Flexor tendon repair rehabilitation protocols: a systematic review

The value of local dexmedetomidine as an adjuvant to ultrasound-guided wide awake local anesthesia no tourniquet (WALANT) in flexor tendon repair surgeries: a randomized controlled trial

BACKGROUND

The Wide-Awake Local Anesthesia No Tourniquet (WALANT) technique allows intraoperative motor assessment of tendon repair integrity of the hand compared with general anesthesia or brachial plexus block. No studies have tested the effect of adding dexmedetomidine to lidocaine on the analgesic properties of the WALANT technique, which is the aim of our study.

METHODS

A total of 128 patients aged more than 18 years were scheduled for surgical flexor tendon injury repair using WALANT technique. Patients were divided into two equal groups. Ultrasound-guided subcutaneous injection of lidocaine 1% with dexmedetomidine (1 µg/kg), Group D, or without dexmedetomidine, Group C, was performed at four points: proximal to the wrist joint, the distal forearm, palm region, and proximal phalanges. The primary outcome was total morphine consumption throughout the first postoperative day. Secondary outcomes included number of patients requiring rescue analgesia, time to first analgesic request, and pain score.

RESULTS

Total morphine consumption was significantly (P < 0.001) lower in group D (2.66 ± 0.998) than in group C (3.66 ± 1.144) mg. Number of patients requiring rescue analgesia was significantly (P < 0.001) lower in group D (54.7% (35)) than group C (100.0% (64)). The time for first request for analgesia was significantly (P < 0.001) longer in group D (11.31 ± 6.944) than in group C (5.91 ± 4.839) h. Pain score was significantly higher in group C than D at three (P < 0.001), and six (P = 0.001) hours (P = 0.001) postoperatively.

CONCLUSION

Dexmedetomidine significantly improves the analgesic quality of WALANT when added to lidocaine with less opioid consumption.

TRIAL REGISTRATION

(ID: PACTR202203906027106; Date: 31/07/2023).

A Lightweight Dynamic Hand Orthosis With Sequential Joint Flexion Movement for Postoperative Rehabilitation of Flexor Tendon Repair Surgery

During the postoperative hand rehabilitation period, it is recommended that the repaired flexor tendons be continuously glided with sufficient tendon excursion and carefully managed protection to prevent adhesion with adjacent tissues. Thus, finger joints should be passively mobilized through a wide range of motion (ROM) with physiotherapy. During passive mobilization, sequential flexion of the metacarpophalangeal (MCP) joint followed by the proximal interphalangeal (PIP) joint is recommended for maximizing tendon excursion. This paper presents a lightweight device for postoperative flexor tendon rehabilitation that uses a single motor to achieve sequential joint flexion movement. The device consists of an orthosis, a cable, and a single motor. The degree of spatial stiffness and cable path of the orthosis were designed to apply a flexion moment to the MCP joint prior to the PIP joint. The device was tested on both healthy individuals and a patient who had undergone flexor tendon repair surgery, and both flexion and extension movement could be achieved with a wide ROM and sequential joint flexion movement using a single motor.

Current clinical opinion on surgical approaches and rehabilitation of hand flexor tendon injury-a questionnaire study

The management of flexor tendon injury has seen many iterations over the years, but more substantial innovations in practice have been sadly lacking. The aim of this study was to investigate the current practice of flexor tendon injury management, and variation in practice from the previous reports, most troublesome complications, and whether there was a clinical interest in potential innovative tendon repair technologies. An online survey was distributed via the British Society for Surgery of the Hand (BSSH) and a total of 132 responses were collected anonymously. Results showed that although most surgeons followed the current medical recommendation based on the literature, a significant number of surgeons still employed more conventional treatments in clinic, such as general anesthesia, ineffective tendon retrieval techniques, and passive rehabilitation. Complications including adhesion formation and re-rupture remained persistent. The interest in new approaches such as use of minimally invasive instruments, biodegradable materials and additive manufactured devices was not strong, however the surgeons were potentially open to more effective and economic solutions.

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.

Investigation of the barriers to and functional outcomes of telerehabilitation in patients with hand injury

BACKGROUND

Telerehabilitation is an approach that is growing in importance and rapidly becoming more prevalent. However, the potential barriers to this approach and its effectiveness relative to face-to-face treatment still need to be determined.

PURPOSE

The aim of this study was to investigate the technology and access barriers, implementation and organizational challenges, and communication barriers faced by patients undergoing postoperative telerehabilitation after hand tendon repair surgery. It also aimed to investigate the effect of telerehabilitation on pain, kinesiophobia, and functional outcomes.

STUDY DESIGN

Prospective, open-label, nonrandomized comparative clinical study.

METHODS

The study was conducted with 44 patients who underwent tendon repair surgery due to tendon injuries of the extrinsic muscles of the hand. Participants were divided into two groups (face-to-face group and telerehabilitation group). All participants received three physiotherapy sessions per week for 8 weeks from their surgery (via video conference using mobile phones to the telerehabilitation group). An early passive motion protocol was applied for flexor tendon and zone 5-7 extensor tendon repairs. Mallet finger rehabilitation was performed for zone 2 extensor tendon repairs, while an early active short arc approach was used for zone 3-4 repairs. The telerehabilitation and face-to-face groups received the same treatment protocols three times a week. In the eighth week of treatment (in the 24th session), the Turkish version of the Arm, Shoulder, and Hand Injury Questionnaire (DASH-T) and Tampa Scale for Kinesiophobia were administered to all patients. The telerehabilitation group also underwent a barrier questionnaire. A pretreatment assessment could not be conducted. The independent-sample t-test was used for DASH-T data, and the Mann-Whitney U-test was used for Tampa Scale for Kinesiophobia to compare groups.

RESULTS

In the study, there were 24 participants (age: 31.58 ± 12.02 years) in the face-to-face group and 20 participants (age: 39.25 ± 12.72 years) in the telerehabilitation group. The two groups were similar in terms of DASH-T and pain (p = 0.103, effect size = 0.647, and p = 0.086, effect size = 0.652, respectively) in the 8 weeks. However, the telerehabilitation group had a higher fear of movement (p = 0.017, effect size = 3.265). The most common barriers to telerehabilitation practices were the fear of damaging the tendon repair and the need for help during the treatment.

CONCLUSIONS

We determined that face-to-face treatment in acute physiotherapy for patients who have undergone tendon repair may be more effective compared to telerehabilitation, as it appears to be less likely to induce kinesiophobia. However, in situations where face-to-face treatment is not possible (such as lockdown), telerehabilitation can also be preferred after at least one in-person session to teach and perform exercises.

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.

Current rehabilitation recommendations following primary triangular fibrocartilage complex foveal repair surgery: A survey of Australian hand therapists

BACKGROUND

Following injury to the Triangular Fibrocartilage Complex (TFCC), foveal repair surgery may be indicated to restore joint stability and function. Protection of the repaired ligament is a clinical consideration during post-surgical rehabilitation, although no "gold standard" rehabilitation protocol currently exists.

PURPOSE

To describe the professional opinions of Accredited Hand Therapists (AHT) regarding post-operative rehabilitation recommendations following TFCC foveal repair surgery.

STUDY DESIGN

Cross-sectional descriptive study.

METHODS

All Australian AHTs were invited to complete a quantitative, online, 10-item survey between December 2019 and March 2020. The survey included questions regarding clinical recommendations for wrist and forearm immobilization, range of motion and exercise methods, and timeframes. AHT characteristics and experience of patients sustaining a TFCC re-rupture were also collected. Categorical and nominal survey responses were reported descriptively and effects of AHT characteristics on survey responses were assessed using Pearson Chi2, with significance set to <0.05.

RESULTS

Survey responses were received from 135 AHTs or approximately 37% of the available population at the time of completion (March 2020). Recommendations for post-surgery immobilization ranged from "not required" to 8 weeks, 6 weeks representing the most common answer. Wrist and forearm range of motion commencement time ranged from "immediately" to "later than 8 weeks," with 6 weeks also the most common answer. When asked whether post-surgery rupture had been experienced in their respective patient groups, 15 therapists (11%) indicated "Yes." The most recommended thermoplastic orthosis was a Sugartong orthosis (41%) followed by a Muenster orthosis (30%), both of which immobilizes the wrist and forearm.

