P e rc u t a n e o u s R e l e a s e o f Tr i g g e r Fi n g e r s Edson Sasahara Sato, PhD in Orthopedics*, João Baptista Gomes dos Santos, PhD in Orthopedics, João Carlos Belloti, PhD in Orthopedics, Walter Manna Albertoni, PhD in Orthopedics, Flavio Faloppa, PhD in Orthopedics KEYWORDS Trigger Tendon Tenosynovitis finger percutaneous Corticosteroid Surgical Release
KEY POINTS Trigger finger should be treated first by steroid injection because of its low morbidity. Treatment of trigger finger with percutaneous pulley release can only be performed if there is active triggering of the finger. Clear understanding of the location of the A1 pulley is key to successfully performing a percutaneous trigger release.
Trigger finger is a common condition caused by impaired tendon gliding at the level of the A1 pulley. This impairment prevents the tendon from naturally extending and returning to its initial position, often resulting in a locked finger. Several factors, including synovial proliferation and fibrosis flexor sheath, have been associated with triggering, but as yet there is no consensus in the literature regarding its etiology.1 Notta2 described trigger finger as a condition caused by changes to the flexor tendon itself as well as the sheath. Hueston and Wilson3 demonstrated in an anatomic study that the spiral arrangement of the architecture of the intratendon fibers leads to the formation of nodules that form distally to the A1 pulley. The epidemiology of trigger finger has been well studied. It occurs more frequently in women, on
the dominant side, and in the sixth decade of life. The most affected finger is the thumb, although the occurrence of the trigger is also common in the other fingers.4 The symptoms vary from a slight local discomfort to the formation of a tendon blockage, which leads to a deficit in actively extending the finger and to the finger remaining fixed in a flexed position.5 Trigger finger also appears to be linked to other diseases, such as rheumatoid arthritis, gout, carpal tunnel syndrome, De Quervain disease, and diabetes.6,7 Quinnell1 classified the trigger finger using 5 types during flexion and extension: normal movement (type 0), uneven movement (type I), actively correctable (type II), passively correctable (type III), and fixed deformity (type IV) (Table 1). Trigger finger is one of the most common conditions encountered by hand surgeons. There are several treatment options available for trigger fingers. Less invasive measures such as
Trial Registration: Current Controlled Trials, http://www.controlled-trials.com/, ISRCTN19255926. The authors have no conflicts of interest or any financial interests in, or commercial associations with, any of the products or devices in this article. Discipline of Hand and Upper Limb Surgery, Department of Orthopedics and Traumatology, UNIFESP – Federal University of Sa˜o Paulo, Rua Borges Lagoa 786, Sa˜o Paulo City, Cep: 04038-031 Sa˜o Paulo, Brazil * Corresponding author. E-mail address: [email protected] Hand Clin 30 (2014) 39–45 http://dx.doi.org/10.1016/j.hcl.2013.08.017 0749-0712/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
hand.theclinics.com
INTRODUCTION
Sato et al
40
Table 1 Quinnell classification of trigger finger Type
Clinical Symptoms
0 I II III IV
Normal movement Uneven movement Actively correctable Passively correctable Fixed deformity
Data from Quinnell RC. Conservative management of trigger finger. Practitioner 1980;224:187–90.
splinting and corticosteroid injections are well described. Patients may even experience spontaneous cure or a disappearance of their symptoms. However, many patients will ultimately require surgery for release of the A1 pulley.1,5,6,8–13 Splinting can result in resolution of symptoms. One study found a 54% resolution of symptoms in patients splinted for at least 6 weeks.14 However, for splints to be effective they require many hours of wearing, which can be challenging for patients. A corticosteroid injection administered to the flexor tendon sheath has been demonstrated to produce good results with about 50% improvement after 1 injection.1,6,9–13,15 However, this technique can result in a relapse rate of up to 29%, and patients are limited in the number of steroid injections they can receive.10 Open surgical release is the gold standard, and has a high rate of success with minimal morbidity. Recurrence and persistence can occur, often attributable to technical error of inadequate release.16 Other complications such as painful scarring, infections, and nerve damage have been reported.17,18 Open technique is a surgical procedure that requires an incision and appropriate surgical instruments. Given the predictable anatomy of the trigger finger, less invasive and costly measures have been sought for the treatment of trigger fingers. The delicate tenotomy described in 1958 by Lorthioir19 was an early description of a minimal approach to the trigger finger. Since that time
many other investigators have reported good results using percutaneous release of the A1 pulley.5,20–28 The authors performed a percutaneous release in 76 triggers fingers of 65 patients and achieved a remission rate of 96%, with 3 recurrences. There was no need to convert any intervention to the open method.29 Table 2 presents a literature review of percutaneous release, which reveals a high cure rate with few complications (Table 3).
INDICATIONS AND CONTRAINDICATIONS Percutaneous release can be performed in patients with trigger finger of Quinnell classification types II to IV (see Table 1). Percutaneous release should not be performed in a type I finger, which has a history of catching, though this is not demonstrable on physical examination (active triggering is necessary to confirm complete sectioning of the pulley). This technique should also not be performed if synovectomy or tenosynovectomy is a concern, for example in rheumatoid patients.
