Features of surgical treatment for primary injury to the flexor tendons of the three-phalangeal fingers in the second zone: a retrospective cohort study

Introduction Three-phalanx finger flexor tendon injuries in the fibrous-osseous canals of the fingers represent a complex orthopedic problem requiring multifaceted treatment. The functional outcome of flexor tendon reconstruction depends on the surgical strategy, timely provision of necessary rehabilitation support, and patient compliance. Failure to adopt a comprehensive approach to treating patients with this injury often leads to poor clinical and functional outcomes.

The purpose was to determine key surgical and rehabilitation factors that have impact on the outcomes of primary reconstruction of the flexor tendons of the three-phalangeal fingers in the second zone.

Materials and Methods We analyzed the postoperative results of 100 patients who underwent primary reconstruction of the deep flexor tendon of one three-phalangeal finger after damage to both flexor tendons in zone 2 according to the Verdan classification. These included finger function using the Strickland criteria and the Boyes – Lister scale, and clinical and functional assessment of the limb using the validated DASH and MHQ scales. The impact of patient morphological characteristics, anatomical topography of the injury, surgical strategy, and rehabilitation protocol on postoperative outcome was assessed.

Results A statistically significant improvement in function was found according to the Strickland criterion with a surgical incision size not exceeding 1.5 phalanx lengths (p < 0.05). Functional results with the use of a four-thread 3/0 intrasegmental suture and a six-thread 3/0 suture according to the Strickland criterion and the Boyes Lister scale were statistically significantly better (p < 0.05). Poor results according to the Strickland criterion were observed statistically significantly more often in the absence of rehabilitation than with any type of rehabilitation (p < 0.05). Suture ruptured more frequently without rehabilitation (p < 0.001) than if rehabilitation with a hand therapist was provided.

Discussion The obtained results both differ from the published ones in the literature and confirm some parameters. The use of fouror six-thread 3/0 tendon suture configurations and a rehabilitation protocol with a specialist improves functional outcomes in the treatment of flexor tendon injuries of the triphalangeal fingers and reduces the risk of suture rupture. Combined flexor tendon and digital nerve injuries do not show functionally significant differences compared to isolated tendon injuries.

Conclusion A retrospective cohort analysis identified key surgical and rehabilitation factors that influence the outcomes of primary zone 2 flexor tendon reconstruction of the three-phalangeal fingers: the configuration and caliber of the intra-articular suture, the size of the surgical incision, and the availability and type of rehabilitation provided. These factors significantly had a significant impact on the clinical and functional outcomes of treatment.

1. Malishevskij VM, Paskov RV, Sergeev KS. Sergeev K.S. Comparative analysis of hand function after surgical repair of finger flexor tendons. N.N. Priorov Journal of Traumatology and Orthopedics. 2025;32(3):586-594. (In Russ.) doi: 10.17816/vto634380.

2. Weber EV, Zavyalov AP, Avdeev AI, et al. The structure of the number of patients seeking medical help and methods of treating them with hand and wrist joint injuries at the R.R. Vreden National Medical Research Center of Traumatology and Orthopedics. Traumatology and Orthopedics of Russia. 2024;30(4):92-100. (In Russ.) doi: 10.17816/2311-2905-17608.

3. Tang JB, Lalonde D, Harhaus L, et al. Flexor tendon repair: recent changes and current methods. J Hand Surg Eur Vol. 2022;47(1):31-39. doi: 10.1177/17531934211053757.

4. Malishevsky VM, Paskov RV, Sergeev KS. Comparative experimental study of biomechanical features of suture materials in tendon repair. Genij Ortopedii. 2024;30(1):99-106. doi: 10.18019/1028-4427-2024-30-1-99-106.

5. Berezina PA, Zolotov AS, Volykhin RD, et al. Rozov and Kessler tendon sutures: general properties and differences. Traumatology and Orthopedics of Russia. 2022;28(3):167-175. doi: 10.17816/2311-2905-1975.

6. Xu H, Huang X, Guo Z, et al. Outcome of Surgical Repair and Rehabilitation of Flexor Tendon Injuries in Zone II of the Hand: Systematic Review and Meta-Analysis. J Hand Surg Am. 2023;48(4):407.e1-407.e11. doi: 10.1016/j.jhsa.2021.11.013.

7. Xue R, Wong J, Imere A, et al. Current clinical opinion on surgical approaches and rehabilitation of hand flexor tendon injury – a questionnaire study. Front Med Technol. 2024;6:1269861. doi: 10.3389/fmedt.2024.1269861.

