Outcomes Of Flexor Tendon Repair Research Articles

Comparison of the Outcomes of Flexor Tendon Repair in Zone II Using the Original and Adjusted Strickland Scores and the 400-Points Hand Test.

Background: The purpose of this study was to report the outcomes of flexor tendon repair in zone II and compare two analytic tests - the original and adjusted Strickland scores - and a global hand function test, the 400-points test. Methods: We included 31 consecutive patients (35 fingers) with a mean age of 36 years (range 19-82 years) who underwent surgery for a flexor tendon repair in zone II. All patients were treated in the same healthcare facility by the same surgical team. All the patients were followed and evaluated by the same team of hand therapists. Results: At 3 months after the surgery, we found a good outcome in 26% of patients with the original Strickland score, 66% with the adjusted one and 62% with the 400-points test. Among the 35 fingers, 13 of them were evaluated at 6 months after the surgery. All the scores had improved with 31% good outcomes in the original Strickland score, 77% in the adjusted Strickland score and 87% in the 400-points test. The results were significantly different between the original and adjusted Strickland scores. Good agreement was found between the adjusted Strickland score and the 400-points test. Conclusions: Our results suggest that flexor tendon repair in zone II remains difficult to assess based solely on an analytic test. It should be combined with an objective global hand function test, such as the 400-points test, which appears to correlate with the adjusted Strickland score. Level of Evidence: Level IV (Therapeutic).

Outcomes of Flexor Tendon Repair in Patients With Concurrent Neurovascular Injuries of Multiple Digits in Zone 1

We treated several patients with multiple flexor (flexor digitorum profundus; FDP) injuries accompanied by injuries to the digital nerve or vessels around the distal interphalangeal crease (zone 1). Here, we retrospectively report the outcomes and review the literature. Between January 2010 and December 2018, 16 patients who met the study inclusion criteria were investigated. Tendons were repaired using the cross-locked cruciate (Adelaide) technique (6-strand) or modified Becker method (4-strand). The neurovascular structures were repaired under a microscope. Sixteen patients (47 digits) were treated. According to the criteria of Moiemen and Elliot, the lacerated areas were in zones IA and IB in 7 and 40 digits, respectively. The mean ranges of motion were 149.27 ± 7.78 and 66.43 ± 2.04 degrees according to the Strickland and modified Strickland assessments, respectively. The mean 2-point discrimination was 5.00 ± 0.63 mm. Four patients (group 1) presented with injuries to 2 digits, and 9 (group 2) and 3 (group 3) patients had 3 and 4 injured digits, respectively. The outcomes were satisfactory in terms of the mean range of motion; 2-point discrimination; cold tolerance; visual analog scale pain score; Disabilities of the Arm, Shoulder, and Hand score; and grip strength. There were no differences among the groups. Open multiple-finger injuries involving flexor digitorum profundus rupture with concurrent neurovascular injuries on one or both sides occasionally occur in industrial environments. Fortunately, each digit exhibits a consistent injury type in a particular anatomical location; appropriate repair yields satisfactory outcomes despite the presence of multiple injuries.

Functional Outcomes of Flexor Tendon Repair in the Fingers: A Comparison of Wide-Awake Local Anesthesia No Tourniquet Versus Traditional Anesthesia.

Flexor tendon lacerations in the fingers are challenging injuries that can be repaired using the wide-awake local anesthesia no tourniquet (WALANT) technique or under traditional anesthesia (TA). The purpose of our study was to compare the functional outcomes and complication rates of patients undergoing flexor tendon repair under WALANT versus TA. All patients who underwent a primary flexor tendon repair in zone I and II without tendon graft for closed avulsions or open lacerations between 2015 and 2019 were identified. Electronic medical records were reviewed to record and compare patient demographics, range of motion, functional outcomes, complications, and reoperations. Sixty-five zone I (N = 21) or II (N = 44) flexor tendon repairs were included in the final analysis: 23 WALANT and 42 TA. There were no statistical differences in mean age, length of follow-up, proportion of injured digits, or zone of injury between the groups. The final Quick Disabilities of the Arm, Shoulder, and Hand score in the WALANT group was 17.2 (SD: 14.4) versus 23.3 (SD: 18.5) in the TA group. There were no statistical differences between the groups with any final range of motion (ROM) parameters, grip strength, or Visual Analog Scale pain scores at the final follow-up. The WALANT group was found to have a slightly higher reoperation rate (26.1% vs 7.1%; P = .034) than the TA group. This study represents one of the first clinical studies reporting outcomes of flexor tendon repairs performed under WALANT. Overall, we found no difference in rupture rates, ROM, and functional outcomes following zone I and II flexor tendon repairs when performed under WALANT versus TA.

