 Handout 
Flexor Tendon Repairs
□ www.indianahandtoshoulder.com
□ Click on Therapy  Flexor Tendons – Philadelphia
Philadelphia Hand Symposium
March, 2015
Nancy M. Cannon, OTR, CHT
Indianapolis, Indiana
Topics
□ Indiana Early Active Flexor Tendon Program
□ Rationale : Tenodesis Place & Hold Exercise
Indiana Early Motion Program
Initiated 25 Years Ago
□ Modified Duran (PROM) + Place & Hold (AROM)
□ FPL Repairs
□ Considerations for Therapy Programs
Candidates for the Program
□ Surgical Procedure
□  4 strand repair + peripheral suture
□ Select Patients
□ Understand & will adhere
to the program & the precautions
1st – Modified Duran Program
□ Initiated 3-5 Days Postop
□ Edema begins to plateaus
□ Work of flexion & gliding resistance begin to 
[Manske, Amadio, Cao…]
[surgeon/therapist clinical judgment]
□ Postoperatively
□ Digits passively supple
□ Limited edema
( 7mm compared to opposite digit)
□ 2-3 Days Later – Add Place & Hold Exercise
Tenodesis Place & Hold Exercise
□ 1st Stage of the Exercise: Passive Digital
Flexion combined with Active/Passive Wrist
Extension
Tenodesis Place & Hold Exercise
□ Rationale: 1st Stage of the Exercise
□ Tenodesis active wrist extension & relaxed digits
generates minimal force on the FDP  2N – 3N
[Schuind et.al. 1999]
□ Passive positioning - no direct tension on the
profundus repair [Tanaka, Amadio, et.al. JHT 2005]
□ Pre-positioning the digits in flexion reduces the
resistance to the tendons (influenced by edema
&/or joint stiffness)
□ Minimizes the passive resistance of the extrinsic
extensors – wrist extended [Savage – JHS 1988]
Research – Savage
Tenodesis Place & Hold Exercise
□ Wrist Extension & MPJ Flexion -  Force FDP
□ Limits passive resistance – extrinsic extensors
Least force
□ 2nd Stage of the Exercise: Active Hold
Force ± 30% greater
> 100% greater
□ British JHS - Vol. 13-B No. 3 Aug. 1988
Factors  Work of Flexion (WOF) - FDP
Place & Hold Exercise
□ Evans & Thompson 3N* – 9N*
[JHT 1993]
□ Short arc 3N → full arc 9N
□ Kursa 7N*
[J of Orthopaedic Research 2006]
□ Wrist neutral & digits in static flexion
□ * = Does NOT account for the WOF!
□ Pulleys
□ Edema
□ Extrinsic
Extensors
□ Joint
Stiffness
Repair Strength & Gapping
2mm Gapping
□ 2 Strand
20N
14N
□ 4 Strand
40N
37N
□ 6 Strand
60N
45N
□ Peripheral Suture
□ 3-0 vs 4-0 Suture
Tenodesis Place & Hold
□ 3rd Stage: Dropping the Wrist into Flexion
□ Final movement pattern of the tenodesis,
synergistic exercise
7N
10N – 15N
Rationale – Tenodesis Movement Pattern
□ Research Studies  Compared Tenodesis
Movement Pattern to no Wrist Motion
[Kleinert type orthosis & exercise program]
Outcomes – Early Active Flexion
□ Hand Clinics May, 2013
□  passive tendon excursion zones II & III
□ Zone II:
2-5mm
Zone III: 9-18mm
□  differential tendon excursion zones II & III
□ Zone II:
0-2.6mm
Zone III: 0-2.6mm
□  tendon adhesions
□  tendon buckling under the pulley
□  resistance to the tendon
□ No increase in tendon gapping
Outcomes – Tenodesis Place & Hold Ex
□ Trumble et.al. JBJS 2010
MY Clinical Experience – Outcomes
□ Results…in Descending Order
1. Zone III
2. Zone I button
3. Zone II
□ Indiana Program [Modified Duran/Place & Hold]
□ 54 Patients
6 weeks po 1 year postop
□ TAM: PIPJ & DIPJ =
□ Rupture rate: 3.8%
122
156
□ A3 level PIPJ – volar plate – challenge!
4. Zone I direct end to end repair
[AROM DIPJ  45°]
Zone I repair
Differences: Thumb vs. Finger Flexors
□ Small % of Flexor Tendon Injuries [2%]
□ One Tendon System (extrinsic flexor)
□ FPL – Largest of the Flexor Tendons
Narrow muscle
Large surface area
(origin - radius)
□ Width only!
