The Use of Paratenon, Polyethylene Film, or Silastic Sheeting to ...

908 D. M. LICHTMAN, G. R. MACK, R. I. MACDONALD, S. F. GUNTHER, AND J. N. WILSON
14. SHANDS, A. R.. JR., and RANEY, R. B., SR.: Handbook of Orthopaedic Surgery. Ed. 7. St. Louis, C. V. Mosby, 1967.
15. STAHL, FOLKE: On Lunatomalacia (Kienb#{246}ck’s Disease). A Clinical and Roentgenological Study, Especially on Its Pathogenesis and the Late
Results of Immobilization Treatment. Acta Chir. Scandinavica, Supplementum 126, 1947.
16. STEINDLER, A.: The Traumatic Deformities and Disabilities of the Upper Extremity. Springfield. Illinois, Charles C Thomas, 1946.
17. SWANSON, A. B.: Silicone Rubher Implants for the Replacement ofthe Carpal Scaphoid and Lunate Bones. Orthop. Clin. North America. 1:
299-309, 1970.
18. SWANSON, A. B.: Flexible Implant Resection Arthroplasty in the Hand and Extremities. St. Louis, C. V. Mosby, 1973.
19. TUREK, S. L.: Orthopaedics. Principles and Their Application. Ed. 2. Philadelphia, J. B. Lippincott, 1967.
The Use of Paratenon, Polyethylene Film, or
Silastic Sheeting to Prevent
Restricting Adhesions to Tendons in the Hand*
BY HERBERT H. STARK, M.D.t, JOSEPH H. BOYES, M.D.t, LOS ANGELES.
LANNY JOHNSON, M.D.t, EAST LANSING, MICHIGAN,
AND CHARLES R. ASHWORTH, M.D.t, LOS ANGELES, CALWORNIA
ABSTRACT: We treated 132 patients by insertion of
paratenon, polyethylene, or Silastic between a digital
tendon and a bone, ligament, or fixed fascial structure
to prevent adhesions. From 1950 to 1974, autogenous
paratenon was used in thirty patients; from 1956 to
1965, polyethylene film was used in sixty-three pa-
tients; and from 1965 to 1974, Silastic sheeting was
used in thirty-nine patients. By comparing the
preoperative and postoperative measurements of joint
motion and the changes in the distance separating the
pulp of a finger from the palm during fiexion, these pa-
tients were classified as improved, unchanged, or
worse. In some areas the material used appeared to
make little difference, but in other areas one or the
other was superior. Silastic sheeting (non-reinforced)
proved to be the best material for most conditions, but
it should not be employed when the skin is of poor
quality or beneath a pedicle flap, and it should not be
used adjacent to a tendon graft in an area that has re-
covered from an infection Under those circumstances,
paratenon is the preferred material.
During the past twenty-four years, we have tried to
prevent the formation of restricting adhesions by interpos-
ing one of three materials between a scarred tendon and
bone, ligaments, or other fixed structure. We followed 132
patients in whom one of these three materials was used.
Twelve other patients were excluded from this study be-
cause of inadequate follow-up records.
* Read at the Sixth Combined Meeting of the Orthopaedic Associa-
lions of the English-Speaking World, London, England, September 15,
I 976.
1- 2300 South Flower Street, Los Angeles, California 90007.
t 4528 South Hagadorn Road, East Lansing. Michigan 48823.
From 1950 to 1974, we used autogenous paratenon in
thirty patients. Polyethylene film was used in sixty-three
patients operated on from 1956 to 1965. Silastic sheeting
became available in 1965, and since then we have used it
in thirty-nine patients. In most cases, insertion of the in-
terpositional material was just one part of a reconstructive
operation; it was usually combined with other procedures,
such as tenolysis, osteotomy, excision of a scar or bone,
capsulectomy, neurolysis, nerve repair, or shifting of local
skin flaps. Even so, by comparing the preoperative and
postoperative measurements of joint motion and the
changes in the distance separating the pulp of the involved
finger from the palm during flexion, we were able to
classify these patients as improved, unchanged, or worse.
