So, good morning everybody. Dr. Calfee has talked a little bit about Zone 1 and Zone 2 repair and what we're looking to accomplish. I'm going to demonstrate for you the 8-strand Gelberman winter repair. One of the things that I think is important to understand is pulley management with these injuries. I've done an exposure. I'm going to favor a mid-axial exposure, that is, taking the entire mid-axial exposure. What that gives me is a nice gliding surface through which, or under which, the tendon can glide following repair. It involves identification of the digital neurovascular bundle, obviously nerve superficial artery deep on the side that you make your mid-axial incision. I dissect all the way over to the contralateral side of the digit, where deep to a clelans you can actually still see or see the digital neurovascular bundle. I try and make my mid-axial incision on the non-dominant side of the finger in terms of where I think the artery is going to be, the dominant artery of the finger. We know that on the ulnar aspect of the index and middle, the artery is likely to be bigger, and on the radial aspect of the ring and small, the artery is likely to be bigger. So I'll try and make the longitudinal part of my incision on the other side. I like identifying A2, A3, which you can see here, and the A4 pulleys. I used to be, not dogmatic, but I used to like making incisions involving the C1, A3, and C2 pulleys. Now what I will try and do is make my incision into the pulley system distal to A2, proximal to A4, but I like to try to leave A3 intact. The reason for that is I often am perhaps a little heavy-handed with the A4 pulley and will rupture it, and I think trying to repair the A4 pulley is a bit of a fool's errand, at least in my hands. So anyhow, here we see A2, here we see A3, there, and A4. Peter Amadio has done work that shows that you can resect up to 75% of A4 and A2 and still be left with a system that will prevent bowstringing. I won't start by resecting 75%, but I certainly won't be upset if that's what it takes. So I'm going to create a laceration. Now I'm going to create it a little distally just so we don't have that much difficulty in getting the proximal piece. Just for those of you that are anatomists, there we see a nice vinculum longum profundum right there coming from the ladder branch in between the insertion of the superficialis slips there. So here we have the profundus tendon. Do we have a, there we go, 40, not that one, 30, perfect. So this is a 3-0 super mid, it's a looped super mid suture. It's what I like to use. It's beneficial in that it gives you two sutures or two strands for the price of one. So here we see the needle. It is a tapered needle, it is not a cutting needle. I like it better, it's a little harder to push through the tendon, but what it does is it does not cut through the longitudinally running bundles of collagen and create a laceration in the tendon. And we see here the way the two strands come out, and it's looped here. So Hutch has given me a needle driver, and we'll get started. I'm using forceps that have teeth. If I'm going to do that, then I'm going to try and avoid grabbing the part of the tendon that is going to be exposed to the sheath, so as to minimize adhesions. But for the sake of quickness, I'm going to not be too fussed about that now. One thing that people do is they pass the suture this way through the tendon. I find it easier to pass the suture with the tendon rotated 90 degrees, because what happens then is you don't have any worry about the suture coming out either volarly, bless you, or dorsally when you're passing it. So if you pass it that way, and then place it down like that, then you're able to get your suture placed right through the tendon. And if I'm going to have a snap, Hutch, please. Right like that. And we'll just put that there for simplicity's sake. And then coming across this way, you can either lock it here or not. I prefer to not lock it. But you pass your transverse part of the suture in that fashion, pull it through. And then again, with the tendon 90 degrees, pass it through this way, so as to come out of the tendon stump on, in this case, the radial side of the tendon in the midpoint. It doesn't have to be exact, but it's helpful if that can be done that way. Now what Ryan was saying is that this part of the passage of the suture has to be done in a way that allows it to glide so that the tendon itself, or the repair site, will co-act after or immediately following placement of the first four strands. So I'm going to actually break a few rules and just hold it there, pass it like that. So it's coming out the ulnar aspect of the tendon now. And then again, at 90 degrees, Doug has it all positioned for me. I'm sorry, was I in the way? And now what you can see is what Ryan was talking about, is that if you pull the tendon tight now, you have a four-strand repair that, at least at its fundamental level, will be able to withstand the rigors of early passive motion rehabilitation. But what I like to do now, and what we've done experimentally, is do another core suture, basically in this fashion. So it's a little closer to the repair site, and then again through there. And notice the ends of the tendon are very close to one another, because we've already made up the slack, as Dr. Kalfi talked about in his lecture. There's that. And then again, we pass in that fashion there. Not as important to turn the tendon 90 degrees for this second part of the core suture, but if you want to do that, that's certainly fine. Again, you want to come out directly radial, or ulnar, depends on which side you are. And then like that. And there's your eight strands. And then what I do is do a knot, and it's a little bit messy, but what you do now is tie inside the repair site. Again, there's no biomechanical data that would show benefit to either tying the knot in or out of