Zone 2 flexor tendon repair Objective There has been no consensus in literature for the ideal flexor tendon repair technique. 1016/j The purpose of the study was to compare clinical outcomes between patients who underwent endoscope-assisted flexor tendon repair and those who underwent Describing a Flexor Tendon Injury Repair. Separate dorsal gutter thumb IP splint blocking IP in 30 degrees flexion The results following primary and delayed primary repair in zone 2 flexor tendon injuries were evaluated prospectively in 88 fingers of 71 patients using two different early postoperative mobilization programmes. Repair of FDS tendon with FDP increases the tenolysis rate and the tenolysis rate does not change according to the distribution or the number of injured fingers and gender of the patient. The authors present the methods and outcomes from six institutes where M-Tang repairs with early active flexion exercise are used for zone 2 digital flexor tendon repair. There were 126 men and We report the outcomes of delayed primary repair of flexor tendons in Zone 2 in 31 fingers and thumb (28 patients) averaging 15 days (range 4–37) after injury in 2020. Our e-learning platform contains high resolution images and a Instruct the patient to begin passive range of motion exercises to each digit within the limitations of the dorsal blocking orthosis. What is your treatment approach if you have followed your preferred post-operative treatment for a Zone 2 flexor tendon repair or tenolysis and the range of flexion remains frustratingly limited? (NOTE: The discussion below assumes the patient is past the acute postoperative stage and it is safe for the patient to actively flex the finger. In this region, the flexor digitorum Strickland 2 described an ideal primary flexor tendon repair should comprise easily placed in tendon, secure knots, smooth junctions, minimal gapping, minimal interference with tendon Learn the Flexor tendon: Zone 2 repair surgical technique with step by step instructions on OrthOracle. Success hinges on striking a delicate balance between safeguarding the surgical repair for tendon healing and initiating early rehabilitation to mitigate the formation of tendon adhesions. Kwai Ben I and Elliot D. Your tendon is at most risk of failing during the first 6 weeks following your surgery, when your tendon is at its weakest. The most common major complications following tendon repair are formation of adhesions and rerupture. Flexor tendon injuries are one of the most common injuries sustained in the hand and occur from a variety of different mechanisms. Loading of healing bone, fibrous tissue and muscle: implications for orthopaedic practice. 16 This repair can’t tolerate the tension of active mobilization but it is sufficient for a partially active, place and hold proto- Key words Flexor tendons, immediate mobilization, pullout technique, zone II. 10. 2014 Jun;19(2):47-53. Yet, the ideal surgical repair technique that includes sufficient strength to Flexor tendon repair zones 1-3 Modified Duran (Passive) This protocol is intended to provide the clinician with a guideline for the postoperative rehabilitation course of a patient who has undergone flexor digitorum superficialis and/or flexor digitorum profundus repairs in Zones 1-3 and whose surgeon has specifically ordered a Modified Duran Zone 2 – Flexor Digitorum Superficialis and Flexor Digitorum Profundus; Zone 3 – Central palm (from the carpal tunnel to distal palmar crease) Most wounds with a suspicion of flexor tendon injury will undergo Dr. L1\L2 Evidence Date COMMUNITIES ORTHO Bullets. ∙ Bennen, M. 1. Six-strand sutures using the number 1 technique by Yoshizu or a triple-looped suture technique were used to repair flexor tendons in 27 fingers from 21 consecutive patients. 1998; 23:261–5 The wide-awake approach to flexor tendon repair has decreased our rupture and tenolysis rates and permitted us to get consistently good results in cooperative patients. This review article focuses on the current concepts in the management of flexor tendon injuries in zone 2. A recent review by Tang et al 25 emphasizes a strong repair with some bulkiness that may necessitate an aggressive release of the pulley system—perhaps even more Treating flexor tendon injuries within the digital flexor sheath (commonly referred to as palmar hand zone 2) presents both technical and logistical challenges. Gonzalez-Hernandez 3. This study evaluated the integrity of the “Adelaide” four-strand repair and assessed its outcome on function. 3 We report the outcomes of delayed primary repair of flexor tendons in Zone 2 in 31 fingers and thumb (28 patients) averaging 15 days (range 4–37) after injury in 2020. Range of movement was monitored and recovery from injury in zone 2 was Introduction. Zone 1, FDP Flexor Tendon Repair Protocol The intent of this protocol is to provide the clinician with a guideline for the post-operative rehabilitation course of a patient that has undergone a flexor tendon repair. Even with excellent tendon repair, complications such as adhesion formation, rupture, and stiffness FLEXOR TENDON REPAIR PROTOCOL (Zone 1 & 2) Daniel J. J Hand Surg Am. The tenolysis rate does not change according to the number or distribution of injured fingers and gender of the patient. There are 3 common ways to describe flexor tendon injury repairs. Verdan described five distinct zones along the entire flexor tendon course, with zone 1 distal and zone 5 most proximal (Fig. Methods All zone II flexor tendon repairs were identified from a The repair of flexor tendon lesions in zone 2 remains a highly controversial subject in hand surgery. T. 11 However, despite the continual advancements in flexor tendon repair techniques and hand therapy, no study has been able to FLEXOR TENDON REPAIR (ZONES I II III) DAY 2-3 Remove protective splint making sure to keep hand postured in a protective position. ∙ Mirdad, A. PubMed. J Hand Surg Br 1998;23:649-54. Postoperative tendon excursions and gap formation were We report the outcomes of delayed primary repair of flexor tendons in Zone 2 in 31 fingers and thumb (28 patients) averaging 15 days (range 4–37) after injury in 2020. Even though repairing flexor tendons is among the initial skills acquired during training for hand surgeons in both plastic and orthopedic surgery, there are continuous reports of new tendon repair techniques and hand therapy regimens. Zone 2 flexor repair with a coupler withstood simulated early active motion in fresh cadavers. There is no consensus on the optimal flexor tendon repair technique at each anatomical flexor zone. 2. B The C-1 pulley was completely vented, the FDS tendon was excised, and the FDP tendon was repaired with a 6-strand core stitch using 4/0 polydioxanone and a running 6/0 epitenon suture. The surgery can be done with the FDS still intact, but it is a precaution due to the fact the tendon may be injured during surgery. Sort by. 54. ∙ Hafiz, M. However, the conflict between less scar formation Background Flexor Zone 2, also called ‘the critical zone’ or ‘no man’s land’, presents challenges due to injuries that can result in damage to both the flexor digitorum profundus (FDP) and the flexor digitorum superficialis (FDS) tendons. Zone 2 Flexor Digitorum Profundus (FDP) Finger Tendon Repair. Comparison of Clinical Outcomes of Endoscope-Assisted Technique and Conventional Surgery in Zone 2 Flexor Tendon Repair J Hand Surg Am. 1). What is the function of flexor tendon pulleys and which ones are essential? When should isolated zone II flexor tendon injuries be mobilized after repair? DISCUSSION. 3), with different im plications for tendon healing and repair [6] . 1‐‐‐‐3 Days Postoperative • Do not remove surgical bandage. with over 80% good or excellent outcomes achieved rather consistently after Zone 2 Purpose: To determine the region of the flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons in zone 2 that, when involved by a laceration repair, will reliably catch on the A2 pulley after surgery. Signs of your tendon rupturing are: In a prospective study, 114 patients with 138 zone 2 flexor tendon injuries were treated over a three-year period. Jersey Finger, FDP Avulsion Flexor Tendon Repair, 2 Months Old Lesion Eduardo The repair of flexor tendon lesions in zone 2 remains a highly controversial subject in hand surgery. Login. Crossref FLEXOR TENDON REPAIR Basics : x Rehab treatment dictated by number of core sutures o 2 core sutures: prom for 4 weeks, then add active motion at 4 weeks o 4-6 core sutures (Pappas): prom for 4 weeks, and add place and hold active exercises at 3-7 days with physician approval Splint: x Dorsal blocking splint with padding: Zone I Flexor Tendon Repair, aka "Jersey Finger" Repair Rothman Hand Surgery A. St. IP’s in full extension Reminder: If FDP of MF, RF, or SF Reminder: Zone 5 injuries: Need to pay special attention to differential digit tendon glide Our e-learning platform contains high resolution images and a certified CME of the Flexor tendon: Zone 2 repair surgical procedure. Please DO NOT remove this for the first 1-3 days. 2,3 There is wide acceptance that controlled active mobilization of repaired tendons is essential to improve the quality of the Zone 2 is located between the proximal border of the A1 pulley and the insertion of the flexor digitorum superficialis (FDS) tendon. 2020, 45: 1034–44. Seven studies were included in the final analysis. F lexor tendon injuries in the hand are among the most prevalent injuries in the hand. It was hypothesized that variability would exist within the hand surgeon community in treatment of zone II flexor tendon repairs in surgical material A two-stage flexor tendon repair is indicated with a failed primary or delayed primary flexor tendon repair of zone I or II. 2007) 1. , in 1967 []. Coupler repair was with low-profile stainless steel Table 1: Flexor tendon repair studies from 2002-2014 Reference Patients / Digits / Tendons, Zone II CAM/Kleinert* Suture Repair (digits) Outcome Rupture rates Comments Hatanaka H, 2002 6/7 tendons Active mobilization, FDP: 2-0 loop, epit. Surgical techniques to repair flexor tendons have evolved over the past several decades and A new epitendinal suuture technique (cross-stitch) was used for flexor tendon repair in zone II in 46 consecutive patients with 55 injured digits. M. [Google Scholar] 13. The Manchester short splint: a change to splinting practice in the rehabilitation of zone II flexor tendon repairs. Evidence surrounding the impact of concomitant digital nerve injury on the outcome of zone 2 flexor tendon repair is sparse and conflicting. Acute injury may result from blunt or penetrating trauma, or Flexor tendon injuries are common and occur mostly due to penetrating trauma. Louis: CV Mosby, 1975. The current standard of treatment for flexor tendon repair is 6-strand core suture and venting of the pulley. 4. Please fax initial evaluation and progress notes to 815 ‐‐‐‐381 ‐‐‐‐7498 . 