Incisions and technics in tendon grafting

Abstract

W HEN STUDYmO the technics of different surgeons of great experience who perform tendon grafting, it is amazing to note the diversitv of technics they use. Many principles are not accepted unanimously. For instance, incisions are different; the amount of sheath removed is variable; usually the flexor profundus is reconstituted, but reconstitution of the superfieialis is sometimes advantageous; the sources of grafts are numerous. Some surgeons use long incisions to obtain grafts and insist on the value of the paratendon while others utilize a stripper or even intrasynovial tendons; junctures and sutures are various; as far as the suture material is concerned, every one admits that i thas to be thin, resistant, nonirritating, b u t some prefer silk, others wire or nylon. The duration of'immobilization after surgery has also been very controversial and Pulvertaft [2] has noticed, by comparison, that his results were not affected by either early mobilization or three weeks' immobilization. What principles are accepted by all the specialists in this surgery?They are not numerous but they are important [5]:(1) Only one graft of flexor tendon is placed in one finger. Because of fear of adhesion, noonehas, t o m y knowledge, a t tempted to reconstitute tt~e normal anatomy, namely, by two grafts. I t is sometimes possible in selected eases to substitute a graft for the profundus when thesuperfieialis is intact but intact superficialiS is never to be sacrificed. (2) The graft, taken fr0m the patient, is placed in the hand without delay. (3) The graft should be of Small ealiberand its extremities should be fixed Carefully, far from the fibrous sheath. (4 ) I t is preferable to spare at least one pulley to prevent bowstringing, (5) The tension of the graft must be calculated in each case. (6) There is one additional point common to all surgeons who perform this surgery with any success: patience and attention to minutiae. Atraumatic surgery, gentleness and careful suturing are essential for a good prognosis. The technic we use is not original. I t has been borrowed from the leading specialists of this surgery, mainly, Boyes [1 ], Pulvertaft [2] and Littler [3]. With experience wehave modified a few details. We will consider primarily the incisionsand the exposure of the lesions. Normally, the tissues of the fingers are rich in blood supply. This i vaseularization :depends mainly upon: thei: two proper: digital: arteries which are oftenwounded With the tendons: The skin o f t h ~ palm isSupplied: bysmal l vertical arteries whiehperforate the:fasciato nourish it. Conway and Stark i[4]~::: by vascular injection, have : ~lemonstrated: tlire~: i Well ~ V~cularized areas in:the palm:These are atlthelevel of the thenar and hypothenar skin and in the: palmar tissues distal: to:i the ~ transverse distal crease. They poorly mining sharp angles must be avoided. Sensation is imp¢ essential a t the level for ~exposure i Should digital nerves to the ineisein the usual zones of prehension or of pressure.