EARLY ACTIVE MOBILIZATION VS IMMOBILIZATION FOLLOWING MODIFIED KESSLER REPAIR OF EXTRINSIC EXTENSOR TENDONS IN ZONE V TO VII
AbstractBackground: The long-disputed issue of rehabilitation of extensor tendon repairs in zones V–VII has been treated with either complete immobilization or mobilization within the constraints of splint. In recent times, most authors have preferred some mobilization. Many studies have shown good results with early mobilization techniques; however, these studies have limitations. Most of these are retrospective observations. Some prospective studies are without proper controls. This study was conductive to compare the functional outcome of early active mobilization versus immobilization following repair of extensor tendons in zone V–VII. Methods: Functional outcome was determined by total active motion, pain and complications during rehabilitation. Total active motion (TAM) was graded by scores of the American Society for Surgery of Hand as TAM=total active flexion (MCP+PIP+DIP)–total extension deficit (MCP+PIP+DIP). A randomized control trial was conducted including 50 subjects of with extensor tendon injury exclusively in zone V–VII. Patients were divided randomly in two groups. All extensor tendon repairs (zone V to VII) were performed with modified Kessler's method. The pain and TAM was assessed during all visits in both groups except TAM in group B that was assessed after four weeks. Results: We found that outcome of 12% cases in Group A as excellent and no patient fell in category of fair results. While, in comparison, there was no case of excellent result in Group B. 4% cases showed fair results that were treated with immobilization. The pain score at the end of treatment, i.e., at 12 weeks were same in both the groups but, generally the score remained higher in group of EAM. There was significant difference in adhesion formation that was more in patients of immobilization group. The overall suture dehiscence was insignificant and was only 8% in each group. Conclusion: EAM has better outcome in terms of pain and range of motion. Keywords: Extensor tendon injury; Zone V; zone VI; zone VII; Early active mobilization
Doyle J. Extensor tendons: acute injuries. In: Green DP, Hotchkiss RN, Pederson WC, editors. Operative hand surgery. 4th ed. Churchill Living-stone, Philadelphia, 1999; p.1950–70.
Sylaidis P, Youatt M, Logan A. Early active mobilization for extensor tendon injuries. The Norwich regime. J Hand Surg Br 1997;22(5):594–6.
Hung LK, Chan A, Chang J, Tsang A, Leung PC. Early controlled active mobilization with dynamic splintage for treatment of extensor tendon injuries. J Hand Surg Am 1990;15(2):251–7.
Patil R, Koul A. Early active mobilisation versus immobilisation after extrinsic extensor tendon repair: A prospective randomised trial. Indian J Plast Surg 2012;45(1):29–37.
Hauge MF. The results of tendon suture of the hand: a review of 500 patients. Acta Orthop Scand 1954;24(3):258–70.
Miller H. Repair of severed tendons of the hand and wrist: statistical analysis of 300 cases. Surg Gynecol Obstet 1942;75:693–8.
Kelly AP Jr. Primary tendon repairs; a study of 789 consecutive tendon severances. J None Joint Surg Am 1959;41-A(4):581–98.
Zander CL. The use of early mobilization following complex injury to the extensor tendons. J Hand Ther 1987;1(1):38–41.
Browne EZ Jr, Ribik CA. Early dynamic splinting for extensor tendon injuries. J Hand Surg Am 1989;14(1):72–6.
Evans RB, Burkhalter WE. A study of the dynamic anatomy of extensor tendons and implications for treatment. J Hand Surg Am 1986;11(5):774–9.
Ip WY, Chow SP. Results of dynamic splintage following extensor tendon repair. J Hand Surg Br 1997;22(2):283–7.
Kerr CD, Burczak JR. Dynamic traction after extensor tendon repair in zones 6, 7, and 8: a retrospective study. J Hand Surg Br 1989;14(1):21–2.
Walsh MT, Rinehimer W, Muntzer E, Patel J, Sitler MR. Early controlled motion with dynamic splinting versus static splinting for zones III and IV extensor tendon lacerations: a preliminary report. J Hand Ther 1994;7(4):232–6.
Duran R, Houser RG. Controlled passive motion following flexor tendon repair in zone 2 and 3. In: AAOS Symposium on tendon surgery in the hand. Philadephia 1974. St. Louis: CV Mosby Co, 1975; p.105–14.
Minamikawa Y, Peimer CA, Yamaguchi T, Banasiak NA, Kambe K, Sherwin FS. Wrist position and extensor tendon amplitude following repair. J Hand Surg 1992;17(2):268–71.
Brüner S, Wittemann M, Jester A, Blumenthal K, Germann G. Dynamic splinting after extensor tendon repair in zones V to VII. J Hand Surg Br 2003;28(3):224–7.
Chow JA, Dovelle S, Thomes LJ, Ho PK, Saldana J. A comparison of results of extensor tendon repair followed by early controlled mobilisation versus static immobilisation. J Hand Surg Br 1989;14(1):18–20.
Feehan LM, Beauchene JG. Early tensile properties of healing chicken flexor tendons: early controlled passive motion versus postoperative immobilization. J Hand Surg Am 1990;15(1):63–8.
Gelberman RH, Vandeberg JS, Manske PR, Akeson WH. The early stages of flexor tendon healing: a morphologic study of the first fourteen days. J Hand Surg 1985;10(6 Pt 1):776–84.
Hitchcock TF, Light TR, Bunch WH, Knight GW, Sartori MJ, Patwardhan AG, et al. The effect of immediate constrained digital motion on the strength of flexor tendon repairs in chickens. J Hand Surg Am 1987;12(4):590–5.
Evans RB. Early active short arc motion for the repaired central slip. J Hand Surg Am 1994;19(6):991–7.
Keech B, Adams D, Diaz-Doran V, Newport M, editors. Extensor tendon tension in zone VI at maximal isometric contraction. Annual Meeting of the Orthopaedic Research Society and the Annual Meeting of the American Academy of Orthopaedic Surgeons 2004.
Neuhaus V, Wong G, Russo KE, Mudgal CS. Dynamic splinting with early motion following zone IV/V and TI to TIII extensor tendon repairs. J Hand Surg 2012;37(5):933–7.