Zone II Flexor Tendon Repair - Number of Strands, Technique, and Postoperative Rehabilitation: A Narrative Review

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. 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.