Factors that influence the outcome of zone I and zone II flexor tendon repairs in children

PURPOSE: To evaluate the factors that influenced the clinical results of zone I and II flexor tendon repairs in children at a single institution. METHODS: Forty-one fingers (35 patients) in patients ages 2 to 14 years with zone I or II flexor tendon injuries were identified. There was a zone I tendon injury in 16 fingers and a zone II tendon injury in 25 fingers. Concomitant injuries to the digital nerves were seen in 18 fingers. Primary repair was performed within 1 week in 35 fingers and delayed repair (2-9 wk) was performed in 6 fingers. After surgery 22 fingers (21 patients) were treated with early controlled mobilization and 19 fingers (14 patients) were treated with plaster immobilization. RESULTS: All patients were available for evaluation at a mean follow-up period of 42 months. Patients were subdivided into 2 age groups: (1) 0 to 7 years and (2) 8 to 15 years. Digital performance was evaluated by determining the percentage return of normal finger function according to a total active motion formula. Functional evaluation of all digits in both groups showed excellent or good results. Zone I repairs had better results than zone II repairs and isolated tendon repairs had better results than those with associated nerve repairs. The age of the patients nor postoperative protocol did not influence the final digital motion. CONCLUSIONS: A good outcome can be expected after repair of zone I or II flexor tendon injuries in children. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic III.     

Comparison of pullout button versus suture anchor for zone I flexor tendon repair

PURPOSE: To evaluate the clinical outcome after repair of zone I flexor tendon injuries using either the pullout button technique or suture anchors placed in the distal phalanx. METHODS: Between 1998 and 2002 we treated 26 consecutive zone I flexor tendon injuries. Thirteen patients had repairs from 1998 to 2000 using a modified pullout button technique (group A) and 13 patients had repair using suture anchors placed in the distal phalanx (group B). Patient characteristics were similar for both groups. The same postoperative flexor tendon rehabilitation protocol and follow-up schedule were used for both groups. Evaluation included range of motion, sensibility and grip strength, failure, complications, and return to work. The Student t test was used to determine significant differences. RESULTS: All patients completed 1 year of follow-up evaluation. There were 2 infections in group A that resolved with oral antibiotics and no infections in group B. There were no tendon repair failures and no repeat surgeries in either group. At final follow-up evaluation there were no statistically significant differences for the following end points: sensibility (Semmes-Weinstein monofilament testing and 2-point discrimination), active range of motion (at the proximal interphalangeal joint, distal interphalangeal joint, or their combined motion), flexion contracture (at the proximal interphalangeal joint, distal interphalangeal joint, or their combined contracture), and grip strength (injured tendon as a percent of the contralateral uninjured tendon). The suture anchor group had a statistically significant improvement for time to return to work. CONCLUSIONS: There was no significant difference in the clinical outcome after flexor tendon repair using either suture anchors or the pullout button technique. A significant improvement was found for time to return to work for repairs using the suture anchor technique. Flexor tendon repair can be achieved using suture anchors placed in the distal phalanx, thereby avoiding the potential morbidity associated with the pullout button technique. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level III.     

Functional outcome of the hand following flexor tendon repair at the 'no man's land'

PURPOSE: To evaluate the functional outcome of the hand following flexor tendon repair at 'no man's land' using 2 strands of a modified Kessler core suture and combined controlled motion rehabilitation protocol. METHODS: Records of 31 zone-2 flexor tendon injuries in 21 digits of 16 patients between July 2000 and June 2005 were reviewed retrospectively. The injured tendons were repaired within 24 hours using 2 strands of a modified Kessler core suture, reinforced by a continuous circumferential epitendon suture. All patients completed a rehabilitation protocol that included active extension against a rubber band, passive flexion, and controlled passive extension and passive flexion exercises. Functional outcome of the fingers was assessed using the Buck-Gramcko II score. Hand grip strength, rehabilitation period, and rupture rate were also measured. RESULTS: 17 (81%) out of 21 digits in 15 out of 16 patients achieved an excellent-to-good functional grade. The remaining patient with concomitant injuries to 4 (19%) digits attained a poor functional grade, attributable to poor compliance with the rehabilitation protocol. The mean rehabilitation period was 130 days and the mean grip strength was 78% that of the uninjured side. Concomitant digital nerve injury did not adversely affect the final outcome. Only one (4.8%) patient experienced a rupture. CONCLUSION: The surgical method and rehabilitation protocol used for zone-2 flexor tendon injury is safe and results in a reasonably good functional outcome.     

