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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 35  |  Issue : 2  |  Page : 72-75

A prospective comparative study of pull-out suture technique versus modified Kessler technique in flexor tendon repair for Zone I and distal Zone II injuries


Department of Plastic and Reconstructive Surgery, Regional Institute of Medical Sciences, Imphal, Manipur, India

Date of Submission20-Aug-2021
Date of Acceptance21-Aug-2021
Date of Web Publication27-Nov-2021

Correspondence Address:
Akoijam Ibohal Singh
Department of Plastic and Reconstructive Surgery, Regional Institute of Medical Sciences, Imphal West - 795 004, Manipur
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jms.jms_109_21

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  Abstract 


Background: Injuries to the hand are common, and poor functional outcomes can have significant long-term consequences affecting both work and social activities. Good outcomes following flexor tendon lacerations in hand are dependent on a sound surgical repair allowing early active mobilization.
Aims and Objectives: The purpose of the study was to compare the clinical and functional outcomes of Zone I and distal Zone II flexor tendon repair using pull-out suture technique with two-strand modified Kessler method.
Materials and Methods: This hospital-based prospective study was conducted in a tertiary hospital setup in Manipur for 2 years' duration from November 2018 to November 2020. The study was conducted on 26 patients with a total of 30 injured digits, which were then divided into two equal groups of cases and control. Group A included study cases and were treated with pull-out suture technique. Group B included 15 control cases and were treated with modified Kessler technique. Comparison was done between the two different techniques based on patient variables and outcome measured with total active motion (TAM) evaluation system of the American Society for Surgery of Hands.
Statistical Analysis: Data collected were entered into the SPSS version 16. Descriptive analysis of baseline characteristics of both study and control groups was done. The final analysis was done using the Chi-square test and SPSS version 16. P < 0.05 was taken as significant.
Results: In our comparative study, at the 3-month follow-up range of motion was measured and TAM was calculated. Among case group, 2 (13%) belonged to good and 13 (87%) belonged to fair category, whereas among control group, 2 (13%) belonged to good and 1 poor category, and 12 (80%) belonged to fair category. About 50%–75% of functional recovery by 3 months was obtained in 80% of the cases and 73% of the control group.
Conclusion: The pull-out suture technique is a good option for the management of Zone I and distal Zone II flexor tendon injuries.

Keywords: Flexor tendon injury, pull-out suture technique, Zone I and Zone II injury


How to cite this article:
Pebam MS, Singh AI, Das S, Singh LO, Sinam N, Singh SN. A prospective comparative study of pull-out suture technique versus modified Kessler technique in flexor tendon repair for Zone I and distal Zone II injuries. J Med Soc 2021;35:72-5

How to cite this URL:
Pebam MS, Singh AI, Das S, Singh LO, Sinam N, Singh SN. A prospective comparative study of pull-out suture technique versus modified Kessler technique in flexor tendon repair for Zone I and distal Zone II injuries. J Med Soc [serial online] 2021 [cited 2022 Aug 15];35:72-5. Available from: https://www.jmedsoc.org/text.asp?2021/35/2/72/331337




  Introduction Top


The reconstruction of the continuity of flexor tendons disruptions in Zone I and II still remains one of the most challenging problems in hand surgery. The ideal repair has to provide sufficient strength and the possibility of early mobilization in the attempt to obtain a functional range of motion.[1] Verdan described five flexor tendon zones in hand based on anatomic factors influencing the prognosis of repairs. Zone I lies distal to the insertion of the flexor digitorum superficialis (FDS) and contains only the profundus. Zone II begins at the proximal portion of the flexor tendon sheath A1 pulley and extends to the FDS insertion; it corresponds to Bunnell's “no man's land.” It is often called so to indicate the frequent occurrence of restrictive adhesion bands around lacerations in this area.[2]

Tendon can get injured either by lacerations such as those from knives or glass, from crush injuries, and occasionally, they can rupture from where they are joined to the bone. They heal by intrinsic or extrinsic mechanisms.[3] Reconstructing the continuity of finger flexor tendons in Zone II still remains one of the most challenging problems in hand surgery. Considerations such as: Complex local anatomy, demanding technique, demanding skilled and attentive postoperative rehabilitation, and compliance of the patient all play a part in outcome.[4]

In tendon surgery, many repair methods have been developed so as to cope with cohesiveness, gap formation, and rupture in the repair field. Moreover at present, the modified Kessler suture technique, because of its ease and reliability remains the most widely used technique. Many researchers such as Bunnell, Mantero, and Brunell have demonstrated a pull-out suture repair technique for distal flexor tendon injury. The pull-out technique, by moving the tension from the level of disruption to the finger pulp over the tendon insertion, allows the rehabilitation program to begin very early postsurgery.[5]

The ideal repair has to provide sufficient strength and the possibility of early mobilization in the attempt to obtain a functional range of motion.[4] Our study was designed to compare the clinical and functional outcomes of Zone I and distal Zone II flexor tendon repair using pull-out suture technique with two-strand modified Kessler method.


