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Use of Silicone Tubes as Antiadhesion Devices in a Modified Two-Stage Flexor Tendon Reconstruction in Zone II: A Retrospective Study

Published:February 28, 2023DOI:


      This study aimed to assess the outcome of a modified two-stage flexor tendon reconstruction using silicone tubes as antiadhesion devices while performing simultaneous tendon grafting.


      From April 2008 to October 2019, 16 patients (21 fingers) with zone II flexor tendon injuries, who sustained failed tendon repair or neglected tendon laceration, were treated by a modified two-stage flexor tendon reconstruction. The first stage of treatment comprised flexor tendon reconstruction with interposition of silicone tubes to minimize fibrosis and adhesion around the tendon graft; the second stage of treatment comprised silicone tube removal under local anesthesia.


      The patient median age was 38 (range, 22–65) years. After a median follow-up period of 14 (range, 12–84) months, the median total active motion (TAM) of fingers was 220° (range, 150–250°). Excellent and good TAM ratings were identified in 71.4%, 76.2%, and 76.2% according to the Strickland, modified Strickland, and American Society for Surgery of the Hand (ASSH) evaluation systems, respectively. At follow-up, complications included superficial infections in two fingers of one patient whose silicone tube was removed 4 weeks postoperatively. The most common complication was a flexion deformity of the proximal interphalangeal joint (four fingers) and/or distal interphalangeal joint (nine fingers). The rate of failed reconstruction was higher in patients with preoperative stiffness and infection.


      Silicone tubes are suitable antiadhesion devices, and the modified two-stage flexor tendon reconstruction technique is an alternative procedure with a shorter rehabilitation period for complicated flexor tendon injury, compared with current popular reconstructions. Preoperative stiffness and postoperative infection may compromise the final clinical outcome.

      Type of study/level of evidence

      Therapeutic IV.

