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Page 2 of 25 Bertolini et al. Plast Aesthet Res 2023;10:34 https://dx.doi.org/10.20517/2347-9264.2022.121

Despite that, tendon losses may occur concurrently with other peculiar circumstances, such as accidental
events, timing and previous failures. In this article, three topics will be discussed: flexor tendon losses,
extensor tendon losses, and the regenerative surgery approach. This analysis will be principally supported
by the evidence of the latest literature.

RECONSTRUSTRUCTION OF FLEXOR TENDON DEFECTS
Significant improvements in primary flexor tendon repair and postoperative rehabilitation have radically
[1-3]
reduced the need for tendon reconstruction in the last few decades .

In the past, flexor tendon injuries in zone II, also known as “no man’s land” because of its complex and
uncertain treatment, were repaired with a tendon graft as the primary reconstruction method. Currently,
tendon reconstruction is reserved for inveterate injuries, primary repair failures and exceptional cases
characterized by considerable loss of substance, as it may happen in crush injuries or following exposed
fractures [2,4,5] .

The purpose of this section is to describe current concepts on flexor tendon reconstruction, which remains
one of the most challenging topics in hand surgery despite significant surgical and rehabilitative
improvements.

Diagnosis and preoperative evaluation
The diagnosis of flexor tendon injury is based on the patient’s medical history and a thorough clinical
evaluation; then, a standard radiographic investigation allows the exclusion of any associated bone lesions.
Second-level imaging is usually not necessary.

Through clinical evaluation, potential signs of tendon injury such as loss of the digital flexor cascade, loss of
tone, or loss of active flexion of the joint to which the tendon under examination is deputed should be
investigated. Careful preoperative evaluation of the site of injury, any neurovascular injury, flexor digitorum
superficialis (FDS) integrity or adhesion formation, pulley rupture, and joint contracture will permit the
establishment of the most appropriate surgical strategy. The Boyes preoperative classification, whose
[6]
increasing grade is associated with worse prognostic significance [Table 1], is helpful in this context.
Indications
The guidelines for defining the surgical technique to be used in cases of flexor tendon reconstruction are not
[7]
standardized, and a gold standard has not yet been established .

As mentioned before, a careful clinical evaluation should be assessed preoperatively: surgical reconstruction
should be avoided in patients with fixed contractures, joint disruption, hypovascularized fingers, or severe
sensory disturbances .
[7,8]

A single-stage tendon grafting reconstruction may be indicated in patients with delayed presentation and
significant tendon retraction or in patients with loss of tendon substance, who nevertheless still present
poor scar adhesions, good preoperative Range of Motion (ROM), favorable neurovascular condition and
intact tendon sheath.

In case of delayed primary repair, up to 30 days after injury, if tendon shortening causes flexion contracture
and excessive tension force at the suture, 2-3 cm of additional length can be obtained by performing
lengthening at the myotendinous junction, as described by Le Viet .
[9]