Controlled Active Motion Research Articles

Pull-out vs. suture in zone Ia-Ib flexor tendon injuries: clinical results from a multicentre cohort study.

Several surgical techniques have been reported for flexor tendon zone 1a-b lacerations without a clear consensus on the gold standard treatment. The purpose of this multicentre study was to measure the outcomes of zone 1a-b flexor tendon injuries treated with a pull-out suture (POS) versus direct suture (DS) technique. Fifteen patients were treated with the pull-out technique and 22 patients with a direct suture technique between 2014 and 2020. The controlled active motion (CAM) regimen protocol and a standardised follow-up schedule were used in both groups. Data on the demographics, surgery, and treatment characteristics were collected at baseline as well as at week 6 and 13 post-operatively. The primary outcome measurement was the complication rate. Secondary outcome measurements were reoperation rate, finger range of motion (ROM), strength as well as patient satisfaction. The patient age ranged from 18 to 75 years in both groups with all patients having a complete FDP lesion after a clean-cut injury. The complication rate was 41% in the POS group and 16% in the DS group. The reoperation rate was 29% in the POS group and 8% in the DS group. Significant between-group differences in favour of the DS group were found in the passive DIP and passive PIP+DIP ROM at week 6 and week 13. Mean hand strength was 28.7 (11.6) kg in the POS group at week 13 and 21.3 (7.9) kg in the DS group. This difference was statistically significant (p=0.012) with a medium effect size (r=-0.41). Average patient satisfaction at week 13 was 7.5 (2.2) points in the POS and 7.7 (1.3) points in the DS group. The difference between groups was not significant (p=0.839). This register-based study demonstrates lower complication and reoperation rates with the direct suture approach compared with a pull-out button technique. Although clinical results were similar between the two surgery techniques at week 13 post-surgery, a direct suture approach should always be attempted whenever possible. If necessary, other local structures should be included to increase suture strength and allow for early active motion rehabilitation regimens.

Early or delay? The most suitable rehabilitation protocol for “no man's land” injury: Meta-analysis with trial sequential analysis—20 years trends

Objective: The aim of this study is to analyze various rehabilitation protocol and determine which methods will yield a better outcome. Methods: The database reports were searched within 1990 until 2020, using PubMed, Cochrane library database, Ovid, Medline, and the other several published trials. A statistical analysis was made from Review Manager and Trial Sequential Analysis (TSA). Result: The mean of rerupture rate is 3.3% (n = 8) in the combination protocol and 8% (n = 48) in controlled active motion (CAM) protocol. Meta-analysis found no significant difference between Kleinert versus CAM in rerupture rate. Furhtermore, we found no significant difference in Duran versus CAM in rerupture rate. In TSA, the Z-curve does not cross both of the trial sequential boundaries, a further trial with larger sample will be required. The TSA of flexion contracture CAM versus Kleinert was indicated that CAM protocol may be superior than Kleinert to reduce the incidence of flexion contracture with the range of mean flexion contracture 6.6% (n = 18) in CAM to 23.6% (n = 76) in Kleinert protocol. Conclusion: Current meta-analysis proposed that the combination technique will result less rerupture incidence and better functional outcome in flexor zone II injuries than other techniques. The CAM method also results in less flexion contracture than others. However, a further meta-analysis with larger sample trials seems to be required to confirm this review's conclusion.

A retrospective analysis of controlled active motion (CAM) versus modified Kleinert/Duran (modKD) rehabilitation protocol in flexor tendon repair (zones I and II) in a single center

