Open versus percutaneous release for the treatment of trigger thumb

Open Versus Percutaneous Fixation of Trigger Finger: Meta-Analysis of Clinical Outcomes

PURPOSE

With variable and conflicting results to date, it remains unclear whether the percutaneous or open surgical A1 pulley release technique is superior regarding safety and efficacy. The goal of this meta-analysis was to compare the two techniques.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched through August 2023. Eight randomized controlled trials met the inclusion criteria and were included in this meta-analysis.

RESULTS

Of the eight included studies and 548 total patients, there were 278 subjects in the percutaneous release group and 270 subjects in the open release group. There was no significant difference between the two surgical techniques in postoperative rates of revision, complications, or pain.

CONCLUSIONS

This meta-analysis found no significant difference between open and percutaneous techniques regarding the need for revision procedures, complications, or postoperative pain. Therefore, both open and percutaneous releases are appropriate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

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.

Ultrasound-Guided A1 Pulley Release: A Systematic Review

The purpose of this review was to summarize the current literature pertaining to ultrasound-guided percutaneous A1 pulley release procedures. We searched PubMed, Cochrane Library, Embase, and Web of Science for clinical studies examining ultrasound-guided percutaneous A1 pulley release. A total of 17 studies involving 749 procedures were included in this review. The overall success rate was 97%. There were 23 minor complications (4 cases of hematomas, 15 cases of persistent pain, and 4 cases of transient numbness) and no major complications reported. Ultrasound-guided A1 pulley release is an effective and safe procedure for the treatment of trigger fingers and thumb.

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.

Modified Acupotomy versus Percutaneous Release for Trigger Thumb: A Retrospective Study

Background

Acupotomy is now increasingly used for trigger thumb, while recent evidence showed it increased the risk of nerve injury. Based on the close proximity of the neurovascular bundles and the A1 pulley, we designed a modified acupotomy. Given that percutaneous release is the common surgical treatment, this retrospective study aimed to compare the effect and safety of modified acupotomy versus percutaneous release for trigger thumb.

Methods

This is a retrospective study. All patients with trigger thumb were retrieved in the electronic records of the Department of Pain Medicine at the Beijing Hospital of Traditional Chinese Medicine from January 2016 to September 2018. Both short-term (3 months) and long-term (2 years) outcomes were evaluated using the criteria established through Gilberts et al.’s questionnaire, including triggering, residual pain, stiffness, digital nerve injury, scar, infection and satisfaction. Chi-square test or Fisher’s exact test was used to compare differences between two groups.

Results

A total of 305 patients with 334 trigger thumbs treated with either modified acupotomy (n = 194 thumbs) or percutaneous release (n = 140 thumbs) were included. Of them, 221 (72.5%) were female, and the mean age was 56.2 ± 10.0 years. The mean duration of trigger thumb lasted for 7.5 ± 3.6 months. At 3 months, all triggering were alleviated by both therapies. Although more digital nerve injury occurred in the percutaneous release (0 [0%] thumbs vs 5 [3.6%] thumbs, P = 0.012), more residual pain (30 [15.5%] thumbs vs 6 [4.3%] thumbs; rate ratio, 3.61; 95% confidence interval [CI]: 1.54–8.43; P = 0.001) and less satisfaction occurred in the modified acupotomy group. At 2 years, more recurrent triggering, residual pain and digital nerve injury occurred in the percutaneous release group (2 [1.0%] thumbs vs 12 [8.6%] thumbs; rate ratio, 0.12; 95% CI: 0.03–0.53; P = 0.001; 9 [4.6%] thumbs vs 22 [15.7%] thumbs; rate ratio, 0.30; 95% CI: 0.14–0.62 P < 0.001; 0 [0%] thumbs vs 4 [2.9%] thumbs, P = 0.030, respectively). Moreover, satisfaction was significantly better in the modified acupotomy group.

Conclusion

The modified acupotomy had better long-term outcomes and satisfaction than the percutaneous release for trigger thumb, although percutaneous release has less residual pain and better satisfaction in the short term. The modified acupotomy is a treatment option for trigger thumb.

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.

