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Bertolini et al. Plast Aesthet Res 2023;10:34 https://dx.doi.org/10.20517/2347-9264.2022.121 Page 7 of 25

Figure 2. Two pulley reconstructive techniques are shown. On the left, there is Okutsu’s triple-loop reconstruction; on the right, you can
observe Klinert and Weilby’s bone encircling. The tendon graft used for pulley reconstruction is shown in green.

Figure 3. Okutsu’s pulley reconstructive system performed during a CadaverLab for educational purposes.

of reconstructions. In these cases, a surgical release of the joint may be indicated when physical therapy
fails [30,55] . Excessive tensioning or extreme shortness of the graft can result in a quadriga effect with reduced
proper motility of adjacent fingers. The most affected by this complication are III-IV and V fingers, which
can tolerate an advancement of up to 1 cm. Instead, an extremely loose graft tension or its excessive length
can result in lumbrical plus deformities. The latter consists of the paradoxical extension of the finger when
the attempt is to flex it; this is caused by premature contracture of the lumbrical muscles before the FDP can
flex the DIP .
[56]

An uncommon complication is silicone rod synovitis, which leads to a poor outcome because it impairs the
proper gliding canal formation [1,21] . Implant infection is also described: it requires implant removal and
antibiotic therapy, and results in delayed reconstruction .
[55]
The use of WALANT is increasing in hand surgery and tendon repair. Local anesthesia offers significant
advantages in this setting: the possibility of intraoperative mobilization allows simultaneous assessment of
tendon gliding, graft tension, and suture strength [57,58] .