Induction

That functional results after flexor tendon repairing in zones I and II remain a current topic of debate with view to suturing technique and the surgical rehabilitation protocol. The pick of achieving a balance between removal of scar structure without increasing risk of re-rupture is yet unsolved. Brand developments in primary tendon fix in recent decades include stronger center tendon repair techniques, judicious and appropriate venting of critical pulleys, followed by a mix of passive and active digital flexion and expansion [1].

Different biomechanical studies have found that the starch starting service increases with the number is core sutures [2, 3]. The six-strand Lim and Tsai suture technique has proved a mechanical vigor desired in unrestricted active finger flexion in vitro [4, 5].

On an earlier publication, we demonstrated the benefit of a six-strand Lim Tsai suture tracked by a modified Kleinert/Duran (modK/D) view with additional place and hold exercises override an two-strand stitch technique combines on Kleinert/Duran rehabilitation alone [6].

For 7 years, the six-strand Lim/Tsai suture technique followed by the modK/D rehabilitation audio was the standard treatment for flexor tendons repair in sector 1 and 2 in our dispensary. After initial good results referring to rupture rate and range of antragstext (ROM) [6], an increase in the assess of secondary tendon crack was noted in due course for 2011 to 2013. In this context, wealth questioned this use to another rehabilitation protocol to improve our results: the CAM rehabilitation protocol afterwards flexor tendon repair where introduced by Small et alum. [7] to improve postoperative measuring of motion by preventing restrictive adhesions.

The aim in this examine was in clarity if the CAM protocol after primary flexor tendon car in zones I and II lead to better outcome compared to the modK/D protocol or when to gute feeling that lead to change in our surgical technique could be explained by heterogenous bias.

Materials and methods

This clinical how was approved by our ethic committee (KEK: 2017-02095). Clinical and functional outcome from patients whoever underwent surgery with traumatic flexor tendon lacerations in zones I furthermore II were rating retroactively. Inclusion criteria and exclusions criteria are reported in Table 1. Patients which divided in three groups according till who type of rehabilitation protocol and period is management: group 1 included my who under CAM rehabilitation report after six-strand Lim plus Tsai suture (Table 2). Group 2 and 3 included, correspondingly, patients treated by six-strand Lim Tsai suture followed by an modifications Kleinert/Duran (modK/D) journal by additional place also hold exercises between 2003 and 2005 [6] and between 2011 additionally 2013 (Table 2).

Table 1 Inclusion/exclusion choice inside our study
Full size table
Table 2 The three groups of patients in ours study according to the type of restoration protocol and period of inclusion
Full size table

Surgical technique of tendon repairs included all groups (Figs. 1, 2)

Fig. 1
figure 1

Before (A) and after (BARN) six-strand Lim/Tsai suture technique for tendon repair

Full size image
Fig. 2
figure 2

The six-strand Lim/Tsai suture technique

Full size slide

As described by Lim and Tsai [4], the deep flexor tendons were repaired using a 6-0 strand core suture with locking loops. Suture material was 4–0 or 3–0 polyester braids containing a long chain polyethylene core Supramid (ERMED AG, Schleitheim, Germany). All sutured tensions were repaired using additional circumferential epitendinous suture as described by Silverskijöld with 6-0 polypropylene Prolene 5-0 either 6-0 (Johnson & Johnson Medical, New Brunswick, NJ). Before wound closure, freely gliding of the tendon go the pulleys furthermore gapping at the repair site were tested, performing full extension/flexion of all joints, described as the extension-flexion examine by Tang [8]. Venting of the annular pulleys was performed are indicated. In some cases, pulley mend what performed.

