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Sehmbi AS, Syed M, Daruwalla AC, Rae P, Harris I, Shah S, Parry D. Secondary Repair of Jersey Finger: A Novel Method of Tendon Length Estimation via Measurement of Adjacent Landmarks. Cureus 2024; 16:e53963. [PMID: 38469003 PMCID: PMC10926968 DOI: 10.7759/cureus.53963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2024] [Indexed: 03/13/2024] Open
Abstract
Jersey finger describes the rupture of the flexor digitorum profundus (FDP) tendon at its insertion into the distal phalanx. In the absence of an evidence-based approach to tensioning during secondary repair, we aimed to devise a novel method to determine the required tendon length pre/intraoperatively. We measured anatomical landmarks, associated with the FDP tendon, on dissected cadavers, to assess whether these can be used to estimate tendon segment lengths. Eight cadaveric hands were dissected. Three measurements from the distal lumbrical origin to (1) FDP insertion, (2) the distal end of A1 (Annular 1 pulley), and (3) the proximal end of A1 were recorded for digits II-V. Relative ratios for measurement 1 were consistent for all digits, compared to digit III. Linear regression analysis confirmed a strong correlation for measurement 1 between digit II (R2 =0.97) and digit IV(R2 =0.97) compared to digit III across all specimens. Digit III distal lumbrical origin to FDP insertion measurements could facilitate the estimation of the required graft length for digit II or IV during secondary repair. This is a level IV study, providing proof of concept for a novel method of tendon tensioning.
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Affiliation(s)
| | - Mobin Syed
- Anatomy, King's College School of Medicine, Guy's and St Thomas' NHS Foundation Trust, London, GBR
| | | | - Peter Rae
- Trauma and Orthopaedics, University College Hospital, London, GBR
| | - Isaac Harris
- Trauma and Orthopaedics, University College Hospital, London, GBR
| | - Savan Shah
- Otolaryngology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, GBR
| | - David Parry
- Faculty of Life Sciences and Medicine, King's College London, London, GBR
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Zhong WX, Li JH, Chen ZJ, Peng WJ, Gu RB, Chen C, Li YK. Identification of the length and location of the A1 pulley combining palpation technique with palm landmarks: a cadaveric study. Sci Rep 2023; 13:22801. [PMID: 38129463 PMCID: PMC10739722 DOI: 10.1038/s41598-023-49742-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023] Open
Abstract
Through anatomical morphology, to accumulate the relevant parameters of the A1 pulley of each adult finger. A total of 100 fingers were selected, dissected layer by layer, and the A1 pulley and neurovascular of each finger were observed. Measure the length of the A1 pulley, the distance between the needle knife insertion point and the proximal edge of A1 pulley, and the nerves and blood vessels on both sides. (1) The length of A1 pulleys of each finger is 6.18 ± 0.33 mm, 6.58 ± 0.73 mm, 5.98 ± 0.67 mm, 5.36 ± 1.08 mm, 5.63 ± 1.09 mm. (2) The distances between the needle knife entry point of each finger and the volar proper nerve of the ulnar finger are 7.00 ± 1.55 mm, 8.29 ± 1.46 mm, 5.10 ± 0.25 mm, 5.30 ± 0.24 mm, 0 mm; the distances from the volar proper nerve of the radial finger are 9.08 ± 0.87 mm, 4.70 ± 1.10 mm, 7.03 ± 0.72 mm, 6.81 ± 0.22 mm, 7.81 ± 0.57 mm. (3) The distances between the needle knife entry point of each finger and the proper volar artery of the ulnar finger are 10.40 ± 0.75 mm, 8.89 ± 0.53 mm, 6.35 ± 0.44 mm, 7.26 ± 0.16 mm, 0 mm, respectively; The distances from the volar proper artery of the radial finger are 8.75 ± 1.07 mm, 6.10 ± 0.35 mm, 11.44 ± 0.41 mm, 8.19 ± 0.60 mm, 9.78 ± 0.68 mm, respectively. The landmarks of the needle entry points are located at the position corresponding to the highest point of the metacarpal heads, except the tail finger. From the needle knife entry point to distal, cut the proximal edge of the A1 pulley longitudinally along the midline until the patient can flex autonomously, and pay attention to the distance between the two sides of 3.60-11.85 mm neurovascular bundle.
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Affiliation(s)
- Wei-Xing Zhong
- School of Traditional Chinese Medicine, Guangdong Province, Southern Medical University, Guangzhou, 510515, China
| | - Jun-Hua Li
- School of Traditional Chinese Medicine, Guangdong Province, Southern Medical University, Guangzhou, 510515, China
| | - Zu-Jiang Chen
- School of Traditional Chinese Medicine, Guangdong Province, Southern Medical University, Guangzhou, 510515, China
| | - Wei-Jie Peng
- School of Traditional Chinese Medicine, Guangdong Province, Southern Medical University, Guangzhou, 510515, China
| | - Rui-Bin Gu
- School of Traditional Chinese Medicine, Guangdong Province, Southern Medical University, Guangzhou, 510515, China
| | - Chao Chen
- School of Traditional Chinese Medicine, Guangdong Province, Southern Medical University, Guangzhou, 510515, China.
| | - Yi-Kai Li
- School of Traditional Chinese Medicine, Guangdong Province, Southern Medical University, Guangzhou, 510515, China.
- Department of Traditional Chinese Orthopedics and Traumatology, Center for Orthopaedic Surgery, Guangdong Province, The Third Affiliated Hospital of Southern Medical University, Guangzhou, 510630, China.
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Pages L, Cambon A. Ultrasound-guided percutaneous opening of the A1 pulley with surgical knife on anterograde versus retrograde approach: A comparative cadaver study (40 fingers). HAND SURGERY & REHABILITATION 2023; 42:512-516. [PMID: 37544505 DOI: 10.1016/j.hansur.2023.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/27/2023] [Accepted: 07/31/2023] [Indexed: 08/08/2023]
Abstract
OBJECTIVE Trigger finger is one of the most common pathologies of the finger flexor mechanism. Previous studies have shown the value of ultrasound-guided percutaneous tenolysis. The aim of this study was to compare the efficacy and safety of anterograde versus retrograde percutaneous ultrasound-guided tenolysis. MATERIALS AND METHODS This was a comparative cadaver study performed between December 2021 and April 2022 in France, with 40 fresh cadaver fingers. Thumbs were excluded. A single surgeon performed 20 ultrasound-guided anterograde releases and 20 ultrasound-guided retrograde releases, using a second-generation minimally invasive surgical knife, and a multipurpose linear ultrasound transducer. The primary endpoint was the success of ultrasound-guided release, defined as complete opening of the A1 pulley along its entire length. RESULTS The success rate was 90% in the retrograde group and 95% in the anterograde group (non-significant difference: p = 0.56). There was no significant difference in superficial flexor tendon slip injuries or partial A2 pulley injuries. There were no neurovascular pedicle lesions. CONCLUSION The choice of anterograde or retrograde ultrasound-guided tenolysis should be left to the surgeon's discretion.
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Affiliation(s)
- Laure Pages
- Chirurgie Orthopédique et Traumatologique du Membre Supérieur, Clinique Drouot Laffitte Sport & Arthrose, 20 Rue Laffitte 75009, Paris, France.
| | - Adeline Cambon
- Sorbonne University, Orthopaedic, Trauma and Hand Surgery, Saint-Antoine Hospital, Paris, France
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Kim YB, Choi YS, Yoon TH, Lee HD. Prospective Randomized Controlled Trial Comparing Absorbable and Nonabsorbable Sutures in A1 Pulley Release. Hand (N Y) 2023:15589447231210332. [PMID: 37997760 DOI: 10.1177/15589447231210332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
BACKGROUND Both absorbable and nonabsorbable sutures are used to correct palmar incisions or lacerations. Nonabsorbable sutures have been used without complications but require removal at a follow-up appointment. Alternatively, the use of absorbable sutures has increased in popularity as postoperative suture removal is not required but is associated with local immunological and inflammatory responses. In this study, we compared the scar quality and outcomes of nonabsorbable and absorbable sutures in A1 pulley release. METHODS Patients who underwent A1 pulley release were randomized to 1 of 2 suture materials. The Patient Scar Assessment Scale, Observer Scar Assessment Scale, Visual Analogue Scale, and Disabilities of the Arm, Shoulder, and Hand scores were collected at 2, 6, and 12 weeks postoperatively. Among the 41 patients included in the study, 23 were randomized to the nonabsorbable suture group, and 18 to the absorbable suture group. RESULTS There were no significant differences between the two suture groups in the aforementioned assessments. Complication rates were higher in the nonabsorbable suture group, but the difference was not statistically significant. Notably, 1 case in the absorbable suture group had uncontrolled postoperative bleeding and required reoperation. CONCLUSION We found no significant difference between the two materials in terms of the Patient or Observer Scar Assessment Scales, overall complication rates, symptom scores, or pain scores. Therefore, the choice using absorbable or nonabsorbable can be guided by other factors such as physician or patient preference, availability, and cost.
