Flexor tendon repair rehabilitation protocols: a systematic review

Splints, with or without wrist immobilization, following surgical repair of flexor tendon lesions of the hand: A systematic review

Splints with or without wrist immobilization can be used during the rehabilitation of flexor tendon lesions of the hand. The evidence base for these techniques has not previously been studied in a systematic review. We sought to thoroughly review patient-reported functional outcomes and pain to compare splinting with or without wrist immobilization. Five bibliographic databases were searched. Studies were considered for inclusion if they were randomized controlled trials or observational comparative studies reporting the difference in outcome among patients treated with or without wrist immobilization. No limits were set on publication date or language. Study selection was performed independently by two authors, and disagreements were resolved by consensus. The review protocol was preregistered in PROSPERO. There were no randomized controlled trials. No studies could be included based on our inclusion criteria. We decided to qualitatively summarize the most relevant studies although they did not meet our inclusion criteria. This resulted in a narrative review of the studies we found relevant. Based on the current literature, it is impossible to provide evidence-based recommendations for or against wrist immobilization during the rehabilitation period following flexor tendon repair. The lack of high-quality evidence points to a need for randomized clinical trials to guide rehabilitation decisions.

Cell non-autonomous functions of S100a4 drive fibrotic tendon healing

Identification of pro-regenerative approaches to improve tendon healing is critically important as the fibrotic healing response impairs physical function. In the present study we tested the hypothesis that S100a4 haploinsufficiency or inhibition of S100a4 signaling improves tendon function following acute injury and surgical repair in a murine model. We demonstrate that S100a4 drives fibrotic tendon healing primarily through a cell non-autonomous process, with S100a4 haploinsufficiency promoting regenerative tendon healing. Moreover, inhibition of S100a4 signaling via antagonism of its putative receptor, RAGE, also decreases scar formation. Mechanistically, S100a4 haploinsufficiency decreases myofibroblast and macrophage content at the site of injury, with both cell populations being key drivers of fibrotic progression. Moreover, S100a4-lineage cells become α-SMA+ myofibroblasts, via loss of S100a4 expression. Using a combination of genetic mouse models, small molecule inhibitors and in vitro studies we have defined S100a4 as a novel, promising therapeutic candidate to improve tendon function after acute injury.

Biologic and mechanical aspects of tendon fibrosis after injury and repair

Tendon injuries of the hand that require surgical repair often heal with excess scarring and adhesions to adjacent tissues. This can compromise the natural gliding mechanics of the flexor tendons in particular, which operate within a fibro-osseous tunnel system similar to a set of pulleys. Even combining the finest suture repair techniques with optimal hand therapy protocols cannot ensure predictable restoration of hand function in these cases. To date, the majority of research regarding tendon injuries has revolved around the mechanical aspects of the surgical repair (i.e. suture techniques) and postoperative rehabilitation. The central principles of treatment gleaned from this literature include using a combination of core and epitendinous sutures during repair and initiating motion early on in hand therapy to improve tensile strength and limit adhesion formation. However, it is likely that the best clinical solution will utilize optimal biological modulation of the healing response in addition to these core strategies and, recently, the research in this area has expanded considerably. While there are no proven additive biological agents that can be used in clinical practice currently, in this review, we analyze the recent literature surrounding cytokine modulation, gene and cell-based therapies, and tissue engineering, which may ultimately lead to improved clinical outcomes following tendon injury in the future.

Flexor tendon injuries

Flexor tendon injuries have constituted a large portion of the literature in hand surgery over many years. Yet many controversies remain and the techniques of surgery and therapy are still evolving. The anatomical and finer technical considerations involved in treating these injuries have been put forth and discussed in detail including the rehabilitation following the flexor tendon repair. The authors consider, recognition and mastery of these facts form the foundation for a successful flexor tendon repair. The trend is now towards multiple strand core sutures followed by early active mobilization. However, the rehabilitation process appears to be one of the major determinant of the success following a flexor tendon repair. Early mobilization is essential for all the flexor tendon repairs as it is proved to improve the quality of the repaired tendon. The art of achieving the harmony between a stronger repair and unhindered gliding of the repair site through the narrow flexor tendon sheath simultaneously can be mastered with practice added to the knowledge of the basic principles.

