6.2 Early passive mobilisation

materials are not widely used in flexor tendon repair due to the lack of sufficient tensile strength half-life and potential increased tissue reaction and adhesion for-

The original peripheral or epitendinous suture was thought of a "tidying up" suture to improve tendon gliding within the flexor sheath [68]. It has now been shown that the peripheral suture improves the gap resistance and strength of repair [45, 58]. The simple running peripheral suture is the most investigated and used technique in flexor tendon repair because of its simplicity [45]. The strength and

The location and number of knots influence the strength of the tendon repair [72]. Ex vivo studies show that decreasing the number of knots and placing them outside the repair on the tendon surface increase the strength of the repair compared to knots placed between the tendon ends [45]. However, in in vivo studies, the knots placed inside the repair sites were stronger than those outsiders after

An understanding of the postoperative rehabilitation regimen after flexor tendon repair is of equal importance to the repair itself. Noncompliance with rehabilitation may lead to poor outcomes including repair rupture, decreased range of motion and joint stiffness. Current postoperative protocols for patients with flexor tendon injuries are immobilisation, early passive mobilisation and early active

The benefits of early mobilisation on the repair strength, tenocyte healing and formation of adhesions are widely known [22, 75–79]. Immobilisation, however, has its role in certain situations, particularly in patients who are noncompliant with early mobilisation protocols, paediatric patients, patients with cognitive deficits and

It is difficult to encourage early mobilisation in children under the age of 6 [80].

The protocol of Cifaldi, Collins and Schwarze may be used for the noncompliant adult [73, 82]. This protocol involves 3–4 weeks of immobilisation in a forearmbased dorsal splint or cast (20° wrist flexion, MP joints in 50° flexion and the IP joints in full extension) followed by a weaning programme (it may also be used in children) [74, 82]. "Weaning" refers to modifying the splint in such a way that the wrist is in neutral and then instructing the patient to remove the splint every hour to passively flex and extend the injured digit for 10 repetitions. Splint wear is then

immobilised and those who underwent early mobilisation for 4 weeks [81]. However, immobilisation for more than 4 weeks resulted in functional deterioration of

patients with concurrent injuries that may be worsened with early active

O'Connell et al. showed outcomes were equal among children who were

mobilisation (fractures, nerves and vessels) [73, 74].

6. Postoperative rehabilitation following flexor tendon repair

stiffness of the running peripheral suture can be increased by:

• Increasing suture purchase from 1 to 2 or 3 mm [70]

• Increasing the number of suture passes [71]

• Taking deeper suture grasps [69]

mation [45].

Tendons

6 weeks [72].

mobilisation [73, 74].

6.1 Immobilisation

the repaired tendon [81].

112

The inhibition of adhesion formation, promotion of intrinsic healing and production of a stronger repair can be encouraged with early passive mobilisation [77–79, 82–84]. The best known early passive mobilisation protocols are the Duran and Houser and Kleinert regimens [73, 74].

In the Duran and Houser protocol:


In the Kleinert protocol:


• The new splint allows for passive flexion of the digits and active extension of the digits against dynamic traction using rubber bands to facilitate the traction mechanism. These bands are placed on the volar aspect of the splint and directed towards the distal nail plate from just proximal to the wrist.

• By the end of week 1, the patient is expected to have full passive flexion, full

• Discontinuation of the splint occurs between weeks 4 and 6—week 4 for patients with poor tendon gliding and 6 for those who have excellent ROM (defined as full active fist at week 2). At this time, exercises consist of passive

• From week 6, blocking exercises of the individual joint is commenced. If flexion contractures are evident, these will need to be corrected with a splint.

• Progressive strengthening exercises begin 3 weeks after the dorsal block splint is discontinued. Resistance should increase so as to allow the patient to have

It should be noted that EAM protocols should be individualised to the patient [73, 94] because advancement to the next phase of a protocol may be hindered or augmented based on the level of oedema, passive versus active flexion lags and

Irrespective of whether or not a passive or active protocol is used, it has been shown that initiating a mobilisation therapy by postoperative day 5 decreases the

The fine, tailored movements of the flexor tendon are essential to hand function.

The author wishes to acknowledge the immense contribution to flexor tendon

pathology by the researchers, scientists and clinicians cited in this chapter.

It is clear that the consequences of extrinsic healing of flexor tendons must be overcome to achieve optimal outcomes in patients who have injured their flexor tendons. Until the intrinsic healing process can be biologically augmented, surgical repair and rehabilitation of the injured flexor tendon will remain the mainstays of treatment. It is therefore essential that the surgeon bear in mind the basic tenets of

tendon healing and the foundational principles of surgical repair.

rate of secondary procedures and decreases the costs of treatment [95].

active extension and PIP active flexion to 30°.

Physiology of Flexor Tendon Healing and Rationale for Treatment Protocols

ROM and active ROM.

DOI: http://dx.doi.org/10.5772/intechopen.86064

full hand function by week 12.

adhesion formation [94].

7. Conclusion

Acknowledgements

Conflict of interest

None to declare.

115


A major issue with the Kleinert protocol is the development of flexion contractures of the PIP joint [85]. These can be treated with continued intermittent splinting of the IP joints in neutral [86]. In recent years, rubber band traction has been almost completely abandoned, largely because of the problems arising from the flexed resting position of the PIP joint [87].

Continuous passive motion (CPM) uses devices that allow for joints to move through a predetermined arc of motion [73]. The goal is to increase the duration and repetition of exercises. A randomised control comparing traditional early passive motion to CPM exercises [88] showed that, at 6 months, the CPM group had significantly greater range of motion. However, further research in evaluating the CPM following flexor tendon repair is lacking.
