Percutaneous release of trigger fingers

Percutaneous Surgical Treatment of Trigger Finger

Objective  To evaluate the efficacy of percutaneous release therapy for patients with trigger finger. Methods  We obtained the hospital records of 120 patients who underwent percutaneous release, and their final status was evaluated by telephone. Results  The sample was composed of 84 (70%) female and 36 (30%) male patients, with a mean age of 55.4 (range: 30-79) years, and a mean follow-up of 28.6 (range: 6-74) months. Successful results were obtained in 118 (98.3%) patients. In the first week after the procedure, release was performed through the open surgical method in two patients who had complaints of re-entanglement in their fingers. No limitation to the joint range of motion was detected in any finger. Conclusions  Percutaneous release has advantages over the open surgery method in the surgical treatment of trigger finger, due to its low cost, ease of application, performance outside operating room conditions, and similar complication rates.

A cadaveric assessment of percutaneous trigger finger release with 15° stab knife: its effectiveness and complications

Percutaneous release of the A1 pulley has been introduced as a therapeutic approach for trigger fingers and is suggested as an effective and safe alternative, where conservative treatments fail. The aim of the current study was to determine if percutaneous release with a 15° stab knife can effectively result in acceptable efficacy and lower complication rate.

METHODS

In the present study, the percutaneous release of the A1 pulley was evaluated by percutaneous release using a 15° stab knife in 20 fresh-frozen cadaver hands (10 cadavers). One hundred fingers were finally included in the present study. The success rate of A1 pulley release as well as the complications of this method including digital vascular injury, A2 pulley injury, and superficial flexor tendon injury was evaluated, and finally, the data were analyzed by the SPSS software.

RESULTS

The results showed a success rate of 75% for A1 pulley release in four fingers, followed by eleven fingers (90%) and eighty-five fingers (100%). Therefore, the A1 pulley was found to be completely released in eighty-five fingers (100%). Overall, the mean of A1 pulley release for these fingers was determined as 97.9%, indicating that percutaneous trigger finger release can be an effective technique using a 15° stab knife. Furthermore, our findings revealed no significant difference in the amount of A1 pulley release in each of the fingers in the right and left hands. Additionally, 17 fingers developed superficial scrape in flexor tendons, while 83 fingers showed no flexor tendons injuries and no other injuries (i.e., vascular, digital nerve, and A2 pulley injuries).

CONCLUSIONS

Percutaneous release of the A1 pulley using a 15° stab knife was contributed to acceptable efficacy and a relatively good safety in the cadaveric model.

Diagnosis and Treatment of Trigger Finger in Brazil - A Cross-Sectional Study

Objective  The present paper aims to evaluate the therapeutic planning for trigger finger by Brazilian orthopedists. Methods  This is a cross-sectional study with a population composed of participants from the 2018 Brazilian Congress on Orthopedics and Traumatology (CBOT-2018, in the Portuguese acronym), who answered a questionnaire about the conduct adopted for trigger finger diagnosis and treatment. Results  A total of 243 participants were analyzed, with an average age of 37.46 years old; most participants were male (88%), with at least 1 year of experience (55.6%) and from Southeast Brazil (68.3%). Questionnaire analysis revealed a consensus on the following issues: diagnosis based on physical examination alone (73.3%), use of the Quinnell classification modified by Green (58.4%), initial nonsurgical treatment (91.4%), infiltration of steroids combined with an anesthetic agent (61.7%), nonsurgical treatment time ranging from 1 to 3 months (52.3%), surgical treatment using the open approach (84.4%), mainly the transverse open approach (51%), triggering recurrence as the main nonsurgical complication (58%), and open surgery success in > 90% of the cases (63%), with healing intercurrences (54%) as the main complication. There was no consensus on the remaining variables. Orthopedists with different practicing times disagree on treatment duration ( p  = 0.013) and on the complication rate of open surgery ( p  = 0.010). Conclusions  Brazilian orthopedists prefer to diagnose trigger finger with physical examination alone, to classify it according to the Quinnell method modified by Green, to institute an initial nonsurgical treatment, to perform infiltrations with steroids and local anesthetic agents, to sustain the nonsurgical treatment for 1 to 3 months, and to perform the surgical treatment using a transverse open approach; in addition, they state that the main nonsurgical complication was triggering recurrence, and report open surgery success in > 90% of the cases, with healing intercurrences as the main complication.

Ultrasound-guided percutaneous carpal tunnel release in patients on hemodialysis: early experiences and clinical outcomes

Purpose: The purpose of the current study was to evaluate the effectiveness of ultrasound-guided percutaneous carpal tunnel release in hemodialysis patients with carpal tunnel syndrome.

Methods: From February 2009 to April 2013, a prospective review of 113 consecutive cases of ultrasound-guided percutaneous carpal tunnel release was carried out in 84 hemodialysis patients. Results were analyzed by clinical subjective scale, two self-administered questionnaires, and functional evaluations at seven time points (1 week and 1, 3, 6, 12, 18, and 24 months).