Results of 4-strand modified Kessler core suture and epitendinous interlocking suture followed by modified Kleinert protocol for flexor tendon repairs in Zone 2

Objective

There has been no consensus in literature for the ideal flexor tendon repair technique. The results of zone 2 flexor tendon lacerations repaired primarily by 4 strand Modified Kessler core suture and epitendinous interlocking suture technique followed by Modified Kleinert protocol were investigated.

Methods

128 fingers of 89 patients who had flexor tendon laceration in zone 2 built the working group. Functional outcomes were evaluated using the Strickland formula. A statistical analysis was made between Strickland scores and some parameters such as age, gender, follow-up time, co-existing injury existence, repair time, single or multiple finger injury, tendon rupture and the effect of FDS injury and repair.

Results

Excellent, good, fair, poor results were obtained from 71 (55.5%), 46 (35.9%), 8 (6.3%), 3 (2.3%) fingers, respectively. Time of the repair has a significant effect on the strickland scores. Surgery performed within the first 24 hours following the injury gave better results. 3 fingers (2.3%) had tendon ruptures. Existence of ruptures affected the results significantly. Co-existing injuries were found that they did not have any effect on the results. In the fingers in which both FDP and FDS tendons were lacerated, no significant relationship was found between only FDP repair, both FDP and FDS repair and single FDS slip repair. Additionally no significant relationships between follow-up time, gender, single or multiple finger injury and Strickland scores were observed. 13 fingers (10.1%) had PIP joint contracture above 20°.

Conclusion

The low rupture rate (2.3%) and 91.4% ‘good’ and ‘excellent’ scoring rates in our series support the idea that modified Kessler 4-strand core suture and epitendinous interlocking suture repair combined with modified Kleinert protocol gives satisfactory results. Repair time is one of the most important factors affecting the functional results and surgery should not be delayed if there is an experienced surgeon available.

Level of evidence

Level IV, therapeutic study.

Primary flexor tendons repair in zone 2: Current trends with GEMMSOR survey results

The repair of flexor tendon lesions in zone 2 remains a highly controversial subject in hand surgery. Currently, there is no consensus about the management of these lesions intra- and postoperatively, but the literature suggests that a solid suture will allow early active motion. We hypothesized that the management of flexor tendon injury in zone 2 varies widely. Two online surveys were conducted with surgeons and hand therapists. The questions captured the demographics of the surveyed population, surgical technique, common complications, postoperative management (duration of immobilization, type of splint, rehabilitation techniques and principles of self-rehabilitation). The responses were compared to current literature data. We collected 366 responses to the "surgery" survey and 206 responses to "rehabilitation" survey. Most surgeons performed suture repair with at least 4 strands (75.9%). Active rehabilitation protocols were used in 48.9% of cases. The "rehabilitation" survey underlined the lack of information provided to therapists by surgeons. Therapists used active protocols in 79.7% of cases. This study found a large variation in the management of flexor tendon injuries, which is not always consistent with current published recommendations. Ideally, the suture repair should be a 4-strand pattern with an epitendinous circumferential suture and a release of the pulley in the suture area. Mobilization and rehabilitation should be started on the 3rd day using an active protocol.

Flexor Tendon Injuries

Flexor tendon injuries of the hand are uncommon, and they are among the most challenging orthopaedic injuries to manage. Proper management is essential to ensure optimal outcomes. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site.

Optimal early active mobilisation protocol after extensor tendon repairs in zones V and VI: A systematic review of literature

Introduction

Early mobilisation protocols after repair of extensor tendons in zone V and VI provide better outcomes than immobilisation protocols. This systematic review investigated different early active mobilisation protocols used after extensor tendon repair in zone V and VI. The purpose was to determine whether any one early active mobilisation protocol provides superior results.

