Shai Luria and Christopher H. Allan
DEFINITION
Flexor tendon trauma and repair are commonly complicated by adhesions, limiting the gliding capacity of the tendons.
These injuries have long been highly challenging.
The infamous “no man’s land” or zone II injuries were treated in the past only after the acute phase, when the delay in treatment was perceived to minimize the development of adhesions.
Tendon adhesions result in limited excursion of the tendon in its sheath and occur when the tendon surface is violated either through the injury itself or secondary to surgical manipulation. When limited digital function is the consequence, and no further improvement with therapy is seen, surgical treatment should be considered.
The spectrum of treatment of flexor tendon adhesions ranges from nonoperative treatment to different surgical modalities, from tenolysis to a two-stage tendon reconstruction.
The operative decision is based on different factors, such as the quality of the tendon involved and the integrity of the surrounding sheath. Some of these factors can be evaluated only during the operation.
All treatment options should be discussed preoperatively and the surgeon should be prepared to make the final decision based on operative findings.
Tenolysis consists of surgical release of tendon adhesions to restore tendon gliding and digital motion. This can be a very satisfying procedure in selected cases, particularly when adhesions are localized to just a portion of the sheath.
Proper patient selection is crucial and several questions must be asked: Will the patient cooperate with extensive hand therapy? Is the functional improvement after this complex and time-intensive process likely to be better and more rapid than with fusion of an interphalangeal (IP) joint or even with amputation of the digit?
ANATOMY
Refer to Chapter HA-54.
PATHOGENESIS
Injury (or repair) of the tendon and its synovial sheath is the basis for the development of adhesions.
The initial mode of inflammatory reaction is similar to that after any tissue injury. Initiation of adhesion formation begins with deposition of a fibrin matrix that typically occurs during the coagulation process.
This matrix is gradually replaced by vascular granulation tissue containing macrophages, fibroblasts, and giant cells.
The clots are slow to achieve complete organization. In this process, they consist of erythrocytes separated by masses of fibrin that are covered with layers of flattened cells and contain a patchy infiltrate of mononuclear cells.
The adhesion matures into a fibrous band, often containing small nodules of calcification.
Mature adhesions are often covered by mesothelium, are vascularized, and contain other connective tissue fibers, such as elastin.12
The extracellular matrix, which is composed of collagen, proteoglycans, fibronectin, and elastin, plays a central role in the management of tendon healing as well as the development of adhesions. Degradation products in the matrix are chemotactic for fibroblasts, leukocytes, and endothelial cells.12
During the first few days after trauma, T cells and macrophages accumulate in the location of injury and stimulate the synovial cells to produce fibronectin. Collagen types 1 and 3 accumulate between tenocytes and around the tendon by 1 week after trauma. Adhesions between the tendon and its sheath can be seen by this time as a thickening of the epitenon to five to seven cell layers. Fibronectin is present as well and serves as scaffolding for the developing scar.12
The process described occurs to a lesser extent in the proximal zones of the flexor tendons. Zone II tendon injuries occur in the milieu of two tendons gliding in a constrictive fibroosseous tunnel. In other zones, this potential for development of adhesions exists to a much lesser extent.
Three types of adhesions have been described:
Loose adhesions arising from subcutaneous tissue and allowing some glide of the tendons
Moderately dense adhesions from the synovial sheath or pulleys that are remarkably restrictive of tendon motion
Dense adhesions arising from the bony floor or volar plate, penetrating the dorsal aspect of the tendon
Both dense and moderately dense adhesions prevent tendon motion and jeopardize healing.23
The role of different cytokines has been evaluated in the pathogenesis of adhesions in general and tendon adhesions in specific.16,26
Transforming growth factor-beta (TGF-β) has been shown to be a prominent regulator of tendon healing, although its precise role is still unclear and under extensive research.27 In the laboratory, these factors have been shown to be regulated by physical factors such as shear stress7 as well as by specific neutralizing antibodies32 or chemical modulators such as 5-fluorouracil.18
NATURAL HISTORY
Symptomatic adhesions result in substantial morbidity such as decreased range of motion, joint contracture, decreased strength, and substantial decrease in hand and upper extremity function. Adhesions occur with every tendon injury and depend on the extent of injury, the mobilization of digits after the injury, and the treatment applied. They are especially severe and symptomatic in injuries in zone II. Before the widespread use of early and intensive mobilization protocols after injury and repair, limited success was achieved and tenolysis was frequently required.