SURGICAL TECHNIQUE The technique applied was proposed by Eastwood and colleagues5 in 1992.
Anatomy Before proceeding the surgeon must have a thorough understanding of the location of the A1 pulley, which can be determined using palmar surface landmarks. Anatomic studies indicate that the distance from the palmar digital crease to the proximal interphalangeal crease is approximately equal to the distance from the palmar digital crease to the proximal edge of the A1 pulley. Another finding is that the A2 pulley can be preserved by terminating the A1 pulley release 5 mm proximal to the palmar digital crease (Fig. 1). Landmarks of the A1 pulley include for the index finger the radial border of the pisiform proximally and the midline of the digit distally, and for the small finger the ulnar border of the scaphoid tubercle proximally
Table 2 Percutaneous release Authors,Ref. Year 29
Sato et al, 2004 Eastwood et al,5 1992 Ragoowansi et al,26 2005 Blumberg et al,25 2001
Method
Sample
Complications
Cure (%)
Percutaneous Percutaneous Percutaneous Percutaneous
76 fingers 35 fingers 240 fingers 30 fingers
3 recurrences 2 partial relief 10 recurrences 1 recurrence
96 94 94 97
Percutaneous Release of Trigger Fingers
Table 3 Prospective randomized studiesa Authors,Ref. Year 32
Sato et al,
2012
Gilberts et al,34 2001 Chao et al,35 2009 Zyluk et al,36 2011 a
Method
Sample
Complications
Cure (%)
Corticosteroid Open Percutaneous Open Percutaneous Corticosteroid Percutaneous Corticosteroid Percutaneous
150 fingers
No
100 fingers
1 recurrence
93 fingers
No
105 fingers
No
86 100 100 98 100 26 96 89 100
All were randomized by sealed envelopes.
and the midline of the digit distally (Fig. 2).30,31 Once the location of the A1 pulley has been defined, the authors recommend that the needle be first introduced in the midpoint of the pulley.
After the giving consent, the patient is positioned with the affected hand in supination. The palm and affected digit are prepared with antiseptic solution and the digit is exposed at a sterile surgical drape.
Prep and Patient Positioning This technique can be performed in the office setting. The practitioner will need a sterile drape, a 19-gauge needle, a marking pen, antiseptic solution, a sterile towel, and 2 mL of local anesthetic drawn up.
Fig. 1. A1 pulley landmark.
Surgical Approach The A1 pulley is palpated directly over the metacarpal head, during active flexion-extension motions of the affected finger (Fig. 3). With a
Fig. 2. A1 pulley landmarks of index and small fingers.
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Sato et al
Fig. 3. Trigger finger deformity.
skin-marking pen, a line is drawn over the longitudinal axis of the digit (Fig. 4), and 2 mL of local anesthetic is injected into the subcutaneous tissue around the A1 pulley (Fig. 5).
Surgical Procedure Step 1 The digits are hyperextended over a rolled towel to displace the neurovascular structures dorsally (Fig. 6). Step 2 The needle bevel should be positioned in the cutting direction, parallel with the longitudinal axis of the digit (Fig. 7). Step 3 A hypodermic 19-gauge needle is introduced perpendicularly to the skin in the site corresponding to the A1 pulley (Fig. 8). Step 4 Needle placement within the flexor tendon is confirmed by finger flexion and its simultaneous displacement (Fig. 9).
Fig. 4. Longitudinal axis of outlined digit.
Fig. 5. Anesthetizing skin and subcutaneous tissue.
Step 5 The needle is then withdrawn slowly until removal from flexor tendon. Step 6 Longitudinal movements of the needle are performed for A1 pulley release. Disappearance of a grating sensation indicates complete sectioning. The needle is withdrawn and the patient is asked to flex and extend the digit several times. On occasion, a second or a third needle stick distal or proximal to the initial point is necessary to complete the percutaneous procedure (Fig. 10). No dressings or immobilization are applied.
Immediate Postoperative Care Free motion of the finger is authorized after the procedure, and the patient is instructed to use the hand for activities as tolerated.
Rehabilitation and Recovery Usually there is no need for rehabilitation. If pain persists for more than 7 days, physical therapy may be indicated.
Fig. 6. Metacarpophalangeal joints in extension.
Percutaneous Release of Trigger Fingers
Fig. 7. Correct positioning of needle bevel during its insertion.
Pearls and Pitfalls For trigger release, the first needle insertion should be at the midpoint of the A1 pulley. If triggering persists after the first attempt, the needle should be placed in a slightly different location, distal or proximal to the initial point. The authors believe that continued triggering after the first attempt is likely caused by proximal or distal pulley fibers continuing to catch the tendon. The thumb is different from the fingers. For the thumb, a prominence at the palmar digital crease can be palpated; this corresponds to the flexor pulley. Usually release can be obtained by a single needle insertion.
