The senior author (A.D.

) prefers to use either a modification of Kesslers technique

that adds a separate horizontal mattress suture or a cross-locked cruciate technique
(figure 4). A meta-analysis found that, compared with the modified Kessler suture
configuration, other repair techniques are associated with a higher risk of adhesion
formation. Thus, the senior author (A.D.) uses the modified Kessler repair technique
when a distinclty increased risk of adhesions is anticipated (eg, the repair is
particularly close to the pulleys). In situations where adhesion formation is a less
prominent concern, the cross-locked cruciate technique is used because of its
combination of mechanical strength and minimal bulk. Mechanical testing has
demonstrated that the cross-locked cruciate repair was performed with a 3-0
FiberWire (Arthrex) for the core sutures and a 6-0 polypropylene simple running
circumferentian peripheral suture, the mean ultimate strength was 107 N and the 2mm gap force was 96 N, which greatly exceeds the maximum forces measured
during active motion (27 N) and motion against resistance (50 N) in the study by
Powell and Trail. Of note, the only other four-strand technique (Massachusetts
General Hospital repair) included in the study by Waitayawinyu et al also exceeded
the thresholds.
Core suture placement
Mechanical testing has shown that the ideal placement of the core suture is 7 to 10
mm from the repair site for four-strand repairs. The ideal dorsovolar position of the
core suture is not khown. Although stronger purchase can be obtained in the dorsal
portion of the tendon, this may place the dorsally based blood supply from the
vincular system at risk of injury.
Core suture material
The type and caliber of suture material used is relatively unimportant compared
with suture technique. Although the senior author (A.D.) prefers to use FiberWire,
many surgeons use a type of braided or monofilament nonresorbable suture.
Alavanja et al evaluated braided polyester suture for zone II flexor tendon repair and
found no difference between 3-0 and 4-0 caliber suture with regard to failure
strength.

Perpheral suture
Elongation at the rapair site (gapping) should be avoided because gaps >3 mm
negatively affect the strength of the repair site. Mechanical testing of different
repair techniques indicates that the number of core suture strands and the
purchase of the peripheral suture are the two most influential factors affecting
potential elongation. The peripheral suture serves the dual purpose of preventing
gapping and minimizing the bulk of the rapair. Following completion of the core
suture, the senior author (A.D.) uses a nonlocking 6-0 polypropylene running
peripheral suture. An interlocking horizontal mattress technique can also be used.
The suture is placed 2 mm from the repair site at a depht of 2 mm (as opposed to
purely within the epitenon) to maximize the strength of the repair.
FDS repair

During the initial evaluation of the digit, injury to the FDS should be noted. The
location of the injury influences whether FDS repair should be pursued whithin zone
II. If the FDS proximal to the Campers chiasm and the FDP are repaired, both of te
repaired tendons will lie under the A2 pulley. Tendon gliding and synovial nutrition
are likely to be compromised in this scenario because of the amount of
postoperative edema that will occure. In this particular setting, Tang et al advocate
repair of the FDP alone and excision of the a segment of one FDS slip, with the
intent of minimizing the bulk of the repaired tendon under the A2 pulley. Distal FDS
slips can be repaired individually using a modified Becker configuration with 5-0 or
6-0 propylene suture (Figure 5). It should be noted that, because of their more
dorsal position, the FDS slips in this location should be repaired before the FDP. We
base our decision on whether to repair one or both FDS slips on the smoothness of
intraoperative tendon gliding after the FDP repair. Although we prefer to keep both
FDS slips, we will excise one (and repair the other slip, if also injured) if needed to
facilitate gliding of the repaired tendons.
Final intraoperative evaluation
After the tenorrhaphy is complete and other concurrent injuries are addressed, a
final evaluation of the digit is performed. The repair site is closely examined for
proper coaptation of the tendon ends, with minimal bulk, minimal gapping, and an
appropriate amount of tension. Gliding of the FDP and FDS tendons (within the
flexor sheath) and pulleys is carefully evaluated throughout the arc motion, taking
into consideration that postopertive edema will be present within the tendons and
the surrounding soft tissues. The A2 pulley can be partially divided (up to 50 %) and
the A4 pulley can be completely divided to help restore smooth tendon glinding, but
this should be done cauntiously to avoid unnecessary compromise of the
mechanical efficiency of the flexor apparatus. Flexor tendon sheath repair is
controvesial because it is technically challenging and has not been shown to
improve clinical outcomes. If neurovascular repair is performed, the repair sites are
evaluated during passive motion to assess fo an excessive amount of tension; these
findings are noted in the surgical dictation and considered during the selection of a
post operative rehabilitation protocol. Following meticulous hemostasis and
standard wound closure, the hand is placed in a dorsal blocking splint that extends
beyond the fingertips.
Postoperative Rehabilitation
Early mobolization after flexor tendon repair enhances the strenght of the repair site
and decreases the risk of the repair site and decreases the risk of adhesions and
joint stiffness. It is important to ensure that the load applied to the tendon is
sufficient to induce beneficial amounts of motion, but not so excessive as to expose
the repair site to rupture or elongation (the latter occurring at approximately two
thirds of the repairs ultimate strength). The amount of tendon excursion needed to
prevent adhesion formation is 1.7 to 3.5 mm, which can be provided in passive
mobilization protocols with < 10 N of force. However, having both motion and
tension at the repair site appears to confer the added benefit of mechanical
strength, which provides a rationale for the use of early active motion protocols.
Given that satisfactory results can be achieved with either early passive or early
active motion protocols, the choice of postoperative rehabilitation program is at the

discreation of the surgeon. Factors such as repair integrity, concurrent injuries, and
anticipated patient compliance should be considered during decision making
process.
Ideally, the first visit with the therapist should occur before surgery to educate the
patient about the post operative rehabilitation plan and fabricate the splint.
Communication among the surgeon, patient, and therapist help to optimize the
effectiveness of the rehabilitation plan. It is helpful for the surgeon to inform the
therapist about the location and extent of the injury, the strength of the repair, the
repair technique used, associated injuries (eg, to the flexor pulleys and
neurovascular bundle), and any other particular concerns regarding the
postoperative course.

