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

Ultrasound-guided needle knife release for stenosing tenosynovitis of the flexor pollicis longus: a prospective randomized controlled trial

PURPOSE

This study aimed to evaluate the efficacy and safety of ultrasound-guided needle knife release in the treatment of stenosing tenosynovitis of the flexor pollicis longus.

METHODS

In this prospective trial, 60 patients with clinically and ultrasonographically confirmed stenosing tenosynovitis of the flexor pollicis longus were randomly allocated to 1 of 3 groups: ultrasound-guided needle knife release (n = 20), traditional conservative treatment (n = 20), and open surgery (n = 20). The primary outcome measure was the Quinnell grade of triggering severity. Secondary outcomes comprised pain intensity (on visual analog scale), satisfaction (5-point Likert scale), and complications. Outcomes were evaluated at baseline, 1 week, 1 month and 3 months post-intervention by blinded assessors.

RESULTS

At all follow-up time points, the needle knife release group demonstrated significantly lower Quinnell grades (p < 0.05) and pain scores (p < 0.001) than the conservative treatment group; satisfaction was greater in the needle knife release group compared to the conservative treatment group at 1 month (p = 0.002) and 3 months (p < 0.001). There were no significant differences in outcomes between the needle knife release group and the open surgery group. The overall complications rate was 5% in the needle knife release group, 10% in the conservative treatment group, and 15% in the open surgery group (p = 0.574).

CONCLUSION

Ultrasound-guided needle knife release is an effective and safe treatment for stenosing tenosynovitis of the flexor pollicis longus, with outcomes that are better than with traditional conservative treatment and similar to those of open surgery.

Percutaneous ultrasound-guided A1 pulley release utilizing a modified 20-gauge spinal needle

BACKGROUND

Trigger finger is a common cause of hand pain. Though multiple techniques for percutaneous A1 pulley release have been described in the literature, there is a continued need for safe and effective techniques using inexpensive, familiar, and commonly found instruments. This study evaluated outcomes of percutaneous A1 pulley release performed using a novel technique with a modified 20-gauge spinal needle and ultrasound guidance, with follow-up outcomes at least 6 months after the procedure.

OBJECTIVE

To evaluate the efficacy and safety of a novel percutaneous A1-pulley release technique in individuals with trigger finger.

DESIGN

Retrospective observational study.

SETTING

Private practice outpatient orthopedics clinic.

PARTICIPANTS

Forty digits from 30 unique patients with trigger finger who underwent percutaneous A1 pulley release.

INTERVENTIONS

Percutaneous ultrasound-guided A1 pulley release performed with a modified 20-gauge spinal needle.

MAIN OUTCOME MEASURES

The primary outcome measure was cessation of triggering. Secondary measures examined intraoperative and postoperative pain, postprocedural duration of activity limiting pain, and time to perform the procedure.

RESULTS

Immediate cessation of triggering was achieved in all 40 digits following the procedure, with no recurrence reported at any time at an average follow-up of 11 months (range 6-32). Patients reported returning to normal activity in 2.75 days. Only one minor complication was reported, tenosynovitis, which resolved with a corticosteroid injection.

CONCLUSIONS

Percutaneous, ultrasound-guided A1 pulley release performed with a modified 20-gauge spinal needle can be safely performed with good outcomes and a rapid return to normal activity.

Ultrasound-guided thread versus ultrasound-guided needle release of the A1 pulley: a cadaveric study

PURPOSE

To assess and compare two ultrasound-guided, minimally invasive procedures to release the A1-pulley (needle release and thread release) regarding efficacy and safety in an anatomical specimen model.

MATERIALS AND METHODS

Twenty-one ultrasound-guided needle releases and 20 ultrasound-guided thread releases were performed on digits of Thiel-embalmed anatomical specimens. A scoring system was developed to assess ultrasound visibility, intervention outcome (incomplete, almost complete, or full transection of the A1 pulley), and injury to adjacent structures (neurovascular structures, tendons, A2 pulley). Statistical analysis was performed to compare the score of the two groups (group 1: needle release,group 2: thread release). A P-value of ≤ 0.05 was considered significant.

RESULTS

Needle release was completely successful in 15 cases (71.5%), almost complete release was achieved in four cases (19%), and incomplete transection occurred in two cases (9.5%). Thread release was completely successful in 17 cases (85%), and almost complete transection was observed in the remaining three cases (15%). In both procedures no neurovascular structures were harmed. Slight injury of flexor tendons occurred in two cases (9.5%) in needle release and in five cases (25%) in thread release. There were no significant statistical differences between the groups regarding ultrasound visibility, intervention safety and outcome, (P > 0.05).

CONCLUSION

Ultrasound-guided needle release and ultrasound-guided thread release have similar success of release, both being effective and safe techniques for the release of the A1 pulley.

