Trigger Finger Research Articles

A Simple Physical Exam Maneuver to Distinguish Trigger Digit, Dupuytren's Nodule, and Flexor Sheath Ganglion.

Trigger digit, Dupuytren's disease, and ganglion cysts are 3 common disorders treated by hand surgeons. Despite the varying nature of their pathology, these 3 entities can all present as a mass at the flexor crease in the distal palm. The regional similarity of these presentations can make diagnosis more difficult. In this paper, we describe a simple clinical exam method that can assist in distinguishing between trigger digit, Dupuytren's disease, and flexor sheath ganglion cysts.

Median effective dose of 0.2% ropivacaine for ultrasound-guided median nerve block in young children

ObjectiveTo determine the median effective dose (ED50) and the 95% effective dose (ED95) of 0.2% ropivacaine for ultrasound-guided lower forearm median nerve block in paediatric patients. MethodsEligible children were American Society of Anesthesiologists (ASA) status I–II scheduled to have elective open surgery for trigger thumb repair. Patients were stratified into two age groups: 1- to 3-year-olds and 3- to 6-year-olds. The ED50 was determined by Dixon’s up-and-down method. The first patient received an ultrasound-guided median nerve block by injection of 2 mL of 0.2% ropivacaine. Each subsequent patient’s dose was determined by the response of the previous patient, the doses being adjusted in intervals of 0.2 mL. In addition, the 95% effective dose (ED95) was obtained using a probit regression approach. The patients’ general condition, postoperative pain scores, and adverse events were recorded. ResultsA total of 52 children who were scheduled to undergo open surgery for trigger thumb were included in this study: 28 in the 1- to 3-year-olds group and 24 in the 3- to 6-year-olds group. The ED50 (95% confidence interval) values were 0.9 (0.44–1.36) mL in 1- to 3-year-olds and 1.4 (1.14–1.66) mL in 3- to 6-year-olds. The ED95 (95% confidence interval) values were 1.5 (0.98–1.58) mL in 1- to 3-year-olds and 1.7 (1.54–1.78) mL in 3- to 6-year-olds. No adverse events occurred. ConclusionsA single dose of ropivacaine was an effective agent for young children requiring ultrasound-guided lower forearm median nerve block in open surgery for trigger thumb. The ED50 (95% confidence interval) values were 0.9 (0.44–1.36) mL in 1- to 3-year-olds and 1.4 (1.14–1.66) mL in 3- to 6-year-olds. The ED95 (95% confidence interval) values were 1.5 (0.98–1.58) mL in 1- to 3-year-olds and 1.7 (1.54–1.78) mL in 3- to 6-year-olds.

De Quervain's Release (Cadaver)

De Quervain’s release is a surgical procedure performed to curatively treat stenosing extensor tenosynovitis of the first extensor compartment of the wrist, after nonoperative management fails. This procedure involves surgical release of the first dorsal compartment with care taken to fully release the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) tendons from their respective sheaths, while protecting the radial sensory nerve, in order to decompress the extensor tendons. This video outlines the operative technique used by Dr. Asif Ilyas for performing a De Quervain’s release on a cadaveric wrist.

Efficacy analysis of three kinds of surgery for trigger thumb.

To study the efficacy of three kinds of surgery for trigger thumb. A total of 60 cases of trigger thumb (Quinnell Grade IV) were randomly divided into three groups. The A1 pulley was disconnected at the middle in Group A, at the extreme radial side in Group B, excised in Group C. The following indicators were recorded pre-operatively (D0), and at one (D1), three (D3), seven (D7), 14 (D14), and 28 (D28) days post-operatively: 1. the pain visual analogue score (VAS) when flexing the affected thumb; 2. range of motion (ROM) of the interphalangeal joint with pain tolerance; 3. the time of pain disappearance when flexing the affected thumb. The differences of VAS and ROM between D1 and D0, D3 and D1, D7 and D3, D14 and D7, D28 and D14 were statistically significant (P < 0.05). There was no significant difference in changes of VAS (or ROM) at D1 or D28 in contrast to D0 among the three groups. The differences of VAS (or ROM) changes at D3, D7, and D14 in contrast to D0 among the three groups were statistically significant (P < 0.05). The difference of the time when the pain disappearing in the normal range of motion among the three groups were statistically significant (P < 0.05). Disconnecting the A1-pulley at the extreme radial side is better than another two methods for treating the trigger thumb (Quinnell Grade IV). It has been shown to effectively accelerate postoperative pain relief and functional recovery. Clinical trial registry number: ChiCTR2100051193.