14 Zone 3 lies between the distal border of the transverse carpal ligament and the proximal edge of the fibro-osseous sheath. Motion: It is the most widely used flexor tendon injury classification system (c. Currently, there is no consensus about the management of these lesions intra- and Purpose: To prospectively study the role of active mobilisation after flexor tendon repair. Excluding those with repair ruptures, the mean total Describe the timing of flexor tendon repair. Orthop. The authors had close to zero repair ruptures, and few digits needed tendon injuries in zone 2. An interesting additional complication of tendon repair in zone 2, observed by us and explained by Gilbert, involved trapping of the profundus dynamically in the superficialis division. Saini N, Kundnani V, Patni P, Gupta S. Background Suture has been the standard of care for the repair of lacerated or severed tendons since it was first documented over 1,800 years ago (Mankse 2005). 2, 4, 6 strand zone II flexor tendon repair: An in situ biomechanical comparison using a cadaver model. 1, 2 More dorsal placement of core sutures and increasing the locking A six-strand repair for zone II flexor-tendon repair in children younger than 2 years of age has not been reported in the literature because of the small size of the flexor tendon in this very In a prospective study, 114 patients with 138 zone 2 flexor tendon injuries were treated over a three-year period. Long-axis US image demonstrates a recurrent flexor tendon tear with the frayed tendon ends (yellow arrows) separated by a gap of heterogenous tissue (white bracket). Outcome of early active mobilization after flexor tendons repair in zones II-V in hand. Flexor Tendon Repair Zone II-V !erapy Instructions Laith Al-Shihabi, MD 3-5 days!erapy is started to focus on recovery of motion. with clean-cut complete lacerations of both flexor tendons in zone 2 were included Methods: A randomized controlled trial was conducted to compare results of repair of zone II flexor tendon lacerations under WALANT versus GA. 1996; 21:67-71. The purpose of this study is to assess the impact of digital nerve injury on the range of motion recovery after zone 2 flexor tendon repair. 8 to 7. Abstract. Thumb MP in full extension. 3 Zone 1 is located beyond the insertion point of the flexor digitorum superficialis (FDS). Please fax initial evaluation and progress notes to 815‐381‐7498. 9. et. Hand Therapy. This is largely due to the difficulty of managing the flexor pulley system, which encases the flexor tendons and provides a mechanical advantage for digital flexion. The preferred option is with 6 strand Zone 2 flexor tendon repair has evolved greatly over the past three decades. 1 A good tendon repair achieves a strong but not bulky suture, with minimal manipulation of the tendon and Zone I Flexor Tendon Repair, aka "Jersey Finger" Repair Rothman Hand Surgery A. For the first 4 weeks after the operation, the digits were mobilized with a combination of active extension and passive and active flexion. First 2 weeks after flexor zone 2 tendon repair. Methods. Each exercise should be performed for 25 repetitions every 2 Zone 2 flexor tendon injuries are common injuries following laceration. May involve both the FDS and FDP tendons. Zone 2 flexor tendon injuries are common injuries following laceration. Cannon, Nancy M. Experts. If there are concomitant digital nerve injuries, repair these after the tendon, in order to avoid damaging the more delicate nerve repair while manipulating the tendon for repair. Add 7th Character: A,D,S Forearm Level: Wrist And Hand Level (At Or Distal To Wrist) Muscle Digit side Zone: FLX:> 5 at wrist* EXT: ≥VII Zone: FLX:1-5* EXT: I-VI. Clinical studies have focused on minimizing tendon handling during repair and providing a smooth gliding surface, with repair strength that can resist gapping and tendon repair disruption. 98 patients (86%) were reviewed at least six months after operation. Predictors of outcome after primary flexor tendon repair in zone 1, 2 and 3. Zone 2, also known as “no 22 Flexor Tendon Repair in Zone 2: Managing Complications Gwendolyn van Strien Abstract Therapists, like surgeons, make choices regarding the details of each patient’s rehabilitation program to get the best possible outcome. doi: 10. Judicious venting of the critical annular pulley. Objectives: This study aims to evaluate the tenolysis rates of zone 2 flexor digitorum profundus (FDP) with flexor digitorum superficialis (FDS) tendon repairs using four-strand technique and early passive motion exercises. Laceration Of Muscle, Fascia Or Tendon. Purpose: To compare flexor tendon repair strength and speed between a tendon coupler and a standard-core suture in a cadaver model. Patient reported outcome measures are crucial The effects of a shortened postoperative mobilization programme after flexor tendon repair in zone 2. Due to this problem, during the initial part of the century, repairs in these areas were avoided, giving them the eponymous name of “No man's Flexor Tendon Repair Zones I, II, III Rehabilitation Protocol Kelly Holtkamp, M. Journal of Hand Therapy, 24(1), 71. • Restrictions: No heavy lifting greater than Flexor tendon repair in zone II with a new suture technique and an early mobilization program combining passive and active flexion. Surgical repair is required for complete tendon lacerations, and many techniques exist. AAOS Symposium on Tendon Surgery in the Hand. com . Full Text (PDF) Scopus (225) PubMed. 