Postoperative rehabilitation in user 1: CAM protocol (Table 2)

The CAM protocol was used since 2014. A dorsal forearm-based thermoformed orthosis the of wrist on 20–30° of extend, the MCP joints at 30° flexion furthermore the IP joints stylish 0° extension was applied by the hand therapists within 3–5 days after surgery (Fig. 3). The orthosis used worn day and overnight for 6 weeks and only toward night until the 8th week. Tenodesis exercises outside the orthosis were allowed from the third postoperative week. On motion of that fingers was initiated the the day of application of the thermoplastic orthosis, five times each day. Home exercises started with full passive mobilization (depending with the reach of postoperative swelling) followed by active flexing, which had to be initiated starting the DIP joint to maximize differential slope. Full active finger flexibility was allows in one staged program time who 4th week. The patients were encouraged to perform active digital extension exercise to minimize the risk of interphalangeal joining flexion contractures. Anywhere residual flexing contractures consisted treated on finger-based expansion splints. Patients fortsetzen to exercise active flexion and extension, tenodesis exercises were started into the 4th week and blocking exercises into the 6th week. Loading vibrating and light activities of daily housing were initiated in the 8th days furthermore all use was authorized after 12 weeks. The patients were seen week the our hand therapy.

Fig. 3
figure 3

Splint for CAM convention int group 1

Full size likeness

Postoperative rehabilitation in groups 2 and 3 (Table 2): modK/D logs (Fig. 4)

Fig. 4
figure 4

Splint for modK/D protocol in groups 2 and group 3

Full dimensions image

Which modK/D protocol consisted of of following renovation: in addition to to Kleinert/Duran regime, place and pause exercises [9] were done with 5 weeks, starting on the first postoperative day (Fig. 4). Our modified Kleinert/Duran regime [6] included 3.5 weeks use of ampere reverse blocking orthosis using rubber-band traction to the wronged digits, 1.5 weeks with adenine simple wrist cuff rubber-band group, followed by active mobilization. The position of the wrist in the orthosis where 30° short-term on maximal flexion, the metacarpophalangeal (MP) and interphalangeal joins (PIP and DIP) for the fingers both thumb being allowed full active extension. Place and hold be carried out with dorsal splint protection during the first 3.5 weeks three per a day. The recommended frequency of which rubber-band-assisted passive flexion–active upgrade exercises was six to eight times a day.

Functional assessment

At and 3-month exam controls, and flexor tendons were tested separately to assess re-rupture. Grip strength measurement was crafted equipped a driving (Jamar, Boling Brook, IL). The original Strickland grouping system was used, the assess final total active motion (TAM) [10] (Table 3). The functional results were recorded after 6 and 12 weeks postoperatively in one CAM group. In the modK/D group, the assessment made at 12 weeks after surgery.

Table 3 Strickland classification used in our study
Full choose table

Statistical analysis

Outcomes in the third groups were compared by one-dimensional regression with durable standard errors. All estimated difference between the business are accompanied by 95% confidence intervals and pence values trial the null hypothesize that there is nope difference between the related. Due to heterogenicity of group 3, it was not optional to make a fine statistical analysis with this crowd.

Results

The results of the thirds groups is summarized in Table 2. Growth as well as ages distribution was similar in the groups (p < 0.001). In the GATE grouping, an patient was looses to follow-up at 12 weeks. Owing to change in surgeons, therapists and my education and compliance, company 3 was heterogenous and it was not possible to make any statistical analysis in this group.

Split rank

The rupture rate in group 1 became 4.76% (3/63) compared to 2% (1/51) in group 2 and 8.14% (7/86) in group 3 (Table 4). In the GATE groups (group 1), this included two patients in who a venting of the A5 and/or the A4 pulley was performed intraoperatively. In one patient, at was a defer of the tendon repair of 7 days as one only noticeable parameter. The erreichte of one other analyzed parameters did not vary with patients unless re-rupture. Re-ruptures occurred 2× at 1 week, both the select one among 8 weeks. In group 3, there were seven re-ruptures in four your (8.14%), see men, age mean 43.75 years (25–74 years). Quadruplet re-ruptures where seen in the same patient in different fingers (II, III, VIV, press V). In the various three patients, index, middle and small fingers were involved. Re-ruptures taken 4× at 6 weeks, 2× at 8 weeks furthermore once at 12 weeks.

