COMPARISON OF THE SURGICAL OUTCOMES FOR TRIGGER FINGER AND TRIGGER THUMB: PRELIMINARY RESULTS

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.

Surgical Treatment for Trigger Thumb Using a Radial Approach

The anatomy of the thumb flexor pulley system and surrounding structures differs from the fingers. The hand's positioning during trigger thumb release is troublesome. Iatrogenic radial digital nerve injuries of the thumb following opened or percutaneous A1 pulley release have been reported. We present the radial approach using a transverse incision for surgical release of the trigger thumb. This surgical approach aimed to restore a familiar surgical hand position, prevent radial digital nerve injury and bowstringing of the flexor pollicis longus, and decrease postoperative pain to facilitate recovery of hand function.

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.

Prognostic factors related to recurrence of trigger finger after open surgical release in adults

INTRODUCTION

Recurrent trigger finger after surgery is one of the major adverse events. However, studies to identify factors associated with recurrence after open surgical release in adult trigger finger patients are still limited.

PURPOSE

To identify factors associated with recurrent trigger finger after open surgical release.

METHODS

This 12-year retrospective observational study included 723 patients with 841 trigger fingers who underwent open A1 pulley release. Patients were categorized into 2 groups: those with recurrent trigger finger after surgery and those without. Associations between potential predictors including age, sex, duration of symptoms, occupation status, active smoker status, number of steroid injections before surgery, and types of comorbidities and the outcome of interest, recurrence of trigger finger, were examined using univariable and multivariable analyses. The results are presented as hazard ratios (HR) with a 95% confidence interval (95% CI).

RESULTS

The recurrence rate after trigger finger release was 2.39% (20 of 841 fingers). After adjusting for confounders, more than 3 steroid injections before surgery and manual labor were the independent predictors of recurrent trigger finger (HR = 4.87, 95%CI = 1.06-22.35 and HR = 3.43, 95%CI = 1.15-10.23, respectively).

CONCLUSIONS

More than 3 steroid injections before surgery and manual labor increase the risk of recurrent trigger finger after an open A1 pulley release. There may be limited benefit in administering a fourth steroid injection.

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.

Clinical significance of proximal interphalangeal joint pain in patients with trigger fingers

We investigated incidence, clinical features and surgical outcomes of trigger finger accompanied by proximal interphalangeal joint pain. One-hundred and seventy-nine consecutive patients with trigger finger who had A1 pulley release were recruited. Forty-two patients (24%) complained of proximal interphalangeal joint pain at the time of surgery. Symptom duration was investigated, and tenderness at the proximal interphalangeal joint was palpated. Range of motion and pain score of the affected finger were measured pre- and post-operatively. Bone scan was performed to identify joint lesions. A comparison of the results between the proximal interphalangeal joint pain group and the non-proximal interphalangeal joint pain group shows that the proximal interphalangeal joint pain seemed to result from long symptom duration and consequent joint pathology. The proximal interphalangeal joint pain was incompletely resolved after A1 pulley release. Thus, the surgical outcomes might be worse than expected in spite of resolution of painful clicking, especially when there was additional joint tenderness on palpation. Level of evidence: IV.

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

PURPOSE

This study aimed to investigate the incidence and prognostic factors for prolonged postoperative symptoms after open A1 pulley release in patients with trigger finger, despite absence of any complications.

METHODS

We reviewed 109 patients (78 single-finger involvement, 31 multiple-finger involvement) who underwent open A1 pulley release for trigger finger from 2010 to 2016, with 8 weeks or longer postsurgical follow-up and without postoperative complications. The group had 16 men and 93 women, with mean age of 56 years (range, 21-81 years), and average follow-up period of 24.8 weeks (range, 8.0-127.4 weeks). Prolonged postoperative symptoms were defined as symptoms persisting for longer than 8 weeks after surgery. Factors analyzed for delay in recovery included duration of preoperative symptoms; number of preoperative local corticosteroid injections; preoperative flexion contracture of proximal interphalangeal (PIP) joint; multiplicity of trigger finger lesions; occupation; presence of type 2 diabetes mellitus, other hand disorders like carpal tunnel syndrome, de Quervain disease, or Dupuytren contracture; and fraying or partial tear of the flexor tendon.