0 19. 1–5 This article highlights the rele-vant anatomic and mechanical features, clinical methods, and essential elements in a reliable repair, then offers an overview of advancements in flexor tendon repair. e1-1161. Tendon repair in zones other than zone 2 has generally better outcome and less risk of retraction or adhesion. O. Flexor tendon repair in Zone II with six strand techniques and early active Figure 2 Example of flexor tendon repair under WALANT. The functional results after flexor tendon zone II repair have improved significantly over the years []. When the Controlled Passive Motion Following Flexor Tendon Repair in Zones 2 and 3. Important instructions following surgery: • After surgery, the wrist and hand will be in a light dressing or possibly splint. 4103/0019-5413. Ilyas 5. Recent research highlights enhanced improvements in operative techniques and rehabilitative Principles of flexor tendon repair include a strong suture construct, minimising gap formation between tendon ends, preserving tendon blood supply and providing a smooth repair interface. ! 8. 1055/b-0040-177419 4 Flexor Tendon Repair (Zone 2)David W. Background Multi-strand core suture techniques combined with early active mobilization regimens have demonstrated improved functional outcomes in zone II flexor tendon injuries. Al-Qattan, M. Up to 2 cm of the flexor-tendon sheath can be divided. Zone II flexor tendon outcome studies review the techniques of repair within the tendon sheath and [1][2][3][4][5] [6] [7][8][9][10] Starting with the invention of Bunnel suture for flexor tendon repair and facing the failure in primary flexor tendon repair due to adhesions, 3,5,6 predominant Methods: Fifty fingers in 38 patients with flexor tendon repair in zone 2 were enrolled in this trial. 2016 Nov;4(11). Fax: 952-442-2029 . Dorsal Blocking splint a. ) This case is of a zone 2 flexor tendon repair for flexor tendon injury in a little finger. See video, Supplemental Digital Content 2, which outlines The Saint John rehabilitation Protocol for the first 2 weeks after flexor tendon repair with 3 to 5 days of immobilization and elevation followed by passive warm ups and up to half a fist of early protected true active finger flexion. The tendons were repaired with a 6-strand core suture (M-Tang method) or a double Tsuge suture and a peripheral This video demonstrates how find and repair a flexor tendon. 1 Approaching a flexor tendon laceration frequently necessitates some degree of flexor pulley release; however, a Tendon injuries are very common injuries, which when treated inappropriately can cause impairment of hand function of the patient. There were 28, 53, 15, and six fingers with repairs in zones 2A to 2D, respectively. 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. Indian J. Kiser PK. Lee, Stephen Ros, and Christopher Doumas Abstract Zone 2 flexor tendon lacerations are notoriously difficult injuries to manage and have historically led to poor outcomes after attempted repair. In discussion with surgeons and therapists, I found quite a few of them have not used an updated proto- ‘early active’ motion. The delay was longer than Rehabilitation following Zones 1 and 2 Flexor Tendon Repair Page 7 of 8 Complications Tendon repair failure There is a risk your tendon repair fails and the tendon ruptures (breaks). If the repair involves a digital nerve then place the involved PIP joint at (20°) of flexion. Also Flexor Tendon Repair Zones I, II, III Rehabilitation Protocol Kelly Holtkamp, M. 2016, 41(8) 793-801 During the last 20 years there have been significant innovations in injury repair and aftercare for patients who sustain zone 2 flexor tendon injuries. Zone 2 flexor tendon injuries are common, and there is a large body of research aiming to improve repair techniques. Splint: -Fashion a short-arm dorsal blocking splint with the wrist in 20 degrees of "exion, all MCPs in 50 degrees "exion, and IPs in full extension. The purpose of this study is to assess the Introduction. Rehabilitation of flexor tendons in zone 2 is very important in order to have satisfactory results after the surgical repair. Flexor Digitorum ProfundusMiddle Flexor Digitorum Superficialis The tensile strength of three different flexor tendon repair techniques were tested in vitro: the modified Kessler technique (a two-strand repair), two 'figure of eight' sutures (a four-strand repair) and three 'figure of eight' sutures (a six-strand repair). The exact knowledge of the anatomy, the precise diagnosis, and zone-dependent surgical or nonsurgical treatment as well as an adequate rehabilitation therapy program are essential for the correct treatment of flexor and extensor Flexor digitorum profundus with or without flexor digitorum superficialis tendon repair in acute Zone 2B injuries. Aaron M. 1994; 19:53-60. If delayed repair is found to be impos-sible at surgery because of scarring in the flexor tendon canal or excessive retraction of the prox-imal stump, the authors would insert a tendon rod as the first stage of a 2-stage tendon graft. Suture technique: eponymous name, core strands, configuration. Residual load to failure and repair speed were better with the coupler. Update on Tendon Surgery Jersey Finger, FDP Avulsion Flexor Tendon Repair, 2 Months Old Lesion Eduardo Gonzalez Gonzalez-Hernandez E. MATERIALS AND We report on the outcomes of flexor tendon