Systematic Review of Flexor Tendon Rehabilitation Protocols in Zone II of the Hand

BACKGROUND: Restoration of function following flexor tendon repair in zone II represents a difficult clinical problem. Despite many publications on rehabilitation methods, there exists no consensus as to which method is superior. This study was undertaken to determine which flexor tendon rehabilitation protocol provides the best outcome after surgical repair in zone II. METHODS: Electronic databases were searched for articles published between 1970 and 2009. The population included patients aged 5 years and older who sustained a flexor tendon laceration in zone II. The primary outcome was rupture rate. Secondary outcomes were range of motion and quality of life. The following protocols and their variations were considered: passive flexion and active extension protocols (Kleinert type protocols), controlled passive motion protocols (Duran type protocols), combination of the Kleinert and Duran protocols, and early active motion protocols. RESULTS: Seventy-nine articles were identified. Fifteen studies met the inclusion criteria. The mean rate of rupture was lowest in the combined Kleinert and Duran protocols (2.3 percent) and highest in the Kleinert protocols (7.1 percent). No statistically significant differences were found. The combined Kleinert and Duran protocols and the early active motion protocols exhibited the highest proportion of digits with excellent or good results using the Strickland and Buck-Gramcko systems. One study included a quality-of-life assessment-meaningful comparison was not possible. CONCLUSIONS: Both early active motion protocols and combined Kleinert and Duran protocols result in low rates of tendon rupture and acceptable range of motion following flexor tendon repair in zone II. Future studies should include quality-of-life measurements using validated scales.