CLINICAL RESULTS IN THE LITERATURE The strong safety profile for percutaneous release encouraged the authors to perform a randomized prospective study comparing the efficacy of corticosteroid injection, percutaneous release of the A1 pulley, and conventional open surgery in terms
Fig. 8. The needle is inserted until it reaches the flexor tendon.
Fig. 9. Needle displacement when bending the finger.
of their rates of cure, relapse, and complications. A randomized study was performed on a homogeneous population to compare the effectiveness of these 3 methods.32 This trial included patients older than 15 years with a trigger on any finger. The study was different in that the authors included all fingers, whereas other studies such as that by Bain and colleagues33 excluded the thumb and small finger because of concerns for greater risk of injury to the neurovascular bundle with the percutaneous approach. The authors included Quinnell trigger types II to IV. Type I was not included because their prior work had shown that there must be active triggering for the percutaneous method. Preprocedure triggering is required because smooth flexionextension at the completion of the release is evidence that the pulley has been incised. With type I fingers the trigger occurs sporadically at the time of surgery and, thus, smooth gliding of the finger after release does not guarantee that the pulley has been completely released. At the conclusion of the study, the authors found that open and percutaneous surgery had similar cure and relapse rates, and that both were superior to injection. In the injection group, a 57% cure rate of the trigger was achieved. Those who did not have relief were given a second injection, which increased the cure rate to 86% over a 6-month follow-up period. A third injection was not offered, and the relapses were considered failures. The patients in the percutaneous and open release groups had cure rates of 100%. These findings were similar to those of the randomized prospective study by Gilberts and colleagues34 comparing the percutaneous method with the open method, in which cure rates were reported of 98% with open surgery and 100% with the percutaneous method. The patients in the injection group experienced a lower incidence of pain in the first month of followup when compared with those of the open and
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Sato et al
Fig. 10. (A) Sectioning the A1 pulley. (B) Sectioning the A1 pulley. (Arrows indicate needle displacement direction).
percutaneous groups, which had similar incidences. Investigators such as Chao and colleagues35 and Zyluk and Jagielski36 compared the percutaneous and injection methods, and reported that the group given injections also presented a lower incidence of pain in the first month after the procedure in comparison with the percutaneous release group. For all 3 groups, total active motion (TAM) values at the sixth month of follow-up were greater than the values observed before treatment, similar to the findings of Marcus and colleagues.37 The open group had lower TAM values than the injection and percutaneous groups after 1, 2, and 4 months of follow-up, which may be explained by the greater morbidity of the open surgery. The authors did not observe any injury to the digital nerve among their 3 treatment groups. The authors believe that the keys to safe percutaneous release are demarcation of the longitudinal axis of the tendon and precise anatomic knowledge of the pulleys. These tenets have been borne out in other anatomic studies.30,31 Taylor and colleagues38 found a complication in a 60year-old man undergoing chronic anticoagulation therapy who presented a digital artery pseudoaneurysm following percutaneous trigger thumb release. Percutaneous release is a blind technique that the authors have found to be safe and effective. Others have tried to use ultrasonography to allow for visualization while maintaining the percutaneous nature of the procedure.39 The authors believe that ultrasonography adds extra expense, whereas with clear understanding the procedure can be performed without additional imaging.
SUMMARY Open surgery has been indicated as the surgical treatment for trigger finger for many years; however, minimally invasive techniques are replacing conventional methods. Minimally invasive techniques enable early recovery of the patient
with minimal damage to soft tissues. The authors’ study showed that levels of effectiveness of open surgical and percutaneous methods were superior to those of the conservative method using corticosteroid based on the cure and reappearance rates of the trigger. Percutaneous pulley release for treating trigger finger is a safe, effective, and minimally invasive surgical alternative.
REFERENCES 1. Quinnell RC. Conservative management of trigger finger. Practitioner 1980;224:187–90. 2. Notta A. Research on a particular condition of tendon sheaths of the hand, characterized by the development of a nodule in the path of flexor tendons and blocking their movements. Arch Gen Med 1850;24:142–61. 3. Hueston JT, Wilson WF. The aetiology of trigger finger. Hand 1972;4:257–60. 4. Weilby A. Trigger finger. Incidence in children and adults and the possibility of a predisposition in certain age groups. Acta Orthop Scand 1970;41:419–27. 5. Eastwood DM, Gupta KJ, Johnson DP. Percutaneous release of the trigger finger: an office procedure. J Hand Surg Am 1992;17:114–7. 6. Freiberg A, Mulholland RS, Levine R. Nonoperative treatment of trigger fingers and thumbs. J Hand Surg Am 1989;14:553–8. 7. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg Am 2006;31:135–46. 8. Patel MR, Bassini L. Trigger fingers and thumb: when to splint, inject, or operate. J Hand Surg Am 1992;17:110–3. 9. Kolind-Sorensen V. Treatment of trigger fingers. Acta Orthop Scand 1970;41:428–32. 10. Rhoades CE, Gelberman RH, Manjarris JF. Stenosing tenosynovitis of the fingers and thumb. Clin Orthop Relat Res 1984;190:236–8. 11. Marks MR, Gunther SF. Efficacy of cortisone injection in treatment of trigger fingers and thumbs. J Hand Surg Am 1989;14:722–7.
