Outcomes and evaluation of flexor tendon repair

Complications of flexor tendon repair

This article reviews and highlights complications of flexor tendon repairs. Although the outcomes of flexor tendon repairs have improved over the years, fair or poor functional outcomes are seen, especially in patients whose trauma involves multiple structures of the hand and in zone 5 with multiple tendon lacerations. Rupture of the flexor tendon after repair is no longer a major problem if current repair principles are carefully adhered to. Different degrees of adhesion formations and interphalangeal (IP) joint stiffness still occur in a few patients. Early active postoperative mobilization and use of a shorter splint with sparing of the wrist are effective measures to prevent adhesion formation and IP joint stiffness. Given the overall poor results and high rate of complications with flexor digitorum profundus (FDP) repairs in zone 1, a direct repair of the FDP tendon to any short remnant of the distal insertion with 10-strand or even stronger core suture repair is adopted by many units.

Outcome of Flexor Tendon Repair Using Eight-Strand Core Stitch Without Postoperative Finger Splinting

BACKGROUND

There are no reports that detail clinical outcomes using the 8-strand suture techniques and early active mobilization. We aim to report the outcome of using an 8-strand double-cruciate core suture followed by early active motion without finger splinting.

MATERIALS AND METHODS

Thirty-five patients with 41 affected digits were operated and followed up for at least 6 months. A double cruciate repair with 4 single cross-grasping stitches on either side was employed. Active full-range finger flexion/extension exercises were allowed from the third postoperative day with the wrist held in the neutral position.

RESULTS

The total active motion (TAM) calculated for the proximal interphalangeal and distal interphalangeal joints averaged 151° ± 22°, and the TAM% averaged 86% ± 13%. Based on the original Strickland-Glocovac criteria, excellent and good outcomes were achieved in 25 of 29 fingers (86.2%). An average extension lag of 21° ± 11° (range 10°-40°) was observed in 11 (38%) fingers. The Buck-Gramcko scale showed excellent and good results in 10 (83.4%) thumbs. Active interphalangeal range of motion averaged 68° ± 23°. An average extension lag of 12° ± 4° (range 10°-20°) was observed in 7 (58%) thumbs. Complications occurred in 4 thumbs, including bowstringing (2), rupture (1), and flexion contracture of 60° (1).

CONCLUSIONS

Using the 8-strand repair technique and active mobilization performed by the patient is both practical and cost-saving. Intensive supervision of a hand therapist is generally not required. Notably improved outcomes have been achieved while preventing adhesions at the repair site. Further clinical outcome studies devoted specifically to the flexor pollicis longus are recommended to validate early-phase active mobilization following the 8-strand repair.

Early active movement with relative motion flexion splint for the management of zone 1-2 flexor tendon repairs: Case series

BACKGROUND

There is limited literature evidence on the use of relative motion flexion splint after flexor tendon repairs.

OBJECTIVES

We aimed to report the clinical use of early active movement with a relative motion flexion splint and to determine the outcomes of a consecutive series in patients with zone 1-2 flexor tendon repair.

METHODS

We included 14 patients with one-stage flexor tendon repair. An active rehabilitation program was initiated in the first week with a static dorsal block splint, which was removed in the third week, and patients started to use the relative motion flexion splint. Total active motion (TAM) of the injured finger at 8, 12, and 16 weeks after surgery was assessed as described by Strickland and Glogovac.

RESULTS

The mean TAM of the injured fingers was as follows: 102.5 ± 41.49° (25°-180°) at week 8; 123.42 ± 40.94° (45°-190°) at week 12; and 148 ± 38.18° (90°- 200°) at week 16. Final TAM grades of the patients at week 16 were as follows: excellent (six patients); good (five patients); and fair (three patients). There were no tendon ruptures and secondary surgeries.

CONCLUSION

Early active movement and the use of relative motion flexion splint seem to be promising strategies for flexor tendon zone 1-2 repair management.

Influence of the direction of suture strands on the tensile strength after flexor tendon repairs

We assessed the influence of different directions of suture strands using the double Tsuge repair on the resistance to gap formation and mode of failure. In total, 25 porcine flexor digitorum profundus tendons were split into two groups. One group was repaired using a conventional double Tsuge suture created by two bands of looped suture placed longitudinally parallel (parallel method), and the other group was repaired using a new technique comprising two bands of looped suture placed in a crossed fashion in the anterior and posterior half of the tendon (cruciate method). The repaired tendons were subjected to linear, non-cyclic load-to-failure tensile testing. The cruciate method had a significantly higher mean load at a 2-mm gap tensile load (29.7 N [SD, 8.3]) than the parallel method (21.6 N [SD, 4.9]) and failed significantly more often due to suture pull-out. The direction of a core suture and its location within the tendon affect both gap resistance and the mode of failure of repair when using the double Tsuge suture technique, with a cruciate configuration achieving a greater gap resistance than a parallel one.

Encircling tendon repair site with collagen sheet in flexor zone 2: retrospective study

BACKGROUND

Peritendinous adhesion is the most common complication of tendon repairs in the hand and often requires surgical intervention, resulting in increased labor loss and increased treatment costs. Many agents used to reduce tendon adhesion in animal models, however these agents have not entered clinical use. This study is the first-ever clinical study that evaluates encircling tendon repair site with collagen sheet as an anti-adhesion barrier.

METHODS

Between December 2014 and January 2020, 156 patients included in this study, with clean cut isolated flexor digitorum profundus (FDP) tendon injury in flexor tendon zone 2. All tendons repaired with modified double Kessler technique. In 76 patients, tendon repair site encircled with collagen sheet. 80 patients were randomly selected from our clinical records and functional results are compared with Strickland's total active motion grading system.

RESULTS

The mean total range of motion was 79% in the control group and 81% in the collagen sheet group, and there was no statistically significant difference between the two groups (Z: - 1.393, p = 0.164). In the control group, very good and good repair according to Strikland classification was 65/80 (81%). In the collagen sheet group, it was 62/76 (82%), respectively. There was statistically significant difference between 5 FDP TAM measurements between collagen sheet and control group (t(35) = 0.29, p = 0.016, p < 0.05). The mean TAM of the 5 FDP tendons in the collagen sheet group: 83.8 (SD: 8.2) in the and 76.1 (SD: 9.5) in the control group.

CONCLUSIONS

For the first time in the literature, functional results of Zone 2 flexor tendon repair using collagen sheets in patients with clean cut tendon injuries reported. However, there were no statistical difference about total active motion between control and collagen sheet group, 5th FDS tendon repairs encircled with collagen sheets had better outcomes. Prospective studies in patient groups with high adhesion risk are recommended.

