Controlled active motion following primary flexor tendon repair: A prospective study over 9 years

CONTROLLED ACTIVE MOTION FOLLOWING PRIMARY FLEXOR TENDON REPAIR: A PROSPECTIVE STUDY OVER 9 YEARS C. K. KITSIS, P. J. E WADE, S. J. KRIKLER, N. K. PARSONS and L. K. NICHOLLS

From the Orthopaedic Department, Coventry and WarwickshireHospital, Coventry, UK 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.

Journal of Hand Surgery (British and European Volume, 1998) 23B: 3:344-349 Because it was thought that adhesions to the surrounding tissues were needed for divided tendons to heal (Potenza, 1962; 1963), immobilization has been used after primary tendon repair. Verdan (1966) felt that primary repair should be the treatment of choice when there were facilities to carry it out. Kleinert et al (1973) described the repair of flexor tendon injuries using a careful surgical technique, followed by controlled postoperative motion with improved results. Matthews and Richards (1976) showed that the combination of splintage, suture and excision of the tendon sheath in flexor tendon repairs in the rabbit resulted in dense adhesion formation with little evidence of any healing activity by the tendon cells. Immobilization following flexor tendon repair tends to lead to adhesions but unrestricted motion may lead to a higher rate of rupture. More recently, attention has been given to the postoperative care of these injuries. Regimes such as that used in Belfast (Small et al, 1989), and others (Bainbridge et al, 1994; Baktir et al, 1996; Cullen et al, 1989; Elliot et al, 1994; Silfverski61d and May, 1993; 1994) have attempted to provide active motion of the repaired tendon, while protecting against the excessive loading which may lead to rupture. This study was undertaken prospectively to test a combination of high-strength suture technique followed by a more aggressive regime than the standard Kleinert regime. The suture technique was that described previously (Wade, 1995; Wade et al, 1989). This study was carried out in a general hospital containing within it a specialist hand service and a dedicated hand physiotherapy unit. There were eight orthopaedic consultants supplying trauma and orthopaedic services for 350,000 people. There were no alterations in technique or in the postoperative regime during the period of study.

PATIENTS AND M E T H O D S

All patients with flexor tendon lacerations in the hand less than 4 weeks old underwent primary surgical repair and were then referred to the hand physiotherapy unit the following day. Flexor tendon repair was carried out by orthopaedic consultants, senior registrars or postfellowship registrars. The skin lacerations were extended when necessary with a Brunet zig-zag incision of the affected digit, extending as far into the palm as necessary to retrieve the tendon and to ensure that the tendons were replaced in proper alignment through the pulleys in the flexor tendon sheath. If access to the tendon in the finger was inadequate, extension of the original laceration in the sheath was made, except in the area of the annular pulleys. In particular, wherever possible the A2 and A4 pulleys were preserved. Tendon repair was carried out with a multistrand technique using as the core a "modified Kessler" grasping suture using 4/0 Ethibond (braided polyester) and a strong peripheral running suture of the Halsted or Lembert configuration using 5/0 Ethibond or occasionally 5/0 Ethilon (nylon) (Fig 1). This repair requires a load of 58 newtons before a gap forms between the ends (Wade et al, 1989) and has similar strength to other techniques such as those described by Savage and Risitano (1989) and Aoki et al (1997). The physiotherapy regime is described in detail in Table I. It is essentially a regime which protects the tendon in the splint, but allows and encourages a full range of active movement while under physiotherapy supervision. A modified Kleinert lively splint (Fig 2) was worn continuously, apart from active movement under supervision starting the first week (Wade, 1995). The splint was removed 5 to 6 weeks postoperatively and after that physiotherapy was continued only as necessary. Any PIP joint contractures were splinted with a Capener splint and joint stiffness was treated with active and passive physiotherapy.

344

CONTROLLED ACTIVE MOTION AFTER TENDON REPAIR

i i ( ,,I.

