Abstract
Dear Editor,
Re: Akyurek M et al. Influence of palmar plate injury on outcomes of zone 2 flexor tendon repair. J Hand Surg Eur. 2024, doi:10.1177/17531934241300510
We read this article with interest. The report is an extraordinary effort to look at outcomes of the repair in a 9-year period. The conclusions are reasonable. The outcomes were worse if there was an accompanying volar plate injury. We have a few questions which may help us or other readers to make full use of the information and value of this report:
The authors reported injury of the volar plate, but did not mention whether the injury was treated. We wish to know that information, as treating this injury or not would have different outcomes. We wonder whether the authors have modified their postoperative protocols, as rubber band traction with a volar bar is no longer used in most of the hand units. This is considered outdated. Our question is whether the authors still use this protocol. One valid question is if this protocol is used in the case of volar plate injury (with repair or without repair). Extension lag at the proximal interphalangeal (PIP) joint is very likely, because PIP joint contracture will be more severe. The main problem with rubber band traction is that it causes finger joint contracture with extension lag. If the motion protocol was updated to one with active flexion without a rubber band (Tang, 2021, 2018, 2022), such an effect of the volar plate may no longer exist or at least be less significant. Rupture occurred in four patients (at least four fingers), so the rupture rate is 8%, which is a higher rupture rate compared with that in many recent reports. Does this high rupture rate relate to an early removal of the splint? In this report, the splint was removed at the fourth week, which is very early. The splint is usually removed at the end of the fifth week to avoid repair rupture. Healing of the repaired tendon is still weak in the fourth and fifth weeks, so protection is necessary. The Ethibond suture is loose and very elastic, and it is not commonly used in zone 2 repair. The authors used this suture in zone 2, which may be another factor contributing to a higher rupture rate. We have never used this material for zone 2, and always use a monofilament or monofilament-like suture material in zone 2 (Pan et al., 2019; 2020, Tang et al., 1994; 2017, 2022). It is very reasonable to see an 8% rupture rate when the Ethibond is used. In other words, this study shows that Ethibond sutures used in zone 2 lead to a higher rupture rate. The rupture rate in the case series with Nylon or Supramid sutures is reported to be 0–2% or at most 4–5% (Hoffmann et al., 2008, Pan et al., 2019, 2022; Tang et al., 2017; 2023; Tobler-Ammann et al., 2023; Svingen et al., 2022). We suggest that the authors avoid using Ethibond in zone 2 flexor tendon repair in the future.
In summary, we congratulate the authors on the efforts and the report, and we draw their attention to the postoperative protocols they have used. We consider that the effects of volar plate injury are probably associated with the motion protocol that the authors used. We suggest that the authors update the motion protocol, which will probably decrease the impact of the associated volar plate injury and improve the outcomes.
References
Mustafa Akyurek1,*, Gunes Hafiz1 and Mihrican Sayan2
1Department of Plastic Reconstructive and Aesthetic Surgery, Canakkale Onsekiz Mart University, Canakkale, Turkey
2Department of Anesthesiology and Reanimation, Canakkale Onsekiz Mart University, Canakkale, Turkey
*Corresponding Author:
Dear Editor,
We are grateful for the interest in our article. We appreciate the opportunity to address the points raised and provide clarification regarding our study.
In patients with confirmed palmar plate injuries, the decision to repair was guided by the following principle: ‘If approximating the injured ends of the palmar plate did not result in a flexion posture at the PIP joint, the laceration was repaired using 5–0 polydioxanone (PDS, Ethicon, Inc., Somerville, NJ, USA) sutures. No specific reconstruction protocols were applied.’ Unfortunately, our sample size was not sufficient to allow for a direct comparison of outcomes between patients with and without palmar plate repair. However, based on intraoperative observations, if spontaneous PIP joint flexion occurred after repair and the repair was disrupted during forced extension, we believe it is preferable not to repair the palmar plate in such cases.
Our rehabilitation protocol consisted of the following steps: the wrist was immobilized in a dorsal splint with 30° flexion, MCP joints at 60° flexion and IP joints in full extension immediately after surgery. On postoperative day 3, elastic traction was applied solely to the injured fingers, and a volar bar was placed on the palmar side of the hand or wrist. Patients began hourly active extension and passive flexion glide exercises, with frequency incrementally increased each day. At night, the repaired finger was removed from traction and aligned with other fingers for immobilization. Starting in the second postoperative week, adjustments to the dorsal splint were made for patients with stiffness or difficulty extending the PIP joint, to facilitate tendon gliding and improve active PIP extension. By the fourth postoperative week, a protocol allowing for mild active flexion was introduced. However, we emphasize that angular adjustments to the splint during the second week varied based on individual patient needs (Renberg et al., 2024; Jokinen et al., 2023; Wirtz et al., 2023). In our patient population, early controlled active flexion protocols were not always feasible owing to specific demographic and clinical challenges.
Among the four patients who experienced tendon rupture, non-compliance with the prescribed rehabilitation and splinting protocols was noted. Therefore, we believe that these ruptures were unrelated to the repair technique or the planned rehabilitation protocol.
One of the key considerations during flexor tendon repair is ensuring that the tendon can move smoothly through the pulleys without catching post-repair (Tang, 2014). We found that using braided non-absorbable sutures (Ethibond) in flexor tendon repairs reduces the likelihood of ‘bulge’ formation and ensures secure knot fixation. This choice minimizes impingement risk, thereby allowing for safer and more effective implementation of rehabilitation protocols. Studies have demonstrated that Ethibond sutures outperform nylon in terms of stiffness, gap formation force and ultimate force testing (Lawrence & Davis, 2005). In our experience, Ethibond sutures provide reliable performance, particularly in maintaining joint range of motion during recovery.
The primary aim of this study is to evaluate the contribution of the palmar plate, an anatomical structure that has never been previously addressed in the context of zone 2 flexor tendon repairs, to postoperative recovery. Despite its well-documented anatomical structure and histological properties, the palmar plate’s role in tendon repair and functional recovery has remained largely unexplored in the literature. Historically, investigations into this structure have been limited to its involvement in closed injuries, leaving a significant gap in understanding its impact in open injuries or surgical interventions. Given the critical biomechanical and functional role of the palmar plate in maintaining joint stability and its potential influence on surgical outcomes, we believe that this topic warrants further detailed investigation. Shedding light on the interplay between palmar plate injuries and tendon repair outcomes may pave the way for more refined surgical techniques and rehabilitation protocols, ultimately improving patient outcomes in this complex anatomical region.
We sincerely appreciate the valuable feedback and believe that this discussion contributes significantly to advancing knowledge in this area. Thank you again for engaging with our work.