Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study.

The aim of this study was to compare an early active motion (EAM) regimen to a modified Kleinert passive motion therapy in Zone 2 flexor tendon injuries with regards to range of motion (ROM), grip strength and patient-reported outcome measures (PROMs). Seventy-two patients were included. At 3 months postoperatively, we found no difference in total active motion (TAM) between the EAM and the Kleinert groups (median 195.5°, range 115°-273° versus median 191.5°, range 113°-260°), but a significantly better grip strength (median 76%, range 44%-99% versus median 54%, range 19%-101%; p < 0.0005) in the EAM group. Disabilities of the Arm, Shoulder and Hand (DASH) score as well as patient-reported weakness, cold intolerance and problems in daily activities also favoured the EAM group. At 12 months postoperatively, there was no difference in TAM, grip strength or any of the PROMs used. We conclude that EAM leads to a quicker recovery in terms of grip strength and PROMs, but that both regimens lead to similar results at 12 months.Level of evidence: I.

Surgical Considerations for Flexor Tendon Repair: Timing and Choice of Repair Technique and Rehabilitation.

Flexor tendon injuries are common and occur mostly due to penetrating trauma. Surgical repair is required for complete tendon lacerations, and many techniques exist. This article reviews the principles of tendon structure, function, healing, and anatomy. Repair techniques are discussed in detail for each flexor tendon zone. Postoperative rehabilitation greatly influences outcomes, and several protocols are described.

Relative motion orthoses for early active motion after finger extensor and flexor tendon repairs: A systematic review.

BACKGROUND: The relative motion (RM) orthosis was introduced over 40 years ago for extensor tendon rehabilitation and more recently applied to flexor tendon repairs. PURPOSE: We systematically reviewed the evidence for RM orthoses following surgical repair of finger extensor and flexor tendon injuries including indications for use, configuration and schedule of orthosis wear, and clinical outcomes. STUDY DESIGN: Systematic review. METHODS: A PRISMA-compliant systematic review searched eight databases and five trial registries, from database inception to January 7, 2022. The protocol was registered prospectively (CRD42020211579). We identified studies describing patients undergoing rehabilitation using RM orthoses after surgical repair of acute tendon injuries of the finger and hand. RESULTS: For extensor tendon repairs, ten studies, one trial registry and five conference abstracts met inclusion criteria, reporting outcomes of 521 patients with injuries in zones IV-VII. Miller's criteria were predominantly used to report range of motion; with 89.6% and 86.9% reporting good or excellent outcomes for extension lag and flexion deficit, respectively. For flexor tendon repairs, one retrospective case series was included reporting outcomes in eight patients following zones I-II repairs. Mean total active motion was 86%. No tendon ruptures were reported due to the orthosis not protecting the repair for either the RME or RMF approaches. DISCUSSION: Variation was seen in use of RME plus or only, use of night orthoses and orthotic wear schedules, which may be the result of evolution of the RM approach. Since Hirth et al's 2016 scoping review, there are five additional studies, including two RCTs reporting the use of the RM orthosis in extensor tendon rehabilitation. CONCLUSIONS: There is now good evidence that the RM approach is safe in zones V-VI extensor tendon repairs. Limited evidence currently exists for zones IV and VII extensor and for flexor tendon repairs. Further high-quality clinical studies are needed to demonstrate its safety and efficacy.

Early active movement with relative motion flexion splint for the management of zone 1-2 flexor tendon repairs: Case series.

BACKGROUND: There is limited literature evidence on the use of relative motion flexion splint after flexor tendon repairs. OBJECTIVES: We aimed to report the clinical use of early active movement with a relative motion flexion splint and to determine the outcomes of a consecutive series in patients with zone 1-2 flexor tendon repair. METHODS: We included 14 patients with one-stage flexor tendon repair. An active rehabilitation program was initiated in the first week with a static dorsal block splint, which was removed in the third week, and patients started to use the relative motion flexion splint. Total active motion (TAM) of the injured finger at 8, 12, and 16 weeks after surgery was assessed as described by Strickland and Glogovac. RESULTS: The mean TAM of the injured fingers was as follows: 102.5 ± 41.49° (25°-180°) at week 8; 123.42 ± 40.94° (45°-190°) at week 12; and 148 ± 38.18° (90°- 200°) at week 16. Final TAM grades of the patients at week 16 were as follows: excellent (six patients); good (five patients); and fair (three patients). There were no tendon ruptures and secondary surgeries. CONCLUSION: Early active movement and the use of relative motion flexion splint seem to be promising strategies for flexor tendon zone 1-2 repair management.

