Measurement of range of motion of the finger after flexor tendon repair in zone II of the hand

The purpose of this study was to compare classification systems of active range of motion of the finger after flexor tendon surgery in zone II of the hand. Active range of motion of 20 fingers

(16 subjects) was classified according to five systems. Agreement between the systems was only fair. Strickland’s original system and the Louisville system rated the results most strictly, followed

by Strickland’s adjusted system. Buck-Gramcko’s systems (in centimeters and degrees) rated the results least strictly. Strickland’s systems conformed most closely to measurement principles. This article concludes that at this time Strickland’s original classification system is preferable for scientific and clinical purposes. However, additional research is needed to evaluate reliability of the measurement, the variability of the scaling factor of 175 degrees, the sensitivity of the measurement, and the validity of the measurement with regard to functional use of the finger and gliding of the repaired tendon. (J HAND SURG 1993;18A:411-7.)

Caroline W. Stegink Jansen, MS, PT, and Mary G. Watson, MBA, PhD, Houston, Texas

T he treatment of flexor tendon injuries in zone II of the hand continues to be a subject of intense research. Results are measured by a variety of classi- fication systems and measurement techniques. Studies report that results measured by various systems are not comparable. I-6

The purposes of this study were (1) to quantify dif- ferences between existing classification systems, (2) to

determine a preferred system of measurement of finger joint motion, and (3) to suggest research needed to complete development of the measurement.

Full flexion of the finger in the metacarpophalangeal (MP), proximal interphalangeal (PIP), and distal inter- phalangeal (DIP) joints into a complete fist and exten-

From the School of Physical Therapy and the Department of Psy-

chology and Philosophy, Texas Woman’s University, Houston,

Texas.

This research was supported by a grant from NIDRR, NIDRR

40341.

Received for publication June 17, 1992; accepted in revised form

Oct. 30, 1992.

No benefits in any form have been received or will be received from

a commercial party related directly or indirectly to the subject of

this article.

Reprint requests: Caroline W. Stegink Jansen, MS, PT, Texas

Woman’s University, School of Physical Therapy, 1130 M. D.

Anderson Blvd., Houston, TX 77030.

311144486

sion of the finger in the same joints is commonly used

to evaluate active range of motion (AROM) of the finger

after flexor tendon surgery in the hand. However, dif- ferent systems measure, record, and classify motion of

the finger differently. Six commonly used classification systems have

emerged in the literature. Buck-Gramcko2 (Table I) offers two systems: Flexion

of the injured finger is measured either goniometrically

or in centimeters by determining the distance between the tip of the finger and the palm of the hand. Extension of the finger is measured in degrees of motion. Hy-

perextension in the MP, PIP, and DIP joints is not considered. The system consists of a summation of points for the degree of flexion, extension deficit, and

excursion of the finger and classifies the results in four categories: excellent, good, fair, and poor.

The Louisville system’ (Table II) measures flexion of the injured finger by determining the minimal dis-

tance between the pulp of the finger and the distal pal- mar crease in centimeters. The extension deficit is mea- sured in degrees as the angle between the metacarpal and the distal phalanx. Hyperextension of the MP, PIP, and DIP joints is not considered. The Louisville system classifies the results in four categories: excel- lent, good, fair, and poor.

The Committee on Tendon Injuries’ proposed a sys- tem, based on total active range of motion (TAM) of

412 Jansen and Watson The Journal of

HAND SURGERY

Table I. Buck-Gramcko’s classification system

Measurement

Combined flexion (cm/degrees)

o.o-2.5/?200

2.5-4.0/~180

4.0-6.O/s150

>6.0/<150

Table III. Strickland’s original and adjusted classification system*

Extension deficit (degrees)

O-30

31-50

51-70

>70

Excursion (degrees)

2160

2140

2120

<I20

Rating

Excellent

Good

Fair

Poor

14, 15

11-13

7-10

O-6

Table II. The Louisville classification system

Flexion deficit (cm) I - ~~ Extensron dejcit (degrees)

