Early active mobilization after eight-strand flexor tendon repair using double-stranded sutures: Outcomes of a digitally supervised rehabilitation protocol in zones II–V

Flexor tendon injuries in zones II–V are challenging because of the risk of adhesions and rupture. Although early passive mobilization limits rupture, it often compromises the functional recovery. Recent approaches favor early active mobilization with strong, multi-stranded core sutures to enhance outcomes. This study evaluated early active mobilization after eight-strand core repair in a tertiary care setting. In this prospective study, 143 tendons from 30 patients who underwent surgery were followed up. The injured tendons were repaired using an eight-strand cross-locked cruciate technique with a double-stranded 4-0 suture, providing the tensile strength of eight strands with the same number of suture passes as in traditional four-core repairs, thereby reducing operative time without increasing bulk. Early active mobilization was initiated on postoperative day 2. The patients underwent digitally supervised physiotherapy and were monitored using a dedicated WhatsApp group, which enabled real-time guidance and compliance monitoring. The outcomes were measured in terms of total active motion, grip strength, pinch strength, time to return to work, postoperative pain, and complications. Of the 30 patients, 28 (93.3%) had fair-to-excellent outcomes, whereas only 2 (6.7%) had poor outcomes. Most patients (93.3%) returned to work within 12 weeks postoperatively. Four (13.3%) patients had complications, such as wound infection and skin necrosis. The patients showed significant changes in grip strength (45.2%) and pinch strength (70.7%) between weeks 8 and 12. No tendon ruptures were observed. The eight-core suturing technique used for flexor tendon repair withstood the forces of early active mobilization, which began on the second day after surgery, resulting in fair-to-excellent outcomes. It supports digitally supervised physiotherapy through app-based monitoring, enhancing patient compliance, and reducing reliance on in-person therapy sessions. This combination led to excellent functional recovery with minimal complications.