Strickland and Glogovac21 reported in 1980 on the advantage of early mobilization of zone II flexor tendon injuries. In their report, by 160 days after repair, 10 of 25 patients achieved less than 70% of the expected range of motion of the proximal and distal IP joints. Although there are limited reports regarding the natural history of these injuries when untreated, this report gives us a sense of the typical outcome of flexor tendon repair in the era before early motion protocols.
Tenolysis is by far the most common secondary procedure performed after digit replantation, according to a recent metaanalysis.29 Although stiffness of a replanted finger is a result of multiple causes, the adhesion of tendons is a leading cause of this problem.
Tang3 estimates that 10% of repaired flexor tendons will need surgical treatment of adhesions. Moderately dense adhesions of the synovial sheath or pulley and dense adhesions of the bone to tendon are difficult to alter once they have formed. These adhesions should be treated surgically.
Proximal to zone II, the limitation in range of motion and need for flexor tenolysis are less common, even in the setting of a severe injury.30
PATIENT HISTORY AND PHYSICAL FINDINGS
Evaluate both passive and active range of motion.
Note the skin integrity and the location and condition of scars and previous surgical incisions.
Look for other deforming conditions, such as malaligned fractures.
The examiner should search for other factors limiting range of motion, such as intra-articular pathology, scar contracture of the skin, extensor tendon contracture or adhesions, interosseous muscle contractures, or capsular and collateral ligament contractures.
The neurovascular status of the digit is documented.
The continuity of both flexor tendons in all digits is evaluated:
Continuity of the flexor digitorum superficialis (FDS)tendon
Active flexion of the proximal interphalangeal (PIP) joint is evaluated for each digit separately. The adjacent digits are held in full extension by the examiner at the metacarpophalangeal (MP), PIP, and distal interphalangeal (DIP) joints to assess for intact fibers of the FDS inserting into the middle phalanx. This does not exclude a partial tear of the tendon.
Continuity of the flexor digitorum profundus (FDP) tendon
Active flexion of the DIP while the examiner grasps the middle phalanx to assess for intact fibers of the FDP inserting into the distal phalanx. This does not exclude a partial tear of the tendon.
Range of motion (ROM): If passive ROM exceeds active, the pathology is at least partly musculotendinous (tendon adherent, incompetent, or both).
The “seesaw effect”: The examiner should passively extend and flex the DIP, PIP, and MP joints. Extend one joint followed by the other to assess for the seesaw effect. Nonarticular contracture is revealed when one joint is flexed, the other can be extended, and vice versa.
The Bunnell intrinsic tightness test is performed to evaluate flexion of the PIP joint with the MP joint extended and then flexed. With intrinsic tightness, there is less passive flexion of the PIP joint when the MP joint is held extended than when the MP joint is flexed (therefore, the surgeon may need to release the intrinsics as part of treatment).
Evaluate for lumbrical contracture: An intrinsic tightness test is performed with the fingers radially or ulnarly deviated. With lumbrical contracture, there is less passive flexion of the PIP joint with the finger deviated or with the DIP joint flexed in comparison to intrinsic testing. If present, this suggests lumbrical muscle contracture as part of the pathology.
Alternatively, the test is performed with the DIP joint flexed as well as the PIP joint.
Evaluate for extensor contractures: The examiner flexes the wrist and MP joints and examines flexion of the PIP and DIP joints. With extensor contractures there will be limited flexion of the digit IP joints with flexed wrist and MP joints.
Evaluate for flexor contractures: The examiner extends the wrist and MP joints and examines extension of the IP joints. With flexor contracture, there will be limited extension of the digit IP joints with extension of the wrist and MP joints.
The Landsmeer test is performed for evaluation of contracture of the oblique retinacular ligament (extending from the volar aspect of the PIP joint to the dorsal aspect of the DIP joint). In a positive test, passive extension of the PIP joint will result in extension of the DIP joint as well. Continued shortening of the ligament will result in a boutonnière deformity.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Radiographs of the hand are taken to evaluate for bony and articular pathology as well as the presence and location of implants. Skeletal deformity secondary to avulsion injuries may be seen.
CT scans may be helpful in selected cases for bony and articular pathology.
Magnetic resonance imaging (MRI) or ultrasound may be useful in identifying tendon or capsular injury as well as aiding in the differential diagnosis of severe tendon adhesions versus rupture.