Results: Satisfactory symptom improvement in patients was 82%, 80%, 86%, 89%, 90%, 91%, and 90% at 1 week and 1, 3, 6, 12, 18, and 24 months postoperatively, respectively. Moderate pain was suffered in 11.5% of patients within 1 week, 8.8% within 1 month, 2.7% within 3 months, and none after 12 months postoperatively. Static two-point discrimination and Semmes–Weinstein monofilament examinations presented significant improvements after 1 week and 1 month postoperatively and with time. Postoperative grip power demonstrated recovery and a significant increase after 3 and 6 months postoperatively. Three-jaw chuck-pinch strength showed significant increase after 1 month postoperatively. There were no operative complications.

Conclusion: Ultrasound-guided percutaneous carpal tunnel release is an effective and safe procedure in hemodialysis patients with carpal tunnel syndrome. The advantages include a less invasive procedure, no tourniquet needed, only limited infiltration anesthesia, minimal soft-tissue exploration, and relatively short operation time. Our data suggest this technique can reliably relieve clinical symptoms, with early restoration of grip and pinch strength.

Epidermal Inclusion Cyst following Percutaneous Trigger Finger Release

Epidermal inclusion cyst is a benign lesion that commonly occurs due to inclusion of epidermal cells into the dermal or deeper layers in a trauma event. Percutaneous release is a minimally invasive technique, and good surgical outcomes can be achieved. However, the percutaneous procedure is a puncture injury, and the epidermal inclusion cyst is reasonable to become a possible complication. In this article, we presented a case of trigger finger in left middle finger. The patient underwent percutaneous release as the treatment and a second percutaneous release 5 months later due to recurrence of the symptoms. An epidermal inclusion cyst was noted 5 months thereafter, and it was treated with excision. With this case, we need to be more aware of this possibility if a mass lesion without infection signs occurs in the released area and recommend sonography if there is a mass lesion a few months after the procedure.

Outcomes of percutaneous trigger finger release with concurrent steroid injection

Percutaneous release (PR) of the A1 pulley is a quick, safe, and minimally invasive procedure for treating trigger fingers. The purpose of this study is to identify if PR with additional steroid injections can shorten the recovery to reach unlimited range of motion. Between January 2013 and December 2013, we included 432 trigger fingers with actively correctable triggering or severer symptoms without previous surgical release or steroid injections from two hand clinic offices (A and B). The same experienced surgeon performed PR at the office. Patients from Clinic A received PR with steroid injections and those from Clinic B received PR without steroid injections. Patients returned for follow-up 1 week, 6 weeks, and 12 weeks after the procedure. Between the steroid group and the nonsteroid group, there is no significant difference in the mean time for patients to return to normal work and the rate of residual extensor lag. Middle fingers showed a 5.09-fold chance of having a residual extensor lag over that of the other fingers. High grade trigger fingers recovered more slowly than low grade ones. The success rate of a 12-week follow-up was 98.4%. There was no significant difference between the steroid group (97.5%) and the nonsteroid group (99.1%). PR can treat trigger fingers effectively, but additional steroid injection does not provide more benefit. Some fingers showed temporary extensor lag, especially in middle fingers and high grade trigger fingers, but 85% of those will eventually reach full recovery after self-rehabilitation without another surgical release.

Acupuncture for the treatment of trigger finger in adults: a prospective case series

OBJECTIVE

To determine the effect of acupuncture performed at the synovial and ligamentous tendon sheath (A1 pulley site) on pain during snapping and the severity of the snapping phenomenon in patients with trigger finger.

METHODS

In this observational study, changes in the patients' condition were compared before and after acupuncture treatment. Acupuncture was performed on 19 fingers of 15 patients. Acupuncture needles were inserted into the radial and ulnar sides of the flexor tendon at the A1 pulley of the affected finger. Treatment was performed daily up to a maximum of five times. Before and after each treatment, pain during snapping and the severity of snapping were evaluated using a visual analogue scale (VAS).

RESULTS

VAS scores for pain and snapping severity were significantly improved immediately after the first treatment (p<0.001). Pain during snapping, assessed before each treatment, improved over time, reaching statistical significance from the second treatment onwards (p<0.001); similarly, a significant improvement in the severity of snapping was observed, also from the second treatment (p<0.001). Patients with clinically significant improvements (≥50%) in pain and snapping severity had a significantly shorter duration of the disorder than those with <50% improvement (p<0.05).

CONCLUSIONS

Acupuncture at the impaired A1 pulley site may be an effective treatment for trigger finger. We postulate that acupuncture may reduce inflammation/swelling of the synovial membrane of the tendon sheath, which predominates when the disorder is of short duration. Further research is required to confirm the efficacy/effectiveness of acupuncture for trigger finger and its mechanisms of action.

Percutaneous Trigger Finger Release: A Cost-effectiveness Analysis

INTRODUCTION

Percutaneous trigger finger releases (TFRs) performed in the office setting are becoming more prevalent. This study compares the costs of in-hospital open TFRs, open TFRs performed in ambulatory surgical centers (ASCs), and in-office percutaneous releases.

METHODS

An expected-value decision-analysis model was constructed from the payer perspective to estimate total costs of the three competing treatment strategies for TFR. Model parameters were estimated based on the best available literature and were tested using multiway sensitivity analysis.

