Review Article

Journal of Hand Surgery

(European Volume)
Recent evolutions in flexor tendon 0(0) 1–5
! The Author(s) 2018
repairs and rehabilitation Reprints and permissions:
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DOI: 10.1177/1753193418773008
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Jin Bo Tang

Abstract
This article reviews some recent advancements in repair and rehabilitation of the flexor tendons. These
include placing sparse or no peripheral suture when the core suture is strong and sufficiently tensioned,
allowing the repair site to be slightly bulky, aggressively releasing the pulleys (including the entire A2 pulley
or both the A3 and A4 pulleys when necessary), placing a shorter splint with less restricted wrist positioning,
and allowing out-of-splint active motion. The reported outcomes have been favourable with few or no repair
ruptures and no function-disturbing tendon bowstringing. These changes favour easier surgeries. The recent
reports have cause to re-evaluate long-held guidelines of a non-bulky repair site and the necessity of a
standard peripheral suture. Emerging understanding posits that minor clinically noticeable tendon bowstring-
ing does not affect hand function, and that free wrist positioning and out-of-splint motion are safe when
strong surgical repairs are used and the pulleys are properly released.

Keywords
Flexor tendons, peripheral sutures, tensioning of the repair sites, pulley venting, active motion

Date received: 2nd April 2018; accepted: 4th April 2018

Introduction
Though multi-strand core suture, pulley-venting, and
early active flexion have been practised over past two
decades for flexor tendon repair in zone 2, we have
seen several recent advancements in surgical tech-
niques and rehabilitation. This review summarizes a
few striking recent developments, which hold prom-
ises for further reshaping flexor tendon repair.
Sparse or no peripheral sutures
Peripheral sutures have been an integral part of the
surgical repair of the lacerated flexor tendons.
Methods commonly used range from a simple run-
ning suture to cross-stitching and other methods.
However, the peripheral sutures are now considered
optional or superfluous by a number of surgeons
when a strong core suture is used (Giesen et al.,
2009, 2017, 2018). These surgeons ensure the appli-
cation of sufficiently tensioned and strong core
sutures, which not only tightly close any gap, but
also bunch the tendon ends a bit to prevent gapping
during early active motion.
When a strong and tensioned core suture is used,
two or three separate sutures, or a running stitch
sparsely placed on the palmar or palmar and lateral
aspects of the tendon, serve to tighten the junction
site adequately, which my colleagues and I have
sometimes used. More boldly, peripheral sutures
may not be necessary, as recently suggested
(Giesen et al., 2017, 2018; Reissner et al., 2018),
which simplifies the surgery.
Ensure slightly bulky repair site
Ensuring a smooth and non- or minimally bulky
repair has been a guideline in repairing flexor
tendon in zone 2, but now, allowance for a certain
degree of bulkiness may replace this guideline.
Such a change stems from the understanding that
tension across the core suture is important for gap
resistance (Wu and Tang, 2012). Ensuring adequate
Department of Hand Surgery, The Hand Surgery Research Center,
Affiliated Hospital of Nantong University, Nantong, Jiangsu, China
Corresponding Author:
Jin Bo Tang, Department of Hand Surgery, The Hand Surgery
Research Center, Affiliated Hospital of Nantong University,
Nantong, Jiangsu 226001, China.
Email: jinbotang@yahoo.com
2 Journal of Hand Surgery (Eur) 0(0)

