Percutaneous A1 Pulley Release Research Articles

A study of 60 patients with percutaneous trigger finger releases: clinical and ultrasonographic findings

We present the clinical results and ultrasonographic findings of 61 trigger digits treated with percutaneous A1 pulley release. An endoscopic carpal tunnel knife was used for the release in the outpatient department. The mean follow-up period was 3.5 months. A total of 55 digits (90%) had complete relief of their triggering postoperatively. Six digits (10%) had Grade 2 triggering clinically in the early postoperative period.The complications included six cases of insufficient release (10%), scar sensitivity in one patient, short-term hypoaesthesia in three digits (5%), and flexor tendon laceration noted on postoperative ultrasonography in eight digits (13%). No neurovascular damage was noted on the postoperative ultrasonography. Ultrasonograpy provides information about tendon laceration and changes in thickness of the pulleys and confirm A1 pulley release after surgery, but it does not alter clinical decision-making. We believe that pre- and postoperative ultrasonograpy does not need to be included as a routine examination.

Complex Regional Pain Syndrome Following Percutaneous Trigger Thumb Release

Trigger finger is one of the most common causes of hand pain and disability. Persistent trigger finger after conservative treatment has been managed with surgical release of the A1 pulley. Percutaneous A1 pulley release is being increasingly performed and many authors have reported comparable outcomes with open surgical release. However, complications have been reported, including incomplete release, flexor tendon injury, and neurovascular injury due to the blind nature of the procedure. We report on a case of a 49-year-old female who presented with features of a type I complex regional pain syndrome (CRPS) following percutaneous A1 pulley release. CRPS is a relatively common complication occurring after trauma and surgical procedures of the upper extremities. We experienced a case of CRPS following percutaneous A1 pulley release which was treated effectively following early diagnosis and through a multidisciplinary approach including physical therapy and medication.

Percutaneous A1 Pulley Release by the Tip of a 20-G Hypodermic Needle Before Open Surgical Procedure in Trigger Finger Management

The objective of the study was to assess the safety, the efficacy, and the result of percutaneous A1 pulley release, using the tip of a 20-G hypodermic needle; the study included 17 patients with 27 trigger digits (18 grade IIIA, 8 grade IIIB, and 1 grade IV). All the patients were assessed by the total range of motion of the affected digit, the visual analog scale score, and the Disability of Arm Shoulder Hand score, before and after the procedure and during the follow-up at 2, 6, 12, and 24 weeks, and then every 3 months, and the improvement was assessed by one sample t test. Sixteen patients with 26 trigger digits (95.4%) showed complete relief of symptoms with no recurrence and a statistically significant improvement in the range of motion, the visual analog scale score, and the Disability of Arm Shoulder Hand score with a P-value <0.0001, which concludes that the procedure is safe, effective, and highly successful with good results and lower complications, comparable to those reported in papers on open release for grade III and IV trigger fingers.

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

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. 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. 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. 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). 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.

Development of a special needle knife for percutaneous A1 pulley release

Development of a special needle knife for percutaneous A1 pulley release

Sonographically Guided Percutaneous First Annular Pulley Release

The purpose of this study was to assess the safety of sonographically guided percutaneous finger and thumb first annular (A1) pulley releases performed using needle and hook knife techniques in an unembalmed cadaveric model. A single operator completed 50 (40 fingers and 10 thumbs) sonographically guided percutaneous A1 pulley releases in unembalmed cadavers using previously described needle and hook knife techniques and simulated local anesthesia. Half of the fingers and thumbs were completed with each technique. An experienced observer blinded to the technique dissected each specimen and assessed for neurovascular, flexor tendon, and A2 pulley injury. Completeness of release was also recorded as a secondary outcome. No neurovascular or A2 pulley injury occurred in any digit, regardless of technique. No significant flexor tendon injury was seen in any digit, although minor surface scratches were visualized in 3 cases (6%; 2 knife and 1 needle). The hook knife technique was significantly more likely to result in a complete pulley release compared to the needle technique (22 of 25 [88%] versus 8 of 25 [32%]; P < .001). Sonographically guided percutaneous A1 pulley releases can be performed safely using previously described needle and hook knife techniques. The safety margin for thumb releases is less than that for finger releases, particularly with respect to the radial digital nerve. These cadaveric data support recently published clinical investigations recommending consideration of sonographically guided percutaneous A1 pulley release in the management of patients with a disabling trigger finger.

Anatomic Outcome of Percutaneous Release Among Patients With Trigger Finger

To investigate the adequacy and safety of percutaneous trigger finger release on symptomatic patients. Two orthopedic non-hand surgeons performed percutaneous A1 pulley release on the thumb, index, middle, and ring fingers with the use of a 19-gauge needle in 25 fingers of 24 patients. Open inspection was then performed to determine the extent of release and any injury to the surrounding anatomic structures. Triggering was eliminated in all fingers. Of the 25 A1 pulleys, 19 were partially released; only 6 were completely released. Noted injury included only superficial abrasions in 15 tendons. None of the patients had injury to the digital artery or nerve. In the percutaneous release of trigger fingers, complete anatomic release of the A1 pulley is not always adequately achieved, even though clinically patients experience relief of triggering. It is a safe procedure for the thumb, index, middle, and ring fingers as long as the recommended technique is observed.

