Is releasing pulleys during flexor tendon repair "part and parcel"? Narrative review of the current evidence

Eur J Orthop Surg Traumatol. 2021 Oct 1. doi: 10.1007/s00590-021-03128-4. Online ahead of print.


Background: The complex hand flexors pulleys system is essential in achieving efficient flexor tendons' function. Previous cadaveric studies demonstrated that A2 and A4 are the crucial pulleys in maintaining normal digits biomechanics. Realistically, the preservation of A2 and A4 pulleys during repairing flexor tendon laceration in zones one and two can be extremely challenging. We review the current published evidence in this article to answer the question of whether releasing the pulleys cause bowstringing or affects clinical outcomes.

Methods: Literature search of the available databases.

Results: There was no published comparative evidence. Retrospective case series have reported that no clinical bowstringing was noted after releasing flexor pulleys during flexor tendon repairs. Outcomes have been reported according to Tang and or Strickland criteria to assess range of motion (ROM). No functional hand scores or patients' satisfactions scores have been reported.

Conclusion: Releasing flexor pulleys during tendon repair to allow access or prevent impingement of the repaired tendon does not seem to cause bowstringing or affect outcome based on the limited available evidence. Future research is needed.

Level of evidence: Level 4.

Keywords: A2; A4; Bowstringing; Flexor pulleys; Flexor tendon repair.

Publication types

  • Review