IntroductionThe aim of this study was to analyze primary flexor tendon repair results in zones I and II, comparing the rupture rate and clinical outcomes of the controlled active motion (CAM) protocol with the modified Kleinert/Duran (mKD) protocol.Materials and methodsPatients who underwent surgery with traumatic flexor tendon lacerations in zones I and II were divided in three groups according to the type of rehabilitation protocol and period of management: group 1 included patients who underwent CAM rehabilitation protocol with six-strand Lim and Tsai suture after May 2014. Group 2 and 3 included patients treated by six-strand Lim Tsai suture followed by a modified Kleinert/Duran (modK/D) protocol with additional place and hold exercises between 2003 and 2005 (group 2) and between 2011 and 2013 (group 3).ResultsRupture rate was 4.7% at 12 weeks in group 1 (3/63 flexor tendon repairs) compared to 2% (1/51 flexor tendon repairs) in group 2 and 8% in group 3 (7/86 flexor tendon repairs). The grip strength at 12 weeks was significantly better in group 2 compared to the group 1 (35 kg/25 kg, p = 0.006). The TAM in group 1 [113° (30–175°)] was significantly worse (p < 0.001) than the TAM in group 2 [141° (90–195°)] but with similar extension deficits in both groups. The assessment of range of motion by the original Strickland classification system resulted in 20% excellent and 15% good outcomes in the CAM group 1 compared with 42% and 36% in the modK/D group 2. Subanalysis demonstrated improvement of good/excellent results according to Strickland from 45% at 3 months to 63.6% after 6-month follow-up in the CAM group.ConclusionThe gut feeling that lead to change in our rehabilitation protocol could be explained by the heterogenous bias. A precise outcome analysis of group 1 could underline that in patients with complex hand trauma, nerve reconstruction, oedema or early extension deficit, an even more intensive and individual rehabilitation has to be performed to achieve better TAM at 6 or 12 weeks. Our study explicitly demonstrated a significant better outcome in the modK/D group compared to CAM group. This monocenter study is limited by its retrospective nature and the low number of patients.

A pneumatic-muscle-actuator-driven knee rehabilitation device for CAM therapy.

In this paper a novel knee joint rehabilitation device made for controlled active motion (CAM) therapy is presented and tested. More precisely, the system is a redesign of an originally passive CAM device, called CAMOped. Instead of a break, the adjustable resistance, which is needed for CAM therapy, is now provided via a torque-controlled pneumatic-muscle-actuator-driven joint. These actuators are inherently compliant and can produce both a variable resistance and, by co-contraction, a variable stiffness. It will be shown that, by measuring the foot contact forces and using them as feedback information, the foot load can be adjusted very precisely up to 100 N. Furthermore, it will be demonstrated that, in contrast to passive systems, the presented active systems is capable of varying the resistance while the device is in use. This facilitates adapting the resistance to the patient's needs in real time and to use joint-angle- or foot-position-dependent resistance curves.

A randomized clinical trial comparing early active motion programs: Earlier hand function, TAM, and orthotic satisfaction with a relative motion extension program for zones V and VI extensor tendon repairs

Study DesignRandomized clinical trial with parallel groups. IntroductionEarly active mobilization programs are used after zones V and VI extensor tendon repairs; two programs used are relative motion extension (RME) orthosis and controlled active motion (CAM). Although no comparative studies exist, use of the RME orthosis has been reported to support earlier hand function. Purpose of the StudyThis randomized clinical trial investigated whether patients managed with an RME program would recover hand function earlier postoperatively than those managed with a CAM program. MethodsForty-two participants with zones V-VI extensor tendon repairs were randomized into either a CAM or RME program. The Sollerman Hand Function Test (SHFT) was the primary outcome measure of hand function. Days to return to work, QuickDASH (Disabilities of Arm, Shoulder and Hand) questionnaire, total active motion (TAM), grip strength, and patient satisfaction were the secondary measures of outcome. ResultsThe RME group demonstrated better results at four weeks for the SHFT score (P = .0073; 95% CI: −10.9, −1.8), QuickDASH score (P = .05; 95% CI: −0.05, 19.5), and TAM (P = .008; 95% CI: −65.4, −10.6). Days to return to work were similar between groups (P = .77; 95% CI: −28.1, 36.1). RME participants were more satisfied with the orthosis (P < .0001; 95% CI: 3.5, 8.4). No tendon ruptures occurred. DiscussionParticipants managed using an RME program, and RME finger orthosis demonstrated significantly better early hand function, TAM, and orthosis satisfaction than those managed by the CAM program using a static wrist-hand-finger orthosis. This is likely due to the less restrictive design of the RME orthosis. ConclusionsThe RME program supports safe earlier recovery of hand function and motion when compared to a CAM program following repair of zones V and VI extensor tendons.

