I have few cases that felt ok following the procedure, but few months later have swelling, pain, limited motion and synovitis - there is no apparent infection.
I operated on some of them - nothing special except synovitis. In a few, the A1 was incompletely released.
A history of IDDM is associated with recurrent tenosynovitis - in my clinical experience, this is always the subgroup with poorest results. The other subgroup with less encouraging results are the heavy scarrers who have pain and restricted tendon glide from the proliferation of scar tissue post-op that is slow to remodel and mature. I would suggest splinting the MCP in extension at night in conjunction with silicone gel sheets until the inflammatory phase of scarring has completely resolved (often many months).
A recent paper in J Hand Surg Am. 2014 Feb;39(2):280-5 looked at the development of flexor tenosynovitis after carpal tunnel release in persons with and without diabetes, and found a much higher rate in the diabetic cohort. This illustrates the final subgroup, those who develop trigger finger associated with secondary inflammation and scarring from another surgery or trauma.
In fact, trigger finger,, carpal tunnel syndrome, are directly depending from the evolution of the tenosynovitis. We don't know at what time we operate, the growth phase of tenosynovitis. If the etiology is still effective and active, diabetes for example, the increasing of the diameter of digital canal / carpal tunnel, might stay not enough wide, regardless of the technics. The most frequent etiology remains the relative deficit in estrogen around the menopause. In this specific example, it's an easy situation, cause the period of acute tenosynovitis is most of the time limited. but in the diabetes,, kidney involution or hypothyroid disease, you may have chronicle and severe tenosynovitis, with sometimes, real difficulties of therapy.
Thank you but i am thinking about something more technical like incomplete release or release which is too proximal or too distal
Dear Hagar,
I do not practise percutaneous release anymore for the very same reasons. It is not an incomplete release but reformation of the A1 pulley by scarring / fibrosis.
Incomplete release is another possibility, but the symptoms would be apparent earlier.
Also f the patient has been started on cholesterol lowering agents, there is a tendency to trigger!
Thank you very much! by the way - I don't see this recurrence in thumbs , may be because the pulley is narrower in thumbs?
Do it open !
Local anaesthesia
1.5cm transverse skin incision in flexor crease. Division of A1 with fine blunt scissors
Check absence of triggering on active flexion.
Two subutaneous 5/0 transparent PDS sutures.
1 week dressing.
Tell the patient the scar can remain tender for up to 3 months but will become invisible.
Based on 2800 personal procedures.
The point is not "doing percutaneous", it's making the patient happy.
I always do them open and usually will do a synovectomy. Oftentimes, the synovium is inflamed; its removal I believe reduces "recurrence".
I think every hand surgeon have some of these cases. The reason why is often not clear. I try to be as atraumatic as possible: Incision in the palmar crease - not in the fat pad. Try to get no hematoma - got blood vessel cauterization. After surgery a good dressing with local pressure is important. Incision of the pulley in second finger on radial side and in little finger on ulnar side to preserve the hypomochlion-function of the pulley. Complete transsection of the A1-pulley - if the palmar aponeurosis pulley and the A2 pulley is intact. In some cases of Dupuytren-disease or previous trauma the palmar aponeurosis pulley is removed in earlier operation. In these cases I reconstruct the A1-pulley with advancement. If necessary I do synovialectomie. I am still wondering: cut or resect the longitudinal fibres of the palmar aponeurosis?
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