|Year : 2019 | Volume
| Issue : 2 | Page : 630-639
Results of flexor tendon grafting with early active mobilization
Hesham M El-Mowafy1, Hassan A Neanaa1, Mohamed A Ahmed2
1 Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Orthopedic Surgery, Ministry of Health, Cairo, Egypt
|Date of Submission||02-Oct-2017|
|Date of Acceptance||19-Nov-2017|
|Date of Web Publication||25-Jun-2019|
Mohamed A Ahmed
12 Okba Ben Nafea Street, Almoatamadeya, Al Mahalla, Gharbeya
Source of Support: None, Conflict of Interest: None
The aim was to evaluate the results of early active motion regimen after hand flexor tendon grafting.
The application of proper postoperative rehabilitation program is an integral part to achieve good results after hand flexor tendon grafting. The aim of application of early, active mobilization rehabilitation program is to limit adhesion formation which limits active motion.
Patients and methods
Twenty-three fingers were managed by flexor tendon grafting and assessed from February 2015 till August 2016 at Menoufia University Hospital. In all, 17 fingers had two stages tendon grafting and six fingers had single-stage tendon grafting. Early active mobilization rehabilitation regimen was applied for all patients. Postoperative assessment was done by the American Society for Surgery of the Hand system, Strickland system, Buck-Gramcko method, and LaSalle formula.
Final assessment was done at 6 months postoperatively and the results were as follows: good (52.17%), fair (39.13%), and poor (8.7%) according to the American Society for Surgery of the Hand system. According to the Strickland system, the results were excellent (13.04%), good (34.78%), fair (39.13%) and poor (13.04%). According to the Buck-Gramcko score, the results were excellent (21.7%), very good (17.4%), good (39.1%) good, fair (8.7%), and poor. (13.1%) According to LaSalle formula, the results were excellent (34.78%), good (52.17%), fair (8.7%), and poor (4.4%). Complications were adhesion formation (8.7%), infection (8.7%), flexor pulley rupture (4.3%), graft rupture (4.3%), and tourniquet palsy (4.3%).
The results were found to be affected by sex, dominance of affected hand, affected tendon(s), flexor pulley integrity, type of procedure, and by the type of tendon graft.
Keywords: active mobilization, early postoperative, flexor tendon, graft
|How to cite this article:|
El-Mowafy HM, Neanaa HA, Ahmed MA. Results of flexor tendon grafting with early active mobilization. Menoufia Med J 2019;32:630-9
|How to cite this URL:|
El-Mowafy HM, Neanaa HA, Ahmed MA. Results of flexor tendon grafting with early active mobilization. Menoufia Med J [serial online] 2019 [cited 2019 Sep 20];32:630-9. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/630/260909
| Introduction|| |
Flexor tendon grafting, either single stage or two stages, is a reliable solution for neglected flexor tendon injuries. Appropriate procedure selection according to the condition of each patient and proper management of fibro-osseous sheath affection are important keys of success.
Patients who present either in a delayed fashion or who have segmental tendon loss are unable to be adequately treated with primary repair. In these patients, the decision needs to be made whether to reconstruct the flexor tendons in a single setting or to perform a staged reconstruction. Both preoperative and intraoperative assessment is necessary for a successful outcome. Substantial injury to the flexor tendon without extensive involvement of the pulley system or tendon sheath can be treated with primary tendon reconstruction. The finger must have a viable neurovascular supply with joints free of contracture and the patient must be able to comply with a highly involved rehabilitation program. Frequently staged reconstruction is selected because of inadequacy of the soft tissues, sheath, and pulley system. An adequate and functional pulley system is needed before implant of the temporary silicone graft. Once the decision to proceed with staged reconstruction has been made, the soft tissues must be prepared for the eventual implantation of a final tendon graft. This involves several steps, including reconstruction of the pulley and sheath system, placement of a temporary implant, and guided rehabilitation to regain maximum flexibility before the second-stage reimplantation.
The application of proper postoperative rehabilitation program is an integral part to achieve good results. Initially the flexor tendon grafts were managed postoperatively by immobilization based on the theory of intrinsic healing of tendons that assumed that adhesion formation is an integral part in tendon healing and revascularization of tendon grafts.