Outcomes of 218 primary single-finger flexor tendon repairs up to 1 year after surgery: a multicentre cohort study

In this retrospective multicentre cohort study, we present the results of primary single-finger flexor tendon repairs in zones 1 to 3 between 2014 and 2021. Data from 218 patients were retrieved with their demographics, injury and surgery characteristics and therapy outcomes. The data were systematically collected and analysed at predefined time points up to 1 year after surgery. A good to excellent return of motion was achieved by 77% (Tang classification) and 92% (American Association for Surgery of the Hand classification) of patients at 1 year. The tendon rupture rate was 8.7%. Time had a significant impact on the recovery of finger motion and grip strength of up to 1 year, of patient satisfaction and upper extremity function up to 26 weeks, and of pain up to 13 weeks after surgery. Our results demonstrate that it is worthwhile to assess therapy outcomes over various measurement periods, as some outcomes may continue to improve up to 1 year after flexor tendon repair surgery.Level of evidence: III.

Flexor Tendon Repair: Avoidance and Management of Complications

The proper technique for flexor tendon repair has been well established through numerous bench science and clinical studies. However, less is known about strategies to avoid and manage postoperative complications. This article discusses the common complications after flexor tendon repair, such as repair site rupture and adhesion formation. This article also addresses strategies to prevent and manage these complications. The foundation for preventing many of these complications is ensuring a strong repair without gapping at time zero, which will enable the accrual of tensile strength through early initiation of motion.

Outcomes of Primary Flexor Tendon Repairs in Zones 2 and 3: A Retrospective Cohort Study

Purpose

The aims of this retrospective cohort study were to present outcomes of zone 2 and 3 primary flexor tendon repairs and to evaluate how clinical outcomes change over time within and between zones of injury at weeks 6, 13, and 26.

Methods

Data were retrieved from a multicenter flexor tendon cohort registry from 2014 to 2021. The inclusion criteria were: (1) adult patients after primary flexor tendon surgery in zone 2 or 3, (2) flexor digitorum profundus laceration of >50%, (3) 4-6 multistrand flexor digitorum profundus core suture, and (4) early active motion protocol. The primary outcome was the range of motion. Secondary outcomes were strength, patient satisfaction on an 11-point Likert scale, and self-reported physical function measured with the Disability of the Arm, Shoulder, and Hand questionnaire 6, 13, and 26 weeks after surgery.

Results

We evaluated 33 patients after 39 tendon repairs in zone 3 and 174 repairs in zone 2 of 163 patients. Range of motion significantly improved over time in both zones (P < .001 to .01). Between-group range of motion differences were nonsignificant except for week 26 (P < .001) for the zone 3 group. Hand strength significantly improved in both zones over time (P < .001 to .01), while between-zone strength differences were statistically nonsignificant (P = .37 to .93). Patient satisfaction was generally good to high (mean 6.8 to 8.0 points) with significant within-group changes in both zones (P < .001). There were no relevant between-zone differences in Disability of the Arm, Shoulder, and Hand scores at any time point.

Conclusions

Patients had significantly improved clinical outcomes in both zones. The zone of injury significantly affected the total active motion scores at the final assessment after 26 weeks for the zone 3 injuries. For the secondary outcomes hand strength, patient satisfaction, and Disability of the Arm, Shoulder, and Hand scores, we discovered no significant between-group differences.

Type of study/level of evidence

Therapeutic IV.

Relationship between pain, nerve injury and clinical outcomes after flexor tendon injuries in zones 1-2: a retrospective cohort study

Introduction

The influence of pain and a concomitant digital nerve injury on the course of rehabilitation after flexor tendon injury remains ambiguous. The objectives of the study were to: i) analyse the evolution of pain spanning one year after a primary flexor tendon repair in zones 1-3; ii) examine the differences in pain levels in patients with and without digital nerve injury; and iii) evaluate the relationship between pain, digital nerve injury and pain medication, total active motion (TAM), DASH scores and patient satisfaction.

Methods

Data from 189 patients were retrieved from a flexor tendon registry between 2014 and 2020. Differences in pain, TAM, DASH and patient satisfaction were analysed. Multiple linear and binary logistic regression analyses were performed to determine the relationship between clinical outcomes.

Results

Pain significantly decreased in the course of rehabilitation (p < 0.001 to 0.006). No relationship could be identified between nerve injury and pain (p = 0.21-0.97). In week 6, the presence of pain and a nerve injury were significantly associated with lower TAM scores (p = 0.001). In week 13, pain during motion (p < 0.001) and the presence of a nerve injury (p = 0.036) were significantly associated with worse DASH scores. Patient satisfaction was significantly inversely correlated to pain during motion in weeks 13 and 26 (p < 0.001).

Conclusion

We found a significant relationship between pain during motion and pain medication intake, TAM, DASH scores and patient satisfaction. It is therefore advisable to closely monitor this parameter after flexor tendon injuries.

Study registration

This multi-center cohort study is registered under https://clinicaltrials.gov: NCT04312412.

Surgical Considerations for Flexor Tendon Repair: Timing and Choice of Repair Technique and Rehabilitation

Flexor tendon injuries are common and occur mostly due to penetrating trauma. Surgical repair is required for complete tendon lacerations, and many techniques exist. This article reviews the principles of tendon structure, function, healing, and anatomy. Repair techniques are discussed in detail for each flexor tendon zone. Postoperative rehabilitation greatly influences outcomes, and several protocols are described.

Flexor Tendon Reconstruction

Chronic injury to the flexor tendon system of the hand remains a challenging problem for the hand surgeon to treat. Both single- and two-stage techniques remain important in the reconstruction of the flexor tendon deficient digit. Modern advances include the use of allograft composites that aim to reduce the time and donor-site morbidity compared with conventional autograft techniques. Regardless of technique, restoring a gliding tendon-pulley system with a functional arc of motion is the primary goal of flexor tendon reconstruction.