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Affiliation(s)
- Young Bae Kim
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul, Korea
| | - Yun Seong Choi
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul, Korea
| | - Tae Hyuck Yoon
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul, Korea
| | - Hee Dong Lee
- Department of Orthopaedic Surgery, Veterans Health Service Medical Center, Seoul, Korea
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Sutter D, Treier A, Vögelin E. Sonographically controlled minimally-invasive A1 pulley release using a new guide instrument - a case series of 106 procedures in 64 patients. BMC Musculoskelet Disord 2023; 24:875. [PMID: 37950217 PMCID: PMC10636860 DOI: 10.1186/s12891-023-06982-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/20/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND With percutaneous and minimally-invasive pulley release becoming more popular, safety and reliability of such minimally-invasive procedures remain a concern. Visualization of the technical steps by ultrasound suggests increased safety but shows the potential for harm to tendons, nerves and vessels without proper instrumentation. We present the results of implementing a sonographically guided minimally-invasive procedure in 106 trigger digits of 64 patients between 2018-2021. METHODS A guide instrument for use with a commercially available hook knife was developed and tested in 16 cadaver hands. Due to complication early in our clinical series this guide was modified in due course. A revised design of the guide has been in use since November 2019 with improved performance and safety. RESULTS One hundred six procedures in 64 patients were performed. After guide revision, we report a success rate of 97.3%. Complications after instrument revision include two cases of incomplete pulley release and one case of inadvertent skin laceration. The majority of patients report returning to all strenuous activities within two weeks at most apart from four individuals with prolonged postoperative discomfort. CONCLUSION We present the results of the development and implementation of a novel guide instrument for use with a hook knife to treat trigger finger. Despite several limitations of this study, we show that sonographically controlled, minimally-invasive A1 pulley release can be performed safely and effectively with appropriate surgical instruments and practice.
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Affiliation(s)
- Damian Sutter
- Department of Hand Surgery, University Hospital Berne, Inselspital Bern, Freiburgstrasse 10, CH-3010, Berne, Switzerland.
| | - Aline Treier
- Department of Hand Surgery, University Hospital Berne, Inselspital Bern, Freiburgstrasse 10, CH-3010, Berne, Switzerland
| | - Esther Vögelin
- Department of Hand Surgery, University Hospital Berne, Inselspital Bern, Freiburgstrasse 10, CH-3010, Berne, Switzerland
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Jeon N, Yoo SG, Kim SK, Park MJ, Shim JW. Failure rates and analysis of risk factors for percutaneous A1 pulley release of trigger digits. J Hand Surg Eur Vol 2023; 48:857-862. [PMID: 36988215 DOI: 10.1177/17531934231161764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
This study aimed to identify the rates and risk factors for failure of percutaneous A1 pulley release. We retrospectively analysed patients who underwent percutaneous A1 pulley release between 2015 and 2019. We defined failure as (1) pain or discomfort at the final follow-up, (2) when open release or revision percutaneous release was performed, or (3) when steroid injections were administered three or more times for symptom control. A total of 331 digits from 251 patients were included. The mean follow-up duration was 47 months (minimum 24 months). Complete resolution was achieved in 287 cases (87%), but 21% required steroid injection before symptoms settled. There was failure in 44 cases (13%). Involvement of the index, middle and ring fingers was significantly different between the successful and failure groups. Percutaneous A1 pulley release has a long-term success rate of 87%. The failure rate was higher when the procedure was performed on the index, middle or ring fingers.Level of evidence: III.
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Affiliation(s)
- Neunghan Jeon
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
| | - Sang Gil Yoo
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
| | - Seong Kyong Kim
- Department of Nursing, Hanseo University, Haemi-myun, Seosan-si, Chungcheongnam-do, Korea
| | - Min Jong Park
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
| | - Jae Woo Shim
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Gangnam-gu, Seoul, Korea
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Alowais FA, Alnaeem H. Identifying Palmar Skin Surface Landmark for Locating A2 Pulley during Cadaveric Dissection of the Hand. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5138. [PMID: 37496981 PMCID: PMC10368382 DOI: 10.1097/gox.0000000000005138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/30/2023] [Indexed: 07/28/2023]
Abstract
The A2 and A4 pulleys are fibro-osseous structures that support the flexor tendon function. Injury to these pulleys can result in bowstringing and limited tendon excursion. Thus, having an understanding of the skin surface landmark of the A2 pulley is crucial to safeguard it during hand surgery. Methods We performed cadaveric dissection of 62 hands. For 248 fingers, the measurement of distance A, which is half the distance between the palmar digital crease and proximal interphalangeal crease reflected in the palm, and distance B, which is the distance between the A2 pulley's starting point and the palmar digital crease, were taken by a caliber. Statistical analysis was performed using the paired sample t test to determine whether there was a significant difference between distances A and B. Results Our study revealed that there was no significant difference (p>0.05) between the measured starting point of the A2 pulley and its proposed surface landmark for the index, middle, and small fingers. Conversely, the ring finger showed a statistically significant difference of 1 mm more proximal. Conclusions By measuring the distance between the palmar digital crease and proximal interphalangeal crease and reflecting it proximally in the palms, one can anticipate the location of the A2 pulley's starting point for each digit, except for the ring finger. The ring finger's starting point is 1 mm more proximal than the other digits. Knowing the starting point of the A2 pulley will help hand surgeons limit incisions and avoid accidental injury during hand surgery.
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Affiliation(s)
- Fahad Abdullah Alowais
- From the Department of Plastic and Reconstructive Surgery, Security Forces Hospital, Riyadh, Saudi Arabia
| | - Hassan Alnaeem
- From the Department of Plastic and Reconstructive Surgery, Security Forces Hospital, Riyadh, Saudi Arabia
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Mirza A, Mirza J, Zappia L, Thomas TL, Corabi J, Talay R. Single-Portal Antegrade Endoscopic Trigger Finger Release: Cadaveric and Clinical Outcomes. Hand (N Y) 2023:15589447221150512. [PMID: 36726337 DOI: 10.1177/15589447221150512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND This study aimed to examine the relationship between anatomical surface landmarks in fresh frozen cadavers as related to in vivo endoscopic trigger finger release (ETFR) and present clinical outcomes after a single-portal antegrade ETFR technique. METHODS Endoscopic trigger finger release was performed on 40 cadaveric digits. Each digit was dissected and the following measurements were recorded: distance from palmar digital crease and A1 pulley, length of the A1 pulley, percentage of A1 pulley released, and injury to vulnerable anatomy. A retrospective chart review was performed on 48 patients (62 digits) treated with ETFR. Outcome measures included grip and pinch strength, range of motion, Disability of Arm, Shoulder, and Hand (DASH) questionnaires, and Visual Analog Scale (VAS) pain scores. RESULTS Release of the A1 pulley was achieved in 33 of the 40 cadaveric digits (83%) with an A2 pulley laceration rate of 25%. No flexor tendon or neurovascular injuries occurred. Gross grasp, lateral pinch, 3-jaw chuck, and precision pinch strength had 85%, 90%, 82%, and 90% recovery, respectively. At the final follow-up, average metacarpophalangeal joint, proximal interphalangeal joint, and distal interphalangeal joint range of motion were within the normal limits. Mean VAS scores decreased from 5.7 preoperatively to 1.0 postoperatively and mean DASH score at the final follow-up was 4.8. CONCLUSIONS With the use of anatomical surface landmarks, ETFR may be performed in an efficient and reproducible manner. Patients treated with ETFR had low complication rates, good functional recovery, and improved pain at short-term follow-up. Further study of long-term outcomes and cost-effectiveness of ETFR is warranted.
