Factors Causing Prolonged Postoperative Symptoms Despite Absence of Complications After A1 Pulley Release for Trigger Finger

Surgical treatment of trigger finger: a comparative study of A1 pulley opening versus ulnar superficialis slip resection

Trigger finger is a common condition. Surgery most frequently involves opening the A0 and A1 pulleys. However, this shows limited effectiveness in correcting proximal interphalangeal joint fixed flexion deformity. The present study aimed to compare clinical outcomes between two surgical techniques for trigger finger treatment. This retrospective study included 127 patients, 72 of whom underwent resection of the ulnar slip of the flexor superficialis, and 55 underwent opening of the pulleys. Study data comprised patient characteristics, range of motion, proximal interphalangeal fixed flexion deformity measurement, Quick-DASH and PRWE scores, and overall satisfaction. There were no significant differences between the two groups in terms of Quick-DASH or PRWE scores. Fixed flexion deformity correction was slightly but not significantly better with resection of the ulnar slip of the flexor superficialis (100%) compared to opening of the pulleys (88%). LEVEL OF EVIDENCE: : Level IV.

Isolated A1 pulley release surgery for trigger finger leads to significant increase in tip-to-tip pinch strength

BACKGROUND

Even in the first application of patients with early complaints of trigger finger, pinch strength of the hand may be affected. Therefore, it is difficult to assess the change of strength as a result of treatment in this problem. In this study, we aimed to evaluate the change of strength taking into account both measured and expected pinch strengths before and after A1 pulley release surgery.

METHODS

Thirty fingers (9 thumbs, 12 middle, 8 ring and 1 index fingers) of 26 patients (17 women, 9 men) who underwent A1 pulley release were included into this study. The mean age of the patients was 53 (16-71). Tip-to-tip finger pinch strengths were measured pre-operatively and at 3 months postoperatively. The expected strengths were calculated using the values obtained from the healthy side and taking into account the dominance effect. In the analysis, pre-operative and postoperative measured strength/expected strength ratios were compared.

RESULTS

The mean of measured pinch strength/expected pinch strength ratio was 0.91 ± 0.3 pre-operatively and 1.14 ± 0.3 postoperatively (p < 0.05).

CONCLUSION

With the calculation method used in this study, it was found that there was a significant increase in the tip-to-tip pinch strength after surgical A1 pulley release for the trigger finger.

LEVEL OF EVIDENCE

III (Retrospective cohort study).

Comparative Study of A1 Pulley Release and Ulnar Superficialis Slip Resection in Trigger Finger With Flexion Contracture of the Proximal Interphalangeal Joint

PURPOSE

The purpose of this study was to compare the clinical outcomes of A1 pulley release with ulnar superficialis slip resection (group A) and simple A1 pulley release (group B) in trigger finger with flexion contracture of the proximal interphalangeal (PIP) joint.

METHODS

From January 2016 to December 2019, the 2 surgical procedures were performed alternately every year for trigger fingers with preoperative PIP joint flexion contractures of ≥10°. Twenty-six fingers in group A and 29 fingers in group B that were followed up for >1 year were reviewed in this retrospective study. The visual analog scale (VAS) score; Disabilities of the Arm, Shoulder, and Hand (DASH) score; degree of PIP joint flexion contracture; grip strength; and pinch strength were measured after surgery and compared.

RESULTS

The differences in postoperative PIP joint flexion contracture between groups were <4° at 2 and 6 weeks, and there were no clinically relevant differences at 6 weeks and 12 months. At the final follow-up, PIP joint flexion contractures of 5° were observed in 2 fingers in each group. The difference in VAS scores between groups was less than half of a point until 3 months, and there were no clinically relevant differences at 6 weeks and 12 months. The DASH score did not show any difference between groups at the final follow-up. There were clinically relevant differences in the grip and pinch strengths between groups at 6 weeks. However, there were no clinically relevant differences at the final follow-up.

CONCLUSIONS

Proximal interphalangeal joint flexion contracture measurements and clinical scores did not differ between groups at the final follow-up. Therefore, we recommend use of a simple A1 pulley release, which is simpler than an A1 pulley release with ulnar superficialis slip resection, in cases of trigger finger with PIP joint flexion contracture.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.

The management of trigger fingers: commentary and personal opinion

Trigger fingers are common. Although the options for management are well-described, including conservative measures such as steroid injection, or surgical options such as open or percutaneous release, there remains variations in the way these are administered. In addition, there is a recent emphasis on patient-reported outcome measures in this condition. The purpose of this further knowledge article is to look at three recently published articles to gather some evidence about best practice in the management of this painful but common condition.