CONCLUSIONS

Rehabilitation varied widely between AHTs. Further prospective research is recommended to explore whether patient-related or rehabilitation factors influence outcomes following TFCC repair.

Flexor Tendon Zone II Repair

Background

Flexor-tendon injury is a historically challenging problem for orthopaedic surgeons. Much research has been dedicated to finding solutions that offer balance in terms of the strength and ease of the repair versus the rate of complications such as adhesions. The number of core sutures, distance from the tendon edge, and use of an epitendinous stitch have been shown to affect repair strength1-4. A number of configurations have been described for the placement of the suture; however, none has been identified as a clear gold standard5. This article will highlight the preferred tendon repair technique of the senior author (R.J.S.), the Strickland repair with a simple running epitendinous stitch. Relevant anatomy, indications, operative technique, and postoperative management will be discussed.

Description

The flexor tendon is typically accessed via extension of the laceration that caused the initial injury. After the neurovascular structures and pulleys are assessed, the tendon is cleaned and prepared for repair. A 3-0 braided nylon suture is utilized for the 4-core strand repair and placed in the Strickland fashion. A 5-0 polypropylene suture is then utilized for the simple running epitendinous stitch.

Alternatives

Multiple alternative techniques have been described. These vary in the number of core strands, the repair configuration, the suture caliber, and the use of an epitendinous or other suture. Nonoperative treatment is typically reserved for partial flexor-tendon laceration, as complete tendon discontinuity will not heal and requires surgical intervention.

Rationale

The 4-core strand configuration has been well established to increase the strength of the repair as compared with 2-core strand configurations, while also being easier to accomplish and with less suture burden than other techniques1. The presently described technique has excellent repair strength and can allow for early active range of motion, which is critical to reduce the risk of postoperative adhesions and stiffness.

Expected Outcomes

Excellent outcomes have been demonstrated for primary flexor-tendon repair if performed soon after the injury1,2,6,7. Delayed repair may lead to adhesions and poor tendon healing8. Early postoperative rehabilitation is vital for success9. There are advocates for either active or passive protocols10-12. The protocol at our institution is to begin early active place-and-hold therapy at 3 to 5 days postoperatively, which has been shown in the literature to provide improved finger motion as compared with passive-motion therapy13-16.Important Tips:: The proximal end of the tendon may need to be retrieved via a separate incision if it is not accessible through the flexor-tendon sheath.The proximal end of the tendon may be held in place with a 25-gauge needle in order to best place sutures into both ends of the tendon.The epitendinous suture is run around the back wall before the core sutures are tied down, in order to prevent the tendon and repair from bunching up and becoming overly bulky.The entire A4 pulley and the distal A2 pulley can be divided for exposure if necessary.Up to 2 cm of the flexor-tendon sheath can be divided.If there are concomitant digital nerve injuries, repair these after the tendon, in order to avoid damaging the more delicate nerve repair while manipulating the tendon for repair.The most common major complications following tendon repair are formation of adhesions and rerupture. Acronyms and Abbreviations:: FDS = flexor digitorum superficialisFDP = flexor digitorum profundusMCP = metacarpophalangealPIP = proximal interphalangealDIP = distal interphalangeal.

Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study

The aim of this study was to compare an early active motion (EAM) regimen to a modified Kleinert passive motion therapy in Zone 2 flexor tendon injuries with regards to range of motion (ROM), grip strength and patient-reported outcome measures (PROMs). Seventy-two patients were included. At 3 months postoperatively, we found no difference in total active motion (TAM) between the EAM and the Kleinert groups (median 195.5°, range 115°-273° versus median 191.5°, range 113°-260°), but a significantly better grip strength (median 76%, range 44%-99% versus median 54%, range 19%-101%; p < 0.0005) in the EAM group. Disabilities of the Arm, Shoulder and Hand (DASH) score as well as patient-reported weakness, cold intolerance and problems in daily activities also favoured the EAM group. At 12 months postoperatively, there was no difference in TAM, grip strength or any of the PROMs used. We conclude that EAM leads to a quicker recovery in terms of grip strength and PROMs, but that both regimens lead to similar results at 12 months.Level of evidence: I.

Volar Scapholunate Interosseous Ligament Reconstruction in Acute Traumatic Wrist: A Review of Volar-Based Repairs/Reconstructions

The volar scapholunate interosseous ligament is an important stabilizer of the wrist. In 2015, van Kampen et al described the technique for reconstruction of an isolated palmar injury using a long radiolunate ligament in the subacute or chronic setting; however, its use has not been described in the acute, traumatic setting. We describe the use of their technique in a 22-year-old man who presented with a traumatic right open transradiocarpal disarticulation with underlying bony, tendinous, ligamentous, and neurovascular injuries secondary to a motor vehicle accident. At 3 months after surgery, the patient had improved range of motion, no pain, normal scapholunate angle at 59.6°, and no scapholunate gap.

Hand Flexor Tendon Repair: From Biology to Surgery and Rehabilitation

Tendon biology and anatomy are crucial to manage hand flexor tendon injuries, not only for surgical treatment but also for rehabilitation; surgeon and physical therapist have to choose zone by zone the best way to manage and restore the normal function of hand flexor tendons.

Systematic review: Zone IV extensor tendon early active mobilization programs

STUDY DESIGN

Systematic review INTRODUCTION: Early active mobilization (EAM) of tendon repairs is preferred to immobilization or passive mobilization. Several EAM approaches are available to therapists; however, the most efficacious for use after zone IV extensor tendon repairs has not been established.

PURPOSE OF THE STUDY

To determine if an optimal EAM approach can be identified for use after zone IV extensor tendon repairs based on current available evidence.

METHODS

Database searching was undertaken on May 25, 2022 using MEDLINE, Embase, and Emcare with further citation searching of published systematic/scoping reviews and searching of the Australian New Zealand Clinical Trials Registry, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials. Studies involving adults with repaired finger zone IV extensor tendons, managed with an EAM program, were included. Critical appraisal using the Structured Effectiveness Quality Evaluation Scale was performed.

RESULTS

Eleven studies were included, two were of moderate methodological quality, and the remainder was low. Two studies reported results specific to zone IV repairs. Most studies utilized relative motion extension (RME) programs; two utilized a Norwich program, and two other programs were described. High proportions of "good" and "excellent" range of motion (ROM) outcomes were reported. There were no tendon ruptures in the RME or Norwich programs; small numbers of ruptures were reported in other programs.

CONCLUSIONS

The included studies reported minimal data on outcomes specific to zone IV extensor tendon repairs. Most studies reported on the outcomes for RME programs which appeared to provide good ROM outcomes with low levels of complications. The evidence obtained in this review was insufficient to determine the optimal EAM program after zone IV extensor tendon repair. It is recommended that future research focus specifically on outcomes of zone IV extensor tendon repairs.

LEVEL OF EVIDENCE

I.

Patients' experiences of flexor tendon rehabilitation in relation to adherence: a qualitative study

PURPOSE

To explore patients' experiences of early active motion flexor tendon rehabilitation in relation to adherence to restrictions and outcome of rehabilitation.

METHOD

Seventeen patients with a flexor tendon injury in one or several fingers participated in qualitative interviews performed between 74 and 111 days after surgery. Data were analysed using directed content analysis with the Health Belief Model (HBM) as a theoretical framework.

RESULTS

Perceived severity of hand function and susceptibility to loss of hand function affected the participants' behaviour. A higher perceived threat increased motivation to exercise and be cautious in activities. During rehabilitation, the perceived benefits or efficacy of doing exercise and following restrictions were compared to the cost of doing so, leading to adherence or non-adherence behaviour. Perceived self-efficacy was affected by previous knowledge and varied through the rehabilitation period. External factors and interaction with therapists influenced the perception of the severity of the injury and the cost and benefits of adhering to rehabilitation.

