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

Complications and Clinical Outcomes Following Zone I Flexor Tendon Repair Using All-Inside Suture Fixation

PURPOSE

The purpose of this study was to evaluate complications and outcomes of an all-inside repair technique for flexor digitorum profundus (FDP) avulsions.

METHODS

A retrospective review of a single institution database identified all FDP avulsions that were repaired using an all-inside technique by a single surgeon. In this method, 2 Keith needles are drilled from the volar to dorsal aspect, exiting proximal to the nail matrix and within the extensor tendon. Nonabsorbable sutures were placed in the flexor tendon and passed through the bone tunnels, tying dorsally over the distal phalanx. The demographics characteristics, injury characteristics, the surgical procedure, postoperative complications, and outcomes were reviewed.

RESULTS

Seventeen patients were included in the study. The average age was 40 years (range, 21-68 years), and 2 patients were women. Seventeen fingers were included: 14 ring fingers, 1 index finger, and 2 little fingers. Six patients had an associated distal phalanx fracture and one had an associated distal interphalangeal joint dislocation. The average time between injury and surgery was 9 days (range, 2-18 days). Four patients had complications: 3 with erythema related to infection, which appeared to be a reaction to the suture prompting removal, and 1 with a subungual mass related to the suture at removal. One patient had persistent pain. Postoperative range of motion, assessed using the Strickland criteria, was excellent or good in 5 (33%) of 15 patients, but this was predominantly due to motion at the proximal joints as overall DIP motion was limited. Patients had a mean distal interphalangeal joint range of motion of 24° (range, 0° to 55°).

CONCLUSIONS

In our series, repair of FDP avulsions via all-inside suture fixation is associated with limited distal interphalangeal joint motion and an incidence of infection (24%) at final follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

The Effect of Timing Between Traumatic Flexor Tendon Injury of the Hand and Surgical Intervention on Repair Failure Rates

Flexor tendon injuries of the hand, especially in zone II, pose a challenge for hand surgeons because of the region's intricate pulley mechanism and local avascularity, and post-surgical complications such as repair failure are not uncommon. One proposed predictor of outcomes following flexor tendon repair has been timing of surgery from initial injury. However, the effect of the timing of flexor tendon repair on failure rates remains controversial and understudied. The purpose of this study was to compare the failure rates of zone II flexor tendon repairs in patients at various time intervals from onset of injury. A retrospective chart review was conducted using data from hand surgery specialists at our level 1 trauma center from January 1, 2010, through May 31, 2020. This retrospective review included 407 zone II flexor tendon repairs. The primary outcome was failure of repair. Among 407 flexor tendon repairs, there were 12 reported repair failures. The failure rate was 2.9%. In the non-failure group, the mean number of days between the date of injury and the date of surgery was 7±13 days. For the failure group, this value was 14±17 days. Repairs occurring within 14 days had a failure rate of 2.3%, while repairs occurring beyond 14 days had a failure rate of 7.7%. This study demonstrates that there is a benefit to repairing the tendon within a 14-day window, as evidenced by a lower failure rate. More research is required to determine if other complications and overall health of the hand are also improved when a repair is performed in a more expedient manner. [Orthopedics. 2024;47(2):113-117.].

Short-Term and Long-Term Therapeutic Results of Deep Flexor Tendon Repair in Zone II in Patients Referred to Imam Khomeini Hospital, Ahvaz, Southern Iran

Background

Hand injury as an important concern for the surgeon and the patient requires proper and timely treatment to prevent complications such as infection and adhesions, and with a proper rehabilitation program, the patient returns to maximum function as soon as possible. We aimed to investigate the short-term and long-term treatment results of deep flexor tendon repair in in zone II.

Methods

This retrospective study was performed on 34 patients with 45 injured fingers in the zone II referred to Ahvaz Imam Khomeini Hospital, Ahvaz, Iran during 2017-2019. The results of deep flexor tendons repair in two groups, immediate and delayed primary repair were assessed.

Results

The mean age of the patients was 27.76 years. There was no significant remarkable between male and female in the incidence of complications such as infection, tendon rupture and adhesions. 29.4% (n=10) had poor outcome, 8.8% (n=3) had fair outcome, 29.4% (n=10) had good outcome and 32.4% (n=11) had excellent outcomes. 26.5% had adhesion and infection rate was 11.8%.

