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Flexor Tendon Rehabilitation
EVIDENCE-BASED MEDICINE
Evidence-Based Medicine
Flexor Tendon Rehabilitation Marissa R. Matarrese, MD, Warren C. Hammert, MD THE PATIENT A 36-year-old physical therapist cut her nondominant ring and small fingers slicing a bagel and could not bend the digits at the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. She had repairs of complete lacerations of both the flexor digitorum superficialis (FDS) and the flexor digitorum profundus in zone II within 48 hours of injury using a 4-strand repair with nonabsorbable braided suture and a running 6-0 nonabsorbable monofilament epitendinous repair. She was splinted postoperatively in a dorsal extension block splint. THE QUESTION What is the best exercise program after repair of a zone II flexor tendon laceration? CURRENT OPINION Certified hand therapists (CHTs) usually supervise postoperative exercises starting within 5 days of operative repair. A dorsal extension block splint with the wrist in neutral or slight flexion, the metacarpophalangeal (MCP) joints flexed, and the interphalangeal (IP) joints in full extension is used during the postoperative period. Both passive flexion and active extension with rubber bands (Kleinert)1 and passive flexion and passive extension (Duran and Houser)2 are commonly used. With stronger tendon repairs, there is interest in active exercises, with either place-and-active-hold or active flexion,3 but active flexion protocols are not as widely used to date. THE EVIDENCE Passive flexion exercises Lister et al, in 1977,1 described 156 tendon injuries in 68 patients, including 79 injuries in zone II. They exFrom the Department of Orthopaedic Surgery and Division of Plastic Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY. Received for publication December 2, 2011; accepted in revised form July 21, 2012. W.C.H. is a consultant for Synthes. Corresponding author: Warren C. Hammert, MD, Department of Orthopaedic Surgery, University of Rochester Medical Center, 601 Elmwood Ave., Box 665, Rochester, NY 14642; e-mail: [email protected]. 0363-5023/12/37A11-0031$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2012.07.020
2386 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
cised the FDS in 25% of the zone II injuries and used passive flexion with rubber bands attached to the nail. At 18 months of follow-up, they reported 75% good to excellent outcomes for zone II injuries and 84% for other zones.1 In 1980, Strickland and Glogovac4 compared 25 flexor tendon injuries treated with passive motion with 25 treated with 3.5 weeks of immobilization. The passive motion group had 56% excellent or good results with 1 rupture and the immobilization group did not have any excellent and only 12% good results with 4 ruptures. May et al5 studied 178 flexor tendon injuries with 3 variations of the Kleinert program. One group had a rubber band on the injured digit or digits and performed active extension and flexion with the rubber band (Kleinert group). The second group added passive flexion of the injured digit with the opposite hand, so as to allow greater passive flexion (passive group). The third group placed rubber bands on all 4 fingers and used active extension and passive flexion with rubber bands and the opposite hand as in the second group (4-finger group). At 12 months, they reported 72% excellent or good in the Kleinert group, 62% excellent or good in the passive group, and 83% excellent or good in the 4-finger group. In addition, the 4-finger group had the highest percentage of excellent results (55% vs 35% in the other 2 groups). Karlander et al6 compared 2 variations of the Kleinert program in 85 fingers (1 involving only the injured digit and 1 involving all digits) and reported 96% excellent or good results when all fingers were treated compared with 51% excellent or good results when the program focused only on the injured digit. Cetin et al7 treated 74 digits in 37 patients (21 zone II injuries) with a combined passive rubber band flexion with active extension and passive flexion–passive extension rehabilitation program starting within 4 days of injury. Unrestricted use of the hand was allowed at 8 weeks. Using the Buck-Gramcko classification, they reported 97% excellent or good results overall and 90% excellent or good for zone II injuries. There was 1 rupture of a zone II injury. Age of the patient and zone of injury were the only statistically significant predictors of final total active motion (TAM).