Carpal tunnel syndrome and trigger finger as related to benign prostatic hyperplasia: A retrospective nationwide cohort investigation.

To describe the incidence of benign prostatic hyperplasia (BPH) after a diagnosis of carpal tunnel syndrome or trigger finger. We performed a retrospective study on national health registry comparing the incidence of BPH between a cohort of 9720 study patients and a comparison cohort of 38,880 control individuals. The crude hazard ratio (HR) and the adjusted HR were estimated by the univariable and the multivariable Cox proportional hazard model, respectively. The risks of BPH in different age groups and patients with or without comorbidities were also investigated. The cumulative incidence curves were obtained by the Kaplan-Meier method and assessed by the Log-rank test. Compared to the control cohort, patients with carpal tunnel syndrome increased the risk of BPH by 1.36 times (95% confidence intervals [CI] = 1.29, 1.43). Patients only diagnosed with trigger finger raised the risk of BPH by 1.31 times (95% CI = 1.22, 1.40). The HR of BPH for patients with both carpal tunnel syndrome and trigger finger relative to the controls was 1.43 (95% CI = 1.33, 1.54). We concluded that the likelihood of developing BPH was increased in patients with carpal tunnel syndrome or trigger finger.

Comparison of ceftriaxone and cefazolin as prophylactic antibiotics for surgical site infection in orthopedic upper extremity surgery: The nationwide shortage of cefazolin in March 2019

BackgroundDue to the nationwide supply shortage of cefazolin in March 2019 in Japan, ceftriaxone was used as an alternative prophylaxis antibiotic agent. This retrospective study was designed to investigate the impact of cefazolin and ceftriaxone as a prophylactic antibiotic agent for surgical site infection (SSI) in orthopedic upper extremity surgery. MethodsWe used cefazolin for antibiotic prophylaxis to prevent SSI before March 2019. Because of cefazolin shortage, ceftriaxone was used as an alternative agent in our hospital. From April 2014 to May 2021, 2493 upper extremity surgeries were reviewed. The exclusion criteria in this study were as follows: patients aged under 16 years, those with an open wound, those with infectious diseases, those who underwent trigger finger surgery, and those who underwent percutaneous pinning surgery. The incidence of deep SSI was evaluated according to the Centers for Disease Control and Prevention guidelines. ResultsAmong the 2493 eligible cases, 1674 were included in this study. In the cefazolin group, 1140 cases were included, whereas, in the ceftriaxone group, 534 cases were included. No significant differences in the demographic data of the patients were observed between the two groups. The incidence of deep SSI was 0.08% (1/1140 cases) in the cefazolin group and 1.1% (6/534 cases) in the ceftriaxone group, with a significant difference between the two groups (odds ratio, 12.9; p = 0.005). ConclusionsThis study indicated that the use of ceftriaxone instead of cefazolin after upper extremity surgery increases the risk of deep SSI.

Tendon injections - upper extremity.

