Flexor Tendon Injuries In Zone Research Articles

A human acellular dermal matrix coated with zinc oxide nanoparticles accelerates tendon repair in patients with hand flexor tendon injuries in zone 5 of the hand

Introduction: Flexor tendon injuries are common and require surgery. Acellular dermal matrix (ADM) is a natural graft used to repair tissues, though infections represent the primary cause of its therapeutic failure. In this study, zinc oxide nanoparticles (ZnO-NPs) were coated on the ADM in order to add antibacterial potential as well as enhance healing properties. Also, the produced ADM/ZnO-NPs graft was applied to accelerate fifth zone flexor tendon repair following the reconstructive surgery. Methods: Morphological, mechanical, cell viability, and antibacterial tests were performed to evaluate the physical and biological properties of the fabricated ADM/ZnO-NPs graft. For clinical evaluations, 20 patients with a flexor tendon injury in zone 5 were randomly divided into control and treatment with ADM/ZnO-NPs groups (n=10 each). The control group had routine reconstructive surgery, while the other group received the ADM/ZnO- NPs graft during their surgery. Postoperative functional outcomes were evaluated 4, 6, and 8 weeks following the tendon repair surgery according to the Buck-Gramcko II criteria. Results: The ADM/ZnO-NPs had natural derm specifications as well as dense and integrated morphology with intermediate antibacterial properties. According to the Buck- Gramcko II criteria, the postoperative functional outcome scores were significantly higher in the ADM/ZnO-NPs group in comparison with the control group at 4 (P<0.01), 6 (P<0.01), and 8 (P<0.001) weeks after the surgery. Conclusion: The present findings revealed that the ADM/ZnO-NPs graft can accelerate the healing of the damaged tendon without common post-operative functional complications and adhesions following the tendon repair surgery. However, more comprehensive clinical trials are still needed.

FTP1.9 Two-Stage flexor tendon repair versus Primary repair: An evaluation of subjective and functional outcomes at a Regional Centre for Plastic Surgery

Abstract Aims The hand, as the primary executing organ, is at the centre of nearly all daily activities. In the anatomical extremity, the hand is frequently exposed to the potential risk of injury. If a flexor tendon is injured and recognized as needing surgical intervention, two main options are available; Two-stage Flexor Tendon (TSFT) repair or Primary repair. We evaluated the subjective and functional outcomes of the two surgical methods described above in patients presenting with flexor tendon injury in Zone I or II over a 5-year period. Methodology A retrospective study employing 35 patients (and a total of 42 tendon injuries) requiring TSFT repair over a 5-year period and 190 patients requiring primary flexor tendon repair between 2012-2014. Data collected included patient demographics, injury details, intraoperative findings and post-operative outcomes. Results Of the 35 digital injuries assessed, 15.8% had a good outcome, 21.1% with a fair outcome and 63.2% with a poor outcome, based upon the Strickland grading system. In comparison, of those undergoing primary flexor tendon repair, 51.5% had a good / Excellent outcome, leaving 48.5% with a poor outcome. Rupture rates post-surgery were higher in those undergoing TSFT repair than primary repair; 23.8% versus 12.0% respectively. Conclusion A damaged flexor tendon requiring surgery should ideally be repaired within 72 hours of initial insult via primary repair. Delayed presentation and subsequent scar formation with proximal stump retraction warrants a two-stage approach. It is widely accepted that a reconstruction in two-stages can yield effective results in restoring digital function, but these results are often superseded by a primary repair.

Patient-reported outcome measures and their association to the original Strickland classification after flexor tendon repair.

