Zone II Thumb Flexor Tendon Repair: A Functional Outcome Report

Document Type : Original Article

Authors

The Department of Plastic, Reconstructive and Maxillofacial Surgery, Faculty of Medicine, Ain Shams University

Abstract

Background: Although the utmost importance of the thumb
to hand biomechanics, the reports discussing thumb flexor
tendon repair are few if compared to other digits. A reliable
report for flexor tendon repair should include a standard
surgical technique, rehabilitation and evaluation protocols,
and the outcomes in correlation to the surgeons' level of
expertise. We report our experience in management of flexor
pollicis longus (FPL) tendon injuries at zone II.
Patients and Methods: Between 2015 and 2022, a retrospective
study included 26 patients with zone II FPL tendon
injuries were included. By using a goniometer, the percent of
the total active range of motion in comparison to the contralateral
thumb was assessed and graded according to Tang
criteria of assessment.
Results: The follow-up period ranged from 7 to 28 months
with average 10.5 months. The total active thumb range of
motion was graded excellent in 15.3% (n=4), good in 42.3%
(n=11), fair in 30.7 (n=8), poor in 11.5% (n=3), and zero
incidence of tendon rupture. The only documented major
complication was poor functional outcome that needed a
session of tenolysis. The remaining of the complications were
managed conservatively. The zone V retrieval incision showed
the least functional outcome and were used in 8 patients.
Seven out of the 8 patients were graded as poor to fair and
only one patient was graded as good. Among 20 repairs done
by level 4 surgeons, 60% (n=12) of patients showed excellent
to good functional outcome grading, and 25% (n=5) incidence
of minor complications. Among 6 repairs done by level 3
surgeons, only 50% (n=3) of patients showed excellent to
good functional outcome grading, and 33% (n=2) incidence
of complications, one was major complication that needed
another session of tenolysis.
Conclusion: In consideration to its importance, more
studies should be directed to report the FPL tendon injuries.
The reports including the surgeons' level of expertise are more
informative and reliable for interpretation of the functional
outcome.