Imaging-guided tendon procedures aim to reduce pain and increase function by controlling inflammation and stimulating healing. Ultrasound is the preferable guiding modality due to its high resolution and real-time demonstration of the tendinous anatomy and needle positioning. The technique includes appropriate patient positioning, which varies depending on the targeted tendon, as well as sterile and proper draping. For most procedures, we prefer the "in-plane" approach, which demonstrates the entire needle as it advances through different tissue layers. Upper limb injections commonly use corticosteroids and anesthetics with different reported short- and long-term results depending on the tendon treated; better results are obtained in the treatment of tenosynovitis (sliding tendons such as trigger finger and De Quervain's tenosynovitis). Shoulder and elbow tendinopathies (anchor tendons) may also benefit from injections containing irritants or healing stimulants such as dextrose (prolotherapy) and platelet-rich plasma or by the stimulation of healing via tendon perforations (fenestration). The hyaluronic acid injection has also been used in the treatment of both tenosynovitis and tendinopathies. For tendons passing through osteofibrous tunnels, an additional release may be performed, and the techniques are discussed in this review. Therefore, this article provides practicing musculoskeletal radiologists and trainees with a comprehensive review of tendon injection musculoskeletal image-guided procedures.

Incidence of Carpal Tunnel Syndrome Requiring Surgery May Increase in Patients Treated with Trigger Finger Release: A Retrospective Cohort Study.

PurposeThe correlation between carpal tunnel syndrome (CTS) surgery and trigger finger (TF) surgery is unclear; we conducted this nationwide population-based study to assess the development of severe CTS requiring surgery after TF surgery.Patients and MethodsThis retrospective cohort study used the data of patients diagnosed as having TF between January 1, 2001, and December 31, 2017, and they were divided into two comparative groups. Patients who underwent surgical release within 1 year of diagnosis were included in the TF-OP group, and those who did not undergo TF release during the same period were included in the TF-NOP group. The primary outcome was the new incidence of CTS release (CTR), and data on the related risk factors were collected for analysis.ResultsA total of 8232 patients each were enrolled into the TF-OP and TF-NOP groups and were 1:1 propensity score matched (mean patient age, 54.7 ± 10.1 years; mean follow-up duration, 6.58 years). The incidence rate of CTR was 1.1 per 1000 person-years in the TF-OP group and 0.7 per 1000 person-years in the TF-NOP group. The adjusted hazard ratio of TF surgery was 1.51. The factors significantly correlated with an increased incidence of CTR were age, female sex, diabetes mellitus, and chronic renal failure. In subgroup analysis, patients aged >65 years and female patients in the TF-OP group were still at significantly higher risks of CTR than were their counterparts in the TF-NOP subgroups. The cumulative incidence of CTR after TF surgery linearly increased with time in both groups.ConclusionPatients undergoing TF release may have a higher incidence of CTR 1 year later, especially women and patients aged >65 years. Diabetes mellitus and chronic renal failure may be risk factors.

An Acute Hip Injury Correlated With An Exacerbation Of Urinary Symptoms In A Dancer

HISTORY23-year-old female dancer sustained an acute right hip/groin injury during a rond-de-jambe movement (requiring a combination of hip abduction, extension and external rotation). She had a sensation of a pop at the time of injury, followed by difficulty with external rotation as she attempted to continue to dance. Subsequent days were characterized by bruising to the inner groin and progressive medial thigh discomfort. She concurrently experienced a significant worsening of pre-existing urinary dysfunction characterized by episodes of urge incontinence and a sensation of incomplete voiding. She then developed secondary lateral hip, sacroiliac and low back discomfort. PHYSICAL EXAMShe presented to our office 6 weeks after the initial injury. She had a normal gait and symmetric hip range of motion. Right hip exam with pain at end range of passive hip flexion, and pain also with resisted testing of hip adduction, internal rotation and external rotation. She had tenderness over the anterior hip flexor tendons and at the proximal medial thigh just inferior to the pubic ramus. She was not tender to the pubic ramus. Thomas test was negative bilaterally, but she had significant tightness of quadriceps bilaterally noted on Ely’s test. An internal exam separately completed by her urogynecologist identified tightness of the pelvic floor musculature. DIFFERENTIAL DIAGNOSIS adductor muscle strain, strain of deep hip rotator muscles (obturator externus, obturator internus), hip flexor tendonitis (as primary or secondary diagnosis), labral tear, pelvic floor muscle strain/tear/dysfunction, primary or secondary tightness of pelvic floor musculature, hormonal and/or bladder irritants affecting urinary function TESTS AND RESULTS 1. Xray pelvis/hip series: Well-formed acetabula, slight predisposition to CAM type FAI 2. Hip MRI: Shallow right acetabulum with mild uncovering of lateral femoral head, signs of possible labral tear, small partial intramuscular tear of the R obturator externus, strain of R iliopsoas muscle 3. Dynamic hip ultrasound - pending FINAL WORKING DIAGNOSIS 1.Obturator externus strain with comorbid strain of iliopsoas muscle 2.Pelvic floor dysfunction TREATMENT AND OUTCOMES 1. Dance specific PT for core and peri-pelvic stabilization 2. Pelvic floor physical therapy 3. Gradual return to dance

