A1 Pulley Research Articles

Agrandissement des poulies de l’appareil fléchisseur des doigts par plastie en oméga : étude comparant la désinsertion d’un ou de deux côtés de la poulie A2 et ou A4

The omega plasty on one side of the A2 and or A4 pulley improves the gliding of repaired flexor tendons in zone II. The purpose of this study was whether or not the enlargement of the digital channel was better after the release of one or both sides of each pulley. In fresh cadavers, the technique was to first disinsert the ulnar attachments of the A2 and A4 pulleys and then the radial insertions. An ultrasound was used to measure the large axis, the circumference and the cross-sectional surface of each of A2 and A4 pulleys before release, after ulnar release and after radial release. The release of the A2 pulley reduces the risk of conflict in the sutured flexor tendons in the digital channel. The release of the A4 pulley seems less effective than that of A2. The release of the 2 pulleys reduces the risk of conflict in one sutured zone of the flexor tendons in the digital channel. In all, if there is a conflict between the flexor tendons sutured opposite A2, we recommend an omega plasty on the 2 sides of the pulley. If the conflict appears opposite A4, we recommend the plasty of the 2 sides of A4 and A2.

Ultrasound-guided trigger finger release: A new surgical procedure (50 cases)

Ultrasound-assisted percutaneous trigger finger release, with needles, has shown some incomplete releases and morbidities on tendons and bundles. Some authors have used blades, underlining the necessity of a specially designed blade, which could allow a peroperative ultrasound control with the benefits of percutaneous procedures. Our objective was to analyze the outcomes of a new specific blade to perform an ultrasound-guided percutaneous trigger finger release. Methods Blade specifications: a blunt tip to penetrate intrasheath followed by a sharp blade to cut the pulley, percutaneous (< 2 mm), cheap (no disposable). Cadaveric lab: 6 specimens were operated on both sides, on each fingers except thumbs (48 fingers). We used our specific blade and a Logic GE ultrasound device with a high frequency transducer. We performed a 2 mm incision in the MP skinfold enabling a retrograde section of the A1 pulley during an in-plane approach. Then, we evaluated the tendons and the neurovascular bundles with an open technique. Prospective clinical series: under local anesthesia, 30 consecutive patients were included, 16 grade III–IV, 7 failures of steroid injection in grade I–II and 7 grade I–II diabetic patients without previous injection: 2 forefingers, 19 thirds, 7 middles and 2 littles. Ultrasound-guided steroid injection was done at the end of the procedure in each case. A dressing was kept for two days and a clinical examination was performed after 1 and 3 months. Results Cadaveric (n = 48) none impairment of bundles, 2 superficial tendons lacerations, incomplete section of A1 pulley was observed in only 2 fingers (little). Peroperative (n = 30) duration of surgery was 10 minutes (5–18), trigger release was obtained immediately in all grade III & IV. Clinical outcomes (n = 30): no recurrence of trigger finger was noticed, none sensitive disorders. The satisfaction rate was 96%. Three patients were still painful after 3 months but improved in all three cases: one was a grade IV, two grades I, two littles and one forefinger. Discussion In order to improve our results, we concentrated our work on a dedicated blade, a retrograde section so that we strictly avoided impairment of the A2 pulley an in-plane ultrasound approach to get a continuous and direct visualization of the A1 pulley section, a steroid injection at the end of the procedure to improve pain relief and efficiency. Ultrasound-guided trigger finger release, with this procedure, is reliable and efficient on trigger release, without specific morbidity.

