Primary Flexor Tendon Repair Research Articles

Intérêt de la mobilisation en flexion active protégée après suture des tendons fléchisseurs en zone 2

Primary repair of flexor tendons in zone II of the hand and early post-operative rehabilitation is no longer challenged. However, early rehabilitation methods vary from one unit to another. Although currents techniques such as of Kleinert's and Duran's have brought considerable improvements in functional outcomes, they do not allow early active motion of repaired flexor tendons. A promising method of active controlled mobilization has been proposed by the Bordeaux Hand Unit and adopted by our rehabilitation unity since 1995. The aims of this method are: to avoid of proprioceptive inhibition linked to passive methods and prevention of adhesions. This method has been assessed by a prospective study of 22 consecutive patients with average follow-up of 11.8 months. Our rating was based on the Strickland scoring technique. 81% of good and excellent results were observed. Our score rates confirm the results published by others authors who have applied the same active protocols. The results observed in our series tend to confirm the advantages of early controlled active mobilization techniques and lead us to pursue their application in the future.

Development of flexor tendon surgery: twenty-five years of progress.

Regaining satisfactory digital function after flexor tendon laceration and repair within the digit has long been one of the most difficult problems in hand surgery. Until the 1960s it was universally recommended that tendons divided in the digit (then referred to as “no man's land”) should not be repaired. Bunnell taught that “it is better to remove the tendons entirely from the finger and graft in new tendons smooth throughout its length.” 1 Bunnell S. Repair of tendons in the fingers and description of two new instruments. Surg Gynecol Obstet. 1918; 26: 103-110 Google Scholar That dictum remained sacrosanct until the 1960s when reports by Verdan, 2 Verdan CE. Primary repair of flexor tendons. J Bone Joint Surg. 1960; 42A: 647-657 Crossref Google Scholar , 3 Verdan CE. Practical considerations for primary and secondary repair in flexor tendon injuries. Surg Clin North Am. 1964; 44: 951-970 PubMed Google Scholar Kleinert et al, 4 Kleinert HE Kutz JE Ashbell TS Martinez E. Primary repair of lacerated flexor tendons in “no man's land.”. J Bone Joint Surg. 1967; 49A (abstr): 577 Google Scholar and Kessler and Nissim 5 Kessler I Nissim F. Primary repair without immobilization of flexor tendon division within the digital sheath: an experimental and clinical study. Acta Orthop Scand. 1969; 40: 587-601 Crossref PubMed Scopus (0) Google Scholar challenged the concept that flexor tendons should not be repaired primarily. These investigators noted that when done correctly, immediate tendon suture would outperform secondary free tendon grafting. Armed by those encouraging reports, there was a gradual and cautious development of the concept and practice of primary flexor tendon repair. Initially, primary tendon repair was often combined with anecdotal protocols by Duran et al, 6 Duran RJ Houser RG Coleman CR Stover MG. Management of flexor tendon lacerations in zone 2 using controlled passive motion postoperatively. in: Tendon surgery in the hand. : CV Mosby, St Louis1978: 178-182 Google Scholar Lister et al, 7 Lister GD Kleinert HE Kutz JE Atasoy E. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg. 1977; 2: 441-451 Abstract Full Text PDF PubMed Google Scholar and Strickland and Glogovac 8 Strickland JW Glogovac SV. Digital function following flexor tendon repair in zone II: a comparison of immobilization and controlled passive motion techniques. J Hand Surg. 1980; 5: 537-543 Abstract Full Text PDF PubMed Google Scholar for applying varying amounts of early post-repair motion to the repaired tendons.

Flexor tendon lengthening in zone II injuries.

Primary repair of acute severed flexor tendons in zone II has replaced the "no-man's-land" concept, which advocates secondary procedures. Primary repair can be difficult when there are severe soft-tissue and bony injuries, and may lead to unfavorable results. The authors describe a technique that is simple, quick, and safe, and eliminates the need for tendon harvesting or other secondary procedures. It can also be used when a flexor profundus tendon gap occurs due to the injury.