Grade 1 cl.0 Grade 1 cl5

Grade 2 cl.5 Grade 2 15< x <30

Grade 3 <3.0 Grade 3 30< x <50

Raring Score Excellent Flexion deficit and extension deficit grade 1

Good Both deficits at most grade 2

Fair Both deficits at most grade 3

Poor Either deficit worse than grade 3

the finger.’ Flexion of the MP, PIP, and DIP joints of the involved fingers was measured in degrees, as were extension deficits in these joints. TAM resulted from the summation of llexion of the MP, PIP, and DIP joints minus the extension deficits. Hyperextension and ex-

tension deficits were considered abnormal, and these values were deducted from the extension value. TAM was measured preoperatively and expressed as a per- centage of the same measure taken from the contralat-

era1 unaffected finger. The procedure was repeated post- operatively. The preoperative value was deducted from the postoperative value, and a percentage of improve- ment was obtained. A system of classification of the AROM of the involved finger was recommended: (1) excellent-normal; (2) good-TAM greater than 75% of the normal side; (3) fair-TAM greater than 50%

Excellent 85-100 150 + Excellent 75- 100 132;

Good 70-84 125-149 Good 50-74 88-131

Fair 50-69 90-124 Fair 25-49 44-87 Poor <50 <go Poor <25 <44

*(PIP + DIP) flexion - (PIP + DIP) extension deficit

175 degrees x loo =

% of normal active PIP + DIP motion.

of the normal side; (4) poor-TAM less than 50% of the normal side; and (5) worse-TAM worse than be-

fore surgery. The Committee warned that there is no universally normal TAM value. Unfortunately, the clas- sification of excellent was not numerically defined,

which restricts clinical and statistical use of this system.

Strickland’s two systems (Table III) were simplifi- cations of the TAM system.“, ” According to his ex- perience, the motion of the MP joint was usually not affected after flexor tendon injury in zone II of the hand.

Therefore he postulated that measurement of the MP joint biased the measurement of the functional result. A system was proposed whereby the flexion of the PIP and DIP joints was measured in degrees and summed. Extension deficits in these joints were measured in de- grees, summed, and deducted from the flexion mea- surements. Hyperextension was considered abnormal but was not included in the measurement. The total flexion minus the extension deficit was then compared with a theoretical finger in which this value would be

175 degrees. A codification system developed in 1980” classified the motion of the involved finger (in degrees of motion as well as in a percentage score compared with 175 degrees) into four categories: excellent, good, fair, and poor. The codification of this system was ad- justed in 1985.” The difference between StricMand’s original system and the adjusted system exists only in the definition of the categories, not in what is being measured.

This study compared five classification systems: the Buck-Gramcko system in degrees and in centimeters,* the Louisville system,’ and the two systems by Strick- land.‘“* ” The system proposed by the Committee on

Vol. 18A, No. 3 May 1993 Finger ROM after flexor tendon repair in zone II 413

Tendon Injuries* could not be included in the statistical analysis, since the excellent category was not numer-

ically defined. Two questions were asked: (1) To what extent do the five systems agree when evaluating the same injured fingers? (2) Are some systems stricter in the classification of the outcomes than other systems? The scientific hypotheses stated that (1) there was agree- ment among classifications by the five systems and (2) there was a systematic difference in the classification of the finger by the five systems. The level of signifi- cance was set at 0.05.

Method

Subjects. Sixteen subjects with 20 injured fingers participated in the study. The subjects ranged in age from 19 to 52 years (mean, 33 years; standard deviation, 8 years). Patients were approached by mail and invited to return to the clinic for evaluation. Ten subjects un- derwent surgical repair of the flexor digitorum profun- dus (FDP), and 10 subjects had surgical repair of the FDP and flexor digitorum supeticialis (FDS).

Procedures. Goniometric measurements of the MP, PIP and DIP joints” were taken when the subject was (1) making a complete fist and (2) extending the finger

of interest. The wrist and the forearm were placed in a neutral position, and this position was maintained throughout the goniometric measurements. Also, the

distance between the pulp of the finger and the distal palmar crease was measured. For this measurement, the wrist was placed in a neutral position and the forearm was placed in full supination as illustrated by Cam- bridge.” All measurements were performed by the same therapist. The AROM of the affected finger(s) of each subject was classified according to the systems of Buck- Gramcko, the adjusted and original classification of Strickland, and the Louisville system. Strickland’s clas-

sifications based on percentage scores were used for the statistical analyses.

Statistical analyses. Kappa was calculated to quan- tify agreement among all five systems as a whole and between each pair of systems. I3 Kappa ranges from 0 (no agreement) to 1 (complete agreement) and indicates agreement, adjusted for agreement that would exist on the basis of chance alone. Significance means that kappa is significantly different from zero.

Sign tests evaluate whether differences in classifi- cation are random or systematic.13 A significant sign test indicates that differences are systematic; that is, one system consistently rates the outcome more strictly than another system.

