Relative motion extension management of zones V and VI extensor tendon repairs: Does international practice align with the current evidence?

Relative Motion Extension Splint after Extensor Tendon Reconstruction

Recently, the wide-awake local anesthesia no tourniquet (WALANT) technique and relative motion extension (RME) splint changed practice in extensor tendon reconstruction and therapy. We wanted to share our approach for zones 5 to 8 extensor tendon management following the up-to-date developments. The impacts of surgery under WALANT and early active motion therapy with RME splinting were explained frankly and shown in several videos throughout the article.

Comparison of two relative motion extension approaches (RME with versus without an additional overnight orthosis) following zones V-VI extensor tendon repairs: A randomized equivalence trial

STUDY DESIGN

Multi--center randomized controlled trial with two intervention parallel groups. An equivalence trial.

INTRODUCTION

Relative motion extension (RME) orthoses are widely used in the postoperative management of finger extensor tendon repairs in zones V-VI. Variability in orthotic additions to the RME only (without a wrist orthosis) approach has not been verified in clinical studies.

PURPOSE OF THE STUDY

To examine if two RME only approaches (with or without an additional overnight wrist-hand-finger orthosis) yields clinically similar outcomes.

METHODS

Thirty-two adult (>18 years) participants (25 males, 7 females) were randomized to one of two intervention groups receiving either 1) a relative motion extension orthosis for day wear and an overnight wrist-hand-finger orthosis ('RME Day' group), or 2) a relative motion extension orthosis to be worn continuously ('RME 24-Hr' group); both groups for a period of four postoperative weeks.

RESULTS

Using a series of linear mixed models we found no differences between the intervention groups for the primary (ROM including TAM, TAM as a percentage of the contralateral side [%TAM], and Millers Criteria) and secondary outcome measures of grip strength, QuickDASH and PRWHE scores. The models did identify several covariates that are correlated with outcome measures. The covariate 'Age' influenced TAM (P = .006) and %TAM (P = .007), with increasing age correlating with less TAM and recovery of TAM compared to the contralateral digit. 'Sex' and 'Contralateral TAM' are also significant covariates for some outcomes.

DISCUSSION

With similar outcomes between both intervention groups, the decision to include an additional night orthosis should be individually tailored for patients rather than protocol-based. As the covariates of 'Age' and 'Sex' influenced outcomes, these should be considered in clinical practice.

CONCLUSIONS

A relative motion extension only approach with or without an additional overnight wrist-hand-finger orthosis yielded clinically similar results whilst allowing early functional hand use, without tendon rupture.

The use of exercise relative motion orthoses to improve proximal interphalangeal joint motion: A survey of Australian hand therapy practice

STUDY DESIGN

Cross-sectional online survey.

INTRODUCTION

Exercise relative motion (RM) orthoses are prescribed by hand therapists to improve finger motion but there is limited scientific evidence to guide practice.

PURPOSE OF THE STUDY

To describe Australian hand therapists' use of exercise RM orthoses to improve PIPJ motion, including trends in orthosis design, prescription, clinical conditions, and their opinions on orthosis benefits and limitations.

METHODS

870 Australian Hand Therapy Association members were sent an electronic survey that included multiple choice, Likert scale and open-ended questions under four subgroups: demographics, design trends, prescription, and therapist opinions. Data analysis consisted of predominantly descriptive statistics and verbatim transcription.

RESULTS

108 Australian therapists completed the survey, over a third with ≥ 20 years of clinical experience. Exercise RM orthoses were prescribed weekly to monthly (82%) for between 2-6 weeks duration (81%) and used during exercise and function (87%). The most common differential MCPJ position was 11-30° extension (98%) or flexion (92%). Four-finger designs were most common for border digits (OR ≥3.4). Exercise RM orthoses were more commonly used for active and extension deficits compared to passive (OR ≥3.7) and flexion deficits (OR ≥1.4), respectively. Clinicians agreed that the orthosis allowed functional hand use (94%), increased non-intentional exercise (98%), and was challenging to use with fluctuating oedema (60%).

DISCUSSION

This survey highlights notable clinical trends despite only reaching a small sample of Australian hand therapists. Exercise RM orthoses were frequently being used for active PIPJ extension and flexion deficits. A common MCPJ differential angle was reported, while the number of fingers incorporated into the design depended on the digit involved. Therapists' preferences mostly agreed with the limited available evidence.

CONCLUSION(S)

This limited survey identified common exercise RM orthosis fabrication and prescription trends amongst Australian therapists. These insights may inform future biomechanical and clinical research on this underexplored topic.

Implementing an internal audit to change practice: Current evidence and review of patient outcomes enabled transition to the relative motion extension approach in the postoperative management of zones IV-VI extensor tendon repairs

BACKGROUND

Evidence supports use of the relative motion extension (RME) approach following extensor tendon repairs in zones V-VI yielding good or excellent outcomes.

PURPOSE

To demonstrate how a 3-year internal audit and regular review of emerging evidence guided our change in practice from our longstanding use of the Norwich Regimen to the RME approach using implementation research methods. We compared the outcomes of both approaches prior to the formal adoption of the RME approach.

STUDY DESIGN

Prospective clinical audit.

METHODS

A prospective audit of all consecutive adult finger extensor tendon repairs in zones IV-VII rehabilitated in our tertiary public health hand centre was undertaken between November 2014 and December 2017. Each audit year, outcomes were reviewed regarding the Norwich regimen and the RME early active motion approaches. As new evidence emerged, adjustments were made to our audit protocol for the RME approach. Discharge measurements of the range of motion of the affected and contralateral fingers and complications were recorded.