tension across the repair site is key in tendon repair,
which inevitably results in a degree of repair site
bulkiness. The bulkiness of the repair is tolerable,
however, in current surgical settings, where restrict-
ing annular pulleys are released to favour tendon
gliding. Pulley-venting improves tendon gliding and
lowers the risks of triggering or impingement of the
slightly bulky repair site against the pulleys.
My colleagues and I suggest that the bulkiness of
the repair site can reach 120%–130% of the diameter
of the normal part of the repaired tendon with tension
to core sutures (Tang et al., 2017) (Figure 1). Giesen
et al. (2017, 2018) noted that when the repair site
bulkiness was 150% of that of the normal tendons,
active gliding of the repaired tendons was not
impeded. Such a range of allowable bulkiness pro-
vides surgeons rooms to tension the repair to resist
gapping. However, to ensure that the slightly bulky
tendon can glide adequately, the surgeon should per-
form an extension–flexion test of the digit to ascertain
that critical pulleys are properly released.
More aggressive pulley-venting
Venting of the A2 or A4 pulleys was once considered
aggressive because both pulleys had been con-
sidered sacrosanct. In recent years, this consider-
ation no longer prevails. Judicious venting of either
a part of the A2 pulley or the entire A4 pulley is now a
key step for many hand surgeons and it is an import-
ant measure in attaining optimal outcomes. The crit-
ical pulleys, such as A2 or A4, are released when the
other annular pulleys are intact and at least a small
part of the A2 pulley is preserved (Tang, 2005, 2007,
2014; Tang et al., 2017; Wu and Tang, 2014a). A few
recent reports describe more aggressive approaches
in pursuing the pulley-venting (Giesen et al., 2017,
2018; Moriya et al., 2016a, 2016b) (Figure 2). These
approaches include venting the entire A2 pulley when
the retained small portion of the A2 pulley blocks full
motion of the repaired tendons, and venting the A4
and A3 pulleys together when an intraoperative digi-
tal extension–flexion test indicates such a need.
Surgeons sometimes vent any pulleys that they find
blocking tendon motion, especially when noted
during active finger flexion during a wide-awake sur-
gical procedure (Elliot et al., 2016; Lalonde, 2017;
Lalonde and Martin, 2013). They have not emphasized
identifying which pulleys to be vented, but a length
limit of 1.5–2 cm. Recent reports indicated that
patients who occasionally had to have the entire A2
pulley vented do not have remarkable clinical prob-
lems (Giesen et al., 2018; Moriya et al., 2016b).
Giesen et al. (2018) have noted no clinically dysfunc-
tional bowstringing when they vented the A3 and A4
pulleys together and found any bowstringing at the
proximal interphalangeal joint would be much less
functionally disturbing than at the metacarpophalan-
geal joint (Figure 2). Therefore, they do not hesitate
release of the A4 and A3 pulleys and the sheath
between them when that favours free tendon gliding.
Findings of my colleagues corroborate this notion
(Tang et al., 2017).
Two critical points should be clarified. First,
anatomical bowstringing is not equal to a clinically
functional disturbance. It appears reasonable that