Active flexion exercises Biomechanical data suggest that the strength of many tendon repairs is not adequate to allow active motion and that increasing force does not accelerate the timedependent accrual of strength.8 Animal studies have demonstrated that work of flexion, or the resistance caused by edema of the digit and increased gliding resistance through the tendon sheath, also substantially increases the force required for motion.9 In spite of this, multistrand tendon repairs have become prevalent, and with increased strength of the repair, there is interest in active motion programs. Trumble et al10 reported a prospective randomized trial with 102 digits in 89 patients, comparing active motion with place-and-hold to passive motion. At both 6 weeks and 1 year, total arc of motion at the PIP joint was significantly better with the place-and-active-hold protocol (122° ⫾ 16° at 6 wk and 156° ⫾ 25° at 1 year compared with 82° ⫾ 14° at 6 wk and 128° ⫾ 22° at 1 year, P ⬍ .05). Hung et al11 prospectively collected data on 46 digits, 24 of which had zone II injuries. They began active PIP motion and tenodesis motion on day 3 and then began place-and-hold on days 7 to 10. There were 3 ruptures (2 zone II and 1 zone III). Seventy-one percent of the digits were classified as good or excellent according to the American Society for Surgery of the Hand (ASSH) TAM score. Baktir et al12 prospectively evaluated 88 digits, comparing Kleinert passive mobilization to an active motion protocol beginning on the first postoperative day. Active motion involved a splint with the wrist in neutral position and a program consisting of alternating active and passive motion of the digits every 4 hours throughout the day. There were 2 ruptures in each group. The passive group (Kleinert protocol) had 78% excellent (34%) and good (44%) results, and the active motion group had 85% excellent (45%) and good (40%) results using Strickland’s criteria; however, the difference was not statistically significant. A recent systematic review of the literature compared early active motion protocols, including both place-and-hold and active flexion and extension, to various passive motion protocols and demonstrated that range of motion was significantly better when active range of motion protocols were used (P ⬍ .001). Average rupture rates range from 2.3% to 7.1%, with an overall average rupture rate of 4.8%. The highest average rupture rate was with a Kleinert protocol, but these results may have been skewed by 1 multicenter study involving 4 centers (3 in South Africa). Patient compliance was felt to be responsible for the rupture rate of
2387
17.6%. When excluding this 1 study, the rupture rate using the Kleinert protocol is 4.4%. When this study was excluded, there was not a significantly/clinically important difference in rupture rates between active and passive motion programs.3 Children Most of us cast children after flexor tendon repair, but a few have tried to have them exercise. Elhassan et al13 reported on 41 fingers with zone I or II flexor tendon injures in patients between 2 and 14 years of age. The patients were subdivided into age 0 to 7 and 8 to 14 and were assigned randomly to a Duran and Houser passive mobilization protocol (19 fingers) or cast for 3 weeks (age 2–7) or 4 weeks (age 8 –14) followed by unrestricted active use of the hand. zone II injuries and concomitant nerve injury regained less TAM. There were no differences by age or exercise program. Berndtsson and Ekeskar14 compared 46 zone I tendon injuries in children; 27 digits were treated with Kleinert passive mobilization and 19 were treated with plaster immobilization. Final motion correlated with age of patient at the time of injury, but not with postoperative regimen, other associated injuries, delayed tendon repair, or type of injury. Specialized therapy training One unit was able to reduce their relatively high rupture rate (30%) to 17% by referring patients to practitioners with specialized training in hand rehabilitation as compared with a general rehabilitation consultant.15 Trumble et al10 also showed that patients had significantly better combined active flexion of the injured digit with less PIP and DIP joint contracture when they were treated by CHTs as compared with uncertified therapists. Patients were also more satisfied with the care they had received. Unrestricted activity Adolfsson et al16 studied 91 digits in a prospective randomized trial using a passive flexion–active extension protocol and found no differences in functional results, rupture rates, grip strength, or subjective assessment 16 weeks after repair when patients were allowed unrestricted use of their injured hand at 8 compared to 10 weeks. SHORTCOMINGS OF THE EVIDENCE Many of the existing studies advocate a specific technique and most have no controls. Even the few con-
JHS 䉬 Vol A, November
Evidence-Based Medicine
FLEXOR TENDON REHABILITATION
2388
FLEXOR TENDON REHABILITATION
Evidence-Based Medicine
trolled trials vary with respect to suture repairs, splinting positions, days to initiation of therapy, and outcome assessment. DIRECTIONS FOR FUTURE RESEARCH We advocate the ASSH TAM measure to assess flexor tendon injuries. Randomized trials should address the following: the splinted position of the wrist; the number of days between surgery and initiation of exercises; methods for passive digit flexion; active versus passive extension; place and active hold; active flexion; and when to allow the patient unrestricted use of the hand. Randomization is important to account for known and unknown confounders and limit bias. It is also important to use blinded independent assessors. OUR CURRENT CONCEPTS FOR THIS PATIENT After operative repair of the injured tendons and placement of a dorsal extension block splint, we initiate exercises under the supervision of a CHT within 4 days of surgery. We favor splinting the wrist in neutral and beginning with passive flexion using the other hand, active extension, place and active hold, and initiation of full and unrestricted use of the hand 8 weeks after surgery. Patient compliance is an important component of rehabilitation and must be considered when determining the progression of the program. As a therapist, this patient should have a good understanding of the goals of rehabilitation following this injury and be compliant; we would progress with caution to active flexion without resistance following ability to perform place and hold exercises. REFERENCES 1. Lister GD, Kleinert HE, Kutz JE, Atasoy E. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg 1977; 2:441– 451.