□ Height & cross-sectional area of the tendon
2nd smallest of all the digits [Boyer et.al. JHS 2001]
□ Pulleys not as thick, as narrow or as rigid
□ Easier tendon gliding
□ Early repair advocated
□ Muscle/tendon unit retract & shorten – few days
FPL
□ Cadaver Dissection
Volar forearm anterior surface
Therapy Programs – FPL Repairs
□ Modified Duran
□ Two strand repairs
□ Four strand repairs under tension
□ Modified Duran & Place & Hold (in DBO)
□ Button (tension on repair)
□ Modified Duran & Early Active Flexion
□ Button (no reported tension on repair)
□  4 strand repairs
FPL Repair – Zone III
□ 58 y/o Dentist
□ Diagnosis: Lacerated FPL, UDN & RDN, APB &
FPB – Dominant Right Hand
□ Surgery: Repair FPL, UDN, RDN, APB, FPB
□ Therapy Initiated: 3 Days Postop
FPL Repair – Zone III
□ Modified Duran PROM Program
□ Therapy orders – Modified Duran program
□ Follow Up Doctor Appointment
□ 12 Days Postop
FPL Repair – Zone III
□ Operative Report
□ 4 strand core sutures 3-0 Supramid
□ Epitendinous repair 5-0 Prolene
FPL Repair – Zone III
□ 12 Days Postop
□ Modified Duran PROM Program + Place & Hold
□ Therapy Orders
□ Modified Duran PROM Program
□ 3 Weeks Postop
FPL Repair
□ AROM out of orthosis (gentle active extension)
□ Edema glove
FPL Repair
□ 5 Weeks Postop
□ Blocking Orthosis
FPL Repair
□ 4 Weeks Postop
□ Ultrasound
□ NMES
FPL Repair
□ 6 Weeks Postop
□ Discontinued dorsal blocking orthosis
□ Blocking exercises
FPL Repair
□ 6 Weeks Postop
□ Exercise orthosis
FPL Repair
□ 7 Weeks
FPL Repair
□ 6 Weeks Postop
□ Gel sleeve - day
□ Scar pad in orthosis – night
FPL Repair
□ Blocking Orthosis with NMES
□ Heat & stretch - wrist
FPL Repair
□ 8 Weeks Postop
□ Putty
□ Patient education
□ May resume normal use of syringes
FPL Repair
□ 9 Weeks Postop
□ Passive extension IPJ
FPL Repair
□ 10 Weeks Postop
FPL Repair – Zone III
□ 12 Weeks Postop
□ Patient education
□ No work restrictions
□ Golf → limited to half shots
□ MPJ 0/50
□ IPJ 0/55
□ Left thumb IPJ +25 / 60
Case Example – Button – Zone I
Case Example – Four Strand – Zone II
□ DBO – Modified Duran + Place & Hold
□ Modified Duran & Early Active Flexion
□ Repair under considerable tension
FPL Repair – Four Strand – Zone II
FPL Four Strand Repair – Zone III
□ New Patient
□ Ten Weeks Postop
□ IPJ 0/45
60
□ Jagged laceration on sheet metal
□ Delayed repair – 10 days
□ FPL repair – 4 strand +
epitendinous repair
□ Repaired under tension
FPL – Four Strand Repair – Zone III
□ Modified Duran Exercises
FPL Repairs – Early Active Motion
□ Patient Handouts – updated – on website
FPL Repair – Modified Duran Program
□ Patient Handouts – updated – on website
Considerations – Orthosis Design
□ Immobilize the Thumb MPJ in Extension
□ Repairs along the proximal phalanx
□ Achieve up to 70% more passive tendon gliding
□ Excursion 3.8mm (along proximal phalanx)
JHS 1984
Considerations – Orthosis Design
□ Immobilize the Thumb MPJ in Extension
□ Kleinert type program
□ Modified Duran (passive)
□ Place & hold (active)
Percival & Sykes [JHS B 1989]
Considerations – Orthosis Design
□ Include the Index Finger
□ Particularly active patients
□ Physically demanding jobs
□ Athletes
[Elliott, Evans]
Anomaly – FPL
Accessory tendon from FPL to FDP index
□ Linburg-Comstock Syndrome
□ 25% - one hand
□ 6% - bilaterally
Considerations – Orthosis Design
□ Tight Fist with Four Fingers
□  resistance on the FPL
□  19N force with tight grasp [Schuind JHS March 1992]
□ Tight Fist with Three Fingers Significantly 
]
Considerations – Orthosis Design
□ DBO – Wrist in Ulnar Deviation
FPL Repairs – Outcomes & Rupture Rates
□ Hand Clinics 2013
□ Reduce tension on repair & minimize the angle
the FPL tracks across the wrist
□ Delayed repair or repair noted to be under tension
FPL Ruptures–Volar Plating Distal Radius
□ PQ not Repaired or Plate Edge too far Distal
FPL Rupture – Volar Plating Distal Radius
□ Kristin Valdes
[HAND 2011]
□ Four case examples with 8-strand repairs
□ Customized therapy programs [Klein program]
□ Component of early active flexion
□ Results: Thumb TAM 96% of the opposite thumb
PQ repair
FPL rupture
□ Gold standard for the zone V ruptures!
Recommended “Light” Reads…
□ Tendon Surgery of the Hand 2012
□ Hand Clinics May, 2013
□ Rehabilitation of the Hand & Upper Extremity
6th edition 2011
Chapter 36