{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,4]],"date-time":"2026-09-04T20:56:49Z","timestamp":1788555409679,"version":"build-2803163510"},"reference-count":49,"publisher":"Open Medical Publishing","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"abstract":"<jats:p>Zone II flexor tendon injuries remain among the most technically demanding challenges in hand surgery. The confined anatomy, dual-tendon configuration, and complex pulley system render this region particularly vulnerable to adhesion formation, repair gapping, and stiffness. Over the past decades, advances in multistrand core suture techniques, epitendinous augmentation, and early controlled mobilization protocols have markedly improved repair strength and postoperative function.<\/jats:p>\n                  <jats:p>This narrative review synthesizes current evidence on surgical techniques and rehabilitation strategies in Zone II tendon repair, emphasizing the interplay between biomechanical stability and functional mobility. It explores the anatomical and biomechanical considerations unique to Zone II, evaluates the evolution from traditional two-strand to modern four- and six-strand repairs, and discusses the critical contribution of epitendinous sutures to tensile strength and tendon glide. Additionally, it reviews the rationale and safety of pulley venting, delineating when partial A2 or A4 release may be beneficial. Finally, the review examines postoperative rehabilitation protocols, from immobilization to early passive and active motion; and their relative effects on rupture risk, adhesion formation, and range of motion. Despite technological progress, optimal management still requires individualized decision-making that balances repair robustness with safe mobilization to achieve the best possible functional outcome.<\/jats:p>","DOI":"10.52965\/001c.161329","type":"journal-article","created":{"date-parts":[[2026,5,11]],"date-time":"2026-05-11T20:14:37Z","timestamp":1778530477000},"source":"Crossref","is-referenced-by-count":1,"title":["Zone II Flexor Tendon Repair \u2013 Number of Strands, Technique, and Postoperative Rehabilitation: A Narrative Review"],"prefix":"10.52965","volume":"18","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-6644-0572","authenticated-orcid":true,"given":"Elyssa","family":"Kiwan","sequence":"first","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01xvwxv41","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Balamand","department":["Orthopedics and Traumatology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rita","family":"Saad","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01xvwxv41","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Balamand","department":["Orthopedics and Traumatology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joseph","family":"Najjar","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01xvwxv41","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Balamand","department":["Orthopedics and Traumatology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Johnny","family":"Saadeh","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01xvwxv41","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Balamand","department":["Orthopedics and Traumatology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rima","family":"Osman","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01xvwxv41","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Balamand","department":["Orthopedics and Traumatology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Anthony","family":"Akleh","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01xvwxv41","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Balamand","department":["Orthopedics and Traumatology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Omar","family":"Al Fakih","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01xvwxv41","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Balamand","department":["Orthopedics and Traumatology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wendy","family":"Ghanem","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01xvwxv41","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Balamand","department":["Orthopedics