Revision of incompletely released trigger fingers by percutaneous release: results and complications

PURPOSE: Percutaneous trigger digit release has been reported as a safe, effective, and quick procedure, but most surgeons convert to an open method for residual triggering after percutaneous release. This study evaluates the safety and efficacy of repeated percutaneous release for patients who had residual triggering after the initial percutaneous release. METHODS: Between January 2000 and December 2002, 31 patients with a mean age of 55 years had a repeat percutaneous release to treat residual snapping or locking symptoms. Surgery was performed in the physician's office using the tip of a 19-gauge needle mounted on a 2-mL syringe. Patients received regular postoperative follow-up examinations at 1, 6, and 12 weeks after surgery, and at the last visit, they completed a questionnaire regarding the duration of pain or swelling and when were they able to return to normal work. RESULTS: Twenty-eight digits (90%) were completely free of triggering. Three digits (10%) during follow-up evaluation had residual snapping. Of these, 1 patient had repeated percutaneous release, which achieved an excellent outcome; 1 patient favored an open-release technique, and 1 patient refused further treatment. No complications were identified at the final follow-up examinations. Almost all patients returned to normal work within 3 days. CONCLUSIONS: Percutaneous A1 pulley release is an effective, safe, and convenient technique for the primary trigger finger and as a secondary procedure for patients who have residual triggering after the initial surgical procedure. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Prospective randomized trial of open versus percutaneous surgery for trigger digits.

Various methods for the treatment of trigger digits exist. This study was designed to compare the results of an open surgical technique with those of a percutaneous surgical technique for the treatment of trigger digits. Ninety-six patients with 100 trigger digits were randomized to either open (n = 46) or percutaneous (n = 54) surgical release of the first annular pulley. Operation time, duration of postoperative pain, recovery of motor function, and surgical complications were assessed. Trigger digits were successfully treated in 98% of the cases using the open surgical technique and in 100% of the cases using the percutaneous technique. Mean operation time was significantly longer using the open technique. Mean duration of postoperative pain and time to recovery of motor function were significantly shorter for patients treated with the percutaneous method. No serious complications were observed in either group. We conclude that percutaneous correction of trigger digits is a quicker procedure, is less painful, and shows significantly better results in rehabilitation than open surgery.     

A1 pulley release of locked trigger digit by percutaneous technique

We performed 118 percutaneous releases of the locked trigger digits in an office setting using a specially designed knife. Thirty-five digits were locked in flexion, 79 digits in extension and the remaining four were fixed in a semiflexed position. Successful percutaneous release was achieved for 107 digits (91%), with the remaining 11 digits requiring an open surgical procedure. Although there were no persistent triggering in 98 digits with a follow-up of at least 6 months, painful stiffness at the interphalangeal joints remained in ten digits despite of physical therapy. No neurovascular injury occurred. We suggest that a locked trigger digit can be successfully released with the percutaneous technique.     

Open versus percutaneous release of the A1-pulley for stenosing tendovaginitis: a prospective randomized trial

A prospective randomized trial for release of the first annular pulley (A-1 pulley) in trigger fingers with a percutaneous technique versus the open surgical technique is presented. Thirty-six patients were randomized to either open (n = 16) or percutaneous (#15 blade; n = 20) release of the A-1 pulley. All patients were evaluated for grip strength, active range of motion of the proximal interphalangeal joint, and residual pain at 1 and 12 weeks after release. Furthermore, the operation time was assessed, and the costs were calculated. Overall, 100% success in terms of grip strength, active range of motion of the proximal interphalangeal joint, and residual pain was obtained in both groups. Mean operation time was significantly longer with the open technique. Because of lower costs and quicker procedure with equal functional outcome when compared with open surgery, we recommend the percutaneous technique using a #15 blade for trigger finger release.     

Sonographically assisted percutaneous release of the a1 pulley: a new surgical technique for treating trigger digit

This study introduces a sonographically assisted percutaneous technique for releasing trigger digits which provides direct visualization of the release and avoids the risks of incomplete release and injury to adjacent neurovascular structures associated with other percutaneous release techniques. The "safe zone" and an estimate of the size of the A1 pulley were determined in a separate cadaver study. We then used these landmarks in a prospective clinical study of 107 digits in 83 consecutive patients treated by this technique. During the follow-ups of between 9 and 15 months, we evaluated 104 digits in 80 patients. Pain was absent in 101 digits (97%) and considerably improved in the other three (3%). All mechanical problems had been resolved and none recurred during follow-up. This technique allows the surgeon to see and monitor, precisely, the percutaneous division of the A1 pulley without open surgery and, therefore, to avoid the inherent risks of percutaneous and open surgical release.     