Assessment of short-term response and review of technique of ultrasound-guided percutaneous A1 pulley release for the treatment of trigger finger

INTRODUCTION

Ultrasound-guided percutaneous first annular pulley (A1) release is a non-surgical management for the treatment of trigger finger, also known as stenosing tenosynovitis. Trigger finger occurs secondary to inflammation and retinacular sheath hypertrophy with subsequent restriction of the flexor tendons. Trigger finger can have a marked functional impact, with current conservative measures including steroids and/or splinting, and surgical therapy involving open release.

METHODS

A population of 20 adult patients with ultrasound proven trigger finger underwent percutaneous release with refined technique. Patients with additional ultrasound proven tenosynovitis received steroid injection.

RESULTS

Of the 20 cases, 18 cases involved the fingers, 2 cases involved the thumb and 14 cases had additional tenosynovitis. All procedures involving the fingers were well tolerated with initial symptomatic and functional relief. At 1-week post-intervention, 2 finger cases without concurrent steroid injection represented with pain but not triggering. Cases which did not receive concurrent steroid injection described post-procedural pain requiring oral analgesia. One case involving the thumb was complicated by no relief with a mild radial digital nerve neuropraxia, with near complete resolution at 6 weeks. The second thumb case reported only partial relief of triggering.

CONCLUSION

US-guided percutaneous release of the A1 pulley is an effective procedure in achieving at least short-term resolution of trigger finger. It is best reserved for fingers due to the challenging anatomy of the thumb.

Minimally invasive thread trigger digit release: a preliminary report on 34 digits of the adult hands

The trigger finger release was performed in 34 digits (11 thumbs and 23 fingers) of 24 patients through the thread transecting technique with the tip-to-tip approach, in which a 22-gauge needle inserts into a 18-gauge needle when both needles are inside the hand, guiding the 22-gauge needle to exit the hand at the same access point of 18-gauge needle. We prospectively evaluated the effectiveness and functional recovery of these patients. In all 34 digits, triggering and locking were resolved, and complete extension and flexion occurred immediately following the release. There were no complications, such as incomplete release, neurovascular or flexor tendon or A2 pulley injury, infection, or tendon bow-stringing. Patients did not require prescription pain medications. Most patients used their hands to meet their basic living needs the same day of the procedure. The hand function evaluated with the Quick Disabilities of the Arm, Shoulder and Hand questionnaire, and scored 4 within 3 months. Level of evidence: II.

Does Bowstringing Affect Hand Function in Patients Treated With A1 Pulley Release for Trigger Fingers?: Comparison Between Percutaneous Versus Open Technique

We aimed to inspect bowstringing after percutaneous and open release of the A1 pulley for trigger digits and its influence on hand function. Sixty-two patients with a resistant trigger digit were randomized to undergo either open release or percutaneous release of the A1 pulley. We quantified bowstringing of the digit using ultrasonography preoperatively and at 12 and 24 weeks after surgery. Pain on a visual analog scale; Disabilities of the Arm, Shoulder, and Hand questionnaire; pinch power; and grip strength were assessed. Bowstringing was significantly increased at 12 weeks after surgery in both groups, and the mean value of the open release group was significantly greater than that of the percutaneous group (2.30 ± 0.58 mm vs 1.46 ± 0.51 mm, respectively; P = 0.035). However, the bowstringing was decreased at 24 weeks without showing significant difference between the 2 groups. The clinical outcomes of each cohort improved significantly, with no difference between the groups at final follow-up. No association was found between bowstringing and any clinical outcome measure. Bowstringing occurred by A1 pulley release with either the percutaneous or open technique does not affect clinical hand function in patients with trigger fingers.

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 Cadaveric Study of the Thread Trigger Finger Release: The First Annular Pulley Transection Through Thread Transecting Technique

BACKGROUND

After the thread transecting technique was successfully applied for the thread carpal tunnel release, we researched using the same technique in the thread trigger finger release (TTFR). This study was designed to test the operational feasibility of the TTFR on cadavers and verify the limits of division on the first annular (A1) pulley to ensure a complete trigger finger release with minimal iatrogenic injuries.

METHODS

The procedure of TTFR was performed on 14 fingers and 4 thumbs of 4 unembalmed cadaveric hands. After the procedures, all fingers and thumbs were dissected and visually assessed.

RESULTS

All of the digits and thumbs demonstrated a complete A1 pulley release. There was no injury to the neurovascular bundle (radial digital nerve in case of thumb), flexor tendon, or A2 pulley for each case.

