RESEARCH SCHOLARS INITIATIVE Comparing Three Postoperative Treatment Protocols for Extensor Tendon Repair in Zones V and VI of the

Hand
Barbara Hall, Hoe Lee, Rohan Page, Lorna Rosenwax, Andy H. Lee

KEY WORDS  comparative effectiveness research  nger injuries  immobilization  motion therapy, continuous passive  tendon injuries

OBJECTIVE. This pilot study compared the effectiveness of 3 postoperative rehabilitation protocols for
patients with Zones V and VI extensor tendon lacerations.

METHOD. Twenty-seven patients were recruited from 3 sites and randomly assigned to 1 of 3 established
treatment protocols: immobilization, early passive motion (EPM), and early active motion (EAM). Outcome measures were collected at 3, 6, and 12 wk after treatment and included total active motion (TAM).

RESULTS. At the end of Week 12, data on 24 injured digits of 18 patients were available for analysis. When data at Weeks 3, 6, and 12 were compared, patients in all groups showed steady improvement in TAM, but digits under the EAM treatment improved to a greater extent over time (F [2, 46] 5 75.6, p < .001). CONCLUSION. Patients with Zones V and VI extensor tendon injuries treated with the EAM protocol
recovered range of motion more rapidly.
Hall, B., Lee, H., Page, R., Rosenwax, L., & Lee, A. H. (2010). Research Scholars InitiativeComparing three postoperative treatment protocols for extensor tendon repair in zones V and VI of the hand. American Journal of Occupational Therapy, 64, 682688. doi: 10.5014/ajot.2010.09091

Barbara Hall, MHS, is Certied Hand Therapist and Senior Occupational Therapist, Occupational Therapy Hand and Upper Limb Clinic, Sir Charles Gairdner Hospital, Perth, Western Australia. Hoe Lee, PhD, is Senior Lecturer, School of Occupational Therapy and Social Work, Curtin Health Innovation Research Institute, Curtin University of Technology, GPO Box U1987, Perth, Western Australia, Australia; Hoe.Lee@curtin.edu.au Rohan Page, MD, is Consultant Plastic Surgeon, Plastic Surgery Department, Sir Charles Gairdner Hospital, Perth, Western Australia. Lorna Rosenwax, PhD, is Professor and Head, School of Occupational Therapy and Social Work, Curtin University of Technology, Perth, Western Australia. Andy H. Lee, PhD, is Professor of Biostatistics, School of Public Health, Curtin University of Technology, Perth, Western Australia.

