Prevention of adhesions in surgery of the flexor tendons of the hand: what is the evidence?

INTRODUCTION: Despite advances in knowledge and refinements of technique, the management of flexor tendon injuries within the digital sheath continues to present a formidable challenge. This in turn has led to a massive expansion in search of modified surgical therapies and various adjuvant therapies, which could prevent adhesion formation without compromising digital function. SOURCES OF DATA: A search of PubMed, Medline, CINAHL and Embase databases was performed using the keywords 'tendon adhesion prevention', 'tendon healing', 'adhesion prevention in tendons' and 'adjuvants for adhesion prevention'. Studies detailing the use of surgical, pharmacological and non-pharmacological agents for adhesion prevention in digital flexor tendons were identified, and their bibliographies were thoroughly reviewed to identify further related articles. This search identified 41 studies, which investigated the use of various pharmacological agents in adhesion prevention in digital tendons. AREAS OF AGREEMENT: There is a need to develop and utilize an optimal method for the prevention of adhesions in the flexor tendons of the hand, due to post-surgical complications. AREAS OF CONTROVERSY: Even though there have been significant advances in the prevention of adhesions in flexor tendons, it remains to be proved which, if any, of the current methods are the most beneficial. GROWING POINTS: The only thing that appears clinically justified in adhesion prevention is the need for early post-operative mobilization of digits after tendon injury or repair but the best method of mobilization remains controversial. AREAS TIMELY FOR DEVELOPING RESEARCH: Suggested changes in surgical techniques and various proposed pharmacological and non-pharmacological modalities need to withstand the test of adequately powered human trials, before their justification for potential benefit in clinical practice is accepted.