Is conservative management of partial zone II flexor tendon laceration possible? A systematic literature review and meta-analysis

Figures & data

Figure 1. Search strategy. From Moher D, Liberati A, Tetzlaff J, Altman DG. The PRISMA group. Preferred Reporting Items for Systematic Reviews and Meta-analyses: the PRISMA statement. PLoS Med. 2009;6:e1000097. For more information, visit www.prisma-statement.org.

Table 1. Inclusion and exclusion criteria.

Inclusion criteria

Articles published until 2021 with no limitation on the start of the publication year Articles written in English Original articles and randomized controlled or clinical trials or observational, cross-sectional, or cohort studies A full-text version of the article is available Studies included a sample population of children who can obey to rehabilitation protocol (age ≥6 years) Studies included a sample population of participants diagnosed with zone II flexor tendon laceration Studies including ≥1 of the following outcome measures: Total arc of motion angle measurement Final outcome of the capability of touching the distal palmar crease in composite flexion (i.e. total active flexion) Active flexion angles of each finger at each joint were measured, and the lack of normal extension in degrees was subtracted from the flexion. The range of motion for the distal interphalangeal, proximal interphalangeal and metacarpophalangeal joints were added together to give the total active motion. Studies had a sample size of ≥10 Studies included the number of participants lost to follow-up

Exclusion

Articles published after December 2021 Articles written in a language other than English Studies that were not an original article or randomized controlled trial Review articles, discussions or abstracts Studies that included participants aged <6 years, cadavers, or animals Studies that included treatments for other conditions (i.e. other than partial zone II flexor tendon injury) Studies with a sample size of <10 Studies did not include information regarding the individual treatment groups Studies did not specify the number of participants lost to follow-up Meta-analyses and reviews

Table 2. Treatment characteristics, outcome measures and corresponding results, including complications.

Author, year, country	No. of patients (M/F)	No. of partially lacerated tendon	Age (year, range)	CSA < 50%	50 ≤ CSA < 75%	CSA ≥ 75%	Mean cross sectional area of partially lacerated tendon (%)	Study type	Outcome	Complications	Mean follow-up, months (range)
Wray and Weeks [12] USA	26	34	NR	6	17	11	60	Observational study	Excellent 24 Good 1 Fair 0 Poor 0	Only 1 complication: mild triggering finger which resolved spontaneously over 2 months	NR
McGeorge and Stilwell [10], England	14	18	28.3	6	12	0	54	Cohort study	Excellent 14 Good 0 Fair 0 Poor 0	No complications	22.2 (2.5–40)
Stahl et al. [11], Israel	12 (8/4)	19	7.4	13	6	0	40	Observational study	Excellent 11 Good 1 Fair 0 Poor 0	Only 1 complication: mild local infection	18.3
al-Qattan [15], Saudi Arabia	15 (13/2)	17	35.0	0	7	10	71	Observational study	Excellent 14 Good 1 Fair 0 Poor 0	No complications	26
Wray et al. [6], U.S.A	17	20	25.0 (10–46)	3	11	6	60	Observational study	Excellent 16 Good 0 Fair 1 Poor 0	No complications	NR

NR: not recorded.

Table 3. The revised and validated version of MINORS [16].

Methodological items for non-randomized studies

Score^a

A clearly stated aim: the question addressed should be precise and relevant in the light of available literature. Inclusion of consecutive patients: all patients potentially fit for inclusion (satisfying the criteria for inclusion) have been included in the study during the study period (no exclusion or details about the reasons for exclusion). Prospective collection of data: data were collected according to a protocol established before the beginning of the study. Endpoints appropriate to the aim of the study: unambiguous explanation of the criteria used to evaluate the main outcome which should be in accordance with the question addressed by the study. Also, the endpoints should be assessed on an intention-to-treat basis. Unbiased assessment of the study endpoint: blind evaluation of objective endpoints and double-blind evaluation of subjective endpoints. Otherwise the reasons for not blinding should be stated. Follow-up period appropriate to the aim of the study: the follow-up should be sufficiently long to allow the assessment of the main endpoint and possible adverse events. Loss to follow up less than 5%: all patients should be included in the follow up. Otherwise, the proportion lost to follow up should not exceed the proportion experiencing the major endpoint. Prospective calculation of the study size: information of the size of detectable difference of interest with a calculation of 95% confidence interval, according to the expected incidence of the outcome event, and information about the level for statistical significance and estimates of power when comparing the outcomes. Additional criteria in the case of comparative study An adequate control group: having a gold standard diagnostic test or therapeutic intervention recognized as the optimal intervention according to the available published data. Contemporary groups: control and studied group should be managed during the same time period (no historical comparison). Baseline equivalence of groups: the groups should be similar regarding the criteria other than the studied endpoints. Absence of confounding factors that could bias the interpretation of the results. Adequate statistical analyses: whether the statistics were in accordance with the type of study with calculation of confidence intervals or relative risk.

^a The items are scored 0 (not reported), 1 (reported but inadequate) or 2 (reported and adequate). The global ideal score being 16 for non-comparative studies and 24 for comparative studies.

Figure 2. The forest plot of included studies. It can be seen that the large intra-study variance is the paper published in 1992 by DD McGeorge and Stilwell and the paper published in 2000 by al-Qattan et al., and the large inter-study variance is the paper published in 1992 by McGeorge and Stilwell and the paper published in 1977 by Wray et al.

Figure 3. The funnel plot. In general, small-scale studies are distributed widely at the bottom, and large-scale studies are distributed narrowly at the top of the funnel. In this plot, there are one distribution to the left and four distributions to the right outside the funnel.

Wray RC Jr, Weeks PM. Treatment of partial tendon lacerations. Hand. 1980;12(2):163–166.

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McGeorge DD, Stilwell JH. Partial flexor tendon injuries: to repair or not. J Hand Surg Br. 1992;17(2):176–177.

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Stahl S, Kaufman T, Bialik V. Partial lacerations of flexor tendons in children. Primary repair versus conservative treatment. J Hand Surg Br. 1997;22(3):377–380.

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al-Qattan MM. Conservative management of zone II partial flexor tendon lacerations greater than half the width of the tendon. J Hand Surg Am. 2000;25(6):1118–1121.

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Wray RC Jr, Holtman B, Weeks PM. Clinical treatment of partial tendon lacerations without suturing and with early motion. Plast Reconstr Surg. 1977;59(2):231–234.

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Slim K, Nini E, Forestier D, et al. Methodological Index for Non-randomized Studies (MINORS): development and validation of a new instrument. ANZ J Surg. 2003;73(9):712–716.

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Data availability statement

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