Percutaneous Surgery for Trigger Finger Treatment Using a Novel Surgical Device: An Experimental Study on Fresh Cadavers

Purpose

Trigger finger, a stenosing tenosynovitis of the flexor tendon at the A1 pulley, can cause pain and impair daily activities. Despite common surgical interventions, postsurgical complications are frequent, prompting the search for less invasive techniques.

Methods

An experimental study was conducted on fresh cadavers to compare three techniques: the first using a PulleyCut without ultrasound guidance, the second using a PulleyCut with ultrasound guidance, and the third using a percutaneous needle technique. The complete release of the A1 pulley, integrity of the A2 pulley, flexor tendons, and neurovascular bundles were assessed.

Results

The new device group and the ultrasound-guided group demonstrated 100% complete release of the A1 pulley, whereas the needle group achieved only 38% success. There were no A2 pulley injuries in any group. Flexor tendons were injured in 7% of cases in the new device group and 77% in the needle group. A neurovascular injury occurred in the needle group.

Conclusions

Compared with the percutaneous needle technique, the new device proved safe and effective for A1 pulley release, minimizing damage to flexor tendons and neurovascular structures. Ultrasound did not provide significant advantages, suggesting that the new device can be confidently used without ultrasound assistance. The PulleyCut represents a promising percutaneous technique for trigger finger treatment, demonstrating superiority over the needle technique in terms of efficacy and safety. These results encourage future clinical investigations to validate its practical application.

Type of study/level of evidence

Therapeutic IIc.

Serious Complications of the Percutaneous A1 Pulley Release: Case Reports and Literature Review

Percutaneous first annular pulley (A1 pulley) release, which has been increasingly used to treat trigger fingers, has been widely established as a safe and simple procedure. Multiple studies have reported positive results of percutaneous A1 pulley release. In this study, however, we report cases of patients who developed complications after undergoing percutaneous A1 pulley release at local clinics. A total of six patients visited our hospital for infectious complications after percutaneous A1 pulley release. Various sequelae such as damage to normal structures, insufficient procedure, and tissue necrosis were observed during the exploration. A retrospective study was conducted to identify the cause and trend of the observed complications by instruments (HAKI knife or needle). In the HAKI knife group, there was a tendency for damage to normal structures, while in the needle group, an insufficient release or serious soft tissue necrosis was observed. Based on these cases, our findings confirm the existence and characteristics of infectious complications following the percutaneous A1 pulley release. We further identify that the type of instrument used predicts the nature of complications. Thus, reliable and skilled performance of the procedure by experts is essential for safe treatment.

Ultrasound-guided percutaneous opening of the A1 pulley with surgical knife on anterograde versus retrograde approach: A comparative cadaver study (40 fingers)

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.

Sonographically controlled minimally-invasive A1 pulley release using a new guide instrument - a case series of 106 procedures in 64 patients

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.

Failure rates and analysis of risk factors for percutaneous A1 pulley release of trigger digits

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.

Ultrasound-Guided A1 Pulley Release Versus Classic Open Surgery for Trigger Digit: A Randomized Clinical Trial

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.

National Benchmarks for the Efficacy of Trigger Finger and the Risk Factors Associated With Failure

BACKGROUND

The purpose of this study was to compare the efficacy of single and multiple corticosteroid injections used for symptomatic trigger finger. The rates of subsequent injections and the rate of tendon sheath release are reported along with the identification of risk factors correlated with failure of injection.

METHODS

A retrospective review of a national healthcare database was conducted identifying patients with a diagnosis of trigger finger or thumb. Inclusion required a tendon sheath injection on the same day or within six weeks of diagnosis. Patient cohorts were further stratified based on treatment success and those requiring additional injections within 6 months or surgery within 1 year of initial diagnosis.

RESULTS

Thirty-one thousand seven hundred fifty-one patients met inclusion criteria and underwent an initial injection within the study period. The efficacy of initial, second, and third injection was 66.3%, 79.4%, and 79.6%, respectively. Of the patients who failed an injection, 9.4% had tendon sheath release after a primary injection, 23.1% had surgery after a second injection, and 30.4% had surgery after a third injection. Only obesity (OR 1.2; P < 0.0001) and concomitant diagnosis of carpal tunnel syndrome (OR 1.4; P < 0.0001) were found to be significant for injection failure on multivariate logistic regression analysis.

DISCUSSION

Overall corticosteroid injections were effective in greater than 65% of patients. This information may help guide treatment practice because there seems to be continued additional benefit to repeat corticosteroid injections after injection failure.