Conclusion

Among surgeons, there is consensus for the primary repair of tendon injury, but there was no significant difference between the results of immediate and delayed primary repair. Although physiotherapy has been suggested as an effective factor in improving hand function, its positive effect on the range of motion of the fingers has not been proven.

Zone 1 and 2 flexor tendon repair via a longitudinal incision crossing the volar distal interphalangeal joint: functional and cosmetic outcomes

INTRODUCTION

The primary aim of this study was to present patient-reported functional outcomes after zone 1 and 2 flexor tendon repair using a novel longitudinal volar approach crossing the distal interphalangeal joint (DIPJ) perpendicularly. The secondary aims were to investigate the cosmetic outcomes, satisfaction and complication rates associated with this technique.

METHODS

Over a 6-year period, 75 patients underwent flexor tendon repair using this technique. The quick version of the Disabilities of the Arm, Shoulder and Hand (QuickDASH), five-level EQ-5D (EQ-5D-5L), Patient and Observer Scar Assessment Scale (POSAS) and satisfaction questionnaires were collected. QuickDASH scores were available for 59 patients (79%), and POSAS scores were available for 45 patients (60%) at a mean follow-up of 48 months. Concomitant nerve repairs were undertaken in 24 cases.

RESULTS

The median QuickDASH score was 4.5 (interquartile range [IQR] 1.1-12.5) and median POSAS score was 12 (IQR 8-16). No significant difference was observed in median QuickDASH score between patients with and without a concomitant nerve repair (4.5 vs 6.8; p = 0.36). Fifty-six patients (94%) were satisfied. Two patients required open tenolysis, and a single case of early re-rupture occurred that required revision open repair.

CONCLUSIONS

Utilising validated patient-reported functional outcomes, this study demonstrated that a direct longitudinal incision over the DIPJ for zone 1 and 2 flexor tendon repairs can result in excellent functional and cosmetic outcomes, with high rates of patient satisfaction and low rates of complications. This challenges previously held dogma that longitudinal incisions crossing flexion creases should be avoided.

Autonomous Patient-Controlled Mobilization Protocol After Flexor Tendon Repair: A Case Series

BACKGROUND

Despite many publications on rehabilitation after repair of flexor tendon injuries of the hand, there is no consensus as to which method is superior. It is clear that nonadherence to postoperative therapy adversely affects the outcome after flexor tendon surgery. In the context of a developing country, the most important factor associated with poor outcome is late onset of rehabilitation therapy. An autonomous rehabilitation program is proposed, with the use of a low-cost splint and based on an online illustrative video with the expectation to improve adherence and patient compliance, thus ensuring satisfactory outcome.

METHODS

Twenty-two consecutive digits of 14 patients after flexor tendon repair in zone II were included. Autonomous early passive mobilization physical therapy and splinting started shortly after surgery, supported by an online available video depicting prescribed exercises; follow-up was continued until postoperative week 20. Patients were evaluated regarding range of motion, grip strength, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) disability scale.

RESULTS

Range of motion after 20 weeks according to the scoring system of the American Society of Surgery of Hand was excellent in 4, good in 11, and fair in 4 fingers. The mean total active motion score was 86% (95% confidence interval, 78%-93%). The mean grip strength at final follow-up was 86% of the contralateral hand. The mean QuickDASH score was 12.5 (2.3-31.8).

CONCLUSION

This protocol achieves good results in range of motion and early return of function of the hand. We propose this simple, nonexpensive method to developing countries with less than optimal availability of health care.

Variation in patient information and rehabilitation regimens after flexor tendon repair in the United Kingdom

Introduction

There is clinical uncertainty regarding the optimal method of rehabilitation following flexor tendon repair. Many splint designs and rehabilitation regimens are reported in the literature; however, there is insufficient evidence to support the use of any one regimen. The aim of this study was to describe rehabilitation guidelines used in the United Kingdom (UK) following zone I/II flexor tendon repair.

Methods

Using a cross-sectional design, hand units in the UK were invited to complete a short survey and to upload their flexor tendon rehabilitation guidelines and patient information material. Approval was granted by the British Association of Hand Therapists. Data were extracted in duplicate, using a pre-piloted form, and analysed using descriptive statistics.

