Effects Of Early Motion Exercise On Recovery Of Hand Function After Primary Flexor Tendon Repair In Zone Ⅱ

Objective: The purpose of this study was to determine the efficacy andsafety of the protocol used in this prospective case-control trial, and may providesome helpful evidence for the further randomized controlled trial study indifferent protocols or the treatment of some complicated injuries such asassociated with fractures and so on. Method: Thirty-nine patients (67 digits) that injuried flexor tendons in zoneII were repaired with a modified Kessler suture were divided into 2 groupaccording to the difference of the early postoperative therapy. There were 20patients (35 digits) in the experimental group, and there were 19 patients (32digits) in the controlled group. In the experimental group, controlled mobilization was begun on the 4th daypostoperative, modified Kleinert splint with a palmar pulley was fitted on allpatients. This splint was placed on the forearm, extending to just beyond thefingertips, with the wrist positioned about 45 degrees of flexion, MP joint alsopositioned about 40 degrees of flexion, and interphalangeal (IP) joints wereallowed to assume complete active extension. After application of the dorsal splint,a nylon fishing line was attached to the fingernail hook of the injured finger orfingers. The fishing line was then run through the eye of the palmar pulley to arubber band anchored at the proximal forearm. The length of the fishing line waslong enough to allow for full extension of the involved digit or digits withoutmaking contact with the palmar pulley, the junction of the nylon line, and therubber band. The tension of the rubber band was adjusted to be light enough toallow full active extension of the IP joints and strong enough to pull the fingersback into flexion. In the first 3 week postoperative, early controlled active extension exerciseswere initiated after the fabrication and application of the dorsal splint and thepalmar pulley dynamic traction system. The patients were instructed to activelyextend the involved digit or digits against the tension of the rubber band 10 timesper hour, 5 groups per day (2 in the morning, 2 in the afternoon and 1 before sleepat night), the 10times should be finished within 1 minute during the 1st and the 3rdweek postoperative, and this should be done 1 time every 5 minutes during the 2ndweek. The IP joints are strapped in extension between exercises instead of rubberband traction and at night. Patients who could not actively extend the involveddigit or digits against the rubber-band tension were allowed to manually releasesome rubber-band tension during the exercise to reach full active extension of theIP joints. In addition, a passive exercise program was engaged 4 times (2 in themorning and 2 in the afternoon ) per day for all digits, including uninvolved digits.All passive exercises were performed by the patients themselves. Passive flexionexercises were performed for isolated MP, proximal interphalangeal (PIP), anddistal interphalangeal flexion followed by full passive flexion of these three joints.During passive extension of the IP joints, the MP joint was held at 90 degrees offlexion to avoid excessive tension on the repair site. All passive exercises wererepeated 10 times, and each position was held for 5 sec. Patients were instructedto keep the hand and limb elevated for edema control, not to replace the splint,and not to actively flex the involved digit or digits.At the beginning of the 4th week, the dorsal splint was removed and activefinger flexion exercises were begun with the protect of the wrist neutral staticsplint, 10 times per group,8 groups per day, include the hook-fist, straight-fist, andfull-fist. During the 6th and the 7th week the splint was removed and patients werepermitted to use the involved hand in light daily activities. Resistive exerciseshould not be started until 8 weeks.In the controlled group there were no rehabilitation intervening during thefirst 5 weeks, but the protocol was same with that of the experimental group's.All the patients were followed-up 12 weeks. At the 4th, 6th, 8th,10th week andthe 12th weekend, the range of motion measurements of MP and IP joints weremade with a standard finger goniometer, and extension past 0 degrees were notincluded in the measurements of range of motion. At the 12th weekend, the gripstrength of both hands were measured, and the percentage of the injuried handcompared with the uninjuried hand was calculated and recorded. At the 6th and the12th weekend, JHFT (Jebsen Hand Function Test) was measured, the unit wassecond (S).SPSS 11.5 for Windows software was used for all data management andanalysis. In all cases, a level of 0.05 was considered to be statistically significant.Results: The results showed that, at the 4th, 6th, 8th, 10th week and the 12thweekend, the variables of TAM measurements in the experimental group werebetter than that in the controlled group, the variables between these two groupsshowed significant difference (P<0.01). In the experimental the results wereexcellent in 5.71% of the fingers, good in 80%, fair in 14.29%, and none wasrated poor according to Strickland's standards and were excellent in 60% of thefingers, good in 22.9%, fair in 17.14%, and none was rated poor according to theTAM standards. In the controlled group the results were good in 34.4% of thefingers, fair in 56.25 %, and poor in 9.4% according to Strickland's standards andwere good in 28.1% of the fingers, poor in 46.9% according to the TAM standards.There was some consistency (P<0.01) between the two standards according toKappa test, but the consistency was not very satisfactory as the Kappa value was0.333 (<0.4). At the 12th weekend, mean grip strength was (55.62±6.626)% of theuninjured hand in the experimental group and (36.39±10.918) % in the controlledgroup, the variables between these two groups showed significant difference(P<0.01) according to Independent-Samples T Test. There were significantdifference (P<0.01 or 0.05) for within-subject values of all items of JHFT betweenthe 4th week and the 12th weekend except for the JHFT6 of dominant hand(P>0.05). Difference between the two groups for JHFT1-4 of non-dominant handwas significant (P<0.01 or 0.05), and also for JHFT5-6 of non-dominant handexcept for the JHFT5 of the 12th weekend (P>0.05). To the dominant hand, therewere significant difference (P<0.01 or 0.05) between the two groups for JHFT1-3,and there were no significant difference (P>0.05) for JHFT4-6.Conclusions: It is concluded that the protocol used in this trial, which isbased the regimen of modified Kleinert and modified Duran techniques and withthe delimitation of the beginning time, frequency and total amount of motionexercise, provides an effective way of achieving satisfactory results and is verysafe. There was some consistency (P<0.01) between the Strickland's standard andthe TAM standard, but the consistency was not very satisfactory, and theStrickland's standard is more suit for the evaluation of the function of the flexortendon in zone II. The mean maximum grip strength at the 12th weekend is onlyabout 50%, so the resistive exercise should be designed scientifically, but theoptimum regimen still wait for further study. TAM have the more obviouslyinfluence on the fine operate ability, so it should be given more attention whendesigning the OT regimen, especially for the patients associated with the injury ofthe Index or the Middle fingers.