Effect of a Text Message-Based Support Program on Outcomes of Patients After Flexor Tendon Injury Repair.

PURPOSE: Although the effectiveness of using text messages in home-based rehabilitation programs has been investigated, its ability to engage patients in home rehabilitation exercises and, as a result, improve hand outcomes, specifically in patients with flexor tendon injuries, has not been evaluated. The aim of this study was to determine whether the addition of a text message-based intervention to usual care is effective in improving hand outcomes in patients with flexor tendon injuries after repair. METHODS: In this 2-arm parallel randomized controlled trial, 40 patients were randomly assigned to either the intervention group (usual care plus the support program) or the control group (usual care only). Intervention included an automated package of instructional text messages containing links to a secure website for instructional rehabilitation videos delivered over 12 weeks. The Quick Disabilities of the Arm, Shoulder, and Hand and visual analog scale for pain scores were assessed at 6 and 12 weeks. Physician-reported grip strength and total active motion were assessed after 12 weeks. RESULTS: The study was completed by 90% (36 of 40) of the patients who were enrolled. There were statistically significant differences between the 2 groups with respect to Quick Disabilities of the Arm, Shoulder, and Hand and visual analog scale scores at the 6-week and 12-week assessments. In addition, there were statistically significant differences between the 2 groups with respect to total active motion and grip strength at 12 weeks. Finally, a high level of satisfaction with the intervention was reported. CONCLUSIONS: The text message-based program was associated with improved outcomes over the first 12 weeks after flexor tendon repair. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.

Simplified prosthetic rehabilitation of a patient with partial finger amputation after a firearm injury.

OBJECTIVE: This study reports a clinical case of rehabilitation of a patient who had her left little finger amputated at the mesial phalanx because of a gunshot wound. The finger prosthesis was custom- made using a silicone. CASE DESCRIPTION: This study presents a clinical case of a female patient who had her left little finger amputated at the mesial phalanx because of a gunshot wound in 2016. The patient was attended at a reference center in maxillofacial rehabilitation in the city of Brasilia, Distrito Federal, Brazil, for the manufacture of a finger prosthesis. After molding, a finger waxing was obtained using the right little finger as a template. The waxing was later adjusted on the plaster model of the affected stump. The prosthesis was manufactured with silicone and intrinsically stained with a makeup powder. A water-based adhesive and a ring were used to generate a slight compression so that the prosthesis was retained on the stump. OUTCOMES: The rehabilitation showed satisfactory levels of stability, retention, and aesthetics, and it was usable and clinically acceptable, as observed in a follow-up appointment in February 2020. CONCLUSIONS: The complete or partial reestablishment of functions performed by important structures, such as the fingers, is essential to increase the quality of life of individuals, improving their performance of daily activities. In addition, reporting on this public health problem allows scientific advancement in the area.

Ultrasonographic assessment in vivo of the excursion and tension of flexor digitorum profundus tendon on different rehabilitation protocols after tendon repair.

STUDY DESIGN: Interpretive description study. PURPOSE: In management of patients with flexion tendon injuries, passive, control active and active motion protocols were proposed after repair to minimize tendon adhesion. The purpose of this study was to compare the excursion distance and the tension of Flexor Digitorum Profundus (FDP) during simulated active and passive motion using ultrasonography techniques using normal subjects. METHODS: Ultrasonographic assessment of FDP tendon of the middle finger was performed at the wrist level on 20 healthy college students using 3 types of treatment protocols: modified Kleinert protocol, modified Duran protocol, and active finger flexion protocol. The excursion distance was measured following the musculotendinous junction of FDP using the B mode ultrasound system. The elasticity of FDP tendon was measured using the shear wave elastography technique. The excursion distance and the elasticity value were compared among 3 protocols using one-way ANOVA analysis. RESULTS: Twelve male and 8 female students with mean age of 22.6 ± 1.8 years were invited to join the study. The excursion distance of FDP was 21.82 ± 3.77 mm using the active finger flexion protocol, 8.59 ± 2.59 mm using the modified Duran protocol, and 12.26 ± 2.71 mm using the modified Kleinert protocol. The elasticity was significantly higher in extension position when compared to passive flexion positions, but found lower than active flexion position. DISCUSSION: The active finger protocol was found to require strongest tension of the tendon and with longest excursion. There was similar tension generated using both passive motion protocols. The modified Duran protocol appeared to create less excursion upon movements than the modified Kleinert approach using the objective ultrasonic evaluation. It is suggested that if the surgical repair was strong and without any complications, the active flexion protocol might work best to regain tension excursion. However, if there are complex problems involved, then the Kleinert approach or Duran approach would be chosen.

