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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

RELEASE RELEASE

FOR OBTAINING OF NORMAL FOR OBTAINING OF NORMAL

PIP PIP

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 ROM Active ROM << passive ROM passive ROM

Intact flexor tendon??Intact flexor tendon??Not irreparable involved jointsNot irreparable involved jointsFinger sensory condition OKFinger sensory condition OKCirculation condition OKCirculation condition OK

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f. tenolysis,INDICATION.contf. tenolysis,INDICATION.cont

Difficult technique,should not be take Difficult 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/ Localized Best candidate? Repaired ten.w/ Localized adhesion.adhesion.but: more freq. long segment involvement but: more freq. long segment involvement wh/ req.extensive exposure.w/ joint wh/ req.extensive exposure.w/ joint problem is your caseproblem is your case

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f. tenolysis,TIMING f. tenolysis,TIMING Exact timing of tenolysis??Exact timing of tenolysis??

Reasonable period of time should be Reasonable 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 in Tenolysis is absolutely contraindicated in patients with: patients with:

active infection, active infection,

motor-tendon problems secondary to motor-tendon problems secondary to denervation,denervation,

and unstable underlying fractures and 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 in assessing Radiographs of the digit are critical in assessing the status of the joints and the osseous the status of the joints and the osseous elements.elements.High-frequency ultrasound investigation can be High-frequency ultrasound investigation can be used to evaluate the tendons, with an accuracy used to evaluate the tendons, with an accuracy rate in the range of 84-90% and a false-positive rate in the range of 84-90% and a false-positive rate of 10%rate of 10%MRI depicts isolated peritendinous adhesions MRI 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 callus specificity, 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 through Sheath,pulley system, saving w/ working through retinacular windows.retinacular windows.First, 2 tendons should be mobilized fully at the First, 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 far Then 2 tendons should be dissected as far proximally as they are distinct structures.as N.Ly proximally as they are distinct structures.as N.Ly

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f.tenolysis,TECHNIQUE. Op f.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 fallowed beneath Dissection of plane should be fallowed beneath pulleys, by creation of windowpulleys, by creation of window(s).(s).

Result should be checked by: 1- active flexion Result should be checked by: 1- active flexion or complete by it. 2- passive traction of tendon or 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. Op f.tenolysis,TECHNIQUE. Op contcont. .

Then FDP&FDS should be dissected one from Then 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 directions Then 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 traction Tenolysis 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, maneuver Tourniquet should be released, maneuver should be repeated.should be repeated.

Scar segment may be too long, causing the Scar segment may be too long, causing the tendon to be incompetent for either or both of tendon 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 & firm Wound should be closed by a little closer suture & firm knots.knots.Wrist should be immobilized in extension, and Wrist should be immobilized in extension, and tenolized digit in flexion. tenolized digit in flexion. In order to give maximum power to flexor& clot In 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 condition Rubber 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 as Unresisted active ex. Throughout the day as soon as possible.possible.On no account should the operated hand be used to On 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 pulleys Rupture 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,gelatin rubber sheathing, polyethylene film,gelatin sponge, amniotic membrane, fascia, sponge, amniotic membrane, fascia, paratenon…..paratenon…..

کامل آزادسازی از تر ومطمئن بهتر اقدامی کامل هیچ آزادسازی از تر ومطمئن بهتر اقدامی هیچاقل حد ها پلی و غالف نگهداری اقل چسبندگیها حد ها پلی و غالف نگهداری آنوالر 22چسبندگیها آنوالر پلی پلی

نیست- 44و و 22 ها تاندون سازی لغزنده نیست- وتمرینات ها تاندون سازی لغزنده وتمرینات . .

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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 flx Principles and techniques are the same as flx tenolysis, except without critical pulley tenolysis, except without critical pulley system ,but sagittal band (shroud fibers) should system ,but sagittal band (shroud fibers) should be protected.be protected.Extrinsic extensor tendon release = separation Extrinsic extensor tendon release = separation of dual extrinsic-intrinsic extensor control of PIP of dual extrinsic-intrinsic extensor control of PIP joint.joint.So, careful ph. exame is important for diagnosis So, 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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