Original Article the Therapeutic Effects of the Minimally Invasive Repair of Hand Flexor Tendon Injuries

Int J Clin Exp Med 2019;12(12):13706-13711 www.ijcem.com /ISSN:1940-5901/IJCEM0101060

Original Article The therapeutic effects of the minimally invasive repair of hand flexor tendon injuries

Jiqiang Cheng1, Yejin Feng2, Bin Liu1, Guiqing Gong1, Haiyong Yu3

1Third Department of Orthopaedics, 2Fourth Department of Orthopaedics, Ji’nan Zhangqiu District Hospital of Traditional Chinese Medicine, Ji’nan, Shandong Province, China; 3Department of Orthopedics, Wendeng Orthopaedic and Traumatologic Hospital of Shandong Province, Weihai, Shandong Province, China Received August 16 2019; Accepted October 10, 2019; Epub December 15, 2019; Published December 30, 2019

Abstract: Objective: To compare the therapeutic effects of the minimally invasive repair and conventional therapy of hand flexor tendon injuries. Methods: This study recruited 98 patients with flexor tendon injuries of the hand who were randomly divided into a control group (49 patients who received traditional surgery) and an experimental group (49 patients who were treated with minimally invasive repair). The excellent and good treatment rates, the complication rate, the visual simulation self-assessment scale (VAS) score, the patient satisfaction rate, and the short form 36 questionnaire (SF-36) scale were compared between the two groups. Results: The excellent and good treatment rates, the patient satisfaction rate, and the SF-36 scale in the experimental group were significantly higher than they were in the control group (all P<0.05). Meanwhile, the complication rate and the VAS score in the experimental group were significantly decreased compared with the control group (all P<0.05). Conclusion: For patients with flexor tendon injury, a minimally invasive repair can effectively improve hand function, reduce the incidence of complications, and raise the quality of life. A surgery with a high patient satisfaction rate, minimally invasive repair is worth promoting.

Keywords: Hand flexor tendon injury, minimally invasive repair, excellent and good treatment rates, complications

Introduction ficial tendons need to be preserved during surgery [6, 7]. The hand is the most flexible organ of the human body. The tendon of the hand plays an With the development of minimally invasive sur- important role in maintaining the normal func- gery, the advantages of the minimally invasive tions of the fingers, including free movement, repair of the tendon gradually become appar- stretching, flexion, etc. Damage of the tendon ent, including less trauma and a quick recovery. of the hand can seriously impact patients’ work This surgery, which is highly recognized and and lives [1, 2]. It is reported that hand trauma endorsed by physicians, preserves the integrity accounts for 30% of injuries commonly seen in of tendon sheath and trochlea to the greatest clinical practice [3]. The repair capacity of tradi- extent, reducing damage to the synovial mem- tional surgery is limited. The tendon consists of brane [8]. Here, a retrospective analysis of clini- the deep and superficial tendons. Traditional cal data was performed for 98 patients diag- surgery excises the superficial tendon, but not nosed with hand flexor tendon injury at the the deep tendon. The deep tendon only needs Wendeng Orthopaedic and Traumatologic Hos- to be sutured. The blood supply of the deep ten- pital of Shandong Province from February 2017 don is closely related to the superficial tendon. to February 2019. Therefore, the traditional surgical removal of the superficial tendon influences the blood sup- Materials and methods ply of the deep tendon, resulting in an insuffi- cient blood supply and an unsatisfied therapeu- General information tic effect [4, 5]. In order to improve the hand functions of patients with flexor tendon injuries This study was approved by the Ethics Com- as much as possible, both the deep and super- mittee of Wendeng Orthopaedic and Trauma- Therapeutic effect of minimally invasive repair of hand flexor tendon injury

blood system diseases and surgical contraindi- cations; patients who had serious psychologi- cal, cognitive, or mental disorders; patients with malignant tumors; patients with heart and respiratory failure.