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Affiliation(s)
- Ather Mirza
- North Shore Surgi-Center, Smithtown, NY, USA
- Mirza Orthopedics, Smithtown, NY, USA
- Stony Brook University, NY, USA
| | - Justin Mirza
- North Shore Surgi-Center, Smithtown, NY, USA
- Mirza Orthopedics, Smithtown, NY, USA
- Stony Brook University, NY, USA
- New York Institute of Technology, Old Westbury, USA
| | - Luke Zappia
- Mirza Orthopedics, Smithtown, NY, USA
- New York Institute of Technology, Old Westbury, USA
| | - Terence L Thomas
- Mirza Orthopedics, Smithtown, NY, USA
- Thomas Jefferson University, Philadelphia, PA, USA
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Khoury A, Gannot G, Oron A. Trigger Finger Due to Anomaly of Lumbrical Insertion: A Case Report and Review of Literature. JBJS Case Connect 2023; 13:01709767-202303000-00018. [PMID: 36706216 DOI: 10.2106/jbjs.cc.22.00504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 11/24/2022] [Indexed: 01/28/2023]
Abstract
CASE Trigger finger (TF), or stenosing synovitis, is a common condition that can usually be diagnosed by physical examination. We recently operated on a patient with TF who did not respond to conservative treatment. At surgery, we found an anomalous insertion of the fourth lumbrical muscle to the A1 pulley. This insertion was observed to cause mechanical narrowing of the pulley due to a pulling effect by the muscle, which was relieved by resection. CONCLUSION Although rare, the operating surgeon should be aware that local anatomical anomalies, such as insertion of a lumbrical into the A1 pulley, can be a cause of trigger finger.
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Affiliation(s)
- Ayman Khoury
- Kaplan Medical Center, Affiliated with Hebrew University Medical School, Hebrew, Israel
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Qiu Z, Li H, Shen Y, Jia Y, Sun X, Zhou Q, Li S, Zhang W. Safety and efficacy of ultrasound-guided percutaneous A1 pulley release using a needle knife: An anatomical study. Front Surg 2022; 9:967400. [PMID: 36204345 PMCID: PMC9530260 DOI: 10.3389/fsurg.2022.967400] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/29/2022] [Indexed: 11/16/2022] Open
Abstract
Objective The present study aimed to assess the efficacy and safety of ultrasound-guided percutaneous A1 pulley release using a needle knife. Methods The author performed percutaneous A1 pulley release in 84 cadaveric hands fixed with 10% formalin. The cadaveric hands were divided into three groups: 28 hands in each group (group U: ultrasound-guided needle knife pushing group, group N: non-ultrasound-guided needle knife pushing group, group T: classical needle knife operation puncture group). Percutaneous A1 pulley release was performed, the soft tissue was dissected layer by layer, and the relevant anatomical data were measured. Results The injured cases were as follows: group U, 29 (20.7%); group N, 36 (25.7%); and group T, 28 (20.0%). There is no significant difference between different tissue injury types in different intervention methods. The missed release cases were as follows: group U, 8 (5.7%); group N, 4 (2.9%); and group T, 13 (9.3%). The percentage of released A1 pulley were as follows: group U, 71.4% ± 30.7%; group N, 66.0% ± 20.3%; and group T, 61.0% ± 30.4%. The percentage of released A1 pulley of the three groups were compared: group U > group N > group T, and there was statistical difference between the three groups. The full release rates of the three groups were compared: group U(31.4%) > group N(15.7%) > group T(13.6%), and there were significant difference in the full release of A1 pulley between group U and group T, group N. Conclusion Based on the cadaver specimen, the length and percentage of released A1 pulley is longer by ultrasound-guided percutaneous A1 pulley release using a needle-knife. and there was no statistical difference in the injury rate between the three techniques. Type of Study and Clinical Relevance Clinical anatomic study. To test the efficacy and safety of ultrasound-guided percutaneous A1 pulley release using a needle knife in cadaveric hands, and provide an anatomically based support in clinic.
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Affiliation(s)
- Zuyun Qiu
- Department of Traditional Chinese Medicine Bone-Setting, Beijing Jishuitan Hospital, Beijing, China
| | - Hui Li
- Department of Acupuncture and Moxibustion, China-Japan Friendship Hospital, Beijing, China
| | - Yifeng Shen
- Department of Traditional Chinese Surgery, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yan Jia
- Department of Acupuncture and Moxibustion, China-Japan Friendship Hospital, Beijing, China
| | - Xiaojie Sun
- Department of Acupuncture and Moxibustion, China-Japan Friendship Hospital, Beijing, China
| | - Qiaoyin Zhou
- Chinese Medicine College, Fujian University of Traditional Chinese Medicine, Fuzhou, China
| | - Shiliang Li
- Department of Acupuncture and Moxibustion, China-Japan Friendship Hospital, Beijing, China
- Correspondence: Shiliang Li Weiguang Zhang
| | - Weiguang Zhang
- Department of Human Anatomy, School of Basic Medical Sciences, Peking University, Beijing, China
- Correspondence: Shiliang Li Weiguang Zhang
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Cromheecke M, Haignère V, Mares O, De Keyzer PB, Louis P, Cognet JM. An Ultrasound-guided Percutaneous Surgical Technique for Trigger Finger Release Using a Minimally Invasive Surgical Knife. Tech Hand Up Extrem Surg 2022; 26:103-109. [PMID: 34446675 DOI: 10.1097/bth.0000000000000367] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Triggering of the finger at the A1 pulley is one of the most frequent pathologies encountered in hand surgery and a common cause of hand pain. Open release of the A1 pulley is currently still regarded as the golden-standard procedure. Nevertheless, there is an increasing interest in minimally invasive percutaneous techniques for the treatment of this condition. Current techniques range from percutaneous needle techniques without imaging, to the use of hook knives, with ultrasound guidance. Because of concerns about possible complications or incomplete releases, hand surgeons remain wary. The objective of this study was to introduce a new ultrasound-guided percutaneous surgical technique for trigger finger release, using a second-generation minimally invasive surgical knife. In this series of 78 releases, complete resolution of the symptoms was found in 98.7% of the cases. One recurrence of triggering was observed. There were no tendon injuries, infections, or neurovascular lesions recorded. This paper contains technical pearls and possible pitfalls to ensure the surgeon of a complete release and to avoid complications. A video of the technique was also included as Supplemental Digital Content (http://links.lww.com/BTH/A143). We can conclude that the procedure can be considered as safe and highly effective for the treatment of triggering at the A1 pulley.
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Affiliation(s)
- Michiel Cromheecke
- SOS Mains Champagne Ardenne/Medipole, Bezannes
- AZ Maria Middelares, Ghent, Belgium
| | | | - Olivier Mares
- Orthopedic Surgery Unit, CHU Caremeaux, Nîmes, France
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Dinç U, Şengezer E, Beger O, Yılmaz MŞ, Kurtoğlu Olgunus Z. Morphological features of the chiasma tendinum and its relation with surface landmarks and pulleys: a cadaveric study. Surg Radiol Anat 2021; 43:1623-1633. [PMID: 34196774 PMCID: PMC8455381 DOI: 10.1007/s00276-021-02783-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 06/04/2021] [Indexed: 11/22/2022]
Abstract
Aim Chiasma tendinum (Camper’s chiasm) is of great importance in the delicate movements and stability of the fingers and takes place poorly in the literature. This study aims to reveal the morphometric details of the chiasma tendinum in relation with pulleys and other relevant structures. Materials and methods Palm and 2nd to 5th fingers of 10 (6 male, 4 female) formalin fixed cadavers were used bilaterally. After determining the superficial reference points on the fingers, the skin and the tendon sheath were incised, and then measurements of chiasma tendinum and related tendons were performed. The measurements were analyzed with respect to fingers, genders, and sides. Finally, the types of chiasma tendinum were identified and then grouped as symmetrical, asymmetrical, and pseudo chiasm. Results Pulley and chiasma tendinum positions were correlated with finger length (p < 0.01). Pulley lengths were significantly less in females. Asymmetrical chiasma tendinum types were found in 45% of the fingers. In most comparisons, values for fifth finger were significantly different than that of other fingers and chiasma tendinum types differed according to fingers and gender. The case of no fiber exchange was observed only in the 5th finger in 15%. Conclusion Findings related to the prediction of location of the pulleys and chiasma tendinum according to the superficial signs, awareness of cases where one of the two arms of the flexor digitorum superficialis is extremely thin and no fiber exchanges that may be risk factors for spontaneous tendon rupture may help provide more accurate approaches in relevant clinical applications.
