Autonomous Patient-Controlled Mobilization Protocol After Flexor Tendon Repair: A Case Series

Abstract

Background:

Despite many publications on rehabilitation after repair of flexor tendon injuries of the hand, there is no consensus as to which method is superior. It is clear that nonadherence to postoperative therapy adversely affects the outcome after flexor tendon surgery. In the context of a developing country, the most important factor associated with poor outcome is late onset of rehabilitation therapy. An autonomous rehabilitation program is proposed, with the use of a low-cost splint and based on an online illustrative video with the expectation to improve adherence and patient compliance, thus ensuring satisfactory outcome.

Methods:

Twenty-two consecutive digits of 14 patients after flexor tendon repair in zone II were included. Autonomous early passive mobilization physical therapy and splinting started shortly after surgery, supported by an online available video depicting prescribed exercises; follow-up was continued until postoperative week 20. Patients were evaluated regarding range of motion, grip strength, and the Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) disability scale.

Results:

Range of motion after 20 weeks according to the scoring system of the American Society of Surgery of Hand was excellent in 4, good in 11, and fair in 4 fingers. The mean total active motion score was 86% (95% confidence interval, 78%-93%). The mean grip strength at final follow-up was 86% of the contralateral hand. The mean QuickDASH score was 12.5 (2.3-31.8).

Conclusion:

This protocol achieves good results in range of motion and early return of function of the hand. We propose this simple, nonexpensive method to developing countries with less than optimal availability of health care.

Introduction

Several approaches to flexor tendon repair rehabilitation are described in the literature, namely, immobilization, early passive mobilization, and early active mobilization. Each of these methods is based not only on the mechanical and biological knowledge of the flexor tendon healing process but also on patient characteristics and expected compliance to a particular program.^1,2 Discouraging results of rehabilitation with uncontrolled early active mobility were first published by Harmer in 1917. Conversely, rehabilitation through an early passive mobilization program initially described by Young and Harmon and used for subsequent decades as Kleinert and Duran regimens yielded increasingly favorable results.^2-4 With the advent of new surgical techniques and suture materials that offer greater resistance to failure, the current literature also supports early controlled active mobility protocols with lower adhesion and low rupture rates; nevertheless, no clear evidence of the superiority of multistrand suture technique or aggressive active motion protocols has been demonstrated in recently published systematic reviews.^2,5,6 Despite many publications on rehabilitation after surgical repair of flexor tendon injuries of the hand, there is no hard evidence supporting any protocol over others. However, it is clear that nonadherence to postoperative therapy protocols adversely affects the outcome after flexor tendon surgery. In the context of a developing country, the most important factor associated with poor outcome is the late onset of physical therapy. ⁷

We propose a self-directed rehabilitation program with the use of a low-cost splint and based on an online illustrative video with the expectation to improve adherence and patient compliance, thus ensuring satisfactory outcome. The proposed protocol follows the principles of any tendon repair rehabilitation: early motion with protection in a splint during the first 6 weeks.^7-10

Materials and Methods

This case series comprised all patients treated for flexor tendon injuries during the period between November 2015 and October 2016. Fourteen patients with 22 flexor tendons repaired in zone II of the hand were the subject of this report. All patients had their tendon(s) repaired between day 1 and 30 after trauma (Table 1). Patients with extensor tendon injuries, infection, and skin cover defect over 4 weeks after trauma were excluded. Self-directed passive mobilization and dorsal splinting started on the fifth day after surgery with support through an online available video depicting prescribed exercises. The researchers made sure each patient had internet access and ensured sufficient understanding of the protocol. Patients were assessed regarding range of motion, grip strength, and the quick disabilities of the arm, shoulder and hand (QuickDASH) disability scale. Clinical assessments were performed at 3, 6, 12, and 20 weeks.

Table 1.

Demographic Data.

Patients	14
Sex
Female	5
Male	9
Dominance
Right	13
Left	1
Affected side
Right	9
Left	5
Mean age (min-max)	35 (19-59)
Average days from injury to repair (min-max)	11 (1-30)
Injured tendons
FPL	3
FDS	2
FDP	9
FDS/FDP	8
Associated lesions (nerve injury)	8

Note. FPL = flexor pollicis longus; FDS = flexor digitorum superficialis; FDP = flexor digitorum profundus.