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.

Treatment of advanced trigger finger by ulnar superficialis slip resection: Long-term outcome and predictive factors for poor prognosis

The aim of this study was to evaluate the outcome of ulnar superficialis slip resection and to determine predictive factors for poor prognosis in patients with advanced trigger finger. Over a 5-year-period, 55 patients (58 fingers) were included. After surgery, two groups were identified: group 1, with complete extension or <10° extension deficit in the proximal interphalangeal (PIP) joint (n = 27 fingers/27 patients); and group 2, with ≥10° residual PIP extension deficit (n = 31 fingers/28 patients). Factors associated with PIP extension deficit were assessed on logistic regression. There was a median extension gain of 20° (range, 10-30°) after surgery. The difference between pre- and post-operative extension deficits was significant (p < 0.001). There was no significant inter-group difference in DASH score (p > 0.9). Two predictive factors were found: >12 months' preoperative symptom duration (OR = 1.02; p = 0.045), and lack of self-rehabilitation (OR = 20; p < 0.001). Ulnar superficialis slip resection was effective in advanced trigger finger. Hand surgeons should operate early on these patients, and encourage self-rehabilitation. LEVEL OF EVIDENCE: 4.

Dorsal proximal interphalangeal joint tenderness is associated with prolonged postoperative pain after A1 pulley release for trigger fingers

BACKGROUND

In some trigger finger patients, tenderness is found in the dorsal proximal interphalangeal (PIP) joint. The etiology and prevalence of this condition are unclear. Furthermore, surgical outcomes for trigger fingers with coexisting dorsal PIP tenderness have not been reported. This study (1) determined the prevalence and risk factors for PIP joint tenderness in trigger fingers and (2) compared postoperative outcomes for trigger fingers with and without joint tenderness.

METHODS

This prospective cohort study was conducted between August 2018 and March 2020. We enrolled 190 patients diagnosed with single-digit trigger fingers undergoing open A1 pulley release. The incidence, demographic data, and surgical outcomes of patients with dorsal PIP tenderness were investigated. Factors associated with tenderness were analyzed, including patient occupation, finger involvement, trigger finger grading, duration of symptoms, previous corticosteroid injections, and presence of diabetes mellitus. A numeric pain scale, a patient-specific functional scale, and the range of motion were evaluated preoperatively and 1, 2, and 6 weeks after surgery, with telephone follow-ups at 3 and 6 months.

RESULTS

Of 190 patients, 46.8% had tenderness of the dorsal PIP joint. Patients with joint tenderness had significantly more overall postoperative pain for up to 6 weeks and reported residual minor pain for up to 3 months. The functional scale and range of motion of the 2 groups did not differ during follow-up. The only risk factor observed was the occupation of the patients.

CONCLUSION

Dorsal PIP tenderness is more common in trigger fingers than previously thought. It is also associated with higher and prolonged levels of postoperative pain after A1 pulley release. Therefore, patients with pre-existing PIP tenderness should be informed about the possibility of sustaining residual minor pain for up to 3 months after surgery.

LEVEL OF EVIDENCE

II.

Factors associated with self-reported pain and hand function following surgical A1 pulley release

Surgical A1 pulley release can considerably reduce pain and improve hand function, but individual outcomes are highly variable. This study aimed to identify factors contributing to self-reported pain and hand function 3 months postoperatively. We included 2681 patients who had received surgical treatment for a trigger finger or thumb and who completed the Michigan Hand outcomes Questionnaire (MHQ). Hierarchical linear regression models were used to investigate patient and clinical characteristics associated with postoperative pain and hand function. For both pain and hand function, the most influential factors associated with worse outcomes were worse MHQ scores at baseline (β 0.38 and 0.33, respectively) and ≥3 preoperative steroid injections (β -0.36 and -0.35). These factors indicated that patients with severe preoperative symptoms represent a group with a more advanced disease that is more difficult to treat. These findings can assist clinicians in patient counselling, expectation management and decision-making about the timing of the intervention.Level of evidence: II.

Current Concepts in the Management of Advanced Trigger Finger: A Critical Analysis Review

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While the majority of patients with trigger finger obtain excellent outcomes from nonoperative treatment or release of the A1 pulley, a subset of patients with advanced trigger finger, defined as trigger finger with loss of active or passive range of motion, may have incomplete symptom relief and warrant specific attention.

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Advanced trigger finger is more refractory to complete symptom resolution from corticosteroid injection, and particular attention should be paid to incomplete improvement of flexion contractures.

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Unlike simple trigger finger, the pathology in advanced trigger finger involves not only the A1 pulley but also the flexor tendon, including thickening and degeneration.