Percutaneous Release,Open Surgery,or Corticosteroid Injection,Which Is the Best Treatment Method for Trigger Digits?

Background

Percutaneous A1 pulley release surgery for trigger digit (finger or thumb) has gained popularity in recent decades. Although many studies have reported the failure rate and complications of percutaneous release for trigger digit, the best treatment for trigger digit remains unclear.

Questions/purposes

Our aim was to identify the relative risk of treatment failure, level of satisfaction, and frequency of complications, comparing percutaneous release with open surgery or corticosteroid injections for adult patients with trigger digits.

Methods

We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs), comparing percutaneous release with open surgery or corticosteroid injections. Seven RCTs involving 676 patients were identified. Methodologic quality was assessed by the Detsky quality scale. After data extraction, we compared results using a fixed meta-analysis model.

Results

There were no differences in the failure rate (risk ratio [RR] = 0.93; 95% CI, 0.14–6.25) and complication frequency (RR = 0.83; 95% CI, 0.15–4.72) between patients undergoing percutaneous release and open surgery. Patients treated with percutaneous release had fewer failures (RR = 0.07; 95% CI, 0.02–0.21) and a greater level of satisfaction (RR = 2.01; 95% CI, 1.62–2.48) compared with the patients treated with corticosteroid injections. We found no difference in complication frequency between percutaneous release and corticosteroid injection (RR = 3.19; 95% CI, 0.51–19.91).

Conclusions

The frequencies of treatment failure and complications were no different between percutaneous release surgery and open surgery for trigger digit in adults. Patients treated with percutaneous releases were less likely to have treatment failure than patients treated with corticosteroid injections.     

Percutaneous release of trigger digits

Twenty nine patients with 31 trigger digits were treated by percutaneous release under local anaesthesia using an 18 gauge needle. One patient was lost to follow up, and the remainder were examined at a mean follow-up of 14 months. One patient (one thumb) experienced recurrent symptoms, and required an open release. The remaining 27 patients with 29 trigger digits had complete relief of their symptoms.     

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.     

Percutaneous trigger thumb release in children

The objective of this study was to determine whether percutaneous release of the A1 pulley is an adequate treatment of trigger thumb in children. Twenty-three children under the age of 6 years with 27 trigger thumbs fixed in flexion were evaluated prospectively. All were treated with a percutaneous release of the A1 pulley in an ambulatory setting and followed for at least 1 year. Interphalangeal and metacarpophalangeal joint range of motion, pinch strength, static two-point discrimination sensibility, and triggering were examined and compared with the unaffected thumb at the end of follow-up. After a mean follow-up of 3 years, 25 of the thumbs had an excellent result without residual triggering. Two of these thumbs had mild metacarpophalangeal extension deficit 1 month after surgery that resolved completely with specific exercises. One thumb relapsed and required subsequent open release and was considered a poor result. One child was lost to follow-up. There were no sensibility defects, strength loss, interphalangeal motion loss, or metacarpophalangeal hyperextension deformities. Percutaneous release of the A1 pulley is an effective and safe option in the treatment of trigger thumb in children.     

Treating Trigger Finger in Diabetics using Excision of the Ulnar Slip of the Flexor Digitorum Superficialis with or without A1 Pulley Release

The purpose of this study was to evaluate the results of excision of the ulnar slip of the flexor digitorum superficialis tendon, with or without A1 pulley release, for the treatment of trigger finger in diabetic patients. We performed a retrospective review with long-term follow-up examinations. Short-term data was obtained on 18 consecutive patients (37 fingers). Long-term information was collected on 14 of these patients (24 fingers) at an average of 48 months after surgery. Short-term follow-up revealed average proximal interphalangeal joint (PIP) flexion of 81°. One patient had slight residual triggering. At long-term follow-up, 93% of patients were completely or very satisfied with the procedure. Total active finger motion averaged 218°, and PIP extension deficit averaged less than 5°. Pinch strength was equal to the contralateral corresponding finger. There were no significant complications. One finger had minimal residual triggering. In conclusion, this procedure is a safe and effective treatment for the often-difficult problem of stenosing flexor tenosynovitis in the diabetic patient.     