Methods

An extensive literature search was conducted to identify articles investigating the outcomes of early active mobilisation protocols after extensor tendon repair in zone V and VI. Databases searched were AMED, Embase, Medline, Cochrane and CINAHL. Studies were included if they involved participants with extensor tendon repairs in zone V and VI in digits 2–5 and described a post-operative rehabilitation protocol which allowed early active metacarpophalangeal joint extension. Study designs included were randomised controlled trials, observational studies, cohort studies and case series. The Structured Effectiveness Quality Evaluation Scale was used to evaluate the methodological quality of the included studies.

Results

Twelve articles met the inclusion criteria. Two types of early active mobilisation protocols were identified: controlled active motion protocols and relative motion extension splinting protocols. Articles describing relative motion extension splinting protocols were more recent but of lower methodological quality than those describing controlled active motion protocols. Participants treated with controlled active motion and relative motion extension splinting protocols had similar range of motion outcomes, but those in relative motion extension splinting groups returned to work earlier.

Discussion

The evidence reviewed suggested that relative motion extension splinting protocols may allow an earlier return to function than controlled active motion protocols without a greater risk of complication.

Influence of wrist position on maximum grip force in a post-operative orthosis

BACKGROUND

Flexor tendon repair in the hand remains challenging in avoiding tendon rupture and adhesion formation. Post-operative mobilization has been shown to be critical in regaining functional range of motion.

OBJECTIVES

The objective of this study is 2-fold: to assess the influence of wrist position on maximum grip force generated in a post-operative orthosis and to determine the correlation between this maximum grip force and an individual's grip strength.

STUDY DESIGN

Clinical measurement Methods: A total of 30 uninjured wrists of right-handed men were given a post-operative orthosis with an incorporated Caroli-hinge. The maximum grip force was measured according to a different wrist position ranging from -30° extension until 80° of flexion using a 10° interval. These measurements were plotted out on a graph for regression analysis. A correlation was determined between measurements in a neutral wrist position and maximum grip strength generated without an orthosis. To assess the coherence of the measurements, a mean intraclass correlation coefficient was used.

RESULTS

The maximum grip force values were statistically significantly different in every wrist position and decreased progressively with an increasing flexion angle ( p < 0.05). This relationship is expressed in a logistic regression curve f( x) = -4.98 + 16.92/(1 + (x/8.59))^2.24. A wrist position of 4.4° of flexion was derived from this function to cause a maximum grip force reduction of 33%. Further analysis showed a force decrease of 50% at 23.2° and 66% at 51.8° of wrist flexion. The grip strength measured without an orthosis showed a positive correlation with previous measurements (Spearman's correlation coefficient = 0.74 for the right hand and 0.72 for the left hand ( p < 0.001)).

CONCLUSIONS

The obtained logistic function allowed to derive the wrist position needed in a post-operative orthosis to obtain a desired amount of maximum grip force reduction. Clinical relevance Measuring a high grip force in a clinical setting of flexor tendon repair on the contralateral non-affected hand could indicate the use of an increased flexion angle in a post-operative orthosis. This reduces the load transferred on the tendon repair when involuntary contractions take place, for example, during sleeping when positioned in a post-operative orthosis.

Zone II Flexor Tendon Repairs in the United States: Trends in Current Management

PURPOSE

The repair of zone II flexor tendon injuries is an evolving topic in hand surgery with current literature suggesting the use of a 4-strand repair; 3-0 or 4-0 braided, nonabsorbable sutures; and an epitendinous repair. It was hypothesized that variability would exist within the hand surgeon community in treatment of zone II flexor tendon repairs in surgical material used, surgical technique, and postoperative rehabilitation protocol.

METHODS

An online single-answer multiple-choice survey was distributed to the American Society for Surgery of the Hand members' database. Surgeons were asked questions about demographics, surgical technique, suture type, common complications, postoperative management, and the factor that plays the largest role in guiding their surgical preferences. Responses were compared with current medical evidence.