Outcomes of percutaneous trigger finger release with concurrent steroid injection

Percutaneous release (PR) of the A1 pulley is a quick, safe, and minimally invasive procedure for treating trigger fingers. The purpose of this study is to identify if PR with additional steroid injections can shorten the recovery to reach unlimited range of motion. Between January 2013 and December 2013, we included 432 trigger fingers with actively correctable triggering or severer symptoms without previous surgical release or steroid injections from two hand clinic offices (A and B). The same experienced surgeon performed PR at the office. Patients from Clinic A received PR with steroid injections and those from Clinic B received PR without steroid injections. Patients returned for follow-up 1 week, 6 weeks, and 12 weeks after the procedure. Between the steroid group and the nonsteroid group, there is no significant difference in the mean time for patients to return to normal work and the rate of residual extensor lag. Middle fingers showed a 5.09-fold chance of having a residual extensor lag over that of the other fingers. High grade trigger fingers recovered more slowly than low grade ones. The success rate of a 12-week follow-up was 98.4%. There was no significant difference between the steroid group (97.5%) and the nonsteroid group (99.1%). PR can treat trigger fingers effectively, but additional steroid injection does not provide more benefit. Some fingers showed temporary extensor lag, especially in middle fingers and high grade trigger fingers, but 85% of those will eventually reach full recovery after self-rehabilitation without another surgical release.

High-resolution ultrasound in the diagnosis of trigger finger and evaluation of response to steroid injection

No studies have reported the use of ultrasound for the evaluation of trigger finger after steroid injection. We evaluated the clinical features and ultrasound appearance of trigger finger before and after steroid injection under ultrasound guidance. Thirty-eight digits with triggering were included. A single steroid injection into the tendon sheath was administered. Ultrasound findings and clinical symptoms, including pain, triggering, and the Quinnell score, were analyzed before injection and at 1 and 3weeks after injection. Ultrasound indicated that the thickness of the flexor tendons and the thickness of A1 pulleys were significantly greater in the trigger fingers than in controls before steroid injection. Three weeks after injection, these two parameters decreased, and there was no significant difference in the two parameters between the trigger finger and the controls. The visual analogue scales at 1 and 3weeks after the injection were significantly lower than those before the injection. The Quinnell grading system scores significantly improved at 1 and 3weeks after injection compared with the scores before injection. Moreover, a tendency was seen for the more clinically severe cases to show more swelling of the tendon and pulley. In conclusion, ultrasound assessments could reveal that the thickened A1 pulley and flexor tendon significantly improved after steroid injection, which enables us to confirm the therapeutic effects of the steroid injection. Therefore, ultrasound assessments can be a useful adjunct to understand the response to treatment with the steroid injection.

Acupuncture for the treatment of trigger finger in adults: a prospective case series.

To determine the effect of acupuncture performed at the synovial and ligamentous tendon sheath (A1 pulley site) on pain during snapping and the severity of the snapping phenomenon in patients with trigger finger. In this observational study, changes in the patients' condition were compared before and after acupuncture treatment. Acupuncture was performed on 19 fingers of 15 patients. Acupuncture needles were inserted into the radial and ulnar sides of the flexor tendon at the A1 pulley of the affected finger. Treatment was performed daily up to a maximum of five times. Before and after each treatment, pain during snapping and the severity of snapping were evaluated using a visual analogue scale (VAS). VAS scores for pain and snapping severity were significantly improved immediately after the first treatment (p<0.001). Pain during snapping, assessed before each treatment, improved over time, reaching statistical significance from the second treatment onwards (p<0.001); similarly, a significant improvement in the severity of snapping was observed, also from the second treatment (p<0.001). Patients with clinically significant improvements (≥50%) in pain and snapping severity had a significantly shorter duration of the disorder than those with <50% improvement (p<0.05). Acupuncture at the impaired A1 pulley site may be an effective treatment for trigger finger. We postulate that acupuncture may reduce inflammation/swelling of the synovial membrane of the tendon sheath, which predominates when the disorder is of short duration. Further research is required to confirm the efficacy/effectiveness of acupuncture for trigger finger and its mechanisms of action.

Commentaries on Clinical results of releasing the entire A2 pulley after flexor tendon repair in zone 2C. K. Moriya, T. Yoshizu, N. Tsubokawa, H. Narisawa, K. Hara and Y. Maki. J Hand Surg Eur. 2016, 41: 822-28.

Commentaries on Clinical results of releasing the entire A2 pulley after flexor tendon repair in zone 2C. K. Moriya, T. Yoshizu, N. Tsubokawa, H. Narisawa, K. Hara and Y. Maki. J Hand Surg Eur. 2016, 41: 822-28.