Institutional ethical committee approval was obtained for this study, and signed informed consent was obtained from each patient at the first postoperative visit, independent of the surgical consent.

Operative Technique

Under regional anesthesia, palmar zigzag incisions described by Brunner were made, and tenorrhaphy was performed by a 4-strand core-locked cruciate suture using 4.0 polypropylene monofilament and by a continuous epitenon suture using 6.0 polypropylene monofilament. In all cases, A2 and A4 pulleys were preserved or repaired.

Postoperative Treatment

The hand was protected by a dorsal splint from below the elbow to fingertips, with the wrist in 20° flexion, the metacarpophalangeal (MP) joint in 70° flexion, and the interphalangeal joints in neutral position (Figure 1). Passive mobilization started 5 days after surgery. Patients initiated a 3-phase program guided by an online available video specially developed for this study (https://www.youtube.com/watch?v=dZ3h1hfjfjk). Phase 1 emphasizes on swelling control and passive flexion/extension exercises of distal interphalangeal (DIP), proximal interphalangeal (PIP), and MP joints 10 times per hour while awake. At day 20 (week 3), the patient initiated phase 2 based on “Hold and Release” exercises for 3 seconds to maximize intrasynovial excursion. At this time, passive mobilization should have been completed. Phase 3 was initiated at day 42 (week 6). Splint was removed, and active mobilization exercises for muscle strengthening were added to this regimen.

Figure 1.

Plaster splint elaborated at the office for use during rehabilitation. Velcro straps assure safe positioning during rest periods and allow frequent exercises as prescribed.

Two late postoperative controls at 84 (week 12) and 140 days (week 20) were conducted. The total active motion (TAM) of DIP, PIP, and MP joints measured with goniometer is reported according to the American Society of Surgery of the Hand (ASSH; TAM score) (Figure 2). Patients were also evaluated regarding grip strength and the QuickDASH disability scale. Complications were actively sought and recorded.

Figure 2.

Motion result after 20 weeks in patient 1 (total active motion = 92%).

Results

Results were measured 20 weeks after surgery. Two patients (3 fingers) were excluded from the analysis due to inability to comply with follow-up visits. Range of motion after 20 weeks according to the scoring system of the ASSH was excellent, good, and fair in 7, 9, and 3 fingers respectively. The mean TAM score was good (Table 2). There were no poor results. The mean grip strength at final follow-up was 86% of the contralateral hand. The mean QuickDASH score was 12.5. Tenolysis was indicated in 1 patient because adhesions were recorded at week 12. This patient obtained a good TAM according to the ASSH through an early passive mobilization program (Kleinert protocol) with a hand therapist after surgery.

Table 2.

Clinical Results (20 Weeks).

Patient	Tendon/digit	TAM score, %	Grip strength, %	QuickDASH score
1	FDP ring	92	100	9.1
2	FDP/FDS little	61	91	25.9
3	FDP/FDS middle	75	53	31.8
	FDP/FDS index	64
4	FDS ring	96	40	27.3
	FDS middle	100
	FDP/FDS index	100
5	FDP little	51	95	15.9
6	FDP little	90	100	2.3
	FDP ring	92
7	FDP middle	100	100	2.3
	FDP ring	96
8	FDP/FDS little	100	94	2.3
	FDP ring	96
9	FDP/FDS ring	80	97	4.5
	FDP/FDS little	78
	Mean	86	86
	SD	16%
10	FPL	195°		12.6
11	FPL	200°		2.3
12	FPL	190°		13.6
	Mean	195°	Mean (all patients)	12.5
			SD	10.8

Note. FPL = flexor pollicis longus; FDS = flexor digitorum superficialis; FDP = flexor digitorum profundus; QuickDASH = Quick Disabilities of the Arm, Shoulder, and Hand; TAM = total active motion.

Adherence rate was 85%, which reflects a high patient compliance with this protocol.

