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The senior author (A.D.) prefers to use either a modication of Kesslers technique

that adds a separate horizontal mattress suture or a cross-locked cruciate technique

(gure ). A meta-anal!sis found that" compared #ith the modied Kessler suture

conguration" other repair techniques are associated #ith a higher risk of adhesion

formation. Thus" the senior author (A.D.) uses the modied Kessler repair technique

#hen a distinclt! increased risk of adhesions is anticipated (eg" the repair is

particularl! close to the pulle!s). $n situations #here adhesion formation is a lessprominent concern" the cross-locked cruciate technique is used %ecause of its

com%ination of mechanical strength and minimal %ulk. &echanical testing has

demonstrated that the cross-locked cruciate repair #as performed #ith a '-

i%er*ire (Arthre+) for the core sutures and a ,- pol!prop!lene simple running

circumferentian peripheral suture" the mean ultimate strength #as / and the 0-

mm gap force #as 1, /" #hich greatl! e+ceeds the ma+imum forces measured

during acti2e motion (0 /) and motion against resistance (3 /) in the stud! %!

4o#ell and Trail. 5f note" the onl! other four-strand technique (&assachusetts

6eneral 7ospital repair) included in the stud! %! *aita!a#in!u et al also e+ceeded

the thresholds.

8ore suture placement

&echanical testing has sho#n that the ideal placement of the core suture is to

mm from the repair site for four-strand repairs. The ideal dorso2olar position of the

core suture is not kho#n. Although stronger purchase can %e o%tained in the dorsal

portion of the tendon" this ma! place the dorsall! %ased %lood suppl! from the

2incular s!stem at risk of in9ur!.

8ore suture material

The t!pe and cali%er of suture material used is relati2el! unimportant compared

#ith suture technique. Although the senior author (A.D.) prefers to use i%er*ire"

man! surgeons use a t!pe of %raided or monolament nonresor%a%le suture.

Ala2an9a et al e2aluated %raided pol!ester suture for zone $$ :e+or tendon repair and

found no di;erence %et#een '- and - cali%er suture #ith regard to failure

strength.

4erpheral suture

) should %e a2oided %ecause gaps ?' mm

negati2el! a;ect the strength of the repair site. &echanical testing of di;erent

repair techniques indicates that the num%er of core suture strands and the

purchase of the peripheral suture are the t#o most in:uential factors a;ecting

potential elongation. The peripheral suture ser2es the dual purpose of pre2enting

gapping and minimizing the %ulk of the rapair. ollo#ing completion of the core

suture" the senior author (A.D.) uses a nonlocking ,- pol!prop!lene running

peripheral suture. An interlocking horizontal mattress technique can also %e used.

The suture is placed 0 mm from the repair site at a depht of 0 mm (as opposed to

purel! #ithin the epitenon) to ma+imize the strength of the repair.

D@ repair

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During the initial e2aluation of the digit" in9ur! to the D@ should %e noted. The

location of the in9ur! in:uences #hether D@ repair should %e pursued #hithin zone

$$. $f the D@ pro+imal to the 8ampers chiasm and the D4 are repaired" %oth of te

repaired tendons #ill lie under the A0 pulle!. Tendon gliding and s!no2ial nutrition

are likel! to %e compromised in this scenario %ecause of the amount of

postoperati2e edema that #ill occure. $n this particular setting" Tang et al ad2ocate

repair of the D4 alone and e+cision of the a segment of one D@ slip" #ith theintent of minimizing the %ulk of the repaired tendon under the A0 pulle!. Distal D@

slips can %e repaired indi2iduall! using a modied ecker conguration #ith 3- or

,- prop!lene suture (igure 3). $t should %e noted that" %ecause of their more

dorsal position" the D@ slips in this location should %e repaired %efore the D4. *e

%ase our decision on #hether to repair one or %oth D@ slips on the smoothness of

intraoperati2e tendon gliding after the D4 repair. Although #e prefer to keep %oth

D@ slips" #e #ill e+cise one (and repair the other slip" if also in9ured) if needed to

facilitate gliding of the repaired tendons.