Biomechanical Study of Asymmetric Flexor Tendon Repair Using 3 Different Suture Materials.

Background: The asymmetric technique for flexor tendon repairs has various advantages but further improvement is possible by using a suitable suture material. In this study, we compare the biomechanical performance of asymmetric repairs using 3 suture materials: Supramid Extra II 4-0, Tendo-Loop 4-0, and FiberLoop 4-0. Methods: We divided 30 porcine flexor tendons into 3 arms. Each arm of tendons were repaired by using 1 of the 3 proposed suture materials. Each repaired tendon was tested by using a mechanical tester. Ultimate tensile strength (UTS), load to 2 mm gap force, failure mechanism and stiffness of the tendons were investigated. Results: FiberLoop® achieved the highest UTS (90.4 ± 17.9 N), followed by Tendo-Loop (85.3 ± 10.3 N). The difference was no statistically significant. The UTS of repairs using Supramid® was significantly lower (64.0 ± 8.4 N). For load to 2 mm gap force, FiberLoop® achieved 20.7 ± 4.8 N while Tendo-Loop® had 20.5 ± 4.2 N. The difference was also no statistically significant. The repairs using Supramid® had a significantly lower load to 2 mm gap force of 14.2 ± 2.7 N. The stiffness of asymmetric repairs using FiberLoop® and Tendo-Loop® was 5.64 ± 1.7 N/mm and 5.63 ± 0.7 N/mm. The difference was also no statistically significant. The repairs using Supramid® had a significantly lower stiffness of 4.15 ± 1.0 N/mm. Failure mechanisms for the repaired specimens were reported as such: Supramid had 100% suture rupture; Tendo-Loop had 90% suture rupture and 10% suture pullout; FiberLoop had 20% suture rupture and 80% suture pullout. Conclusions: The asymmetric repair configuration is able to produce superior biomechanical performance by using Tendo-Loop® or FiberLoop®. Improvement of the asymmetric technique by using Tendo-Loop® or FiberLoop® could potentially contribute to better surgical outcomes of flexor tendon repair.

Operative outcomes for wide awake local anesthesia versus regional and general anesthesia for flexor tendon repair

Operative repair of flexor tendons after traumatic injury may be performed under general anesthesia (GA), regional blocks, or a wide-awake local anesthesia no tourniquet (WALANT) technique. To our knowledge there are currently no large-scale reports evaluating outcomes of flexor tendon repair in patients where wide-awake anesthesia was utilized in comparison to regional anesthesia (RA) and general anesthesia. We performed a retrospective analysis of patients who underwent treatment for flexor tendon injuries at a tertiary referral center for hand surgery over a two-year period. A total of 151 patients were included (53 WALANT, 57 RA, and 41 GA) and a total of 251 tendons were repaired (63 WALANT, 104 RA and 84 GA). No statistically significant difference was observed in rates of tendon rupture, adhesions, infection, or hand function. Flexor tendon repair under WALANT is found to be safe and presents comparable operative and functional outcomes to more traditional anesthetic techniques. Additional advantages, including the ability to test the repair intraoperatively, patient education, and the potential for boosting theatre efficiency. Further studies, preferably utilizing a randomized trial methodology, may further elucidate the benefits and risks of WALANT versus regional and general anesthesia.