2. Boyer MI, Strickland JW, Engles D, Sachar K, Leversedge FJ. Flexor tendon repair and rehabilitation: state of the art in 2002. J Bone Joint Surg 2003;84A:1684 –1706. 3. Chesney A, Chauhan A, Kattan A, Farrokhyar F, Thoma A. Systematic review of flexor tendon rehabilitation protocols in Zone II of the hand. Plast Reconstr Surg 2011;127:1583–1592. 4. Strickland JW, Glogovac SV. Digital function following flexor tendon repair in Zone II: a comparison of immobilization and controlled passive motion techniques. J Hand Surg 1980;5:537–543. 5. May EJ, Silfverskiold KL, Sollerman CJ. Controlled mobilization after flexor tendon repair in Zone II: a prospective comparrison of three methiods. J Hand Surg 1992;17A:942–952. 6. Karlander LE, Berggren M, Larsson M, Soderberg G, Nylander G. Improved results in Zone 2 flexor tendon injuries with a modified technique of immediate controlled mobilization. J Hand Surg 1993; 18B:26 –30. 7. Cetin A, Dincer F, Kecik A, Cetin M. Rehabilitation of flexor tendon injuries by use of a combined regimen of modified Kleinert and modified Duran techniques. Am J Phys Med Rehabil 2001;80:721–728. 8. Boyer MI, Gelberman RH, Burns ME, Dinopoulos H, Hofem R, Silva MJ. Intrasynovial flexor tendon repair: an experimental study comparing low and high levels of in vivo force during rehabilitation in canines. J Bone Joint Surg 2001;83A:891– 899. 9. Cao Y, Tang JB. Investigation of resistance of digital subcutaneous edema to gliding of the flexor tendon: an in vitro study. J Hand Surg 2005;30A:1248 –1254. 10. Trumble TE, Vedder NB, Seiler JG III, Hanel DP, Diao E, Pettrone S. Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy. J Bone Joint Surg 2010;92A:1381–1389. 11. Hung LK, Pang KW, Yeung PL, Cheung L, Wong JM, Chan P. Active mobilisation after flexor tendon repair: comparison of results following injuries in Zone 2 and other zones. J Orthop Surg 2005; 13:158 –163. 12. Baktir A, Turk CY, Kabak S, Sahin V, Kardas Y. Flexor tendon repair in Zone 2 followed by early active mobilization. J Hand Surg 1996;21B:624 – 628. 13. Elhassan B, Moran SL, Bravo C, Amadio P. Factors that influence the outcome of Zone I and Zone II flexor tendon repairs in children. J Hand Surg 2006;31A:1661–1666. 14. Berndtsson L, Ejeskar A. Zone II flexor tendon repair in children. A retrospective long term study. Scand J Plast Reconstr Surg Hand Surg 1995;29:59 – 64. 15. Peck FH, Kennedy SM, Watson JS, Lees VC. An evaluation of the influence of practitioner-led hand clinics on rupture rates following primary tendon repair in the hand. Br J Plast Surg 2004;57:45– 49. 16. Adolfsson L, Soderberg G, Larsson M, Karlander LE. The effects of a shortened postoperative mobilization programme after flexor tendon repair in Zone 2. J Hand Surg 1996;21B:67–71.