Results

Thirty-five hand units responded (21%), providing 52 treatment guidelines. Three splinting regimens were described, and all involved early active mobilisation: (i) long dorsal-blocking splint (DBS); (ii) short DBS; and (iii) relative motion flexion splint. Duration of full-time splint wear ranged from 4 to 6 weeks. There were variations in splint design and composition of home exercise programmes, particularly for the long DBS. Where reported, recommended return to driving ranged from 8 to 12 weeks, and return to light work activities ranged from 5 to 10 weeks.

Discussion

Treatment guidelines varied across UK hand therapy departments, suggesting that patients receive differing advice about how to protect, move and use their hand after zone I/II flexor tendon repair. The disparity in splint wear duration, home exercise frequency and prescribed functional restrictions raises potential financial and social implications for patients. Future research should explore rehabilitation burden in addition to clinical outcomes.

Dynamic Tendon Grip (DTG™) novel knot array compared to traditional sutures for zone two flexor tendon injury - a biomechanical feasibility study

BACKGROUND

Flexor tendon injuries pose many challenges for the treating surgeon, the principal of which is creating a strong enough repair to allow early active motion, preserving a low-profile of the repair to prevent buckling and subsequent pulley venting. A main concern is that a low-profile repair is prone to gap formation and repair failure. The Dynamic Tendon Grip (DTG™) all suture staple device claims to allow a strong and low-profile repair of the flexor tendon. The purpose of this study is to test the effects of the DTG™ device in early active motion simulation on range of motion, load to failure and gap formation and to compare it to traditional suturing technique.

METHODS

Twelve fresh-frozen cadaveric fingers were assigned to two groups: DTG™ device (n = 9) and traditional suturing (double Kessler 4-core suture and a peripheral suture, n = 3). The deep flexor was incised and repaired in zone 2, and active motion simulation was carried out with a cyclic flexion-extension machine. Finger range of motion and gap formation were measured, as well as load to failure and method of repair failure.

RESULTS

Following motion simulation, ROM decreased from 244.0 ± 9.9° to 234.5 ± 5.8° for the DTG™ device compared to 234.67 ± 6.51° to 211.67 ± 10.50° for traditional suturing. The DTG™ repair demonstrated gap formation of 0.93 ± 0.18 mm in 3 of 8 specimens after applying 1 kg load, which negated after load removal. Load to failure averaged 76.51 ± 23.15 N for DTG™ and 66.31 ± 40.22 N for the traditional repair. Repair failure occurred as the suture material broke for the DTG™ array and at the knot level for the traditional repair.

CONCLUSIONS

The DTG™ all-suture stapling concept achieved a strong low-profile repair in zone 2 flexor tendon injury after active motion simulation. Further clinical studies will be needed to determine the effectiveness of this device compared to traditional techniques.

Outcomes at 3 Months of a Place and Active Hold Method of Flexor Tendon Rehabilitation Following Zone II Injury

Background: Previous studies have shown that outcomes following a place and active hold (PAH) are better than a passive flexion protocol after a two-strand core-suture repair of flexor tendons injuries in zone II. This study aims to determine the outcomes of a PAH protocol of flexor tendon rehabilitation following a four-strand core-suture plus an epitendinous suture repair of the flexor digitorum profundus (FDP) combined with a simple horizontal loop repair of the flexor digitorum superficialis (FDS). Methods: This is a prospective study of patients with complete injury to both flexor tendons in zone II. All tendons were repaired with a simple horizontal loop for FDS and four-strand core-suture plus epitendinous suture for FDP. The PAH protocol was used postoperatively for 6 weeks. The outcome was evaluated using flexion contracture and total active motion (TAM), interpreted using Strickland criteria and categorised as excellent, good, fair and poor at 6 weeks and 3 months. The linear regression model was used to determine predictors of outcomes. Results: The study included 32 patients with flexor tendon injury in 46 fingers. No repairs ruptured, and 24 (52%) digits achieved good or excellent motion 6 weeks after surgery using the Strickland criteria. According to the Strickland criteria, 41 (89%) digits ranked as excellent and good with no poor result at a 3-month follow-up. Four patients had 5-10° of flexion contracture. Age was the predictor of TAM at 6 weeks and accounted for 13% of its variation. Improvement of TAM from 6 weeks to 3 months was related to age and flexion contracture at 6 weeks. Conclusions: The PAH protocol can be considered a safe technique for flexor rehabilitation after four-strand core-suture repair of FDP in zone II. Level of Evidence: Level IV (Therapeutic).