RESULTS

A total of 410 individuals responded to the survey. In regards to technique, the majority of surgeons reported using a 4-strand repair; with 3-0 or 4-0 core braided, nonabsorbable sutures; and performing an epitendinous repair. Only 20% of surgeons surveyed reported ever using wide-awake local anesthesia, no tourniquet and postoperative protocols were split between early active and early passive rehabilitation. Senior surgeons (≥ 15 years in practice) were more likely than their colleagues to use a 2-strand repair and a passive rehabilitation protocol.

CONCLUSIONS

This study demonstrates that the majority of respondents are performing zone II flexor tendon repairs in accordance with the best currently available evidence, although there is variability with respect to suture material, surgical technique, and rehabilitation protocols.

CLINICAL RELEVANCE

There is still a need for high-quality studies on surgical technique and rehabilitation protocols.

Effect of wrist and interphalangeal thumb movement on zone T2 flexor pollicis longus tendon tension in a human cadaver model

INTRODUCTION

Therapy after flexor pollicis longus (FPL) repair typically mimics finger flexor management, but this ignores anatomic and biomechanical features unique to the FPL.

PURPOSE OF THE STUDY

We measured FPL tendon tension in zone T2 to identify biomechanically appropriate exercises for mobilizing the FPL.

METHODS

Eight human cadaver hands were studied to identify motions that generated enough force to achieve FPL movement without exceeding hypothetical suture strength.

RESULTS

With the carpometacarpal and metacarpophalangeal joints blocked, appropriate forces were produced for both passive interphalangeal (IP) motion with 30° wrist extension and simulated active IP flexion from 0° to 35° with the wrist in the neutral position.

DISCUSSION

This work provides a biomechanical basis for safely and effectively mobilizing the zone T2 FPL tendon.

CONCLUSION

Our cadaver study suggests that it is safe and effective to perform early passive and active exercise to an isolated IP joint.

LEVEL OF EVIDENCE

NA.

Pathomechanics and Management of Secondary Complications Associated with Tendon Adhesions Following Flexor Tendon Repair in Zone II

Despite the number of rehabilitation strategies and guidelines developed to maximize the gliding amplitude of repaired tendons, secondary complications, such as decreased range of motion and stiffness associated with tendon adhesions, commonly arise. If left untreated, these early complications may lead to secondary pathomechanical changes resulting in fixed deformities and decreased function. Therefore, an appropriate treatment regimen must not only include strategies to maintain the integrity of the repaired tendon, but must also avoid secondary complications due to reduced gliding amplitude. This review presents a biomechanical analysis of the dynamics of tendon gliding following repair in zone II and rehabilitation strategies to minimize secondary complications related with tendon adhesions.

The benefit of early rehabilitation following tendon repair of the hand: A population-based claims database analysis

STUDY DESIGN

A retrospective cohort.

INTRODUCTION

The benefits of early rehabilitation after hand tendon repair have not been analyzed using population-based datasets.

PURPOSE OF THE STUDY

to analyze whether early rehabilitation reduces the resurgery risk and the use of rehabilitation resources.

METHODS

Patients (n = 1219) who underwent hand tendon repairs followed by rehabilitation were identified from a nationwide claims database and divided into 3 groups: early (<1 wk after tendon repair), intermediate (1-6 wk), or late (>6 wk) rehabilitation. The resurgery rate and the use of rehabilitation resources after tendon repair were calculated. Cox proportional hazards models were used to evaluate the relevant predictors of resurgery.

RESULTS

The early rehabilitation group exhibited the lowest resurgery rate and used the fewest rehabilitation resources. Compared with late rehabilitation, early or intermediate rehabilitation conferred protective effects against resurgery in patients without a concomitant upper-limb fracture.

CONCLUSION

Our findings suggest the benefit of early rehabilitation after hand tendon repair.