CONCLUSION

Patient's perception of the injury, the effectiveness of exercises, context and social support to manage daily life affected adherence to restriction, motivation and commitment to rehabilitation. The HBM as a theoretical framework can be beneficial for understanding factors that influence patients' adherence.Implications for RehabilitationInformation regarding the injury and consequences for the patient should be presented at different time points and in different ways, tailored to the patient.It' is important to aid patients to perceive the small gradual improvements in hand function to create motivation to adhere to exercise.Strategies to reduce the cost of adherence in terms of managing everyday life should be addressed by individually based strategies.Instructions regarding exercise and restrictions should be less complex and consider the patient's individual needs.

How controlled motion alters the biophysical properties of musculoskeletal tissue architecture

INTRODUCTION

Movement is fundamental to the normal behaviour of the hand, not only for day-to-day activity, but also for fundamental processes like development, tissue homeostasis and repair. Controlled motion is a concept that hand therapists apply to their patients daily for functional gains, yet the scientific understanding of how this works is poorly understood.

PURPOSE OF THE ARTICLE

To review the biology of the tissues in the hand that respond to movement and provide a basic science understanding of how it can be manipulated to facilitate better functionThe review outlines the concept of controlled motion and actions across the scales of tissue architecture, highlighting the the role of movement forces in tissue development, homeostasis and repair. The biophysical behaviour of mechanosensitve tissues of the hand such as skin, tendon, bone and cartilage are discussed.

CONCLUSION

Controlled motion during early healing is a form of controlled stress and can be harnessed to generate appropriate reparative tissues. Understanding the temporal and spatial biology of tissue repair allows therapists to tailor therapies that allow optimal recovery based around progressive biophysical stimuli by movement.

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).

Knotless Tendon Repair with a Resorbable Barbed Suture: An In-vivo Comparison in the Turkey Foot

Background: Un-knotted barbed suture constructs are postulated to decrease repair bulk and improve tension loading along the entire repair site resulting in beneficial biomechanical repair properties. Applying this repair technique to tendons has shown good results in ex-vivo experiments previously but thus far no in-vivo study could confirm these. Therefore, this current study was conducted to assess the value of un-knotted barbed suture repairs in the primary repair of flexor tendons in an in-vivo setting. Methods: Two groups of 10 turkeys (Meleagris gallapovos) were used. All turkeys underwent surgical zone II flexor tendon laceration repairs. In group one, tendons were repaired using a traditional four-strand cross-locked cruciate (Adelaide) repair, while in group two, a four-strand knotless barbed suture 3D repair was used. Postoperatively repaired digits were casted in functional position, and animals were left free to mobilise and full weight bear, resembling a high-tension post-op rehabilitation protocol. Surgeries and rehabilitations went uneventful and no major complications were noted. The turkeys were monitored for 6 weeks before the repairs were re-examined and assessed against several outcomes, such as failure rate, repair bulk, range of motion, adhesion formation and biomechanical stability. Results: In this high-tension in-vivo tendon repair experiment, traditionally repaired tendons performed significantly better when comparing absolute failure rates and repair stability after 6 weeks. Nevertheless, the knotless barbed suture repairs that remained intact demonstrated benefits in all other outcome measures, including repair bulk, range of motion, adhesion formation and operating time. Conclusions: Previously demonstrated ex-vivo benefits of flexor tendon repairs with resorbable barbed sutures may not be applicable in an in-vivo setting due to significant difference in repair stability and failure rates. Level of Evidence: Level IV (Therapeutic).

Relative motion orthoses for early active motion after finger extensor and flexor tendon repairs: A systematic review

BACKGROUND

The relative motion (RM) orthosis was introduced over 40 years ago for extensor tendon rehabilitation and more recently applied to flexor tendon repairs.

PURPOSE

We systematically reviewed the evidence for RM orthoses following surgical repair of finger extensor and flexor tendon injuries including indications for use, configuration and schedule of orthosis wear, and clinical outcomes.

STUDY DESIGN

Systematic review.

METHODS

A PRISMA-compliant systematic review searched eight databases and five trial registries, from database inception to January 7, 2022. The protocol was registered prospectively (CRD42020211579). We identified studies describing patients undergoing rehabilitation using RM orthoses after surgical repair of acute tendon injuries of the finger and hand.

RESULTS

For extensor tendon repairs, ten studies, one trial registry and five conference abstracts met inclusion criteria, reporting outcomes of 521 patients with injuries in zones IV-VII. Miller's criteria were predominantly used to report range of motion; with 89.6% and 86.9% reporting good or excellent outcomes for extension lag and flexion deficit, respectively. For flexor tendon repairs, one retrospective case series was included reporting outcomes in eight patients following zones I-II repairs. Mean total active motion was 86%. No tendon ruptures were reported due to the orthosis not protecting the repair for either the RME or RMF approaches.

DISCUSSION

Variation was seen in use of RME plus or only, use of night orthoses and orthotic wear schedules, which may be the result of evolution of the RM approach. Since Hirth et al's 2016 scoping review, there are five additional studies, including two RCTs reporting the use of the RM orthosis in extensor tendon rehabilitation.

CONCLUSIONS

There is now good evidence that the RM approach is safe in zones V-VI extensor tendon repairs. Limited evidence currently exists for zones IV and VII extensor and for flexor tendon repairs. Further high-quality clinical studies are needed to demonstrate its safety and efficacy.

Clinical Outcomes After Aggressive Active Early Motion and Modified Kleinert Regimens: Comparison of 2 Consecutive Cohorts

BACKGROUND

Modern multistrand repairs can withstand forces present in active flexion exercises, and this may improve the outcomes of flexor tendon repairs. We developed a simple home-based exercise regimen with free wrist and intrinsic minus splint aimed at facilitating the gliding of the flexor tendons and compared the outcomes with the modified Kleinert regimen used previously in the same institution.

METHODS

We searched the hospital database to identify flexor tendon repair performed before and after the new regimen was implemented and invited all patients to participate. The primary outcome was total active range of motion, and secondary outcomes were Disabilities of Arm, Shoulder, and Hand; grip strength; globally perceived function; and the quality of life.

RESULTS

The active range of motion was comparable between the groups (mean difference = 14; 95% confidence interval [CI], -8 to 36; P = .22). Disabilities of Arm, Shoulder, and Hand; grip strength; global perceived function; and health-related quality of life were also comparable between the groups. There was 1 (5.3%) rupture in the modified Kleinert group and 4 (15.4%) in the early active motion group (relative risk = 0.3; 95% CI, 0.04-2.5; P = .3).

CONCLUSIONS

Increasing active gliding with a free wrist and intrinsic minus splint did not improve the clinical outcomes after flexor tendon injury at a mean of 38-month follow-up.

A retrospective analysis of controlled active motion (CAM) versus modified Kleinert/Duran (modKD) rehabilitation protocol in flexor tendon repair (zones I and II) in a single center

INTRODUCTION

The aim of this study was to analyze primary flexor tendon repair results in zones I and II, comparing the rupture rate and clinical outcomes of the controlled active motion (CAM) protocol with the modified Kleinert/Duran (mKD) protocol.

MATERIALS AND METHODS

Patients who underwent surgery with traumatic flexor tendon lacerations in zones I and II were divided in three groups according to the type of rehabilitation protocol and period of management: group 1 included patients who underwent CAM rehabilitation protocol with six-strand Lim and Tsai suture after May 2014. Group 2 and 3 included patients treated by six-strand Lim Tsai suture followed by a modified Kleinert/Duran (modK/D) protocol with additional place and hold exercises between 2003 and 2005 (group 2) and between 2011 and 2013 (group 3).

RESULTS

Rupture rate was 4.7% at 12 weeks in group 1 (3/63 flexor tendon repairs) compared to 2% (1/51 flexor tendon repairs) in group 2 and 8% in group 3 (7/86 flexor tendon repairs). The grip strength at 12 weeks was significantly better in group 2 compared to the group 1 (35 kg/25 kg, p = 0.006). The TAM in group 1 [113° (30-175°)] was significantly worse (p < 0.001) than the TAM in group 2 [141° (90-195°)] but with similar extension deficits in both groups. The assessment of range of motion by the original Strickland classification system resulted in 20% excellent and 15% good outcomes in the CAM group 1 compared with 42% and 36% in the modK/D group 2. Subanalysis demonstrated improvement of good/excellent results according to Strickland from 45% at 3 months to 63.6% after 6-month follow-up in the CAM group.