Adhesions between a tendon and surrounding fixed
tissue usually restrict voluntary motion. When such adhe-
sions are long, loose, and elastic, and when they connect a
tendon to mobile tissues such as those in the forearm or
palm, a tendon may still glide a reasonable distance. How-
ever, short and inelastic adhesions that are attached to
fixed tissues tether the tendon and greatly restrict volun-
tary motion of the digit.
Prior attempts to prevent such adhesions have been of
three types. Rods, tubes, or ribbons of inert material have
been inserted to provoke the formation of a pseudosheath
through which a tendon is passed later. Silver 17 tan-
talum 22 stainless steel 15,1820.25.26 plastic, and Silas-
tic 2.7,11.13.14 have been used in this manner. Of these,
Silastic rods have been most successful, if used under the
proper conditions. A second method has been to encircle
the tendon with some substance l,2.912,16.17.21,2729 but re-
gardless of the material used this method has failed, for
scar forms at the ends of these materials and limits gliding
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USE OF PARATENON TO PREVENT RESTRICTING ADHESIONS TO TENDONS IN THE HAND 909
of the tendon 1,2.18 Even membranes with selective per-
meability have failed to prevent restricting adhesions if
wrapped about a tendon A third method has been to in-
sert an interpositional material in a limited area where ten-
don gliding is restricted because of its attachment to a fixed
structure 3.6.24.28 In the past, many materials have been
used in this procedure. Foreign substances have included
vaseline bismuth paste “, cellophane 10.27 Millipore ‘,
Silastic 2.7.13 latex , gelatin foam 21.27 Oxycel cotton 27
celloidin 17 Ivalon 12 and polyethylene film 5,11,20,25
Materials derived from animals that have been used in this
manner include cargile membrane ‘, amniotic mem-
brane , allantoin membrane , sheet catgut ‘, beef
cecum , bovine fibrin film 27 and cortisone acetate 531
Autogenous materials such as fascia “‘, paratenon ,
veins fibrin film27, and tunica vaginalis29 have also
been used.
VOL. 59-A, NO. 7, OCTOBER 1977
Paratenon
Paratenon is a thin, transparent layer of loose, filmy
tissue found covering the deep fascia overlying a muscle
compartment. We obtained the material from the lateral
aspect of the thigh in seventeen patients, from the wrist or
distal part of the forearm in twelve, and from the posterior
aspect of the arm (over the triceps tendon) in one patient.
This delicate tissue must be handled carefully, for it is fri-
able and tears easily. It was fixed in position with fine cat-
gut sutures which were brought out through the skin and
tied (Fig. 1).
The substance was used in thirty patients (Table I).
Twenty had improved motion, five were unchanged, and
five were worse after operation. The minimum period of
FIG. I
Interpositional material is kept in place between a tendon and bone by
fine catgut sutures which are brought out through the skin and tied.
tion.
Site
TABLE I
PARATE NON (THIRTY PATIENTS)
Result
Improved Unchanged Worse Total
Beneath extensor tendons
Wristorhand 4 1 1 6
Metacarpophalangeal I I
joint
Proximal phalanx 4 2 3 9
Total 9 3 4 16
Beneath flexor tendons
Carpal canal 3 3
Palm 2 2
Metacarpophalangeal
joint 2 2
Proximal phalanx 3 2 5
Middle phalanx 1 1
Total II 2 0 13
Special situations
Full-length of flexor
tendon of thumb I I
Total 0 0 1 1
Grand total 20 5 5 30
observation was three months and the maximum was
sixty-two months (average, fifteen months).
Paratenon gave a satisfactory result when used as a
local patch between a flexor or extensor tendon and a
phalanx after tenolysis. It was beneficial when used in the
carpal canal, for it helped prevent restricting adhesions be-
tween the flexor tendons and the floor or roof of the canal.