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Affiliation(s)
- Uğur Dinç
- Faculty of Medicine, Justus Liebig University , Gießen, Germany. .,Department of Anatomy, Faculty of Medicine, Mersin University, Mersin, Turkey.
| | - Ecem Şengezer
- Faculty of Medicine, Mersin University, Mersin, Turkey
| | - Orhan Beger
- Department of Anatomy, Faculty of Medicine, Gaziantep University, Gaziantep, Turkey
| | - Merve Şehide Yılmaz
- Department of Family Medicine, Sisli Etfal Training and Research Hospital, Istanbul, Turkey
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Projection of the A1-Pulley of the Thumb onto Superficial Anatomical Landmarks: An Anatomical Study and a Useful Guide to Surgeons. Indian J Orthop 2021; 55:330-335. [PMID: 34306545 PMCID: PMC8275720 DOI: 10.1007/s43465-021-00397-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Accepted: 03/22/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND The aim of our study was to project the A1-pulley of the thumb onto the total thumb length to enable its complete division with and without direct sight. MATERIALS AND METHODS The study involved 50 hands from adult human cadavers. The proximal and distal borders of the A1-pulley were measured with reference to the first metacarpophalangeal joint (MCPJ). The length of the thumb was defined as the interval between the first carpometacarpal joint (CMCJ) and the apex of the thumb. The length of the pulley is calculated proportionally with reference to the line between the first CMCJ and apex of the thumb. RESULTS Approximated by computing 95% confidence intervals, the pulley can be expected to lie in an area between 34.0% (proximal border) and 57.8% (distal border) alongside this line. CONCLUSION Percutaneous and minimally-invasive division of the A1-pulley needs to be performed between 34.0 and 57.8% of the length between the first CMCJ and apex of the thumb.
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Abstract
Trigger finger (TF) is one of the most common causes of hand disability. Immobilization of TF with a joint-blocking orthosis has been demonstrated to effectively relieve pain and improve function. The efficacy of steroid injections for TF varies based on the number of affected digits and the clinical severity of the condition. Up to three repeat steroid injections are effective in most patients. When conservative interventions are unsuccessful, open surgical release of the A1 pulley effectively alleviates the subjective and objective manifestations of TF and currently remains the benchmark procedure for addressing TF. Although several studies have emerged suggesting that a percutaneous approach may result in improved outcomes, this technique demands a learning curve that may predispose patients to higher risk of procedure-related complications. There is no role for preoperative antibiotics in patients who undergo elective soft-tissue procedures of the hand. WALANT anesthesia has gained popularity because it has been associated with improved patient outcomes and a clear cost savings; however, proper patient selection is critical. Similar to other soft-tissue hand procedures, TF surgery rarely necessitates a postoperative opioid prescription.
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Xie P, Zhang QH, Zheng GZ, Liu DZ, Miao HG, Zhang WF, Ye JF, Du SX, Li XD. Stenosing tenosynovitis : Evaluation of percutaneous release with a specially designed needle vs. open surgery. DER ORTHOPADE 2019; 48:202-206. [PMID: 30623237 DOI: 10.1007/s00132-018-03676-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of conventional open surgery and percutaneous release with a specially designed needle for treating stenosing tenosynovitis in terms of cure, relapse and complication rates. METHODS In this study 89 fingers from 76 patients were randomly assigned and allocated to one of the treatment groups. A total of 37 patients were treated with open surgery in group 1 and 39 patients with percutaneous release using a specially designed needle in group 2. A patient-based 4-inch visual analogue scale (VAS), Quinnell grading (QG), disability of arm shoulder and hand (DASH) score and finger total joint range of motion (FTROM) score were evaluated before treatment and after 7, 30 and 180 days. When finger QG scores were equal or greater than 2 points at follow-up at 180 days this was defined as recurrence.. RESULTS There were no significant differences between the two groups (P > 0.05) in terms of VAS, DASH and QG scores and the degree of FTROM. At 7 days all the data were significantly different (p < 0.05) compared with preoperative data, 30 days was significantly different (p < 0.05) compared with 7 days while at 180 days no significant differences could be found (p > 0.05) compared with 30 days. The recurrence rate in group 1 was 4.65% and 6.55% in group 2. CONCLUSION The percutaneous release and open surgery methods displayed similar effectiveness regarding the cure and recurrence of trigger finger disorder. The use of a specially designed needle for release is a safe and reliable method.
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Affiliation(s)
- Peng Xie
- Department of Orthopedics, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, 518000, Shenzhen, Guangdong, China
| | - Qi-Hao Zhang
- Department of Orthopedics, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, 518000, Shenzhen, Guangdong, China
| | - Gui-Zhou Zheng
- Department of Orthopedics, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, 518000, Shenzhen, Guangdong, China
| | - De-Zhong Liu
- Department of Emergency, First Affiliated Hospital, Shantou University Medical College, 515041, Shantou, Guangdong, China
| | - Hou-Guang Miao
- Department of Orthopedics, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, 518000, Shenzhen, Guangdong, China
| | - Wei-Fang Zhang
- Department of Orthopedics, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, 518000, Shenzhen, Guangdong, China
| | - Jian-Feng Ye
- Department of Orthopedics, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, 518000, Shenzhen, Guangdong, China
| | - Shi-Xin Du
- Department of Orthopedics, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, 518000, Shenzhen, Guangdong, China.
| | - Xue-Dong Li
- Department of Orthopedics, The Third Affiliated Hospital (The Affiliated Luohu Hospital) of Shenzhen University, 518000, Shenzhen, Guangdong, China.
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Gnanasekaran D, Veeramani R, Karuppusamy A. Topographic anatomical landmarks for pulley system of the thumb. Surg Radiol Anat 2018; 40:1007-1012. [PMID: 29671018 DOI: 10.1007/s00276-018-2029-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/13/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE Knowledge of anatomical landmark to pulley system of the thumb is essential in successful treatment of trigger thumb release either by percutaneous or by minimally invasive technique. Though surgical release of trigger thumb is done commonly, there is paucity of data in the literature regarding its surface landmarks. The purpose of this study is to identify palmar surface anatomical landmarks to the pulley system of the thumb. METHODS Dissection was performed on 55 fresh frozen adult cadaveric thumbs. The palmar thumb creases were given names as the proximal-proximal crease (PPC) present at the metacarpophalangeal joint, the distal-proximal crease (DPC) over the middle of the proximal phalanx and the distal crease (DC) at interphalangeal joint. The distance between the proximal edges of each pulley to the three thumb creases and longitudinal length of A1, A2, oblique and Av pulley was measured using digital vernier caliper and was expressed in mean and standard deviation. RESULTS The proximal edge of A1 pulley was 1.98 ± 1.61 mm proximal to the PPC. The mean longitudinal length of the A1 pulley was measured to be 5.06 ± 0.87 mm, so the distal edge of the A1 pulley was calculated to lie 3.08 mm distal to PPC. The proximal edge of Av and oblique pulley was situated 7.78 ± 2.5 and 15.72 ± 3.22 mm distal to PPC, respectively. The proximal edge of A2 pulley was very nearer and 2.88 ± 1.79 mm proximal to DC. CONCLUSION The knowledge of anatomical skin surface landmarks is helpful in the percutaneous release or minimally invasive procedure. The PPC serves as a definite landmark for A1, Av and oblique pulley whereas it is the DC for A2 pulley.
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Affiliation(s)
- Dhivyalakshmi Gnanasekaran
- Department of Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar, Pondicherry, 605006, India
| | - Raveendranath Veeramani
- Department of Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar, Pondicherry, 605006, India.
| | - Aravindhan Karuppusamy
- Department of Anatomy, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Dhanvantri Nagar, Pondicherry, 605006, India
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Guo D, Guo D, Guo J, McCool LC, Tonkin B. A Cadaveric Study of the Thread Trigger Finger Release: The First Annular Pulley Transection Through Thread Transecting Technique. Hand (N Y) 2018; 13:170-175. [PMID: 28720008 PMCID: PMC5950968 DOI: 10.1177/1558944717697433] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND After the thread transecting technique was successfully applied for the thread carpal tunnel release, we researched using the same technique in the thread trigger finger release (TTFR). This study was designed to test the operational feasibility of the TTFR on cadavers and verify the limits of division on the first annular (A1) pulley to ensure a complete trigger finger release with minimal iatrogenic injuries. METHODS The procedure of TTFR was performed on 14 fingers and 4 thumbs of 4 unembalmed cadaveric hands. After the procedures, all fingers and thumbs were dissected and visually assessed. RESULTS All of the digits and thumbs demonstrated a complete A1 pulley release. There was no injury to the neurovascular bundle (radial digital nerve in case of thumb), flexor tendon, or A2 pulley for each case. CONCLUSIONS The cadaveric study showed that the technique of TTFR was safe and effective, and the future clinical study is necessary to verify the findings of this study.