CONCLUSION

The gut feeling that lead to change in our rehabilitation protocol could be explained by the heterogenous bias. A precise outcome analysis of group 1 could underline that in patients with complex hand trauma, nerve reconstruction, oedema or early extension deficit, an even more intensive and individual rehabilitation has to be performed to achieve better TAM at 6 or 12 weeks. Our study explicitly demonstrated a significant better outcome in the modK/D group compared to CAM group. This monocenter study is limited by its retrospective nature and the low number of patients.

Functional outcomes of a modified Duran postoperative rehabilitation protocol after primary repairs of pediatric hand flexor tendon injuries

The objective of this study was to determine whether pediatric patients undergoing flexor tendon repair who underwent 4 weeks of immobilization followed by a modified Duran controlled passive motion rehabilitation protocol will have favorable outcomes. A study was performed at a tertiary pediatric hospital of patients <18 years who underwent primary flexor tendon repairs in zones 1-4. Outcomes were calculated by total active motion and classified by the original Strickland criteria or Buck-Gramcko criteria. Twenty-eight patients with 34 injured fingers were included. Mean age was 11.4 years (range 2.4-17.9) with 17 males (61%) and 11 females (39%). Thirty-five percent of injuries occurred in zone 1; 35% zone 2; 6% zone 3; and 24% zone 4. All underwent a modified Duran postoperative rehabilitation protocol following a period of immobilization. The majority of patients achieved favorable outcomes, with 86% of cases classified as good/excellent. Thirty (88%) cases received surgery acutely (within 3 weeks). Of these, 70% achieved excellent outcomes, 17% good, and 13% fair. Four (12%) chronic cases underwent primary repair (range 24-68 days), achieving excellent outcomes in 50%, good in 25%, and fair in 25%. Three (75%) patients with delayed primary repair exhibited stiffness, which was greater than the 17% of patients with acute repairs ( P = 0.03). Approximately 1 month of immobilization followed by a modified Duran rehabilitation protocol leads to favorable outcomes in children with flexor tendon repairs. Children with delayed surgery (>3 weeks) who underwent primary repair generally still achieved good outcomes but were more likely to have stiffness. Level of evidence: III.

Effectiveness of Sodium Hyaluronate and ADCON-T/N for the Prevention of Adhesions in Hand Flexor Tendon Surgery: A Systematic Review and Meta-Analysis

PURPOSE

A common complication after digital flexor tendon repair in the hand is postoperative adhesions that can cause loss of motion and compromise hand function. The aim of this review of relevant published literature was to assess the effectiveness of locally administered sodium hyaluronate or ADCON-T/N for the prevention of adhesions after hand flexor tendon repair.

METHODS

A literature search was conducted in June 2020 in multiple databases for randomized controlled trials . Our primary outcome was measurement of active finger motion. Follow-up was defined as short-term (< 12 weeks), mid-term (12 weeks to 6 months) and long-term (> 6 months). Mean differences (MD) and standardized mean differences (SMD) of total active motion (TAM) of the interphalangeal joints (IPJs) and active motion of the IPJs separately were calculated where results were meta-analyzed.

RESULTS

Six randomized controlled trials were included. For ADCON-T/N, no benefits were detected for TAM of the IPJs (MD 1.71 [-21.54, 24.96]) or active motion of the IPJs separately (proximal: MD 4.77 [-4.47, 14]; distal: MD 1.17 [-10.33, 12.66]) in the short-/mid-term. The mid-term benefit in TAM of sodium hyaluronate over standard care (placebo/no treatment) did not reach statistical significance (SMD 0.31 [0, 0.63]); however, a subgroup comparison of repeated administration of sodium hyaluronate versus standard care was both statistically and clinically significant (SMD 0.55 [0.11, 0.98]).

CONCLUSIONS

Repeated administration of sodium hyaluronate at the tendon repair site may be effective in improving postoperative active finger motion after primary hand flexor tendon repair in the mid-term.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

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.

Variation in patient information and rehabilitation regimens after flexor tendon repair in the United Kingdom

Introduction

There is clinical uncertainty regarding the optimal method of rehabilitation following flexor tendon repair. Many splint designs and rehabilitation regimens are reported in the literature; however, there is insufficient evidence to support the use of any one regimen. The aim of this study was to describe rehabilitation guidelines used in the United Kingdom (UK) following zone I/II flexor tendon repair.

Methods

Using a cross-sectional design, hand units in the UK were invited to complete a short survey and to upload their flexor tendon rehabilitation guidelines and patient information material. Approval was granted by the British Association of Hand Therapists. Data were extracted in duplicate, using a pre-piloted form, and analysed using descriptive statistics.

Results

Thirty-five hand units responded (21%), providing 52 treatment guidelines. Three splinting regimens were described, and all involved early active mobilisation: (i) long dorsal-blocking splint (DBS); (ii) short DBS; and (iii) relative motion flexion splint. Duration of full-time splint wear ranged from 4 to 6 weeks. There were variations in splint design and composition of home exercise programmes, particularly for the long DBS. Where reported, recommended return to driving ranged from 8 to 12 weeks, and return to light work activities ranged from 5 to 10 weeks.

Discussion

Treatment guidelines varied across UK hand therapy departments, suggesting that patients receive differing advice about how to protect, move and use their hand after zone I/II flexor tendon repair. The disparity in splint wear duration, home exercise frequency and prescribed functional restrictions raises potential financial and social implications for patients. Future research should explore rehabilitation burden in addition to clinical outcomes.

A Biomechanical Comparison of Gliding Resistance between Modified Lim Tsai and Asymmetric Tendon Repair Techniques in Zone II Flexor Tendon Repairs

Background: Early active motion protocols have shown better functional outcomes in zone II flexor tendon lacerations. Different techniques of tendon repair have different effects on gliding resistance, which can impact tendon excursion and adhesion formation. For successful initiation of early active mobilisation, the repair technique should have high breaking strength and low gliding resistance. Previous studies have shown the Modified Lim-Tsai technique demonstrates these characteristics. The Asymmetric repair has also shown superior ultimate tensile strength. This study aims to compare the gliding resistance between the two techniques. Methods: FDP tendons from ten fresh frozen cadaveric fingers were randomly divided into two groups, transected completely distal to the sheath of the A2 pulley and repaired using either the Modified Lim-Tsai or Asymmetric technique. The core repair was performed with Supramid 4-0 looped sutures and circumferential epitendinous sutures were done with nylon monofilament Prolene 6-0 sutures. The gliding resistance and ultimate tensile strength were then tested. Results: The gliding resistance of the Asymmetric and Modified Lim-Tsai repair techniques were 0.2 and 0.95 N respectively. This difference was significant (p = 0.008). The Modified Lim-Tsai technique had a higher ultimate tensile strength and load to 2 mm gap formation, though this was not significant. Conclusions: Gliding resistance of the Asymmetric repair is significantly less than that of Modified Lim-Tsai. Ultimate tensile strength and load to 2 mm gap formation are comparable.

Passive Mobilization With Place and Hold Versus Active Motion Therapy After Flexor Tendon Repair: A Randomized Trial

PURPOSE

Mobilization after flexor tendon repair in fingers has been a subject of debate for several years. Many hand surgery clinics have turned to early active mobilization. However, there is no strong scientific evidence suggesting that early active mobilization produces a better range of motion (ROM) than the Kleinert regimen when place and hold is added. Therefore, the purpose of this prospective randomized trial was to investigate whether active mobilization is superior to passive mobilization with place and hold after flexor tendon repair in the fingers. Our hypothesis was that patients who follow the active mobilization protocol have a better ROM than those who follow the passive protocol with place and hold.

METHODS

Sixty-four patients with a flexor tendon injury in zone I or II were included. After surgery, randomization to undergo either active mobilization or passive mobilization with place and hold was performed. The patients were followed-up for 12 months using outcome measurements, including ROM, strength, rupture frequency, Disabilities of the Arm, Shoulder and Hand score, ABILHAND questionnaire, and performance on the Purdue Pegboard test.

