Functional outcomes of two-stage flexor tendon reconstruction in zone 2 of the hand

Ahmed H. Alshukaili; Gopal Malhotra; Patil R. Krishnarao

doi:10.18203/issn.2455-4510.IntJResOrthop20262924

Authors

Ahmed H. Alshukaili Department of Orthopedic, Surgery, Khoula Hospital Muscat, Oman
Gopal Malhotra Department of Hand Surgery, Khoula Hospital Muscat, Oman
Patil R. Krishnarao Department of Hand Surgery, Khoula Hospital Muscat, Oman

DOI:

https://doi.org/10.18203/issn.2455-4510.IntJResOrthop20262924

Keywords:

Flexor tendon injury, Prognostic factors, Staged tendon reconstruction, Outcomes, Paneva-Holevich, Oman

Abstract

Zone II flexor tendon injuries with delayed presentation or failed primary repair remain among the most challenging conditions in hand surgery due to adhesion formation and compromised pulley systems. Two-stage reconstruction using the Paneva-Holevich technique has demonstrated favorable outcomes internationally; however, data from the Middle Eastern region are scarce. We present a retrospective case series of 21 patients who underwent two-stage flexor tendon reconstruction in zone II at a tertiary referral center in Oman between 2012 and 2020. Functional outcomes were assessed using total active motion (TAM), Adjusted Strickland score, Buck-Gramko rating system, and QuickDASH questionnaire. The mean TAM was 85.4% of the contralateral digit, and the mean Adjusted Strickland score was 82.2%. According to Buck-Gramko criteria, 90.5% achieved excellent outcomes. The mean QuickDASH score was 8.5, indicating minimal disability. Patient satisfaction was 95%, and 85% returned to their previous occupation. Complications requiring reoperation occurred in 28.6% of patients. This case series demonstrates that the Paneva-Holevich technique provides reliable functional restoration in complex Zone II injuries within our population.

References

Tang JB. Flexor tendon repair: recent changes and current methods. J Hand Surg Eur. 2015;40(9):853-63.

Strickland JW. Flexor tendon injuries: I. Foundations of treatment. J Am Acad Orthop Surg. 1995;3(1):44-54.

Freilich AM, Chhabra AB. Secondary flexor tendon reconstruction: a review. J Hand Surg Am. 2007;32(9):1436-42.

Momeni A, Grauel E, Chang J. Complications after flexor tendon injuries. Hand Clin. 2010;26(2):179-89.

Samora JB, Klinefelter RD. Flexor tendon reconstruction. J Am Acad Orthop Surg. 2016;24(1):9-19.

Langer MF, Wieskötter B, Oeckenpöhler S. Staged flexor tendon reconstruction: indications and results. Handchir Mikrochir Plast Chir. 2019;51(3):174-81.

Chesney A, Chauhan A, Kattan A. Systematic review of flexor tendon rehabilitation protocols in zone II of the hand. Plast Reconstr Surg. 2021;147(2):449-59.

Hunter JM, Salisbury RE. Flexor-tendon reconstruction in severely damaged hands. J Bone Joint Surg Am. 1971;53(5):829-58.

Paneva-Holevich E. Two-stage reconstruction of the flexor tendons. Int Orthop. 1982;6(2):133-8.

O’Shea K, Wolfe SW. Two-stage reconstruction with the modified Paneva-Holevich technique. Hand Clin. 2013;29(2):223-33.

Beris AE, Darlis NA, Korompilias AV. Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft. J Hand Surg Am. 2003;28(4):652-60.

Beris AE, Lykissas MG, Korompilias AV. Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft: long-term results. J Hand Surg Eur. 2011;36(4):304-11.

Al-Qattan MM, Al-Zahrani K. Flexor tendon injuries in the hand: factors influencing results in Saudi Arabia. Saudi Med J. 2009;30(1):78-82.

Ibrahim AM, Kim PS, Rabie AN. A systematic review of flexor tendon rehabilitation protocols. Plast Reconstr Surg Glob Open. 2015;3(11):e557.