A biomechanical study of Tang's multiple locking techniques for flexor tendon repair

This study was designed to biomechanically compare Tang's multiple looped locking techniques with various suture techniques for flexor tendon repair in the hand. Fifty flexor digitorum profondus tendons taken from pig toes were used as models; The tendons were transected in the middle part of zone 2 defined as the area beneath bifurcation of the flexor digitorum superficialis tendons, and were repaired by five different suture methods: (1) modified Kessler, (2) Tsuge's suture, (3) double Kessler, (4) modified Kessler plus Tsuge, and (5) Tang's suture. The repaired tendons were placed in an Instron tensile testing machine to determine the tensile properties of the repair. 2 mm gap formation force and ultimate tensile strength were measured during the test. Maximal work to failure were calculated according to area under the load-displacement curve of the test. 2 mm gap formation force was 21.5 N for the Kessler, 20.6 N for the Tsuge, 31.6 N for double Kessler, 30.9 N for the Kessler plus Tsuge and 41.4 N for the Tang. Ultimate tensile strength was 23.5 N for the Kessler, 22.9 N for the Tsuge, 34.5 N for the Kessler plus Tsuge and 45.6 N for the Tang. Statistically, Tang's suture had the greatest gap formation force, ultimate strength and energy for failure among the five techniques (p < 0.01 or p < 0.001). Gap formation force, ultimate strength and energy to failure for double Kessler or the Kessler plus Tsuge were significantly greater than those for the Kessler or the Tsuge (p < 0.05 or < 0.01). The tendons repaired by Tang's method tolerated a significantly higher tensile load (133 to 198% of the other techniques) than the other methods. Among the methods tested, Tang's multiple looped locking suture provides sufficient gap resistance and tensile strength that may be able to withstand early active mobilization after primary flexor tendon repair.

Controlled active motion following primary flexor tendon repair: A prospective study over 9 years

One hundred and thirty patients with 339 divided flexor tendons affecting 208 fingers were studied prospectively between 1988 and 1996, to assess a regime of primary flexor tendon suture and active postoperative motion, combined with a modified Kleinert dynamic traction splint. The tendon suture technique used was a high-strength multistrand technique using a modified Kessler core and a Halsted peripheral stitch. The results were influenced by the zone in which the tendon was divided, by the physiotherapy and to a lesser extent by the grade of surgeon operating. Overall results by Strickland criteria were 92% excellent or good, 7% fair and 1% poor. There were 43 complications in 31 patients including five zone 2 ruptures (5.7%) and one further rupture in zone 5. This method of flexor tendon repair requires good physiotherapy and splint-making capability but gives good results with minimal need for further surgery.

A comparative study of two methods of controlled mobilization of flexor tendon repairs in zone 2

This prospective study compares subjects following primary repair of flexor tendons in zone 2 using either controlled active motion or a modified Kleinert regime. A matched pairs design was employed, subjects being matched for gender, age and injury characteristics. Twenty-six pairs of subjects with 92 tendon injuries in 52 digits were assessed 12 weeks postoperatively in respect of range of motion and dehiscence. Outcomes were defined using the Strickland criteria. No statistically significant differences in respect of range of motion were demonstrated between the groups. Incidence of rupture, however, was significantly less in the modified Kleinert group (7.7%) than in the controlled active motion group (46%).

Primary management of flexor tendon injuries of the hand

The repair of interrupted flexor tendons of the hand and their return to satisfactory function has been one of the most difficult and challenging tasks and problems even for the hand surgeon. Accordingly, nearly all publications have dealt with suture techniques, suture material and even the number of knots with regard to vascularization, course of sheaths and biology of healing. The aim of all surgical intentions is intrinsic healing, with as few adhesions as possible. On the one hand, this requires non-traumatic treatment of the tendon, respecting the dorsally located blood support and, on the other, early motion, jeopardizing the continuity of sutures. These diametrical requirements are the crux of flexor tendon surgery. Many authors-including-prefer a combination of Kleinerts intratendinously knotted suture with Ikuta's technique with the knot sunk below the tendon surface. Closure of the severed sheath is recommended, as is reconstruction of both tendons, provided that both are injured. The repair of partial lacerations is different, however. Kleinert's early motion treatment in the rubber-hand-protected flexion position is the postoperative management that has the most acceptance. In two consecutive follow-up studies (1974-1987 and 1988-1994) of 253 patients with 348 injured fingers, we achieved excellent and good results in 84.8% in the earlier group and in only 80.3% in the later one, which involved more surgeons with varying amounts of experience in hand surgery.

