Flexor Subzone II A-D Range of Motion Progression during Healing on a No-Splint, No-Tenodesis Protection, Immediate Full Composite Extension Regimen

Use of a relative motion flexion orthosis after epitendinous zone II flexor tendon repair: A case report

STUDY DESIGN

Case report INTRODUCTION: Relative motion flexion (RMF) orthoses are emerging as an option for early active motion (EAM) postoperatively.

PURPOSE OF THE STUDY

To describe the rationale and implementation of an RMF orthosis to manage a patient after partial zone II epitendinous flexor tendon repairs.

METHODS

This case involves a female who sustained partial flexor tendon lacerations to her middle finger in zone II, 60% flexor digitorum superficialis (FDS) and 90% flexor digitorum profundus (FDP). After epitendinous repair she was referred to therapy for EAM with a no orthosis request. The unusual circumstances prompted the therapist, concerned about the risk of tendon rupture to engage in discussion with the surgeon. Following discussion, a decision was made to use an RMF orthosis for controlled EAM to protect the epitendinous zone II FDS and FDP repairs. Outcomes of range of motion (ROM), total active motion (TAM), %TAM, grip, and quickDASH are reported.

RESULTS

Neither the FDP or FDS tendons ruptured, nor were there any joint contractures. "Good" %TAM outcomes were achieved at 12-week postoperatively. Quick DASH scores improved 61 points indicating a clinically meaningful difference of improved function.

DISCUSSION

The lack of a multi-strand core suture repair is unusual in combination with EAM. The positive outcomes reported in this single patient have raised questions about the protective benefit of the RMF orthosis when used with a zone II epitendinous repair of a 90% FDP laceration. Epitendinous repair of a partial (60%) FDS injury, however, is not uncommon and often not repaired at all.

CONCLUSIONS

In this single case report the epitendinous repairs of zone II 90% FDP and 60% FDS with digital nerve involvement were successfully managed with an RMF only orthosis. The use of EAM with an epitendinous repair is in conflict to the current surgical and therapy literature.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Therapeutic IV.