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Bruin LL, Lans J, Wang F, Eberlin KR, Chen NC. Reoperation Following Zone II Flexor Tendon Repair. Hand (N Y) 2023; 18:960-969. [PMID: 35220786 PMCID: PMC10470236 DOI: 10.1177/15589447211043220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The goal of zone II flexor tendon surgery is to perform a repair with sufficient strength to withstand the forces encountered during rehabilitation. Postoperative rerupture and adhesion formation may lead to reoperation. This study aimed to determine the factors associated with reoperation after primary zone II flexor tendon repair. METHODS In this retrospective case series, a total of 252 fingers in 201 patients underwent zone II flexor tendon repair. A medical record review was performed to collect data regarding patient demographics, injury and treatment characteristics and postoperative complications including reoperation. Reoperation was defined as any unplanned surgical procedure performed after initial flexor tendon repair. RESULTS There were 49 fingers (19%) in 42 patients that underwent reoperation at a median of 5.5 (interquartile range: 2.8-7.9) months. Older age, workers' compensation, and a Kessler-type repair of the flexor digitorum profundus were independently associated with reoperation. CONCLUSIONS In vitro studies suggest that Kessler-type repairs are inferior compared with other suture configurations. Our study demonstrates a clinical correlation to these biomechanical studies. Our results suggest that Kessler-type repairs are inferior compared with non-Kessler-type repairs, due to postoperative complications requiring secondary surgeries.
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Beckmann-Fries V, Calcagni M, Schrepfer L, Kaempfen A, Vögelin E, Tobler-Ammann B. Relationship between pain, nerve injury and clinical outcomes after flexor tendon injuries in zones 1-2: a retrospective cohort study. HAND THERAPY 2023; 28:60-71. [PMID: 37904861 PMCID: PMC10584069 DOI: 10.1177/17589983231159187] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 02/06/2023] [Indexed: 11/01/2023]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Esther Vögelin
- Inselspital Bern, Bern, Switzerland
- University of Bern, Bern, Switzerland
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Abstract
BACKGROUND Evidence surrounding the impact of concomitant digital nerve injury on the outcome of zone 2 flexor tendon repair is sparse and conflicting. The purpose of this study is to assess the impact of digital nerve injury on the range of motion recovery after zone 2 flexor tendon repair. We hypothesized that digital nerve injury is independently associated with decreased motion after zone 2 flexor digitorum profundus (FDP) repair. METHODS This is a single-institution, multisurgeon retrospective analysis of patients treated with primary zone 2 FDP repair. Patients with or without digital nerve injuries were included. Patients with fracture, extensor tendon injury, dysvascularity, follow-up duration of less than 10 weeks, and younger than 15 years were excluded. The primary outcome measure was Strickland percentage at the last therapy visit. Bivariate analysis was performed using simple linear regression. These results were used to guide backward stepwise multivariable analysis of qualifying exploratory variables. RESULTS Forty-one patients with a total of 54 zone 2 FDP injuries qualified. Mean follow-up duration was 24 ± 10 weeks, and mean age was 38 ± 18 years. Thirty-three digits had a concomitant digital nerve injury, 26 digits had multidigit involvement, and 42 digits had combined FDP and flexor digitorum superficialis (FDS) injuries. Both older age and concomitant FDS injury exhibited independent relationships with poorer range of motion outcomes (P < .05). Digital nerve injury, follow-up duration, gender, and multidigit involvement did not influence final digital motion. CONCLUSIONS In patients undergoing zone 2 FDP repair, concomitant digital nerve injury is not independently associated with poorer postoperative active range of motion.
