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Flexor TENO LYSISFlexor TENO LYSIS
Surgical releasing ofSurgical releasing of
Non gli...
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TENOLYSIS,(extensor)TENOLYSIS,(extensor)
EXTRINSIC – INTRINSIC TIGHTNESSEXTRINSIC – INTRINSIC TIGHTNES...
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f. tenolysis, INDICATIONf. tenolysis, INDICATION
Plateau progress through exercise &Plateau progress t...
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f. tenolysis,INDICATION.contf. tenolysis,INDICATION.cont
Difficult technique,should not be takeDifficu...
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f. tenolysis,TIMINGf. tenolysis,TIMING
Exact timing of tenolysis??Exact timing of tenolysis??
Reasonab...
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TENOLYSIS ,ContraindicationsTENOLYSIS ,Contraindications
Tenolysis is absolutely contraindicated inTe...
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TENOLYSIS ,ContraindicationsTENOLYSIS ,Contraindications
Relative contraindications include :Relative...
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Imaging Studies:Imaging Studies:
Radiographs of the digit are critical inRadiographs of the digit are...
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f.tenolysis,TECHNIQUE. opf.tenolysis,TECHNIQUE. op
Tenolysis=exploration!!??Tenolysis=exploration!!??...
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f.tenolysis,TECHNIQUE. Opf.tenolysis,TECHNIQUE. Op contcont..22
Pulleys never be divided.Pulleys neve...
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f.tenolysis,TECHNIQUE. Opf.tenolysis,TECHNIQUE. Op contcont..
Then FDP&FDS should be dissected one fr...
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f.tenolysis,POST. Op.f.tenolysis,POST. Op.
Why full motion is not achieved?.Why full motion is not ac...
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f.tenolysisf.tenolysis ,POST OP.cont.,POST OP.cont.
Complete hemostasis should be achieved.Complete h...
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Flexor TENO LYSIS complicationFlexor TENO LYSIS complication
Rupture of repaired tendon.Rupture of re...
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Adjunct to TENO LYSISAdjunct to TENO LYSIS
SteroidsSteroids
Inter positional materials: cellophane, s...
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EXTENSOR TENOLYSISEXTENSOR TENOLYSIS
Extrinsic extensor tendon tightness.Extrinsic extensor tendon ti...
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Flexor tenolysis by Dr Ga

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Flexor tenolysis by Dr Ga

  1. 1. 12:30 PM12:30 PM 12:30 PM12:30 PM 11 Flexor TENO LYSISFlexor TENO LYSIS Surgical releasing ofSurgical releasing of Non gliding adhesions formNon gliding adhesions form Along the surface ofAlong the surface of TENDONTENDON After injury &After injury & repairrepair
  2. 2. 12:30 PM 12:30 PM 2
  3. 3. 12:30 PM 12:30 PM 3 TENOLYSIS,(extensor)TENOLYSIS,(extensor) EXTRINSIC – INTRINSIC TIGHTNESSEXTRINSIC – INTRINSIC TIGHTNESS RELEASERELEASE FOR OBTAINING OF NORMALFOR OBTAINING OF NORMAL PIPPIP JOINT FLEXIONJOINT FLEXION
  4. 4. 12:30 PM 12:30 PM 4
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  6. 6. 12:30 PM 12:30 PM 6 f. tenolysis, INDICATIONf. tenolysis, INDICATION Plateau progress through exercise &Plateau progress through exercise & splinting. Age? Occupation? Motivation?splinting. Age? Occupation? Motivation? OA hand? 50% ROM is enough?!OA hand? 50% ROM is enough?! Active ROMActive ROM << passive ROMpassive ROM Intact flexor tendon??Intact flexor tendon?? Not irreparable involved jointsNot irreparable involved joints Finger sensory condition OKFinger sensory condition OK Circulation condition OKCirculation condition OK
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  8. 8. 12:30 PM 12:30 PM 8 f. tenolysis,INDICATION.contf. tenolysis,INDICATION.cont Difficult technique,should not be takeDifficult technique,should not be take lightlylightly.. It is a surgical onslaught.It is a surgical onslaught. Unsuccessful tl begets worse.Unsuccessful tl begets worse. Best candidate? Repaired ten.w/Best candidate? Repaired ten.w/ Localized adhesion.Localized adhesion. but: more freq. long segment involvementbut: more freq. long segment involvement wh/ req.extensive exposure.w/ jointwh/ req.extensive exposure.w/ joint problem is your caseproblem is your case
  9. 9. 12:30 PM 12:30 PM 9 f. tenolysis,TIMINGf. tenolysis,TIMING Exact timing of tenolysis??Exact timing of tenolysis?? Reasonable period of time should beReasonable period of time should be allowed,for:allowed,for: softening of wound,softening of wound, Remodeling of adhesions,Remodeling of adhesions, Scar tissues maturation,Scar tissues maturation, Ex th. hand th. tendon mobilization.Ex th. hand th. tendon mobilization. 22 wks. 12wks………………9 mon.22 wks. 12wks………………9 mon. Judgment of surgeon is prime importance.Judgment of surgeon is prime importance.