"- - ~

~ t,.f

Lv r

'

~

i i

~'~'1 ""~ ~J

"KESSLER" CORE STITCH 4 / 0 Braided Polyester (ETHIBOND)

PERIPHERAL STITCH 5 I 0 Braided Polyester (ETHIBOND)

-

COMPLETED STITCH

Fig 1 "Kessler" core with Halsted peripheral suture. Loss o f tendon gliding due to adhesions was treated by tenolysis usually 3 to 4 m o n t h s after initial repair. Rupture was treated with immediate exploration and re-repair. Infection was treated with antibiotics (usually fluctoxacillin). The active regime continued t h r o u g h o u t any treatment for these complications. All the patients were reviewed 6 m o n t h s and 1 year after repair and repeated attempts were m a d e to recall

345

the patients who failed to attend for follow-up. Measurement o f the range o f m o v e m e n t o f the operated fingers was carried out by a physiotherapist and the surgeon using the Strickland m e t h o d (Strickland and Glogovac, 1980) (Table 2). The results were analysed according to the grade o f surgeon who had performed the operation and the zone o f injury. RESULTS D a t a was available for 186 patients. The 17 patients who had isolated t h u m b injuries were excluded and 39 patients either failed to attend follow-up or removed the splintage and did n o t attend physiotherapy. There is no record o f the results for these patients. in the 130 patients for w h o m full data is available, 339 tendons affecting 208 fingers were repaired in the period between January 1988 and F e b r u a r y 1996. The distribution o f injuries per zone is as shown in Figure 3. These included 87 digits (137 repairs) in zone 2. The o u t c o m e by Strickland grade in all zones is shown in Figure 4, and for zone 2 in Figure 5. I n zone 2 there were 56% excellent 33% good, 9% fair and 2% p o o r results. Figures 6 and 7 show results by grade o f surgeon in all zones and zone 2 respectively. The complications which occurred in these patients are shown in Table 3. In 208 injured fingers, 31 patients had 43 complications recorded. There were 17 moderate joint contractures (more t h a n 20 ° at the P I P or D I P joint). Where infection, sympathetic dystrophy or skin problems were encountered, the physiotherapy regime continued unaltered. DISCUSSION We believe that m o v e m e n t o f freshly-repaired tendons encourages healing and discourages the formation o f adhesions. (Gelberman et al, 1981; Hitchcock et al, 1987; K u b o t a et al, 1996; L u n d b o r g et al, 1980; Silfverski61d et al, 1992; Silfverski61d and May, 1993; 1995; W o o et al,

Table 1--The Coventry-Kleinert early active motion regime

• Splint made within 2448 hours postoperatively • Active motion from day one With Coventry Dynamic ~I'ractionin situ 1. Activeextension all fingers against elastic, gaining full range into extension of MCPJ, PIPJ, and DIPJ. 2. Return to flexed position passively by recoil of the dynamic component (elastic and coil). 3. Overpress MCPJ, PIPJ and DIPJ to gain full passive flexion. Remove Coventry Dynamic Kleinert Traction: 1. Actively make a fist, curling all fingers into flexion. Relax and open out hand actively extending all fingers repeat x2. 2. Block FDP function all fingers. Individually isolate FDS and encourage function in each finger. Perform 5 active FDS flexions. 3. Block FDS function at each finger in turn. Individually isolate FDP and encourage function in each finger. Perform 5 active FDP flexions. 4. Maintain passive extension in all finger joints (MCP, PIP, and DIP) by stretching joints with flexor tendon resting in a slackened position. 5. Maintain passive flexion in all finger joints (MCP, PIP, and DIP) by overpressingjoints into flexion. 6. Encourage active movements at all joints in the upper limb (shoulder, elbow, radioulnar, wrist and thumb). • In no circumstances: 1. Put the affected tendon(s) on full stretch. 2. Apply resistance until 7 weeks postoperatively. 3. Should the splint be removed by the patient except in physiotherapy treatment sessions.

THE JOURNAL OF HAND SURGERY VOL. 23B No. 3 JUNE 1998

346

Fig 2 (a,b)

The Kleinert

Coventry Splint.

