FLEXOR
TENDON REPAIR IN ZONE 2 FOLLOWED CONTROLLED ACTIVE MOBILISATION
BY
K. W. CULLEN, PAMELA TOLHURST, D. LANG and R. E. PAGE From the Department of Plastic Surgery, Northern General Hospital, Shefield
Over a two-year-period, 34 adult patients who had suffered zone two flexor tendon injuries to 38 fingers (70 tendons) were managed post-operatively by a regime of early active mobilisation. The results of this technique, assessed by the Strickland criteria after a mean follow-up period of 10.2 months, compared favourably with other more cumbersome methods. Journal of Hand Surgery (British Volume, 1989) 14B: 392-395
Some form of mobilisation following flexor tendon repair undoubtedly helps to minimise adhesions of tendon and stiffness of joints which, in the past, have compromised results. Flexor tendon injuries in zone 2 present the greatest challenge to the hand surgeon (Tonkin and Lister, 1986). If any new method is to displace existing techniques, it must be shown to be superior in the most difficult cases. A regime involving passive and active flexion, controlled within a simple plaster with the interphalangeal joints extended at rest, seemed worthy of further study. One of us (P-T.) had gained experience of such a method in the Belfast Plastic Surgery Unit. Active mobilisation is not a new concept (Ketchum, 1977; Becker, 1978; Savage, 1985) but has not been widely adopted, probably because of the fear of an unacceptably high rupture rate.
obstruction by plaster to finger flexion. All hands were elevated after operation. The patients were separated into two groups. Where the wound was confined to the palm, the fingers were mobilised after 24 hours. Those with a wound extending into the digit started movement 48 hours after the operation. The movements were demonstrated by the physiotherapist and consisted of two active movements
Patients and methods During the study period, flexor tendon repairs in zone 2 were performed using a modified Kessler suture of 3/O Tycron and a circumtendinous suture of 6/O Prolene. The skin was closed with 5/O Prolene or Ethilon. The surgeons ranged in experience from senior house officers to consultants. Sutures were left in for a minimum of two weeks but on occasions were left longer without any ill effects. Active mobilisation was not used for more severe injuries with extensive tissue loss or complex fractures. The key to implementation of the method was the application of the dorsal plaster-or-Paris splint in theatre in the correct position (Fig. 1). Following haemostasis and wound suture, the plaster was applied and the wound left without dressings. Premature cessation of anaesthesia must be guarded against, to allow the splint to set correctly. On rare occasions when a dressing was required, it was applied after the splint in such a manner as to be easily removed next day by nursing staff without disturbing the plaster. The dorsal slab was applied with the wrist in full flexion minus 30” and the forearm in midpronation/supination. The plaster hood extended at least 2 cm beyond the fingertips. The M.P. joints were flexed to 90” and the plaster moulded around the curve of the hand. A wrist flange was incorporated to secure the hand in position and a check made that there was no 392
Fig. 1. The position of the hand in splintage immediately following tendon repair.
of the fingers (against “fresh air”), two passive flexion movements into the palm and two active extension movements to the plaster hood. This sequence of two passive and four active movements was repeated every four hours during the day. The patient was cautioned against exceeding these movements and warned not to THE
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use the hand in any other way. Some patients moved very readily in plaster and, where appropriate, these “fast movers” were instructed to reduce active movements to every six hours. If the joints were becoming stiff, the passive movements were increased to every two hours. Contractures were carefully watched for, particularly in the P.I.P. joints: if there was evidence of contracture developing, the patient was instructed to place a pen dorsal to the P.I.P. joint to act as a fulcrum for extension. Any sudden decrease in motion was reported to the surgeon and, where rupture had occurred, immediate exploration and re-repair was undertaken. The plaster was removed after four weeks in most cases, but retained for a further week in “fast movers”. Over the next four weeks, the patient was discouraged from gripping. Between eight and twelve weeks after injury, the use of the hand was increased, the aim being a return to full function after this time. All patients who underwent tendon repairs on our unit were seen by the hand physiotherapist daily, commencing the day after operation and their details recorded on a card index. Using this index, the notes of all patients with tendon injuries were reviewed. Those not treated by active mobilisation were excluded. Patients under review in clinics were assessed and others recalled for measurement. It was decided to recall only patients who had sustained injuries in zone 2, since it was felt that review of this group would discriminate most effectively between good and bad results. Results 34 patients underwent repair of tendons in zone 2. 38 fingers were involved and a total of 70 tendons were repaired. 27 patients attended for review and 31 fingers previously operated on were reviewed. In this review group, 56 tendons had been repaired. The mean time between initial repair and assessment was 10.2 months. The results were measured using Strickland’s (1980) criteria. Of 31 fingers, 22 (71%) were classed as excellent. Two fingers were classed as good and one as fair (6.5% and 3.5% respectively). Poor results were found in six cases (19%). Seven patients failed to attend for formal assessment and their notes were examined. All had been reviewed six months after injury. None had suffered tendon rupture during this period. The individual results are shown in Table 1. Complications Two early ruptures were identified and immediately rerepaired. These occurred ten and fourteen days after the initial repair. Both of these patients attended for later review and were then classified as having good results. No other ruptures were diagnosed on examination at up to four months in the entire group. The theoretical risk VOL.