RESULTS

We were unable to find any significant difference between the 2 groups for any of the outcome measurements, ROM, grip strength, key pinch, rupture frequency, Disabilities of the Arm, Shoulder and Hand score, ABILHAND questionnaire, and performance on the Purdue Pegboard test.

CONCLUSIONS

The outcomes were equivalent for both the mobilization groups.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Outcomes at 3 Months of a Place and Active Hold Method of Flexor Tendon Rehabilitation Following Zone II Injury

Background: Previous studies have shown that outcomes following a place and active hold (PAH) are better than a passive flexion protocol after a two-strand core-suture repair of flexor tendons injuries in zone II. This study aims to determine the outcomes of a PAH protocol of flexor tendon rehabilitation following a four-strand core-suture plus an epitendinous suture repair of the flexor digitorum profundus (FDP) combined with a simple horizontal loop repair of the flexor digitorum superficialis (FDS). Methods: This is a prospective study of patients with complete injury to both flexor tendons in zone II. All tendons were repaired with a simple horizontal loop for FDS and four-strand core-suture plus epitendinous suture for FDP. The PAH protocol was used postoperatively for 6 weeks. The outcome was evaluated using flexion contracture and total active motion (TAM), interpreted using Strickland criteria and categorised as excellent, good, fair and poor at 6 weeks and 3 months. The linear regression model was used to determine predictors of outcomes. Results: The study included 32 patients with flexor tendon injury in 46 fingers. No repairs ruptured, and 24 (52%) digits achieved good or excellent motion 6 weeks after surgery using the Strickland criteria. According to the Strickland criteria, 41 (89%) digits ranked as excellent and good with no poor result at a 3-month follow-up. Four patients had 5-10° of flexion contracture. Age was the predictor of TAM at 6 weeks and accounted for 13% of its variation. Improvement of TAM from 6 weeks to 3 months was related to age and flexion contracture at 6 weeks. Conclusions: The PAH protocol can be considered a safe technique for flexor rehabilitation after four-strand core-suture repair of FDP in zone II. Level of Evidence: Level IV (Therapeutic).

Hand Transplants, Daily Functioning, and the Human Capacity for Limb Regeneration

Unlike some of our invertebrate and vertebrate cousins with the capacity to regenerate limbs after traumatic loss, humans do not have the ability to regrow arms or legs lost to injury or disease. For the millions of people worldwide who have lost a limb after birth, the primary route to regaining function and minimizing future complications is via rehabilitation, prosthetic devices, assistive aids, health system robustness, and social safety net structures. The majority of limbs lost are lower limbs (legs), with diabetes and vascular disorders being significant causal contributors. Upper limbs (arms) are lost primarily because of trauma; digits and hands are the most common levels of loss. Even if much of the arm remains intact, upper limb amputation significantly impacts function, largely due to the loss of the hand. Human hands are marvels of evolution and permit a dexterity that enables a wide variety of function not readily replaced by devices. It is not surprising, therefore, for some individuals, dissatisfaction with available prosthetic options coupled with remarkable advances in hand surgery techniques is resulting in patients undertaking the rigors of a hand transplantation. While not “regeneration” in the sense of the enviable ability with which Axolotls can replace a lost limb, hand transplants do require significant regeneration of tissues and nerves. Regaining sophisticated hand functions also depends on “reconnecting” the donated hand with the areas of the human brain responsible for the sensory and motor processing required for complex actions. Human hand transplants are not without controversy and raise interesting challenges regarding the human regenerative capacity and the status of transplants for enabling function. More investigation is needed to address medical and ethical questions prior to expansion of hand transplants to a wider patient population.

Effect of electromyographic biofeedback training on functional status in zone I-III flexor tendon injuries: a randomized controlled trial

BACKGROUND

Despite advances in hand therapy and surgery, functional deficits persist after flexor tendon repair especially in zone I-III. This suggests that methods applied may be insufficient. Electromyographic (EMG) biofeedback may provide an effective tendon gliding through visual and auditory feedback.

PURPOSE

The purpose of this study was to investigate the effect of EMG biofeedback training applied in addition to early passive motion protocol on functional status in zone I-III flexor tendon injuries.

METHODS

Patients were randomly assigned into two groups, each consisted of 11 patients. In addition to early passive motion method, EMG biofeedback training was applied in the first group. The second group was followed only with early passive motion protocol. Joint range of motion (ROM), Michigan Hand Outcomes Questionnaire (MHQ) and grip strength were evaluated.

RESULTS

There were no significant differences between the groups in terms of the ROM, MHQ scores and grip strength (p ≥ .087). However, there were clinically important differences in the results of the 12th week ROM (effect size = 0.70), 24th week activity of daily living (ADL) score in MHQ (effect size = 0.68), 12th week gross, tip pinch and lateral grip strength (effect sizes = 0.59, 0.52, 0.81, respectively) and 24th week gross, tip pinch and lateral grip strength (effect sizes = 0.69, 0.73, 0.69, respectively) between the two groups.

CONCLUSIONS

EMG biofeedback training was clinically but not statistically superior to early passive motion method in terms of the effect on functional status.

Outcomes After Flexor Tendon Injuries in the Pediatric Population: A 10-Year Retrospective Review

Background: Pediatric outcomes after flexor tendon repairs are variable, and evidence in the literature remains scarce. Methods: Repair of pediatric flexor tendon injuries was reviewed over a 10-year period (2005-2015). Data collection consisted of patient demographics, injury characteristics, anesthetic choice, repair technique, rehabilitation protocol, American Society for Surgery of the Hand Total Active Motion (TAM) scores, and complications. Results: There were 109 patients included in our study, with a total of 162 digits injured and 235 flexor tendon injuries. The mean age was 12 ± 4.6 years. The small finger (48 of 162; 30%) and the flexor digitorum profundus tendon (126 of 235) were the most commonly injured. The mechanism of injury was mainly from a knife (46 of 109; 42.2%) in zone II (82 of 159; 52%). Injuries were mostly repaired under general anesthetic (61 of 104; 56%). The Kessler technique was the predominant repair mechanism (111 of 225 repairs; 49%). Most patients (103 of 109; 95%) had excellent or good TAM scores with 5 postoperative ruptures reported. The most common complication was stiffness (17 of 121 complications; 14%), with most patients having no complications ( 74 of 109 patients; 68%). Patients were commonly immobilized (mean 8.4 ± 10.3 weeks) with a splint (93 of 109; 85%). There were 85 patients who followed a postoperative rehabilitation protocol for 12 ± 18 weeks. Patient demographics, time of repair, injury characteristics, anesthetic choice, and rehabilitation protocol were not significantly correlated with TAM scores or complication rates. Conclusions: Pediatric tendon injuries have good outcomes with no predictive factors identified. Surgical repairs performed under local anesthetic have similar outcomes without increased rates of complications, but remain underused in the pediatric population.

Outcome of Surgical Repair and Rehabilitation of Flexor Tendon Injuries in Zone II of the Hand: Systematic Review and Meta-Analysis

PURPOSE

We performed a systematic review and meta-analysis to determine an optimal rehabilitation protocol following surgical repair for flexor tendon injury in zone II of the hand.

METHODS

Records from PubMed, Embase, and Cochrane were retrieved from their establishment to January 12, 2020. Seven studies were included in the final analysis. A total of 569 digits with a flexor tendon injury in zone II of the hand were included in this meta-analysis: 135 in a place and hold group; 161 in an active flexion and extension group; and 273 in an early passive motion group.

RESULTS

There was no significant difference between the place and hold and early passive motion regimes in the incidence of rupture. There was a significant difference between the active flexion and extension and early passive motion regimes in the incidence of rupture. In the early active motion group, the possibility of 1 or more grades of improvement on the Strickland grading system was increased.