Functional outcomes of a modified Duran postoperative rehabilitation protocol after primary repairs of pediatric hand flexor tendon injuries.

The objective of this study was to determine whether pediatric patients undergoing flexor tendon repair who underwent 4 weeks of immobilization followed by a modified Duran controlled passive motion rehabilitation protocol will have favorable outcomes. A study was performed at a tertiary pediatric hospital of patients <18 years who underwent primary flexor tendon repairs in zones 1-4. Outcomes were calculated by total active motion and classified by the original Strickland criteria or Buck-Gramcko criteria. Twenty-eight patients with 34 injured fingers were included. Mean age was 11.4 years (range 2.4-17.9) with 17 males (61%) and 11 females (39%). Thirty-five percent of injuries occurred in zone 1; 35% zone 2; 6% zone 3; and 24% zone 4. All underwent a modified Duran postoperative rehabilitation protocol following a period of immobilization. The majority of patients achieved favorable outcomes, with 86% of cases classified as good/excellent. Thirty (88%) cases received surgery acutely (within 3 weeks). Of these, 70% achieved excellent outcomes, 17% good, and 13% fair. Four (12%) chronic cases underwent primary repair (range 24-68 days), achieving excellent outcomes in 50%, good in 25%, and fair in 25%. Three (75%) patients with delayed primary repair exhibited stiffness, which was greater than the 17% of patients with acute repairs ( P = 0.03). Approximately 1 month of immobilization followed by a modified Duran rehabilitation protocol leads to favorable outcomes in children with flexor tendon repairs. Children with delayed surgery (>3 weeks) who underwent primary repair generally still achieved good outcomes but were more likely to have stiffness. Level of evidence: III.

Management and outcomes of flexor tendon repairs at a peripheral hospital: a New Zealand case series study.

BACKGROUND: Current evidence for flexor tendon repair management and outcomes performed at peripheral centres is unclear. Most studies are based on evidence from specialist hand centres. This study evaluated a peripheral hospital in New Zealand; where all flexor tendon repairs were performed by a generalist Orthopaedic service. The purpose of the study was to benchmark management and outcomes from a peripheral hospital in comparison to international standards. METHODS: A retrospective single-centre consecutive case series of Zones I and II flexor tendon repairs was extracted between 1 January 2014 and 1 January 2018. Medical records were used to evaluate management and outcomes of repairs. Hand therapy notes were used to evaluate rehabilitation protocols provided. The primary objective was to measure re-rupture and re-operation rates. Secondary objectives included auditing operative management and hand therapy compliance. RESULTS: Forty-six patients (76 tendon repairs) were included in our final analysis. Mean follow up time to last clinical appointment was 11.8 weeks, and to last patient episode was 4.9 years. Most patients received timely surgery with a four-core repair using 3-0 or larger suture. All hand therapy followed a controlled active motion protocol. The re-operation rate was 19.6% (P = <0.05) and the re-rupture rate was 8.7% (P = 0.28). CONCLUSIONS: Most flexor tendon injuries at this peripheral centre were managed according to international standards. However, high complication rates including re-operation and re-rupture occurred. Due to a lack of local comparison studies, confounding factors cannot be excluded as a contributor for these results.

Outcomes of Early and Intensive Use of a Palm and Digit Extension Orthosis in Young Children After Burn Injury.