  Materials and Methods Top


This hospital-based prospective study was conducted in a tertiary hospital setup in Manipur for 2 years duration from November 2018 to November 2020. The inclusion criteria were (a) sharp and complete flexor digitorum profundus (FDP) lacerations in Zone I and distal Zone II, with or without concomitant FDS lacerations or neurovascular damage, (b) patients presenting within 48 h of injury. Exclusion criteria were (a) cases below 15 years of age and (b) those with bone, joint, and severe soft tissue damage. Twenty-six patients with a total of 30 injured digits were divided into two equal groups of cases and control. Group A included study cases and were treated with pull-out suture technique. Group B included 15 control cases and were treated with modified Kessler technique.

Techniques

Regional anesthesia in the form of axillary block was given in all the patients. Tourniquet applied for hemostasis. Under aseptic condition, preexisting wound extended by zigzag incision or mid-lateral incision. Tendon explored and retracted cut ends retrieved.

The pull-out suture technique-under aseptic condition, prolene 3-0 sutures were passed from the pulp of the injured digit and through the distal cut end of the flexor tendon. The suture exited from the distal cut end of the tendon. The sutures are then passed through the cut end of the proximal part of the tendon. After taking a transverse bite, the suture reexited through the cut end of the proximal part of the tendon. The suture passes through the distal cut end of the tendon and exited in the pulp. A knot was made on the pulp under tension over a button for uniform distribution of tension [Figure 1] and [Figure 2].
Figure 1: Flexortendoninjury

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Figure 2: Pulloutsuturetechnique

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Modified Kessler repair with two-strand polypropylene (4-0) technique performed for the control group. Modified two-strand Kessler core suture with polypropylene (4-0) and a simple running epitendinous stitch with polypropylene (6-0) suture.

A postoperative cast maintained the wrist at 20° flexion and MP joints at 80°–90° of flexion, allowing full IP extension. Early Active mobilization was started after 48 h following Belfast protocol.

Study variables used were age sex, place of residence, occupation of the patient, mode of injury, and total active motion (TAM) evaluation system of the American Society for Surgery of Hands (ASSH).[6] The range of motion was measured using goniometer at 12 weeks. TAM = Total active flexion– total extension deficit (MCP, PIP, and DIP), score % = TAM of the injured finger/TAM of the contralateral finger.

Scoring based on TAM % : (A) Excellent – Normal; (B) Good - >75%; (C) Fair – 50-75%; (D) Poor - < 50%; (E) Worst – Preoperative level.

Ethical issues

Written informed consent was obtained from each patient before recruiting for the study. The problems and the benefits which the patient may face were explained to them thoroughly. Confidentiality was strictly maintained. Ethical approval was obtained from the Institutional Ethics Committee, RIMS, Imphal, at the beginning of the study.

Statistical analysis

Data collected were entered in the SPSS version 16. Descriptive analysis of baseline characteristics of both study and control groups was done. The final analysis was done using the Chi-square test and SPSS version 16 (IBM, Chicago, Illinois, USA). P <0.05 was taken as significant.


  Results Top


The study was conducted on 26 patients with a total of 30 injured digits which were then divided into two equal groups of cases and control. Altogether 26 patients fit the criteria, four patients had multiple injuries and they were included in both case and control groups. On analysis, male patients constituted 20 (77%) of total sample, age group ranged from 17–47 years. The maximum number of patients was in the age group of 15–25 years. Occupation wise 11 were students, seven were laborers, two were housewives, and six were employed in various jobs. Mode of injury included accidental knife injury in eight patients, self-inflicted knife injury in three patients, glass cut injuries in six patients, bamboo stick injury in three patients, and another six patients suffered from crush injuries.