CONCLUSIONS

The cadaveric study showed that the technique of TTFR was safe and effective, and the future clinical study is necessary to verify the findings of this study.

Surgery for trigger finger

BACKGROUND

Trigger finger is a common clinical disorder, characterised by pain and catching as the patient flexes and extends digits because of disproportion between the diameter of flexor tendons and the A1 pulley. The treatment approach may include non-surgical or surgical treatments. Currently there is no consensus about the best surgical treatment approach (open, percutaneous or endoscopic approaches).

OBJECTIVES

To evaluate the effectiveness and safety of different methods of surgical treatment for trigger finger (open, percutaneous or endoscopic approaches) in adults at any stage of the disease.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and LILACS up to August 2017.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that assessed adults with trigger finger and compared any type of surgical treatment with each other or with any other non-surgical intervention. The major outcomes were the resolution of trigger finger, pain, hand function, participant-reported treatment success or satisfaction, recurrence of triggering, adverse events and neurovascular injury.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trial reports, extracted the data and assessed the risk of bias. Measures of treatment effect for dichotomous outcomes calculated risk ratios (RRs), and mean differences (MDs) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CIs). When possible, the data were pooled into meta-analysis using the random-effects model. GRADE was used to assess the quality of evidence for each outcome.

MAIN RESULTS

Fourteen trials were included, totalling 1260 participants, with 1361 trigger fingers. The age of participants included in the studies ranged from 16 to 88 years; and the majority of participants were women (approximately 70%). The average duration of symptoms ranged from three to 15 months, and the follow-up after the procedure ranged from eight weeks to 23 months.The studies reported nine types of comparisons: open surgery versus steroid injections (two studies); percutaneous surgery versus steroid injection (five studies); open surgery versus steroid injection plus ultrasound-guided hyaluronic acid injection (one study); percutaneous surgery plus steroid injection versus steroid injection (one study); percutaneous surgery versus open surgery (five studies); endoscopic surgery versus open surgery (one study); and three comparisons of types of incision for open surgery (transverse incision of the skin in the distal palmar crease, transverse incision of the skin about 2-3 mm distally from distal palmar crease, and longitudinal incision of the skin) (one study).Most studies had significant methodological flaws and were considered at high or unclear risk of selection bias, performance bias, detection bias and reporting bias. The primary comparison was open surgery versus steroid injections, because open surgery is the oldest and the most widely used treatment method and considered as standard surgery, whereas steroid injection is the least invasive control treatment method as reported in the studies in this review and is often used as first-line treatment in clinical practice.Compared with steroid injection, there was low-quality evidence that open surgery provides benefits with respect to less triggering recurrence, although it has the disadvantage of being more painful. Evidence was downgraded due to study design flaws and imprecision.Based on two trials (270 participants) from six up to 12 months, 50/130 (or 385 per 1000) individuals had recurrence of trigger finger in the steroid injection group compared with 8/140 (or 65 per 1000; range 35 to 127) in the open surgery group, RR 0.17 (95% CI 0.09 to 0.33), for an absolute risk difference that 29% fewer people had recurrence of symptoms with open surgery (60% fewer to 3% more individuals); relative change translates to improvement of 83% in the open surgery group (67% to 91% better).At one week, 9/49 (184 per 1000) people had pain on the palm of the hand in the steroid injection group compared with 38/56 (or 678 per 1000; ranging from 366 to 1000) in the open surgery group, RR 3.69 (95% CI 1.99 to 6.85), for an absolute risk difference that 49% more had pain with open surgery (33% to 66% more); relative change translates to worsening of 269% (585% to 99% worse) (one trial, 105 participants).Because of very low quality evidence from two trials we are uncertain whether open surgery improve resolution of trigger finger in the follow-up at six to 12 months, when compared with steroid injection (131/140 observed in the open surgery group compared with 80/130 in the control group; RR 1.48, 95% CI 0.79 to 2.76); evidence was downgraded due to study design flaws, inconsistency and imprecision. Low-quality evidence from two trials and few event rates (270 participants) from six up to 12 months of follow-up, we are uncertain whether open surgery increased the risk of adverse events (incidence of infection, tendon injury, flare, cutaneous discomfort and fat necrosis) (18/140 observed in the open surgery group compared with 17/130 in the control group; RR 1.02, 95% CI 0.57 to 1.84) and neurovascular injury (9/140 observed in the open surgery group compared with 4/130 in the control group; RR 2.17, 95% CI 0.7 to 6.77). Twelve participants (8 versus 4) did not complete the follow-up, and it was considered that they did not have a positive outcome in the data analysis. We are uncertain whether open surgery was more effective than steroid injection in improving hand function or participant satisfaction as studies did not report these outcomes.