RESULTS

Twenty-six fingers (19.3%) showed prolonged postoperative symptoms, with mean time until complete relief being 14.0 ± 6.4 weeks (range, 9-34 weeks). Risk factors associated with prolonged postoperative symptoms included duration of preoperative symptoms, preoperative flexion contracture of the PIP joint, and fraying or partial tear of the flexor tendon.

CONCLUSIONS

Physicians should consider the duration of preoperative symptoms and preoperative flexion contracture of the PIP joint when deciding timing of surgery for trigger finger patients. In addition, they should explain to patients with a positive history of these factors and in whom flexor tendon injury is found during surgery about the possibility of prolonged postoperative symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

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.

Biomechanical analyses of the human flexor tendon adhesion models in the hand: A cadaveric study

Patients with longstanding trigger finger may develop flexion contracture at the proximal interphalangeal (PIP) joint that persists even after division of the A1 pulley. The purpose of this study was to explore the hypothesis that flexion deformity of the PIP joint in advanced trigger finger is caused by severe adhesion between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Ten freshly frozen cadaveric hands were used in the experiments. After preparation of the extrinsic flexor, extrinsic extensor, and intrinsic muscle tendons, we applied weights to the flexor tendons and minimal tension to the extrinsic extensor and intrinsic muscle tendons. We then measured the initial flexion angles of the metacarpophalangeal (MCP) and PIP joints. Next, we measured the flexion angles of the MCP and PIP joints as increasing tension was applied to the extrinsic extensor and intrinsic muscle tendons, respectively. We repeated these experiments after constructing flexor tendon adhesion model. The initial flexion angles of the MCP and PIP joints were greater in the adhesion model, as were the average tensions required for full extension of these joints. Our results suggest that adhesion between two flexor tendons contributes to progression of flexion deformity in the PIP joint.

Finger movement function after ultrasound-guided percutaneous pulley release for trigger finger: effects of postoperative rehabilitation

OBJECTIVE

To develop and test a postoperative rehabilitation protocol for use by individuals with trigger finger undergoing ultrasound-guided percutaneous pulley release.

DESIGN

Nonrandomized controlled trial.

SETTING

Hospital and local community.

PARTICIPANTS

Individuals suffering from trigger finger with joint contracture (N=21) were recruited and grouped into an intervention group (n=9) or a control group (n=12).

INTERVENTIONS

All the participants underwent the same surgical procedure performed by the same surgeon. A 4-week postoperative rehabilitation program was designed based on the wound healing process. The intervention group received postoperative rehabilitation after the surgery, whereas the control group received no treatment after the surgery.

MAIN OUTCOME MEASURES

The finger movement functions were quantitatively evaluated before and 1 month after the surgery using a 3-dimensional motion capture system. The fingertip workspace and joint range of motion (ROM) were evaluated while the participant was performing a sequential 5-posture movement, including finger extension, intrinsic plus, straight fist, full fist, and hook fist.

RESULTS

The intervention group demonstrated significantly more improvements than the control group in the fingertip workspace (49% vs 17%), ROM of the distal interphalangeal (DIP) joint (16% vs 4%), ROM of the proximal interphalangeal (PIP) joint (21% vs 5%), and total active ROM (17% vs 5%).

CONCLUSIONS

This pilot study evaluated a postoperative rehabilitation protocol for trigger finger and demonstrated its effects on various finger functions. Participants who underwent the rehabilitation program had significantly more improvements in the fingertip workspace, ROM of the DIP and PIP joints, and total active ROM.