Burns to the palmar aspect of the hand are prevalent in young children. The development of scar tissue across the flexor surface of the hand combined with the years of growth ahead may result in considerable complications. This study was undertaken to describe outcomes of early and intensive use of a palm and digit extension orthosis with the elbow immobilized at 90° flexion following a palmar hand burn. A retrospective review of 107 children (mean age 18 months [SD 10]) treated at a statewide Pediatric Burns Unit from 2012 to 2016 was performed. Three children (3%) developed contracture during the 24-month study follow-up period. The other 104 children (97%) had full ROM at 24 months or at either the point of discharge or loss to follow-up. Early signs of contracture, defined as loss of full movement or significant banding, developed in 26 children (24%) in the first 9 months after burn. With intensive physiotherapy, 23 children regained full movement by 12 months after burn. Children who did not achieve complete wound healing at 1 month after burn and children with hypertrophic scarring at 2 months after burn were significantly more represented among cases of early signs of contracture (P = .013). When undertaken with regular clinical review, early and intensive use of a palm and digit extension orthosis can maintain full extension of the palm and digits in children after palmar burn.

A smartphone application to facilitate adherence to home-based exercise after flexor tendon repair: A randomised controlled trial.

OBJECTIVE: Evaluate the effect of a smartphone application on exercise adherence, range of motion and self-efficacy compared to standard rehabilitation after repair of the flexor digitorum profundus tendon. DESIGN: Prospective multi-centre randomised controlled trial. SETTING: Four hand surgery departments in Sweden. SUBJECTS: A total of 101 patients (35 women) (mean age 37.5 ± 12.8) were randomised to control (n = 49) or intervention group (n = 52). INTERVENTION: A smartphone application to facilitate rehabilitation. MAIN OUTCOME MEASURES: Adherence assessed with the Sport Injury Rehabilitation Adherence Scale at two and six weeks (primary outcome). Secondary outcomes were self-reported adherence in three domains assessed at two and six weeks, self-efficacy assessed with Athlete Injury Self-Efficacy Questionnaire at baseline, two and six weeks. Range of motion and perceived satisfaction with rehabilitation and information were assessed at 12 weeks. RESULTS: Twenty-five patients were lost to follow-up. There was no significant between group difference in Sport Injury Rehabilitation Adherence Scale at two or six weeks, mean scores (confidence interval, CI 95%) 12.5 (CI 11.8-13.3), 11.8 (CI 11.0-12.8) for the intervention group, and 13.3 (CI 12.6-14.0), 12.8 (CI 12.0-13.7) for the control group. Self-reported adherence for exercise frequency at six weeks was significantly better for the intervention group, 93.2 (CI 86.9-99.5) compared to the controls 82.9 (CI 76.9-88.8) (P = 0.02). There were no differences in range of motion, self-efficacy or satisfaction. CONCLUSION: The smartphone application used in this study did not improve adherence, self-efficacy or range of motion compared to standard rehabilitation for flexor tendon injuries. Further research regarding smartphone applications is needed. LEVEL OF EVIDENCE: I. Randomised controlled trial.

Advantages and Limitations of Leap Motion from a Developers', Physical Therapists', and Patients' Perspective.

BACKGROUND: Physical rehabilitation exergames (PREGs) are suitable for motivating patients toward completing treatments. Leap Motion (LM) is a motion sensor that may be useful for developing PREGs targeted at hands and fingers rehabilitation. Therefore, knowing the advantages and limitations of LM is relevant to understand under which conditions this sensor may be suitable. OBJECTIVE: In this article, we present a qualitative study to identify the main advantages and limitations of LM for PREGs. METHODS: We collect data using interviews with a group of PREGs developers, physical therapy experts, and patients. We employ the thematic analysis method to analyze the collected data. RESULTS: We found that the advantages and limitations of LM are related to (1) the role as PREG development tool that enables hand movements detection, (2) the capability to be a mobile and easy-to-use capturing technology, and (3) the contribution to add value in rehabilitation therapy by motivating physical therapists and patients to use PREGs. CONCLUSION: The analysis shows that LM is a suitable and cost-effective solution for developing usable PREGs for some hand and finger rehabilitation movements with a moderate development effort. However, the development maturity of LM poses limitations related to reliability and robustness, preventing the use of LM as a standalone physical rehabilitation tool. Our findings serve as guidelines for developers and physical therapists during the development and use of PREGs targeted at hands and fingers, guiding the decision-making process during feasibility analysis and design stages.

Tenolysis rate after zone 2 flexor tendon repairs.

