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

• Local infiltration anesthesia with fine needle
• Intravenous regional anesthesia
• Plexus anesthesia
• General anesthesia

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

• The surgeon should sit on the side where the dominant hand points the scissor tip distally
• An assistant sits opposite if necessary
• The scrub nurse positions themselves at the head end of the hand table

• It is advisable to use a hand holder such as a lead hand or similar
• The application of an upper arm tourniquet is recommended
• The use of magnifying optics such as loupes is recommended
• A hand instrument set is used
• Special instrument sets are not necessary for the open method

Postoperative Analgesia

Follow the link here to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline Treatment of acute perioperative and posttraumatic pain.

Medical Follow-up Care

• Regular wound inspection
• Elastic compression bandage (Caution: Constriction!) for a few days
• Suture removal after 14 days
• If necessary, fatty ointment for scar care (special scar ointment not necessary)
• Release for weight-bearing after 14 days

Thrombosis Prophylaxis

• not applicable

Mobilization

• immediate

Physiotherapy

• Active exercise treatment with possible physiotherapeutic support with complete extension and fist closure of the fingers from the 1st postoperative day (prevents hand edema and finger stiffness)
• Specific hand therapy measures for advanced findings with restricted movement of the PIP joint or tendon adhesions

Diet Build-up

• not applicable

Stool Regulation

• not applicable

Incapacity for Work

• Usually 14-21 days, depending on manual activity (maximum 6 weeks)