(1) Tendon suture requirements ① Tendon suture method should be simple and practical, with good tensile strength and little influence on blood circulation of tendon stump. ② Observe the non-invasive operation technique, and the suture site should be smooth to avoid long-term exposure. ③ Non-invasive tendon suture with good tensile property and little tissue reaction was selected. A circular needle should be used for tendon suture to reduce the injury to tendon.
(2) Tendon suture method ① Tendon end-to-end suture method: it is suitable for fresh tendon rupture suture or tendon suture with the same diameter. A.Bunnell sewing method: sewing with double-needle straight-needle polyester monofilament (3-0). This method is complicated to operate and suture will affect the blood circulation of tendon, so it is basically not used now. B "8" stitch method: stitch with single needle monofilament (3-0). This method is simple to operate and the tension resistance of tendon suture is weak. C. Pulling out steel wire method: 36 # ~ 38 # steel wire or 5-0 non-invasive steel wire tendon suture is selected. The proximal end of the tendon is stitched into a figure of eight, which passes through the skin through the distal end of the tendon and is fixed on the skin surface with buttons to reduce the tension at the tendon connection. After 4 weeks, cut the steel wire under the button with scissors and pull it out from the proximal end. D. Kessler sewing method: sewing with double straight needles and polyester silk thread (5-0). This method has strong tension resistance and can be used for tendon suture in tendon sheath. The cooperative branch has controlled the early passive activity. Kessler method is improved. On the basis of the original method, a circle of intermittent suture was added to the tendon suture to strengthen the local tensile strength and make the suture smooth and flat. E.Kleinert suture method: 3-0 non-invasive straight needle single thread suture. The suture method is simple, has strong tension resistance and little interference to the blood circulation of the broken tendon. In order to make the broken seam smooth and have good tensile strength, it is stitched intermittently at the periphery. F.Becker suture method: cut the broken end of tendon into inclined plane and suture it intermittently with 5-0 non-invasive single silk thread. This method has strong tension resistance, because there are many suture lines, the ends of tendons need to overlap, and the length of tendons is affected, so it is suitable for ectopic suture of tendons. G. thread embedding method: suture both ends of tendon vertically with single-needle annular non-invasive suture, and the coils at the needle inlet and outlet are fixed with 8-shaped suture, most of which are embedded in tendon. H. Tsuge suture method: suture the suture line (3-0 or 5-0) straight, and traverse a needle about 1.0cm away from the broken tendon. After the needle is taken out, put in the coil and tighten the aponeurosis and tendon bundle a little. Then insert the needle longitudinally into the tendon and pull the needle and thread out from the palm side of the broken tendon. Then penetrate into the opposite broken end, enter the needle on the palm side, and exit the needle at 1.0 cm away from the broken end. Pull the wire to make the broken ends of the tendons meet, cut one of the steel wires, cross a needle at the needle outlet, and tie a knot with the end of the cut steel wire. ② Unilateral suture of tendon end: A. When one dynamic tendon is transferred to multiple tendons, it should be sutured by knitting method. B. Ribs with different diameters can also be woven and stitched. C tendons with equal diameters can also be stitched by weaving. ③ Fishbone suture: used for tendon transplantation with different diameters. ④ Tendon-bone suture method: suitable for suture when tendon stops on bone.
There are many methods of tendon suture, and each method has its own advantages and disadvantages. No matter which method is adopted, it should be easy to operate, strong in tension resistance, less in interference with blood circulation at the tendon end, and smooth and flat in suture, so it should be selected according to specific conditions.
2. Fresh flexor tendon repair
Although there are still different practices, it is basically unified to do regular surgery in an emergency.