Tourniquet Does Not Affect Long-term Outcomes in Minor Hand Surgery: A Randomized Controlled Trial.

Background:Surgeons often prefer to use a tourniquet during minor procedures, such as carpal tunnel release (CTR) or trigger finger release (TFR). Besides the possible discomfort for the patient, the effect of tourniquet use on long-term results and complications is unknown. Our primary aim was to compare the patient-reported outcomes 1 year after CTR or TFR under local anesthesia with or without tourniquet. Secondary outcomes included satisfaction, sonographically estimated scar tissue thickness after CTR‚ and postoperative complications.Methods:Between May 2019 and May 2020, 163 patients planned for open CTR or TFR under local anesthesia were included. Before surgery, and at 3, 6, and 12 months postoperatively, Quick Disabilities of the Arm, Shoulder and Hand and Boston Carpal Tunnel questionnaires were administered, and complications were noted. At 6 months postoperatively, an ultrasound was conducted to determine the thickness of scar tissue in the region of median nerve.Results:A total of 142 patients (51 men [38%]) were included. The Quick Disabilities of the Arm, Shoulder and Hand questionnaire and Boston Carpal Tunnel Questionnaire scores improved significantly in both groups during follow-up, wherein most improvements were seen in the first 3 months. No difference in clinical outcome and scar tissue formation was found between the two groups after 12 months. The complication rate was comparable between both groups. Thirty-two (24%) patients had at least one complication, none needed surgical interventions, and no recurrent symptoms were seen.Conclusions:Our study shows similar long-term clinical outcomes, formation of scar tissue, and complication rates for patients undergoing CTR or TFR with or without a tourniquet. Tourniquet usage should be based on shared decision-making.

Out-of-Pocket and Total Costs for Common Hand Procedures From 2008 to 2016: A Nationwide Claims Database Analysis

Rising patient out-of-pocket (OOP) costs and financial distress have been associated with reduced access to and delays in care. We evaluated whether OOP and total costs for common hand procedures have increased from 2008 to 2016 and identified key drivers of these costs. Using the IBM MarketScan Research Databases, we identified patients who underwent trigger finger release, open carpal tunnel release, thumb carpometacarpal joint arthroplasty, cubital tunnel release, or open treatment of distal radius fracture in the outpatient setting between 2008 and 2016. Patient OOP costs included copayment, coinsurance, and deductible payments. Costs not directly related to medical care, such as transportation and childcare costs, were not included. The overall cost was defined as the sum of the patient OOP cost and insurer reimbursements. We calculated changes in OOP and total overall costs over the study period. We also performed multivariable linear regressions to evaluate the associations between costs and procedure type, insurance type, region, and site of service. The mean patient OOP cost increased by 55% to 71% and the total overall cost increased by 20% to 45%, depending on the procedure, between 2008 and 2016. Facility overall costs increased by 38%, whereas professional overall costs increased by 9%. Procedures performed in an office-based setting were associated with the lowest patient OOP and total overall costs, whereas high-deductible health plans were associated with the highest OOP costs. Patient OOP and total overall costs increased for the most common hand procedures between 2008 and 2016, driven by a substantial increase in facility costs. Office-based procedures were associated with the lowest costs. To alleviate the rising patient cost burden, hand surgeons could incorporate OOP cost considerations into shared decision-making tools, identify patients who may benefit from financial counseling, and shift procedures to an office-based setting.