Comparison of the Outcomes of Flexor Tendon Repair in Zone II Using the Original and Adjusted Strickland Scores and the 400-Points Hand Test

Background: The purpose of this study was to report the outcomes of flexor tendon repair in zone II and compare two analytic tests - the original and adjusted Strickland scores - and a global hand function test, the 400-points test. Methods: We included 31 consecutive patients (35 fingers) with a mean age of 36 years (range 19-82 years) who underwent surgery for a flexor tendon repair in zone II. All patients were treated in the same healthcare facility by the same surgical team. All the patients were followed and evaluated by the same team of hand therapists. Results: At 3 months after the surgery, we found a good outcome in 26% of patients with the original Strickland score, 66% with the adjusted one and 62% with the 400-points test. Among the 35 fingers, 13 of them were evaluated at 6 months after the surgery. All the scores had improved with 31% good outcomes in the original Strickland score, 77% in the adjusted Strickland score and 87% in the 400-points test. The results were significantly different between the original and adjusted Strickland scores. Good agreement was found between the adjusted Strickland score and the 400-points test. Conclusions: Our results suggest that flexor tendon repair in zone II remains difficult to assess based solely on an analytic test. It should be combined with an objective global hand function test, such as the 400-points test, which appears to correlate with the adjusted Strickland score. Level of Evidence: Level IV (Therapeutic).

Zone 1 and 2 flexor tendon repair via a longitudinal incision crossing the volar distal interphalangeal joint: functional and cosmetic outcomes

INTRODUCTION

The primary aim of this study was to present patient-reported functional outcomes after zone 1 and 2 flexor tendon repair using a novel longitudinal volar approach crossing the distal interphalangeal joint (DIPJ) perpendicularly. The secondary aims were to investigate the cosmetic outcomes, satisfaction and complication rates associated with this technique.

METHODS

Over a 6-year period, 75 patients underwent flexor tendon repair using this technique. The quick version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), five-level EQ-5D (EQ-5D-5L), Patient and Observer Scar Assessment Scale (POSAS) and satisfaction questionnaires were collected. QuickDASH scores were available for 59 patients (79%), and POSAS scores were available for 45 patients (60%) at a mean follow-up of 48 months. Concomitant nerve repairs were undertaken in 24 cases.

RESULTS

The median QuickDASH score was 4.5 (interquartile range [IQR] 1.1-12.5) and median POSAS score was 12 (IQR 8-16). No significant difference was observed in median QuickDASH score between patients with and without a concomitant nerve repair (4.5 vs 6.8; p = 0.36). Fifty-six patients (94%) were satisfied. Two patients required open tenolysis, and a single case of early re-rupture occurred that required revision open repair.

CONCLUSIONS

Utilising validated patient-reported functional outcomes, this study demonstrated that a direct longitudinal incision over the DIPJ for zone 1 and 2 flexor tendon repairs can result in excellent functional and cosmetic outcomes, with high rates of patient satisfaction and low rates of complications. This challenges previously held dogma that longitudinal incisions crossing flexion creases should be avoided.

The Outcomes of Flexor Tendon Injury Repair of the Hand: A Clinico-Epidemiological Study

Background and objective The incidence of flexor tendon injury is estimated to be 7-14 per 100,000 population. In India, such injuries are common and about 5% of these injuries require repair of the flexor tendon. In the present study, we share our experience of hand flexor tendon repair at a tertiary care center in western India. Material and methods Over a period of three years, 45 patients were admitted for tendon repair. After performing a proper evaluation, patients were taken for tendon repair. Primary outcome and secondary outcome parameters were assessed at the end of three months. Physiotherapy was continued for a longer duration in patients with movement restrictions. Data were compiled at each stage. Results The mean age of the patients was 28.84 years (range: 13-68 years) with a majority of the cases belonging to the age group 15-60 years. The majority of hand injuries were accidental (caused by work-related accidents, machine injuries, or animal bites) amounting to 80% (n=36), followed by assault cases (11%, n=5) and self-inflicted injuries, i.e., attempted suicides (around 9%, n=4). Among all injuries, the majority were in zone V (60%, n=27) followed by 24.4% (n=11) of cases in zone II. A few cases were in zone I, III, and IV (2.2%, 11.2%, and 2.2% respectively). The Buck-Gramcko scoring for primary injury was excellent with a recovery rate of 57.78%. Conclusion Flexor tendon injuries should be repaired with the aim of recovering strength as well as mobility. For optimal outcomes, total active motion protocol should be commenced immediately after the surgical repair. However, long-term physiotherapy may be required for attaining desired benefits.

Biomechanical Analysis of a New Eight-Strand Suture for Flexor Tendon Repair

Background The placement of multistrand sutures during flexor tendon repair requires complicated surgical skills; such suturing is difficult. We developed a new, simpler eight-strand suture, which we term the Yoshizu cross-lock. This reduces the numbers of suture passages through the tendons, as well as the numbers of knots.

Methods Fourteen porcine flexor tendons were transected and repaired using the Yoshizu cross-lock system; no peripheral sutures were placed. Our system is a modification of the published, exposed cross-lock repair method that employs a 4–0 monofilament nylon two-strand line and two needles. The repaired tendons were subjected to linear, noncyclic load-to-failure tensile testing. The initial gap, the 2-mm gap force, and the ultimate strength were measured.

Results The initial gap force was 12.6 ± 5.6 Newtons (N), the 2-mm gap force was 33.9 ± 10.9 N, and the ultimate strength was 70.1 ± 17.0 N. All tendons subjected to Yoshizu cross-lock repair failed due to suture rupture rather than pullout.

Conclusions Our biomechanical study revealed that Yoshizu cross-lock repair had sufficient tensile strength but was associated with wide variation in the 2-mm gap load (standard deviation = 10.9 N). This study is clinically relevant, showing that the Yoshizu cross-lock repair combined with peripheral suturing may allow a repaired flexor tendon to withstand the stresses encountered during early active mobilization. This simple eight-strand technique will be particularly useful to surgeons who commonly employ the cross-lock stitch for primary flexor tendon repair following early mobilization.

Trends in digital joint motion following surgical reconstruction of a tendon rupture after distal radius fracture

BACKGROUND

Tendon rupture has been recognized as a complication of distal radius fracture (DRF); however, the clinical outcome of reconstructive surgery for this injury remains unclear. We examined prognostic factors for the outcomes of reconstructive surgery in patients with a tendon rupture after DRF.

METHODS

This study was a retrospective review of a case series. Seventy-five consecutive patients were treated at our institution for tendon rupture after DRF. The cohort included 14 males and 61 females with a mean age of 67.7 years at the time of tendon reconstruction. Sixty-four and eighteen tendon ruptures occurred after non-operative management for DRF and palmar locking plate fixation, respectively. Seven ruptured tendons received a free tendon graft from the palmaris longus tendon, and the others underwent tendon transfers. All patients were managed postoperatively by our hand therapy unit according to a controlled active mobilization regime.