JHS 䉬 Vol A, November
Evidence-Based Medicine
Flexor Tendon Rehabilitation Marissa R. Matarrese, MD, Warren C. Hammert, MD THE PATIENT A 36-year-old physical therapist cut her nondominant ring and small fingers slicing a bagel and could not bend the digits at the proximal interphalangeal (PIP) or distal interphalangeal (DIP) joints. She had repairs of complete lacerations of both the flexor digitorum superficialis (FDS) and the flexor digitorum profundus in zone II within 48 hours of injury using a 4-strand repair with nonabsorbable braided suture and a running 6-0 nonabsorbable monofilament epitendinous repair. She was splinted postoperatively in a dorsal extension block splint. THE QUESTION What is the best exercise program after repair of a zone II flexor tendon laceration? CURRENT OPINION Certified hand therapists (CHTs) usually supervise postoperative exercises starting within 5 days of operative repair. A dorsal extension block splint with the wrist in neutral or slight flexion, the metacarpophalangeal (MCP) joints flexed, and the interphalangeal (IP) joints in full extension is used during the postoperative period. Both passive flexion and active extension with rubber bands (Kleinert)1 and passive flexion and passive extension (Duran and Houser)2 are commonly used. With stronger tendon repairs, there is interest in active exercises, with either place-and-active-hold or active flexion,3 but active flexion protocols are not as widely used to date. THE EVIDENCE Passive flexion exercises Lister et al, in 1977,1 described 156 tendon injuries in 68 patients, including 79 injuries in zone II. They exFrom the Department of Orthopaedic Surgery and Division of Plastic Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, NY. Received for publication December 2, 2011; accepted in revised form July 21, 2012. W.C.H. is a consultant for Synthes. Corresponding author: Warren C. Hammert, MD, Department of Orthopaedic Surgery, University of Rochester Medical Center, 601 Elmwood Ave., Box 665, Rochester, NY 14642; e-mail: [email protected]. 0363-5023/12/37A11-0031$36.00/0 http://dx.doi.org/10.1016/j.jhsa.2012.07.020
2386 䉬 © ASSH 䉬 Published by Elsevier, Inc. All rights reserved.
cised the FDS in 25% of the zone II injuries and used passive flexion with rubber bands attached to the nail. At 18 months of follow-up, they reported 75% good to excellent outcomes for zone II injuries and 84% for other zones.1 In 1980, Strickland and Glogovac4 compared 25 flexor tendon injuries treated with passive motion with 25 treated with 3.5 weeks of immobilization. The passive motion group had 56% excellent or good results with 1 rupture and the immobilization group did not have any excellent and only 12% good results with 4 ruptures. May et al5 studied 178 flexor tendon injuries with 3 variations of the Kleinert program. One group had a rubber band on the injured digit or digits and performed active extension and flexion with the rubber band (Kleinert group). The second group added passive flexion of the injured digit with the opposite hand, so as to allow greater passive flexion (passive group). The third group placed rubber bands on all 4 fingers and used active extension and passive flexion with rubber bands and the opposite hand as in the second group (4-finger group). At 12 months, they reported 72% excellent or good in the Kleinert group, 62% excellent or good in the passive group, and 83% excellent or good in the 4-finger group. In addition, the 4-finger group had the highest percentage of excellent results (55% vs 35% in the other 2 groups). Karlander et al6 compared 2 variations of the Kleinert program in 85 fingers (1 involving only the injured digit and 1 involving all digits) and reported 96% excellent or good results when all fingers were treated compared with 51% excellent or good results when the program focused only on the injured digit. Cetin et al7 treated 74 digits in 37 patients (21 zone II injuries) with a combined passive rubber band flexion with active extension and passive flexion–passive extension rehabilitation program starting within 4 days of injury. Unrestricted use of the hand was allowed at 8 weeks. Using the Buck-Gramcko classification, they reported 97% excellent or good results overall and 90% excellent or good for zone II injuries. There was 1 rupture of a zone II injury. Age of the patient and zone of injury were the only statistically significant predictors of final total active motion (TAM).