The advances in basic science research, suture materials and techniques, and encouraging results of early active mobilization with tendon repair had a role in shifting the concept of postoperative rehabilitation after flexor tendon grafting toward mobilization techniques such as Kleinert (controlled passive motion), Duran (active extension, passive flexion), and finally early active mobilization regimens,,.
In 1997, Khan et al. reported the results of their series about early active mobilization after flexor tendon grafting with no cases of graft rupture and encouraging results.
This study presents the final functional results of early active motion regimen after hand flexor tendon grafting.
| Patients and Methods|| |
This study was conducted on 23 fingers in 19 patients with complicated hand flexor tendon injuries. The patients were admitted to the Department of Orthopedic Surgery, Menoufia University Hospital and had flexor tendon grafting during the period from February 2015 till August 2016 and followed up for 6 months after tendon grafting.
The study was approved by the ethics committee of the college and an informed consent was obtained from each participant or the parents.
The study population included all patients with torn hand flexor tendons who attended the orthopedic outpatient clinic at Menoufia University Hospital in the period from February 2015 till August 2016 and met the inclusion criteria.
Criteria of inclusion
Patients aged 5 years or older with neglected tendon injury for more than 1 month or failed primary flexor tendon repair with no active infection, intact articular surface of finger joints, and good vascularity of the affected finger.
Criteria of exclusion
Patients aged less than 5 years (as early active motion needs patient co-operation), finger infection, articular damage of finger joints, or poor vascularity of the finger.
The included patients were 12 (63.20%) men and seven (36.80%) women, with age ranging from 5 to 43 years with a mean age of 25.174 years. All patients were right handed. The dominant hand was affected in nine (47.4%) patients and the nondominant was the affected hand in 10 (52.6%) patients. There were 16 (84.2%) patients with single finger affection, two (10.5%) patients with two-finger affection, and one (5.3%) patient with three-finger affection. So, there are 19 patients with 23 total finger affections. The anatomical distribution of the affected fingers was as follows: five (21.7%) index fingers, seven (30.4%) middle fingers, four (17.5%) ring fingers, and seven (30.4%) little fingers. The cause of initial tendon injury was caused by sharp trauma in 17 (89.5%) patients, blunt trauma in one (5.25%) patient and iatrogenic injury during carpal tunnel release in one (5.25%) patient. The distribution according to hand flexor tendons zones was as follows: 20 fingers in zone 2 (86.96%), one finger in zone 4 (4.35%), and two fingers in zone 5 (8.70%). In 13 (56.52%) fingers, the primary repair was done at the time of initial injury and in 10 (43.48%) fingers the tendon injury was missed at initial assessment and no repair was done. According to Boyes grade [Table 1], the preoperative condition of the fingers was as follows: grade 1 in eight (34.78%) fingers, grade 2 in eight (34.78%) fingers, grade 3 in one (4.35%) finger, grade 4 in two (8.70%) fingers, and grade 5 in four (17.39%) fingers. The time interval between initial tendon injury and starting tendon grafting procedures ranged from 1 to 48 months with a mean period of 9.696 months.
All patients were operated under general anesthesia in supine position using a tourniquet.
In single-stage grafting, the zigzag incision of Bruner was used in the fingers with proximal continuation in the palm, and an ulnarly curved volar incision was used in the forearm [Figure 1]. The neurovascular bundles were protected throughout the dissection. The area of injury to the sheath was noted, and the damaged sheath was minimally resected, and uninjured flexor sheath was preserved as much as possible. Approximately 1 cm of the flexor digitorum profundus (FDP) stump was preserved distally.
