Trigger Finger Treatment by Ulnar Superficialis Slip Resection (U.S.S.R.)

Surgical treatment of trigger finger: a comparative study of A1 pulley opening versus ulnar superficialis slip resection

Trigger finger is a common condition. Surgery most frequently involves opening the A0 and A1 pulleys. However, this shows limited effectiveness in correcting proximal interphalangeal joint fixed flexion deformity. The present study aimed to compare clinical outcomes between two surgical techniques for trigger finger treatment. This retrospective study included 127 patients, 72 of whom underwent resection of the ulnar slip of the flexor superficialis, and 55 underwent opening of the pulleys. Study data comprised patient characteristics, range of motion, proximal interphalangeal fixed flexion deformity measurement, Quick-DASH and PRWE scores, and overall satisfaction. There were no significant differences between the two groups in terms of Quick-DASH or PRWE scores. Fixed flexion deformity correction was slightly but not significantly better with resection of the ulnar slip of the flexor superficialis (100%) compared to opening of the pulleys (88%). LEVEL OF EVIDENCE: : Level IV.

A Comparison of Patient Characteristics and Outcomes Between Patients Receiving Flexor Digitorum Superficialis Slip Excision or Isolated A1 Pulley Release for Trigger Finger

PURPOSE

Resection of the radial or ulnar slip of the flexor digitorum superficialis (FDS) tendon is a known treatment option for persistent trigger finger. Risk factors for undergoing FDS slip excision are unclear. We hypothesized that patients who underwent A1 pulley release with FDS slip excision secondary to persistent triggering would have a higher comorbidity burden compared to those receiving A1 pulley release alone.

METHODS

We identified all adult patients who underwent A1 pulley release with FDS slip excision because of persistent triggering either intraoperatively or postoperatively from 2018 to 2023. We selected a 3:1 age- and sex-matched control group who underwent isolated A1 pulley release. Charts were retrospectively reviewed for demographics, selected comorbidities, trigger finger history, and postoperative course. We performed multivariable logistic regression to assess the probability of FDS slip excision after adjusting for several variables that were significant in bivariate comparisons.

RESULTS

We identified 48 patients who underwent A1 pulley release with FDS slip excision and 144 controls. Our multivariable model showed that patients with additional trigger fingers and a preoperative proximal interphalangeal (PIP) joint contracture were significantly more likely to undergo FDS slip excision.

CONCLUSIONS

Patients who underwent A1 pulley release with FDS slip excision were significantly more likely to have multiple trigger fingers or a preoperative PIP joint contracture. Clinicians should counsel patients with these risk factors regarding the potential for FDS slip excision in addition to A1 pulley release to alleviate triggering of the affected digit.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Efficacy of Minimally Invasive Ulnar Superficialis Slip Resection for Unfavourable Results after Trigger Finger Release

Background: This study aimed to evaluate the efficacy of ulnar superficial slip resection (USSR) for improving hand function after unfavourable results after triggering finger release using a minimally invasive approach. Methods: We evaluated 17 consecutive fingers of 16 patients who complained of unfavourable outcomes after primary trigger finger release. The chief complaints of the two index and 15 middle fingers were proximal interphalangeal (PIP) joint pain during movement, flexion contracture of the PIP joint and snapping at the A2 pulley in eight, seven and two fingers, respectively. The joint arc of the active range of motion and extension loss of the PIP joint, grip strength, visual analogue score (VAS) of PIP joint pain and Quick Disability of the Arm, Shoulder and Hand were evaluated before and after surgery. Results: Thirteen fingers could release joint contracture and snapping by the USSR procedure. However, four fingers of three patients required total flexor digitorum superficialis resection to resolve the unsatisfactory conditions of the intraoperative decision. The joint arc of active range of motion and extension loss of the PIP joint, grip strength and VAS score significantly improved (mean of 16.1 months follow-up). Finally, 15 patients (88.2%) were satisfied with the symptom relief outcomes. Conclusions: USSR is an effective and satisfactory procedure for unfavourable conditions after trigger finger release, including PIP joint pain, joint contracture and snapping at the A2 pulley. Level of Evidence: Level IV (Therapeutic).

