Thanks in advance.
The right middle finger was approached volarly with a Brunner incision. We went ahead and utilized the previous incision, which was oblique over the A1 pulley. This was extended proximally. We extended it distally across the MP joint, PIP joint, and then DIP joint. Incising the skin sharply, we elevated up radially and ulnarly full-thickness flaps. We identified the flexor tendon sheath, identified the radial and ulnar neurovascular bundles extending out to the middle finger. Exposing the flexor tendon sheath, there was clear recurrence of the giant cell tumor right at the site of the previous lesion. We then went ahead and fully developed the sheath distally. The tumor had recurred and basically tracked down the sheath and it popped up distal to the A2 pulley over the PIP joint and all the way out to the DIP joint past the A5 pulley. We created a window, excising the lesion at the A1 pulley level. We resected the remnants of the A1 pulley, which had obvious involvement of the giant cell tumor. There was a large component of giant cell tumor behind the superficialis tendon. There was actually tumor that appeared to be in the chiasm of the superficialis. Basically working between the pulley windows, we then went ahead and resected all the tumor that we could visualize out past A2. Just distal to A2, there was another lesion, kind of within the sheath itself. We pulled the superficialis and profundus out of the way and got the tumor there, and then working our way out distally, resected everything that we could while retaining the pulleys and the flexor tendons themselves. Once tumor had been excised all the way out to the DIP joint level, we, once again, inspected in and around the profundus and superficialis at every single level, making sure there were no remnants. Behind the A1 pulley over the volar aspect of the MP joint, it did appear that there was a lesion, which did extend through the volar capsule and possibly could have been the original lesion. We excised the small component of volar capsule and got into the MP joint volarly. There was no obvious lesion within the MP joint. The wounds were thoroughly irrigated. We then went ahead and closed the wounds using a 4-0 nylon in an interrupted fashion. We did place a small piece of Esmarch in proximally as a drain. A sterile dressing was applied.
