod uckling, silicone synovitis nd proximl or distl grft tenorrhphy rupture [Figure 19]. DISCUSSION Tle 3: Results otined s per Stricklnd scle Rnge of motion n (%) 85-100 (excellent) 49 (70) 70-84 (good) 14 (20) 50-69 (fir) 5 (7.1) 0-49 (poor) 2 (2.9) Totl 70 of proximl nd distl ends of tendon, dhesion formtion nd collpse of the firo osseous cnl. Therefore, tendon grfting is usully needed to restore the flexion function of digits. In 1936, Myer nd Rnsohoff stted tht dhesions to trnsplnted tendon cn e prevented y voiding trum to the gliding mechnism of the tendon. They found tht 90% good or excellent results were otined in tendon trnsplnttion for prlysed lims where no dmge to gliding mechnism of tendon ws involved while s results of tendon trnsplnttion in trumtic fingers were extremely disppointing due to pthologicl chnges occurring fter division of flexor tendon. [7] In the 1950s, Bssett nd Crroll egn using flexile silicone ruer rods to uild pseudosheth in dly scrred fingers. [8] The method ws lter refined to two stge reconstruction of the digitl flexor tendons y Hunter nd Slisury. [2] This procedure ws used for ptients who hd their FDP, FDS nd tendon sheth ll severely injured, especilly in zone II, nd it effectively decresed dhesion formtion. Hunter s technique is worthwhile for delyed flexor tendon injury in zone II to [2,3, 9 20] prevent dhesion formtion. Old flexor tendon injuries, especilly in zone II, re usully ssocited with complictions such s retrction In 1998, Kurn et l. did experimentl study in rts nd found pseudosheths formed following sucutneous Indin Journl of Plstic Surgery Septemer-Decemer 2016 Vol 49 Issue 3 326
Ahmd, et l.: Silicone ctheter s lterntive to Hunter s rod in Tendon Figure 14: () Flexor digitorum superficilis nd flexor digitorum profundus injury in index, middle nd ring finger (efore surgery). () After 6 months of completion of stged tendon reconstruction Figure 13: Result otined fter completion of stged tendon reconstruction Figure 16: () Ptient with flexor digitorum profundus injury in right middle nd ring finger. () Finl results fter stged tendon reconstruction Figure 15: () Flexor digitorum superficilis nd flexor digitorum profundus injury in right index finger (efore surgery). () Flexion chieved fter completion of stged tendon reconstruction Figure 17: () Ptient with tendon injury in left little finger. () Results otined fter stged tendon reconstruction of flexor digitorum profundus tendon plcement of Hunter s rod nd silicone ctheter were similr in their thickness, cellulrity, tensile strength s well s in their microscopic fetures.[4] Atik et l.[5] lso used silicone ctheter in plce of Hunter s rod nd otined excellent results in 36.4%, good in 27.3%, moderte in 18.2% nd poor in 18.2% of operted fingers, wheres results in stged reconstruction of the flexor pollicis longus were excellent in 16.7%, good in 33.33%, 327 Figure 18: Ptient with post stge I infection in little finger fir in 33.33% nd poor in 16.7% of cses. Complictions oserved in this study were infection in two (11.8%) ptients, tendon grft dhesions in three (17.6%) ptients nd dehiscence of tenorrhphy in one (5.9%) of the ptients. Considering ove studies, we used silicone Foley s ctheter in plce of Hunter s rod nd otined excellent results in 70%, good in 20%, fir in 7.1% nd poor in Indin Journl of Plstic Surgery Septemer-Decemer 2016 Vol 49 Issue 3
