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A Retrospective Review of Two-Stage Flexor Tendon Grafts
tendon gliding and pain will be presented. Deviations from the protocols will be outlined in a flow chart format. Observations: Both the Kleinert and Duran protocols are presented and deviations from the established protocols are explored. One component of the algorithm is devoted to the classic protocols while the other components explore the findings from patients whose rehabilitation is accelerated or delayed due to their clinical presentation. Conclusion: Treatment pathways based on the evidence and expert opinion are presented. Evidencebased changes to the protocols are presented. Relevance to Hand Therapy: The typical zone II flexor tendon repair patient does not always progress as the rehabilitation protocols suggest. Deviations from the protocol occur. This algorithm will provide rationale management approaches that will help guide the hand therapist. Impressions: Patients who meet postoperative clinical benchmarks in a timely fashion typically proceed through their rehabilitation without deviating from the protocols. Others, however, require changes in the management approach. This clinical presentation will outline these changes and the potential outcomes that drive the next step in rehabilitation.
A Retrospective Review of TwoStage Flexor Tendon Grafts. Shrikant J. Chinchalkar, BScOT, OTR, CHT Purpose: To review the Hand and Upper Limb Centre (HULC) experience with 2-stage tendon reconstruction (2STR) in patients with flexor tendon injuries that were missed or failed primary repair. Methods: Between Jan. 1, 1994 and Dec. 31, 2004, 41 patients underwent 2STR at the HULC. Of those 22 patients were identified (20 males, 2 females) for a chart review with diagnoses of: jersey finger (n ¼ 6), missed flexor tendon lacerations (n ¼ 6), failed primary repair (n ¼ 9), and failed 1-stage tendon grafting (n ¼ 1). Eleven patients were successfully contacted and 8 appeared for repeat functional assessment and completed the Disabilities of the Arm Shoulder and Hand (DASH) functional outcome survey; 11
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patients were lost to follow-up. However, chart data were sufficient for range of motion (ROM) assessment in 4 patients. In total, 12 patients had sufficient data available for quantitative analysis. Results: The affected fingers in this group and those fingers for which range of motion data was available were as follows: thumb, 3/1; index, 1/1; long, 3/2; ring, 5/0; little, 10/8. Age (mean 6 SD) at initiation of therapy was 31.26 6 10.76 yrs after a mean 1.95 6 4.52 yrs following the original injury. The mean interval between first- and second-stage operations was 17.14 6 6.55 weeks. According to Strickland’s modified criteria of finger ROM, 11 of 12 (91.6%) patients had either excellent (5/12) or good (6/12) results. While not quantitative, chart records indicated an additional 6 of 10 patients had ‘‘normal’’ (4/10) or ‘‘near-normal’’ (2/10) finger ROM. Complications after the first stage included 2 infections, 1 ruptured rod, and 1 rod buckling (4/22 ¼ 18%). Following the second stage, complications included 5 contractures treated with splinting, 2 proximal ruptures, 1 distal rupture, 1 swan neck deformity, 1 mallet finger, 1 intrinsic plus finger, 1 extensor tendinitis (for a total of 12 of 22 patients; 55%). Reoperations were required in 6 patients (27%), including 3 repeat tenorraphies for rupture, 1 arthrodesis, 1 replacement of the Hunter Rod, and 1 intrinsic release. No tenolyses and no amputations were performed in this group. Summary: Despite a higher than expected complication rate in this group, 2STR did permit a high degree of functional success in the majority of cases and represents a good option for patients with missed closed or open injuries to the flexor tendons or those patients for whom primary repair has failed. Effectiveness of Cast Immobilization in Closed Mallet Finger Injury: A Prospective Randomized Comparison with Thermoplastic Splinting. Silvio Tocco, BScOT, BScBiol Purpose: Conservative treatment through splinting has gained favorable recognition over the various surgical approaches for closed tendinous or bony (Type I) mallet injuries.
