Zone II Flexor Tendon Repair: Surgical Principles, Rehabilitation Strategies, And Functional Outcomes

Abstract

Zone II flexor tendon injuries remain among the most challenging conditions in hand surgery because they involve a narrow fibro-osseous tunnel containing both the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) tendons, surrounded by a pulley system that is essential for digital motion. Although advances in suture design, multistrand core repair, epitendinous augmentation, wide-awake local anesthesia no tourniquet (WALANT) techniques, and early controlled rehabilitation have improved outcomes, the management of zone II injuries continues to require careful balance between repair strength, tendon gliding, pulley preservation, and prevention of adhesions or rupture. This narrative review summarizes contemporary evidence regarding surgical timing, operative technique, anesthesia selection, pulley management, rehabilitation protocols, complication prevention, and functional outcomes after zone II flexor tendon repair. Current evidence supports strong multistrand repair, meticulous handling of tendon and sheath structures, early protected motion when feasible, close communication between surgeon and hand therapist, and individualized rehabilitation based on repair strength, patient factors, and adherence risk. Despite substantial progress, complications such as adhesions, stiffness, rupture, reoperation, and delayed return of function remain clinically relevant.