Range of motion (ROM) exercises are not initiated until at least 4 days (but no later
than 7 days) after surgery because the work of flexion is increased by the amount of
soft tissue edema present in the first 3 days. If possible, therapy should begin
before 7 days postoperatively; waiting longer has resulted in an increased risk of
adhesion formation in an animal model. Due to the mechanical benefits conferred
by both motion and tension at the repair site, the senior author (A.D.) prefers a
modification of the Duran and Houser protocol that adds immediate place and hold
active motion. In this protocol, a dorsal blocking splint is applied to the hand with
the wrist in 10 flexion, the metacarpophalangeal joints in 70 flexion, and the
interphalangeal joints in full extension. Passive PIP, distal interphalangeal (DIP), and
composite flexion as well as active PIP/DIP extension exercises are performed with
the hand in the splint. Place and hold PIP flexion (the PIP joint is passively flexed and
actively held in flexion while the wrist is extended) is initiated immediately after the
splint is removed. Place and hold DIP flexion in a hook fist (PIP and DIP joints flexed
with the metacarpophalangeal joint in extension) is also initiated immediately to aid
in differential gliding between the FDS and FDP tendons. The patient is transitioned
to active flexion at 3 to 4 weeks postoperatively, with light resistive exercises at 7
to 8 weeks.
Although numerous early passive and early active mobilization protocols have been
described, a systematic review of the literature has shownn that both types of
protocols can be used to deliver adequate motion, with an acceptable risk of
complications. In reviewing data from 15 studies with a minimum 3 month follow up
periode after zone II repair, Chesney et al reported 29 ruptures in 590 early passive
motion cases (4,9 %) and 13 ruptures in 275 early active motion cases (4,1%). In
the inly randomized controlled trial that has directly compared the two types of
protocols, patients who underwent an active place and hold protocol (with a
tenodesis splint for the first 2 weeks) showed greater patient satisfication than did
those hwo underwent an early passive motion protocol. Although Trumble et al
reported a relatively high rate of rupture in small fingers treated with early active
motion, the senior author (A.D.) has noted this in his practice. Given that there is a
strong relationship between repair rupture and patient compliance with
postoperative restrictions, the surgeon must select a rehabilitation protocol that
matches the anticipated ability of the patient to adhere to the programs

restrictions. The role and importance of the therapist in the rehabilitation process
should not be overlooked; treatment by a certified hand therapist has been
associated with better motion and greater patient satisfication
Complications
The overall rate of reoperation after flexor tendon repair (in all zones) is 6%, based
on both a meta analysis of the literature and epidemiologic data. In New York state,
the median time to reoperation was 140 days. The rate of repair rupture reported in
the literature is 4%, whereas the rate of the reoperation for repair rupture is 2,3% in
New York stase. In evaluating the patient with a stiff finger after flexor tendon
repair. Active and passive ROM should be compared to differentiate between
stiffness caused by tendon adhesions and/or contractures of the interphalangeal
joints. The reported rate of tendon adhesions is 4%, and the rate of tenolysis
performed after flexor tendon repair is 3,6% in New York state. Other possible
complications include triggering, pulley failure, quadriga, and lumbrical plus
deformity. Although it is impossible to completely avoid complications, the
aforementioned principles of careful soft-tissue handling, apposition of tendon
edges with a strong multistrand repair, minimizing repair gapping and bulk with a
peripheral suture, and appropriate implementation of early motion are critical to
decrease the risk of adverse events after flexor tendon repair.
Outcomes
Because of the heterogeneity of studies on flexor tendon repair techniques and
rehabilitation protocols, the variability in reporting digit motion, and the lack of
widespread use of patient reported outcome measures, it is difficult to draw
conclutions regarding the reported outcomes of flexor tendon repair. According to
the limited comparative literature available on rehabilitation protocols, early active
motion protocols reliably restore good to excellent digit motion, whereas outcomes
are less consistent with the use of the early passive motion protocols. Patients with
multiple digit injuries, those with concurrent nerve injuries, and those who smoke
are more likely to have poor outcomes. The relative influence of an injury to a single
digit on patient function and quality of life is difficult to descern, but it can be
inferred that patients with better digit motion will have better hand function.
Although arbitrary, we classify patients who are able to flex the affected digit to the
palm as having a good outcome. In a randomized study of zone II flexor tendon
repair, assessment of disability using the Disability of the Arm, Shoulder, and Hand
score indicated that disability was relatively low 1 year postoperatively (mean
score, 2.0 at 52 weeks after an active motion protocol). Another study found that
function returned to near baseline by 6 months after zone II flexor tendon repair.
Reported rates of patient satisfaction was greater after early active mobilization.
Summary
Flexor tendon repair has evolved remarkably in the past 50 years. Modern surgical
techniques and rehabilitation protocols have produced consistent satisfactory
clinical results. Collaborations between clinician investigators and basic science
researchers have advanced clinical practice. Recent investigation into biologic
modifications that may enhance tendon healing and gliding have shown promising

results in animal models and have the potential to continue to improve clinical
outcomes of flexor tendon repair.