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. 2020 May 11;11(4):637–641. doi: 10.1016/j.jcot.2020.05.003

Ordinary PVC feeding tube: A low-cost alternative to silicon rod for staged flexor tendon reconstruction in zone II of hand

Pawan Agarwal 1,∗, Dhananjaya Sharma 1
PMCID: PMC7355062  PMID: 32684702

Abstract

Background

Staged flexor tendon reconstruction is most appropriate treatment for delayed zone II flexor tendon injuries of hand. The Hunter’s silicon rod used in this procedure is costly and not simply available. The aim of this study was to evaluate the results using PVC feeding tube as a cheaper and readily available alternative.

Materials and methods

this study include 6 patients(8 digits) were treated by the staged flexor tendon reconstruction using PVC feeding tube for first stage followed by tendon graft in second stage and the patients were followed for mean period of 6 months.

Results

Excellent results were seen in 5 digits and good results in 3 digits, according to both LaSalle system and Strickland-Glogovac grading system.

Conclusions

PVC feeding tube is a cost effective, simply accessible and an effective alternative to Hunter’s silicon rod for staged flexor tendon reconstruction.

Keywords: Cost effective, Silicon rod, Flexor tendon reconstruction, Frugal innovation, PVC feeding tube

1. Introduction

Early primary repair of flexor tendon injuries (i.e. within days) gives the best result. However, this may not always be possible because of the missed injury, failed primary repair, and if general condition of the hand or patient is not suitable for immediate repair. Secondary repair of flexor tendon injury is very challenging procedure in hand surgery and as a rule it is done in a staged manner. Secondary repair of flexor tendon using Hunter’s silicon rod has been the gold standard, but it is expensive and may not be readily available.1,2 The present study was conducted to find out the efficacy of PVC tube, a low-cost easily available alternative to silicon rod for secondary flexor tendon reconstruction.

2. Material and methods

It is a prospective study conducted from June 2018 to June 2019, in a tertiary referral centre in Central India. Institutional ethics board approval and written informed consent from patients was acquired before starting the study. Patient’s tendon injuries were classified according to Boyes grading for tendon injuries.3

Grade 1: Tendon is injured, no soft tissues injury, mobile joints and minimal scarring.

Grade 2: Tendon is injured and notable scar, mild contracture.

Grade 3: Injury to tendon and joint damage with decrease active/passive range of motion.

Grade 4: Injury to tendon and nerve injury.

Grade 5: Multiple injury combination of 2, 3, and 4.

3. Operative steps

Stage 1 surgery was performed under tourniquet control and loop magnification. Fingers were approached through a volar zigzag incision from the distal phalanx to the level of previous injury scar in the palm (Fig. 1). Neurovascular bundles were identified and protected. Scarred flexor tendons were excised, preserving a distal end of the FDP tendon for subsequent suture to tendon graft. The proximal end of FDP tendon was dissected out (Fig. 2). Pulleys were assessed and if found damaged only A1 and A2 pulleys were reconstructed using excised tendon. Now Poly Vinyl Chloride (PVC) feeding tube (Romsons Scientific & Surgical Pvt. Ltd, Agra Uttar Pradesh India 282006) of size 10 was passed through the pulley and sutured to the FDP stump and proximal end was sutured to end of FDP tendon in the palm (Fig. 3). Tourniquet was now released, haemostasis was achieved and skin incisions were closed using simple interrupted sutures (Fig. 4).

Fig. 1.

Fig. 1

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Fingers were approached through a volar zigzag incision from the distal phalanx to the level of previous injury scar in the palm.

Fig. 2.

Fig. 2

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The proximal end of FDP tendon was dissected out.

Fig. 3.

Fig. 3

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Feeding tube passed through the pulley and sutured to the proximally and distally.

Fig. 4.

Fig. 4

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Skin incisions were closed.

Patients were taken for Stage II surgery after 8–12 weeks. Incisions in the digit and palm were reopened and proximal and distal stump of the FDP tendon implant was identified and formation of pseudosheath around the feeding tube was observed. Next, palmaris longus tendon was identified and harvested as tendon graft from the same limb (Fig. 5). End of the palmaris longus tendon was tied to the feeding tube and pulled from proximal to distal through the pseudosheath. First distal end of palmaris longus was sutured to end of FDP tendon and after proper tension adjustment proximal stump of the palmaris longus tendon graft was sutured by Pulvertaft weave to the flexor profundus tendon with 4–0 Ethilon suture (Made by Johnson & Johnson Private Limited, Mumbai India 400 060) (Fig. 6). Appropriate tension of the graft was obtained by inspection of hand cascade and passive tenodesis. Meticulous haemostasis was obtained and skin incisions were closed by simple interrupted sutures. Postoperatively posterior plaster slab, maintaining the wrist in neutral position, metacarpo-phalangeal joints in 70° of flexion, and IP joints extended was applied for 3 weeks. After 3weeks patient was advised combination of active and passive range of motion.

