DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Right small finger flexor tendon contracture.
2. Proximal interphalangeal joint contracture.
3. Distal interphalangeal joint contracture.
POSTOPERATIVE DIAGNOSES:
1. Right small finger flexor tendon contracture and adhesions.
2. Proximal interphalangeal joint contracture.
3. Distal interphalangeal joint contracture.
4. Flexor tendon rupture.
OPERATIONS PERFORMED:
1. Right small finger flexor tendon tenolysis.
2. Proximal interphalangeal joint capsulectomy and complete joint release.
3. Distal interphalangeal joint capsulectomy and complete joint release.
4. Flexor tendon repair to the distal phalanx.
SURGEON: John Doe, MD
ANESTHESIA: General anesthesia.
ANESTHESIOLOGIST: Jane Doe, MD
FLUIDS: 600 mL of lactated Ringer's.
ESTIMATED BLOOD LOSS: Minimal.
TOURNIQUET TIME: 86 minutes.
DESCRIPTION OF OPERATION: Following informed consent, administration of IV antibiotics and site marking of the right small finger and forearm of the right arm, the patient was taken to the operating room and placed supine on the operating table. Following site verification and time-out of the right small finger, the hand, and forearm, the patient was placed under general anesthesia and the right arm was placed on the hand table. The operating table was turned 90 degrees and a nonsterile tourniquet was placed in the proximal right arm and the right arm and hand were sterilely prepped and draped in the usual fashion. The right arm was wrapped in Esmarch and tourniquet was inflated and left inflated a total of 86 minutes. Following inflation of the tourniquet, a Brunner incision extending from the mild pulp of the distal aspect of the right small finger and extending down the length of the finger down into the palm proximal to the A1 pulley Brunner incisions, zig-zag type incision was made. A sharp dissection was carried through skin and dense scar to the flexor tendon. The A3 pulley that was really just a scar tissue was elevated off of the flexor tendon. The neurovascular bundles, both radial and ulnarly, were left undisturbed during the procedure. The A3 pulley was opened. The flexor tendon was observed. The flexor digitorum superficialis tendon was noted to not be intact. The patient had a single flexor digitorum profundus tendon to the right small finger. There was noted to be sutures distal to the A4 pulley, where the tendon repair had been repaired to a very small stump at the distal attachments of the flexor digitorum profundus tendon at the base of the distal phalanx. Again, the A3 pulley was opened. The A2 and A4 pulleys were left intact. The A4 pulley was very small, but it was intact. The A2 pulley was intact. The A1 pulley was intact as well. The flexor digitorum superficialis tendon was retracted from the proximal interphalangeal joint.
Using the Beaver blade, a capsulectomy of the volar aspect of the proximal interphalangeal joint releasing the collateral ligaments was performed as well as the volar plate and the proximal interphalangeal joint could be extended to full extension. Attention was then turned to the distal interphalangeal joint. Again, the flexor tendon was retracted. A capsulectomy and complete collateral ligament release of the distal interphalangeal joint was performed in a complete extension, to 0 degrees of the distal interphalangeal joint was possible. The joints appeared to be normal with normal articular cartilage. The skin and subcutaneous tissues were dissected free from the tendon proximal to the A1 pulley. The tendon was noted to be intact. Using a Freer, adhesions were broken up surrounding the flexor digitorum profundus tendon through the A1 and A2 pulleys. In the process of doing that, the distal attachment repair site of the flexor digitorum profundus tendon completely ruptured. The flexor tendon was completely released from adhesions down into the mid palm through the pulley system in the finger, and it was noted to have full free movement of the flexor digitorum profundus tendon with complete release of all adhesions through the pulley system, as well as to the bone and surrounding soft tissue.
The distal flexor tendon was then repaired to the base of the distal phalanx. The prior sutures were removed. The micro-Mitek suture anchor was drilled into the base of the distal phalanx and the suture was used to reapproximate the flexor digitorum profundus tendon to the base of the distal phalanx with an intact A4 pulley. The #4 Ethibond sutures were used to secure the distal tendon to the surrounding tissue, and then, using two Keith needles, these were drilled through the distal phalanx exiting through the proximal aspect of the nail dorsally and 3-0 Prolene suture in a Bunnell-type suture pattern was sutured to the distal flexor digitorum profundus tendon, passed through the Keith needles through a button on the dorsum of the nail of the right small finger and tied in place to further secure the attachment of the flexor digitorum profundus tendon to the distal phalanx. The flexor digitorum profundus tendon was noted to be intact and held in its position. The right small finger could be fully extended. The metacarpophalangeal and proximal interphalangeal joints and distal interphalangeal joint could be extended to approximately flexion of about 30 degrees before tension on the flexor digitorum profundus tendon was noted. The finger could be completely flexed by pulling on the tendon proximal to the A1 pulley down into a fully flexed position touching the palm with the tip of the small finger.
The tourniquet was deflated at 86 minutes. Hemostasis was achieved. The distal finger had capillary refill less than 2 seconds. The wound was copiously irrigated and the skin was closed with interrupted 5-0 nylon sutures. A sterile soft dressing and a dorsal hood splint with the right small finger, the wrist flexed approximately 20 degrees, metacarpophalangeal joint flexed approximately 20 to 30 degrees, the proximal interphalangeal joint flexed about 20 degrees and the distal interphalangeal joint flexed about 45 degrees, was placed. The patient was extubated in the operating room and taken to the recovery room in stable condition.