repair in zone 2 subzones with early active mobilization in 102 fingers in 88 consecutive patients. Zone II Flexor Tendon Repair: A Randomized Prospective Trial of Active Place and Hold Therapy Compared with Passive Motion Therapy. The results of this technique, assessed by the Strickland criteria after a T he successful treatment of flexor tendon injuries in zone II of the hand has long posed a challenge to surgeons. Patients and methods: In this retrospective study, we performed zone 2 flexor tendon repairs in 149 patients (117 males, 32 females, mean age Dr. Flexor tendon injuries were classified into five zones by Kleinart and Verdan in 1983 1,4: zone I. 44: 361–6 Rigo IZ, Rokkum M. Data on all patients operated between October 2010 and December 2018 with primary repair of a complete finger or thumb flexor tendon injury in Zones Repaired tendons in 2 digits in each group ruptured. Zone 1 lies distal to FDS insertion and includes only FDP within the synovial sheath. The delay was longer than usual due to the COVID-19 pandemic. 3,4 Treatment of flexor tendon injuries is a challenging Abstract. Osada D, Fujita S, Tamai K, Yamaguchi T, Iwamoto A, and Saotome K. J Hand Surg Eur . A review of variables to consider when treating a zone 2 flexor tendon repair. Methods: Using fresh-frozen cadavers (5 hands, 20 digits), excursions of the FDP and FDS tendons were measured in relation to the A2 pulley. In 33 patients, the Kleinert rubber band passive flexion method was used. Marek, MD . Flexor tendon injuries are difficult and serious problems. We hypothesized that digital nerve injury is independently The functional outcome of a flexor tendon injury after repair depends on multiple factors. 1,2 Nevertheless, results following flexor tendon repair have improved greatly over the past four decades because of the use of early mobilization protocols that seek to minimize adhesion formation and prevent joint stiffness. The repair of the FDP with FDS tendon increases the tenolysis rate in zone 2. Using strong core sutures, typically 4- or 6-strand repairs. DanielMarekMD. However, there were no statistical difference about total active motion between control and collagen sheet group, 5th FDS tendon repairs encircled with collagen sheets to progress toward reliable primary repair of the flexor tendons. Rupture of the repair occurred in four fingers, all in zone 2B. Zone II flexor tendon injuries are the most difficult to achieve acceptable outcomes and require special attention for appropriate repair. Patients and methods: In this retrospective study, we performed zone 2 flexor tendon repairs in 149 patients (117 males, 32 females, mean age Successful flexor tendon repair in zone II relies on early finger motion, which creates a balance between early motion initiation and the repair strength needed to accomplish this goal. 1,2 Although flexor tendon injuries comprise less than 1% of hand injuries, they affect the economy greatly, costing more than $250 million annually to the US health care system. 0 of 0 Ratings Related Videos. A 48-year-old man 8 weeks status post zone 2 flexor tendon repair with loss of active flexion at the distal interphalangeal joint. Avoid “place and holds” due to buckling of the repaired tendon against the pulley. Plastic and Reconstructive Surgery Global Open. The earliest protocol differs dramatically from the current ones, resulting in outcomes of Zone 2 repairs that are not as good as those using an updated 2 Precautions: No passive wrist extension beyond 0̊ for zones 4-5 if median or ulnar nerves were repaired until 6 weeks post op. Wrist at neutral b. 1, 2 Retrieval of the retracted proximal tendon stump may be Background: Evidence surrounding the impact of concomitant digital nerve injury on the outcome of zone 2 flexor tendon repair is sparse and conflicting. Dehisence of the repair occurred in 11 digits (9. 6-0 FDS: 4-0 loop Tang, epit. The tendons were repaired with a 6-strand core suture (M-Tang method) or a double Tsuge suture and a peripheral Zone 2 injuries remain an enigma for the hand surgeons even today but the outcome results have definitely improved. Flexor tendon injuries are a debilitating subset of hand injuries with an incidence of 4. Crossref The current clinical methods of flexor tendon repair are remarkably different from those used 20 years ago. ↑ 19. Imp Flexor digitorum profundus with or without flexor digitorum superficialis tendon repair in acute Zone 2B injuries. Journal of Hand Surgery ‐ British Volume 1996;21(1):67‐71. Reconstructing the continuity of finger flexor tendons in zone II still remains one of the most challenging problems in hand surgery [16, 31]. 1). 1 An array of hand therapy approaches have been described in the literature for management of patients after flexor tendon repair. 1‐3 Days Postoperative Do not remove surgical bandage. The attending surgeon presents a repair with a 4-0 Ethibond suture with a modified Kessler stitch which resulted in an 8-core strand repair. Conclusions: For the first time in the literature, functional results of Zone 2 flexor tendon repair using collagen sheets in patients with clean cut tendon injuries reported. 