Perioperative management - Flexor tendon suture according to Kirchmayr-Kessler

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

• Local or general conditions that surgically or anesthesiologically contraindicate an elective operation or that can be improved 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 outpatient procedure
• Assessment of contraindications for bloodless field (e.g., existing shunt in dialysis)

Information on

• surgical method
• extension procedures such as e.g. reconstruction of artery, nerve, flexor tendon sheath; change of procedure to replacement plastic or tendon transplant

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

• specific surgical risks
  • postoperative scarring
  • flexor tendon sheath infection
  • secondary tendon ruptures due to failure of the 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 dominant hand points the scissor tip distally
• An assistant sits opposite if necessary
• The instrument nurse positions themselves at the head end of the hand table

• The application of an upper arm tourniquet is recommended
• A hand fixation system is helpful (e.g., lead hand)
• A hand instrument set is used, possibly microinstrument set 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.
• If necessary, application of cold packs as a local physical measure.

Medical Follow-up Treatment

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

Thrombosis Prophylaxis

• not applicable

Mobilization 

• immediate

Follow-up Treatment Protocol

In the majority, early passive movement protocols are still applied currently, e.g., according to Kleinert:

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

Diet Build-up

• not applicable

Stool Regulation

• not applicable

Inability to Work

• Depending on manual activity up to 12 weeks.