Palmaris longus (PL) was used as a graft in three fingers (three patients) and long toe extensors were used in the other three fingers (one patient). The graft was passed beneath the flexor pulleys. The pull-out technique was used for the distal attachment of the tendon graft, and a Pulvertaft fish mouth weave for the proximal attachment using polyprolene 3-0 sutures (Covidien IIc, Mansfield, Massachusetts, USA) [Figure 2].
|Figure 2: Graft attachment during single-stage grafting. Distal attachment was done first by the pull-out technique (star) and proximal attachment then was done by Pulvertaft technique (arrow).|
Click here to view
After tourniquet deflation and achieving a satisfactory hemostasis, the wound was sutured. Then a bulky compression dressing was applied and a short-arm dorsal splint was used to maintain the wrist at about 35° of flexion, the metacarpophalangeal (MCP) joints in 70° of flexion, and the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints in full extension.
In staged tendon grafting, the first stage was done using the same incision described in single-stage grafting. A stump of the profundus tendon, 1 cm long, was left attached to the distal phalanx. Scarred tendons, sheath, and retinaculum then were excised. Undamaged portions of the flexor fibro-osseous retinaculum that are not contracted were retained. Any portion of the retinaculum that can be dilated instrumentally with a hemostat was also preserved; the remainder was excised. Reconstruction of damaged pulley system was done in six patients and augmentation using remnants of flexor digitorum superficialis (FDS) was done in one patient.
The silicone spacer (Silimed-Industria de implantes Ltda, Rio de Janeiro, Brasil) was passed under fibro-osseous retinaculum [Figure 3]. The distal end of the silicone spacer was sutured beneath the stump of the profundus tendon. The wound was sutured after achieving satisfactory hemostasis and compressive dressing was applied. Then the patients started passive manipulation of the finger to obtain maximal passive range of motion before the second stage.
|Figure 3: The silicone spacer placement under the retained annular pulleys during first stage tendon grafting.|
Click here to view
The second stage was done 3 months after the first stage. The replacement of the silicone implant by a free tendon graft was performed by using the terminal portions of the previous stage one digital and distal forearm incisions. Great care was taken not to open the pseudosheath proximal to the DIP joint or to injure any of the middle phalangeal pulleys. The implant was identified and uncovered at its attachment to the stump of the FDP tendon over the base of the distal phalanx and the connecting sutures were divided. The implant was tagged temporarily with a hemostat and the stump of the FDP was mobilized and retained at its insertion for suturing to the free tendon graft. The proximal end of the implant was retrieved through the forearm–wrist incision and any excess pseudosheath was resected to assure free gliding of the proximal graft juncture. The appropriate motor tendon (proximal stump) was selected and fully mobilized. The proximal end of the implant was tagged, and then the appropriate tendon graft was obtained.
In patients treated by two-stage tendon reconstruction, PL was used as tendon graft in 10 patients (10 fingers), toes extensors were used in four patients (five fingers), and torn FDS of the affected finger in one patient (two fingers). The graft was sutured to the proximal end of the tendon spacer, then the implant was pulled through the sheath, trailing the tendon graft with it through the well-formed sheath [Figure 4]. The implant was separated from the tendon graft and discarded. The pull-out technique was used for the distal attachment of the tendon graft, and a Pulvertaft fish mouth weave for the proximal attachment using polyprolene 3-0 sutures (Covidien IIc).
|Figure 4: Graft placement beneath the well-formed sheath during second-stage tendon grafting by attaching it to the proximal end of silicone spacer and pulling the spacer distally.|
Click here to view
After tourniquet deflation and achieving a satisfactory hemostasis, wound closure, dressing, and splinting was done in the same manner as in a single-stage tendon grafting.
The rehabilitation program started during the first postoperative day (after the single-stage grafting or the second stage of staged tendon grafting) in the form of active flexion of the fingers in combination with active extension passive flexion and passive mobilization of the joints [Figure 5]. The patients were kept in dorsal blocking splint during the first, 6 postoperative weeks, after which the splint was removed and the patients started gradual stretching and strengthening exercises.
|Figure 5: Postoperative early active motion rehabilitation regimen: active flexion (a) and active extension (b) in dorsal blocking splint.|
Click here to view
The patients came for follow-up visits every week during the first postoperative months, every 2 weeks during the second month, and every 3 weeks after that. The final assessment was done at the sixth postoperative month using these outcome scores: total active motion (TAM) method of American Society for Surgery of the Hand (ASSH), Strickland formula, Buck-Gramcko score, and LaSalle Formula.
