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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 33  |  Issue : 2  |  Page : 683-687

Comparative study between early mobilizations vs late mobilization after flexor tendon repair in the hand


1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Plastic Surgery, Shibin El-Kom Teaching Hospital, Menoufia, Egypt

Date of Submission18-Nov-2019
Date of Decision02-Dec-2019
Date of Acceptance07-Dec-2019
Date of Web Publication27-Jun-2020

Correspondence Address:
Mostafa G Hanot
Shebin Elkom, Menoufia 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_351_19

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  Abstract 


Objective
The aim was to study the different types of mobilization after flexor tendon repair and their effect on the prognosis of healing and rehabilitation.
Background
Tendon injuries are the second most common hand injury type. Most tendon injuries require surgical repair and rehabilitation to restore hand function. Postsurgical rehabilitation improves the functions and outcomes and is an essential step in managing repaired tendons.
Patients and methods
The study included 60 patients after repair of flexor tendons in the hand, who were divided into early, intermediate, and late groups as A, B, and C, respectively (randomized controlled clinical trial). To clarify the timing distribution of rehabilitation after tendon repair, the authors subdivided the patients into three groups: early rehabilitation (<1 week), intermediate rehabilitation (1–6 weeks), and late rehabilitation (>6 weeks) after tendon repair. The period selection (<1 week, 1–6 week, and > 6 week) was based on the physiology of tendon healing. The resurgery rate and the use of rehabilitation resources after tendon repair were calculated. Complications were studied and compared (reduced range of finger movement, rupture of the repair, and flexor tendon adhesion).
Results
The resurgery rate was highest (12.08%) in those commencing rehabilitation more than 6 weeks after tendon repair, and lowest (3.81%) in those commencing it within 1 week. Patients in the early rehabilitation group required fewer rehabilitation sessions (median: 11.5 sessions) than did those in the intermediate (29 sessions) and late (33 sessions) rehabilitation groups.
Conclusion
The early rehabilitation group exhibited the lowest resurgery rate and used the fewest rehabilitation resources. Compared with late rehabilitation, early or intermediate rehabilitation conferred protective effects against resurgery and fewer complications.

Keywords: active mobilization, flexor tendon repair, hand surgery, rehabilitation resources, resurgery rate


How to cite this article:
Lolah MA, Elsakka DM, Samy MA, Hanot MG. Comparative study between early mobilizations vs late mobilization after flexor tendon repair in the hand. Menoufia Med J 2020;33:683-7

How to cite this URL:
Lolah MA, Elsakka DM, Samy MA, Hanot MG. Comparative study between early mobilizations vs late mobilization after flexor tendon repair in the hand. Menoufia Med J [serial online] 2020 [cited 2020 Jul 14];33:683-7. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/683/287785




  Introduction Top


Most tendon injuries require surgical repair and rehabilitation to restore hand function. Advances in surgical technology and materials have improved the outcome of tendon repairs in the hand, but complications remain common. The rates of tendon rupture and tendon adhesion following flexor tendon repairs have been reported as 4–10% and 4–9%, respectively. These circumstances require secondary repairs, such as tenolysis or tendon reconstruction using a graft or prosthesis[1],[2].

Although the mechanisms and sites of tendon injuries are the key prognostic factors, postsurgical rehabilitation improves the functions and outcomes following tendon repairs in the hand and is an essential step in managing repaired tendons[3],[4].

Several protocols have been developed, including immobilization, early passive motion, and early active motion. These protocols usually allow gradual finger movement with orthotic protection, followed by a stepwise increase in resistance to facilitate tendon gliding. Their differences depend on how the injured tendons are approached in the earliest stages of healing. For flexor tendons, motions begun 4–5 days after repair are classified as 'early'; for extensor tendons, those begun after 0–4 days are classified as 'immediate,' and after 5–10 days as 'early.' Immobilization protects the repair site at the cost of undesirable edema, scarring, and adhesion[5].

Early passive or active motion promotes tendon gliding and avoids adhesion but carries the risk of early repair-site rupture. Despite these concerns, several clinical studies have demonstrated the greatest benefits of early mobilization when they were initiated within 1 week after surgery[6].