inal intraoperati2e e2aluation

After the tenorrhaph! is complete and other concurrent in9uries are addressed" a

nal e2aluation of the digit is performed. The repair site is closel! e+amined for

proper coaptation of the tendon ends" #ith minimal %ulk" minimal gapping" and an

appropriate amount of tension. 6liding of the D4 and D@ tendons (#ithin the

:e+or sheath) and pulle!s is carefull! e2aluated throughout the arc motion" taking

into consideration that postoperti2e edema #ill %e present #ithin the tendons and

the surrounding soft tissues. The A0 pulle! can %e partiall! di2ided (up to 3 B) and

the A pulle! can %e completel! di2ided to help restore smooth tendon glinding" %ut

this should %e done cauntiousl! to a2oid unnecessar! compromise of the

mechanical eCcienc! of the :e+or apparatus. le+or tendon sheath repair is

contro2esial %ecause it is technicall! challenging and has not %een sho#n to

impro2e clinical outcomes. $f neuro2ascular repair is performed" the repair sites are

e2aluated during passi2e motion to assess fo an e+cessi2e amount of tension these

ndings are noted in the surgical dictation and considered during the selection of a

post operati2e reha%ilitation protocol. ollo#ing meticulous hemostasis and

standard #ound closure" the hand is placed in a dorsal %locking splint that e+tends

%e!ond the ngertips.

4ostoperati2e Eeha%ilitation

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discreation of the surgeon. actors such as repair integrit!" concurrent in9uries" and

anticipated patient compliance should %e considered during decision making

process.

$deall!" the rst 2isit #ith the therapist should occur %efore surger! to educate the

patient a%out the post operati2e reha%ilitation plan and fa%ricate the splint.

8ommunication among the surgeon" patient" and therapist help to optimize thee;ecti2eness of the reha%ilitation plan. $t is helpful for the surgeon to inform the

therapist a%out the location and e+tent of the in9ur!" the strength of the repair" the

repair technique used" associated in9uries (eg" to the :e+or pulle!s and

neuro2ascular %undle)" and an! other particular concerns regarding the

postoperati2e course.

Eange of motion (E5&) e+ercises are not initiated until at least da!s (%ut no laterthan da!s) after surger! %ecause the #ork of :e+ion is increased %! the amount of

soft tissue edema present in the rst ' da!s. $f possi%le" therap! should %egin

%efore da!s postoperati2el! #aiting longer has resulted in an increased risk of

adhesion formation in an animal model. Due to the mechanical %enets conferred

%! %oth motion and tension at the repair site" the senior author (A.D.) prefers a

modication of the Duran and 7ouser protocol that adds immediate place and hold

acti2e motion. $n this protocol" a dorsal %locking splint is applied to the hand #ith

the #rist in G :e+ion" the metacarpophalangeal 9oints in G :e+ion" and the

interphalangeal 9oints in full e+tension. 4assi2e 4$4" distal interphalangeal (D$4)" and

composite :e+ion as #ell as acti2e 4$4HD$4 e+tension e+ercises are performed #iththe hand in the splint. 4lace and hold 4$4 :e+ion (the 4$4 9oint is passi2el! :e+ed and

acti2el! held in :e+ion #hile the #rist is e+tended) is initiated immediatel! after the

splint is remo2ed. 4lace and hold D$4 :e+ion in a hook st (4$4 and D$4 9oints :e+ed

#ith the metacarpophalangeal 9oint in e+tension) is also initiated immediatel! to aid

in di;erential gliding %et#een the D@ and D4 tendons. The patient is transitioned

to acti2e :e+ion at ' to #eeks postoperati2el!" #ith light resisti2e e+ercises at

to I #eeks.

