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Two philosophies of pyogenic tenosynovitis treatment
LETTERS TO THE EDITOR
Two philosophies of pyogenic tenosynovitis treatment To the Editor: I read with great interest the paper of Dr. Neviaser l about his approach to tendon sheath irrigation. It was of particular interest to me, as I had published a paper on a technique, which may have been of interest to him, in the February, 1976, issue of Hand. 2 Surprisingly, he did not comment on that paper. The points that Dr. Neviaser made are valid regarding the evacuation of the sheath; however, in my experience, once the tendon sheath has been debrided, the infection can be cleared up rapidly by repeated injections of small amounts of antibiotic fluid . The advantage of this system is that , as it is fully closed, a more complete irrigation is performed, which allows the antibiotics to have a more prolonged action. Michael I. B. Besser, F .R .C.S.E., F.R.C.S. Department of Orthopedics B Rambam University Hospital Haifa. Israel
REFERENCES I. Neviaser RJ: Closed tendon sheath irrigation for pyogenic flexor tenosynovitis. J HAND S URG 3:462-6, 1978 2. Besser MIS: Digital flexor tendon irrigation. Hand 8:72, 1976
Reply To the Editor: In response to Dr. Besser's comments on the technique for treating pyogenic tenosynovitis, I want to
emphasize two points. First, the technique which I described and that which he advises are both modifications of that which Sylvester Carter outlined in 1966. This was pointed out in the introduction to my article . Second, what he advocates , i.e. , instillation of antibiotic solution through a single portal of entry into the tendon sheath, in my experience, has proven to produce only disastrous results. I am sure that in his hands this technique works well. The few patients that I have seen in whom others have used that technique have not had satisfactory results . A significant case in point is the child whom I used as an illustration in my article . Fig. 9 in the article demonstrates the potential disasters which can occur from irrigating a tendon sheath through one incision. Therefore, it would appear that not only does the technique which Dr. Besser utilizes differ from mine but that his philosophy also differs from mine. I believ~ that the real effectiveness lies with the through-andthrough mechanical lavage of the tendon sheath. It would appear that he believes that instillation of antibiotics is the more crucial aspect and that irrigation of the sheath is not as important. This is a question which I do not feel can be satisfactorily resolved , since there is a difference in overall philosophy and this is a very personal thing. Robert J. Neviaser , M.D . Department of Orthopaedic Surgery The George Washington University Medical Center . The H . B . Burns Memorial Bldg . 2150 Pennsylvania Ave ., N .W. Washington, DC 20037
THE JOURNAL OF HAND SURGERY
495
Two philosophies of pyogenic tenosynovitis treatment To the Editor: I read with great interest the paper of Dr. Neviaser l about his approach to tendon sheath irrigation. It was of particular interest to me, as I had published a paper on a technique, which may have been of interest to him, in the February, 1976, issue of Hand. 2 Surprisingly, he did not comment on that paper. The points that Dr. Neviaser made are valid regarding the evacuation of the sheath; however, in my experience, once the tendon sheath has been debrided, the infection can be cleared up rapidly by repeated injections of small amounts of antibiotic fluid . The advantage of this system is that , as it is fully closed, a more complete irrigation is performed, which allows the antibiotics to have a more prolonged action. Michael I. B. Besser, F .R .C.S.E., F.R.C.S. Department of Orthopedics B Rambam University Hospital Haifa. Israel
REFERENCES I. Neviaser RJ: Closed tendon sheath irrigation for pyogenic flexor tenosynovitis. J HAND S URG 3:462-6, 1978 2. Besser MIS: Digital flexor tendon irrigation. Hand 8:72, 1976
Reply To the Editor: In response to Dr. Besser's comments on the technique for treating pyogenic tenosynovitis, I want to
emphasize two points. First, the technique which I described and that which he advises are both modifications of that which Sylvester Carter outlined in 1966. This was pointed out in the introduction to my article . Second, what he advocates , i.e. , instillation of antibiotic solution through a single portal of entry into the tendon sheath, in my experience, has proven to produce only disastrous results. I am sure that in his hands this technique works well. The few patients that I have seen in whom others have used that technique have not had satisfactory results . A significant case in point is the child whom I used as an illustration in my article . Fig. 9 in the article demonstrates the potential disasters which can occur from irrigating a tendon sheath through one incision. Therefore, it would appear that not only does the technique which Dr. Besser utilizes differ from mine but that his philosophy also differs from mine. I believ~ that the real effectiveness lies with the through-andthrough mechanical lavage of the tendon sheath. It would appear that he believes that instillation of antibiotics is the more crucial aspect and that irrigation of the sheath is not as important. This is a question which I do not feel can be satisfactorily resolved , since there is a difference in overall philosophy and this is a very personal thing. Robert J. Neviaser , M.D . Department of Orthopaedic Surgery The George Washington University Medical Center . The H . B . Burns Memorial Bldg . 2150 Pennsylvania Ave ., N .W. Washington, DC 20037
THE JOURNAL OF HAND SURGERY
495