Management Of Flexor Tendon Injuries Research Articles

WALANT vs standard anaesthesia in the management of flexor tendon injuries: A systematic review and meta-analysis

WALANT vs standard anaesthesia in the management of flexor tendon injuries: A systematic review and meta-analysis

Flexor Tendon Injuries and Hand Tendinorrhaphy: A Comprehensive Review

Flexor tendon injuries of the hand represent a challenging clinical entity with significant functional implications. This comprehensive article delves into the intricate realm of flexor tendon injuries, shedding light on the pathophysiology, diagnostic approaches, and treatment modalities, with a primary focus on the surgical technique of tendinorrhaphy. The article commences with an exploration of the anatomy and biomechanics of flexor tendons, elucidating the pivotal role they play in hand function. It subsequently outlines the diverse etiologies that lead to tendon injuries, encompassing traumatic, iatrogenic, and spontaneous causes, while emphasizing the importance of prompt and accurate diagnosis through clinical assessment, imaging, and functional testing. A detailed exposition of the principles and techniques of tendinorrhaphy follows, elucidating the surgical intricacies involved in repairing damaged flexor tendons. The article discusses suture materials, repair methods, and rehabilitation protocols, highlighting the importance of postoperative care and meticulous hand therapy in optimizing outcomes. Furthermore, this article critically reviews emerging trends and innovations in the field, including the use of tissue engineering, biomaterials, and minimally invasive approaches, all of which hold promise for enhancing the management of flexor tendon injuries. In conclusion, this article offers a comprehensive overview of flexor tendon injuries in the hand and underscores the pivotal role of tendinorrhaphy as a cornerstone in their treatment. With a holistic perspective on the subject, it provides clinicians and researchers with a valuable resource to navigate the intricacies of this challenging clinical scenario and fosters ongoing advancements in the field of hand surgery.

Management of flexor tendon injuries in the digits: an update

Currently used techniques of flexor tendon repair and methods of postoperative rehabilitation differ significantly from those used still 10-15 years ago. Techniques of the repair evolved from 2-strand sutures (the Kessler suture) in the direction of much stronger 4-strand and 6-strand sutures (the Adelaide and Savage sutures), what reduced the risk of failure of the repair and made possible more intensive rehabilitation. Also rehabilitation regimes changed on more comfortable for patients than older protocols and allowed to achieve better functional outcomes of the treatment. This study presents updated trends in management of flexor tendon injuries in the digits, with regard to operative technique and postoperative rehabilitation protocols.

228 Single Centre Compliance to National Guidelines for Management of Flexor Tendon Injuries, Clinical Audit

Abstract Aim To evaluate compliance to British Society for Surgery of the Hand (BSSH) guidelines for timing of review and surgical management of Flexor tendon injuries. Method Retrospective data collection over a period of (February 2021) for the first cycle, and (June 2021) for the second cycle through EPR and Galaxy soft wares. Results Time from injury to review by Plastic Surgery team: 100% of patients were reviewed within the national timeframe in both cycles. Time from injury to definitive surgical procedure: 86% compliance to national timeframe on both cycles. Conclusions Flexor tendon injuries require further prioritization for operative management. Increase theatre capacity to accommodate the need.

Post-operative management of flexor tendon injuries at zone II and flexor pollicis longus – a survey of Irish practice

Purpose The post-operative management of flexor tendon injuries has been the focus of considerable exploration and there continues to be variation in approaches and methods of mobilisation. The purpose of this paper is to explore therapy management following repair to flexor tendons at zone II and flexor pollicis longus (FPL) (all zones) in Ireland. Design/methodology/approach A descriptive survey questionnaire design through an online format was used. Therapists were recruited through the Irish Association of Hand Therapists, the national bodies for occupational therapy and physiotherapy, and therapy managers in acute hospitals, with 29 therapists participating in the study. Descriptive statistics were used to analyse the survey data. Findings Patients were generally seen three to five days following surgery. Early active mobilisation approaches were favoured by all but one therapist, with 62% using the Belfast protocol and 34% the Manchester Short Splint (MSS) protocol. Each early active protocol exercise session commences with passive motion followed by graded active flexion. Tenodesis is incorporated by the majority of respondents within the first four weeks. Therapy programme and splints are modified based on patient presentation. Resistance exercises are commenced from week seven. Patient compliance was identified as the most influential factor in the post-operative intervention approach taken. Originality/value This study provides the first Irish profile of current practice in the post-operative management of flexor tendon repairs at zone II and FPL which has not previously been reported. Further research should explore the reasoning behind the interventions chosen and also the implications for practice of changes to surgical techniques.