DIFFERENTIAL DIAGNOSIS
Intrinsic muscle contracture
Capsular or collateral ligament contractures
Malalignment of fracture
Extensor tendon adhesions
Rheumatoid arthritis
Dupuytren’s disease
Neurologic causes
Burns
Congenital anomalies
Complex regional pain syndrome
NONOPERATIVE MANAGEMENT
ROM exercises as well as pain management play a role in several clinical situations:
During the period after repair of the injury
When the functional results are satisfactory to the patient and meet his or her needs
Delayed healing of soft tissue or bony injury
Limited passive range of motion
When the patient is uncooperative with perioperative care and therapy
The therapy should include full active as well as resistive exercises designed at maximizing the active ROM achieved, before surgical treatment.
SURGICAL MANAGEMENT
Tenolysis of the flexor tendon requires intact tendons and pulleys in order to succeed. Patients for whom tenolysis is appropriate have reached a plateau in function despite appropriate therapy, and have significantly greater passive than active range of motion.
Prerequisites for tenolysis also include healing of all fractures and wounds with soft, pliable skin and minimal inflammatory reaction around scars.
The timing of tenolysis is the subject of debate. Recommendations range from 3 to 9 months after the tendon repair or grafting. Strickland20 recommends waiting at least 3 months after repair, with 4 to 8 weeks without measurable improvement in active motion with intensive therapy.
Concomitant procedures should be considered carefully and limited to those procedures that will not affect postoperative therapy.
Capsulotomies of the PIP or DIP are often necessary in these cases and may be performed,20 although some authors warn of inferior results with this addition.24
Pulley reconstruction with tenolysis should be avoided if possible, although successful combined procedures have been described.8
Procedures requiring immobilization should not be performed concomitantly with the tenolysis. Examples include tendon lengthening or shortening, free skin grafts, or osteotomies.8,28
Local anesthetic supplemented by intravenous analgesia and tranquilizing drugs was popularized by Schneider.19 This allows the surgeon to evaluate the extent of adhesiolysis achieved by having the patient actively flexing the digit during surgery. The patient can also see the results, motivating him or her to achieve a similar range of motion postoperatively.
Anesthetic options include local infiltration into the palm and a wrist block.
The use of local anesthesia is limited by the use of a tourniquet, which causes paralysis of the muscles after 30 minutes and may be difficult for the patient to tolerate past that time. To deal with these problems, a sterile forearm tourniquet may be elevated 30 minutes into the procedure, releasing the arm tourniquet.
Regional and general anesthesia are additional techniques suitable for a tenolysis procedure. General anesthesia is necessary in cases of questionable patient cooperation, tolerance to pain or other contraindication to local or regional anesthesia, or where time to completion of tenolysis (and any associated procedures) is expected to exceed the likely duration of a local or regional block.
Foucher et al8 report that they have abandoned local anesthesia or “selective sensory blocks” except in late tenolysis where they have doubts about the performance of the muscle. Instead, they use a separate incision in the palm or forearm to test flexion at the end of the procedure.
Preoperative Planning
Surgical supplies including implants necessary to perform a staged tendon reconstruction should be available.
Positioning
The patient is positioned supine with the upper extremity on a hand table. A lead hand splint is recommended.
Approach
Wide exposure of the flexor tendon is necessary. This may be accomplished either by a zigzag (Brunner-type) incision or by a midlateral incision (FIG 1).1
The Brunner zigzag incision provides the best exposure of the tendon and pulley system.
A midlateral exposure will protect the neurovascular structures dorsally and will cause less scar directly over the tendon. It may also cause less wound tension during early therapy.
FIG 1 • Either a zigzag (Brunner-type) incision or a midlateral incision can be used to expose the tendons. The incisions are designed taking into account the previous scars. In this case, the ring finger palmar scars (marked with a dotted line) were extended (solid line) to a Brunner-type exposure. In the small finger, the scars (dotted lines) were midlateral and the exposure was planned in that fashion. (Courtesy of Dr. T.E. Trumble.)
TECHNIQUES
FLEXOR TENOLYSIS
Expose the flexor tendons starting from the unaffected region and proceeding to the involved areas (TECH FIG 1A).
Define the borders of the tendons (TECH FIG 1B).
Raise both flexor tendons as one, carefully lysing the adhesions around them.
This may be performed using a scalpel, tenotomy scissors, or a Freer elevator (TECH FIG 1C).
Retraction and manipulation of the elevated tendons should be accomplished in as atraumatic a fashion as possible using a Penrose drain or blunt instrument.
If possible, separate FDS from FDP tendons.
