In Reply

Abstract

We are happy to reinforce the idea that surgery should not be taken lightly—even a trigger release, which is arguably 1 of the simplest and smallest surgeries in any field. On the other hand, our motivation for doing this study was the fact that studies of small series of patients report more minor and major complications than are consistent with our experience. Our concern is that surgeons with a few bad outcomes might decide to publish a small subset of their experience that is neither internally nor externally valid. The data to date are consistent in that most of the adverse outcomes are short-term pain, stiffness, and swelling issues, and major complications such as nerve injury or deep infection are uncommon. Release of an idiopathic trigger digit is an extremely common procedure, so additional data should be easy to come by. Because most hand surgeons release about 100 trigger digits a year, studies of trigger digit should include a minimum of 500 to 1,000 patients. If a practice with 3 to 4 hand surgeons collects information prospectively, it would take about 2 to 3 years to complete a large study. Looking retrospectively as we did is easier, but it will only reliably catch major complications such as nerve injury and deep infection. It is also important to distinguish surgery for pain from surgery for triggering, as we did. In our opinion, saying that 40% of patients have an adverse event after release of a trigger digit is misleading, when this is 1 of the safest and most successful procedures in hand surgery. On the other hand, it is high time that we acknowledge and take a more proactive approach to the human protective response to postoperative pain, even expected pain such as transient scar tenderness. Pain intensity and magnitude of disability after minor hand surgery correlate with symptoms of depression, catastrophic thinking and low self-efficacy, and anxiety in response to pain, with symptoms of depression predominating.1Vranceanu A.M. Jupiter J.B. Mudgal C.S. Ring D. Predictors of pain intensity and disability after minor hand surgery.J Hand Surg. 2010; 35A: 956-960Abstract Full Text Full Text PDF Scopus (153) Google Scholar Our current research focuses on preoperative screening with 2-question measures of symptoms of depression and pain self-efficacy, looking toward preoperative coaching using either a workbook or a 1-on-1 coach, and postoperative telephone or even Web- or app-based coaching to help limit the normal human tendency to feel protective and prepare for the worst in response to pain. This “human safety system” is particularly problematic for intuitive people (concrete thinkers): People who are used to trusting their feelings are less able to distinguish true and false alarms and are therefore less prepared to manage the natural human protective tendencies. Letter Regarding “Adverse Events of Open A1 Pulley Release for Idiopathic Trigger Finger”Journal of Hand SurgeryVol. 37Issue 11PreviewIt was with great interest that we read Bruijnzeel et al's article “Adverse Events of Open A1 Pulley Release for Idiopathic Trigger Finger” in your journal.1 In this large retrospective, the authors found interesting data, especially regarding trigger finger and diabetic disease. The number of patients was impressive, and the authors did a great job. However, the authors stated that about 1 in 20 fingers experienced a mild, transient adverse event (most commonly pain or stiffness) after surgical release of the A1 pulley for idiopathic trigger finger and that about 1 in 200 had a second surgery. Full-Text PDF