Perioperative management - Flexor tendon suture according to Kirchmayr-Kessler

• Severance of both flexor tendons with loss of flexion
• Severance of the deep flexor tendon (FDP) with preserved superficial flexor tendon (FDS) in manually active patients

• Local or general diseases that contraindicate an elective surgery surgically or anesthesiologically, or are improvable preoperatively

• Clinical examination:
  → Loss of active flexion of the middle and/or distal joint of the finger

• no special preparation of the patient necessary
• generally an outpatient procedure
• clarification of contraindication for bloodlessness (e.g., existing shunt in dialysis)

Information about

• surgical method
• additional procedures such as reconstruction of artery, nerve, flexor tendon sheath; change of procedure to replacement plastic or tendon graft

• general surgical risks
  • wound healing disorder
  • tendon injury
  • functional deficit of wrist/hand
  • CRPS = Sudeck's disease

• specific surgical risks
  • postoperative scarring
  • flexor tendon sheath infection
  • secondary tendon ruptures due to failure of primary suture

• Plexus anesthesia
• General anesthesia

• Supine positioning
• Positioning of the hand on a hand table
• Recommended: Application of upper arm tourniquet

• The surgeon should sit on the side where the leading hand points distally with the scissor tip
• Opposite, an assistant may sit
• The instrument nurse positions themselves at the head of the hand table

• It is recommended to apply an upper arm tourniquet
• A hand fixation system (e.g., lead hand) is helpful
• A hand instrument set is used, possibly micro-instruments for reconstruction of vessels or nerves
• For the reconstruction of vessels and nerves, the use of magnifying optics such as loupes is recommended

Postoperative Analgesia

• Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management).
• Follow the link here to the current guideline Treatment of Acute Perioperative and Posttraumatic Pain.
• Possibly apply cold packs as a local physical measure.

Medical Follow-up Treatment

• Regular wound inspection, elastic compression bandage (Caution: constriction!) for a few days
• Suture removal after 14 days

Thrombosis Prophylaxis

• not applicable

Mobilization

• immediate

Follow-up Protocol

Currently, early passive movement protocols are still predominantly used, e.g., according to Kleinert:

• The initial dorsal splinting includes flexion at the wrist (20–30°) and MCP joint (50–70°) as well as extension of the interphalangeal joints.
• The exercise involves active extension from a passive flexion created, for example, by rubber bands. These rubber bands as a dynamic traction component keep the fingers in passive flexion. The dorsal Kleinert orthosis dictates the extent of maximum extension, which the patient repeats hourly.
• After 3–6 weeks, active flexion is allowed, after 6–8 weeks active flexion against resistance.

Dietary Progression

• not applicable

Bowel Regulation

• not applicable

Incapacity for Work

• Depending on manual activity, up to 12 weeks.