Evidence base for the management of flexor tendon injuries

Evidence base for the management of flexor tendon injuries

Letter to editor: The evidence-base for the management of flexor tendon injuries of the hand: Review

Letter to editor: The evidence-base for the management of flexor tendon injuries of the hand: Review

The evidence-base for the management of flexor tendon injuries of the hand: Review.

•There is no consensus on the optimal flexor tendon repair technique at each anatomical flexor zone.•There is paucity of high quality evidence.•Heterogenous study designs limit inter-study comparisons.•Patient reported outcome measures are crucial but there is a perennial need for robust disease-specific tools to be utilised.

Flexor Tendon: Development, Healing, Adhesion Formation, and Contributing Growth Factors.

Management of flexor tendon injuries of the hand remains a major clinical problem. Even with intricate repair, adhesion formation remains a common complication. Significant progress has been made to better understand the mechanisms of healing and adhesion formation. However, there has been slow progress in the clinical prevention and reversal of flexor tendon adhesions. The goal of this article is to discuss recent literature relating to tendon development, tendon healing, and adhesion formation to identify areas in need of further research. Additional research is needed to understand and compare the molecular, cellular, and genetic mechanisms involved in flexor tendon morphogenesis, postoperative healing, and mechanical loading. Such knowledge is critical to determine how to improve repair outcomes and identify new therapeutic strategies to promote tissue regeneration and prevent adhesion formation.

Barbed sutures versus conventional tenorrhaphy in flexor tendon repair: An ex vivo biomechanical analysis.

BackgroundThe management of flexor tendon injuries has evolved in recent years through industrial improvements in suture materials, refinements of repair methods, and early rehabilitation protocols. However, there is no consensus on the ideal suture material and technique. This study was conducted to compare the tensile strength, repair time, and characteristics of 4-strand cruciate, modified Kessler, and 4-strand horizontal intrafiber barbed sutures for flexor tenorrhaphy with a 12-mm suture purchase length in an animal model.MethodsThe right third deep flexors of 60 adult Leghorn chicken feet were isolated and repaired with a 12-mm suture purchase length. The tendons were randomly assigned to three groups of equal number (n=20 each). Groups 1 and 2 received 4-strand cruciate and modified Kessler repair with conventional suture materials, respectively. A 4-strand horizontal intrafiber barbed suture technique was used in group 3. The repaired tendons were biomechanically tested for tensile strength, 2-mm gap resistance, and mode of failure. Repair times were also recorded.ResultsThe maximum tensile strength until failure was 44.6±4.3 N in group 1, 35.7±5.2 N in group 2, and 56.7±17.3 N in group 3. The barbed sutures were superior to the other sutures in terms of the load needed for 2-mm gap formation (P<0.05). Furthermore, the barbed sutures showed the shortest repair time (P<0.05).ConclusionsThis study found that 4-strand horizontal intrafiber barbed suture repair with a 12-mm purchase length in a chicken flexor tendon injury model showed promising biomechanical properties and took less time to perform than other options.

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.

Flexor Tendon Injuries.

Flexor tendon injuries of the hand are uncommon, and they are among the most challenging orthopaedic injuries to manage. Proper management is essential to ensure optimal outcomes. Consistent, successful management of flexor tendon injuries relies on understanding the anatomy, characteristics and repair of tendons in the different zones, potential complications, rehabilitation protocols, recent advances in treatment, and future directions, including tissue engineering and biologic modification of the repair site.