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

PURPOSE

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

The Effectiveness of Rehabilitation after Open Surgical Release for Trigger Finger: A Prospective, Randomized, Controlled Study

BACKGROUND

It is not clear whether rehabilitation after surgery for trigger finger is effective. The aim of this study was to reveal its effectiveness for trigger finger.

METHODS

This study was a randomized, controlled trial that included patients who underwent operations for trigger fingers. The patients in the rehabilitation group had postoperative occupational therapy (OT) for 3 months, while the patients in the control group were not referred for rehabilitation but received advice for a range of motion exercises. We evaluated the severity of trigger finger, Disability of Arm-Shoulder-Hand (DASH) score, pain-visual analogue scale (VAS), grip strength, whether they gained a full range of motion (ROM), and complications before and after surgery.

RESULTS

Finally, 29 and 28 patients were included in the control and rehabilitation groups, respectively. At final follow-up, the DASH score, grip strength, and ROM were significantly improved in the rehabilitation group compared to that preoperatively. At final follow-up, pain was significantly improved in both groups from that preoperatively. There were no significant differences in the results, including the DASH score, grip strength, ROM and pain-VAS between the control and rehabilitation groups at the final follow-up. Subgroup analysis showed that there is a significant difference in the DASH score of patients doing housework or light work and those with a duration of symptoms >12 months between the control and rehabilitation groups at the final follow-up.

Primary Resection of the Ulnar Slip of Flexor Digitorum Superficialis in the Persistently Triggering Patient After A1 Pulley Release

BACKGROUND

The purpose of this study was to determine the occurrence of patients undergoing primary trigger finger release (TFR) that underwent ulnar superficialis slip resection (USSR) for decompression and to determine which digit was most commonly affected.

METHODS

A retrospective chart review was conducted of all cases of open TFR performed by a single surgeon. The following data were obtained: age, sex, laterality, affected digit, and consideration for USSR. All patients failed nonoperative treatment of at least 1 steroid injection. The occurrence of patients who underwent TFR and USSR and which digit(s) most commonly underwent USSR were determined. The average patient age that underwent USSR, frequency by sex, and relative occurrence of USSR in each digit were computed. Statistical calculations were conducted using χ2 analysis (P < .05).

RESULTS

A total of 911 primary open TFRs were performed in 631 patients over a 16-year period. A total of 20 TFRs in 20 patients underwent USSR (2.2%). The long finger was the most commonly affected digit (40%) that required simple decompression. Within all USSR cases, the long finger was the most commonly affected digit. The index finger was the second most affected (30%), and there were no cases in the small finger.

CONCLUSIONS

This study determined the occurrence of primary TFR cases that underwent USSR, with the long finger being the most commonly affected digit. Surgeons may consider this additional procedure to perform a larger decompression than simple A1 pulley release alone.

Flexor Digitorum Superficialis Excision for Trigger Finger - A Systematic Literature Review

Background: Division of one or more slips of the flexor digitorum superficialis (FDS) tendon has been posited as an effective surgical modality for advanced or recurrent trigger finger. This may be an effective approach among patients with diabetes or rheumatoid arthritis, or in those with fixed flexion deformities who have poor outcomes from A1 pulley release alone. However, there is limited evidence regarding the effectiveness of this procedure. The role of this study was to systematically review the evidence on functional outcomes and safety of partial or complete FDS resection in the management of trigger finger. Methods: A systematic review was performed according to PRISMA guidelines. PubMed, Cochrane CENTRAL and Ovid Medline databases were electronically queried from their inception until February 2022. English language papers were included if they reported original data on postoperative outcomes and complications following resection of one or more slips of FDS for adult trigger finger. Results: Seven articles were eligible for inclusion, encompassing 420 fingers in 290 patients. All included studies were retrospective. Isolated ulnar slip FDS resection was the most described surgery. Mean postoperative fixed flexion deformity at the proximal interphalangeal joint was 6.0° compared to 31.5° preoperatively, and the proportion of patients with fixed flexion deformity reduced by 58%. Mean postoperative total active motion was 228.7°. Recurrence was seen in 4.7% of digits, and complications occurred in 11.2% of cases. No post-surgical ulnar drift or swan neck deformities were observed. Conclusions: FDS resection for long-standing trigger finger, or in diabetic or rheumatoid populations, is an effective and safe technique with low rates of recurrence. Prospective and comparative studies of this technique would be beneficial. Level of Evidence: Level III (Therapeutic).