The aim of this study was to examine the relationship between patient-reported outcome measures (PROMs) and the original Strickland classification after flexor tendon injuries in Zones 1 and 2. Data were collected from the Swedish national health care registry for hand surgery (HAKIR). The studied PROMs were the Quick Disabilities of Arm, Shoulder and Hand (QuickDASH) and the patient questionnaire from the HAKIR (HQ-8). Complete data of both range of motion (ROM) and PROMs were available for 215 patients at 3 months after surgery, and for 150 patients at 12 months after surgery. We found that QuickDASH values were low and similar between all groups as classified by the Strickland system at 12 months. A statistically significant difference between PROM values (for stiffness and satisfaction) was found only between the Strickland groups Fair and Good, but not between Poor and Fair or Good and Excellent. This suggests that further categorization according to the Strickland classification is less important to the patients as long as they regain 70% of their ROM.Level of evidence: III.

Relationship between pain, nerve injury and clinical outcomes after flexor tendon injuries in zones 1-2: a retrospective cohort study.

The influence of pain and a concomitant digital nerve injury on the course of rehabilitation after flexor tendon injury remains ambiguous. The objectives of the study were to: i) analyse the evolution of pain spanning one year after a primary flexor tendon repair in zones 1-3; ii) examine the differences in pain levels in patients with and without digital nerve injury; and iii) evaluate the relationship between pain, digital nerve injury and pain medication, total active motion (TAM), DASH scores and patient satisfaction. Data from 189 patients were retrieved from a flexor tendon registry between 2014 and 2020. Differences in pain, TAM, DASH and patient satisfaction were analysed. Multiple linear and binary logistic regression analyses were performed to determine the relationship between clinical outcomes. Pain significantly decreased in the course of rehabilitation (p < 0.001 to 0.006). No relationship could be identified between nerve injury and pain (p = 0.21-0.97). In week 6, the presence of pain and a nerve injury were significantly associated with lower TAM scores (p = 0.001). In week 13, pain during motion (p < 0.001) and the presence of a nerve injury (p = 0.036) were significantly associated with worse DASH scores. Patient satisfaction was significantly inversely correlated to pain during motion in weeks 13 and 26 (p < 0.001). We found a significant relationship between pain during motion and pain medication intake, TAM, DASH scores and patient satisfaction. It is therefore advisable to closely monitor this parameter after flexor tendon injuries. This multi-center cohort study is registered under https://clinicaltrials.gov: NCT04312412.

The efficiency of Coban bandage on acute phase edema among patients undergoing a flexor tendon repair

Introduction: To evaluate the efficiency of 3M Coban self-adherent wrap application on early (1-4 weeks) edema among patients undergoing surgery following a flexor tendon injury in Zone V or distal.&#x0D; Material and Method: The study included 56 patients who had flexor tendon injuries. The patients were randomized into two groups by the computerized randomization method. Both groups were applied the "Modified Duran Protocol" (MDP) early passive mobilization exercises and "Retrograde Edema Massage". In addition, was applied 3M Coban self-adherent wrap to Group II. Finger circumferences was measured using a tape measure, and the pain intensity was evaluated with a visual analog scale (VAS). A goniometer was used to measure the joint range of motion (ROM), the Duruoz hand index (DHI) to evaluate functionality level, and the quality of life was investigated using the short form-36 (SF-36).&#x0D; Results: The results showed that was statistically significant differences in both groups compared to pre-treatment (p

Passive Mobilization With Place and Hold Versus Active Motion Therapy After Flexor Tendon Repair: A Randomized Trial

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. 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. 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. The outcomes were equivalent for both the mobilization groups. Therapeutic I.

Outcome of Surgical Repair and Rehabilitation of Flexor Tendon Injuries in Zone II of the Hand: Systematic Review and Meta-Analysis

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. 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. 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. 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. Therapeutic IV.

The Transosseous Internal Four Strand Technique: A New All-Inside Technique for Zone 1 Flexor Tendon Repairs.