In ASSH, the TAM is calculated for MCP, PIP, and DIP joints of the involved finger according to the following formula: active flexion (MCP+PIP+DIP)−extension deficits (MCP+PIP+DIP) and expressed as percentage of the normal contralateral finger. The result is stratified as follows: excellent (100%), good (75%), fair (50%), and poor (<50%).
In Strickland formula, the TAM is calculated for PIP and DIP of the involved finger according to the following formula: active flexion (PIP+DIP)−extension deficits (PIP+DIP) and expressed as percentage of the normal contralateral finger. The result is stratified as follows: excellent (85–100%), good (70–84%), fair (50–69%), and poor (<50%).
Buck-Gramcko evaluation system is a 17-point score based on fingernail to distal palmar crease distance in centimeters (six points), total extension lag (three points), and (eight points) for modified TAM score which equals: (MCP+2PIP+3DIP). The result is stratified as follows: excellent (16–17 points), very good (14–15 points), good (11–13 points), fair (7–10 points), and poor (0–6 points).
LaSalle formula compares the preoperative passive interphalangeal joint motion with the postoperative active interphalangeal joint motion according to the following formula: (postoperative active PIP+DIP flexion − extension loss)/(preoperative passive PIP+DIP flexion − extension loss) × 100. The results are stratified as follows: excellent (75–100%), good (50–74%), fair (25–49%), and poor (0–24%).
The data were collected, tabulated, and analyzed by using the statistical package for social sciences (version 16.0; SPSS Inc., Chicago, Illinois, USA). A P value of less than 0.05 was considered statistically significant.
Two types of statistics were done:
- Descriptive statistics, such as percentage and mean
- Analytic statistics, such as the χ2-test and t-test.
| Results|| |
The results of the current study were as follows: according to the ASSH system, excellent results were not achieved in any finger, good results were achieved in 12 (52.17%) fingers, fair results were achieved in nine (39.13%) fingers, and poor results were achieved in two (8.7%) fingers. According to the Strickland system, excellent results were achieved in three (13.04%) fingers, good results were achieved in eight (34.78%) fingers, fair results were achieved in nine (39.13) fingers, and poor results were achieved in three (13.04%) fingers. According to the Buck-Gramcko score, excellent results were achieved in five (21.7%) fingers, very good results were achieved in four (17.4%) fingers, good results were achieved in nine (39.1%) fingers, fair results were achieved in two (8.7%) fingers, and poor results were achieved in three (13.1%) fingers. According to the LaSalle formula, excellent results were achieved in eight (34.78%) fingers, good results were achieved in 12 (52.17%) fingers, fair results were achieved in two (8.7%) fingers, and poor results were achieved in one (4.4%) finger. The difference in results between different scores was found to be statistically significant [Table 2].
|Table 2: Overall results and statistical difference between different evaluation systems|
Click here to view
It was noted that the male patients achieved better results than the female patients according to Buck-Gramcko score (P = 0.017). Patients with dominant hand affection achieved better results than patients with nondominant hand affection according to ASSH, Strickland, Buck-Gramcko, and LaSalle scores (P = 0.006, 0.030, 0.044, and 0.023, respectively). Patients with injured FDP tendon achieved better results than those who had combined FDP and FDS tendon injuries according to Strickland and Buck-Gramcko scores (P = 0.014, 0.015, respectively). Patients with intact flexor pulley system achieved better results than patients with affected pulley system according to Strickland, Buck-Gramcko, and LaSalle scores (P = 0.036, 0.014, and 0.015, respectively). Patients who had single-stage flexor tendon grafting achieved better results than patients who had two-stage tendon grafting according to Strickland, Buck-Gramcko, and LaSalle scores (P = 0.014, 0.015, and 0.036, respectively). Patients, in whom, long toe extensors were used as donor grafts achieved better results than patients in whom FDS or PL were used as donor grafts according to Strickland score (P = 0.089) [Table 3],[Table 4],[Table 5],[Table 6].