Sonographic analyses of pulley and flexor tendon in idiopathic trigger finger with interphalangeal joint contracture

This study investigated the sonographic appearance of the pulley and flexor tendon in idiopathic trigger finger in correlation with the contracture of the interphalangeal (IP) joint in the thumb or proximal IP (PIP) joint in the other digits. Sonographic measurements using axial images were performed in 177 affected digits including 17 thumbs and 34 other digits judged to have IP or PIP joint contracture and 77 contralateral control digits. The A1 pulley of the contracture group was significantly thicker than that of the non-contracture group in all digits, whereas the flexor tendon was thicker only in digits other than the thumb. In the analysis using calculated cut-off values, A1 pulley thickening in the thumb and A1 pulley and flexor tendon thickening in the other digits showed statistically significant correlations with IP or PIP joint contracture. This study sonographically confirmed previous reports showing that enlargement of the flexor tendons contribute to the pathogenesis of PIP joint contracture.

Resection of the flexor digitorum superficialis for trigger finger with proximal interphalangeal joint positional contracture

PURPOSE

Open release of the A1 pulley is a widely known procedure for the treatment of trigger finger. A subset of patients presents with both trigger finger and a positional contracture of the proximal interphalangeal (PIP) joint. These patients usually have a long history of trigger finger or have already undergone a surgical release of the annular pulley. This study is a retrospective review of the outcomes of resection of the flexor digitorum superficialis (FDS) for patients whose trigger finger was associated with a positional contracture of the PIP joint.

METHODS

Thirty-six patients (39 fingers) were treated by resection of the FDS after section of the A1 pulley. The mean age of the patients was 63 years (range, 45-90 y). Seven patients (19 %) had previously undergone an open release of the A1 pulley and had developed a positional contracture of the PIP joint 2 to 5 months afterward. We performed a retrospective review with a mean follow-up of 30 months (range, 12-60 mo). No patient was lost to follow-up. The active range of motion was recorded at the PIP joint before and after surgery.

RESULTS

The mean preoperative positional contracture of the PIP joint was 24° (range, 15°-30°). The mean postoperative positional contracture of the PIP joint was 4° (range, 0°-10°). The most commonly affected digit was the middle finger (26 fingers, 67%). In 28 fingers (72%), full extension was achieved following only the surgical procedure. The remaining 11 fingers (28%) had a postoperative residual positional contracture (range, 5°-10°). However, all fingers achieved a full range of motion after physical therapy and an injection of betamethasone. All of the resected tendons had histological damage.

CONCLUSIONS

This technique is a useful treatment for selected patients whose trigger finger is associated with a positional contracture.

Follow-up investigation of open trigger digit release

PURPOSE

The purpose of this retrospective study was to identify the postoperative complications and disorders associated with open trigger finger release. Factors that were investigated by this study included demographic details, the number of digits affected, BMI, level of manual strain, trauma, received systemic medication, hand dominance, pre-treatment with steroid injection, and concomitant diseases.

METHODS

One hundred and three patients, who underwent open release surgery for 117 trigger fingers and thumbs, were followed up until complete resolution of all complaints. Patients' age, BMI, hand dominance, occupational manual strain, and previous medical history regarding trigger finger or thumb were obtained. Associated conditions and medical treatment, trauma, and previous hand surgical interventions were included as well. Details regarding duration of complaints, ROM, visual analogue pain scale, swelling, recurrence of the disease following previous surgical release, and persistence of complaints following corticosteroid injection were examined.

RESULTS

The dominant hand was not significantly more frequently affected than the non-dominant hand. Occupation also did not influence the incidence of trigger digit. Patients with systemic steroid therapy had a significantly shorter duration of postoperative symptoms with a mean duration of 29.3 days (range, 28-31 days ± 1.3). Significantly less postoperative swelling was noticed in patients with a pre-surgical steroid injection. The mean duration of symptoms before and after surgery was significantly shorter for a trigger thumb than for trigger finger.

DISCUSSION

Open trigger digit release constitutes an adequate low-risk surgical procedure for treatment of trigger digit. In this study, we could show that the incidence of this disease is not significantly correlated with the manual strain, trauma, BMI, hand dominance or concomitant diseases like diabetes mellitus, rheumatoid arthritis, renal insufficiency, and hypothyroidism. Additionally, this study illustrates the importance of a careful postoperative follow-up treatment to avoid potential persistent functional limitations.

