Ruptured flexor tendon tenorrhaphies in zone II: Repair and rehabilitation Seven patients with ruptured flexor tenorrhaphies in zone II had surgical repair of the rupture and completed a second rehabilitation program of active flexion and extension exercises identical to that prescribed after the primary repair. The period between the primary repair and the rupture ranged from 14 to 72 days, with an average of 38 days. The period between the rupture and the secondary repair ranged between 1 and 14 days, with an average of 6 days. Four patients (57 %) achieved good to excellent active motion at follow-up. These results are comparable to those obtained by patients with uncomplicated primary repairs that were treated early with passive motion exercises. We conclude that prompt repair of ruptured flexor tenorrhaphies and rehabilitation with active motion exercises is effective and that it should be considered before one chooses flexor tendon grafting. (J HAND SURG 1987;12A: 18-21.)
Brent N. Allen, M.D., Gary K. Frykman, M.D., Robert S. Unsell, M.D., and Virchel E. Wood, M.D., Loma Linda, Calif.
T he management of acute rupture of pre-
viously repaired flexor tendon(s) in zone II is not clearly defined in the literature. Leddy! states that "the preferred treatment is prompt re-exploration and repair. ' , However, no series of such secondary repairs has been reported; neither has there been any reported research comparing flexor tendon repair in this situation with flexor tendon grafts. Many series of acute primary repairs in this area have a small percentage of failures from rupture. 2 -8 However, relatively little has been written on the treatment of the rupture when it occurs. 9 Serage7 describes three ruptures in a series of 69 primary repairs. Each rupture required two-stage reconstruction. Schneider et al. 4 describes two ruptures in a series of 51 primary repairs. One rupture was not repaired. The second rupture occurred 22 days after the initial repair; the patient underwent an attempted secondary repair that did not restore function. From the Department of Orthopaedic Surgery, Lorna Linda University School of Medicine, Lorna Linda, Calif. Received for publication July I, 1985; accepted in revised form March 28, 1986. This article was accepted for publication before July I, 1986. No conflict-of-interest statement wa, requested from the authors. Reprint requests: Gary K. Frykman , M.D., Department of Orthopaedic Surgery, Lorna Linda University School of Medicine, Lorna Linda, CA 92350.
18
THE JOURNAL OF HAND SURGERY
Materials and methods Data were collected on 61 patients who had primary flexor tendon repair at the Lorna Linda University Medical Center between 1980 and 1983. In every patient, the flexor tendon had been severed in zone II" and there were no associated fractures or thumb flexion injuries. In eight of these patients, the primary repair had ruptured. One patient declined repair of the rupture; this left seven patients in our series. The six men and one woman had an average age of 27.7 years. The long finger was involved in three cases, the index finger in two, and the ring and small fingers in one case each. Lacerated structures included both the flexor tendons, the palmar plate, and the digital nerves. The period between the rupture and secondary repair ranged between 1 and 14 days, with an average of 6 days.
Surgical technique of the primary repair All primary tendon repairs were accomplished within 6 hours of the accident. Tendons were repaired with the modified Kessler! technique, using a No. 4-0 Mersilene suture and an epitendinous running suture of No. 6-0 Mersilene. The sheath was similarly closed with a No. 6-0 Mersilene suture when possible. Adorsal plaster splint was applied with the wrist flexed 30°, the metacarpophalangeal (MP) joints flexed from 70° to 90°, and the interphalangeal (IP) joints protected against forceable extension but allowed potentially full and active IP extension against the tension of a rubber band. The rubber band was applied to a nail suture and, in
Vol. 12A, No.1 January 1987
Ruptured flexor tendon tenorrhaphies
19
Fig. 1. Patient no. 6 lacerated both flexor tendons in the middle segment of the index finger. Only the profundus ruptured, but exploration of the palm to retrieve and reconstruct the A2 pulley was required. Follow-up at 5 months. Flexion (A) and extension (8) 5 months after surgery.
tum, attached to the forearm dressing with a safety pin, drawing the finger into flexion.