Percutaneous Sonographically Guided Release of Carpal Tunnel and Trigger Finger: Biomechanics, Clinical Results, Technical Developments

The interventional use of sonography is growing fast, and percutaneous sonographically guided release is more and more used as minimally invasive treatment of carpal tunnel syndrome as well as trigger finger digit. The benefits of these procedures seem promising in clinical studies, but biomechanical studies comparing these procedures with open classical surgery are scarce. Minimally invasive releases of carpal tunnel and trigger finger could limit the phenomenon of tendon bowstringing observed after open surgery. A new model is presented to compare the biomechanical effects of open and sono-guided carpal tunnel and trigger finger releases.

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

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Projection of the A1-Pulley of the Thumb onto Superficial Anatomical Landmarks: An Anatomical Study and a Useful Guide to Surgeons

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.

Endoscopic Retrograde Approach for Trigger Finger Release: A Cadaver Study

Trigger finger is one of the most common causes of disability and pain in the hand. Current surgical techniques for trigger finger release fall short in that they are performed blindly with trauma to, or require incision of, the palmar fascia, which can be a source of significant and long-lasting morbidity. Retrograde endoscopic release of the A1 pulley was performed through a single incision at the proximal digital crease in cadaveric specimens. The fingers were then dissected to assess for completeness of release and inspected for injury to nearby structures. Complete release of the A1 pulley was noted in 16 of 16 fingers. No significant injuries to the A2 pulley and flexor tendon were found, and no injuries to the digital nerves or vasculature occurred. The described technique, as demonstrated in cadaveric specimens, is a feasible alternative approach in the treatment of trigger finger. The technique allows complete visualization of A1 pulley release through a single palmar fascia sparing incision.

Ultrasound-Guided Microinvasive Trigger Finger Release Technique Combined With Three Tests to Confirm a Complete Release

OBJECTIVE

Trigger finger at the A1 pulley is a common cause of hand pain leading to functional limitations. This study evaluated the outcomes of patients treated with a microinvasive ultrasound-guided trigger finger release technique using an 18 blade and described three tests that confirm a complete release.

DESIGN

A retrospective chart review and cross-sectional study of 46 cases of A1 pulley trigger finger releases in 28 patients performed at a private, sports medicine clinic using this technique were completed, meeting power criteria. The primary outcome measure was the resolution of mechanical catching/locking; secondary outcome measures were reduction in visual analog scale for pain and improvement of function in the modified Nirschl scale.

RESULTS

Complete release was achieved in all patients, with no recurrence of catching/locking during the first year (P < 0.0001). Ninety-eight percent of patients had significant pain and functional improvement (P < 0.0001). There were no complications perioperatively and postoperatively. The three confirmatory tests ensured that all cases obtained a successful outcome.

CONCLUSION

This technique combined with confirmatory tests resulted in full resolution of the locking for all patients and statistically significant reduction in pain and improvement in function.

The Use of a Novel Perfusion-Based Human Cadaveric Model for Simulation of Dural Venous Sinus Injury and Repair

BACKGROUND

Dural sinus injuries are potentially serious complications associated with acute blood loss. It is imperative that neurosurgery trainees are able to recognize and manage this challenging scenario.

OBJECTIVE

To assess the feasibility of a novel perfusion-based cadaveric simulation model to provide the fundamentals of dural sinus repair to neurosurgical trainees.

METHODS

A total of 10 perfusion-based human cadaveric models underwent superior sagittal sinus (SSS) laceration. Neurosurgery residents were instructed to achieve hemostasis by any method in the first trial and then repeated the trial after watching the instructional dural flap technique video. Trials were timed until hemostasis and control of the region of injury was achieved. Pre- and post-trial questionnaires were administered to assess trainee confidence levels.

RESULTS

The high-flow extravasation of the perfusion-based cadaveric model mimicked similar conditions and challenges encountered during acute SSS injury. Mean ± standard deviation time to hemostasis was 341.3 ± 65 s in the first trial and 196.9 ± 41.8 s in the second trial (P < .0001). Mean trainee improvement time was 144.4 s (42.3%). Of the least-experienced trainees with longest repair times in the initial trial, a mean improvement time of 188.3 s (44.8%) was recorded. All participants reported increased confidence on post-trial questionnaires following the simulation (median pretrial confidence of 2 vs post-trial confidence of 4, P = .002).

CONCLUSION

A perfusion-based human cadaveric model accurately simulates acute dural venous sinus injury, affording neurosurgical trainees the opportunity to hone management skills in a simulated and realistic environment.

Comparison of the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the A1 pulley in treating trigger finger

OBJECTIVE

To compare the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the A1 pulley in treating trigger finger.

METHODS

A total of 60 patients with trigger finger were enrolled in this retrospective study. Among them, 30 patients were treated with ultrasound-guided needle release of the A1 pulley with corticosteroid injection (group A) and 30 patients were treated with single ultrasound-guided corticosteroids injection (group B). The following parameters were evaluated including clinical parameters (pain degree, function of joint, finger tendon function, postoperative satisfaction), and ultrasound parameter (thickness of A1 pulley).

