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A prospective randomized controlled trial of controlled passive mobilization vs. place and active hold exercises after zone 2 flexor tendon repair.
Abstract and Figures
Purpose: The rehabilitation program after flexor tendon repair of zone II laceration varies. We designed a Prospective Randomized Controlled Trial of controlled passive mobilization (modified Kleinert) vs. Place and active hold exercises after zone 2-flexor tendon repair by two-strand suture (Modified kessler).
Methods: Sixty-four fingers in 54 patients with zone 2 flexor tendon modified Kessler repairs were enrolled in a prospective randomized controlled trial comparing place and active hold exercises to controlled passive mobilization (modified Kleinert). The primary outcome measure was total active motion eight weeks after repair as measured by an independent and blinded therapist.
Results: Patients treated with place and active hold exercises had significantly greater total active motion (146) eight weeks after surgery than patients treated with controlled passive mobilization (114) (modified Klinert). There were no ruptures in either group.
Conclusions: Place and hold achieves greater motion than controlled passive mobilization after a two-strand repair for zone 2 flexor tendon repairs.
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... Está reportado en la bibliografía que los hombres tienen un mayor índice de lesiones en la mano en comparación con las mujeres, esto probablemente tiene relación con las actividades que más frecuentemente desempeñan en su trabajo. (1)(2)(3)(4)(5)(6)(7) Se observa que efectivamente la mayor parte de las lesiones se presentan en las etapas productivas de la vida, por lo que esto repercute directamente en implicaciones económicas porque cuando ocurre una lesión se exceptúa a un trabajador por un periodo de tiempo variable de acuerdo con el tipo de lesión y su evolución. (5)(6) A pesar de que en la bibliografía esta reportado que las lesiones en la zona II flexora son las que tienen más repercusión funcional en los pacientes, en nuestra muestra no se evidenció dicha aseveración, siendo la zona II la más frecuentemente lesionada, sin embargo con una recuperación funcional buena en la mayoría de los casos. ...
Introducción:
Las lesiones de la mano son uno de los padecimientos más frecuentemente atendidos en el Servicio de Cirugía Plástica y Reconstructiva del Hospital Central Militar, dentro de la amplia variedad de estas lesiones se encuentran las lesiones del sistema flexor.
Objetivo:
Estimar la incidencia, funcionalidad y tiempo de reintegración laboral en pacientes con lesiones de sistema flexor de la mano tratados en el Hospital Central Militar en el periodo del 1º de marzo del 2020 al 1º de marzo del 2022.
Metodología:
Estudio observacional, retrospectivo, longitudinal descriptivo en pacientes adultos con lesión de sistema flexor de la mano, en los cuales la causa de la lesión no haya condicionado un trauma complejo de la mano. Se utilizó como referencia los criterios de recuperación funcional de Strickland y Goglovac.
Resultados:
A pesar de que las lesiones de la zona II flexora en la literatura presentan un peor pronóstico para la recuperación de la función normal de la mano, los resultados demuestran que la mayor parte de los pacientes se encuentra en una escala funcional buena.
Limitaciones del estudio:
El estudio fue llevado a cabo durante el periodo comprendido por la pandemia COVID, por lo que las consultas subsecuentes con tiempos más alargados y el inicio tardío de las consultas de rehabilitación pudieron haber contribuido hacia una recuperación más deficiente de la recuperación funcional de los pacientes.
... Tại thời điểm theo dõi nhóm A có 71,4% tốt và rất tốt; nhóm B có 83,3 %. Kết quả nghiên cứu này cũng tương đồng với Nguyễn Quốc Thắng[12] khâu gân gấp các vùng bằng 4 sợi trục: 85,7% tốt và rất tốt, Khương Thiện Nhơn[13] khâu gân gấp vùng 2 bằng kỹ thuật 4 sợi trục: 80,3% tốt và rất tốt, Maryam Farzad[14] khâu gân gấp vùng 2 bằng kỹ thuật 4 sợi trục và tập chủ động sớm với 77% tốt và rất tốt. Kết quả biên độ vận động của nhóm được khâu bằng 4 sợi trục tốt hơn có thể do các bệnh nhân mổ với 4 sợi trục có thể được tập gấp chủ động sớm hơn. ...