Discussion

Restoring hand function after a flexor tendon injury is a challenge. To a great extent, its success depends on the rehabilitation process. Early active motion has proven benefits over a purely passive range of motion program, with equal or better reported outcomes and no increase in tendon rerupture.^8-11 Protocols should be designed not only based on the characteristics of the injury and repair technique but also depending on patients’ access to these rehabilitation programs.^12,13 Adherence to hand therapy has been studied, and it has been demonstrated that the final outcome is affected when the patient assumes that he or she has to bear part of the rehabilitation cost, must move, or needs to request time at work to perform physical therapies.^1,14 The public health care system in our country is less than ideal, and access of patients to postoperative physical therapy with a hand therapist is quite difficult. This explains why the factor with the greatest impact for unfavorable outcomes is poor adherence to these rehabilitation programs, mainly due to delays in obtaining an adequate splint and waiting for the initiation of therapies. ⁷

Considering these facts, a self-directed rehabilitation program was designed and established based on the use of a low-cost splint that would improve patient compliance and adherence to the program, avoiding a crucial factor responsible for inadequate outcome in tendon repair surgery. Moreover, the follow-up was solely the responsibility of the surgeon, who can determine changes in the design of the splint and protocol, taking into account the type of injury or repair. ¹⁵

A small series of patients is reported in this article, and all patients had access to internet so that they could and did repeatedly watch the video recommended for auto therapy guidance. Their compliance to the protocol was confirmed during regular clinic visits, thus assuring their adherence to the proposed protocol. We did not observe any tendon ruptures, which is one of the most important goals of this and any other rehabilitation protocol.^6,16 Khor et al ¹⁷ performed a critical analysis of the current literature and presented rerupture rates of several studies, ranging from 0 in most, to 11% in wide-awake surgery and up to 20% in an earlier report with the use of early active motion.

Outcomes in flexor tendon repair are usually reported by the use of Strickland, Buck-Gramcko, or TAM score; however, there are wide variations in the way each author reports his or her clinical results. It should be noted that an excellent result under TAM score is only a finger with 100% TAM, that is, full flexion and extension with no extension lag; meanwhile, in the Strickland score, an excellent result is a finger with more than 75% (adjusted score) or 85% (original score) TAM; hence, it is preferred to report TAM as the percentage of maximum normal motion. A trend is gaining force to develop diagnosis-specific patient-reported tools for tendon surgery, as several studies have found moderate to poor correlation with general measures such as DASH or Michigan hand scores.^6,13,18,19

We have reported our results through TAM score, grip strength as a percentage of the contralateral side, and QuickDASH. The mean TAM score was 86%, which is considered a good result ¹⁸ and has been found to correlate well with the Strickland score. Limited correlation was found between TAM and QuickDASH scores (0.34) in this series; this is in agreement with the report by Libberecht et al. ¹⁸ Four of the 16 fingers had a fair result (50%-75%), 2 of them were little fingers and 2 others were product of a multifinger injury, and all others had near normal or normal motion, including 4 fingers with 100%.

Neiduski and Powell ⁶ recently reported a systematic review of rehabilitation protocols; they included 9 interventional studies comparing either passive motion with place-and-hold rehabilitation programs or true active flexion with place-and-hold and/or passive rehabilitation. They found notable variability in evaluation methods and group distribution, so they were not able to perform a meta-analysis. The TAM scores are reported in most of the included articles, with results ranging from 29% of good and excellent results after active rehabilitation protocol, ¹² 42% after Kleinert protocol, ¹⁶ 86% after Silfverskiold protocol, 88% after Strickland protocol, ²⁰ 87% after Washington protocol, ²¹ and 90% after a place-and-hold protocol. ²² Our series reports 86% of good and excellent results for TAM score; this is comparable to results reported in good-quality comparative studies. ²³ Similarly, grip strength and QuickDASH scores were in a good to excellent range.^11,21 These results should be carefully examined, given the small size of the current series and the lack of a control group; nevertheless, they encourage us to propose this simple, nonexpensive method not only to developing countries or isolated areas with less than optimal availability of health care but also to many patients unable to get hand therapy following flexor tendon repair despite an adequate health system.