Evidence-based flexor tendon repair

[Current Trends in Flexor Tendon Surgery: Results of a National Online Survey]

Within the last 50 years, there has been a change in trend in flexor tendon surgery. After the introduction of the 2-strand technique, the 4-strand technique was propagated in the 1990s. In order to obtain a status quo of which technique is used in Germany and if the gold standard of the 4-strand suture has changed in favour of a 6-strand suture, we conducted an online survey among members of the DGH ("Deutsche Gesellschaft für Handchirurgie", German Society for Hand Surgery) on the suture technique of flexor tendon injuries zone 2.

MATERIAL AND METHODS

An online survey was conducted and sent out by email to all DGH members. The questionnaire included 7 questions. Participants accessed the survey via a link.

RESULTS

155 hand surgeons from Germany participated in the survey. All of them answered the questionnaire in full and all questionnaires were included in the evaluation. The main question of how many strands are currently used for core suturing was answered as follows: 21% (n=32) of the 155 participants (TN) stated that they use a 2-strand suture, 53% used (n=82) a 4-strand suture and 10% used a 6-strand suture. Regarding techniques, 81 TN used the Kirchmayr-Kessler technique or a modification of it, 9 TN used the M-Tang technique, and 15 TN indicated "other technique". The question about the application of an epitendinous suture was overwhelmingly answered with "yes". Here, 98.2% agreed. Only with regard to the suture material, different opinions were found. 68% (n=106) use an absorbable monofilament suture (such as PDS). Just under a quarter (23%, n=36) use a non-absorbable monofilament suture (such as Prolene).

CONCLUSION

Flexor tendon surgery has changed considerably due to intensive advances in research during the last decades. It was interesting to note in our survey that German hand surgeons have adapted their suture technique within the last years based on the results of the literature. Our results clearly show that convincing scientific data has an influence on the choice of surgical technique and that discussions about new techniques, e. g. in the context of annual meetings, may well stimulate the auditorium to rethink.

Autonomous Patient-Controlled Mobilization Protocol After Flexor Tendon Repair: A Case Series

BACKGROUND

Despite many publications on rehabilitation after repair of flexor tendon injuries of the hand, there is no consensus as to which method is superior. It is clear that nonadherence to postoperative therapy adversely affects the outcome after flexor tendon surgery. In the context of a developing country, the most important factor associated with poor outcome is late onset of rehabilitation therapy. An autonomous rehabilitation program is proposed, with the use of a low-cost splint and based on an online illustrative video with the expectation to improve adherence and patient compliance, thus ensuring satisfactory outcome.

METHODS

Twenty-two consecutive digits of 14 patients after flexor tendon repair in zone II were included. Autonomous early passive mobilization physical therapy and splinting started shortly after surgery, supported by an online available video depicting prescribed exercises; follow-up was continued until postoperative week 20. Patients were evaluated regarding range of motion, grip strength, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) disability scale.

RESULTS

Range of motion after 20 weeks according to the scoring system of the American Society of Surgery of Hand was excellent in 4, good in 11, and fair in 4 fingers. The mean total active motion score was 86% (95% confidence interval, 78%-93%). The mean grip strength at final follow-up was 86% of the contralateral hand. The mean QuickDASH score was 12.5 (2.3-31.8).

CONCLUSION

This protocol achieves good results in range of motion and early return of function of the hand. We propose this simple, nonexpensive method to developing countries with less than optimal availability of health care.

Zone II Flexor Pollicis Longus Repair: Thumb Flexion and Complications

Background: The aim of flexor pollicis longus (FPL) repair is to create a construct that is strong enough to withstand forces encountered during rehabilitation and to achieve an optimal active range of motion. The aim of this study was to: (1) assess factors influencing active thumb interphalangeal (IP) joint flexion; and (2) assess the factors associated with reoperation. Methods: Retrospectively, 104 patients with primary repair of a Zone II FPL laceration from 2000 to 2016 were identified. A medical chart review was performed to collect patient-, injury-, and surgery characteristics as well as the degree of postoperative active IP-flexion and occurrence of reoperation. Bivariate analyses were performed to identify factors influencing active IP-flexion and factors associated with reoperation. Results: The reoperation rate was 17% (n = 18) at a median of 3.4 months (range: 2.3-4.4). Indications for reoperation mainly included adhesion formation (n = 10, 56%) and re-rupture (n = 5, 28%). The median range of active IP-flexion was 30° (interquartile range [IQR]: 20-45) at a median of 12.4 weeks (IQR: 8.1-16.7). Solitary injury to the thumb (β = 17.9, P = .022) and the use of epitendinous suture (β = 10.0, P = .031) were associated with increased active IP-joint flexion. No factors were statistically associated with reoperation. Conclusions: About 1 in 5 patients undergo reoperation following primary repair of a Zone II FPL laceration, mostly within 6 months of initial surgery. The use of epitendinous suture is associated with greater active IP-flexion. Patients with multiple digits injured accompanying a Zone II FPL laceration have inferior IP-joint motion.

