Perioperative management - Removal of a tendon sheath hygroma/Extensor tendon synovectomy with retinaculum plasty

• Pain and swelling
• Failed conservative therapy attempt over 6 months

• Local or general conditions that surgically or anesthesiologically contraindicate an elective operation or are amenable to preoperative improvement

• Clinical examination:
  → Inspection/Palpation of a painful thickening along the course of the 4th SSF, which moves with the extensor tendons
• Ultrasound: Detection of a fluid-filled cavity with connection to the extensor tendons
• If necessary, MRI in case of unclear findings

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

Information on

• surgical method
• extension procedure such as e.g. tendon suture, tendon reconstruction, retinaculum plasty

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

• specific surgical risks
  • injury to the extensor tendons
  • protracted scar pain (usually subsides after 6 months)
  • persistent complaints
  • revision surgery
  • secondary tendon rupture

• intravenous regional anesthesia
• Plexus anesthesia
• General anesthesia

• Supine position
• Positioning of the hand on a hand table
• Recommended: Upper arm tourniquet application

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

• The application of an upper arm tourniquet is recommended
• A hand instrument set is used

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 Care

• Regular wound checks, elastic compression bandage (Caution: constriction!) for 3 weeks
• Suture removal after 14 days
• If necessary, recommendation of fatty ointment for scar care (special scar ointment not necessary)
• Release of loading depending on tendon quality

Thrombosis Prophylaxis

• not applicable

Mobilization

• immediate

Physical Therapy: 

• Active exercise treatment with possible physical therapy 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 in advanced findings and risk of two-stage tendon rupture.

Diet Build-up

• not applicable

Bowel Regulation

• not applicable

Inability to Work

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