Percutaneous A1 pulley release vs steroid injection for trigger digit: the results of a prospective, randomized trial

This study compared the results of percutaneous A1 pulley release and steroid injection in 105 trigger digits in 95 patients. The patients were randomly assigned to either surgery (43 patients, 46 digits) or steroid injection (52 patients, 59 digits). The results were assessed at 1 and 6 months and the measurements included rate of recurrence (primary outcome measure), pain on movement, active range of movement of the affected digit and grip strength. No recurrences were seen at 1 month. At the 1 month assessment, patients after steroid injection achieved greater active range of movement of the fingers (270° vs 264°) and stronger grip (99% vs 85%) than those treated by percutaneous release. At the 6 month assessment six recurrences (11%) occurred in the steroid injection group and none in the percutaneous release group (P = 0.005). Patients after percutaneous release had less pain on movement of the involved digit (VAS 0.4 vs 1.3), but still had lower AROM of the fingers (265° vs 270° after steroid injection). We conclude that percutaneous A1 pulley release is more effective medium-term therapy for trigger digit than steroid injection, because of lower risk of recurrence.

The efficacy of percutaneous A1 pulley release fortrigger finger treatment

The efficacy of percutaneous A1 pulley release fortrigger finger treatment

Percutaneous release of trigger thumb: do we really need steroid?

We would like to comment on the article by Cebesoy et al. entitled “Percutaneous release of the trigger thumb: is it safe, cheap and effective?” [2]. First, we would like to congratulate the authors for their contribution to the relevant literature. We know that percutaneous A1 pulley release is being increasingly used as an alternative to open surgical release and conservative treatment of the trigger digit. However, most hand surgeons are hesitant to release the A1 pulley of thumb percutaneously due to the close proximity to the digital nerve. That is why most surgeons choose open surgery or steroid injection alone for the trigger thumb. In the authors’ study, 84% of trigger thumbs (21 of 25) were cured by percutaneous release of the A1 pulley with steroid injection [2]. In a recent valuable study, authors found that a percutaneous trigger digit release resulted in high percentage of successful releases of A1 with no steroid injection [1, 3, 4]. In another study, steroids are found to be a highly effective treatment of trigger digits [5]. In the authors’ study, was this high success rate related more to percutaneous release or more related with steroid injection? And what is the contribution of steroid injection to this procedure? The authors’ study is extremely valuable, but if they had an isolated control group consisting of patients treated by percutaneous release of A1 pulley or by steroid injection group, then the comparison and distinction would be much easier. We agree with the authors: percutaneous release is a safe and effective technique which provides significant cost savings. But do we need to increase this cost by using steroids?

Percutaneous Release of A1 Pulley

We performed 100 percutaneous releases of the trigger digits in a cadaveric model using an 18-gauge needle. Successful percutaneous release was achieved for only 59 digits (59%). No neurovascular injury occurred. We found that a percutaneous trigger digit release resulted in high percentage of incomplete releases of A1 pulley, especially in the thumb, index, and little fingers.

Efficacy of a Percutaneous A1 Pulley Release Technique With Identification of Anatomic Differences Between Genders

This cadaver study investigates the efficacy and safety of the Biomet knife and technique for percutaneous A1 pulley release. We also evaluate the anatomic relationship between specific palmar surface landmarks and relevant underlying structures and identify differences between genders. Eighty percutaneous A1 pulley releases, excluding the thumb, were performed on 20 fresh human cadaver hands (10 male, 10 female). Complete release was obtained in 60 of 80 fingers. Success rates for each surgeon improved markedly as the study progressed. There were no significant differences between males and females regarding the distance between a standardized incision site and the proximal edge of the A1 pulley. A learning curve exists for percutaneous A1 pulley release using the Biomet knife and technique. The extended distal palmar crease is a reasonable incision site for percutaneous release of the index, middle, and ring A1 pulleys in both men and women as the A1 pulley begins just distal to this surface landmark.