Bringing Patient-Reported Outcome Measures (PROMs) Into Practice: A Review of the Latest Developments in PROM Use in the Evaluation and Treatment of Carpal Tunnel Syndrome

As health care systems globally shift toward optimizing value, defined as health outcomes achieved per dollar spent across a full cycle of care, there has been increasing focus on using patient-reported outcome measures (PROMs) to gauge success. Patient-reported outcome measures are validated questionnaires that allow patients to share their health status across several domains (eg, pain or physical function). This trend has been particularly notable in hand surgery, with PROM use investigated for many common hand conditions, including carpal tunnel syndrome, Dupuytren contracture, trigger finger, osteoarthritis, and wrist ganglion. The purpose of this article is to review recent developments in the use of PROM instruments, including the Boston Carpal Tunnel Questionnaire; Michigan Hand Outcomes Questionnaire; Disabilities of the Arm, Shoulder, and Hand; and Patient-Reported Outcomes Measurement Information System, for the evaluation and treatment of patients with carpal tunnel syndrome. The considerable progress in establishing PROMs for use in carpal tunnel syndrome is reviewed, and future improvements are proposed to standardize PROM use and bring PROMs into day-to-day clinical practice for individualized patient treatment decision-making and counseling.

EP-86 Preventable errors in hand surgery: analysis of data from NHS England

Abstract Background Avoidable medical errors and never events represent a significant problem with negative consequences on the patient, the healthcare professionals, and the healthcare facilities. Hand surgery is a unique multidisciplinary speciality in which orthopaedics, plastic and general surgery are usually involved in the care of their patients, which makes this speciality prone to medical errors. The study highlights these preventable errors in hand surgery in NHS England. Methods We analysed hand surgery-related preventable medical errors published by the NHS England during the last ten years from 2012 till July 2021. Results Out of 3742 never events during the review period, only 50 never events related to hand surgery were found, representing (1.3%). The majority were under wrong-site surgery category 30 (60%), which included 17 (57%) wrong finger or digit surgery followed by five wrong digit or thumb injections, three wrong K wire placement, and three scaphoid bones were mistakenly removed during trapeziectomy. The second most common category was wrong incision 15 (30%), with 13 wrong finger incisions, two wrong carpal tunnel incisions for trigger finger release. Four patients had wrong procedures, including CTR rather than trigger finger or Dequervain release or an unnecessary carpal tunnel release in addition to one wrong hand tendon transfer. Lastly, only one patient had a wrong injection for carpal tunnel that was intended for another patient. Conclusions Hand surgery-related medical errors represent 1.3% of the whole Never Events reported. Awareness of these incidents will help prevent their occurrence in the future.

Shared genetic susceptibility between trigger finger and carpal tunnel syndrome: a genome-wide association study.

