Hand Surgery, Vol. 13, No.

1 (2008) 45–50
© World Scientific Publishing Company

NEW IDEAS AND TECHNICAL TIPS

CLINICAL RESULTS OF EARLY ACTIVE MOBILISATION
AFTER FLEXOR TENDON REPAIR

C. H. Yen, W. L. Chan, J. W. C. Wong and K. H. Mak

Department of Orthopaedics and Traumatology
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Kwong Wah Hospital, Hong Kong SAR

Received 7 November 2007; Accepted 28 February 2008

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ABSTRACT
Between 2005 and 2006, ten patients with flexor digitorum profundus zone II injuries were included. The mean age was 41 (19–84)
years. One thumb, two index, four middle, one ring and two little fingers were injured. Repair method comprised four-strand core
suture and 6-0 circumferential sutures. Post-operative rehabilitation included immediate active extension, progressive passive full
flexion and active hold in dorsal block splint. Follow-up was four (three to seven) months. Grip strength, pinch strength, ROM was
90% (70%–90%), 90% (60%–110%) and 90% (80%–100%) of normal digit, respectively. Mayo wrist scores were five excellent,
two good and three fair. All patients were satisfied. Compared with another group of ten patients with the same suture method and
Kleinert splintage, grip strength, pinch strength and ROM were 50%, 40% and 40% of normal side, respectively. All differences
between these two groups were statistically significant ( p < 0.01) by paired samples T-test. There was no re-rupture.

Keywords: Flexor Tendon; Repair; Mobilisation.

INTRODUCTION METHODS
Satisfactory range of active movement of fingers without com- Between October 2005 and April 2006, ten consecutive patients
plication following flexor tendon repair should be the ultimate admitted with acute flexor tendon injuries in zone II were
goal of hand surgeons.1,2 Recent biomechanical studies of ten- included. Inclusion criteria for this study were strictly followed
don suture methods advocate the use of four- or six-strand core (Table 1). Other patients would be excluded by exclusion cri-
suture,3,4 which is of adequate tensile strength to withstand the teria (Table 2). Before surgery, all patients were informed
active finger movement in the first week. In return, a stronger of and consented to the suture method, rehabilitation proto-
flexor tendon repair may allow early active mobilisation, which col and follow-up assessment. All surgeries were performed
is essential in achieving maximal range of motion by minimis- under Bier’s block using 40 ml 0.5% lignocaine intravenous
ing restrictive adhesion. Based upon available evidence in these local anaesthesia. Arm tourniquet pressure was set to be
studies, a prospective cohort study is designed to review clini- 100 mmHg above systolic brachial pressure. The wound was
cal results of early active mobilisation following flexor tendon extended by Brunner skin incision. All pulleys were preserved.5
repair in a regional hospital. Flexor sheath was not repaired. Flexor digitorum profundus

Correspondence to: Dr. Chi Hung Yen, Department of Orthopaedics and Traumatology, Kwong Wah Hospital, 25 Waterloo Road, Yau Ma Tei, Hong Kong Special
Administrative Region. Tel:(+852) 2332-2311, Fax: (+852) 3517-8204, E-mail: chihungyenyen@yahoo.com.hk

45
 46 C. H. Yen et al.

Table 1 Inclusion Criteria. Table 3 Rehabilitation Protocol for Early Active Mobil-
isation Following Flexor Tendon Repair (Kwong Wah
1. Age between 18 years and 85 years. Hospital Protocol).
2. Single digit, isolated complete flexor digitorum profundus or
flexor pollicis longus tear in flexor zone II. ◦ Early Stage (0–4 Weeks)
3. Guillotine injury with non-infected wound suitable for primary ◦ Splint
closure. • Post-operative cast maintains: wrist at 30◦ flexion, MPJ at
4. Consent to strictly following rehabilitation protocol. 70◦ flexion, allow full IP extension.
5. Available for final follow-up assessment. • Cast extends 2 cm beyond finger tips to avoid use of hand.
6. Follow-up for at least four months. ◦ Exercise
• Start day 2.
• Two repetitions every four hours within splint.
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Table 2 Exclusion Criteria. • Full passive flexion.

• Active hold for five seconds.
1. Mentally unfit for giving informed consent for surgery. • Active extension.
2. Partial tear of flexor digitorum profundus or flexor pollicis ◦ Goal (first week)
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longus tear. • Full passive flexion, active extension.