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Affiliation(s)
| | - Danzhu Guo
- BayCare Clinic, Green Bay, WI, USA,Danzhu Guo, BayCare Clinic, 164 N Broadway, Green Bay, WI 54303, USA.
| | - Joseph Guo
- Ridge & Crest Company, Monterey Park, CA, USA
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Abstract
BACKGROUND Trigger finger is a common clinical disorder, characterised by pain and catching as the patient flexes and extends digits because of disproportion between the diameter of flexor tendons and the A1 pulley. The treatment approach may include non-surgical or surgical treatments. Currently there is no consensus about the best surgical treatment approach (open, percutaneous or endoscopic approaches). OBJECTIVES To evaluate the effectiveness and safety of different methods of surgical treatment for trigger finger (open, percutaneous or endoscopic approaches) in adults at any stage of the disease. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and LILACS up to August 2017. SELECTION CRITERIA We included randomised or quasi-randomised controlled trials that assessed adults with trigger finger and compared any type of surgical treatment with each other or with any other non-surgical intervention. The major outcomes were the resolution of trigger finger, pain, hand function, participant-reported treatment success or satisfaction, recurrence of triggering, adverse events and neurovascular injury. DATA COLLECTION AND ANALYSIS Two review authors independently selected the trial reports, extracted the data and assessed the risk of bias. Measures of treatment effect for dichotomous outcomes calculated risk ratios (RRs), and mean differences (MDs) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CIs). When possible, the data were pooled into meta-analysis using the random-effects model. GRADE was used to assess the quality of evidence for each outcome. MAIN RESULTS Fourteen trials were included, totalling 1260 participants, with 1361 trigger fingers. The age of participants included in the studies ranged from 16 to 88 years; and the majority of participants were women (approximately 70%). The average duration of symptoms ranged from three to 15 months, and the follow-up after the procedure ranged from eight weeks to 23 months.The studies reported nine types of comparisons: open surgery versus steroid injections (two studies); percutaneous surgery versus steroid injection (five studies); open surgery versus steroid injection plus ultrasound-guided hyaluronic acid injection (one study); percutaneous surgery plus steroid injection versus steroid injection (one study); percutaneous surgery versus open surgery (five studies); endoscopic surgery versus open surgery (one study); and three comparisons of types of incision for open surgery (transverse incision of the skin in the distal palmar crease, transverse incision of the skin about 2-3 mm distally from distal palmar crease, and longitudinal incision of the skin) (one study).Most studies had significant methodological flaws and were considered at high or unclear risk of selection bias, performance bias, detection bias and reporting bias. The primary comparison was open surgery versus steroid injections, because open surgery is the oldest and the most widely used treatment method and considered as standard surgery, whereas steroid injection is the least invasive control treatment method as reported in the studies in this review and is often used as first-line treatment in clinical practice.Compared with steroid injection, there was low-quality evidence that open surgery provides benefits with respect to less triggering recurrence, although it has the disadvantage of being more painful. Evidence was downgraded due to study design flaws and imprecision.Based on two trials (270 participants) from six up to 12 months, 50/130 (or 385 per 1000) individuals had recurrence of trigger finger in the steroid injection group compared with 8/140 (or 65 per 1000; range 35 to 127) in the open surgery group, RR 0.17 (95% CI 0.09 to 0.33), for an absolute risk difference that 29% fewer people had recurrence of symptoms with open surgery (60% fewer to 3% more individuals); relative change translates to improvement of 83% in the open surgery group (67% to 91% better).At one week, 9/49 (184 per 1000) people had pain on the palm of the hand in the steroid injection group compared with 38/56 (or 678 per 1000; ranging from 366 to 1000) in the open surgery group, RR 3.69 (95% CI 1.99 to 6.85), for an absolute risk difference that 49% more had pain with open surgery (33% to 66% more); relative change translates to worsening of 269% (585% to 99% worse) (one trial, 105 participants).Because of very low quality evidence from two trials we are uncertain whether open surgery improve resolution of trigger finger in the follow-up at six to 12 months, when compared with steroid injection (131/140 observed in the open surgery group compared with 80/130 in the control group; RR 1.48, 95% CI 0.79 to 2.76); evidence was downgraded due to study design flaws, inconsistency and imprecision. Low-quality evidence from two trials and few event rates (270 participants) from six up to 12 months of follow-up, we are uncertain whether open surgery increased the risk of adverse events (incidence of infection, tendon injury, flare, cutaneous discomfort and fat necrosis) (18/140 observed in the open surgery group compared with 17/130 in the control group; RR 1.02, 95% CI 0.57 to 1.84) and neurovascular injury (9/140 observed in the open surgery group compared with 4/130 in the control group; RR 2.17, 95% CI 0.7 to 6.77). Twelve participants (8 versus 4) did not complete the follow-up, and it was considered that they did not have a positive outcome in the data analysis. We are uncertain whether open surgery was more effective than steroid injection in improving hand function or participant satisfaction as studies did not report these outcomes. AUTHORS' CONCLUSIONS Low-quality evidence indicates that, compared with steroid injection, open surgical treatment in people with trigger finger, may result in a less recurrence rate from six up to 12 months following the treatment, although it increases the incidence of pain during the first follow-up week. We are uncertain about the effect of open surgery with regard to the resolution rate in follow-up at six to 12 months, compared with steroid injections, due high heterogeneity and few events occurred in the trials; we are uncertain too about the risk of adverse events and neurovascular injury because of a few events occurred in the studies. Hand function or participant satisfaction were not reported.
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Affiliation(s)
- Haroldo Junior Fiorini
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, n 783, 5° andarSão PauloBrazil04038‐032
| | - Marcel Jun Tamaoki
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, n 783, 5° andarSão PauloBrazil04038‐032
| | - Mário Lenza
- Faculdade Israelita de Ciencias da Saude Albert Einstein and Hospital Israelita Albert EinsteinOrthopaedic Department and School of MedicineAv. Albert Einstein, 627/701São PauloSão PauloBrazilCEP 05651‐901
| | - Joao Baptista Gomes dos Santos
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, n 783, 5° andarSão PauloBrazil04038‐032
| | - Flávio Faloppa
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, n 783, 5° andarSão PauloBrazil04038‐032
| | - Joao carlos Belloti
- Universidade Federal de São PauloDepartment of Orthopaedics and TraumatologyRua Borges Lagoa, n 783, 5° andarSão PauloBrazil04038‐032
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Wang H, Wang P, Amajoyi O, Chen CJ, Chen GY. The Safety of Percutaneous Trigger Digit Release Increased by Neurovascular Displacement with Local Hydraulic Dilatation: An Anatomical and Clinical Study. Med Sci Monit 2017; 23:5034-5040. [PMID: 29055964 PMCID: PMC5665611 DOI: 10.12659/msm.904676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background Although percutaneous trigger digit release is common, controversy exists regarding its safety. The purpose of this study was to evaluate the feasibility and safety of the neurovascular displacement by local hydraulic dilatation (LHD) during percutaneous trigger digit release. Material/Methods Ten cadaver hands with 50 digits were dissected in this anatomical study. The distance between bilateral neurovascular bundles in each digit was measured before LHD and after LHD. The difference between the measured data before LHD and those after LHD in the same digit was compared to assess the feasibility of the neurovascular displacement by LHD. A further 81 patients with 106 trigger digits were treated by percutaneous release with neurovascular displacement by LHD in our clinical series. All patients were followed for 12 months. During the follow-up period, the presence of any postoperative complication and patient satisfaction were recorded. Results In our anatomical study, there was a statistically significant difference (p<0.05) comparing the average distance of bilateral neurovascular bundles before LHD with that after LHD. In the current series, no complications, such as digital neurovascular injury or recurrence of trigger, were encountered. On subjective assessment, 80/81 patients (98.8%) with 105/106 digits (99.1%) were graded as satisfactory with complete resolution of symptoms by percutaneous release under LHD. Conclusions Based on our study anatomical and clinical results, the neurovascular displacement by LHD may be a feasible adjunctive technique that may play a role in increasing the safety of percutaneous trigger digit release.