Numerous rehabilitation regimens are in use today. There are, main, three types of early rehabilitation programs: early passive mobilization with active extension-passive flexion with rubber bands to maintain the involved fingers in flexion, or passive flexion and extension supplied by the patient; active hold (i.e., place and hold) where the patient passively flexes the fingers and maintains them actively in flexion; and early active motion, with the patient actively flexing their treated fingers. Active mobilization protocols may have a higher risk of rupture of the repair, whereas passive protocols may have a higher risk of tendon adhesion and loss of digit range of motion. No consensus exists concerning the best type of motion or the ideal hand posture during rehabilitation[7].

The aim of this study was to study the different types of mobilization after flexor tendon repair and their effect on the prognosis of healing and rehabilitation. The study recommended the early rehabilitation programs showing their benefits through the comparative study.


  Patients and Methods Top


Patients

This study was conducted through the year 2019 at Menofia University Hospital and Shebin Elkom Teaching Hospital. The study included 60 patients after repair of flexor tendons in the hand, who were divided into early, intermediate, and late groups as groups A, B, and C, respectively (randomized controlled clinical trial). Informed consent was taken from all patients after detailed description of the procedure before entry to the study. The consent was taken by the principal author from the patients themselves. Approval by the Ethical Committee was obtained before initiating this study. Inclusion criteria were patients over the age of 5 years who presented acutely for treatment of flexor tendon injury and patients who are healthy either general or local (no bone or joint injury). Exclusion criteria were patients who are mentally retarded or with severe central neurological injuries, patients with bone and joint injuries, those requiring replantation or revascularization of fingers, patients who sustained severe crush lacerations of the distal palm or division of many of the other longitudinal structures in the wound, and patients who presented for tendon repair at 9 and 11 days after injury. Number of the excluded patients was 15 patients for the previous causes.

Methods

Preoperative, history taking, clinical examination, laboratory investigations, and radiological examination were done. Preoperative management included type of anesthesia, whether local anesthesia or local intravenous anesthesia. The repair technique was as follows: all tendons were repaired using a four-strand core suture with locking loops. Core sutures of 3/0 or 4/0 polypropylene (prolen) and a continuous epitendinous suture of 5/0 or 6/0 nylon or polypropylene were used in all fingers except those with divisions of the flexor digitorum superficialis (FDS) tendons close to their insertions, where the tendon slips are too flat to use this technique. These were repaired with horizontal mattress sutures of 4/0 or 5/0 nylon or polypropylene (atraumatisches Nahtmaterial, Ethicon, Prolen, nicht resorbierbar, 45 cm firma; Johnson & Johnson company: New Brunswick City, New Jersey, U.S.A).

Plan of study and methods of rehabilitation: to clarify the timing distribution of rehabilitation after tendon repair, we subdivided the patients into three groups: early rehabilitation (<1 week), intermediate rehabilitation (1–6 weeks), and late rehabilitation (>6 weeks) after tendon repair. The period selection (<1 week, 1–6 weeks, and > 6 weeks) was based on the physiology of tendon healing, which could be divided into three overlapping phases: inflammation (0–5 days), fibroplasia (3 days–6 weeks), and remodeling (6 weeks–6 months).

Four rehabilitation maneuvers for study included the following: first, place and hold – the surgeon passively flexed all fingers from a fully extended position to a fully flexed posture (full fist). The patient maintained the fingers actively in a flexed position for 3 s before actively extending them to the fully extended starting point [Figure 1]; second, active finger flexion – the patient actively flexed all fingers from a fully extended position until their fingertips lightly touched their palm, maintained the fully flexed position for 3 s before actively extending the fingers to the fully extended starting point [Figure 2]; third, isolated flexor digitorum profundus (FDP) flexion – the patient actively flexed the FDP tendon alone while the surgeon immobilized the FDS tendon by holding the middle phalanx with the metacarpophalangeal and proximal interphalangeal joints extended [Figure 3]; and fourth, isolated FDS flexion – the patient actively flexed the FDS tendon of the index finger alone while the surgeon immobilized the FDP tendons by holding the other three fingers in full extension.
Figure 1: Place and hold.

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Figure 2: Active finger flexion.

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Figure 3: Isolated flexor digitorum profundus flexion.