Early ultrasound therapy for rehabilitation after zone II flexor tendon repair

Background:

In our Institute, most of the patients treated for hand injuries were industrial workers with poor compliance. For rehabilitation after zone II flexor tendon repair, we had tried various early mobilization protocols. As these protocols demanded a degree of commitment from the patients, our results were suboptimal. Hence, to improve the results, we implemented a new rehabilitation protocol by administering the pulsed ultrasound therapy during the early phase of tendon healing.

Materials and Methods:

This is a prospective study done over a period of five years from January 2008 to January 2013. A total of 100 patients and 139 digits with zone II flexor tendon injuries were studied. After randomization, we administered pulsed ultrasound therapy of different frequencies and intensities for a total of 72 patients and 99 digits and formulated three groups. The results of ultrasound treated cases were compared with each other and with the results of cases treated by immobilization protocol. The results were analyzed using ‘Original Strickland’ criteria.

Results:

72% excellent-good results in ultrasound (Group 1) protocol, 75% excellent-good results in ultrasound (Group 2) protocol, and 77% excellent-good results in ultrasound (Group 3) protocol were achieved. There was no case of rupture in the first two groups. The rupture rate was 7% in ultrasound (Group 3) protocol. Only 25% excellent-good results were obtained in the immobilization protocol.

Conclusion:

After zone II flexor tendon repair, pulsed ultrasound therapy during the early rehabilitation phase is safe and effective. The results are comparable to early mobilization protocols.KEY WORDS: Early ultrasound therapy, zone II flexor tendon repair, PIP Joint flexion contracture     

Optimizing independent finger flexion with zone V flexor repairs using the Massachusetts General Hospital flexor tenorrhaphy and early protected active motion

PURPOSE: Independent FDS action has been cited to be problematic with repair of multiple tendons in zone V owing to adhesion formation between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Of the several described flexor repair techniques the ideal tendon repair should be strong enough to allow for early active motion to minimize adhesion formation and maximize tendon healing. Biomechanical studies have proven the Massachusetts General Hospital (MGH) repair to be strong enough to allow for early active motion. The purpose of this study was to examine the use of the MGH technique for zone V flexor tendon injuries to allow for early protected active motion to achieve independent finger flexion through better differential gliding of the tendons. METHODS: We performed a retrospective review 168 zone V finger flexor tendon repairs for 29 patients performed consecutively over 4 years when early active motion was not contraindicated. The same early protected active motion protocol was used for all of these patients. We reviewed total active motion, independent flexion, rupture, and need for tenolysis. These injuries involved 103 FDS and 65 FDP tendons to 103 fingers. The median follow-up period was 24 weeks. Of these 29 patients 19 were men and 10 were women. The average patient age was 28 years. RESULTS: The total active motion for these zone V repairs was 236 degrees +/- 5 degrees Overall 97 of 103 digits attained good to excellent function and 88 of 103 developed some differential glide. One of these patients required a tenolysis. Three repairs ruptured in 1 patient owing to suture breakage that was associated with noncompliance with the dorsal extension block splint. CONCLUSIONS: Our retrospective review of 168 consecutive flexor tendon repairs showed that the MGH technique allowed for early protected active motion, which provided good to excellent functional outcomes with 88 of 103 developing independent finger flexion at an acceptably low complication risk.     

A comparative analysis of the outcome of flexor tendon repair in the index and little fingers: does the little finger fare worse?

The clinical and hand therapy notes of 180 patients who had single digit flexor tendon repairs in zones I and II from January 2000 to December 2004 were reviewed. Data from 60 index and 108 little fingers at 5 weeks, 8 weeks and 12 weeks follow-up visits were included. In zone I injuries, there was a statistically significant difference in flexion contracture (worse in the little fingers ) at all follow-up points. Although the range of motion and percentage of patients in the excellent category of the Strickland and Glogovac criteria were greater in the index finger group than the little finger for zone I and II injuries, these differences were not statistically significant. The rupture rate was also higher in the little finger group.     