OBJECTIVES: This study aims to evaluate the tenolysis rates of zone 2 flexor digitorum profundus (FDP) with flexor digitorum superficialis (FDS) tendon repairs using four-strand technique and early passive motion exercises. PATIENTS AND METHODS: In this retrospective study, we performed zone 2 flexor tendon repairs in 149 patients (117 males, 32 females, mean age 33.3±12.9 years; range, 13 to 72 years) (82 right and 67 left hands) between November 2014 and January 2019. A total of 194 FDP and FDS tendons were repaired primarily by using modified Kessler and Bunnell methods. Patients underwent pure passive motion protocols after surgery according to modified Duran's protocol. No active flexion components were added until postoperative fourth week. RESULTS: Twenty-three out of 149 patients and 28 out of 194 fingers (14.43%) had tenolysis. There was no significant relationship between the number of operated fingers, gender, and tenolysis rate (p=0.836, p=0.584, respectively). CONCLUSION: The repair of the FDP with FDS tendon increases the tenolysis rate in zone 2. The tenolysis rate does not change according to the number or distribution of injured fingers and gender of the patient.

[Postoperative treatment and rehabilitation following flexor tendon injuries]. / Weiterbehandlung und Rehabilitation nach Beugesehnenverletzungen.

BACKGROUND: The ideal surgical and postoperative treatment for flexor tendon injuries, especially in zone 2, is still subject to continuous modifications and professional discussions. OBJECTIVE: Presentation of established rehabilitation concepts, specific problems and new treatment approaches with practical recommendations for application. MATERIAL AND METHODS: Comparison of commonly used treatment concepts by assessing surgical flexor tendon repair, splint choice and clinical application in patients. Discussion of new surgical approaches and standards and their influence on postoperative therapy after flexor tendon injuries. RESULTS: The Washington regimen has retained its status as the standard in the current follow-up treatment of flexor tendon injuries. New suture materials and techniques enable early active rehabilitation of sutured flexor tendons with good clinical results, such as increased range of motion for interphalangeal joint extension and improved distal interphalangeal joint flexion with overall acceptable frequencies of suture rupture. CONCLUSION: A stable tendon repair with smooth gliding is the foundation for treatment after flexor tendon injuries. After intraoperative active digital extension-flexion testing of the sutured tendon an early active rehabilitation approach should follow. New splint designs in combination with primary stable tendon suture techniques have the potential to improve the postoperative outcome, presupposing a reliable cooperation of the patient.

Use of a relative motion flexion orthosis for postoperative management of zone I/II flexor digitorum profundus repair: A retrospective consecutive case series.

STUDY DESIGN: A retrospective, single-center, consecutive case series. INTRODUCTION: In concept, a relative motion flexion (RMF) orthosis will induce a "quadriga effect" on a given flexor digitorum profundus (FDP) tendon, limiting its excursion and force of flexion while still permitting a wide range of finger motion. This effect can be exploited in the rehabilitation of zone I and II FDP repairs. PURPOSE OF THE STUDY: To describe the use of RMF orthoses to manage zone I and II FDP 4-strand repairs. METHODS: Medical record review of 10 consecutive zone I and II FDP tendon repairs managed with RMF orthosis for 8 to 10 weeks in combination with a static dorsal blocking or wrist orthosis for the initial 3 weeks. RESULTS: Indications included sharp lacerations (n = 6), ragged lacerations (n = 2), staged flexor tendon reconstruction (n = 1), and type IV avulsion (n = 1). In 8 of the 10 cases that completed follow-up, the mean arc of proximal interphalangeal/distal interphalangeal active motion were as follows: sharp, 0° to 106°/0° to 75°; ragged, 0° to 90°/0° to 25°; reconstruction, 0° to 90°/10° to 45°; and avulsion, 0° to 95°/0° to 20°. Grip performance available for 6 of 10 cases was 62% to 108% of the dominant hand. There were no tendon ruptures, secondary surgeries, or proximal interphalangeal joint contractures. CONCLUSION: Based on this small series, the RMF approach appears to be safe and effective. It can lead to similar mobility and functional recovery as other early active motion protocols, with certain practical advantages and without major complications. Further investigation with larger, multicenter, prospective, longitudinal cohorts and/or randomized clinical trials is necessary.

Replantation of Nine Fingers in a Patient: A case report.