RESULTS

During the 3-year audit, data was available on 79 patients (56 RME group including 59 fingers with 71 tendon repairs; 23 Norwich group including 28 fingers with 34 tendon repairs) with simple (n = 68) and complex (n = 11) finger extensor tendon zones IV-VI repairs (no zone VII presented during this time). Over time, the practice pattern shifted from the Norwich Regimen approach to the RME approach (and with the use of the RME plus [n = 33] and RME only [n = 23] approaches utilized). All approaches yielded similar good to excellent outcomes per total active motion and Miller's classification, with no tendon ruptures or need for secondary surgery.

CONCLUSIONS

An internal audit of practice provided the necessary information regarding implementation to support a shift in hand therapy practice and to gain therapist or surgeon confidence in adopting the RME approach as another option for the rehabilitation of zone IV-VI finger extensor tendon repairs.

Use of relative motion orthoses from the perspective of hand-injured patients: A qualitative study

BACKGROUND

Relative motion (RM) orthoses have gained popularity with therapists as their versatility lends to "protective," "exercise," and "adaptive" uses.

PURPOSE OF THE STUDY

To ask for comments from patients wearing RM orthoses for protective or exercise reasons.

STUDY DESIGN

Interpretive descriptive qualitative study.

METHODS

Semi-structured face-to-face interviews comprised of nine open-ended questions were conducted with 20 hand injured patients who were advised to wear a protective or exercise RM orthosis for at least 4 weeks.

RESULTS

Twenty patients participated in the interviews. Thirteen patients wore the protective RM orthoses had a mean age of 28 years (range,16-54) and the mean age was 34 years (range, 20-51) for 7 patients using exercise RM orthoses. Interviews generated 4 major themes: physical characteristics of the orthoses, challenges in daily living activities, emotional response to orthotic wear, and impact of social environment.

DISCUSSION

Comments from both groups of patients suggested the small size of the orthosis contributed to wearing the orthosis as advised. Most found the orthosis comfortable, when not, comments were related to rubbing of the orthosis causing pain and rigidity of the orthosis resulting in finger swelling. A few were impacted by the orthosis drawing attention to their injured hand. Those wearing the exercise RM orthosis often removed it instead of using it for nonintentional exercise.

CONCLUSIONS

Comments obtained from the limited structured interview of 20 patients wearing protective or exercise RM orthosis may offer therapists with some understanding from the patient's perspective. Additional study is worthwhile.

Relative motion flexion following zone I-III flexor tendon repair: Concepts, evidence and practice

STUDY DESIGN

Narrative review and case series.

INTRODUCTION

The relative motion approach has been applied to rehabilitation following flexor tendon repair. Positioning the affected finger(s) in relatively more metacarpophalangeal joint flexion is hypothesized to reduce the tension through the repaired flexor digitorum profundus by the quadriga effect. It is also hypothesized that altered patterns of co-contraction and co-inhibition may further reduce flexor digitorum profundus tension, and confer protection to flexor digitorum superficialis.

METHODS

We reviewed the existing literature to explore the rationale for using relative motion flexion orthoses as an early active mobilization strategy for patients after zone I-III flexor tendon repairs. We used this approach within our own clinic for the rehabilitation of a series of patients presenting with zone I-II flexor tendon repair. We collected routine clinical and patient reported outcome data.

RESULTS

We report published outcomes of the clinical use of relative motion flexion orthoses with early active motion, implemented as the primary rehabilitation approach after zone I-III flexor digitorum repairs. We also report novel outcome data from 18 patients.

DISCUSSION

We discuss our own experience of using relative motion flexion as a rehabilitation strategy following flexor tendon repair. We explore orthosis fabrication, rehabilitation exercises and functional hand use.

CONCLUSIONS

There is currently limited evidence informing use of relative motion flexion orthoses following flexor tendon repair. We highlight key areas for future research and describe a current pragmatic randomized controlled trial.

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.

Postoperative management of zones V-VI extensor tendon repairs: A survey of practice in Malaysia and comparison to IFSHT member countries

Introduction

A survey of International Federation of Societies for Hand Therapy (IFSHT) member countries identified relative motion extension as the preferred approach to management of zones V-VI extensor tendon repairs. The aims of this survey were to identify and compare hand therapy practice patterns in Malaysia (a non-IFSHT member country) with findings of the IFSHT survey including an IFSHT subset of Asia-Pacific therapists and to investigate if membership status of the Malaysian Society for Hand Therapists (MSHT) influenced therapy practice patterns.

Methods

An online English-language survey was distributed to 90 occupational therapists and physiotherapists including MSHT members and non-members. Participation required management of at least one extensor tendon repair in the preceding year. Five approaches were surveyed: immobilisation, early passive motion (EPM) with dynamic splinting, and early active motion (EAM) delivered by resting hand (RH), palmar resting interphalangeal joints free (PR), and relative motion extension (RME) splints.

Results

Thirty-seven of the 53 therapists (68%) who commenced the survey completed it. The most used approach was dynamic/EPM (28%), followed by RH/immobilisation (22%) and RH/EAM (22%). A preference for RME/EAM was identified with implementation barriers being surgeon preference and hand therapist confidence.

Discussion

Approach selection for Malaysian therapists differed from the combined IFSHT and Asia-Pacific respondents, with the former using dynamic/EPM and RH/immobilisation compared to IFSHT respondents who predominately used RME/EAM and PR/EAM. This survey provides valuable insights into Malaysian hand therapists' practices. If implementation barriers and therapist confidence are addressed, Malaysian practice patterns may change to better align with current evidence.