Recent evolutions in flexor tendon repairs and rehabilitation

2018 ◽  
Vol 43 (5) ◽  
pp. 469-473 ◽  
Author(s):  
Jin Bo Tang
Keyword(s):  
Flexor Tendon ◽  
Hand Function ◽  
Active Motion ◽  
Repair Site ◽  
Flexor Tendons ◽  
The Core ◽  
A2 Pulley

This article reviews some recent advancements in repair and rehabilitation of the flexor tendons. These include placing sparse or no peripheral suture when the core suture is strong and sufficiently tensioned, allowing the repair site to be slightly bulky, aggressively releasing the pulleys (including the entire A2 pulley or both the A3 and A4 pulleys when necessary), placing a shorter splint with less restricted wrist positioning, and allowing out-of-splint active motion. The reported outcomes have been favourable with few or no repair ruptures and no function-disturbing tendon bowstringing. These changes favour easier surgeries. The recent reports have cause to re-evaluate long-held guidelines of a non-bulky repair site and the necessity of a standard peripheral suture. Emerging understanding posits that minor clinically noticeable tendon bowstringing does not affect hand function, and that free wrist positioning and out-of-splint motion are safe when strong surgical repairs are used and the pulleys are properly released.

Zone 2 flexor tendon repairs using a tensioned strong core suture, sparse peripheral stitches and early active motion: results in 60 fingers

2019 ◽  
Vol 44 (4) ◽  
pp. 361-366 ◽  
Author(s):  
Zhang Jun Pan ◽  
Yun Fei Xu ◽  
Lei Pan ◽  
Jing Chen
Keyword(s):  
Flexor Tendon ◽  
Tendon Repair ◽  
Flexor Digitorum Profundus ◽  
Level Of Evidence ◽  
Active Motion ◽  
Repair Site ◽  
The Core ◽  
Active Flexion ◽  
Flexor Digitorum

We report the outcomes of zone 2 tendon repairs in 60 fingers using a strong core suture, sparse peripheral stitches and early active motion. From January 2014 to April 2016, we repaired 60 flexor digitorum profundus tendons with a tensioned 4-strand or 6-strand core suture and three to four peripheral stitches. The A2 or A4 pulleys were vented as necessary. Following early active flexion of the repaired tendons, no repairs ruptured and 52/60 (87%) fingers recovered to good or excellent function using the Tang criteria after follow-up of 8–33 months. We conclude that tensioned multi-strand strong core repairs only require sparse peripheral stitches and are safe for early active flexion. Standard peripheral sutures are not necessary. The core sutures should be properly tensioned to prevent gapping at tendon repair site and pulleys should be sufficiently vented to allow tendon motion. Level of evidence: IV

Triggering Secondary to an Untreated Partially-Cut Flexor Tendon

1989 ◽  
Vol 14 (4) ◽  
pp. 419-421
Author(s):  
P. R. FREWIN ◽  
L. R. SCHEKER
Keyword(s):  
Flexor Tendon ◽  
Tendon Sheath ◽  
Flexor Digitorum Superficialis ◽  
Flexor Tendons ◽  
A2 Pulley ◽  
Post Traumatic ◽  
Flexor Digitorum ◽  
Proximal Border ◽  
Partial Division

A case is reported where a flap cut of the radial slip of the flexor digitorum superficialis triggered on the proximal border of the A2 pulley within a healed intact tendon sheath. Shaving the flap resolved the problem. This illustrates another post-traumatic mechanical cause of triggering after partial division of flexor tendons.