Sonographically guided intrasheath percutaneous release of the first annular pulley for trigger digits, part 1: clinical efficacy and safety

OBJECTIVES

For trigger digits, intrasheath sonographically guided first annular (A1) pulley release has shown safety and effectiveness in cadavers. This clinical study describes sonographically guided A1 pulley release results in terms of resolution of symptoms, safety, and functional recovery.

METHODS

Sonographically guided A1 pulley release (11-MHz probe) was used in 48 digits of 48 patients prospectively followed for 11.3 months and examined 1, 3, and 6 weeks, 3 and 6 months, and 1 year later. Resolution of triggering (primary variable of interest) was expressed as the "success rate" per digit. The time for taking postoperative pain killers, range of motion recovery, grip strength, QuickDASH test scores, return to normal activities (including work), cosmetic results, satisfaction, and complications were assessed.

RESULTS

The success rate was 100%, and no cases recurred. Mean times were 1.9 days for taking pain killers, 6.6 days for returning to normal activities, and 9.9 and 3.8 days for complete extension and flexion recovery, respectively. Mean QuickDASH scores were 39.8 preoperatively and 7.8, 1.7, and 0 after 6 weeks, 6 months, and 1 year postoperatively. Grip strength reached greater than 90% of the individual's normal strength by the sixth week in men and by the third month in women (P < .001). Radial digital nerve numbness developed in 1 finger, which disappeared by the third week. No other complications were noted. All wounds were cosmetically excellent, and final satisfaction was excellent or good in 98%.

CONCLUSIONS

With adequate anatomic knowledge, technical training, and a basic ultrasound machine, sonographically guided A1 pulley release can be performed safely and successfully, offering an alternative to classic open surgery in the ambulatory setting.

Percutaneous intrasheath ultrasonographically guided first annular pulley release: anatomic study of a new technique

OBJECTIVE

The purpose of this study was to define in volunteers a safe area for performing a percutaneous intrasheath first annular (A1) pulley release under ultrasonographic guidance in cadavers for the treatment of trigger fingers.

METHODS

First, in 100 fingers of 10 volunteers, we used Doppler ultrasonography to determine the limits of the sectors enclosing structures at risk (arteries and tendons). From the synovial sheath's most volar point, we determined the relative position of the arterial walls and the distance to the flexor tendons. A scatterplot overlay of the arterial positions was digitally analyzed for determining the limits of the safe area. Second, we released the A1 pulley in 46 fingers from 5 cadavers, directing the edge of the cutting device toward our safe area from an intrasheath instrument position. The precision, safety, and efficacy of the release were evaluated by surgical exposure of the A1 and A2 pulleys and the neurovascular bundles.

RESULTS

In our volunteers, we observed a volar safe area from +6.1° to +180°. Surgical precision was good in the cadavers, with no injuries to adjacent structures, a complete release in 44 fingers (95.7%), and an incomplete release of less than 1.6 mm in 2 fingers.

CONCLUSIONS

This study determined a safe volar area for aiming surgical instruments from an intrasheath position for percutaneous ultrasonographically guided A1 pulley release. The technique can be performed safely in all fingers, but we suggest being cautious in the thumb and converting the surgery to an open procedure if ultrasonographic visualization is not optimal.

Long-term results of surgical release of trigger finger and trigger thumb in adults

INTRODUCTION

Trigger finger and thumb are amongst the most common hand disabilities seen by orthopaedic surgeons. Surgical release of the first annular pulley (A1) is generally indicated when non-operative treatment fails. We present the long-term results of open operative treatment of trigger finger or trigger thumb in adults performed by a single surgeon.

METHOD

From July 1988 to 1998, 305 trigger fingers or thumbs in 276 consecutive patients were treated operatively, including 179 women and 97 men. The average age at operation time was 46.2 years.

