Pulvertaft Debate, 6 Flexor Fixes, & Going Live with PLASTA

Image of the Week

This week’s image shows a cadaveric demonstration of a vascularised tendon graft, highlighting both arterial and venous anastomoses. These grafts are valuable in complex tendon reconstruction, particularly when both structural and biological support is needed to optimise healing.

The image shows the completed vascular connections and the preparation of the tendon within the fibrous canal. Vascularised tendon grafts are increasingly relevant in secondary reconstruction where the tendon bed is scarred or poorly vascularised, such as in chronic injuries or post-infection settings.

Keep an eye out for the inset detail showing <1 mm anastomoses; a reminder of the precision and microsurgical finesse required.

Technique Tip of the Week

This week’s tip focuses on a fundamental but critical move during dorsal hand approaches: safe and strategic extensor tendon retraction.

In both the diagram and intra-op image shown, you’ll notice the use of Senn retractors and mosquito clips to protect and mobilize the extensor tendons. Careful retraction improves access to the underlying structures (e.g., metacarpals, joints, plates) while preserving tendon integrity.

Tip: Retract longitudinally, not laterally, while avoiding excessive tension to reduce the risk of tendon fraying or delayed repair issues.

This technique is especially relevant when working around dorsal plates, midshaft fractures, or when exposing intrinsic muscles for reconstruction.

The Pulvertaft weave remains a standard technique for tendon grafts and transfers in hand surgery, though several modifications and alternatives have been developed to improve biomechanical performance.

Van Royen et al. (2021) demonstrated that a modified core suture Pulvertaft weave using FiberLoop 4.0 showed significantly superior biomechanical properties compared to the traditional technique, with 5 times greater strength in stiffness, first failure load, and ultimate failure load. Crook et al. (2013) introduced a novel loop weave that demonstrated significantly higher initial failure and ultimate strengths compared to the Pulvertaft weave, with failures occurring through tendon splitting rather than suture failure. Duprat et al. (2017) found no significant difference in failure load between Pulvertaft weave and step-cut suture techniques (116N vs 103N), though step-cut repairs had smaller cross-sectional areas. Bidic et al. (2009) showed that lasso repairs achieved equivalent maximum load to Pulvertaft weaves (155.8N vs 159.7N) while requiring less weave time and tendon length.

Can Flexor Tendon Defects Be Reconstructed in a Single Stage? (Cavadas, 2014)

Single-stage vascularized FDS tendon transfers based on the ulnar vessels achieved ~178° total active motion with fewer complications than staged grafting, offering a viable alternative in select cases.

When Should You Combine Tendon and Nerve Transfers in the Upper Extremity? (Giuffre, 2014)

For Sunderland IV-V injuries, tendon and nerve transfers are often used together, nerve transfers being increasingly popular for excellent outcomes, and tendon transfers being a reliable backup if nerve recovery fails.

Are Hamstring Tendons Viable Grafts for Flexor Tendon Reconstruction? (Lynch, 2023)

Cadaveric analysis shows the gracilis tendon matches flexor tendon dimensions for staged reconstruction (except in the little finger), while the semitendinosus is too thick for use in intact pulley systems.