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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: 1] [Impact Index Per Article: 1.0] [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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Rodríguez-Maruri G, Rojo-Manaute JM, Capa-Grasa A, Chana Rodríguez F, Cerezo López E, Vaquero Martín J. Ultrasound-Guided A1 Pulley Release Versus Classic Open Surgery for Trigger Digit: A Randomized Clinical Trial. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2023; 42:1267-1275. [PMID: 36478278 DOI: 10.1002/jum.16139] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 09/28/2022] [Accepted: 11/14/2022] [Indexed: 05/18/2023]
Abstract
OBJECTIVES We compared an ultra-minimally invasive ultrasound-guided percutaneous A1 pulley release and a classic open surgery for trigger digit. METHODS We designed a single-center randomized control trial. All cases had clinical signs of primary grade III trigger digit. Concealed allocation (1:1) was used for assigning patients to each group and data collectors were blinded. The Quick-Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire was our primary variable. Quick-DASH, two-point discrimination, grip strength, time until stopping analgesics, having full digital range of motion and restarting everyday activities were registered on the 1st, 3rd, and 6th weeks, 3rd and 6th months, and 1st year after the procedure. RESULTS We randomized 84 patients to ultrasound-guided release and classic open surgery. Quick-DASH scores significantly favored the percutaneous technique until the 3rd month: 7.6 ± 1.2 versus 15.3 ± 2.4 (mean ± standard error of the mean). The percutaneous group obtained significantly better results in all the variables studied: time until stopping analgesics, achieving full range of motion and restarting everyday activities. Grip strength was significantly better in the percutaneous group for the 1st week only. Five cases of moderate local pain were observed in the open technique. There was one case of transient nerve numbness per group. CONCLUSIONS The ultra-minimally invasive ultrasound-guided A1 pulley release was clinically superior to the classic open surgery in functional recovery with a lower complication rate.
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Affiliation(s)
- Guillermo Rodríguez-Maruri
- Primary Care Musculoskeletal Unit, Area V, Servicio de Salud del Principado de Asturias, SESPA, Gijón, Spain
| | - Jose Manuel Rojo-Manaute
- Unit of Hand Surgery, Department of Orthopedics, Medcare Orthopedics and Spine Hospital, Dubai, United Arab Emirates
| | - Alberto Capa-Grasa
- Department of Physical and Rehabilitation Medicine, University Hospital La Paz, Madrid, Spain
| | | | | | - Javier Vaquero Martín
- Department of Orthopaedic Surgery, University Hospital Gregorio Marañón, Madrid, Spain
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Zhong WX, Chen ZJ, Peng WJ, Gu RB, Li JH, Li YK. Morphometric study of percutaneous A1 pulley of thumb release. Sci Rep 2022; 12:20944. [PMID: 36470935 PMCID: PMC9722786 DOI: 10.1038/s41598-022-24759-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 11/21/2022] [Indexed: 12/12/2022] Open
Abstract
Through anatomy, microscope, histopathology, and simulating needle knife operation on specimens, to accumulate the relevant parameters of the A1 pulley of thumb, and to provide an anatomical evidence for the needle knife therapy of stenosing flexor tenosynovitis. A total of 20 fingers were selected from 20 intact adult upper limb specimens, a small amount of emerald green waterproof dye was injected from the needle insertion point, dissected layer by layer, and the A1 pulley and neurovascular bundle were observed. Observe the loosening of the thumb A1 pulley after 5 and 10 times of simulated needle knife cutting on the specimen; observe the relationship between the needle knife entry point and the A1 pulley under the thumb extension and abduction, and the thumb extension neutral position respectively; further observe the histological characteristics, and the relationship between needle entry point and A1 pulley by microscope. ① In general observation, the A1 pulleys of each finger were transverse fibers perpendicular to the flexor tendon, tough in texture, connected with synovial fibers at the proximal end. It is difficult to distinguish, and connected with oblique fibers at the distal end. ② The release rate of the thumb A1 pulley after 5 and 10 times of simulated needle knife cutting on the specimen were (40.46 ± 2.22)% and (63.52 ± 4.49)%, respectively. ③ In the neutral position of the thumb straightening, the needle entry point is 3.06 ± 0.14 mm from the proximal side of the proximal edge of the A1 pulley, which overlaps with the needle entry point where the thumb is straight and abducted. ④ Observed under a microscope, the A1 pulley is a dense transverse fiber with a pale yellow dense connective tissue, both ends are continuous with the synovial fibers. It is thin and translucent, and loose connective tissue. The A1 pulley is a dense transverse fiber with a pale yellow dense connective tissue. The anatomical key points of the needle knife therapy lie in the extended and abducted position of the thumb. Currently, it is believed that cutting the proximal edge of the A1 pulley is sufficient, and there is no need to cut the entire A1 pulley.
