Tendon lacerations in the hand are common. Primary tendon repair follows the principles of tendon repair that have evolved to today’s debates on repair techniques, core suture number, and early mobilization (1,2). However, primary end-to-end repair is occasionally not possible and tendon grafting is needed. Alternatively, the desired outcome of the primary repair is unacceptable, and secondary procedures are required to restore function. The secondary procedures may include tenolysis, tendon transfer, tendon grafting (single- and two-stage approaches), and pulley reconstruction. Tenolysis alone to restore function requires and intact tendon and pulley system. Intercalary tendon grafting is needed when the substance of the tendon is absent. Lexer reported on the first series of flexor tendon graft use in the hand in 1912 (3). In 1963, Basset and Carroll described secondary reconstruction of tendons using silicone implants. Later in 1971, Hunter expanded upon the staged technique of flexor tendon reconstruction (4).

Intercalary tendon grafting and pulley reconstruction are discussed in detail in the pages that follow.

Tenolysis procedures are occasionally required to release adherent tendons from the bone or surrounding soft tissue. The fingers usually have good passive motion but poor active motion. Periarticular contractures may also contribute to poor motion at the metacarpal (MP) or interphalangeal (IP)
joints (proximal interphalangeal, PIP, and distal phalangeal, DIP). Complete release of all offending restrictive soft tissue fibrosis will aid in the postoperative active and passive range of motion (4,5,6,7,8). The timing of tenolysis after primary repair, or reconstructive grafting, has been controversial. Most authors recommend waiting 3 months after the initial surgery and when therapy plateaus before embarking upon tenolysis (2,6,8). Prior to this tenolysis may endanger nutritional supply and increase risk of rupture (8).

Intercalary tendon grafting can be divided up into two groups: single stage, which is generally considered acute (primary), and two stage, which is delayed (secondary) (4). The indications for acute single-stage free tendon graft are limited (4) (Table 16-1). Outside of these narrow parameters for acute single-stage graft repair, two-stage tendon grafting is performed. Boyes provided a preoperative injury classification system meant to aid in decision making for primary or secondary tendon grafting (8,9,10) (Table 16-2). Outside of Boyes’ level 1, most tendon grafting (Boyes’ levels 2 to 5) will need a staged reconstruction. In general terms, most surgeons use the criteria in Table 16-3 for their indications for staged tendon grafting.

Contraindications to tendon grafting are included in Table 16-4 (2,3,4). In an attempt to salvage useful finger function in more significantly damaged fingers (Boyes’ grades 2 to 5), two-stage reconstruction should be pursued. Also, if the pulley systems require reconstruction, single-stage reconstruction should be abandoned, and efforts turned to two-stage reconstruction (2). With all of this information in mind, a well-informed consent is fundamental. Each patient needs to understand that an intraoperative evaluation of the tendons during tenolysis procedures, primary tendon repair or grafting, or joint releases may require a staged reconstruction to provide the optimum result.