SummaryBackgroundTrigger finger and carpal tunnel syndrome are the two most common non-traumatic connective tissue disorders of the hand. Both of these conditions frequently co-occur, often in patients with rheumatoid arthritis. However, this phenotypic association is poorly understood. Hypothesising that the co-occurrence of trigger finger and carpal tunnel syndrome might be explained by shared germline predisposition, we aimed to identify a specific genetic locus associated with both diseases.MethodsIn this genome-wide association study (GWAS), we identified 2908 patients with trigger finger and 436579 controls from the UK Biobank prospective cohort. We conducted a case-control GWAS for trigger finger, followed by co-localisation analyses with carpal tunnel syndrome summary statistics. To identify putative causal variants and establish their biological relevance, we did fine-mapping analyses and expression quantitative trait loci (eQTL) analyses, using fibroblasts from healthy donors (n=79) and tenosynovium samples from patients with carpal tunnel syndrome (n=77). We conducted a Cox regression for time to trigger finger and carpal tunnel syndrome diagnosis against plasma IGF-1 concentrations in the UK Biobank cohort.FindingsPhenome-wide analyses confirmed a marked association between carpal tunnel syndrome and trigger finger in the participants from UK Biobank (odds ratio [OR] 11·97, 95% CI 11·1–13·0; p<1 × 10–300). GWAS for trigger finger identified five independent loci, including one locus, DIRC3, that was co-localised with carpal tunnel syndrome and could be fine-mapped to rs62175241 (0·76, 0·68–0·84; p=5·03 × 10–13). eQTL analyses found a fibroblast-specific association between the protective T allele of rs62175241 and increased DIRC3 and IGFBP5 expression. Increased plasma IGF-1 concentrations were associated with both carpal tunnel syndrome and trigger finger in participants from UK Biobank (hazard ratio >1·04, p<0·02).InterpretationIn this GWAS, the DIRC3 locus on chromosome 2 was significantly associated with both carpal tunnel syndrome and trigger finger, possibly explaining their co-occurrence. The disease-protective allele of rs62175241 was associated with increased expression of long non-coding RNA DIRC3 and its transcriptional target, IGBP5, an antagonist of IGF-1 signalling. These findings suggest a model in which IGF-1 is a driver of both carpal tunnel syndrome and trigger finger, and in which the DIRC3-IGFBP5 axis directly antagonises fibroblastic IGF-1 signalling.FundingWellcome Trust, National Institute for Health Research, Medical Research Council.

Hand and Upper Extremity

In pediatric hand and upper extremity surgery, numerous situations arise where there is variability or doubt in which code to use for a particular procedure. Was that an open reduction or closed reduction with percutaneous fixation of a fracture? Should we code trigger fingers and thumbs the same way? And, when is post-axial polydactyly a reconstruction versus excision? This JPOSNA Coding Corner will present case scenarios encountered by pediatric orthopaedic surgeons who care for common upper limb conditions. The intent is to provide guidance to aid proper surgical billing; however, it is important the ultimate code selection reflects the procedure performed and supporting documentation.

Prevalence, Burden, and Sources of Out-of-Network Billing in Elective Hand Surgery: A National Claims Database Analysis

Surprise out-of-network (OON) bills can represent a considerable cost burden on patients. However, OON billing remains underexplored in elective, outpatient surgery procedures, which have greater latitude for patient choice. We aimed to answer the following questions: (1) What is the prevalence and magnitude of OON charges in hand surgery? (2) What are the sources of OON charges? and (3) What factors are associated with OON charges? We analyzed patient-level data from the Clinformatics Data Mart database. We identified patients undergoing carpal tunnel release, trigger finger release, wrist ganglion removal, de Quervain release, limited palmar fasciectomy, or thumb carpometacarpal arthroplasty at in-network facilities with an in-network primary surgeon. The primary outcome was the proportion of surgical episodes with at least 1 OON charge. Secondary outcomes included the magnitude of potential balance bills (portion of OON bill exclusive of the standardized payment and expected patient cost-sharing), sources of OON charges, and factors associated with OON charges. Of 112,211 elective hand surgery episodes, 8% (9,158) had at least 1 OON charge. OON charges ranged from $1,154 (95% confidence interval, $1,018-$1,289) for wrist ganglion removal to $3,162 (95% confidence interval, $2,902-$3,423) for thumb carpometacarpal arthroplasty. In episodes with OON charges, the major sources of OON charges were anesthesiologists (75% of episodes), durable medical equipment (10% of episodes), and pathologists (9% of episodes). Site of service, geographic region, and health exchange-purchased plans were highly associated with OON charges. Out-of-network billing can represent a substantial cost burden to patients and should be considered in perioperative decision-making in elective hand surgery. Understanding the potential costs related to OON services during a surgical episode, and its drivers, allows surgeons to consider detailed cost discussions during perioperative decision making.

Patient Likelihood to Repeat Surgery After Highly "Successful" Hand Procedures.

