Hello, it's June 18, 2016, and we are here at the Curtis National Hand Center at Union Memorial Hospital. We are fortunate enough to have Dr. Marty Boyer from Washington University in St. Louis with us as our visiting professor this year as part of our graduation ceremonies. He has had a long weekend of excellent talks and dissections, patient evaluations, and conferences. Our first dissection was done yesterday, which was recorded separately, and that was on proximal fibular fissial vascularized transfer, the harvest of that flap. And today, in our second section, Marty is going to be doing some dissection to demonstrate zone 2 flexor tendon repairs, and he has just completed giving us his keynote lecture on state-of-the-art flexor tendon repairs 2016. Marty? Thanks, Dr. Higgins. So if you think about flexor tendon repair, zone 2 is going to begin at A1, and depending on what you believe zone 2 to be, end around the end of the A4 pulley where the superficialis finally inserts. But to me, zone 2 is, it's not defined perfectly as much as it is where there are two tendons and where the sheath is narrow. I'm going to mark out the mid-axial points of the finger, and that's where I make my incision when approaching a flexor tendon, and then I make a V-shaped incision proximally and a Brunner-type extension distally. One of my favorite stories about the Hand Society is when, apparently, I don't know if this is true or not, but decades ago, there was a presentation made on the Brunner incisions, and this gentleman gets up at the end of the presentation, we're just going to start the mid-axial incision, and says, well, my understanding is the Brunner incision involves X, Y, and Z, and the speaker said, well, you know, sir, with all due respect, I've done research on this, I've read the papers, I've done the analyses, and I think you are mistaken. And of course, we all know what's going to happen next, the old gentleman goes to the microphone and says, yes, but I am Brunner. I don't know if it's true or not, and I obviously didn't tell it very well, because I thought it was pretty funny. We edited out all the laughs. Yeah. A ton of laughs. Yeah. And let's have some scissors here. Actually, you know what, I'm just going to extend it here, because... I'm going to pepper you with questions. Pepper? Yes. Pepper Martin, the former infielder for the Cardinals in the 20s? Yes. Okay. Good. I think he was a Cardinal. So we have an institutional bias for mid-axial incisions here as well, and most of our faculty perform these and prefer them over Brunner's incisions. And we will routinely leave the nerve vascular bundle... Yeah. This is Mike Murphy downstairs. As someone who suffers from a lot of backtracking, would you tell us... Yeah. I just want to tell you that that story you just told about Julius Brunner, I've been told that by Shaw. Oh. And Sandy is shaking his head that that is actually true. It is true. Yes. But, you know, Shaw will be there this evening. We can get the corroboration. But I've heard that exact same story from Shaw. There it is. There it is. Mike, I was about to say something profound, and you interrupted me. Yeah, Mike, STFU, okay? So, Marty. Yes, James. We would all leave the nerve vascular bundle on the ipsilateral side dorsal like you're doing right now. That's what I'm doing. That's what I'm attempting to do. Believe it or not, I've heard people advocate doing just the opposite. Okay. Meaning trying to keep that nerve vascular bundle with the flap. I think in a Moberg you do that. That's a good practice for elevation of a Moberg flap. That being said, you know, this is the way I do it. So what can I say now? I'm showing poor technique by grabbing the skin with my forceps. Please forgive me if you can. But if you notice, elevation of this flap really is full thickness. And I am elevating it all the way to the other mid-axial line so that we can have a full unimpeded view of the flexor sheath. Now, just for illustration's sake, I'll come through Cleland, which is now visible because I've elevated the flap, and show you the other nerve just so that you know where it is and are happy that it's there. We know that the dominant artery of the small finger is going to be radial. Dominant artery of the ring finger is going to be radial. Dominant artery of the middle finger is going to be ulnar, and the index finger will be ulnar. And the way you remember that is the more protected of the two sides of the finger is going to have the dominant artery most of the time. So we see here a 2. We see here a 4. Very thinned out in between. I know I said I don't do it this morning, but... Oh, here it is. Thank you. I'm going to elevate a flap of retinacular tissue of C1, A3, and C2. Just to give us a wide exposure. Just to make life a tiny little bit sweeter. So there it is. Here we see the decussation of the pyramids. There we see the decussation of the FDS. It's going to be underneath A2. And here we see the profundus tendon. So what I'm going to do is have a nice, clean laceration of the profundus. So you just said there that you were going to give us a nice wide view, and you took out C1, A3, C2. That would imply that you don't always do that. No, I try and leave A3 intact. Because I worry about A4, and I figure if A4 is going to go, if I have A3 intact, at least it mitigates the problems associated with that. So you're opening up C1 and C2 and jumping back and forth before and after A3. That's exactly right. So imagine that this is a Kirschner wire that is smaller or a hypodermic needle that I use to hold the flexor tendon proximal stump in three-dimensional space. You notice these are forceps with teeth. I usually use them without teeth. Do we have such forceps? Do they exist at this latitude and longitude? Give me the DeBakeys. DeBakeys are okay. This is great. DeBakeys are fine. So what you try and do is view the tendon on end. And what a lot of people have trouble doing is passing the suture from the center of each tendon side. You can see the tendons in two sides. This is the center. This