Modifications to simplify intrathecal irrigation for pyogenic flexor tenosynovitis.

Abstract

Dear Sir, We describe two modifications to simplify cannulation and passage of fine feeding catheter through flexor sheath for closed irrigation of infective flexor tenosynovitis. Cannulating the flexor sheath and controlled passage of fine feeding catheter through the retinacular system can be difficult due to its pliability, often requiring multiple attempts and causing additional trauma to flexor tendons. Conventionally, irrigation solution is pumped out through the tip of the catheter and intrathecal lavage is dependent on the pressure jet and continuous flow [2]. The potential drawbacks of the latter are incomplete evacuation of infected material and tedious dressings. Other authors have described single and multiple fenestrations along catheter in human and veterinary patients [1, 4]. The advantage of side fenestration is the delivery of irrigation solution to sanctuaries such as the sub-chiasms and intertendinous interfaces. Based on the above techniques, we have modified the closed irrigation technique in two ways to ease cannulation and intrathecal lavage. In all cases, the flexor sheath is visualized and accessed through hemi-Brunner incision centered over A4/5 or A3/4, and a palmar crease incision centered on the A1. The first modification introduces an intraluminal 24-gauge wire to stiffen the tube for cannulation at either A3/4 or A4/5 and retrograde passage to the A1 window (Fig. 1). The second modification involves fenestrating the catheter along its middle portion to increase turbulence of intrathecal flow. During irrigation, the catheter is drawn back and forth, while an assistant flushes the tube after clamping its tip. The end point is the evacuation of clear fluid from the A1 window. Fig. 1 Middle segment of a feeding catheter is marked (black arrows) and fenestrated with a no. 11 blade. Intraluminal 24-gauge wire to increase stiffness of catheter to ease cannulation and manipulation of catheter We believe that the combination of mechanical lavage and fluid flow through the fenestrations increases direct clearance of intrathecal material as opposed to indirect methods that rely on continuous flow (Fig. 2). The catheter is removed after irrigation and postoperative irrigation is not practiced due to the lack of perceived benefits [3]. Fig. 2 Left to right. Direct irrigation—tip of catheter clamped to facilitate intrathecal flow of irrigation fluid (blue arrows), and oscillating motion (thick black arrows) to promote mechanical lavage. Indirect irrigation—flexor sheath is ...