Percutaneous Release of Trigger Fingers 12. Newport ML, Lane LB, Stuchin SA. Treatment of trigger finger by steroid injection. J Hand Surg Am 1990;15:748–50. 13. Benson LS, Ptaszek AJ. Injection versus surgery in the treatment of trigger finger. J Hand Surg Am 1997;22:138–44. 14. Colbourn J, Heath N, Manary S, et al. Effectiveness of splinting for the treatment of trigger finger. J Hand Ther 2008;21(4):336–43. 15. Ring D, Lozano-Caldero´n S, Shin R, et al. A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger. J Hand Surg Am 2008; 33:516–22. 16. Bruijnzeel H, Neuhaus V, Fostvedt S, et al. Adverse events of open A1 pulley release for idiopathic trigger finger. J Hand Surg Am 2012;37(8):1650–6. 17. Turowski GA, Zdankiewicz PD, Thomson JG. The results of surgical treatment of trigger finger. J Hand Surg Am 1997 Jan;22(1):145–9. 18. Thorpe AP. Results of surgery for trigger finger. J Hand Surg Am 1988;13:199–201. 19. Lorthioir J. Surgical treatment of trigger-finger by a subcutaneous method. J Bone Joint Surg Am 1958;40:793–5. 20. Tanaka J, Muraji M, Negoro H, et al. Subcutaneous release of trigger thumb and fingers in 210 fingers. J Hand Surg Br 1990;15:463–5. 21. Lyu SR. Closed division of the flexor tendon sheath for trigger finger. J Bone Joint Surg Br 1992;74:418–20. 22. Cohen TJ. Percutaneous treatment of trigger finger. Ver Bras Ortop 1996;31:690–2. 23. Nagoshi M, Hashizume H, Nishida K, et al. Percutaneous release for trigger finger in idiopathic and hemodialysis patients. Acta Med Okayama 1997;51: 155–8. 24. Cihantimur B, Akin S, Ozcan M. Percutaneous treatment of trigger finger. Acta Orthop Scand 1998;69: 167–8. 25. Blumberg N, Arbel R, Dekel S. Percutaneous release of trigger digits. J Hand Surg Br 2001;26:256–7. 26. Ragoowansi R, Acornley A, Khoo CT. Percutaneous trigger finger release: the ‘lift-cut’ technique. Br J Plast Surg 2005;58:817–21. 27. Wang HC, Lin GT. Retrospective study of open versus percutaneous trigger thumb in children. Plast Reconstr Surg 2005;115:1963–70. 28. Fu YC, Huang PJ, Tien YC, et al. Revision of incompletely released trigger fingers by percutaneous
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
release: results and complications. J Hand Surg Am 2006;31:1288–91. Sato ES, Albertoni WM, Leite VM, et al. Trigger finger: a prospective analysis of 76 fingers treated surgically by percutaneous release. Rev Bras Ortop 2004;396:309–22. Wilhelmi BJ, Mowlavi A, Neumeister MW, et al. Safe treatment of trigger finger with longitudinal and transverse landmarks: an anatomic study of the border fingers for percutaneous release. Plast Reconstr Surg 2003;112:993–9. Fiorini HJ, Santos JB, Hirakawa CK, et al. Anatomical study of the A1 pulley: length and location by means of cutaneous landmarks on the palmar surface. J Hand Surg Am 2011;36:464–8. Sato ES, Gomes Dos Santos DB, Belloti JC, et al. Treatment of trigger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery. Rheumatology (Oxford) 2012;51(1):93–9. Bain GI, Turnbull J, Charles MN, et al. Percutaneous A1 pulley release: a cadaveric study. J Hand Surg Am 1995;20:781–4. Gilberts EC, Beekman WH, Stevens HJ, et al. Prospective randomized trial of open versus percutaneous surgery for trigger digits. J Hand Surg Am 2001;26:497–500. Chao M, Wu S, Yan T. The effect of miniscalpelneedle versus steroid injection for trigger thumb release. J Hand Surg Eur Vol 2009;34:522–5. Zyluk A, Jagielski G. Percutaneous A1 pulley release vs steroid injection for trigger digit: the results of a prospective, randomized trial. J Hand Surg Eur Vol 2011;36(1):53–6. http://dx. doi.org/10.1177/1753193410381824. Marcus AM, Culver JE Jr, Hunt TR 3rd. Treating trigger finger in diabetics using excision of the ulnar slip of the flexor digitorum superficialis with or without A1 pulley release. Hand 2007;2: 227–31. Taylor SA, Osei DA, Jain S, et al. Digital artery pseudoaneurysm following percutaneous trigger thumb release: a case report. J Bone Joint Surg Am 2012; 94(2):e6. http://dx.doi.org/10.2106/JBJS.K.00300. Rojo-Manaute JM, Soto VL, De las Heras Sa´nchezHeredero J, et al. Percutaneous intrasheath ultrasonographically guided first annular pulley release: anatomic study of a new technique. J Ultrasound Med 2010 Nov;29(11):1517–29.