RESULTS

The mean follow-up period was 28 weeks (range: 12-80 weeks). Patients with extensor tendon ruptures were significantly younger than those with flexor tendon ruptures regardless of the initial DRF treatment. The mean percentage active range of motion of the injured digits relative to normal active motion (%AROM) at the final follow-up was 70% (range: 30-101%) in all patients. The %AROM after flexor tendon reconstruction for patients after non-operative management was significantly inferior to that of other patients. Multiple regression analysis revealed that aging and non-operative management of DRF are independent risk factors for poor %AROM.

CONCLUSIONS

This study confirmed that advanced age and non-operative management of DRF were prognostic factors for digital joint motion following surgical reconstruction for tendon rupture. Our results suggest that it may be difficult to achieve good clinical outcomes in elderly patients with tendon ruptures (particularly flexor tendon ruptures) following non-operative management of DRF.

Direct Repair of Flexor Tendons Close to Bony Insertion and Ruptured Collateral Ligaments

Lacerated flexor tendons close to bony junction are commonly repaired using a pullout suture. However, these injuries very close to the tendon-bone junction can be repaired with robust direct suture repair of the proximal tendon stump with the short residual tendon stump and any local tissues such as periosteum and joint volar plate. Subacute or chronic traumatic rupture at the midpart of the collateral ligaments can also be repaired by "refreshing" the divided ligament ends and repairing the ligament stumps to local tissues with multiple sutures often combined with tightening the elongated joint capsule.

Flexor digitorum profundus tendon injuries in Zone 2 repaired with a modified Mantero technique

From January 2010 to January 2017, 81 complete flexor digitorum profundus tendon disruptions in Zones 2B and 2C were treated using the modified Mantero technique. The patients were re-examined at a mean of 62 months (range 30-96) after operation. We analysed outcomes against ages, gender, pulley integrity, associated injuries and follow-up times. The median total range of motion of both interphalangeal joints, distal interphalangeal joint alone and Quick DASH scores were significantly better for the group with pulley vented versus no pulley vented. According to the Strickland and Glogovac criteria, 76 (91%) had excellent or good, five fair and none had poor results. There were no complications except for one deep and one superficial infection at the site of the injury. There were no tendon ruptures and only three patients (3.7%) required secondary tenolysis. The modified Mantero repair is recommended as an alternative in the repair of tendon disruptions in Zone 2B and 2C. The good results and absence of ruptures suggest that the tendon healing and strength of repair are adequate for immediate postoperative motion.Level of evidence: IV.

Investigations into flexor tendon repair: a research journey over three decades

In this article, I review how my team and I addressed clinical concerns in Zone 2 flexor tendon repair, and how major findings in each step of our research were translated into clinical practice. The focus of the article is on the thought processes behind each new investigation, the interpretation of research findings and conclusions drawn from the basic and clinical studies.

Comparison of bridge graft and end-to-side transfer for treatment of closed rupture of the flexor tendons in the little finger

The purpose of this study was to compare the outcomes of bridge tendon grafts and end-to-side tendon transfers for treating closed ruptures of the flexor tendons in Zones 3 to 5 of the little finger. We selected the surgical procedure based on the passive distraction amplitude of the proximal part of the ruptured flexor tendon. Eleven patients comprised the bridge tendon graft group and ten patients comprised the end-to-side tendon transfer group. We found no significant between-group differences in the total active motion, percentage of total active motion, functional assessment by the Strickland and Glogovac criteria and grip strength compared with the unaffected hand. We believe that choosing the surgical procedure after determining the passive distraction amplitude of the ruptured tendon can be useful in clinical practice.Level of evidence: III.

Outcomes of Wide-Awake Flexor Tendon Repairs in 58 Fingers and 9 Thumbs

PURPOSE

The purpose of this study was to present the outcomes of wide-awake flexor tendon repairs in zones 1 and 2 in a major hand trauma referral center.

METHODS

Zone 1 and zone 2 wide-awake flexor tendon repairs performed between August 2018 and March 2020 were analyzed retrospectively. Outcomes were assessed by the original Strickland-Glogovac criteria for fingers and Buck-Gramcko scoring system for thumbs. Further descriptive analysis of the groups according to potential negative factors, such as injury mechanism, concomitant neurovascular injury, and the extent of injury in zone 2, were performed.

RESULTS

A total of 94 tendons were repaired in 67 digits (58 fingers, 9 thumbs) of the 61 patients included in the study. Satisfactory results were achieved in 89.6% of the fingers and 77.8% of the thumbs. Intraoperative gapping was corrected after active digital extension-flexion test in 1 patient. Rupture was seen in 1 patient for a rate of 1.5%. The tenolysis indication rate was 5.1% for fingers and 11.1% for thumbs.

CONCLUSIONS

In our series, functional outcome scores, tenolysis, and rupture rates remained similar with findings in the literature. The outcome of a flexor tendon repair is influenced by many factors that cannot be controlled intraoperatively. To assess the effect of performing the repair in a wide-awake setting on the outcome, clinical trials with large patient groups are needed.

LEVEL OF EVIDENCE

Therapeutic IV.

Outcome measurement in adult flexor tendon injury: A systematic review

BACKGROUND

Defining the optimal, evidence-based management of flexor tendon injury remains challenging. Lack of consensus on which measures to use to assess the outcome of interventions is a key issue, especially with regard to patient-reported outcome measures (PROMs). This systematic review defines the landscape of outcome measurement in studies on interventions for flexor tendon injuries to guide future research.

METHODS

A PRISMA-compliant systematic review was conducted using bespoke search strategies applied to MEDLINE, EMBASE, PsycINFO, CENTRAL, CINAHL and AMED. A protocol was developed and registered prospectively (CRD42020186780). We identified all studies describing adult patients undergoing interventions for acute hand flexor tendon injuries.

RESULTS

Of the 4844 studies, 114 studies met the final inclusion criteria for evaluating the outcomes of 8127 participants with 9071 injured digits. Studies included 24 randomised controlled trials, 19 cohort studies and 61 case series. Nine different PROMs were used in 24 studies (22%): three site-specific PROMs, one generic quality-of-life measure and four visual analogue scales. Clinician-reported outcome measures were used in 103 studies (96%), such as the range of motion reported in 102 studies (94%). Adverse outcomes were reported in 96 studies (89%), with the most frequently reported adverse outcomes being tendon rupture and infection. Re-operation was reported in 21 studies (19%). The most frequently reported health economic outcome measure was the length of work absence, reported in ten studies (9%).

