Controlled mobilization after flexor tendon repair in zone II: A prospective comparison of three methods

doi:10.1016/0363-5023(92)90475-5

The Journal of Hand Surgery

Volume 17, Issue 5, September 1992, Pages 942-952

https://doi.org/10.1016/0363-5023(92)90475-5 Get rights and content

Abstract

A new controlled-motion program that incorporates dynamic flexion traction to all four digits, a short splint leaving the interphalangeal joints free, and a nighttime extension splint was prospectively compared with a modification of the Kleinert technique and a combination of the modified Kleinert technique and passive movements. Each program was applied to approximately one third of 178 consecutively treated digits with tendon injuries in zone II. The mean total active interphalangeal joint range of motion 6 weeks and 1 year postoperatively was significantly better and extension deficits were significantly less frequent in the digits mobilized with the new program. The postoperative treatment input, in terms of frequency of reviews and time spent in therapy sessions, is not greater than with more traditional controlled-motion programs. Our results indicate that the new program is a safe, reliable, and cost-effective method that produces very good results in a general population.

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Cited by (67)

Passive Mobilization With Place and Hold Versus Active Motion Therapy After Flexor Tendon Repair: A Randomized Trial
2022, Journal of Hand Surgery
Mobilization after flexor tendon repair in fingers has been a subject of debate for several years. Many hand surgery clinics have turned to early active mobilization. However, there is no strong scientific evidence suggesting that early active mobilization produces a better range of motion (ROM) than the Kleinert regimen when place and hold is added. Therefore, the purpose of this prospective randomized trial was to investigate whether active mobilization is superior to passive mobilization with place and hold after flexor tendon repair in the fingers. Our hypothesis was that patients who follow the active mobilization protocol have a better ROM than those who follow the passive protocol with place and hold.
Sixty-four patients with a flexor tendon injury in zone I or II were included. After surgery, randomization to undergo either active mobilization or passive mobilization with place and hold was performed. The patients were followed-up for 12 months using outcome measurements, including ROM, strength, rupture frequency, Disabilities of the Arm, Shoulder and Hand score, ABILHAND questionnaire, and performance on the Purdue Pegboard test.
We were unable to find any significant difference between the 2 groups for any of the outcome measurements, ROM, grip strength, key pinch, rupture frequency, Disabilities of the Arm, Shoulder and Hand score, ABILHAND questionnaire, and performance on the Purdue Pegboard test.
The outcomes were equivalent for both the mobilization groups.
Therapeutic I.
Concomitant injuries affect prognosis in patients with central slip tear
2018, Journal of Plastic, Reconstructive and Aesthetic Surgery
Central slip tears often occur with concomitant hand injuries. However, the outcome of a central slip tear and the effect of concomitant injuries are rarely reported. We evaluated 67 fingers in 63 patients with central slip tears who underwent primary surgery in our hospital between April 2009 and June 2017. We performed multivariate analyses, with proximal interphalangeal (PIP) joint active range of motion (AROM) and existing extension lag greater than 10° as dependent variables and age, existence of concomitant fractures, skin defects, collateral ligament injuries, ruptured lateral bands, ruptured flexor tendons or vascular injury in the injured finger as independent variables. Concomitant injuries of tendons in the adjacent fingers were also independent variables. The average AROM of the PIP joint was 62°, and extension lag occurred in 34 fingers (51%). Patients aged > 40 years with fractures of the injured finger or flexor tendon injuries in an adjacent finger had low decreases in AROM (partial regression coefficient [95% confidence interval, CI]: −13.7 [43–66], −31.6 [30–57], −34.5 [32–60] and −33.5 [10–43]). Extensor tendon injuries in an adjacent finger caused significantly more extension lag in the PIP joint (odds ratio [95% CI]: 3.2 [1.0–9.6]). The present study indicated the negative impact of a tendon injury on adjacent fingers, a circumstance widely known as the quadriga phenomenon. Ultimately, we can use these prognostic factors in surgical repair planning, particularly when comparing treatments such as central slip reconstruction and primary arthrodesis.
Flexor Tendon Repair
2016, Hand and Upper Extremity Rehabilitation: A Practical Guide
Flexor tendon repair rehabilitation protocols: A systematic review
2013, Journal of Hand Surgery
To systematically review various flexor tendon rehabilitation protocols and to contrast those using early passive versus early active range of motion.
We searched PubMed and Cochrane Library databases to identify articles involving flexor tendon injury, repair, and rehabilitation protocols. All zones of injury were included. Articles were classified based on the protocol used during early rehabilitation. We analyzed clinical outcomes, focusing on incidence of tendon rupture and postoperative functional range of motion. We also analyzed the chronological incidence of published tendon rupture with respect to the protocol used.