  10. 10. 12:30 PM 12:30 PM 10
  11. 11. 12:30 PM 12:30 PM 11 TENOLYSIS ,ContraindicationsTENOLYSIS ,Contraindications Tenolysis is absolutely contraindicated inTenolysis is absolutely contraindicated in patients with:patients with: active infection,active infection, motor-tendon problems secondary tomotor-tendon problems secondary to denervation,denervation, and unstable underlying fracturesand unstable underlying fractures requiring fixation and immobilization.requiring fixation and immobilization. Poor circulation.Poor circulation.
  12. 12. 12:30 PM 12:30 PM 12 TENOLYSIS ,ContraindicationsTENOLYSIS ,Contraindications Relative contraindications include :Relative contraindications include : extensive adhesions .extensive adhesions . immature previous scars .immature previous scars . severe posttraumatic underlining arthrosis.severe posttraumatic underlining arthrosis.
  13. 13. 12:30 PM 12:30 PM 13
  14. 14. 12:30 PM 12:30 PM 14 Imaging Studies:Imaging Studies: Radiographs of the digit are critical inRadiographs of the digit are critical in assessing the status of the joints and theassessing the status of the joints and the osseous elements.osseous elements. High-frequency ultrasound investigation can beHigh-frequency ultrasound investigation can be used to evaluate the tendons, with an accuracyused to evaluate the tendons, with an accuracy rate in the range of 84-90% and a false-positiverate in the range of 84-90% and a false-positive rate of 10%rate of 10% MRI depicts isolated peritendinous adhesionsMRI depicts isolated peritendinous adhesions (sensitivity, 91%; specificity, 100%).(sensitivity, 91%; specificity, 100%). Additionally, frank rupture (sensitivity, 100%;Additionally, frank rupture (sensitivity, 100%; specificity, 100%) or elongated callusspecificity, 100%) or elongated callus (sensitivity, 100%; specificity, 94%) is seen.(sensitivity, 100%; specificity, 94%) is seen.
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  16. 16. 12:30 PM 12:30 PM 16 f.tenolysis,TECHNIQUE. opf.tenolysis,TECHNIQUE. op Tenolysis=exploration!!??Tenolysis=exploration!!?? Anesthesia: Local?,regional?,general?Anesthesia: Local?,regional?,general? Active motion? Passive gliding? In op field.Active motion? Passive gliding? In op field. Tip to palm,zigzag incision.Tip to palm,zigzag incision. Sheath,pulley system, saving w/ working throughSheath,pulley system, saving w/ working through retinacular windows.retinacular windows. First, 2 tendons should be mobilized fully at theFirst, 2 tendons should be mobilized fully at the pip window. Despite of difficulties.pip window. Despite of difficulties. FDP should be released distally as sole tendon.FDP should be released distally as sole tendon. Then 2 tendons should be dissected as farThen 2 tendons should be dissected as far proximally as they are distinct structures.as N.Lyproximally as they are distinct structures.as N.Ly
  17. 17. 12:30 PM 12:30 PM 17 f.tenolysis,TECHNIQUE. Opf.tenolysis,TECHNIQUE. Op contcont..22 Pulleys never be divided.Pulleys never be divided. Pulleys should be handled by hook or right-Pulleys should be handled by hook or right- angled retractor.angled retractor. Dissection of plane should be fallowedDissection of plane should be fallowed beneath pulleys, by creation of windowbeneath pulleys, by creation of window(s).(s). Result should be checked by: 1- active flexionResult should be checked by: 1- active flexion or complete by it. 2- passive traction of tendonor complete by it. 2- passive traction of tendon at palm or above the wrist.at palm or above the wrist.
