Mobilize The Pip Tendon Without Stretching The Site Of Repair In The Fdp Tendon?

• Journal List
• Indian J Orthop
• v.44(3); Jul-Sep 2010
• PMC2911933

Indian J Orthop. 2010 Jul-Sep; 44(three): 314–321.

Consequence of early on active mobilization afterward flexor tendons repair in zones Ii–Five in hand

Narender Saini

Section of Orthopaedics, SMS Medical College, Jaipur, Rajasthan, India

Vishal Kundnani

¹Bombay Hospital, Mumbai, SMS Medical College and fastened group of Hospitals, Jaipur, Rajasthan, India

Purnima Patni

ⁱⁱHand Surgery Unit, SMS Medical College and attached group of Hospitals, Jaipur, Rajasthan, Republic of india

SP Gupta

^threeOrthopaedic Unit of measurement Iv, SMS Medical College and attached group of Hospitals, Jaipur, Rajasthan, India

Abstract

Groundwork:

The functional outcome of a flexor tendon injury afterward repair depends on multiple factors. The postoperative direction of tendon injuries has paved a body of water through many mobilization protocols. The improved understanding of splinting techniques has promoted the understanding and implication of these mobilization protocols. We conducted a written report to detect and record the results of early on active mobilization of repaired flexor tendons in zones II–Five.

Materials and Methods:

25 cases with 75 digits involving 129 flexor tendons including 8 flexor pollicis longus (FPL) tendons in zones Ii–V of thumb were subjected to the early on active mobilization protocol. Eighteen (72%) patients were below 30 years of historic period. Twenty-four cases (96%) sustained injury by precipitous instrument either accidentally or by attack. Ring and petty finger were involved in 50% instances. In all digits, either a primary repair (n=26) or a delayed primary repair (n=49) was done. The repair was done with the modified Kessler core suture technique with locking epitendinous sutures with a knot inside the repair site, using polypropylene 3-0/4-0 sutures. An end-to-finish repair of the cutting fretfulness was washed under loupe magnification using a 6-0/viii-0 polyamide suture. The rehabilitation plan adopted was a modification of Kleinert's regimen, and Silfverskiold regimen. The final assessment was done at fourteen weeks post repair using the Louisville arrangement of Lister et al.

Results:

Eighteen of excellent results were attributed to ring and niggling fingers where there was a flexion lag of < 1 cm and an extension lag of < xv°. FPL showed 75% (n=half-dozen) excellent flexion. 63% (n=47) digits showed splendid results whereas expert results were seen in 19% (due north=14) digits. Nine percent (north=7) digits showed off-white and the same number showed poor results. The cases where the median (due north=four) or ulnar nerve (due north=6) or both (n=3) were involved led to some deformity (clawing/ape pollex) at 6 months postoperatively. The cases with digital or common digital nervus involvement (north=7 with 17 digits) showed five excellent, two good, four fair, and 6 poor results. Complications included tendon ruptures in ii (3%) cases (one thumb and one ring finger) and contracture in 2 (iii%) cases whereas superficial infection and flap necrosis was seen in 1 instance each.

Conclusion:

The early on active mobilization of cut flexor tendons in zones II–V using the modified mobilization protocol has given adept results, with minimal complications.

Keywords: Early on mobilization, repair of flexor tendons, splints

INTRODUCTION

The restoration of digital function afterwards a flexor tendon injury continues to be the greatest challenge in the field of paw surgery. Scarring, adhesion formation, and subsequent stiffness have been the major hindrance to practiced results later on a flexor tendon repair. The functional outcome of a flexor tendon injury after a repair depends on multiple factors such as age, injury level and type, type of repair, and mail service repair therapy. Nigh variables except mobilization protocols have been established and defined in the past.^{1 – 5}

The postoperative management of tendon injuries has paved a body of water through many mobilization protocols,^{i – 5} each having its own claim and demerits. The ultimate aim of all postoperative rehabilitation protocols is the aforementioned –"Potent tendon that glides freely." In concluding 100 years, the direction of tendon injuries has not only seen advances in chief intendance, repair technique, suture technique, agreement of biomechanics and postoperative evaluation protocol,^{6 – xiii} but also a drastic modify in mobilization protocols ranging from strict immobilization to early/delayed agile mobilization.