Results

Active flexion of the MP joints ranged from 84 to 105 degrees (mean, 92 degrees; standard deviation, 6 degrees). Total tlexion in MP, PIP, and DIP joints ranged from 158 to 295 degrees (mean, 218 degrees; standard deviation, 36 degrees). There was no extension deficit in the MP joints. The combined extension def- icits of the PIP and DIP joints ranged from 0 to 48 degrees (mean, 26 degrees; standard deviation, 17 de- grees). The summed flexion of PIP and DIP joints minus the extension deficits at the same joints ranged from 33 to 179 (mean, 99; standard deviation, 45 degrees).

Classifications by the five systems are presented in Table IV. The overall kappa for five classification sys- tems was 0.25 (p < 0.001). Significant agreement ex- isted among only three of the ten possible pairs of classification systems: (1) between the Louisville sys- tem and Strickland’s original system (K = 0.57); (2) between Buck-Gramcko’s system in degrees and in cen-

timeters (K = 0.56); and (3) between the adjusted sys- tem of Strickland and Buck-Gramcko’s system in cen- timeters (K = 0.37).

Table V summarizes the ratings by the five systems and lists the most frequently occurring score for each system (mode). Sign tests were significant for all pos- sible pairs of systems, except for the Louisville system and Strickland’s original system (p < 1.0) and for Buck-Gramcko’s two systems (p < 0.06). The Louis- ville and Strickland’s original systems classified 14 of the 20 fingers the same. Of the remaining fingers, three were classified more strictly by the Louisville system and three were classified more strictly by Strickland’s original system. Classification differed by only one cat-

egory in all except one case. Buck-Gramcko’s two sys- tems rated 15 fingers the same. The remaining five fingers were all rated more strictly by the system in centimeters.

Discussion

The five classification systems of the AROM of the finger after surgical repair of flexor tendon injuries in zone II of the hand do not agree. Agreement among all five systems was significantly different from zero, but the level of agreement (K = 0.25) was only fair.14 These findings support concerns that results classified by different systems are not comparable. The qualitative interpretation of the outcome after surgical intervention depends on the rating system being used. Even the highest agreement (between the Louisville system and Strickland’s original system) was 0.57, which,

414 Junsen and Watson The Journal of

HAND SURGERY

Table IV. Classifications according to five classification systems of active range of motion of 20 fingers after surgical repair of flexor tendon(s) in zone II of the hand

Subject

Buck- Gramcko

measured in centimeters

Buck- Gramcko

measured in degrees

Adjusted Strickland

% Degrees

Original Strickland

% Degrees Louisville

1 Good

2 Excellent

3 Poor

4 Excellent

5 Good

6 Poor

7 Poor

8 Excellent

9 Excellent

10 Fair

11 Excellent

12 Excellent

13 Good

14 Fair

15 Excellent

16 Excellent

17 Fair

18 Excellent

19 Excellent

20 Excellent

Excellent

Excellent

Poor

Excellent

Good

Poor

Fair

Excellent

Excellent

Fair

Excellent

Excellent

Excellent

Good

Excellent

Excellent

Excellent

Excellent

Excellent

Excellent

Good

Good

Poor

Good

Fair

Poor

Fair

Excellent

Excellent

Fair

Fair

Excellent

Good

Fair

Excellent

Good

Fair

Good

Good

Good

Good

Good

Poor

Good

Fair

Poor

Fair

Excellent

Excellent

Fair

Fair

Excellent

Good

Fair

Excellent

Good

Fair

Good

Good

Good

Good

Fair

Poor

Fair

Poor

Poor

Poor

Excellent

Excellent

Poor

Poor

Good

Good

Poor

Excellent

Fair

Poor

Fair

Fair

Good

Fair

Fair

Poor

Fair

Poor

Poor

Poor

Excellent

Excellent

Poor

Poor

Good

Good

Poor

Excellent

Fair

Poor

Fair

Fair

Fair

Fair

Fair

Poor

Fair

Poor

Poor

Poor

Excellent

Excellent

Poor

Fair

Excellent

Poor

Fair

Excellent

Fair

Poor

Fair

Fair

Fair

Table V. Summary table

Buck-Gramcko Buck-Gramcko Adjusted Strickland Original Strickland

(cm) (degree) % Degrees % Degrees Louisville

Excellent 11 14 4 4 3 3 4

Good 3 2 8 8 4 2 0

Fair 3 2 6 6 5 7 9

Poor 3 2 2 2 8 8 I

Mode Excellent Excellent Good Good Poor Poor Fair

Numbers in the table reflect the number of subjects in a category.

