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      Practice Patterns in Operative Flexor Tendon Laceration Repair: A 15-Year Analysis of Continuous Certification Data from the American Board of Plastic Surgery

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          Background:

          The American Board of Plastic Surgery has been collecting practice data on operative repair of flexor tendon lacerations since 2006, as part of its Continuous Certification program.

          Methods:

          Data on operative repair of flexor tendon lacerations from 2006 to 2014 were reviewed and compared with those from 2015 to 2020. National practice trends observed in these data were evaluated and reviewed alongside published literature and evidence-based medicine.

          Results:

          In total, 780 patients with flexor tendon laceration injuries were included. Mean patient age was 38 years; mean time between tendon injury and first evaluation was 4 days, and the mean time from injury to operative repair was 12 days. Four-strand sutures remain the most common technique of tendon repair (57%). In the recent cohort, there were significant decreases in tourniquet use (94% versus 89%), general anesthesia (88% versus 74%), and monofilament sutures (44% versus 35%), with a significant increase reported in preserving the A1 pulley (20% versus 29%). Postoperative movement was described as “almost full range of motion” or “good” in 70% of cases, and 74% of patients were satisfied with their results. Postoperative adverse events were reported in 26% of cases, with the most common complications being tendon adhesions (14%) and rupture (3%).

          Conclusions:

          Review of The American Board of Plastic Surgery tracer data for operative repair of flexor tendon lacerations establishes a framework by which surgeons can evaluate how their current practice aligns with that of their peers, and whether their practice patterns remain current relative to recommendations from evidence-based medicine.

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          Most cited references86

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          A multicenter prospective study of 3,110 consecutive cases of elective epinephrine use in the fingers and hand: the Dalhousie Project clinical phase.

          To examine prospectively the incidence of digital infarction and phentolamine rescue in a large series of patients in whom local anesthesia with adrenaline was injected electively into the hand and fingers. There continues to be a commonly held belief that epinephrine injection is contraindicated in the finger despite a lack of valid evidence to support this concept in the literature. From 2002 to 2004 there were 9 hand surgeons in 6 cities who prospectively recorded each consecutive case of elective hand and finger epinephrine injection. They recorded each instance of skin or tissue loss and the number of times phentolamine reversal of adrenaline vasoconstriction was required. There were 3,110 consecutive cases of elective injection of low-dose epinephrine (1:100,000 or less) in the hand and fingers and none produced any instance of digital tissue loss. Phentolamine was not required to reverse the vasoconstriction in any patients. The true incidence of finger infarction in elective low-dose epinephrine injection into the hand and finger is likely to be remote, particularly with the possible rescue with phentolamine.
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            Clinical outcomes associated with flexor tendon repair.

            Review of the outcomes of clinical flexor tendon repairs reported over the past 15 years showed advances in the outcomes with excellent or good functional return in more than three fourths of primary tendon repairs following a variety of postoperative passive/active mobilization treatments. Strickland and Glogovac criteria are the most commonly adopted methods to assess function. Repair ruptures (4%-10% for zone II finger flexors and 3%-17% for the FPL tendon), adhesion formations, and stiffness of finger joints remain frustrating problems in flexor tendon repairs and rehabilitation. Four approaches are suggested to improve outcomes of the repairs and to solve these difficult problems,which include stronger surgical repairs, appropriate pulleys or sheath management, optimization of rehabilitation regimens, and modern biologic approaches.
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              Optimal time delay between epinephrine injection and incision to minimize bleeding.

              The time until maximal cutaneous vasoconstriction after injection of lidocaine with epinephrine is often given in textbooks and multiple choice examinations as 7 to 10 minutes. However, in our experience, there is significantly less cutaneous bleeding if one waits considerably longer than 7 to 10 minutes after injection of local anesthesia with epinephrine for most procedures on human skin.
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                Author and article information

                Journal
                Plast Reconstr Surg Glob Open
                Plast Reconstr Surg Glob Open
                GOX
                Plastic and Reconstructive Surgery Global Open
                Lippincott Williams & Wilkins (Hagerstown, MD )
                2169-7574
                07 October 2022
                October 2022
                : 10
                : 10
                : e4558
                Affiliations
                From the [* ]Division of Plastic Surgery, Ann and Robert H. Lurie Children’s Hospital, Chicago, Ill.
                []Division of Plastic Surgery, Mayo Clinic, Rochester, Minn.
                Author notes
                Joshua P. Weissman, BBA, Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, 420 East Ohio St, Apt 16F, Chicago, IL 60611, E-mail: joshpw@ 123456northwestern.edu
                Article
                00012
                10.1097/GOX.0000000000004558
                9542854
                9a54f746-591d-49c7-b371-74c68d8d9fd5
                Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

                History
                : 17 July 2022
                : 9 August 2022
                Categories
                Hand
                Original Article
                Custom metadata
                TRUE
                UNITED STATES

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