Flexor tendon repair

In 1979 Verdan wrote, "whatever the situation may be, adhesions are until now certainly not a technically avoidable accident, but rather a consequence of the physiological healing process. As long as we have no technical solution to the problem of accurately maintaining the two cut ends in an intact synovial sheath without interfering with the blood supply, adhesions will remain a biologic inevitability." Although his admonition remains applicable, advances are occurring in our understanding of tendon healing and nourishment, the pulley system, techniques of repair, and the modification of adhesions. Armed with this information, each surgeon dealing with interruptions of flexor tendons must develop a rational, systematic approach to the management of these difficult injuries. The principles of atraumatic technique, as set down many years ago by Bunnell, remain inviolate. Repair procedures should be carried out by surgeons who are thoroughly knowledgeable and well trained in the area of flexor tendon surgery. Primary or delayed primary tendon repair of both the profundus and superficialis tendons should be carried out in almost all patients in all zones of flexor tendon interruption. The use of nonabsorbable sutures with a modified Kessler or Tajima "core suture" has proved to be effective, and, whenever possible, repair of the flexor tendon sheath seems to be appropriate. A well supervised program of early motion utilizing either active or passive techniques is also beneficial in suitable individuals. The restoration of function to a digit following flexor tendon interruption may be a long and tedious undertaking, requiring strong rapport between surgeon, therapist, and patient. When initiating the care of a patient with such an injury, the surgeon should spend considerable time explaining the problems related to the particular injury, the likelihood of achieving success, and the number of procedures that may be required. A high degree of patient motivation must be established to insure the proper participation in the demanding postoperative regimen associated with these procedures. With the important advances occurring in many areas of flexor tendon surgery, it is realistic to believe that in the future the techniques described in this article will be substantially altered and modified. Results should continue to improve until the patient and surgeon can expect all digits to return to nearly full function after flexor tendon interruption.