Multiple techniques for the repair of flexor tendon injuries in zone 1 have been proposed over time. While pull-out suture techniques and bone anchor seem to be stronger than internal suture techniques, they are associated with a higher complication rate. We therefore developed an alternative internal suture repair with similar biomechanical stability to those of pull-out sutures and bone anchors. Twenty porcine distal phalanges and deep flexor tendons were randomized to 2 groups of 10 each. The tendons were transsected at the level of the distal interphalangeal joint. In group 1, repairs were performed with a well-established intraosseous suture repair and in group 2 with our new multistrand technique. The repairs were biomechanically tested with linear distraction until failure. We recorded a significantly higher 2-mm gap force (2GF)-and thus higher stability-of the repairs in group 1 in comparison to group 2. With a 2GF of more than 50 N, our suture technique allows for a modern early active motion rehabilitation protocol. Breakage of the suture construct occurred at random places in the repair in both groups. No pull-outs were noted. This study presents a strong transosseous multistrand repair technique for flexor tendon repair in zone 1 that is simple and fast to perform and should have enough strength to withstand early active motion rehabilitation.

Evaluation of flexor tendon repair (zone II) with Wide Awake Anesthesia

Abstract Background Recent advances in hand surgery has been the movement away from tourniquet surgery, which often requires sedation or GA and the patient will be awake and cooperative. Wide awake approach depends on the safety of adrenaline which is now well established. This review will evaluate the role of the wide awake approach in reducing rupture and tenolysis rate after flexor tendon repair zone 2. Objective To evaluate the functional outcome of flexor tendon repair zone II (most challengeable) under wide awake anesthesia. Patients and Methods After approval of local ethical committee of faculty of medicine Ain Shams University, this Prospective study has been conducted targeting patients with acute zone II flexor tendon injuries admitted at El Sahel Teaching Hospital within the period from September 2019 till January 2020, and their follow up for minimum three months at outpatient clinic. A Written informed consent explaining the whole procedure under study in this research has been obtained from all patients and absolute confidentiality as regard the patients’ names and addresses was given special care and attention. Final outcome evaluated by Original Strickland evaluation system. Results Using the wide awake technique provides an optimal opportunity to test repair strength through Intra-operative Total Active Movement (ITAM) making the surgeon much more comfortable to initiate early active motion. Besides, rising trend toward using early active rehabilitation protocol in case of strong repair using four or more strands repairs is recently supported in literature. This study adopted early active rehabilitation protocol with slight differences among them Conclusion This preliminary study assessing the outcomes of primary tendon repair in flexor tendon injuries in zone II using the wide-awake technique demonstrates encouraging results, being satisfactory for both surgeons and patients that makes this new approach a competitive to the other approaches of flexor tendon repair implemented under conventional methods of anesthesia.

Technical challenges in chronic zone 2 flexor tendon reconstruction and analysis of function in toddler: A rare case Report

Introduction: Flexor tendon injury in zone 2 is challenging to treat, when child was presented late. As flexor tendon are smaller in size, the repair or reconstruction technique along with rehabilitation becomes very challenging. We report a technical challenge in chronic zone 2 flexor tendon reconstruction in toddler presented two month post accidental glass cut injury. Case presentation: An 18-month-old male toddler presented with inability to flex left little finger after twomonths post accidental glass cut injury proximal to proximal interphalangeal (PIP) joint in zone two of left index finger. The passive range of motion (RoM) of DIP was zero degree to 60 degrees and PIP joint RoM was zero to 95 degrees. Child was unable to do active flexion of PIP and DIP joint movement. The parents of child were counselled for exploration and staged reconstruction of flexor digitorum profundus (FDP) tendon using either flexor superficialis (FDS) slip or palmaris longus. One slip of FDS graft was harvested and utilised to reconstruct FDP. At two years follow up, the injured index finger was normal in cosmesis and function. The active DIP joint movement was 50 degrees with complete healing of surgical site. Conclusion: Zone two flexor tendon injury in toddlers needs thorough clinical judgement and assessment by ultrasonography to locate the cut ends of tendons. Reconstruction of pulley, FDP reconstruction using FDS slip and supervised rehabilitation is recommended surgical option to achieve excellent function.