Wound debridement: in order to facilitate the operation, it is necessary to make an extended incision, make a Z-shaped or continuous zigzag incision on fingers and palms, and make a longitudinal Z-shaped incision on wrists and forearms to fully expose deep tissues and find out various tissue injuries. In addition to tendons and tendon sheaths, nerves and blood vessels need to be seen clearly and treated at the same time. After the flexor tendon is broken, the distal broken end retracts to the distal side because the knuckle is straight. Generally, when the finger joint is injured, it bends into an angle, and the broken end can be exposed at the wound. Proximal end often retracts far away. If the long tendon buckle is complete and continuous, the long tendon buckle can limit its retraction. If the fracture is close to the attachment point of the long tendon buckle, the proximal fracture can be retracted, the second fracture can be retracted into the palm, and the third fracture can be retracted into the carpal tunnel. Firstly, the wrist joint and metacarpophalangeal joint should be passively flexed, and the abdomen of forearm flexor muscle should be squeezed, so that the broken tendon can slide to the vicinity of the fracture along the original path. In order to facilitate observation or surgical operation, the tendon sheath should be cut into L shape, and the transverse carpal ligament can also be cut off at one end of the wrist area. It is forbidden to clamp hemostatic forceps blindly in the sheath or palm walking path, which will cause injury and extensive adhesion after operation, seriously affecting the function. After the broken end is found, it will be repaired according to different partitions.
Area I: The flexor digitorum profundus or flexor pollicis longus tendon breaks near the short tendon buckle and can be sutured directly by Kessler method. If the retraction is far away, the tendon near the broken end can be pulled out and stitched into an "8" shape. The steel wire tail goes out from the back side of the nail stump and winds on the rubber pad, so that the proximal tendon cannot be retracted, and then the tendon is stitched end to end. Alternatively, the transverse section of the distal flexor tendon can be divided into two parts, and the proximal tendon head can be sandwiched between them for mattress suture; Or cut a seam at the phalanx where the flexor digitorum profundus tendon stops, lift the bone block, bury the tendon head in the bone seam, and then suture the tendon.
Area 2: changed the principle and broke the restricted area. Primary repair is the most satisfactory treatment. Z-shaped incision was used to expose the flexor tendon sheath and protect the proper blood vessels and nerve bundles of fingers. If the meridian is broken, the tendon will be repaired together after suture.
Make an L-shaped incision near the tendon sheath of the wound, cut the tendon sheath of the cruciate ligament as much as possible, avoid the annular ligament, and stretch the traction line at the angle of the triangular flap so as to see the structure in the tube. Flex each joint, press the muscle abdomen, make the broken ends of both tendons slip out of the orifice of tendon sheath respectively, observe the injury, debridement and repair. First, the proximal flexor tendon is extracted. In order to prevent retraction, an injection needle can be inserted through the tendon sheath at its proximal end 1.5 ~ 2 cm for support. Deep tendon and superficial tendon should be kept together so as not to interfere with each other's blood supply connection. First, make a semi-Kessler on the deep tendon or use other suture methods to pull from the broken lead. The specific repair method should be determined according to the location of superficial tendon rupture at the intersection of campers. If the fracture is far from the intersection point, the two tendons are sutured in the shape of "8" respectively; When the fracture is near the intersection, Kessler suture can be used, and the surface must be smooth. If the superficial tendon cannot be repaired, the proximal segment can be cut off; When the deep tendon slides, the posterior tendon bed is reserved at the distal end. Too short distal superficial tendon often leads to hyperextension deformity after proximal interphalangeal joint surgery. After superficial tendon repair, deep tendon repair. No matter what method is used, the suture depth is kept at half of the metacarpal side and the knot is buried in the tendon. The surface is stitched intermittently with 9-0 monofilament nylon thread to make it smooth. Tendon sheath is also carefully sutured. After taking out the injection needle, the wrist is bent 30 degrees, and then the finger joints are gently extended and flexed to see if the sutured tendon can be repaired freely through the tendon sheath. Keep the wrist and fingers in position, and don't let the suture leave the tendon. Repair the nerve and suture the skin, put a collar hook on the nail and fix it with Kleinert splint.
If the tendon sheath rupture cannot be repaired, some people use autologous or heterogeneous biomaterials or synthetic materials to repair it, with different effects; This part of tendon sheath can also be cut off. Generally speaking, A2 and A4 annular ligaments should be partially preserved to retain their pulley function. If the injury is at the proximal end of zone II, pulley A 1 will move away without hindrance, just like zone III moves forward.
Zone ⅲ: tendon and common digital nerve can be repaired easily with good effect. The suture is wrapped with vermiform muscle to prevent adhesion.