Figure 1. (a) A smooth tensionless repair site (upper drawing) would easily gap when the tendon is pulled to glide during
active finger flexion and extension (lower). (b) A slightly bulky repair site, after tension is added to the core suture (upper),
would become flatter but without gapping (lower) when the tendon is pulled.
Tang
smooth tendon gliding in the presence of minor bow-
stringing does not affect function. Minor bowstringing
of tendons does not cause as big a problem as
restriction of tendon gliding by adhesions and pul-
leys. Second, venting should be judiciously per-
formed and limited to only the extent necessary.
We should not encourage venting of the entire A2
pulley or combination of A4 and A3 pulleys, if venting
only a part of the A2 pulley or the entire A4 pulley
alone is sufficient.
Shorter splint and free wrist positioning
Though post-surgical oedema risks compressing the
tendon, when surgical repairs are reliable and
restricting pulleys are released, resistance to gliding
and risks of repair ruptures are notably decreased.
Wrist and finger positions are no longer a consider-
ation in lessening tension on the repair. The repaired
tendon should be able to tolerate tension in any wrist
position except extreme flexion or extension.
Because the patient may be uncomfortable with the
wrist in marked flexion or extension, a neutral or
slightly flexed or extended position will suffice. The
finger joints should be fully extendable to favour full
passive finger motion exercises and to prevent digital
joint stiffness. The metacarpophalangeal joint is held
in mild or moderate flexion to lessen tension on the
repaired tendon.
The splint prevents undue tension and serves as a
cautionary reminder rather than maintaining the wrist
and fingers in specific positions. For this purpose,
Figure 2. (a) Release of a combination of the A3 and A4 pulleys (shown with a red line in the upper drawing) would result
in tendon bowstinging (red line in the lower drawing), but this bowstringing causes less functional disturbance than that at
the metacarpophalangeal joint. (b) Release of the entire A2 pulley (shown with a red line), when very necessary, was
reported to have not caused a major functional problem.
3
a short forearm splint extending from the middle or
distal forearm, or wrist to the fingertips suffices. The
Manchester short splint ends proximally at the wrist,
and this allows free wrist motion except for marked
extension (Howell and Peck, 2013; Wong and Peck,
2014). I consider this simplification wise and innova-
tive. Yet a short forearm splint from the distal forearm
appears easier to apply and more protective, which
I currently prefer. Nevertheless, these patients are
urged to perform out-of-splint active finger flexion
anyway, regardless of how short the splint is.
Out-of-splint active motion
Out-of-splint passive and active finger motion follow-
ing a strong tendon repair has been safe for compli-
ant patients. The out-of-splint active motion is better
performed with the wrist in a functional position. In
non-compliant patients, we incorporate fewer active
components in their motion protocols and allow
finger motion only within a splint.
In early active finger flexion exercises, the keys
are to avoid full active flexion in the initial 2.5–4
weeks and to always perform full passive extension
and flexion before starting active flexion exercise
(Tang, 2007, 2013, 2014; Wu and Tang, 2014a). Exact
protocols can be adjusted to fit individual patients
and according to the preferences of the surgeon
and therapist. Any motion regimes reflecting the
above two keys are sensible, which are modified for
individual patients according to degree of postopera-
tive swelling, associated injuries, and compliance.
4 Journal of Hand Surgery (Eur) 0(0)
The outcomes in recent reports
Reports in the last 3 years indicate ruptures after
primary repairs are scarce or non-existent when
strong repair methods (typically a 6-strand core
suture) and the pulley venting has been performed
by either experienced senior hand surgeons or less
experienced juniors (Giesen et al., 2018; Moriya et al.,
2017, Pan et al., 2017; Tang et al., 2017, Zhou et al.,
2017). If updated repair principles are carefully fol-
lowed, repair rupture is no longer a major problem.
Adhesion formations still present a problem for
some patients. In these reports, the incidence of
tenolysis was typically 5%–10%. We should note
that these reports are not based on the repairs in
unfavourable injury conditions (such as with frac-
tures or with severe vascular injuries). It is likely
that tendon repairs result in less satisfactory out-
comes when the injuries are more severe. I also
speculate that unsatisfactory outcomes do exist and
not all surgeons actually master or follow all the
updated surgical guideline details. As many of the
surgical details have been updated rather rapidly,
consequently practising surgeons could have mas-
tered some rather than most or all requirements of
surgery.
From the practices and outcomes reflected in
recent reports, we seem to be heading toward an
era with fewer restrictions in wrist or finger position-
ing for postoperative protection, latitude in whether a
peripheral suture is added, how much immobilization
a splint provides, and whether the fingers can move
with or without protection. I believe, with a strong
surgical repair and proper and sufficient venting of
the annular pulleys, postoperative splinting is only to
protect the patients from additional injury and to pre-
vent unwanted use of the hand, rather than to ensure
a specific protective position; additionally out-of-
splint exercises offer well-motivated patients a
safe, easy, and more efficient method of exercise.
Future perspectives
The 6-strand repairs made with 4-0 or 3-0 sutures
currently represent strong core sutures and ensure a
greater safety margin than the 4-strand repairs
(Giesen et al., 2017; Kozono et al., 2018; Leppänen
et al., 2016). We observed during surgery that
6-strand repairs better stabilize the tendon seg-
ments encompassed by the core sutures and elimin-
ate micro-motion at the junction of two tendon
stumps, which may be present with a 4-strand
repair (Tang et al., 2017). The repair site is further
stabilized with asymmetrical core sutures (Wu and
Tang, 2014b). Stronger suture materials without
increased diameter are desirable. Fiberwire, how-
ever, seems to be too stiff (Giesen et al., 2017,
2018; Hay et al., 2017; Rigó et al., 2017), and many
surgeons do not consider it suitable for zone 2 flexor
tendon repair.
In summary, recent reports include using sparse
or no peripheral sutures when strong core sutures
are placed and sufficiently tensioned. Although this
makes the repair site slightly bulky, it is permissible
and effective when the pulleys are properly vented. In
addition, surgeons reported venting of the entire A2
pulley or combination of the A3 and A4 pulleys when
necessary, using a shorter protective splint, and car-
rying out out-of-splint active motion. These reports
call on re-evaluation of the long-held repair guide-
lines of ensuring a slender repair supplemented with
a customary peripheral suture. The resultant digital
motion does not seem to be adversely affected by
minor bowstringing of the flexor tendons, use of a
short splint with free wrist positioning, and rehabili-
tation using out-of-splint motion.
Declaration of conflicting interests The authors
declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding The author received no financial support for the
research, authorship, and/or publication of this article.
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