American Society for Surgery of the Hand. Clinical Assessment Committee: Clinical Assessment Recommendations. 2nd ed. ASSH. 1992.

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(6):537-43.

Buck-Gramcko D. A new method for evaluation of results in flexor tendon repair. Handchirurgie. 1976;8(2):65-9.

Gummesson C, Ward MM, Atroshi I. The shortened disabilities of the arm, shoulder and hand questionnaire (QuickDASH): validity and reliability based on responses within the full-length DASH. BMC Musculoskelet Disord. 2006;7:44.

Boyes JH, Stark HH. Flexor-tendon grafts in the fingers and thumb: a study of factors influencing results in 1000 cases. J Bone Joint Surg Am. 1971;53(7):1332-42.

Darlis NA, Beris AE, Korompilias AV. Two-stage flexor tendon reconstruction in zone 2 of the hand in children. J Pediatr Orthop. 2005;25(3):382-6.

Naam NH. Staged flexor tendon reconstruction using pedicled tendon graft from the flexor digitorum superficialis. J Hand Surg Am. 1997;22(2):323-7.

Walbeehm ET, Duraku LS, Jupiter JB. Patient-reported outcome measures in hand surgery. J Hand Surg Eur. 2015;40(8):771-5.

Shauver MJ, Chung KC. The minimal clinically important difference of the Michigan Hand Outcomes Questionnaire. J Hand Surg Am. 2009;34(3):509-14.

Soucacos PN, Beris AE, Malizos KN. Two-stage treatment of flexor tendon ruptures: silicon rod complications analyzed in 109 digits. Acta Orthop Scand. 1997;68(275):48-51.

Frakking TG, Depuydt KP, Kon M. Retrospective outcome analysis of staged flexor tendon reconstruction. J Hand Surg Br. 2000;25(2):168-74.

Tang JB, Zhou X, Pan ZJ. Strong digital flexor tendon repair, extension-flexion test, and early active flexion: experience in 300 tendons. Hand Clin. 2017;33(3):455-63.

Djerbi I, Chammas M, Mirous MP. Prognostic factors in two-stage flexor tendon reconstruction: is it possible to predict surgical failure? Orthop Traumatol Surg Res. 2016;102(1):53-9.

Dy CJ, Hernandez-Soria A, Ma Y, Timothy RR, Aaron D. Complications after flexor tendon repair: a systematic review and meta-analysis. J Hand Surg Am. 2012;37(3):543-51.

Kotwal PP, Varshney A, Soral A. Comparison of outcomes of tendon repair in zone II flexor tendon injuries under wide-awake anesthesia versus general anesthesia. J Hand Surg Asian Pac. 2019;24(2):166-71.

Higgins A, Lalonde DH. Wide-awake flexor tendon repair: current trends. Plast Reconstr Surg. 2017;140(4):734e-6e.

Tang JB, Amadio PC, Boyer MI, Robert S, Chunfeng Z, Michael S, et al. Current practice of primary flexor tendon repair: a global view. Hand Clin. 2013;29(2):179-89.

Trumble TE, Vedder NB, Seiler JG. Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy. J Bone Joint Surg Am. 2010;92(6):1381-9.

Chesney A, Chauhan A, Kattan A, Forough F, Achilleas T. Systematic review of flexor tendon rehabilitation protocols in zone II of the hand. Plast Reconstr Surg. 2021;147(2):449-59.

Schreuders TA, Roebroeck ME, Jaquet JB, Steven ERH, Henk JS. Measuring the strength of the intrinsic muscles of the hand in patients with ulnar and median nerve injuries: reliability of the Rotterdam Intrinsic Hand Myometer. J Hand Surg Am. 2004;29(2):318-24.

Groth GN. Pyramid of progressive force exercises to the injured flexor tendon. J Hand Ther. 2004;17(1):31-42.

Evans RB. Managing the injured tendon: current concepts. J Hand Ther. 2012;25(2):220-33.