The improved understanding of splinting techniques has promoted these mobilization protocols. It has been proven that postoperative immobilization leads to increased inability catamenia, weak tensile strength, decreased final functional capacity, stiffness, and deformity.¹⁴ Further early postoperative mobilization leads to improved tendon healing, increased tensile force, decreased adhesion formation, early render of function, and less stiffness and deformity equally compared to the immobilization protocol. Even so, every bit any other process information technology has its own demerits in the form of rupture of repaired tendons. We conducted a written report to evaluate the outcome of early on agile mobilization of repaired flexor tendons in zones II–Five.

MATERIALS AND METHODS

34 patients with cut flexor tendons in zones 2–V who reported during the written report period of 2 years (from November 2004 to Oct 2006) constitute the clinical cloth. Out of these, nine patients were lost to follow-upwardly and were thus excluded. xviii (72%) of our patients were below thirty years of age, with 52% (north=13) being in the 21-30 year age group. 23 of our patients were males. 24 sustained injury by sharp musical instrument either accidentally or past set on; one case was of suicidal effort. Patients (n=25) with cutting flexors in zones 2–V with or without an associated vessel or nervus injury and presenting within 7 days of the injury were included in the study. Patients with fracture, simultaneous injury to extensor tendons, gross contamination of wound, and massive skin loss, psychologically impaired and noncompliant patients, and children less than eight years of age were excluded from the written report.

In all cases except ane where secondary repair was done, either a primary repair (n=26 fingers in ix patients) or a delayed primary repair (n=49 fingers in fifteen patients) was done, nether axillary block or general anesthesia with tourniquet control. The primary repair was washed within half-dozen–8 h of injury where the wound was clean, while in others either due to late presentation or potential infection delayed primary repair was done. The initial management in patients with delayed master repair constituted of debridement of wound with antibiotic cover and to brand sure before surgery that there is no infection. The wounds were extended or opened as necessary to retrieve retracted tendons. The zone II wounds were extended with a palmar zig-zag incision or the modified Brunner lateral incision strictly following the surgical principles of Verdan.^{15 – sixteen} The flexor sheath was opened enough to facilitate the repair, the pulleys were not excised, and the damaged pulleys were repaired with a polypropylene six-0 suture. In zones III–V, lazy S or L incisions were used to expose the cut tendon. In all cases, an end-to-end repair of the cut tendons was done afterward freshening of cut ends. The repair was done with the modified Kessler¹⁷ core suture technique with locking epitendinous sutures with a knot inside the repair site. The repair was washed with polypropylene 3-0/four-0 sutures. The end-to-end repair of the cut nerves was done under loupe magnification using a half-dozen-0/viii-0 polyamide suture. 20 patients had nerve injury; 4 median, six ulnar, iii both and 7 digital fretfulness. Vascular repair was not washed in whatsoever case. Postoperative immobilization was washed with a splint in 10°–xv° palmar flexion of the wrist and seventy° flexion of metacarpophalangeal joints and interphalangeal joints in mild flexion [Figure ​ 1a, ​ b].

Photographs (a, b) showing the cocky made plaster of paris Splint

Rehabilitation was started 24 h postoperatively. The rehabilitation plan adopted was a modification of Kleinert's regime¹⁸ and Silfverskiold authorities.¹⁹ The rehabilitation protocol consisted of active extension, with initial active flexion and later passive flexion by Kleinert'southward^xviii regimen and and so further passive flexion. The wrist following nervus repair was kept in 5° palmar flexion and in cases of ulnar nerve cut, Metacarpophalangeal joint (MCP) was kept at 90° flexion. A detailed rehabilitation protocol is shown in Table ane. The patient was strictly brash not to passively stretch the repaired tendons, not to remove the splint unless instructed, avoid belongings the manus in a dependent position, and non to increase the do session by self.