Re-repture after primary flexor tendon repair of the hand

Re-repture after primary flexor tendon repair of the hand

Flexor Tendon Injuries: I. Foundations of Treatment.

During the past 20 years, the difficult process of reestablishing satisfactory function after primary repair of flexor tendons has evolved from scientifically unsupported trial-and-error efforts to protocols based on sound laboratory and clinical investigations. Enhanced appreciation of tendon structure, nutrition, and biomechanical properties and investigation of factors involved in tendon healing and adhesion formation have had significant clinical applications. In particular, it has been found that repaired tendons subjected to early motion stress will increase in strength more rapidly and develop fewer adhesions than immobilized repairs. As a result, new and stronger tendon repair techniques have evolved, permitting the application of early passive and even light active forces. The author reviews the most recent and clinically pertinent research in flexor tendon surgery and discusses repair techniques and rehabilitation protocols based on the information provided by these studies.

Primary flexor tendon repair

Restoring digital function after flexor tendon injury continues to be one of the great challenges in hand surgery. Advances in our understanding of tendon anatomy, nutrition, healing, and postoperative rehabilitation have generated an evolution of techniques that have enhanced the results of flexor tendon repair. Despite the many gains, problems of stiffness, scarring, and functional impairment persist in frustrating the most experienced hand surgeons and compliant patients. Treatment of flexor tendon injuries requires a thorough knowledge of hand anatomy, atraumatic surgical technique, and a structured program of postoperative rehabilitation.

Primary flexor tendon repair: Surgical techniques based on the anatomy and biology of the flexor tendon system

The anatomy, biology and bio-mechanics of the flexor tendon system demand a precise approach to flexor tendon repair. Within the fibroosseous canal, the synovial fluid and a complex intratendinous vascular network provide nutrition for intrinsic flexor tendon healing. Retention of the synovial sheath theoretically maintains an enclosed tendon/tendon sheat environment in which the tendon repair is bathed in synovial fluid, and may glide within a smooth tunnel. The preservation of the intricate double tendon inter-relationship and the annular pulley system is vital to the efficiency of finger flexion. This review details surgical and postoperative techniques aimed at restoring the normal anatomy and providing optimal conditions for the return of flexor tendon function.

RESULTS OF PRIMARY TENDON REPAIR WITH CLOSURE OF THE TENDON SHEATH

This study reports the results of primary flexor tendon repair combined with closure of the tendon sheath in 31 Zone 2 injuries. In 3 digits, the profundus tendon alone was divided. In a further 7 digits, one tendon was completely divided and the other was incompletely divided. The remaining 21 digits involved complete division of both tendons. Assessment of the results according to the total active motion (TAM) system found 86% of the repairs in the excellent, good and fair categories. Two ruptures occurred (6%). A second assessment employed the criteria of Strickland, excluding the motion of the metacarpophalangeal joint. The results obtained following suture of both tendons were: excellent (39%); good (36%); fair (14%); poor (4%); and rupture (7%). These results lend support to the belief that closure of the tendon sheath decreases external adhesion formation and improves motion without increasing the risks of rupture.

The mechanical effect of partial resection of the digital fibrous flexor sheath

In the context of primary flexor tendon repair, a study has been made to determine how much of the flexor sheath may be opened without causing mechanical disadvantage to the finger. In five cadaver hands, measurement of profundus tendon excursion, distance from nail to distal palmar crease, profundus flexion force, and tendon bow-stringing, showed that there was no material change of these parameters when up to four contiguous pulleys were divided. Along with other individual pulleys, A2 and A4 cannot be regarded as inviolate.