and Traumatology"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ramzi","family":"Moucharafieh","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01xvwxv41","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Balamand","department":["Orthopedics and Traumatology"]},{"name":"Department of Orthopedics and Traumatology, Clemenceau Medical Center, Lebanon"},{"name":"Department of Orthopedics and Traumatology, European University of Cyprus"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohamad","family":"Badra","sequence":"additional","affiliation":[{"id":[{"id":"https:\/\/ror.org\/01xvwxv41","id-type":"ROR","asserted-by":"publisher"}],"name":"University of Balamand","department":["Orthopedics and Traumatology"]},{"name":"Department of Orthopedics and Traumatology, Clemenceau Medical Center, Lebanon"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"30777","published-online":{"date-parts":[[2026,5,11]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"192","DOI":"10.1186\/s13018-015-0331-4","article-title":"Bunnell or cross-lock Bunnell suture for tendon repair? Defining the biomechanical role of suture pretension","volume":"10","author":"M. C. Jordan","year":"2015","journal-title":"J Orthop Surg Res"},{"issue":"3","key":"ref2","doi-asserted-by":"publisher","first-page":"16","DOI":"10.17305\/bjbms.2005.3265","article-title":"Updates in flexor tendon repair at zone ii","volume":"5","author":"M. Mujadzi\u0107","year":"2005","journal-title":"Bosn J Basic Med Sci"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"1","DOI":"10.1016\/j.amsu.2019.10.006","article-title":"The evidence-base for the management of flexor tendon injuries of the hand: Review","volume":"48","author":"A. Ishak","year":"2019","journal-title":"Ann Med Surg (Lond)"},{"issue":"4","key":"ref4","doi-asserted-by":"publisher","first-page":"686","DOI":"10.1016\/j.jhsa.2013.12.037","article-title":"A systematic review of 2-strand versus multistrand core suture techniques and functional outcome after digital flexor tendon repair","volume":"39","author":"J. T. Hardwicke","year":"2014","journal-title":"J Hand Surg Am"},{"issue":"2","key":"ref5","doi-asserted-by":"publisher","first-page":"34","DOI":"10.52547\/wjps.12.2.34","article-title":"Comparison of Six-strand and Four-strand Techniques on the Repair of Injured Deep Flexor Tendons of Zone II of the Hand: A Randomized Controlled Clinical Trial","volume":"12","author":"M. B. Heydari","year":"2023","journal-title":"World J Plast Surg"},{"issue":"4","key":"ref6","doi-asserted-by":"publisher","first-page":"552","DOI":"10.1016\/j.jhsa.2009.12.025","article-title":"The effect of epitendinous suture technique on gliding resistance during cyclic motion after flexor tendon repair: a cadaveric study","volume":"35","author":"T. Moriya","year":"2010","journal-title":"J Hand Surg Am"},{"issue":"2","key":"ref7","doi-asserted-by":"publisher","first-page":"135","DOI":"10.1016\/0266-7681(85)90001-4","article-title":"In vitro studies of a new method of flexor tendon repair","volume":"10","author":"R. Savage","year":"1985","journal-title":"J Hand Surg Br"},{"issue":"1","key":"ref8","doi-asserted-by":"publisher","first-page":"489","DOI":"10.1186\/s13018-021-02645-6","article-title":"Evaluation of biomechanical properties on partial and complete epitendinous suture in human cadaver flexor tendon repair","volume":"16","author":"T. Kanchanathepsak","year":"2021","journal-title":"J Orthop Surg Res"},{"issue":"7","key":"ref9","doi-asserted-by":"publisher","first-page":"975","DOI":"10.2106\/00004623-199907000-00010","article-title":"The effect of gap formation at the repair site on the strength and excursion of intrasynovial flexor tendons. An experimental study on the early stages of tendon-healing in dogs","volume":"81","author":"R. H. Gelberman","year":"1999","journal-title":"J Bone Joint Surg Am"},{"issue":"1","key":"ref10","doi-asserted-by":"publisher","first-page":"39","DOI":"10.1002\/jor.1100020107","article-title":"Flexor tendon repair in vitro: