All right, well, we'll start off with zone 1 and 2 flexor tendon repairs, and I need to acknowledge Dr. Boyer and Dr. Gelbman, both who have contributed mightily with pictures and information from my talk. So we'll start with zone 2. And so I think the goals right now of a zone 2 flexor tendon repair need to be getting a repair with a failure force of over 50 newtons. And that's to allow that early active unrestricted range of motion type of rehab, which is going to impart about 34 newtons, so you want a little bit of leeway. And we need gap formation less than 3 millimeters. And that's based on the data from Boyer and Gelbman. When we found that that 3 millimeter gap, if you get to that critical number, you no longer are going to accrue strength in your tendon repair during healing. And so that's going to prohibit that full strength later on and possibly lead to late ruptures. So how do we get there? So I think in 2013, just as a quick summary for the suture repairs, you're going to look for a core suture repair with four strands at least crossing the repair site, possibly even six or eight. I don't know if Marty's going to demonstrate an eight-strand repair or not. But then I think that you want to get a core suture purchase, so biting away from the cut ends of about a centimeter. I think the data would say a minimum of 7 millimeters is adequate to give you the proper strength. And then an epitendinous suture that's somewhat deep and back from the cut edge, about 2 millimeters deep, 2 millimeters back, based on work by Greg Merrill, who's here today. So what are some initial considerations thinking about zone 2 repairs? I think number one, if both digital nerves are out, I would just presume both arteries are out as well, even if the finger is perfused. And so it's important to remember to have the appropriate instrumentation available to you to fix those if need be. And then the second thing that I like to do is just open the traumatic wound and take a look before you do your big extensile exposure. Because every once in a while, those tendons are tethered and you can do a nice repair without opening much. And we need to determine that necessary repair window, and we're going to talk about this a little bit more in just a second. So my preferred incision would be a mid-lateral approach. I know a lot of you here probably like a Brunner incision. I think the couple of advantages of a mid-lateral is that, number one, there's no wound to dehisce over the flexor tendon. So if that wound opens up a little bit with early motion or because of the trauma, it's way off to the side. You're not going to see any tendons. And there's no small flaps to dehisce like you do with the Brunner. Now a couple of technical points. When you raise that flap along the side, you got to be palmer to the digital nerve and artery so that you can raise that flap untethered and kind of just flap open the entire finger. And I think what I like to do with resins is sort of identify the nerve and artery, give you one spread with the scissors, just palmer to the nerve, and then you're right down on the pulley system and you can do everything else with a knife and kind of raise this as one big full thickness flap that's going to keep everything healthy. Now I think the textbook, you know, when you read it, it says you open up the flexor pulley system and then you open up a window between A2 and A4 to do your repair. But I think you need to take a look at what we're going to have to repair where before you do that. And the reason is, is that sometimes you get that FTP cut a little bit distally, even though it's in zone two, and that repair is definitely going to fall under A4. If that's the case, I think that I've gone to just releasing A4 without worrying or feeling too bad about it. And I think partly based on data from Tang, indicating that yes, the cruciate pulleys in A3 do contribute to preventing bow stringing. And if your repair is directly under A4, sometimes releasing that, I think, not unexpectedly can decrease the friction on your repair site when you're working on initial motion. But the key thing is that if you just release A4 to do your repair, you've saved the rest of this pulley system and I think you're going to be okay. If you've already made that standard opening and then you realize your repair is directly under A4, if you release that, you've ended up with basically only A2 holding down the pulley. And I think you've nearly guaranteed yourself a lot of bow stringing and probably a less than optimal outcome. So I think getting an idea of where the repair is going to be before you open everything is good. All right. Retrieving the tenons. Once you've figured out where you're going to do that repair, you can locate FTP or FDS sometimes just proximal to A1. I like the technique of just taking a malleable wire, something say 20 to 26 gauge, looping it, putting it under the pulleys, and then having put a core stitch in the tendon, use that to deliver your suture and tendon out distally. You can also use the classic pediatric feeding tube using a freer as a shoe horn. I know there's some commercially available things also to help you get the tendon back under the pulleys now. And then having to dilate the pulleys at times, those pediatric cervical dilators are great. Positioning the tendon. I think a lot of people just do the standard technique of taking a small needle like a 25 gauge, passing it through the tendon and pull it approximately to hold it out to length. The technical things that I've realized, you know, you got to keep the tip of the needle in the soft tissues. Otherwise, you tend to stab yourself. I've done that. And then trying to avoid the neurovascular bundles with that needle. So then once you've got everything lined up, setting up for the repair, getting that finger in the right posture, usually flex to be able to see the proximal and distal ends. Whether you use a smooth pickup or one with teeth, try to grab that tendon in one very small area. And then once you start passing the suture, using the suture to be your holding force. So you no longer have to grab the tendon. And then obviously doing FDS first because it's hidden by the FTP. So the actual repair, the one popularized by Winter and Galperman is an eight-strand repair. We'll show this. I know not every tendon is going to get an eight-strand repair, but just realize that this is no more complicated than the traditional four-strand repair with basically two Kessler sutures just using a loop suture to get two sutures per pass. So here's your loop suture with your two strands coming off the needle. Like a super mid, we usually use 3-0 or 4-0. And then here it is. This is, I know, pictured in zone three, but basically the same technique where you come in from the cut end about a centimeter back to make sure you have good enough purchase. Come across