Functional Outcome of Flexor Tendon Repair in Zone-II

Functional Outcome of Flexor Tendon Repair in Zone-II

The effect of hyaluronic acid injection on the outcome of flexor tendon repair in zone II of the hand

Background and objective: Flexor tendon injuries of the hand are common, especially in zone II. Various pharmacologic agents have been used to improve the outcome of primary tendon repair. One must select an option that accomplishes an excellent total active movement of the repaired tendon. This study aimed to find out the effect of hyaluronic acid injections in the restoration of normal gliding and power of the repaired tendon. Methods: An interventional study of 47 cases of zone II flexor tendon injury managed from May 2017 to May 2018. The data were assembled in a questionnaire. Standardized photographs for pre-, intra-, and postoperative were taken. Hyaluronic acid injections were used in selected cases. Results: Sharp injury (34 cases, equal to 72%) was found to be the commonest mechanism of flexor tendon injury. Male predominance was noticed (38 cases out of 47) due to their working nature. The hyaluronic acid injection was delivered to selected cases (10 cases, equal to 21%) based on preoperative evaluation. Eighty percent of repairs regained total active movement uneventfully. Few complications happened which responded to conservative management. The P value of total active movement in relation to hyaluronic acid injection was 0.036, which is considered statistically significant. Conclusion: This study shows that intraoperative injection of high molecular weight of hyaluronic acid improves the outcome of flexor tendon repair, presumably by decreasing the chance of adhesion.

Outcomes of flexor tendon repairs in the zone 1 subzones with an immobilization protocol

We report on the outcomes of flexor tendon repair in zone 1 subzones with an immobilization protocol in four fingers in four consecutive patients (29% of the patients undergoing zone 1 tendon repairs in the same period). One finger had a zone 1A injury, two had zone 1B injuries, and one had a zone 1C injury. The mean active range of motion of the distal interphalangeal joint was 34°. Using Moiemen’s criteria, one finger (zone 1A) was rated as excellent and three as poor. Not all zone 1 injuries treated with immobilization protocols had poor outcomes in our series. The functional results of an immobilization protocol for zone 1A seemed to be superior to those for zones 1B and 1C. We speculate that differences in the local anatomy of the flexor digitorum profundus tendon and neighboring structures may influence the outcomes in the zone 1 subzones with an immobilization protocol.

Utility of early active motion for flexor tendon repair with concomitant injuries: A multivariate analysis

IntroductionFlexor tendon injury often occurs with concomitant injuries such as fracture, vascular injury, and extensor tendon injury. These injuries are repaired independently, without a comprehensive strategy. We aimed to identify the effect of concomitant injuries and treatment choice on the outcome of flexor tendon repair. Patients and methodsWe evaluated 118 fingers of 102 adult patients with zone 1–3 flexor digitorum profundus (FDP) tendon injuries who underwent primary surgery at our hospital between April 2009 and December 2017. The 2-strand pull-out, 4-strand Tsuge, 6-strand Lim & Tsai, and 8-strand cross-locked cruciate suturing techniques were used. We performed multivariate analyses, with the active range of motion (AROM) of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints as dependent variables, and age, existence of concomitant injuries, and their treatment as independent variables. ResultsThe average AROM of the PIP + DIP joints was 130° at the last follow-up, and ‘excellent’ or ‘good’ function was obtained in 74 (63%) of 118 fingers by using the Strickland criteria. Old age, concomitant diaphyseal fractures, and specific methods of osteosynthesis, such as pinning, flexor digitorum superficialis injury, and immobilisation for 3 weeks, significantly worsened the results. However, wiring for osteosynthesis and early active motion protocol improved postoperative functional outcome. Although the outcome did not differ among the suture techniques, the 4-strand Tsuge procedure was performed for the two surgically confirmed ruptures of repair that occurred in our series. DiscussionWe clarified the superiority of early mobilisation protocols with rigid osteosynthesis procedure, other than pinning. To minimise tendon adhesion or joint stiffness, surgeons should repair the tendon and fractured bone appropriately, to ensure early mobilisation without serious complications.

