Two-stage pedicled tenoplasty for the reconstruction of multiple flexor tendons in zone V: case report

Abstract

The two-stage tenoplasty for zone II flexor tendon injuries in single digits was reported by Paneva-Holevich in 1965 with results comparable to or better than the standard free tendon graft reconstruction [15]. This technique has the advantage of the use of the flexor digitorum superficialis as an intrasynovial “pedicled” tendon graft and allowed healing of the proximal tenorrhaphy site so that mobilization after the second stage procedure can begin immediately to minimize tendon scarring [16]. In 1972, Kessler described the combination of this technique with the use of silicone rods [3] as described by Carroll in 1964 [6] and refined and popularized by Hunter in 1970 [8] as a “space saver” and to create a pseudosheath to facilitate gliding of the tendon graft. Since then, several other series using the pedicled tendon graft technique have been reported in both adults and children for the management of zone II injuries in single or multiple digits with silicone rods and various modifications [3, 5, 20]. In 1997, Naam reported a series of 47 patients using the combined technique as previously described [14]. However his series also included five patients with injuries in zone III and three in zone IV. In these cases as in the others, reconstruction included replacement of the tendon in zone II with attachment of the distal tendon graft to the distal phalanx with a pull-out wire technique. The results for zone III and zone IV injuries were comparable to that for zones I and II. The pedicled tenoplasty technique has well-described advantages for reconstruction in zone II but offers an alternative technique with other advantages that may be applicable to flexor tendon reconstruction outside of zone II as well [9, 16]. The tendon “loop” that is constructed at the first stage will be healed by the second stage, and as such, there is less concern about the nutrient supply for adequate healing, early disruption at the proximal tenorrhaphy site, and vascular ingrowth leading to scar formation to promote healing but which may limit tendon gliding. The use of intrasynovial tendons such as the flexor digitorum superficialis (FDS) may still provide favorable characteristics for gliding, especially in a scarred wound bed even if used for reconstruction outside of zone II [1, 7, 11, 18]. Our purpose is to present the first report of the use of the two-stage pedicled tenoplasty technique for the reconstruction of multiple flexor tendons in zone V in association with a chronic wound bed, major nerve injury requiring reconstruction, and soft tissue defect requiring flap coverage.