Dorsiflexory Phalangeal Osteotomy for Grade II Hallux Rigidus: Patient-Focused Outcomes at Eleven-Year Follow-Up

Dorsiflexory phalangeal osteotomy has been shown to be an effective treatment for mild to moderate hallux rigidus in short- to medium-term follow-up studies. It is speculated that the procedure alters the mechanical function of the joint and reduces the demand for hallux dorsiflexion by elevating the proximal phalanx into a more dorsiflexed position. However, it has been demonstrated that the first metatarsophalangeal (MTP) joint space and joint range of motion are reduced by the procedure, calling into question the long-term effectiveness of the operation. This study reviewed 27 dorsiflexory phalangeal osteotomy cases at an average of 11 years postoperatively. Twenty-one (77%) patients reported that they were completely satisfied with the results of their surgery; 4 (15%) patients reported that they were satisfied with reservations; and 2 (7%) patients reported that they were dissatisfied. The patients who were satisfied with reservations complained of interphalangeal (IP) joint pain or stiffness. One patient developed second MTP joint metatarsalgia after surgery, and in 1 patient first MTP joint pain returned at 24 months after surgery. One dissatisfied patient complained of second MTP joint metatarsalgia, and a second patient required revision excisional arthroplasty for continued joint pain. Ten patients (38%) reported stiffness of the first MTP joint, but only 2 patients reported any restriction of activity. Footwear restrictions were reported by 15 (58%) patients preoperatively and by 9 (35%) patients at final follow-up. Dorsiflexory phalangeal osteotomy maybe a reliable long-term treatment for grade II or moderate hallux rigidus and is a safe and effective alternative to first MTP joint fusion in joints where movement is still present and joint cartilage is viable.     

Percutaneous release of the trigger finger: an office procedure.

A new technique for percutaneous release of the trigger finger is described. A 21-gauge hypodermic needle is used to release the A1 pulley. The technique is effective, convenient, safe, and well tolerated by patients. Thirty-three of 35 procedures (94%) led to complete relief of symptoms, and in the remaining two digits partial symptomatic relief was achieved. There were no significant complications. After a mean follow-up of 13 months, there had been no recurrences. This technique should be the treatment of choice for the established trigger finger with symptoms of more than 4 months' duration.     

Plantar fascia release through a transverse plantar incision.

A transverse plantar incision for plantar fascial release was assessed for pain relief, numbness, and subsequent heel pad symptoms. Twenty-seven feet in 26 patients who underwent plantar fascia release were reviewed with a minimum follow-up of 2 years after surgery (average, 37.6 months). Comprehensive data were obtained on 25 feet (24 patients) (93% response rate). The plantar fascia origin was completely transected in all cases. This led to complete resolution of symptoms in 19 feet and residual minor symptoms in six feet. After 2 years, four patients had developed recurrent symptoms, two in the area of surgery and two on the dorsum of the foot, in association with a pes planus foot. Two patients had some continued persistence of heel pain after surgery, although significantly less pain than preoperatively.Thus, 76% of patients had complete relieve of there symptoms, 12% of patients had mild symptoms not affecting daily activities, and 12% of patients had moderate symptoms that limited some activities. No patient suffered heel pad symptoms or numbness after surgery. It is concluded that plantar fascia release through a transverse plantar incision is a successful procedure for long-term relief of symptoms which avoids unnecessary heel pad numbness and scar morbidity. The benefits of a transverse incision include greater intraoperative vision, to ensure adequate release and spur excision, and an incision parallel to the medial calcaneal branches of the tibial nerve.     

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. © 2008 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 27: 891–896, 2009     

Arthroscopic medial meniscectomy on stable knees

We reviewed 74 partial medial meniscectomies in 57 patients with stable knees, to assess the long-term functional and radiological outcome. The International Knee Documentation Committee score and the residual laxity were assessed in both knees. At the time of surgery the mean age of the patients was 36 +/- 11 years and the mean follow-up was 12 +/- 1 years. All had a limited medial meniscectomy. The anterior cruciate ligament was intact in all cases. The meniscal tear was vertical in 95% and complex in 5%. The posterior part of the meniscus was removed in 99%. A peripheral rim was preserved in all cases. After 12 years 95% of the patients were satisfied or very satisfied with their knee(s). Objectively, 57% had grade A function and 43% were grade B. The outcome correlated only with the presence of anterior knee pain at final follow-up. In the 49 cases of arthroscopic meniscectomy for which there was a contralateral normal knee there was narrowing of the 'joint-space' in 16% of the operated knees. There was no correlation between this and other parameters such as age or different meniscal pathologies.     