The FDS tendon may need to be sacrificed if the scarring is extremely severe19 in order to achieve adhesiolysis under the pulleys and smooth gliding of the tendon.
Resection of a slip of FDS has been shown to improve FDP gliding after repair in zone II injuries.33
In some cases it may be preferable not to separate severely adhesed tendons, allowing them to act as one, where a single combined tendon is mobilized to its insertion.
TECH FIG 1 • A. The tendons are first exposed in an unaffected area, proximal and distal to the scar. B. The borders of the adhesed tendons are defined from the sheath and from each other. C. A Freer elevator, as well as a scalpel or tenotomy scissors, may be used to lyse the adhesions surrounding the tendons. (Courtesy of Dr. T.E. Trumble.)
ADHESIOLYSIS
Adhesiolysis may be facilitated using these instruments and techniques:
A modified 69 Beaver blade (McDonough and Stern 45-degree Beaver blade) with an angle of 45 degrees (TECH FIG 2A).
Schreiber knee arthroscopy blades.
Braided suture (0 Mersilene, 2-0 Prolene) or dental wire may be inserted between the tendon and phalanx2 and used as a Gigli saw to separate the tendon from bone by pulling on the suture ends back and forth along the tendon (TECH FIG 2B).
This technique may be advantageous when separating adhesed FDP and FDS tendons or when performing tenolysis under a pulley or preserved sheath.
Alternatives to collect and pass the suture include use of a blunt elevator with a hole at its distal tip, which may be inserted under the pulley from a proximal to distal direction,6 and a wire loop or a needle inserted backward in the gutter between the phalanx, the tendon, and the sheath.2
Meals developed a set of instruments specifically designed for tenolysis (George Tiemann & Co, Hauppauge, NY).
The necks of these tenolysis knives follow the natural curvature of the finger and have semisharp blades that conform to the circumference of the tendon sheath with either a convex or a concave edge1(TECH FIG 2C).
Débride the tendons free of previous suture material or frayed edges.
TECH FIG 2 • A. A modified 69 Beaver blade with an angle of 45 degrees is at a comfortable angle to perform the adhesiolysis of the tendons. B. A suture or a dental wire may be inserted between the tendons or between the tendons and phalanx or sheath and pulled under the pulleys (as a Gigli saw) to lyse the adhesions while preserving the pulleys. C. Flexor tenolysis with a Meals tenolysis knife. (A: Courtesy of Dr. T.E. Trumble.)
ADDRESSING THE PULLEY SYSTEM
Preserve as much of the pulley system as possible. It is crucial to preserve the A2 and A4 pulleys to prevent bowstringing and loss of tip-to-palm contact in full flexion. This may be performed by creating transverse windows along the course of the tendon. Some resection of the pulleys is possible (TECH FIG 3).
In case sacrifice of part of these pulleys is crucial to achieve better tendon excursion or to facilitate the release of adhesions, about half of a pulley can be incised.17
Widening of the pulleys may be performed with small pediatric urethral dilators or cardiac coronary artery dilators.
TECH FIG 3 • Exposing the tendons while preserving the pulleys is performed by creating transverse windows along the course of the tendon. (Courtesy of Dr. T.E. Trumble.)
EVALUTION OF ADEQUACY OF RELEASE
Adequacy of release must be evaluated and may be assessed using several techniques.
If the patient is awake, he or she can actively flex the digit. Otherwise a traction flexion check should be performed for each of the flexor tendons separately.
Through the palmar extension of the exposure, pull on the tendon with a blunt tendon hook or retractor (TECH FIG 4A).
If the expected excursion cannot be tested through the palmar incision, proximal exposure of the tendon may be necessary through a separate incision proximal to the wrist (TECH FIG 4B).
An Allis clamp may be placed around the tendon and pulled gently to examine the tendon’s excursion.
TECH FIG 4 • A. A traction flexion check may be performed through the palmar extension of the exposure, pulling on each tendon with a blunt hooked instrument. B. If the expected excursion cannot be tested through the palmar incision, proximal exposure of the tendon may be necessary, through a separate incision proximal to the wrist. (A: Courtesy of Dr. T.E. Trumble.)
CLOSURE
The tourniquet is deflated before closure to ensure adequate hemostasis. If needed, a Penrose drain is placed and removed the next day.
Hematoma formation will lead to scarring and have a negative impact on the final result.
The skin is closed using nonabsorbable suture and a soft, mildly compressive dressing is applied that allows for early range of motion.