MANAGEMENT OF FLEXOR TENDON INJURIES — PART 2: CURRENT PRACTICE IN AUSTRALIA AND GUIDELINES FOR TRAINING YOUNG SURGEONS

This study aims to gain a better understanding of current practice for the surgical management and rehabilitation of flexor tendon injuries in Australia, with the intent of establishing common guidelines for training of young surgeons. A survey was distributed to the membership of the Australian Hand Surgery Society to determine whether a consensus could be obtained for: suture material and gauge; core and epitenon suture techniques; sheath and pulley management; and post-operative protocols for primary flexor tendon repair. The predominant materials used for core suture are Ticron™ Suture (Tyco Healthcare Group LP, Norwalk, Connecticut, USA) (34%) and Ethibond™ Polyester Suture (Ethicon, Somerville, New Jersey, USA) (24%). The two core suture configurations commonly used are the Adelaide (45%) and Kessler (32%) repair. The predominant materials used for epitendinous sutures are 6-0 Prolene™ Polypropylene Suture (Ethicon, Somerville, New Jersey, USA) (56%), 5-0 Prolene™ (21%) and 6-0 Ethilon™ Nylon Suture (Ethicon, Somerville, New Jersey, USA) (13%); and the majority (63%) use a running epitendinous technique. The management of critical pulleys is variable, with 89% prepared to perform some release of A2 and A4 pulleys. Rehabilitation protocols vary widely, with 24% of respondents using the same method for all patients, while 76% tailor their approach to each patient. Some component of active motion was used by most. There exists some consensus on the management of flexor tendon injuries in Australia. However, the management of critical pulleys and methods of post-operative rehabilitation remain varied. For the training of young surgeons, a majority advise a 3-0 gauge braided polyester core suture of four strands, combined with a 6-0 Prolene™ simple running epitendinous suture for increased tendon repair strength and smooth glide. Trainees should attempt to retain the integrity of the A2 and A4 pulleys. Post-operative rehabilitation should include a component of active flexion.

Management of flexor tendon injuries - Part 1: Australian contributions.

This review article describes the contribution of Australian authors to the basic science and clinical management of flexor tendon injuries.

Flexor tendon injuries in the child

This review aims to highlight the differences in the management of flexor tendon injuries between children and adults. These include differences in epidemiology, anatomy, classification, diagnosis, incisions and skin closure, the size of the flexor tendons, technical aspects of zones I and II repairs, core suture purchase length, rehabilitation, results, and complications of primary flexor tendon repair. Finally, one- versus two-stage flexor tendon reconstruction in children is reviewed.

Zone 2 flexor tendon injuries: Venturing into the no man’s land

Flexor tendon injuries are seen commonly yet the management protocols are still widely debated. The advances in suture techniques, better understanding of the tendon morphology and its biomechanics have resulted in better outcomes. There has been a trend toward the active mobilization protocols with development of multistrand core suture techniques. Zone 2 injuries remain an enigma for the hand surgeons even today but the outcome results have definitely improved. Biomolecular modulation of tendon repair and tissue engineering are now the upcoming fields for future research. This review article focuses on the current concepts in the management of flexor tendon injuries in zone 2.

Management of Extensor Tendon Injuries

Extensor tendon injuries are very common injuries, which inappropriately treated can cause severe lasting impairment for the patient. Assessment and management of flexor tendon injuries has been widely reviewed, unlike extensor injuries. It is clear from the literature that extensor tendon repair should be undertaken immediately but the exact approach depends on the extensor zone. Zone I injuries otherwise known as mallet injuries are often closed and treated with immobilisaton and conservative management where possible. Zone II injuries are again conservatively managed with splinting. Closed Zone III or ‘boutonniere’ injuries are managed conservatively unless there is evidence of displaced avulsion fractures at the base of the middle phalanx, axial and lateral instability of the PIPJ associated with loss of active or passive extension of the joint or failed non-operative treatment. Open zone III injuries are often treated surgically unless splinting enable the tendons to come together. Zone V injuries, are human bites until proven otherwise requires primary tendon repair after irrigation. Zone VI injuries are close to the thin paratendon and thin subcutaneous tissue which strong core type sutures and then splinting should be placed in extension for 4-6 weeks. Complete lacerations to zone IV and VII involve surgical primary repair followed by 6 weeks of splinting in extension. Zone VIII require multiple figure of eight sutures to repair the muscle bellies and static immobilisation of the wrist in 45 degrees of extension. To date there is little literature documenting the quality of repairing extensor tendon injuries however loss of flexion due to extensor tendon shortening, loss of flexion and extension resulting from adhesions and weakened grip can occur after surgery. This review aims to provide a systematic examination method for assessing extensor injuries, presentation and management of all type of extensor tendon injuries as well as guidance on mobilisation pre and post surgery.