Percutaneous Trigger Release in Non-Triggering Digits: Infiltration of Normal Saline into Tendon Substance to Induce Triggering.

Percutaneous trigger release is recognized as an effective minimally invasive procedure with a low complication rate. One prerequisite for percutaneous trigger release is a trigger of Quinnell Type II or higher; that is, a digit that is actively triggering. We describe an additional step in percutaneous trigger release, which enables the surgeon to perform the procedure in digits that are not actively triggering at the point of surgery. This step involves the infiltration of normal saline into the tendon substance distal to the A1 pulley in order to induce triggering.

The Flexor Tendon Pulley System and Rock Climbing

Rock climbing has increased in popularity over the past two decades. Closed traumatic rupture of the finger flexor tendon pulleys is rare among the general population but is seen much more commonly in rock climbers. This article reviews the anatomy and biomechanics of the finger flexor tendon pulleys, how they may be injured in rock climbing and how these injuries are best diagnosed and managed.

Quantitative Measurements of Cross-sectional Configuration of Flexor Pollicis Longus Tendon Using Ultrasonography in Patients With Pediatric Trigger Thumb

Hypothesis: Pediatric trigger thumb is characterized by flexion deformity of the interphalangeal joint of the thumb. It usually occurs spontaneously in the childhood and can be resolved spontaneously without any treatments. The purpose of this study is to verify the causes of the flexion deformity of the thumb. Methods: We enrolled 42 patients who were diagnosed as pediatric trigger thumb with unilateral involvement and underwent ultrasonographic measurements of the flexor pollicis longus tendon at the level of A1 pulley and 1 cm proximal to the A1 pulley. The measurements were repeated in the contralateral normal side. The average age at the time of measurements was 33 months. Results: In the side of pediatric trigger thumb, the average anteroposterior and radioulnar diameters of the flexor pollicis longus tendon at the level of A1 pulley were 2.9 and 2.3 mm, respectively, and those 1 cm proximal to the A1 pulley were 4.5 and 2.7 mm, respectively. In the contralateral normal side, the average anteroposterior and radioulnar diameters of the flexor pollicis longus tendon at the level of A1 pulley were 3.0 and 2.0 mm, respectively, and those 1 cm proximal to the A1 pulley were 3.3 and 1.8 mm, respectively. The average ratio of the anteroposterior diameter of the flexor pollicis longus tendon 1 cm proximal to the A1 pulley compared with the A1 pulley was 1.58 in the side of pediatric trigger thumb, and 1.08 in the contralateral normal side. The average ratio of the radioulnar diameter of the flexor pollicis longus tendon 1 cm proximal to the A1 pulley compared with the A1 pulley was 1.17 in the side of pediatric trigger thumb, and 0.95 in the contralateral normal side. Conclusions: In the comparison of the cross-sectional configuration of the flexor pollicis long tendon and inner area of the A1 pulley, the anteroposterior and radioulnar diameters of the flexor pollicis longus tendon were more increased than those of inner area of the A1 pulley. The anteroposterior diameter of the flexor pollicis longus tendon was 58% longer than that of inner area of the A1 pulley, and the radioulnar diameter of the flexor pollicis longus tendon was 17% longer than that of inner area of the A1 pulley. The flexor deformity of the interphalangeal joint can be caused by increased anteroposterior diameter of the flexor pollicis longus tendon.

