www.PRSJournal.com 913e T he management of flexor tendon injuries remains one of the most published top- ics in hand surgery, with the numbers of publications on this subject seeing a year-on- year increase (Fig. 1). The perfect repair and outcome continue to evade us, 1 despite the flexor tendon repair being one of the earliest skills acquired as a hand surgeon in either plas- tic or orthopedic surgery training. 2 New tendon repairs and hand therapy regimens are reported regularly. Occasionally, there is an announce- ment of a new treatment modality that promises hope for this clinical conundrum, but this rarely becomes part of standard practice. Over the past 50 years, there have been many innovations, but overall outcomes have not changed dramati- cally. For example, the best series published in the 1970s showed that a two-strand repair with simple circumferential suture and a Kleinert type rehabilitation regimen had a 5 percent rupture rate, with 75 percent of patients achieving good to excellent functional outcomes in 28 zone II injuries. 3 This compares favorably with more recent studies showing that a four-strand repair and early active mobilization regimen had a 5 percent rupture rate, with 71 percent achieving good to excellent outcomes in 73 cases. 4 Real paradigm shifts in this area require us to rethink the whole process of flexor tendon biology Disclosure: Neither author has a financial interest in any of the products or devices mentioned in this article. Copyright © 2014 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000000749 Jason K. F. Wong, M.B.Ch.B., Ph.D. Fiona Peck, M.S.C.P. Manchester, United Kingdom Background: The global time and effort attributed to improving outcomes in the management of flexor tendon injury are large, but the degree of advance- ment made over the past 50 years is relatively small. This review examines the current perceived wisdom in this field and aims to explore the limitations to the authors’ understanding of the tendon healing process, examining how this may be a factor that has contributed to the authors’ modest progress in the field. Methods: The authors critically evaluate the sum of laboratory and clinical literature on the topic of zone II flexor tendon management that has guided their practice and provide evidence to support their methods. Results: The review highlights some of the key developments over the years and assesses their influence on changing current practice. It also highlights recent innovations, which have the potential to influence flexor tendon outcomes by altering the surgical approach, techniques, and rehabilitation regimens. Future innovations in the field will also be discussed to examine their potential in expanding the development in the management of flexor tendon injury. Conclusions: A better understanding of flexor tendon biology will allow prog- ress in developing new therapies for flexor tendon injuries; however, there are as yet few real breakthroughs that will dramatically change current prac- tice. (Plast. Reconstr. Surg. 134: 913e, 2014.) From the University Hospital South Manchester, Wythen- shawe Hospital; Plastic Surgery Research, Institute of In- flammation and Repair, University of Manchester. Received for publication March 10, 2014; accepted May 21, 2014. Improving Results of Flexor Tendon Repair and Rehabilitation Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s Web site (www. PRSJournal.com). HAND/PERIPHERAL NERVE