Beugesehnenverletzung der Hand

At last, flexor tendon injuries of the hand and digit are no longer nearly impossible to treat. Many recent studies have reported a more than 75% success with excellent results, in particular in zone 2, in some cases reaching 98% satisfactory outcomes. The challenge inherent in treating and rehabilitating the zone 2 flexor tendon injury remains, however, even for the skilled hand surgeon. We must remain diligent, obeying principles outlined earlier by the first surgeons willing to attempt these repairs, while carefully gleaning the helpful and critical recommendations of the now sophisticated researchers in the subject of flexor tendon repair and rehabilitation.     

Flexor tendon injuries of the hand

At last, flexor tendon injuries of the hand and digit are no longer nearly impossible to treat. Many recent studies have reported a more than 75% success with excellent results, in particular in zone 2, in some cases reaching 98% satisfactory outcomes. The challenge inherent in treating and rehabilitating the zone 2 flexor tendon injury remains, however, even for the skilled hand surgeon. We must remain diligent, obeying principles outlined earlier by the first surgeons willing to attempt these repairs, while carefully gleaning the helpful and critical recommendations of the now sophisticated researchers in the subject of flexor tendon repair and rehabilitation.     

Zone I flexor tendon rehabilitation with limited extension and active flexion.

This article describes an immediate active motion protocol for primary repair of zone I flexor tendons treated with tendon to tendon, or tendon to bone repair, and reviews clinical results. A rehabilitation protocol is proposed that will limit excursion of the zone I repair by blocking full distal interphalangeal (DIP) extension and by applying controlled active tension to both the unrepaired flexor digitorum superficialis (FDS) and the repaired flexor digitorum profundus (FDP). The rehabilitation technique utilized a dorsal protective splint with a relaxed position of immobilization with 30 degrees of wrist flexion, 40 degrees of metacarpophalangeal (MP) joint flexion, and a neutral position for the proximal interphalangeal (PIP) joints without dynamic traction. In addition, within the confines of the dorsal splint, the involved DIP joint was splinted at 40-45 degrees to prevent DIP joint extension during the early wound healing phases. Relaxed composite flexion was used to apply active tension to both the uninjured FDS, and the repaired FDP. This technique applies excursion of approximately 3 mm to the zone I tendon in a limited arc (45-75 degrees). The modified position of active flexion applies low loads of force (< 500 g), even with drag considered. This technique is supported by previous mathematical studies of excursion and internal tendon force, and clinical experience. Forty nine cases treated over a 10-year period were reviewed, and eight were excluded for incomplete follow-up. The use of this protocol for 41 zone I flexor digitorum profundus repairs by 12 different surgeons using varied surgical techniques was evaluated. None of the tendon to tendon repairs used more than two suture strands for the core repairs. Mean total active range of motion was 142 degrees (PIP 95 degrees plus DIP 47 degrees), or 81% of normal. Three tendons ruptured in non-protocol-related incidents and were excluded from the study. Results from this clinical study support the use of limited DIP extension combined with active tension with conventional repair in zone I.     

Results of zone II flexor tendon repair in children younger than age 6 years: botulinum toxin type A administration eased cooperation during the rehabilitation and improved outcome

The inability of young children with a zone II flexor tendon repair to cooperate in postoperative care and rehabilitation may represent a high risk for medical and surgical complications. To forestall that risk, botulinum toxin type A (2.5 U/kg, 7 U/kg) injection was used during surgery to induce forearm flexor muscle relaxation in seven children under 6 years old with zone 2 flexor tendon repairs. Patients received a controlled passive motion regimen after surgery. Results were evaluated on the basis of the acquisition of muscle tone and active finger movements, total range of motion of affected joints, postoperative grip strength, muscle atrophy, and phalangeal length. In this prospective clinical study, the mean follow-up was 18 months. All the children had good and excellent results based on the Strickland criteria. As for postoperative complications, one patient had bowstring and another had poor finger sensibility and first web space contracture that required Z-plasty. The selective use of botulinum toxin type A to weaken the targeted muscles generated a sufficient reduction in spontaneous activity of the fingers, permitting an improved rehabilitation program. Botulinum toxin type A administration could be an effective form of therapy, serving as an alternative or adjunct to conventional rehabilitation modalities in these children.     

The aetiology of acute rupture of flexor tendon repairs in zones 1 and 2 of the fingers during early mobilization.