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Affiliation(s)
- Wei-xing Zhong
- grid.284723.80000 0000 8877 7471School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong China
| | - Zu-jiang Chen
- grid.284723.80000 0000 8877 7471School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong China
| | - Wei-jie Peng
- grid.284723.80000 0000 8877 7471School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong China
| | - Rui-bin Gu
- grid.284723.80000 0000 8877 7471School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong China
| | - Jun-hua Li
- grid.284723.80000 0000 8877 7471School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong China
| | - Yi-kai Li
- grid.284723.80000 0000 8877 7471School of Traditional Chinese Medicine, Southern Medical University, Guangzhou, Guangdong China
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Finnoff JT, Awan TM, Borg-Stein J, Harmon KG, Herman DC, Malanga GA, Master Z, Mautner KR, Shapiro SA. American Medical Society for Sports Medicine Position Statement: Principles for the Responsible Use of Regenerative Medicine in Sports Medicine. Clin J Sport Med 2021; 31:530-541. [PMID: 34704973 DOI: 10.1097/jsm.0000000000000973] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 07/19/2021] [Indexed: 02/02/2023]
Abstract
ABSTRACT Many sports medicine physicians are currently considering introducing regenerative medicine into their practice. Regenerative medicine and the subclassification of orthobiologics are a complicated topic and have produced widely varying opinions. Although there is concern by government regulators, clinicians, scientists, patient advocacy organizations, and the media regarding the use of regenerative medicine products, there is also excitement about the potential benefits with growing evidence that certain regenerative medicine products are safe and potentially efficacious in treating musculoskeletal conditions. Sports medicine physicians would benefit from decision-making guidance about whether to introduce orthobiologics into their practice and how to do it responsibly. The purpose of this position statement is to provide sports medicine physicians with information regarding regenerative medicine terminology, a brief review of basic science and clinical studies within the subclassification of orthobiologics, regulatory considerations, and best practices for introducing regenerative medicine into clinical practice. This information will help sports medicine physicians make informed and responsible decisions about the role of regenerative medicine and orthobiologics in their practice.
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Affiliation(s)
- Jonathan T Finnoff
- Department of Physical Medicine and Rehabilitation, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Tariq M Awan
- Department of Orthopedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Joanne Borg-Stein
- Division of Sports and Musculoskeletal Rehabilitation, Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, Massachusetts
| | - Kimberly G Harmon
- Departments of Family Medicine and Orthopedics and Sports Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Daniel C Herman
- Department of Orthopedics and Rehabilitation, University of Florida, Gainesville, Florida
| | - Gerard A Malanga
- Department of Physical Medicine and Rehabilitation, Rutgers School of Medicine-New Jersey Medical School, Newark, New Jersey
| | - Zubin Master
- Biomedical Ethics Research Program and the Center for Regenerative Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota
| | - Kenneth R Mautner
- Department of Physical Medicine and Rehabilitation, Emory University, Atlanta, Georgia
- Department of Orthopedics, Emory University, Atlanta, Georgia; and
| | - Shane A Shapiro
- Department of Orthopedic Surgery, Mayo Clinic College of Medicine and Science, Jacksonville, Florida
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Abdoli A, Asadian M, Banadaky SHS, Sarram R. A cadaveric assessment of percutaneous trigger finger release with 15° stab knife: its effectiveness and complications. J Orthop Surg Res 2021; 16:426. [PMID: 34217345 PMCID: PMC8254281 DOI: 10.1186/s13018-021-02566-4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/17/2021] [Indexed: 12/20/2022] Open
Abstract
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.
