Primary Flexor Tendon Repair in Zone II. Update and Surgical Technique
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Published:
Oct 10, 2021
Keywords:
Flexor tendon, primary repair, zone II
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Abstract
Primary flexor tendon repair in zone II has been a challenge since the emergence of hand surgery as a specialty after World War II. From Bunnell to today, the way of operating and rehabilitating these tendons has evolved and changed considerably thanks to anatomical, biological and—above all—mechanical studies. Currently, the surgical technique is based on performing a strong and neat suture, which does not suffer friction within the sheath and which tolerates the load necessary for the active motion of the finger without resistance. Multiple suture configurations with different materials have been described. Under local anesthesia, the intraoperative active flexion-extension test reveals the resistance of the type of suture chosen and has gained importance in defining the rehabilitation protocol. Treatment of flexors in zone II is, so far, an inseparable set of surgical technique and a suitable rehabilitation protocol. Biological strategies to enhance the tendon healing process are currently the main field of research.
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How to Cite
Levy, V. D. (2021). Primary Flexor Tendon Repair in Zone II. Update and Surgical Technique. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 86(5), 681-695. https://doi.org/10.15417/issn.1852-7434.2021.86.5.1356
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Postgraduate instruction
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References
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Bone Joint Surg Am 1967;49:577. https://doi.org/10.1201/b17524-8
13. Kessler I, Nissim F. Primary repair without immobilization of flexor tendon division within the digital sheath: an experimental and clinical study. Acta Orthop Scand 1969;40(5):587-601. https://doi.org/10.3109/17453676908989524
14. Strickland JW. Development of flexor tendon surgery: twenty-five years of progress. J Hand Surg Am
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16. Tang JB, Xie RG, Cao Y, Ke ZS, Xu Y. A2 pulley incision or one slip of the superficialis improves flexor tendon
repairs. Clin Orthop Relat Res 2007;456:121-7. https://doi.org/10.1097/01.blo.0000246564.96208.b0
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fiberwire on grasping and locking core sutures. J Hand Surg Am 2007;32(5):591-6. https://doi.org/10.1016/j.jhsa.2007.03.003
20. Wu YF, Cao Y, Zhou YL, Tang JB. Biomechanical comparisons of four-strand tendon repairs with double-stranded sutures: effects of different locks and suture geometry. J Hand Surg Eur 2011;36(1):34-9.
https://doi.org/10.1177/1753193410379554
21. Su BW, Protopsaltis TS, Koff MF, Chang KP, Strauch RJ, Crow SA, et al. The biomechanical analysis of a tendon
fixation device for flexor tendon repair. J Hand Surg Am 2005;30(2):237-45. https://doi.org/10.1016/j.jhsa.2004.07.020
22. Hirpara KM, Sullivan PJ, O’Sullivan ME. A new barbed device for repair of flexor tendons. J Bone Joint Surg Br
2010;92(8):1165-70. https://doi.org/10.1302/0301-620X.92B8.23029
23. Duran RJ, Houser RG, Coleman CR, Stover MG. Management of flexor tendon lacerations in zone 2 using
controlled passive motion postoperatively. En: Hunter JM, Schneider LH, Mackin EJ (eds). Rehabilitation of the
hand. St. Louis: Mosby; 1978:217-24.
24. Zhao CF, Amadio PC, Zobitz ME, Momose T, Couvreur P, An K. Effect of synergistic motion on flexor digitorum
profundus tendon excursion. Clin Orthop Relat Res 2002;396:223-30. https://doi.org/10.1097/00003086-200203000-00033
25. Silfverskiöld KL, May EJ, Törnvall AH. Flexor digitorum profundus excursions during controlled motion after
flexor tendon repair in excursions during controlled motion after flexor tendon repairs in zone II: aprospective
clinical study. J Hand Surg Am 1992;17(1):122-31. https://doi.org/10.1016/0363-5023(92)90127-b