transversely. Dr. Galperman likes to go kind of palmer to dorsal to then keep the two Kesslers in kind of different planes. But you basically then come on back out the cut end again and then go ahead. Now you've got your nice grasping suture on that first end. Do the same thing on the other end. Now you want to get everything opposed just like this before you make that next pass of kind of coming back across to get those extra four strands. Because even though this may not be a locking stitch, it's no longer going to slide easily through the tendon at this stage. And then finally, when you're tying it down, one knot inside the repair site, at least is the way that we've been doing it. And the data by Wu in 2012 would suggest that if you just bunch the tendon slightly, about a 10% tightening, you're going to minimize gap formation. And then that epitendin in the suture, I think some thoughts on that to be really slick or to start it with a little bit of a buried knot so your small knot is also inside the repair site. Leave a small tail so you can go around the tendon and tie back to that same spot. And then at times, depending on how much time we have and how easy the repair is, sometimes doing the dorsal side epitendin is even before the core suture can work very nicely. For distal FDS repairs, I would do more of a smaller suture in a little bit of a locking fashion like a modified Becker suture. And I think that the key thing is that if you really cut that FDS really distally where you're really close to that insertion, you don't have much tendon to sew back to, you don't need any glide. You just need to reestablish that insertion. So feel free to sew it down to periosteum, to the edge of the pulley system. You just need an anchor to hold that out to flex the FD, sorry, PIP. So sometimes I'll even just tie that on the outside of the pulley system there. Couple practical considerations or acknowledgments. You know, the elegance of your repair obviously decreases as the magnitude of the trauma increases. And just remember that a-strand repair is really no harder than a four-strand without a loop suture. And then finally, I tend to repair FTP and FDS, but you know, depending on the nature of the injury, repairing just FTP is certainly acceptable. For zone one, we've got our FTP avulsions. Ring finger is the most common, most often in football, followed by other sports. You know, the classifications, I'm not big on classifications, but this is one of those backwards ones where the type three is better than a type one. And it's relevant because of how we can treat these time-wise. And I know you guys are familiar, but I would suggest that, you know, acutely under three weeks, you can probably repair just about all of these. It's going to take a little dilation of that A4 pulley at times. More chronically, maybe up to eight weeks, it's going to be possible, but only if that tendon is stuck at A4 because that's going to keep that tendon and the muscle out to length, allow you to get it back to the distal phalanx, and also keep that A4 dilated since it's not empty collapsing down. Later, I don't think I can repair these. I have a lot of patients come in, you know, months later. What can we do? Can we fix it? I don't think anyone recommends grafting multistage things through an intact FDS, but you can fuse DIP joints or excise painful scar. So the exposure here is no different than the zone twos where you basically take a look at the open wounds and then extend as you need to. Here's an example where that FTP gets a little bit tethered on the volar plate of the DIP joint, which is kind of nice because it's right there and you can go ahead and repair it. I think I just debride a little bit of that insertion point on the footprint and then use the dilators to get up A4 big enough to put that poor tendon back underneath there. I think there's some different core suture options. I'm not sure which Dr. Boyer is going to demonstrate. I think you can use a larger stitch and just get a two-strand repair, sometimes a smaller suture with a little bit of locking on either side to give you four strands. I don't think you need to get excessive. Dr. Boyer says four, either way will work. And there's a couple different fixation options. So I think my three favorite techniques would be either doing the standard, taking your Keith needles on a K-wire driver, putting them through the distal phalanx, coming out in the sterile matrix of the nail, putting a button over it. That's fine. Or I think another option with the button is when you have a laceration and there's sort of a little stump of FTP out there distally, it feels kind of nice to take those Keith needles, just pass them deep to that stump along the volar periosteum and just put your button at the tip of the finger. So you're basically pulling that end out so the two tendon ends will oppose and you can add some additional suture on the inside, but you're not relying on those inside sutures because there's not a big stump. And that was a way that Dr. Ackleman had taught me. And then the other option, which is fairly slick at times, is to take those Keith needles and just pass them directly posterior on that distal phalanx from that footprint. You're trying to exit basically between the terminal tendon and the germinal matrix so that you can exit them on the back of the finger and make a small dorsal incision and just tie it down on bone. That's kind of nice if people are worried about a button. You have a patient that you think may knock it off or be in dirty situations. So then you don't have to remove the button later. That's a little bit more fussy. I think the one technical thing there is that you want to make this transverse incision to retrieve those sutures. Make it just proximal to where the sutures actually come out. Otherwise you end up trying to close that skin right over the knot and there's not much soft tissue there and it's kind of hard to get it to fit in there nicely. For rehab, I think it's for zone one early active, or sorry, early passive range of motion because it's not really robust repairs. Active motion and cutting off buttons at six weeks and then I let full power grip at three months, but maybe I'm being too conservative. And in my mind, I would expect better outcomes than zone two because all the scarring is really right at the insertion where you don't need gliding. You just need it to hold on there. And then finally, in the world of Dr. Boyer here, you want to remember the person attached to the tendon that you're working on, okay? So once again, we're working on the tendon, but here's one of my favorite patients who drilled AC holes in his splint for himself, then came in without the splints wearing a very classic t-shirt. So don't get too elegant sometimes. All right. Thanks guys.

zone 1

zone 2

flexor tendon repairs

failure force

range of motion