Amputation of multiple fingers of both hands is a rare and serious injury. We report a case of a 41-year-old male patient who presented to Khoula Hospital, Muscat, Oman, in 2015 with the amputation of nine fingers due to a workplace injury. With two teams working in tandem, all the amputated fingers were re-attached. A total of seven fingers survived and the patient regained reasonable functionality of his hands. To the best of the authors' knowledge, this is the first case of several finger amputations in Oman.

Postsurgical Rehabilitation of Flexor Tendon Injuries.

Rehabilitation after surgical repair of flexor injuries is a controversial topic. Motion at the repair site decreases risk for adhesions but increases risk for rupture. We review the current concepts behind various rehabilitation protocols based on zone of injury and the evidence behind each.

Postoperative Management and Rehabilitation of the Replanted or Revascularized Digit.

Postoperative care of amputated digits begins before replantation. Detailed informed consent should be obtained and completion amputation discussed if revascularization is not ultimately successful. Complications and failure of the replanted digit should also be addressed. Postoperative pharmacologic treatment should consist of aspirin, at minimum. Complications, such as venous congestion or occlusion, and arterial thrombosis, should be dealt with expediently. Digital motion rehabilitation should start after 5 to 7 days of digital viability and splinting of the affected digit. Early protective motion protocol is implemented to maintain digital motion with emphasis on tendon glide and joint motion.

Patient-Reported and Functional Outcomes After Revision Amputation and Replantation of Digit Amputations: The FRANCHISE Multicenter International Retrospective Cohort Study.

Importance: Optimal treatment for traumatic digit amputation is unknown. Objective: To compare long-term patient-reported and functional outcomes between patients treated with revision amputation or replantation for digit amputations. Design, Setting, and Participants: Retrospective cohort study at 19 centers in the United States and Asia. Participants were 338 individuals 18 years or older with traumatic digit amputations with at least 1 year of follow-up after treatment. Participants were enrolled from August 1, 2016, to April 12, 2018. Exposures: Revision amputation or replantation of traumatic digit amputations. Main Outcomes and Measures: The primary outcome was the Michigan Hand Outcomes Questionnaire (MHQ) score. Secondary outcomes were the 36-Item Short Form Health Survey (SF-36), Disabilities of the Arm, Shoulder, and Hand (DASH), and Patient-Reported Outcomes Measurement Information System (PROMIS) upper-extremity module scores and functional outcomes. Results: Among 338 patients who met all inclusion criteria, the mean (SD) age was 48.3 (16.4) years, and 85.0% were male. Adjusted aggregate comparison of patient-reported outcomes (PROs) between patients with revision amputation and replantation revealed significantly better outcomes in the replantation cohort measured by the MHQ (5.93; 95% CI, 1.03-10.82; P = .02), DASH (-4.29; 95% CI, -8.45 to -0.12; P = .04), and PROMIS (3.44; 95% CI, 0.60 to 6.28; P = .02) scores. In subgroup analyses, DASH scores were significantly lower (6 vs 9, P = .05), indicating less disability and pain, and PROMIS scores higher (78 vs 75, P = .04) after replantation. Patients with 3 or more digits amputated (including thumb) had significantly better PROs after replantation than those managed with revision amputation (22 vs 42, P = .03 for DASH and 61 vs 36, P = .01 for PROMIS). Patients who underwent replantation after 3 or more digits amputated (excluding thumb) had higher MHQ scores, which did not reach statistical significance (69 vs 65, P = .06). Revision amputation in the subgroup with single-finger amputation distal to the proximal interphalangeal joint resulted in better 2-point discrimination (6 vs 8 mm, P = .05). Compared with revision amputation, replantation resulted in better 9-hole peg test times in the subgroup with 3 or more digits amputated (including thumb) (46 vs 81 seconds, P = .001), better Semmes-Weinstein monofilament test in the subgroup with 3 or more digits amputated (excluding thumb) (3 vs 21 g, P = .008), and better 3-point pinch test in the subgroup with 2 digits amputated (excluding thumb) (6.7 vs 5.6 kg, P = .03). Conclusions and Relevance: When technically feasible, replantation is recommended in 3 or more digits amputated and in single-finger amputation (excluding thumb) distal to the proximal interphalangeal joint because it achieved better PROs, with long-term functional benefit. Thumb replantation is still recommended for its integral role in opposition.