|Table 3: Factors affecting the results according to the American Society for Surgery of the Hand system|
Click here to view
|Table 4: Factors affecting the results according to the Strickland evaluation system|
Click here to view
|Table 5: Factors affecting the results according to the Buck-Gramcko evaluation system|
Click here to view
Complications occurred in seven patients (seven fingers). Two fingers in two (8.7%) patients were complicated by adhesion formation. One of these two patients was a 6-year-old girl, who was not perfectly compliant to early active motion program. They were diagnosed early by limitation of movement and managed by physiotherapy and achieved fair final results and both patients were satisfied with these results and refused tenolysis as a suggested option for better outcome. Also, there was graft rupture in only one case with single finger affection (4.34%). This patient was scheduled for another session of two-stage tendon reconstruction. There was a single digit complicated by flexor pulley rupture (4.34%). In this digit the flexor pulley system was augmented during the first stage using remnants of FDS tendon. Pulley rupture occurred during the fifth postoperative month due to aggressive manipulation during physiotherapy. It was diagnosed by bowstringing of the tendon and decrease of previously achieved active flexion range of the digit. The patient achieved poor results according to Strickland and fair results according to LaSalle at final assessment. The patient was satisfied by this result and refused any further intervention to improve function. Two patients (two fingers) (8.7%) were complicated by superficial wound infection. One patient, who had single-stage tendon grafting, developed superficial wound infection 1 week postoperatively, diagnosed by local erythema, hotness, and superficial discharge during dressing change and was managed by appropriate antibiotics and the infection resolved. At final assessment, the patient achieved a good result according to Strickland. The other patient, who had two-stage tendon reconstruction, developed superficial wound infection 1 week after the second stage and was also diagnosed by local erythema, hotness, and superficial discharge and was managed by appropriate antibiotics with resolution of infection and at final assessment the patient achieved fair results according to Strickland. One patient with single finger affection (4.34%) developed tourniquet palsy during the first stage of tendon grafting. The condition resolved spontaneously within 3 weeks and the patient achieved good results according to Strickland at the final assessment.
| Discussion|| |
Flexor tendon grafting provides surgeons with a reliable method for treating neglected flexor tendon injuries. Initially flexor tendon grafts were managed by immobilization for few weeks postoperatively based on the theory of extrinsic healing of tendons reported by Potenza. Postoperative immobilization was thought to allow the necessary revascularization of the tendon graft from the surrounding structures. It also allowed uncontrolled formation of adhesions, which limited active movement. Tonkin et al.were the first to show that flexor tendon grafting can be managed postoperatively with the Kleinert technique with reduced rates of rupture and tenolysis of the graft than in an immobilized group. An active mobilization technique has been reported after tendon grafting by Khan et al..
Four methods of assessment of digital function were used for evaluation of results: ASSH score, the postoperative grading system recommended by Strickland et al., Buck-Gramcko grading system, and LaSalle formula.
The results of this study were found to be comparable with the results of other studies which used an early active mobilization regimen. In Khan et al., the results were as follows: excellent in 34%, good in 22%, fair in 22%, and poor in 22%, according to the Buck-Gramcko system. In Mount Vernon study, the results were as follows: excellent in 50%, good in 27%, fair in 15%, and poor in 8%, according to the LaSalle evaluation system.
In the current study, postoperative complications were adhesion formation in two (8.7%) fingers, infection in two (8.7%) fingers, flexor pulley rupture in one finger (4.3%), graft rupture in one finger (4.3%) and tourniquet palsy in one patient (one finger) (4.3%). When reviewing the literature of flexor tendon grafting, the rate of formation of adhesion varied from 4 to 47% in different studies using different postoperative rehabilitation protocols,,,. In Mount Vernon study, which applied early active mobilization, there was adhesions in one (4%) finger, whereas in Khan et al. study, which also used early active motion regimen, there was no report about adhesion formation. In other studies, which did not apply early active motion, like Naam study, in which the Kleinert protocol was applied for the first, 3 weeks postoperatively, the rate of adhesion formation was 9% whereas in LaSalle et al. study, which applied immobilization for the initial 3 postoperative weeks, the rate of adhesion formation was 47%. Also, the reported rate of graft rupture varied from 4 to 14%,,,,,. In Mount Vernon study (early active motion), the rate of graft rupture was 8%. In Khan et al. study (early active motion) and in Naam study, there was no reported cases of graft rupture. In Coyle et al., in which Duran postoperative rehabilitation regimen was used, the rate of graft rupture was 9%. In Amadio et al. study, the reported rate of infection was 15%.