Excursion of the flexor digitorum profundus tendon: a kinematic study of the human and canine digits.

The most common problem following primary flexor tendon repair is the failure of the tendon apparatus to glide, secondary to the formation of adhesions. Early motion following tendon repair has been shown to be effective in reducing adhesions between the tendon and the surrounding sheath. Therefore, it is important to determine the amount of flexor tendon excursion along the digit during joint motion. In this study, the excursion between the flexor digitorum profundus (FDP) tendon and the sheath was examined in both human and canine digits. Based on roentgenographic measurements and joint kinematic analysis, the motion of the bones, the FDP tendon, and the sheath were measured with respect to joint rotations. It was found that the canine flexor tendon apparatus behaved similarly to that of the human for the motions studied. The amount of tendon excursion was very small in regions distal to the joint in motion (approximately 0.1 mm/10 degrees of joint rotation). There was little displacement of the sheath (0.2-0.3 mm), except at the metacarpal joint region during metacarpophalangeal (MCP) joint motion and at the proximal interphalangeal (PIP) joint region during PIP joint motion. Tendon excursion relative to the tendon sheath was the largest in zone II during PIP joint rotation (1.7 mm/10 degrees of joint rotation). These results suggest that PIP joint motion may be most effective in reducing adhesions following tendon repair in zone II.

Early mobilisation after primary flexor tendon repair in 152 fingers (excluding zone II) and in 60 thumbs. "France Ouest Main Service".

The results of classical treatment (suture plus immobilisation) and of Kleinert's technique (suture under magnification with early semipassive movement), were compared in 290 primary flexor tendon repairs. The site of injury and the nature of associated injuries were the major prognostic factors. Kleinert's rehabilitation program was of particular value when a large range of movement was needed in simple lesions of zones III and IV. When tendon rupture must be avoided and preservation of strength is more important than achieving a full range of movement, immobilisation after an atraumatic suture is preferred.

An evaluation of early motion management following primary flexor tendon repair: Zones 1–3

This study examined consecutive clinic charts for 95 patients with primary or delayed primary repair of traumatically severed flexor superficialis or profundus tendons without concomitant fractures or joint trauma, in digits 2–5, zones 1–3. Patient traits, wound characteristics, surgical variables, therapeutic programs, and intervention outcomes including rupture, need for tenolysis, and total active motion (TAM) were examined. The study included 117 injured fingers and 174 lacerated tendons. The average number of therapy visits was 8.6. The dorsal blocking splint was almost universally used in conjunction with a modified Duran approach. Outcomes of intervention included the following: 7% of patients required follow-up tenolysis; 4% of repaired tendons ruptured; mean TAM at discharge was 217°. Mann-Whitney U and one-way analysis of variance tests indicated that discharge TAM for injuries involving both tendons in a finger and injuries occurring in zone 2 were significantly lower than TAM for injuries involving only the profundus or occurring in zone 1. Pearson correlation identified independent variables that correlated with TAM. Further investigation of the effects of wound and intervention variables on outcome is warranted.

Primary repair of flexor tendons in no-man's land using the Becker repair.

Forty-three digits with severed flexor tendons in no-man's land have been repaired using a modified Becker's technique. The results are analysed according to the type of laceration and associated injuries. Using White's method, 70% obtained satisfactory, 8% fair, and 22% poor results. There were three ruptures but most poor results were due to stiffness after crushing injuries or when both vascular bundles had been divided.

Primary flexor tendon repair

Primary flexor tendon repair

Primary repair of flexor tendons in the hand with early passive mobilization.

Flexor tendon injuries in zones I-III in the hand were treated by meticulous suture of the tendons and peritendinous structures, followed by early passive mobilization of the injured fingers, the remaining fingers being kept extended by a plaster splint. This method was used in 51 cut tendons in 38 patients. The functional recovery approached normal in 72%, and only 8% were poor.

Primary Flexor Tendon Repair

Primary Flexor Tendon Repair