Table VI. Comparison of six measurement systems of AROM of the finger after flexor tendon surgery in

the hand based on measurement theory

Measurement system Unit of score Highest level of

measurement Qualitafive

categories defined Possible ambiguous

results

Buck-Gramcko (cm)

Buck-Gramcko (degrees)

Strickland (adjusted)

Strickland (original)

Louisville

Committee on Tendon

Injuries

Category

Category

Degrees, percentage,

category

Degrees, percentage,

category

Category

Degrees, percentage,

category

Ordinal

Ordinal

Ratio

Ratio

Ordinal

Ratio

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

Yes

Vol. 18A, No. 3

May 1993 Finger ROM after jexor tendon repair in zone II 415

according to Landis and Koch,14 is only mod- improved treatment methods, both clinically and in the

erate . laboratory.

Fortunately, there is a systematic pattern to the dif- ferences in the ratings among the five systems: Results are rated most strictly by Strickland’s original system and the Louisville system, followed by Strickland’s adjusted system. The systems by Buck-Gramcko (in centimeters and in degrees) classify results least

strictly. Even though there is a consensus about what to mea-

sure after flexor tendon surgery, there is controversy on how to measure the motion of the finger optimally and in an unambiguous manner. Many controversies can be resolved by applying principles from measure-

ment theory (Table VI). Measurement techniques that use the highest level of

measurement, resulting in scores such as percentages, degrees, or centimeters (ratio data), are preferred over techniques that result in scores in categories of excel- lent, good, etc. (ordinal data). Ratio data are more precise and allow for the use of more powerful statistical techniques. Ratio data can be transformed to ordinal data, but not vice versa. l3 Buck-Gramcko’s systems and the Louisville system of assigning points or grades to flexion and extension deficits result in a total score that can be expressed only in categories (ordinal data). Strickland’s two systems and the system proposed by the Committee on Tendon Injuries result in total scores expressed in degrees of motion or percentages (ratio data). These systems therefore provide scientifically preferred data.

Two aspects of the classification have been debated: (1) exclusion of measurement of the MP joint’, I0 and (2) use of the standard reference.* Strickland’s report” that motion of the MP joint was usually not limited

after flexor tendon surgery was supported in our group of patients. McGrouther and Ahmed” found that motion of up to 60 degrees in the MP joint did not move the FDP and FDS tendons in zone II of the hand in a cadaver study and in vivo in one case study. Excluding mea- surement of the motion of the MP joint therefore prob- ably does not result in a loss of discriminative power.

Mallon et al., I6 found that TAM increased from the

index finger to the more ulnarly located fingers in 60 normal subjects. Increase in TAM was directly

attributable to the increase in MP flexion in the more ulnar fingers. Exclusion of the measurement of the MP joint during measurement of the complete fist position thus adds to the stability of the measurement for all

fingers.

Strickland’s systems are preferable over the system proposed by the Committee on Tendon Injuries because they allow clinicians to make qualitative interpretations. In the system of the Committee on Tendon Injuries, the excellent category is not clearly numerically defined. Also, use of the system of the Committee on Tendon Injuries results in an ambiguous score inasmuch as both hyperextension and a lack of extension of the MP, PIP, and DIP joints are considered a deficit and are deducted from the TAM. Two fingers with a different appearance can thus achieve the same score.

It has been debated whether a standard should be used for qualitative interpretation of the motion of the involved finger. Some systems use no reference.2, ’

Strickland’s systems”, I’ use a standard of 175 degrees, and the system by the Committee on Tendon Injuries* uses the uninvolved contralateral finger of the patient.

However, an uninvolved normal contralateral finger is not always available. Strickland’s system is preferable

because it provides comparison with a norm, and the availability of a normal contralateral finger is not a prerequisite for the measurement. If a normal contra- lateral finger is available, AROM of this finger can be compared with the 175-degree standard to determine whether the patient’s finger is more or less mobile than the standard. The percentage score of the contralateral finger can then serve as a basis for clinicians to set individual treatment objectives for the patient.

On the basis of measurement theory principles, Strickland’s systems are preferred at this time. They result in a ratio level of measurement, categories are clearly defined, and the results are unambiguous. In our opinion, Strickland’s original system is preferred

over the adjusted system because its stricter rating of the outcome tends to set higher clinical goals and is therefore most likely to inspire continued search for

Continued research is needed to complete develop-

ment of the measure. Values reported by Mallon et al. I6 for the scaling factor of 175 degrees ranged from 169 to 176 degrees. Even though these values were close to the standard score of 175 degrees proposed, further research is needed to investigate the central tendency and the variability of this score in a variety of popu- lations .