Table 2--Striekland formula 9O7

[Active PIP + D I P flexion] Extension lag x 100 175 = % of normal active PIP and D I P movement Excellent 75-100 Good 50 74 Fair 25-49 Poor 054

70

6O

:t l

1981). Provided the repair is of sufficient mechanical strength and provided that the patient is cooperative and well supervised, it should be possible to start active movement the day after surgery. Work on suturing techniques has shown that increases in the strength of flexor tendon repair can be achieved using existing materials and that all components of the suture technique are important in achieving significant percentage gains in strength (Diao et al, 1996; Savage and Risitano, 1989; Strickland, 1989; Wade et al, 1986; 1989). Softening of the tendon ends is thought to be one of the factors responsible for failure of tendon repairs, but contemporary suture techniques place the suture away from the cut end to avoid this potential soft area. The tendon repair used in this study conforms with these concepts and the extra strength of the repair helps make the more aggressive physiotherapy regime possible. The postoperative regime we have adopted, and which was constant throughout this trial, is more energetic than the original Kleinert regime. It is a hybrid active and passive flexion regimen that combines the original Kleinert passive flexion/active extension regime with early active movement. The results obtained are better than those obtained using conventional techniques: 92% of our repairs gave an excellent or good result (89% in zone 2). The series of Kleinert and colleagues (1975) showed 80% good or excellent results and the Belfast technique produced 77% good or excellent results (Cullen et al, 1989; Small et al, 1989). Table 4 sets out a comparison of regimes in the literature.

~° 1 1o

1

Z

3

4

6

ZONE

Fig 3

Distribution of injuries by zone.

The advantages of having a removable splint with an active regime are not confined to the flexor tendon itself. Wound-healing problems can be treated by other forms of physiotherapy, such as electrotherapy, and all joints can be kept supple. Apart from those patients who clearly were not going to cooperate with any form of postoperative physiotherapy, there were few problems with compliance. The data for the time to return to work are incomplete. This may be due to the high unemployment rate in this area in general and in this group of patients in particular, but in those patients for whom it was recorded, the time to return to work averaged 7 weeks (range, 1-20 weeks). The results did not vary significantly with the grade of the surgeon. This may initially appear surprising but there are several possible explanations. Many of the junior staff were very experienced and well supervised by senior staff in this unit. Also the more difficult lacerations were more likely to be explored by a consultant,

CONTROLLED ACTIVE MOTION AFTER TENDON REPAIR

347

16o

:toi

142 NUMBER OF FINGERS

35 3o 25 ;

2o 15 lO

/ 50

EXCELLENT

o~ GOOD

58%

FATR

33%

POOR

2%

9%

STRICKLAND

INDEX

2

FAIR

24%

7%

POOR

Fig 5

Outcome zone 2.

1%

STRICKLAND INDEX

Fig4

I EXCELLENT

GOOD

68%

2

5

8000% 70.70%

Outcome allzones.

7000~

6000%

50.00%

lSeriesl

3ooooh Dse~es2 .Consultant~

~'~~°~t 20O0%

I10% EXCELLENT

GOOD

FAIR

POOR

STRICKLAND-INDEX

EXCELLENT

GOOD

FAIR

pOOR

Fig 7

Results zone 2

juniors and consultants.

STFIIGKLANDINDEX

Fig 6

Results all zones -juniors and consultants. Table 3~Complications Ruptures

and in particular a consultant hand surgeon. We were not certain of this because of the difficulty of comparing different injuries. Nevertheless, we feel that, provided the repair is carried out adequately with a strong tendon suture, it is the postoperative rehabilitation that is the most critical factor in determining outcome. Although recent research (Van Alphen et al, 1996) does not support the concept that flexor muscles are relaxed during resisted extension in the Kleinert splint, we still believe that Kleinert's method is relatively safe in most people's hands. We are confident that the major problems (ruptures and requirement for tenolysis) are recorded accurately,

Needing resuture, 3; tenodesis, 2; graft, 1 Contractures and adhesions

Needing tenolysis: 12 Infections Partial or no recovery of nerve lesions Skin hypersensitivity - desensitisation Non-viable skin - skin grafting Reflex sympathetic dystrophy Double crush syndrome

Zone Zone Zone Zone Zone Total Zone Zone Zone Zone Zone Total

1 2 3 4 5 1 2 3 4 5

0 5 0 0 1 6 1 10 0 0 6 17 9 7 1 1 1 1

348

THE JOURNAL OF HAND SURGERY VOL. 23B No. 3 JUNE 1998

Table 4---Comparison of results with other series and various rehabilitation regimes

Passive extension/Passive flexion Duran and Houser (1975) Strickland and Glogovac (1980) Active extension/passive flexion (Kleinert) Lister et al (1977) Gault ( 1987) Chow et al (1987) Chow et al (1988) Saldana et al (1991) Controlled active motion Small et al (1989) Cullen et al (1989) Elliot et al (1994) Baktir et al (1996) Early active and passive flexion Silfverski61d and May (1994) Wade et al (this study)