      Key Words

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        • Hill C.
        • Riaz M.
        • Mozzam A.
        • Brennen M.D.
        A regional audit of hand and wrist injuries. A study of 4873 injuries.
        J Hand Surg Br. 1998; 23: 196-200
        • de Jong J.P.
        • Nguyen J.T.
        • Sonnema A.J.
        • Nguyen E.C.
        • Amadio P.C.
        • Moran S.L.
        The incidence of acute traumatic tendon injuries in the hand and wrist: a 10-year population-based study.
        Clin Orthop Surg. 2014; 6: 196-202
        • Freilich A.M.
        • Chhabra A.B.
        Secondary flexor tendon reconstruction, a review.
        J Hand Surg Am. 2007; 32: 1436-1442
        • Dy C.J.
        • Hernandez-Soria A.
        • Ma Y.
        • Roberts T.R.
        • Daluiski A.
        Complications after flexor tendon repair: a systematic review and meta-analysis.
        J Hand Surg Am. 2012; 37: 543-551.e1
        • Luo J.
        • Mass D.P.
        • Phillips C.S.
        • He T.C.
        The future of flexor tendon surgery.
        Hand Clin. 2005; 21: 267-273
        • Kim H.M.
        • Nelson G.
        • Thomopoulos S.
        • Silva M.J.
        • Das R.
        • Gelberman R.H.
        Technical and biological modifications for enhanced flexor tendon repair.
        J Hand Surg Am. 2010; 35: 1031-1037
        • Boyes J.H.
        Flexor-tendon grafts in the fingers and thumb; an evaluation of end results.
        J Bone Joint Surg Am. 1950; 32: 489-499
        • Bassett A.L.
        • Carroll R.F.
        Formation of tendon sheaths by silicone rod implants. Proceedings of the American Society for Surgery of the Hand.
        J Bone Joint Surg. 1963; 45A: 884-885
        • Hunter J.M.
        • Salisbury R.E.
        Flexor-tendon reconstruction in severely damaged hands. A two-stage procedure using a silicone-dacron reinforced gliding prosthesis prior to tendon grafting.
        J Bone Joint Surg Am. 1971; 53: 829-858
        • Battiston B.
        • Triolo P.F.
        • Bernardi A.
        • Artiaco S.
        • Tos P.
        Secondary repair of flexor tendon injuries.
        Injury. 2013; 44: 340-345
        • Meier Burgisser G.
        • Buschmann J.
        History and performance of implant materials applied as peritendinous antiadhesives.
        J Biomed Mater Res B Appl Biomater. 2015; 103: 212-228
        • Beaton D.E.
        • Wright J.G.
        • Katz J.N.
        Upper Extremity Collaborative Group. Development of the QuickDASH: comparison of three item-reduction approaches.
        J Bone Joint Surg Am. 2005; 87: 1038-1046
        • Kleinert H.E.
        • Bennett J.B.
        Digital pulley reconstruction employing the always present rim of the previous pulley.
        J Hand Surg Am. 1978; 3: 297-298
        • Leddy J.P.
        Avulsions of the flexor digitorum profundus.
        Hand Clin. 1985; 1: 77-83
        • Kang N.
        • Marsh D.
        • Dewar D.
        The morbidity of the button-over-nail technique for zone 1 flexor tendon repairs: Should we still be using this technique?.
        J Hand Surg Eur. 2008; 33: 566-570
        • Tripathi A.K.
        • Mee S.N.
        • Martin D.L.
        • Katsarma E.
        The “transverse intraosseous loop technique” (TILT) to re-insert flexor tendons in zone 1.
        J Hand Surg Eur. 2009; 34: 85-89
        • Sun S.
        • Ding Y.
        • Ma B.
        • Zhou Y.
        Two-stage flexor tendon reconstruction in zone II using Hunter’s technique.
        Orthopedics. 2010; 33: 880
        • Pulvertaft R.G.
        Suture materials and tendon junctures.
        Am J Surg. 1965; 109: 346-352
        • Koopman J.E.
        • Hundepoo C.A.
        • Duraku L.S.
        • Kreulen M.
        • Zuidam J.M.
        Biomechanical study comparing Pulvertaft, double side-to-side, and locking side-to-side tendon suture techniques.
        J Hand Surg Am. 2021; 46: 246.e1-246.e7
        • Fuchs S.P.
        • Walbeehm E.T.
        • Hovius S.E.
        Biomechanical evaluation of the Pulvertaft versus the ‘wrap around’ tendon suture technique.
        J Hand Surg Eur. 2011; 36: 461-466
        • Groth G.N.
        Current practice patterns of flexor tendon rehabilitation.
        J Hand Ther. 2005; 18: 169-174
        • Sueoka S.S.
        • Lastayo P.C.
        Zone II flexor tendon rehabilitation: a proposed algorithm.
        J Hand Ther. 2008; 21: 410-413
        • Crosby C.A.
        • Wehbe M.A.
        • Mawr B.
        Hand strength: normative values.
        J Hand Surg Am. 1994; 19: 665-670
        • Hosokawa T.
        • Tajika T.
        • Suto M.
        • Chikuda H.
        Relationship between hand dominance and treatment outcomes for distal radius fractures in the elderly in the short-term.
        J Hand Surg Glob Online. 2020; 2: 212-216
        • Kleinert H.E.
        • Verdan C.
        Report of the Committee on Tendon Injuries.
        J Hand Surg Am. 1983; 8: 794-798
        • Strickland J.W.
        • Glogovac S.V.
        Digital function following flexor tendon repair in zone II: a comparison of immobilization and controlled passive motion techniques.
        J Hand Surg Am. 1980; 5: 537-543
        • Leversedge F.J.
        • Zelouf D.
        • Williams C.
        • Gelberman R.H.
        • Seiler III, J.G.
        Flexor tendon grafting to the hand: an assessment of the intrasynovial donor tendon-A preliminary single-cohort study.
        J Hand Surg Am. 2000; 25: 721-730
        • Samora J.B.
        • Klinefelter R.D.
        Flexor tendon reconstruction.
        J Am Acad Orthop Surg. 2016; 24: 28-36
        • Zhao C.
        • Ozasa Y.
        • Reisdorf R.L.
        • et al.
        CORR ® ORS Richard A. Brand Award for Outstanding Orthopaedic Research: engineering flexor tendon repair with lubricant, cells, and cytokines in a canine model.
        Clin Orthop Relat Res. 2014; 472: 2569-2578
        • Zhao C.
        • Sun Y.L.
        • Kirk R.L.
        • et al.
        Effects of a lubricin-containing compound on the results of flexor tendon repair in a canine model in vivo.
        J Bone Joint Surg Am. 2010; 92: 1453-1461
        • Majewski M.
        • Betz O.
        • Ochsner P.E.
        • Liu F.
        • Porter R.M.
        • Evans C.H.
        Ex vivo adenoviral transfer of bone morphogenetic protein 12 (BMP-12) cDNA improves Achilles tendon healing in a rat model.
        Gene Ther. 2008; 15: 1139-1146
        • Zhou H.
        • Lu H.
        Advances in the development of anti-adhesive biomaterials for tendon repair treatment.
        Tissue Eng Regen Med. 2021; 18: 1-14
        • Wehbé M.A.
        • Mawr B.
        • Hunter J.M.
        • Schneider L.H.
        • Goodwyn B.L.
        Two-stage flexor-tendon reconstruction. Ten-year experience.
        J Bone Joint Surg Am. 1986; 68: 752-763
        • Amadio P.C.
        • Wood M.B.
        • Cooney III, W.P.
        • Bogard S.D.
        Staged flexor tendon reconstruction in the fingers and hand.
        J Hand Surg Am. 1988; 13: 559-562
        • Finsen V.
        Two-stage grafting of digital flexor tendon: a review of 43 patients after 3 to 15 years.
        Scand J Plast Reconstr Surg Hand Surg. 2003; 37: 159-162
        • Beris A.E.
        • Darlis N.A.
        • Korompilias A.V.
        • Vekris M.D.
        • Mitsionis G.I.
        • Soucacos P.N.
        Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft.
        J Hand Surg Am. 2003; 28: 652-660
        • Kessler F.B.
        Use of a pedicled tendon transfer with a silicone rod in complicated secondary flexor tendon repairs.
        Plast Reconstr Surg. 1972; 49: 439-443
        • Paneva-Holevich E.
        Two-stage tenoplasty in injury of the flexor tendons of the hand.
        J Bone Joint Surg Am. 1969; 51: 21-32
        • Abrahamsson S.-O.
        • Gelberman R.H.
        • Lohmander S.L.
        Variations in cellular proliferation and matrix synthesis in intrasynovial and extrasynovial tendons: an in vitro study in dogs.
        J Hand Surg Am. 1994; 19: 259-265