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Avoiding Flexor Tendon Repair Rupture with Intraoperative Total Active Movement Examination

Higgins, Amanda B.Sc.O.T.; Lalonde, Donald H. M.D.; Bell, Michael M.D.; McKee, Daniel B.Sc.; Lalonde, Jan F. R.N., C.P.S.N.

Plastic and Reconstructive Surgery: September 2010 - Volume 126 - Issue 3 - p 941-945
doi: 10.1097/PRS.0b013e3181e60489
Hand/Peripheral Nerve: Original Articles

Background: Wide-awake flexor tendon repair in tourniquet-free unsedated patients permits intraoperative Total Active Movement examination (iTAMe) of the freshly repaired flexor tendon. This technique has permitted the intraoperative observation of tendon repair gapping induced by active movement when the core suture is tied too loosely. The gap can be repaired intraoperatively to decrease postoperative tendon repair rupture rates. The authors record their rupture rate in the first 15 years of experience with iTAMe.

Methods: This was a retrospective chart review of 102 consecutive patients with wide-awake flexor tendon repair (no tourniquet, no sedation, and pure locally injected lidocaine with epinephrine anesthesia) in which iTAMe was performed by two hand surgeons in two Canadian cities between 1998 and 2008. Intraoperative gapping and postoperative rupture were analyzed.

Results: The authors observed intraoperative bunching and gap formation with active movement in flexor tendon repair testing (iTAMe) in seven patients. In all seven cases, they redid the repair and repeated iTAMe to confirm gapping was eliminated before closing the skin, and those seven patients did not rupture postoperatively. In 68 patients with known outcomes, four of 122 tendons ruptured (tendon rupture rate, 3.3 percent) in three of 68 patients (patient rupture rate, 4.4 percent). All three patients who ruptured had accidental jerk forced rupture. All those patients who did what we asked them did not rupture.

Conclusions: Tendons can gap with active movement if the core suture is tied too loosely. Gapping can be recognized intraoperatively with iTAMe and repaired to decrease postoperative rupture.

Saint John, New Brunswick, and Ottawa, Ontario, Canada

From Saint John Regional Hospital, Dalhousie University, and Ottawa University.

Received for publication January 10, 2010; accepted February 23, 2010.

Presented at the 2010 Annual Meeting of the American Association for Hand Surgery, in Boca Raton, Florida, January 6 through 11, 2010.

Disclosures: Dr. Lalonde is a consultant for ASSI instruments, which has no bearing on the contents of this article. None of the other authors has any financial disclosures to report.

Donald H. Lalonde, M.D., Hilyard Place, Suite C204, 600 Main Street, Saint John, New Brunswick E2K 1J5, Canada,

©2010American Society of Plastic Surgeons