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American Association for Hand Surgery

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Two-Stage Technique for Flexor Tendon Reconstruction in Zone II: A Systematic Review and Analysis
Megan Gray, MD1, Maxene Weinberg, BS1, Michael Lanni, MD2, Joseph A Ricci, MD1 and Ashit Patel, MBChB1, (1)Albany Medical Center, Albany, NY, (2)Division of Plastic Surgery, University of Pennsylvania, Philadelphia, PA

Introduction
Flexor tendon repair in Zone II remains challenging. Hunter originally described the technique in 1971 using a Dacron-reinforced silicone prosthesis to promote pseudosheath formation with subsequent delayed tendon repair. Many surgeons have employed various iterations of this method, but there has been incomplete reporting of outcomes.
Methods
A systematic review of Pubmed, EMBASE, Ovid, Cochrane, Scopus and Clinicaltrials.gov was performed including published papers or trials on long term complications and outcomes of delayed flexor tendon repairs using the two-stage technique in Zone II. Abstracts, posters, and conference proceedings were excluded, as well as non-English language papers, single case reports and studies including children under age 17. Information on demographics, procedural details, severity of injury, functional outcomes, hand therapy protocols and complications were analyzed.
Results
We identified 1316 titles after excluding duplicates, and 79 full text articles were reviewed. Ten studies were included for qualitative analysis, all retrospective studies, with a total of 305 patients and 369 digits affected. Most patients were male (84%) with ages ranging from 17-63 years old. The time from injury to first stage of reconstruction was 8-384 weeks, and delay between first and second stage ranged from 6-88 weeks. Eight authors performed tendon grafting at the second stage, one used the Paneva-Holevich technique and one employed both modalities.
The Adjusted Strickland classification was reported in seven studies. Excellent and good outcomes were observed in 153 digits. However, fair and poor outcomes were seen in 74 patients, even following revision procedures.
Seven studies described their occupational therapy (OT) protocols. Initiation of OT after stage 1 ranged from immediate to 21 days with most beginning with passive range of motion (ROM). After stage 2, OT commencement ranged from 0-21 days. Two authors utilized active ROM after a period of splinting, two employed a dynamic flexion traction or passive kleinert rubber band splint, and three authors used a combination of passive and active ROM.
All studies except one mentioned revisions or complications. In stage 1, implant malposition was noted in 1/10 studies, and infectious complications were rare. Tendon rupture after stage 2 was observed in 13 patients from 1 week to 15 months post-operatively. Rates of tenolysis in five studies ranged from 25-50%.
Conclusions
Significant variability exists with little data to guide surgeons on the optimal timing, surgical technique, and rehabilitation protocols. Future studies focusing outcomes and complications are warranted to improve the two-stage technique in Zone II.


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