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Topic Title: Flexor Pollicis Longus Tendon Repair with Tendon Graft
Topic Summary: Need CPT code for px - appreciate input
Created On: 11/17/2009 09:20 AM

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 11/17/2009 09:20 AM
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Joined: 12/23/2008

Right thumb rupture of flexor pollicis longus.
Right thumb deep rheumatoid nodule.

Right thumb excision of deep mass.
Right thumb reconstruction of flexor pollicis longus tendon rupture with free tendon graft.

This is a 65-year-old male who lost flexion of right thumb. Furthermore, he had a large mass consistent with rheumatoid nodule at the level of the IP crease of the right thumb. Options of surgery and risks and complications were discussed including wound healing complications, infection, need for later surgery, and so on. Realistic expectations were emphasized. Alternatives were reviewed. He voiced understanding and requested that we proceed.

After administration of a supraclavicular block anesthetic and intravenous antibiotics, the right hand and upper extremity were sterilely prepared and draped in the usual fashion. The operative site had been marked preoperatively and the patient identified in the holding area. Preoperative time-out confirmed patient, site and procedure once again. Subsequently, the arm was elevated and exsanguinated with a Martin bandage. Tourniquet was inflated to 250 mmHg.

A chevron-shaped incision was utilized at the level of the IP crease of the right thumb. The large mass was approximately 2 cm diameter and was carefully elevated from the skin. It infiltrated the neurovascular bundle. It was carefully dissected right down to the IP joint. The mass was carefully dissected free from surrounding soft tissues with care taken to protect the neurovascular bundle on this side. The lesion was then excised in its entirety and sent for analysis. It was dense and nodular with somewhat poorly defined margins consistent with rheumatoid nodule.

Attention was then directed to the flexor tendon itself. At the level of the IP joint, there was marked synovitis. Synovectomy was performed. The findings indicated complete rupture of flexor pollicis longus at the level of the IP joint. There was approximately 1 cm or so of stump remaining distally. The area was thoroughly debrided with care taken to make sure that the volar surface of the distal phalanx at this level was smooth at the level of the IP joint.

An incision was then made over the flexor pollicis longus proximal to the wrist flexion crease. Dissection proceeded with loupe magnification. Hemostasis was ensured with bipolar cautery. Cutaneous nerves were protected. The radial artery and superficial arch were protected. The flexor pollicis longus muscle and tendon appeared to be quite healthy proximally. Therefore, it was felt in the patient's best interest to proceed with a free tendon graft to reconstruct this.

Attention was turned to the flexor carpi radialis tendon. He did not have a palmaris longus. A 14 cm graft was necessary to bridge all the way from the IP joint to the distal forearm. The entire flexor carpi radialis tendon was then mobilized from the wrist flexion crease up to the musculotendinous junction for 14 cm with good quality tendon obtained.

The FPL tendon was then retrieved from beneath the 1st annular pulley in the thenar eminence using a feeding catheter. Complete synovectomy was performed at the IP joint distal to the A1 pulley which was carefully preserved along with a portion of the flexor tendon sheath over the proximal portion of the proximal phalanx of the thumb.

The tendon graft was then advanced from proximal to distal using the feeding tube. A Mitek anchor was placed into the distal phalanx. The tendon graft was secured distally after being passed through the thenar eminence down through the flexor sheath and A1 and flexor sheath over the proximal phalanx. It was then secured by way of the suture anchor using a Krackow type of grasping suture with 2-0 Ethibond suture. The repair was further reinforced at the insertion with additional sutures through the remaining stump of FPL distally. With traction, excellent range of motion was able to be achieved of the IP joint from proximalward. Irrigation followed. Hemostasis was ensured in the distal incision which was then approximated with interrupted nylon suture.

The tendon graft was then secured proximally to the FPL at the musculotendinous junction level with an interweave type Pulvertaft juncture using 3-0 Surgilon suture. Tenodesis testing was quite satisfactory in terms of excursion without undue tension. Irrigation followed. Hemostasis was ensured. Skin closure followed. Sterile dressing and bulky wrap and splint followed.
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