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Affiliation(s)
- Abbas Abdoli
- Department of Orthopedics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Majid Asadian
- Department of Orthopedics, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.
| | | | - Rabeah Sarram
- Shahid Sadoughi University of Medical Sciences, Yazd, Iran
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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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Association between Stenosing Tenosynovitis and Dupuytren's Contracture in the Hand. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2088. [PMID: 30859045 PMCID: PMC6382223 DOI: 10.1097/gox.0000000000002088] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 11/06/2018] [Indexed: 12/31/2022]
Abstract
Background: Both stenosing tenosynovitis and Dupuytren’s contracture are common conditions encountered in hand surgery. Connections between 2 diseases have been suggested in literature. The purpose of this study was to examine whether there’s an association between the 2 processes. Methods: A retrospective chart review was performed to include all patients seen by a single surgeon between 2014 and 2017 with the diagnosis of either trigger finger or Dupuytren’s contracture in the same hand. Patients’ demographics, medical history, social and surgical histories are recorded. Univariate and multivariate analysis were conducted. Results: A cohort of 238 patients was identified. One hundred ninety-two patients were diagnosed with trigger finger. Eighty-nine patients were diagnosed with Dupuytren’s contracture. Forty-three patients carried both diagnoses. Median age was 61.6 (56–72). Half were male (50.4%) and 66.8% reported current alcohol intake. Other factors include history of former or current tobacco use (52.9%), diabetes (23.9%), and manual labor (31.1%). In the univariate model, trigger finger, sex, and age were significantly associated with the diagnosis of Dupuytren’s contracture, and Dupuytren’s contracture and sex were significantly associated with the trigger finger diagnosis. Diabetes, manual labor, use of alcohol and tobacco were not significant. In the multivariate model, age and trigger finger were significantly associated with Dupuytren’s contracture. Conclusions: Significant association between stenosing tenosynovitis and Dupuytren’s contracture was identified in our patient cohort. Patients with stenosing tenosynovitis may be at an increased risk of developing Dupuytren’s contracture or vice versa.
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Chang CJ, Chang SP, Kao LT, Tai TW, Jou IM. A Meta-analysis of Corticosteroid Injection for Trigger Digits Among Patients With Diabetes. Orthopedics 2018; 41:e8-e14. [PMID: 28776635 DOI: 10.3928/01477447-20170727-02] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 04/17/2017] [Indexed: 02/03/2023]
Abstract
A majority of patients with diabetes have trigger digits. Initial management of symptomatic trigger digits commonly involves corticosteroid injection. However, varying outcomes have been reported for patients with diabetes who receive corticosteroid injections. The authors conducted a meta-analysis to evaluate the effect of diabetes on outcome after corticosteroid injection for trigger digit. PubMed and other Internet databases were searched for the period 1977 to 2015. Five articles, involving 381 diabetic digits and 449 non-diabetic digits, were included in the meta-analysis. The authors found treatment failure rates of 78% for patients with insulin-dependent diabetes, 47% for patients with non-insulin-dependent diabetes, and 49% for patients without diabetes when a single injection of corticosteroid was administered for trigger digit. After 3 injections, the failure rates were 57%, 39%, and 30%, respectively. The pooled data showed that patients with insulin-dependent diabetes and patients with non-insulin-dependent diabetes had worse prognoses after corticosteroid injection for trigger digit than patients without diabetes. Furthermore, the patients with insulin-dependent diabetes had a trend toward multiple digit involvement and much worse treatment outcomes than the patients with non-insulin-dependent diabetes. The authors conclude that more aggressive treatment, such as surgical intervention, should be considered for those patients expected to have high failure rates after injection. [Orthopedics. 2018; 41(1):e8-e14.].