8. Stevens KA, Caruso JC, Fallahi A-KM, Patiño JM. Flexor Tendon Lacerations. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.

9. Zenchenko AV, Chernyakova YuM. Technology of temporary isolation of the deep flexor digitorum tendon and patient management with delayed suture in the second zone. Genij Ortopedii. 2019;25(3):290-296. doi: 10.18019/1028-4427-2019-25-3-290-296.

10. Kiseleva AN, Nakonechny DG, Sudyakova MYu, Kalashnikova MR. Factors influencing the result of treatment of patients with injury of the flexor tendons. Modern problems of science and education. 2022;(1). (In Russ.) doi: 10.17513/spno.31485.

11. Ovsyannikova AD. Rehabilitation and postoperative management after flexor tendon repair. Issues of Reconstructive and Plastic Surgery. 2018;(2):62-73. (In Russ.) doi 10.17223/1814147/65/08.

12. Renberg M, Turesson C, Borén L, et al. Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study. J Hand Surg Eur Vol. 2023;48(8):783-791. doi: 10.1177/17531934231166336.

13. Pearce O, Brown MT, Fraser K, Lancerotto L. Flexor tendon injuries: Repair & Rehabilitation. Injury. 2021;52(8):2053- 2067. doi: 10.1016/j.injury.2021.07.036.

14. Shaw AV, Holmes DG, Rodrigues JN, et al. Outcome measurement in adult flexor tendon injury: A systematic review. J Plast Reconstr Aesthet Surg. 2022;75(4):1455-1466. doi: 10.1016/j.bjps.2021.08.033.

15. Mawhinney JA, Wormald JC, Ng M, et al. Epidemiology of acute flexor tendon injury and an analysis of outcomes - a study of 91,239 patients in England and Wales. J Hand Surg Eur Vol. 2025;50(11):1470-1477. doi: 10.1177/17531934251342419.

16. Svingen J, Arner M, Turesson C. Patients' experiences of flexor tendon rehabilitation in relation to adherence: a qualitative study. Disabil Rehabil. 2023;45(7):1115-1123. doi: 10.1080/09638288.2022.2051081.

17. McLaughlin MT, Moura SP, Edalatpour A, et al. Insurance Status Predicts Hand Therapy Adherence following Flexor Tendon Repair: A Retrospective Cohort Study. Plast Reconstr Surg. 2024;153(5):942e-951e. doi: 10.1097/PRS.0000000000010702.

18. Kaskutas V, Powell R. The impact of flexor tendon rehabilitation restrictions on individuals' independence with daily activities: implications for hand therapists. J Hand Ther. 2013;26(1):22-28. doi: 10.1016/j.jht.2012.08.004.

19. Powell RK, von der Heyde RL. The inclusion of activities of daily living in flexor tendon rehabilitation: a survey. J Hand Ther. 2014;27(1):23-29. doi: 10.1016/j.jht.2013.09.007.

20. Keane G, Stonner M, Pet MA. Does Digital Nerve Injury Affect Range of Motion Recovery After Zone 2 Flexor Tendon Repair? Hand (N Y). 2023;18(2):230-235. doi: 10.1177/15589447211003187.

21. Isaacs J, Eswaran S, Ilyas A, et al. Digital Nerve Repair With Flexor Tendon Injury: Conduits are Less Effective. Hand (N Y). 2025:15589447251406917. doi: 10.1177/15589447251406917.

22. Sanal-Toprak C, Yigit O, Kuzu Z, Baysal O. Effect of hand dominance on functional outcomes in paediatric patients with flexor tendon injuries: A cross-sectional study. Int J Clin Pract. 2021;75(8):e14323. doi: 10.1111/ijcp.14323.

23. Shaharan S, Bage T, Ibrahim N, et al. Rupture Rates Between 2-Strand and 4-Strand Flexor Tendon Repairs: Is Less More? Ann Plast Surg. 2020;84(1):43-46. doi: 10.1097/SAP.0000000000002113.

24. Hardwicke JT, Tan JJ, Foster MA, Titley OG. A systematic review of 2-strand versus multistrand core suture techniques and functional outcome after digital flexor tendon repair. J Hand Surg Am. 2014;39(4):686-695.e2. doi: 10.1016/j.jhsa.2013.12.037.

25. Neiduski RL, Powell RK. Flexor tendon rehabilitation in the 21st century: A systematic review. J Hand Ther. 2019;32(2):165-174. doi: 10.1016/j.jht.2018.06.001.