Evaluation of the role of unconjugated hyaluronic acid repetitive injection during the primary repair of flexor tendons in no man’s land: a randomized control trial
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Zone 2 flexor tendon injuries are prone to poor results following repair due to adhesions. Different repair methods and physiotherapy protocols have been devised to improve outcomes, with variable results. Hyaluronic acid (HA) is a polysaccharide produced by the innermost layer of the tendon sheath that facilitates gliding in zones where the sheath is continuous.
Sixty-two flexor tendons that were repaired using a double-stranded core suture were divided between groups A (n = 32) and B (n = 30). In the former, non-cross-linked HA was repeatedly instilled at the repair site, with a total of three injections per digit. The repair outcomes were assessed using the Strickland criteria, the ratio of total active motion to total passive motion (TAM/TPM), and active range of motion (AROM) for individual joints.
A total of 31.1% of group A patients had excellent to good outcomes in contrast to 13.3% in group B. The mean difference in TAM was 105° in group A and 71° in group B (p value ˂ 0.05). The mean TAM/TPM was 0.65 in group A and 0.56 in group B (p value = 0.06).
HA significantly improves the results of flexor tendon repair in zone 2.
Level of Evidence: I.
KeywordsZone 2 Hyaluronic acid Flexor tendons Adhesions Primary repair
Compliance with ethical standards
Omar Mohamed Nouh, Ahmed Safwat Salem, Youssif Ahmed Khachaba, Tarek Seif Eldin Ashour, and Khaled Makeen ElRefaei declare that they have no conflict of interest.
Ethical committee approval
Plastic surgery department, Cairo University, ethical committee approval was obtained prior to the study.
Informed consent was obtained from all patients enrolled in the study. The study included four minors in whom informed consent was acquired from their legal guardians. The consent included details of the preoperative measures, the operative procedure, and the postoperative treatment, including the physiotherapy program and potential complications. Patients or their legal guardians (in four cases) approved enrolment in the study and publication.
The authors did not receive any funding for the completion of this work.
- 2.Martin E. Flexor tendon injury, acute injuries. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH (ed.) Green’s operative hand surgery 7th edition, 2017. Churchill Livingstone/Elsevier. P. 189–201Google Scholar
- 3.Sinnatmby CS (2011) Wrist and hand, upper limb. In: Sinnatmby CS (ed) Last’s anatomy. Elsevier, Churchill Livingstone, pp 86–90Google Scholar
- 4.Bluman EM, Allen SD, Fadale PD (2006) Tendon repair and regeneration: an overview. In Walsh WR (ed.), Repair and regeneration of ligaments, tendons, and joint capsule. . Humana Press. P. 3:8Google Scholar
- 7.Seiler JG III.(2017) Flexor tendon injury. In Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS (ed.) Green’s operative hand surgery 7th edition; Elsevier. P. 183–230Google Scholar
- 12.Strickland JW (1985) Results of flexor tendon surgery in zone II. Hand Clin 1(1):167–179Google Scholar
- 14.St Onge R, Weiss C, Denlinger JL, Balazs EA (1980) A preliminary assessment of Na-hyaluronate injection into “no man’s land” for primary flexor tendon repair. Clin Orthop Relat Res (146):269–275Google Scholar
- 19.Thomas SC, Jones LC, Hungerford DS (1986) Hyaluronic acid and its effect on postoperative adhesions in the rabbit flexor tendon: a preliminary look. Clin Orthop (206):281–289Google Scholar
- 20.Gaughan EM, Nixon AJ, Krook LP, Yeager AE, Mann KA, Mohammed H, Bartel DL (1991) Effects of sodium hyaluronate on tendon healing and adhesion formation in horses. Am J Vet Res 52:764–773Google Scholar
- 21.Foland JW, Trotter GW, Powers BE, Wrigley RH, Smith FW (1992) Effect of sodium hyaluronate in collagenase-induced superficial digital flexor tendinitis in horses. Am J Vet Res 53:2371–2376Google Scholar