RESULTS

Two hundred and ten (76%) of the operations were performed for a single trigger digit release, 76 (24%) for multiple trigger digits in individual patients. All operations were done under tourniquet control with local infiltration anaesthesia under outpatient conditions using a transverse incision just distal to the distal palmar crease or on the flexor crease of the thumb at the metacarpophalangeal joint. At latest follow-up after an average of 14.3 years (min: 10, max: 20) 234 patients could be evaluated and were out of complaints, there were no serious complications such as nerve transection or bowstringing or recurrencies.

CONCLUSION

We recommend open surgery of trigger finger and trigger thumb.

Kinematical and functional improvements of trigger digits after sonographically assisted percutaneous release of the A1 pulley

We present evidence of kinematic and functional improvements of the trigger digit after sonographically assisted percutaneous release using quantitative motion analyses and functional assessments, respectively. Twenty-two patients with idiopathic trigger digits, who received the surgery, were recruited. A motion tracking system was used to measure the assigned kinematics parameters at the presurgical visit and at 1, 4, and 12 weeks after surgery. The hand strength and functional outcome were also obtained using dynamometer and self-report questionnaire assessments. The hand strength, maximal workspace, and joint range of motion of the involved digit were significantly smaller than that of the intact finger on the contralateral hand before surgery. The triggering phenomenon of the involved digit was significantly higher than that of the corresponding finger in the intact hand using a subscribed angular acceleration factor. The repeated measures showed that the workspace, joint range of motion, hand strength, and triggering effect of the involved hand significantly improved in follow-up examinations after the surgical intervention. Painful movement or insufficient tendon excursion of the trigger digit can cause loss of movement and strength, thus interfering with functional performance. After the disappearance of the pain and triggering by sonographically assisted percutaneous release, improvements in kinematics and function were objectively quantified in this study.

[Aspects of finger mobility]

The movements of the finger, centrally induced and controlled via open or closed loops, need the simultaneous action of several muscles and muscle groups. In this way, rigid differentiation between antagonists and synergists is functionally abolished. Synchronous flexion and extension of a finger needs not only a palmar flexion and a dorsal extension motor system but also a third oblique running motor system. This is given by the interosseous-lumbricalis system. Opposition and repositioning of the thumb require muscle configuration other than that provided by the other fingers.

Outcome of open trigger digit release

This study was undertaken to review the outcome of open trigger digit release of 483 digits in 373 consecutive patients over a 1 year period. Parameters were obtained from case records. The patients were followed up for a minimum of 6 months postoperatively. The most commonly affected digits were the ring (42%) and middle (26%) fingers. Based on the classification by Wolfe [Tenosynovitis. In: Green DP (Ed). Operative hand surgery, 5th Edn. New York, Churchill Livingstone, 2005: 2137-2159], Grade II (51%) and III (33%) trigger digits accounted for majority of affected digits. Non-operative treatment was the first line modality for 82% of the patients. Primary surgical release (18% of patients) was performed for patients who had refractory conditions, grade IV triggering and those who requested this treatment. The overall complication rate was 1%. These included superficial wound dehiscence, extension lag and postoperative residual stiffness. There were no recurrences of triggering. Steroid injection is recommended as the first line treatment. Surgical release is recommended for refractory and severe triggering.

Corticosteroid injections in the treatment of trigger finger: a level I and II systematic review

Trigger finger is a tendinitis (stenosing tenosynovitis) with multiple management approaches. We conducted an evidence-based medicine systematic review of level I and II prospective randomized controlled trials to determine the effectiveness of corticosteroid injection in managing trigger finger. MEDLINE, Cochrane database, and secondary references were reviewed to locate all English-language prospective randomized controlled trials evaluating trigger finger treatment. Four studies using injectable corticosteroids were identified, based on the following inclusion criteria: all were prospective randomized controlled trials of adults with >85% follow-up. This review indicates that the incidence of trigger finger is greatest in women (75%), with an average patient age range of 52 to 62 years. Combined analysis of these four studies shows that corticosteroid injections are effective in 57% of patients.