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Affiliation(s)
- Grace Keane
- Washington University School of Medicine in St. Louis, MO, USA
| | - Macyn Stonner
- Washington University School of Medicine in St. Louis, MO, USA
| | - Mitchell A. Pet
- Washington University School of Medicine in St. Louis, MO, USA
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Stonner MM, Keane G, Berlet L, Goldfarb CA, Pet MA. The Impact of Social Deprivation and Hand Therapy Attendance on Range of Motion After Flexor Tendon Repair. J Hand Surg Am 2022; 47:655-661. [PMID: 35623922 DOI: 10.1016/j.jhsa.2022.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 02/09/2022] [Accepted: 03/23/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To examine the influence of social deprivation and hand therapy attendance on active range of motion (AROM) outcomes following flexor tendon repair. METHODS We performed a retrospective analysis of patients who underwent primary zone I-III flexor tendon repair between November 2016 and November 2020. Area deprivation index (ADI) was used to quantify social deprivation. Medical record review determined each patient's demographic characteristics, injury details, total hand therapy visits, and final AROM outcome. Active range of motion was converted to Strickland's percentage for analysis. Spearman correlation and simple and multivariable linear regression models were used to assess relationships between explanatory variables and outcomes. RESULTS There were a total of 109 patients, with a mean ADI of 53 and mean therapy attendance of 13 visits. Higher ADI and lower therapy attendance were correlated, and each was associated with significantly decreased Strickland's percentage. In the multivariable model, therapy attendance, ADI, zone 2 injury, and age maintained significant associations with Strickland's percentage. CONCLUSIONS Socially deprived patients attend fewer therapy sessions and obtain poorer AROM after flexor tendon repair. Social deprivation is likely to contribute to poor outcomes both by its association with decreased therapy attendance and by other potential pathways that make it difficult for deprived patients to achieve good surgical outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Macyn M Stonner
- Milliken Hand Rehabilitation Center, Washington University School of Medicine, St. Louis, MO.
| | - Grace Keane
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
| | - Logan Berlet
- Milliken Hand Rehabilitation Center, Washington University School of Medicine, St. Louis, MO
| | - Charles A Goldfarb
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
| | - Mitchell A Pet
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, MO
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Outcomes of Flexor Tendon Repair in Patients With Concurrent Neurovascular Injuries of Multiple Digits in Zone 1. Ann Plast Surg 2022; 89:173-179. [PMID: 35703203 DOI: 10.1097/sap.0000000000003214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE We treated several patients with multiple flexor (flexor digitorum profundus; FDP) injuries accompanied by injuries to the digital nerve or vessels around the distal interphalangeal crease (zone 1). Here, we retrospectively report the outcomes and review the literature. MATERIALS AND METHODS Between January 2010 and December 2018, 16 patients who met the study inclusion criteria were investigated. Tendons were repaired using the cross-locked cruciate (Adelaide) technique (6-strand) or modified Becker method (4-strand). The neurovascular structures were repaired under a microscope. RESULTS Sixteen patients (47 digits) were treated. According to the criteria of Moiemen and Elliot, the lacerated areas were in zones IA and IB in 7 and 40 digits, respectively. The mean ranges of motion were 149.27 ± 7.78 and 66.43 ± 2.04 degrees according to the Strickland and modified Strickland assessments, respectively. The mean 2-point discrimination was 5.00 ± 0.63 mm. Four patients (group 1) presented with injuries to 2 digits, and 9 (group 2) and 3 (group 3) patients had 3 and 4 injured digits, respectively. The outcomes were satisfactory in terms of the mean range of motion; 2-point discrimination; cold tolerance; visual analog scale pain score; Disabilities of the Arm, Shoulder, and Hand score; and grip strength. There were no differences among the groups. CONCLUSIONS Open multiple-finger injuries involving flexor digitorum profundus rupture with concurrent neurovascular injuries on one or both sides occasionally occur in industrial environments. Fortunately, each digit exhibits a consistent injury type in a particular anatomical location; appropriate repair yields satisfactory outcomes despite the presence of multiple injuries.
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Duru Ç, Yaşar B, Ergani HM, Acicbe O, Utku Ö, Ünlü RE. Outcomes of Wide-Awake Flexor Tendon Repairs in 58 Fingers and 9 Thumbs. J Hand Surg Am 2022:S0363-5023(22)00054-5. [PMID: 35365356 DOI: 10.1016/j.jhsa.2022.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 11/10/2021] [Accepted: 01/06/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Çağdaş Duru
- Department of Plastic Reconstructive and Aesthetic Surgery, Ankara City Hospital, Ankara, Turkey.