Ⅳ: The tendon is in carpal tunnel, where * * * passes through 9 tendons and median nerve. Make a Z-shaped incision in the skin, cut the transverse carpal ligament from one end, repair the flexor digitorum profundus tendon and flexor pollicis longus tendon, and cut off a section of flexor digitorum superficialis tendon at the distal and proximal ends to prevent adhesion. If only the superficial tendon is broken, it will be completely repaired, and the median nerve will be sutured without suturing the transverse carpal ligament, and no bowstring will be formed.
Zone ⅴ: The tendon starts from the carpal tunnel, and there is peritendinous tissue around it. All fractures are repaired. If median nerve and ulnar nerve are damaged, they should be repaired together. Do controlled activities after operation.
3. Tendon repair in each district
Using (1) zone I tendon to repair the injury of flexor digitorum profundus tendon in zone I, because there are tendon buckles and vermiform muscles at the proximal end of the fracture, the retraction distance will not be too great. ① Direct suture of the broken tendon or tendon advancement near the broken tendon: The proximal end of flexor profundus tendon is long enough, and the distal end is longer than 1cm, so the broken tendon can be directly sutured. If the distal end is shorter than 1cm, the distal residual tendon can be removed, and the proximal end can be moved forward to rebuild the anchorage. If the proximal end retracts more, the deep tendon can no longer pass through the bifurcation of the flexor digitorum superficialis tendon, or it can be moved forward and sutured with the distal end of the flexor digitorum profundus tendon. After the tendon broken end moves forward, the extension of the injured finger in the early stage may be limited by excessive tension, which can be corrected after proper functional exercise. ② Tendon fixation: The distal end of the flexor digitorum profundus tendon was longer than 65438±0cm after its zone I rupture, but the proximal end could not be sutured directly due to excessive retraction. In the case of good function of flexor digitorum superficialis tendon, tendon fixation can be used. That is, the distal end is fixed on the middle phalanx, so that the distal interphalangeal joint is in a functional position, which is convenient for kneading and stability. ③ Fusion of distal interphalangeal joint: Functional interphalangeal joint fusion is feasible when the proximal end of flexor digitorum profundus tendon has been shortened or defective, the function of flexor digitorum superficialis tendon is normal, the passive motion of distal interphalangeal joint is poor, or the interphalangeal joint is also damaged. This method has a reliable effect on restoring the pinching function of injured fingers.
(2) zone Ⅱ tendon repair: zone Ⅱ flexor digitorum superficialis tendon injury does not need to be repaired, but flexor digitorum profundus tendon can compensate for most functions. The injury of flexor digitorum profundus tendon refers to the normal function of flexor digitorum superficialis tendon and the feasibility of distal interphalangeal joint fusion or tendon fixation. If both flexor digitorum profundus tendon and flexor digitorum superficialis tendon are broken, free tendon transplantation or tendon transfer should be carried out to rebuild the function of flexor digitorum profundus tendon.
(3) It takes a short time to repair the tendon injury, and its proximal end retracts to the palm or wrist, and both the deep and superficial flexors can be directly sutured. For a long time, simple flexor digitorum superficialis tendon injury may not be repaired if it cannot be sutured directly. When flexor digitorum profundus is injured or both flexor digitorum superficialis and flexor digitorum profundus are injured at the same time, it is feasible to reconstruct the function of flexor digitorum profundus with free tendon transplantation. When flexor digitorum superficialis and flexor digitorum profundus are injured in different planes, the proximal long tendon can be sutured with the distal flexor digitorum profundus to restore the function of flexor digitorum profundus.
(4) There are many carpal tunnel tendons repaired by zone ⅳ tendons, mainly flexor digitorum profundus and flexor pollicis longus. When free tendon transplantation is needed, the tendon suture should be located in zone ⅲ and ⅴ.
(5) Repair the damaged tendon in the ⅴ area. If there is no defect, it can be directly sutured to repair the flexor digitorum superficialis and flexor digitorum profundus, flexor pollicis longus and flexor carpi respectively. When the tendon rupture is not at the same level, and each tendon cannot be directly sutured due to shortening or defect, the proximal long tendon can be transferred to the distal end of the flexor digitorum profundus tendon.