Keywords

Main Subjects

References

1- Jonathan Lans, Jan Jonas van Hernen, Beatriz Eusami,
Chris Langhammer, Kyle R. Eberlin and Neal C. Chen:
The Flexor Pollicis Longus Tendon Does Not Lie Parallel
to the Thumb Metacarpal. J. Hand Surg. Am., Jan. 14 (1):
86-90, 2019.
2- Nunley J.A., Levin L.S., Devito D., Goldner R.D. and
Urbaniak J.R.: Direct end-to-end repair of flexor pollicis
longus tendon lacerations. J. Hand Surg Am., 17: 118-21,
1992.
3- Christopher J. Dy, Aaron Daluiski, Huong T. Do, Alexia
Hernandez-Soria, Robert Marx and Stephen Lyman. The
epidemiology of reoperation after flexor tendon repair.
J. Hand Surg. Am., May 37(5):919-924, 2012.
4- Starnes T., Saunders R.J. and Means K.R. Jr.: Clinical
outcomes of zone II flexor tendon repair depending on
mechanism of injury. J. Hand Surg. Am., Dec. 37 (12):
2532-2540, 2012.
5- Hua Shen, Susumu Yoneda, Shelly E. Sakiyama-Elbert,
Qiang Zhang, Stavros Thomopoulos and Richard H.
Gelberman: Flexor Tendon Injury and Repair: The Influence
of Synovial Environment on the Early Healing
Response in a Canine Model. J. Bone Joint Surg. Am.,
May 05; 103 (9): e36. doi:10.2106/JBJS.20.01253, 2021.
6- Pan Z.J., Qin J., Zhou X. and Chen J.: Robust thumb
flexor tendon repairs with a six-strand M-Tang method,
pulley venting, and early active motion. J. Hand Surg.
Eur., Vol. Nov. 42 (9): 909-914. doi: 10.1177/17531934177
23238, 2017.
7- Tang J.B.: Outcomes and Evaluation of Flexor Tendon
Repair. Hand Clin., May 29 (2): 251-9. doi: 10.1016/
j.hcl.2013.02.007, 2013.
8- Tang J.B. and Giddins G.: Why and how to report surgeons'
levels of expertise. J. Hand Surg. Eur., Vol. May 41 (4):
365-6. doi: 10.1177/1753193416641590, 2016.
9- Oliver Pearce, Matthew T. Brown, Katrina Fraser and
Luca Lancerotto: Flexor tendon injuries: Repair & Rehabilitation.
Injury, Aug. 52 (8): 2053-2067. doi: 10.1016/
j.injury.2021.07.036, 2021.
10- Murphy F.G.: Repair of laceration of flexor pollicis longus
tendon. J. Bone Joint Surg., 19: 1121-3, 1937.
11- Elliot D. and Southgate C.M.: New concepts in managing
the long tendons of the thumb after primary repair. J.
Hand Ther., Apr-Jun. 18 (2): 141e56, 2005.
330 Vol. 46, No. 4 / Zone II Thumb Flexor Tendon Repair
12- Tang J.B.: Indications, methods, postoperative motion,
and outcome evaluation of primary flexor tendon repairs
in Zone 2. J. Hand Surg. Eur. Vol. Apr. 32 (2): 118-29.
doi: 10.1016/J.JHSB.2006.12.009, 2007.
13- Koji Moriya, Takae Yoshizu and Yutaka Maki: Early active
mobilization after primary repair of the flexor pollicis
longus tendon. J. Orthop. Sci., Sep. 26 (5): 792-797. doi:
10.1016/j.jos.2020.08.003, 2021.
14- Tang J.B.: New developments are improving flexor tendon
repair. Plast. Reconstr. Surg., Jun. 141 (6): 1427e37, 2018.
15- Tang J.B.: Flexor Tendon Injuries. Clin. Plastic Surg., 46:
295-306 https://doi.org/10.1016/j.cps.2019.02.003, 2019.
16- Tang J.B.: Rehabilitation after flexor tendon repair and
others: A safe and efficient protocol. J. Hand Surg. Eur.,
Vol. Oct. 46 (8): 813-817. doi: 10.1177/1753193421
1037112, 2021.
17- Schubert M.F., Shah V.S., Craig C.L. and Zeller J.L.:
Varied anatomy of the thumb pulley system: Implications
for successful trigger thumb release. J. Hand Surg. Am.,
Nov. 37 (11): 2278-85.doi: 10.1016/j.jhsa.2012.08.005,
2012.
18- Tang J.B.: Clinical outcomes associated with flexor tendon
repair. Hand Clin., May 21 (2): 199-210. doi: 10.1016/
j.hcl.2004.11.005, 2005.
19- Doyle J.R. and Blythe W.F.: Anatomy of the flexor tendon
sheath and pulleys of the thumb. J. Hand Surg. Am., Mar.
2 (2): 149-51. doi: 10.1016/s0363-5023(77)80101-9, 1977.
20- Zissimos A.G., Szabo R.M., Yinger K.E. and Sharkey