Table 1

Rehabilitation protocol

1 to 28 days	Kleinert's regimen (elastic bands) applied to all fingers with the elastic band extended from the blast to the volar aspect of wrist. Splint: Dorsal splint with wrist 0°–5° dorsiflexion, MCP 70° flexion, and IP full extension (if nerve repair was done, the wrist was kept in 5° palmar flexion and in cases of an ulnar nerve cut, MCP was kept at 90° flexion)
	Exercises: Shoulder, elbow, supination/pronation promoted
	Hand: ten times/session and 3 sessions/day
	Step one: Active extension of all fingers afterwards tension on Kleinert's bands released, gaining full extension at IP and MCP joints blocked only by a splint
	Pace two: Agile flexion of all fingers to possible flexion position without a forceful effort
	Step three: Release tension on Kleinert's bands to bring added passive flexion of fingers by rubber band tension
	Step 4: Passively flex the fingers at IP joints with the assist of other mitt
4–8 weeks	Kleinert's bands removed
	Splint: Intermittant, volar splint with wrist 10°–15° palmar flexion, MCP 70° flexion and IP extension; removed during practice; scar mobilization done
	Exercises: Shoulder, elbow, and wrist exercises continued
	Hand: x times/session and three sessions/day
	Active tunnel block exercises with isolated FDP/FDS. Block FDP of all fingers and isolated FDS function, and block FDS of all fingers and exercise isolated FDP contraction. Actively make fist, curling of all fingers into flexion; release and open actively extending to full extent
	If PIP joint contracture was present, passive stretching was started in the volar splint with cotton wool scroll padding. Passive overflexion and extension with tender strokes were promoted to keep paw supple
eight–12 weeks	Volar splint in 15°–25° dorsiflexion, MCP 50°–70° flexion IP total extension (used simply equally night splint)
	Scar mobilization continued
	Power grip allowed; brawl exercises five times each session
	Resume calorie-free work, food, drinking, push button knots, etc.
	Avoid heavy work
	Exercises: Ambitious shoulder, wrist radioulnar articulation, and elbow exercises
	Manus: Ball exercises with a soft sponge 20 times per session and 4 times/solar day
12–14 weeks	No splintage
	Cease scar mobilization
	Power grip continued
	Resume to daily household piece of work but avert heavy work
	Practise: Hand – go along same equally above with an increased frequency of 50 times per session and five sessions per day

The flexion lag was measured as the lurid-to-palm distance in centimeters, where as the extension lag was measured every bit the amount of extension remaining in caste, comparing to normal digits. Since we accept a rehabilitation protocol for 12 weeks, hence the concluding assessment was done at 14 weeks postrepair using the Louisville organization of Lister et al.¹⁸ [Table ii].

Table ii

Louisville organization

Excellent	Flexion lag < ane cm/extension lag < 15°
Good	Flexion lag 1–1.5 cm/extension lag 15°–xxx°
Fair	Flexion lag 1.5–iii cm/extension lag xxx°–50°
Poor	Flexion lag >3 cm/extension lag > 50°

RESULTS

Of the 75 digits, majority (n=forty) were zone V injuries while injury in zones Ii, III, and IV included 4, 17, and fourteen fingers, respectively. The thumb was involved in 8 instances, while index finger, heart finger, ring finger and little finger were Involved in 14, 17, 22, 14 instances respectively. The study involved eight FPL, 66 Flexor digitorum superficialis (FDS), and 55 Flexor digitorum profundus(FDP) tendons. A total of 96% (n=24) of our cases were repaired inside 7 days and only one case was repaired later on this menstruation.

Thirteen cases where the median (north=four) or ulnar nervus (due north=6) or both (n=3) were involved led to some deformity (clawing/ape thumb) at 6 months postoperatively. The ulnar nerve involvement was plant to be more disabling due to clawing and intrinsic negative hand resulting in scarce MCP joint flexion and preventing IP joint extension hence decreasing the overall gliding and excursion of repaired tendons. The cases with digital or common digital nerve interest (n=seven with 17 digits) showed v excellent, two good, four fair, and vi poor results.

Isolated median nervus involvement did not pose much problem regarding the excursion of repair tendons. However, isolated ulnar nerve and both nervus injury hampered the circuit more than commonly due to involvement of intrinsic muscles.

The average follow-up of each patient was 6 months. Results of tendon excursion were evaluated at 14 -16 weeks. The evaluation of functional ability/inability was washed at the final follow-up (vi months).

Most (northward=eighteen) of the injuries due to accidents were in zones II, III, and V, whereas nigh of assault and suicidal injuries (n=7) involved zone V. A full of 64% (due north=16) of our cases were injured in zones 4 and 5. Ring and little finger were most common digits to be involved (50%, n=13).

Three patients had single digit involvement, while the residual 22 patients had more than ane digit involved. Twenty-one digits (including viii thumbs) had single tendon involvement while 54 digits had more than than i tendon involvement. All cases except ane had either primary repair (26 digits and 9 patients) or delayed master repair (48 digits and 15 patients).

