Zone II Flexor Tendon Rehabilitation: A Proposed Algorithm

Zone II Flexor Tendon Rehabilitation: A Proposed Algorithm

correlation between even a minimal PIP joint flexion contracture and limited independent gliding of the FDP tendon (Evans, 1997). Purpose: We present ...

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correlation between even a minimal PIP joint flexion contracture and limited independent gliding of the FDP tendon (Evans, 1997). Purpose: We present a dynamic pulley system design to reduce the incidence of PIP flexion contractures following primary flexor tendon repair. The design incorporates a pulley placed between the finger line and dynamic tension. As a result, there is a subjective decrease in progressive resistance to finger extension. Method: This novel concept is illustrated in a single case involving a primary repair of the FDP tendon in zone II of the small finger. On the third postoperative day, a dorsal blocking splint with dynamic pulley system was fabricated. A combined early mobilization (Lister, 1977) and controlled passive motion (Duran, 1975) program was initiated. Active range of motion measures were collected for PIP joint extension and composite small finger flexion at 1 and 6 weeks. Results: Measures at day 3 demonstrated a 308 PIP active flexion contracture and measures at 6 weeks demonstrated a 08 active flexion contracture. Active composite flexion to distal palmar flexion crease for the small finger was 0.5 cm at 6 weeks. This measure was not collected at initial visit due to concerns regarding tendon healing. Conclusion: This dynamic pulley system appears to have the potential to reduce rehabilitation related flexion contractures while protecting the healing tendon from rupture. Additional investigation of this system is warranted to better understand the biomechanics of adding a pulley and its impact on the injured finger during rehabilitation. The presentation and further investigation of the dynamic pulley system provide another option for individual postoperative management of flexor tendon repair.

Clinical Management for Thumb Basilar Joint Mesh Arthroplasty. Kimberly Goldie Staines, OTR, CHT, Evans D. Collins, MD, John Thornby, PhD Introduction: Multiple surgical procedures are indicated in advanced stage thumb basilar joint osteoarthritis (OA). Use of a new biodegradable

polycaprolactone-based mesh implant (Artelon TMC Spacer: Small Bone Innovations, NY, NY) has shown promise in the management of younger and more active patients (Nilsson, 2005). The mesh implant is used to stabilize the basilar joint through augmentation of the joint capsule and resurfacing of the trapezium. For the purpose of this study, the placement of the mesh implant was altered from that described by the manufacturer to use the entire implant as a joint spacer. Although the surgical technique, indications, and histology have been reported, no clinical postoperative management has been described in detail in the recent literature. Purpose: This preliminary study will describe a clinical protocol for therapeutic management with statistical support from functional outcomes. Methods: A prospective convenience design was used to evaluate commonly collected measures following minimal therapeutic intervention in 5 patients. Measures collected include bilateral thumb total active range of motion (TAM) for the IP/ MP joint, thumb opposition to distal palmar flexion crease, grip strength (position II), tripod pinch strength, Functional Dexterity Test (FDT), Disability Assessment for Shoulder and Hand (DASH), and Patient Rated Wrist Evaluation (PRWE). Patients were evaluated preoperatively, and at 2, 4, 8, 12, and 24 weeks postoperatively. Patients were immobilized for 4 weeks postoperatively in a short arm cast, with a thermoplastic hand-based thumb opponens orthotic for an additional 4 weeks. At 4 weeks, an extensive home exercise program was issued for AROM including wrist flexion/extension, composite finger flexion/extension, thumb IP/MP flexion/extension, and thumb opposition. At 8 weeks, patients were issued putty strengthening exercises for finger and thumb strengthening, AROM exercises for thumb abduction, and gradual resumption of all activities of daily living by 12 weeks. Patients were seen in clinic for formal therapy visits at the time of data collection only. Results were analyzed using descriptive statistics and t-test analysis. Results: Participants’ age range was 42 to 66 years (n ¼ 5). Participant measures preoperative to 12 weeks

postoperative were found to demonstrate functional improvement for TAM in 3 of 5 subjects (mean, 129.88 ; SD, 27.398 ), opposition in 4 of 5 subjects (mean, 1.3 cm; SD, 1.2 cm), grip II in 5 of 5 subjects (mean, 26.69 kg; SD, 9.77 kg), pinch in 3 of 5 subjects (mean, 5.0 kg; SD, 1.68 kg), FDT in 3 of 5 subjects (mean, 34.6 sec; SD, 13.9 sec), and DASH in 4 of 5 subjects (mean, 29.99; SD, 26.7). Improvement in grip was found to be statistically significant from preoperative to 12 weeks postoperative measures (P ¼.0225). PRWE demonstrated improvement in frequency of pain occurrence in 4 of 5 subjects (mean, 3.0; SD, 1.87), average level of pain in 4 of 5 subjects (mean, 2.53; SD, 2.56), specific activities in 4 of 5 subjects (mean, 3.0; SD, 2.8), usual activities in 4 of 5 subjects (mean, 2.8; SD, 2.39), and composite score average in 4 of 5 subjects (mean, 2.92; SD, 2.43). Surgical revision was required on 1 participant who was on an immune-suppressive regime secondary to organ transplant. Conclusion/Relevance: Although results are preliminary, minimal therapeutic visits for the mesh arthroplasty as a joint spacer presents as a potential option for management of basilar joint OA. Grip strength was significantly improved and .50% improvement was noted in all other outcome measures. The fact that pinch strength and TAM did not improve to the same level as other measures may imply that increased formal therapy visits are indicated for full functional recovery after 4 weeks of immobilization.

Zone II Flexor Tendon Rehabilitation: A Proposed Algorithm. Stephanie Sato Sueoka, DPT, CHT, Paul LaStayo, PT, PhD, CHT Purpose: To describe an algorithmic approach to postoperative zone II flexor tendon rehabilitation with a controlled passive protocol. Description: An algorithm based on the available evidence and expert opinion will provide the platform from which a series of clinical questions and management approaches will be presented. Exemplar patients who progress appropriately and patients who experience the typical swelling, joint stiffness, impaired

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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