Fig. 5.

Fig. 5

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Palmaris longus tendon was identified and harvested as tendon graft.

Fig. 6.

Fig. 6

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Palmaris longus was passed through pseudosheath and sutured to end of FDP tendon and after proper tension adjustment.

Postoperative results were assessed by measuring the active range of movements of involved fingers by LaSalle grading. The return of 75%–100% of active motion was rated as excellent, 50%–74% as good, 25%–49% as fair, and 0%–24% as poor.4 We have also measured the active flexion of PIP plus distal interphalangeal (DIP) joints minus any extension lag. (Strickland and Glogovac grading Results were rated as excellent when active degree of flexion of PIP plus DIP more than 1500, good when 1250-1490, fair when 900-1240 and as poor when < 900.5

4. Results

Six patients (8 digits) with missed initial injury were included in the study. Patients were categorized according to Boyes’ classification.6 There were 4 patients in Boyes grade-I, 1 patient in grade II and 1 patient in grade IV. There were 5 male and 1 female, with age ranging from 14 to 50 years (average age - 35 years). Mechanism of injury was incised wound in zone II in all cases. Average time elapsed since injury to stage of operation was five months (range- 3 to 8 months). Index finger was involved in 3 digits, middle finger in 3 digits and ring finger in 2 digits. Both the tendons (FDS, FDP) were cut in all patients. There were no fractures but 1 patient has associated unilateral digital nerve injury. None of the patient had history of any treatment after injury. Pulley restoration was carried out in stage 1 (n = 2 patients). All patients underwent same surgical procedure and postoperative recovery protocol and all six patients were available for 6 months postoperative follow-up.

At 6 months follow up, according to LaSalle system excellent results were observed in 5 fingers and good in 3 fingers. According to Strickland and Glogovac grading system there was excellent results in 5 fingers and good in 3 fingers (Fig. 7) (Table 1). Flexion contracture of the PIP/DIP joints occurred in 2 fingers and ranged from 80 to 450. There were no complications like infections, extrusion, ruptures of the implant/tendon, bow-stringing of tendon, skin necrosis, rod buckling/migration or synovitis.

Fig. 7.

Fig. 7

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Post operative results.

Table 1.

Post-operative results of the six patients (8 digits).

Evaluation grading Excellent Good Fair Poor
LaSalle system 5 digits 3 digits 0 digits 0 digits
Strickland system 5 digits 3 digits 0 digits 0 digits
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5. Discussion

Acute flexor tendon injuries comprises of <1% injuries of hand which occur in young working male and represent a significant economic burden to the individual and society.7 The final economic burden includes the cost of lost productivity in addition to that of surgery and physiotherapy. Approximately 17% of primary tendon injury patients end up in secondary reconstructive surgery of flexor tendon due to complications.8 Poor results of primary tendon repair in Zone II of hand had prompted the pioneers of tendon surgery of this era to label this area as the “critical zone” or “no man’s land.9, 10, 11 Chances of adhesion formation in this area are greatest due to the presence of complex fibrous flexor sheath which contain multiple pulleys and two tendons which leads to impaired free motion of the tendon and adhesion after injury or repair.12, 13, 14 Other negative predictors of results include failure to preserve the tendon sheath or pulley, significant scarring of hand, complex injury (associated fractures, neurovascular injury), inadequate rehabilitation; non-compliant patients and technical errors.15 In such a scenario staged surgery can improve overall results.

The concept of staged tendon reconstruction dates back to 1914 when the first experimental study trying to prevent post-operative adhesions was published.16 It was followed by a clinical study in which reconstruction of the pseudo-synovial sheath was done using a biologically inert implant, to provide a smooth gliding surface for the tendon graft.17 Technique of two-stage tendon grafting was subsequently refined and standardized by Hunter who reported long-term follow-up.1,2,18 Since then indications for 2-stage tendon reconstruction have been well recognized and include severe soft tissue injury to the skin, tendon sheath, pulleys, missed primary injury, complications of primary surgery mainly rupture, excessive scarring and loss of tendon length.19, 20, 21 Similarly, prerequisite for two stage tendon reconstruction have become well known and include full passive range of motion, good skin coverage, healed fractures and absence of neurovascular injury. The two stage reconstruction gives an opportunity to reconstruct pulley system, replacement of lost or scarred skin, repair of neurovascular bundle and time for healing of fractures.22

Following the understanding that prevention of adhesions is crucial; many physical, surgical and pharmacological modalities were unsuccessfully tried to reduce/prevent adhesions of the flexor tendons.23 In 1971, the publication of classic paper by Hunter and Salisbury had a major impact on tendon repair surgery. In this they showed that fundamental to successful 2nd stage tendon repair was use of silicon rods in the first stage of tendon reconstruction to obtain a suitable smooth pseudo-sheath permitting placement of flexor tendon grafting.1 Others started following this idea, and satisfactory results started appearing in literature.24 However, cost and ready availability (250 US$; Made by Wright Medical Technology, Memphis, Tennessee 38117 USA) of these Hunter silicon rods were the major constraints, more so in the developing countries.

