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

Outcomes of Zone II Flexor Tendon Repair Under General Versus Wide Awake Local Anesthesia: A Randomized Controlled Trial

PURPOSE

Wide awake local anesthesia no tourniquet (WALANT) is gaining popularity with flexor tendon repair. We hypothesized that results of zone II flexor tendon repair performed under WALANT would be superior to those performed under general anesthesia (GA).

METHODS

A randomized controlled trial was conducted to compare results of repair of zone II flexor tendon lacerations under WALANT versus GA. Following sample size estimation, 86 digits were included and randomized into two groups. All surgeries were performed by a single surgeon using a six-stranded core stitch and running epitenon suture. All patients followed the same early active rehabilitation protocol. The primary outcome was recovery calculated using the Strickland and Glogovac criteria. Secondary outcomes included rupture rate, complication rate, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. All outcomes were reported at the 6-month visit for all patients.

RESULTS

Of the 86 digits, three were lost to follow-up. Analysis was performed on 43 digits in the WALANT group and 40 in the GA group. Demographic characteristics including age and sex were comparable in both groups. Rupture of the repair occurred in two digits in each of the WALANT and GA groups. An excellent or good outcome was achieved in 49% and 56% of the digits in the WALANT and GA groups, respectively. This difference was not statistically significant. DASH scores averaged 12.9 and 8.4 for the WALANT and GA groups, respectively.

CONCLUSIONS

WALANT may not be superior to GA in regards function, rates of rupture, and patient-reported outcomes in repair of zone II flexor tendon lacerations. Surgeons can be confident in choosing either technique if rigorous patient selection, sound surgical technique, and proper hand therapy are employed.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

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.

Functional Outcomes of Flexor Tendon Repair in the Fingers: A Comparison of Wide-Awake Local Anesthesia No Tourniquet Versus Traditional Anesthesia

BACKGROUND

Flexor tendon lacerations in the fingers are challenging injuries that can be repaired using the wide-awake local anesthesia no tourniquet (WALANT) technique or under traditional anesthesia (TA). The purpose of our study was to compare the functional outcomes and complication rates of patients undergoing flexor tendon repair under WALANT versus TA.

METHODS

All patients who underwent a primary flexor tendon repair in zone I and II without tendon graft for closed avulsions or open lacerations between 2015 and 2019 were identified. Electronic medical records were reviewed to record and compare patient demographics, range of motion, functional outcomes, complications, and reoperations.

RESULTS

Sixty-five zone I (N = 21) or II (N = 44) flexor tendon repairs were included in the final analysis: 23 WALANT and 42 TA. There were no statistical differences in mean age, length of follow-up, proportion of injured digits, or zone of injury between the groups. The final Quick Disabilities of the Arm, Shoulder, and Hand score in the WALANT group was 17.2 (SD: 14.4) versus 23.3 (SD: 18.5) in the TA group. There were no statistical differences between the groups with any final range of motion (ROM) parameters, grip strength, or Visual Analog Scale pain scores at the final follow-up. The WALANT group was found to have a slightly higher reoperation rate (26.1% vs 7.1%; P = .034) than the TA group.

CONCLUSIONS

This study represents one of the first clinical studies reporting outcomes of flexor tendon repairs performed under WALANT. Overall, we found no difference in rupture rates, ROM, and functional outcomes following zone I and II flexor tendon repairs when performed under WALANT versus TA.

Medium-term clinical outcomes of Zone 2B/2C finger flexor tendon repairs: influence of management of flexor digitorum superficialis

III.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Therapeutic IV.

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

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

Flexor tendon repair: recent changes and current methods

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

The impact of transverse components on 4-strand tendon repairs

We investigated the effects of the transverse components of a tendon core suture on tensile resistance and strength of 4-strand repairs. Forty-four pig flexor tendons were repaired with one of the following four methods: double Tsuge, U-shaped, 4-strand cross and 4-strand rectangular repairs. We recorded the number of the repaired tendons that formed a 2 mm gap between the tendon ends during cyclic loading for 20 cycles, stiffness of the tendon at the 1st and 20th cycle, gap distance at the repair site and ultimate strength of the repair at the 20th cycle. When transverse components were added to the core suture, a greater number of tendons formed a 2 mm gap during cyclic loading. The stiffness gradually decreased, and the repair site's gap distance after cyclic loading increased with the presence of transverse components of the sutures. We conclude that the core suture's transverse components negatively impact the tensile resistance of 4-strand tendon repairs.

The impact of transverse components on resistance and ultimate strength of 6-strand tendon repairs

We assessed the effects of tendon core sutures' transverse components on the tensile resistance of two commonly used 6-strand tendon repairs. Tang and Yoshizu #1 repairs (6-strand) were tested and compared with 4-strand rectangular and double Kessler sutures (4-strand). A total of 40 pig flexor tendons were tested under cyclic loading. We recorded the number of tendons that formed a 2-mm gap between two tendon ends during 20 cycles of cyclic loading test, stiffness at the 1st and 20th loading cycle, and gap distance at the repair site and the ultimate repair strength at the 20th cycles. We found that the Yoshizu #1 repairs were more prone to form gaps and their ultimate strength was significantly lower than that of the Tang repair. The transverse components in a 6-strand repair affect gap formation and failure strength.

Flexor pollicis longus zone 2 tendon repair under WALANT with ultrasound assistance

A feature of the flexor pollicis longus tendon injury is the frequency of palmar retraction so that a wrist approach is needed for retrieval of the proximal stump. We are reporting on our first outpatient zone T2 flexor pollicis longus tendon repair under WALANT with ultrasound guidance. In the event of zone T2 flexor pollicis rupture, ultrasound location of tendon extremities is used to plan surgical WALANT strategy and to guide the injection of lidocaine with epinephrine whilst limiting the injected volume to what is strictly necessary.