45
KEY POINTS Trigger finger should be treated first by steroid injection because of its low morbidity. Treatment of trigger finger with percutaneous pulley release can only be performed if there is active triggering of the finger. Clear understanding of the location of the A1 pulley is key to successfully performing a percutaneous trigger release.
Trigger finger is a common condition caused by impaired tendon gliding at the level of the A1 pulley. This impairment prevents the tendon from naturally extending and returning to its initial position, often resulting in a locked finger. Several factors, including synovial proliferation and fibrosis flexor sheath, have been associated with triggering, but as yet there is no consensus in the literature regarding its etiology.1 Notta2 described trigger finger as a condition caused by changes to the flexor tendon itself as well as the sheath. Hueston and Wilson3 demonstrated in an anatomic study that the spiral arrangement of the architecture of the intratendon fibers leads to the formation of nodules that form distally to the A1 pulley. The epidemiology of trigger finger has been well studied. It occurs more frequently in women, on
the dominant side, and in the sixth decade of life. The most affected finger is the thumb, although the occurrence of the trigger is also common in the other fingers.4 The symptoms vary from a slight local discomfort to the formation of a tendon blockage, which leads to a deficit in actively extending the finger and to the finger remaining fixed in a flexed position.5 Trigger finger also appears to be linked to other diseases, such as rheumatoid arthritis, gout, carpal tunnel syndrome, De Quervain disease, and diabetes.6,7 Quinnell1 classified the trigger finger using 5 types during flexion and extension: normal movement (type 0), uneven movement (type I), actively correctable (type II), passively correctable (type III), and fixed deformity (type IV) (Table 1). Trigger finger is one of the most common conditions encountered by hand surgeons. There are several treatment options available for trigger fingers. Less invasive measures such as
Trial Registration: Current Controlled Trials, http://www.controlled-trials.com/, ISRCTN19255926. The authors have no conflicts of interest or any financial interests in, or commercial associations with, any of the products or devices in this article. Discipline of Hand and Upper Limb Surgery, Department of Orthopedics and Traumatology, UNIFESP – Federal University of Sa˜o Paulo, Rua Borges Lagoa 786, Sa˜o Paulo City, Cep: 04038-031 Sa˜o Paulo, Brazil * Corresponding author. E-mail address: [email protected] Hand Clin 30 (2014) 39–45 http://dx.doi.org/10.1016/j.hcl.2013.08.017 0749-0712/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
hand.theclinics.com
INTRODUCTION
Sato et al
40
Table 1 Quinnell classification of trigger finger Type
Clinical Symptoms
0 I II III IV
Normal movement Uneven movement Actively correctable Passively correctable Fixed deformity
Data from Quinnell RC. Conservative management of trigger finger. Practitioner 1980;224:187–90.
splinting and corticosteroid injections are well described. Patients may even experience spontaneous cure or a disappearance of their symptoms. However, many patients will ultimately require surgery for release of the A1 pulley.1,5,6,8–13 Splinting can result in resolution of symptoms. One study found a 54% resolution of symptoms in patients splinted for at least 6 weeks.14 However, for splints to be effective they require many hours of wearing, which can be challenging for patients. A corticosteroid injection administered to the flexor tendon sheath has been demonstrated to produce good results with about 50% improvement after 1 injection.1,6,9–13,15 However, this technique can result in a relapse rate of up to 29%, and patients are limited in the number of steroid injections they can receive.10 Open surgical release is the gold standard, and has a high rate of success with minimal morbidity. Recurrence and persistence can occur, often attributable to technical error of inadequate release.16 Other complications such as painful scarring, infections, and nerve damage have been reported.17,18 Open technique is a surgical procedure that requires an incision and appropriate surgical instruments. Given the predictable anatomy of the trigger finger, less invasive and costly measures have been sought for the treatment of trigger fingers. The delicate tenotomy described in 1958 by Lorthioir19 was an early description of a minimal approach to the trigger finger. Since that time
many other investigators have reported good results using percutaneous release of the A1 pulley.5,20–28 The authors performed a percutaneous release in 76 triggers fingers of 65 patients and achieved a remission rate of 96%, with 3 recurrences. There was no need to convert any intervention to the open method.29 Table 2 presents a literature review of percutaneous release, which reveals a high cure rate with few complications (Table 3).
INDICATIONS AND CONTRAINDICATIONS Percutaneous release can be performed in patients with trigger finger of Quinnell classification types II to IV (see Table 1). Percutaneous release should not be performed in a type I finger, which has a history of catching, though this is not demonstrable on physical examination (active triggering is necessary to confirm complete sectioning of the pulley). This technique should also not be performed if synovectomy or tenosynovectomy is a concern, for example in rheumatoid patients.
SURGICAL TECHNIQUE The technique applied was proposed by Eastwood and colleagues5 in 1992.
