Flexor Tendon Lacerations

This is a devastating complication of flexor tendon repair - complete re-rupture at 3 weeks with significant tendon end degeneration making immediate re-repair not feasible. The timing is in the worst possible window - too early for the tendon ends to have healed and matured (they are mushy and degenerated), but already retracted and shortened with scar tissue formation. My options are limited and all have significant compromises. The first option is attempting immediate re-repair despite the poor tissue quality. I could trim back the frayed, degenerated ends to healthier tissue, but this creates a gap between the ends. If the gap is small (less than 1cm), I could attempt repair with the finger in flexion to reduce tension, but the quality of tissue would make the repair very tenuous and likely to fail again. Given he already failed once due to non-compliance, I would not favor this option. The second option is staged reconstruction. The gold standard for chronic flexor tendon problems is the two-stage Hunter rod technique. Stage 1 involves thorough debridement of the scarred flexor sheath, excision of the failed repair and necrotic tendon, insertion of a silicone Hunter rod through the sheath from palm to fingertip, and reconstruction of the A2 and A4 pulleys using grafts if they are damaged (typically using extensor retinaculum or palmaris longus). The rod stays in situ for 3-4 months allowing formation of a pseudo-sheath around it. Stage 2, performed 3-4 months later, involves removing the rod and passing a tendon graft (palmaris longus autograft is first choice, if absent can use plantaris or toe extensors) through the pseudo-sheath, then securing it distally to the distal phalanx with pullout suture or anchor and proximally with a Pulvertaft weave to the FDP muscle in the forearm. This is followed by early active motion rehabilitation. The success rate is approximately 60-70% for achieving good function (TAM greater than 175 degrees) but it requires two operations, 6-12 months total treatment time, and intensive hand therapy. The third option is salvage with arthrodesis - fusing the DIP and PIP joints in functional position (DIP 10-15 degrees flexion, PIP 30-40 degrees flexion) to give him a stable, sensate post for grip. This sacrifices motion but gives a predictable outcome and is a single operation. For a builder requiring power grip, this may be acceptable. Given his non-compliance with previous post-operative restrictions, his occupation requiring early return to work, and the poor tissue quality making immediate re-repair very unlikely to succeed, I would recommend two-stage reconstruction with realistic counseling that this is a salvage procedure with guarded prognosis. I would emphasize that he will need to be off work for at least 4 months (3 months between stages plus recovery from stage 2), that final outcome may only be fair (60-70% of normal motion at best), that he has a significant risk of stiffness requiring tenolysis, and that if the graft fails, we may ultimately need to consider arthrodesis. I would also discuss his return-to-work decision-making and whether his occupation is compatible with the intensive rehabilitation requirements. This case illustrates that flexor tendon repair requires strict compliance with rehabilitation protocols, and premature return to work can result in catastrophic failure requiring complex salvage procedures with compromised outcomes.