Methods

The control group (the patients who received traditional surgery): After admission, the patients received wound treatments, such as disinfection, cleansing, and hemostasis in a timely Figure 1. Impaired parts of blood vessels were anas- fashion. The incision location was selected ac- tomosed by microsurgical instruments. cording to the actual condition of patient’s injury. After successful anesthesia, the injury sites of the deep and superficial tendons were sutured (Figure 1).

The experimental group (the patients who were treated with minimally invasive repair): After enrollment, the patients received wound treatments, such as disinfection, cleansing, and hemostasis in a timely fashion. The location and extent of the injury were defined before the surgery. The impaired parts of the blood vessels were anastomosed using a microsurgical instrument. Flexion and straight are the main types of tendon injury. For patients with a Figure 2. The tendon and damaged extima were sutured using the Kessler method. straight type injury: The proximal end of the tendon rupture was pulled along the tendon sheath, and the fracture site was then fixed; the tologic Hospital of Shandong Province and tendon and damaged extima were sutured recruited 98 patients diagnosed with hand flex- using the Kessler method. For patients with a or tendon injury in Wendeng Orthopaedic and flexion type injury: An incision was made at a Traumatologic Hospital of Shandong Province distance of 0.5 cm from the fracture site; the from February 2017 to February 2019. These length of the incision was 2-3 cm; the whole patients were randomly divided into a control procedure included cutting the sheath, sutur- group (49 patients who received traditional sur- ing, pulling, fixing the proximal fracture site, gery) and an experimental group (49 patients loosening the tourniquet, and fixing with plaster who were treated with minimally invasive re- (Figure 2) [5, 6]. pair). Outcome measures and evaluation criteria Inclusion criteria: Patients who consented to traditional surgery or minimally invasive repair; The excellent and good treatment rates, the patients who were diagnosed with hand flexor complication rate, the VAS score, the patient tendon injury by MRI and CT; patients who could satisfaction rate, and the SF-36 scale were communicate normally; patients and their fami- compared between the two groups. lies who were aware of this study and signed the informed consent form. The criteria for excellent and good treatment rate included: The total active motion (TAM) Exclusion criteria: Women who were lactating close to the healthy side was judged as excel- or pregnant; patients who received relevant tr- lent; the TAM close to 75% of the healthy side eatment prior to enrollment; patients with im- was judged as good; the TAM close to 50% of paired kidney and liver function; patients with the healthy side was judged as fine; the TAM

13707 Int J Clin Exp Med 2019;12(12):13706-13711 Therapeutic effect of minimally invasive repair of hand flexor tendon injury

Table 1. Comparison of the basic data P value was less than Experimental Control group 0.05. Group χ2 value P value group (n=49) (n=49) Results Gender (n) 0.167 0.683 Male 29 27 Basic data Female 20 22 Mean age (years) 48.62±5.44 48.71±5.41 0.082 0.935 As shown in Table 1, Mean duration of injury (hours) 6.15±0.68 6.11±0.64 0.299 0.765 there were no significant Type of injury (n) 2.872 0.238 differences concerning gender, mean age, mean Contusion 18 19 duration of injury, or type Electric saw injury 20 29 of injury between the two Cutting injury 11 11 groups (all P>0.05).