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

2017 ◽  
Vol 42 (9) ◽  
pp. 896-902 ◽  
Author(s):  
K. Moriya ◽  
T. Yoshizu ◽  
N. Tsubokawa ◽  
H. Narisawa ◽  
S. Matsuzawa ◽  
...  
Keyword(s):  
Flexor Tendon ◽  
Tendon Repair ◽  
Level Of Evidence ◽  
Active Motion ◽  
Risk Of Rupture ◽  
Total Active Motion ◽  
A2 Pulley ◽  
Active Mobilization ◽  
The Mean ◽  
Difficult Area

We report on the outcomes of flexor tendon repair in zone 2 subzones with early active mobilization in 102 fingers in 88 consecutive patients. There were 28, 53, 15, and six fingers with repairs in zones 2A to 2D, respectively. Rupture of the repair occurred in four fingers, all in zone 2B. Excluding those with repair ruptures, the mean total active motion was 230° (range 143°–286°). Evaluated with Tang’s criteria, the outcomes were ranked excellent in 39 fingers, good in 46, fair in ten, poor in three, and failure in four. The outcomes in zone 2C were significantly inferior to those in zones 2B and 2D ( p = 0.02). Our results suggest that the tendon laceration in the area covered by the A2 pulley (zone 2C) is the most difficult area to obtain satisfactory active digital motion and tendon repair in zone 2B is the area where the risk of rupture is highest. Level of evidence: IV

Controlled Active Motion Following Primary Flexor Tendon Repair: A Prospective Study Over 9 Years

1998 ◽  
Vol 23 (3) ◽  
pp. 344-349 ◽  
Author(s):  
C. K. KITSIS ◽  
P. J. F. WADE ◽  
S. J. KRIKLER ◽  
N. K. PARSONS ◽  
L. K. NICHOLLS
Keyword(s):  
Prospective Study ◽  
Flexor Tendon ◽  
Tendon Repair ◽  
High Strength ◽  
Suture Technique ◽  
Flexor Tendon Repair ◽  
Active Motion ◽  
Tendon Suture ◽  
Flexor Tendons ◽  
A Prospective Study

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.

Robust thumb flexor tendon repairs with a six-strand M-Tang method, pulley venting, and early active motion

2017 ◽  
Vol 42 (9) ◽  
pp. 909-914 ◽  
Author(s):  
Z. J. Pan ◽  
J. Qin ◽  
X. Zhou ◽  
J. Chen
Keyword(s):  
Flexor Tendon ◽  
Tendon Repair ◽  
Level Of Evidence ◽  
Active Motion ◽  
Post Surgery ◽  
A2 Pulley ◽  
Tendon Ruptures ◽  
Flexor Pollicis Longus Tendon ◽  
Thumb Motion ◽  
Tendon Laceration

We present the outcomes of flexor pollicis longus tendon repairs in 34 thumbs using a six-strand M-Tang repair with venting of one or two pulleys according to site of tendon laceration. The A2 pulley was vented in all three thumbs with zone 1 injury. In 31 thumbs with zone 2 injuries, the oblique pulley was vented partially or entirely. Twenty-two thumbs had both the A1 and oblique pulleys vented. Six to 46 months post-surgery, 14 thumbs with zone 2 injuries were rated excellent, 13 good, three fair and one failure according to Tang criteria. No tendon ruptures or bowstringing occurred. Fourteen of 34 thumbs had deficits in interphalangeal joint extension averaging 13°. We conclude that venting of one or two pulleys may ensure recovery of thumb function without risking tendon bowstringing and that early active thumb motion is safe with a robust tendon repair. Level of evidence: IV

The mechanical interaction between three geometric types of nylon core suture and a running epitenon suture in repair of porcine flexor tendons

2013 ◽  
Vol 38 (7) ◽  
pp. 788-794 ◽  
Author(s):  
T. de Wit ◽  
E. T. Walbeehm ◽  
S. E. R. Hovius ◽  
D. A. McGrouther
Keyword(s):  
Failure Load ◽  
Flexor Tendon ◽  
Tendon Repair ◽  
Mechanical Effect ◽  
Mechanical Interaction ◽  
Flexor Tendon Repair ◽  
Flexor Tendons ◽  
The Core ◽  
Pull Out ◽  
Mode Of Failure

