Treatment Of Flexor Tendon Injuries Research Articles

Diagnosis and treatment of flexor tendon injuries of the hand: what the radiologist needs to know.

This article reviews the diagnosis and treatment of flexor tendon injuries of the hand highlighting flexor tendon anatomy, important pre-operative imaging findings, surgical options, and post-operative complications. Imaging plays a key role in guiding treatment of these difficult to manage injuries. Thus, it is important for radiologists to have a sound understanding of factors important in treatment decision-making. In the pre-operative setting, accurately identifying the location of the torn proximal tendon stump in subacute and chronic injuries helps dictate whether the patient is a candidate for a primary flexor tendon repair or may require a tendon reconstruction to restore function. In the post-operative setting, the status of the repair and presence of surrounding adhesions help dictate if and when the patient will require subsequent surgery and whether that surgery will be a tenolysis, revision repair, reconstruction, or fusion.

Principles of Tendon Structure, Healing, and the Microenvironment.

Tendon is a strong viscoelastic tissue, responsible for conducting force from muscle to bone. In the hand, flexor tendons course through fibro-osseous sheaths, composed of an intricate tenosynovium and fibrocartilaginous pulley system. After flexor tendon laceration, changes occur in tendon force transduction as well as vascularity, affecting tendon healing on a tissue and cellular level. Tendon healing occurs through intrinsic and extrinsic mechanisms, which in combination with local anatomy, can predispose to adhesion formation. Understanding the relationship between microenvironmental cues and tendon healing on the cellular and tissue level will improve our knowledge and treatment of flexor tendon injuries.

Wide-Awake Local Anesthesia No Tourniquet (WALANT) for Flexor Tendon Repairs as Change in Practice During the COVID-19 Pandemic: A Retrospective Cohort Study With Outcomes.

The coronavirus disease 2019 (COVID-19) pandemic forced many changes. In our unit, there was a significant shift from traditional anesthesia (TA) which included general or regional anesthesia, to Wide-Awake Local Anesthesia No Tourniquet (WALANT) for the treatment of flexor tendon injuries. Zones I and II injuries have always beena challenge. The primary aim of this study is to compare the 12-week range of motion (ROM) flexor tendon repair outcomes between the TA group and wide-awake (WA) group patients.The secondary aim is to compare the complications and the follow-up rate between the two groups. All patients who underwent a primary finger flexor tendon repair in zone I or II without tendon graft for closed avulsions or open lacerations between April 2020 and March 2021 were included in the study. Electronic medical records were reviewed to record demographics, follow-up, ROMoutcomes and complications. Forty-four patients with 49 injured fingers were in the WA group, and 24 patients with 37 injured fingers were in the TA group. A complete follow-up with 12-week ROM outcomes was available for 15 patients with 16 injured fingers in the WA group and nine patients with 13 injured fingers in the TA group. Excellent to good outcomes in the WA group were reported in 56% of the cases versus 31% in the TA group, although the difference was not statistically significant. There were similar complications in both groups, with an overall rupture rate of 11.6%, a tenolysis rate of 3.5% and a reoperation rate of 9.3%. Complete 12-week follow-up was completed by 41% of patients overall after taking tendon ruptures into account. This is one of the first studies comparing zones I and II flexor tendon ROM outcomes between WA anesthesia and TA. Overall, there was a trend toward superior ROM outcomes in the WA group, with similar complication rates in both groups. The difference between ROM outcomes was not statistically significant and the small sample size undermined the strength of the study. To provide stronger evidence, better-designed prospective studies are suggested that would compare WA techniques with TA techniques.

Is microsurgical experience essential in Zone II flexor tendon injuries?

This study aims to investigate whether microsurgical experience was necessary for the treatment of Zone II flexor tendon injuries. Between October 2018 and October 2021, a total of 73 Zone II flexor tendon injuries in 71 patients (53 males, 18 females; mean age: 39.6±12.1 years; range, 21 to 57 years) who underwent surgical intervention in our center were retrospectively analyzed. All patients in the study had flexor digitorum profundus (FDP) tendon injury. The clinical outcomes of patients with digital artery injury, nerve injury or phalanx fracture accompanying FDP tendon injury were evaluated separately according to the American Society for Surgery of the Hand (ASSH) scores. The scores of multiple injuries accompanying FDP tendon injury in patients with FDP+flexor digitorum superficialis (FDS)+digital nerve injury and FDP+FDS+digital artery+nerve injury were evaluated. The mean ASSH score was 69.4±28.2 in the group with FDP tendon injury accompanying digital nerve injury and 62.9±19.7 in the group with FDP tendon injury and digital artery injury. The clinical outcomes were significantly lower in patients with digital nerve injury and digital artery injury respectively, compared to patients without accompanying injuries (p=0.029 and p=0.012, respectively). The lowest mean score (45.3±10.2) was in patients with fracture accompanying FDP tendon injury and ASSH score was significantly lower than in patients without fracture (p<0.001). Zone II flexor tendon injuries are frequently accompanied by digital artery or nerve injuries, which usually require microsurgical repair. If left untreated, treatment outcome may be poor. Surgical centers and departments undertaking the treatment of flexor tendon injuries should be able to perform microsurgery.