a comparative histologic study of the rabbit, chicken, dog, and monkey","volume":"2","author":"R. H. Gelberman","year":"1984","journal-title":"J Orthop Res"},{"key":"ref11","series-title":"StatPearls","article-title":"Flexor Tendon Lacerations","author":"K. A. Stevens","year":"2023"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"1269861","DOI":"10.3389\/fmedt.2024.1269861","article-title":"Current clinical opinion on surgical approaches and rehabilitation of hand flexor tendon injury-a questionnaire study","volume":"6","author":"R. Xue","year":"2024","journal-title":"Front Med Technol"},{"issue":"1","key":"ref13","doi-asserted-by":"publisher","first-page":"139","DOI":"10.1007\/s00402-017-2836-2","article-title":"The impact of different peripheral suture techniques on the biomechanical stability in flexor tendon repair","volume":"138","author":"B. Wiesk\u00f6tter","year":"2018","journal-title":"Arch Orthop Trauma Surg"},{"issue":"3","key":"ref14","doi-asserted-by":"publisher","first-page":"455","DOI":"10.1016\/j.jhsa.2004.12.012","article-title":"Effects of locking area on strength of 2- and 4-strand locking tendon repairs","volume":"30","author":"R. G. Xie","year":"2005","journal-title":"J Hand Surg Am"},{"issue":"12","key":"ref15","doi-asserted-by":"publisher","first-page":"2525","DOI":"10.1016\/j.jhsa.2014.06.005","article-title":"Flexor pulley system: anatomy, injury, and management","volume":"39","author":"B. Zafonte","year":"2014","journal-title":"J Hand Surg Am"},{"issue":"1","key":"ref16","doi-asserted-by":"publisher","first-page":"105","DOI":"10.1007\/s11552-013-9547-0","article-title":"Importance of proximal A2 and A4 pulleys to maintaining kinematics in the hand: a biomechanical study","volume":"9","author":"J. C. Chow","year":"2014","journal-title":"Hand (N Y)"},{"issue":"7","key":"ref17","doi-asserted-by":"publisher","first-page":"1090","DOI":"10.1177\/15589447241259804","article-title":"Effects of A2 Pulley Venting on Bowstringing and Tendon Slack: A Biomechanical Investigation","volume":"20","author":"T. Shipley","year":"2025","journal-title":"Hand (N Y)"},{"issue":"5","key":"ref18","doi-asserted-by":"publisher","first-page":"649","DOI":"10.1016\/s0266-7681(98)80020-x","article-title":"\"Venting\" or partial lateral release of the A2 and A4 pulleys after repair of zone 2 flexor tendon injuries","volume":"23","author":"I. Kwai Ben","year":"1998","journal-title":"J Hand Surg Br"},{"issue":"8","key":"ref19","doi-asserted-by":"publisher","first-page":"1634","DOI":"10.1016\/j.jhsa.2012.05.018","article-title":"The effects of oblique or transverse partial excision of the A2 pulley on gliding resistance during cyclic motion following zone II flexor digitorum profundus repair in a cadaveric model","volume":"37","author":"T. Moriya","year":"2012","journal-title":"J Hand Surg Am"},{"issue":"3","key":"ref20","doi-asserted-by":"publisher","first-page":"439","DOI":"10.1016\/j.jhsa.2010.11.041","article-title":"Quantification of partial or complete A4 pulley release with FDP repair in cadaveric tendons","volume":"36","author":"O. I. Franko","year":"2011","journal-title":"J Hand Surg Am"},{"issue":"11","key":"ref21","doi-asserted-by":"publisher","first-page":"2300","DOI":"10.1016\/j.jhsa.2014.08.025","article-title":"Release of the A4 pulley to facilitate zone II flexor tendon repair","volume":"39","author":"J. B. Tang","year":"2014","journal-title":"J Hand Surg Am"},{"key":"ref22","doi-asserted-by":"publisher","first-page":"10470236","DOI":"10.3389\/fsurg.2023.10470236","article-title":"Current concepts of flexor tendon repair and rehabilitation","volume":"10","author":"Y., et al. Xu","year":"2023","journal-title":"Front Surg"},{"issue":"2","key":"ref23","doi-asserted-by":"publisher","first-page":"133","DOI":"10.1016\/j.jhsb.2005.09.024","article-title":"Flexor tendon pulley V-Y plasty: an alternative to pulley venting or resection","volume":"31","author":"E. Dona","year":"2006","journal-title":"J Hand Surg Br"},{"issue":"6","key":"ref24","doi-asserted-by":"publisher","first-page":"485","DOI":"10.1016\/j.jhsa.2020.11.003","article-title":"Use of Thermoplastic Rings