CONCLUSIONS

There is variability in the use of outcome measures used to study interventions for flexor tendon injuries. An independent systematic review of the psychometric properties of the identified outcome measures and a specific multi-stakeholder consensus process may support optimal choice and standardisation for future studies.

Outcomes of staged reconstruction of Zone 2 flexor tendon injuries in recent wide-awake surgical settings and an earlier case series

We report outcomes of patients who were managed with two-stage tendon grafting for neglected Zone 2 flexor tendon injuries from 2012 until 2019. The patients were divided into two cohorts: recent series (Series 1) included patients treated with local anaesthesia and epinephrine (16 fingers, from 2015), and earlier series (Series 2) included patients treated with either general or local intravenous anaesthesia and tourniquet (12 fingers, before 2015). The patients in Series 1 achieved statistically better mean total active motion of the operated fingers and grip compared with the contralateral hand than the earlier series (p = 0.03, p = 0.01, respectively). With the Tang grading system, excellent and good results were achieved in 13 and six fingers of the patients in Series 1 and Series 2, respectively. We conclude that wide-awake second stage of staged flexor tendon grafting provides fine-tuned adjustment of length and tension of the graft, but we cannot conclude about comparative outcomes between two series because the sample size is small and the earlier series was operated by the same surgeons with lower expertise level.Level of evidence: IV.

Flexor tendon repair: recent changes and current methods

The current clinical methods of flexor tendon repair are remarkably different from those used 20 years ago. This article starts with a review of the current methods, followed by presentation of past experience and current status of six eminent hand surgery units from four continents/regions. Many units are using, or are moving toward using, the recent strong (multi-strand) core suture method together with a simpler peripheral suture. Venting of the critical pulleys over less than 2 cm length is safe and favours functional recovery. These repair and recent motion protocols lead to remarkably more reliable repairs, with over 80% good or excellent outcomes achieved rather consistently after Zone 2 repair along with infrequent need of tenolysis. Despite slight variations in repair methods, they all consider general principles and should be followed. Outcomes of Zone 2 repairs are not dissimilar to those in other zones with very low to zero incidence of rupture.

Wide-Awake Approach for Flexor Digitorum Superficialis Tendon Transfer Followed by Early Active Mobilization

Background The standard clinical practice to treat closed ruptures of the flexor digitorum profundus (FDP) tendons includes free tendon grafting; however, it is not suitable when the muscle amplitude of the ruptured FDP is not sufficient. We report outcomes of six patients who underwent flexor digitorum superficialis (FDS) tendon transfer of the ring finger using the wide-awake approach to repair the closed rupture of the FDP tendon of the little finger in zone 3 or 4. Methods The patients were identified by reviewing our institutional billing records from January 2012 to October 2019 for the International Classification of Disease 10 code M66.3 that describes the diagnosis as "spontaneous rupture of flexor tendons." Results The patients comprised two men and four women with an average age of 72.2 years (standard deviation [SD], 8.4 years). All patients were hospitalized after surgery to undergo early active mobilization. The average total active motion at the final evaluation was 201.8° (range: 85-248°). According to Strickland's criteria, outcomes were excellent for two, good for three, and poor for one patient. No patients complained about the ring finger. Conclusion These results suggest that FDS tendon transfer is recommended when the muscle amplitude of the ruptured FDP is insufficient. We believe that the wide-awake approach and early active mobilization may contribute to satisfactory outcomes.

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

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.

Measurement of finger joint motion after flexor tendon repair: smartphone photography compared with traditional goniometry

The purpose of our study was to determine whether smartphone photography is as reliable and valid as clinical goniometry for measuring interphalangeal joint range of motion. We conducted a retrospective review of 37 fingers in 33 patients after flexor tendon repair. The measurements on photographs taken with a smartphone by a surgeon were compared with manual measurements with goniometry by the same surgeon. Pearson coefficients and interclass correlation coefficients were all above 0.85, and Bland-Altman analysis demonstrated that at least 35 of 37 measurements were within the 95% confidence interval in all variables. According to the Tang criteria, the total number of excellent and good results were equivalent according to both methods. There was high interobserver reliability between measurements by surgeons and a therapist. We conclude that if the pictures are properly taken, the measurement of the angles in the smartphone pictures are as reliable as measuring the angles with goniometry and that grading of the results according to the two methods gives identical results.

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.

Investigating the effects of flexor tendon shortening on active range of motion after finger tendon repair

Evaluation of surgical effects is often done using simple cadaver experimentation. This study uses a robotic testbed to estimate the best-case clinical outcomes of flexor tendon shortening during repair surgery on cadaver hands. Nine fresh-frozen cadaver subjects were connected to an extrinsic index finger robotic muscle testbed and measurement system. The flexor digitorum profundus tendons were severed and surgically repaired at different shortening levels. The index finger's extrinsic tendons were robotically actuated using Hill-type muscle models to emulate the muscle force-length relationships. Extensor muscles were then activated to estimate the active range of motion (ROM) of the all-finger joints after surgery. The effects of metacarpophalangeal (MCP) joint extension limits and extensor muscle activation were also investigated. The resulting interphalangeal joint ROM was clinically graded. Active ROM of the finger decreases as tendon shortening increases ( η p 2 = 0.92 ), like passive ROM. This results in a clinical reduction of functionality grade from excellent to good at 10 mm of shortening. Blocking MCP joint ROM and extensor activation also showed significant effects on recovered ROM ( η p 2 = 0.72 and 0.86). Significant two-way interactions were also observed between shortening and MCP joint blocking ( η p 2 = 0.80 ) and between shortening and extensor activation ( η p 2 = 0.78 ). Results support clinical recommendations of limiting shortening to 10 mm. While this article provides additional experimental evidence for current surgical recommendations, it also validates a new robotic-cadaver methodology for predicting active hand recovery in terms of clinical measurements.

Early active mobilization after primary repair of the flexor pollicis longus tendon

BACKGROUND

There have been few studies regarding primary flexor tendon repair of the thumb following early active mobilization, whereas there have been multiple such studies of the finger. This study examined the outcomes of patients who underwent early active mobilization after primary repair of the flexor pollicis longus tendon.

METHODS

This study was a retrospective case series. Between 1993 and 2019, 17 thumbs of 17 consecutive patients with complete flexor pollicis longus tendon lacerations were treated using the Yoshizu #1 technique, followed by early active mobilization. The mean time between injury and primary flexor tendon repair was 2 days. Two thumbs had zone T1 injuries and 15 had zone T2 injuries. Mobilization of the thumb began on the first postoperative day with a combination of active extension and passive and active flexion. The mean follow-up period was 8 months. The percentage of total active motion of the thumb was regarded as the sum of the active motion of the two joints, divided by 140°. Functional outcomes were graded in accordance with the Strickland criteria.