Active flexion exercises Biomechanical data suggest that the strength of many tendon repairs is not adequate to allow active motion and that increasing force does not accelerate the timedependent accrual of strength.8 Animal studies have demonstrated that work of flexion, or the resistance caused by edema of the digit and increased gliding resistance through the tendon sheath, also substantially increases the force required for motion.9 In spite of this, multistrand tendon repairs have become prevalent, and with increased strength of the repair, there is interest in active motion programs. Trumble et al10 reported a prospective randomized trial with 102 digits in 89 patients, comparing active motion with place-and-hold to passive motion. At both 6 weeks and 1 year, total arc of motion at the PIP joint was significantly better with the place-and-active-hold protocol (122° ⫾ 16° at 6 wk and 156° ⫾ 25° at 1 year compared with 82° ⫾ 14° at 6 wk and 128° ⫾ 22° at 1 year, P ⬍ .05). Hung et al11 prospectively collected data on 46 digits, 24 of which had zone II injuries. They began active PIP motion and tenodesis motion on day 3 and then began place-and-hold on days 7 to 10. There were 3 ruptures (2 zone II and 1 zone III). Seventy-one percent of the digits were classified as good or excellent according to the American Society for Surgery of the Hand (ASSH) TAM score. Baktir et al12 prospectively evaluated 88 digits, comparing Kleinert passive mobilization to an active motion protocol beginning on the first postoperative day. Active motion involved a splint with the wrist in neutral position and a program consisting of alternating active and passive motion of the digits every 4 hours throughout the day. There were 2 ruptures in each group. The passive group (Kleinert protocol) had 78% excellent (34%) and good (44%) results, and the active motion group had 85% excellent (45%) and good (40%) results using Strickland’s criteria; however, the difference was not statistically significant. A recent systematic review of the literature compared early active motion protocols, including both place-and-hold and active flexion and extension, to various passive motion protocols and demonstrated that range of motion was significantly better when active range of motion protocols were used (P ⬍ .001). Average rupture rates range from 2.3% to 7.1%, with an overall average rupture rate of 4.8%. The highest average rupture rate was with a Kleinert protocol, but these results may have been skewed by 1 multicenter study involving 4 centers (3 in South Africa). Patient compliance was felt to be responsible for the rupture rate of
2387
17.6%. When excluding this 1 study, the rupture rate using the Kleinert protocol is 4.4%. When this study was excluded, there was not a significantly/clinically important difference in rupture rates between active and passive motion programs.3 Children Most of us cast children after flexor tendon repair, but a few have tried to have them exercise. Elhassan et al13 reported on 41 fingers with zone I or II flexor tendon injures in patients between 2 and 14 years of age. The patients were subdivided into age 0 to 7 and 8 to 14 and were assigned randomly to a Duran and Houser passive mobilization protocol (19 fingers) or cast for 3 weeks (age 2–7) or 4 weeks (age 8 –14) followed by unrestricted active use of the hand. zone II injuries and concomitant nerve injury regained less TAM. There were no differences by age or exercise program. Berndtsson and Ekeskar14 compared 46 zone I tendon injuries in children; 27 digits were treated with Kleinert passive mobilization and 19 were treated with plaster immobilization. Final motion correlated with age of patient at the time of injury, but not with postoperative regimen, other associated injuries, delayed tendon repair, or type of injury. Specialized therapy training One unit was able to reduce their relatively high rupture rate (30%) to 17% by referring patients to practitioners with specialized training in hand rehabilitation as compared with a general rehabilitation consultant.15 Trumble et al10 also showed that patients had significantly better combined active flexion of the injured digit with less PIP and DIP joint contracture when they were treated by CHTs as compared with uncertified therapists. Patients were also more satisfied with the care they had received. Unrestricted activity Adolfsson et al16 studied 91 digits in a prospective randomized trial using a passive flexion–active extension protocol and found no differences in functional results, rupture rates, grip strength, or subjective assessment 16 weeks after repair when patients were allowed unrestricted use of their injured hand at 8 compared to 10 weeks. SHORTCOMINGS OF THE EVIDENCE Many of the existing studies advocate a specific technique and most have no controls. Even the few con-
JHS 䉬 Vol A, November
Evidence-Based Medicine
FLEXOR TENDON REHABILITATION
2388
FLEXOR TENDON REHABILITATION
Evidence-Based Medicine
trolled trials vary with respect to suture repairs, splinting positions, days to initiation of therapy, and outcome assessment. DIRECTIONS FOR FUTURE RESEARCH We advocate the ASSH TAM measure to assess flexor tendon injuries. Randomized trials should address the following: the splinted position of the wrist; the number of days between surgery and initiation of exercises; methods for passive digit flexion; active versus passive extension; place and active hold; active flexion; and when to allow the patient unrestricted use of the hand. Randomization is important to account for known and unknown confounders and limit bias. It is also important to use blinded independent assessors. OUR CURRENT CONCEPTS FOR THIS PATIENT After operative repair of the injured tendons and placement of a dorsal extension block splint, we initiate exercises under the supervision of a CHT within 4 days of surgery. We favor splinting the wrist in neutral and beginning with passive flexion using the other hand, active extension, place and active hold, and initiation of full and unrestricted use of the hand 8 weeks after surgery. Patient compliance is an important component of rehabilitation and must be considered when determining the progression of the program. As a therapist, this patient should have a good understanding of the goals of rehabilitation following this injury and be compliant; we would progress with caution to active flexion without resistance following ability to perform place and hold exercises. REFERENCES 1. Lister GD, Kleinert HE, Kutz JE, Atasoy E. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg 1977; 2:441– 451.