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Affiliation(s)
- Honggang Wang
- Department of Orthopedics, California Hospital Medical Center, Los Angeles, CA, USA.,Department of Orthopaedic and Microsurgery, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Ping Wang
- Department of Medical Ultrasonic, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China (mainland)
| | - Obioma Amajoyi
- Department of Orthopaedics, California Hospital Medical Center, Los Angeles, CA, USA
| | - Clark J Chen
- University of California Los Angeles, Los Angeles, CA, USA
| | - Gary Y Chen
- Department of Orthopedics, California Hospital Medical Center, Los Angeles, CA, USA.,University of California Los Angeles, Los Angeles, CA, USA
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Watkins CJ, Zivaljevic N, Eberlin KR, Rivlin M, Mudgal CS. The Relationship Between the Intercrease Line and the A1 Digital Pulley: A Cadaveric Study. Hand (N Y) 2017; 12:297-300. [PMID: 28453336 PMCID: PMC5480663 DOI: 10.1177/1558944716661998] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Accurate identification of surface anatomy is critical to identify the location of the A1 pulley. The intercrease line (ICL) describes a transverse line between the radial edge of the proximal palmar crease and the ulnar edge of the distal palmar crease. We hypothesize that this easily identifiable surface landmark approximates the location of the A1 pulley. METHODS The ICL was marked on 7 cadaver hands. We marked a point proximal to the proximal digital crease (PDC) equal to the distance between each digit's proximal interphalangeal crease (PIC) and PDC (the PIC/PDC point). We calculated the distance between PIC/PDC points and proximal edge of the A1 pulleys. RESULTS The ICL was proximal to A1 in all digits. The PIC/PDC point was distal to A1 in the ring finger, and proximal to A1 in the index, middle, and small fingers. The PIC/PDC point was closer to the A1 pulley than the ICL in the middle and ring fingers. CONCLUSIONS Despite less accuracy than the PIC/PDC point at approximating the location of the A1 pulley, the ICL is reliably proximal to the A1 pulley.
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Affiliation(s)
| | | | | | | | - Chaitanya S. Mudgal
- Harvard Medical School, Boston, MA, USA,Chaitanya S. Mudgal, Associate Professor in Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Hand Service, Yawkey Center, Suite 2C, MA 02114, USA.
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Abstract
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.
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Colio SW, Smith J, Pourcho AM. Ultrasound-Guided Interventional Procedures of the Wrist and Hand: Anatomy, Indications, and Techniques. Phys Med Rehabil Clin N Am 2016; 27:589-605. [PMID: 27468668 DOI: 10.1016/j.pmr.2016.04.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Acute and chronic wrist and hand conditions are commonly seen by neuromuscular and musculoskeletal specialists. High-frequency diagnostic ultrasonography (US) has facilitated advances in the diagnosis and interventional management of wrist and hand disorders. US provides excellent soft tissue resolution, accessibility, portability, lack of ionizing radiation, and the ability to dynamically assess disorders and precisely guide interventional procedures. This article review the relevant anatomy, indications, and interventional techniques for common disorders of the wrist and hand, including radiocarpal joint arthritis, scaphotrapeziotrapezoidal joint arthritis, trapeziometacarpal joint arthritis, phalangeal joint arthritis, first dorsal compartment tenosynovitis, ganglion cysts, and stenosing tenosynovitis.
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Affiliation(s)
- Sean W Colio
- Department of Physical Medicine and Rehabilitation, Swedish Spine, Sports, and Musculoskeletal Center, Swedish Medical Group, Seattle, WA, USA
| | - Jay Smith
- Departments of Physical Medicine & Rehabilitation, Mayo Clinic Sports Medicine Center, Mayo Clinic, Rochester, MN, USA; Department Radiology, Mayo Clinic Sports Medicine Center, Mayo Clinic, Rochester, MN, USA; Department Anatomy, Mayo Clinic Sports Medicine Center, Mayo Clinic, Rochester, MN, USA
| | - Adam M Pourcho
- Department of Physical Medicine and Rehabilitation, Swedish Spine, Sports, and Musculoskeletal Center, Swedish Medical Group, 600 E. Jefferson Street, Suite 300, Seattle, WA 98112, USA.
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Abstract
Trigger fingers are common tendinopathies representing a stenosing flexor tenosynovitis of the fingers. Adult trigger finger can be treated nonsurgically using activity modification, splinting, and/or corticosteroid injections. Surgical treatment options include percutaneous A1 pulley release and open A1 pulley release. Excision of a slip of the flexor digitorum superficialis is reserved for patients with persistent triggering despite A1 release or patients with persistent flexion contracture. Pediatric trigger thumb is treated with open A1 pulley release. Pediatric trigger finger is treated with release of the A1 pulley with excision of a slip or all of the flexor digitorum superficialis if triggering persists.
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Affiliation(s)
- Juan M Giugale
- Department of Orthopaedic Surgery, University of Pittsburgh, Suite 1010, Kaufmann Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA
| | - John R Fowler
- Department of Orthopaedic Surgery, University of Pittsburgh, Suite 1010, Kaufmann Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA.
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Collins AM, Quinlan CS, Dolan RT, O'Neill SP, Tierney P, Cronin KJ, Ridgway PF. Audiovisual preconditioning enhances the efficacy of an anatomical dissection course: A randomised study. J Plast Reconstr Aesthet Surg 2015; 68:1010-5. [PMID: 25865740 DOI: 10.1016/j.bjps.2015.03.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 03/06/2015] [Indexed: 10/23/2022]
Abstract
UNLABELLED The benefits of incorporating audiovisual materials into learning are well recognised. The outcome of integrating such a modality in to anatomical education has not been reported previously. The aim of this randomised study was to determine whether audiovisual preconditioning is a useful adjunct to learning at an upper limb dissection course. Prior to instruction participants completed a standardised pre course multiple-choice questionnaire (MCQ). The intervention group was subsequently shown a video with a pre-recorded commentary. Following initial dissection, both groups completed a second MCQ. The final MCQ was completed at the conclusion of the course. Statistical analysis confirmed a significant improvement in the performance in both groups over the duration of the three MCQs. The intervention group significantly outperformed their control group counterparts immediately following audiovisual preconditioning and in the post course MCQ. Audiovisual preconditioning is a practical and effective tool that should be incorporated in to future course curricula to optimise learning. Level of evidence This study appraises an intervention in medical education. LEVEL OF EVIDENCE Kirkpatrick Level 2b (modification of knowledge).
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Affiliation(s)
- Anne M Collins
- Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland.
| | | | | | | | | | - Kevin J Cronin
- Mater Misericordiae University Hospital, Eccles Street, Dublin, Ireland
| | - Paul F Ridgway
- University of Dublin, Trinity College at Adelaide and Meath Hospital, Incorporating the National Children's Hospital, Tallaght, Dublin 24, Ireland
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Hoevenaren IA, Maal TJJ, Krikken E, de Haan AFJ, Bergé SJ, Ulrich DJO. Development of a three-dimensional hand model using 3D stereophotogrammetry: Evaluation of landmark reproducibility. J Plast Reconstr Aesthet Surg 2015; 68:709-16. [PMID: 25665488 DOI: 10.1016/j.bjps.2014.12.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2014] [Revised: 11/11/2014] [Accepted: 12/13/2014] [Indexed: 12/01/2022]
Abstract
BACKGROUND Using three-dimensional (3D) photography, exact images of the human body can be produced. Over the last few years, this technique is mainly being developed in the field of maxillofacial reconstructive surgery, creating fusion images with computed tomography (CT) data for accurate planning and prediction of treatment outcome. However, in hand surgery, 3D photography is not yet being used in clinical settings. METHODS The aim of this study was to develop a valid method for imaging the hand using 3D stereophotogrammetry. The reproducibility of 30 soft tissue landmarks was determined using 3D stereophotogrammetric images. Analysis was performed by two observers on 20 3D photographs. Reproducibility and reliability of the landmark identification were determined using statistical analysis. RESULTS The intra- and interobserver reproducibility of the landmarks were high. This study showed a high reliability coefficient for intraobserver (1.00) and interobserver reliability (0.99). Identification of the landmarks on the palmar aspect of individual fingers was more precise than the identification of landmarks of the thumb. CONCLUSIONS This study shows that 3D photography can safely produce accurate and reproducible images of the hand, which makes the technique a reliable method for soft tissue analysis. 3D images can be a helpful tool in pre- and postoperative evaluation of reconstructive trauma surgery, in aesthetic surgery of the hand, and for educational purposes. The use in everyday practice of hand surgery and the concept of fusing 3D photography images with radiologic images of the interior hand structures needs to be further explored.
