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Two-Stage Flexor Tendon Reconstruction: A Systematic Review and Meta-Analysis
Niek J. Nieuwdorp, MSc, Anika A. Castel, BSc, L. S. Samantha Cheng, BSc, Floris W. van de Kamp, BSc, Daan Stam, BSc, Caroline A. Hundepool, MD, PhD; J. Michiel Zuidam, MD, PhD
Erasmus MC, Rotterdam, Netherlands
Introduction: Primary repair is the preferred treatment for flexor tendon injuries. However, in cases of delayed presentation, missed injuries, or failed primary repairs, it may not be feasible. In such scenarios, two-stage flexor tendon reconstruction remains a salvage option, especially when scarring, joint contractures, or pulley damage is present. Despite its established role, reported outcomes vary widely. There is ongoing debate regarding the optimal timing of both the initial surgery and the interval between the two stages. Additionally, the effect of graft type on postoperative function remains unclear. While intrasynovial grafts are believed to promote better tendon gliding and reduce adhesion formation, extrasynovial grafts such as the palmaris longus are more readily available and commonly used in practice. This systematic review and meta-analysis evaluates the functional outcomes of two-stage flexor tendon reconstruction and explores whether surgical timing and graft choice influence postoperative outcomes.
Material & Methods: A systematic literature search in Embase, MEDLINE, and Web of Science was performed up to May 2025. The search targeted clinical studies reporting functional outcomes, surgical timing, and graft types used for two-stage flexor tendon reconstruction in the hand. Meta-analyses were performed to estimate the pooled proportion of normal total active motion (TAM) restored and the percentage of patients achieving good to excellent outcomes, based on Strickland or Buck-Gramcko scales. Meta-regression was used to assess the relationship between graft type, surgical timing, and TAM.
Results: From 2,084 articles identified, 33 studies involving 995 patients and 1,139 affected digits met the inclusion criteria. On average, two-stage flexor tendon reconstruction restored 73% of normal TAM (95% confidence interval [CI]: 68%-79%) and resulted in good to excellent outcomes in 67% of patients (95% CI: 57%-75%). Meta-regression analysis showed no significant relationship between TAM and the time from injury to Stage I surgery (p = 0.197), the interval between the two surgical stages (p = 0.321), or the type of tendon graft used (p = 0.656).
Conclusions: Two-stage flexor tendon reconstruction restores approximately 74% of normal finger motion and achieves good to excellent outcomes in about two-thirds of patients. No evidence was found that delays between injury and Stage I surgery negatively impact functional outcomes. In the absence of evidence guiding timing or graft selection, these decisions should rely on the surgeon's clinical judgment and experience.
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