RESULTS

The postoperative visual analogue scale (VAS) and Quinnell scores in two groups were significantly lower than that before operation (p < 0.05). The postoperative Quinnell score of group A was significantly lower than that in group B (p < 0.05). The TAM results showed that the postoperative overall excellent and good rate of group A was significantly higher than that in group B (p < 0.05). The postoperative survey showed that more than 80% patients reported satisfaction in the two groups. The ultrasound imaging results showed that the postoperative thickness of A1 pulley in two groups were thinner than that before operation (p < 0.05). There were no adverse effects and complications in the two groups.

CONCLUSIONS

Both approaches had treatment benefit in trigger finger. Ultrasound-guided needle release of the A1 pulley with corticosteroid injection had better treatment benefits than single ultrasound-guided corticosteroids injection in improving finger tendon function and joint function.

A Critical Appraisal of Adult Trigger Finger: Pathophysiology, Treatment, and Future Outlook

Trigger finger (TF) is a common referral to a hand surgeon, with people with diabetess being the most at-risk population. Abnormal thickening, scarring, and inflammation occur at the A1 pulley and flexor tendon, and histological changes correlate well with the clinical severity of TF. Corticosteroid injections decrease the thickness of the A1 pulley and are considered a first-line treatment. However, corticosteroids are only moderately effective, especially for people with diabetes. Patients may elect for surgery if nonoperative treatments prove ineffective; some may choose immediate surgical release instead. To release the A1 pulley, patients have the option of an open or percutaneous approach. The open approach has a greater risk of infection and scar tissue formation in the short run but an overall superior long-term outcome compared with the percutaneous approach.

METHODS

We critically reviewed the efficacy and cost-effectiveness of the treatment methods for TF through a comprehensive search of the PubMed Database from 2003 to 2019.

RESULTS

To reduce costs, while still delivering the best possible care, it is critical to consider the likelihood of success for each treatment method in each subpopulation. Furthermore, some patients may need to return to work promptly, which ultimately may influence their desired treatment method.

CONCLUSIONS

Currently, there is no universal treatment algorithm for TF. From a purely financial standpoint, women without diabetes presenting with a single triggering thumb should attempt 2 corticosteroid trials before percutaneous release. It is the most cost-effective for all other subpopulations to elect for immediate percutaneous release.

Ultrasound-Guided Percutaneous Release of A1 Pulley by Using a Needle Knife: A Prospective Study of 41 Cases

Objective: The purpose of this study was to evaluate the efficacy of ultrasonography-guided percutaneous A1 pulley release with the needle knife for trigger finger. Methods: The prospective study included 21 patients (21 fingers) who underwent blind release with the needle knife and 20 patients (20 fingers) who underwent ultrasonography-guided release with the needle knife. The thickness and width of A1 pulley, clinical grade before and after release, complications, and operation time were compared between the groups. Results: The results showed that the ultrasonography-guided group had significantly better grade postoperatively and reached to 100% complete release in one time compared to the blind group (p < 0.05). Moreover, no any complications had been happened in the ultrasonography-guided group. A relatively longer operation time of the ultrasonography-guided group was observed compared to the time of the blind group. Conclusions: The needle knife is a very good tool for release of triggering fingers. Ultrasound provides a direct and precise visualization of the thickness, width and location of A1 pulley lesion. The combined use of ultrasound and the needle knife can achieve the best result for trigger finger. Moreover, the combination changes the traditional opinion and operator-dependent mode that were once widely adopted in the hospital of Chinese Medicine.

Identification of the location of the A1 pulley combining palpation technique with palm landmarks and percutaneous release of A1 pulley with a 19-gauge needle: A cadaveric study

The aims of this study were to identify the location of the A1 pulley combining palpation technique with superficial palm landmarks and to determine the efficacy and safety of A1 pulley percutaneous release with a 19-gauge needle. Fourteen fresh frozen cadaveric specimens were used: 56 fingers and 14 thumbs. The location of the A1 pulley was based on anatomical landmarks and was identified in all digits. Complete release of the A1 pulley occurred in 60 of the 70 digits (85.7%). The length of the A1 pulley in thumbs was 5.7 mm and in other fingers 4.5 mm. There were no signs of neurovascular bundle injuries. The mean distance between needle pathway and neurovascular bundle was 4.3 mm in the thumbs and 6.5 mm in the other fingers. There were no total flexor tendon injuries. The location of the A1 pulley can be predicted with success. Percutaneous release of the A1 pulley with a 19-gauge needle shows acceptable results in both safety and efficacy.

A Meta-analysis of Corticosteroid Injection for Trigger Digits Among Patients With Diabetes

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.].

Outcomes of percutaneous trigger finger release with concurrent steroid injection

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