The impairments and functional outcomes of patients post flexor tendon repair of the hand at an academic hospital in Johannesburg, South Africa

Abstract

Background: Flexor tendon injuries (FTI) are common hand injuries for which optimal surgical and post-operative treatment has not yet been established. The variability in results is great, with good outcomes being achieved in specialised hands units in developed countries. Minimal research has been undertaken in developing countries, in particular South Africa, regarding flexor tendon repair (FTR) and the outcomes thereof. Purpose: The purpose of this study was to describe the demographic details of patients who sustained FTI and underwent FTR, to establish the range of movement (ROM), grip strength and hand function at six months post FTR as well as to determine the factors that affect the impairments and functional outcomes at six months post FTR. Method: The study was conducted at Chris Hani Baragwanath Academic Hospital (CHBAH), Soweto, South Africa between January 2013 and September 2015. One hundred and twenty six participants were recruited consecutively post FTR. Inclusion criteria: flexor tendon injury (in any zone, in any finger, with any associated injury), primary FTR performed at CHBAH and over the age of 14. Exclusion criteria: previous injury to the affected hand resulting in ROM or strength deficit, previous or current injury to the unaffected hand resulting in a ROM or strength deficit and tendon grafting or reconstruction (i.e. secondary repair) performed. At one, three and six months post FTR the ROM of the injured and contralateral finger(s) were measured. The Total Active Motion (TAM) classification system was applied to each affected digit and the average TAM determined for the participants' affected hand. At three and six months post FTR the participants' bilateral power and pinch grip strength were measured. The power and pinch grip strengths were calculated as a percentage of the unaffected hand. At three and six months post FTR participants performed the Jebsen Hand Function Test (JHFT) and a Quick Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was administered in an interview format. All assessments were done by the first author. Data were analysed using Stata version 14. Results: One hundred and twenty six participants (n=126) enrolled in the study. There was a drop out rate of 48%, leaving 65 participants that completed six months follow up, 41 males (63%) and 24 females (37%) aged 32 (SD±10, n=65). Out of 65 participants 2% (n=1) had an excellent outcome, 32% (n=21) had a good outcome, 32% (n=21) had a fair outcome and 34% (n=22) had a poor outcome with regards to TAM. At six months post FTR the average power grip was 60% (SD±25, n=65) of the unaffected hand while the average pinch grip was 52% (SD±42, n=65) of the unaffected hand. The average time taken for the JHFT at six months was 74 seconds (SD±33, n=65) for the non-dominant hand and 62 seconds (SD±54, n=65) for the dominant hand. The average score on the Quick DASH questionnaire was 19.34 (SD±16.89, n=65) at six months. Of the 41 participants who were employed prior to injury, 71% (n=29) had returned to work by six months post-surgery and scored an average of 15.89 (SD±23.74 n=24) on the Quick DASH work module. Sixty eight percent (n=44) of patients had post operative complications: the most common complication was tenodesis/adhesions (25%, n=16), followed by contracture (22%, n=14). There were only four patients who had ruptures (6%, n=4) in this sample. Eleven participants (17%) underwent further surgery. The factors found to significantly affect the impairments and functional outcome at six months post FTR include: age, zone of injury, associated injury, delay between injury and surgery, OT protocol used and language barrier. Conclusion: Although there were some promising outcomes, during this period, participants did not consistently achieve the good or excellent functional outcomes that are achieved in developed countries. More research needs to be conducted regarding the outcome of FTR in South Africa.