(6) Repair the injury of flexor pollicis longus tendon In any area with flexor pollicis longus tendon, the broken end should be sutured directly if it is not shortened. Slight shortening of tendon or muscle can be overcome by wrist flexion, and the hand can be restored to normal sliding range through functional exercise after operation. The suture joint of tendon should avoid metacarpophalangeal joint and wrist joint, otherwise adhesion will easily occur. Tendon defect can be repaired by tendon lengthening, transplantation and displacement. When the above methods are unconditionally implemented, tendon fixation or joint fusion of interphalangeal joints is feasible. ① Lengthening of flexor tendon: Flexor pollicis longus tendon is a monophyletic muscle, and the muscle side tendon is longer. It is feasible to extend the tendon in a "Z" shape and directly suture the broken end or reconstruct the tendon stop. ② transposition of flexor digitorum superficialis tendon: flexor digitorum superficialis tendon and flexor pollicis longus tendon are synergistic muscles. The flexor digitorum superficialis tendon was cut from the proximal edge of the short tendon group, extracted from the proximal end of the transverse carpal ligament, and transferred to the flexor pollicis longus tendon through the carpal tunnel.
4. Pulley reconstruction
After tendon sheath injury, if pulley A2 and pulley A4 still exist, finger function can be basically guaranteed. When these two annular ligaments are destroyed, the flexor tendon will be bowstring-shaped, and the function of the flexor will be greatly affected. If necessary, it can be reconstructed in the second-stage tendon repair.
The material of pulley reconstruction can be the split of palmaris longus tendon or other tendons, and the soft tissue can be separated from the phalanx and extensor tendon on this side until it can be connected with both sides. In hand surgical instruments, the head of pulley clamp is a hook with a semi-circular arc, which is convenient for passive separation of tissues. Pull the tendon around the opposite side, with the side with peritendinous tissue facing the center, tighten the suture, and turn the suture to the extensor dorsi tendon.
5. Free tendon transplantation
Free tendon transplantation is suitable for repairing tendon defects in various areas of the hand. But it is more used to repair tendon defects in finger tendon sheath.
6. Free donor tendon
Palmaris longus tendon, extensor digitorum longus tendon, plantar tendon, extensor digitorum proper tendon and flexor digitorum superficialis tendon can all be used as graft tendons. The palmaris longus tendon is flat, and the longest is 15cm, which is the first choice for tendon transplantation. The extensor digitorum longus tendon is long and flat, and there are many tendon joints between tendons, so the extensor digitorum longus tendon from the second toe to the third toe is often cut off. Plantar tendon is the longest tendon in the whole body, twice as long as palmaris longus tendon, and the existence rate of this tendon is 93%. Because it is not easy to check whether the tendon is missing before operation, and it is deep and difficult to cut off, so few people use it now. The extensor digitorum proprum tendon is rarely used for free tendon transplantation, and its tendon is short, which can generally be cut off by 8cm. The flexor digitorum superficialis tendon is thick and easy to adhere after transplantation, so it is rarely used.
7. Tension regulation of transplanted tendon
The tension of transplanted tendon is too high, and the finger extension is limited; If the tension is small, the finger flexion is not complete. Proper tendon tension regulation is an important factor for tendon transplantation to achieve good function. Adjust the tendon tension with the rest position of adjacent fingers as reference. After tendon transplantation, the position of the affected finger should be slightly larger than the other adjacent fingers.
If the proximal tendon adheres near the original wound, or the injury time is short, and the muscle tension of the severed finger has no obvious change, the flexion adjustment of the transplanted tendon finger can be consistent with that of the adjacent finger at rest. If the injury lasts for a long time, muscle contracture occurs, and the muscle tension is high when pulling the broken end, the tension of tendon transplantation should be relaxed appropriately, that is, after tendon suture, the injured finger is slightly straighter than the adjacent finger in the rest position, so as to avoid the injured finger from being completely straightened after operation. When muscle atrophy is useless, relax the muscle tension when pulling the tendon, and the tension is slightly tight when transplanting the tendon to avoid finger flexion after operation, and the strength is weak.
8. Staged flexor tendon surgery
If the blood circulation of fingers is poor, there are many scars on injured fingers or it is not conducive to one-stage free tendon transplantation, staged tendon transplantation can be done.
(1) In the first stage of operation, silicone rubber strips, a tendon substitute, were implanted in the tendon to be transplanted. The distal end is fixed at the base of phalanx, and the proximal end is placed in the tissue of palm or forearm. Finger passive flexion and extension after wound healing. Pseudotendinous sheath gradually formed around the silicone rubber strip.