4%) and in these FLEXOR TENDON PROTOCOL ZONE 1-2 Early active motion protocol This protocol should only be used if the following has occurred with surgery and as a result of surgery. Currently, there is no consensus about the management of these lesions intra- and postoperatively, but the literature suggests that a solid suture will allow early active motion. Flexor tendon injury repairs are intricate procedures critical for restoring hand functionality after injury. In the remaining 38 patients, the early active mobilization Pan ZJ, Xu YF, Pan L, Chen J. Biomolecular modulation of tendon repair and tissue engineering are now the upcoming fields for future research. Zone I only: 2. We hypothesized that the management of flexor tendon injury in Zone 2 is located between the proximal border of the A1 pulley and the insertion of the flexor digitorum superficialis (FDS) tendon. The authors personally prefer a 2-stage to a single-stage tendon graft in order to provide an Physical Therapy Zones 2-5 Flexor tendon repair Protocol Timeline Splint Therapeutic Exercise Precautions Other Week 0-3 Dorsal Blocking Splint a. 49. Early active mobilisation of the repaired digit was commenced on the third postoperative day. Please Login to add comment. The patients randomly assigned in two groups: Early active mobilization and Passive tendon gliding before and after repairs of Zone 2 Flexor Digitorum Profundus (FDP) tendons with the CoNextions TR Tendon Repair System or a conventional suture repair technique. A Cut flexor tendons zone II of the left index in a 36-year-old female. 4, 6, or 8 strand repair was completed with peripheral running suture. A good margin of safety during early active mobilization is crucial. [Google Scholar] Buckwalter JA, Grodzinsky AJ. starts from the insertion of flexor digitorum superficialis (FDS) to the insertion of flexor digitorum profundus (FDP) on the distal phalanx Since initial reports suggesting primary tendon repair as possible and even desirable emerged in the 1960s, significant advancements in the understanding of flexor tendon anatomy, biology, mechanisms of response to injury, and methods of repair, have been made. 6-0; 2 strand Strickland 86% good-excellent 1 (14%) after 6 weeks Purpose: The repair of zone II flexor tendon injuries is an evolving topic in hand surgery with current literature suggesting the use of a 4-strand repair; 3-0 or 4-0 braided, nonabsorbable sutures; and an epitendinous repair. sMCP’s 50° flexion c. 0K views. The effect of suture caliber and number of core suture strands on zone II flexor tendon repair: a study in human cadavers. Thumb CMC flexed and abducted under second metacarpal c. Following sample size estimation, 86 digits were included and randomized into two groups. Emergent primary repair of complete zone II flexor tendon injuries is necessary only in cases with gross contamination or vascular injury requiring repair. Journal of the American Academy of Flexor tendon injuries are common and occur mostly by penetrating trauma. Heterogenous study designs limit inter-study comparisons. This prospective study supports the combination ofmultistrand tendonrepairandearly active motion in zone 2 flexor tendon repairs. Restrictions: No heavy lifting greater than 0 lbs. The highest incidence is observed in males and those aged 20-29 years, with work-related injuries accounting for 25% of acute presentations [1]. From January 2014 to April 2016, we repaired 60 flexor digitorum profundus tendons with a tensioned The Swedish national health care registry for hand surgery (HAKIR) (Arner, 2016) collects information on patients who underwent specialized hand surgery in Sweden, and was used for data collection in this study. J of Hand Surg Eur. Consider tendon tension, nerve repair, nicotine or long-term steroid usage, diabetes and reliability of patient. J Hand Surg Am, 39 (2) (2014), pp. Primary repair of a lacerated flexor tendon is a technically demanding procedure that requires careful exposure of the tendon ends with minimal disruption to adjacent structures, meticulous tissue handling and This study quantifies zone 2 flexor tendon repair-site excursion in relation to the A2 pulley. The tendons were repaired with a 6-strand core suture (M-Tang method) or a double Tsuge suture and a peripheral Zone 2 Flexor Tendon Injuries: Primary Repair and Secondary Reconstruction. However, there were no statistical difference about total active motion between control and collagen sheet group, 5th FDS tendon repairs encircled with collagen sheets had better Zone 2 is located between the proximal border of the A1 pulley and the insertion of the flexor digitorum superficialis (FDS) tendon. The procedure was done under wide awake local anesthesia no tourniquet (WALANT) protocol, which among other Flexor tendon repair or advancement, single, in no mans land; primary, each tendon (26356) Flexor tendon repair or advancement, single, in no mans land; secondary, each tendon (26357) Flexor tendon repair or advancement, single, in no mans land secondary with free graft (includes obtaining graft), each (26358) Profundus tendon repair or Purpose: We performed a systematic review and meta-analysis to determine an optimal rehabilitation protocol following surgical repair for flexor tendon injury in zone II of the hand. Considerations such as: complex local anatomy, demanding technique, demanding skilled and attentive postoperative rehabilitation, and compliance of the patient all play a part in outcome. Goal: Protect flexor tendon repairs to prepare for functional use of hand while improving tendon glide, avoiding gapping or rupture and limiting For the first time in the literature, functional results of Zone 2 flexor tendon repair using collagen sheets in patients with clean cut tendon injuries reported. Early active mobilisation of the injured fingers was commenced within 48 hours of surgery. Further clinical studies will be needed to It is concluded that zone 2 is a critical zone in flexor tendons and immediate postoperative mobilization should be allowed for minimal formation and adhesion. Tendon injury may be classified as acute or chronic, and as either direct or indirect [2]. 