xtensor tendon laceration is one of the most common industrial accidents among young manual workers, but it does not receive as much attention in the literature as exor tendon injury. Treatment protocols available for extensor tendon rehabilitation are often complex and unsuited to young patients whose goal is early return to work, which poses a unique challenge for occupational therapists striving for evidence-based practice and excellence in clinical interventions. Three clinical approaches to the rehabilitation of extensor tendon repairs are (1) immobilization (IM), (2) early passive motion (EPM), and (3) early active motion (EAM; Tang, 2006). IM is the oldest technique. It involves complete immobilization of the wrist at 4045 with the metacarpophalangeal joints (MCP) and interphalangeal joints (IP) at 0 for 3 wk in a splint (Miller, 1942). The potential risk of rupture of a newly repaired tendon treated with an IM protocol is reduced because the patient is neither mobilizing nor required to follow a precise home exercise program when the tendon is at its weakest. Because of its simplicity, IM is often recommended for noncompliant patients (Evans, 1995b). Although IM appears simple to implement, the rehabilitation that follows the immobilization period is frequently complicated by attenuation, extension lags on MCP movement, extrinsic tightness, and adhesions resulting in exion loss (Newport, Blair, & Steyers, 1990). The complications require intensive therapy and additional treatment to correct (Crosby & Wehbe, 1999). In the 1980s, EPM was promoted as best practice when it was discovered that passive, protected mobilization promoted the intrinsic healing capacity of tendons in experimental dog models (Gelberman et al., 1991; Gelberman, Woo, Lothringer, Akeson, & Amiel, 1982; Takai, Woo, Horibe, Tung, &
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Celberman, 1991). Evans (1986, 1989) published a controlled EPM treatment protocol that focused on the passive glide of the repaired extensor tendon by using the recoil of elastic bands of a dynamic extension splint. The splint also immobilized the wrist at 4045 extension, and the splints palmar block allowed full passive extension and maximum 40 active exion at the MCP joint (Evans, 1986). Several researchers have compared IM with this type of EPM and reported that patients in the latter protocol had better functional outcomes and fewer problems with adhesions (Browne & Ribik, 1989; Chow, Dovelle, Thomes, Ho, & Saldana, 1989; Evans, 1989). Despite its popularity, some authors (Purcell, Eadie, Murugan, ODonnell, & Lawless, 2000) were critical of the EPM protocol and its dynamic splint because of the rehabilitation regimens demanding nature and the cost and time required to fabricate the splint. In the 1990s, researchers recommended EAM to enhance gliding of the healing tendon and reduce the potential for adhesions or tendon bunching (Crosby & Wehbe, 1999; Evans, 1995b; Newport, 1998). In clinical practice, the popular active motion premise has led to many labor-intensive and often complex treatment protocols (Newport, 1998). Sylaidis, Youatt, and Logan (1997) proposed a simplied EAM protocol using a splint that positions the wrist joints at 45 extension and MCP joints at 50 exion. A palmar block on the splint prevents full active exion but allows active extension of the IP joints of the digits. Patients performed active MCP extension with IP held in either extension or exion from Day 1 postoperation. Recovery of Zones V and VI extensor tendon injury of the hand is often plagued by MCP extension lags, extrinsic tightness, and adhesions that prohibit full composite exion of the digits. Anatomically, Zone V is over the MCP joint and is generally distal to the juncturae tendinum, and Zone VI is over the dorsum of the hand, distal to the extensor retinaculum, and includes the juncturae (Kleinert & Verdan, 1983). Khandwala, Webb, Harris, Foster, and Elliot (2000) conducted a prospective randomized controlled trial (RCT) involving 100 patients with Zone V and VI injuries and compared an EAM blocking splint protocol with an EPM protocol using a dynamic extension splint. The EAM protocol used was similar to that of Sylaidis et al. (1997), except the blocking splint extended only to the middle of the proximal phalanx, leaving the IP free to move. Khandwala et al. (2000) concluded no difference existed in treatment outcomes between the EAM and EPM protocols. However, they advocated EAM as a superior protocol because of its easy-to-wear and less-effortto-maintain palmar blocking splint. Four RCTs investigated
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postoperative rehabilitation outcomes for extensor tendon injury in the literature (Bulstrode, Burr, Pratt, & Grobbelaar, 2005; Chester, Beale, Beveridge, Nancarrow, & Titley, 2002; Khandwala et al., 2000; Mowlavi, Burns, & Brown, 2005), but none compared the three accepted clinical approaches (IM, EPM and EAM) together and established the best practice among them. In this pilot study, we compared the effectiveness of IM developed by Evans (1995b) on the basis of Millers (1942) techniques, EPM using a dynamic extension splint (Evans, 1986, 1989), and EAM using a palmar blocking splint (Khandwala et al., 2000) in the management of patients with acute extensor tendon repairs in Zones V and VI. The hypothesis was that the three rehabilitation protocols would have different treatment effects on patients. The ndings would contribute to the postoperative management of extensor tendon injuries by occupational therapists.

Method
Patient Recruitment We estimated the sample size needed for this pilot study on the basis of the primary outcome measure, total active motion (TAM). We estimated that the standard deviation of the TAM was 150 in extensor tendon injury patients and the expected increase in TAM with treatment was 100. Seven patients were required in each comparison group. To allow for 25% attrition, 27 patients requiring tendon repairs in Zones V and VI were recruited from three teaching hospitals in Western Australia and allocated randomly to the three treatment groups. They were referred to occupational therapy by hand surgeons within 5 days of their operation. The project was approved by the human research ethics committee of the hospitals and informed consent was obtained from each participant. Patients were excluded if they had associated pathology that limited their ability to comply with the assigned protocol or they had only one tendon repaired in the index or little nger. Treatment Protocols Postoperatively, all patients were immobilized in a volar plaster slab with the wrist in 3045 extension, the MCP joints in 030 exion, and the IP joints immobilized in neutral. All patients received edema and scar management regardless of their treatment group allocation. In the IM group, patients were tted with a resting splint and immobilized for 3 wk. Patients in the EPM group were tted with a dorsal dynamic extension splint and commenced early controlled passive motion in the rst 5 days after surgery. The EAM patients were tted with a simple
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palmar blocking splint and commenced early active motion in the rst 5 days. Figure 1 shows details of the three treatment protocols. A manual was developed to ensure that patients received uniform treatment in each protocol, and it was issued to all the treating therapists. The manual consisted of weekly treatment instructions with photographs, as well as home program handouts for the patients. In developing the manual, we conducted an extensive literature review and adopted best practice in each protocol. An expert panel composed of hand surgeons and senior hand therapists reviewed the treatment manuals quality. On average, the treating therapists (n 5 4) had 2.85 yr (standard deviation [SD] 5 1.2) experience in hand rehabilitation. Among patients in the three treatment groups, we found no differences with respect to total contact time with the therapist (mean [M ] 5 409 min,

