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Outcomes of Zone IV/V and TI to TIV Extensor Tendon Repair Using Running Interlocking Horizontal Mattress Technique
Grant Altobelli, MD1; Stacy Conneely, CHT/OT2; Christina Haufler, CHT/OT2; Maura Walsh, CHT/OT2; David Ruchelsman, MD2;
1Tufts Medical Center, 2Newton-Wellesley Hospital


Biomechanical evidence has demonstrated that the running interlocking horizontal mattress repair (RIHM) for extensor tendon lacerations is a significantly stronger and stiffer repair resulting in less shortening compared to other techniques. We investigated the efficacy and safety of primary extensor tendon repair using RIHM technique followed by immediate controlled active motion (ICAM).

Materials and Methods

Retropective review of all patients undergoing extensor tendon repair from August 2009 to April 2012 by a single surgeon in an academic hand surgery practice. The inclusion criteria were simple extensor tendon repairs in zone IV-V and TI-TIV, and primary repair performed using RIHM technique.  Eight consecutive patients with 9 tendon lacerations were included. There were 3 thumb tendon lacerations and 6 zone IV-V lacerations. One patient underwent concomitant dorsal rotation flap for coverage over the metacarpalphalangeal joints. Technique: 3-0 nonabsorbable braided suture is used to perform a running simple suture in one direction to obtain a tension-free tenorrhaphy followed by a running interlocking horizontal mattress corset-type suture using the same strand in the opposing direction. Average time to surgery was 10 days (range 3-33). One patient underwent delayed primary repair for a zone IV laceration. Mean follow-up was 79 days (range 15-179). All digital repairs began the ICAM protocol by postoperative day 5. A dynamic extension protocol was used for thumb extensor repairs.


All 9 tendon lacerations achieved full recovery with no extension lag. By Miller's criteria all 9 tendon repairs achieved excellent/good results. There were no tendon ruptures or wound complications. No patients required secondary surgery for extensor tenolysis or joint release.


The running interlocking horizontal mattress technique for primary extensor tendon repairs in zone IV and V and T1-TIV is safe, allows for immediate postoperative controlled active motion, achieves good to excellent functional outcomes, and minimizes the need for secondary surgeries. These outcomes support prior biomechanical data.

Figure Legends

Figure 1. (a) Schematic of steps of RIHMrepair. (b) Intraoperative photos of RIHM technique within zone 5 of the extensor system. (c) Intraoperative photo of RIHM technique zone 1 of the thumb extensor system (T1)

Figure 2. Clinical results following RIHM repair of zone 5 extensor tendon laceration.

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