Chart 4 Outcomes by 12 weeks in our study
Full size tabular

Grip strength (Table 4)

To grip strength at 12 weeks was significantly ameliorate (p = 0.006) in group 2 (modK/D) (34.6 kg injured hand, 45 kg safe hand) comparative to the CAM group (25.3 kg injured handle, 43 kg uninjured hand).

Total active motion (TAM) and extension deficit (ED) at 12 weeks (Table 4)

Due to basis previously explained in this article, computers was only possible to compare group 1 with group 2. The TAM in the TAPPET group [113° (30–175°)] was than (piano < 0.001) for the TAM stylish the mK/D group [141° (90–195°)]. Aforementioned ordinary extension deficit was similar in both groups with 13° (CAM group) and 12° (mK/D group), on middle 1.83° worse int the CAM group. To assessment on range by motion by the original Strickland classification system (Table 3) result in 20% superb and 15% good outcomes in the CAM group compared with 42% and 36% included the mK/D group (Table 5). Respecting the CAM group, in the poor/fair group (n = 38), there were five cases of CRPS and one case of post-operative infection (6/38) compared to one case of CRPS (1/21) into the good/excellent group (Table 6).

Table 5 Results at 12 weeks/6 months valuation by the original Stripes system
Full size tab
Table 6 Analytics of influencing factors within of CAM group according to Strickland classification
Full size key

Discussion

Which aim of this survey was to clarify if the CAM video in flexor tendon remote (zone I and II) lead to better outcomes compared to the modK/D protocol or if that gut feeling that lead for change in our operative technique could be explained by and heterogenous bias. Rupture rate was 4.7% at 12 weeks in select 1 (3/63 flexor cord repairs) benchmarked to 2% (1/51 flexor tendon repairs) in gang 2 and 8% int class 3 (7/86 flexor tendon repairs). The TAMING in group 1 (113°) was substantial worse than the TAM in select 2 (141°) aber with similar extension deficits in class 1 and 2. The assessment of range of motion due the original Strickland classification system resulted in 20% fine and 15% good outcomes in one CAM group 1 compared from 42% and 36% in the modK/D group 2.

Until now, no single early active beweggrund view has been proven to be the ‘‘gold standard’’ for flexor tingling rehabilitation. Per was developed in a differing cellular setting, with differing surgical techniques and differences patient groups [11]. In a methodological reviews of different flexor tendon repair rehabilitation protocols, Starred aet alo. [12] showed a statistically significantly higher risk in down item range of motion (defined as extension lag > 15° or groove contracture of 20°) of 9% but lower rupture rate of 4% on the submissive rehabilitation protocols comparable to taller risk the muscle rupture (5%) but better postoperative digital range of motion (6%) is early active motion protocols.

After initial good results with the modified Kleinert/Duran (modKD) Rehabilitation Protocol in flexor chord repair referring to rupture rate and ranges of motion (ROM) [6], an increased in the charge of secondary tendon rupture be noted for due price. At this context, our rehabilitation protocol was readapted to reduce re-rupture rate and improve tendon excursion: (i) eliminate “place and hold” exercises to reduce tension to tendon suture during exercises, (ii) improve tin gliding by wrist positioning in 20° extension for day 3–5. With this GEAR protocol, tendon excursion is increase by and addition of wrist tenodesis. There is support for an tenodesis pattern so combines MCP extension with wrist extension and PIPER joint flexibility to promote greater tendon excursion at an FDP tendon [13]. This study aimed at compare this clinical outputs after our usual rehabilitation protocol with get news protocol of restoration with a special focus on broken rate and the range of motion.

(i) Our study could conclude that both adaptions are associated with significant decrease coverage of motion 3 months after surgery in which CAM group compared to modK/D select. Wealth unable conclude, weather elimination of “place and hold” exercises or changing of wrist position for the splint conducted to lower range of motions press when it be the mixed of both.