Anatomy Before proceeding the surgeon must have a thorough understanding of the location of the A1 pulley, which can be determined using palmar surface landmarks. Anatomic studies indicate that the distance from the palmar digital crease to the proximal interphalangeal crease is approximately equal to the distance from the palmar digital crease to the proximal edge of the A1 pulley. Another finding is that the A2 pulley can be preserved by terminating the A1 pulley release 5 mm proximal to the palmar digital crease (Fig. 1). Landmarks of the A1 pulley include for the index finger the radial border of the pisiform proximally and the midline of the digit distally, and for the small finger the ulnar border of the scaphoid tubercle proximally
Table 2 Percutaneous release Authors,Ref. Year 29
Sato et al, 2004 Eastwood et al,5 1992 Ragoowansi et al,26 2005 Blumberg et al,25 2001
Method
Sample
Complications
Cure (%)
Percutaneous Percutaneous Percutaneous Percutaneous
76 fingers 35 fingers 240 fingers 30 fingers
3 recurrences 2 partial relief 10 recurrences 1 recurrence
96 94 94 97
Percutaneous Release of Trigger Fingers
Table 3 Prospective randomized studiesa Authors,Ref. Year 32
Sato et al,
2012
Gilberts et al,34 2001 Chao et al,35 2009 Zyluk et al,36 2011 a
Method
Sample
Complications
Cure (%)
Corticosteroid Open Percutaneous Open Percutaneous Corticosteroid Percutaneous Corticosteroid Percutaneous
150 fingers
No
100 fingers
1 recurrence
93 fingers
No
105 fingers
No
86 100 100 98 100 26 96 89 100
All were randomized by sealed envelopes.
and the midline of the digit distally (Fig. 2).30,31 Once the location of the A1 pulley has been defined, the authors recommend that the needle be first introduced in the midpoint of the pulley.
After the giving consent, the patient is positioned with the affected hand in supination. The palm and affected digit are prepared with antiseptic solution and the digit is exposed at a sterile surgical drape.
Prep and Patient Positioning This technique can be performed in the office setting. The practitioner will need a sterile drape, a 19-gauge needle, a marking pen, antiseptic solution, a sterile towel, and 2 mL of local anesthetic drawn up.
Fig. 1. A1 pulley landmark.
Surgical Approach The A1 pulley is palpated directly over the metacarpal head, during active flexion-extension motions of the affected finger (Fig. 3). With a
Fig. 2. A1 pulley landmarks of index and small fingers.
41
42
Sato et al
Fig. 3. Trigger finger deformity.
skin-marking pen, a line is drawn over the longitudinal axis of the digit (Fig. 4), and 2 mL of local anesthetic is injected into the subcutaneous tissue around the A1 pulley (Fig. 5).
Surgical Procedure Step 1 The digits are hyperextended over a rolled towel to displace the neurovascular structures dorsally (Fig. 6). Step 2 The needle bevel should be positioned in the cutting direction, parallel with the longitudinal axis of the digit (Fig. 7). Step 3 A hypodermic 19-gauge needle is introduced perpendicularly to the skin in the site corresponding to the A1 pulley (Fig. 8). Step 4 Needle placement within the flexor tendon is confirmed by finger flexion and its simultaneous displacement (Fig. 9).
Fig. 4. Longitudinal axis of outlined digit.
Fig. 5. Anesthetizing skin and subcutaneous tissue.
Step 5 The needle is then withdrawn slowly until removal from flexor tendon. Step 6 Longitudinal movements of the needle are performed for A1 pulley release. Disappearance of a grating sensation indicates complete sectioning. The needle is withdrawn and the patient is asked to flex and extend the digit several times. On occasion, a second or a third needle stick distal or proximal to the initial point is necessary to complete the percutaneous procedure (Fig. 10). No dressings or immobilization are applied.
Immediate Postoperative Care Free motion of the finger is authorized after the procedure, and the patient is instructed to use the hand for activities as tolerated.
Rehabilitation and Recovery Usually there is no need for rehabilitation. If pain persists for more than 7 days, physical therapy may be indicated.
Fig. 6. Metacarpophalangeal joints in extension.
Percutaneous Release of Trigger Fingers
Fig. 7. Correct positioning of needle bevel during its insertion.
Pearls and Pitfalls For trigger release, the first needle insertion should be at the midpoint of the A1 pulley. If triggering persists after the first attempt, the needle should be placed in a slightly different location, distal or proximal to the initial point. The authors believe that continued triggering after the first attempt is likely caused by proximal or distal pulley fibers continuing to catch the tendon. The thumb is different from the fingers. For the thumb, a prominence at the palmar digital crease can be palpated; this corresponds to the flexor pulley. Usually release can be obtained by a single needle insertion.
CLINICAL RESULTS IN THE LITERATURE The strong safety profile for percutaneous release encouraged the authors to perform a randomized prospective study comparing the efficacy of corticosteroid injection, percutaneous release of the A1 pulley, and conventional open surgery in terms
Fig. 8. The needle is inserted until it reaches the flexor tendon.