is the center. Okay. What I find easy to do to do that is turn the tendon 90 degrees, hold it there, and pass it through. And it always ends up exactly where you want it without coming out the back or coming out the front of the tendon. Okay? Does everybody understand that? Turning the tendon 90 degrees is helpful. Now, I don't want this much suture just because it's irritating, so I'm going to cut that. Okay? Now, we are using a single-strand suture, but I want you to imagine it's a loop super mid suture, so there's two strands. This next pass is going to be transverse. Okay? And then the lock is going to be on the next pass, which is going to come back behind. And again, 90 degrees. And out the end of the tendon. Slightly imperfect, but certainly on the right side and not coming out the volar dorsal aspect. So there's a four-strand. Again, I want you to imagine they're a loop suture. Proximally, rather distally. We're now going to do the proximal incision, or the proximal tendon. As soon as I stop seizing. And again, turning the tendon 90 degrees. Coming out about a centimeter proximal. Okay? Coming across. Yep. And this one is going to be locked. Yep. And now I'm going to pass this through. Again, you try and turn it 90 degrees. I'm not going to do it just for the sake of expediency. But now I take this out, and I tension it. So we're going to just relax. Okay? So there's our four strands in the tendon. It's co-apted nicely. And now I'm going to put strands 5, 6, 7, and 8. And now I'm going to put strands 5, 6, 7, and 8. So I gently displace the tendon. Come in there. Proximal to where it was before. Across. And the difference now is going to be, I'm going to come right through to the other side. Just like Jim Morrison tells us. Everybody know the reference? Break on through to the other side. There we go. A little bit of Doors trivia. So you know the song, I Got My Mojo Risin'? What does Mojo Risin' represent? That's right. It's for Jim Morrison. Is that Clifton Mills that got that one? Yes. Yes. Who was the woman on Jefferson's starship with whom Jim Morrison ostensibly had an affair? Grace Slick. Very good. Grace Slick. Who were the other members of Jefferson's starship? Founding members, that is. So really, there we go. And all I've done is a double modified Kessler where the tendon is co-apted and then the knot is buried within the flexor tendon repair site. It doesn't have to be over-tightened and it doesn't have to be cinched ridiculously tight. But that's your Zone 2 repair. And what I would do now is do a running epitendinous stitch. It's fairly straightforward. With the first pass, you just threw one knot when you took your first pass, correct? Correct. The lock was here and then here. But I had to make sure that I was able to bring the ends together because once you have a lock on either side, they're not going to come together. So the lock was here and then the lock was here and it was loose. There. It was loose, but then after I tightened it up, it was okay. Okay? Very good. So that's a Zone 2 repair. What I will do now is a Zone 1 repair. And I'll do it on the same finger so you guys can have the rest of the specimen to practice on rather than have me mess it up. No, I worry, Mike. I worry about everything. I worry about everything. Right now I'm worried about our election and I'm worried about the Middle East and the Brexit. I'm worried about Brexit. Okay. Hey, Marty, I wonder if you could comment on your eight-core repair and the knot inside the tenorifice site in terms of bulk. I know you touched on that briefly during your lecture. You know, I don't know if you all heard Jim's question, but he's asking about repair site bulk with eight strands and a core suture inside the repair site. And there's no question it's going to be bulkier, but I think the work of flexion, we don't measure that. We didn't measure that in those studies, but I think the work of flexion would be less than if there were knots on the outside of the tendon. Yeah, I guess I was thinking in terms of the granuloma at the healing cross-sectional area. It has never shown to be an issue, histologically anyway and biomechanically, although I can certainly understand that at least theoretically it would be. So here we see a profundus insertion. I'm going to lift it off of the bone so that we have the end of the tendon. Marty, just going back to your zone two repair, Sandy McClinton asked, following the repair, do you ever close the sheath? I do not. There have never been any data that show that you have to. I will say, however, that it's entirely reasonable to do if you want to. I think Sandy proposed the question thinking that it would facilitate the colliding of the repair. Yeah, it probably would. You know, it wouldn't take anything to put this back. I agree. It's kind of like repairing the pronator, except with me repairing the pronator, it would just, the first time they would supinate, it would pop off, for me anyway. Marty, let's say you hadn't already dissected this finger and you were doing what you knew was a zone one repair. What's your decision? Same thing. I would start distally, come proximally, probably till A3. I would expose all of A4, dilate it if necessary, and then deliver the profundus tendon deep to it. So let me actually draw the suture for you before we do it. So here's the stump, okay? Divide the tendon in half. And then take a suture where you have a needle and a suture and a needle. Back here, you're going to pass a suture in to the sheet. Let me see that. No. No, no, no. You know, the 6-0 will work. The 6-0 will work. It'll be a little flimsy, but that's okay. You pass it out so that you now have string coming out here and you crisscross applesauce, okay? And then you come back and you crisscross it and you come back and you crisscross it and then you bring them out here. And that shouldn't make any sense at all, but it will in a minute, okay? So this is a thin proline stitch, the middle of which I'm going to mark with a black marker. And you'll see why in a