Transosseous Sutures in Tendon-to-Bone Repairs: the Role of the Epitendinous Suture

Background: Numerous transosseous fixation techniques for flexor tendon injuries in Zone 1 of the hand have been described in the literature. While relatively high maximal loads to failure are documented in different biomechanical experiments, several tests revealed a low 2 mm gapping resistance of the tendon-to-bone repairs. We therefore aimed to investigate the effect on gap formation adding a peripheral suture to an established transosseous fixation technique. In addition, we analyzed the influence of different suture materials (braided vs. non-braided) on the stability of the core suture. Method: A total of 30 porcine flexor digitorum profundus tendons were divided into 3 groups (n = 10 each) and repaired using the transverse intraosseous loop technique (TILT). In group 1 and group 2 the repairs were performed using PDS 3-0 or Ethibond 3-0, respectively. In group 3, a peripheral suture was added to the core suture (PDS 3-0) consisting of two figure-of-eight stitches with PDS 5-0. The biomechanical performance of the repaired tendons was analyzed using a standardized protocol. Results: The suture material and peripheral suture showed no effect on the ultimate failure load in our testing. However, the addition of a peripheral suture led to a statistically significantly higher 2 mm gap force when compared with the repair with a core suture only. Conclusion: In conclusion, addition of a palmar epitendinous suture to the transosseous core suture significantly increases the load to 2 mm gap formation in Zone 1 flexor tendon repairs and thus allows an immediate controlled mobilization.

Rehabilitation following surgery for flexor tendon injuries of the hand.

Rehabilitation following surgery for flexor tendon injuries of the hand.

Mid-term Results of Two-Stage Tendon Reconstruction of Zone II Flexor Tendon Injuries.

Secondary repair of flexor tendon injuries remains a challenging procedure for hand surgeons. Usually, secondary reconstruction should be performed by a staged approach. Two-stage surgical reconstruction of the flexor tendons by the Hunter technique is the salvage option in case of a severely damaged fibro-osseous canal or neglected flexor tendon injury. We report the results of staged flexor tendon reconstruction in 10 patients (10 fingers) with neglected or failed primary repair of flexor tendon injuries in zone II. Between 2012-2016, patients who underwent two-stage tendon reconstruction due to flexor digitorum profundus (FDP) sectioning or tearing in zone II with destruction of flexor pulleys and extensive scarring in the flexor tendon bed were included in the study. Ten patients included to study with a mean follow-up of 34 months (range 12-70 months) and the results were assessed by clinical examination and questionnaire. According to the Strickland score, one (20%) of the results were excellent, five (50%) were good, two (20%) were fair and two (20%) were poor. After the second stage, good to excellent results were achieved in 60% of patients, one patient needed graft tenolysis. These results were similar to the subjective scores given by the patients, four of whom complained of functional problems in daily life at follow-up. There was no complication after the first stage. But after the second stage, there was one bowstringing and one adhesion that require tenolysis. Hunter technique is still the reference procedure for the reconstruction of flexor tendons. The results of our study showed that two-stage tendon reconstruction which is applied in patients with tendon sheath disruption as a result of acute or delayed tendon injuries which are not possible for primary repair is reliable and satisfactory.