Although numerous earl! passi2e and earl! acti2e mo%ilization protocols ha2e %een

descri%ed" a s!stematic re2ie# of the literature has sho#nn that %oth t!pes of

protocols can %e used to deli2er adequate motion" #ith an accepta%le risk of

complications. $n re2ie#ing data from 3 studies #ith a minimum ' month follo# up

periode after zone $$ repair" 8hesne! et al reported 01 ruptures in 31 earl! passi2e

motion cases ("1 B) and ' ruptures in 03 earl! acti2e motion cases ("B). $n

the inl! randomized controlled trial that has directl! compared the t#o t!pes of

protocols" patients #ho under#ent an acti2e place and hold protocol (#ith a

tenodesis splint for the rst 0 #eeks) sho#ed greater patient satiscation than did

those h#o under#ent an earl! passi2e motion protocol. Although Trum%le et al

reported a relati2el! high rate of rupture in small ngers treated #ith earl! acti2e

motion" the senior author (A.D.) has noted this in his practice. 6i2en that there is a

strong relationship %et#een repair rupture and patient compliance #ithpostoperati2e restrictions" the surgeon must select a reha%ilitation protocol that

matches the anticipated a%ilit! of the patient to adhere to the programs

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restrictions. The role and importance of the therapist in the reha%ilitation process

should not %e o2erlooked treatment %! a certied hand therapist has %een

associated #ith %etter motion and greater patient satiscation

8omplications

The o2erall rate of reoperation after :e+or tendon repair (in all zones) is ,B" %ased

on %oth a meta anal!sis of the literature and epidemiologic data. $n /e# Jork state"

the median time to reoperation #as da!s. The rate of repair rupture reported in

the literature is B" #hereas the rate of the reoperation for repair rupture is 0"'B in

/e# Jork stase. $n e2aluating the patient #ith a sti; nger after :e+or tendon

repair. Acti2e and passi2e E5& should %e compared to di;erentiate %et#een

sti;ness caused %! tendon adhesions andHor contractures of the interphalangeal

9oints. The reported rate of tendon adhesions is B" and the rate of tenol!sis

performed after :e+or tendon repair is '",B in /e# Jork state. 5ther possi%le

complications include triggering" pulle! failure" quadriga" and lum%rical plus

deformit!. Although it is impossi%le to completel! a2oid complications" the

aforementioned principles of careful soft-tissue handling" apposition of tendon

edges #ith a strong multistrand repair" minimizing repair gapping and %ulk #ith a

peripheral suture" and appropriate implementation of earl! motion are critical to

decrease the risk of ad2erse e2ents after :e+or tendon repair.

5utcomes

ecause of the heterogeneit! of studies on :e+or tendon repair techniques and

reha%ilitation protocols" the 2aria%ilit! in reporting digit motion" and the lack of

#idespread use of patient reported outcome measures" it is diCcult to dra#

conclutions regarding the reported outcomes of :e+or tendon repair. According tothe limited comparati2e literature a2aila%le on reha%ilitation protocols" earl! acti2e

motion protocols relia%l! restore good to e+cellent digit motion" #hereas outcomes

are less consistent #ith the use of the earl! passi2e motion protocols. 4atients #ith

multiple digit in9uries" those #ith concurrent ner2e in9uries" and those #ho smoke

are more likel! to ha2e poor outcomes. The relati2e in:uence of an in9ur! to a single

digit on patient function and qualit! of life is diCcult to descern" %ut it can %e

inferred that patients #ith %etter digit motion #ill ha2e %etter hand function.

Although ar%itrar!" #e classif! patients #ho are a%le to :e+ the a;ected digit to the

palm as ha2ing a good outcome. $n a randomized stud! of zone $$ :e+or tendon

repair" assessment of disa%ilit! using the Disa%ilit! of the Arm" @houlder" and 7and

score indicated that disa%ilit! #as relati2el! lo# !ear postoperati2el! (mean

score" 0. at 30 #eeks after an acti2e motion protocol). Another stud! found that

function returned to near %aseline %! , months after zone $$ :e+or tendon repair.

Eeported rates of patient satisfaction #as greater after earl! acti2e mo%ilization.

@ummar!

le+or tendon repair has e2ol2ed remarka%l! in the past 3 !ears. &odern surgical

techniques and reha%ilitation protocols ha2e produced consistent satisfactor!

clinical results. 8olla%orations %et#een clinician in2estigators and %asic scienceresearchers ha2e ad2anced clinical practice. Eecent in2estigation into %iologic

modications that ma! enhance tendon healing and gliding ha2e sho#n promising

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results in animal models and ha2e the potential to continue to impro2e clinical

outcomes of :e+or tendon repair.