This prompted research workers to search for low-cost but effective alternatives. This effort received a boost with the publication of landmark experimental work in Albino Wistar rats by Kuran et al. in 1998. They compared the pseudosheaths formation of a Silicon urinary catheter, Hunter’s silicone rod prosthesis, Rubber catheter, and an Angiocatheter. It was found that pseudosheaths induced by silicone rod and silicon urinary catheter had similar histology, polymorphonuclear and lymphocyte cell infiltration and tensile strength. Additionally, there was no microorganism colonization or foreign body reaction.25 This seminal work became the basis for use of alternative material which can be can be used safely.

Since then successful clinical use of many easily available, low-cost alternatives like Silicon urinary catheter, Silicon infusion tube, Silicon drainage tube, Redon drain catheter, Nasogastric tube, and PVC infant feeding tube has been demonstrated.26, 27, 28, 29, 30, 31, 32(Table 2) Closer inspection of Table 2 shows that outcome was excellent/good with most low-cost alternatives. Taken together, these results suggest that these did not provoke foreign body reactions.

Table 2.

Cheap alternatives to silicon rod and their results.

S no Cost effective alternatives Number of cases Complications Outcome
1 Silicon urinary catheter Atik et al.78 17 Infection (n = 2) adhesions (n = 3)
dehiscence of tenorrhaphy (n = 1)		 Excellent results in 36.4%, good in 27.3%, moderate in 18.2% and poor in 18.2%
2 Infant feeding tube Kulkarni et al.8 1 Nil Good functional recovery
3 Silicon urinary catheter Ahmad et al.29 35 Wound infection (n = 2) catheter exposed (n = 2) Strickland scale, active motion obtained was excellent in 70%, good in 20%, fair in 7.1% and poor in 2.9%
4 Silicon infusion tube Kibadi et al.30 1 Nil Full recovery of the range of motion with active flexion of PIP and DIP of four fingers in the right hand
5 Nasogastric tube
Saad AL-Qahtani31 		1 Nil Full active flexion of both DIP/PIP joints with nail to palm distance of zero
6 Nasogastric tube/Redon drain
Lahsika et al.32 		11 Bow stringing (n = 1) stiffness of PIP and DIP (n = 1) 20% excellent results, 30% good results, 40% average results and only 10% poor results
7 Silicone drainage tube Ersoy26 2 Disruption and invagination of the
Pseudotendon sheath inside the tube
Tube breakage		 NA
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DIP- Distal inter-phalangeal joint.

PIP- Proximal inter-phalangeal joint.

NA- Not available.

In our study we used PVC infant feeding tube (Romsons Scientific & Surgical Pvt. Ltd, Agra, Uttar Pradesh, India 282006) which costs only INR 6. All patients had excellent to good results with no implant related complications. Our finding is consistent with that of other authors and our study, along with studies summarised in Table 2, confirm that making innovative use of what is low-cost and easily available, in the face of resource constraints is possible and such a ‘Frugal innovation’ is safe and effective.

However, these frugal innovations are not without challenges. Use of perforated and hollow tube may lead to invagination of the newly formed pseudo-sheath causing disruption of continuity and rough interior surface. In addition, perforations make the tube potentially weak leading to possible breakage.26 Another concern with use of a hollow tube, as compared to solid silicon rod; is possibility of collection of fluid in the lumen leading to more chances of infection. Therefore perforated end of tubes should not be used and both the end of tube should remain open so chances of collection are minimal.

A limitation of this study is that we had small number of cases; short follow up of 6 months and no comparison were made with silicon rod. However; after tendon repair/graft it takes approximately 12 weeks for a flexor tendon to regain enough tensile strength and function like grasping, holding, or lifting objects during daily activities. Therefore follow-up of 6 months are enough.33

6. Conclusion

This study set out to assess efficacy of PVC tube as a low-cost, easily available alternative to silicon rod for secondary flexor tendon reconstruction. We have successfully shown that using PVC tube has a satisfactory outcome and such frugal innovations are very useful for developing countries.

Funding

Nil.

CRediT authorship contribution statement

Pawan Agarwal: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing - original draft, Writing - review & editing. Dhananjaya Sharma: Formal analysis, Investigation, Methodology, Writing - review & editing.

Declaration of competing interest

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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