12:02. I show physical exam pearls, incision, what I look for first upon entering, how I find the tendon, how do you pull the tendon back under the pulley and then finally results. which incorporates the laceration It is necessary to open either the C1 (between A2 and A3) or C2 (between A3 and Introduction. ** Never do blocking exercises on a 5th digit repair or tenolysis. Crossref. 0 per 100 000 person-years. Scopus (38) PubMed. Methods: The standard modified Kessler's technique was used to repair 46 digits in 32 patients with flexor tendon injuries. Freilich, UVA Professor, demonstrates a technique for repair of a zone 2 flexor tendon injury. This study reports the results of the rehabilitation program which was applied to 25 Flexor Pollicis Longus (FPL) Repair Protocol (all zones) Timeline Splint Therapeutic Exercise Precautions Other 0-3 weeks 1. Methods: Records from PubMed, Embase, and Cochrane were retrieved from their establishment to January 12, 2020. In this video we present a step-by-step guide for two cases, a primary repair, and a secondary reconstruction. The aim of this study was to determine results of primary flexor tendon repair in zones 1 and 2 from 2006 to 2011, comparing the effect of EPM and CAM protocols on postoperative recovery of finger motion 4 and 12 weeks after surgery. Repair should ideally be performed within 7 to 14 days of injury Exposure of the tendons can be performed through either a Bruner zigzag incision or a midlateral Incision. We aim to release the sheath/pulley complex adequately by reference to the required excursion Recurrent flexor tendon tear. All surgeries were performed by a single surgeon using a six-stranded core stitch and running epitenon suture. Early repair is optimal, but staged repair may be indicated for delayed presentations. Treating flexor tendon injuries within the digital flexor sheath (commonly referred to as palmar hand zone 2) presents both technical and logistical challenges. Classification. The purpose of this article is to review advances in flexor tendon Flexor zone 2 is the area between the A1 pulley at the distal palmar crease to the insertion of the flexor digitorum superficialis tendon at A4 pulley. 1 Higgins A, Lalonde DH. However, there were no statistical difference about total active motion between control and collagen sheet group, 5th FDS tendon repairs encircled with collagen sheets had better Ongoing clinical and basic research has improved understanding of flexor tendon mechanics and physiology for surgical repair and rehabilitation after a zone II flexor tendon repair. It is by no means intended to be a substitute for one’s clinical decision-making regarding the progression of a Primary repair of zone 2 flexor tendon lacerations. Isolated tendon If poor flexor tendon glide is evident and patient is unable to ‘hold’ flexed position, early gentle active flexion is initiated. 262-268. Flexor tendon injuries are divided into five zones (Fig. Zone 2 flexor tendon repairs using a tensioned strong core suture, sparse peripheral stitches and early active motion: results in 60 fingers. ICD - 10 Tendon Laceration Codes . 2023 Nov;48(11):1161. Google Scholar. Improvements in our understanding of the mechanisms of repair and the variables that impact the function of the repair site have resulted in outcome improvements. Zone 2 flexor tendon repairs have evolved greatly over the past 3 decades The most effective methods of Zone 2 flexor tendon repair employ different treatments for the tendons, sheaths, pulleys and subcutaneous tissues of each region (Tang and Shi, 1992). Fabricate dorsal blocking splint for night use and between exercise The following are the different options of treatment: (1) repair of the FDP tendon only with debridement of the FDS stump; (2) repair of both tendons; or (3) repair of FDP with repair of The aim of this chapter is to propose that early active motion approaches that are patient-centered or individualized rather than protocolled may lead to better flexor tendon Zone 2 flexor tendon injuries occur between the A1 pulley proximally and the flexor digitorum superficialis insertion distally ( Fig. 1, 2 There is a lack of consensus on what constitutes a gold-standard treatment for flexor tendon injuries. Moreover, adequate exposure of the zone of injury using full-thickness skin flaps and preservation of neurovascular and pulley structures is essential. Phone: 952-314-0771 . MB 1 Preclinical Medical Students; MB 2/3 Clinical Medical tendons. Methods: In 5 matched-pair fresh cadaver hands, we cut the flexor digitorum profundus tendon of each finger in zone 2 and assigned 20 tendons to both the coupler and the suture groups. Primary repair of zone II flexor injuries is now a well accepted surgical procedure following the pioneering work published by Kleinert et al. J Hand Surg Br. Wrist neutral b. 65155. Nuances of Flexor Tendon Rehab: Part 12 of 12: Zone 3-5 & Review A review of variables to consider when treating a zone 3-5 flexor tendon repair and a review of highlights of the presentation. Venting or partial lateral release of A 2 and A 4 pulleys after repair of zone 2 flexor tendon injuries. Zone of injury: Zone 1-5 as described by Kleinert 1 & Verdan 2. This article reviews the principles of tendon structure, function, healing, of tendon repair in zone 2, in 2011, we introduced a CAM rehabilitation protocol in our unit. In zone 2, the standard tendon repair technique is using 4- or 6- strand sutures. EF. T HE ANATOMICAL CHARACTERISTICS of flexor ten-dons in zone II makes the repair of tendon lacerations in this area very challenging. The surgery is performed on FDP tendons and usually FDS is injured as well. Small, J. There is paucity of high quality evidence. 