CONCLUSIONS

The early active motion group obtained greater total active motion than the early passive motion group. A higher risk of rupture was noted in the active flexion and extension subgroup repaired by 2-strand core suture. The 2-strand technique was not sufficient for active flexion and extension protocols. Further study in multistrand tendon repair technique with early active exercise in zone II should be undertaken to determine its efficacy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Patient-reported outcome measures for patients with hand-specific impairments-A scoping review

BACKGROUND

Patient-reported outcome measures (PROMs) are increasingly used to provide evidence for treatment effects and to guide rehabilitation. To our knowledge, no disease-specific PROM exists for the assessment of patients with flexor tendon lesions of the hand. We believe that PROMs used to assess hand function, regardless of diagnosis, contain relevant items for patients with flexor tendon lesions of the hand.

PURPOSE

The aim of our study was to identify and collect items from pre-existing PROMs used by clinical experts to assess the health status and function in patients with reduced hand function.

STUDY DESIGN

A scoping review searching for PROMs with hand-specific content was conducted to ensure face validity. As these items are assumed to have been through an evaluation process by the clinical specialists, they have the advantage and likelihood of being useful.

METHODS

We searched five bibliographic databases. All PROMs with hand-specific content used to assess hand function were considered for inclusion. Questionnaires written in English, Danish, Swedish, and Norwegian were included. An analysis of content redundancy was conducted, and items were grouped according to The World Health Organization's International Classification of Functioning, Disability and Health.

RESULTS

Seventy-three PROMs were included with a total of 1,582 items. The majority of the items were redundant across measurement instruments, and redundant items were consolidated, resulting in 179 nonredundant items. All nonredundant items were classified according to the International Classification of Functioning, Disability and Health components.

CONCLUSIONS

This review presents a collection of 179 items ensuring face validity for patients with hand-related disease/injury.

Management and outcomes of flexor tendon repairs at a peripheral hospital: a New Zealand case series study

BACKGROUND

Current evidence for flexor tendon repair management and outcomes performed at peripheral centres is unclear. Most studies are based on evidence from specialist hand centres. This study evaluated a peripheral hospital in New Zealand; where all flexor tendon repairs were performed by a generalist Orthopaedic service. The purpose of the study was to benchmark management and outcomes from a peripheral hospital in comparison to international standards.

METHODS

A retrospective single-centre consecutive case series of Zones I and II flexor tendon repairs was extracted between 1 January 2014 and 1 January 2018. Medical records were used to evaluate management and outcomes of repairs. Hand therapy notes were used to evaluate rehabilitation protocols provided. The primary objective was to measure re-rupture and re-operation rates. Secondary objectives included auditing operative management and hand therapy compliance.

RESULTS

Forty-six patients (76 tendon repairs) were included in our final analysis. Mean follow up time to last clinical appointment was 11.8 weeks, and to last patient episode was 4.9 years. Most patients received timely surgery with a four-core repair using 3-0 or larger suture. All hand therapy followed a controlled active motion protocol. The re-operation rate was 19.6% (P = <0.05) and the re-rupture rate was 8.7% (P = 0.28).

CONCLUSIONS

Most flexor tendon injuries at this peripheral centre were managed according to international standards. However, high complication rates including re-operation and re-rupture occurred. Due to a lack of local comparison studies, confounding factors cannot be excluded as a contributor for these results.

Tendon: Principles of Healing and Repair

Tendon stores, releases, and dissipates energy to efficiently transmit contractile forces from muscle to bone. Tendon injury is exceedingly common, with the spectrum ranging from chronic tendinopathy to acute tendon rupture. Tendon generally develops according to three main steps: collagen fibrillogenesis, linear growth, and lateral growth. In the setting of injury, it also repairs and regenerates in three overlapping steps (inflammation, proliferation, and remodeling) with tendon-specific durations. Acute injury to the flexor and extensor tendons of the hand are of particular clinical importance to plastic surgeons, with tendon-specific treatment guided by the general principle of minimum protective immobilization followed by hand therapy to overcome potential adhesions. Thorough knowledge of the underlying biomechanical principles of tendon healing is required to provide optimal care to patients presenting with tendon injury.

Relative motion flexion splinting for the rehabilitation of flexor tendon repairs: A systematic review

Introduction

Relative motion splinting has been used successfully in the treatment of extensor tendon repairs and has recently been applied in flexor tendon rehabilitation. The purpose of this systematic review was to identify articles reporting use of relative motion flexion (RMF) splinting following flexor tendon repair and to examine indications for use and clinical outcomes.

Methods

Seven medical databases, four trials registries and three grey literature sources were systematically searched and screened against pre-specified eligibility criteria. Screening, data extraction and quality appraisal were independently performed by two reviewers.

Results

A total of 12 studies were identified, of which three met the review eligibility criteria: one retrospective case series; one cadaveric proof of concept study; and one ongoing prospective case series. The type of splint (including metacarpophalangeal joint position and available movement), exercise programme, and zone of tendon injury varied between studies. Both case series presented acceptable range of movement and grip strength outcomes. The prospective series reported one tendon rupture and two tenolysis procedures; the retrospective series reported no tendon ruptures or secondary surgeries.

Discussion

We found limited evidence supporting the use of RMF splinting in the rehabilitation of zones I-III flexor tendon repairs. Further prospective research with larger patient cohorts is required to assess the clinical outcomes, patient reported outcomes and safety of RMF splinting in comparison to other regimes. Application of the relative motion principles to flexor tendon splinting varied across the included studies, and we suggest an operational definition of relative motion in this context.

Use of a relative motion flexion orthosis for postoperative management of zone I/II flexor digitorum profundus repair: A retrospective consecutive case series

STUDY DESIGN

A retrospective, single-center, consecutive case series.

INTRODUCTION

In concept, a relative motion flexion (RMF) orthosis will induce a "quadriga effect" on a given flexor digitorum profundus (FDP) tendon, limiting its excursion and force of flexion while still permitting a wide range of finger motion. This effect can be exploited in the rehabilitation of zone I and II FDP repairs.

PURPOSE OF THE STUDY

To describe the use of RMF orthoses to manage zone I and II FDP 4-strand repairs.

METHODS

Medical record review of 10 consecutive zone I and II FDP tendon repairs managed with RMF orthosis for 8 to 10 weeks in combination with a static dorsal blocking or wrist orthosis for the initial 3 weeks.

RESULTS

Indications included sharp lacerations (n = 6), ragged lacerations (n = 2), staged flexor tendon reconstruction (n = 1), and type IV avulsion (n = 1). In 8 of the 10 cases that completed follow-up, the mean arc of proximal interphalangeal/distal interphalangeal active motion were as follows: sharp, 0° to 106°/0° to 75°; ragged, 0° to 90°/0° to 25°; reconstruction, 0° to 90°/10° to 45°; and avulsion, 0° to 95°/0° to 20°. Grip performance available for 6 of 10 cases was 62% to 108% of the dominant hand. There were no tendon ruptures, secondary surgeries, or proximal interphalangeal joint contractures.

CONCLUSION

Based on this small series, the RMF approach appears to be safe and effective. It can lead to similar mobility and functional recovery as other early active motion protocols, with certain practical advantages and without major complications. Further investigation with larger, multicenter, prospective, longitudinal cohorts and/or randomized clinical trials is necessary.

Flexor tendon injuries: Repair & Rehabilitation

Flexor tendon injuries are common and occur mostly by penetrating trauma. Suspected flexor tendon injuries require a thorough clinical assessment and often are not isolated injuries. A detailed understanding of flexor tendon anatomy and spatial relationships is essential, especially when repairing multi-tendon injuries. Principles of flexor tendon repair include a strong suture construct, minimising gap formation between tendon ends, preserving tendon blood supply and providing a smooth repair interface. Moreover, adequate exposure of the zone of injury using full-thickness skin flaps and preservation of neurovascular and pulley structures is essential. In this article an overview of contemporary management strategies is presented. Today's hand surgeons and therapists can choose from a variety of treatment options when managing these important and potentially life-changing injuries.

Patient outcomes and costs after isolated flexor tendon repairs of the hand

BACKGROUND

Acute flexor tendon injuries are challenging injuries for patients, surgeons, and therapists alike. There is ongoing debate about the optimal timing and amount of therapy after these injuries.