Five hundred and eight patients with 840 acute complete flexor tendon injuries in 605 fingers in zones 1 and 2 underwent surgery and postoperative mobilization in a controlled or early active motion (active flexion-active extension) regimen over a period of 7.5 years. Sixty-eight patients with 79 finger flexor divisions who did not complete the rehabilitation programme were excluded. Of the 440 patients with 728 complete tendon divisions in 526 fingers included in the study, 23 patients ruptured 28 tendon repair(s) in 23 fingers, an overall rupture rate of 4%. One hundred and twenty-nine fingers with zone 1 injuries had a rupture rate of 5%. Three hundred and ninety-seven fingers with zone 2 injuries had a rupture rate of 4%. This study analyses the 23 patients with flexor tendon rupture(s) to identify causative factors. In approximately half of these patients, tendon rupture followed acts of stupidity. The implications of this are discussed. There was no significant relationship between tendon rupture and the age or sex of the patients, smoking or delay between injury and tendon repair and there was no particular prevalence of zone 2C level injuries among the fingers in which tendon rupture occurred.     

In vitro cyclic tensile testing of combined peripheral and core flexor tenorrhaphy suture techniques

Early tenorrhaphy mobilization increases repair site strength and decreases adhesions. Preliminary unpublished data suggest that early active mobilization improves clinical outcome compared with traditional passive motion protocols. We loaded cadaver flexor profundus tendon repairs to 8.0 kg (78.4 N) for up to 5,000 cycles to simulate the loads and cycle number of our active flexor tendon rehabilitation protocol. 3-0 Ethibond (Ethicon, Somerville, NJ) and 6-0 Prolene (Surgi-pro; US Surgical, Norwalk, CT) were used for core and peripheral sutures, respectively. Four different groups were tested: 2-strand Tajima core suture with either a running interlocking (2R) or a Silfverski?ld cross-stitch (2S) peripheral suture and 4-strand Tajima plus horizontal mattress core suture with either a running interlocking (4R) or a Silfverski?ld peripheral suture (4S). Repairs failed in the suture midsubstance or at the knot. There was considerable variability within groups and no significant difference in the number of cycles to failure between the 2R, 4R, and 2S repairs, which failed after 2 +/- 2, 304 +/- 249, and 560 +/- 987 cycles, respectively. All 4S repairs were intact after 5,000 cycles. Our data suggest that flexor tenorrhaphy with the 4S repair can withstand the cyclic loads we estimate would be present during an active rehabilitation protocol.     

手屈肌腱损伤Ⅰ期显微修复及功能康复97例 临床报告

目的：探讨手屈肌腱损伤Ⅰ期显微修复的方法及疗效。方法：本组97例182条肌腱损伤,其中男59例,女38例;平均年龄32岁（6-65岁）;玻璃割伤22例,刀伤32例,电锯伤29例,挤压伤14例;Ⅰ区12例,Ⅱ区35例,Ⅲ区28例,Ⅳ区8例,V区14例。合并血管神经损伤68例,合并骨折53例,均I期采用改良Kessler法缝接肌腱,术后早期循序渐进康复锻炼。结果：本组97例均获随访,时间3-24个月,按TAM法评定疗效,优48例,良39例,可8例,差2例。结论：修复肌腱损伤应彻底清创,无创操作,具备牢固光滑的肌腱吻合技术及自始至终贯穿功能康复理念。     

Pediatric flexor tendon injuries: A 10-year outcome analysis

BACKGROUND:

Primary flexor tendon repair was first introduced in the 1960s. Since then, major advances in the understanding of flexor tendon anatomy and biology have led to improved outcomes following repair. Relative to the adult population, sparse knowledge exists as to which operative and postoperative treatments are most successful in children. This is due, in part, to the rarity of pediatric tendon lacerations compared with the adult population, but also related to challenges when working with smaller anatomy and the decreased compliance in children with respect to rehabilitation protocols. Published reports indicate that the incidence of ‘good’ flexor tendon repair outcomes is as low as 53%.

OBJECTIVE:

To determine the injury pattern and demographics of pediatric flexor tendon injuries involving zones I, II and III over the past decade, and to report results and identify treatment paradigms that are associated with optimal outcomes.

METHODS:

A retrospective chart review of all flexor tendon injuries involving zones I, II and III between April 2001 and December 2010 was performed. Parameters reviewed included demographics, injury mechanism, repair technique, outcomes and complications.