Following Venting of Flexor Tendon Pulleys: A Biomechanical Analysis","volume":"46","author":"A. Kadar","year":"2021","journal-title":"J Hand Surg Am"},{"issue":"6","key":"ref25","doi-asserted-by":"publisher","first-page":"485","DOI":"10.1016\/j.jhsa.2020.11.003","article-title":"Use of Thermoplastic Rings Following Venting of Flexor Tendon Pulleys: A Biomechanical Analysis","volume":"46","author":"A. Kadar","year":"2021","journal-title":"J Hand Surg Am"},{"key":"ref26","article-title":"Flexor Tendon Injuries","author":"L. Ahn","year":"2022"},{"issue":"10","key":"ref27","doi-asserted-by":"publisher","first-page":"721","DOI":"10.1097\/00002060-200110000-00003","article-title":"Rehabilitation of flexor tendon injuries by use of a combined regimen of modified Kleinert and modified Duran techniques","volume":"80","author":"A. Cetin","year":"2001","journal-title":"Am J Phys Med Rehabil"},{"issue":"4","key":"ref28","doi-asserted-by":"publisher","first-page":"1583","DOI":"10.1097\/PRS.0b013e318208d28e","article-title":"Systematic review of flexor tendon rehabilitation protocols in zone II of the hand","volume":"127","author":"A. Chesney","year":"2011","journal-title":"Plast Reconstr Surg"},{"issue":"4","key":"ref29","doi-asserted-by":"publisher","first-page":"e22.00057","DOI":"10.2106\/JBJS.ST.22.00057","article-title":"Flexor Tendon Zone II Repair","volume":"13","author":"D. Y. Hong","year":"2023","journal-title":"JBJS Essent Surg Tech"},{"issue":"5","key":"ref30","doi-asserted-by":"publisher","first-page":"100152","DOI":"10.1016\/j.jham.2024.100152","article-title":"Maximizing hand function following zone II flexor tendon repair: A systematic review and meta-analysis of rehabilitation strategies","volume":"16","author":"H. Mortada","year":"2024","journal-title":"J Hand Microsurg"},{"issue":"3","key":"ref31","doi-asserted-by":"publisher","first-page":"16","DOI":"10.17305\/bjbms.2005.3265","article-title":"Updates in flexor tendon repair at zone ii","volume":"5","author":"M. Mujadzi\u0107","year":"2005","journal-title":"Bosn J Basic Med Sci"},{"issue":"2","key":"ref32","doi-asserted-by":"publisher","first-page":"128","DOI":"10.5455\/medarh.2014.68.128-131","article-title":"Physical therapy and splinting after flexor tendon repair in zone II","volume":"68","author":"S. Rrecaj","year":"2014","journal-title":"Med Arch"},{"issue":"7","key":"ref33","doi-asserted-by":"publisher","first-page":"587","DOI":"10.1016\/j.jhsa.2023.02.015","article-title":"Advances in flexor tendon repair: current techniques and outcomes","volume":"48","author":"J., et al. Ball","year":"2023","journal-title":"J Hand Surg"},{"issue":"2","key":"ref34","doi-asserted-by":"publisher","first-page":"87","DOI":"10.5704\/MOJ.2207.011","article-title":"A Survey of Zone II Flexor Tendon Repair Techniques and Rehabilitation Protocols Preferred by Malaysian Orthopaedic Practitioners","volume":"16","author":"A. Shalimar","year":"2022","journal-title":"Malays Orthop J"},{"issue":"9","key":"ref35","doi-asserted-by":"publisher","first-page":"1712","DOI":"10.1016\/j.jhsa.2013.06.025","article-title":"Flexor tendon repair rehabilitation protocols: a systematic review","volume":"38","author":"H. M. Starr","year":"2013","journal-title":"J Hand Surg Am"},{"key":"ref36","series-title":"StatPearls [Internet]","article-title":"Flexor Tendon Lacerations. [Updated 2023 Jun 20]","author":"K. A. Stevens","year":"2025"},{"issue":"5","key":"ref37","doi-asserted-by":"publisher","first-page":"853","DOI":"10.1016\/j.jcot.2019.08.005","article-title":"Flexor tendon injuries","volume":"10","author":"H. Venkatramani","year":"2019","journal-title":"J Clin Orthop Trauma"},{"key":"ref38","doi-asserted-by":"publisher","DOI":"10.21608\/ejhm.2022.270740","article-title":"Relative Motion Protocol Versus Place and Hold Protocol After Hand Zone II Flexor Tendon Repair: A Prospective Randomized Controlled Trial","author":"A. Zarraa","year":"2022","journal-title":"The Egyptian journal of hospital medicine"},{"issue":"4","key":"ref39","doi-asserted-by":"publisher","first-page":"407.e1","DOI":"10.1016\/j.jhsa.2021.11.013","article-title":"Outcome of