MANAGEMENT OF PYOGENIC FLEXOR TENOSYNOVITIS: A TEN-YEAR RETROSPECTIVE STUDY OF 300 PATIENTS

Introduction & Aim Pyogenic flexor tenosynovitis remains a surgical emergency associated with substantial morbidity, including stiffness and amputation. Despite advances in surgical techniques and antibiotic therapy, there is no consensus regarding the optimal management strategy. This study aimed to identify determinants of treatment failure in order to optimize care pathways. Methods A retrospective single-center study was conducted at a tertiary hospital over a 10-year period (2014–2024). All patients who underwent surgical treatment for pyogenic flexor tenosynovitis were included. Diagnosis was based on Kanavel's signs. Patients with adjacent infections were excluded. Surgical management was adapted to the intraoperative Michon stage, ranging from bipolar irrigation to open tenosynovectomy, tendon resection, or amputation. The primary outcome was infectious failure, defined as the need for revision surgery. Secondary outcomes included functional recovery. Statistical analysis was performed using univariate and multivariate logistic regression. Results A total of 300 patients (332 digits) were analyzed, with a mean follow-up of 753 (IQR, 25-1189) days. The overall infectious failure rate was 12.3% (37 patients), with a digital amputation rate of 1% (5 patients). Patients in the failure group were significantly older (mean 61 vs. 42 years, p<0.001) and had higher comorbidity burdens, with a Charlson score >2 increasing failure risk fourfold (OR 4.17; 95% CI, 1.56-11.14; p<0.005). Delayed surgical management beyond three days significantly increased failure risk (OR=1.03; 95 %CI, 1.00-1.06; p=0.04). An identifiable sharp injury was protective (OR=0.41; 95 %CI, 0.18-0.92; p=0.03), whereas unknown or atypical portals of entry increased failure rates (OR=2.71; 95% CI, 1.16-6.32; p=0.02). Preoperative antibiotic therapy did not significantly affect outcomes, while preoperative non-steroidal anti-inflammatory drugs use showed a negative trend without reaching statistical significance (OR=3.79; 95 %CI, 0.91-15.88; p=0.37). Empirical postoperative therapy with amoxicillin–clavulanate was associated with better outcomes (OR=0.287; 95 %CI, 0.132-0.628; p=0.002), whereas clindamycin significantly increased the risk of failure (OR=2.889; 95 %CI, 1.274-6.553; p=0.011). In multivariate analysis, advanced disease stage (Michon ≥2A) was strongly associated with failure (OR 38.9; 95 %CI, 2.262-669.31; p=0,012), while amoxicillin–clavulanate remained protective (OR 0.044; 95 %CI, 0.008-0.252; p<0.001). Conclusions Advanced stage at presentation, delayed surgery, older age, and significant comorbidities are the main predictors of infectious failure. Early surgical intervention tailored to disease stage remains the cornerstone of successful management of pyogenic flexor tenosynovitis, and should be combined with empirical antibiotic therapy using amoxicillin–clavulanate in the absence of contraindications. These findings support aggressive early surgical management and close monitoring of high-risk patients to reduce complications.