case_images: PMC10901604_01
case_images: A 53-year-old woman with suppurative tenosynovitis after percutaneous A1 pulley release using a HAKI knife. (
  A
  ) The patient presented with swelling and pain. (
  B
  ) Clinical evaluation revealed inflammation accompanied by pus. (
  C
  ) Surgical exploration identified additional injury to the flexor tendon (yellow arrow) and insufficient A1 pulley release (green arrow). (
  D
  ) Ultimately, the patient developed a sequela characterized by adhesion of the flexor tendon, leading to functional limitations. A1 pulley, first annular pulley.
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case_images: PMC10901604_01_10-1055-a-2179-3911-i23feb0264oa-2.jpg
case_images: FI23feb0264oa-2
case_images: Two weeks after the initial surgery, swelling and pain were observed ( Fig. 2A ). Fig. 2B, C ). Following a 2-week course of intravenous antibiotics, the patient exhibited an improvement in the inflammatory condition and was subsequently discharged. Nevertheless, a final limitation in the range of motion was noted as a sequela ( Fig. 2D ).
case_images: PMC10901604_02
case_images: A 46-year-old man with suppurative tenosynovitis after percutaneous A1 pulley release using a HAKI knife. (
  A
  ) The patient visited due to swelling and pain that occurred 1 week after undergoing the procedure. (
  B
  ) During the exploration, it was confirmed that the patient had both a flexor tendon injury (green arrow) and an accompanying A2 pulley injury (yellow arrow). A1 pulley, first annular pulley; A2 pulley, second annular pulley.
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case_images: PMC10901604_02_10-1055-a-2179-3911-i23feb0264oa-3.jpg
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case_images: The patient manifested symptoms of swelling and pain 1 week postoperatively ( Fig. 3A ). Nevertheless, concomitant longitudinal injuries to the flexor tendon and compromise of the second annular pulley (A2 pulley) were identified ( Fig. 3B ).
case_images: PMC10901604_03
case_images: A 54-year-old woman with suppurative tenosynovitis after percutaneous A1 pulley release using a HAKI knife. (
  A
  ) The patient visited due to swelling and pain that occurred 1 week after undergoing the procedure. (
  B
  ) During the exploration, severe inflammation in the surrounding area and an accompanying A2 pulley injury were identified (yellow arrow). A1 pulley, first annular pulley; A2 pulley, second annular pulley.
case_images: 10-1055-a-2179-3911-i23feb0264oa-4.jpg
case_images: PMC10901604_03_10-1055-a-2179-3911-i23feb0264oa-4.jpg
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case_images: One week postoperatively, the patient manifested infectious complications and sought medical care at our facility ( Fig. 4A ). Immediate surgical intervention was undertaken, and during the I&D procedure, injury to the A2 pulley was identified ( Fig. 4B ).
case_images: PMC10901604_04
case_images: A 82-year-old woman with chronic inflammation after percutaneous A1 pulley release using a needle. (
  A
  ) The patient had undergone ongoing incision and drainage at another hospital and experienced a recurrence of the infection after wound closure. Swelling accompanied by pus was present at the palmar crease level. (
  B
  ) During the exploration, chronic inflammation resulted in granulomatous inflammation and tissue hypertrophy at the A1 pulley. A1 pulley, first annular pulley.
case_images: 10-1055-a-2179-3911-i23feb0264oa-5.jpg
case_images: PMC10901604_04_10-1055-a-2179-3911-i23feb0264oa-5.jpg
case_images: FI23feb0264oa-5
case_images: I&D at an alternative medical facility, the patient experienced a recurrence of infection and subsequently sought care at our hospital ( Fig. 5A ). Immediate surgical exploration was executed. Fig. 5B ). Following a 5-week regimen of intravenous antibiotics, the patient demonstrated an improvement in the inflammatory condition and was subsequently discharged.
case_images: PMC10901604_05
case_images: A 45-year-old man with soft tissue necrosis after percutaneous A1 pulley release using a needle. (
  A
  ) The patient presented to our facility with tendon exposure due to soft tissue necrosis, despite undergoing repeated incision and drainage at another hospital following the development of suppurative tenosynovitis after a percutaneous A1 pulley release. (
  B
  ) Inflammation was confirmed along the flexor digitorum profundus up to the proximal interphalangeal joint level. (
  C, D
  ) A hypothenar perforator free flap was elevated to cover the soft tissue defect that occurred after debridement. (
  E
  ) Flap insetting was performed. (
  F
  ) Follow-up photographs taken 1 year later. A1 pulley, first annular pulley.
case_images: 10-1055-a-2179-3911-i23feb0264oa-6.jpg
case_images: PMC10901604_05_10-1055-a-2179-3911-i23feb0264oa-6.jpg
case_images: FI23feb0264oa-6
case_images: Despite undergoing three attempts at debridement and flexor tendon reconstruction at an alternative medical facility, the patient developed soft tissue necrosis and consequently sought care at our hospital ( Fig. 6A ). During surgical exploration, signs of inflammation were observed extending to the level of the proximal interphalangeal joint in the flexor digitorum profundus, and a longitudinal soft tissue defect was evident postdebridement ( Fig. 6B ). Fig. 6C-E ). Following a 2-week regimen of intravenous antibiotics, the patient was discharged. Long-term follow-up revealed no issues concerning flap coverage ( Fig. 6F ); however, an additional tendon transfer was necessitated to restore the range of motion.
case_images: PMC10901604_06
case_images: A 57-year-old man with soft tissue necrosis after percutaneous A1 pulley release using a needle. (
  A, B
  ) The patient had received a procedure 2 years ago but continued to show signs of chronic inflammation despite undergoing repeated incision and drainage, as well as flexor tendon reconstruction at different hospitals due to recurring infectious complications, including tendon ligament infections. (
  C
  ) Chronic infection-induced inflammation was observed in the surrounding areas. (
  D, E
  ) After performing debridement, a hypothenar perforator free flap was used for defect coverage. (
  F
  ) Follow-up photographs taken 1 year later. A1 pulley, first annular pulley.
case_images: 10-1055-a-2179-3911-i23feb0264oa-7.jpg
case_images: PMC10901604_06_10-1055-a-2179-3911-i23feb0264oa-7.jpg
case_images: FI23feb0264oa-7
case_images: Despite these efforts, the site continued to exhibit persistent necrosis and inflammation, culminating in the patient's transfer to our hospital ( Fig. 7A ). Chronic inflammation involving the flexor digitorum profundus mandated extensive debridement ( Fig. 7B, C ). A hypothenar perforator free flap, based on the fourth common digital artery perforator, was performed to address the ensuing soft tissue defect  ( Fig. 7D, E ). Long-term follow-up showed no signs of inflammation in the flap coverage area ( Fig. 7F ); however, a secondary tendon reconstruction was subsequently required.