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Statistical analysis

Statistical analyses were conducted using the Statistical Analysis System (SAS) software (Version 9.3; SAS Institute Inc., Cary, North Carolina, USA). Continuous variables were expressed as means with SD or medians with interquartile ranges (IQR). To compare the various rehabilitation schedules, we employed analysis of variance on patient age, and the Kruskal–Wallis test for time to resurgery, number of rehabilitation sessions, and total rehabilitation time. Statistical significance was set at P less than 0.05 for all analyses. The Kaplan–Meier curves were plotted using STATA (Version 12; Stata Corp., College Station, Texas, USA).

Our objectives were the maximum return of hand function and finger movement, which can be measured by range of movement, ultrasonography, and physiotherapy consultation.


  Results Top


The 60 study participants (45 men and 15 women) comprised 23 (38.33%) patients who began rehabilitation within the first week, 27 (45%) 1–6 weeks, and 10 (16.66%) more than 6 weeks after tendon repair. Patient demographics showed younger patients might have greater motivation to begin rehabilitation to return to work earlier [Table 1].
Table 1: Patient demographics

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The patients who underwent delayed rehabilitation (>6 weeks after repair) were older, more likely to live in rural areas, and underwent surgical hand tendon repair at local hospitals, for example, a patient started his/her first rehabilitation session after 6 weeks and was noncompliant, causing tendon adhesions [Figure 4].
Figure 4: Late rehabilitation (a male patient with cut of flexor digitorum profundus of the right ring finger was repaired on the same day; the patient started his first rehabilitation session after 6 weeks and was noncompliant, causing tendon adhesions).

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Summarizing the patient outcomes following tendon repairs and rehabilitation. Six (6.66%) patients had complications during the follow-up period and required a secondary operation. The median interval from tendon repair to resurgery was 3.29 months (IQR: 1.81–15), which did not differ among patients receiving distinct rehabilitation schedules. The resurgery rate was highest (12.08%) in those commencing rehabilitation more than 6 week after tendon repair, and lowest (3.81%) in those commencing it within 1 week (P < 0.0001). Patients in the early rehabilitation group required fewer rehabilitation sessions (median: 11.5 sessions, IQR ¼ 2–82) than did those in the intermediate (29 sessions, IQR ¼ 6–197) and late (33 sessions, IQR ¼ 4–225) rehabilitation groups (P < 0.0001). Patients in the early rehabilitation group also required shorter rehabilitation time (median ¼ 13 days, IQR ¼ 0–60.5), compared with those in the intermediate (45 days, IQR ¼ 24–100) and late (103 days, IQR ¼ 68–35) rehabilitation groups (P < 0.0001) [Table 2].
Table 2: Outcomes information

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  Discussion Top


In this study, we observed that the early rehabilitation group exhibited the lowest resurgery rate (3.81%) following tendon repair and also used fewer rehabilitation resources than did the intermediate or late rehabilitation groups. A primary concern for early rehabilitation is the risk of tendon rupture. Animal studies have provided supporting evidence for early mobilization. Early controlled mobilization 1 week after surgery increased tendon tensile strength, avoided large callus formation, and reduced tendon adhesion. By contrast, continual immobilization during the fibroblastic phase resulted in disorganized cross-links among newly formed collagen fibers, leading to contracture of ligaments, joint capsules, and volar plates[8],[9].

Clinical studies have also demonstrated the safety of early mobilization. A meta-analysis summarized the complication rates following flexor tendon repairs: the risk of tendon rupture was 3.6% for early passive motions and 5.3% for early active motions, compared with 16.0% for those receiving immobilization. For extensor tendon injuries, the risk of tendon rupture is rarely addressed, but certain clinical series have indicated a risk of 0–4% for those receiving early active motions. Although our data did not specify the rates of tendon rupture, a lower resurgery rate in the early rehabilitation group suggested a low risk[10].

In contrast to early rehabilitation, delaying it by more than 6 weeks was associated with a higher resurgery rate (12.08%). This might have been because of excessive calluses formed around the tendon repair site by the time the rehabilitation began, thus increasing the risk of adhesion and the need for resurgery. However, we cannot exclude the possibility that patients in this group had severe medical conditions that delayed the rehabilitation and worsened the outcome. For instance, we observed that patients in the late rehabilitation group were older and more likely to have comorbidities, as well as concomitant fracture in the upper extremity. A recent study revealed that even 5 days of immobilization can cause substantial loss in skeletal muscle mass and strength, as well as with activation of the catabolic molecular signaling pathway. These disadvantages might not affect the resurgery rate directly but might compromise hand function and slow down the recovery, and thus increase health care resource usage[11].