Outcome measurement in adult flexor tendon injury: A systematic review

BACKGROUND

Defining the optimal, evidence-based management of flexor tendon injury remains challenging. Lack of consensus on which measures to use to assess the outcome of interventions is a key issue, especially with regard to patient-reported outcome measures (PROMs). This systematic review defines the landscape of outcome measurement in studies on interventions for flexor tendon injuries to guide future research.

METHODS

A PRISMA-compliant systematic review was conducted using bespoke search strategies applied to MEDLINE, EMBASE, PsycINFO, CENTRAL, CINAHL and AMED. A protocol was developed and registered prospectively (CRD42020186780). We identified all studies describing adult patients undergoing interventions for acute hand flexor tendon injuries.

RESULTS

Of the 4844 studies, 114 studies met the final inclusion criteria for evaluating the outcomes of 8127 participants with 9071 injured digits. Studies included 24 randomised controlled trials, 19 cohort studies and 61 case series. Nine different PROMs were used in 24 studies (22%): three site-specific PROMs, one generic quality-of-life measure and four visual analogue scales. Clinician-reported outcome measures were used in 103 studies (96%), such as the range of motion reported in 102 studies (94%). Adverse outcomes were reported in 96 studies (89%), with the most frequently reported adverse outcomes being tendon rupture and infection. Re-operation was reported in 21 studies (19%). The most frequently reported health economic outcome measure was the length of work absence, reported in ten studies (9%).

CONCLUSIONS

There is variability in the use of outcome measures used to study interventions for flexor tendon injuries. An independent systematic review of the psychometric properties of the identified outcome measures and a specific multi-stakeholder consensus process may support optimal choice and standardisation for future studies.

Six-Strand Flexor Pollicis Longus Tendon Repairs With and Without Circumferential Sutures: A Multicenter Study

BACKGROUND

The purpose of this study is to assess outcomes in flexor pollicis longus tendon repairs with 6-strand core sutures with and without circumferential sutures.

METHODS

A 6-strand core suture technique with and without circumferential sutures was used. Thirty-three patients were summarized in the C group (circumferential group) and 16 patients in the NC group (non-circumferential group). After the surgery, the wrist was stabilized with a dorsal blocking splint and a controlled early active motion protocol was applied. At weeks 6, 13, and 26 data on demographics, type of injury, surgery, postoperative rehabilitation, complications such as re-rupture and the following outcome measurements were collected: range of motion and its recovery according to the Tang criteria, Kapandji score, thumb and hand strengths, Disabilities of the Arm, Shoulder and Hand score, and satisfaction.

RESULTS

There were no significant differences in range of motion and strength between the 2 treatment groups. In both groups, the outcome measurements increased over time and they expressed similar satisfaction with the surgical treatment. In 4 patients of the C group tendon repair ruptured and in 1 patient of the NC group.

CONCLUSIONS

Six-strand repair technique is an effective procedure to assure early active motion after flexor pollicis longus tendon injuries and good results can also be achieved by omitting the circumferential suture.

Relative motion flexion splinting for the rehabilitation of flexor tendon repairs: A systematic review

Introduction

Relative motion splinting has been used successfully in the treatment of extensor tendon repairs and has recently been applied in flexor tendon rehabilitation. The purpose of this systematic review was to identify articles reporting use of relative motion flexion (RMF) splinting following flexor tendon repair and to examine indications for use and clinical outcomes.

Methods

Seven medical databases, four trials registries and three grey literature sources were systematically searched and screened against pre-specified eligibility criteria. Screening, data extraction and quality appraisal were independently performed by two reviewers.