Đặt vấn đề: Vết thương do vật sắc nhọn cắt gây đứt gân gấp ở chi trên rất thường gặp. Gân gấp các ngón tay được chia làm 5 vùng theo giải phẫu, mỗi vùng có thể có những cách phẫu thuật khâu nối gân khác nhau. Trong đó vùng 2 là vùng khó khâu nối và gặp biến chứng dính gân nhiều nhất. Khâu nối gân vùng 2 như thế nào để đủ vững chắc giúp tập được vận động chủ động sớm tránh biến chứng dính gân mà gân không bị đứt lại là một thách thức điều trị. Mục tiêu: Nhằm đánh giá và so sánh kết quả phẫu thuật khâu nối gân gấp vùng 2 ở bàn tay cũng như tỷ lệ biến chứng đứt lại giữa kỹ thuật khâu 2 sợi trục (nhóm A) tập vận động gấp thụ động sớm với 4 sợi trục (nhóm B) tập vận động gấp chủ động sớm. Đối tượng và phương pháp nghiên cứu: Nghiên cứu hồi cứu mô tả 58 bệnh nhân (88 ngón tay) bị vết thương đứt gân gấp vùng 2 bàn tay được khâu nối thì đầu tại Bệnh viện Chấn thương chỉnh hình TP. HCM từ 01/2021 – 06/2023, trong đó nhóm khâu 2 sợi trục (A) có 28 bệnh nhân với 45 ngón, nhóm khâu 4 sợi trục (B) có 30 bệnh nhân với 43 ngón. Đánh giá kết quả điều trị dựa vào đo lực nắm, tổng biên độ vận động chủ động của ngón tay (TAM), thời gian phẫu thuật, tỷ lệ gân bị đứt lại. Kết quả: Nhóm B khâu 4 sợi trục phục hồi biên độ vận động của ngón tốt hơn nhóm A khâu 2 sợi trục với P = 0,038. Không có sự khác biệt về lực nắm giữa 2 nhóm, với P = 0,16. Tỷ lệ đứt lại nhóm B là 2,3 %, nhóm A là 11,1%. Kết luận: Khâu gân gấp vùng 2 bàn tay với 4 sợi trục tạo điều kiện tập vận động gấp chủ động sớm, giúp hồi phục tầm vận động khớp tốt hơn hẳn khâu 2 sợi trục, và tỷ lệ đứt lại thấp hơn.
... The included number of patients is relatively small, but in our opinion, sufficient for what was needed according to our sample size calculation. This is also the case in similar studies (Chevalley et al., 2022;Farzad et al., 2014;Rig o et al., 2017). Also, we chose to exclude non-compliant patients. ...
The aim of this study was to compare an early active motion (EAM) regimen to a modified Kleinert passive motion therapy in Zone 2 flexor tendon injuries with regards to range of motion (ROM), grip strength and patient-reported outcome measures (PROMs). Seventy-two patients were included. At 3 months postoperatively, we found no difference in total active motion (TAM) between the EAM and the Kleinert groups (median 195.5°, range 115°–273° versus median 191.5°, range 113°–260°), but a significantly better grip strength (median 76%, range 44%–99% versus median 54%, range 19%–101%; p < 0.0005) in the EAM group. Disabilities of the Arm, Shoulder and Hand (DASH) score as well as patient-reported weakness, cold intolerance and problems in daily activities also favoured the EAM group. At 12 months postoperatively, there was no difference in TAM, grip strength or any of the PROMs used. We conclude that EAM leads to a quicker recovery in terms of grip strength and PROMs, but that both regimens lead to similar results at 12 months.
Level of evidence: I
... Patients were advised to passively flex the fingers using their other hand then hold the finger position actively, holding for three to five seconds ,then relax (from the 3 rd day to 2 nd week). The Patients started gliding tendon exercise and allowed to active flex their fingers at 3rd week post-surgical repair then blocking and resistive exercises were initiated at the 6th week .These exercises were done for 15 repetitions (Farzad et al. 2014) Early active dynamic protocol: ...
