Two-stage flexor tendon reconstruction with silicone rod

A two-stage flexor tendon reconstruction is typically used to reconstruct a severely damaged flexor tendon system in patients who cannot undergo single-stage tendon grafting. when significant joint contracture release is needed ( Fig. 79.1 A-B), or pulley reconstruction is required.

The first stage requires placement of a silicone rod in the tendon bed to permit formation of a pseudosheath to receive a tendon graft in the future.

The second stage is the placement of the tendon graft, which is performed approximately 3 months after the first operation.

The patient must understand the complexity of the injury and be willing to participate in the time-consuming postoperative rehabilitation. In some instances, arthrodesis or amputation may be a better alternative.

Frequently, patients undergoing two-stage flexor tendon reconstruction require tenolysis to improve motion sometime after the second stage. Patients should be counseled about this common complication, often referred to as the “third stage.”

Radiographs may be taken if evaluation of bone and joint structures is needed.

A hand radiograph before the second stage of the operation is useful to make sure the silicone rod has not migrated.

The preoperative examination should localize the area of tendon injury and assess for scarring and joint contractures in the fingers and palm. Frequently, the need to address contractures and stiffness necessitates a two-stage reconstruction rather than a primary repair or immediate tendon graft.

Scars should be supple, fingers should be free of edema, and joints should have regained passive flexibility before embarking on the second stage of the reconstruction (tendon graft placement).

The flexor tendons have five annular (ring-shaped) and three cruciate pulleys, and the thumb has two annular and an oblique pulley ( Fig. 79.2 ).

Usually the proximal end of the tendon graft is repaired to the proximal end of the native flexor digitorum profundus (FDP) tendon in the palm because the lumbrical muscle, if uninjured, prevents further proximal retraction of the FDP tendon. If the palm and lumbrical muscles are also injured, the proximal juncture should be placed in the wrist.