Postoperative management of the primary repair Active extension exercises against the tension of the rubber band were begun on the first postoperative day. The patient was referred to the hand therapist within 2 to 5 days after surgery; at that time a new thermoplastic dorsal splint that was to be worn 24 hours a day was applied. The patient was to continue with the active extension exercises and was started on active and assistive flexion exercises that were to be performed 10 times an hour during waking hours. The patient was seen by the hand therapist once or twice each week.
After 3 weeks the dorsal splint was replaced with a wrist cuff that continued the traction on the finger. After 4 weeks I-ounce resistive exercises and weight-well exercises were added to the active flexion and extension exercises. The cuff was discontinued 5 weeks after surgery. At 6 weeks dynamic extension splinting was begun, and all activities except heavy lifting and squeezing were allowed. Patients who exhibited a tendency to scar excessively (i.e., to have 20 or less of active DIP flexion at 3 weeks) were put on a more aggressive hand therapy program that involved I-ounce resistive exercises at 3 weeks and the wrist cuff was stopped at 4 weeks (none of these patients ruptured the repaired tendons). 0
20
The Journal of HAND SURGERY
Allen et al.
Table I. Patients with repairs of ruptures flexor tendon tenorrhapies in zone II
Case No .
Segment of zone II'"
Age/sex
Hand
Finger
26 M
Left
Long
Distal
5
18 29 34 23
M M M M
Left Right Left Left
Small Long Ring Long
Proximal Middle Distal Distal
6
27F
Right
Index
Middle
7
37 M
Left
Index
Middle
Average
28
2 3 4
Structures lacerated FDP + one slip of FDS , palmar plate Both FDP + FDS Both FDP + FDS Both FDP + FDS Both FDP + FDS , palmar plate Both FDP + FDS, one nerve FDP + one slip of FDS, one nerve
Surgical technique of the secondary repair Ruptured tendons are sometimes not discovered until several days after the rupture occurs; consequently, in some of our cases, immediate repair was not possible. Most repairs were done electively as soon as they could be conveniently scheduled. We reopened the Bruner incision and skin was debrided as necessary. Repaired digital nerves were inspected to ensure that they had not ruptured. The repaired flexor tendon sheath was reopened , and the superficialis repair was inspected for a rupture . We cleared the tendon ends of the suture material and any ragged or frayed fibers were debrided, but we did not resect major portions of any tendon. The tendon was sutured with a modified Kessler suture of No. 4-0 Mersilenein most instances placing the transverse segment of the suture farther away from the cut tendon end than we had in the original repair. The suture through the epitenon was placed, and the sheath was repaired when possible. The incision was closed routinely without drains, and the patient received a first-generation cephalosporin antibiotic intraoperatively and for 2 days postoperatively. Postoperative management of the secondary repair After surgery all patients repeated the rehabilitation program outlined for primary repairs. Results All seven patients achieved full metacarpophalangeal (MP) motion (Table I). Strickland and Glogovac 6 noted that active MP mo-
Cause of injury Fan Knife Steel Glass Transmission Knife Knife
Activity of rupture Catching self from fall Exercising Tying knot Exercising Squeezing Pressing aerosol can Pushing with splint
Days between repair and rupture 37 72 28 27 39 46 14
tion does not depend on long flexor tendon function; thus, its measurement need not be considered. Instead, they measured total IP flexion, subtracted IP extension loss, and compared the total to a norm of 175°. A total greater than 150° is considered excellent, 125° to 149° is good, 90° to 124° is fair, and less than 90° is poor. By these criteria we achieved the following results: two excellent, two good, two fair, and 1 poor. A typical case is shown in Fig. 1. The patient with poor response developed a postoperative infection, which necessitated debridement of the flexor tendons . Discussion As the repaired tendons ruptured an average of 38 days after surgery, we believe the ruptures indicate a slowing of tendon healing rather than a failure of the sutures or of surgical technique. Strickland and Glogovac6 noted that 55% of patients with uncomplicated zone II repairs established good or excellent flexion when