Flexor Tenosynovectomy Research Articles

Flexor tendon ruptures in the rheumatoid patient

In patients with rheumatoid arthritis, flexor tendon ruptures are much less common than extensor tendon ruptures. The most common cause of flexor tendon rupture is direct abrasion on a bony prominence. The most common flexor tendon rupture is the flexor pollicis longus (FPL) attritional rupture within the carpal canal. The best treatment for flexor tendon rupture is prevention. Flexor tenosynovectomy is indicated when medical management does not control wrist tenosynovitis. A variety of techniques are available for reconstruction of flexor tendon ruptures. Irrespective of the reconstructive method, the results of reconstruction for rheumatoid flexor tendon rupture are poor.

Surgical treatment of carpal tunnel syndrome and trigger digits in children with mucopolysaccharide storage disorders

The role of surgical intervention for carpal tunnel syndrome (CTS) and trigger digits in children with mucopolysaccharide storage disorders (MPSDs) has not been clearly defined, particularly as the treatment of the underlying disease has advanced to include bone marrow transplantation. This study reviews our experience in the treatment of CTS and trigger digits in 22 children with MPSDs who were evaluated for CTS by electromyographic (EMG)/nerve conduction velocity (NCV) testing. Seventeen children were diagnosed with CTS by EMG/NCV testing and were treated with bilateral open surgical release with or without flexor tenosynovectomy. The EMG/NCV testing revealed normal results in 5 patients who are subsequently being monitored. Forty-five digits in 8 children were diagnosed clinically with trigger digits. Nineteen digits were treated by annular pulley release alone. Twenty-six digits were treated by annular pulley release with partial flexor digitorum superficialis tendon resection. The average age at the time of hand surgery was 6.3 years, and at the time of follow-up, 9.6 years. Postoperative EMG/NCV testing in 7 children showed 1 with improvement and 6 with normalization. None of the patients undergoing carpal tunnel release went on to develop thenar atrophy or absent sensibility, as has been reported in untreated cases. Patients were evaluated for triggering digits both by preoperative tendon palpation and by intraoperative flexor tendon excursion at the time of open carpal tunnel release. All patients undergoing trigger release had improved active digital flexion seen at the final follow-up visit. Because of the very high incidence of CTS and trigger digits in this population, the authors currently recommend routine screening of EMG/NCV for all children with MPSDs. Early surgical intervention for nerve compression and stenosing flexor tenosynovitis can maximize hand function in these children.

Flexor tenosynovectomy and tenolysis in longstanding rheumatoid arthritis: A long-term review of 49 hands

A total of 43 patients (49 hands; 424 flexor tendons), who had rheumatoid arthritis of more than 15 years duration at the time of surgery, were clinically assessed at a mean follow-up of 5.7 years (range, 1.2-12 years). Pain and inability to flex actively despite a good passive range of motion were the main surgical indications. The results suggest that the patients had excellent sustained pain relief (mean score = 0.9) and were highly satisfied with the outcome of the procedure (mean score = 2.2). 81% had adequate pulp-to-pulp and key pinch. Range of finger motion (total active motion, TAM) was excellent to good in 45% and fair in 22%. Thirty-three per cent were graded as poor and these were found to be multifactorial in origin, with associated significant joint disease, preoperative tendon ruptures, extensive digital surgery, readhesions and combinations of operative procedures which adversely affect the rehabilitation programme. Flexor tenosynovectomy with tenolysis is a useful procedure with a low rate of recurrence.

RHEUMATOID FLEXOR TENOSYNOVITIS AND RUPTURE

Rheumatoid flexor tenosynovitis at the wrist can cause locking, limitation of motion, nerve compression, and rupture of tendons. To prevent and treat these conditions, a flexor tenosynovectomy, combined with nerve decompression and tendon reconstruction as indicated, is necessary. If tendons are ruptured, the flexor pollicis longus and profundus to the index finger are most commonly affected. On the fingers flexor tenosynovitis can also cause locking, decrease in range of motion and rupture tendons. Flexor tenosynovitis of the fingers should be treated with decompression of the tendons health with preservation of the pulley system.