Surgical treatment of the pediatric trigger finger

PURPOSE: The purpose of this investigation is to assess the efficacy of a standardized surgical technique in the treatment of symptomatic trigger fingers in pediatric patients. METHODS: A retrospective study was performed of 18 consecutive patients with 23 trigger fingers treated at our institution between 1996 and 2006. Average age at the time of presentation was 4.5 years (range, 1-12 years). Involved digits included 2 index, 12 long, 3 ring, and 6 small fingers. All patients had surgical treatment consisting of A1 pulley release and resection of a single slip of the flexor digitorum superficialis (FDS) tendon. Average clinical follow-up evaluation was 43 months (range, 3-111 months). RESULTS: In almost half of the cases, triggering was noted to occur at the level of the FDS tendon decussation. In 9 cases, specific tendon pathology was observed, including fusiform thickening, nodular thickening, calcific tendonitis, and cyst formation. Overall, 21 of 23 (91%) fingers demonstrated successful resolution of triggering without recurrence after surgical treatment. One patient had recurrent triggering, which was successfully treated by a second procedure to resect the remaining FDS slip. Another patient was successfully treated with excision of an aberrant muscle belly from the FDS. Both of these patients remained asymptomatic after their revision procedures. No other complications were observed. All patients returned to full activities, and 17 of 18 (94%) patients were satisfied with the results of surgery at most recent follow-up evaluation. CONCLUSIONS: The pediatric trigger finger may be safely and predictably treated by surgical release of the A1 pulley and resection of a single FDS tendon slip.     

Results of surgery after failed attempt at repair of irreparable rotator cuff tear

Twelve patients who had surgery to repair a rotator cuff tear, which could not be repaired because the residual tendon tissue was of poor quality, insufficient, or both, were followed up for a mean of 33 months. At surgery, the deltoid was detached from the acromion for 4 to 6 cm and an acromioplasty was done. Preoperatively, all patients except one had mild to severe pain. The mean active forward flexion, abduction, and external rotation were 75 degrees, 61 degrees, and 22 degrees, respectively. After surgery, of the 11 patients who had shoulder pain preoperatively, 10 reported partial relief of pain and one was pain-free. However, shoulder function deteriorated in 11 patients and remained unchanged in one patient who had a pseudoparalytic shoulder before and after surgery. The mean postoperative values of forward flexion, abduction, and external rotation were 49 degrees, 43 degrees, and 16 degrees, respectively. Only one patient was satisfied with the result of surgery because of pain relief. Two patients had repeat surgery (total shoulder replacement or latissimus dorsi transfer) 6 and 4 months after the index surgery because of unsatisfactory functional results. Attempts at open repair of an irreparable cuff tear should be avoided because functional results generally are poor. When there is a risk that an irreparable tear will be found, open surgery should not be done or alternative procedures should be planned before surgery.     

Trigger thumb: results of a prospective randomised study of percutaneous release with steroid injection versus steroid injection alone

One hundred and twenty-seven trigger thumbs in 115 adult patients were randomised to either percutaneous release with steroid injection (n=66) or steroid injection alone (n=61). Two patients, one from each group, were lost to follow-up. Percutaneous release with steroid injection produced satisfactory results in 91% of cases whereas steroid injection alone produced satisfactory results in 47% of cases. One case in the percutaneous group developed stiffness and one in the injection group developed cellulitis. No digital nerve injury occurred in either group. We conclude that percutaneous trigger thumb release combined with steroid injection has a higher success rate than that of steroid injection alone.     

Early arthroscopic release in refractory shoulder stiffness

Frozen shoulder is still an enigma in shoulder surgery. It is reported that at 2 years after onset most patients will have recovered whether treated or not. To decrease time to recovery and improve the results of this condition, a number of different treatment modalities have been used. In our unit, all patients with frozen shoulder were selected for the arthroscopic release technique if a conservative program of physical therapy had failed to restore motion after 6 months and if they had no known extra-articular contractures. A prospective study was undertaken of 36 patients with refractory frozen shoulder who were treated with an arthroscopic capsulotomy between November 1997 and October 1999. There were 22 women and 14 men with an average age of 49 years (range 32-63 years). All of the patients were assessed for pain, function, and range of motion before surgery. Five patients were diabetic. An arthroscopic capsular release improved motion in all patients, with substantial relief of pain. Follow-up averaged 18 months (range 10-26 months). The median preoperative Constant score rose from 29 to 66 at the time of follow-up. By a mean of 8 weeks after treatment, 75% of the patients had returned to work. One patient developed recurrent refractory stiffness. There were no complications related to the procedure. This study demonstrates that arthroscopic capsular release can be a safe and effective tool in the management of refractory shoulder stiffness and is an effective way of shortening the course of an apparently self-limiting disease.