Number o f patients

Number o f digits

27 25

29

60 67 66 57

140 160 44 78 60

117 34 203 38 46 130

but the 43 complications recorded may slightly underestimate the minor complications. The rupture rate was 2.9% (six of 208 fingers) for all zones and 5.7% (five of 87) in zone 2 and is comparable to other reports. Four ruptures occurred spontaneously and the other two, both in zone 2, were due to inappropriate activities (one patient carried out manual work with his injured hand and the other was involved in a street fight). This study has shown that this suture technique followed by a hybrid postoperative regime of controlled active movement protected with a Kleinert type splint is safe, has a low rupture rate and achieves very good results. References Aoki M, Kubota H, Pruitt DL, Manske PR (1997). Biomechanical and histological characteristics of canine flexor tendon repair using early postoperative mobilization. Journal of Hand Surgery, 22A: 107 114. Bainbridge LC, Robertson C, Gillies D, Elliot D (1994). A comparison of postoperative mobilisation of flexor tendon repairs with "Passive FlexionActive Extension" and "Controlled Active Motion" techniques. Journal of Hand Surgery, 19B: 517-521. Baktir A, Tiirk CY, Kabak S, Sahin V, Kardas Y (1996). Flexor tendon repair in Zone 2 followed by early active mobilization. Journal of Hand Surgery, 21B: 624-628. Chow JA, Thomas LJ, Dovelle S, Milnor WH, Seyfor AE, Smith AC (1987). A combined regimen of controlled motion following~flexortendon repair in "no man's land". Plastic and Reconstructive Surgery, 79: 447455. Chow JA, Thomas LJ, Dovelle S, Monsivais J, Milnor WH, Jackson JP (1988). Controlled motion rehabilitation after flexor tendon repair and grafting. A multi-centre study. Journal of Bone and Joint Surgery, 70B: 591 595. Cullen KW, Tolhurst P, Lang D, Page RE (1989). Flexor tendon repair in zone 2 followed by controlled active mobilisation. Journal of Hand Surgery, 14B: 392-395. Diao E, Hariharan JS, Soejima O, Lotz J C (1996). Effect of peripheral suture depth on strength of tendon repairs. Journal of Hand Surgery, 21A: 234-239. Duran R J, Houser RG. Controlled passive motion following flexor tendon repair in zones 2 and 3. In." American Academy of Orthopaedic Surgeons: Symposium on tendon surgery in the hand. St Louis, C V Mosby, 1975. Elliot D, Moiemen NS, Flemming AFS, Harris SB, Foster AJ (1994). The rupture rate of acute flexor tendon repairs mobilized by the controlled active motion regimen. Journal of Hand Surgery, 19B: 607-612. Gault DT (1987). A review of repaired flexor tendons. Journal of Hand Surgery, 12B: 321 324.

Study period (months)

Good and excellent

Rupture rate (digits)