LEVEL OF EVIDENCE

4.

Early Passive Movement in flexor tendon injuries of the hand

INTRODUCTION

Flexor tendon injuries are underestimated considering their anatomical function in the hand. According to the publications of Kleinert, Verdan and Kessler, primary suturing of the flexor tendon combined with immediate postoperative physiotherapy in terms of "Early Passive Movement" became the standard form of therapy following acute flexor tendon injuries of the hand.

MATERIALS AND METHODS

In a study between 2007 and 2009, a total of 115 flexor tendon injuries were analysed retrospectively. All patients were treated using a two-strand repair technique according to Zechner. They received physiotherapy from the first postoperative day according to the Viennese flexor tendon rehabilitation protocol. For statistical purposes, the factors: age, gender, range of motion (ROM), follow up interval, affected flexor tendon and zone were analysed. The time between injury and surgery was also determined, classified into groups and included in the study. On the basis of the range of motion AROM, the Buck-Gramcko and modified Strickland Score was calculated.

RESULTS

The mean follow-up interval was 7 months. Using the Buck-Gramcko and Strickland Score an "excellent" overall result was achieved. Complications occurred in 3.5 %, one secondary rupture (0.9 %), two tendon adhaesions requiring tenolysis (1.7 %) and one case of infection (0.9 %). The time interval between injury and operation, gender, affected zone, flexor tendon and affected finger nerve had no influence on the Buck-Gramcko and Strickland Score.

CONCLUSIONS

Using Zechner's core suture technique as the primary treatment, combined with immediate postoperative physiotherapy in terms of "Early Passive Movement" according to the Viennese flexor tendon rehabilitation programme, an excellent clinical outcome and low complication rate was acchieved.

LEVEL OF EVIDENCE

IV: case series.

A multicentre, randomized, double-blind trial of the safety and efficacy of mannose-6-phosphate in patients having Zone II flexor tendon repairs

The safety, tolerability and preliminary efficacy of mannose 6-phosphate in enhancing the outcome in Zone II flexor tendon repair was studied in a multicentre parallel double-blinded randomized controlled trial. Eight UK teaching hospitals were involved in treating repaired flexor tendons with a single intraoperative intrathecal dose of 600 mM mannose 6-phosphate, with follow-up over 26 weeks. A total of 39 patients (mannose 6-phosphate, n = 20; standard care, n = 19) were randomized. Seven were excluded from the safety and tolerability analysis because of intraoperative findings and eight were excluded due to early dropout (n = 4) or tendon rupture (n = 4), leaving 24 (mannose 6-phosphate, n = 13; standard care, n = 11) for assessment of total active motion. The safety, tolerability and other side effects were comparable between the groups. There was no significant difference between the two groups in the total active motion at Week 26. We concluded that mannose 6-phosphate, although safe and tolerable, had no beneficial effect on finger range of motion after Zone II tendon division.Level of evidence 1b.

In vivo flexor tendon forces generated during different rehabilitation exercises

We measured in vivo forces in the flexor digitorum profundus and the flexor digitorum superficialis tendons during commonly used rehabilitation manoeuvres after flexor tendon repair by placing a buckle force transducer on the tendons of the index finger in the carpal canal during open carpal tunnel release of 12 patients. We compared peak forces for each manoeuvre with the reported strength of a flexor tendon repair. Median flexor digitorum profundus force (24 N) during isolated flexor digitorum profundus flexion and median flexor digitorum superficialis force (13 N) during isolated flexor digitorum superficialis flexion were significantly higher than during the other manoeuvres. Significantly higher median forces were observed in the flexor digitorum superficialis with the wrist at 30° flexion (6 N) compared with the neutral wrist position (5 N). Median flexor digitorum profundus forces were significantly higher during active finger flexion (6 N) compared with place and hold (3 N). Place and hold and active finger flexion with the wrist in the neutral position or tenodesis generated the lowest forces; isolated flexion of these tendons generated higher forces along the flexor tendons.

