Extensor Tendon Repairs Zones 4 to 8

Abstract

Objective/Hypothesis: This audit purposed to compare the early active motion (EAM) and immediate controlled active motion (ICAM) regimes postextensor tendon repair in zones 4 to 8. No previous comparison of these regimes was found. In 2005, Wyndell Merritt et al. introduced the ICAM regime, which includes a wrist and yoke splint. The ICAM regime was presented at International Federation of Societies of Hand Therapy (IFSHT) 2013 and was trialed at our unit from 2015. Materials and Methods: A prospective audit was conducted between November 2015 and November 2016 of all extensor zones 4 to 8 patients. Patients were treated by either EAM or ICAM regime dependent on patient suitability, staff skills, and regime criteria. Demographics, outcome, and complication data were recorded. Results: Totally, 51 patients and 63 digits (70% index or middle) were audited. Twenty-six patients were in the EAM group (mean age, 34 years) and 25 in the ICAM group (mean age, 43 years). Of the EAM patients, 21 had a single digit (9 with multiple tendons affected either extensor indicis proprius [EIP]/ extensor digiti minimi [EDM]), 3 patients had 2 digits, 1 patient had 3 digits, and 1 patient had 4 digits affected. Of the ICAM patients, 23 had a single digit affected (4 multiple tendons), and the remainder had 2 digits affected. Injury zone was consistent with EAM:ICAM; zone 4, 5:5; zone 5, 17:18; and zone 6, 4:2. Days from injury to repair was 1 to 5 except for 3 delayed presentations, mean EAM was 2.5 and ICAM was 4.3. Mean days from repair to therapy was 2.9 for EAM and 2.5 for ICAM patients. In the EAM group, 5 patients were transferred to peripheral hospitals, 9 did not attend their appointments, and 1 patient with 4 digits involved was excluded from analysis to allow direct comparison between groups. For the remainder the mean therapy, attendances was 6.8 (range, 3-19) over 8.6 weeks. In the ICAM group, 1 patient transferred and 4 DNA’d. For the remainder the mean therapy, attendances were 5 (range, 2-9) over 7.6 weeks. Two range of motion (ROM) outcomes were used to allow comparison with other studies. Results for EAM:ICAM groups for total active motion were as follows: excellent, 5:9 and good, 6:11; and Millers: excellent, 4:9; good, 5:8; and fair, 2:3. No ruptures presented, but 6 EAM patients experienced scar tethering. At 6 weeks, 5 EAM patients returned to light work duties. At 5 days, 2 ICAM patients returned to light duties and a further 11 with yoke at 4 weeks. The remaining data were not captured. Despite audit limitations of opportunistic regime allocation and demographic variation, it adds valuable data to advancing extensor tendon rehabilitation. Conclusions: Our audit supports the growing evidence that the ICAM regime with low-profile, low-cost splints provides good/excellent outcomes with no complications, fewer therapy attendances, and supports early return to work. In response to the literature and an audit presented at British Association of Hand Therapists (BAHT) conference 2015 involving a yoke-only regime with good/excellent outcomes and no ruptures, we have progressed to a yoke-only ICAM regime and continue to audit the results. Despite the favorable outcomes, there is no level 1 evidence of the ICAM regime. A multicenter clinical trial is planned.