PURPOSE: Flexor tendon injuries in zone 2, commonly referred to as “no man’s land”, have high incidence of postoperative stiffness. Historically, it was thought that release or venting of the A2 or A4 pulley would lead to bowstringing and weakness. Building upon the success of acellular dermal matrix (ADM) to maintain strength and avoid adhesions in hostile abdominal hernia repair environments, our group has developed a novel technique for zone 2 flexor tendon repair that includes pulley release and reconstruction using ADM. Here we report our technique and experience with zone 2 flexor tendon repair with pulley release and ADM reconstruction.
METHODS: A retrospective review was performed to identify all patients at a University Level 1 Trauma Center who underwent zone 2 flexor tendon repair with pulley release and ADM reconstruction. Outcomes were reviewed and descriptive statistics performed. Our technique begins, when possible, with wide awake surgery with local anesthesia and no tourniquet. Brunner incisions are made, and the proximal and distal cut tendon ends are identified and retrieved. The entire pulley overlying the tendon repair is released by longitudinal midline incision. FDP is repaired with core and epitendinous sutures, and both FDS are repaired for an anatomic reconstruction. The patient then actively ranges the finger and additional liberal pulley release is performed if necessary. Next, pulley reconstruction is performed with 2 × 4 cm ADM, custom-cut and secured to the cut ends of the pulley with tension sufficient to hold the tendons in anatomic position. The finger is again actively ranged to confirm gliding under the ADM. The skin is closed and a splint applied. Early active motion therapy follows, when appropriate.
RESULTS: Twelve patients who underwent zone 2 flexor tendon repair with ADM pulley reconstruction were identified over an 18-month period. Six patients were excluded due to follow-up shorter than 2 months, leaving 6 patients with 10 fingers treated for inclusion. Mean age was 39 years and mean follow-up 3.0 months. All 10 fingers suffered lacerations to FDP and FDS in zone 2. FDP and FDS were repaired in 80% of fingers, with 20% forgoing FDS repair due to multilevel laceration. Sixty-six percent of patients were noncompliant with hand therapy. No patients demonstrated evidence of bowstringing at last follow-up. Minimal or no stiffness was observed in 60% of patients, including 1 patient who was noncompliant with therapy. Significant stiffness was observed in 40% of fingers, all in patients noncompliant with therapy.
CONCLUSION: Successful management of zone 2 flexor tendon injuries can be accomplished with pulley release and reconstruction using ADM, with no concern for bowstringing. Therapy compliance remains important to minimizing stiffness. Further comparative studies will be required to evaluate cost-effectiveness and identify specific patients who will benefit most from this technique.