RESULTS:

A total of 47 patients with a median age of eight years experienced 100 tendon injuries. The most common cause of injury was glass (n=22), with the most common digit injured being the small finger (n=30). Tendon injuries included the following: flexor digitorum superficialis (n=46); flexor digitorum profundus (n=45), flexor pollicis longus (n=8); and adductor pollicis longus (n=1). Zone III had the highest number of injuries (n=47), followed by zone II (n=39). Ninety tendons were repaired using polyester suture, the most common size being 4-0. The modified Kessler technique was used in the majority of cases (n=62). Only 22 tendons underwent an epitendinous repair. Splint immobilization was used in 30 patients and a full cast in 17. The median duration of immobilization was four weeks. Forty-two patients underwent postoperative hand therapy. Using the American Society for Surgery of the Hand Total Active Motion (TAM) score, 40 of 47 patients experienced 100% recovery with no functional limitations. Two patients had a score <100%, not necessitating further surgery. A second operation was required for five patients. All patients in this group demonstrated 100% TAM at one year.

CONCLUSION:

Pediatric flexor tendon injuries remain rare and usually involve the dominant hand holding or manipulating an object. An excellent outcome was found in 95.9% of patients assessed by TAM scores. Repair technique was chosen according to the size of tendon involved. Patients not treated with hand therapy and not immobilized in a cast were often too young to participate in rehabilitation. Based on the results, immobilization of young children for four weeks is safe and does not worsen functional outcomes. Of the patients requiring a second procedure, no predictive variables for poorer outcomes were found on analysis of age, outcome, cause, location, repair technique, rehabilitation protocol or zone of injury.     

Clinical outcomes associated with flexor tendon repair

Review of the outcomes of clinical flexor tendon repairs reported over the past 15 years showed advances in the outcomes with excellent or good functional return in more than three fourths of primary tendon repairs following a variety of postoperative passive/active mobilization treatments. Strickland and Glogovac criteria are the most commonly adopted methods to assess function. Repair ruptures (4%-10% for zone II finger flexors and 3%-17% for the FPL tendon), adhesion formations, and stiffness of finger joints remain frustrating problems in flexor tendon repairs and rehabilitation. Four approaches are suggested to improve outcomes of the repairs and to solve these difficult problems,which include stronger surgical repairs, appropriate pulleys or sheath management, optimization of rehabilitation regimens, and modern biologic approaches.     

Relative motion flexion following zone I-III flexor tendon repair: Concepts,evidence and practice.

Study DesignNarrative review and case series.IntroductionThe relative motion approach has been applied to rehabilitation following flexor tendon repair. Positioning the affected finger(s) in relatively more metacarpophalangeal joint flexion is hypothesized to reduce the tension through the repaired flexor digitorum profundus by the quadriga effect. It is also hypothesized that altered patterns of co-contraction and co-inhibition may further reduce flexor digitorum profundus tension, and confer protection to flexor digitorum superficialis.MethodsWe reviewed the existing literature to explore the rationale for using relative motion flexion orthoses as an early active mobilization strategy for patients after zone I-III flexor tendon repairs. We used this approach within our own clinic for the rehabilitation of a series of patients presenting with zone I-II flexor tendon repair. We collected routine clinical and patient reported outcome data.ResultsWe report published outcomes of the clinical use of relative motion flexion orthoses with early active motion, implemented as the primary rehabilitation approach after zone I-III flexor digitorum repairs. We also report novel outcome data from 18 patients.DiscussionWe discuss our own experience of using relative motion flexion as a rehabilitation strategy following flexor tendon repair. We explore orthosis fabrication, rehabilitation exercises and functional hand use.ConclusionsThere is currently limited evidence informing use of relative motion flexion orthoses following flexor tendon repair. We highlight key areas for future research and describe a current pragmatic randomized controlled trial.     

