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Factors Affecting the Prognosis of Pyogenic Flexor Tenosynovitis
Hee-Nee Pang, MBBS, MRCSEd1; Lam-Chuan Teoh, MBBS, FRCS(Glasg), MMed(Surg), FAMS1; Andrew K.T. Yam, MBBS, MRCSEd, MMed(Surg)1; Jonathan Yi-Liang Lee, MB, BCh, BAO, MRCSEd, MMed(Surg), FAMS1; Mark E. Puhaindran, MBBS, MRCSEd, MMed(Surg)1; Agnes Beng-Hoi Tan, MBBS, FRCS(Glasg), FRCSEd, FAMS1
1 Department of Hand Surgery, Singapore General Hospital, Outram Road, Singapore 169608. E-mail address for H.-N. Pang: pangheenee@hotmail.com
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Hand Surgery, Singapore General Hospital, Singapore

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Aug 01;89(8):1742-1748. doi: 10.2106/JBJS.F.01356
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Background: Pyogenic flexor tenosynovitis is a closed space infection involving the digital flexor tendon sheaths of the upper extremity that can cause considerable morbidity. The purpose of the present report is to describe the various risk factors leading to poor outcomes and to recommend a clinical classification system for this condition.

Methods: We studied seventy-five patients with pyogenic flexor tenosynovitis over a six-year period. The amputation rate and total active motion were used as outcomes measures. The clinical factors influencing outcomes were identified and analyzed.

Results: The five risk factors associated with poor outcomes were (1) an age of more than forty-three years, (2) the presence of diabetes mellitus, peripheral vascular disease, or renal failure, (3) the presence of subcutaneous purulence, (4) digital ischemia, and (5) polymicrobial infection. On the basis of the clinical findings and outcomes, three distinct groups of patients could be identified, each with a progressively worse outcome. Patients in Group I had no subcutaneous purulence or digital ischemia; these patients had the best prognosis, with no amputations and a mean 80% return of total active motion. Patients in Group II demonstrated the presence of subcutaneous purulence but no ischemic changes; these patients had an amputation rate of 8% and a mean 72% recovery of total active motion. Patients in Group III had both extensive subcutaneous purulence and ischemic changes; these patients had the worst prognosis, with an amputation rate of 59% and a mean 49% return of total active motion.

Conclusions: We propose a three-tier clinical classification system that can aid in prognosis and guidance in the treatment of pyogenic flexor tenosynovitis of the upper extremity.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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