In a systematic review by Starr et al.[12], passive motion protocols showed a statistically significantly decreased risk for tendon rupture. On the contrary, range of motion was significantly higher in patients rehabilitated with early active protocols. Dy et al.[13] analyzed patients who received flexor tendon repairs between 1998 and 2005 in New York, the USA, using a statewide hospital administrative database. They reported that 6% of the patients required resurgery; older patients and those with workers' compensation were more likely to undergo resurgery. In our study, the resurgery rate (5.74%) was similar, but age and concomitant nerve conditions were not significant predictors for resurgery. Both the studies were with similar methodologies (using the claims databases and standardized procedure coding to define the therapeutic outcomes). The difference might exist in the distinct variables of interest included in the analyses, because our data did not consider the financial payer status of the patients, whereas the US study did not consider the time distribution of rehabilitation[13].


  Conclusion Top


Our study highlighted the benefits and safety of early rehabilitation following hand tendon repairs. Our findings have crucial implications for the clinicians and patients as well as the health policy planners. Randomized prospective clinical trials on larger patient population are necessary to validate the results.

Recommendations of our study

Early diagnosis and intervention of hand injures, good repair of tendons, postsurgical control of infection and edema, effective physiotherapy by early rehabilitation protocols, and adequate hospital supplies are needed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
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2.
Battiston B, Triolo PF, Bernardi A, Artiaco S, Tos P. Secondary repair of flexor tendon injuries. Injury 2013; 44 :340–345.  Back to cited text no. 2
    
3.
Kitis PT, Buker N, Kara IG. Comparison of two methods of controlled mobilisation of repaired flexor tendons in zone 2. Scand J Plast Reconstr Surg Hand Surg 2009; 43 :160–165.  Back to cited text no. 3
    
4.
Rrecaj S, Martinaj M, Murtezani A, Ibrahimi-Kacuri D, Haxhiu B, Zatriqi V. Physical therapy and splinting after flexor tendon repair in zone II. Med Arch 2014; 68 :128–131.  Back to cited text no. 4
    
5.
Howell JW, Peck F. Rehabilitation of flexor and extensor tendon injuries in the hand: current updates. Injury 2013; 44 :397–402.  Back to cited text no. 5
    
6.
Schoffl V, Heid A, Kupper T. Tendon injuries of the hand. World J Orthop 2012; 3 :62–69.  Back to cited text no. 6
    
7.
Frueh FS, Kunz VS, Gravestock I, Held L, Haefeli M, Giovanoli P, et al. Primary flexor tendon repair in zones 1 and 2: Early passive mobilization versus controlled active motion. J Hand Surg Am 2014; 39 : 1344–1350.  Back to cited text no. 7
    
8.
Villeco JP. Edema: a silent but important factor. J Hand Ther 2012; 25 :153–161.  Back to cited text no. 8
    
9.
Dorf E, Blue C, Smith BP, Koman LA. Therapy after injury to the hand. J Am Acad Orthop Surg 2010; 18 :464–473.  Back to cited text no. 9
    
10.
Hsiao PC, Yang SY, Ho CH, Chou W, Lu SR. The benefit of early rehabilitation following tendon repair of the hand: A population-based claims database analysis.J Hand Ther. 2015; 28 :20-5.  Back to cited text no. 10
    
11.
Wall BT, Dirks ML, Snijders T, Senden JM, Dolmans J, van Loon LJ. Substantial skeletal muscle loss occurs during only 5 days of disuse. Acta Physiol 2014; 210 :600–611.  Back to cited text no. 11
    
12.
Starr HM, Snoddy M, Hammond KE, Seiler JG. Flexor tendon repair rehabilitation protocols: a systematic review. J Hand Surg Am 2013; 38 :1712–1717.  Back to cited text no. 12
    
13.
Dy CJ, Daluiski A, Do HT, Hernandez-Soria A, Marx R, Lyman S. The epidemiology of reoperation after flexor tendon repair. J Hand Surg Am 2012; 37 :919–924.  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

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