PURPOSE

We sought to investigate the relationship between hand therapy utilization and reoperation rates after flexor tendon repair and quantify reoperation rates and costs associated with flexor tendon repair. We hypothesize there will be an inverse relationship between the number of hand therapy visits and later reoperation rates and a positive correlation between reoperation rates and total cost of care.

STUDY DESIGN

A retrospective cohort study of patients undergoing primary flexor tendon repair was pursued.

METHODS

A commercially available database was utilized to access insurance claims data for 20.9 million patients in the US from 2007 to 2015. Patients undergoing primary flexor tendon repair were included and followed for one year. Patients with fractures, vascular injuries, or digit replantation were excluded. We studied post-operative rehabilitation utilization, reoperation rates, and costs. Chi-Square tests and multivariable logistic regressions were used to assess the relationship between therapy utilization and reoperation rates and costs.

RESULTS

The one-year reoperation rate was 11.4 percent at a median time of 100.0 days amongst 1,129 patients undergoing primary tendon repair. In multivariable analysis, age between 30 and 59, male sex, and utilization of over 21 therapy sessions were associated with increased odds of reoperation. Mean insurance reimbursement one year following primary flexor repair was $14,533 per patient but $27,870 if patients went on to reoperation.

CONCLUSION

Continued therapy utilization after primary flexor tendon repair is an independent predictor of reoperation need. These findings may help surgeons counsel patients who require a large number of visits after flexor tendon repair on when to revisit surgical options.

Evaluation of Tension at Median and Ulnar Nerve Repairs at the Wrist in a Cadaveric Model

Background: Median and ulnar nerve lacerations at the wrist are often combined with zone 5 tendon injury. The inability to provide early range of motion leads to increased adhesions. Current therapy protocols recommend the wrist be held in 30° of flexion post operatively to protect the nerve repair. However, if tension and elongation across the nerve repair stay under a critical level in less wrist flexion, postoperative splinting in more extension could allow for better tendon excursion and less adhesions. Methods: Six cadaveric specimens were used. After appropriate dissection, the median and ulnar nerves were transected and repaired with a single 10-0 nylon suture. The wrist was ranged from 30° flexion to 45° extension to see if the repair would fail. Next, an epineural repair was accomplished with 9-0 nylon suture. The percent elongation along the nerve repair was measured at set increments from 30° flexion to 45° extension. Results: In all 6 specimens, median and ulnar nerve repairs with a single 10-0 nylon suture did not fail with wrist range of motion from 30° flexion to 45° extension. Mean percent elongation stayed under critical levels in up to 30° of extension. Conclusions: Both median and ulnar nerve repairs stayed under critical levels of tension and elongation in up to 30° of wrist extension. We believe it is possible to be more aggressive with wrist positioning in wrist level median and ulnar nerve repairs.

Getting Better Results in Flexor Tendon Surgery and Therapy

Recently, better outcomes have been reported when up-to-date developments in flexor tendon surgery and therapy were followed. Slightly tensioned multistrand repairs, judicious venting of pulleys, and early active motion are widely accepted principles. In addition to these principles, tailoring of the repair according to intraoperative active movement with wide awake local anesthesia no tourniquet (WALANT) surgical setting is recommended for better results. We aimed to describe our up-to-date approach to flexor tendon surgery and therapy with the help of visual communication tools of this age. The ideal primary repair of flexor tendons, the management of delayed presentation flexor tendon injuries, the key steps to achieve better results with flexor tendon therapy, and the tele-rehabilitation experience during COVID-19 pandemic will be highlighted. Zone 2 flexor tendon injuries are the most demanding part and will be focused on.

Rehabilitation following surgery for flexor tendon injuries of the hand

BACKGROUND

Various rehabilitation treatments may be offered following surgery for flexor tendon injuries of the hand. Rehabilitation often includes a combination of an exercise regimen and an orthosis, plus other rehabilitation treatments, usually delivered together. The effectiveness of these interventions remains unclear.

OBJECTIVES

To assess the effects (benefits and harms) of different rehabilitation interventions after surgery for flexor tendon injuries of the hand.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials, the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, MEDLINE, Embase, two additional databases and two international trials registries, unrestricted by language. The last date of searches was 11 August 2020. We checked the reference lists of included studies and relevant systematic reviews.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs that compared any postoperative rehabilitation intervention with no intervention, control, placebo, or another postoperative rehabilitation intervention in individuals who have had surgery for flexor tendon injuries of the hand. Trials comparing different mobilisation regimens either with another mobilisation regimen or with a control were the main comparisons of interest. Our main outcomes of interest were patient-reported function, active range of motion of the fingers, and number of participants experiencing an adverse event.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, assessed risk of bias and assessed the quality of the body of evidence for primary outcomes using the GRADE approach, according to standard Cochrane methodology.

MAIN RESULTS

We included 16 RCTs and one quasi-RCT, with a total of 1108 participants, mainly adults. Overall, the participants were aged between 7 and 72 years, and 74% were male. Studies mainly focused on flexor tendon injuries in zone II. The 17 studies were heterogeneous with respect to the types of rehabilitation treatments provided, intensity, duration of treatment and the treatment setting. Each trial tested one of 14 comparisons, eight of which were of different exercise regimens. The other trials examined the timing of return to unrestricted functional activities after surgery (one study); the use of external devices applied to the participant to facilitate mobilisation, such as an exoskeleton (one study) or continuous passive motion device (one study); modalities such as laser therapy (two studies) or ultrasound therapy (one study); and a motor imagery treatment (one study). No trials tested different types of orthoses; different orthosis wearing regimens, including duration; different timings for commencing mobilisation; different types of scar management; or different timings for commencing strengthening. Trials were generally at high risk of bias for one or more domains, including lack of blinding, incomplete outcome data and selective outcome reporting. Data pooling was limited to tendon rupture data in a three trial comparison. We rated the evidence available for all reported outcomes of all comparisons as very low-certainty evidence, which means that we have very little confidence in the estimates of effect. We present the findings from three exercise regimen comparisons, as these are commonly used in clinical current practice. Early active flexion plus controlled passive exercise regimen versus early controlled passive exercise regimen (modified Kleinert protocol) was compared in one trial of 53 participants with mainly zone II flexor tendon repairs. There is very low-certainty evidence of no clinically important difference between the two groups in patient-rated function or active finger range of motion at 6 or 12 months follow-up. There is very low-certainty evidence of little between-group difference in adverse events: there were 15 overall. All three tendon ruptures underwent secondary surgery. An active exercise regimen versus an immobilisation regimen for three weeks was compared in one trial reporting data for 84 participants with zone II flexor tendon repairs. The trial did not report on self-rated function, on range of movement during three to six months or numbers of participants experiencing adverse events. The very low-certainty evidence for poor (under one-quarter that of normal) range of finger movement at one to three years follow-up means we are uncertain of the finding of zero cases in the active group versus seven cases in the immobilisation regimen. The same uncertainty applies to the finding of little difference between the two groups in adverse events (5 tendon ruptures in the active group versus 10 probable scar adhesion in the immobilisation group) indicated for surgery. Place and hold exercise regimen performed within an orthosis versus a controlled passive regimen using rubber band traction was compared in three heterogeneous trials, which reported data for a maximum of 194 participants, with mainly zone II flexor tendon repairs. The trials did not report on range of movement during three to six months, or numbers of participants experiencing adverse events. There was very low-certainty evidence of no difference in self-rated function using the Disability of the Arm, Shoulder and Hand (DASH) functional assessment between the two groups at six months (one trial) or at 12 months (one trial). There is very low-certainty evidence from one trial of greater active finger range of motion at 12 months after place and hold. Secondary surgery data were not available; however, all seven recorded tendon ruptures would have required surgery. All the evidence for the other five exercise comparisons as well as those of the other six comparisons made by the included studies was incomplete and, where available, of very low-certainty.

AUTHORS' CONCLUSIONS

There is a lack of evidence from RCTs on most of the rehabilitation interventions used following surgery for flexor tendon injuries of the hand. The limited and very low-certainty evidence for all 14 comparisons examined in the 17 included studies means that we have very little confidence in the estimates of effect for all outcomes for which data were available for these comparisons. The dearth of evidence identified in this review points to the urgent need for sufficiently powered RCTs that examine key questions relating to the rehabilitation of these injuries. A consensus approach identifying these and establishing minimum study conduct and reporting criteria will be valuable. Our suggestions for future research are detailed in the review.