Excellent and good treat- close to or less than 50% of the healthy side ment rate was judged as poor. Excellent and good treatment rate = (excellent cases + good cases)/ As displayed in Table 2, the excellent and good total cases in each group * 100.00% [9]. treatment rates in the experimental group were significantly higher than they were in the control Complication rate: The tendon adhesion, joint group (92.92% vs. 73.47%, P<0.05). stiffness, and infection rates were calculated. Complication rate VAS: The total score was 10 points; no pain was 0 points, severe pain was 10 points; the higher The complication rate in the experimental the score, the greater the pain [10]. group was decreased more than it was in the control group (4.08% vs. 20.41%, P<0.05, Table The patient satisfaction rate was evaluated ba- 3). sed on the departmental self-made questionnaire: The total score was 100 points: very sat- VAS score isfied (≥80 points); satisfied (≤79 points and ≥60 points); unsatisfied (≤59 points). Total sat- As illustrated in Table 4 and Figure 3, though isfaction rate = (very satisfied cases + satisfied the VAS scores were significantly decreased in cases)/total cases in each group * 100.00%. both groups after the treatment when compared with the scores before treatment, after Quality of life, including mental health, activity, the treatment, the VAS score in the experimen- general health status, social ability, physical tal group was significantly lower than it was in pain, and physiological and emotional functi- the control group (P<0.05). ons were assessed using the SF-36 scale. The higher the score, the better the quality of life Patient satisfaction rate [11, 12]. As shown in Table 5, the patient satisfaction Statistical methods rate in the experimental group was significantly increased compared with the rate in the control All data were analyzed using SPSS statistical group (93.88% vs. 71.34%, P<0.05). software version 25.0. The measurement data were expressed as the mean ± standard devia- SF-36 scale tion, and a paired t-test was applied for the intergroup comparisons, and an independent Though the SF-36 scale scores were signifi- sample t test was used for comparisons _be- cantly increased in both groups after the treat- tween the two groups and were calculated ( x ± ment when compared with the scores before sd). The enumeration data were calculated as treatment, the SF-36 scale score in the experi- number/percentage (n/%); the comparisons mental group after treatment was significantly were conducted using a chi-squared test. The higher than it was in the control group (P<0.001, difference was statistically significant when the Table 6).

13708 Int J Clin Exp Med 2019;12(12):13706-13711 Therapeutic effect of minimally invasive repair of hand flexor tendon injury

Table 2. Comparison of the excellent and good treatment rates (n, %) Group Excellent Good Fine Poor Excellent and good Experimental group (n=49) 20 (40.82) 27 (55.10) 2 (4.08) 0 (0.00) 47 (95.92) Control group (n=49) 15 (30.61) 21 (42.86) 10 (20.41) 3 (6.12) 36 (73.47) χ2 value 9.525 P value 0.002

Table 3. Comparison of the complication rate (n, %) eration. Flexor tendon inju- Tendon Joint ries of the hand are mainly Group Infection Complication adhesion stiffness caused by contusions, elec- Experimental group (n=49) 1 (2.04) 1 (2.04) 0 (0.00) 2 (4.08) tric saw injuries, and cutting injuries, which can constrain Control group (n=49) 3 (6.12) 3 (6.12) 4 (8.16) 10 (20.41) 2 the patients’ limb functions χ value 6.078 and independent movement, P value 0.014 causing severe adverse effects on both their lives and _ work [13, 14]. Traditional op- Table 4. Comparison of the VAS scores ( x ± sd) en surgery is a great trauma Before After and is prone to causing im- Group treatment treatment t P paired tendon sheaths. After (score) (score) surgery, patients are not able Experimental group (n=49) 5.62±0.65 1.58±0.12 42.785 0.000 to move spontaneously, and Control group (n=49) 5.68±0.61 3.06±0.34 26.262 0.000 face a high probability of ad- t 0.471 28.734 herent tendon. In sum, traditional surgery fails to meet P 0.639 0.000 the clinical needs [15, 16]. Clinical reports have suggest- ed that compared with traditional surgery, minimally invasive repair is safe and effec- tive for patients with flexor tendon injury of the hand, and has clear advantages [17].

Minimally invasive repair has unique and evident advantages compared with traditional surgery [18, 19]. During minimally invasive repair, the tendon sheath and tendon fracture surface are com- pletely exposed. The superfi- Figure 3. Comparison of the VAS score. Compared with the control group, cial and deep fracture sur- ***P<0.001. face is sutured using the Kessler method, which would Discussion not bring significant influence on the blood cir- culation at the back of the tendon, but increas- Flexor tendon injury is a common type of hand es the smoothness of the surface of the tendon injury, accounting for about 30% of hand inju- and strengthens the anti-tension, providing a ries. Most flexor tendon injuries are the open suitable and favorable condition for the healing type. Patients also generally have bone and joi- of the tendon, which ensures a sufficient blood nt injuries, nerve vascular injuries, etc. There- supply to the impaired limb and promotes the fore, it is prone to deteriorate to a closed lac- healing of the endogenous incision of the ten-