The effect of core suture geometry on the mechanical interaction with the epitenon suture in terms of gap prevention, failure strength and mode of failure was investigated in a flexor tendon repair model. A total of 48 porcine flexor tendons were repaired using three techniques with distinct core suture geometry: single Kessler; double Kessler; and cruciate repair. Cyclic linear testing was carried out with and without a simple running epitenon suture. At failure load the epitenon suture reduced gapping by 87% in the double Kessler, 42% in the single Kessler and 15% in cruciate repairs. It increased the strengths of the repairs by 58%, 33% and 24%, respectively. Kessler repairs failed mainly by suture rupture, with and without epitenon suture, but cruciate repairs failed mainly by suture pull-out. The epitenon suture did not have a significant mechanical effect on the three repairs. Rather, its effect varied with the core suture geometry. The greatest effect occurred with double Kessler repairs.

Zone 2 lacerations of both flexor tendons of all fingers in the same patient

2010 ◽  
Vol 36 (3) ◽  
pp. 205-209 ◽  
Author(s):  
M. M. Al-Qattan
Keyword(s):  
Surgical Technique ◽  
Flexor Tendon ◽  
Full Extension ◽  
Active Motion ◽  
Pulley System ◽  
Flexor Tendons

Over an eight-year period, the author has treated five males (mean age of 31 years) with clean-cut zone 2 lacerations of both flexor tendons of all fingers using the same surgical technique (profundus only repair using three ‘figure of eight’ core sutures and proximal venting of the pulley system) and the same postoperative mobilization programme (a dorsal blocking splint with immediate active motion that allowed full extension at the interphalangeal joints). There were no ruptures of the repaired 20 fingers. At final follow-up (mean of 22 months after surgery), the outcome was considered excellent in 12 fingers, good in four fingers and fair in the remaining four fingers by the Strickland–Glogovac criteria. The outcome was similar in all four fingers for every patient supporting the hypothesis of previous studies that the outcome of repair of clean-cut flexor tendon lacerations in zone 2 is related to the psychological and biologic characteristics of the patient.

Minimally invasive thread trigger digit release: a preliminary report on 34 digits of the adult hands

2018 ◽  
Vol 43 (9) ◽  
pp. 942-947 ◽  
Author(s):  
Danqing Guo ◽  
Logan McCool ◽  
Alexander Senk ◽  
Brionn Tonkin ◽  
Joseph Guo ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Functional Recovery ◽  
Preliminary Report ◽  
Flexor Tendon ◽  
Hand Function ◽  
Access Point ◽  
Level Of Evidence ◽  
Complete Extension ◽  
Pain Medications ◽  
A2 Pulley

The trigger finger release was performed in 34 digits (11 thumbs and 23 fingers) of 24 patients through the thread transecting technique with the tip-to-tip approach, in which a 22-gauge needle inserts into a 18-gauge needle when both needles are inside the hand, guiding the 22-gauge needle to exit the hand at the same access point of 18-gauge needle. We prospectively evaluated the effectiveness and functional recovery of these patients. In all 34 digits, triggering and locking were resolved, and complete extension and flexion occurred immediately following the release. There were no complications, such as incomplete release, neurovascular or flexor tendon or A2 pulley injury, infection, or tendon bow-stringing. Patients did not require prescription pain medications. Most patients used their hands to meet their basic living needs the same day of the procedure. The hand function evaluated with the Quick Disabilities of the Arm, Shoulder and Hand questionnaire, and scored 4 within 3 months. Level of evidence: II

The Effects of Polysulphated Glycosaminoglycan on the Healing of Collagenase Induced Tendinitis

1999 ◽  
Vol 12 (01) ◽  
pp. 48-55 ◽  
Author(s):  
L. C. Booth ◽  
R. R. Pool ◽  
W. R. Redding
Keyword(s):  
Treatment Group ◽  
Flexor Tendon ◽  
Tendon Healing ◽  
Treated Group ◽  
Histological Evaluation ◽  
Control Group ◽  
Image Analysis System ◽  
Flexor Tendons ◽  
The Core ◽  
Superficial Digital Flexor Tendon