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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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Hoang D, Lin AC, Essilfie A, Minneti M, Kuschner S, Carey J, Ghiassi A. Evaluation of Percutaneous First Annular Pulley Release: Efficacy and Complications in a Perfused Cadaveric Study. J Hand Surg Am 2016; 41:e165-73. [PMID: 27180952 DOI: 10.1016/j.jhsa.2016.04.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 03/29/2016] [Accepted: 04/13/2016] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Don Hoang
- Department of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Ann C Lin
- Department of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Anthony Essilfie
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Michael Minneti
- Department of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Stuart Kuschner
- Department of Hand Surgery, Cedars Sinai Medical Center, Los Angeles, CA
| | - Joseph Carey
- Department of Plastic and Reconstructive Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alidad Ghiassi
- Department of Orthopedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.
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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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Werthel JD, Cortez M, Elhassan B. Modified percutaneous trigger finger release. HAND SURGERY & REHABILITATION 2016; 35:179-182. [DOI: 10.1016/j.hansur.2016.02.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2015] [Revised: 01/29/2016] [Accepted: 02/18/2016] [Indexed: 11/30/2022]
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Abstract
Tendinopathies involving the hand and wrist are common. Many are diagnosed easily, and in many cases, the management is straightforward, provided the pathology and principles are understood. Common conditions involving the tendons of the hand and wrist include trigger finger, tenosynovitis of the first through sixth dorsal extensor compartments, and flexor carpi radialis tendonitis. Management strategies include nonsurgical treatments, such as splinting, injection, or therapy, and surgical techniques such as tendon release.
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16
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Chew WYC, Sreedharan S. Percutaneous Trigger Release in Non-Triggering Digits: Infiltration of Normal Saline into Tendon Substance to Induce Triggering. J Hand Microsurg 2015; 7:93-5. [PMID: 26078511 DOI: 10.1007/s12593-015-0170-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Accepted: 01/02/2015] [Indexed: 10/24/2022] Open
Abstract
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.
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Affiliation(s)
- Winston Yoon Chong Chew
- Hand and Microsurgery Section, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, Singapore
| | - Sechachalam Sreedharan
- Hand and Microsurgery Section, Department of Orthopaedic Surgery, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, Singapore
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17
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Orbach H, Wolovelsky A, Rinott M, Rubin G, Rozen N. Synovial Fistula as a Complication of Release of A1 Pulley for Trigger Finger. J Hand Microsurg 2015; 7:136-9. [PMID: 26078526 DOI: 10.1007/s12593-014-0121-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2013] [Accepted: 02/07/2014] [Indexed: 01/08/2023] Open
Affiliation(s)
- Hagay Orbach
- Orthopaedic Department, Ha'Emek Medical Center, Afula, Israel ; Kibuts Shluhot, Beit Shean Valley 10910 Israel
| | | | - Micha Rinott
- Orthopaedic Department, Ha'Emek Medical Center, Afula, Israel ; Faculty of Medicine, Technion, Haifa, Israel
| | - Guy Rubin
- Orthopaedic Department, Ha'Emek Medical Center, Afula, Israel ; Faculty of Medicine, Technion, Haifa, Israel
| | - Nimrod Rozen
- Orthopaedic Department, Ha'Emek Medical Center, Afula, Israel ; Faculty of Medicine, Technion, Haifa, Israel
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18