Further discussion is needed to decide whether and how hyperextension at the MP, PIP, or DIP joints should be reflected in the classification of the finger after flexor tendon surgery. In guidelines provided by the American

416 Jansen and Watson The Journal of

HAND SURGERY

Medical Association, hyperextension is added to the extension value, l9 which would eliminate the ambiguity

in the score but possibly alter the standard score of 175 degrees.

Even though reliability estimates have been estab- lished for ROM measurement of individual finger joints I8 the reliability of the system as a whole has not been investigated.

Sensitivity of the measure has not been investigated. Scientifically, Strickland’s original system has been used successfully to find differences between groups of patient treated with different surgical and rehabilitative methods. 19-** However, other measurement techniques, such as measurement of the ratio between AROM and passive range of motion of the injured finger22 or mea- surement of the PIP and DIP excursion while extension is maintained in the MP joint,23 may be more sensitive than the technique used in Strickland’s original clas- sification system.

Further investigations of validity are needed to add meaning to the measurement of AROM of the finger and to the qualitative categories. The relationship be- tween the gliding of intact flexor tendons has been in- vestigated in cadavers and in vivo15, 24 for various hand positions, but further research is needed to relate deficits in AROM of the involved finger to deficits in gliding of the repaired tendon(s) at the location of the repair. Functional meaning needs to be added to AROM mea- surements by relating lack of motion of the involved finger to other aspects of functional performance, such as the capability to apply pressure during grip strength**. *’ and the patient’s own evaluation of the postoperative function of the finger.26 Perhaps most im- portant, it needs to be related to lack of function during the wide variety of common activities of daily living, including work and leisure activities.27

Optimal function of the patient as a whole after sur- gical repair of flexor tendon(s) in zone II of the hand remains the main concern of both the clinician and the scientist. Reliable, valid, sensitive, and unambiguous measurement of the motion of the finger in a manner universally accepted by health care providers will con- stitute a major cornerstone in the total assessment of the patient.

The Houston Hand Rehabilitation Center, Inc., Houston, Texas, provided assistance with regard to the data collection from patients treated at their facilities. Dorit Haenosh Aaron, MA, OTR, and Scott M. Hasson, EdD, PI, FACSM, are acknowledged for valuable comments during manuscript

preparation.

REFERENCES

1. Strickland JW. Flexor tendon surgery. J HAND SURG

1989;14B:261-72.

2. Buck-Gramcko D, Dietrich FE, Gogge S. Bewertungs-

kriterien bei Nachuntersuchungen von Beugesehnen- wiederherstellungen. Handchirurgie 1976;8:65-9.

3. Chow JA, Thomes LJ, Dovelle S, Milnor WH, Seyfer

AE, Smith AC. A combined regimen of controlled mo-

tion following flexor tendon repair in “no man’s land.” Plast Reconstr Surg 1987;79:447-55.

4. Small JO, Brennen MD, Colville J. Early active mobi-

lization following flexor tendon repair in zone 2. J HAND SURG 1989;14B:383-91.

5. Bunker TD, Potter B, Barton NJ. Continuous passive

motion following flexor tendon repair. J HAND SURG

1989;14B:406-11.

6. Gelberman RH, Nunley JA II, Osterman L, Breen TF,

Dimick MP, Woo SL-Y. Influences of the protected passive mobilization interval on flexor tendon healing. Clin Orthop 1991;264:189-96.

7. Lister GD, Kleinert HE, Kutz JE, Atasoy E. Primary

flexor tendon repair followed by immediate controlled mobilization. J HAND SURG 1977;2:441-51.

8. Kleinert HE, Verdan C. Report of the Committee on

Tendon Injuries. J HAND SURG 1983;8:794. 9. American Society for Surgery of the Hand: Clinical As-

sessment Committee Report. 1976. 10. Strickland JW, Glogovac V. Digital function following

flexor tendon repair in zone II: a comparison of immo- bilization and controlled passive motion techniques. J HAND SURG 1980;5:537-43.