Variations of the Pulley System of the Thumb

Background: Originally described by Doyle and Blythe, and perpetuated in hand surgery treaties since, 3 pulleys have been described in the thumb: A1, O, and A2. Ever since Schmidt in 1999 showed that these pulleys were only present in 10% of all thumbs, this system has been in revision. Multiple authors have found variations both in the disposition and quantity of elements that form them. Methods: This is an observational study, based on dissection of 17 hands in our human anatomy department. In 3 of the cadavers, only one hand was dissected, due to prior injury or prior dissection without preservation of the pulley system. Under surgical loupes of 3.5 × magnification, we performed a Brunner-type zig-zag incision on the column of the thumb, allowing identification of the thumb’s sheath and pulleys. Two independent investigators determined pulley type and measurement with a manual caliper, with the thumb in extension. The average of both measurements was used. Results: Five pulley types were identified and cataloged according to Schubert’s classification. Type I is the original disposition with an A1 pulley, an oblique pulley, and an A2 pulley. Type II presents an A1, a variable pulley (Av), oblique, and A2, with A1 and Av being parallel. Type III presents A1, Av, oblique, and A2, with A1 and A2 fused. We found a fifth type, with A1, Av, oblique, cruciform, and A2. Our results show type I 11.8% (n = 2), II 17.7% (n = 3), III 29.4% (n = 5), IV 29.4% (n = 5), and V 5.8% (n = 1). Conclusions: From the literature reviewed and our own series, we have found that the classical description of the pulley system is not the most frequent one. As a matter of fact, it represents only 11.8% in our series, with systems in which 4 pulleys were present accounting for 76.7% and 5 pulleys 5.8%. This fact must be accounted for in current hand surgery to avoid misconceptions in thumb anatomy. We believe that accurate anatomical of the pulley system of the thumb may have repercussions for some procedures, such as triggering thumb surgery.

Multistrand Tendon Repairs With Early Active Motion Versus 2-Strand Repairs With Passive Motion

Objective: To report the results of an audit of repair of zone 2 flexor tendons in 68 digits using two different repair methods and rehabilitation protocols. Materials and Methods: From January 2014 to January 2015, we treated 35 digits in 21 consecutive patients who had complete divisions of flexor tendons in zone 2. All tendon repairs followed an established surgical and rehabilitation protocols. The flexor digitorum profundus (FDP) tendons in 31 fingers and flexor pollicis longus tendons in 4 thumbs were repaired using either 6-strand M-Tang or 4-strand U-Tang methods. In 13 fingers, we vented part of the A2 pulley, and the entire A4 pulley was vented in 5 fingers. Active digital motion started from 4 days post-surgery. In 2013, the same surgical team repaired zone 2 flexor tendons in 25 consecutive patients (33 digits) with a conventional 2-strand modified Kessler repair with a passive motion protocol. Their outcomes were collected as the historical controls. Results: In evaluations of 35 digits with multistrand repair with early active motion 10 to 16 months postsurgery, the outcomes were excellent in 27 (80%), good in 3 (8.5%), fair in 3 (8.5%), and poor in 1 (2.2%) digits according to Strickland and Glogovac criteria. There were no repair ruptures. Four thumbs were all rated as excellent. No bowstringing was found in the 18 fingers, where either a part of the A2 pulley or entire A4 pulley was vented. The outcomes of 33 digits with a modified Kessler repair with passive motion were excellent in 13 (39.3%), good in 9 (27.2%), fair in 4 (12.1%), and poor in 7 (21.1%) digits. Repair ruptures were noted in 6 (18.2%) digits. Conclusions: Multi-strand core repairs with early active motion significantly improve outcomes over a conventional 2-strand repair with early passive motion in zone 2 flexor tendon repair.

The Role of Botulinum Toxin A in the Treatment of Raynaud Phenomenon.

Raynaud phenomenon (RP) is a transient digital ischemia that occurs after exposure to cold temperature or emotional distress. It presents with a triphasic course: the initial white phase is followed by cyanotic discoloration and, subsequently, erythema. The attacks may be associated with pain, paresthesia, and complicate with nonhealing ulceration often leading to amputation. To date, there are no clear-cut therapeutic guidelines and many medications are used off-label. Encouraging results were reported with the use of botulinum neurotoxin-A (BoNT-A). However, there is still ongoing debate regarding indications, contraindications, best injection technique, and mechanism of action. The aim of this study was to address these issues by providing an up-to-date and detailed overview of the use of BoNT-A in RP.A PubMed database search was conducted. The available studies and techniques were evaluated and compared.The search yielded a total of 29 studies. Ten papers, published between 2004 and 2014, were considered relevant. A total of 128 patients underwent BoNT-A injections. Seventy-five percent to 100 % of the patients reported pain reduction after treatment. Healing of ulcers was reported in 75% to 100% of the affected patients. The most common complication was temporary hand weakness, with an average incidence of 14.1%. Injections targeting the neurovascular bundle at or slightly proximal to the A1 pulley were the most commonly performed.Botulinum neurotoxin-A injection proved to be a valid approach in both primary and secondary RP. The available evidence shows the achievement of both symptomatic and functional improvements in this debilitating condition. However, the patient should be adequately informed about the risk of transient hand weakness.