they were treated early with passive motion exercises . Four of our seven patients (57%) achieved good or excellent results . Although our study involved only seven patients, they had at least twice the operative trauma to the tendons as patients with uncomplicated primary tendon repairs, yet they eventually achieved comparable results. We believe that our group consisted of "non-scarformers," those who form less scar tissue than usual-that is, less adhesion and, perhaps, slowing of tendon healing. Our patients progressed well in the rehabilitation program and achieved excellent motion early. If rupture had not occurred, their results might have been among the best. We do not know if this group of patients had biologic
Vol. 12A, No.1 January 1987
Tendons ruptured and repaired
FOP
Ruptured flexor tendon tenorrhaphies
Days between rupture and surgery
Degrees of active motion at last follow-up MP
I
PIP
I
DIP
TAM
Percent of normal TAM (normal = 270)
IP TAM'
Months between repair and follow-up
0-90°
15-95°
0-65°
235
87
145
3
8
0-90° 0-90° 0-85° 0-90°
55-95° 20-90° 10-105° 10-90°
0-90° 0-70° 0-75° 1_40°
220 230 255 210
81 85 94 77
130 140 170 120
22 3 2 4
FOP
3
0-90°
0_105°
0-75°
270
100
180
5
FOP
14
0-90°
0_10°
0
100
37
10
34
6
0-89°
16-84°
0-59°
217
80
FOP,FOS FOP FOP,FOS FOP
7
7 I
differences or was simply more enthusiastic during rehabilitation. It appears that the repeat repair of the ruptured flexor tendons need not be performed as emergency surgery. Delays from a few days to a week did not prevent good results. There is probably a time span after which repair of the rupture is inappropriate, but we have not defined it. When repair is inappropriate a flexor tendon graft is indicated. Good results are more difficult to obtain in uncomplicated primary repairs delayed by I month, although Leddy! states that delays of up to 6 weeks are not prohibitive, especially in children. Poorest result was obtained after a delay of 14 days; however, the role of the delay and of the infection that developed in this patient is not known. Boyes and Stark IO reported on flexor tendon grafts in 19 patients, with failed primary repairs. Their results, reported only in the degrees of flexion, preclude complete comparison with our results; but, of their 19 patients, 12% could flex the fingertip to the distal palmar crease, and 69% could flex to within 2.5 cm of the distal palmar crease. Early exploration and repeat repair offer the advantage of not having to wait for the inflammation to recede, avoid the longer and more involved grafting procedure, and, it is hoped, avoid stiffness that can occur when the patient loses interest in rehabilitation. Repeat repair also saves the patient time away from work. Thus, we advocate the consideration of prompt repair of ruptured flexor tendon tenorrhaphies before choosing flexor tendon grafting. The authors thank Ms. Deborah Seibly, O.T.R., and Janet Waylett-Randall, O.T.R., for their assistance in the care of
21
Rating' Good
Fair Good
Excellent
Fair
Excellent
Poor
these patients and their helpful advice in the preparation of this article.
REFERENCES 1. Leddy JP: Flexor tendons-acute injuries. In Green DP, editor: Operative hand surgery. New York, 1982, Churchill Livingstone, pp 1347-74 2. Duran RJ, Houser RG: Controlled passive motion following flexor tendon repair in zones 2 & 3. In AAOS symposium on tendon surgery in the hand. St. Louis, 1975, The CV Mosby Co, pp 105-14 3. Jensen EG, Weilby A: Primary tendon suture in the thumb and fingers. Hand 6:297-303, 1974 4. Schneider LH, Hunter JM, Norris TR, et al: Delayed flexor tendon repair in no man's land. J HAND SURG 2:452-5, 1977 5. Becker H, Davidoff M: Eliminating the gap in flexor tendon surgery. A new method of suture. Hand 9:3068, 1977 6. Strickland JW, Glogovac SV: Digital function following flexor tendon repair in zone 2: A comparison of immobilization and controlled passive motion techniques. J HAND SURG 5:537-43, 1980 7. Serage H: Elongation of the repair configuration following flexor tendon repair in no man's land. J HAND SURG 8:182-5, 1983 8. Green WL. Niebauer 11: Flexor tendon repairs in no man's land. J Bone Joint Surg [Am] 56:1216-22, 1974 9. Lister G: Pitfalls and complications of flexor tendon surgery. Hand Clinics 1:133-46, 1985 10. Boyes JH, Stark HH: Flexor tendon grafts in the fingers and thumb. A study of factors influencing results in 1000 cases. J Bone Joint Surg [Am] 53:1332-42, 1971