A Survey of Zone II Flexor Tendon Repair Techniques and Rehabilitation Protocols Preferred by Malaysian Orthopaedic Practitioners.

Introduction:Flexor tendon repair is challenging mainly due to the need to balance between a strong repair technique, ease of tendon gliding and early mobilisation to prevent adhesions while preventing tendon rupture. While different countries have different preferences in repair techniques, core sutures and suture types, there is still no study in Malaysia regarding our preference and whether we are following the current evidence.Materials and methods:We performed a survey with a standard questionnaire distributed during our annual national orthopaedic meeting in 2019. The standard questionnaire consisted of 24-objective multiple-choice questions concerning the treatment of flexor tendon injury were distributed with consent. A total of 290 questionnaires that were filled out correctly were included in this study.Results:The majority of respondents preferred the Modified Kessler technique (n=96, 33.1%) followed by the Adelaide technique (n=81, 27.9%) and Double Modified Kessler (n=45, 15.5%). However, for the number of core strands in the repair, the majority utilised the 4-strand (n=203, 70%), followed by 2-strand (n=34, 11.7%) and 6-strand (n=21, 7.2%). The majority utilised Prolene sutures (n=259, 89.3%) with a suture size of 4/0 (n=157, 54.1%). For rehabilitation, 56.9% (n=165) preferred early passive motion, 27.6% (n=80) early active motion and 14.8% (n=43) would strictly immobilise.Conclusion:There is still no consensus as to the best technique; however, the aim of tendon repairs is still the same around the world. It would be helpful to know our preferences to improve our current practice and outcomes following these common flexor tendon injuries in hand.

Application of biological materials in preventing basketball sports injury

Basketball often leads to injury of the flexor tendon. And surgery is an effective way to perform flexor tendon injuries. Collagen biofilm can effectively prevent postoperative tendon adhesion. Because of this, we analyzed the effect of collagen biofilm in preventing postoperative adhesion of flexor tendon injury caused by basketball. This article discusses 80 patients who came to our hospital for treatment and were diagnosed with basketball flexor tendon injuries. We randomly divide them into two groups. In the observation group, 3-0 or 4-0 atraumatic suture modified Kessler’s method, or internal “8” suture was used to repair the flexor tendon with (1–2) × 4 cm biofilm or liquid coating around the suture of the tendon. The control group was treated by suturing the wound after hemostasis. Compare the efficacy of the two and other biological indicators. The study found statistical differences in the postoperative mobility and excellent and good rate of the two groups of patients. For this reason, we believe that collagen biofilm can be effective in the surgical treatment of flexor tendon injuries caused by basketball. This method is worthy of clinical application.

Primary treatment of flexor tendon injuries

The treatment of flexor tendon injuries is still challenging, especially in the region of the narrow annular ligaments and tendon sheaths of the 3‑segment fingers and the thumb (zone2). In the course of time, the primary suture of the flexor tendons has prevailed over traditional recommendations for asecondary tendon replacement after healing of the wound. Improvements regarding suture techniques and materials and, above all the follow-up treatment, have been crucial for better results and remarkable changes in flexor tendon surgery. The suture techniques are determined by the location of the injury but the experience and preferences of the surgeon are also important. Although no technique was found to be optimal, published research and clinical experiences provide important indications for the presumption of successful treatment. To achieve this an early functionally active protocol should be implemented. The tendon suture should enable this by having ahigh primary strength and therefore at least a4-strand core suture technique with a ring suture should be given preference. Further important prerequisites for success are the undisturbed gliding of the repaired tendon in its "bed" paying special attention to the annular ligaments and preservation of the blood supply to the tendons.

Treatment of flexor tendon injuries in children

Injuries to the flexor tendons in children are less common than in adults. The clinical examination and diagnostics require extensive experience. Leaving flexor tendons untreated will result in growth disorders of the affected finger. Therefore, the indications for operative exploration of any type of open injury in achild's hand should be liberally applied. As for adults the primary treatment of flexor tendon injuries as an emergency is rarely indicated. In the recent literature various tendon suture techniques and rehabilitation protocols have been differently assessed. According to the Ulm algorithm flexor tendon injuries in children are treated by a2-strand core stitch technique followed by acontinuous circular suture. Children under 6years of age are postoperatively immobilized for 3weeks with a fist bandage. Children older than 6years are treated like adults with a dynamic aftercare as described by Kleinert for 5weeks. The results are comparable with those of other aftercare protocols.

