title: Primary pulley enlargement in zone 2 by incision and repair with an extensor retinaculum graft.
abstract: OBJECTIVE
  This retrospective study documents the results of primary enlargement of tendon sheath pulleys by incision and extensor retinaculum graft repair during flexor tendon repairs in zone 2 in 9 fingers.
  
  
  METHODS
  The entire A2 or A4 pulley was enlarged by complete incision and repaired with an interposed extensor retinaculum graft at the time of primary flexor tendon repair in a total of 9 fingers in 7 patients, ages 15 to 54 years. The indication for primary pulley enlargement was failure of the tendon repair to glide smoothly and without snagging through the normally tight-fitting pulley system. In no case was more than one major pulley enlarged, and the entire A1 pulley was never enlarged. The zone 2 tendon repairs were done using a 2-strand modified Kessler 3-0 core suture and a 6-0 nylon running circumferential suture. The follow-up averaged 3.6 years. Interphalangeal total active motion and Strickland-Glogovac grade in patients with adequate follow-up of more than 6 months or obtaining full range of motion were obtained from a retrospective chart review.
  
  
  RESULTS
  Interphalangeal total active motion averaged 127 degrees and the scores according to the Strickland-Glogovac system were excellent for 3, good for 2, fair for 2, and poor for 2. There were no tendon ruptures. Two fingers in one patient required a tenolysis and a third finger had secondary skin scar lengthening. Two fingers had visible and palpable bowstringing when seen at long-term follow-up and there was an average flexion contracture of 21 degrees.
  
  
  CONCLUSIONS
  Primary pulley enlargement using a free graft in zone 2 tendon injuries may achieve the 3 goals of providing a good gliding environment, avoiding triggering, and minimizing bowstringing. These initial clinical outcomes are average for zone 2 tendon repair, but encouraging. Further research and refinement in surgical technique and rehabilitation method are needed to minimize flexion contractures.
authors.affiliation: Bone and Joint Research Center, Department of Orthopaedic Surgery, University of North Texas Health Science Center, Fort Worth, TX, USA.
authors.forename: Robert E
authors.initials: RE
authors.lastname: Bunata
mesh_terms: D000293:Adolescent; D000328:Adult; D005260:Female; D005383:Finger Injuries / Q000601:surgery*; D006801:Humans; D008023:Ligaments, Articular / Q000637:transplantation; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000379:methods; D013708:Tendon Injuries / Q000601:surgery*; D013710:Tendons / Q000601:surgery*; D055815:Young Adult