{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,6]],"date-time":"2026-09-06T03:57:58Z","timestamp":1788667078332,"version":"build-2803163510"},"reference-count":27,"publisher":"MDPI AG","issue":"16","license":[{"start":{"date-parts":[[2025,8,16]],"date-time":"2025-08-16T00:00:00Z","timestamp":1755302400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background\/Objective: Traumatic injuries to the flexor tendons of the hand are frequently treated by hand surgeons. Late repair is not classically considered to be feasible due to the high risk of failure and functional complications. The present study aims to present the functional results of primary flexor tendon repairs performed more than three months after trauma, along with evidence regarding the time limit for primary flexor tendon repair. Methods: The clinical outcomes of direct flexor tendon repairs in zones 1 and 2 of the long fingers or thumb are reported herein. A scoping review was undertaken using Medline and CINHAL to identify studies reporting the functional outcomes of flexor repair following trauma. Results: In this series, four patients were treated with direct M-Tang and epitendinous suture or pull-out reinsertion. Accessory procedures were required to perform a direct repair. The mean delay was 5.5 months, and the follow-up period was 24 months. The mean total active movement was 195\u00b0. Extension lags of 10\u00b0 and 20\u00b0 were registered at the proximal interphalangeal and distal interphalangeal joints, respectively. While a literature review showed that most cases treated with primary repair after three months resulted in functional complications, these procedures were performed around 40 years ago and no recent reports were found. Conclusions: In the small cohort of patients here reported it has been possible to repair flexor tendons in zones 1 and 2, and to reinsert a jersey finger, even three months after trauma. Accessory procedures were required. Accurate patient selection and counseling is mandatory before surgery to inform patients about alternatives. The literature review confirmed that no positive results have previously been reported in the literature on this topic. It is thought that modern materials and surgical techniques for flexor tendon repair should extend the edge for primary repair in selected patients, as compared to previous practices.<\/jats:p>","DOI":"10.3390\/jcm14165796","type":"journal-article","created":{"date-parts":[[2025,8,18]],"date-time":"2025-08-18T15:34:53Z","timestamp":1755531293000},"page":"5796","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Direct Flexor Tendon Repair More than 3 Months After Trauma: Clinical Outcomes of Four Consecutive Cases and Scoping Review on Time Limits"],"prefix":"10.3390","volume":"14","author":[{"given":"Alessandro","family":"Crosio","sequence":"first","affiliation":[{"name":"UOC Chirurgia Della Mano E Microchirurgia Ricostruttiva, Asst Gaetano Pini-Cto Milano, Piazza Cardinale Ferrari, 1, 20122 Milan, Italy"},{"name":"SSD Microchirurgia Ortopedico Traumatologica, Ortopedia e Traumatologia 2, Chirurgia Della Mano, AOU Citt\u00e0 Della Salute E Della Scienza\u2014Po CTO, Via Zuretti 29, 10126 Torino, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alice","family":"Clemente","sequence":"additional","affiliation":[{"name":"UOC Chirurgia Della Mano E Microchirurgia Ricostruttiva, Asst Gaetano Pini-Cto Milano, Piazza Cardinale Ferrari, 1, 20122 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Arturo Sebastiano","family":"Nozzolillo","sequence":"additional","affiliation":[{"name":"UOC Chirurgia Della Mano E Microchirurgia Ricostruttiva, Asst Gaetano Pini-Cto Milano, Piazza Cardinale Ferrari, 1, 20122 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5766-3276","authenticated-orcid":false,"given":"Sara","family":"Dimartino","sequence":"additional","affiliation":[{"name":"SC Ortopedia, AOU Policlinico \u201cG. Rodolico\u2014San Marco\u201d, PO San Marco, Piazzale C.A. Ciampi, 95121 Catania, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3900-1927","authenticated-orcid":false,"given":"Simona","family":"Odella","sequence":"additional","affiliation":[{"name":"UOC Chirurgia Della Mano E Microchirurgia Ricostruttiva, Asst Gaetano Pini-Cto Milano, Piazza Cardinale Ferrari, 1, 20122 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0404-3297","authenticated-orcid":false,"given":"Davide","family":"Ciclamini","sequence":"additional","affiliation":[{"name":"Ortopedia e Traumatologia, AOU Ospedale Maggiore Della Carit\u00e0, Corso Mazzini 18, 28100 Novara, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-1349-7082","authenticated-orcid":false,"given":"Pierluigi","family":"Tos","sequence":"additional","affiliation":[{"name":"UOC Chirurgia Della Mano E Microchirurgia Ricostruttiva, Asst Gaetano Pini-Cto Milano, Piazza Cardinale Ferrari, 1, 20122 Milan, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,8,16]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"814","DOI":"10.1302\/2046-3758.1111.BJR-2022-0181.R1","article-title":"The incidence of musculoskeletal injuries: A systematic review and meta-analysis","volume":"11","author":"Ponkilainen","year":"2022","journal-title":"Bone Jt. Res."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1016\/j.hcl.2004.11.005","article-title":"Clinical Outcomes Associated with Flexor Tendon Repair","volume":"21","author":"Tang","year":"2005","journal-title":"Hand Clin."},{"key":"ref_3","first-page":"279","article-title":"Flexor Tendon Repair in No Man\u2019s Land","volume":"14","year":"1980","journal-title":"Scand. J. Plast. Reconstr. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"474","DOI":"10.1016\/j.aott.2019.07.003","article-title":"Comparison of surgical trends in zone 2 flexor tendon repair between Turkish and international surgeons","volume":"53","author":"Unsal","year":"2019","journal-title":"Acta Orthop. Traumatol. Turc."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"295","DOI":"10.1016\/j.cps.2019.02.003","article-title":"Flexor Tendon Injuries","volume":"46","author":"Tang","year":"2019","journal-title":"Clin. Plast. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"647","DOI":"10.2106\/00004623-196042040-00009","article-title":"Primary repair of flexor tendons","volume":"42-A","author":"Verdan","year":"1960","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_7","unstructured":"American Society for Surgery of the Hand (1990). The Hand: Examination and Diagnosis, Churchill Livingstone. [3rd ed.]."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"365","DOI":"10.1177\/1753193416641590","article-title":"Why and how to report surgeons\u2019 levels of expertise","volume":"41","author":"Tang","year":"2016","journal-title":"J. Hand Surg. Eur. Vol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"239","DOI":"10.1097\/00000637-198609000-00010","article-title":"Flexor Tendon Lengthening by Tenotomy at the Musculotendinous Junction","volume":"17","year":"1986","journal-title":"Ann. Plast. Surg."},{"key":"ref_10","first-page":"171","article-title":"Repair of rupture of flexor pollicis longus by \u201cZ\u201d lengthening at the wrist","volume":"7","author":"Vigliani","year":"1981","journal-title":"Ital. J. Orthop. Traumatol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"264","DOI":"10.1016\/j.bjps.2011.06.039","article-title":"One-stage treatment of delayed \u2018jersey finger\u2019 by z-step lengthening of the flexor digitorum profundus tendon at the wrist","volume":"65","author":"Sawaya","year":"2012","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"141","DOI":"10.1016\/0072-968X(76)90035-8","article-title":"Delayed flexor tendon repair in the digital sheath with end-to-end suture and fascial graft","volume":"8","author":"Suzuki","year":"1976","journal-title":"Hand"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"677","DOI":"10.1177\/1753193410366364","article-title":"FDP to FDP hemi-tendon transfer\u2014A new technique for delayed repair of the flexor digitorum profundus in zones I and II of the finger","volume":"35","author":"Durand","year":"2010","journal-title":"J. Hand Surg. Eur. Vol."},{"key":"ref_14","first-page":"145","article-title":"Late Repair of Flexor Tendon Lacerations Within the Digital Sheaths","volume":"80","author":"Ayalon","year":"2022","journal-title":"Bull. Hosp. Jt. Dis."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"267","DOI":"10.1302\/2633-1462.16.BJO-2020-0057","article-title":"Restarting elective orthopaedic services during the COVID-19 pandemic","volume":"1","author":"Chang","year":"2020","journal-title":"Bone Jt. Open"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"1123","DOI":"10.2106\/00004623-197355060-00001","article-title":"Laceration of the flexor pollicis longus tendon: Delayed repair by advancement, free graft or direct suture. A clinical and experimental study","volume":"55","author":"Urbaniak","year":"1973","journal-title":"J. Bone Jt. Surg. Am."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1e","DOI":"10.1097\/PRS.0b013e3182174593","article-title":"Tendon Disorders of the Hand","volume":"128","author":"Lalonde","year":"2011","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1016\/j.ocl.2014.09.004","article-title":"Flexor Tendon Injury, Repair and Rehabilitation","volume":"46","author":"Lutsky","year":"2015","journal-title":"Orthop. Clin. N. Am."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"818","DOI":"10.1177\/17531934211024435","article-title":"Up to five-week delay in primary repair of Zone 2 flexor tendon injuries: Outcomes and complications","volume":"46","author":"Munz","year":"2021","journal-title":"J. Hand Surg. Eur. Vol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"167","DOI":"10.1016\/j.jhsg.2021.04.003","article-title":"Patient Perceptions of COVID-19 Precautions and Their Effects on Experiences With Hand Surgery","volume":"3","author":"Tawfik","year":"2021","journal-title":"J. Hand Surg. Glob. Online"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"28","DOI":"10.5435\/JAAOS-D-14-00195","article-title":"Flexor Tendon Reconstruction","volume":"24","author":"Samora","year":"2016","journal-title":"J. Am. Acad. Orthop. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"277","DOI":"10.1016\/0266-7681_88_90085-X","article-title":"Post-Operative Management of Flexor Tendon Grafting","volume":"13","author":"Tonkin","year":"1988","journal-title":"J. Hand Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"581","DOI":"10.1053\/jhsu.2002.34319","article-title":"Staged flexor tendon reconstruction fingertip to palm","volume":"27","author":"Coyle","year":"2002","journal-title":"J. Hand Surg. Am."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"652","DOI":"10.1016\/S0363-5023(03)00146-1","article-title":"Two-stage flexor tendon reconstruction in zone II using a silicone rod and a pedicled intrasynovial graft","volume":"28","author":"Beris","year":"2003","journal-title":"J. Hand Surg. Am."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"635","DOI":"10.1177\/15589447211064364","article-title":"Functional Outcomes of Flexor Tendon Repair in the Fingers: A Comparison of Wide-Awake Local Anesthesia No Tourniquet Versus Traditional Anesthesia","volume":"18","author":"Townsend","year":"2023","journal-title":"Hand"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"e72","DOI":"10.2106\/JBJS.K.00601","article-title":"The Hook Plate Technique for Fixation of Phalangeal Avulsion Fractures","volume":"94","author":"Kang","year":"2012","journal-title":"J. Bone Jt. Surg."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1007\/s11552-009-9199-2","article-title":"Type IV FDP Avulsion: Lessons Learned Clinically and through Review of the Literature","volume":"4","author":"Henry","year":"2009","journal-title":"Hand"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/16\/5796\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T18:28:52Z","timestamp":1760034532000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/14\/16\/5796"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,8,16]]},"references-count":27,"journal-issue":{"issue":"16","published-online":{"date-parts":[[2025,8]]}},"alternative-id":["jcm14165796"],"URL":"https:\/\/doi.org\/10.3390\/jcm14165796","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,8,16]]}}}