Primary pulley enlargement in zone 2 by incision and repair with an extensor retinaculum graft

This retrospective study documents the results of primary enlargement of tendon sheath pulleys by incision and extensor retinaculum graft repair during flexor tendon repairs in zone 2 in 9 fingers.

The entire A2 or A4 pulley was enlarged by complete incision and repaired with an interposed extensor retinaculum graft at the time of primary flexor tendon repair in a total of 9 fingers in 7 patients, ages 15 to 54 years. The indication for primary pulley enlargement was failure of the tendon repair to glide smoothly and without snagging through the normally tight-fitting pulley system. In no case was more than one major pulley enlarged, and the entire A1 pulley was never enlarged. The zone 2 tendon repairs were done using a 2-strand modified Kessler 3-0 core suture and a 6-0 nylon running circumferential suture. The follow-up averaged 3.6 years. Interphalangeal total active motion and Strickland-Glogovac grade in patients with adequate follow-up of more than 6 months or obtaining full range of motion were obtained from a retrospective chart review.

Interphalangeal total active motion averaged 127 degrees and the scores according to the Strickland-Glogovac system were excellent for 3, good for 2, fair for 2, and poor for 2. There were no tendon ruptures. Two fingers in one patient required a tenolysis and a third finger had secondary skin scar lengthening. Two fingers had visible and palpable bowstringing when seen at long-term follow-up and there was an average flexion contracture of 21 degrees.

Primary pulley enlargement using a free graft in zone 2 tendon injuries may achieve the 3 goals of providing a good gliding environment, avoiding triggering, and minimizing bowstringing. These initial clinical outcomes are average for zone 2 tendon repair, but encouraging. Further research and refinement in surgical technique and rehabilitation method are needed to minimize flexion contractures.