26. Strickland JW. Flexor tendon repair: Indiana method. Indiana Hand Center Newsletter 1993;1:1-12.
27. Groth GN. Pyramid of progressive force exercises to the injured flexor tendon. J Hand Ther 2004;17(1):31-42.
https://doi.org/10.1197/j.jht.2003.10.005
28. Savage R. The influence of wrist position on the minimum force required for active movement of the
interphalangeal joints. J Hand Surg 1988;13(3):262-8. https://doi.org/10.1016/0266-7681(88)90082-4
29. Paneva-Holevich E. Two-stage reconstruction of the flexor tendons. Int Orthop 1982;6(2):133-8.
https://doi.org/10.1007/BF00268657
30. Yao J, Korotkova T, Riboh J, Chong A, Chang A, Smith R. Bioactive sutures for tendon repair: assessment of a
method of delivering pluripotential embryonic cells. J Hand Surg Am 2008;33(9):1558-64. https://doi.org/10.1016/j.jhsa.2008.06.010
31. Chan BP, Fu S, Qin L, Rolf CG, Chan K. Effects of basic fibroblast growth factor (bFGF) on early stages of tendon healing: a rat patellar tendon model. Acta Orthop Scand 2000;71(5):513-8. https://doi.org/10.1080/000164700317381234
32. Thomopoulos S, Das R, Silva MJ, Sakiyama-Elbert S, Harwood FL, Zampiakis E, et al. Enhanced flexor tendon
healing through controlled delivery of PDGF-BB. J Orthop Res 2009;27(9):1209-15. https://doi.org/10.1002/jor.20875
33. Kaplitt MG, Feigin A, Tang C, Fitzsimons HL, Mattis P, Lawlor PA, et al. Safety and tolerability of gene therapy
with an adeno-associated virus (AAV) borne GAD gene for Parkinson’s disease: an open label, phase I trial. Lancet 2007;369(9579):2097-105. https://doi.org/10.1016/S0140-6736(07)60982-9
34. Moran S, Ryan C, Orlando G, Pratt C, Michalko K. Effects of 5-fluorouracil on flexor tendon repair. J Hand Surg
Am 2000;25:242-50. https://doi.org/10.1053/jhsu25a0242
35. Moro-oka T, Miura H, Mawatari T, Kawano T, Nakanishi Y, Higaki H, et al. Mixture of hyaluronic acid and
phospholipid prevents adhesion formation on the injured flexor tendon in rabbits. J Orthop Res 2000;18(5):835-40. https://doi.org/10.1002/jor.1100180523
36. Liu C, Bai J, Yu K, Liu G, Tian S, Tian D. Biological amnion prevents flexor tendon adhesion in zone II:
acontrolled, multicentre clinical trial. Biomed Res Int 2019;2019:2354325. https://doi.org/10.1155/2019/2354325
2008;39(12):1338-44. https://doi.org/10.1016/j.injury.2008.06.021
2. Kaplan EB, Hunter JM. Functional anatomy of the flexor tendon system: The muscles and tendon systems of the fingers. En: Hunter JM, Schneider LH, Mackin EJ (eds). Tendon and nerve surgery in the hand. A third decade. St. Louis, Mosby; 1997:240-52.
3. Fussey JM, Chin KF, Gogi N, Gella S, Deshmukh SC. An anatomic study of flexor tendon sheaths: a cadaveric
study. J Hand Surg Eur 2009;34:762-5. https://doi.org/10.1177/1753193409344529
4. Doyle JR. Anatomy of the finger flexor tendon sheath and pulley system. J Hand Surg Am 1988;13:473-84.
https://doi.org/10.1016/s0363-5023(88)80082-0
5. Strauch B, de Moura W. Digital flexor tendon sheath: an anatomic study. J Hand Surg Am 1985;10:785-9.
https://doi.org/10.1016/s0363-5023(85)80152-0
6. Ochiai N, Matsui T, Miyaji N, Merklin RJ, Hunter JM. Vascular anatomy of flexor tendons. I. Vincular system and
blood supply of the profundus tendon in the digital sheath. J Hand Surg Am 1979;4(4):321-30.
https://doi.org/10.1016/s0363-5023(79)80068-4
7. Gelberman RH, Goldberg V, An KN, Banes A. Tendon. En: Woo SLY, Buckwalter JA (eds). Injury and repair of the
musculoskeletal soft tissues. Park Ridge, IL: American Academy of Orthopaedic Surgeons; 1988:5-40.