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Zhao JG, Kan SL, Zhao L, Wang ZL, Long L, Wang J, Liang CC. Percutaneous first annular pulley release for trigger digits: a systematic review and meta-analysis of current evidence. J Hand Surg Am 2014; 39:2192-202. [PMID: 25227600 DOI: 10.1016/j.jhsa.2014.07.044] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 07/22/2014] [Accepted: 07/23/2014] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the overall success rate and potential influencing factors within the current evidence for percutaneous first annular pulley release. METHODS We searched PubMed, EMBASE, and the Cochrane Library for all clinical studies of percutaneous release. The rates of successful procedure and complication were extracted and analyzed. We charted the overall success rate on a forest plot with 95% confidence intervals. Data of success rates were analyzed in 5- and 10-year intervals to determine whether the rate of success had increased chronologically. We then performed 3 subgroup analyses according to instrument type (needles vs knife blades), cortisone use (cortisone vs noncortisone), and sonography guidance (sonography vs non-sonography guidance). Pooled success rates were calculated in the subgroups and compared using chi-square test. RESULTS A total of 34 studies involving 2,114 percutaneous procedures were included in this systematic review and meta-analysis. The total success rate was 94%. There was a trend toward increasing number of publications in the past 20 years. We found a statistically significant trend showing that overall success rates had increased over time. Chi-square test revealed that percutaneous release with sonography guidance had a significantly higher success rate than non-sonography guidance. There were no significant differences in other subgroup analyses including instrument type and cortisone use. CONCLUSIONS Percutaneous release is an effective and safe procedure for the treatment of trigger digit. It has become progressively popular in recent years, with a trend toward increased overall success. Sonography might be a helpful tool for maximizing success. The success rates were not affected by instruments and cortisone use. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
- Jia-Guo Zhao
- Departments of Orthopaedic Surgery, Hand Surgery, Sports Medicine and Arthroscopic Surgery, Orthopaedic Radiology, and Orthopaedic Traumatology, Tianjin Hospital, Clinical College of Orthopaedic Surgery, Tianjin Medical University, Tianjin, China.
| | - Shi-Lian Kan
- Departments of Orthopaedic Surgery, Hand Surgery, Sports Medicine and Arthroscopic Surgery, Orthopaedic Radiology, and Orthopaedic Traumatology, Tianjin Hospital, Clinical College of Orthopaedic Surgery, Tianjin Medical University, Tianjin, China
| | - Li Zhao
- Departments of Orthopaedic Surgery, Hand Surgery, Sports Medicine and Arthroscopic Surgery, Orthopaedic Radiology, and Orthopaedic Traumatology, Tianjin Hospital, Clinical College of Orthopaedic Surgery, Tianjin Medical University, Tianjin, China
| | - Zeng-Liang Wang
- Departments of Orthopaedic Surgery, Hand Surgery, Sports Medicine and Arthroscopic Surgery, Orthopaedic Radiology, and Orthopaedic Traumatology, Tianjin Hospital, Clinical College of Orthopaedic Surgery, Tianjin Medical University, Tianjin, China
| | - Lei Long
- Departments of Orthopaedic Surgery, Hand Surgery, Sports Medicine and Arthroscopic Surgery, Orthopaedic Radiology, and Orthopaedic Traumatology, Tianjin Hospital, Clinical College of Orthopaedic Surgery, Tianjin Medical University, Tianjin, China
| | - Jia Wang
- Departments of Orthopaedic Surgery, Hand Surgery, Sports Medicine and Arthroscopic Surgery, Orthopaedic Radiology, and Orthopaedic Traumatology, Tianjin Hospital, Clinical College of Orthopaedic Surgery, Tianjin Medical University, Tianjin, China
| | - Cong-Cong Liang
- Departments of Orthopaedic Surgery, Hand Surgery, Sports Medicine and Arthroscopic Surgery, Orthopaedic Radiology, and Orthopaedic Traumatology, Tianjin Hospital, Clinical College of Orthopaedic Surgery, Tianjin Medical University, Tianjin, China
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19
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Sakai D. Commentary: Percutaneous release of the A1 pulley using a modified Kirschner wire: a cadaveric study. J Orthop Surg (Hong Kong) 2014; 22:141. [PMID: 25163941 DOI: 10.1177/230949901402200203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Daisuke Sakai
- Department of Orthopaedic Surgery, Tokai University School of Medicine, Japan
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20
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Fowler JR, Baratz ME. Percutaneous trigger finger release. J Hand Surg Am 2013; 38:2005-8. [PMID: 23643795 DOI: 10.1016/j.jhsa.2013.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Accepted: 03/03/2013] [Indexed: 02/02/2023]
Affiliation(s)
- John R Fowler
- Department of Orthopaedics, University of Pittsburgh; and Orthopaedic Specialists - University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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