Surgical Repair and Rehabilitation of Flexor Tendon Injuries in Zone II of the Hand: Systematic Review and Meta-Analysis","volume":"48","author":"H. Xu","year":"2023","journal-title":"J Hand Surg Am"},{"issue":"4","key":"ref40","doi-asserted-by":"publisher","first-page":"348","DOI":"10.1016\/j.jhsa.2021.11.031","article-title":"Passive Mobilization With Place and Hold Versus Active Motion Therapy After Flexor Tendon Repair: A Randomized Trial","volume":"47","author":"S. Chevalley","year":"2022","journal-title":"J Hand Surg Am"},{"issue":"8","key":"ref41","doi-asserted-by":"publisher","first-page":"783","DOI":"10.1177\/17531934231166336","article-title":"Rehabilitation following flexor tendon injury in Zone 2: a randomized controlled study","volume":"48","author":"M. Renberg","year":"2023","journal-title":"J Hand Surg Eur Vol"},{"issue":"12","key":"ref42","doi-asserted-by":"publisher","first-page":"1203","DOI":"10.1016\/j.jhsa.2024.08.003","article-title":"Range of Motion Following Flexor Tendon Repair: Comparing Active Flexion and Extension With Passive Flexion Using Rubber Bands Followed by Active Extension","volume":"49","author":"M. Renberg","year":"2024","journal-title":"J Hand Surg Am"},{"key":"ref43","doi-asserted-by":"publisher","DOI":"10.1016\/j.jht.2025.02.014","article-title":"A randomized controlled trial comparing controlled active motion and early passive mobilization protocols for rehabilitation of repaired flexor tendons in zone II","author":"E. Ahmed","year":"2025","journal-title":"J Hand Ther"},{"issue":"4","key":"ref44","doi-asserted-by":"publisher","first-page":"e22.00057","DOI":"10.2106\/JBJS.ST.22.00057","article-title":"Flexor Tendon Zone II Repair","volume":"13","author":"D. Y. Hong","year":"2023","journal-title":"JBJS Essent Surg Tech"},{"key":"ref45","doi-asserted-by":"publisher","first-page":"10863944","DOI":"10.1016\/j.jot.2024.10863944","article-title":"Novel strategies and controversies in flexor tendon healing","volume":"50","author":"H., et al. Zhang","year":"2024","journal-title":"J Orthop Translat"},{"issue":"6","key":"ref46","doi-asserted-by":"publisher","first-page":"960","DOI":"10.1177\/15589447211043220","article-title":"Reoperation Following Zone II Flexor Tendon Repair","volume":"18","author":"L. L. Bruin","year":"2023","journal-title":"Hand (N Y)"},{"issue":"5","key":"ref47","doi-asserted-by":"publisher","first-page":"100152","DOI":"10.1016\/j.jham.2024.100152","article-title":"Maximizing hand function following zone II flexor tendon repair: A systematic review and meta-analysis of rehabilitation strategies","volume":"16","author":"H. Mortada","year":"2024","journal-title":"J Hand Microsurg"},{"issue":"1","key":"ref48","doi-asserted-by":"publisher","first-page":"CD012479","DOI":"10.1002\/14651858.CD012479.pub2","article-title":"Rehabilitation following surgery for flexor tendon injuries of the hand","volume":"1","author":"S. E. Peters","year":"2021","journal-title":"Cochrane Database Syst Rev"},{"issue":"2","key":"ref49","doi-asserted-by":"publisher","first-page":"165","DOI":"10.1016\/j.jht.2018.03.003","article-title":"Flexor tendon rehabilitation in the 21st century: a systematic review","volume":"32","author":"R. L. Neiduski","year":"2019","journal-title":"J Hand Ther"}],"container-title":["Orthopedic Reviews"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/orthopedicreviews.openmedicalpublishing.org\/article\/161329-zone-ii-flexor-tendon-repair-number-of-strands-technique-and-postoperative-rehabilitation-a-narrative-review","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,5,11]],"date-time":"2026-05-11T20:15:39Z","timestamp":1778530539000},"score":1,"resource":{"primary":{"URL":"https:\/\/orthopedicreviews.openmedicalpublishing.org\/article\/161329-zone-ii-flexor-tendon-repair-number-of-strands-technique-and-postoperative-rehabilitation-a-narrative-review"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,5,11]]},"references-count":49,"URL":"https:\/\/doi.org\/10.52965\/001c.161329","relation":{},"ISSN":["2035-8164"],"issn-type":[{"value":"2035-8164","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,5,11]]}}}