The outcome of Flexor Tendon Repair based on the number of core suture, mechanism and zone of injury in Erbil

Background and objective: Principles of surgical treatment of flexor tendon injuries include early primary repair with a strong core stitch combined with an epitendinous suture. This study aimed to evaluate the outcomes of primary flexor tendon repair according to the mechanism, zone of injury and number of core sutures. Methods: This study was conducted in Erbil from May 2013 till March 2015. Injured flexor tendons were repaired for 121 patients. The patients were followed up for six months. We used the Strickland scoring system to evaluate the results. Results: Sharp tools represented the main cause of trauma 68.6%, excellent results were found in 51.8% of cases with a sharp injury. The worst results were obtained in zone II with 44.7% fair to a poor result. Excellent results found in 43.4% with four strand core sutures while 24.4% in two strand core sutures (P ˂0.01). Conclusion: Four strand core sutures have the better result with a low rate of tendon rupture than two strand core sutures. Sharp injuries had better results than crush injuries. The zone with worst results was zone II.

Outcomes of flexor tendon repairs in zone 2 subzones with early active mobilization.

IV.

The Impairments and Functional Outcomes of Patients Post Flexor Tendon Repair of the Hand

Backgrounds: Flexor tendon injuries are common hand injuries for which optimal surgical and postoperative treatment has not yet been established. The variability in results is great, with good outcomes being achieved in specialized hands units in developed countries. Minimal research has been undertaken in developing countries, in particular South Africa, regarding flexor tendon repair (FTR) and the outcomes thereof. Objectives: The purpose of this study was to establish the range of movement (ROM), grip strength, and hand function at 6 months post FTR as well as to determine the factors that affect the impairments and functional outcome at 6 months post FTR. Materials and Methods: The study was conducted at a tertiary hospital in South Africa. At 1, 3, and 6 months post FTR, the ROM of the injured and contralateral finger(s) were measured using a finger goniometer. The Total Active Motion (TAM) classification system was applied to each affected digit, and the average TAM was determined for the participants’ affected hand. At 3 and 6 months post FTR, the participants’ bilateral power and pinch grip strength were measured using a Jamar dynamometer and a pinch meter. The power and pinch grip strengths were calculated as a percentage of the unaffected hand. At 3 and 6 months post FTR, participants performed the Jebsen Hand Function Test (JHFT), and a Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire was administered in an interview format. Results: A total of 126 participants enrolled in the study. There was a dropout rate of 48%, leaving 65 participants who completed 6 months follow-up, 41 males (63%) and 24 females (37%) aged 32 years (SD ± 12, n = 65). Out of 65 participants, 2% (n = 1) had an excellent outcome, 32% (n = 21) had a good outcome, 32% (n = 21) had a fair outcome, and 34% (n = 22) had a poor outcome with regard to TAM. At 6 months post FTR, the average power grip was 60% (SD ± 25, n = 65) of the unaffected hand while the average pinch grip was 52% (SD ± 42, n = 65) of the unaffected hand. The average score on the QuickDASH questionnaire was 19.34 (SD ± 16.89) at 6 months. Of the 41 participants who were employed prior to injury, 71% (n = 29) had returned to work by 6 months post surgery and scored an average of 15.89 (SD ± 23.74) on the QuickDASH work module. Sixty-eight percent (n = 44) of the patients had postoperative complications: the most common complication was tenodesis/adhesions (25%, n = 16), followed by contracture (22%, n = 14). There were only 4 ruptures (6%, n = 4) in this sample. Eleven participants (17%) underwent further surgery. The factors that affect the impairments and functional outcome at 6 months post FTR include age, zone of injury, number of digits injured, associated injury, delay between injury and surgery, and language barrier. Conclusion: Although there were some promising outcomes, during this period, participants did not consistently achieve the good or excellent functional outcomes achieved in developed countries. More research needs to be conducted regarding the outcome of FTR in South Africa, particularly in the public sector.