SD 5 93, range 5 335580 min, p 5 .218) and visits to the clinic per week (M 5 1.75, SD 5 0.6, p 5 .32). Outcome Measures Before the study began, therapists received training from Barbara Hall on the data collection procedure. During the initial assessment, each patients demographic data and vocational history were recorded. Patients were reassessed at 3, 6, and 12 wk on self-reported functional capability, extension lag, range of motion (ROM), and grip strength. ROM measurements for exion and extension were recorded for the MCP, proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints using a standardized nger goniometer and following American Society of Hand Therapists (1992) techniques. Measurements were converted to TAM for analysis. The TAM score was calculated by subtracting the total extension decits of

Figure 1. Summary of the three treatment protocols. IP 5 interphalangeal; MCP 5 metacarpophalangeal.

p

Comprehensive hand assessment conducted by treating therapist at Weeks 3, 6, and 12.

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nger joints (MCP, PIP, and DIP) from the total nger joint exion of the same digit (American Society of Hand Therapists, 1992). Functional ability within the past 24 hr was measured by a self-report 10-point visual analog scale (VAS) ranging from 0 (unable to perform any functional task) to 10 (no difculty to perform functional tasks). Ability to extend the affected nger was measured; 0 indicated ability to fully extend the nger joint, and a positive value indicated an extension lag. Grip strength was measured at Week 12 using a standardized protocol (American Society of Hand Therapists, 1992) with a calibrated Jamar dynamometer (Patterson Medical/Sammons Preston Corporate, Bolingbrook, IL) on both the affected hand and the unaffected hand. Statistical Analysis Descriptive statistics were used to prole the patients demographic, vocational, and clinical characteristics. Changes within and between groups in TAM, selfreported function, extension lag, and grip strength were assessed by repeated-measures analysis of variance (ANOVA) F tests and post hoc analyses. Because the sample sizes were relatively small, we also applied the corresponding nonparametric Friedmans test (Portney & Watkins, 2009). We made a Bonferroni adjustment of a level to .017 to reduce the chance of Type I errors in repeated measures. All statistical analyses were performed using SPSS Version 16 (SPSS, Inc., Chicago).

for immobilization against the passive motion protocol (t [46] 5 0.56, p 5 .581). We also conducted a repeated-measures ANOVA to examine the change in TAM over time and found no apparent violations of statistical assumptions. Signicant increasing trends over time were identied in the three comparison groups, suggesting that all patients showed steady improvement during the study period (F [2, 46] 5 75.6, p < .001). Similar results were also obtained from the nonparametric Friedmans test (p < .001). Patients in EAM were observed to have less extension lag over 12 wk, but the differences among the three groups were not signicant (F [2, 46] 5 3.45, p 5 .897): IM, M 5 14.6, SD 5 2.4; EPM, M 5 14.3, SD 5 1.9; and EAM, M 5 7.87, SD 5 1.5. Although EAM patients reported more improvement in function, the mean VAS scores were similar across groups (F [2, 34] 5 9.14, p 5 .073): IM, M 5 2.78, SD 5 0.56; EPM, M 5 3.15, SD 5 0.61; and EAM, M 5 3.45, SD 5 0.63. Moreover, we found no difference in grip strength at Wk 12 among the three groups (F [2, 15] 5 6.84, p 5 .097): IM, M 5 34.9, SD 5 2.91; EPM, M 5 35.6, SD 5 2.98; and EAM, M 5 38.9, SD 5 2.26.