LEVEL OF EVIDENCE

III (controlled trial without randomization).

Systemic EP4 Inhibition Increases Adhesion Formation in a Murine Model of Flexor Tendon Repair

Flexor tendon injuries are a common clinical problem, and repairs are frequently complicated by post-operative adhesions forming between the tendon and surrounding soft tissue. Prostaglandin E2 and the EP4 receptor have been implicated in this process following tendon injury; thus, we hypothesized that inhibiting EP4 after tendon injury would attenuate adhesion formation. A model of flexor tendon laceration and repair was utilized in C57BL/6J female mice to evaluate the effects of EP4 inhibition on adhesion formation and matrix deposition during flexor tendon repair. Systemic EP4 antagonist or vehicle control was given by intraperitoneal injection during the late proliferative phase of healing, and outcomes were analyzed for range of motion, biomechanics, histology, and genetic changes. Repairs treated with an EP4 antagonist demonstrated significant decreases in range of motion with increased resistance to gliding within the first three weeks after injury, suggesting greater adhesion formation. Histologic analysis of the repair site revealed a more robust granulation zone in the EP4 antagonist treated repairs, with early polarization for type III collagen by picrosirius red staining, findings consistent with functional outcomes. RT-PCR analysis demonstrated accelerated peaks in F4/80 and type III collagen (Col3a1) expression in the antagonist group, along with decreases in type I collagen (Col1a1). Mmp9 expression was significantly increased after discontinuing the antagonist, consistent with its role in mediating adhesion formation. Mmp2, which contributes to repair site remodeling, increases steadily between 10 and 28 days post-repair in the EP4 antagonist group, consistent with the increased matrix and granulation zones requiring remodeling in these repairs. These findings suggest that systemic EP4 antagonism leads to increased adhesion formation and matrix deposition during flexor tendon healing. Counter to our hypothesis that EP4 antagonism would improve the healing phenotype, these results highlight the complex role of EP4 signaling during tendon repair.

Management of complications of flexor tendon injuries

Innovations in operative techniques, biomaterials, and rehabilitation protocols have improved outcomes after treatment of flexor tendon injuries. However, despite these advances, treatment of flexor tendon injuries remains challenging. The purpose of this review is to highlight the complications of flexor tendon injuries and review the management of these complications.

Evidence-based flexor tendon repair

The goal of flexor tendon repair is to achieve normal range of motion of the finger or thumb. The surgical approach depends on the level of injury. Multistrand core suture repairs are recommended for primary flexor tendon repair. It is evident that at least 4 strands are required to an initiate and active range of motion protocol. The epitendinous suture can also increase the strength of the repair. Careful attention to the post-operative therapy regiment is critical to a successful repair.

Power tool injuries to the hand and wrist

Power tool injuries to the hand and wrist are complex injuries which can have a profound impact on the function of the patient. This article gives an overview of the principles, and provides a systematic approach, to the management and rehabilitation of the injured limb and patient required to minimize future disability.

Rehabilitation of the upper extremity following nerve and tendon reconstruction: when and how

Following upper extremity nerve and tendon reconstruction, rehabilitation is necessary to achieve optimal function and outcome. In this review, the authors present current evidence and literature regarding the strategies and techniques of rehabilitation following peripheral nerve and tendon reconstruction.

Flexor tendon injury, repair and rehabilitation

Injuries to the flexor tendons remain among the most difficult problems in hand surgery. Historically, lacerations to the intrasynovial portion of the flexor tendons were thought to be unsuitable for primary repair. Despite continuing advances in our knowledge of flexor tendon biology, repair, and rehabilitation, good results following primary repair of flexor tendons remain challenging to achieve.

