AAPS, American Association of Plastic Surgeons
AAPS, American Association of Plastic Surgeons
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89th Annual Meeting Abstracts

Systematic Review of Flexor Tendon Rehabilitation Protocols in Zone II of the Hand
Amy Chesney, MD, Amitabh Chauhan, BSc, Forough Farrokhyar, PhD; MSc, Achilles Thoma, MD; FRCS(C); FACS.
McMaster University, Hamilton, ON, Canada.

This study was undertaken to address the question of which flexor tendon rehabilitation protocol provides the best outcome after surgical repair in zone II. The primary outcome was rupture rate. Secondary outcomes were range of motion (ROM) and quality of life (QOL).
The following electronic databases were searched: CINAHL, Cochrane, Embase, Healthstar, Medline and PEDro. The search involved articles published in English between January 1, 1970 and January 1, 2009. The population considered included patients age 5 and over who sustained a complete laceration of one or more flexor tendons in zone II.
All rehabilitation protocols published were examined. For the purposes of this review the following protocols and their variations were considered:
Group 1.
Controlled Passive Motion (Duran)
Group 2.
Passive Flexion and Active Extension (Louisville, Kleinert)
Group 3.
Combination of Group 1 and Group 2
Group 4.
Early Active Motion
Both observational studies and randomized controlled trials (RCTs) were included. Two independent assessors evaluated the methodological quality of the observational studies using the MINORS scale while the Detsky scale was applied to the RCTs. Data related to tendon ruptures, ROM and QOL were extracted by two independent assessors.
Range of motion was assessed using the Strickland scale (original and modified version) and the Buck-Gramcko scale.
Seventy-nine potentially relevant articles were identified. Fifteen studies met the inclusion criteria. The kappa statistic for agreement among reviewers was 61.9% (95% CI: 43.3% to 79.5%). Using the MINORS scale, 2 of 12 observational studies were found to be of high quality. Two of the 3 RCTs were high quality. No difference in the primary or secondary outcomes was observed between the high and low quality studies.
Primary Outcome (rupture rate):
The rate of tendon rupture within each rehabilitation protocol is reported in Table 1. The rupture rate was lowest in Group 3 (2.3%). The highest rupture rate was seen in Group 2 (7.1%).
Table 1. Average rupture rate per protocol.

ProtocolNo. of StudiesNo. of DigitsNo. of
Average Rupture
Rate (%)
Group 1210143.8
Group 25245187.1*
Group 3524472.3
Group 45275134.1

* This result may be skewed because one contributing study reported a disproportionately high rupture rate of 17.6%.
Secondary Outcomes (ROM & QOL):
With regards to range of motion, Groups 3 and 4 exhibited the highest proportion of digits with excellent or good results (Table 2).
Table 2. Functional assessment with the Strickland and Buck-Gramcko classifications.
Strickland’s Original ClassificationStrickland’s Modified ClassificationBuck-Gramcko Classification
ProtocolNo. of DigitsExcellent/Good
(average %)
(average %)
No. of DigitsExcellent/Good
(average %)
(average %)
No. of DigitsExcellent/Good
(average %)
(average %)
Group 1n/an/an/a685941298614
Group 2123673351683268928
Group 320573271593720955
Group 4127946145946n/an/an/a

One study included a quality of life assessment (DASH score). Meaningful comparison was not possible.
The results of this review indicate that both “early active motion” protocols (Group 4) as well as protocols that combine “controlled passive motion” AND “passive flexion and active extension” (Group 3) result in low rates of tendon rupture and acceptable ROM following flexor tendon repair in zone II. Future studies should include QOL measurements using validated scales.


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