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Zone-II Flexor Tendon Repair: A Randomized Prospective Trial of Active Place-and-Hold Therapy Compared with Passive Motion Therapy
Thomas E. Trumble, MD1; Nicholas B. Vedder, MD1; John G. Seiler, III, MD2; Douglas P. Hanel, MD1; Edward Diao, MD3; Sarah Pettrone, MD4
1 Department of Orthopaedics, University of Washington Medical Center, Box 354740, 4245 N.E. Roosevelt Way, Seattle, WA 98105. E-mail address for T.E. Trumble: trumble@u.washington.edu
2 Georgia Hand and Microsurgery PC, 1819 Peachtree Road, Suite 425, Atlanta, GA 30309
3 450 Sutter Street, Suite 500, San Francisco, CA 94108
4 Commonwealth Orthopaedics, 19450 Deerfield Avenue, Suite 400, Leesburg, VA 20176
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Orthopaedic Research and Education Foundation. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

A commentary by James Chang, MD, and Armin Kraus, MD, is available at www.jbjs.org/commentary and as supplemental material to the online version of this article.
Investigation performed at the Department of Orthopaedics, University of Washington Medical Center, Seattle, Washington

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Jun 01;92(6):1381-1389. doi: 10.2106/JBJS.H.00927
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In order to improve digit motion after zone-II flexor tendon repair, rehabilitation programs have promoted either passive motion or active motion therapy. To our knowledge, no prospective randomized trial has compared the two techniques. Our objective was to compare the results of patients treated with an active therapy program and those treated with a passive motion protocol following zone-II flexor tendon repair.


Between January 1996 and December 2002, 103 patients (119 digits) with zone-II flexor tendon repairs were randomized to either early active motion with place and hold or a passive motion protocol. Range of motion was measured at six, twelve, twenty-six, and fifty-two weeks following repair. Dexterity tests were performed, and the Disabilities of the Arm, Shoulder, and Hand (DASH) outcome questionnaire and a satisfaction score were completed at fifty-two weeks by ninety-three patients (106 injured digits).


At all time points, patients treated with the active motion program had greater interphalangeal joint motion. At the time of the final follow-up, the interphalangeal joint motion in the active place-and-hold group was a mean (and standard deviation) of 156° ± 25° compared with 128° ± 22° (p < 0.05) in the passive motion group. The active motion group had both significantly smaller flexion contractures and greater satisfaction scores (p < 0.05). We could identify no difference between the groups in terms of the DASH scores or dexterity tests. When the groups were stratified, those who were smokers or had a concomitant nerve injury or multiple digit injuries had less range of motion, larger flexion contractures, and decreased satisfaction scores compared with patients without these comorbidities. Treatment by a certified hand therapist resulted in better range of motion with smaller flexion contractures. Two digits in each group had tendon ruptures following repair.


Active motion therapy provides greater active finger motion than passive motion therapy after zone-II flexor tendon repair without increasing the risk of tendon rupture. Concomitant nerve injuries, multiple digit injuries, and a history of smoking negatively impact the final outcome of tendon repairs.

Level of Evidence: 

Therapeutic Level I. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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