Summary Objective. To examine the effects of polysulphated glycosaminoglycan on tendon healing in a controlled collagenase injury model. Design. The study used a completely randomized design with four horses assigned to each of two groups, control and treated. The superficial digital flexor tendons from each horse were measured weekly by ultrasound techniques. The differences between groups were evaluated using t-statistics and trends summarized by simple linear regression. Animals. Eight horses (four Thoroughbreds and four Standardbreds) with normal superficial flexor tendons were divided into two groups of four. Group #1 control horses were not treated. Group #2 horses were treated with polysulphated glycosaminoglycans. Procedure. All of the horses had tendinitis induced in the superficial flexor tendon of both forelimbs by the injection of 4000 IU of collagenase. The treated group received 500 mg of polysulphated glycosaminoglycan (PSGAG) IM every five days for seven treatments beginning 24 h after injection of collagenase. The control group received saline at the same time periods. Ultrasound examination of each limb was performed on days 1, 3, 5, and 7 post-injection and weekly thereafter for eight weeks. An image analysis system was used to measure the proportion of tendon area damaged in mm2 on the recorded images, and these values were plotted over time. The horses were euthanatized at eight weeks and histological evaluation was performed on longitudinal sections of excised tendons. Results. The size of the tendon core defects created by the collagenase enzyme, represented as the proportion of area damaged, decreased significantly faster in the treatment group (ρ <0.01). Histologic evaluation of the core defects confirmed what was seen sonographically. Conclusion. Polysulphated glycosaminoglycans had a positive effect on tendon healing in a collagenase induced tendinitis model. Clinical relevance. Polysulphated glycosaminoglycans may be beneficial in managing clinical cases of tendinitis.Eight horses had experimental core defects induced in the superficial digital flexor tendon of both forelimbs. One group of four horses received PSGAG IM every 5 days for seven treatments. The control group received saline. The core defects in the PSGAG treatment group developed echogenic ultrasound patterns earlier, and the mean ratio of area of the tendon decreased significantly faster in the treatment group.

A Prospective Study of Flexor Tendon Repair in Zone 5

1998 ◽  
Vol 23 (5) ◽  
pp. 642-648 ◽  
Author(s):  
N. W. YII ◽  
M. URBAN ◽  
D. ELLIOT
Keyword(s):  
Prospective Study ◽  
Range Of Motion ◽  
Flexor Tendon ◽  
Tendon Repair ◽  
Flexor Digitorum Profundus ◽  
Active Motion ◽  
Flexor Tendons ◽  
Active Flexion ◽  
A Prospective Study ◽  
Flexor Digitorum

A prospective study of postoperative mobilization of flexor tendon repairs in zone 5 was conducted over a 2-year period between 1994 and 1996 using a controlled active motion (active extension - active flexion) regimen of mobilization. Fifty-two patients, who had a total of 151 flexor digitorum superficialis (FDS) and 103 flexor digitorum profundus (FDP) divisions, were available for review at a mean follow-up of 10 months. Of the 161 fingers with division of one or both flexor tendons, 66% exhibited independent FDS function and 90% achieved good or excellent results of digital range of motion. No rupture of an FDP tendon repair occurred during the study period. The data allowed us to define a new method of classifying the results of treatment of these injuries in terms of the injured wrists as a whole and not simply as a series of isolated observations for each individual finger with divided flexor tendons. The results of recovery of independent FDS action and range of finger movement achieved for injuries in which the flexors of all four fingers had been divided indicate a statistically significant interdependence of injuries of finger flexors of adjacent fingers at the wrist. Multivariate analysis showed the presence of a “spaghetti wrist” injury to have a significant adverse effect on the recovery of the independent FDS action but not on the recovery of the digital range of motion.

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