Bulk of fantabulous results (north=26 fingers) were attributed by ring and little fingers where in that location was a flexion lag of < ane cm and an extension lag of < 15°. FPL showed 75% (n=half dozen thumbs) excellent flexion and no poor results were seen in the middle finger. The poor results (five fingers) were mostly due to the flexion lag rather than extension lag [Tables ​ 3 and ​ 4]. Digits with a flexion lag did not necessarily show increased extension lag and thus a discrepancy existed in overall results as compared to the individual flexion/extension lag. However, if whatever of the above criteria showed poor/fair event, tendons were attributed to a lower grade.

Table 3

Flexion lag at the final evaluation of results

Digits	No. of digits	Up to 1 cm	ane–ii cm	ii–3 cm	>3 cm
Thumb	8	6	i	0	i
IF	14	seven	v	1	ane
MF	17	ten	4	3	0
RF	22	15	iv	2	1
LF	14	11	1	0	2

Table 4

Extension lag at final evaluation of results

Digits	No. of digits	<fifteen°	sixteen–thirty°	31–45°	>45°
Pollex	8	half dozen	1	1	0
IF	14	9	5	0	0
MF	17	12	v	0	0
RF	22	17	5	0	0
LF	14	12	2	0	0

Due to discrepancy in the flexion and extension lag between each involved finger, tabulated results were evaluated/graded as per the Louisville criteria.¹⁸ Sixty-iii percent (47/75) fingers showed first-class results whereas expert results were seen in 19% (14/75) digits. Nine percent (7/75) digits showed off-white and the same number showed poor results. On comparison the results zone-wise, it was observed that zone Two results were poor in 25% cases and fair in equal number, whereas in zones III and 4, sixty–seventy% first-class to practiced results were seen with the early active mobilization protocol. Excellent to adept results were seen in 100% cases in zone V with this early mobilization protocol [Table v]. [Figures ​ 2A, ​ 2B, ​ 2C].

Clinical photographs of 31 yrs old male, assault with Axe showing (a) cut FPL, FDS/FDP of alphabetize, eye and ring fingers (ZONE IV), cut median nerve and radial artery with cut I and Iii extensor compartment and distal radius fracture. (b) Splint practical and mobilization taught.

Clinical photographs showing (a) ii weeks post operative- flexion of fingers. (b) 2 weeks mail service operative- extension of fingers. (c) 5 weeks post operative flexion of fingers. (d) 5 weeks post operative extension of fingers.

Clinical photographs at 8months follow upwards showing (a) extension with ape thumb. (b) flexion with 1 cm flexion lag.

Table 5

Zone-wise results

	Zone II (n=iv)		Zone Iii (due north=17)		Zone Iv (due north=14)		Zone V (n=40)
	No.	%	No.	%	No.	%	No.	%
Splendid	2	50	vi	35.29	half dozen	42.85	35	87.5
Adept	0	0	three	17.60	4	28.57	5	12.5
Fair	1	25	iii	17.60	iii	21.42
Poor	ane	25	5	29.41	one	7.14

Laceration occurring proximal to the carpal tunnel and involving wrist and finger flexors, median, ulnar or both nerves with both arteries cutting as well known as spaghetti wrist or full house syndrome was the nigh common pattern of injury in zone V. The interest of ulnar structures with FCU, flexors of little and ring fingers with ulnar nervus and ulnar artery injury was the second most common design of involvement.

Five tendons in our written report had frayed ends as compared to balance. The frayed tendons showed fair to poor results, whereas sharply cut tendons (n=124) showed fantabulous to good recovery.

Injuries occurring proximal to the carpal tunnel and involving wrist and finger flexors, and median or ulnar or both nerves with both arteries cut were the most common pattern of injury in zone V (12 patients). The involvement of ulnar structures with FCU, flexors of little and ring fingers with ulnar nerve, and ulnar artery injury was the second almost mutual blueprint of interest [Figures ​ 3A, ​ 3B].

Clinical photographs nineteen years sometime male cut right wrist due to attack (sword cut)showing (a) cut FPL, FDS/FDP of index and centre fingers, cutting FDS of band and little finger is Zone III, Four. cut median north, radial avenue. (b), (c) seven weeks post operative, showing good flexion. (d) At 24 weeks follow up- Correct side showing skillful grip.