3. Flexor tendon injury other than zone II. • Active flexion to 30◦ flexion at PIPJ.
4. More than one digit flexor digitorum profundus tear. • Active flexion to 10◦ flexion at DIPJ.
5. Pulley injury not amenable to repair. • Active flexion gradually increases over the following
6. Isolated or associated flexor digitorum sublimis tear. weeks.
7. Phalangeal or carpal bone fracture in the same hand. • Active flexion (from 30◦ ) to 90◦ flexion at PIPJ.
8. Wound infection. • Active flexion (from 10◦ ) to 60◦ flexion at DIPJ.
9. Previous surgery or congenital anomaly of hand. • Increase passive flexion to every two hours if joint
10. Uncontrolled hypertension (systolic pressure above 200 mmHg) stiffness.
precludes use of IVLA. • Pen behind PP for greater IP active extension if flexion
11. Arterial injury amenable to vascular repair. contracture.
◦ Intermediate Stage (4–6 Weeks)
◦ Splint
• Tendon glide GOOD: continue till sixth week.
repair was standardised as follows: four-0 four-strand Pro- • Tendon glide POOR (above aims): discontinue.
lene (Ethicone® Polypropylene) suture irrespective of tendon ◦ Exercise
dimension and six-0 circumferential Prolene sutures repaired • Active flexion and extension exercise, stepping up light
all tendons after approximating both tendon ends by two 23G resistance till full strengthening.
• In flexion contracture: passive IP extension protected by
hypothermic needles.6 Associated common digital nerve tears
MP flexion at 90◦ .
were also repaired in the same setting. • Heavy hand use at eight weeks.
All patients were discharged the same day to the hand therapist • Full function at 12 weeks.
following the same rehabilitation protocol, which included early
mobilisation with active extension, progressive active and pas-
sive flexion and active hold in a dorsal splint with 30◦ wrist
flexion (Table 3). Measurements of active ROM of all fin- of 16.5 months (whose demographic data were tabulated in
ger joints by goniometer, grip strength by SPRI Jamar hand Table 5) using the same flexor repair method but following a
dynamometer and key pinch strength by pinch meter, were different rehabilitation regime of Kleinert splintage with palmer
made by one author to minimise inter-observer errors, and all bar was compared to this cohort.7 They were included accord-
of these data compared to the normal side at a minimum of 12 ing to the same criteria described in Tables 1 and 2. This
weeks after surgery. Patient satisfaction would be categorised control group had a longer follow-up period because their
into poor, fair, good and excellent. Results were also compared surgery was performed before the beginning of a new reha-
with reference to Mayo wrist score (Table 4). Major complica- bilitation protocol commencing in October 2005. Data were
tions such as tendon re-rupture would be recorded. An age- and analysed by paired-samples T-test taking p ≤ 0.05 as statistical
sex-matched control group of ten patients with mean follow-up significance.
 Clinical Results of Early Active Mobilisation After Flexor Tendon Repair 47

Table 4 Clinical Results of Flexor Tendon Repair.

Mayo Wrist ROM Left ROM Right

EAM Score Injury Grip/kg (L/R) Pinch/kg (L/R) (DIP/PIP/MCP) (DIP/PIP/MCP)
Patient 1 Excellent Right MF 38 36 11 11 70 110 90 70 110 90
Patient 2 Excellent Left MF 25.3 26.7 7.5 7.7 90 110 95 90 110 95
Patient 3 Fair Left FPL 20 23.3 7 7 35 80 80 80
Patient 4 Good Right MF 22 20 8 9 80 100 90 20 100 100
Patient 5 Good Right IF 44.7 38 12 12 80 120 90 70 80 90
Patient 6 Excellent Right RF 39.3 42 12.7 14 75 120 100 70 70 90
Patient 7 Excellent Left LF 11.3 10 5.2 5.3 20 70 100 40 100 90
Patient 8 Fair Left IF 32 48 5.7 10 20 90 80 60 95 90
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Patient 9 Excellent Right LF 25 22 10 10 30 85 90 35 80 95

Patient 10 Fair Left MF 32 48 5.7 10 40 90 75 65 100 90
Mayo Wrist ROM Left ROM Right
KS Score Injury Grip/kg (L/R) Pinch/kg (L/R) (DIP/PIP/MCP) (DIP/PIP/MCP)
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Patient 1 Poor Left LF 6.3 14 2.3 6 0 65 90 50 100 90

Patient 2 Fair Left LF 18 30 5.3 11 10 75 70 50 110 100
Patient 3 Poor Right LF 20 7 6.7 4.7 80 100 100 10 45 70
Patient 4 Poor Right LF 18 10 8.3 5.7 80 110 95 0 45 60
Patient 5 Poor Right LF 32 14 12.7 7 80 80 90 0 10 80
Patient 6 Poor Left IF 9 14 4 7 5 35 65 75 110 100
Patient 7 Fair Left IF 20 34 4 14 10 65 85 80 110 90
Patient 8 Fair Left MF 22 38 3.7 12 15 85 90 90 105 100
Patient 9 Poor Right IF 22 4 8 2 80 100 100 20 5 30
Patient 10 Poor Right MF 24 4 8 2 90 110 100 15 15 35
EAM: Early active mobilisation cohort, IF: index finger, MF: middle finger, RF: ring finger, LF: little finger, KS: Kleinert splintage, ROM: range of motion,
FPL: flexor pollicis longus.