The main objective of the study is to determine the differences between the effect of early dynamic flexion protocol and place and hold on flexor tendon excursion and adhesion after repair.30 participants who underwent zone II flexor tendon primary modified Kessler repair. (23 males and 7 females with age ranged from 18 to 50). The participants were divided into two groups: group A (PAH) and group B (EAD) protocol. The participants were selected from Cairo university hospital (Egypt), Department of physical therapy. Group(A) composed of 15 patients who received place and hold protocol 3rd day post-operative and Group (B) who received early active dynamic protocol 3rd day post-surgical repair. Patients in each group received the treatments (3sessions /week) from 3rd day post-operative till 6th week post-operative. All patients were assessed by ultrasound to detect tendon excursion at 3rd and 6th week postsurgical repair. There was a significant increase in the tendon excursion at 6 weeks compared with 3 weeks post treatment in group A and B. There was no significant difference in adjusted mean of tendon excursion at 6 weeks between both groups. The present study demonstrated that both active protocols affected the excursion of the flexor tendon zone II after surgical repair Keywords: (Early active dynamic flexion ,place and hold ,flexor tendon repair)
... [11,12] On the other hand, if the extrinsic healing factors predominates will result in poor clinical outcome, persistence pain, adhesions between the repaired tendon and surrounding structures and consequent joint stiffness. [13] Three stage of tendon healing are seen, the first phase is the inflammatory phase which start at 48 to 72 hours after repair, the second phase is the fibroblastic phase (or collagenproducing phase) which starts from 5 days to 4 weeks after repair and the third phase is the remodelling phase which continue up to 4 month after repair. [14,15] These different stages of tendon healing are correlated with changes of sonographic morphology in our study, the early predominantly hypoechogenic tendon pattern in 48 to 72 hours after repair correlates with the inflammatory phase as a result of edema and increased vascularity. ...
Introduction: Tendon injury represents a common cause of morbidity worldwide and of the commonest causes of disability especially among the worker group. Aims: Assessment of early healing progress and exclusion of any deviation in normal healing process using high resolution ultrasound regarding the changes in morphology and function of deep flexor tendon after surgical repair with and without PRP injection and correlate ultrasound picture with clinical outcome to reduce the post operative immobility period. Setting and design: Prospective, controlled study. Method and materials: We included 40 patients and compared between tendon healing and the early return to activities. 20 patients had an intraoperative PRP injection, while 20 others did not. Results: All repaired tendons in both groups shows a spindle like shape after 2 week. A persistent spindle shape of the tendon in ultrasound more than 12 weeks was related to significant improvement of tendon excursion and better dynamic movement of the repaired tendons (p < 0.05). The increased Power Doppler signal of the tendons more than 12 weeks was related to a significant increased tendon excursion and a so better dynamic movement of the fingers (p < 0.05). Ultrasound shows that PRP injection in primary tendon repair significantly improved the time needed to resume activities after tendon injuries, with a median of 6 weeks (SD 6-8) in Control Group and a median of 4 weeks (SD 4-6) in PRP Group. Post-operative pain was significantly improved in the second and third week in the PRP Group. Conclusions: The gray scale and Duplex ultrasound might be useful to rate and predict outcome of repaired tendon, reduce the post operative immobility period and rapid regain of hand function.
Background: There is no concrete evidence to define the optimal mobilization strategy following zone I/II flexor tendon repair. The Saint John Protocol is an active motion regime which utilizes wrist movement to facilitate better clinical outcomes. Our objective was to compare the outcomes of patients who underwent the conventional Kleinert protocol versus the Saint John protocol. Methods: 20 fingers in the Kleinert group and 18 fingers in the Saint John group were included in this retrospective study. Pain score, range of movement, grip strength, and complications were studied at 6 and 12 weeks postoperatively. Results: The Saint John protocol showed significantly less pain at 6 week (0.167 vs 1.08, P = 0.032) and less flexion contracture at the PIPJ at 6 weeks (3.33 vs 12.25, P = 0.032). Both groups showed similar rerupture rates (5.5% vs 5%). Conclusions: Saint John protocol demonstrated better clinical outcomes while not sacrificing the integrity of repair.
Post-treatment of flexor tendon injuries is very complex due to the variety of suture techniques as well as different post-treatment regimens for flexor tendon injuries and is still practiced differently. In addition to an overview of current principles and methods, this article will also provide a view on future treatment options.
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)
Objectives: Despite numerous studies, having the best outcome is challenging after flexor tendon repairs in zone 2. This study were done to test the hypothesis that immediate postoperative active mobilization will achieve similar outcomes to passive mobilization.
Methods: Fifty fingers in 38 patients with flexor tendon repair in zone 2 were enrolled in this trial. The patients randomly assigned in two groups: Early active mobilization and Passive mobilization. They were assessed eight week post operating. Outcomes were defined using “Strickland” and “Buck-Gramko” criteria. The analysis was done according to intention-to-treat principles and with use of mean imputation for missing data.