(2) Two months after the silicone rubber strip was placed in the second operation, the implant was taken out and the tendon was transplanted in the false sheath.
9. Rehabilitation after flexor tendon repair
Adhesion is easy to occur after flexor tendon repair, and adhesion is the most important complication affecting function, followed by finger joint stiffness. The best way to avoid adhesion and joint stiffness is exercise. So far, there is no suture material and method that allows patients to bend their fingers as soon as possible without causing fractures. At present, there are various drugs and membranes to prevent adhesion, but the possibility of preventing adhesion and other complications is not enough to make various methods widely popularized. The more useful methods at home and abroad are controlled autonomous activity (Kleinert method) and continuous passive activity, or a combination of the two.
Kleinert restrictive dynamic splint method: after operation, the wrist joint was fixed at 45 degrees and the metacarpophalangeal joint was fixed at 60 degrees with plaster splint, and the back of splint was longer than the fingertip. A collar hook and a rubber band were attached to the nail with 502. A safety pin is tied to the wrist bandage, and the other end of the rubber band is hung. Under its elasticity, the affected finger remained in passive flexion position, and the finger was actively extended from the next day, 50 times per hour. The interphalangeal joint flexes passively, each joint flexes independently, and the joint flexes 5 times per hour. Due to the limitation of dorsal plaster, the repaired flexor tendon slides in the sheath and will not be pulled apart under tension. The range and frequency of exercise are adjusted according to the severity of injury and the patient's tolerance to pain. At the fourth week, if the proximal interphalangeal joint is under-extended by more than 20 degrees, it is fastened with an aluminum splint with sponge pad at night to fix it in a straight position. In the fifth week, the splint was removed for 2 hours every day, and 10 wrist flexion and extension and 10 finger comprehensive flexion and extension (40 ~ 60) were performed. In the sixth week, do the whole flexion and extension exercise. In the seventh week, the dorsal splint was removed, and the resistance joint activity was gradually carried out until 12 weeks. Physical therapy is essential during this period.
Continuous passive exercise, there is a special CPM exerciser on the market, which was originally equipped with type I, slowly pulling the fingers to stretch and flex, and keeping the wrist flexion. Four weeks later, type ⅱ was installed, and the extension and flexion of fingers and wrists were coordinated. Domestic companies are in the stage of trial production and trial operation, lacking mature experience.
Rehabilitation medicine is in the initial stage in China, and most hospitals and centers lack the formal guidance of professional physiotherapists, which greatly reduces the effect of flexor tendon surgery.
10. Flexor tendon release
In the era of exogenous healing theory, tendon healing must persist. Under the current surgical methods and routine treatment of postoperative rehabilitation, adhesion is greatly reduced and alleviated after tendon repair. However, there are still 15% ~ 4 1% patients from different authors who need secondary release. Whether tendon release is needed and can get good results needs detailed examination by experienced experts before deciding. Blind exploration, sometimes due to excessive dissection, tendon ischemia and necrosis, spontaneous rupture during exercise, sometimes aggravated trauma and heavier adhesion.
The time of tendon release should be after tendon healing, wound softening, adhesion and scar remodeling by physical therapy. For ankylosing joints, tendon release has no effect; If the joint freezes, it must be done when the joint resumes a wide range of activities. It is generally believed that tendon repair should be released 3 months after operation and tendon transplantation should be released 6 months after operation.
Tendon release requires the cooperation of patients, and local anesthesia plus intravenous anesthesia can be used. The operation must be carried out in the state of blood drawing. Make a zigzag incision on your finger and remove all adhesions in a programmed way. Keep the blood supply, keep the pulley, and at least keep the A2 and A4 annular ligaments. After modification, the function of pulley will be reduced. If the adhesion between the superficial flexor tendon and the deep flexor tendon is serious, and both of them can move effectively or may be adhered again, the superficial tendon should be removed and the deep tendon should be preserved. Sometimes the superficial tendon slides well, and the deep tendon is hard to slide because of its heavy adhesion. Therefore, tendon fixation or fusion of distal interphalangeal joint is very important for functional recovery.
The application research of drugs and the research of placing biofilm or synthetic spacer to prevent re-adhesion have emerged one after another, but they have not been recognized by the public.