Surgical Principles and Planning for the Rheumatoid Hand and Wrist

Each surgical procedure available for the rheumatoid hand has a score card. The most indicated and necessary procedures include: extensor tenosynovectomy and Darrach for the impending or already ruptured extensor tendons; flexor tenosynovectomy and carpal tunnel release for the patient with impaired median nerve function; stabilization of the deformed unstable thumb with MP or IP arthrodesis; and flexor tenosynovectomy in the palm and finger of a motivated patient with significant disparity between active and passive motion. Relative indications for surgery include arthrodesis for the unstable wrist; MP arthroplasty for the fixed MP volar and ulnar subluxation with inability to open the hand; synovectomy for the occasional patient with painful boggy synovitis of the MP or PIP joint; and reconstruction of the fixed swan neck deformity with relatively good PIP joints. Both MP and PIP joints can and should be operated on at the same time. Extensive wrist surgery, that is, tenosynovectomy and Darrach or arthrodesis, should not be performed at the same time as MP arthroplasty. Try to do the "winner operations" first.

RECONSTRUCTION OF THE TRANSVERSE CARPAL LIGAMENT TO RESTORE MEDIAN NERVE GLIDING

Two clinical and four surgical steps can be taken to return gliding and nutritional balance to the median nerve after revision surgery for a recurrent median nerve neuropathy: Step One (Clinical): An accurate diagnosis of the median nerve traction neuropathy. Consider brachial plexopathy and terminal neuropathies. Step Two (Surgical): Comprehensive exploration and meso-epineurolysis of the median nerve from the radial remnants of the divided TCL and fibrosed radial and ulnar bursae by resection of the bursae and flexor tenosynovectomy. Step Three (Surgical): Fasciotomy of the volar carpal ligament to lengthen the ulnar leaf of the TCL; permits visualization of the ulnar artery and neurolysis of the ulnar motor nerve. Step Four (Surgical): Mobilize the previously released radical leaf TCL and motor median nerve from the origin of the thenar muscles. Step Five (Surgical): Restore the inner gliding surface and strength of the flexor retinaculum of the hand and wrist by reconstruction of the TCL and the forearm antebrachial fascia. Step Six (Clinical): An immediate postoperative hand therapy program to restore gliding to the median nerve and flexor tendons. Protocols for upper extremity nerve gliding should be carried out under supervision at selected daily intervals. A prevailing brachial plexopathy requires positive supervised therapy for nerve gliding and posture control.

Long-term results following digital flexor tenosynovectomy in rheumatoid arthritis

A retrospective review of flexor tenosynovectomy for rheumatoid flexor tenosynovitis in the palm and digit was performed. Fifteen patients (61 fingers) were reviewed for at least 1 year (average, 4 years) after surgery. An average of 2.2 cm improvement in active flexion (pulp to distal palmar crease) was observed. A significant difference in preoperative and postoperative results was found. Sixty-seven percent of digits were classified as having excellent or good results, 21% fair results, and 12% poor results. The clinical recurrence rate was 31% and the reoperation rate was 15%. Only minimal complications from the extended surgical approach were observed. Debulking the fibro-osseous canal by excising a slip of flexor digitorum superficialis was associated with a reduction in the recurrence and reoperation rates.

The A1 pulley in rheumatoid flexor tenosynovectomy To retain or divide?

We report a detailed comparative evaluation of flexor tenosynovectomy in 55 fingers in which the A1 pulley was divided and 45 fingers in which the A1 pulley was retained. The metacarpophalangeal joint subluxed volarly in 49% when the A1 pulley was divided, compared to 11% when the pulley was preserved. Bowstringing occurred in 7% and only when the A1 pulley was divided. Ulnar deviation was 7° worse when the pulley was divided. Active range of movement was limited in both groups. It was 11° less when the A1 pulley was divided.