AUTHORS' CONCLUSIONS

Low-quality evidence indicates that, compared with steroid injection, open surgical treatment in people with trigger finger, may result in a less recurrence rate from six up to 12 months following the treatment, although it increases the incidence of pain during the first follow-up week. We are uncertain about the effect of open surgery with regard to the resolution rate in follow-up at six to 12 months, compared with steroid injections, due high heterogeneity and few events occurred in the trials; we are uncertain too about the risk of adverse events and neurovascular injury because of a few events occurred in the studies. Hand function or participant satisfaction were not reported.

The Safety of Percutaneous Trigger Digit Release Increased by Neurovascular Displacement with Local Hydraulic Dilatation: An Anatomical and Clinical Study

Background

Although percutaneous trigger digit release is common, controversy exists regarding its safety. The purpose of this study was to evaluate the feasibility and safety of the neurovascular displacement by local hydraulic dilatation (LHD) during percutaneous trigger digit release.

Material/Methods

Ten cadaver hands with 50 digits were dissected in this anatomical study. The distance between bilateral neurovascular bundles in each digit was measured before LHD and after LHD. The difference between the measured data before LHD and those after LHD in the same digit was compared to assess the feasibility of the neurovascular displacement by LHD. A further 81 patients with 106 trigger digits were treated by percutaneous release with neurovascular displacement by LHD in our clinical series. All patients were followed for 12 months. During the follow-up period, the presence of any postoperative complication and patient satisfaction were recorded.

Results

In our anatomical study, there was a statistically significant difference (p<0.05) comparing the average distance of bilateral neurovascular bundles before LHD with that after LHD. In the current series, no complications, such as digital neurovascular injury or recurrence of trigger, were encountered. On subjective assessment, 80/81 patients (98.8%) with 105/106 digits (99.1%) were graded as satisfactory with complete resolution of symptoms by percutaneous release under LHD.

Conclusions

Based on our study anatomical and clinical results, the neurovascular displacement by LHD may be a feasible adjunctive technique that may play a role in increasing the safety of percutaneous trigger digit release.

Outpatient Percutaneous Release of Trigger Finger: A Cost Effective and Safe Procedure

INTRODUCTION

Trigger finger is a common cause of pain and disability of the hand. Percutaneous release results in earlier functional recovery and patient satisfaction. This is a rapid and cost-effective method which saves a surgical procedure and results in better functional outcome.

MATERIALS AND METHODS

This is a prospective observational study conducted on fifty-two fingers and thumbs in 52 patients treated from 1st July 2014 till 31st December 2014, in the Orthopaedic Section, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan. All the baseline characteristics of the patients, like demographics, symptoms, Quinell's criteria and functional outcome were recorded. The patients were treated at our hospital with trigger finger, managed with percutaneous release using an 18 gauge needle and followed up for a minimum period of three months. The follow-up information included range of motion scoring, patient satisfaction and overall outcome of the procedure in terms of patient acceptance. The data was analyzed to determine the functional outcome at three months.

RESULTS

There was complete release of A1 pulleys in 52 out of 52 digits (100%) in the patients undergoing percutaneous release and significant patient satisfaction. No recurrence was observed.

CONCLUSION

Percutaneous release of trigger finger with needle was not only associated with excellent functional outcome and recovery in terms of patient satisfaction and range of finger motion three months post-procedure but also was found to be cost effective.

Comparative clinical study of ultrasound-guided A1 pulley release vs open surgical intervention in the treatment of trigger finger

AIM

To investigate the effectiveness of ultrasound-guided release of the first annular pulley and compare results with the conventional open operative technique.

