A tendon cut today can usually be sewn back together. One cut months ago has retracted, the ends have degenerated and the tunnel it ran through has scarred shut. That tendon has to be rebuilt rather than repaired.
Tendon reconstruction replaces a tendon that can no longer be directly repaired, using a graft taken from elsewhere in the body. It is used for injuries presenting late, for repairs that have failed, and where the tendon bed has scarred. In a scarred finger it is done in two stages: a silicone rod first to create a smooth tunnel, then the graft three months later.
A freshly cut tendon has two healthy ends a short distance apart, and sewing them together works well. Time changes all of that. The muscle pulls the proximal end back up the forearm and gradually shortens, so the ends can no longer meet. The cut ends themselves soften and fray. And the fibrous tunnel the tendon glided through fills with scar, so even a perfect repair would seize.
Reconstruction addresses all three. A length of expendable tendon is taken from elsewhere, commonly palmaris longus at the wrist or a toe extensor, and used to bridge from healthy tendon in the forearm to the bone at the fingertip.
Whether that is done in one stage or two depends on the tunnel. If the sheath is supple and the finger moves passively, a graft can go straight in. If the tunnel is scarred, or the joints are stiff, putting a graft into that environment simply produces a scarred graft. There, a silicone rod is placed first. The body forms a smooth lining around it over about three months, and at the second operation the rod is withdrawn and the graft drawn through the tunnel it created.
Passive movement is the gatekeeper for all of it. A finger that cannot be bent passively will not bend after reconstruction either, because the problem is the joint rather than the tendon. Therapy comes before surgery in that situation, not after.
The commitment required afterwards is as important as the anatomy. This operation fails quietly in patients who cannot attend therapy.
The joints are tested. If the finger will not bend passively, therapy comes first and surgery waits.
A supple sheath takes a graft directly. A scarred one gets a silicone rod first.
Scar is cleared from the tunnel, pulleys are reconstructed where needed, and a silicone rod is placed to hold the space.
A smooth lining forms around the rod while therapy maintains passive movement.
An expendable tendon is harvested, attached to bone at the fingertip, drawn through the tunnel and set at the correct tension in the forearm.
Too loose and the finger will not bend; too tight and it will not straighten. This judgement determines the result more than any other step.
Protective splint. Controlled movement begins within days under a hand therapist, because complete immobilisation guarantees adhesions.
Range of movement increases under supervision. No gripping or lifting; the graft is at its weakest and rupture risk is highest now.
Strengthening begins gradually. Splint is weaned. Most functional gain happens in this period.
Continued strengthening and scar management. Tenolysis to free adhesions is considered from around six months if movement has plateaued.
A good result is a finger that bends usefully and contributes to grip, not one that matches the other side. Some loss of the final degrees of bend and of full straightening is usual. Results are considerably better in a supple finger with a healthy bed than in a stiff, scarred one, and better in a single finger than where several are involved. Rupture of the graft is a recognised complication, most often in the first six weeks, and a further operation to free adhesions is needed in a proportion of patients.
Adhesions and rupture are the two that dominate, and both are influenced by how therapy is followed.
Hand therapy here is not rehabilitation after the operation. It is part of the operation.
Direct repair may no longer be possible, but reconstruction with a graft frequently is, even years later, provided the joints are supple and sensation is reasonable.
A good result is a useful finger that contributes to grip. Some loss of the last degrees of bend and straightening is usual.
Complete rest is what causes adhesions. Controlled movement under a therapist, started early, is what keeps the graft gliding.
Palmaris longus is absent altogether in a significant proportion of people and is not missed when taken. The same is true of the toe extensors used.
Most disappointing tendon results come from operating on a stiff finger or from therapy that did not happen. Getting the joints supple first, and arranging therapy before the date is booked, changes the outcome more than the graft technique does.
Reconstruction after trauma is commonly covered by health insurance and by government schemes. Two stage reconstruction means two admissions and is estimated as a plan rather than a single procedure. Hand therapy is an ongoing cost and is included in the planning. A written estimate follows assessment.
Most come from people told their injury is now too old to repair.
Ask your question →Probably not. Direct repair is no longer possible, but reconstruction with a graft is often still worthwhile, provided the finger can be bent passively and sensation is reasonable. Those two things matter far more than how long ago the injury was.
Because a graft placed into a scarred tunnel simply scars too. A silicone rod placed first lets the body form a smooth lining over about three months, and the graft is then drawn through that. Where the tunnel is already supple, one stage is enough.
No. Palmaris longus is expendable and is completely absent in a substantial proportion of people who never notice. Toe extensor grafts are similarly well tolerated.
It is the difference between a working finger and a stiff one. A technically perfect graft that is not moved early and correctly will scar to everything around it. If regular therapy is not possible, that should be discussed before surgery rather than after.
Then therapy comes first. Reconstruction restores the pulling mechanism; it does not loosen a stiff joint. Operating on a finger that will not bend passively produces a finger that still will not bend.
Seeing patients from across the city and beyond: read about the practice on the plastic surgeon in Surat page, or check what a written estimate covers on the costs and insurance page.