the repair site. There may or may not be a difference in glide, and I think Peter Amadio has done a substantial amount of work in this regard, but I can't speak to that. And there's your core suture. Now I've only done two knots, or two throws, but that's basically it. Now what I like doing is just cutting one, and then doing the epitendinous suture, which is basically a running 6-0 proline. Do we have that? You know, I'm going to let the people start doing their own specimens, Pat, but basically it's a 6-0 proline. We just published data in the Journal of Orthopedic Research that state that the two most important factors in a flexor tendon repair are, number one, the actual amount of strands across the flexor tendon repair site. I prefer eight if at all possible. Six is not as good, and four is not as good, but four is a bare minimum. And the second thing is that the epitendinous suture should be placed deeply within the repair site. So number of strands across the repair site, deeply placed epitendinous sutures through the repair site. It's less important to have a 3-0 than a 4-0, and it's really fairly unimportant to have a 5-0 versus 6-0 epitendinous, or to have a wide placement of the core suture rather than a narrow placement of the core suture. And that's in the Journal of Orthopedic Research last year, I believe. Thanks. No, it's not the needle driver. So just to give you an idea of the depth of passage, I like to start outside. I know Dr. Kalfi says he likes to bury the knot. That would require starting inside the repair site. But notice I take a deep pass of the suture through the flexor tendon at the area of the repair site. Ed Diao has done work that shows pretty conclusively that not only does this epitendinous suture matter for tidying up the repair site, but it actually matters for the strength of the repair site as well. If this needle driver is, perhaps. But that's basically what we do. I like leaving the end long because sometimes it will help me invert the tendon if I'm doing the back wall. And then the rest of the epitendinous suture is done in that fashion. So let's cut that. Marty, that's a great demo. Does anybody have any questions that might be pertinent to everybody for Dr. Boyer? And then I just want to demonstrate the Zone 1 repair. So, the question is, do I ever have to, and I'm going to paraphrase, you can correct me if I'm wrong, okay, do I ever have to do my repair before retrieving the tendon, or do I ever have, in other words, do my repair proximal to A2 and then pass the suture along with the tendon with the core underneath A2 or A3? Sometimes I do, A2 is much more forgiving than A4, A3 is, you know, kind of in between them literally and figuratively, but I think that, you know, at times you will have to do the first part of the core and then pass the sutures underneath the pulley and then the tendon underneath the pulley, but that requires pre-dilation of the pulley or transection of part of the pulley, the distal part of the pulley. Is that what you're asking? Okay. Other questions? Sir? Yes, that's correct. Yeah, they meet in the middle because basically the tendons are coming together, the tendon stumps are coming together like this after the first core, so I'm not really cinching it at all at the end, I'm just tying, you're absolutely right, the radial part with the ulnar part at the end, but you're right, that is the way I did it. Hey, Marty? Yeah? It's 8 o'clock, you want to have them do the zone 2 or you want to take time and do the zone 1 real quick and let them do both? Let me do the zone 1 real quick, and I just want to show them how I do the suture, because the suture passage is a little bit tricky for the zone 1. This is a mass general or modified banal type repair. The suture is also super mid, the needles are also cutting, or tapered rather, excuse me, but this is not a looped suture, it is a double armed suture. So you can see here that there are two needles, one at each end of the stitch. Now what I do is, I do two of these stitches, one on the radial side of the tendon, one on the ulnar side of the tendon. I come back about a centimeter, pass it through, is that okay, can you see? Till they're about equal, and then what I'm going to try and do is get an alternating criss-cross type stitch. So I will come through there, leave it, and Hutch asked me if I'm ever worried about passing my needle through and cutting the tendon that I've just cut, or just cutting the suture that I've just passed, and the answer is, of course I am, but in doing this, it tends to obviate against that. So you can see by doing this type of a stitch, I'm going to actually pull this back, you can see that I am grasping right here, and I'll come to your tables and show this to you if you like as well, grasping the tendon distally, and then I do two more passages of the suture like that, and just very simply you can see, just with one pass of the suture of Hutch, if you can let go, it's got really nice grip on those longitudinally running bundles of collagen. If you add two more passes of this, and then two or three on the other side of the tendon here on the radial side, you can see that you really have a nice grip on that tendon. And then what I do is I pass Keith needles through the base of the distal phalanx, and I like using a button, either with or without some Xeriform gauze dorsally. So Jeff, I think people can perhaps start their dissections and start their zone 2 and then zone 1 repairs. That was excellent, Doug. One thing that I would encourage everybody here to do is to ask questions of the faculty, and ask the same question of more than one faculty, because you see that we have a lot of years of experience here, and tricks and techniques that a lot of us use that are helpful in difficult cases.

Gelberman winter repair

flexor tendon injuries

pulley management

suture repair

zone 1 repair technique