Ulnar Superficial Slip Resection for Resistant Trigger Finger: A Minimally Invasive Technique

Primary trigger finger is a common hand disorder for which nonoperative treatment or release of A1 pulley is usually effective. For resistant or recurrent cases, there are different surgical techniques including partial or complete opening of A2 pulley, reduction tenoplasty, and resection of the ulnar slip of the flexor digitorum superficialis tendon. Here, we present our minimally invasive technique for ulnar superficial slip resection surgery. Our indications are the patients with persistent residual proximal interphalangeal joint contracture after A1 pulley release and also the recurrent cases. Then, we report the clinical outcomes of our patients operated using this technique.

Treatment of advanced trigger finger by ulnar superficialis slip resection: Long-term outcome and predictive factors for poor prognosis

The aim of this study was to evaluate the outcome of ulnar superficialis slip resection and to determine predictive factors for poor prognosis in patients with advanced trigger finger. Over a 5-year-period, 55 patients (58 fingers) were included. After surgery, two groups were identified: group 1, with complete extension or <10° extension deficit in the proximal interphalangeal (PIP) joint (n = 27 fingers/27 patients); and group 2, with ≥10° residual PIP extension deficit (n = 31 fingers/28 patients). Factors associated with PIP extension deficit were assessed on logistic regression. There was a median extension gain of 20° (range, 10-30°) after surgery. The difference between pre- and post-operative extension deficits was significant (p < 0.001). There was no significant inter-group difference in DASH score (p > 0.9). Two predictive factors were found: >12 months' preoperative symptom duration (OR = 1.02; p = 0.045), and lack of self-rehabilitation (OR = 20; p < 0.001). Ulnar superficialis slip resection was effective in advanced trigger finger. Hand surgeons should operate early on these patients, and encourage self-rehabilitation. LEVEL OF EVIDENCE: 4.

Recurrent Trigger Finger Caused by Herniation of Flexor Digitorum Profundus through the Chiasma – A Case Report

Trigger digit is a common condition which is largely idiopathic in etiology. Less frequently, it has been described secondary to anatomical variations or space occupying lesions. We describe a patient who developed a recurrent trigger finger after a surgical release of the first annular pulley. Intraoperatively, the trigger was noted to be caused by herniation of the flexor digitorum profundus (FDP) tendon into a noose formed by the two slips of the flexor digitorum superficialis tendon (FDS) and the proximal edge of the second annular pulley.

Level of Evidence: Level V (Therapeutic)

An Ultrasound-guided Percutaneous Surgical Technique for Trigger Finger Release Using a Minimally Invasive Surgical Knife

Triggering of the finger at the A1 pulley is one of the most frequent pathologies encountered in hand surgery and a common cause of hand pain. Open release of the A1 pulley is currently still regarded as the golden-standard procedure. Nevertheless, there is an increasing interest in minimally invasive percutaneous techniques for the treatment of this condition. Current techniques range from percutaneous needle techniques without imaging, to the use of hook knives, with ultrasound guidance. Because of concerns about possible complications or incomplete releases, hand surgeons remain wary. The objective of this study was to introduce a new ultrasound-guided percutaneous surgical technique for trigger finger release, using a second-generation minimally invasive surgical knife. In this series of 78 releases, complete resolution of the symptoms was found in 98.7% of the cases. One recurrence of triggering was observed. There were no tendon injuries, infections, or neurovascular lesions recorded. This paper contains technical pearls and possible pitfalls to ensure the surgeon of a complete release and to avoid complications. A video of the technique was also included as Supplemental Digital Content (http://links.lww.com/BTH/A143). We can conclude that the procedure can be considered as safe and highly effective for the treatment of triggering at the A1 pulley.