Randomized, prospective, monocentric study to compare the outcome of continuous passive motion and controlled active motion after total knee arthroplasty.

The number of patients requiring a total knee arthroplasty (TKA) is increasing and postoperative care is an important factor for the recovery of knee function. It is discussed controversially, if the benefits of controlled active motion (CAM) therapies are comparable to continuous passive motion (CPM) therapies. Comparison of postoperative outcomes using a device in CAM and CPM settings, in addition to standard physiotherapeutical exercises immediately after TKA. TKA patients were randomized to either CAM or CPM therapy performed with an identical device (ARTROMOT® ACTIVE-K, Ormed GmbH). All patients received an additional physiotherapeutic program. Pain, knee associated problems (KOOS), active range of motion (ROM), and adverse events were documented before surgery, during the stationary stay and after an outpatient period. We included 50 patients (70 ± 8 years). During the postoperative period, KOOS scales improved significantly in both groups, but the CAM group showed a significantly better improvement of pain and quality of life scale. Furthermore, postoperative course of pain intensity and knee flexion was significantly better in the CAM group. CAM and CPM lead to significant improvements after TKA, but CAM shows better results in terms of flexion, pain and quality of life.

Relative motion orthoses in the management of various hand conditions: A scoping review

Study DesignScoping review. IntroductionThe relative motion (RM) concept and immediate controlled active motion (ICAM) program, originally applied after zones IV-VII extensor tendon repairs, have been modified and extended to a variety of hand conditions, such as sagittal band injury, boutonniere deformity, and extensor lag. Purpose of the StudyTo scope the published and unpublished literature to review ICAM modifications, hand conditions for which the RM concept is used, and describe the preferred degree of relative metacarpophalangeal joint extension/flexion reported and spectrum of orthosis design. MethodsElectronic and manual searches of scientific and gray literature and expert consultation were conducted. Documents with quantitative data were assessed with Oxford Levels of Evidence and the Structured Effectiveness Quality Evaluation Scale. ResultsFifteen references met the inclusion criteria; 1 was level III evidence, and others were level IV evidence. RM-ICAM modifications, preferred degree of relative extension/flexion, orthotic design, management of other hand conditions and knowledge gaps were identified. ConclusionRM orthoses may improve outcomes in a variety of hand conditions; however, high-quality studies that contribute to the evidence base for its use are needed. Level of EvidenceNot applicable.

Can Relative Motion Extension Splinting Provide Earlier Return to Hand Function Than a Controlled Active Motion Protocol? A Randomized Clinical Trial