Postoperative treatment and rehabilitation following flexor tendon injuries

The ideal surgical and postoperative treatment for flexor tendon injuries, especially in zone2, is still subject to continuous modifications and professional discussions. Presentation of established rehabilitation concepts, specific problems and new treatment approaches with practical recommendations for application. Comparison of commonly used treatment concepts by assessing surgical flexor tendon repair, splint choice and clinical application in patients. Discussion of new surgical approaches and standards and their influence on postoperative therapy after flexor tendon injuries. The Washington regimen has retained its status as the standard in the current follow-up treatment of flexor tendon injuries. New suture materials and techniques enable early active rehabilitation of sutured flexor tendons with good clinical results, such as increased range of motion for interphalangeal joint extension and improved distal interphalangeal joint flexion with overall acceptable frequencies of suture rupture. Astable tendon repair with smooth gliding is the foundation for treatment after flexor tendon injuries. After intraoperative active digital extension-flexion testing of the sutured tendon an early active rehabilitation approach should follow. New splint designs in combination with primary stable tendon suture techniques have the potential to improve the postoperative outcome, presupposing areliable cooperation of the patient.

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.

Range of movement, power and pinch grip strength post flexor tendon repair

Background: Flexor tendon injuries (FTI) are common hand injuries that pose a challenge to the multi-disciplinary team. Despite being the most researched topic in hand literature, the optimal surgical and post-operative treatment of FTI remains unclear and results after flexor tendon repair (FTR) continue to be unpredictable.Purpose: The purpose of this study was to determine the range of movement (ROM), power and pinch grip strength post FTR and to establish factors that may affect these.Method: The study was conducted at an academic hospital in Gauteng, South Africa, between January 2013 and September 2015. At one, three and six months post FTR, the ROM of the injured and contralateral finger(s) were measured. At three and six months post FTR the participants’ bilateral power and pinch grip strength were also measured.Results: One hundred and twenty-six participants (n=126) enrolled in the study. There was a drop-out rate of 48%, leaving 65 participants that completed six months’ follow-up: 41 males (63%) and 24 females (37%) with mean age of 32 years (SD±10, n=65). Out of 65 participants, 2% (n=1) had an excellent outcome, 32% (n=21) a good outcome, 32% (n=21) a fair outcome and 34% (n=22) a poor outcome with regard to ROM. At six 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. Sixty-eight per cent (n=44) of patients had post-operative complications: the most common complication was tenodesis/adhesions (25%, n=16), followed by contracture (22%, n=14). Four patients (6%) had ruptures and 11 (17%) underwent further surgery. Factors that had a positive effect on outcome at six months post FTR were: younger age, no associated injury, less duration between injury and surgery, having controlled active motion instead of passive motion occupational therapy protocol, and not having a language barrier. Injury in zone IV was associated with worse ROM and power grip strength than other zones.Conclusion: Although there were some promising outcomes, during this period participants did not consistently achieve the good or excellent outcomes that are achieved in some developed countries.Level of evidence: Level 4

Cell and Biologic-Based Treatment of Flexor Tendon Injuries

The two primary factors leading to poor clinical results after intrasynovial tendon repair are adhesion formation within the digital sheath and repair-site elongation and rupture. As the outcomes following modern tendon multi-strand repair and controlled rehabilitation techniques are often unsatisfactory, alternative approaches, such as the application of growth factors and mesenchymal stem cells (MSCs), have become increasingly attractive treatment options. Successful biological therapies require carefully controlled spatiotemporal delivery of cells, growth factors, and biocompatible scaffold matrices in order to simultaneously (1) promote matrix synthesis at the tendon repair site leading to increased biomechanical strength and stiffness and (2) suppress matrix synthesis along the tendon surface and synovial sheath preventing adhesion formation. This review summarizes recent cell and biologic-based experimental treatments for flexor tendon injury, with an emphasis on large animal translational studies.

A Review of Current Concepts in Flexor Tendon Repair: Physiology, Biomechanics, Surgical Technique and Rehabilitation.

Historically, the surgical treatment of flexor tendon injuries has always been associated with controversy. It was not until 1967, when the paper entitled Primary repair of flexor tendons in no man’s land was presented at the American Society of Hand Surgery, which reported excellent results and catalyzed the implementation of this technique into worldwide practice. We present an up to date literature review using PubMed and Google Scholar where the terms flexor tendon, repair and rehabilitation were used. Topics covered included functional anatomy, nutrition, biome-chanics, suture repair, repair site gapping, and rehabilitation. This article aims to provide a comprehensive and complete overview of flexor tendon repairs.

