Perioperative management - Division of the A1 pulley

• Irreversible movement disorder in the sense of a trapped finger
• Relevant and impairing the patient (not improved by conservative measures) painful snapping phenomenon

• Local or general conditions that surgically or anesthesiologically contraindicate an elective operation or that can be improved preoperatively
• Cortisone injection in the area of the surgical field within the last three months (increased complication rate such as wound healing disorder, synovial fistula)

• History of typical clinical presentation:
  – Pressure pain in the area of the palmar flexion crease
  – Restriction of finger movement, typically at the beginning in the morning after getting up
  – Classic snapping phenomenon with locking of the finger in maximum flexion, extension of the finger is only possible passively with the help of the other hand
• Clinical examination:
  – Inspection/palpation of a painful thickening in the area of the A1 pulley, the nodule moves with the flexor tendon and sometimes gets stuck at the pulley itself
  – Demonstration of the snapping phenomenon by the patient
  – in advanced cases (so-called Digitus incarnatus): The finger is maximally flexed in the PIP joint and can no longer be extended even passively, or it is fixed in extension and can no longer be flexed.

Tip: in both cases, the patient reports a long-standing snapping symptom in the past, which then could no longer be corrected after a certain time.

• no special preparation of the patient necessary
• generally outpatient procedure
• Clarification of contraindication for bloodless field (e.g. existing shunt in dialysis)

• Informed consent regarding the operative method
• Informed consent regarding extension procedures such as e.g. accompanying tenosynovectomy, tenolysis or arthrolysis especially in advanced findings (Digitus incarnatus)
• Informed consent regarding general surgical risks (wound healing disorder, hematoma)

Informed consent regarding specific surgical risks, which, depending on pre-existing conditions (diabetes mellitus, immunosuppression) and literature can amount to up to 43 %:

• Injury to digital nerves with neuropathic pain
•  Prolonged scar pain (usually subsides after 6 months) 
• Persistent complaints, revision surgery 
• Risk of recurrence (increased in patients with rheumatic synovitis and diabetes mellitus)
• Pyogenic synovitis
• Tendon/vascular injury
• Synovial fistula (extremely rare)
• Functional deficit of wrist/hand
• CRPS (extremely rare)
• Incomplete success with remaining restriction of movement in pre-existing tenodesis and joint stiffness