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Affiliation(s)
- Inge A Hoevenaren
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
| | - Thomas J J Maal
- Department of Oral and Maxillofacial Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - E Krikken
- Department of Oral and Maxillofacial Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands; Technical Medicine, University of Twente, Enschede, The Netherlands
| | - A F J de Haan
- Department for Health Evidence, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - S J Bergé
- Department of Oral and Maxillofacial Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - D J O Ulrich
- Department of Plastic, Reconstructive and Hand Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
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Sahu R, Gupta P. Experience of Percutaneous Trigger Finger Release under Local Anesthesia in the Medical College of Mullana, Ambala, Haryana. Ann Med Health Sci Res 2014; 4:806-9. [PMID: 25328798 PMCID: PMC4199179 DOI: 10.4103/2141-9248.141558] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Trigger finger is a common disorder of upper extremity. Majority of the patients can be treated conservatively but some resistant cases eventually need surgery. Aim: The aim of this study is to evaluate the results of percutaneous trigger finger release under local anesthesia. Subjects and Methods: This is a prospective study carried out from July 2005 to July 2010, 46 fingers in 46 patients (30 females and 16 males) were recruited from outpatient department having trigger finger for more than 6 months. All patients were operated under local anesthesia. All patients were followed for 6 months. The clinical results were evaluated in terms of pain, activity level and patient satisfaction. Statistical Analysis Used: Statistical analysis was limited to calculation of percentage of patients who had excellent, good and poor outcomes. Results: The results were excellent in 82.6% (38/46) patients, good in 13.0% (6/46) patients and poor in two 4.3% (2/46) patients respectively. Complete Pain relief was achieved in 82.6% (38/46) patients, partial pain relief in 13.0% (6/46) patients and no pain relief in 4.3% (2/46) patients just after surgery. There was no recurrence of triggering. Range of motion was preserved in all cases. There were no digital nerve or tendon injuries. On subjective evaluations, 82.6% (38/46) patients reported full satisfaction, 13.0% (6/46) patients partial satisfaction and 4.3% (2/46) patients dissatisfaction with the results of treatment respectively. Conclusions: Percutaneous trigger finger release under local anesthesia is a minimal invasive procedure that can be performed in an outpatient setting. This procedure is easy, quicker, less complications and economical with good results.
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Affiliation(s)
- Rl Sahu
- Department of Orthopedics, School of Medical Science and Research, Sharda University, Uttar Pradesh, India
| | - P Gupta
- Department of Obstetric and Gynecology, Post Graduate Institute of Medical Sciences and Research ESIC, Basai Darapur, New Delhi, India
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Abstract
Open surgery has been indicated as the surgical treatment for trigger finger for many years; however, minimally invasive techniques are replacing conventional methods. Minimally invasive techniques enable early recovery of the patient with minimal damage to soft tissues. The authors’ study showed that levels of effectiveness of open surgical and percutaneous methods were superior to those of the conservative method using corticosteroid based on the cure and reappearance rates of the trigger. Percutaneous pulley release for treating trigger finger is a safe, effective, and minimally invasive surgical alternative.
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Affiliation(s)
- Edson Sasahara Sato
- Discipline of Hand and Upper Limb Surgery, Department of Orthopedics and Traumatology, UNIFESP - Federal University of São Paulo, Rua Borges Lagoa 786, São Paulo City, Cep: 04038-031 São Paulo, Brazil.
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Patel RM, Chilelli BJ, Ivy AD, Kalainov DM. Hand surface landmarks and measurements in the treatment of trigger thumb. J Hand Surg Am 2013; 38:1166-71. [PMID: 23591023 DOI: 10.1016/j.jhsa.2013.02.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 02/08/2013] [Accepted: 02/08/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine hand surface landmarks and measurements that may be useful in localizing the A1 pulley and digital neurovascular structures in the treatment of trigger thumb. METHODS We highlighted 4 surface landmarks in 20 adult cadaveric hands: the radial border of the index finger, the ulnar border of the thumb, the thumb interphalangeal joint flexion creases, and the thumb metacarpophalangeal joint creases. We injected the radial arteries with red latex and dissected the thumbs. RESULTS The proximal margin of the A1 pulley was located an average of 0.3 mm proximal (range, 3.2 mm proximal to 2.3 mm distal) to the most proximal metacarpophalangeal joint flexion crease. The ratio of measurements from the thumb tip to the midpoint of the interphalangeal joint flexion creases and from this point to the proximal margin of the A1 pulley averaged 1.1:1. The radial digital nerve crossed obliquely over the flexor pollicis longus tendon and approached the proximal margin of the A1 pulley at a mean distance of 2.7 mm (range, 0-12.9 mm). The ulnar digital nerve was located deep to intersecting lines drawn along the radial border of the index finger and the ulnar border of the thumb and coursed parallel to the A1 pulley at a mean distance of 5.4 mm (range, 0-11.1 mm). At the level of the A1 pulley, the digital arteries were positioned dorsal to the digital nerves, and both nerves were located 1.0 to 4.2 mm from the skin surface. CONCLUSIONS The findings from our study clarify hand surface landmarks in localizing the thumb A1 pulley and digital neurovascular structures. CLINICAL RELEVANCE Awareness of topographical landmarks in localizing the A1 pulley and digital neurovascular structures and the relationships between the digital neurovascular structures and the A1 pulley may improve the safety and efficacy of trigger thumb treatment.
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Affiliation(s)
- Ronak M Patel
- Department of Orthopaedic Surgery and the Northwestern Center for Surgery of the Hand, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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McClelland WB, McClinton MA. Proximal interphalangeal joint injection through a volar approach: anatomic feasibility and cadaveric assessment of success. J Hand Surg Am 2013; 38:733-9. [PMID: 23453898 DOI: 10.1016/j.jhsa.2013.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 01/02/2013] [Accepted: 01/04/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The proximal interphalangeal (PIP) joint is a challenging joint to access reliably for corticosteroid injection. Literature has confirmed both a relatively high failure rate for injections performed with the traditional dorsal approach and an improved clinical response rate for confirmed intra-articular injections. We describe a technique for injecting the PIP joint through a volar approach, assess its reliability through cadaveric dissection, and determine its reproducibility by comparing success rates with the dorsal approach in a cadaver model. METHODS We dissected the PIP joint of 10 cadaveric digits to document necessary anatomic landmarks for this technique. We then used 20 matched pairs of cadaver hands for the remainder of our study. Four PIP joints on each hand (thumb excluded) were injected with a solution of saline and radio-opaque dye using the dorsal approach. We injected each joint on the contralateral matched hand through the volar approach. We obtained standardized fluoroscopic images of each joint immediately after injection, which were reviewed by an independent observer who was blinded to the technique and who rated outcomes as success, failure, or mixed. Success rates were evaluated based on approach used, digit injected, and degree of pre-existing arthritis. RESULTS We found reproducible anatomic landmarks that justified our injection technique. The rates of absolute failure were similar in the 2 cohorts. The volar approach demonstrated a higher percentage of successful injections with a smaller percentage of mixed results, although results did not reach statistical significance. There was no statistically significant difference in success rates based on digit injected or grade of arthritis in either cohort. CONCLUSIONS The volar approach to injecting the PIP joint demonstrated success similar to that of the traditional dorsal approach. Reproducible surface landmarks exist to guide practitioners using this technique. Further study is needed to determine the potential complications and clinical outcomes of the volar approach. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Walter B McClelland
- Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD 21218, USA.
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Toia F, Marchese M, Boniforti B, Tos P, Delcroix L. The little finger ulnar palmar digital artery perforator flap: anatomical basis. Surg Radiol Anat 2013; 35:737-40. [PMID: 23443276 DOI: 10.1007/s00276-013-1091-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 02/12/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE The aim of this study was to explore the cutaneous vascularization of the hypothenar region and investigate the anatomical basis for perforator propeller flaps for coverage of the flexor aspect of the little finger. METHODS The area between the pisiform and the base of the little finger was studied in 14 hands of fresh cadavers injected with red latex. An oval flap 1.5 cm large was raised along the axis between these two points. Perforators going into the flap were dissected up to their origin from the ulnar palmar digital artery of the little finger, and their distance from the proximal edge of the A1 pulley was recorded. RESULTS The mean number of perforator arteries entering the flap was 5.8 (range 4-8). A constant sizeable perforator was identified within 0.7 cm from the proximal margin of the A1 pulley in all 14 specimens. In the majority of cases (64 %), the most distal perforator was located at this level. Dissection of the flap was carried out suprafascially on the most distal perforator and 180° rotation allowed the flap to reach the flexor surface of the fifth finger. The donor site was closed primarily. CONCLUSION Distal perforators of the ulnar palmar digital artery of the little finger are constantly found. Our anatomical findings support the possibility of raising a propeller perforator flap from the hypothenar region for coverage of the flexor aspect of the little finger. Its clinical application could provide a quick and straightforward single-stage option with a negligible donor-site morbidity for reconstruction of such defects.