RESULTS statistical significance level of p = 0.004, p = 0.003, and p =

In the early active mobilisation group, there were seven male 0.012, respectively. In addition, EAM group also enjoyed a better
and three female patients. The mean age was 41 (19–84) years. grip (mean = 28 vs. 11 kg) and pinch (mean = 8.7 vs. 4 kg)
There were one thumb, two index, four middle, one ring and two strength. These two differences were statistically significant with
little finger injuries (Table 5). Mean follow-up was four (three- p = 0.003 and p = 0.001, respectively.
seven) months. There was no default at final follow-up. Mean There was no re-rupture or major complications like infec-
grip strength was 90% (70%–90%) of normal digit. Mean pinch tion or neurovascular injury. Three patients regarded stiffness
strength was 90% (60%–110%) of normal digit. Mean total (despite total active ROM being 80% of normal digit) as com-
ROM was 90% (80%–100%) of normal digit. According to Mayo plication of surgery. All patients in EAM group resumed their
wrist score, five were excellent, two were good and three were previous job earlier after a mean of 2.4 months after the injury,
fair. All patients were satisfied with surgery (five rated excel- in contrast to 3.2 months in the Kleinert group.
lent and five good). Compared with the age- and sex-matched In the Kleinert group (patient 1), there was one tendon rup-
control group of ten patients using Kleinert splintage, pinch ture at the fifth week after primary tendon repair. Exploration
strength, grip strength and ROM were 40% (30%–70%), 50% and direct tendon repair was performed, ending up in flex-
(20%–60%) and 40% (20%–65%) of normal side, respectively ion contracture at DIPJ and PIPJ. In the Kleinert group, active
(Table 4). ROM at DIPJ and PIPJ was also limited to a mean of 8.3◦ (0◦ –
By stratification of active ROM between these two groups, 20◦ ) and 44.5◦ (5◦ –85◦ ), respectively. These differences in
EAM resulted in better ROM in DIPJ (mean = 48 vs. 8◦ ), PIPJ joint stiffness, when compared to that of the EAM group, were
(mean = 84 vs. 45◦ ) and MCPJ (mean = 89.5 vs. 67.5◦ ), with statistically significant using paired-samples T-test(Table 6).
 48 C. H. Yen et al.

Table 5 Demographic Data of Both Groups of Patients. early as the 18th century, John Hunter rightly pointed out the
contribution of tension and motion at the repair site to the
FU/
EAM Age Sex Injury Nerve Month Dominance
tendon healing, which had been reiterated by Sterling Bunnell
in the 20th century.10 Despite different variety of rehabilitation
Patient 1 47 M Right MF 7 Right
Patient 2 34 M Left MF 3 Right
protocols, such stronger flexor repair did not translate to good
Patient 3 45 F Left FPL 4 Right clinical outcomes.11 In contrast, an unacceptable rupture rate
Patient 4 21 M Right MF 6 Right was reported after zealous uncontrolled movement during early
Patient 5 19 M Right IF Radial 3 Right phase of tendon healing.6,12 The culprit is restrictive adhesion
digital between tendon and bone and surrounding soft tissue. And
Patient 6 44 M Right RF Radial 5 Right
effort should be made to mobilise repaired tendon in order to
digital
minimise extrinsic healing during flexor tendon rehabilitation,
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Patient 7 84 F Left LF 6 Right

Patient 8 45 M Left IF 3 Right and yet safe enough to avoid tendon re-rupture.13,14
Patient 9 30 F Right LF Both 4 Right Our protocol, based on the “early active mobilisation pro-
Patient 10 45 M Left MF 3 Right gramme of Belfast and Sheffield”, together with modifications
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FU/ by Strickland as in an “active-hold” or “place-hold active mobil-