Objective: Various active mobilization protocols are used after repair of extensor tendons in zone V and VI. These include relative motion extension splinting (RMES) and controlled active motion (CAM) protocols. Similar outcomes are reported for most early active mobilization protocols, however reports on RMES protocols suggest a possible earlier return to work and functional use of the affected hand. To date no published prospective trials have compared the RMES to other early active mobilization protocols. This randomized clinical trial prospectively investigated whether patients with extensor tendon repairs in zone V and VI managed with an RMES protocol would return to functional use of the hand sooner than those managed with an extensor CAM protocol. Methods: Between January 2015 and February 2016, 42 participants who had undergone extensor tendon repair in zone V and/or VI were recruited to the study. They were randomized into 2 groups: one group was treated using a CAM protocol, the other an RMES yoke-only protocol. Participants were reviewed at 4 and 8 weeks post-operatively. The primary outcome was the Sollerman Hand Function Test (SHFT) score. Secondary outcomes were days to return to work, total active motion (TAM), grip strength and questionnaires including the QuickDASH (Disabilities of Arm, Shoulder and Hand) and satisfaction. Incidence of tendon rupture was recorded. Results: Results are as follows: SHFT mean score at 4 weeks: RMES 66 (SD: 7), CAM 59 (SD: 10), (p = 0.0073), SHFT at 8 weeks RMES 76 (SD: 2), CAM 75 (SD: 5), (p = 0.63). Median days to return to work: RMES: 20 (IQR: 12, 57), CAM: 18 (IQR: 6, 55), (p = 0.77). QuickDASH 4 weeks: RMES 28.4 (SD: 14.5), CAM 40.7 (SD: 18), (p = 0.05). QuickDASH 8 weeks: RMES 11 (SD: 11), CAM 14 (SD: 13.1), (p = 0.35). TAM 4 weeks: RMES 185.9° (SD: 48.3), CAM 147.9° (SD: 41.7), (p = 0.008). TAM 8 weeks: RMES 236.4° (SD: 28.3), CAM 209.1° (SD: 37.6), (p = 0.030). Mean grip strength percentage of contralateral hand at 8 weeks: RMES 82.8% (SD: 23.7), CAM 73.8% (SD: 22.1), (p = 0.47). Mean percentage satisfaction with splint: RMES 75.9% (SD: 17.3), CAM 43% (SD: 22.2), (p &lt; 0.0001). No tendon ruptures occurred, one RMES participant underwent tenolysis surgery. Conclusions: This is the first randomized clinical trial to prospectively compare an RMES protocol to a CAM protocol. Participants treated with an RMES protocol demonstrated better early return to functional use of the hand than those treated with a CAM protocol, and RMES participants continued to show better range of motion to CAM participants at eight weeks. RMES participants were also more satisfied with splinting than CAM participants. There was no difference in return to work timeframes, possibly due to factors outside the control of the study. No ruptures occurred in either group, complication rates were low and not significantly different between groups. This study has demonstrated that an RMES protocol provides an earlier return to hand function than a CAM protocol for the patients who have undergone extensor tendon repair in zones V and VI.

Extensor Tendon Repairs Zones 4 to 8

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.

Primary Flexor Tendon Repair in Zones 1 and 2: Early Passive Mobilization Versus Controlled Active Motion

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

Outcomes of Digital Zone IV and V and Thumb Zone TI to TIV Extensor Tendon Repairs Using a Running Interlocking Horizontal Mattress Technique

Biomechanical evidence has demonstrated that the running interlocking horizontal mattress (RIHM) repair for extensor tendon lacerations is significantly stronger, with higher ultimate load to failure and less tendon shortening compared with other techniques. We investigated the efficacy and safety of primary extensor tendon repair using the RIHM repair technique in the fingers followed by the immediate controlled active motion protocol, and in the thumb followed by a dynamic extension protocol. We conducted a retrospective review of all patients undergoing extensor tendon repair from August 2009 to April 2012 by single surgeon in an academic hand surgery practice. The inclusion criteria were simple extensor tendon lacerations in digital zones IV and V and thumb zones TI to TIV and primary repair performed using the RIHM technique. We included 8 consecutive patients with 9 tendon lacerations (3 in the thumb). One patient underwent a concomitant dorsal hand rotation flap for soft tissue coverage. We used a 3-0 nonabsorbable braided suture to perform a running simple suture in 1 direction to obtain a tension-free tenorrhaphy, followed by an RIHM corset-type suture using the same continuous strand in the opposite direction. Average time to surgery was 10 days (range, 3-33 d). Mean follow-up was 15 weeks (range, 10-26 wk). We applied the immediate controlled active motion protocol to all injuries except those in the thumb, where we used a dynamic extension protocol instead. Using the criteria of Miller, all 9 tendon repairs achieved excellent or good results. There were no tendon ruptures or extensor lags. No patients required secondary surgery for tenolysis or joint release. No wound complications occurred. The RIHM technique for primary extensor tendon repairs in zone IV and V and T1 to TIV is safe, allows for immediate controlled active motion in the fingers and an immediate dynamic extension protocol in the thumb, and achieves good to excellent functional outcomes. These clinical outcomes support prior biomechanical data. Therapeutic IV.