8. Kryger GS, Chong AK, Costa M, Pham H, Bates S, Chang J. A comparison of tenocytes and mesenchymal stem
cells for use in flexor tendon tissue engineering. J Hand Surg Am 2007;32(5):597-605. https://doi.org/10.1016/j.jhsa.2007.02.018
9. Manning CN, Havlioglu N, Knutsen E, Sakiyama-Elbert SE, Silva M, Thomopoulos S, et al. The early inflammatory response after flexor tendon healing: a gene expression and histological analysis. J Orthop Res 2014;32(5):645-52. https://doi.org/10.1002/jor.22575
10. Bunnell S. Repair of tendons in the fingers and description of two new instruments. Surg Gynecol Obstet
1918;26:103-10.
11. Verdan CE. Practical considerations for primary and secondary repair in flexor tendon injuries. Surg Clin North Am 1964;44:951-70. https://doi.org/10.1016/s0039-6109(16)37336-4
12. Kleinert HE, Kutz JE, Ashbell TS, Martinez E. Primary repair of lacerated flexor tendons in “no man’s land”. J
Bone Joint Surg Am 1967;49:577. https://doi.org/10.1201/b17524-8
13. Kessler I, Nissim F. Primary repair without immobilization of flexor tendon division within the digital sheath: an experimental and clinical study. Acta Orthop Scand 1969;40(5):587-601. https://doi.org/10.3109/17453676908989524
14. Strickland JW. Development of flexor tendon surgery: twenty-five years of progress. J Hand Surg Am
2000;25(2):214-35. https://doi.org/10.1053/jhsu.2000.jhsu25a0214
15. Tang JB, Amadio PC, Guimberteau JC, Chang J. Primary flexor tendon surgery. En: Tendon surgery of the hand. Philadelphia: Elsevier; 2012:79-258.
16. Tang JB, Xie RG, Cao Y, Ke ZS, Xu Y. A2 pulley incision or one slip of the superficialis improves flexor tendon
repairs. Clin Orthop Relat Res 2007;456:121-7. https://doi.org/10.1097/01.blo.0000246564.96208.b0
17. Tang JB. Wide-awake primary flexor tendon repair, tenolysis, and tendon transfer. Clin Orthop Surg 2015;7(3):275-81. https://doi.org/10.4055/cios.2015.7.3.275
18. Lalonde DH, Martin AL. Wide-awake flexor tendon repair and early tendon mobilization in zones 1 and 2. Hand Clin 2013;29(2):207-13. https://doi.org/10.1016/j.hcl.2013.02.009
19. Miller B, Dodds SD, deMars A, Zagoreas N, Waitayawinyu T, Trumble T. Flexor tendon repairs: the impact of
fiberwire on grasping and locking core sutures. J Hand Surg Am 2007;32(5):591-6. https://doi.org/10.1016/j.jhsa.2007.03.003
20. Wu YF, Cao Y, Zhou YL, Tang JB. Biomechanical comparisons of four-strand tendon repairs with double-stranded sutures: effects of different locks and suture geometry. J Hand Surg Eur 2011;36(1):34-9.
https://doi.org/10.1177/1753193410379554
21. Su BW, Protopsaltis TS, Koff MF, Chang KP, Strauch RJ, Crow SA, et al. The biomechanical analysis of a tendon
fixation device for flexor tendon repair. J Hand Surg Am 2005;30(2):237-45. https://doi.org/10.1016/j.jhsa.2004.07.020
22. Hirpara KM, Sullivan PJ, O’Sullivan ME. A new barbed device for repair of flexor tendons. J Bone Joint Surg Br
2010;92(8):1165-70. https://doi.org/10.1302/0301-620X.92B8.23029
23. Duran RJ, Houser RG, Coleman CR, Stover MG. Management of flexor tendon lacerations in zone 2 using
controlled passive motion postoperatively. En: Hunter JM, Schneider LH, Mackin EJ (eds). Rehabilitation of the
hand. St. Louis: Mosby; 1978:217-24.