Clinical photographs of same patient with left side showing (a) Cutting FDS/FDP ring and pinkie in Zone Iv, cut ulnar nerve, ulnar avenue. (b), (c) 7 weeks post operative. (d) At 24 weeks follow up- showing good fist germination.

Some complications did occur. Ruptures were seen in 2 (iii%) cases, in one FPL ruptured in zone Half dozen and in some other FDS/FDP of band finger ruptured in zone 2 [Figure 4]. In both cases, at that place was a sudden loss of movement in the involved digit, and in both cases secondary repair with tendon graft was done. Contracture in 2 (three%) digits whereas superficial infection and flap necrosis was seen in i digit each. No tenolysis was required in our report. Then results of primary and delayed main repair were identical.

Clinical photographs showing complication- rupture of flexor tendon repair and Flexion lag

DISCUSSION

Flexor tendon injuries are amongst the virtually common injuries of manus, occurring ordinarily in young males of the working class. Our report consisted of 25 patients, by and large males with a flexor tendon injury involving 75 digits with 129 tendons. Nosotros started our study to manage flexor tendon injuries with an aim to achieve full range of motion at IP, MCP, and wrist joints inside 3.five months with least possible complications.

Results after a flexor tendon injury repair are inversely proportional to the delay in the repair of the tendon⁶. The added benefits of a principal/delayed primary repair are decreased rehabilitation time, adhesion formation, and rupture charge per unit, and increased healing rate with acceptable tensile strength. Ninety-half dozen percent of our cases were repaired within vii days and only i case was repaired after this flow.

Sharp cut tendons with transverse/oblique edges in our written report showed improve healing (n=124) and alignment equally compared to those in which edges were found to be frayed. This has been earlier reported by Gault^eleven (1988) stating delayed vascularization in later cases to be the cause of poor healing.

Verdan et al.^xv classified flexor tendon injury in digit and pollex in five zones and we have followed the same classification. A total of 53.five% (n=40) of digits in our study were injured in zone V, whereas eighteen.5% (due north=14) in zone 4 and 21% (n=17) in zone III. Zone V injuries commonly involved multiple tendons and had 1/both fretfulness injured, whereas zone 2 and III injuries were more unremarkably reported to have a unmarried tendon injury along with a neurovascular injury always associated.

Laceration occurring proximal to the carpal tunnel and involving wrist and finger flexors and median or ulnar or both fretfulness with both arteries cut too known as spaghetti wrist²¹ or full firm syndrome was the most common pattern of injury in zone V. The interest of ulnar structures with FCU, flexors of little and band fingers with ulnar nervus, and ulnar artery injury was the second well-nigh common blueprint of interest.

Pucket and Meyer²¹ in there series of 38 spaghetti wrists accomplished 87% good to excellent range of movement at IP, MCP, and wrist joints using active and passive mobilization protocol. Windgrow²² reported 19 cases using a definition of 10 injured structures including at least ane major nerve and one major vessel called equally spaghetti wrist. He reported good to splendid results in 95% of patients; nonetheless, protective sensation at 12 weeks was nowadays in only 36% of cases, hampering the overall result. Hudson and Dejarger²³ studied 15 patients with simultaneous laceration of the median and ulnar nerve of 76 repaired tendons. Their study showed 41% good to first-class results and 35% off-white to poor results. In our study, 100% of tendon repair in zone 5 showed fantabulous to expert results with protective sensation tested in the democratic zone for each nervus present in 96% of cases at fourteen weeks and average 2 PD (static ii point bigotry) at 24 weeks to be at 9 mm. Our results are superior to any other study and so far conducted.

Isolated median nerve involvement did not pose much problem regarding the excursion of repaired tendons. Although the involvement of the ulnar or median nerve did not bear upon the overall final gliding and circuit of tendons but circuit and gliding of tendon was more commonly hampered in early on stages of spaghetti wrist. Even so, an isolated ulnar nerve injury hampered the excursion more commonly than any other form of nerve involvement and required some modification of splint (Flexion of MCP joints to 90° was done) to achieve proficient results. The overall render of office in all zones with nerve injuries was ultimately dependent on the return of protective sensation and terminal results were more hampered with median and ulnar nerve involvement as compared to the isolated injury to the nerve.