Synovite des fléchisseurs induite à distance de l'utilisation d'un lac textile

A thirty year old woman underwent trigger finger release of her left middle finger after two injections failed to give relief. Several months later, she developed an area of nodular tenosynovitis localized to the operative site. Her finger had recovered full function, her general health was good, and routine lab work was normal. Because of the persistent mass, flexor tenosynovectomy was performed. Histologic examination revealed synovial hyperplasia associated with a filamentous birefringent foreign material. The bluish color of the foreign material indicated that it came from a fabric retraction loop used during the original operation. She made an uneventful recovery, and three years later her hand remained normal. As a result of this unusual complication, we recommended the use of retraction loops made of plastic rather than fabric. Whenever a micro-foreign body remains in the flexor tendon shealth, there is risk of aseptic tenosynovitis.

Ténosynovectomie des fléchisseurs dans la polyarthrite rhumatoïde: Etude analytique à court et à long terme de la mobilité des chaînes digitales

Between 1970 and 1988, 115 patients with rheumatoid arthritis underwent flexor tenosynovectomy. Fifty patients were reviewed (64 hands). The diagnosis of flexor tenosynovitis remains a clinical diagnosis. Three main groups can be distinguished: isolated carpal tenosynovitis (20%), palmodigital tenosynovitis (50%), diffuse tenosynovitis (30%). Standard surgical techniques were used, particularly in terms of the incisions. All patients underwent rehabilitation in the same rehabilitation centre. The authors analyse their results by comparing overall preoperative and postoperative mobility of the fingers (TAM: Total Active Motion, TPM: Total Passive Motion) and the angular gain in each joint (MCP, PIP, DIP). They report the results obtained at 4 months to eliminate the bias related to progression of the disease. The long-term results (8 years of follow-up) are also analysed. Statistical analysis compares two groups depending on whether flexor tenosynovectomy was isolated (44%) or combined with a dorsal surgical procedure at the same operation (extensor synovectomy, articular synovectomy, stabilisation-realignment of the dorsal aspect of the wrist, resection of the ulnar head) (56%). Ninety percent of patients declared themselves to be subjectively improved. Objectively, mobility was always improved at 4 months then deteriorated to return to its preoperative level at 8 years. Only three patients were reoperated for recurrence. Flexor tenosynovectomy in rheumatoid arthritis is an excellent operation. Its analgesic effect is maintained in time and, when performed early, it appears to protect the patient from the risk of subsequent tendon rupture.

Flexor Tendon Ruptures in Rheumatoid Arthritis

Flexor tendon ruptures in rheumatoid arthritis are caused by either attrition on bone spurs or by direct invasion of the tendon by hypertrophic tenosynovium. All attrition ruptures occur within the carpal canal and represent the most common cause of tendon rupture. Removal of the causative bone spur is imperative in the treatment of this condition. Ruptures due to invasive tenosynovitis also are frequently found within the carpal canal. These ruptures may be unanticipated, and may be discovered as an incidental finding during flexor tenosynovectomy. Ruptures due to invasive tenosynovitis within the digit carry an unfavorable prognosis. The prognosis for restoring flexion in the event of a flexor tendon rupture is determined by the location of the rupture, the etiology, the degree of articular involvement from the rheumatoid disease, and to a lesser extent, by the number of ruptured tendons. In general, isolated or double ruptures within the carpal canal due to attrition have a better prognosis than those caused by invasive tenosynovitis since the condition of the tendons is more favorable for reconstruction; however, as the number of ruptures increases, the prognosis in both conditions worsens. Rupture of both tendons within the digital sheath is quite difficult to treat, with ruptures in zone 2 carrying the worst prognosis for the restoration of flexion. The severity of the patient's rheumatoid arthritis and articular disease has a great effect on the outcome of the reconstructive surgery. Prevention of tendon ruptures by early tenosynovectomy and the removal of bone spurs should be the goal of the surgeon.