Results

A total of 12 studies were identified, of which three met the review eligibility criteria: one retrospective case series; one cadaveric proof of concept study; and one ongoing prospective case series. The type of splint (including metacarpophalangeal joint position and available movement), exercise programme, and zone of tendon injury varied between studies. Both case series presented acceptable range of movement and grip strength outcomes. The prospective series reported one tendon rupture and two tenolysis procedures; the retrospective series reported no tendon ruptures or secondary surgeries.

Discussion

We found limited evidence supporting the use of RMF splinting in the rehabilitation of zones I-III flexor tendon repairs. Further prospective research with larger patient cohorts is required to assess the clinical outcomes, patient reported outcomes and safety of RMF splinting in comparison to other regimes. Application of the relative motion principles to flexor tendon splinting varied across the included studies, and we suggest an operational definition of relative motion in this context.

Role of Ultrasound in Flexor Tendon Injuries of the Hand: A New Insight

This study was aimed at validating the diagnostic accuracy of ultrasound (US) scans in pre-operative evaluation of flexor tendon injuries in the hand and to determine its value in the management of such injuries and in the prediction of patient outcome. This descriptive cross-sectional prospective study included 35 patients with penetrating trauma to the volar aspect of the hand or wrist with questionable clinical findings. They had 50 injured tendons and were candidates for exploratory surgery versus physiotherapy. They underwent pre-operative US to guide their management. Ultrasound results were compared with the operative findings as the gold standard test. Patients were followed up postoperatively, and functional outcome was assessed and correlated with pre-operative sonographic findings. Our results indicate that sonographic examination of hand tendon injury has high accuracy in diagnosing complete or partial flexor injuries, with 100% accuracy, sensitivity and specificity in diagnosing full-thickness tears as well as tenosynovitis of hand flexor tendons. Zonal II injury was the most frequent among our study population and correlated with poorest functional outcome after rehabilitation at 3 mo follow-up. US of the hand is a fast, inexpensive and potentially indispensable dynamic tool for accurate assessment of flexor tendon injuries. It provides data on the extent of injury that effectively helps both set up an appropriate operative plan and predict the patient's functional outcome post-operatively, which in turn will have a direct impact on the patient's rehabilitation plan and lifestyle. Thus, it should be a fundamental part of the management of patients with tendon injuries.

Wire Extrusion After Flexor Tendon Repair with a Multifilament Stainless Steel Cable-Crimp Suture System: A Case Report

CASE

We report the case of a 22-year-old man with a ruptured flexor tendon repair associated with wound drainage. The patient subsequently underwent flexor tendon revision with a multifilament stainless steel cable-crimp suture system. Two years after the revision repair, a blister ruptured over the patient's operative site, exposing the stainless steel wire from the revision repair. The wire was removed, and the patient regained full flexion.

CONCLUSIONS

As extrusion of metallic suture material from the skin represents a complication, surgeons should be prepared to recognize this rare complication and to preoperatively counsel patients as to this risk.

The sole rupture of flexor digitorum tendons to the index finger following volar locking plate fixation of distal radius fracture: A case report

Distal radius fracture is a common injury, especially in elderly people, and internal fixation with volar locking plate (VLP) is becoming an increasingly popular technique for the management of displaced and/or unstable distal radius fractures. One of the most common complications of this treatment is the flexor tendon rupture, mostly of the flexor pollicis longus (FPL). While the rupture of flexor digitorum tendons to the index (FDI) mostly occurs concomitantly with the rupture of FPL after the treatment using volar plating for distal radial fracture, sole rupture of the FDI without FPL rupture is very rare. Here, we report a case of the sole rupture of FDI after volar locking plating and analyze its pathogenesis indicating that the lift-up of the distal ulnar edge of the plate related to the malcorrection of the fracture site is the culprit for this specific complication.

Hand tendon injuries

This article provides a comprehensive overview of hand tendon injuries. It has been tailored towards healthcare professionals who will be the first to assess these injuries and instigate appropriate management. It discusses the essential hand anatomy to be aware of, how to assess tendon injuries, their initial management and also the definitive surgical interventions used, if required. Rehabilitation techniques are also discussed, as this is also key to good functional outcomes. Missed injuries, or delay in their diagnosis and referral to specialist hand surgeons, can cause a large amount of morbidity for patients and therefore it is important that they are picked up in a timely manner.