Outcomes of staged reconstruction of Zone 2 flexor tendon injuries in recent wide-awake surgical settings and an earlier case series

We report outcomes of patients who were managed with two-stage tendon grafting for neglected Zone 2 flexor tendon injuries from 2012 until 2019. The patients were divided into two cohorts: recent series (Series 1) included patients treated with local anaesthesia and epinephrine (16 fingers, from 2015), and earlier series (Series 2) included patients treated with either general or local intravenous anaesthesia and tourniquet (12 fingers, before 2015). The patients in Series 1 achieved statistically better mean total active motion of the operated fingers and grip compared with the contralateral hand than the earlier series ( p = 0.03, p = 0.01, respectively). With the Tang grading system, excellent and good results were achieved in 13 and six fingers of the patients in Series 1 and Series 2, respectively. We conclude that wide-awake second stage of staged flexor tendon grafting provides fine-tuned adjustment of length and tension of the graft, but we cannot conclude about comparative outcomes between two series because the sample size is small and the earlier series was operated by the same surgeons with lower expertise level. Level of evidence: IV

Post-operative management of flexor tendon injuries at zone II and flexor Pollicis Longus – a survey of Irish practice

Purpose The post-operative management of flexor tendon injuries has been the focus of considerable exploration and there continues to be variation in approaches and methods of mobilisation. The purpose of this paper is to explore therapy management following repair to flexor tendons at zone II and flexor pollicis longus (FPL) (all zones) in Ireland. Design/methodology/approach A descriptive survey questionnaire design through an online format was used. Therapists were recruited through the Irish Association of Hand Therapists, the national bodies for occupational therapy and physiotherapy and therapy managers in acute hospitals, with 29 therapists participating in the study. Descriptive statistics were used to analyse the survey data. Findings Patients were generally seen three to five days following surgery. Early active mobilisation approaches were favoured by all but one therapist, with 62% using the Belfast protocol and 34% the Manchester Short Splint (MSS) protocol. Each early active protocol exercise session commences with passive motion followed by graded active flexion. Tenodesis is incorporated by the majority of respondents within the first four weeks. Therapy programme and splints are modified based on patient presentation. Resistance exercises are commenced from week seven. Patient compliance was identified as the most influential factor in the post-operative intervention approach taken. Originality/value This study provides the first Irish profile of current practice in the post-operative management of flexor tendon repairs at zone II and FPL which has not previously been reported. Further research should explore the reasoning behind the interventions chosen and also the implications for practice of changes to surgical techniques.

Evaluation of flexor tendon repair (zone II) with Wide Awake Anesthesia

Background Recent advances in hand surgery has been the movement away from tourniquet surgery, which often requires sedation or GA and the patient will be awake and cooperative. Wide awake approach depends on the safety of adrenaline which is now well established. This review will evaluate the role of the wide awake approach in reducing rupture and tenolysis rate after flexor tendon repair zone 2. Objective To evaluate the functional outcome of flexor tendon repair zone II (most challengeable) under wide awake anesthesia. Patients and Methods After approval of local ethical committee of faculty of medicine Ain Shams University, this Prospective study has been conducted targeting patients with acute zone II flexor tendon injuries admitted at El Sahel Teaching Hospital within the period from September 2019 till January 2020, and their follow up for minimum three months at outpatient clinic. A Written informed consent explaining the whole procedure under study in this research has been obtained from all patients and absolute confidentiality as regard the patients’ names and addresses was given special care and attention. Final outcome evaluated by Original Strickland evaluation system. Results Using the wide awake technique provides an optimal opportunity to test repair strength through Intra-operative Total Active Movement (ITAM) making the surgeon much more comfortable to initiate early active motion. Besides, rising trend toward using early active rehabilitation protocol in case of strong repair using four or more strands repairs is recently supported in literature. This study adopted early active rehabilitation protocol with slight differences among them Conclusion This preliminary study assessing the outcomes of primary tendon repair in flexor tendon injuries in zone II using the wide-awake technique demonstrates encouraging results, being satisfactory for both surgeons and patients that makes this new approach a competitive to the other approaches of flexor tendon repair implemented under conventional methods of anesthesia.

A Rare Case of Bilateral Spaghetti Injuries in Children due to Assault by Mother and Analysis of Functional Outcome at Three Years

Management of child abuse with flexor tendons, neurovascular injuries, and life-threatening conditions is challenging. It needs a multisectoral coordinated and synchronized team effort for successful outcomes. We present a case series of children abused by a parent with a sharp object. The children sustained multiple flexor tendon injuries, neurovascular injuries in upper limbs, and tracheal injury compromising respiration. We performed a tracheostomy to save a child and subsequently repaired numerous flexor tendons, nerves, and arteries. During follow-up, these children required secondary reconstruction (tenolysis, tendon lengthening, nerve reconstruction) for flexor contractures, stiffness, and sensory loss in distal forearms. We measured the range of movements and assessed the children’s functional outcome using the Strickland score at 3-year follow-up. The range of movement and functional outcome was excellent in both children in our series. A timely performance of surgery, aided with efficient intensive care, therapy, and consistent posttraumatic psychosocial rehabilitation, produced excellent results in our series.

1350 Wide-Awake Local Anaesthetic No Tourniquet (WALANT) Vs General/Regional Anaesthetic for Flexor Tendon Injuries: A Single-Centre, Retrospective Cohort Study

Aim Flexor tendon repairs are commonly performed under general/regional anaesthesia. Wide-awake local anaesthetic no tourniquet (WALANT) has potential advantages including the ability to test the repair intra-operatively; removal of the risks of general anaesthesia; no aerosol generation, thus reducing COVID-19 transmission risk. An ongoing systematic review identified no comparative studies. This study aimed to compare the functional outcomes and complications of flexor tendon repairs under WALANT and general/regional anaesthetic. Method A single-centre, retrospective cohort study was undertaken (July 2019-August 2020). Consecutive adult patients undergoing flexor tendon repair were included. Exclusion criteria were ≥ 3 injured fingers; concurrent hand fracture; revascularisation; replantation. Data were collected on demographics, injuries, operative technique, and outcomes. Results Overall, 139 patients with 165 injured digits were included. Most (60%) were repaired under general anaesthesia. Local anaesthetic (was used for 46 patients (21 with tourniquet, 25 WALANT). Only 30% (42/139) patients had range of motion data at 6-weeks, dropping to 19% (26/139) at 12-weeks. WALANT patients had fewer ruptures (8% vs 14%), fewer adhesions requiring tenolysis (0% vs 4%) and less complications overall than the general/regional anaesthesia group. The results were not found to be statistically significant. Conclusions The lack of data due to patients not attending follow-up, makes meaningful research on flexor tendon injuries very challenging. This study suggests WALANT may reduce complications but is limited by the inherent bias of a retrospective, non-randomised study, and small numbers. Adequately designed and powered studies are recommended in future to further investigate the potential benefits of wide-awake surgery.