An overview of the management of flexor tendon injuries.

Flexor tendon injuries still remain a challenging condition to manage to ensure optimal outcome for the patient. Since the first flexor tendon repair was described by Kirchmayr in 1917, several approaches to flexor tendon injury have enabled successful repairs rates of 70-90%. Primary surgical repair results in better functional outcome compared to secondary repair or tendon graft surgery. Flexor tendon injury repair has been extensively researched and the literature demonstrates successful repair requires minimal gapping at the repair site or interference with tendon vascularity, secure suture knots, smooth junction of tendon end and having sufficient strength for healing. However, the exact surgical approach to achieve success being currently used among surgeons is still controversial. Therefore, this review aims to discuss the results of studies demonstrating the current knowledge regarding the optimal approach for flexor tendon repair. Post-operative rehabilitation for flexor tendon surgery is another area, which has caused extensive debate in hand surgery. The trend to more active mobilisation protocols seems to be favoured but further study in this area is needed to find the protocol, which achieves function and gliding but avoids rupture of the tendons. Lastly despite success following surgery complications commonly still occur post surgery, including adhesion formation, tendon rupture and stiffness of the joints. Therefore, this review aims to discuss the appropriate management of these difficulties post surgery. New techniques in management of flexor tendon will also be discussed including external laser devices, addition of growth factors and cytokines.

Prevention of adhesions in surgery of the flexor tendons of the hand: what is the evidence?

Despite advances in knowledge and refinements of technique, the management of flexor tendon injuries within the digital sheath continues to present a formidable challenge. This in turn has led to a massive expansion in search of modified surgical therapies and various adjuvant therapies, which could prevent adhesion formation without compromising digital function. A search of PubMed, Medline, CINAHL and Embase databases was performed using the keywords 'tendon adhesion prevention', 'tendon healing', 'adhesion prevention in tendons' and 'adjuvants for adhesion prevention'. Studies detailing the use of surgical, pharmacological and non-pharmacological agents for adhesion prevention in digital flexor tendons were identified, and their bibliographies were thoroughly reviewed to identify further related articles. This search identified 41 studies, which investigated the use of various pharmacological agents in adhesion prevention in digital tendons. There is a need to develop and utilize an optimal method for the prevention of adhesions in the flexor tendons of the hand, due to post-surgical complications. Even though there have been significant advances in the prevention of adhesions in flexor tendons, it remains to be proved which, if any, of the current methods are the most beneficial. The only thing that appears clinically justified in adhesion prevention is the need for early post-operative mobilization of digits after tendon injury or repair but the best method of mobilization remains controversial. Suggested changes in surgical techniques and various proposed pharmacological and non-pharmacological modalities need to withstand the test of adequately powered human trials, before their justification for potential benefit in clinical practice is accepted.

The Role of Ultrasound in the Management of Flexor Tendon Injuries

The use of ultrasound scanning to establish tendon pathologies was assessed retrospectively in 17 patients in 18 digits. The ultrasound scan demonstrated four patterns: (1) normal intact tendons in four, (2) ruptured tendons in three, (3) tendons in continuity but attenuated in five and (4) tendons in continuity but thickened with fibrosis and decreased movement representing adhesions in five patients. Surgery was undertaken in only three cases, confirming the ultrasound diagnosis in two. Surgery was offered to all three patients with ruptures but was declined by two. Ultrasound imaging helped to avoid surgery in 14 cases by excluding flexor tendon re-ruptures. This allowed on-going mobilisation, leading to recovery of function.