Flexor tendon injuries in children are associated with a higher risk of delayed diagnosis compared to adults. Flexor tendon grafting can be performed in either one or two-stages. One-stage is indicated where there is a viable bed within intact pulleys. A two-stage reconstruction is reserved for more severe digital injuries. Guidelines remain unclear on when to perform a one versus a two-stage. In addition, the exact age at which children can undergo flexor tendon grafting remains unclear. This retrospective study of one and two-stage tendon grafting was done in the pediatric population to try and answer some questions.
Twenty children were included in the cohort. The mean follow-up was almost 3 years. A variety of fingers were involved and there was a variety different zones of injury. Thirteen children underwent primary repair of the FDP or FPL. The technique described within the article and is similar to the adult counterpart. The authors choose to do a one-stage grafting for a badly scared digit without neurovascular injury and intact pulleys. Scaring within the pulley sheath and excessive pulley system damage required a two-stage technique. A standard silicone rod was used followed by tendon grafting two months later. Similar postoperative protocol was used in all patients. Immobilization was performed for one month.
The median Strickland index was 70 (range 0 to103) for one-stage grafting and 66 (range 55 to114) for two-stage grafting. No significant difference was observed between the median age at surgery and Strickland index for either group.
The series is similar to other small series regarding tendon grafting in children. The choice between the one and two-stage is injury and surgeon dependant. The children who underwent two-stage tendon grafting did not do as well as the one-stage tendon grafting. However, the status of the digit dictated whether or whether not one or two-stage operation was performed. Therefore, the extent of the initial injury and subsequent condition of the digit is probably the prime outcome determinant, and not necessarily the surgery itself. The small number of children makes global conclusions impossible from this series.