Beyond the Core Suture: A New Approach to Tendon Repair

Despite significant improvements in zone II flexor tendon repair over the last 2 decades, function-limiting complications persist. This article describes 2 novel repair techniques utilizing flexor digitorum superficialis (FDS) autografts to buttress the flexor digitorum profundus (FDP) repair site without the use of core sutures. The hypothesis being that the reclaimed FDS tendon autograft will redistribute tensile forces away from the FDP repair site, increasing overall strength and resistance to gapping in Zone II flexor tendon injuries compared with the current clinical techniques.

Methods

Two novel FDP repair methods utilizing portions of FDS have been described: (1) asymmetric repair (AR), and (2) circumferential repair. Ultimate tensile strength and cyclical testing were used to compare novel techniques to current clinical standard repairs: 2-strand (2-St), 4-strand (4-St), and 6-strand (6-St) methods. All repairs were performed in cadaveric sheep tendons (n = 10/group), by a single surgeon.

Results

AR and circumferential repair techniques demonstrated comparable ultimate tensile strength to 6-St repairs, with all 3 of these techniques able to tolerate significantly stronger loads than the 2-St and 4-St repairs (P < 0.0001). Cyclical testing demonstrated that AR and circumferential repair were able to withstand a significantly higher total cumulative force (P < 0.001 and P = 0.0064, respectively) than the 6-St, while only AR tolerated a significantly greater force to 2-mm gap formation (P = 0.042) than the 6-St repair.

Conclusion

Incorporating FDS as an autologous graft for FDP repair provides at least a comparable ultimate tensile strength and a significantly greater cumulative force to failure and 2-mm gap formation than a traditional 6-St repair.

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.

Wide awake surgery for flexor tendon primary repair: A literature review

Flexor tendon injuries are extremely challenging conditions to manage for hand surgeons. Over the last few years enormous progress has been made for the treatment of these lesions with new surgical approaches being performed. One of these is the wideawake local anesthesia no tourniquet (WALANT) technique, also known as Wide Awake Technique that allows tendon repair under local anesthesia, enabling the tendon to move actively during surgery. Dynamic movement of the tendon during surgery is crucial for the orthopedic surgeon in order to understand if the tendon has been correctly repaired before leaving the operatory table. An electronic literature research was carried out on Pubmed, Google Scholars and Cochrane Library using ((Flexor tendon injury) OR (flexor tendon) OR (injury muscle tendon) OR (flexor pollicis longus tendon) AND ((wide awake repair) OR (wide awake) OR (wide awake hand surgery))as search terms. Authors believe that WALANT is an enormous add-on in the management of patients with flexor tendon injuries mainly because it allows direct visualization of the repair during flexion and extension movement of the fingers and also because it avoids general anesthesia or brachial plexus being more cost effective. The aim of these review was therefore to sum up the evidences available so far on the wade awake technique as an emerging treatment for patients with flexor tendon injuries.

Closed rupture of flexor digitorum profundus in zone III

Closed ruptures of the flexor digitorum profundus (FDP) tendon cause a loss of active flexion at the distal interphalangeal joint. Commonly referred to as a 'jersey finger' because of its association with tackling sports, the distal aspect of FDP is avulsed from its insertion on the distal phalanx in zone I, with or without a fragment of bone. Because of this classic injury mechanism and pattern, providers may not seek advanced imaging beyond plain radiographs. Although rare, injury to FDP more proximally may occur. More often this injury is associated with a weak underlying tendon because of repetitive microtrauma or anomalous anatomy, for example. We present a case of a closed rupture of the FDP in zone III, and stress the importance of maintaining a high clinical suspicion and the potential use of adjunct ultrasound imaging to localise the site of injury.

Does earlier splint removal truly affect functional recovery and kinesiophobia after tendon repair?

Splinting how the hand can be used in daily life. Therefore, earlier splint removal is thought to improve functional recovery. The aim of our study was to assess the outcomes of patients who removed their splint and started using their hand earlier and compare them to patients who received routine care. Patients with tendon repairs were divided into two groups: Group 1 (Early) started daily use of their hand at the 5th postoperative week and Group 2 (Later) at the 6th week. Patients received regular therapy consisting of an early motion protocol. Assessments were performed at three consecutive time points. Grip and pinch strength was measured and Nine-Hole Peg Test (9HPT) was performed. Disabilities of the Arm, Shoulder and Hand (DASH) and Tampa Scale for Kinesiophobia (TSK) were filled out. Both within-group and between-group analyses were performed. A total of 58 patients with flexor or extensor tendon repairs were analyzed. All parameters improved significantly over time within both groups (P<0.05). When the time effect was ignored, kinesiophobia, disability and functional results - except grip strength - were statistically better in Group 2 group than in Group 1 (P<0.05). Our results showed that, despite the clinically observed recovery, earlier splint removal and start of daily hand use did not truly improve the functional results. To us, this means that the remarkable advances in surgical techniques do not accelerate the physiological healing process. Therefore, clinical recommendations should always be supported with evidence-based data.

Prognostic factors for digital range of motion after intrasynovial flexor tendon injury and repair: Long-term follow-up on 273 patients treated with active extension-passive flexion with rubber bands

STUDY DESIGN

Observational cohort study.

INTRODUCTION

Investigating prognostic factors using population-based data may be used to improve functional outcome after flexor tendon injury and repair.

PURPOSE OF THE STUDY

The aim of this study is to investigate the effect of concomitant nerve transection, combined flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendon transection and the age of the patient, on digital range of motion (ROM) more than 1 year after FDP tendon transection and repair in zone I and II.

METHODS

Two hundred seventy-three patients with a total of 311 fingers admitted for FDP injury in zone I and II were treated with active extension-passive flexion with rubber bands and followed for at least 1 year. We compared outcome by evaluating digital mobility using Strickland's evaluation system.

RESULTS

At 12 months 72% of patients aged > 50 had fair or poor ROM compared to 17% of patients aged 0-25 years. At 24 months the results for patients aged > 50 had improved to 33% with fair or poor ROM, whereas no improvement had occurred for patients aged 0-25 (17% with fair or poor ROM). Concomitant nerve transection and FDS tendon transection had no negative effects on digital mobility.

DISCUSSION

Age above 50 was significantly associated with impaired digital ROM during the first year after flexor tendon injury and repair but not at 2 years follow-up. Concomitant nerve transection and combined transection of FDP and FDS do not affect digital mobility.

CONCLUSIONS

Older patients are likely to have a slower healing process and impaired digital ROM during the first year after surgery.

Comparison of surgical trends in zone 2 flexor tendon repair between Turkish and international surgeons

Objectives

The aim of this study was to evaluate Turkish trends in zone 2 flexor repair with regards to surgical technique, suture materials, anesthesia and post-operative rehabilitation and compare this with international surgeons by modifying Gibson's survey.

Methods

A printed and online survey consisting of 19 questions modified from Gibson's survey was sent to 590 Turkish and international surgeons. The surgeon's years in practice, province of practice, residency type, number of zone 2 flexor tendon repairs done in a year, preferred surgical technique, suture material, complications and postoperative protocols were asked to the respondents.

Results

A total of 194 surgeons completed the survey (a 25% response rate). Of those who completed the survey, 91 were international (mostly from far eastern countries) and 103 were Turkish surgeons. Years in practice and educational background had influence on the decision-making. There were differences between the Turkish and international surgeons in the core and epitendinous suture thickness preference and flexor tendon sheath repair. There was a statistically significant relationship between the province of practice and the use of WALANT (Wide awake local anesthesia no tourniquet) (p < 0.05). While the majority of respondents who preferred postoperative early passive motion protocol were from Turkey (61.5%), the majority of respondents who preferred early active motion protocol were practicing abroad (73.9%).

Conclusion

Despite some variations the surgeons involved in this study follow to a large extent the current literature.

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.