Exceptional laceration of flexor digitorum tendons proximal to a severe palmar hand wound: a case report with literature review

Hand wounds are common, poor functional outcomes are marked because of sequelae inherent to posttraumatic and postoperative complications. Suitable surgery repair in emergency can ensure best results. Classically, tendon's injuries occur near the injured area and their repair depend on traumatized zone, sutures techniques, associated lesions and surgeon's abilities. We report a case of a farmer who has sustained of a severe hand wound due to blades of a combine harvester. Clinical examination showed exceptional laceration of 2^nd and 3^rd flexor digitorum tendons from musculo-tendinous junction, without any lesion in their palmar section. We proceeded; after extensive debridement, abundant lavage and removal of foreign body; to modified Kessler sutures using PDS 4.0 followed by dorsal splint for protecting tendons repair, and progressive rehabilitation program. Final result was interesting after 12 weeks. Thinking to tendon laceration is important, when manipulating machines with rotational movements.

A new modified Tsuge suture for flexor tendon repairs: the biomechanical analysis and clinical application

Purpose

This study is to develop a new suturing technique for flexor tendon repair by modifying the extant Tsuge repair techniques and to use biomechanical analysis to compare the new method with four established repair techniques and evaluate its clinical efficacy in the repair of 47 flexor tendons in 22 patients.

Methods

The biomechanical analysis relied on 50 flexor digitorum profundus tendons harvested from fresh cadavers. The tendons were randomly divided into five groups, transected, and repaired by use of a 1. double-loop suture, 2. double modified locking Kessler, 3. four-strand Savage, 4. modified six-strand Savage, and 5. the new technique. The tensile force and breaking force of all repaired tendons were measured by static loading trials. For clinical application, 22 patients with acute flexor tendon injuries were treated with the new modified Tsuge suture and follow-up for more than 12 months.

Results

While differences in the tensile force and breaking force in the modified Tsuge sutures and modified six-strand Savage sutures were not statistically significant, static loading trials showed the tensile force, in the form of a 2-mm gap formation, and the breaking force of the new modified Tsuge sutures were, statistically, both higher than the ones characteristic of double-loop sutures, double modified locking Kessler, and four-strand Savage sutures. After 12 months, restored functions were observed in all the patients during the postoperative 12 months. Total active motion (TAM) score demonstrated that more than 90% fingers were estimated as excellent or good.

Conclusion

The new modified Tsuge sutures described here have evident higher tensile and breaking forces compared to other four-strand core suture techniques, suggesting, in turn, that this new technique is a good alternative for flexor tendon repairs in clinical applications.

Primary flexor tendon repair in zones 1 and 2: early passive mobilization versus controlled active motion

PURPOSE

To compare early passive mobilization (EPM) with controlled active motion (CAM) after flexor tendon surgery in zones 1 and 2.

METHODS

We performed a retrospective analysis of collected data of all patients receiving primary flexor tendon repair in zones 1 and 2 from 2006 to 2011, during which time 228 patients were treated, and 191 patients with 231 injured digits were eligible for study. Exclusion criteria were replantation, finger revascularization, age younger than 16 years, rehabilitation by means other than EPM or CAM, and missing information regarding postoperative rehabilitation. This left 132 patients with 159 injured fingers for analysis. The primary endpoint was the comparison of total active motion (TAM) values 4 and 12 weeks after surgery between the EPM and the CAM protocols. The analysis of TAM measurements under the rehabilitation protocols was conducted using t-tests and further linear modeling. We defined rupture rate and the assessment of adhesion/infection as secondary endpoints.

RESULTS

There was a statistically significant difference between the TAM values of the EPM and the CAM protocols 4 weeks after surgery. At 12 weeks, however, there was no significant difference between the 2 protocols. Older age and injuries with finger fractures were associated with lower TAM values. Rupture rates were 5% (CAM) and 7% (EPM), which were not statistically different.

CONCLUSIONS

This study showed a favorable effect of CAM protocol on TAM 4 weeks after surgery. The percent rupture rate was slightly lower in the patients with CAM than in the patients with EPM regime. Further studies are required to confirm our results and to investigate whether faster recovery of TAM is associated with shorter time out of work.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.