Internal neurolysis and flexor tenosynovectomy: adjuncts in the treatment of chronic median nerve compression at the wrist in hemodialysis patients.

This retrospective clinical study reports our results with surgical treatment of chronic median nerve compression at the wrist in 27 hemodialysis patients with a mean follow-up of 22 months. Due to the high incidence of amyloidosis in our patient population, an extensive tenosynovectomy was done in all patients. Statistically significantly (P = .03) better results were obtained when a microsurgical internal neurolysis was added to the procedure, than simple decompression alone (82% vs. 63% good to excellent results).

Mycobacterium marinum Flexor Tenosynovitis

Four culture-positive cases of flexor tenosynovitis of the hand caused by Mycobacterium marinum are reported. The organisms were cultured at 32 degrees. All patients were treated with a combination of flexor tenosynovectomy and antimycobacterial treatment with ethambutol and rifampin. The length of antimycobacterial treatment ranged from nine to 22 months. All four patients responded to treatment with cessation of signs of infection, increased range of motion, and complete wound healing.

Coverage of a carpal tunnel wound dehiscence with the abductor digiti minimi muscle flap

A 41-year-old man who was taking 60 mg of prednisone a day for dermatomyositis developed a wound dehiscence following a carpal tunnel release and flexor tenosynovectomy. Coverage of the exposed carpal contents was provided by using the abductor digiti minimi as a local transposition flap.

Sarcoid flexor tenosynovitis of the finger: A case report

A case report of flexor tenosynovitis of the right ring finger in a 27-year-old black woman leading to the diagnosis of sarcoidosis is presented. Sarcoidosis of a flexor tendon sheath is rare. Flexor tenosynovectomy provided material for histologic diagnosis and increased the function of the hand.

Flexor tenosynovectomy in the rheumatoid finger

The usual operation fo stenosing flexor tenosynovitis is resection of the proximal pulley. In the rheumatoid hand this operation may not be proper because motion still may be limited by the thickened synovium more distally, and also because there is a greater chance for the production of ulnar drift later on if the proximal pulley system is obliterated. The operation we recommend for the finger with rheumatoid tenosynovitis is a tenosynovectomy, but with maintainence of the pulley system and resection of one slip of the superficialis in order to decompress the digital theca. We have performed this operation on 54 fingers with satisfactory results.

Stiffness of the proximal interphalangeal joints in rheumatoid arthritis. The role of flexor tenosynovitis

In nineteen hands (seventy-four fingers) of eleven women and one man with rheumatoid arthritis there was restriction of active and passive motion of the proximal interphalangeal joints, with signs of flexor tenosynovitis but no clinical or roentgenographic evidence of involvement of the joint. The nineteen hands were treated by flexor tenosynovectomy (palm only in nine, palm and carpal tunnel in five, both palm and digits in four, and digit, palm, and wrist in one) combined with manipulation of the joint under regional anesthesia. After an average follow-up of twenty-one months (range, six to thirty-six months), the average range of active motion had increased from 40 to 84 degrees and the average range of passive motions, from 57 to 87 degrees. Only three patients had unsatisfactory results, one because of persistent unexplained swelling and two because of recurrence of the tenosynovitis.

Preventive Surgery — Tenosynovectomy and Synovectomy

The goal of preventative rheumatoid hand surgery is the eradication of the diseased synovium or tenosynovium before irreparable joint or tendon destruction occurs. Although there is general agreement that both dorsal and flexor tenosynovectomy are reliable and effective procedures to prevent the complications of tenosynovitis, the case for synovectomy is less well established. We have discussed the indications for both tenosynovectomy and synovectomy and described the surgical techniques used for dorsal tenosynovectomy and flexor tenosynovectomy in the wrist, palm, and digits. In addition, the treatment of both extensor and flexor tendon ruptures has been presented.