Fig. 9. Needle displacement when bending the finger.
of their rates of cure, relapse, and complications. A randomized study was performed on a homogeneous population to compare the effectiveness of these 3 methods.32 This trial included patients older than 15 years with a trigger on any finger. The study was different in that the authors included all fingers, whereas other studies such as that by Bain and colleagues33 excluded the thumb and small finger because of concerns for greater risk of injury to the neurovascular bundle with the percutaneous approach. The authors included Quinnell trigger types II to IV. Type I was not included because their prior work had shown that there must be active triggering for the percutaneous method. Preprocedure triggering is required because smooth flexionextension at the completion of the release is evidence that the pulley has been incised. With type I fingers the trigger occurs sporadically at the time of surgery and, thus, smooth gliding of the finger after release does not guarantee that the pulley has been completely released. At the conclusion of the study, the authors found that open and percutaneous surgery had similar cure and relapse rates, and that both were superior to injection. In the injection group, a 57% cure rate of the trigger was achieved. Those who did not have relief were given a second injection, which increased the cure rate to 86% over a 6-month follow-up period. A third injection was not offered, and the relapses were considered failures. The patients in the percutaneous and open release groups had cure rates of 100%. These findings were similar to those of the randomized prospective study by Gilberts and colleagues34 comparing the percutaneous method with the open method, in which cure rates were reported of 98% with open surgery and 100% with the percutaneous method. The patients in the injection group experienced a lower incidence of pain in the first month of followup when compared with those of the open and
43
44
Sato et al
Fig. 10. (A) Sectioning the A1 pulley. (B) Sectioning the A1 pulley. (Arrows indicate needle displacement direction).
percutaneous groups, which had similar incidences. Investigators such as Chao and colleagues35 and Zyluk and Jagielski36 compared the percutaneous and injection methods, and reported that the group given injections also presented a lower incidence of pain in the first month after the procedure in comparison with the percutaneous release group. For all 3 groups, total active motion (TAM) values at the sixth month of follow-up were greater than the values observed before treatment, similar to the findings of Marcus and colleagues.37 The open group had lower TAM values than the injection and percutaneous groups after 1, 2, and 4 months of follow-up, which may be explained by the greater morbidity of the open surgery. The authors did not observe any injury to the digital nerve among their 3 treatment groups. The authors believe that the keys to safe percutaneous release are demarcation of the longitudinal axis of the tendon and precise anatomic knowledge of the pulleys. These tenets have been borne out in other anatomic studies.30,31 Taylor and colleagues38 found a complication in a 60year-old man undergoing chronic anticoagulation therapy who presented a digital artery pseudoaneurysm following percutaneous trigger thumb release. Percutaneous release is a blind technique that the authors have found to be safe and effective. Others have tried to use ultrasonography to allow for visualization while maintaining the percutaneous nature of the procedure.39 The authors believe that ultrasonography adds extra expense, whereas with clear understanding the procedure can be performed without additional imaging.
SUMMARY Open surgery has been indicated as the surgical treatment for trigger finger for many years; however, minimally invasive techniques are replacing conventional methods. Minimally invasive techniques enable early recovery of the patient
with minimal damage to soft tissues. The authors’ study showed that levels of effectiveness of open surgical and percutaneous methods were superior to those of the conservative method using corticosteroid based on the cure and reappearance rates of the trigger. Percutaneous pulley release for treating trigger finger is a safe, effective, and minimally invasive surgical alternative.
REFERENCES 1. Quinnell RC. Conservative management of trigger finger. Practitioner 1980;224:187–90. 2. Notta A. Research on a particular condition of tendon sheaths of the hand, characterized by the development of a nodule in the path of flexor tendons and blocking their movements. Arch Gen Med 1850;24:142–61. 3. Hueston JT, Wilson WF. The aetiology of trigger finger. Hand 1972;4:257–60. 4. Weilby A. Trigger finger. Incidence in children and adults and the possibility of a predisposition in certain age groups. Acta Orthop Scand 1970;41:419–27. 5. Eastwood DM, Gupta KJ, Johnson DP. Percutaneous release of the trigger finger: an office procedure. J Hand Surg Am 1992;17:114–7. 6. Freiberg A, Mulholland RS, Levine R. Nonoperative treatment of trigger fingers and thumbs. J Hand Surg Am 1989;14:553–8. 7. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg Am 2006;31:135–46. 8. Patel MR, Bassini L. Trigger fingers and thumb: when to splint, inject, or operate. J Hand Surg Am 1992;17:110–3. 9. Kolind-Sorensen V. Treatment of trigger fingers. Acta Orthop Scand 1970;41:428–32. 10. Rhoades CE, Gelberman RH, Manjarris JF. Stenosing tenosynovitis of the fingers and thumb. Clin Orthop Relat Res 1984;190:236–8. 11. Marks MR, Gunther SF. Efficacy of cortisone injection in treatment of trigger fingers and thumbs. J Hand Surg Am 1989;14:722–7.