Statistical comparison between this study and related studies was not feasible and beyond the scope of this study due to heterogeneity of these studies especially as regards the methods of assessment. However, further research work on early, active mobilization after flexor tendon grafting is needed with larger patient numbers and longer follow-up periods. Also, comparative studies between early active mobilization and other rehabilitation methods are recommended.
| Conclusion|| |
Early active motion regimen is associated with encouraging results with relatively low rate of adhesion formation and graft rupture. The results of this technique in this study were found to be affected by patient sex, dominance of affected hand, affection of FDP alone or both FDP and FDS, flexor pulley integrity, the type of procedure (either single or two stages) and the type of tendon graft.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Smith P, Jones M, Grobbelaar A. Two-stage grafting of flexor tendons: results after mobilisation by controlled early active movement. Scand J Plastic Reconstr Surg Hand Surg 2004; 38
Freilich AM, Chhabra AB. Secondary flexor tendon reconstruction, a review. J Hand Surg Am 2007; 32
Moore T, Anderson B, Seiler JG. Flexor tendon reconstruction. J Hand Surg Am 2010; 35
Potenza AD. Critical evaluation of flexor-tendon healing and adhesion formation within artificial digital sheaths: an experimental study. J Bone Joint Surg Am 1963; 45
Strickland JW. Development of flexor tendon surgery: twenty-five years of progress. J Hand Surg Am 2000; 25
Chesney A, Chauhan A, Kattan A, Farrokhyar F, Thoma A. Systematic review of flexor tendon rehabilitation protocols in zone II of the hand. Plast Reconstr Surg 2011; 127
Khan K, Riaz M, Murison MS, Brennen MD. Early active mobilization after second stage flexor tendon grafts. J Hand Surg Am 1997; 22
Fletcher DR, McClinton MA. Single-stage flexor tendon grafting: refining the steps. J Hand Surg Am 2015; 40
Strickland JW. Delayed treatment of flexor tendon injuries including grafting. Hand Clin2005; 21
Kleinert HE, Verdan C. Report of the committee on tendon injuries. J Hand Surg Am 1983; 8
Strickland JW, Glogovac SV. Digital function following flexor tendon repair in zone II: a comparison of immobilization and controlled passive motion techniques. J Hand Surg Am 1980; 5
Buck-Gramcko DA. New method of evaluation of results in flexor tendon repair. Handchirurgie 1976; 8
LaSalle WB, Strickland JW. An evaluation of the two-stage flexor tendon reconstruction technique. J Hand Surg Am 1983; 8
Tonkin M, Hagberg L, Lister G, Kutz J. Post-operative management of flexor tendon grafting. J Hand Surg Br 1988; 13
Lister GD, Kleinert HE, Kutz JE, Atasoy E. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg Am 1977; 2
Naam NH. Staged flexor tendon reconstruction using pedicled tendon graft from the flexor digitorum superficialis. J Hand Surg Am 1997; 22
Coyle MP, Leddy TP, Leddy JP. Staged flexor tendon reconstruction fingertip to palm. J Hand Surg Am 2002; 27
Amadio PC, Wood MB, Cooney WP, Bogard SD. Staged flexor tendon reconstruction in the fingers and hand. J Hand Surg Am 1988; 13
Wehbé MA, Mawr B, Hunter JM, Schneider LH, Goodwyn BL. Two-stage flexor-tendon reconstruction. Ten-year experience. J Bone Joint Surg Am 1986; 68
Wilson RL, Carter MS, Holdeman VA, Lovett WL. Flexor profundus injuries treated with delayed two-staged tendon grafting. J Hand Surg Am 1980; 5
Beris AE, Darlis NA, Korompilias AV, Vekris MD, Mitsionis GI, Soucacos PN. Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft. J Hand Surg Am 2003; 28
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]