11. Strickland JW. Results of flexor tendon surgery in zone

II. Hand Clin 1985;1:167-79. 12. Cambridge C. Range of motion measurement. In: Hunter

JM, Schneider LH, Mackin EJ, eds. Rehabilitation of

the hand. 3rd ed. St Louis: CV Mosby, 1990:82-94. 13. Siegel S, Castellan NJ Jr. Nonparametric statistics for

the behavioral sciences. 2nd ed. New York: McGraw-

Hill, 1988:284-91, 80-7, 23-36. 14, Landis JR, Koch GG. The measurement of observer

agreement for categorical data. Biometrics 1977;33:159-

74. 15. McGrouther DA, Ahmed MR. Flexor tendon excursions

in “no man’s land.” Hand 1981;13:129-41. 16. Mallon WJ, Brown HR, Nunley JA. Digital ranges of

motion: normal values in young adults. J HAND SURG

1991;16A:882-7. 17. American Medical Association. Guides to the evaluation

of permanent impairment. 3rd ed (revised). 1990:18. 18. Hamilton GF, Lachenbruch PA. Reliabilities in goni-

ometers in assessing finger joint angle. Phys Ther

1969;49:465-9. 19. Nielsen AB, Jensen PO. Primary flexor tendon repair in

“no man’s land.” J HAND SURG 1984;9B:279-81.

Vol. 18A, No. 3 May 1993 Finger ROM after jexor tendon repair in zone II

20. Creekmore H, Bellinghausen H, Young VL, Wray RC, Weeks P, Grasse PS . Comparison of early passive motion and immobilization after flexor tendon repairs. Plast Re- constr Surg 1985;75:75-9.

21. Amadio PC, Hunter JM, Jaeger SH, Wehbe MA, Schnei- der LH. The effect of vincular injury on the results of flexor tendon surgery in zone 2. J HAND SURG 1985;lOA:626-32.

22. Stegink Jansen CW, Minerbo G. A comparison between early dynamically controlled mobilization and immobi- lization. J Hand Ther 1990;1:20-5.

23. Rank BK, Wakefield AR. The repair of flexor tendons in the hand. Br J Plast Surg 1951;4:244-53.

24. Wehbe MA, Hunter JM. Flexor tendon gliding in the hand. Part 2. Differential gliding. J HAND SURG 1985;lOA:575-9.

25. Gault DT. Reduction of grip strength, finger flexion pres- sure, finger pinch pressure and key pinch following flexor tendon repair. J HAND SURG 1987;12B: 182-4.

26. Tubiana R, McMeniman P, Gordon S. Evaluation des resultats apres reparation des tendons longs flechisseurs des doigts. Ann Chir 1979;33:659-62.

27. Hume MC, Gellman H, McKellop H, Brumfield RH. Functional range of motion of the joints of the hand. J HAND SURG 1990:15A:240-3.

The nerve gap dilemma: A comparison of nerves

repaired end to end under tension with nerve

grafts in a primate model

The objective of thii study was to compare, in a clinically relevant primate model, axon regen-

eration after epineurial repair under tension (15 mm gap) with interfascicular nerve grafts with

the use of either standard microsuture techniques or a new interfascicular nerve graft technique

termed fascicular tubulization that uses a hypoantigenic collagen membrane formed into a tube

to approximate nerve ends. Electrophysiologic analysis demonstrated that the percentage of

proximal axons that conducted across the repair site was greater in those nerves repaired under

tension with epineurially placed sutures than in either of the tensionless repairs involving inter-

fascicular graft techniques. The mean diameters of the regenerated axons repaired under tension

with epineurial sutures were greater than those of the nerves repaired with interfascicular grafts,

although the difference was not statistically significant. Interfascicular nerve grafting with tub-

ulization using the current collagen tube resulted in regeneration equal to the sutured interfas-

cicular nerve grafts. For modest defects (perhaps up to 3 to 4 cm in the adult), it seems advan-

tageous to accept the modest tension associated with an epineurial repair rather than to use an

autograft (or artificial graft) to achieve a tension-free repair. (J HAND SURC 1993;18A:417-25.)

Vincent R. Hentz, MD, Joseph M. Rosen, MD, Shao-Jun Xiao, MD, Stanford, Calif., Kevin C. McGill, PhD, and Gordon Abraham, MD, Palo Alto, Calif.

From Stanford University Medical Center, Stanford, Calif., and the

Rehabilitation Research and Development Center, Veterans Ad- ministration Medical Center, Palo Aho, Calif.

This work was supported by VAH Merit Review Grant.

311143557

Received for publication Dec. 27, 1991; accepted in revised form

Sept. 11, 1992.

No benefits in any form have been received or will be received from

a commercial party related directly or indirectly to the subject of

this article.

Reprint requests: Vincent R. Hentz, MD, 520 Sand Hill Rd., Palo

Alto, CA 94305.

THEJOURNALOFHANDSURGERY 417