Discussion
An immobilization protocol is routinely prescribed for noncompliant patients because of its low-maintenance splint and straightforward instructions. Some clinicians consider IM an acceptable treatment option for all patients with Zones V and VI extensor tendon injuries (Carl, Forst, & Schaller, 2007; Purcell et al., 2000). However, the risk of active extension lags of the MCP, extrinsic tightness, and adhesions resulting in digital exion loss may offset the benets gained from the IM protocol. To reduce the risk of adhesions, participants in this study were immobilized for 3 wk, in contrast to the 4 wk suggested by Bulstrode et al. (2005) and Mowlavi et al. (2005). Our participants showed adequate progress over the 12 wk. When compared with EAM, IM patients appeared to have lower ROM and more extension lags at 3, 6, and 12 wk. In an RCT, Mowlavi et al. (2005) showed that EPM patients achieved better short-term results in TAM and grip strength than did IM patients, but long-term recovery of patients in 6 mo was found to be similar. Our study also demonstrated that the pairwise comparison of the IM and EPM over 12 wk was not signicant. Numerous authors have been critical of EPM splints as being time consuming to fabricate and expensive and inconvenient to wear (Chester et al., 2002; Khandwala et al., 2000; Russell, Jones, & Grobbelaar, 2003). The complexity of the protocol has made it suitable only for
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Results
Twenty-seven patients (M age 5 30.4, SD 5 3.7) consented to participate voluntarily and attended the initial assessment. Nine patients dropped out of treatment at Wk 6: 5 from the IM group and 4 from the EPM group. The defaulters (M age 5 33.8, SD 5 2.7 yr) declined to continue the rehabilitation or to take part in the exit assessment and claimed that they had already recovered and no further treatment was necessary. At Wk 12, 18 patients (M age 5 31.6, SD 5 3.8 yr) had completed the rehabilitation program, and a total of 24 injured digits were available for analysis. The patients demographic information and the characteristics of their injured ngers are summarized in Table 1. The sample had no fractures of the phalanges, metacarpal, or carpal bones. To assess differences between the three treatment protocols at each time point, we conducted an ANOVA; the results are presented in Table 2. Patients in the EAM protocol appeared to improve to a greater extent at Wk 3, 6, and 12. Post hoc tests indicated that all pairwise differences between protocols were signicant, except
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Table 1. Demographic Prole of Patients (N 5 18) and Characteristics of Injured Fingers (N 5 24) in the Three Treatment Groups
Characteristic Men Women Total Total no. of injured ngers Injuries involved dominant hand Injury zonesa Zone V Zone VI Occupation Manual laborer Clerical worker/student Unemployed Mechanism of injurya Sharp laceration Fight bite Rupture after laceration Saw Grinder Multiple ngers injury Fingers involved Degree of laceration Complex injuryb
a

Immobilization 4 0 4 5 3 (4) 1 (1) 3 1 0 3 (4) 1 (1) 1 2 index, 2 middle, 1 ring three 100%, two 30%

Early Passive Motion 4 1 5 8 2 3 (4) 2 (4) 3 1 1 4 (6) 1 (2) 3 3 index, 3 middle, 2 ring four 100%, three 50%, one 80% 1

Early Active Motion 9 0 9 11 6 7 (8) 2 (3) 4 3 2 5 (6) 1 (1) 1 (1) 2 (3) 2 3 index, 4 middle, 4 ring eight 100%, two 60%, one 80% 7

Number in parentheses indicates number of injured ngers. b Metacarpal phalangeal joint capsule damage, infection of interosseous muscle and nger joints.

motivated patients who have a strong desire to recover and resume normal hand functions (Mowlavi et al., 2005). Further clinical trials to investigate the application of EPM treatment procedures are warranted. The EAM protocol involves fabrication of an uncomplicated blocking splint and easy-to-follow exercise regimens, an approach that would indicate early return to hand functions with fewer tendon-healing complications. This studys results suggest that when compared with patients in the EPM and IM groups, patients treated with the EAM protocol achieved greater active ROM, less active extension lag, and better self-report function score. The ndings support the commonly held belief that EAM can lead to better recovery in tendon injury (Bulstrode et al., 2005; Carl et al., 2007; Mowlavi et al., 2005; Newport & Tucker, 2005). The literature has shown that experienced clinicians recommend EAM because it enhances intrinsic tendon strength, promotes
Table 2. Results of Total Active Motion (TAM; N 5 24)
Immobilization (n 5 5) TAM (degree) At Week 3
a