| | - Burak Yaşar
- Department of Plastic Reconstructive and Aesthetic Surgery, Ankara City Hospital, Ankara, Turkey
| | - Hasan Murat Ergani
- Department of Plastic Reconstructive and Aesthetic Surgery, Ankara City Hospital, Ankara, Turkey
| | - Okan Acicbe
- Department of Plastic Reconstructive and Aesthetic Surgery, Ankara City Hospital, Ankara, Turkey
| | - Özge Utku
- Department of Plastic Reconstructive and Aesthetic Surgery, Ankara City Hospital, Ankara, Turkey
| | - Ramazan Erkin Ünlü
- Department of Plastic Reconstructive and Aesthetic Surgery, Ankara City Hospital, Ankara, Turkey; Department of Plastic Reconstructive and Aesthetic Surgery, Sağlık Bilimleri University, Istanbul, Turkey
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Abstract
Background: The aim of flexor pollicis longus (FPL) repair is to create a construct that is strong enough to withstand forces encountered during rehabilitation and to achieve an optimal active range of motion. The aim of this study was to: (1) assess factors influencing active thumb interphalangeal (IP) joint flexion; and (2) assess the factors associated with reoperation. Methods: Retrospectively, 104 patients with primary repair of a Zone II FPL laceration from 2000 to 2016 were identified. A medical chart review was performed to collect patient-, injury-, and surgery characteristics as well as the degree of postoperative active IP-flexion and occurrence of reoperation. Bivariate analyses were performed to identify factors influencing active IP-flexion and factors associated with reoperation. Results: The reoperation rate was 17% (n = 18) at a median of 3.4 months (range: 2.3-4.4). Indications for reoperation mainly included adhesion formation (n = 10, 56%) and re-rupture (n = 5, 28%). The median range of active IP-flexion was 30° (interquartile range [IQR]: 20-45) at a median of 12.4 weeks (IQR: 8.1-16.7). Solitary injury to the thumb (β = 17.9, P = .022) and the use of epitendinous suture (β = 10.0, P = .031) were associated with increased active IP-joint flexion. No factors were statistically associated with reoperation. Conclusions: About 1 in 5 patients undergo reoperation following primary repair of a Zone II FPL laceration, mostly within 6 months of initial surgery. The use of epitendinous suture is associated with greater active IP-flexion. Patients with multiple digits injured accompanying a Zone II FPL laceration have inferior IP-joint motion.
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Affiliation(s)
| | | | | | - Neal C. Chen
- Harvard Medical School, Boston, MA,
USA,Neal C. Chen, Department of Orthopaedic
Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital,
Harvard Medical School, Yawkey Center for Outpatient Care 2C, 55 Fruit Street,
Boston, MA 02114, USA.
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Beyond the Core Suture: A New Approach to Tendon Repair. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3280. [PMID: 33425594 PMCID: PMC7787298 DOI: 10.1097/gox.0000000000003280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 10/08/2020] [Indexed: 11/26/2022]
Abstract
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.
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Tuna Z, Oskay D, Gökkurt A, Mete O, Bağlan Yentür S, Ambarcioğlu P. Does earlier splint removal truly affect functional recovery and kinesiophobia after tendon repair? HAND SURGERY & REHABILITATION 2020; 39:310-315. [PMID: 32088423 DOI: 10.1016/j.hansur.2020.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/07/2020] [Accepted: 01/19/2020] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Z Tuna
- Gazi University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Emniyet Mah. Muammer Yaşar Bostancı Cad. No:16, 06560 Beşevler, Ankara, Turkey.
| | - D Oskay
- Gazi University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Emniyet Mah. Muammer Yaşar Bostancı Cad. No:16, 06560 Beşevler, Ankara, Turkey
| | - A Gökkurt
- Gazi University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Emniyet Mah. Muammer Yaşar Bostancı Cad. No:16, 06560 Beşevler, Ankara, Turkey
| | - O Mete
- Yildirim Beyazit University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Kızılca Mahallesi, 06760 Çubuk, Ankara, Turkey
| | - S Bağlan Yentür
- Gazi University, Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Emniyet Mah. Muammer Yaşar Bostancı Cad. No:16, 06560 Beşevler, Ankara, Turkey
| | - P Ambarcioğlu
- Ankara University, Faculty of Veterinary Medicine, Department of Biostatistics, Ziraat, Şht. Ömer Halisdemir Blv, 06110 Altındağ, Ankara, Turkey
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