Flexor tenolysis by Dr Ga

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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

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TENOLYSIS,(extensor)TENOLYSIS,(extensor)
EXTRINSIC – INTRINSIC TIGHTNESSEXTRINSIC – INTRINSIC TIGHTNESS
RELEASERELEASE
FOR OBTAINING OF NORMALFOR OBTAINING OF NORMAL
PIPPIP
JOINT FLEXIONJOINT FLEXION

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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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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

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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.

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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.

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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.

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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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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

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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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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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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.

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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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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

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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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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.

Flexor tenolysis by Dr Ga

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