RESULTS

Percutaneous TFR performed in the office and then, if needed, revised open TFR performed in the ASC, was the most cost-effective strategy, with an attributed cost of $603. The cost associated with an initial open TFR performed in the ASC was approximately 7% higher. Initial open TFR performed in the hospital was the least cost-effective, with an attributed cost nearly twice that of primary percutaneous TFR.

DISCUSSION

An initial attempt at percutaneous TFR is more cost-effective than an open TFR. Currently, only about 5% of TFRs are performed in the office; therefore, a substantial opportunity exists for cost savings in the future.

LEVEL OF EVIDENCE

Decision model level II.

Evaluation of Percutaneous First Annular Pulley Release: Efficacy and Complications in a Perfused Cadaveric Study

PURPOSE

Trigger finger is the most common entrapment tendinopathy, with a lifetime risk of 2% to 3%. Open surgical release of the flexor tendon sheath is a commonly performed procedure associated with a high rate of success. Despite reported success rates of over 94%, percutaneous trigger finger release (PFTR) remains a controversial procedure because of the risk of iatrogenic digital neurovascular injury. This study aimed to evaluate the safety and efficacy of traditional percutaneous and ultrasound (US)-guided first annular (A1) pulley releases performed on a perfused cadaveric model.

METHODS

First annular pulley releases were performed percutaneously using an 18-gauge needle in 155 digits (124 fingers and 31 thumbs) of un-embalmed cadavers with restored perfusion. A total of 45 digits were completed with US guidance and 110 digits were completed without it. Each digit was dissected and assessed regarding the amount of release as well as neurovascular, flexor tendon, and A2 pulley injury.

RESULTS

Overall, 114 A1 pulleys were completely released (74%). There were 38 partial releases (24%) and 3 complete misses (2%). No significant flexor tendon injury was seen. Longitudinal scoring of the flexor tendon was found in 35 fingers (23%). There were no lacerations to digital nerves and one ulnar digital artery was partially lacerated (1%) in a middle finger with a partial flexion contracture that prevented appropriate hyperextension. The ultrasound-assisted and blind PTFR techniques had similar complete pulley release and injury rates.

CONCLUSIONS

Both traditional and US-assisted percutaneous release of the A1 pulley can be performed for all fingers. Perfusion of cadaver digits enhances surgical simulation and evaluation of PTFR beyond those of previous cadaveric studies. The addition of vascular flow to the digits during percutaneous release allows for Doppler flow assessment of the neurovascular bundle and evaluation of vascular injury.

CLINICAL RELEVANCE

Our cadaveric data align with those of published clinical investigations for percutaneous A1 pulley release.

Clinical results of a percutaneous technique for trigger digit release using a 25-gauge hypodermic needle with corticosteroid infiltration

Clinical results of a percutaneous needle trigger digit release (PNTDR) technique using a 25-gauge needle with corticosteroid infiltration are reported. This prospective study assessed 52 digits that underwent PNTDR. Experimental results were compared with those of a control group with only steroid injection. Patients who underwent PNTDR were divided into diabetic and nondiabetic groups, and assessed after 1 week, and 1, 2, 3, and 6 months post surgery. The quick disability of the arm, shoulder, and hand (QuickDASH) questionnaire and visual analog scale (VAS) score for pain were completed both before and after surgery. PNTDR showed better statistical results than the control group. At final follow-up, 94% of patients were rated as excellent or good, recurrence was observed in 3 digits, and QuickDASH and VAS score significantly decreased. This technique was equally effective in patients with moderate or well-controlled diabetes with favorable results.

Outcomes and complications after percutaneous release for trigger digits in diabetic and non-diabetic patients

We compared the short-term (3 months) and long-term (2 years) outcomes and complications of percutaneous release of 187 trigger digits of 154 patients treated between 2009 and 2012, all treated by a single surgeon. The 154 patients included 48 patients with diabetes mellitus and 106 non-diabetic patients. The only short-term complication was pain, occurring in three digits (5%) in the diabetic patients and six digits (5%) in the non-diabetic patients. The long-term complications were pain in 15 digits (25%) in the diabetic patients and 18 digits (14%) in the non-diabetic patients. This was not significant (p = 0.058). Recurrent triggering occurred in nine digits (15%) in the diabetic patients, which was significantly greater than the six digits (5%) in the non-diabetic patients (p = 0.013). The non-diabetic patients were significantly more satisfied.

LEVEL OF EVIDENCE

level III.

Percutaneous Trigger Release in Non-Triggering Digits: Infiltration of Normal Saline into Tendon Substance to Induce Triggering

Percutaneous trigger release is recognized as an effective minimally invasive procedure with a low complication rate. One prerequisite for percutaneous trigger release is a trigger of Quinnell Type II or higher; that is, a digit that is actively triggering. We describe an additional step in percutaneous trigger release, which enables the surgeon to perform the procedure in digits that are not actively triggering at the point of surgery. This step involves the infiltration of normal saline into the tendon substance distal to the A1 pulley in order to induce triggering.