Pulley Reconstruction to Correct the Dynamic Direction of the Finger for Treatment of IIB Cleft Hand

Purpose: Manske IIB cleft hand is the most common type, which is characterized by severely narrowed first web and rotation of index finger. Some patients suffered from ulnar displacement of flexor tendon system. However, the ulnar displacement was poorly corrected during index to middle transposition during previous procedures and would usually lead to dysfunction of pinch and grip. Here, we developed a new method to correct finger dynamic direction by pulley transposition. Method: In 15 cases with Type IIB cleft hand, incisions from A1 to A2 pulleys were made with pedicle transposition of the flexor tendon and sheath system to the central. A1 pulleys of index and ring fingers were separated to reconstruct transverse ligament. Snow-Littler procedures were performed to reconstruct the first web. Postoperative assessment included subjective considerations of appearance, parent satisfaction, and ability to perform daily activities. Objective assessment included measurement of first web space, index-ring metacarpal separation, pinch strength, and rotation of the index finger. Results: All the patients and parents claimed to be satisfied with the surgery. Pinch grip reached 72% of the opposite hand when that was normal. The radiological measurement of the angle between the first and second metacarpals was 60.8º and the distance between the adjacent metacarpals across the closed cleft was 8 mm. Index rotation was only 1º and the mean thumb-index pinch was 5.6 kg. Conclusions: Pulley transposition can correct the ulnar displacement of flexor tendon system and improve pinch grip strength in Manske IIB cleft hand, which is a supplemental method for physiological and aesthetic reconstruction of cleft hand.

Outcomes of the 6-Strand M-Tang Repair for Zone 2 Primary Flexor Tendon Repair in 45 Digits

Objective: To report the clinical and functional outcomes of our patients with complete divisions of flexor tendons in zone 2 using a 6-strand core M-Tang repair method and partial early active motion protocol and examines the possible factors affecting the functional outcomes. Materials and Methods: We conducted a retrospective review of all patients who underwent flexor tendon in zone 2 of digits repair from November 2013 to July 2015 by a single surgeon in our department. A total of 45 digits (8 thumbs and 37 fingers) in 36 consecutive patients (9 females and 27 males) with complete divisions of flexor digitorum profundus (FDP) tendon, with or without concomitant flexor digitorum superficialis (FDS) lacerations in zone 2 of digits were included. We repaired flexor tendons in zone 2 using a 6-strand core M-Tang repair method using two groups of looped nylon sutures and partial early active motion protocol starting from postoperative day 4. We analyzed the different excellent and good rates of digits of different variables using the Fisher discriminate analysis. Results: The patients were followed for 7 to 18 months after surgery, and functional outcomes were evaluated with Strickland criteria. The recovery of function was excellent in 31 (68.9%), good in 8 (17.8%), and fair in 6 (13.3%) digits. There were no repair ruptures. No bowstringing was found in the fingers after venting of a part of the A2 pulley during follow-up. No significant differences were observed in the excellent/good rate among all different digits. However, we found that the recovery outcome of male patient was greater than female patient ( P, .002). Conclusions: We conclude that the 6-strand M-Tang core repair combined with partial early active motion is safe, and outcomes of the repair are generally good or excellent when surgeons and therapist follow the surgical and rehabilitation guidelines.