RESULTS

Three repair ruptures occurred in thumbs treated by inexperienced surgeons. Excluding tendon ruptures, the mean percentage of total active motion of the thumb was 83%. The mean active flexion of the interphalangeal and metacarpophalangeal joints was 62° and 64°. The mean extension deficit was 8.8° at the interphalangeal joint and 7.5° at the metacarpophalangeal joint. According to Strickland's criteria, repairs to eight thumbs were ranked excellent, three were good, one was fair, and five were poor.

CONCLUSIONS

Our results are not inferior to the findings of previous reports regarding early postoperative mobilization after primary flexor pollicis longus tendon repair, in terms of the acquisition of active thumb motion. Poor outcomes result from repair rupture and increased extension deficits of the interphalangeal and metacarpophalangeal joints.

Ultrasonographic assessment in vivo of the excursion and tension of flexor digitorum profundus tendon on different rehabilitation protocols after tendon repair

STUDY DESIGN

Interpretive description study.

PURPOSE

In management of patients with flexion tendon injuries, passive, control active and active motion protocols were proposed after repair to minimize tendon adhesion. The purpose of this study was to compare the excursion distance and the tension of Flexor Digitorum Profundus (FDP) during simulated active and passive motion using ultrasonography techniques using normal subjects.

METHODS

Ultrasonographic assessment of FDP tendon of the middle finger was performed at the wrist level on 20 healthy college students using 3 types of treatment protocols: modified Kleinert protocol, modified Duran protocol, and active finger flexion protocol. The excursion distance was measured following the musculotendinous junction of FDP using the B mode ultrasound system. The elasticity of FDP tendon was measured using the shear wave elastography technique. The excursion distance and the elasticity value were compared among 3 protocols using one-way ANOVA analysis.

RESULTS

Twelve male and 8 female students with mean age of 22.6 ± 1.8 years were invited to join the study. The excursion distance of FDP was 21.82 ± 3.77 mm using the active finger flexion protocol, 8.59 ± 2.59 mm using the modified Duran protocol, and 12.26 ± 2.71 mm using the modified Kleinert protocol. The elasticity was significantly higher in extension position when compared to passive flexion positions, but found lower than active flexion position.

DISCUSSION

The active finger protocol was found to require strongest tension of the tendon and with longest excursion. There was similar tension generated using both passive motion protocols. The modified Duran protocol appeared to create less excursion upon movements than the modified Kleinert approach using the objective ultrasonic evaluation. It is suggested that if the surgical repair was strong and without any complications, the active flexion protocol might work best to regain tension excursion. However, if there are complex problems involved, then the Kleinert approach or Duran approach would be chosen.

Effects of Different Core Suture Lengths on Tensile Strength of Multiple-Strand Sutures for Flexor Tendon Repair

Purpose

To compare 2 types of newly devised 8-strand quadruple-looped suture (QLS) techniques with a 6-strand triple-looped suture (TLS) technique; and to assess the effects of different core suture lengths (CSLs) (the length between 2 locking sites of a suture strand) within each suture row on tensile strength.

Methods

We repaired 24 flexor tendons from 12 rabbits using the TLS and QLS techniques, with equal CSL (QLS) or unequal CSL (unequal QLS) among each suture row. The QLS was composed of 4 looped sutures on the anterolateral and posterolateral aspects of the tendon. The cross-sectional area of the locking portion of each thread in the QLS was equal to that in the TLS. In the QLS technique, the CSL on each aspect of the tendon was 13 mm. In the unequal QLS technique, the CSL on each aspect of the tendon was 13 and 17 mm. The load at 1- and 2-mm gaps, the maximum load until the 3-mm gap, and the ultimate load were compared among the 3 techniques.

Results

The QLS was significantly stronger than the unequal QLS and the TLS for loads at 1-mm and 2-mm gaps, maximum load until 3-mm gap, and ultimate load. There was no significant difference between the unequal QLS and TLS techniques. The QLS technique showed an approximately 30% increase in gap resistance and ultimate strength compared with the TLS technique.

Conclusions

The QLS technique showed an estimated increase in tensile strength proportional to the number of suture strands compared with the TLS technique. Our study suggests that a consistent CSL in each suture row provides the highest strength in multistrand sutures consisting of the same configuration of suture rows.

Clinical relevance

The QLS technique may reduce the risk for tendon rupture associated with early active mobilization after flexor tendon repair.

Flexor digitorum profundus with or without flexor digitorum superficialis tendon repair in acute Zone 2B injuries

A total of 53 patients with complete cuts of two flexor tendons in Zone 2B treated over a 9-year period was reviewed. Twenty-three patients (28 fingers) had only flexor digitorum profundus repair, while 30 patients (36 fingers) had both flexor digitorum profundus and flexor digitorum superficialis repairs, with a mean follow-up of 21 months (range 12-84). The decision to repair the flexor digitorum superficialis was made according to intraoperative judgement of ease of repair and gliding of the flexor digitorum profundus tendon. Two groups of patients showed no significant differences in total range of active or passive digital motion and power grip percentage to the contralateral hand. However, the values of power grip were statistically superior in the patients with both tendons repaired. The patients after flexor digitorum profundus-only repairs showed significantly greater but still mild flexion contracture (mean 20 °) of the operated digits. The Tang gradings were the same with 89% good and excellent rates in both groups. The conclusion is that although repair of both flexor digitorum profundus and flexor digitorum superficialis tendons is slightly more preferable based on increased grip strength, the repair of the flexor digitorum superficialis together with flexor digitorum profundus is not mandatory. Whether or not to repair flexor digitorum superficialis is an intraoperative decision based on the ease of gliding of the repaired tendon(s).Level of evidence: III.

Effect of Time to Hand Therapy following Zone II Flexor Tendon Repair

This population-based study aimed to define how time to hand therapy following isolated zone II flexor tendon repairs impacts complications and secondary procedures.

METHODS

Insurance claims from the Truven MarketScan Databases were used to evaluate outcomes after isolated zone II flexor tendon repairs between January 2009 and October 2015. Cohorts differing in time to hand therapy were compared to evaluate the impact on complications, reoperation, and number of therapy sessions. Secondary outcomes analyzed how the number of therapy sessions affected rates of reoperation.