minute. Okay? Okay? So you've got to trust me, it's black in the middle. Okay. So the first pass is going to be proximal on the one side of the tendon, in and out, until the black is there. Okay? Now, what you have to do at this point is you see where the suture is coming in and out. If you want a crisscross outside the tendon, the dorsal strand has to come volar to dorsal and the volar strand has to come volar, excuse me, dorsal to volar. Yeah, maybe. Thanks. Okay, see what we have is we have the sutures crossing one another inside the tendon, and that's this hatched area here. But by doing it this way, you also have sutures, strands outside the tendon, proximal to where they were inside the tendon. Hopefully this will work out, but you'll see that there will be an X right here. See? The blue proline makes an X on the outside of the tendon, and we know it's made an X on the inside of the tendon. So we repeat that a couple of times. You know, instead of me struggling with this with a small stitch, why don't we use that bigger stitch and why don't I show it to you on a bigger tendon because it's just illustrative anyway. Is that okay? So let's do FCR just for shits and grins. Instead of throwing both stitches at the exact same time, could you just run one stitch all the way down and then run the other stitch all the way down? No, because then they won't crisscross properly. You're assuming that I have skill. So again, imagine this is a single-strand, double-needled proline or supermid. So I'm just going to do, imagine this is half of a tendon. We're going to come well back. We're going to come through, and I'm being rough with the tendon clearly. Okay, there's the black, so we stay in the middle. Now, we're going to go back to the other side, come through, and then we're going to come again this way. Oops, excuse me, brain fart. Come this way. Now, if you notice, there's going to be a crisscross on the inside of the tendon, but there'll also be an X on the outside of the tendon. And when you pull, you'll be able to see both. So there's the external X, and we also know there's an internal X now as well. And in order to get another internal X, we're going to come back around this way, come there, and we're going to take this tendon strand and come this way. And in doing so, create another external grasp or lock, I guess. And then finally, we're running out of room. We come out here, and we come out here, pull them through, and we get... Yeah, I'll bring it over. A third X. And I'll tell you something. I'm pulling the crap out of that, and that's not going to come out of the tendon. So that's how you do a mass general or a modified Becker stitch. Imagine this is half of the tendon, and you do each one with a 3-0 or a 4-0 single-arm double-needled or single-strand double-needled super mid. Then you bring it through the nail, bring it through a piece of xeriform, a button, tie it over the button with the finger inflection, and you're done. So, Marty, you're bringing two strands out of each hemi tendon, so there's going to be four strands coming out of the end of the FTP tendon. That's correct. And then two of them are going to go through the radial hole. Yes, and two are going to go through the ulnar hole. And you're going to tie all four of them down over the button. Yes, one tie. Why don't you just do this in the entire thickness of the tendon? Because I think four strands is better than two. This one goes to 11? Yes, Mike. Yeah. All right, so four. So that's the mass general stitch, the bountified becker. This is a variant on a modified Kessler. The difference between Kessler and modified Kessler is where you start. So the regular Kessler stitch starts out here. And then the knot is there. The modified Kessler starts in here, and the knot is going to be there. And then the four-strand is that, plus another one, and the eight-strand is double of that. Some people think that two strands there, two strands there, two there, and two there. Two there and two there. I usually just try and keep them all in the same line. I don't know that it matters. It would seem to me that what you've drawn requires access to a fair length of tendon as compared to the cruciate repair, meaning you're making one centimeter, one centimeter. One proximal swipe. One centimeter, one centimeter. I did a wide exposure here, but I don't think wide exposures in flexor tendon surgery are bad. I think if it minimizes the trauma to the epiteneon, and I think if it allows you complete visualization, then it's a good thing. And I don't think, as Sandy and Mike were saying, if you're able to repair sheath, so if you look at the sheath, you're always going to see the pulleys from the inside better than from the outside. There's A3. Really quite a nice view. There, there. You see the shine? A3. And then, of course, C1 and C2. If an eight-course suture eclipses early active motion so greatly in terms of rupture strength, and an epitendinous suture increases drag, I mean, what do you think about just not doing an epitendinous suture? Well, I'm waiting for Sam's product to become available. And I'm not just saying that. I mean, that was truly impressive. I really would like to see in vivo data and in vivo histology and in vivo time zero, time three weeks, and time six weeks, strength data, as well as joint mobility data. Because a lot of the problem with the TinoFix, as you know, is it didn't go around corners. It was a very rigid appliance. And your device looks like it isn't. So. Agreed. I wonder, though, if next week, I should consider just not putting an epitendinous suture on an eight-core repair if it sits nice. If I'm looking at it and I say, boy, that's sitting really well. I like the contour. Done. If I let you in on a little secret and you promise not to tell anybody, if it's a distal repair and it's a really tight space, I will often not do an epitendinous. Got it. All right. Okay. That's it.

Dr. Marty Boyer

zone 2 flexor tendon repair

suturing technique

epitendinous stitch

TinoFix device

sheath closure

surgical techniques