24. Zhao CF, Amadio PC, Zobitz ME, Momose T, Couvreur P, An K. Effect of synergistic motion on flexor digitorum
profundus tendon excursion. Clin Orthop Relat Res 2002;396:223-30. https://doi.org/10.1097/00003086-200203000-00033
25. Silfverskiöld KL, May EJ, Törnvall AH. Flexor digitorum profundus excursions during controlled motion after
flexor tendon repair in excursions during controlled motion after flexor tendon repairs in zone II: aprospective
clinical study. J Hand Surg Am 1992;17(1):122-31. https://doi.org/10.1016/0363-5023(92)90127-b
26. Strickland JW. Flexor tendon repair: Indiana method. Indiana Hand Center Newsletter 1993;1:1-12.
27. Groth GN. Pyramid of progressive force exercises to the injured flexor tendon. J Hand Ther 2004;17(1):31-42.
https://doi.org/10.1197/j.jht.2003.10.005
28. Savage R. The influence of wrist position on the minimum force required for active movement of the
interphalangeal joints. J Hand Surg 1988;13(3):262-8. https://doi.org/10.1016/0266-7681(88)90082-4
29. Paneva-Holevich E. Two-stage reconstruction of the flexor tendons. Int Orthop 1982;6(2):133-8.
https://doi.org/10.1007/BF00268657
30. Yao J, Korotkova T, Riboh J, Chong A, Chang A, Smith R. Bioactive sutures for tendon repair: assessment of a
method of delivering pluripotential embryonic cells. J Hand Surg Am 2008;33(9):1558-64. https://doi.org/10.1016/j.jhsa.2008.06.010
31. Chan BP, Fu S, Qin L, Rolf CG, Chan K. Effects of basic fibroblast growth factor (bFGF) on early stages of tendon healing: a rat patellar tendon model. Acta Orthop Scand 2000;71(5):513-8. https://doi.org/10.1080/000164700317381234
32. Thomopoulos S, Das R, Silva MJ, Sakiyama-Elbert S, Harwood FL, Zampiakis E, et al. Enhanced flexor tendon
healing through controlled delivery of PDGF-BB. J Orthop Res 2009;27(9):1209-15. https://doi.org/10.1002/jor.20875
33. Kaplitt MG, Feigin A, Tang C, Fitzsimons HL, Mattis P, Lawlor PA, et al. Safety and tolerability of gene therapy
with an adeno-associated virus (AAV) borne GAD gene for Parkinson’s disease: an open label, phase I trial. Lancet 2007;369(9579):2097-105. https://doi.org/10.1016/S0140-6736(07)60982-9
34. Moran S, Ryan C, Orlando G, Pratt C, Michalko K. Effects of 5-fluorouracil on flexor tendon repair. J Hand Surg
Am 2000;25:242-50. https://doi.org/10.1053/jhsu25a0242
35. Moro-oka T, Miura H, Mawatari T, Kawano T, Nakanishi Y, Higaki H, et al. Mixture of hyaluronic acid and
phospholipid prevents adhesion formation on the injured flexor tendon in rabbits. J Orthop Res 2000;18(5):835-40. https://doi.org/10.1002/jor.1100180523
36. Liu C, Bai J, Yu K, Liu G, Tian S, Tian D. Biological amnion prevents flexor tendon adhesion in zone II:
acontrolled, multicentre clinical trial. Biomed Res Int 2019;2019:2354325. https://doi.org/10.1155/2019/2354325