2. Boyer MI, Strickland JW, Engles D, Sachar K, Leversedge FJ. Flexor tendon repair and rehabilitation: state of the art in 2002. J Bone Joint Surg 2003;84A:1684 –1706. 3. Chesney A, Chauhan A, Kattan A, Farrokhyar F, Thoma A. Systematic review of flexor tendon rehabilitation protocols in Zone II of the hand. Plast Reconstr Surg 2011;127:1583–1592. 4. Strickland JW, Glogovac SV. Digital function following flexor tendon repair in Zone II: a comparison of immobilization and controlled passive motion techniques. J Hand Surg 1980;5:537–543. 5. May EJ, Silfverskiold KL, Sollerman CJ. Controlled mobilization after flexor tendon repair in Zone II: a prospective comparrison of three methiods. J Hand Surg 1992;17A:942–952. 6. Karlander LE, Berggren M, Larsson M, Soderberg G, Nylander G. Improved results in Zone 2 flexor tendon injuries with a modified technique of immediate controlled mobilization. J Hand Surg 1993; 18B:26 –30. 7. Cetin A, Dincer F, Kecik A, Cetin M. Rehabilitation of flexor tendon injuries by use of a combined regimen of modified Kleinert and modified Duran techniques. Am J Phys Med Rehabil 2001;80:721–728. 8. Boyer MI, Gelberman RH, Burns ME, Dinopoulos H, Hofem R, Silva MJ. Intrasynovial flexor tendon repair: an experimental study comparing low and high levels of in vivo force during rehabilitation in canines. J Bone Joint Surg 2001;83A:891– 899. 9. Cao Y, Tang JB. Investigation of resistance of digital subcutaneous edema to gliding of the flexor tendon: an in vitro study. J Hand Surg 2005;30A:1248 –1254. 10. Trumble TE, Vedder NB, Seiler JG III, Hanel DP, Diao E, Pettrone S. Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy. J Bone Joint Surg 2010;92A:1381–1389. 11. Hung LK, Pang KW, Yeung PL, Cheung L, Wong JM, Chan P. Active mobilisation after flexor tendon repair: comparison of results following injuries in Zone 2 and other zones. J Orthop Surg 2005; 13:158 –163. 12. Baktir A, Turk CY, Kabak S, Sahin V, Kardas Y. Flexor tendon repair in Zone 2 followed by early active mobilization. J Hand Surg 1996;21B:624 – 628. 13. Elhassan B, Moran SL, Bravo C, Amadio P. Factors that influence the outcome of Zone I and Zone II flexor tendon repairs in children. J Hand Surg 2006;31A:1661–1666. 14. Berndtsson L, Ejeskar A. Zone II flexor tendon repair in children. A retrospective long term study. Scand J Plast Reconstr Surg Hand Surg 1995;29:59 – 64. 15. Peck FH, Kennedy SM, Watson JS, Lees VC. An evaluation of the influence of practitioner-led hand clinics on rupture rates following primary tendon repair in the hand. Br J Plast Surg 2004;57:45– 49. 16. Adolfsson L, Soderberg G, Larsson M, Karlander LE. The effects of a shortened postoperative mobilization programme after flexor tendon repair in Zone 2. J Hand Surg 1996;21B:67–71.
JHS 䉬 Vol A, November