Pucket and Meyer²¹ and Windgrow²² showed that protective sensation was nowadays in 40% of cases at 12 weeks and 2 PD at 24 weeks was 12 mm on average. The return of motor function was delayed up to 5 years in cases with median and ulnar injuries as reported by Rogers²⁴ and but 48% of cases showed motor recovery at 2-year follow-up. In our serial, 100% of cases involving median/ulnar or both showed ape pollex/clawing at half-dozen-month follow-upward and support the theory that motor recovery was tardily and never consummate; however, protective awareness was nowadays at boilerplate 12-xiv weeks and render to activities of daily living was possible in all (96%) patients except ane who had delayed return of protective awareness (24 weeks).In our study, we kept strict vigilance over cases with nerve injuries and modified our splints to overcome the factors hampering results and increase the excursion of tendons and their gliding properties²⁴.

In ulnar nervus injury intrinsic negative manus lead to decrease of tendons excursion, due to clawing and hyperextension at MCP joints, attempting flexion was wasted at IP joints with a tendency to develop contracture at PIP joint and no flexion was brought at MCP joint, decreasing the overall gliding of the tendons. To overcome this we adjusted/inverse the splint and kept the MCP dorsal block to xc° flexion and released Kleinert's elastic safe bands at three weeks.

Edinburg and Biddulph²⁵ in their study of zone Three injuries repaired primarily and active mobilization showed 71% fair to excellent and 29% poor results. In our written report 42% of cases were in zones III and 4. 58% and 71% of results in zones 3 and IV, respectively, were reported with 29% excellent/practiced and 7% poor results, respectively.

In our written report all tendons were repaired past modified Kessler's core suture and continuous locking epitendinous sutures. This two-strand core suture not only gives adequate strength to the tendon but also prevents adding of majority to the tendon which prevents gliding of the tendon in edematous repair zones and flexor sheath. Thurman²⁶ compared strength between two-, four- and 6-strand technique and stated that the two-/4-strand technique with modified Kessler/Tajima repair and epitendinous suture provides adequate strength to prevent rupture without adding bulk with an increased tensile strength of the repaired tendon. In all cases, a knot was placed inside the repair site as promoted past Aoki,²⁷ Pruitt,²⁸ and Mashadi.²⁹

Early mobilization in our series showed a reduced rupture rate of 3% (ii digits) as compared to 4-17% in other series.

The early on active mobilization shows benefits of increased healing charge per unit and tensile strength and decreased adhesion formation and rupture.^{thirty – 37} The results are ranging from lxx% excellent in Cullen³⁰ and Chow³¹ to 100% splendid to fair in Silfverskiold.³⁴ Our study showed 82% excellent to skilful results with nine fair and poor each as per the Louisville system criteria.¹⁸

In our series, eight FPL were repaired and subjected to early on active mobilization. Eighty-seven pct (vii digits) showed excellent to skilful results and one had poor results due to the associated FPL rupture. Perceival and Sykes,³⁸ Nunley,³⁹ and Thomazean^xl accept used immobilization/controlled mobilization as the method of FPL rehabilitation with the rupture rate ranging from 8% to 17% and 44-71% showing first-class to good results. Our study has shown superior results in this context.

Complications reported in our series were skin flap necrosis in one case, managed surgically by a rotation flap, contracture at a PIP joint in ii cases managed conservatively by Capner's dynamic splinting, and rupture in two digits, one FPL zone V and 1 FDP zone II. The FPL rupture was cutting and adherent with a slight functional deficit and did non require any surgery.

To conclude, master or delayed primary repair of sharply cut flexor tendons with a modified Kessler core suture and locking epitendinous circumferential suture increases the overall strength, allowing active mobilization, which causes cyclic tension loading, leading to prevention of adhesions and good tendon healing. Thus the primal to success for a flexor tendon repair lies in principal or delayed primary repair with early active mobilization protocol in a compliant patient having a zeal to get well before long.

Footnotes

Source of Back up: Cypher

Conflict of Interest: None.