Outcomes for routine hand procedures, such as carpal tunnel release, trigger finger release, and first dorsal compartment release, are typically reported as "highly successful" with "infrequent complications" based on classic literature. No contemporary study has utilized a large prospective registry to assess patient willingness to repeat surgery. We utilized a prospective hand registry to evaluate the proportion of patients that would repeat surgery after common hand procedures. We utilized a prospective, hand surgery registry to collect postoperative patient likelihood to repeat surgery in patients undergoing surgery for 9 common hand procedures. All measures were reported at 12, 24, or 52 weeks. We analyzed the percentage of patients that would repeat the procedure for all diagnoses, as well as stratified by the most common 9 isolated diagnoses. At the time of analysis, 1905 patients met our inclusion criteria. The average percentage of patients across all procedures that would repeat surgery was 81.6%. When stratified by the most common 9 diagnoses the percentage of patients that would repeat surgery ranged from 51.9% (ulnar nerve surgery at the elbow) up to 87.5% (endoscopic carpal tunnel release). After undergoing routine hand procedures, a significant percentage of patients would choose not to repeat surgery. Hand surgeons can do better in setting clear and realistic preoperative expectations when counseling patients prior to even routine hand surgeries.

Comparative Study of A1 Pulley Release and Ulnar Superficialis Slip Resection in Trigger Finger With Flexion Contracture of the Proximal Interphalangeal Joint

The purpose of this study was to compare the clinical outcomes of A1 pulley release with ulnar superficialis slip resection (group A) and simple A1 pulley release (group B) in trigger finger with flexion contracture of the proximal interphalangeal (PIP) joint. From January 2016 to December 2019, the 2 surgical procedures were performed alternately every year for trigger fingers with preoperative PIP joint flexion contractures of ≥10°. Twenty-six fingers in group A and 29 fingers in group B that were followed up for >1 year were reviewed in this retrospective study. The visual analog scale (VAS) score; Disabilities of the Arm, Shoulder, and Hand (DASH) score; degree of PIP joint flexion contracture; grip strength; and pinch strength were measured after surgery and compared. The differences in postoperative PIP joint flexion contracture between groups were <4° at 2 and 6 weeks, and there were no clinically relevant differences at 6 weeks and 12 months. At the final follow-up, PIP joint flexion contractures of 5° were observed in 2 fingers in each group. The difference in VAS scores between groups was less than half of a point until 3 months, and there were no clinically relevant differences at 6 weeks and 12 months. The DASH score did not show any difference between groups at the final follow-up. There were clinically relevant differences in the grip and pinch strengths between groups at 6 weeks. However, there were no clinically relevant differences at the final follow-up. Proximal interphalangeal joint flexion contracture measurements and clinical scores did not differ between groups at the final follow-up. Therefore, we recommend use of a simple A1 pulley release, which is simpler than an A1 pulley release with ulnar superficialis slip resection, in cases of trigger finger with PIP joint flexion contracture. Therapeutic IV.

Saving Money and Reducing Waste With a Tailored Hand Surgery Kit.

There is growing interest in containing cost and decreasing waste in the operating room. As part of a quality improvement initiative, we redesigned the supply kit used for 2 common surgical procedures (carpal tunnel release and trigger finger release) performed under local anesthesia. A hand surgeon, a medical student, and an operating room nurse examined each item that would be necessary for performing carpal tunnel release and trigger finger release. A new disposable supply kit was formulated on the basis of their recommendations and was implemented over a 7-month period. Cost savings and waste avoidance were calculated. The streamlined kit ($43.40) produced a 53% cost savings relative to the standard hand pack ($92.83) per case. The local pack (2.896 kg) was 41% lighter than the standard pack (4.938 kg), translating to significant waste avoidance. The local hand pack was used for 46 cases from September 2020 to April 2021, saving a total of $2246.78 and avoiding 94 kg of waste. There have been no noted interruptions in delivery of surgical care. Our redesign of the local hand pack led to substantial cost savings and waste avoidance. We believe there are many opportunities for surgical teams to use similar strategies to decrease cost and environmental waste.

Percutaneous Release of Trigger Finger by Needle Technique

Percutaneous Release of Trigger Finger by Needle Technique