However, conservative treatment outcomes vary greatly in part due to the heterogeneity of the splint models and treatment protocols available to hand therapists. One common denominator is the necessity to clean the finger regularly to prevent skin ulceration beneath the splint. No study to date was found in the literature that addressed the potential impact of this inevitable cleansing process. The aim of this study was to evaluate the effectiveness of fulltime cast immobilization in the treatment of closed mallet fingers in comparison with the traditionally used custom-made thermoplastic splint, which requires removal for skin hygiene. Method: This prospective trial included 60 closed mallet finger injuries divided in group A (n ¼ 30) and group B (n ¼ 27; 3 cases lost to follow-up). Subjects (age range, 17 to 79 yrs) were consecutively randomized and treated conservatively with custom-made thermoplastic lever-type splint for group A and with QuickcastÒ finishing tape for group B. Immobilization periods lasted 6 weeks for acute injuries (#21 days old) and 8 weeks for chronic injuries, regardless of the group assignment. The post-immobilization phase consisted of 2 weeks of home-based exercises and intermittent splint use, followed by a final 2 weeks of splint wear at night only. To be included in this trial subjects had to present with a minimum of 208 DIPj active extensor lag, with an injury onset less than 3 months. Patients referred with a history of failed conservative treatment within 3 months of onset were included. Patients suffering from osteoarthritis, having sustained previous injuries or surgeries to the affected finger, presenting with a mallet thumb or bony fragments superior to 1/3 of the joint surface were excluded from the trial. At baseline, groups were similar for subject age, sex ratio, time of presentation from injury, presence of bony fragment, and acuteness of injury. Pain, splint discomfort and aesthetic appreciation, ADL, work and leisure performance, perceived rehabilitation difficulty, and final outcome satisfaction were assessed with the visual analogue scale
A Retrospective Review of TwoStage Flexor Tendon Grafts. Shrikant J. Chinchalkar, BScOT, OTR, CHT Purpose: To review the Hand and Upper Limb Centre (HULC) experience with 2-stage tendon reconstruction (2STR) in patients with flexor tendon injuries that were missed or failed primary repair. Methods: Between Jan. 1, 1994 and Dec. 31, 2004, 41 patients underwent 2STR at the HULC. Of those 22 patients were identified (20 males, 2 females) for a chart review with diagnoses of: jersey finger (n ¼ 6), missed flexor tendon lacerations (n ¼ 6), failed primary repair (n ¼ 9), and failed 1-stage tendon grafting (n ¼ 1). Eleven patients were successfully contacted and 8 appeared for repeat functional assessment and completed the Disabilities of the Arm Shoulder and Hand (DASH) functional outcome survey; 11
362
JOURNAL OF HAND THERAPY
patients were lost to follow-up. However, chart data were sufficient for range of motion (ROM) assessment in 4 patients. In total, 12 patients had sufficient data available for quantitative analysis. Results: The affected fingers in this group and those fingers for which range of motion data was available were as follows: thumb, 3/1; index, 1/1; long, 3/2; ring, 5/0; little, 10/8. Age (mean 6 SD) at initiation of therapy was 31.26 6 10.76 yrs after a mean 1.95 6 4.52 yrs following the original injury. The mean interval between first- and second-stage operations was 17.14 6 6.55 weeks. According to Strickland’s modified criteria of finger ROM, 11 of 12 (91.6%) patients had either excellent (5/12) or good (6/12) results. While not quantitative, chart records indicated an additional 6 of 10 patients had ‘‘normal’’ (4/10) or ‘‘near-normal’’ (2/10) finger ROM. Complications after the first stage included 2 infections, 1 ruptured rod, and 1 rod buckling (4/22 ¼ 18%). Following the second stage, complications included 5 contractures treated with splinting, 2 proximal ruptures, 1 distal rupture, 1 swan neck deformity, 1 mallet finger, 1 intrinsic plus finger, 1 extensor tendinitis (for a total of 12 of 22 patients; 55%). Reoperations were required in 6 patients (27%), including 3 repeat tenorraphies for rupture, 1 arthrodesis, 1 replacement of the Hunter Rod, and 1 intrinsic release. No tenolyses and no amputations were performed in this group. Summary: Despite a higher than expected complication rate in this group, 2STR did permit a high degree of functional success in the majority of cases and represents a good option for patients with missed closed or open injuries to the flexor tendons or those patients for whom primary repair has failed. Effectiveness of Cast Immobilization in Closed Mallet Finger Injury: A Prospective Randomized Comparison with Thermoplastic Splinting. Silvio Tocco, BScOT, BScBiol Purpose: Conservative treatment through splinting has gained favorable recognition over the various surgical approaches for closed tendinous or bony (Type I) mallet injuries.
However, conservative treatment outcomes vary greatly in part due to the heterogeneity of the splint models and treatment protocols available to hand therapists. One common denominator is the necessity to clean the finger regularly to prevent skin ulceration beneath the splint. No study to date was found in the literature that addressed the potential impact of this inevitable cleansing process. The aim of this study was to evaluate the effectiveness of fulltime cast immobilization in the treatment of closed mallet fingers in comparison with the traditionally used custom-made thermoplastic splint, which requires removal for skin hygiene. Method: This prospective trial included 60 closed mallet finger injuries divided in group A (n ¼ 30) and group B (n ¼ 27; 3 cases lost to follow-up). Subjects (age range, 17 to 79 yrs) were consecutively randomized and treated conservatively with custom-made thermoplastic lever-type splint for group A and with QuickcastÒ finishing tape for group B. Immobilization periods lasted 6 weeks for acute injuries (#21 days old) and 8 weeks for chronic injuries, regardless of the group assignment. The post-immobilization phase consisted of 2 weeks of home-based exercises and intermittent splint use, followed by a final 2 weeks of splint wear at night only. To be included in this trial subjects had to present with a minimum of 208 DIPj active extensor lag, with an injury onset less than 3 months. Patients referred with a history of failed conservative treatment within 3 months of onset were included. Patients suffering from osteoarthritis, having sustained previous injuries or surgeries to the affected finger, presenting with a mallet thumb or bony fragments superior to 1/3 of the joint surface were excluded from the trial. At baseline, groups were similar for subject age, sex ratio, time of presentation from injury, presence of bony fragment, and acuteness of injury. Pain, splint discomfort and aesthetic appreciation, ADL, work and leisure performance, perceived rehabilitation difficulty, and final outcome satisfaction were assessed with the visual analogue scale