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1989
BY CONTROLLED
ACTIVE
MOBILISATION
of early rupture did not prove to be a significant problem in our series. In each of our cases of rupture, the cause was preventable. One patient used the hand for gripping in the early post-operative period. The other sustained a rupture soon after we started using the method: he obtained excellent flexion in the early stage of treatment and exceeded the exercise criteria recommended. These “fast movers” are now identified and treated by reducing the frequency of their exercises. Two patients required tenolysis. Only one of these attended for review: he had a fair result at four months following secondary surgery. One patient, who suffered complete wound breakdown following early removal of sutures in the dressing clinic, later developed an intractable flexion contracture of the little finger and refused further surgery. Another patient who sustained a con.taminated crushing injury developed a severe wound infection. Both these patients had poor results. Discussion An ideal method of suture and post-operative management for flexor tendon injuries has yet to be found. In recent years, the technique of dynamic traction has attracted many followers. Although its use gives good results in many cases (Kleinert and Smith, 1982), the resting finger may remain flexed at the P.I.P. joint for long periods, leading to a fixed flexion contracture. In our experience, this problem has been greater in repairs in the ring and little fingers. The traction requires close supervision and regular adjustment which demand a high level of patient compliance. As flexion of the M.P. joint alone produces little in the way of differential tendon movement, Slattery and McGrouther (1984) were prompted to modify their dynamic splintage to encourage flexion of the D.I.P. joint by introducing a bar across the palm. These authors stressed the importance of blocking flexion of the M.P. joints to encourage differential movement between the profundus and superficialis tendons, which seems especially relevant to injuries in zone 2. The technique of early active mobilisation which fixes M.P. joints to 90” leaving the I.P. joints free to move seems to provide these requirements without relying on any form of traction. Ketchum (1977) analysed factors affecting the strength of tendon repairs and cautioned that early active movement might increase gap formation in tendon repair, but admitted that movement in general leads to stronger repairs than immobilisation. Becker (1978) reported a series of zone 2 repairs managed by early active mobilisation. He did not block M.P. flexion and used a bevel technique and fine sutures for repair. This was not widely adopted, presumably because of fear of rupture and theoretical shortening of the repaired tendon. More recently, Savage (1985) outlined a mu!ti393
K. W. CULLEN, PAMELA TOLHURST, D. LANG AND R. E. PAGE
Table l-Details Patient
of patients and results Injury
Age
D.H. P.D. T.C. C.C. J.C. D.C. D.B. Y.Z. A.W J.W.
18 24 29 17 39 16 22 19 51 32
H.T. S.S. C.S.
20 28 15
H.R. J.P.
40 26
P.N. G.M. T.J. M.H.
61 22 41 19
B.S.
23
FDS FDP FDP FDP FDP FDS FDS FDS FDS FDS FDS FDS FDS FDS FDS FDS FDS FDS FDS FDS FDS FDS FDS FDS
A.P.
21
FDS and FDP (R) index finger
A.L. S.D. M.D. R.C. D.M.
45 25 20 26 20
FDS FDS FDS FDS FDS
D.H.
22
FDS and FDP (R) little finger
and FDP (R) ring finger (R) ring finger (L) little finger (R) little finger (R) little finger and FDP (L) middle finger and FDP (L) index finger and FDP (L) index finger and FDP (R) middle finger and FDP (L) middle firmer and FDP (L) ring fingerand FDP (R) little finger (R) middle finger and FDP (R) little finger and FDP (R) ring finger and FDP (L) middle finger and FDP (R) middle finger and FDP (R) ring finger(L) ring finger and FDP (R) little finger and FDP (R) ring finger and FDP (L) middle finger and FDP (L) ring finger and FDP (R) little finger
and and and and and
FDP FDP FDP FDP FDP
(L) (R) (L) (L) (R)
middle finger little finger little finger ring finger middle finger
Interval between repair and assessment (months) 10 6.2
4
Excellent Excellent Excellent Excellent Excellent Excellent Poor Excellent Excellent Excellent Excellent Poor Excellent Excellent Excellent Poor Excellent Excellent Excellent Poor Excellent Excellent Excellent Fair
6
Good
9 12.5 14 8 11 10.5 9 10.5 8 6 8.5 14 12.5 13 15.5 16
12 11 16 4 7.2
Excellent Poor Excellent Excellent Good
14
PO01
stranded technique of repair which was mechanically stronger than double-stranded methods. He reported the use of this method combined with early active movement but did not analyse the results. We had gained experience with the modified Kessler suture, finding that it was easier to teach junior staff and provided a reliable repair. Comparison with other studies can be effected only when the same method of assessment is used. Chow (1988) obtained excellent results in 80% of cases, using the criteria of Strickland (1980). These repairs were carried out by experienced hand surgeons in Army hospitals. Although our repairs were carried out by surgeons of varied experience, the results compare reasonabiy with this series and that reported by Strickland (1980) using other post-operative regimes; his method of assessing results is strict in comparison with other methods because it excludes M.P. joint flexion. It would seem, however, an appropriate indicator of function, particularly for zone 2 repairs. 394
Result
Comments
Wound infection
following
severe crush
Tenolysis performed six months after surgery. Assessment performed following tenolysis. Ruptured at ten days after repair and immediately re-repaired.