It was also successful when placed beneath a previously
applied abdominal flap after tenolysis. On one occasion, it
was used to encircle a flexor-tendon graft in a thumb
completely. That patient had less motion after surgery,
presumably because of adhesions.
There were no serious complications in the donor
area. One patient, however, had a collection of serum at
the donor site in the thigh which cleared after one aspira-
Polyethylene Film
Polyethylene film, 0.38 millimeter (0.015 inch) in
thickness, was used in sixty-three patients. This material
also was anchored in place with fine catgut sutures brought
out through the skin. Forty-five of the sixty-three patients
were improved, thirteen were unchanged, and five had less
motion after operation. The average follow-up period was
fourteen months; the longest was sixty months and the
shortest, two months. Of the twenty-one patients in whom
polyethylene was used between an extensor tendon and a
proximal phalanx of a finger or thumb, eighteen were im-
proved, two were unchanged, and one was worse. In six
other patients, polyethylene film was placed beneath the
scarred extensor tendon of a finger after removal of a turret
exostosis 30 All six had had limited flexion preoperatively
and regained excellent finger motion after operation. Of
twelve patients in whom the film was used to separate a
flexor tendon from a proximal phalanx, nine were im-

910 H. H. STARK, J. H. BOYES, LANNY JOHNSON, AND C. R. ASHWORTH
Site
TABLE II
POLYETHYLENE (SIxTY-THREE PATIENTS)
Result
Improved Unchanged Worse Total
Beneath extensor tendons
Wristorhand 2 1 1 4
Metacarpophalangeal
joint 1 I
Proximal phalanx 18 2 1 21
Proximal interphalan-
geal joint 1 1 2
Middle phalanx 3 1 4
Total 25 5 2 32
Beneath flexor tendons
Carpalcanal 2 3 5
Palm 2 1 3
Metacarpophalangeal
joint 1 1
Proximal phalanx 9 3 12
Proximal interphalan-
geal joint 2 2
Middle phalanx 1 1
Total 16 5 3 24
Special situations
Interpositional arthroplasty
of proximal
interphalangeal joint 1 1
Between flexor and cxtensor
tendons and
proximal phalanx 1 1
Pulley lining 2 2
Entire flexor surface
offinger 1 1
Between flexor-tendon
graft and proximal
phalanx 2 2
Total 4 3 0 7
Grand total 45 13 5 63
proved and three were unchanged. Seven of the ten in
whom the film was used on the flexor or extensor surface
of a thumb were improved. Polyethylene film was used on
one occasion in primary treatment after open reduction and
internal fixation of a fractured proximal phalanx. A small
patch of film was placed between the badly damaged flexor
tendon and the bone, and the patient regained excellent
finger motion. The results according to anatomical site are
compared in Table II.
The film was not removed unless it caused a compli-
cation (seven patients), or unless the part was re-explored
for some other reason (twenty-five patients). A smooth,
glistening surface was always found next to the film, and
this area was free of adhesions. There was minimum scar
about the material if it remained fixed in position; if it was
fragmented and loose, however, which was a common
finding in the carpal canal, then the polyethylene was sur-
rounded by dense scar tissue.
Polyethylene film was also used in several special sit-
uations. A patient with scarred flexor tendons and a dam-
aged proximal interphalangeal joint was improved by re-
section of the collateral ligaments and coverage of the ar-
ticular surface of the proximal phalanx with polyethylene
film. In another patient, after tenolysis of both the flexor
and the extensor tendons, the film was inserted between
these tendons and the proximal phalanx. In two patients,
pulleys were reconstructed and lined with polyethylene
after excising the scarred and damaged flexor tendons. At
a second operation, the film was removed and a flexor-
tendon graft was inserted through the new pulleys, now
lined with pseudosynovium. Both patients had a satisfac-
tory result. Two patients were unchanged when the film
was placed between a flexor-tendon graft and a phalanx,
and one was unchanged after it was used between a flexor
tendon and the phalanges along the entire length of the
digit.
