Flexor Tenolysis Treatment & Management
- Author: Cato T Laurencin, MD, PhD; Chief Editor: Harris Gellman, MD more...
Although steroid injections to augment tendon repair are notable in the literature,[14, 15, 16] they are not universal, and by the time tendon adhesions occur, there is no currently accepted medical therapy to treat the condition.
Flexor tenolysis is a surgical procedure.
Make sure patient meets all indications for surgery to proceed, including a rigorous examination of external anatomy to check for mature scarring and good passive range of motion.
Since the 1970s, flexor tenolysis has been popularly performed using local anesthesia alone. Benefits for this include the fact that the surgeon may actively engage with the patient to ensure that the tendon is free from adhesions to glide in the tendon canal. Active participation from the patient also establishes whether the musculature for digit flexion is strong enough to power tendon contraction.
General anesthesia can still be considered for patient-specific factors, including inability to irritability, anxiety, or a complicated surgical plan owing to multiple affected tendons. Under circumstances of general anesthesia, active flexion can be ascertained by opening a surgical window proximal to the affected tendon as described by Whitaker et al. Using this opened window, surgeons can pull on the tendons to simulate muscular contraction.
The surgery starts by exposing the full length of the flexor tendon through either a zigzag or midlateral incision. A zigzag incision, championed by Schneider, provides the best operative window to the flexor tendon and pulley system.[18, 19] The midlateral incision is believed to diminish the presence of scarring directly over the affected flexor tendon and puts the neural and vascular structures at less risk.
After exposure, both flexor tendons (FDP and FDS) are raised from underlying structures, and all tendon adhesions are lysed. After adhesions are removed between the tendons and the sheath, it is usually recommended to remove adhesions between the FDP and FDS, with sacrifice of the FDS being necessary if free tendon gliding cannot be accomplished otherwise.
During the process of removing adhesions, the participation of the patient can be critical, especially when trying to differentiate between scar tissue and the pulley system. Although adhesion removal using lasers has been described in rabbits, the practice has failed to gain a wide clinical following in the human population, and most surgeons still use traditional hand instruments modified for the procedure. Preservation of the pulley system, especially the A2 and A4 pulleys, is vital for normal flexor tendon activity. Less commonly, the pulley structures are compromised and a pulley reconstruction may be indicated.[2, 19] Usually, this procedure continues and adhesions are removed until full active flexion can be achieved.
The final stage of the surgery is to assess whether the tendon is robust enough to progress through the rigorous physical therapy necessitated by this complex procedure. Both scarring and substantial tendon tissue loss (>30% width lost) can put the patient at risk, and in such situations it is generally recommended that the patient undergo a 2-stage tendon reconstruction.[11, 18, 19, 20, 22] Some physicians treat patients with steroids at this point in order to abrogate the formation of new adhesions during recovery, but as steroids have a well-described capability to limit the healing response, many abstain from their use altogether. Starting in the 1930s, physicians have described the use of various other natural or synthetic materials to prevent subsequent formation of tendon adhesions,[23, 24] but these techniques have failed to gain widespread acceptance as of yet.
Physical therapy is absolutely necessary for healthy tendon function to return, and poorly controlled pain can hamper the recovery effort. To reduce postoperative pain, most physicians recommend oral analgesia, but every patient is different, and severe cases of pain may necessitate more extreme measures, including indwelling catheters capable of dispensing local anesthesia.
When to start physical therapy in an issue up for debate. As immobilization is necessary for the tendon adhesions to form, some physicians recommend immediate hand exercises, while others recommend waiting for a period of days until the effects of the surgical approach (inflammation, scarring) have diminished.
The level and rigor of physical therapy should take the individual surgery of the patient into consideration. If upon surgical exposure of the flexor tendon, the surgeon notices significant impairment in the health and quality of the tendon, this important information should be relayed to the physical therapist, who may then appropriately modify a treatment plan. Protocols for patients with poor tendon quality are well documented and have shown improved results compared with a protocol for a healthier tendon. A common protocol for patients with a healthy tendon is to undergo physical therapy 3-5 days per week at first and then slowly decrease the frequency of physical therapy over a period of weeks to months, with the goal of decreasing pain and increasing range of motion and strength.
Patient compliance with physical therapy is mandatory for this procedure.
Some studies have shown that as many as 20% of patients who undergo this procedure do not benefit from the operation, and 8% of patients experience frank tendon rupture, with some studies showing rates as high as 15%.[5, 25, 26]
Outcome and Prognosis
As flexor tenolysis is a very individualized procedure, there are widely disparate reports of how much active flexor range of motion will increase. It has been reported that active range of motion increases for between 59% and 90% of all patients.
Future and Controversies
While this procedure has proven to be effective in the majority of cases, the complication rate is still very high, and much research is needed into protocols, surgical techniques, or materials that can restore active range of motion to patients.
One way to combat the formation of adhesions after flexor tenolysis would be to find a therapy that could decrease the immunological response to the surgery.[27, 28] As mentioned before, corticosteroids have been tried, but their limitations are too severe for widespread acceptance.
A crucial aspect of the surgery is to respect the pulley system for the flexor tendons. A safer way to reconstruct the pulley system using natural or synthetic materials could potentially improve the prognosis for this procedure. While significant research has been performed on implantable, interpositional materials, human trials have, to date, been lacking in rigor. A potential candidate that has emerged would be to use the joint matrix protein derivative Seprafilm, which that has emerged as a useful therapeutic in the reduction of adhesions in surgery involving the gastrointestinal tract. Further studies are warranted.
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