A woman in her late 60s presents 63 years after laceration and repair of the flexor tendons of the long and ring fingers in the palm. She has full extension but only about half of normal flexion of the long and ring fingers of her right hand. She only had about one-quarter normal passive extension of the affected fingers. There are scars in the palm where the tendons are stuck in dense adhesions (▶Fig. 10.1).
Adhesions are best avoided in flexor tendon repair by performing the repair wide awake with lidocaine and epinephrine. In the absence of a tourniquet and sedation, patients can comfortably test the flexor tendon repairs to make sure they are not gapping and that they fit through the pulleys. Early protected movement with true active movement would have also prevented this if she had not been a child at the time of injury.
She has stiffness of the joints that limit passive flexion. She had a soft-end feel in her stiff metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints. This means that the joints have a little spring when passively flexed, as opposed to a rock hard–end feel of a bony block that would not respond to therapy. She should not have tenolysis surgery until she has regained all passive motion of the joints with hand therapy.
She was a cooperative patient willing to get the movement back. She was therefore sent to a hand therapist who was able to help the patient get the full passive movement back in 6 months. She was now ready for wide-awake tenolysis surgery (▶Fig. 10.2).
• Get passive movement of all joints before surgery.
• Perform the tenolysis wide awake, so the patient can help you rupture the adhesions.
Fig. 10.1 (a) Preexisting scars are marked. (b) Full extent of the long and ring fingers’ active flexion before surgery.
Fig. 10.2 Full passive range of motion of (a) the ring finger and (b) the long finger obtained with hand therapy before surgery.
• Perform the tenolysis wide awake, so the patient can remember the range of motion she got in the operating room. She will be motivated by that memory to get through postoperative therapy and get that intraoperative range of motion back.
• Immobilize and elevate the hand for 3 to 5 days after the surgery. Avoid immediate movement because it encourages bleeding and clots inside the wound. Blood clots need to be mopped up with vascular infiltration and scar formation, which is not good for movement. You can delay moving for 3 to 5 days because collagen formation does not even start until day 3. Before moving, let the bleeding stop, let the swelling come down, and let the work and friction of movement decrease with immobilization and elevation. The author encourages all patients to move only when they are off all painkillers.
• When you start moving at 3 to 5 days, remember that the tendon repair is very weakened. You have removed most of the collagen around the tendon, so there is very little strength left. You have also removed most of the blood supply by denuding the scar, and so your tendon is now quite avascular. If you force it, it will rupture. Instead, treat it exactly as you would a freshly repaired flexor tendon with gentle protected early true active movement. We allow up to half a fist of true active movement for the first couple of weeks. The patients can move it, but they cannot use it. They do not need a full fist in the beginning. They just do not want it to get stuck.
Before the patient comes into the operating room, inject 10 mL of buffered lidocaine with epinephrine in the palm in the most proximal place that dissection will take place (▶Fig. 10.3, ▶Video 10.1). Do not move the needle for this initial injection. The local anesthesia will find its way. Use a 27-G needle and inject very slowly to minimize pain. After the initial 10 mL, reinsert the needle distally in an area clearly white with epinephrine vasoconstriction to avoid painful needle reinsertion.
Continue tumescing until the palm is visibly swollen with local anesthetic solution, and then inject 2 mL per phalanx in the subcutaneous fat between both digital nerves. Remember that preexisting scars and creases form a natural barrier to local anesthetic solution.
Get into the sheath through transverse sheathotomies. Preserve as much pulley as possible. Use a freer elevator on the palmar and lateral sides of the tendon to separate it from the A2 pulley (▶Fig. 10.4a, ▶Video 10.2). Use tenotomy scissors on the dorsal side of the tendon to sharply dissect it from scar holding it to the bone. Dissect a little. Then, encourage the patient to rupture adhesions with active movement a little. Repeat dissection and active flexion until the patient ruptures the final adhesions. Let the patient see her own final flexion ability so she knows what to aim for with therapy in the rehabilitation (▶Fig. 10.4b).
At the end of tenolysis, tendons are greatly weakened as they are denuded of adjacent collagen and greatly devascularized with removal of scar tissue.