FREQUENCY, DISTRIBUTION AND TREATMENT OF ACUTE FLEXOR TENDON INJURIES IN ZONE V OF HAND

Background: Flexor tendons injuries are common emergency procedures The objectives of this study were to determine the frequency, distribution and results of treatment of acute flexor tendon injuries in zone V of hand in our population. Material and Methods: This descriptive cross-sectional was conducted in the Department of Orthopedic, Gomal Medical College, D.I.Khan, Pakistan from January 2015 to December 2017. Sample size was 30, selected through consecutive technique. Patients having flexor tendon injuries in zone v, admitted through emergency department were included in this study. Demographic variable were sex and age-groups. The research variable were tendon involved, nerves involved, artery involved, mechanism of injury, wound size, duration of injury, season, type of injury, hand involved and results of treatment. All variables, being categorical were analyzed by frequency and percentages using SPSS version 16.0. Results: Out of 30 patients, 22(73.33%) were male. Twenty four (80%) patients were between 21 to 40 years age. Mechanism of injury was glass in 16(53.33%) cases, knife in 10(33.33%) cases. Twenty (66.66%) cases presented in summer. Flexor digitorum sublimus was injured in 21(70.0%), FCR in 11(36.66%), FPL in 8(26.66), FDP in 6(20.0%) and FCU in 4(13.33%) cases. Median nerve was involved in nine (30%) cases. Radial artery was involved in eight (26.66%) cases. Wound size was 2 cm in 24(80%) cases. Sixteen (53.33 %) cases came with self-inflicted injuries. Twenty (66.66 %) cases came after 12 hours. Twenty five (83.33%) patients achieved good to excellent results. Conclusion: Flexor digitorus sublimus was the most common tendon injured in non-dominant hand, especially in young males. Median nerve and radial artery were commonly injured structures mostly with glass. Majority patients presented more than 12 hours after injury, having wound size of 2cm. Mostly the injuries were self-inflicted and occurred in summer season.

Prevention of peritendinious adhesions in zone II primary flexor tendon repair using a vein patch graft: A comparative study

Adhesion after intrasynovial tendon injury is a major clinical problem. Here we assess autogenous vein graft over the primary flexor tendon repair to prevent postoperative peritendinious adhesions. Twenty-six patients (30 digits) had an acute flexor tendon injury in zone II. Primary tenorrhaphy was done using the traditional Kessler repair technique. Patients were divided into two groups according to the management of tendon sheath defects. In group I (n = 15 digits), a patch of a marked forearm vein was harvested, divided and sutured to the tendon sheath window. In group II (n = 15 digits), the tendon sheath was left untreated. Patients were evaluated using the second Buck-Gramcko scale at 8 weeks and 6 months. We detected no statistically significant difference between the groups. For the vein graft group, excellent results were achieved in four digits, five digits with very good results, five digits with good results and one digit with fair results. Using the traditional technique, excellent results were achieved in three digits, very good results were achieved in four digits, good results were achieved in six digits and fair results were achieved in two digits. The use of autologous vein graft has many advantages; it is inexpensive, autologous and will not affect tendon healing. Comparing autologous vein graft to the conventional tendon repair technique, we detected no statistically significant difference. Clinically, less adhesion formation and fewer joint contractures were noted when using the autologous vein graft. Level of Evidence: Level I, therapeutic study.

Zone 2 flexor tendon injuries: Our experience with early active movement protocol for rehabilitation of tendons

Introduction: Flexor tendon injuries of the hand are common occurring these days and its management is still far from ideal. The functional outcome of zone 2 flexor tendon injuries are not good in view of higher incidence of adhesion formation. Numerous studies have been reported but yet nothing is deemed ideal. Objective: This study was conducted to see the results of primary repair of zone 2 flexor tendon injuries with prolene suture and early supervised aggressive mobilization and rehabilitation protocol. Design: Prospective study (Level IV evidence) reporting case series. Setting: Academic hospital associated with a medical college Participants: All patients with isolated flexor tendon injuries in zone 2 of the hand. Interventions: All tendons were repaired with prolene suture using standard operative procedures. Immediate splintage was done with thermoplastic splints and hand kept in dorsal blocking of 20 degrees flexion at wrist and 75 degrees at metacarpophalangeal joint. Rubber elastic springs were used for passive flexion which were fixed at nails and distal forearm. Early postoperative exercises were started after 48 hours of repair under direct supervision with passive extension and flexion. Gradually active exercises were added to the protocol. Finger splint was used for 4 weeks during whole day and after that it was used during night time only. Outcome measures: Outcome (tendon excursion) was evaluated using Strickland evaluation system and categorized as excellent, good, fair and poor. Results: A total of 50 patients (males- 32; females- 18) with zone 2 flexor tendon injuries were included and analyzed. Overall 85.7% digits had excellent or good results. Patients with single digit involvement had 94% excellent result in comparison to 31% in multiple digit involvement group (p

