Reoperation following zone II flexor tendon repair
Luca Bruin, BSc1, Jonathan Lans, MD2, Frederick Wang, MD1, Kyle R Eberlin, MD3 and Neal C Chen, MD4, (1)Massachusetts General Hospital, Boston, MA, (2)Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Massachusetts General Hospital/Harvard Medical School, Boston, MA, (3)Orthopaedic Hand and Upper Extremity Service, Massachusetts General Hospital, Massachusetts General Hospital, Boston, MA, (4)Massachusetts General Hospital/Harvard Medical School, Boston, MA
Background: The goal of surgical tendon repair is to perform a repair with sufficient strength to withstand the forces encountered during rehabilitation. Reoperation have been reported to occur in about 6% of patients. In zone II injuries, older age, injury severity and smoking have been associated with inferior results. Although, clinical studies specifically assessing reoperation after zone II flexor tendon repair are uncommon, non-sharp mechanisms of injury and combined FDP/FDS injuries have been suggested to be associated with reoperation. Biomechanical studies suggest that the strength of repair of core-suture techniques varies widely. However, there are few studies that demonstrate that these biomechanical differences are clinically relevant. We hypothesized that the core-suture technique is related to reoperation after zone II flexor tendon repair.
Methods: We retrospectively identified 237 adult patients that underwent primary zone II flexor tendon repair of 298 fingers, from 2000 to 2016 at three urban academic medical centers. The median patient age was 33 years (IQR:25-45) and 165 (70%) patients were male, these were followed for a median of 1.9 years (IQR:0.3-6.6). Both FDP and FDS tendons were repaired in 209 (70%) fingers, in 48 fingers (16%) the FDS was excised and the FDP was repaired, and in 41 fingers (14%) the FDS was unaddressed and the FDP was repaired. For the FDP tendon, a Kessler-type repair was most commonly performed (n=194, 77%), followed by the Modified Becker repair (n=22, 8.7%). For the FDS, a modified Kessler repair was most common (n=116, 64%), followed by a figure-of-8 suture (n=28, 15%). We performed multivariable analysis to identify factors associated with reoperation.
Results: Fifty-six (19%) fingers in 48 (20%) patients underwent a reoperation at a median of 4.8 (IQR:2.7-7.8) months. Indications for reoperation included adhesions (n=40, 71%), suspected tendon rupture (n=13, 23%) or infection (n=3, 5.4%). Complications without reoperation included finger stiffness (n=44, 20%), clinical re-rupture (n=6, 2.5%) and infection (n=4, 1.7%). Multivariable analysis showed: (1) age above 60 years (OR 7.5, 95% CI:2.5-22.3, p<0.001), (2) insurance through worker's compensation (OR 18, 95% CI:6.3-53, p<0.001), (3) and FDP tendon repair with a Kessler-type repair (OR 3.1, 95% CI:1.4-6.8, p=0.006) compared to other techniques, were independently associated with reoperation.
Conclusion: Kessler repair technique for repair of the FDP was independently associated with reoperation, as well as older age and worker's compensation. The biomechanical strength of the core-suture repair appears to have clinical relevance based on our data.
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