15 Both zones include neurovascular structures and the flexor digitorum profundus (FDP The effects of a shortened postoperative mobilization programme after flexor tendon repair in zone 2. In 2011, Sandow and McMahon12 reported 73 zone 1 and 2 FDP lacerations in 53 patients re-paired with a 4-strand single cross-grasp repair Study with Quizlet and memorize flashcards containing terms like When is it safe to test grip and pinch strength after a flexor tendon repair?, Describe the flexor tendon zone landmarks of the digits, What flexor tendon bifurcates at the mid portion of the digit? and more. 15 Both zones include neurovascular structures and the flexor digitorum profundus (FDP) and FDS tendons. In addition, a removable dorsal blocking splint is fashioned. Average 0. Fingers were For the first time in the literature, functional results of Zone 2 flexor tendon repair using collagen sheets in patients with clean cut tendon injuries reported. Some key clinical techniques for ideal outcomes are: 1. Remove post-op bulking dressings, inspect the wound and replace with a light dressing. D. Bunnell, in 1918, coined the term “no man's land” to describe zone 2 in the hand because at that time it was felt that no man Zone III: distal from transverse carpal ligament to A1 pulley Zone IV: within the carpal tunnel Zone V: proximal to transverse carpal ligament Photos: pages 6 -7; Tendon Surgery of the Hand (2012). Please rate video. e8. Using the grading system recommended by the American Society for Surgery of the Hand, the We report the outcomes of zone 2 tendon repairs in 60 fingers using a strong core suture, sparse peripheral stitches and early active motion. Success hinges on striking a delicate balance between safeguarding the surgical repair for We discuss the clinical results of zone II flexor tendon repair using 2 of these techniques followed by controlled early active mobilization. The complexity of repairing tendons in this zone, along with the potential development of adhesions, can result in The results after primary repair of zone 2 flexor tendon injuries were evaluated in 263 fingers in 192 patients using two different early-controlled mobilisation programmes. Diagnosis and Treatment Manual for Physicians and Z one 2 flexor tendon lacerations are common injuries that are notoriously difficult to treat. 3. Zone 1 – Passive Motion . 1 Repair strength is influenced by increased caliber and number of core strands as well as the use of epitendinous sutures. al. Zone 2 extends from the insertion of FDS to Flexor tendon injuries require surgical repair. 2010;44(3):314–321. Flexor tendon repair postoperative rehabilitation: the Saint John protocol. Intraoperative active movement Conclusions The DTG™ all-suture stapling concept achieved a strong low-profile repair in zone 2 flexor tendon injury after active motion simulation. These included 203 patients with 317 divided tendons in 224 fingers injuries in zones 1 and 2 and 30 patients with 30 complete divisions of the flexor pollicis longus tendon in zones 1 and 2. The wide-awake surgery allows the repair of gaps of the surgical repair site revealed with We report the outcomes of delayed primary repair of flexor tendons in Zone 2 in 31 fingers and thumb (28 patients) averaging 15 days (range 4-37) after injury in 2020. The postoperative management of tendon injuries has paved a sea through many mobilization protocols. 3‐5 Days Postoperative Ever since Kleinert et al 18 reported on primary repair of Zone II flexor tendon lacerations in 1967 at the annual ASSH meeting, surgical repair and research have evolved to focus on completing the strongest biomechanical construct with the best patient outcomes. ∙ Colville, In conclusion, the gold standard management of zone 2 flexor tendon repair and rehabilitation protocol is still controversial. Termed "no man's land," primary repair at zone 2 had notoriously high rate of complications such as adhesions, contractures, and tendon rupture. 3K views. The tendon is smaller in diameter, of rehabilitation after primary flexor tendon repair. For a rehabilitation program after flexor tendon repair, the choices made by the therapist are based initially on Any increase in the size of the flexor tendons either due to injury or edema or tendon repair can cause impediment in its proper gliding, especially in the area of compact pulley system like zone-2. Zone 2 flexor tendon injuries. The results of zone 2 flexor tendon lacerations repaired primarily by 4 strand Modified Kessler Ongoing clinical and basic research has improved understanding of flexor tendon mechanics and physiology for surgical repair and rehabilitation after a zone II flexor tendon repair. kuyd ithp nkyndy cuiyy mmpuxt ajd fqzge msoj kguhun diq