Ahmd, et l.: Silicone ctheter s lterntive to Hunter s rod in Tendon REFERENCES Figure 19: Ptient with exposed ctheter post stge I surgery 2.9% ptients; we hd wound infection in two operted digits (3%) nd ctheter got exposed in two digits (3%). None of our ptients hd skin necrosis, silicone synovitis, distl or proximl grft tenorrhphy rupture or ny flexion contrcture. Our results were similr nd in some cses etter thn the results otined in stged tendon reconstruction using Hunter s rod y Hunter nd Slisury, [2] Frkking et l., [15] Coyle et l., [16] Adul Kder nd Amin [17] nd Sun et l. [18] in their respective studies. In 2013, Elliot nd Giesen presented their experience in deling with ruptured repirs, tethered repirs nd pulley incompetence. Ptients tken for stged tendon reconstruction included those who presented fter long time of the primry insult, hving hd no, or d, previous tretment. [21] CONCLUSION Silicone Foley s ctheter is cheper, esily ville nd n effective lterntive to Hunter s rod in stged flexor tendon reconstruction procedure, yielding high rtes of excellent nd good results with fewer complictions. Finncil support nd sponsorship Nil. Conflicts of interest There re no conflicts of interest. 1. Dvid G, Roert S. Flexor tendon injuries nd reconstruction. In: Mthes SJ, Hentz VR, editors. Text Book of Plstic Surgery. 2 nd ed. phildelphi: Sunder Elsevier; 2006. p. 352. 2. Hunter JM, Slisury RE. Flexor tendon reconstruction in severely dmged hnds. A two stge procedure using silicone dcron reinforced gliding prosthesis prior to tendon grfting. J Bone Joint Surg Am 1971;53:829 58. 3. Wehé MA, Mwr B, Hunter JM, Schneider LH, Goodwyn BL. Two stge flexor tendon reconstruction. Ten yer experience. J Bone Joint Surg Am 1986;68:752 63. 4. Kurn I, Ozcn H, Turn T, Skyz D, Bs L. Serching for lterntives to silicone rods in stged tendon reconstruction. Eur J Plst Surg 1998;21:317 20. 5. Atik B, Srici M, Klender AM, Isik D, Aydin OE. Hunter s technique without Hunter s rod. Act Orthop Belg 2012;78:479 83. 6. Bruner JM. The zig zg volr digitl incision for flexor tendon surgery. Plst Reconstr Surg 1967;40:571 4. 7. Myer L, Rnsohoff N. Reconstruction of the digitl tendon sheth: A contriution to the physiologicl method of repir of dmged finger tendons. J Bone Joint Surg 1936;18:607 16. 8. Bssett CA, Crroll RE. Formtion of tendon sheths y silicone rod implnts. Proceedings of Americn Society for Surgery of the Hnd. J Bone Joint Surg Am 1963;45:884. 9. Americn Society for Surgery of the Hnd (ASSH). Clinicl Assessment Committee Report. Rosemont, IL: Churchill Livingstone; 1976. 10. Unglu F, Bultmnn C, Reiter A, Hhn P. Two stged reconstruction of the flexor pollicis longus tendon. J Hnd Surg Br 2006;31:432 5. 11. Smith P, Jones M, Groelr A. Two stge grfting of flexor tendons: Results fter moilistion y controlled erly ctive movement. Scnd J Plst Reconstr Surg Hnd Surg 2004;38:220 7. 12. Beris AE, Drlis NA, Korompilis AV, Vekris MD, Mitsionis GI, Souccos PN. Two stge flexor tendon reconstruction in zone II using silicone rod nd pedicled intrsynovil grft. J Hnd Surg Am 2003;28:652 60. 13. Stricklnd JW. Development of flexor tendon surgery: Twenty five yers of progress. J Hnd Surg Am 2000;25:214 35. 14. Viegs SF. A new modifiction of two stge flexor tendon reconstruction. Tech Hnd Up Extrem Surg 2006;10:177 80. 15. Frkking TG, Depuydt KP, Kon M, Werker PM. Retrospective outcome nlysis of stged flexor tendon reconstruction. J Hnd Surg Br 2000;25:168 74. 16. Coyle MP Jr., Leddy TP, Leddy JP. Stged flexor tendon reconstruction fingertip to plm. J Hnd Surg Am 2002;27:581 5. 17. Adul Kder MH, Amin MA. Two stge reconstruction for flexor tendon injuries in zone II using silicone rod nd pedicled sulimis tendon grft. Indin J Plst Surg 2010;43:14 20. 18. Sun S, Ding Y, M B, Zhou Y. Two stge flexor tendon reconstruction in zone II using Hunter s technique. Orthopedics 2010;33:880. 19. Drlis NA, Beris AE, Korompilis AV, Vekris MD, Mitsionis GI, Souccos PN. Two stge flexor tendon reconstruction in zone 2 of the hnd in children. J Peditr Orthop 2005;25:382 6. 20. Vlenti P, Gilert A. Two stge flexor tendon grfting in children. Hnd Clin 2000;16:573 8, viii. 21. Elliot D, Giesen T. Tretment of unfvourle results of flexor tendon surgery: Ruptured repirs, tethered repirs nd pulley incompetence. Indin J Plst Surg 2013;46:458 71. Indin Journl of Plstic Surgery Septemer-Decemer 2016 Vol 49 Issue 3 328