REFERENCES

1. Lexer E. Die Verwerthung der freien sehnentransplantation. Archiv Klin Chir. 1912;98:818–25. [Google Scholar]

2. Harmer TW. Tendon suture. Boston Med Surg J. 1917;177:808–10. [Google Scholar]

3. Kirchmayr 50. Zur Technik der Sehnennaht. Zentralbl Chir. 1917;twoscore:906–vii. [Google Scholar]

4. Lahey FH. A tendon suture which permits immediate motion. Boston Med Surg J. 1923;22:851–2. [Google Scholar]

5. Bunnel S. Repair of tendons in the fingers and description of two new instruments. Surg Gynaecol Obstet. 1918;126:103–ten. [Google Scholar]

6. Hsu C, Chang J. Clinical implications of growth factors in flexor tendon wound healing. J Hand Surg Am. 2004;29:551–63. [PubMed] [Google Scholar]

7. Hatano I, Suga T, Diao E, Peimer CA, Howard C. Adhesions from flexor tendon surgery: an animal study comparing surgical techniques. J Mitt Surg Am. 2000;25:252–9. [PubMed] [Google Scholar]

8. Kain CC, Russell JE, Rouse AM, Manske PR. Regional differences in matrix germination in the healing flexor tendon. Clin Orthop Relat Res. 1988;229:308–12. [PubMed] [Google Scholar]

ix. Klein MB, Yalamanchi N, Pham H, Longaker MT, Chang J. Flexor tendon healing in vitro: effects of TGF-beta on tendon prison cell collagen production. J Hand Surg Am. 2002;27:615–xx. [PubMed] [Google Scholar]

10. Zhao C, Amadio PC, Momose T, Couvreur P, Zobitz ME, An KN. The result of suture technique on adhesion formation subsequently flexor tendon repair for partial lacerations in a canine model. J Trauma. 2001;51:917–21. [PubMed] [Google Scholar]

xi. Ketchum LD. Suture materials and suture techniques used in tendon repair. Paw Clin. 1985;one:43–53. [PubMed] [Google Scholar]

12. Hunter JM, Schneider LH, Mackin EJ, editors. Tendon surgery in the manus. St Louis: Mosby; 1987. [Google Scholar]

xiii. Idler RS. Beefcake and biomechanics of the digital flexor tendons. Manus Clin. 1985;one:3–11. [PubMed] [Google Scholar]

14. Takai S, Woo SL, Horibe S, Tung DK, Gelberman RH. The effects of frequency and elapsing of controlled passive mobilization on tendon healing. J Orthop Res. 1991;nine:705–13. [PubMed] [Google Scholar]

15. Verdan CE, Michon J. Le traitement des plaies des tendons flechisseurs des doigts. Revue de Chirugie Orthopedique et Reparatrice de L' Appareil Moteur. 1961;47:290–6. and 386. [Google Scholar]

16. Verdan C. Reparation primaire des flechisseurs en dehors des coulisses osteo-fibreuses des doigts.In Chirurgie Reparatrices et Fonctionnelle des Tendond de la Main. Paris: L'Expansion Scientifique Francaise; 1952. pp. 174–six. [Google Scholar]

17. Kessler I. The "grasping" technique for tendon repair. Paw. 1973;five:253–five. [PubMed] [Google Scholar]

eighteen. Lister GD, Kleinert HE, Kutz JE, Atasoy East. Primary flexor tendon repair followed by immediate controlled mobilization. J Hand Surg Am. 1977;2:441–51. [PubMed] [Google Scholar]

19. Silfverskiold KL, May EJ. Flexor tendon repair in zone Two with new suture technique and an early mobilization program combining passive and active flexion. J Manus Surg Am. 1994;19:53–sixty. [PubMed] [Google Scholar]

20. Gault DT, Quaba AA. The office of cross-finger flaps in the main management of untidy flexor tendon injuries. J Mitt Surg Br. 1988;xiii:62–five. [PubMed] [Google Scholar]

21. Puckett CL, Meyer VH. Results of treatment of extensive volar wrist lacerations: The spaghetti wrist. Plast Reconstr Surg. 1985;75:714–21. [PubMed] [Google Scholar]

22. Widgerow AD. Full-house/spaghetti wrist injuries: Analysis of results. S Afr J Surg. 1990;28:6–10. [PubMed] [Google Scholar]

23. Hudson DA, de Jager LT. The spaghetti wrist.Simultaneous laceration of the median and ulnar fretfulness with flexor tendons at the wrist. J Mitt Surg Br. 1993;18:171–3. [PubMed] [Google Scholar]