POSTOPERATIVE CARE
Hand therapy is initiated the day of surgery in the postanesthesia care unit if an isolated tenolysis is performed without pulley reconstruction.
A detailed referral note or discussion with the therapist is necessary to plan the rehabilitation program for each patient. Patient history, type of injury, surgical intervention and intraoperative findings, motivation, and pain tolerance should be discussed. The condition of the tendon and pulley system and the vascularity of the digit may alter the course of therapy and should be reported.
It is crucial that the patient be motivated and understand the therapy protocol, the need for frequent meetings with the therapist, and the daily exercises to be performed independently.
Adequate pain control is ensured.
Local blocks may be used in selected cases to allow early mobilization.15
Transcutaneous nerve stimulators are recommended by some for postoperative pain reduction in combination with oral medication.
Wound care education should be part of the first therapy meetings.
Edema control is frequently necessary. The patient should be instructed to elevate the hand during the first days after surgery as well as to perform hourly fist pumps with the hand elevated. Gentle compression with a glove, Coban wrap, or elastic bandages should be considered.
Early mobilization of the tendon is crucial to the success of the procedure, although the quality of the tendon should be taken into account. A weak tendon should limit the therapy to a limited exercise protocol, although this may be an indication in itself for staged reconstruction or grafting rather than simple tenolysis.
FIG 2 • In “place and hold” exercises, the digits are passively flexed (A) and then actively held in place by the patient (B).
Various protocols have been described8,10,25 that balance the maintenance of active flexion ROM achieved in the operating room, maintaining the mobility of the joints as well as the full ROM of active extension. The common protocols achieve a small differential gliding of the FDS versus the FDP tendon.11
Blocking and strengthening exercises should be added at a later date. This may depend on the quality of the lysed tendon, although usually after 4 to 6 weeks these exercises are considered not to endanger the tendons’ continuity.8,20
Trumble and Sailer25 begin light resistive exercises at 6 weeks and add progressively more resistance after 8 weeks.
Continuous passive motion (CPM) is under investigation. There have been reports of increased risk of tendon rupture and force required for passive ROM.1 CPM should not be used in place of active ROM exercises. However, it may be of value if passive ROM is limited or the patient is apprehensive about moving actively. It may also minimize edema and scar formation.25
A protective resting wrist-based splint may be necessary in cases with a thin or damaged tendon. A closely supervised therapy program is important in these cases. Static–progressive or dynamic splints may be needed to treat patients with joint stiffness or contractures.
A fabricated pulley ring may be used during active motion exercises if the pulleys are tenuous.25
In patients with a weak tendon, therapy should begin with “place and hold” exercises (FIG 2). In these exercises, the digit is passively flexed and then actively held in place by the patient.
This minimizes the tensile forces on the weak tendon while passing it through its maximal excursion. Further protection may be added when the exercises are performed with the wrist or MP joints flexed. This program should be carried out for 4 to 6 weeks. Active ROM exercises may be added later on.
Hourly exercises by the patient should be part of any protocol.
OUTCOMES
Good outcomes after flexor tenolysis have been reported, but outcome measures have varied across reports (Table 1). Significant complications have been reported in all series, including a significant number of patients with either no improvement or with postoperative worsening. Less information is available but poorer results have been reported after tenolysis in children (under 11) and for the thumb.
Strickland20 reported that 64% of tenolysed digits after zone II injury had at least 50% improvement in active ROM. Twenty percent of the patients had no improvement and 8% had rupture of the tendon.
Jupiter et al13 used the Strickland formula (Table 1) for the evaluation of 37 replanted digits and 4 replanted thumbs treated with flexor tenolysis. They reported good to excellent results with 24 of the 37 digits. Only poor or fair results were found after thumb flexor tenolysis.
Several factors negatively influenced the final results: classification of injury, inferior results of tenolysis with avulsion or crush injuries, number of amputated digits, capsulotomy, level of injury (inferior results with zone II injuries), digit injured (inferior results with thumb procedures), and multiple tenolysed digits.
The authors recommend tenolysis of digit flexors when indicated, but not of the thumb flexor.