Early Active Mobilization Rehabilitation Protocol After Flexor Tendon Repair in Zone II of the Hand

Background: Achieving best outcomes for flexor tendon injuries in zone II of the hand remains a challenge to hand therapists and surgeons. With advances in the understanding of flexor tendon biomechanics and the development of multistrand core suture repair techniques, there has been a trend toward early active mobilization protocols post flexor tendon repair in zone II of the hand. Early active mobilization has been shown to minimize adhesion formation and increase repair strength. Many publications have also reported good outcomes when repaired flexor tendons in zone II were actively mobilized at an earlier stage. Objective: This systematic review seeks to identify an optimal early active mobilization protocol that brings about the best outcomes post flexor tendon zone II repair. Materials and Methods: PubMed, ScienceDirect, and Cochrane Library databases were searched to locate articles published from 1980 to February 2016. English studies that were included involved adult participants who (1) sustained flexor tendon injury to zone II of the hand, (2) had surgical repair done, and (3) underwent early active mobilization rehabilitation which was defined as any form of active digital flexion exercises within the first 4 weeks post repair, including place and hold. Studies that involved the thumb or lack details on the repair technique, rehabilitation protocol, and clinical outcomes were excluded. The primary outcomes were rupture rates and range of motion. In addition, surgical techniques, splint designs, therapy exercises, and regimes were also examined to identify the optimal early active mobilization rehabilitation protocol. Results: One hundred twelve articles were identified. Twelve studies met the inclusion criteria, with evidence ranging from level I to level IV. The rupture rates compared with number of core strand sutures were lowest with 6-strand repair (1.0%) compared with 4 (2.5%) and 2 (9.6%) strand repair. With a postoperative orthosis placing the wrist in neutral position, the rupture rate was low (2.7%) and had the highest excellent to good range of motion (90.6%) according to the original Strickland criteria. During the first 4 weeks of postoperative rehabilitation, a combination of high therapy frequency (daily to once a week) and low daily repetitions of active finger flexion exercises (not more than 2 repetitions per hour) involving active fisting, place and hold and synergistic wrist motion were shown to contribute to low rupture rates (<5%) and excellent range of motion (>85%) according to the original Strickland criteria. Conclusions: The optimal early active mobilization protocol is one that is used on flexor repairs with 4-strand core sutures and above, and a postrepair orthosis that puts the wrist in neutral position. With the integration of intensive therapist supervision and hourly low frequency active mobilization exercise program, this protocol can potentially improve the outcomes of flexor tendon repair in zone II.

Clinical outcomes of early active mobilization following flexor tendon repair using the six-strand technique: short- and long-term evaluations.

We evaluated the factors influencing outcomes of flexor tendon repair in 112 fingers using a six-strand suture with the Yoshizu #1 technique and early postoperative active mobilization in 101 consecutive patients. A total of 32 fingers had injuries in Zone I, 78 in Zone II, and two in Zone III. The mean follow-up period was 6 months; 16 patients (19 fingers) participated in long-term follow-up of 2 to 16 years. The total active motion was 230° SD 29°; it correlated negatively with age. The total active motion was 231° SD 28° after repair of the lacerated flexor digitorum superficialis tendon, and was 205° SD 37° after excision of the flexor digitorum superficialis tendon ends (p = 0.0093). A total of 19 fingers showed no significant increases in total active motion more than 2 years after surgery. The rupture rate was 5.4% in our patients and related to surgeons' level of expertise. Five out of six ruptured tendons were repaired by inexperienced surgeons. Level of Evidence IV.

CORR® ORS Richard A. Brand Award for Outstanding Orthopaedic Research: Engineering flexor tendon repair with lubricant, cells, and cytokines in a canine model.