Ruptured at 14 days after repair and immediately re-repaired. Premature suture removal resulted in wound breakdown. Patient refused further surgery.
The results also compare favourably with a recent retrospective review of flexor tendon repairs carried out in a regional plastic surgery unit (Gaul& 1987). In his study, repairs from all zones were examined. The rupture rate in our series was no higher than his and we experienced a lower incidence of problems with flexion contractures. The flexed position of the wrist in splintage evolved from experience with previous techniques. It has been suggested recently that an extended wrist position relaxes the extensors and reduces the minimum force necessary for active movement of interphalangeal joints (Savage, 1988). It is not known whether this decreases the risk of rupture but it should be considered in further studies. We felt that to splint the wrist in such a position of function might encourage patients to use the hand for normal activities and would increase the risk of rupture. We now use controlled active mobilisation following all tendon repairs, provided wound healing can be rapidly THE JOURNAL OF HAND SURGERY
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TENDON
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FOLLOWED
obtained. It can be used in the presence of bony injuries where rigid skeletal stabilisation can be provided. It is not suitable for more complex injuries. The method requires detailed attention to splintage at the end of the operation and carefully supervised physiotherapy in the early post-operative period; thereafter it is largely “maintenance free” and is useful for patients living some distance from the treatment centre. With further experience of the method, we are now obtaining better results and will publish these in due course. References BECKER, H. (1978). Primary repair of flexor tendons in the hand without immobilisation-Preliminary report. The Hand, 10:1:37-47. CHOW, J. A., TOMES, L. J., DOVELLE, S., MONSIVAIS, J., MILNOR, W. and JACKSON, J. (1988). Controlled motion rehabilitation after Aexor tendon repair and grafting. A multi-centre study. Journal of Bone and Joint Surgery, 70B:591-59.5. GAULT, D. (1987). A review of repaired flexor tendons. Journal of Hand Surgery, 12B:3:321-325. KETCHUM, L. D., MARTIN, N. L. and KAPPEL, D. A. (1977). Experimental Evaluation of Factors Affecting the Strength of Tendon Repairs. Plastic and ReconstructiveSurgery, 59:5:708-719.
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MOBILISATION
KLEINERT, H. E. and SMITH, D. I. Primary and secondary repair of flexor and extensor tendon injuries. In: Flynn, J. E. (Ed), Hand Surgery (3rd edn). Baltimore, Williams and Wilkins, 1982 :220-241. SAVAGE, R. (1985). In Vitro Studies of a New Method of Flexor Tendon Repair. JournalofHand Surgery, lOB:2:135~141. SAVAGE, R. (1988). The influence of wrist position on the minimum force required for active movement of the interphalangeal joints. Journal of Hand Surgery, 13B:3 :262-26X. SLATTERY, P. G. and McGROUTHER, D. A. (1984). A Modified Kleinert Controlled Mobilization Splint Following Flexor Tendon Repair. Journal of HandSurgery, 98:2:217-218. STRICKLAND, J. W. and GLOGOVAC, S. V. (1980). Digitalfunctionfollowing flexor tendon repair in Zone II: A comparison of immobilisation and controlled passive motion techniques. Journal of Hand Surgery, 5:6:537543. TONKIN, M. and LISTER, G. (1986). Flexor Tendon Surgery-Today and Looking Ahead. Clinics in Plastic Surgery, 13:4:221-242.
Accepted: 4Aprill989 K. W. Cullen, Department Sheffield SS 7AU. Q 1989 The British
Society
of
Plastic Surgery, Northern General
for Surgery
Hospital,
Herries
Road,
of the Hand
0266-76X1/89/0014-0392/$10.00
395