Foucher et al8 reported their results after the treatment of 78 digits, 9 of which were thumbs, and excluding replanted digits. They implemented both their technique of pulley reconstruction and of therapy. The therapy included the use of percutaneous catheters for additional pain control for 3 weeks and passive extension exercises beginning 2 days following the tenolysis surgery. A splint providing some flexion (of MP and IP joints) was removed hourly for exercise. The result after a mean period of 21.5 months was graded both by total active motion (TAM) measurement and the Swanson method for functional evaluation (Table 1). Of the 78 digits, 3% were unimproved and 13% were made worse by the tenolysis. For the remainder of the cases, the TAM improved from 135 degrees to 203 degrees. Using Swanson’s assessment the functional deficit improved from 41% to 20%. The thumbs achieved less success, with two cases unimproved, while the rest resulted in an improvement of 65 degrees to 115 degrees, or a decrease in deficit from 12% to 2% according to Swanson. The authors did not separate the results according to the zone of injury and did not report the results for the entire group of patients.
Eggli et al6 evaluated the change in ROM of each joint of the digit in 8 digits treated with flexor tenolysis out of a group of 32 digits with varying zone II injuries requiring tenolysis. They found a decrease of 5 degrees of MP active ROM and an increase of 25 and 35 degrees of PIP and DIP active ROM, respectively. TAM improved by 55 degrees. They found an additional improvement in TAM when the tenolysis was combined with PIP capsulolysis. The authors compared the results of flexor tenolysis with patients treated with flexor and extensor tenolysis in the same digit and found better total active motion (63-degree improvement) and better extension with the second group. The five patients with palmar injury alone achieved 80% good to excellent results according to the Buck-Gramcko scoring system, while only 55% good to excellent results were seen in digits tenolysed after replantation.
Reports of tenolysis in children are rare. Birnie and Idler4 compared treatment of children under and over the age of 11 after repair of zone II and III flexor tendon injuries. They concluded, by using Strickland’s method (Table 1) that under age 11, tenolysis was of no significant benefit. Of the 21 digits of children between the ages of 11 and 16, 13 had good to excellent results, 5 were graded poor, and 2 suffered rupture of the tendon. Of the eight digits of children ages 10 and under, two had fair results and six had poor results. They explained that under the age of 11, the cooperation of the patient necessary for the success of the procedure cannot be expected. Early therapy was more difficult in this group, resulting in inferior results. Within a group of 12 children after flexor tendon repair, Kato et al14 described one successful tenolysis after zone II injury in a child age 3 years 10 months. They reported that the tenolysis was performed 9 months after the initial injury and repair and that the result of the tenolysis was excellent.
COMPLICATIONS
Rupture of the flexor tendon may be the result of poorquality tendon or aggressive therapy as well as patient noncompliance. It may be prevented by limiting tenolysis only to tendons of good quality. Eggli et al6 reported rupture in 3 of 16 flexor tendons tenolysed that were treated successfully with two-stage reconstruction. Jupiter et al13 reported 2 ruptured tendons of 37 replanted digits, both in zone II injuries. Others have claimed this to be a rare yet disastrous complication.1
Rupture of a pulley, more significantly A2 or A4 pulleys, may result from narrowing or fraying of the pulleys as part of the trauma or further compromise with surgical intervention.
Multiple surgical treatments of the digits involved in various trauma mechanisms may result in significant scarring, decreased vascularity, delayed wound healing, and infection, further compromising the functional results. Adherence to careful surgical technique, including atraumatic handling of tissue, is crucial to minimize these complications.1,19
Foucher et al8 reported eight complications in 72 patients (78 digits): two with delayed healing, two with flexor tendon exposure, two with rupture, and two diagnosed using bone scan to have a localized form of reflex sympathetic dystrophy.
Prevention of Recurrence
Bathing the tendon in a steroid solution to prevent recurrence of adhesions has been suggested but has only anecdotal evidence of efficacy. Others have reported that corticosteroids may be associated with smaller, weaker tendons, diminished wound healing, and decreased resistance to infection.16
Biologic and artificial membranes have been used to wrap the repair site and mechanically isolate the tendon. Cellophane, polyethylene film, silicone, paratenon, amniotic membrane, gelatin sponge, and hyaluronic acid derivatives have been studied with mixed results and limited clinical support. Promising results were achieved with ADCON-T/N (Gliatech, Cleveland, OH), a bioresorbable gel of gelatin and carbohydrate polymer that acts as a physical barrier.9 A disappointing prospective double-blind, randomized, controlled clinical trial assessing flexor tendon repair in zone II found no statistically significant effect on TAM. The patients treated with ADCON-T/N did achieve their final range of motion significantly earlier than the control group. The authors also reported a higher rate (although not statistically significant) of tendon rupture with the ADCON-T/N.
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