Adhesions and poor healing are complications of flexor tendon repair. The purpose of this study was to investigate a tissue engineering approach to improve functional outcomes after flexor tendon repair in a canine model. Flexor digitorum profundus tendons were lacerated and repaired in 60 dogs that were followed for 10, 21, or 42 days. One randomly selected repair from either the second or fifth digit in one paw in each dog was treated with carbodiimide-derivatized hyaluronic acid, gelatin, and lubricin plus autologous bone marrow stromal cells stimulated with growth and differentiation factor 5; control repair tendons were not treated. Digits were analyzed by adhesion score, work of flexion, tendon-pulley friction, failure force, and histology. In the control group, 35 of 52 control tendons had adhesions, whereas 19 of 49 treated tendons had adhesions. The number of repaired tendons with adhesions in the control group was greater than the number in the treated group at all three times (p = 0.005). The normalized work of flexion in treated tendons was 0.28 (± 0.08), 0.29 (± 0.19), and 0.32 (± 0.22) N/mm/° at Day 10, Day 21, and Day 42 respectively, compared with the untreated tendons of 0.46 (± 0.19) at Day 10 (effect size, 1.5; p = 0.01), 0.77 (± 0.49) at Day 21 (effect size, 1.4; p < 0.001), and 1.17 (± 0.82) N/mm/° at Day 42 (effect size, 1.6; p < 0.001). The friction data were comparable to the work of flexion data at all times. The repaired tendon failure force in the untreated group at 42 days was 70.2 N (± 8.77), which was greater than the treated tendons 44.7 N (± 8.53) (effect size, 1.9; p < 0.001). Histologically, treated repairs had a smooth surface with intrinsic healing, whereas control repairs had surface adhesions and extrinsic healing. Our study provides evidence that tissue engineering coupled with restoration of tendon gliding can improve the quality of tendon healing in a large animal in vivo model. Tissue engineering may enhance intrinsic tendon healing and thus improve the functional outcomes of flexor tendon repair.

Functional outcome of flexor tendon repair of the hand at Zone 5 and post operative early mobilization of the fingers

Objective : There are few reports on outcome following flexor tendon repair of the hand in zone 5. We hypothesized that early mobilization of the fingers is possible if the suture site of repaired tendon is strong enough. The aim of this study was to assess the results of flexor tendon repair in this zone using modified Kessler method reinforced by peripheral running suture and a post operative early active and passive mobilization of the fingers. Methodology: This prospective study was carried out between April 2006 and Feb 2010, and 171 digits flexor tendons cut in 42 patients were repaired by modified Kessler technique reinforced by running peripheral suture. Early active mobilization and gentle passive motion of the fingers was allowed in a dorsal wrist splint the day after surgery. Wrist Immobilization was performed for one month. Function of the tendons was assessed by Buck-Gramcko score at nine month follow up. Results: Mean age of the patients was 25.4 years (range 17-46 y). Twenty nine flexor policis longus, 77 flexor digitorum superficialis and 65 flexor digitorum profundus tendons of digits were repaired. Middle and index fingers were most commonly involved. Median and ulnar nerve repair was done in 17 and 12 cases respectively. Good to excellent results were seen in of 79.34% of FPL and 74.65% of other finger flexors. One case of FPL rupture was seen. Tenolysis of FDS was performed in one case. Recovery in thenar muscle function was good, fair and poor in 5, 2 and 10 cases after median nerve repair, while all 12 patients with ulnar nerve lesion showed some degrees of clawing of 4th and 5th fingers. Conclusion : Most patients following flexor tendon repair at zone 5 obtained good results. Early motion of the fingers seems to improve outcome in these patients. Concomitant nerve cut in particular of ulnar nerve were associated with a high rate of poor results.

A comparative analysis of the outcome of flexor tendon repair in the index and little fingers: does the little finger fare worse?

The clinical and hand therapy notes of 180 patients who had single digit flexor tendon repairs in zones I and II from January 2000 to December 2004 were reviewed. Data from 60 index and 108 little fingers at 5 weeks, 8 weeks and 12 weeks follow-up visits were included. In zone I injuries, there was a statistically significant difference in flexion contracture (worse in the little fingers ) at all follow-up points. Although the range of motion and percentage of patients in the excellent category of the Strickland and Glogovac criteria were greater in the index finger group than the little finger for zone I and II injuries, these differences were not statistically significant. The rupture rate was also higher in the little finger group.