74% 56%

14% 4%

18 26 42 6-60 30

80% 92% 98% 98% 93%

3% 4% 6.8% 3.9% 5%

205 38 224 47

34 10 41 12

77% 78% 79% 85%

9.4% 6.4% 5.8% 4.3%

55 208

6 97

100% 92%

3.6% 2.9%

Gelberman RH, Amiel D, Gonsalves M, Woo S, Akeson WH (1981). The influence of protected passive mobilisation on the healing of flexor tendons: A biomechanical and microangiographic study. The Hand, 13: 120-128, Hitchcock TE Light TR, Bunch WH et al (1987). The effect of immediate constrained digital motion on the strength of flexor tendon repairs in chickens. Journal of Hand Surgery, 12A: 590 595. Kleinert HE, Kutz JE, Atasoy E, Stormo A (1973). Primary repair of flexor tendons. Orthopedic Clinics of North America, 4: 865-876. Kleinert HE, Kutz JE, Cohen MJ. Primary repair of zone 2 flexor tendon lacerations. AAOS: Symposium on tendon surgery in the hand. St Louis, C V Mosby, 1975. Kubota H, Manske R Aoki M, Larson BJ (1996). Effect of motion and tension on injured flexor tendons in chickens. Journal of Hand Surgery, 21A: 456463. Lister GD, Kleinert HE, Kutz JE, Atasoy E (1977). Primary flexor tendon repair followed by immediate controlled mobilization. Journal of Hand Surgery, 2:441451. Lundborg G, Holm S, Myrhage R (1980). The role of synovial fluid and tendon sheath for flexor tendon nutrition. Scandinavian Journal of Plastic and Reconstrnctive Surgery, 14: 99-107. Matthews P, Richards H (1976). Factors in the adherence of flexor tendon after repair. An experimental study in the rabbit. Journal of Bone and Joint Surgery, 58B: 230-236. Potenza AD (1962). Tendon healing within the flexor digital sheath in the dog. Journal of Bone and Joint Surgery, 44A: 49-64. Potenza AD (1963). Critical evaluation of flexor-tendon healing and adhesion formation within artificial digital sheaths. Journal of Bone and Joint Surgery, 45A: 1217-1233. Saldana MJ, Chow JA, Gerbino P, Westerbeck R Schacherer TG (1991). Further experience in rehabilitation of zone 2 flexor tendon repair with dynamic traction splinting. Plastic and Reconstructive Surgery 87: 543-546. Savage R, Risitano G (1989). Flexor tendon repair using a "six strand" method of repair and early active mobilisation. Journal of Hand Surgery, 14B: 396-399. Schneider LH. Flexor tendon injuries. Boston, Little, Brown and Company, 1985. Siffverski61d KL, May EL T6rnvall AH (1992). Flexor digitorum profundus tendon excursions during controlled motion after flexor tendon repair in zone 2: A prospective clinical study. Journal of Hand Surgery, 17A: 12~131. Silfverski61d KL, May EJ (1993). Gap formation after flexor tendon repair in zone 2. Results with a new controlled motion programme. Scandinavian Journal of Plastic Reconstructive and Hand Surgery, 27: 263-268. Silfverski61d KL, May EJ (1994). Flexor tendon repair in zone 2 with a new suture technique and an early mobilization program combining passive and active flexion. Journal of Hand Surgery, 19A: 53-60. Silfverski61d KL, May EJ (1995). Early active mobilization of tendon grafts using mesh reinforced suture techniques. Journal of Hand Surgery, 20B: 301 307. Small JO, Brennen MD, Colville J (1989). Early active mobilisation following flexor tendon repair in Zone 2. Journal of Hand Surgery, 14B: 383-391.

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C O N T R O L L E D ACTIVE MOTION A F T E R T E N D O N REPAIR Strickland J W (1989). Review articles. Flexor tendon surgery. Journal of H a n d Surgery, 14B: 261 272 and 368-382. Strickland J W, Glogovac S V (1980). Digital function following flexor tendon repair in zone 2: a comparison of immobilization and controlled passive motion techniques. Journal of H a n d Surgery, 5: 537-543. Van Alphen J C, Oepkes C T, Bos K E (1996). Activity of the extrinsic finger flexors during mobilization in the Kleinert splint. Journal of H a n d Surgery, 21A: 77-84. Verdun C. Primary and secondary repair of flexor and extensor tendon injuries. In: Flynn J E (ed): Hand surgery. Baltimore, Williams & Wilkins, 1966: 220 275. Wade P J F, Muir I F K, Hutcheon L (1986). Primary flexor tendon repair: the mechanical limitations of the modified Kessler suture. Journal of H a n d Surgery, llB: 71 76. Wade P J F (1995). Flexor tendon repair. The Video Journal of Orthopaedics, 2(5). Video Medical Journals Ltd, 9, Sibford Rd, Hook Norton, OX15 5LA.

Wade P J F, Wetherell R, Amis A A (1989). Flexor tendon repair: significant gain in strength fi'om the Halsted peripheral suture technique. Journal of Hand Surgery, 14B: 232-235, Woo S L-Y, Gelberman R H, Cobb N G, Amiel D, Lothringer K, Akeson W H (1981). The importance of controlled passive mobilisation on flexor tendon healing. Acta Orthopaedica Scandinavia, 52:615 622.

Received:28 April 1997 Accepted after [evision: 19 Janua12~1998 E J. F. Wade FRCS, Orthopaedic Department, Coventry and WarwickshireHospital, Stoney Stanton Road, Coventry CV1 4FH, UK. © 1998The British Society for Surgery of the Hand