Results: There were significant difference between groups (P
This study defines precise parameters for tendon excursion, force application, and exercise position for an early active short arc motion protocol for the repaired central slip. Recommended active excursion for the extensor digitorum communis (ED) in zone III is 3.75 mm during the early healing phase. Based on the radian concept, the proximal interphalangeal joint (PIP) is actively flexed and extended 28.65° (approximately 30°) or one-half radian to effect this tendon excursion. Resistance applied to the central slip with active extension from 30° to 0° is calculated mathematically at approximately 290 g of force. Tensile strengths for various repairs are reviewed to establish the safety margin between tensile strength of the repair site and force application. Force application for the active extension protocol is considered in terms of anatomic position. The position of wrist flexion at 30° reduces ED work requirement 1) by reducing viscoelastic flexor forces and 2) through a contribution from the interossei. The position of MP at 0° 1) transmits extensor forces to the central slip and 2) reduces ED work requirement through lumbrical and interossei action. The distal interphalangeal joint (DIP) is unrestrained during PIP flexion to allow volar slide of the lateral bands. Isolated DIP exercises with the PIP held at 0° creates a distal glide of the ED in zone IV while reducing tensions in zone III through the action of the lateral bands. The short arc motion protocol as defined in this paper and supported by a companion clinical study is safe and physiologically desirable as determined by this study.
Introduction
No single optimal regimen for the rehabilitation of flexor tendon injuries has yet been determined. We aimed to evaluate if a change in rehabilitation from a modified Kleinert to a controlled active motion (CAM) regimen had an effect on outcomes in a regional plastic surgery unit. We did this by comparing ruptures and range of movement of zone 2 repairs following both Kleinert and CAM regimens.
Methods
We performed a retrospective case series review, analysing data collected prospectively between 2004 and 2007. During 2004 and 2005, patients were rehabilitated with a modified Kleinert regimen, and during 2006 and 2007 a CAM regimen was used. We looked at total active motion (TAM) and ruptures at 12-week follow-up for all zone 2 repairs, and compared the two regimens.
Results
There were 38 patients with 42 injured digits in the Kleinert group, and 34 patients with 39 injured digits in the CAM group. There was no statistically significant difference in TAM achieved between the Kleinert and CAM regimens overall (70% versus 72% of normal in each group respectively, P = 0.70 t-test). Patients over 30 years old achieved significantly worse outcomes in the Kleinert group than in the CAM group ( P = 0.03). One digit ruptured following a Kleinert regimen (2.6%) compared with four digits in the CAM group (11.7%).
Conclusion
In this study, we found no overall difference in outcome following a Kleinert or CAM rehabilitation regimen. Rupture rates were higher in the CAM group by four-fold. In our patients those over 30 years had poorer outcomes when rehabilitated with a Kleinert regimen.
Finger flexor tendon rehabilitation has come a long way, but further advances are possible. Ideally, a healing tendon should move, but under the minimum load necessary to achieve motion. It is possible to design suture repairs that minimize the friction between tendon and sheath while simultaneously maintaining adequate strength to provide a wide margin of safety during therapy. A looped, four-strand modified Kessler repair is a good example of this type of high-strength, low-friction repair. At the same time, rehabilitation methods can also be optimized. A new modified synergistic motion protocol is described in which wrist flexion and finger extension is alternated with wrist and metacarpophalangeal joint extension and finger interphalangeal joint flexion. Based on evidence from basic science studies, the authors hypothesize that this new protocol will deliver more effective proximal tension on the tendon repair than either passive flexion/active extension or synergistic protocols, and may be useful in patients who are not ready for, or are not reliable with, active motion or place and hold protocols. The scientific basis for these new methods is reviewed, and the concept of the “safe zone” for tendon loading, in which tendon motion occurs without gapping of the repair site, is developed.
In this article, a group of international leaders in tendon surgery of the hand provide details of their current methods of primary flexor tendon repair. They are from recognized hand centers around the world, from which major contributions to the development of methods for flexor tendon repair have come over the past 2 decades. Changes made since the early 1990s regarding surgical methods and postoperative care for the flexor tendon repair are also discussed. Current practice methods used in the leading hand centers are summarized, and key points in providing the best possible clinical outcomes are outlined.
Flexor tendon injuries are seen commonly yet the management protocols are still widely debated. The advances in suture techniques, better understanding of the tendon morphology and its biomechanics have resulted in better outcomes. There has been a trend toward the active mobilization protocols with development of multistrand core suture techniques. Zone 2 injuries remain an enigma for the hand surgeons even today but the outcome results have definitely improved. Biomolecular modulation of tendon repair and tissue engineering are now the upcoming fields for future research. This review article focuses on the current concepts in the management of flexor tendon injuries in zone 2.