TAM was recorded for both injured and uninjured similar fingers at 12 weeks were used to calculate the ASSH score. For case group, 13 (87%) patients were in fair (50%–75%) and 2 (13%) patients were in good (>75%) category [Table 1]. For the control groups, 12 (80%) patients belonged to fair (505–75%) category, 2 (13%) patients belonged to good (>75%), and 1 (7%) patient belonged to poor (25%–50%) category [Table 2].
Table 1: Scores in case group

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Table 2: Scores in control group

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The finding of the case and control group were plotted together and was found that by the end of 3 months postoperatively both the groups were in fair category. As a whole, the case group produced a better result than the control group [Table 3] and [Figure 3].
Table 3: Scores among case and control group

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Figure 3: Scores among case and control group

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  Discussion Top


Injuries to the hand are common, and poor functional outcomes can have significant long-term consequences affecting both work and social activities. Good outcomes following flexor tendon lacerations in the hand are dependent on a sound surgical repair allowing early active mobilization.

Although various treatment options are available for the treatment of Zone II like the modified Kessler technique, the pull-out suture technique is another good option, it is less time-consuming and because of the use of more stronger suture material tension is well maintained at the tendon cut ends. In Zone I injuries, the pull-out suture technique is a good option as there is less distal tendon cut end on which suture bites can be taken. Intraoperatively, after exploration, retrieval of tendons ends was done and FDP tendons were repaired with “3-0” polypropylene for the pull-out suture technique. McCallister et al.[7] treated 13 patients using a modified pull-out button technique (Group A) and 13 patients had repair using suture anchors placed in the distal phalanx (Group B).) There were no tendon repair failures and no repeat surgeries in either group.

At the end of 3-months follow-up and physiotherapy, range of motion was measured and TAM was calculated, and scoring was done. Among case group, 2 (13%) belonged to good and 13 (87%) belonged to fair category, whereas among control group, 2 (13%) belonged to good and 1 poor category and 12 (80%) belonged to fair category.

Hence, 50%–75% of functional recovery by 3 months was obtained in 80% of the cases and 73% of the control group. Using the Chi-square test, the difference was not statistically significant (P = 0.34) in our study.

Osada et al.[8] repaired flexor tendons in 27 fingers with triple-looped suture with early active motion protocol. A total of 96% showed excellent results. Tang et al.[9] also showed good results in 78%.

In our study, no patient had rupture in immediate or delayed postoperative period for both case and control groups. Although the difference of results is not significant, but the pull-out suture technique gives equally good results. Further study in large numbers with early active motion rehabilitation may come up with better results with this technique.


  Conclusion Top


The reconstruction of the continuity of flexor tendons disruptions in Zone I and II still remains one of the most challenging problems in hand surgery. The pullout suture technique is a good option for the management of Zone I and distal Zone II flexor tendon injuries, resulting in comparable results as the modified Kessler technique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chang P. Repair and grafting of tendon. In: Mathes SJ, Hentz VR, editors. Mathes Plastic Surgery. 2nd ed. Philadelphia, PA: Elsevier; 2006. p. 591-604.  Back to cited text no. 1
    
2.
Zidel P. Tendon healing and flexor tendon surgery. In: Beasly RW, Aston SJ, Bartlett SP, Gurtner GC, Spear SL, editors. Grabb and Smith Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott; 2007. p. 803-9.  Back to cited text no. 2
    
3.
Sikora S, Lai M, Arneja JS. Pediatric flexor tendon injuries: A 10-year outcome analysis. Can J Plast Surg 2013;21:181-5.  Back to cited text no. 3
    
4.
O'Connell SJ, Moore MM, Strickland JW, Frazier GT, Dell PC. Results of zone I and zone II flexor tendon repairs in children. J Hand Surg Am 1994;19:48-52.  Back to cited text no. 4
    
5.
El hassan B, Moran SL, Bravo C, Amadio P. Factors that influence the outcome of zone I and zone II flexor tendon repairs in children. J Hand Surg Am 2006;31:1661-6.  Back to cited text no. 5
    
6.
Adams L, Greene L, Topoozian E. Range of Motion. In: American Society of Hand Therapists (ASHT), editor. Clinical Assessment Recommendations; Chicago: ASHT 1992: p. 55-70.  Back to cited text no. 6
    
7.
McCallister WV, Ambrose HC, Katolik LI, Trumble T. Eomparison of pullout button versus suture anchor for zone I flexor tendon repair. J Hand Surg Am 2006;31:246-51.  Back to cited text no. 7
    
8.
Osada D, Fujita S, Tamai K, Yamaguchi T, Iwamoto A Saotome K. Flexor tendon repair in Zoe II with six strand technique and early active mobilization. J Hand Surg Am 2006;31:987-92.  Back to cited text no. 8
    
9.
Tang JB, Gu YT, Rice K, Chen F, Pan CZ. Evaluation of four methods of flexor tendon repair for postoperative active mobilization. Plast Reconstr Surg 2001;107:742-9.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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