A randomized controlled trial comparing controlled active motion and early passive mobilization protocols for rehabilitation of repaired flexor tendons in zone II

BACKGROUND

Flexor tendon injuries in zone II of the hand pose serious clinical complications due to the high risk of adhesion formation and suboptimal clinical outcomes, although controlled active motion (CAM) and early passive mobilization (EPM) are standard protocols used during rehabilitation.

OBJECTIVE

This randomized trial compared functional outcomes between CAM and EPM systems after zone II flexor tendon repair.

METHODS

Forty patients with entire zone II flexor digitorum profundus and superficialis tears were randomly assigned to either the CAM or EPM protocol for 12 weeks' rehabilitation. Total active motion (TAM), grip strength, and disability of the arm, shoulder, and hand (DASH) scores were assessed in the 6th and 12th week after the repair. Two-way mixed ANOVA was used to determine the effect of the treatment regarding the type of protocol and time within and between groups, as well as, Cohen's d was used to calculate the effect size.

RESULTS

There was a significant improvement over time in both groups for all measured outcomes (p < 0.001). However, CAM showed superior results than EPM across all time points (6th and 12th week); for TAM (p < 0.05, Cohen's d =11.8 and 9.9), grip strength (p < 0.05, Cohen's d = 7.97 and 9.7), and DASH score (p < 0.05, Cohen's d = 5.8 and 5.5). By 12 weeks, 80% of CAM patients achieved an "excellent" rating according to the Strickland formula of the TAM grading compared with 55% for the EPM group.

CONCLUSION

While both CAM and EPM protocols improve functional status after zone II flexor tendon repair, CAM confers a distinct early advantage in a digital range of motion and manual function compared with EPM. These data support the preferred adoption of the CAM rehabilitation approach after area II flexor tendon surgical repair.

Maximizing hand function following zone II flexor tendon repair: A systematic review and meta-analysis of rehabilitation strategies

Introduction

Injuries to the flexor tendons of the hand pose significant challenges in both surgical repair and postoperative rehabilitation. Despite advancements in techniques, there remains uncertainty about the most effective postoperative rehabilitation protocol/strategy. This study aims to address this debatable issue by evaluating different rehabilitation protocols following surgical repair in zone II flexor tendon repair.

Methods

A systematic review and meta-analysis followed PRISMA guidelines, searching databases up to December 2023. Inclusion criteria covered studies on zone II flexor tendon repair in adults, with various rehabilitation strategies and hand function as primary outcomes. Data extraction and bias assessment employed predefined tools.

Results

Among 916 initial articles, 28 met the inclusion criteria. Published from 1980 to 2023, these studies involved 1414 patients, predominantly affecting the little, index, and middle fingers. Various suture techniques and materials were used, with early active and passive motion as primary rehabilitation protocols.

Conclusion

This review highlights early active and passive motion as common postoperative rehabilitation strategies for zone II flexor tendon repair. While active motion showed greater range of motion improvement, both protocols had comparable reoperation rates and grip strength outcomes. Future research should focus on refining protocols and assessing long-term outcomes to optimize patient care.

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.

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.

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.

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.

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.

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.

Flexor tendon rehabilitation in the 21st century: A systematic review

STUDY DESIGN

Systematic review.

INTRODUCTION

The rehabilitation of patients following flexor tendon injury has progressed from immobilization to true active flexion with the addition of wrist motion over the last 75 years.

PURPOSE OF THE STUDY

This review specifically intended to determine whether there is evidence to support one type of exercise regimen, early passive, place and hold, or true active, as superior for producing safe and maximal range of motion following flexor tendon repair.

METHODS

The preferred reporting items for systematic review and meta-analysis (PRISMA-P 2015) checklist was utilized to format the review. Both reviewers collaborated on all aspects of the research, including identifying inclusion/exclusion factors, search terms, reading and scoring articles, and authoring the paper. Articles were independently scored by each reviewer using the Structured Effectiveness Quality Evaluation Scale (SEQES).

RESULTS

A total of nine intervention studies that included a rehabilitative comparison group were systematically reviewed: one pediatric, four comparing passive flexion protocols to place and hold flexion, and four comparing true active flexion to passive and/or place and hold flexion.

DISCUSSION

This review provides moderate to strong evidence that place and hold exercises provide better outcomes than passive flexion protocols for patients with two to six-strand repairs. The studies included in this review suffered from methodological limitations including short timeframes for follow-up, unequal group distribution, and limited attention to repair site strength.

CONCLUSIONS

Based on a lack of superior benefits following true active motion regimens, there is not sufficient evidence to support true active motion as an effective or preferable choice for flexor tendon rehabilitation at this time.

A prospective randomized controlled trial of controlled passive mobilization vs. place and active hold exercises after zone 2 flexor tendon repair

PURPOSE

The rehabilitation program after flexor tendon repair of zone II laceration varies. We designed a Prospective Randomized Controlled Trial of controlled passive mobilization (modified Kleinert) vs. Place and active hold exercises after zone 2-flexor tendon repair by two-strand suture (Modified kessler).

METHODS

Sixty-four fingers in 54 patients with zone 2 flexor tendon modified Kessler repairs were enrolled in a prospective randomized controlled trial comparing place and active hold exercises to controlled passive mobilization (modified Kleinert). The primary outcome measure was total active motion eight weeks after repair as measured by an independent and blinded therapist.

RESULTS

Patients treated with place and active hold exercises had significantly greater total active motion (146) eight weeks after surgery than patients treated with controlled passive mobilization (114) (modified Klinert). There were no ruptures in either group.

CONCLUSIONS

Place and hold achieves greater motion than controlled passive mobilization after a two-strand repair for zone 2 flexor tendon repairs.

Primary flexor tendon repair in zones 1 and 2: early passive mobilization versus controlled active motion

PURPOSE

To compare early passive mobilization (EPM) with controlled active motion (CAM) after flexor tendon surgery in zones 1 and 2.

METHODS

We performed a retrospective analysis of collected data of all patients receiving primary flexor tendon repair in zones 1 and 2 from 2006 to 2011, during which time 228 patients were treated, and 191 patients with 231 injured digits were eligible for study. Exclusion criteria were replantation, finger revascularization, age younger than 16 years, rehabilitation by means other than EPM or CAM, and missing information regarding postoperative rehabilitation. This left 132 patients with 159 injured fingers for analysis. The primary endpoint was the comparison of total active motion (TAM) values 4 and 12 weeks after surgery between the EPM and the CAM protocols. The analysis of TAM measurements under the rehabilitation protocols was conducted using t-tests and further linear modeling. We defined rupture rate and the assessment of adhesion/infection as secondary endpoints.

RESULTS

There was a statistically significant difference between the TAM values of the EPM and the CAM protocols 4 weeks after surgery. At 12 weeks, however, there was no significant difference between the 2 protocols. Older age and injuries with finger fractures were associated with lower TAM values. Rupture rates were 5% (CAM) and 7% (EPM), which were not statistically different.

CONCLUSIONS

This study showed a favorable effect of CAM protocol on TAM 4 weeks after surgery. The percent rupture rate was slightly lower in the patients with CAM than in the patients with EPM regime. Further studies are required to confirm our results and to investigate whether faster recovery of TAM is associated with shorter time out of work.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.