We identified 170 articles, and 34 met our criteria, with evidence ranging from level I to level IV. Early passive motion, including both Duran and Kleinert type protocols, results included 57 ruptures (4%) and 149 fingers (9%) with decreased range of motion of 1598 tendon repairs. Early active motion results included 75 ruptures (5%) and 80 fingers (6%) with decreased range of motion of 1412 tendon repairs. Early passive range of motion protocols had a statistically significantly decreased risk for tendon rupture but an increased risk for postoperative decreased range of motion compared to early active motion protocols. When analyzing published articles chronologically, we found a statistically significant trend that overall (passive and active rehabilitation) rupture rates have decreased over time.
Analyzing all flexor tendon zones and literature of all levels of evidence, our data show a higher risk of complication involving decreased postoperative digit range of motion in the passive protocols and a higher risk of rupture in early active motion protocols. However, modern improvements in surgical technique, materials, and rehabilitation may now allow for early active motion rehabilitation that can provide better postoperative motion while maintaining low rupture rates.
Therapeutic IV.
An experimental study comparing active mobilization to passive flexion-active extension-active flexion after flexor tendon repair in zone 2
2013, Journal of Hand Surgery
Both passive flexion–active extension and active rehabilitation have shown advantages and disadvantages in tendon healing. The purpose of this study was to measure the effect of a combination of these 2 rehabilitation protocols.
A tendon injury model was used in white Leghorn chickens. Thirty-two animals were randomly assigned into 4 groups. We compared an unrestricted active flexion rehabilitation (UA) group with 3 groups starting passive flexion, active extension, and active flexion (PAA) at 5, 9.5 and 14 days after repair. The tensile properties and range of motion of the 3 interphalangeal joints were evaluated for 3 postoperative weeks.
In terms of tensile properties of the operated foot, PAA-14 was higher than any other group, and PAA-5 was the lowest. There was no significant difference between the PAA-9.5 and UA. For the range of motion, there were significant differences between all 4 groups: UA increased the most, PAA-14 increased the least, and PAA-5 increased more than PAA-9.5. For the rupture rate, UA and PAA-5 were higher than were PAA-9.5 and PAA-14.
The results indicate that the PAA-9.5 and UA may give the best balance (tensile properties, range of motion, rupture rates) of these rehabilitation protocols. PPA-9.5 and UA had similar moderate tensile properties. When considering an increased range of motion, the UA method may be the most appropriate despite its higher rupture rate. When considering a lower rupture rate, PAA-9.5 may be the most suitable.
Therapeutic III.
Clinical outcomes of zone II flexor tendon repair depending on mechanism of injury
2012, Journal of Hand Surgery
To determine whether mechanism of injury affects outcomes of Zone II flexor tendon repairs.
We retrospectively analyzed patients who underwent Zone II flexor tendon repair between 2001 and 2010 with a minimum of 12-month follow-up. Exclusion criteria included fingers with fracture, pulley reconstruction, or flexor tendon bowstringing. The saw group injuries were from saws or from tearing mechanisms; the sharp group had clean transection injuries from knives or glass. At final evaluation, primary outcomes were total passive motion (TPM) and total active motion (TAM) at the proximal interphalangeal and distal interphalangeal joints. Secondary comparisons included strength, Disabilities of the Shoulder, Arm, and Hand (DASH) score, percentage of postoperative tendon rupture, and percentage of patients requiring secondary surgery. The saw group had 13 patients with 17 fingers studied. The sharp group had 21 patients with 24 fingers studied. All patients had primary flexor digitorum profundus repairs in Zone II. Operative records review confirmed for all but 1 patient that flexor digitorum profundus injuries were repaired with a minimum of a 4-strand core suture technique. In the saw group, 9 of 14 fingers with a 50% or greater laceration of flexor digitorum superficialis were repaired; in the sharp group, 15 of 18 such flexor digitorum superficialis injuries were repaired. Average follow-up was 4 years (range, 1–9 y).
The saw group had significantly less TAM and TPM compared with the sharp group. There was no significant difference in DASH scores, strength measurements, or tendon rupture rates. The rate of secondary surgery was significantly higher in the saw group.
Tearing types of injury, such as those caused by saws, led to poorer outcomes for Zone II flexor tendon injuries compared with sharp injuries at an average follow-up of 4 years. Our results can be useful when discussing expected outcomes. Mechanism of injury in Zone II flexor tendon lacerations may eventually help define optimal treatment.
Therapeutic III.

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^☆: The study was supported by grants from The Göteborg Medical Society, The Swedish Medical Society, The University of Göteborg, The Greta and Einar Asker Foundation, The Bertha and Felix Neubergh Foundation, Syskonen Holmströms Donationsfond, and Gunhild Karlsson's Donation.

^☆☆: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Original communicationControlled mobilization after flexor tendon repair in zone II: A prospective comparison of three methods☆,☆☆

Abstract

Orthop Clin North Am

J Hand Surg

Br J Plast Surg

J Hand Surg

J Hand Surg

Hand Clin

J Hand Surg

J Hand Surg

Ann Chir Main

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

J Hand Surg

Original communication
Controlled mobilization after flexor tendon repair in zone II: A prospective comparison of three methods☆,☆☆