Functional outcome in patients with zone V flexor tendon injuries

Introduction Zone V flexor tendon injuries may involve major nerves and arteries as well as the wrist and finger flexors. Although these injuries are not infrequent, few studies have reported functional outcomes. The purpose of this study was to evaluate the functional outcome in patients with flexor tendon repairs in zone V.Materials and methods Eighteen patients with repaired zone V flexor tendon injuries were followed up for an average of 20 months. The postoperative rehabilitation program consisted of a combined regime of modified Kleinert and modified Duran techniques. Outcome parameters were hand function according to the Buck-Gramcko assessment system, grip and key pinch strength values, and return to work status.Results Functional results were excellent in 92.8% of the digits, good in 1.4%, and poor in 5.8%. Grip strength recovered to an average of 77% and pinch strength to 74% of the uninjured hand. Two tendon ruptures occurred in a patient, and tenolysis was required in 3 patients. Of 15 patients who were employed at the time of injury, 13 returned to their original occupations.Conclusion Satisfactory functional results can be obtained when proper surgical technique is coupled with careful postoperative management in patients with zone V flexor tendon injuries.     

Methods of rehabilitation of fingers after the repair of flexor tendon injuries of first and second degree]

Post-operative rehabilitation of fingers after flexor tendon repair is the important part of therapy which considerably affects final result of the treatment. Method of dynamic traction splinting introduced by Kleinert in 1973, resulted in significantly improvement of final outcomes of repaired flexor tendons, particularly in zone II. Several other than Kleinert dynamic splinting rehabilitation programs were described in the paper. These methods are precisely designed protocols including mode and duration of immobilization of the fingers in the cast, daily range and frequency of finger moves and rate of restoration of the full range of motion. The following rehabilitation protocols were described: active flexion-active extension (Billericay and Belfast), active flexion-active extension using an internal profundus splinting, passive flexion-passive extension and combined regimen of controlled motion with dynamic traction splinting. The late results of the treatment using mentioned above rehabilitation protocols were compared, with respect to proportion of excellent and good results and rate of ruptures of repaired tendons in the course of rehabilitation. Combined regimen of controlled motion with dynamic traction splinting appeared to be superior than other presented methods. There was mentioned that Kleinert dynamic traction splinting, which is the most frequently used post-operative protocol after flexor tendon repairs in Poland, is not the only way of rehabilitation and that other presented methods give comparable results and may be used as an effective, alternative technique.     

Relative motion orthoses for early active motion after finger extensor and flexor tendon repairs: A systematic review

BackgroundThe relative motion (RM) orthosis was introduced over 40 years ago for extensor tendon rehabilitation and more recently applied to flexor tendon repairs.PurposeWe systematically reviewed the evidence for RM orthoses following surgical repair of finger extensor and flexor tendon injuries including indications for use, configuration and schedule of orthosis wear, and clinical outcomes.Study DesignSystematic review.MethodsA PRISMA-compliant systematic review searched eight databases and five trial registries, from database inception to January 7, 2022. The protocol was registered prospectively (CRD42020211579). We identified studies describing patients undergoing rehabilitation using RM orthoses after surgical repair of acute tendon injuries of the finger and hand.ResultsFor extensor tendon repairs, ten studies, one trial registry and five conference abstracts met inclusion criteria, reporting outcomes of 521 patients with injuries in zones IV-VII. Miller's criteria were predominantly used to report range of motion; with 89.6% and 86.9% reporting good or excellent outcomes for extension lag and flexion deficit, respectively. For flexor tendon repairs, one retrospective case series was included reporting outcomes in eight patients following zones I-II repairs. Mean total active motion was 86%. No tendon ruptures were reported due to the orthosis not protecting the repair for either the RME or RMF approaches.DiscussionVariation was seen in use of RME plus or only, use of night orthoses and orthotic wear schedules, which may be the result of evolution of the RM approach. Since Hirth et al's 2016 scoping review, there are five additional studies, including two RCTs reporting the use of the RM orthosis in extensor tendon rehabilitation.ConclusionsThere is now good evidence that the RM approach is safe in zones V-VI extensor tendon repairs. Limited evidence currently exists for zones IV and VII extensor and for flexor tendon repairs. Further high-quality clinical studies are needed to demonstrate its safety and efficacy.     

Rehabilitation after flexor tendon surgery

During the last 20 years there have been significant innovations in injury repair and aftercare for patients who sustain zone 2 flexor injuries. Based on improvements in our understanding of the mechanism of repair, new differentiated concepts could be developed. Active extension, passive flexion as introduced by Kleinert is still the standard in flexor tendon surgery. New stronger suture techniques allow immediate active flexion. The purpose of this article is to review the current concepts of flexor tendon and pulley repair as well as reconstruction of these structures and the rehabilitation programs for tenolysis.