tendon gliding, and prevents adhesions (Sylaidis et al., 1997; Thomas, Moutet, & Guinard, 1996). The EAM blocking splint used in the study is simpler and more cost-effective to fabricate than the dynamic splint in the EPM protocol (Khandwala et al., 2000). Over the past 30 yr, several different treatment techniques have been developed, including immobilization of IM patients from between 3 and 6 wk in a splint (Bulstrode et al., 2005; Carl et al., 2007; Evans, 1995a; Mowlavi et al., 2005; Purcell et al., 2000; Russell et al., 2003) and positioning the MP joint at 30, 45, or 50 in EAM protocols (Bulstrode et al., 2005; Mowlavi et al., 2005). Russell et al. (2003) compared 65 patients in IM and EPM but did not commence motion for the EPM group until Week 23, contrary to the standard practice of mobilizing the ngers by Day 5 after surgery (Evans, 1995b; Gelberman et al., 1982, 1991; Takai et al., 1991). The lack of comprehensive treatment guidelines in the literature has led to many

Early Passive Motion (n 5 8) Mean 133.3 197.7 247.8 Standard Deviation 17.2 39.0 22.1

Early Active Motion (n 5 11) Mean 187.9 248.8 266.2 Standard Deviation 41.3 39.4 19.8

Mean 109.8 178.4 239.9

Standard Deviation 52.1 42.3 24.8

At Week 6b At Week 12c

Note. TAM 5 Active (MCP 1 PIP 1 DIP) exion 2 Active (MP 1 PIP 1 DIP) extension. n 5 number of injured ngers; MCP 5 metacarpal phalangeal joint; PIP 5 proximal interphalangeal joint; DIP 5 distal phalangeal joint. a F(2, 21) 5 10.11, p 5 .002. bF(2,21) 5 5.29, p 5 .003. cF(2,21) 5 3.76, p 5 .004.

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variations in clinical treatment protocols and types of splints used by occupational therapists in their rehabilitation of extensor tendon injuries. The absence of detailed and uniform postoperative treatment protocols affects the clinicians ability to objectively measure outcomes. The treatment manual used was a detailed and comprehensive guide that facilitated uniformity of the clinical procedures for the protocols. The participating hospitals have continued to use this manual to train hand surgeons and therapists and as a guideline for further research in extensor tendon injuries. A simplied version of the document is provided in the Appendix (available online at www.ajot.ajotpress.net [navigate to this article, and click on supplemental materials]); a full version is available from the authors on request). This study has several limitations. In comparing the treatment groups, Type I or Type II error was a strong possibility because of the small samples in the IM and EPM groups. The a levels were adjusted to .017 to reduce the chance of Type I errors in repeated measures. Although TAM is widely accepted as a reliable indicator of tendon injury recovery, other measures of treatment effectiveness should also be considered. Therefore, we collected and analyzed self-reported function, grip strength, and extension lag but detected no between-group difference, which may be attributed to the small number of patients involved. The high attrition rate also posed another limitation. The study had 33% loss to follow-up. Similar compliance problems for the same age group in tendon repair rehabilitation have been reported (Carl et al., 2007; Hahn, Konig, & Weihs, 2003; Newport, 1998; Russell et al., 2003). Extensor tendon injury is common among young men, who can be a challenge to treat because of their noncompliance with the rehabilitation protocol (Khandwala et al., 2000). Ultimately, the patients goal is rapid return to work. Therefore, we recommend a clientbased, personalized approach that acknowledges clients life situations and meets their expectations with minimal disturbance to their functional performance and occupational role. Our study suggested that these young men would benet from the EAM protocols simpler splinting and effective exercise program. The mechanism of injury, occurrence of multipledigit involvement, complex and simple tendon injuries, associated injuries among patients, and dissimilarities in skills of treating therapists may have contributed to the variability of the outcome measures. Finally, only patients with Zones V and VI tendon injuries were included, so the clinical ndings are not applicable to other zones of injury. In conclusion, the EAM protocol using a palmar blocking splint may be benecial to patients with Zones V
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and VI extensor tendon injuries. A large prospective study should be conducted to conrm the pilot ndings. The treatment manual developed in this study can be a useful resource for occupational therapists working in extensor tendon rehabilitation. s

Acknowledgments
We sincerely thank the medical and allied health professionals of Sir Charles Gairdner Hospital, Royal Perth Hospital, Fremantle Hospital, and University of Western Australia. The research was supported by the Australian Hand Therapy Association Fund, Fremantle Hospital Fund, and Australian Physiotherapy Association Fund.

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