The Journal of Hand Surgery - European Volume - April 2018 - 6

Journal of Hand Surgery (Eur) 43(Supplement 1)

Delayed Primary Flexor Tendon Repairs: How Late
is Too Late?

Using Electronic PREMs and PROMS to Debunk the
Myth of Procedures of Limited Clinical Value

Ms Rehnuma Hossain and Mr Shekhar Srivastava
University Hospital Coventry and Warwickshire
Time in programme: Thursday 3rd May 2018 10:22

Professor David Warwick, Dr Harry Akerman and
Miss Olivia Halliday
University Hospital Southampton
Time in programme: Friday 4th May 2018 08:35

Objective: Within the UK, most flexor tendon injuries
are repaired within two weeks. There are patients
who present beyond that time, and are not given
the option of primary repair, as it is deemed ''too
late''. We present our experiences at one unit in a
major trauma centre over the past5 decades of
delayed primary repair of flexor tendons.
Methods: We present a series of 7 consecutive
patients who had primary flexor tendon repair and
discuss their outcome. A systematic review did not
find any papers on this subject.
Results: Our consecutive group of 7 patients, aged 24
- 77 years presented from 14to 78 days later. There
were a variety of mechanisms of injuries, though
most occurred in zone1. In all cases the wound was
healed or unidentifiable and the joints were mobile.
Exploration of finger showed that in all these cases
tendon ends could be dissected and stretched to
effect a primary repair using conventional techniques. We used a four strand repair or the Kessler
technique. Following repair active mobilisation was
used in all cases. No repairs ruptured during therapy.
5 patients in this series achieved good to excellent
results. One patient is still in therapy,while another
patient had surgery. One patient with a zone 1 injury
refused the offer of a tenolysis to attempt to improve
DIP flexion.
Conclusion: We recommend that all patients presenting with flexor tendon injury as late as 3
months be explored soon after their presentation to
see if a primary repair is possible. In many cases it
will be possible to repair the flexor tendon primarily
while in very late cases it may be necessary to insert
a silastic rod as a first stage of 2 stage tendon reconstruction although we did not have to do it. Additional
measures to facilitate a primary repair will be
discussed.

Background:
Patient related outcome measures (PROMs) and
Patient Relevant Outcome Measures (PREMs)
allow us to assess the clinical value of the procedures we perform.
Electronic systems increase the efficiency of data
collection.
Commissioners in England have imposed the
pejorative term ''Procedures of Limited Clinical
Value' (PLCV) on some hand surgery procedures.
Aim:
To debunk the term PCLV using an electronic
PROM and PREM system.
Methods: 755 Patients undergoing carpal tunnel
release (CTR), trigger digit release (TDR), finger ganglion excision (FGE)'wrist ganglion excision (WGE)
and fasciectomy (Fas) were assessed with the preoperative PROMs: QuickDASH, EQ5D and VAS pain.
Post-operatively at 6 months the patients were
posed by email link (Cellma, Riomed. UK) the same
PROMs together with three PREMs on an ordinal
scale
PREM 1: ''How are your problems related to your
hand now prepared to before surgery?''
PREM 2: How pleased are you with the result of your
surgery?''
PREM 3: ''If you could go back in time, would you still
have your hand operation?''
Results:
In all procedures the EQ5D remained unchanged
QuickDASH and VAS pain improvedin all
procedures
PREM 1: No problem atall/Much better: CTR
86%;TDR 73%;Fas 79%;FGE 88%;WGE 85%
PREM 2: Very pleased/fairly pleased: CTR
93%;TDR 91%;Fas 85%;FGE 91%;WGE 83%
PREM 3: Would have the procedure again: CTR
92%;TDR 98%;Fas 83%;FGE 81%;WGE 72%
Conclusion:
The EQ5D is not sensitive enough to be used as a
PROM.
QuickDASH and PREMs demonstrate the clinical
value of various hand surgery procedures
The term PLCV is not based on evidence. One
might conclude that the term is used to mask
health care rationing.

Table of Contents for the Digital Edition of The Journal of Hand Surgery - European Volume - April 2018