RESULTS

Hand therapy was identified in 82% of patients (N = 2867) following tendon reconstruction. Therapy initiation occurred within 1 week, 1-4 weeks, and after 4 weeks in 56%, 35%, and 9% of patients, respectively. Univariate analysis showed no difference in non-tendinous complications (27%, 30%, 29%; P = 0.29) or tendon rupture rates (13%, 13%, 10%; P = 0.42) within 90 days between cohorts. Multivariable analysis showed no difference in rates of tenolysis (6.3%, 6%, 4.4%; P > 0.01). In the early initiation cohort, >23 hand therapy sessions were associated with the highest rates of tenolysis (19%).

CONCLUSIONS

Despite being a common fear of hand surgeons, early initiation of hand therapy was not associated with increased tendon rupture rates. Although delayed therapy is a concern for tendon scarring, it did not confer a higher risk of tenolysis. Complication rates do not appear to correlate with timing of hand therapy. Therefore, hand surgeons should promote early mobility following isolated flexor tendon injuries given the known functional outcome benefits.

The Economic Impact of Flexor Tendon Lacerations of the Hand in the United States

PURPOSE

Flexor tendon lacerations are a common and debilitating injury for thousands of Americans annually. Despite this, no study has attempted to estimate the economic impact of these injuries. The objective of this study was to estimate the economic impact of flexor tendon lacerations in America.

METHODS

The cost of flexor tendon lacerations to society was estimated using a validated prevalence-based cost of illness model. The primary cohort was defined as all patients in the United States presenting with complete flexor tendon lacerations who underwent surgical repair. The secondary cohort was defined by all patients who required reoperation within 1 year of their initial operation. For these groups, both direct and indirect costs (lost income, missed workdays, and disability payments) were measured.

RESULTS

Flexor tendon lacerations incur an estimated cost of between US $240.8 and US $409.1 million annually to the American medical system. The total direct cost per injury is estimated to be US $13,725, whereas estimates to the indirect costs range from US $60,786 to US $112,888.

CONCLUSIONS

Flexor tendon lacerations represent an important economic burden to our health care system, even when compared with other common hand conditions. Specifically, indirect costs, such as missed workdays, are the major contributor toward the total cost these injuries incur on society, accounting for upward of 89% of the total cost. This suggests that we should focus our efforts to improve treatments and rehabilitation protocols which decrease these indirect costs.

Arthroscopic realignment and osteosynthesis of unstable scaphoid nonunion with cancellous bone graft from the ipsilateral radius

PURPOSE

The treatment of delayed union and established nonunion of the scaphoid using a volar approach with impaction of bone graft, either a cancellous or cortico-cancellous wedge graft, for osteosynthesis and maintenance of reduction. With the advancement of instruments and techniques of wrist arthroscopy, wider indications for wrist problems can be solved by this minimally invasive technique. We report our results of arthroscopic reduction, cancellous bone grafting to the regional distal radius, and headless screw fixation for the treatment of scaphoid nonunion, even with humpback deformity.

METHODS

Between August 2014 and February 2018, 41 patients (42 wrists) with unstable scaphoid nonunion received arthroscopic surgery. The mean follow-up was 38.1 months (range 24-70 months). We evaluated the results with a function questionnaire and clinical outcomes based on the visual analog scale (VAS) pain score, range of motion and grip strength, and radiologic measurements.

RESULTS

The union rate was 92.6% (38/41 patients) and union time was 4.6 months. Patients regained almost a full range of motion compared with the contralateral wrist. The post-op Quick DASH, Mayo wrist score, and VAS pain score all had significant improvement, with p < 0.05. The scapholunate angle showed significant correction from pre-op 68.0° to post-op 58.3°. The average VAS satisfaction score at final follow-up was 8.7.

CONCLUSION

Arthroscopic realignment and osteosynthesis for the treatment of unstable scaphoid nonunion with ipsilateral radius bone graft, even with humpback deformity, can achieve a high union rate, good radiological correction, and good functional recovery.

A Global View of Digital Replantation and Revascularization

Survival rates of digital replantation vary in different regions and countries, and Asian surgeons see more challenging cases and have developed some unique methods. Replantation of multiple digits in one or both hands can follow a structure-by-structure method or a digit-by-digit method. For replanting all 10 digits, 3 or 4 teams should be organized. Flow-through flaps, often venous flaps, can be taken from the distal forearm or lower extremity to repair defects of soft tissues and arteries. A pedicled digital artery flap from the adjacent digit can also repair tissue defects and supply blood to the replanted digit.

Tenolysis rate after zone 2 flexor tendon repairs

Objectives

This study aims to evaluate the tenolysis rates of zone 2 flexor digitorum profundus (FDP) with flexor digitorum superficialis (FDS) tendon repairs using four-strand technique and early passive motion exercises.

Patients and methods

In this retrospective study, we performed zone 2 flexor tendon repairs in 149 patients (117 males, 32 females, mean age 33.3±12.9 years; range, 13 to 72 years) (82 right and 67 left hands) between November 2014 and January 2019. A total of 194 FDP and FDS tendons were repaired primarily by using modified Kessler and Bunnell methods. Patients underwent pure passive motion protocols after surgery according to modified Duran’s protocol. No active flexion components were added until postoperative fourth week.

Results

Twenty-three out of 149 patients and 28 out of 194 fingers (14.43%) had tenolysis. There was no significant relationship between the number of operated fingers, gender, and tenolysis rate (p=0.836, p=0.584, respectively).

Conclusion

The repair of the FDP with FDS tendon increases the tenolysis rate in zone 2. The tenolysis rate does not change according to the number or distribution of injured fingers and gender of the patient.

The outcome of minimally invasive surgery for digital mucous cyst: a 2-year follow-up of percutaneous capsulotomy

Background: Digital mucous cyst(DMC) is the most common tumor or cyst of the hand. Although many operative methods have been proposed to treat DMCs and lower the recurrence rate, many patients hesitate to have surgery. A minimally invasive treatment using percutaneous capsulotomy for the DMCs could be an alternative choice. However, the clinical results of using this method are still uncertain.Objectives: Here, we introduce the percutaneous capsulotomy method and assess the clinical outcomes and the associated complications of this method. Methods: A total of 42 digits were finally included. All patients accepted percutaneous capsulotomy under a digital ring block. Functional and radiographic assessments were made pre- and postoperatively, with a mean of 28.8 months (range, 24-33 months) of follow-up. Results: The mean duration of the appearance of DMCs before treatment was 11.6 months. Of the 19 digits with nail deformity, 14 showed an improved nail appearance. There were no skin complications. The average visual analogue scale (VAS) satisfaction score was 9.4, only two cases had experienced recurrence at the final follow up. Conclusions: This study reported that percutaneous capsulotomy could be an effective method for DMCs treatment. The recurrence rate was low and patient satisfaction was good. Nail deformities could be improved with treatment.