Safe Treatment of Trigger Finger with Longitudinal and Transverse Landmarks: An Anatomic Study of the Border Fingers for Percutaneous Release

Transverse landmarks have recently been determined to predict the proximal and distal edges of the A1 pulley for trigger finger release. Percutaneous A1 pulley release has been discouraged for the border digits because of the risk of injury to the neurovascular structures of the index and small fingers. The purpose of the study was to identify longitudinal surface landmarks to prevent injury to the neurovascular bundles during percutaneous A1 pulley release of the ulnar and radial border digits. Longitudinal surface landmarks were identified and marked on 29 cadaver hands. Proximal and distal landmarks for the longitudinal vector through which the A1 pulley of the small finger was released include the midline of the proximal digital crease and the scaphoid tubercle. Proximal and distal landmarks for the longitudinal line through which the index finger A1 pulley was released include the midline of proximal digital crease and radial edge of the pisiform. Longitudinal incisions were performed between these landmarks, straight through the skin and deep enough to score the A1 pulley. The distance of the medial edge of the neurovascular structures from the longitudinal incision in the A1 pulley was measured for each small finger and index finger. Using these longitudinal landmarks for the index and small fingers, none of the neurovascular structures was injured while performing these longitudinal incisions through the skin, scoring the A1 pulley. In fact, the average distance for the neurovascular structures from the longitudinal vector of the small finger was 5.4 +/- 1.4 mm radially and 6.7 +/- 1.9 mm ulnarly. The average distance for the neurovascular structures from the longitudinal line of the index finger was 8.5 +/- 1.8 mm radially and 6.2 +/- 1.7 mm ulnarly. Based on the findings of this anatomical study, these longitudinal landmarks can be used to avoid injury to neurovascular structures in the management of trigger finger involving the border digits with steroid-injection, open, or percutaneous A1 pulley release.

Trigger digits: diagnosis and treatment.

Stenosing tenosynovitis of the thumb and fingers is a very common problem seen by the primary-care physician, the orthopaedic surgeon, and the hand surgeon. Primary stenosing tenosynovitis is usually idiopathic and occurs more frequently in middle-aged women than in men, but can be seen even in infancy. Secondary stenosing tenosynovitis of the digits can occur in patients with rheumatoid arthritis, diabetes mellitus, gout, and other disease entities that cause connective tissue disorders. The diagnosis of triggering digits is generally not subtle and can be made on the basis of an adequate clinical examination. Classification according to the type of tenosynovitis and the time from onset of symptoms may be prognostically significant and may also affect the treatment outcome. As many as 85% of triggering fingers and thumbs can be treated successfully with corticosteroid injections and nonsteroidal anti-inflammatory drugs. Surgical release is generally indicated when nonoperative treatment fails. Percutaneous A1 pulley release can now be performed safely as an office procedure.

Percutaneous A1 Pulley Release a Clinical Study.

Percutaneous A1 pulley release is being increasingly used as an alternative to open surgical release and injection of local steroids for the treatment of the trigger digit. In 31 cases (26 patients), a percutaneous release was performed with a 14-gauge intravenous catheter needle under local anaesthesia in the outpatient setting. We report a 97% successful release and only one case of incomplete release. There were no digital nerve injuries, flexor tendon injuries, bowstringing or infections. By two months, all the patients had no pain at the operative site, and their preoperative range of motion had returned or improved. The percutaneous release is a safe and effective technique which provides significant cost savings. We recommend the percutaneous technique for typical cases of trigger finger with a palpable nodule and reproducible mechanical triggering. We recommend a steroid injection for patients with tenosynovitis and those who do not have reproducible triggering at the time of presentation. The open technique is reserved for complicated cases such as florid tenosynovitis, locked digit, failed percutaneous release or those involving the thumb.

Percutaneous treatment of trigger finger. 34 fingers followed 0.5-2 years.

We performed percutaneous A1 pulley release on 34 trigger fingers in 30 patients with an angiocath needle. Complete release was achieved in all fingers. There were no complications and no recurrences during mean 0.5 (1-2) years follow-up.

Percutaneous release for trigger finger in idiopathic and hemodialysis patients.

Sixty-seven trigger fingers of 58 idiopathic and hemodialysis patients were treated by percutaneous A1-pulley release technique. Severity of triggering was classified into five grades for treatment selection and prediction of possible results. Results were excellent in 41 fingers, good in 9, fair in 7, and poor in 10, requiring additional treatment. The results of the lower grades were better, and those of the higher grades were poor. Excellent or good results appeared to depend on the proper selection of the patients according to the grading system and confirmation of triggering disappearance just after the release. There were neither infections nor neuro-vascular deficits after treatment. Compared to conventional open release, this treatment was found to be more useful from the standpoints of ease and safety of the technique, and the patients' quick return to normal life.

Percutaneous A1 pulley release: A cadaveric study

Percutaneous A1 pulley release was performed on 17 fresh-frozen cadaveric hands with a 14-gauge angiocath needle. Each hand was then explored to assess the adequacy of release and the degree of injury to adjacent structures. Complete release of the A1 pulley was obtained in 45 of the 66 fingers and in 10 of the 17 thumbs. Significant injury to the flexor tendons was observed in two digits. All tendon injuries occurred along the line of the fibers. There were no digital nerve injuries. The release was within 2 mm of a thumb digital nerve in seven hands and the little finger ulnar digital nerve in two. In the thumb, the close proximity of the digital nerves makes percutaneous trigger digit release potentially hazardous. With the little finger held in abduction the risk of digital nerve injury or inadequate release is reduced. Percutaneous trigger finger release can be safely performed in the index, long, and ring fingers.