Up to five-week delay in primary repair of Zone 2 flexor tendon injuries: outcomes and complications

We report the outcomes of delayed primary repair of flexor tendons in Zone 2 in 31 fingers and thumb (28 patients) averaging 15 days (range 4-37) after injury in 2020. The delay was longer than usual due to the COVID-19 pandemic. The tendons were repaired with a 6-strand core suture (M-Tang method) or a double Tsuge suture and a peripheral suture. This was followed by an early, partial-range, active flexion exercise programme. Adhesions in four digits required tenolysis. These patients were not with longest delay. Outcomes of two improved after tenolysis. The other two patients declined further surgery. One finger flexor tendon ruptured in early active motion. This was re-repaired, and final outcome was good. Overall excellent and good results using the Tang criteria were in 27 out of 31 fingers and thumbs (87%). The time elapsed between the injury and surgery is not an important risk factor for a good outcome, rather it depends on proper surgical methods, the surgeon's experience and early mobilization, properly applied. Adhesions may occur, but they can be managed with tenolysis.Level of evidence: IV.

Rupture Rate, Functional Outcome and Patient Satisfaction after Primary Flexor Tendon Repair with the Modified 4-Strand Core Suture Technique by Tsuge and Using the Arthrex FiberLoop® with Early Motion Rehabilitation

PURPOSE

Our hypothesis was that the rupture rate after primary flexor tendon repair in the modified 4-strand core suture technique using the FiberLoop^® (Arthrex, Munich, Germany) is lower than in other suture materials and functional outcome and patient satisfaction are superior compared to the current literature.

PATIENTS AND METHODS

A 2-stage retrospective, randomized follow-up study of 143 patients treated with the Arthrex FiberLoop^® after flexor tendon injury in zones 2 or 3 from May 2013 to May 2017 was performed. In the 1^st stage, the rupture rate of all patients was assessed after a follow-up of at least one year by interview to exclude revision surgery. In the 2nd stage, 20% of the patients could be randomly clinically examined. Functional parameters, such as finger and wrist range of motion measured by goniometer, grip strength measured by Jamar dynamometer (Saehan, South Korea), patient satisfaction measured by school grades (1-6), pain levels measured by visual rating scales (0-10) and functional outcome according to the DASH-score were assessed. The Buck-Gramcko and Strickland scores were calculated. The length of sick leave was recorded.

RESULTS

A rupture rate of 2.1% was recorded. 29 patients (20%) were followed up at a mean of 34 ± 7.5 months postoperatively. 10.3% of these patients had an incomplete fingertip palm distance. The mean postoperative grip strength was 24 ± 3.1 kg. 93% of the patients were very satisfied with the treatment. No patient complained of pain postoperatively. The mean postoperative DASH score was 6.7 ± 2.8 points. The mean Buck-Gramcko score was 14 ± 0.2 points. 93% of the patients had excellent and 7% good results according to the Strickland score. 67% of patients had a work accident and returned to work at a mean of 4 ± 0.2 months postoperatively. 31% of patients suffered a non-occupational injury and returned to work at a mean of 3 ± 0.4 months postoperatively.

CONCLUSIONS

Primary flexor tendon repair in the modified 4-strand core suture technique using the Arthrex FiberLoop^® has proven to be a viable treatment option in our series. The rupture rate was lower than in other suture materials. It leads to acceptable pain relief, grip strength and functional outcome.

LEVEL OF EVIDENCE

IV; therapeutic.

Improving Strength and Quality of Epitendinous Repairs

Background: Epitendinous sutures not only join the 2 severed tendon edges but also supply strength and support to the repair. Multiple techniques have been described, but none of them include another thread of suture. This could potentially increase the strength of the repair without affecting gliding. Methods: Caprine tendons were harvested, transected, and sutured with 6-0 Prolene. Four groups were created: single thread running (SR), single thread locking (SL), double thread running (DR), and double thread locking (DL). An Instron 5542 was used to pull the repaired tendons apart, and the energy at the break was calculated (gf/mm). For gliding resistance, we harvested a human A2 pulley. A pre- and postrepair value was obtained, and a ratio was elaborated. A single-factor analysis of variance and independent sample t tests were performed. Results: The SR group had a mean energy at break of 9339.71 ± 1630.212 gf/mm; the SL group, 9629.96 ± 1476.45 gf/mm; and the DR group, 9600.221 ± 976.087 gf/mm, with no statistical significance. The DL group was significantly higher at 14 740.664 ± 2596.586 gf/mm (P < .05). When comparing SR with DL for gliding, SR had less than half of the resistance than DL (0.018 ± 0.004 and 0.049 ± 0.015 N/mm, respectively), with statistical significance (P < .05). Conclusion: Using a single suture thread for running epitendinous repair is no different than locking with a single thread or using an extra thread in a running fashion. Performing a double suture thread with a locking technique is significantly stronger than the previously mentioned repairs, with the disadvantage of more resistance at the pulley.