There were a few complications after the use of
polyethylene. In one patient, the material interfered with
the blood supply of a local skin flap, which was already
thin and ofpoor quality; this resulted in a small skin blister
which eventually healed. In another patient, when the film
was placed beneath the extensor tendon in the middle
segment of a finger, a tiny area of skin became necrotic
and the film was exposed. After removal of the film,
the skin healed promptly. A third patient had local swell-
ing which cleared spontaneously after three months.
All four patients who had polyethylene film placed under
a previous applied pedicle skin flap had some com-
plication that seemed related to interference with the
blood supply to the flap. In three patients, polyethylene
film was used in an area that had recovered from a previous
infection, and two of these three had less motion after
surgery.
Non-Reinforced Silastic Sheeting
Silastic is a flexible, translucent elastomer of
medical-grade silicone. The physical and chemical prop-
erties of this substance were described by Blocksma and
Braley “. Silastic sheeting 0. 13 millimeter (0.005 inch)
thick was used in thirty-nine patients. The average
follow-up period was fifteen months; the shortest was three
months and the longest, thirty-nine months. The youngest
patient was six years old and the oldest was fifty-eight; the
aVerage age was thirty-three years. Twenty-six patients
had improved motion, eleven were unchanged, and two
were worse after operation.
Like polyethylene, Silastic was most commonly
placed between an extensor tendon and a proximal
phalanx. Of the fifteen patients so treated, ten were im-
proved, four were unchanged, and one had less motion
than before operation. In eleven patients the sheeting was
placed between a flexor tendon and a proximal phalanx. Of
these, six were improved and five were unchanged. Con-
sidering all thirty-nine patients, two had less motion after
operation. In one ofthese the material was placed between
the extensor tendon and the proximal phalanx, and in the
other it was placed between the extensor tendon and a
middle phalanx (Table III).
Although patients seldom had a reaction to Silastic, it
was removed at the time of a second operation on six oc-
casions. A good gliding bed was observed in the area
covered by the material, but there were adhesions between
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Site
USE OF PARATENON TO PREVENT RESTRICTING ADHESIONS TO TENDONS IN THE HAND
TABLE III
SILASTIC (THIRTY-NINE PATIENTS)
H /1
I
I
.. I
H--
FIG. 2-A
.1
Limited flexion of the long finger six months after primary repair of
the profundus tendon in the distal part of the palm.
VOL. 59-A, NO. 7. OCTOBER 1977
Result
Improved Unchanged Worse Total
Beneath extensor tendons
Forearm 1 1
Wrist or hand 2 2
Proximal phalanx I 0 4 1 15
Middle phalanx I 1 1 3
Total 14 5 2 21
Beneath flexor tendons
Forearm 1 1
Carpal canal I 1
Palm I 1
Proximal phalanx 6 5 11
Proximal interphalangeal
joint I I
Total 10 5 0 15
Special situations
Dorsum of hand (at time
of primary treatment) 1 1
Beneath extensor tendon
after curettage and
grafting of enchondroma
of proximal phalanx
of finger 1 1
Arthroplasty of proximal
interphalangeal joint 1 1
Total 2 1 0 3
Grand total 26 1 1 2 39
the tendon and soft tissues proximal and distal to the sheet-
ing. However, these adhesions were usually long enough
so the tendon could glide a reasonable distance. One pa-
tient had a sinus tract and serous drainage from the palm.
After removal of the Silastic four months after insertion,
he had no further drainage or difficulty.
Silastic was used in three special situations. In one
patient, it was placed between an extensor tendon and a
FIG. 2-B
FIG. 2-C
Figs. 2-B and 2-C: Flexion and extension two months after removal of
the flexor superficialis, tenolysis ofthe profundus tendon, and insertion
of Silastic sheeting.
proximal phalanx following curettage and bone-grafting of
an enchondroma. Motion ofthe finger was normal both be-
fore and after surgery. In another patient it was used at the
time of injury , placed between the extensor tendons and
the second and third metacarpals in a severely crushed
hand with metacarpal fractures. This patient regained ex-
cellent motion of all fingers. It was also used successfully
in one patient as an interpositional material after arthro-
plasty of the proximal interphalangeal joint of the ring
finger.