N.A.: Biomechanics of the thumb flexor pulley system.
J. Hand Surg. Am. May 19 (3): 475-9. doi: 10.1016/0363-
5023(94)90066-3, 1994.
21- Amir Abdelmalek and John McFarlane: Is releasing pulleys
during flexor tendon repair "part and parcel"? Narrative
review of the current evidence. Eur. J. Orthop. Surg.
Traumatol., Oct. 1.doi: 10.1007/s00590-021-03128-4,
2021.
22- Kwai Ben I. and Elliot D.: “Venting” or partial lateral
release of the A2 and A4 pulleys after repair of zone II
flexor tendon injuries. J. Hand Surg. Br. Oct. 23 (5): 649-
54. doi: 10.1016/s0266-7681(98)80020-x, 1998.
23- Tomaino M., Mitsionis G., Basitidas J., Grewal R. and
Pfaeffle J.: Feasibility of partial A2 and A4 pulley excision:
Effect on finger flexor tendon biomechanics. J. Hand
Surg. Am. Mar. 24 (2): 310-4. doi: 10.1053/jhsu.
1999.0310, 1999.
24- Tomaino M., Mitsionis G., Basitidas J., Grewal R. and
Pfaeffle J.: The effect of partial excision of the A2 and
A4 pulleys on the biomechanics of finger flexion. J. Hand
Surg. Br., Feb. 23 (1): 50-2. doi: 10.1016/s0266-
7681(98)80218-0, 1998.
25- Elliot D.: Primary flexor tendon repair - operative repair,
pulley management and rehabilitation. J. Hand Surg. Br.,
Dec. 27 (6): 507-13. doi: 10.1054/jhsb.2002.0800, 2002.
26- Lalonde D.: Latest advances in wide awake hand surgery.
Hand Clin., Feb. 35 (1): 1-6. doi: 10.1016/j.hcl.2018.
08.002, 2019.
27- Gueffier X., Lalonde D. and Amir Adham Ahmad: Flexor
pollicis longus zone 2 tendon repair under WALANT with
Egypt, J. Plast. Reconstr. Surg., October 2022 331
ultrasound assistance. Trauma Case Rep., Feb. 26; 32:
100446. doi: 10.1016/j.tcr.2021.100446, 2021.
28- Hergenroeder P.T., Gelberman R.H. and Akeson W.H.:
The vascularity of the flexor pollicis longus tendon. Clin.
Orthop. Relat. Res., Jan-Feb. 162: 298-303, 1982.
29-Azar C.A., Culver J.E. and Fleegler E.J.: Blood supply of
the flexor pollicis longus tendon. J. Hand Surg. Am., Jul.
8 (4): 471-5. doi: 10.1016/s0363-5023(83)80210-x, 1983.
30- Kaissar Yammine and Mirela Eri´c: Linburg-Comstock
variation and syndrome. A meta-analysis. Surg. Radiol.
Anat., Mar. 40 (3): 289-296. doi: 10.1007/s00276-017-
1957-1, 2018.
31- Mirela Eri´c, Kaissar Yammine, Vipin Gosh, Georg Feigl
and DusĖ˜ica Mari´c: Prevalence of the Linburg-Comstock
variation through clinical evaluation. Surg. Radiol. Anat.,
Nov. 41 (11): 1307-1314. doi: 10.1007/s00276-019-02265-
0, 2019.
32- Karalezli N., Haykir R., Karakose S. and Yildirim S.:
Magnetic resonance imaging in Linburg-Comstock anomaly.
Acta. Radiol., May 47 (4): 366-8. doi: 10.1080/
02841850600557141, 2006.
33- Miller G., Peck F., Brain A. and Watson S.: Musculotendinous
anomalies in musician and nonmusician hands.
Plast. Reconstr. Surg., Dec. 112 (7): 1815-22; discussion
1823-4. doi: 10.1097/01.PRS.0000091165.93051.9C,
2003.
34- Giesen T., Sirotakova M., Copsey A. and Elliot D.: Flexor
pollicis longus primary repair: Further experience with
the Tang technique and controlled active mobilization, J.
Hand Surg. Eur., Vol. Dec. 34 (6): 758-61. doi: 10.1177/
1753193408096025, 2009.
35- Jenkins M., Bamberger H.B., Black L. and Nowinski R.:
Thumb joint flexion. What is normal? J. Hand Surg. Br.,
Dec. 23 (6): 796-7. DOI: 10.1016/s0266-7681(98)80100-
9, 1998.
36- Ryo Yoshida, Hugh O. House, Rita M. Patterson, Munir
A. Shah and Steven F. Viegas: Motion and morphology
of the thumb metacarpophalangeal joint. J. Hand Surg.
Am., Sep. 28 (5): 753-7. DOI: 10.1016/s0363-5023(03)
00303-4, 2003.
37- Barakat M.J., Field J. and Taylor J.: The range of movement
of the thumb Hand (N Y), Jun. 8 (2): 179-82. doi:
10.1007/s11552-013-9492-y, 2013

Files

Share

How to cite

Statistics