Flexor Tendon Grafting Using Extrasynovial Tendons Followed by Early Active Mobilization

Purpose

This study evaluated the outcomes of early active mobilization after flexor tendon grafts using extrasynovial tendons with a novel distal fixation technique.

Methods

This study was a retrospective case series. The flexor digitorum profundus (FDP) tendons of 7 digits in 7 patients were reconstructed with extrasynovial tendons, which included the palmaris longs, plantaris, and extensor digitorum longus, in a single- or 2-stage procedure between 2008 and 2017. Of the 7 patients, 6 were male and the average patient age was 48 years. The injuries involved 2 middle, 2 ring, and 3 little fingers. The tendons were sutured into the appropriate FDP tendon proximally using end-weave anastomosis; the distal end of the graft was fixed to the distal stump of the FDP using an interlacing suture or a small bone anchor combined with the pull-through technique. The digits were mobilized with a combination of active extension and passive and active flexion in a protective orthosis during the first 6 weeks after surgery. Average follow-up was 18 months. We measured active and passive digit motion both before tendon grafting and at the final evaluation. Outcomes were graded by the LaSalle formula to assess staged flexor tendon reconstruction.

Results

Average passive range of motion (ROM) of the proximal and distal interphalangeal joints before flexor tendon grafting was 146° (SD, 22°). Mean active ROM of these joints at the final evaluation was 123° (SD, 34°). Using the LaSalle formula, mean recovery of active motion was 83%. We encountered no grafted tendon rupture and no finger required tenolysis.

Conclusions

Our proximal and distal fixation techniques allowed the autologous extrasynovial tendon grafts to withstand the stress encountered during early active mobilization with good postoperative ROM and minimal complications.

Type of study/level of evidence

Therapeutic I.

Outcomes of 200 digital flexor tendon repairs using updated protocols and 30 repairs using an old protocol: experience over 7 years

We reviewed outcomes of 230 flexor tendon repairs in 27 thumbs and 203 fingers in Zone 1 and 2 over 7 years. In 2013, we used a 2-strand modified Kessler method followed by passive motion exercise in repairing flexor digitorum profundus tendon injuries in Zone 2 in 30 fingers; 24 fingers were followed, five (26%) had repair ruptures. Between 2014 and 2017, we used a 4- or 6-strand method to repair 111 flexor digitorum profundus tendons in Zone 2, followed by true early active motion. Two had repair ruptures. Among 101 fingers followed over 6 months, two fingers had tenolysis and 87 (87%) good or excellent outcomes. In 2018 to 2019, we used a 6-strand method to repair 42 flexor digitorum profundus tendons in Zone 2 with out-of-splint early active motion. None had repair ruptures or tenolysis. From 2014 to 2019, 27 flexor pollicis longus tendons were repaired in Zone 1 or 2, and 20 fingers had end-to-end flexor digitorum profundus repairs in Zone 1; none had repair ruptures or tenolysis. We conclude that a strong repair and true active motion are necessary for best outcomes of flexor tendon repairs in the thumb and fingers, and out-of-splint true active motion is safe.

Long-term results of modified ligament reconstruction and tendon interposition for thumb basal joint arthritis

BACKGROUND

Thumb basal joint arthritis is a common, disabling condition of the hand. Ligament reconstruction and tendon interposition (LRTI) is one of the more common surgical solutions. We performed a retrospective study to evaluate long-term radiological and clinical outcomes of modified LRTI procedures in treating thumb basal joint arthritis.

METHODS

A total of 91 hands (84 patients) with full chart records were enrolled in this study. The average age was 65.4 years, and the mean follow-up was 11.7 years (range, 1-21.6 years). We evaluated pain, joint stability, power-grip and key pinch strength, and thumb radial abduction angle as the functional outcomes, and measured the height of the trapezial space as the radiographic result.

RESULTS

There were 66 and 23 hands with excellent and good results, respectively. The diminution of the trapezial space was 4.2 mm in the stage III group and 5.2 mm in the stage IV group. Power-grip and key pinch strength, and thumb radial abduction angle were better in those with stage III than in those with stage IV arthritis. Sixty-eight hands were followed up >5 years, and of them, 66 showed excellent or good results.

CONCLUSION

With good and durable surgical outcomes, the modified LRTI procedure could be a good treatment for thumb basal joint arthritis.

Surgical Repair of an Avulsed Distal Flexor Carpi Radialis Tendon in a Boxer: A Case Report

CASE

A 25-year-old professional boxer presented with a right distal flexor carpi radialis (FCR) tendon avulsion after sustaining an injury while boxing. The avulsion was identified and confirmed with magnetic resonance imaging, and the tendon was successfully reinserted into the trapezium. The patient returned to professional boxing 10 months later without complication.

CONCLUSIONS

Distal FCR tendon avulsions are rare. Occasionally, this tendon can avulse after an application of excessive force. For some patients, unrepaired distal FCR tendon avulsions may prevent competitive performance. In this case, the tendon was reattached to the trapezium to aid wrist motion and stability, which are essential for professional boxing.

Incidence of tenolysis and features of adhesions in the digital flexor tendons after multi-strand repair and early active motion

We report seven patients requiring tenolysis after primary or delayed primary flexor tendon repair and early active mobilization out of 148 fingers of 132 consecutive patients with Zone 1 or 2 injuries from 1993 to 2017. Three fingers had Zone 2A, two Zone 2B, and two Zone 2C injuries. Two fingers underwent tenolysis at Week 4 or 6 after repair because of suspected repair rupture. The other five fingers had tenolysis 12 weeks after repair. Adhesions were moderately dense between the flexor digitorum superficialis and profundus tendons or with the pulleys. According to the Strickland and Tang criteria, the outcomes were excellent in one finger, good in four, fair in one, and poor in one. Fingers requiring tenolysis after early active motion were 5% of the 148 fingers so treated. Indications for tenolysis were to achieve a full range of active motion in the patients rated good or improvement of range of active motion of the patients rated poor or fair. Not all of our patients with poor or fair outcomes wanted to have tenolysis. Level of evidence: IV.