Two stage reconstruction of flexor tendon injuries in zone II after missed injury or failed repair

Background: Reconstruction of flexor tendon injury of the hand after failed tendon repair or missed injury is a technically challenging problem. Repair of the tendon within the thin tight pulley system usually invites the formation of adhesion and failure of repair. A combination of a technique described by Paneva-Holevich and Hunter has been used for this problem with variable results. Methods: Twenty-five flexor tendons in 20 patients were reconstructed using a two-stage reconstruction of the flexor tendon injury. The preoperative condition of the finger was evaluated using Boyes and Stark grading modified by Wehbe et al. and all had a poor prognosis. The primary tendon injury was missed in nine patients. Primary tendon repair failed in seven patients and free tendon graft failed in three. One patient had two operative interventions: one failed primary tendon repair and one failed free tendon graft. The dominant hand was affected in (70%) of patients. Results: The average time between the original injury and the first stage operation was 10.6 mo. The mean follow-up after the second stage was 72 mo. The mean strength of pinch grip and power grip were 92.4% and 94.8%, respectively. The mean pulp to distal flexion crease distance was 12.32 mm. According to Buck-Gramcko scoring, excellent results were achieved in 18 fingers (72%), good in five fingers (20%), fair in one (4%), and poor in one (4%). No additional surgery was required after the second stage. Conclusions: The two-stage pedicled flexor digitorum superficialis technique provided a reliable and effective method for reconstruction of failed repair or missed injury of the flexor tendon in the hand in zone II. The modification of the technique presented in this study achieved a high rate of excellent and good results without increasing the rate of complications. Patient compliance is critical for the success of this procedure.

Primary flexor tendons repair in zone 2: Current trends with GEMMSOR survey results

The repair of flexor tendon lesions in zone 2 remains a highly controversial subject in hand surgery. Currently, there is no consensus about the management of these lesions intra- and postoperatively, but the literature suggests that a solid suture will allow early active motion. We hypothesized that the management of flexor tendon injury in zone 2 varies widely. Two online surveys were conducted with surgeons and hand therapists. The questions captured the demographics of the surveyed population, surgical technique, common complications, postoperative management (duration of immobilization, type of splint, rehabilitation techniques and principles of self-rehabilitation). The responses were compared to current literature data. We collected 366 responses to the “surgery” survey and 206 responses to “rehabilitation” survey. Most surgeons performed suture repair with at least 4 strands (75.9%). Active rehabilitation protocols were used in 48.9% of cases. The “rehabilitation” survey underlined the lack of information provided to therapists by surgeons. Therapists used active protocols in 79.7% of cases. This study found a large variation in the management of flexor tendon injuries, which is not always consistent with current published recommendations. Ideally, the suture repair should be a 4-strand pattern with an epitendinous circumferential suture and a release of the pulley in the suture area. Mobilization and rehabilitation should be started on the 3rd day using an active protocol.

Fingertip Winding Suture: Pull-out Suture Technique for Flexor Tendon Repair in Zone I.

Injuries to flexor tendons in zone I has always been challenging during repair. Over the time several techniques were developed and modified to achieve the highest repair strength and thus the best functional outcome. These techniques vary from pull-out sutures with internal and external fixation to the use of bone anchors. All techniques were accompanied with advantages and disadvantages as well as postoperative morbidities related to certain techniques. In the present technique we introduce a subperiosteal pull-out suturing technique. It is a simple, strong, and cost-effective method for repair of flexor tendon injuries in zone I or in the context of tendon grafting.

Rehabilitation following surgery for flexor tendon injuries of the hand

Rehabilitation following surgery for flexor tendon injuries of the hand