13709 Int J Clin Exp Med 2019;12(12):13706-13711 Therapeutic effect of minimally invasive repair of hand flexor tendon injury

Table 5. Comparison of the patient satisfaction rate (n, %) gery, doctors should av- Very Very satisfied oid cutting the tendon Group Satisfied Unsatisfied satisfied and satisfied directly with a clamp as Experimental group (n=49) 20 (40.82) 26 (53.06) 3 (6.12) 46 (93.88) much as possible. Control group (n=49) 14 (28.57) 21 (42.86) 14 (28.57) 35 (71.43) The shortcomings of 2 χ value 8.612 this study are no follow P value 0.003 up data and a limited number of included pa- _ tients, which may cause Table 6. Comparison of the SF-36 scale score ( x ± sd) a bias in the results. In Before treatment After treatment order to provide a more Group t P (score) (score) scientific reference for Experimental group (n=49) 58.86±3.57 88.85±9.47 20.725 0.000 the evaluation of thera- Control group (n=49) 58.84±3.63 70.14±5.04 12.724 0.0000 peutic efficacy and the t 0.028 12.209 safety of minimally inva- P 0.978 0.000 sive repair of hand flex- or tendon injury, we will perform a multicenter don. In this study, we found that the excellent prospective study with an increased sample and good treatment rates, the satisfaction size and a long follow up period. rate, and the SF-36 scale in patients who received minimally invasive repair were signifi- In summary, minimally invasive repair can im- cantly higher than those treated with the tradi- prove the hand functions of patients with flexor tional operation, while the complication rate tendon injury significantly. At the same time, it and VAS score were significantly decreased. In can reduce postoperative complications, reli- a study reported by Jin et al., the excellent and eve pain, and improve quality of life. A surgery good treatment rates of the minimally invasive with high patient satisfaction, minimally inva- repair therapy and traditional surgery were sive repair is worth promoting. 88.64% and 65.91%, respectively [20]. It is obvious that their results are similar to ours. Disclosure of conflict of interest Therefore, we can conclude that minimally invasive repair is of high effectiveness and sa- None. fety. Address correspondence to: Haiyong Yu, Depart- It should be noted that minimally invasive re- ment of Orthopedics, Wendeng Orthopaedic and pair should be strictly conducted at an appro- Traumatologic Hospital of Shandong Province, No. 1 priate time. The sooner, the better. The force Fengshan Road, Wendeng District, Weihai 264400, used to suture the lesions plays an important Shandong Province, China. Tel: +86-0631-8487207; role in determining the result of the surgery. It Fax: +86-0631-8487207; E-mail: yuhaiyong5r8u@ is quite easy for it to fall off when the force is 163.com weak. However, it is prone to prolonging the healing time when the force is too strong. References Similarly, the plaster should be fixed with appro- priate force. The local blood flow can be easily [1] Singer G, Zwetti T, Amann R, Castellani C, Till H affected when the force is too strong. However, and Schmidt B. Long-term outcome of paediat- ric flexor tendon injuries of the hand. J Plast the probability of shedding can be increased Reconstr Aesthet Surg 2017; 70: 908-913. when the force is too weak [21, 22]. Moreover, [2] Duci SB, Arifi HM, Ahmeti HR, Manxhuka-Kerliu patients with flexor tendon injury of the hand S, Mekaj AY, Shahini L and Kurshumliu F. should do functional exercises as early as pos- Histological evaluation of the effects of 5-fluo- sible. Exercise can enhance the ability of the rouracil on partially divided flexor tendon inju- epitendineum cells to synthesize collagen, im- ries in rabbits. Eur J Plast Surg 2016; 39: 1-10. proving hand function and minimizing the rate [3] Freeberg MAT, Farhat YM, Easa A, Kallenbach of tendon adhesion. Additionally, in order to JG, Malcolm DW, Buckley MR, Benoit DSW and reduce the rate of tissue adhesion after sur- Awad HA. Serpine1 knockdown enhances

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