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Progression toward surgical intervention should not be delayed when nonoperative measures fail, and specific attention should be paid to persistent inability to achieve full extension following A1 pulley release.

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Facing substantial residual flexion contracture, reduction flexor tenoplasty and partial or complete resection of the superficialis tendon followed by hand therapy and splinting may be needed to allow patients to regain reliable full range of motion.

Multi-site evaluation of advanced practice hand therapy clinics for the management of patients with trigger digit

STUDY DESIGN

Prospective cohort design.

BACKGROUND

Patient time on Australian public hospital surgical outpatient department (SOPD) waitlists often exceeds clinical recommendations for chronic hand conditions. Diversion to allied health is an alternative option, however evidence regarding patient and organizational outcomes in hand therapy is lacking.

PURPOSE OF THE STUDY

To evaluate clinical and organizational efficacy, patient outcomes and satisfaction of diversion of referrals for patients with trigger digit (TD) from SOPD waitlists to Advanced Practice Hand Therapy (APHT) at 3 Australian hospitals.

METHODS

Data was collected from eligible patients with TD through chart reviews and telephone satisfaction surveys. Data included number of patients requiring SOPD review, repeat referral to SOPD in the 12 months following APHT discharge, patient-rated outcomes, satisfaction scores, wait times to SOPD review and conversion to surgery-rates. Mann Whitney-U, t-test, Pearson's chi-squared test and a Binary Logistic Regression analysis were performed.

RESULTS

104 patients completed APHT treatment. Seventy patients (67%) did not require return to the SOPD waitlist. Repeat referral to SOPD within 12 months of APHT discharge occurred for only 1 patient. Patients requiring SOPD review after APHT treatment were seen within target time frames and demonstrated 88% conversion to surgery-rates. Michigan Hand Outcome Questionnaire scores showed greater improvement in those not requiring SOPD review (P< .001~25.9 vs 4.2). Regression analysis identified a negative association between initial total Michigan Hand Outcome Questionnaire scores and unfavorable discharge outcomes (OR 0.96, P= .007). Most (81%-93%) patients indicated satisfaction with the APHT service.

CONCLUSION

Diversion of referrals for TD from SOPD to APHT is an effective waitlist management strategy, with the propensity to reduce waiting times, improve patient flow, whilst resulting in favorable clinical and patient-rated outcomes and satisfaction.

Current Concepts in the Management of Trigger Finger in Adults

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.

Pain Catastrophizing Scale as a predictor of low postoperative satisfaction after hand surgery

Background

Psychological measures are used increasingly in outcome studies. The Pain Catastrophizing Scale is a 13-item questionnaire used to measure coping skills and negative feelings of pain. In the existing literature it is suggested that the Pain Catastrophizing Scale could be associated with the outcome following surgery. The aim of this study was to examine the effect of catastrophic thinking on postoperative satisfaction after treatment for hand conditions where pain is not the predominant symptom (Dupuytren's disease, trigger finger and wrist ganglia), and further to estimate cut-points on the Pain Catastrophizing Scale.

Methods

A total of 413 patients (53% females) with a mean age of 59 years were included in this one-year prospective follow-up study. The patients were diagnosed with either Dupuytren's disease (N = 133), trigger finger (N = 365), or wrist ganglia (N = 147). Preoperative data included disability (Disability of the Arm, Shoulder and Hand questionnaire (DASH)), quality of life (EuroQol-5D (EQ-5D)), and pain catastrophizing (Pain Catastrophizing Scale (PCS)). One year postoperative, data on DASH score, EQ-5D, and patient satisfaction were collected. We used a classification tree to define the most important cut-points, which could classify patients as low-risk or high-risk of low postoperative satisfaction. These cut-points and the 75th percentile cut-point was then used in logistic regression models with postoperative satisfaction as outcome variable.

Results

The median DASH score improved from 13.5 to 2.6 (p < 0.01), and the median EQ-5D score improved from 0.82 to 1.00, and 90.3% of patients were satisfied or very satisfied with the surgery.Using the 75th percentile (≤12) we did not find a predictive effect of PCS. However, when using the two cut-points from the classification tree (≤27.5 & ≤2.9) all tested models were statistically significant with odds ratios for risk of low satisfaction ranging from 2.81 to 6.44. Only the model using PCS ≤27.5 adjusted for both demographics and disability was insignificant.

Conclusion

This study suggests that PCS can be a valuable tool in predicting postoperative satisfaction in hand conditions where pain is not the predominant symptom, and that ≤27.5 and ≤ 2.9 are the optimal cut-point on the preoperative PCS.