Wyndell Merritt Immediate Controlled Active Motion (ICAM) Protocol following Extensor Tendon Repairs in Zone IV–VII: Review of Literature, Orthosis Design, and Case Study—A Multimedia Article

Controlled post-operative motion of extensor tendon repairs in zones IV-VII is intended to facilitate tendon excursion and minimize adhesion formation. The Wyndell Merritt "relative motion" digital yoke orthosis provides a low-profile option allowing for immediate controlled active motion (ICAM) of the extensor tendon repair. The addition of a multimedia manuscript demonstrating the manufacturing of the Wyndell Merritt digital yoke orthosis may complement current literature on this topic. Two case studies demonstrating the use of the Wyndell Merritt ICAM digital yoke orthosis without wrist immobilization following zone V extensor tendon repair are presented. A literature review was completed. A video was produced highlighting fabrication of the digital yoke orthosis as well as video documentation of case study 1. Case study 1 demonstrated mild limitations in metacarpophalangeal (MP) flexion at 5-week follow-up that resolved by 6weeks. MP hyperextension was attainable for all digits at 5weeks. Grip strength was comparable to the contralateral uninjured hand at 10weeks. The second patient achieved normal composite flexion/extension by 4weeks. Attainment of normal hyperextension at the MP joints and grip strength for case study 2 was unknown, as the patient was lost to follow-up. The Wyndell Merritt ICAM digital yoke orthosis, fabricated with or without wrist immobilization, appears to facilitate the return of normal extensor tendon function after repair in zones IV through VII while minimizing morbidity to adjacent digits. This protocol provides a safe, low-profile, cost-effective alternative for post-operative treatment of zone IV-VII extensor tendon repairs.

Outcome of zone 2 flexor tendon injuries: Kleinert versus controlled active motion therapy regimens

Introduction No single optimal regimen for the rehabilitation of flexor tendon injuries has yet been determined. We aimed to evaluate if a change in rehabilitation from a modified Kleinert to a controlled active motion (CAM) regimen had an effect on outcomes in a regional plastic surgery unit. We did this by comparing ruptures and range of movement of zone 2 repairs following both Kleinert and CAM regimens. Methods We performed a retrospective case series review, analysing data collected prospectively between 2004 and 2007. During 2004 and 2005, patients were rehabilitated with a modified Kleinert regimen, and during 2006 and 2007 a CAM regimen was used. We looked at total active motion (TAM) and ruptures at 12-week follow-up for all zone 2 repairs, and compared the two regimens. Results There were 38 patients with 42 injured digits in the Kleinert group, and 34 patients with 39 injured digits in the CAM group. There was no statistically significant difference in TAM achieved between the Kleinert and CAM regimens overall (70% versus 72% of normal in each group respectively, P = 0.70 t-test). Patients over 30 years old achieved significantly worse outcomes in the Kleinert group than in the CAM group ( P = 0.03). One digit ruptured following a Kleinert regimen (2.6%) compared with four digits in the CAM group (11.7%). Conclusion In this study, we found no overall difference in outcome following a Kleinert or CAM rehabilitation regimen. Rupture rates were higher in the CAM group by four-fold. In our patients those over 30 years had poorer outcomes when rehabilitated with a Kleinert regimen.

Immediate Controlled Active Motion Following Zone 4–7 Extensor Tendon Repair

This article describes a splint management program for zone 4–7 extensor tendon repairs that allows for immediate controlled active motion (ICAM) of the repair and greater arcs of motion for adjacent digits. The splint is designed to relieve tension on the tenorrhaphy by positioning the involved digit in slight metacarpophalangeal joint hyperextension relative to the uninvolved digits with a simple yoke splint designed to control the metacarpophalangeal joints and a second splint to control wrist position. Cadaver and intraoperative trials support this technique, and 140 patient cases managed over 20 years. The majority of patients achieved a rating of excellent for both digital extension and flexion as judged by Miller's criteria. There were very few extension lags and no tendon ruptures. Patients returned to work in the ICAM splint on average in 18 days. The average time to complete the program was seven weeks after repair, and required an average of eight therapy visits. The results of this study demonstrate that the ICAM splinting technique is safe, simple to manage, decreases the morbidity associated with immobilization, is cost effective, and has high patient compliance when compared to other early motion programs.