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Affiliation(s)
- Francesca Toia
- Chirurgia Plastica e Ricostruttiva, Dipartimento di Discipline Chirurgiche ed Oncologiche, Università degli Studi di Palermo, Via del Vespro, 129, 90127, Palermo, Italy,
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Zhang C, Tang T, Fu T. Development of a special needle knife for percutaneous A1 pulley release. J Hand Surg Eur Vol 2012; 37:889-90. [PMID: 22403435 DOI: 10.1177/1753193412436771] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Chunming Zhang
- Department of Orthopedic Surgery, First Affiliated Hospital of Suzhou University, Suzhou, China, and Department of Orthopedic Surgery, 401 Hospital of the Chinese People’s Liberation Army, Qingdao, China
| | - Tiansi Tang
- Department of Orthopedic Surgery, First Affiliated Hospital of Suzhou University, Suzhou, China, and Department of Orthopedic Surgery, 401 Hospital of the Chinese People’s Liberation Army, Qingdao, China
| | - Tingyou Fu
- Department of Orthopedic Surgery, First Affiliated Hospital of Suzhou University, Suzhou, China, and Department of Orthopedic Surgery, 401 Hospital of the Chinese People’s Liberation Army, Qingdao, China
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Habbu R, Putnam MD, Adams JE. Percutaneous release of the A1 pulley: a cadaver study. J Hand Surg Am 2012; 37:2273-7. [PMID: 23101524 DOI: 10.1016/j.jhsa.2012.08.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 08/15/2012] [Accepted: 08/15/2012] [Indexed: 02/02/2023]
Abstract
PURPOSE Percutaneous release of the A1 pulley has been used for treatment of trigger fingers with success. However, lack of direct visualization raises concerns about the completeness of the release and about potential injury to the tendons or neurovascular structures. The purpose of this study was to assess the efficacy and safety of percutaneous release of the A1 pulley in a cadaveric model using a commonly available instrument, a #15 scalpel blade. METHODS Fourteen fresh frozen cadaveric hands (54 fingers, thumbs excluded) were used. Landmarks were established for the A1 pulley based upon cutaneous features. Percutaneous release was performed using a #15 blade. The specimens were then dissected and examined for any tendon or neurovascular injury, and completeness of A1 pulley release was evaluated. RESULTS There were 39 (72%) complete releases of the A1 pulley with 14 partial and 1 missed (failed) release. There was a 22% incidence of release of the proximal edge of the A2 pulley. However, there was no case of release of more than 25% of the A2 pulley length, nor was bowstringing of flexor tendons seen in these specimens. Eleven digits showed longitudinal scoring of the flexor tendons and 3 had partial tendon lacerations. No neurovascular injuries were noted. CONCLUSIONS Percutaneous release of the A1 pulley using a #15 blade was associated with good efficacy and an acceptable margin of safety in this series. CLINICAL RELEVANCE Percutaneous release of trigger digits may assume a greater role in the treatment of patients with trigger finger because of cost containment pressures. The data from this study suggest that the technique used in this study is both safe and effective. With use of proper anatomical guidelines, risk to neurovascular structures is low, although longitudinal scoring of the tendon can occur.
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Affiliation(s)
- Rohan Habbu
- Department of Orthopaedic Surgery, University of Minnesota, Minneapolis, MN 55454, USA
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Affiliation(s)
- Chunming Zhang
- Department of Orthopedic Surgery, First Affiliated Hospital of Suzhou University, Suzhou, China, and Department of Orthopedic Surgery, 401 Hospital of the Chinese People’s Liberation Army, Qingdao, China
| | - Tiansi Tang
- Department of Orthopedic Surgery, First Affiliated Hospital of Suzhou University, Suzhou, China, and Department of Orthopedic Surgery, 401 Hospital of the Chinese People’s Liberation Army, Qingdao, China
| | - Tingyou Fu
- Department of Orthopedic Surgery, First Affiliated Hospital of Suzhou University, Suzhou, China, and Department of Orthopedic Surgery, 401 Hospital of the Chinese People’s Liberation Army, Qingdao, China
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Gordon JA, Stone L, Gordon L. Surface markers for locating the pulleys and flexor tendon anatomy in the palm and fingers with reference to minimally invasive incisions. J Hand Surg Am 2012; 37:913-8. [PMID: 22365712 DOI: 10.1016/j.jhsa.2011.12.036] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2011] [Revised: 12/19/2011] [Accepted: 12/20/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE Palm and finger pulley anatomy has been well described in relation to osseous structures. The goal of this study was to describe skin surface markers that locate the underlying flexor tendon and pulley system. We describe the anatomic detail of these structures and provide a guide for the surgeon for making small incisions. Using this approach, extensile exposure can be avoided, and the integrity of the complex pulley system is maintained. METHODS We dissected 12 palms and 48 fingers in 12 cadaver hands. We marked the palm and finger creases with methylene blue before dissection. We removed palm skin, finger skin, and subcutaneous tissue over the flexor tendon sheath and retained a 2-mm strip of each skin crease in its native position. We divided the palm and palmar surface of the fingers into 4 distinct zones and measured the location of the proximal and distal extent of each pulley and the tendon anatomy relative to the proximal and distal skin crease. RESULTS We documented the location of the proximal and distal extent of the annular and cruciate pulleys as well as the decussation of the flexor digitorum superficialis (FDS) tendon and Camper chiasm. The results allow us to establish a relationship between the skin creases and underlying anatomy by dividing the palm and finger into 4 zones. In zone A, in the palm, the A2 pulley is located in the distal third and the FDS decussation is at the proximal extent of the A2 pulley. Zone B is in the proximal phalanx and A2 lies in the proximal third of this zone, whereas the Camper chiasm lies in the middle third. Zone C is in the middle phalanx and A4 and the insertion of FDS lie in the middle third of this zone. Zone D lies in the distal phalanx and the flexor digitorum profundus tendon inserts into the middle third of this zone. CONCLUSIONS Skin creases can be used as surface markers to accurately locate the underlying pulley and tendon system and plan for limited incisions. CLINICAL RELEVANCE These anatomic descriptions can aid surgeons in preoperative planning and may also help minimize the required exposure for flexor tendon repair and other surgery in the fingers and palm.
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Affiliation(s)
- Joshua A Gordon
- Departments of Anatomy and Orthopaedic Surgery, University of California, San Francisco, CA, USA
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Abstract
Pediatric trigger thumb and trigger finger represent distinct conditions and should not be treated like adult acquired trigger finger. Over the last two decades, our understanding of the natural history of pediatric trigger thumb and the etiology and surgical management of pediatric trigger finger has improved. Pediatric trigger thumb may spontaneously resolve, although resolution may take several years. Open surgical release of the A1 pulley of the thumb is an alternative option that nearly uniformly restores thumb interphalangeal joint motion. Surgical management of pediatric trigger finger with isolated release of the A1 pulley has been associated with high recurrence rates. Awareness of the anatomic factors that may contribute to triggering in the pediatric finger and willingness to explore and address other involved components of the flexor mechanism can prevent surgical failure.
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Sato ES, Gomes Dos Santos JB, Belloti JC, Albertoni WM, Faloppa F. Treatment of trigger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery. Rheumatology (Oxford) 2011; 51:93-9. [PMID: 22039269 DOI: 10.1093/rheumatology/ker315] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The aim of this study is to evaluate the effectiveness of CS injection, percutaneous pulley release and conventional open surgery for treating trigger finger in terms of cure, relapse and complication rates. METHODS One hundred and thirty-seven patients with a total of 150 fingers were randomly assigned and allocated into one of the treatment groups, with treatments allocated into 150 opaque and sealed envelopes. We included patients >15 years of age with a trigger on any finger of the hand (Types II-IV) and used a minimum follow-up time of 6 months. The primary outcome measures were cures, relapses and failures. RESULTS Forty-nine patients were assigned to the conservative group to undergo CS injections, whereas 45 and 56 were assigned to undergo percutaneous release and outpatient open surgery, respectively. The trigger cure rate for patients in the injection method group was 57%, and wherever necessary, two injections were administered, which increased the cure rate to 86%. For the percutaneous and open release methods, remission of the trigger was achieved in all cases. CONCLUSIONS The percutaneous and open surgery methods displayed similar effectiveness and proved superior to the conservative CS method regarding the trigger cure and relapse rates. Trial registration. Current Controlled Trials, http://www.controlled-trials.com/, ISRCTN19255926.
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Affiliation(s)
- Edson S Sato
- Department of Orthopedics and Traumatology, Discipline of Hand and Upper Limb Surgery, UNIFESP - Federal University of São Paulo, São Paulo City, São Paulo, Brazil.
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Kaplan SJ, Floyd WE. Anatomical study of the A1 pulley: length and location by means of cutaneous landmarks on the palmar surface. J Hand Surg Am 2011; 36:1114. [PMID: 21636027 DOI: 10.1016/j.jhsa.2011.03.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Revised: 03/22/2011] [Accepted: 03/23/2011] [Indexed: 02/02/2023]
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