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Page 4 of 25 Bertolini et al. Plast Aesthet Res 2023;10:34 https://dx.doi.org/10.20517/2347-9264.2022.121

Another potential graft is the long toe extensor tendon, the harvesting of which, however, may be difficult
[18]
due to the presence of the extensor retinacula and may result in donor site weakness .
Traditionally, the graft is first fixed distally, either at the level of the residual flexor digitorum profundus
(FDP) stump or at the distal phalanx. Proper tensioning must be established and connected to the proximal
stump with a Pulvertaft suture. There are different fixation methods to the distal phalanx; after performing
the core suture with Prolene or FiberWire (diameter 3-0) in the graft, this is either stabilized by pull-out
technique, or fixed by suture anchor, which can be bioabsorbable or metallic; this reduces the risk of
autolysis associated with the former. Pull-out fixation techniques are preferred in elderly patients or in those
with poor bone quality [19,20] .

Two-stage reconstruction
When the flexor tendon sheath is highly compromised and the pulley system is no longer valid, a two-stage
flexor tendon reconstruction is recommended. Introducing a tendon graft into an injured flexor tendon
sheath carries a significant risk of adhesions and postoperative stiffness [4,21] .

The original technique introduced by Hunter and Salisbury involves the insertion of a silicone rod into the
tendon sheath that induces the formation of a lubricated pseudomembrane coated with mesothelial cells
that later allows tendon gliding within it [22,23] . The implant can have different lengths and can extend from
the distal phalanx to the palm or the forearm. The diameter of the silicone rod should also be chosen
considering the expected size of the intended tendon graft; generally, a diameter of 3 mm is indicated for a
[8]
palmaris longus. The implant should not be too tight to ensure gliding . The rod should be attached distally
to the residual FDP or secured to the distal phalanx (i.e., with a pull-out technique) [16,24,25] . After a waiting
period of 2-3 months, the second surgical time involves filling the new pseudosheath with the tendon
graft [24,26] . According to some authors, however, this technique included two critical points: the simultaneous
healing of the proximal and distal tenorrhaphy of the graft and the inability to predict the graft size during
[24]
the first surgical time .
Subsequently, the Paneva-Holevich technique was developed, adding tenorrhaphy at the palm level between
the distal stumps of FDP and FDS during the first surgical time. The tendon suture can be performed
according to Kessler or with a fish mouth suture. After 2 to 3 months, the FDS will be released at its tendon
muscle junction, creating a new elongated FDP following the now-healed tenorrhaphy. The new FDP will
cross the carpal tunnel, palm, and flexor sheath until it is anchored distally [25,27,28] .

Kessler later provided further development of these techniques, which is the result of the combination of the
two previously described [Figure 1]. In the first stage, the anastomosis between the FDP and FDS is
performed concurrently with the insertion of the silicone rod. Subsequently, the second stage will be similar
to the technique described by Paneva-Holevich, even though it includes the removal of the implant and the
passage of the graft into the pseudosheath [21,29] . In order to avoid excessive adhesion formation, effective
tenolysis of the FDP extended to the carpal tunnel is strongly recommended to achieve complete intra-
operatively mobility and a better postoperative outcome. The graft is commonly anchored to the silicone
rod distal extremity, which is pulled out by dragging the tendon graft into the new pseudosheath. The
pedicle graft will be stabilized distally by pull-out technique or suture anchors [21,30] . Proper suture tensioning
and tightness will be assessed by the harmonic aspect of the digital cascade, the “squeeze test,” or by active
flexion-extension of the patient in case of surgery under Wide-Awake Local Anesthesia (WALANT) . The
[30]
modified Paneva-Holevich technique has two advantages: first, the anastomosis between the FDS and FDP
at the second stage is almost healed; second, during the first stage, it is possible to choose the appropriate