KS Age Sex Injury Nerve Month Dominance isation” protocol, challenges the tensile strength of the repair in
Patient 1 51 M Left LF 15 Right the first two weeks, whereby the repair is weakened by inflam-
Patient 2 42 M Left LF 17 Right mation. From the biomechanical perspective, four-strand core
Patient 3 44 F Right LF 18 Right suture is strong enough to allow early active finger flexion with
Patient 4 69 M Right LF 15 Right
protection of a dorsal extension block splint.4,8,10,15,16 There
Patient 5 35 M Right LF 18 Left
Patient 6 42 M Left IF Radial 20 Right
is still no clinical evidence to support free mobilisation without
digital the use of extension block splint. In addition, the resistance to
Patient 7 25 F Left IF 19 Right motion is significantly increased in the context of pulley repair,
Patient 8 25 M Left MF 19 Right thereby increasing the risk of tendon rupture.5 Therefore, a
Patient 9 44 F Right IF 12 Right progressive increase in active and passive flexion will decrease
Patient 10 44 M Right MF 12 Right
adhesion because of motion on the one hand, whereas tendon
EAM: Early active mobilisation cohort, IF: index finger, MF: middle finger, RF: ring
is healed by intrinsic healing owing to continuous tension at
finger, LF: little finger, KS: Kleinert Splintage, FPL: flexor pollicis longus.
the repair site. From the EAM group, there is no complication
of tendon re-rupture after this fastened protected rehabilitation
Table 6 Statistically Significant Differences in Grip Strength, regime, proving its clinical safety and efficacy in achieving better
Pinch Strength and ROM (Paired Samples T Test) Between Early
clinical results.
Active Mobilisation and Kleinert Splintage Groups.
We have shown that passive flexion also mobilised the DIPJ
Pair Significance (Two-Tailed) to its full extent, which is barely movable in the Kleinert splint.
Grip (EAM) vs. grip (KS) 0.003 This maneouvre is invaluable in preventing restrictive adhesion
Pinch (EAM) vs. pinch (KS) 0.001 from formation especially in no man’s land, thereby ensuring a
Total ROM (EAM) vs. total ROM (KS) 0.001 small tunnel through which the repaired flexor glided smoothly.
DIP (EAM) vs. DIP (KS) 0.004 This extrinsic adhesion is proven to be the culprit in limiting
PIP (EAM) vs. PIP (KS) 0.003 range of motion at DIP, PIP and MCP in zone II flexor tendon
MCP (EAM) vs. MCP (KS) 0.012
repair. Flavourable results in ROM of DIPJ and PIPJ after early
active mobilisation are encouraging and promising even in this
small number of cases. From our clinical results, a palmer bar
DISCUSSION in the Kleinert splint only improves PIPJ motion to a mean of
A strong flexor tendon repair model has been extensively studied 44.5◦ , which is far from the normal ROM of 110◦ .
for the past 40 years for improving tensile strength and minimis- Three patients still complained of stiffness following this early
ing tendon rupture during its course of tendon healing.8,9 As rehabilitation (EAM patient 6, 8, and 10). Despite reasonably
 Clinical Results of Early Active Mobilisation After Flexor Tendon Repair 49

good range of motion being 80% of normal digit, the stiffness contributed to side-to-side difference in strength (patients 4,
especially at DIPJ resulted in 30% loss of grip strength and 40% 6 and 7) and ROM (patient 9). These paradoxical differences
loss of pinch strength of the normal digit. These are disabling are exemplified by these patients, in which strength or ROM of
particularly when one intends to hold tight a small object in one’s injured side is more than 100% of the normal digit.
hand. Early active mobilisation of DIPJ proves to be a success In short, this study could, at its best, serve only as a pilot
in achieving better DIPJ motion, and hence better strength and study, limited by study design, and the small number of patients.
function. Moreover, it sheds light on future study design, hopefully with
In spite of the four-strand core suture, there was only one ten- the aim to improve clinical results in the best interest of the
don rupture in the Kleinert group. The reasons for that are many patient suffering from acute flexor tendon injury.
and varied, including suture method, suture technique, and
most importantly compliance of patient to the rehabilitation.2
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CONCLUSION
We still hold it true that the four-strand core suture is biome-
chanically and clinically proven to be a strong enough method Four-strand core sutures provide a strong and safe repair in
to start early active mobilisation in patients with admirably good flexor tendon injuries; allowing early mobilisation and hence
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compliance to our rehabilitation protocol.9,16–18 better clinical results. Following this early active mobilisation
At the time of the writing of this paper, there has been no after flexor repair, one should expect comparable and better
publication in the English literature on prospective randomised clinical results in total active ROM, grip strength, pinch strength
controlled trial comparing early active mobilisation and Kleinert (all being 90% of the normal digit), as compared with other
splintage after flexor tendon repair. This study is informative as rehabilitation regimes, and hence early resumption of previous
to the future study design, outcome measurements and guidance job because of earlier achievement of better clinical results.
as to modification of clinical practice in flexor tendon surgery.
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