Flexor Tendon Repair, Rehabilitation, and Reconstruction

Flexor tendon injury is a common problem that plastic surgeons are called on to treat. Despite their common nature, they present a challenge, not necessarily in the surgical treatment per se but in the ability to achieve a "normal" finger as the end result. Because of the difficulty in attaining good outcomes, much continues to be studied and written about flexor tendon injury. The current literature on flexor tendon repair, rehabilitation, and reconstruction is reviewed. Aspects reviewed include type of anesthesia, suture material and configuration, repairs in the different flexor tendon zones, types of tendon rehabilitation, complications of flexor tendon surgery, and flexor tendon reconstruction. This review provides an update on the current standards in the treatment of flexor tendon injury.

Effect of Cyclic Strain on Tensile Properties of a Naturally Derived, Decellularized Tendon Scaffold Seeded With Allogeneic Tenocytes and Associated Messenger RNA Expression

Naturally derived tendon scaffolds have the potential to improve the treatment of flexor tendon injuries. Seeded and unseeded tendon scaffolds were maintained in the presence or absence of physiologic strain for 7 days. After 7 days, the tensile properties and associated messenger RNA expression were compared. Seeded scaffolds maintained in the absence of strain had significantly lower tensile properties than unseeded tendons and fresh-frozen tendons. The loss of tensile properties was associated with elevated matrix metalloproteinase-2 and collagen III expression. Tensile properties of seeded scaffolds maintained in the presence of strain for 7 days after seeding did not differ from those of fresh-frozen tendons. This study demonstrates that the tensile properties of seeded, naturally derived tendon scaffolds will degrade rapidly in the absence of cyclic strain. Seeded scaffolds used for tendon reconstruction should be maintained under cyclic strain to maintain essential tensile properties.

ED Treatment of Flexor Tendon Injuries

ED Treatment of Flexor Tendon Injuries

Treatment of flexor tendon injuries in noncompliant patients

Treatment of flexor tendon injuries in noncompliant patients

Complications After Treatment of Flexor Tendon Injuries

The goals of flexor tendon repair are to promote intrinsic tendon healing and minimize extrinsic scarring in order to optimize tendon gliding and range of motion. Despite advances in the materials and methods used in surgical repair and postoperative rehabilitation, complications following flexor tendon injuries continue to occur, even in patients treated by experienced surgeons and therapists. The most common complication is adhesion formation, which limits active range of motion. Other complications include joint contracture, tendon rupture, triggering, and pulley failure with tendon bowstringing. Less common problems include quadriga, swan-neck deformity, and lumbrical plus deformity. Meticulous surgical technique and early postoperative tendon mobilization in a well-supervised therapy program can minimize the frequency and severity of these complications. Prompt recognition of problems and treatment with hand therapy, splinting, and/or surgery may help minimize recovery time and improve function. In the future, the use of novel biologic modulators of healing may nearly eliminate complications associated with flexor tendon injuries.

Reply to the Commentary on the Article of Friedrich, H., D. Bäumel: The Treatment of Flexor Tendon Injuries in Children

vielen Dank für Ihre Zuschrift zu unserer Arbeit „Die Behandlung von Beugesehnenverletzungen im Kindesalter“.

Commentary on the Article of Friedrich, H., D. Bäumel: The Treatment of Flexor Tendon Injuries in Children

Das Bild lässt darauf schließen, dass die Autorinnen sich nicht selbst mit dem Patienten beschäftigt haben. Die Abbildung stellt genau das Gegenteil von dem dar, was eigentlich gezeigt werden sollte: „Physio- und Ergotherapie bedeuten speziell für Kleinkinder große körperliche Anstrengung, wenn sie sich auf eine Extremität konzentrieren sollen“. Auf dem Foto hat der Junge die Hand und Finger fest gekrallt, wobei sich die maximale Kraftanstrengung auf die Muskulatur von Unterarm-, Oberarm-, Schulter- und Halsmuskulatur und auf das ganze Gesicht erstreckt. Es besteht jetzt eine vollständige Blockade nicht nur der ganzen oberen Extremität. Wahrscheinlich ist auch die Atmung in ein kontinuierliches Pressen übergegangen. Wenn tatsächlich mit solcher Anstrengung gearbeitet wird, ist die Zahl von nur zwei Rupturen (145 Finger) nicht wahrscheinlich. Ob bei der Nachuntersuchung die Beugung in den Endgelenken immer untersucht und gemessen wurde? (Kriterien von Buck-Gramcko).