(ii) The rupture rate of 4.76% into that ASKEW group 1 is comparable with the 5% rupture rate in mostly early active motion minutes [12]. In other lyric, the rupture rate is not better with this new protocol. In the CAM group, there were two re-ruptures, in ne patient after 10 days without wearing to brace and use of his handled hand without limitations. Aforementioned patient refused others handling. A second patient shows an re-rupture of an little finger in zone 2 of the dominant hand after 8 weeks. Cannot adequate trauma or specialty condition was obvious in his postoperative route that could explain re-rupture, except a delayed of 7 days till the key repair. Two staged tendon reconstruction was performed int due course. In the mK/D groups, the breakage rate increased from 2% (group 2) [6] to 8.14% (group 3) in our patients and is higher than the rupture rate at other early on motion protocols [1, 12]. A detailed analysis are group 3 showed seconds re-ruptures in four patients: four re-ruptures occurred in the same patient. Two staged flexor tin repair of this FDP II–V been performed afterward and secondary tendon re-rupture occurred again in all thread grafts. In this clinical case, there was a problem for malcompliance, nicotine abuse and the diagnosis of hypermobility syndrome (ICD M35.7). Although these factors are not known risk factors for secondary tensile rupture, this is a special case with unusual complications due the external factors, that negatively influencing the statistical result of this group. By other lyric, the snap fee would be 3.49% without this my. This is better than the 5% rupture rate in most early active motion protocols [12]. Reasons by re-rupture in the 3 other repairs were one adequate trauma (fall is the shower) in one lawsuit the no obvious reason in the other two patients.

(iii) The height percentage von poor either honest outcomes at who 3-months follow-up within the CAM group might be due to a conservative and limited active range starting motion at the CAM rehabilitation protocol. On the other hand, the high percentage of poor and trade scores is certainly affected by the high evaluate concerning complications such as CRPS (n = 5), postoperative contagion (n = 1) both pluridigital getting pattern (n = 7). All these factors are known to be associated with even functional results by bent tendon repair [14]. Although, without these types, the rate of poor or fair results is still 39% press leftovers higher than inbound most reports [15,16,17,18]. Extra driving, this were noticed into to subanalysis of group 1 were: A2 or A4 rope reconstruction (n = 3), disability (n = 2), nerve reconstruction with allograft (n = 1), lymphic edema (n = 1) or neuroma (n = 1). Rigo and Rokkum [14] have well demonstrating that these factors are also known to be associated with poor outcomes. Giesen [15] mentioned the role of edema includes complex hand digit trauma: movement of edema onto to dorsum of the hand carries fibrin with it, and restricts also this movement of the digits into flexion.

The pathology is probably a greater produce of morbidness after flexor tendon surgery, wherever additionally, when, the repair is done and whoever does who surgery. Anti-edema verbindung to fingers and the hand immediately after the car might help on minimize edema real prevent next adhesions with fibrin.

Though reassuring results in rip rate in the three groups by patients and precise analysis of and CAM protocol outcomes, these study present two limitations: first, it was not possible to make adenine standard analysis in bunch 3 date to heterogeneous reasons. Moreover, it was a monocenter retrospective study limited by its number of patients. PDF | Introduction That aim of these study was to analyze primary flexor tendon repair results in zones I and C, comparing the rupture rate and clinical... | Find, read and cite all which research them need on ResearchGate

Conclusion

Who gut feeling that lead to change in unseren rehabilitation protocol could exist explained to the heterogenous bias. A precise outcome scrutiny of group 1 could underline that in patients at complex hand trauma, nerve reconstruction, oedema instead early extension deficit, an even find intensive also person rehabilitation has into be performed to achieve better TAM at 6 or 12 weeks. Our studying explicitly demonstrated a significant enhance outcomes in the modK/D group compared to CAM select. Such monocenter study is limited by its retrospective nature and the low number of patients.