METHODS

In this prospective randomized, single-center, clinical study, 32 patients with trigger finger or trigger thumb, grade II-IV according to Green classification system, were recruited. Two groups were formed; Group A (16 patients) was treated with an ultrasound-guided percutaneous release of the affected A1 pulley under local anesthesia. Group B (16 patients) underwent an open surgical release of the A1 pulley, through a 10-15 mm incision. Patients were assessed pre- and postoperatively (follow-up: 2, 4 and 12 wk) by physicians blinded to the procedures. Treatment 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, QuickDASH test scores (Greek version), return to normal activities (including work), complications and cosmetic results were assessed.

RESULTS

The success rate in group A was 93.75% (15/16) and in group B 100% (16/16). Mean times in group A patients were 3.5 d for taking pain killers, 4.1 d for returning to normal activities, and 7.2 and 3.9 d for complete extension and flexion recovery, respectively. Mean QuickDASH scores in group A were 45.5 preoperatively and, 7.5, 0.5 and 0 after 2, 4, and 12 wk postoperatively. Mean times in group B patients were 2.9 d for taking pain killers, 17.8 d for returning to normal activities, and 5.6 and 3 d for complete extension and flexion recovery. Mean QuickDASH scores in group B were 43.2 preoperatively and, 8.2, 1.3 and 0 after 2, 4, and 12 wk postoperatively. The cosmetic results found excellent or good in 87.5% (14/16) of group A patients, while in 56.25% (9/16) of group B patients were evaluated as fair or poor.

CONCLUSION

Treatment of the trigger finger using ultrasonography resulted in fewer absence of work days, and better cosmetic results, in comparison with the open surgery technique. It is a promising method that represents excellent results without major complications, so that it could be possibly be established as a first-line treatment in the trigger finger’s disease.

Short-term Versus Long-term Outcomes After Open or Percutaneous Release for Trigger Thumb

Good outcomes have been reported after both open and percutaneous surgery to release trigger thumb. This study evaluated short-term and long-term outcomes after treatment of trigger thumb with open or percutaneous release. A total of 126 trigger thumbs in 107 patients were reviewed from 2009 to 2012. Short-term (3 months) and long-term results (2 years) and complications of open release (58 digits) and percutaneous release (68 digits) were recorded and compared. Short-term complications included pain occurring in 9 digits (15.5%) in the open release group and in 2 digits (2.9%) in the percutaneous release group and scarring in 4 digits (6.9%) only in the open release group. Long-term complications included pain in 13 digits (19.1%) in the percutaneous release group and in 4 digits (6.9%) in the open release group; in addition, recurrent triggering occurred in 6 digits (8.8%) in the percutaneous release group and in 2 digits (3.4%) in the open release group. Pain and patient satisfaction were significantly better in the percutaneous release group in the short term, but they were better in the open release group in the long term. Although percutaneous release for trigger thumb is a safe and quick procedure, with good short-term outcomes, open release may provide better long-term outcomes. [Orthopedics. 2017; 40(1):e131-e135.].

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

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.

Early Patient Satisfaction with Different Treatment Pathways for Trigger Finger and Thumb

Little is known about factors related to patient satisfaction with treatment for trigger digits. This study tested the null hypothesis that there are no factors associated with treatment satisfaction 2 months after completion of treatment (absence of triggering) or 4 months after the last visit for patients with a trigger thumb or finger. Secondary null hypotheses were: 1) There are no factors associated with a change in patients' preferred treatment before and after consultation with a hand surgeon; and 2) Initial treatment provided is not different from final received treatment. In an observational study, 63 English-speaking adult patients were enrolled after being diagnosed with one or more new idiopathic trigger digits by one of two hand surgeons, but before the hand surgeon discussed treatment options. Patients were asked to fill out questionnaires at enrollment. Final evaluation was by phone. Satisfaction with treatment was not related to the initial treatment or other patient or disease factors. Twenty-three patients (37 %) had a different preference for treatment after talking with a hand surgeon. Involvement of the long and ring fingers were the only factors associated with staying with pre-visit treatment preferences. There was a significant difference in proportions of the various treatments provided at enrollment and final treatment recorded at the final phone evaluation, 14 patients (22 %) had a subsequent alternative form of treatment. Patients' preferences for trigger finger treatment often change after consulting with a hand surgeon and during treatment, but these choices do not affect treatment satisfaction.

Percutaneous first annular pulley release for trigger digits: a systematic review and meta-analysis of current evidence

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.