Percutaneous Release of Trigger Fingers 12. Newport ML, Lane LB, Stuchin SA. Treatment of trigger finger by steroid injection. J Hand Surg Am 1990;15:748–50. 13. Benson LS, Ptaszek AJ. Injection versus surgery in the treatment of trigger finger. J Hand Surg Am 1997;22:138–44. 14. Colbourn J, Heath N, Manary S, et al. Effectiveness of splinting for the treatment of trigger finger. J Hand Ther 2008;21(4):336–43. 15. Ring D, Lozano-Caldero´n S, Shin R, et al. A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger. J Hand Surg Am 2008; 33:516–22. 16. Bruijnzeel H, Neuhaus V, Fostvedt S, et al. Adverse events of open A1 pulley release for idiopathic trigger finger. J Hand Surg Am 2012;37(8):1650–6. 17. Turowski GA, Zdankiewicz PD, Thomson JG. The results of surgical treatment of trigger finger. J Hand Surg Am 1997 Jan;22(1):145–9. 18. Thorpe AP. Results of surgery for trigger finger. J Hand Surg Am 1988;13:199–201. 19. Lorthioir J. Surgical treatment of trigger-finger by a subcutaneous method. J Bone Joint Surg Am 1958;40:793–5. 20. Tanaka J, Muraji M, Negoro H, et al. Subcutaneous release of trigger thumb and fingers in 210 fingers. J Hand Surg Br 1990;15:463–5. 21. Lyu SR. Closed division of the flexor tendon sheath for trigger finger. J Bone Joint Surg Br 1992;74:418–20. 22. Cohen TJ. Percutaneous treatment of trigger finger. Ver Bras Ortop 1996;31:690–2. 23. Nagoshi M, Hashizume H, Nishida K, et al. Percutaneous release for trigger finger in idiopathic and hemodialysis patients. Acta Med Okayama 1997;51: 155–8. 24. Cihantimur B, Akin S, Ozcan M. Percutaneous treatment of trigger finger. Acta Orthop Scand 1998;69: 167–8. 25. Blumberg N, Arbel R, Dekel S. Percutaneous release of trigger digits. J Hand Surg Br 2001;26:256–7. 26. Ragoowansi R, Acornley A, Khoo CT. Percutaneous trigger finger release: the ‘lift-cut’ technique. Br J Plast Surg 2005;58:817–21. 27. Wang HC, Lin GT. Retrospective study of open versus percutaneous trigger thumb in children. Plast Reconstr Surg 2005;115:1963–70. 28. Fu YC, Huang PJ, Tien YC, et al. Revision of incompletely released trigger fingers by percutaneous
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
release: results and complications. J Hand Surg Am 2006;31:1288–91. Sato ES, Albertoni WM, Leite VM, et al. Trigger finger: a prospective analysis of 76 fingers treated surgically by percutaneous release. Rev Bras Ortop 2004;396:309–22. Wilhelmi BJ, Mowlavi A, Neumeister MW, et al. Safe treatment of trigger finger with longitudinal and transverse landmarks: an anatomic study of the border fingers for percutaneous release. Plast Reconstr Surg 2003;112:993–9. Fiorini HJ, Santos JB, Hirakawa CK, et al. Anatomical study of the A1 pulley: length and location by means of cutaneous landmarks on the palmar surface. J Hand Surg Am 2011;36:464–8. Sato ES, Gomes Dos Santos DB, Belloti JC, et al. Treatment of trigger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery. Rheumatology (Oxford) 2012;51(1):93–9. Bain GI, Turnbull J, Charles MN, et al. Percutaneous A1 pulley release: a cadaveric study. J Hand Surg Am 1995;20:781–4. Gilberts EC, Beekman WH, Stevens HJ, et al. Prospective randomized trial of open versus percutaneous surgery for trigger digits. J Hand Surg Am 2001;26:497–500. Chao M, Wu S, Yan T. The effect of miniscalpelneedle versus steroid injection for trigger thumb release. J Hand Surg Eur Vol 2009;34:522–5. Zyluk A, Jagielski G. Percutaneous A1 pulley release vs steroid injection for trigger digit: the results of a prospective, randomized trial. J Hand Surg Eur Vol 2011;36(1):53–6. http://dx. doi.org/10.1177/1753193410381824. Marcus AM, Culver JE Jr, Hunt TR 3rd. Treating trigger finger in diabetics using excision of the ulnar slip of the flexor digitorum superficialis with or without A1 pulley release. Hand 2007;2: 227–31. Taylor SA, Osei DA, Jain S, et al. Digital artery pseudoaneurysm following percutaneous trigger thumb release: a case report. J Bone Joint Surg Am 2012; 94(2):e6. http://dx.doi.org/10.2106/JBJS.K.00300. Rojo-Manaute JM, Soto VL, De las Heras Sa´nchezHeredero J, et al. Percutaneous intrasheath ultrasonographically guided first annular pulley release: anatomic study of a new technique. J Ultrasound Med 2010 Nov;29(11):1517–29.
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