Cost Savings, Safety, and Patient Satisfication of a Clinic-Based Wide Awake Hand Surgery Practice: A Critical Review of the First 100 Procedures.: Level 2 Evidence

Speakers Bureau: Trimed Inc.(Rhee) Wide awake local anesthesia no tourniquet (WALANT) hand surgery was developed to improve access to hand surgery care while optimizing medical resources. Hand surgery in the clinic setting may result in substantial cost savings and provide a safe alternative to performing similar procedures in the operating room. A prospective cohort study was performed on the first 100 consecutive clinic-based WALANT hand surgery procedures performed at a military medical center from January 2014 to September 2015 by a single hand surgeon. Cost savings analysis was performed by utilizing the Medical Expense & Performance Reporting System (MEPRS), the standard cost accounting system for the military healthcare system (MHS), to compare procedures performed in the clinic versus the operating room during the study period. Utilizing a study-specific questionnaire, patient satisfaction, pain, and perioperative anxiety analyses were performed. The WALANT procedures consisted of carpal tunnel release (CTR, n = 34), A1 pulley release (APR, n = 33), de Quervain release (dQR, n = 4), hardware or foreign body removal (n = 14), phalangeal fracture pin fixation (n = 9), tendon repairs (n = 3), nail horn excisions (n = 2), and extensor carpi ulnar debridement (n = 1). For CTR and APR alone, there was an 85% and 70% cost savings by having the procedures performed in clinic under WALANT compared to the main operating room (OR), respectively. During the 21-month study period, CTR, APR, and dQR performed in the clinic, instead of the OR, amounted to $393,099.53 in cost savings for the MHS. Overall, 94% (62 of 66) of patients stated that they would choose WALANT again for a subsequent procedure. For 71% (47 of 66) of patients, the perioperative pain was less than a dental procedure and the mean anxiety levels (10 being the worst amount of anxiety) before, during, and after the procedures were 2.8 ± 3.4, 2.4 ± 3.2, and 0.4 ± 1.0 respectively. There were 3 complications; however, none were attributable to the WALANT procedure. •A clinic-based WALANT hand surgery program results in considerable cost savings.•Performing clinic-based WALANT hand surgery is safe without any increase in complications attributed to the WALANT procedure.•Patients tolerate the WALANT procedures well with low peri-operative pain and anxiety.•Patient satisfaction is high for clinic-based WALANT hand surgery.

Effect of Metabolic Syndrome on the Outcome of Corticosteroid Injection for Trigger Finger: Matched Case-Control Study

To compare the efficacy of corticosteroid injections in treating trigger finger in patients with and without metabolic syndrome (MS). Fifty-one patients with trigger finger and MS were matched for age and sex with 52 control patients without MS. All patients were treated with a single corticosteroid injection. The response to treatment, including objective triggering, tenderness at the A1 pulley, and Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDASH) were assessed at 6, 12, and 24 weeks' follow-up. Before the 24-week evaluation, 7 in the MS group and 10 in the control group were lost to follow-up. Prior to treatment, patients with MS had Quinnell grades and initial mean QuickDASH scores similar to those in the control group. The proportion of treatment failure for the MS group (49%) was significantly higher than that of control group (19%) after 6 months' follow-up. Unresolved triggering was more prevalent in patients in the MS group at the 12- and 24-week follow-ups. Local tenderness was more persistent in the MS group than in the control group throughout the 24 weeks of follow-up. After 24 weeks of follow-up, 14 patients (27%) in the MS group and 6 (12%) in the control group underwent surgical release. QuickDASH scores of the MS group were worse than those of the control group at the 12- and 24-week follow-ups. Trigger finger patients with MS are at risk of poorer functional outcomes and treatment failure after a single corticosteroid injection than age- and sex-matched controls. Therapeutic III.