The evidence-base for the management of flexor tendon injuries of the hand: Review

•

There is no consensus on the optimal flexor tendon repair technique at each anatomical flexor zone.

•

There is paucity of high quality evidence.

•

Heterogenous study designs limit inter-study comparisons.

•

Patient reported outcome measures are crucial but there is a perennial need for robust disease-specific tools to be utilised.

FREQUENCY, DISTRIBUTION AND TREATMENT OF ACUTE FLEXOR TENDON INJURIES IN ZONE V OF HAND

Background: Flexor tendons injuries are common emergency procedures The objectives of this study were to determine the frequency, distribution and results of treatment of acute flexor tendon injuries in zone V of hand in our population. Material and Methods: This descriptive cross-sectional was conducted in the Department of Orthopedic, Gomal Medical College, D.I.Khan, Pakistan from January 2015 to December 2017. Sample size was 30, selected through consecutive technique. Patients having flexor tendon injuries in zone v, admitted through emergency department were included in this study. Demographic variable were sex and age-groups. The research variable were tendon involved, nerves involved, artery involved, mechanism of injury, wound size, duration of injury, season, type of injury, hand involved and results of treatment. All variables, being categorical were analyzed by frequency and percentages using SPSS version 16.0. Results: Out of 30 patients, 22(73.33%) were male. Twenty four (80%) patients were between 21 to 40 years age. Mechanism of injury was glass in 16(53.33%) cases, knife in 10(33.33%) cases. Twenty (66.66%) cases presented in summer. Flexor digitorum sublimus was injured in 21(70.0%), FCR in 11(36.66%), FPL in 8(26.66), FDP in 6(20.0%) and FCU in 4(13.33%) cases. Median nerve was involved in nine (30%) cases. Radial artery was involved in eight (26.66%) cases. Wound size was 2 cm in 24(80%) cases. Sixteen (53.33 %) cases came with self-inflicted injuries. Twenty (66.66 %) cases came after 12 hours. Twenty five (83.33%) patients achieved good to excellent results. Conclusion: Flexor digitorus sublimus was the most common tendon injured in non-dominant hand, especially in young males. Median nerve and radial artery were commonly injured structures mostly with glass. Majority patients presented more than 12 hours after injury, having wound size of 2cm. Mostly the injuries were self-inflicted and occurred in summer season.

Gliding Resistance After Epitendinous-First Repair of Flexor Digitorum Profundus in Zone II

PURPOSE

The importance of flexor tendon repair with both core and epitendinous suture placement has been well established. The objective of this study was to determine whether suture placement order affects gliding resistance and bunching in flexor digitorum profundus tendons in a human ex vivo model.

METHODS

The flexor digitorum profundus tendons of the index, middle, ring, and little fingers of paired cadaver forearms were tested intact for excursion and mean gliding resistance in flexion and extension across the A2 pulley. Tendons were subsequently transected and repaired with either an epitendinous-first (n = 12) or a control (n = 12) repair. Gliding resistance of pair-matched tendons were analyzed at cycle 1 and during the steady state of tendon motion. The tendon repair breaking strength was also measured.

RESULTS

The mean steady state gliding resistance was less for the epitendinous-first repair than for the control repair in flexion (0.61 N vs 0.72 N) and significantly less in extension (0.68 N vs 0.85 N). Similar results were seen for cycle 1. None of the repairs demonstrated gap formation; however, control repairs exhibited increased bunching. Load to failure was similar for both groups.

CONCLUSIONS

The order of suture placement for flexor tendon repair is important. Epitendinous-first repair significantly decreased mean gliding resistance, allowed for easier placement of core sutures, and resulted in decreased bunching.

CLINICAL RELEVANCE

Epitendinous-first flexor tendon repairs may contribute to improved clinical outcomes compared with control repairs by decreasing gliding resistance and bunching.

Management of traumatic wounds in the Emergency Department: position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES)

Traumatic wounds are one of the most common problems leading people to the Emergency Department (ED), accounting for approximately 5,4 % of all the visits, and up to 24 % of all the medical lawsuits. In order to provide a standardized method for wound management in the ED, we have organized a workshop, involving several Italian and European experts. Later, all the discussed statements have been submitted for external validation to a multidisciplinary expert team, based on the so called Delphi method. Eight main statements have been established, each of them comprising different issues, covering the fields of wound classification, infectious risk stratification, tetanus and rabies prophylaxis, wound cleansing, pain management, and suture. Here we present the results of this work, shared by the Academy of Emergency Medicine and Care (AcEMC), and the World Society of Emergency Surgery (WSES).