Achieving balance in tendon repair

Abstract

Purpose:

Achieving balance in tendon repair is essential for restoring optimal function after tendon injuries, particularly in the hand and upper limb. We review and discuss key steps of ‘balanced’ flexor and extensor tendon repair and rehabilitation.

Flexor tendon repair:

To achieve optimal outcomes of tendon repair, the surgeon needs to consider the balance between mechanical strength and tendon nutrition. Strong multi-strand repairs provide security against gapping and rupture, but overly tight or running epitenon sutures may impair synovial and blood supply to epitenon. Pulley venting in zone 2 is another balance: too little venting risks the repair catching or rupturing, while too much venting risks bowstringing. In the wide-awake setting, intraoperative excursion testing shows the ideal venting length that allows a solid repair to glide freely without clinically significant bowstringing.

In contaminated wounds, delayed repair avoids the risk of infection. Primary repairs are possible 1–2 weeks after injury, and even very late repairs can succeed if strong multi-strand core sutures are used and tension is carefully balanced. Repair tension should be sufficient to ensure that tendon ends are in close contact with slight bulkiness at the repair site to ensure a solid repair that allows early active digital motion.

Extensor tendon repair and rehabilitation:

Extensor tendon injuries proximal to the fingers also require balance between protection and movement. Immobilization risks stiffness, while early relative motion splinting with strong repairs allows safer functional use or early active motion exercise. Pain-guided active mobilization and patient education further help maintain glide without rupture.

Conclusion:

Successful treatment requires a balance of various aspects of the repair process, including anatomical prerequisites, surgical techniques and rehabilitation strategies, through a multifaceted approach that encompasses careful surgical planning, accurate surgical repairs, optimal therapy protocol design and patient engagement.