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PRE-OP DIAGNOSIS:
1. Right volar wrist tenosynovitis with rupture of flexor multiple flexor tendons including flexor pollicis longus and index finger flexor tendons
2. Painful rheumatoid nodule right long finger proximal phalanx

PROCEDURE:
1. Right volar wrist flexor tenosynovectomy 25115
2. Transfer of right index finger flexor digitorum profundus to long finger flexor digitorum superficialis 25310
3. Excision of subcutaneous rheumatoid nodule right long finger proximal phalanx

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INDICATIONS FOR PROCEDURE: rheumatoid arthritis. * ruptures of the flexor tendons of the index finger a painful nodule on the volar aspect of the right long proximal phalanx.
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Findings: There was significant tenosynovitis with multiple tendon ruptures. does have functioning flexor digitorum superficialis to the long finger and flexor digitorum profundus is intact to the long, ring and small fingers with some decreased excursion of the small finger with passive flexion. *The flexor pollicis longus and remaining flexor digitorum superficialis tendons were ruptured with extensive fraying and retraction. *Tenosynovectomy was performed. *The distal stump of the flexor digitorum profundus to the index finger required the transfer be done at the A1 pulley level and just proximal to this. *Due to the quality of the tendons I transferred to the flexor digitorum superficialis of the long finger. *The tourniquet was deflated. *There was no bleeding that required hemostasis. *All fingertips were pink. *The skin was closed in a volar resting splint was applied.

The right upper extremity was elevated and exsanguinated with an Esmarch and the tourniquet was inflated to 250. *A longitudinal incision was made in the palm parallel to the thenar crease. *This incision was angled is across the wrist flexion creases and extended proximally in the volar midforearm. *Blunt dissection was carried out to the fascial layer. *Hemostasis was maintained with bipolar cautery. *There was extensive swelling in the forearm due to the synovitis and fluid. *When the fascia layer was opened a moderate amount of straw-colored fluid was drained. *The deep antebrachial fascia was opened from proximal to distal. *Distally the transverse carpal ligament was opened. *The median nerve was identified. *There were multiple ruptured flexor tendons noted. *The wound was irrigated and gently cleaned. *The median nerve was protected with a vessel loop and also was kept in direct visualization throughout the debridement. *Synovitis was removed along with ruptured tendon and that had retracted to the level of the distal forearm. *The incision was extended distally to the distal palmar crease and then angled active and then ulnar direction.
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The flexor pollicis longus was ruptured with a distal stump near the base of the thumb metacarpal. *Both flexor tendons to the index finger were ruptured with the stumps at the same level. *The long finger flexor digitorum superficialis and profundus were intact. *There was a second intact bundle of tendons which was flexor digitorum profundus to the long, ring and small fingers. *Passive flexion produced good flexion of the long and ring fingers and slightly decreased flexion of the small finger. *The pseudocapsule which had formed around the tenosynovitis was excised. *The ulnar neurovascular bundle was identified and kept under visualization during debridement in the forearm.
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Following tenosynovectomy the index finger flexor tendons were explored. *During exposure the wrenches of the median nerve identified distally as well as the superficial arch. *Due to the level of rupture of the flexor digitorum profundus tendon transfer was performed distal to the superficial palmar arch at the level of the A1 pulley and just proximal to the A1 pulley. *The index flexor digitorum superficialis was excised. *I elected to place the index finger flexor digitorum profundus to the long finger flexor digiti superficialis rather than the profundus so that she would have more independent index finger flexion for writing which was her main functional concern. *Also the quality of the long finger flexor digitorum superficialis and the forearm was superior to the profundus tendon that was already powering 3 fingers.
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The index flexor digitorum profundus stump was passed deep to the common digital nerve in the index–long web space. *A single pass Pulvertaft weave was performed placing the index FDP through the long FDS and this was secured with multiple 3-0 Ethibond sutures taking care that none of the sutures were prominent volarly. *I then placed several mattress sutures securing the stump of the index FDP to the long finger FDS with the stump on the ulnar aspect of the FDS using 3-0 Ethibond. *With passive tension applied to the long finger FDS satisfactory flexion and positioning of the index finger was present.
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I did place TenoGlide between the transferred index FDP and the common digital nerve to the index and long finger and secured this loosely with approximately 5 5-0 Monocryl sutures.
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