Vascularised flexor tendon grafts.

In densely scarred digits, tendon reconstruction fails because of paucity of blood supply. This inevitably leads to adhesion formation and failure of gliding. Staged tendon grafting with silicone spaces can improve results but does not ameliorate the essential problem of reduced vascularity and may indeed worsen it. Tendon grafts can be implanted with their own living sheaths as free or pedicled vascularised transfers from the foot or forearm to either extensor or flexor sites in the hand. These mesenteric tendons with their fascial or synovial sheaths intact and vascularised by adjacent vascular pedicles include the extensor hallucis brevis and longus or the extensor digitorum communis on the dorsalis pedis system, the palmaris longus on the radial arterial system, the sublimus tendons of the ring and little fingers on the ulnar arterial system as well as the extensor indicis on the second metacarpal arterial system. These tendon grafts can be inserted into the intact or reconstructed tunnel systems of the digit and repaired proximally and distally to the tendon remnants. Gliding is enhanced although limitations still potentially occur at the proximal tendon junctions.