Cadaveric Investigation of Active Finger Range of Motion for Detection of Intratendinous Needle Placement

The authors' purpose was to determine if investigators can predict whether a needle is within a finger's flexor tendon by postinsertion tactile and visualization evaluation in an active range-of-motion cadaver model. In 48 cadaver fingers, a 25-gauge needle, with a 1-cc syringe attached, was placed into one of three randomly assigned positions at the A2 pulley level: within the flexor digitorum profundus, within the flexor digitorum superficialis, or outside both flexors and the sheath. Each finger was cycled through full active range of motion as three hand surgeons, blinded to each other's responses and needle position, recorded whether they thought the needle was intratendinous. The initial investigator confirmed needle position after each surgeon's assessment. Active cadaver finger range of motion did not allow surgeons to accurately determine whether a needle was in a flexor tendon. There was no statistically significant agreement among the surgeons about whether the needle was intratendinous. Because of poor interobserver agreement, sensitivity, and negative predictive value, we conclude that finger range of motion is not a reliable test to detect intratendinous needle placement in this cadaver model.

The Relationship Between the Intercrease Line and the A1 Digital Pulley: A Cadaveric Study.

Accurate identification of surface anatomy is critical to identify the location of the A1 pulley. The intercrease line (ICL) describes a transverse line between the radial edge of the proximal palmar crease and the ulnar edge of the distal palmar crease. We hypothesize that this easily identifiable surface landmark approximates the location of the A1 pulley. The ICL was marked on 7 cadaver hands. We marked a point proximal to the proximal digital crease (PDC) equal to the distance between each digit's proximal interphalangeal crease (PIC) and PDC (the PIC/PDC point). We calculated the distance between PIC/PDC points and proximal edge of the A1 pulleys. The ICL was proximal to A1 in all digits. The PIC/PDC point was distal to A1 in the ring finger, and proximal to A1 in the index, middle, and small fingers. The PIC/PDC point was closer to the A1 pulley than the ICL in the middle and ring fingers. Despite less accuracy than the PIC/PDC point at approximating the location of the A1 pulley, the ICL is reliably proximal to the A1 pulley.

Split-tendon Flexor Pulley Reconstruction with Application of Tendon Rod

Purpose: Flexor pulley reconstruction is a challenging surgery. Regardless of the reconstructive technique used, the surgeon should make every effort to imitate the length, tension and glide of the normal pulley. We describe in the present study a new method for pulley reconstruction in using a split tendon graft. Patients and methods: Twelve adult patients had A2 and/or A4 pulley reconstruction using split-tendon during application of tendon rod as a first stage tendon reconstruction. This was followed by application of an autogenous tendon graft in a second stage 12 weeks from the first stage. Patients were followed for 6 months after the second stage. Results: All patients recovered a satisfactory range of motion with an average finger to palm distance of 16 mm. Conclusion: The described technique is versatile and provides an autogenous thin graft that is free of donor site morbidity with excellent tendon gliding.

Impact of Corticosteroid Injection Site on the Treatment Success Rate of Trigger Finger: A Prospective Study Comparing Ultrasound-Guided True Intra-Sheath and True Extra-Sheath Injections

The aim of this study was to investigate whether differences in corticosteroid injection site influence the therapeutic effect on trigger finger and thickness of local structures such as the A1 pulley and flexor tendons. Previously untreated trigger fingers were randomly assigned to receive either a true intra-sheath (group I) or an extra-sheath (group E) injection under ultrasonographic guidance. Symptom remission and recurrence rates and recurrence timing did not significantly differ between the groups. Ultrasonography revealed mean (standard deviation) pre-injection A1 pulley thicknesses of 1.1 (0.3) and 1.1 (0.2) mm in groups I and E, respectively. One month after injection, these decreased to 0.7 (0.2) and 0.8 (0.2) mm, respectively (p < 0.05). Furthermore, mean (standard) pre-injection flexor digitorum tendon thickness was 4.1 (0.4) and 4.0 (0.5) mm in groups I and E, respectively, and, 1 mo after injection, decreased to 3.9 (0.3) and 3.8 (0.5) mm, respectively (p < 0.05). However, the difference at each time point between the two groups was not statistically significant. True intra-sheath injection offers no apparent advantage over extra-sheath injection for treating trigger fingers because both have the same effect on local structures.