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  19. 19. 12:30 PM 12:30 PM 19 f.tenolysis,TECHNIQUE. Opf.tenolysis,TECHNIQUE. Op contcont.. Then FDP&FDS should be dissected one fromThen FDP&FDS should be dissected one from the other, in the palm, out as far as A1 pulley.the other, in the palm, out as far as A1 pulley. Then tenolysis proceeds from both directionsThen tenolysis proceeds from both directions toward the fusion & adhesion area.toward the fusion & adhesion area. Traction on the tendons away from the bed &Traction on the tendons away from the bed & from each other reveals correct plane.from each other reveals correct plane. Use standard knife or Beaver blade.Use standard knife or Beaver blade. Never use forceps for traction. Use rubber bandNever use forceps for traction. Use rubber band
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  22. 22. 12:30 PM 12:30 PM 22 f.tenolysis,POST. Op.f.tenolysis,POST. Op. Why full motion is not achieved?.Why full motion is not achieved?. Tenolysis my not be complete. Strong tractionTenolysis my not be complete. Strong traction by pt. may complete it.by pt. may complete it. Tourniquet time more than 20-30min.Tourniquet time more than 20-30min. Tourniquet should be released, maneuverTourniquet should be released, maneuver should be repeated.should be repeated. Scar segment may be too long, causing theScar segment may be too long, causing the tendon to be incompetent for either or both oftendon to be incompetent for either or both of two reasons:1-quadriga.2-lumrical plus.two reasons:1-quadriga.2-lumrical plus.
  23. 23. 12:30 PM 12:30 PM 23 f.tenolysisf.tenolysis ,POST OP.cont.,POST OP.cont. Complete hemostasis should be achieved.Complete hemostasis should be achieved. Wound should be closed by a little closer suture & firmWound should be closed by a little closer suture & firm knots.knots. Wrist should be immobilized in extension, andWrist should be immobilized in extension, and tenolized digit in flexion.tenolized digit in flexion. In order to give maximum power to flexor& clotIn order to give maximum power to flexor& clot adhesion breakage by passive digit extension.adhesion breakage by passive digit extension. Rubber band traction is applied in very rare conditionRubber band traction is applied in very rare condition wn/ tenuous tendon is accepted. so w/ wrist in flexion.wn/ tenuous tendon is accepted. so w/ wrist in flexion. Unresisted active ex. Throughout the day as soon asUnresisted active ex. Throughout the day as soon as possible.possible. On no account should the operated hand be used toOn no account should the operated hand be used to lift or grasp.lift or grasp.
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  25. 25. 12:30 PM 12:30 PM 25 Flexor TENO LYSIS complicationFlexor TENO LYSIS complication Rupture of repaired tendon.Rupture of repaired tendon. Edema.Edema. Neurovascular injury.Neurovascular injury. Rupture of flexor pulleysRupture of flexor pulleys
  26. 26. 12:30 PM 12:30 PM 26 Adjunct to TENO LYSISAdjunct to TENO LYSIS SteroidsSteroids Inter positional materials: cellophane, silicone,Inter positional materials: cellophane, silicone, rubber sheathing, polyethylene film,gelatinrubber sheathing, polyethylene film,gelatin sponge, amniotic membrane, fascia,sponge, amniotic membrane, fascia, paratenon…..paratenon….. ‫چسبندگیها‬ ‫کامل‬ ‫آزادسازی‬ ‫از‬ ‫تر‬ ‫ومطمئن‬ ‫بهتر‬ ‫اقدامی‬ ‫هیچ‬‫چسبندگیها‬ ‫کامل‬ ‫آزادسازی‬ ‫از‬ ‫تر‬ ‫ومطمئن‬ ‫بهتر‬ ‫اقدامی‬ ‫هیچ‬ ‫اقل‬ ‫حد‬ ‫ها‬ ‫پلی‬ ‫و‬ ‫غل ف‬ ‫نگهداری‬‫اقل‬ ‫حد‬ ‫ها‬ ‫پلی‬ ‫و‬ ‫غل ف‬ ‫نگهداری‬22‫آنولر‬ ‫پلی‬‫آنولر‬ ‫پلی‬22‫و‬‫و‬44‫وتمرینات‬ -‫وتمرینات‬ - ‫نیست‬ ‫ها‬ ‫تاندون‬ ‫سازی‬ ‫لغزنده‬‫نیست‬ ‫ها‬ ‫تاندون‬ ‫سازی‬ ‫لغزنده‬..
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  28. 28. 12:30 PM 12:30 PM 28 EXTENSOR TENOLYSISEXTENSOR TENOLYSIS Extrinsic extensor tendon tightness.Extrinsic extensor tendon tightness. Dorsal tenodesis.Dorsal tenodesis. Principles and techniques are the same as flxPrinciples and techniques are the same as flx tenolysis, except without critical pulley systemtenolysis, except without critical pulley system ,but sagittal band (shroud fibers) should be,but sagittal band (shroud fibers) should be protected.protected. Extrinsic extensor tendon release = separationExtrinsic extensor tendon release = separation of dual extrinsic-intrinsic extensor control of PIPof dual extrinsic-intrinsic extensor control of PIP joint.joint. So, careful ph. exame is important for diagnosisSo, careful ph. exame is important for diagnosis of intrin-extrin cause of PIP extension deformity.of intrin-extrin cause of PIP extension deformity.
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