Discussion
In a twenty-four-year period, we used an interposi-
tional material 128 times after tenolysis (Figs. 2-A, 2-B,
and 2-C). During the same period, we performed over 650
tenolyses. These materials, then, were used only when
911

912 H. H. STARK, J. H. BOYES, LANNY JOHNSON, AND C. R. ASHWORTH
FIG. 3-A
Roentgenogram of the proximal phalanx six weeks after an untreated
fracture.
tendons were densely adherent to fixed tissues or bone, or
when we believed that the tendons would readhere if they
were not protected from contacting these scarred areas
(Figs. 3-A through 3-D). Although we cannot compare
these 128 patients with a similar group treated by tenolysis
alone, our experience with tenolysis leads us to believe
that tendons ordinarily readhere to badly scarred areas un-
less they are separated from the scarred bed by some
method. Altogether, ninety-one patients were improved by
tenolysis and use of an interpositional material. We be-
lieve that very few of them would have regained as good
motion had they been treated by tenolysis alone.
The interpositional material should be placed between
the tendon and the scarred bed, and it should extend ap-
proximately one centimeter beyond the scarred area. The
material should only contact one surface of the tendon; the
tendon should not be wrapped or encircled within it, for
this will prevent revascularization ofthe lysed tendon. Our
FIG. 3-B
postoperative regimen was identical to that used for pa-
tients treated by tenolysis. Occasional active motion under
supervision was commenced between the second and
fourth days after operation, but splint protection was con-
tinued for at least three weeks.
Over two-thirds of the patients had improved motion
after surgery, regardless of the interpositional material
used. However, a detailed study of the results allows a
comparison of the merits of autogenous paratenon with
those ofthe two synthetic materials, polyethylene film and
Silastic sheeting. In some situations the material used
made little difference, but in others one or the other was
superior. All three prevented adhesions between an exten-
sor or flexor tendon and a proximal phalanx if interposed
between the tendon and bone. Paratenon was satisfactory
in all locations, and it gave the best result when conditions
were less than ideal. It was better than the other materials
when used in the palm or carpal canal, or beneath abdomi-
nal flaps or adjacent to flexor-tendon grafts. However, it
was more difficult to use, and the operative time was in-
creased since a second incision was required to obtain it.
Polyethylene and Silastic worked equally well when used
to cover a small scarred area next to a phalanx, or when
inserted as a preliminary procedure to form a localized
gliding bed. Polyethylene was not satisfactory when
placed in the carpal canal. Silastic was used in the carpal
canal on only one occasion, and that patient was im-
proved.
Both synthetic materials failed when placed beneath a
tendon graft or beneath a pedicle flap, or when used in an
area that had been previously infected. Furthermore, this
study indicates that the overlying skin must be of good
quality if polyethylene is used beneath it.
Silastic is the best material for most conditions, for it
The fracture was exposed, aligned, and pinned. Both flexor tendons were badly scarred and fixed to the callus. After the fracture healed, the pins
and the superficialis tendon were removed and Silastic sheeting was placed between the scarred profundus tendon and the proximal phalanx.
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VOL. 59-A, NO. 7, OCTOBER 1977
USE OF PARATENON TO PREVENT RESTRICTING ADHESIONS TO TENDONS IN THE HAND 913
FIG. 3-C
FIG. 3-D
Figs. 3-C and 3-D: Flexion and extension six months after insertion of
the interpositional material.
is readily available in non-reinforced sheets 0. 13 millime- beneath a pedicle flap or a tendon graft, and it should not
ter thick, it is easy to use, and it is usually effective in pre- be placed in an area that has recovered from an infection.
venting the formation of restricting adhesions. It should Under such circumstances, paratenon is the preferred
not be used when the overlying skin is of poor quality or material.
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