24. Rogers GD, Henshall AL, Sach RP, Wallis KA. Simultaneous laceration of the median and ulnar nerves with flexor tendons at the wrist. J Mitt Surg Am. 1990;15:990–v. [PubMed] [Google Scholar]

25. Edinburg M, Widgerow AD, Biddulph SL. Early postoperative mobilization of flexor tendon injuries using a modification of the Kleinert technique. J Hand Surg Am. 1987;12:34–8. [PubMed] [Google Scholar]

26. Thurman RT, Trumble TE, Hanel DP, Trencer AF, Kiser PK. 2, 4, 6 strand zone 2 flexor tendon repair: An in situ biomechanical comparing using a cadaver model. J Hand Surg Am. 1998;23:261–5. [PubMed] [Google Scholar]

27. Aoki M, Manske PR, Pruitt DL, Kubota H, Larson BJ. Piece of work of flexion later flexor tendon repair co-ordinate to the placement of sutures. Clin Orthop Relat Res. 1995;320:205–10. [PubMed] [Google Scholar]

28. Pruitt DL, Manske PR, Fink B. Cyclic stress analysis of flexor tendon repair. J Paw Surg Am. 1991;16:701–7. [PubMed] [Google Scholar]

29. Mashadi ZB, Amis AA. Variation of holding strength of synthetic absorbable flexor tendon sutures with time. J Mitt Surg Br. 1992;17:278–81. [PubMed] [Google Scholar]

30. Cullen KW, Tolhurst P, Lang D, Page RE. Flexor tendon repair in zone Two followed by controlled agile mobilization. J Hand Surg Br. 1989;xiv:392–5. [PubMed] [Google Scholar]

31. Chow SP, Stephens MM, Ngai WK, So YC, Pun WK, Chu Chiliad, et al. A splint for controlled agile move after flexor tendon repair: Design, mechanical testing, and preliminary clinical results. J Paw Surg Am. 1990;15:645–51. [PubMed] [Google Scholar]

32. Elliot D, Moiemen NS, Flemming AF, Harris SB, Foster AJ. Rupture rate of acute flexor tendon repairs mobilized by controlled agile movement regimen. J Paw Surg Am. 1996;21:969–73. [PubMed] [Google Scholar]

33. Kubota H, Aoki M, Pruitt DL, Manske PR. Mechanical properties of various circumferential tendon suture techniques. J Mitt Surg Br. 1996;23B:474–80. [PubMed] [Google Scholar]

34. Silfverskiold KL, May EJ, Tornvall AH. Tendon excursion after flexor tendon repair in zone II: Event with a new controlled movement program. J Mitt Surg Am. 1993;eighteen:403–x. [PubMed] [Google Scholar]

35. Strickland JW. Flexor tendon injuries: I, foundations of treatment. J Am Acad Orthop Surg. 1995;3:44–54. [PubMed] [Google Scholar]

36. Bainbridge LC, Robertson C, Gillies D, Elliott D. A comparing of post operative mobilization of flexor tendon repair with "passive flexion-agile extension" and "controlled agile motion technique" J Manus Surg Br. 1994;xix:517–21. [PubMed] [Google Scholar]

37. Minor JO, Bernnen Thou. D, Colville J.Early active mobilization post-obit flexor tendon repair in zone 2. J Manus Surg Br. 1989;14:383–91. [PubMed] [Google Scholar]

38. Percival NJ, Sykes PJ Flexor pollicis longus tendon repair: A comparing between dynamic and static splintage. J Hand Surg Br. 1989;fourteen:412–v. [PubMed] [Google Scholar]

39. Nunley JA, Levin LS, Devito D, Goldner RD, Urbaniak JR. Direct stop-to-end repair of flexor pollicis longus tendon lacerations. J Hand Surg Am. 1992;17:118–21. [PubMed] [Google Scholar]

xl. Thomazeau H, Attali JY, Dréano T, Langlais F. Contempo isolated lesions of the flexor tendon of the thumb (20 cases): A long-term review. Rev Chir Orthop Reparatrice Appar Mot. 1996;82:590–7. [PubMed] [Google Scholar]

---

Manufactures from Indian Journal of Orthopaedics are provided here courtesy of Indian Orthopaedic Clan

---

Mobilize The Pip Tendon Without Stretching The Site Of Repair In The Fdp Tendon?,

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911933/

Posted by: grahamsheining.blogspot.com

Share this post