Current Concepts in the Management of Advanced Trigger Finger: A Critical Analysis Review

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While the majority of patients with trigger finger obtain excellent outcomes from nonoperative treatment or release of the A1 pulley, a subset of patients with advanced trigger finger, defined as trigger finger with loss of active or passive range of motion, may have incomplete symptom relief and warrant specific attention.

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Advanced trigger finger is more refractory to complete symptom resolution from corticosteroid injection, and particular attention should be paid to incomplete improvement of flexion contractures.

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Unlike simple trigger finger, the pathology in advanced trigger finger involves not only the A1 pulley but also the flexor tendon, including thickening and degeneration.

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Progression toward surgical intervention should not be delayed when nonoperative measures fail, and specific attention should be paid to persistent inability to achieve full extension following A1 pulley release.

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Facing substantial residual flexion contracture, reduction flexor tenoplasty and partial or complete resection of the superficialis tendon followed by hand therapy and splinting may be needed to allow patients to regain reliable full range of motion.

Open Surgery for Trigger Finger Required Combined a1-a2 Pulley Release. A Retrospective Study on 1305 Case

OBJECTIVES

We retrospectively reviewed 1305 open-surgery for idiopathic trigger finger performed by 4 senior hand surgeons between 2014 and 2016.

MATERIAL AND METHODS

Medical records and a telephone interview made with a minimum follow-up of 1 year were used to identify the recurrent rate of triggering and other complications.

RESULTS

This retrospective study let us note that 169 fingers (13%) required simultaneous release of the A1-A2 pulleys because the sectioning of the A1 pulley alone did not lead to complete free sliding of the tendons. We did not record any bowstring complication and we ascribe this to both surgery and bandaging technique. Overall rate of complication was 11.8% and relapse triggering or permanent proximal interphalangeal joint flexion (PPIJF) were among them; notably, however, they occurred only in patients where the A2 pulley was not sectioned.

CONCLUSIONS

Is possible to reduce the percentage of relapse triggering or PPIJF after trigger finger surgery, by performing that combined A1-A2 pulley release.

LEVEL OF EVIDENCE

Level III.

Ultrasound Features of Trigger Finger: Review of the Literature

Trigger finger is a common pathologic condition of the digital pulleys and flexor tendons in the hand. The key clinical finding is a transient blockage of the digit when it is flexed with subsequent painful snapping when it is extended. Imaging is a helpful guide for establishing the severity of the disease, identifying the underlying cause, and deciding the appropriate management. This narrative review aims to recall the anatomic and pathologic bases and describe the ultrasound features of trigger finger, also including common ultrasound findings and complications after therapy. Ultrasound enables an accurate static and dynamic evaluation of trigger finger as well as a comparison with the adjacent normal digits and thus should be considered the radiologic modality of first choice for its diagnosis.

Correlation between Hypervascularization of the First Annular Pulley on Color Doppler Imaging of Trigger Finger and Patients' Backgrounds

OBJECTIVES

The aim of this study was to investigate the correlation between hypervascularization of the first annular (A1) pulley on color Doppler imaging of trigger finger and patients' backgrounds.

METHODS

A total of 148 trigger digits from 144 patients were studied with ultrasound at the time of initial diagnosis. We observed the A1 pulley at the level of the metacarpophalangeal joint in a transverse image and noted the presence or absence of a signal in the A1 pulley on color Doppler imaging. Patients' ages, sexes, clinical grades, symptom durations, prevalence of interphalangeal joint contracture, and visual analog scale pain scores were compared between the groups with positive and negative Doppler findings.

RESULTS

The 144 patients included 45 men and 99 women. Sixty-one of 148 digits (41%) showed positive Doppler findings in the A1 pulley. Patients' ages and visual analog scale scores in the Doppler-positive group were slightly greater than those in the Doppler-negative group (P = .03; P < .01, respectively). The digit with positive Doppler findings tended to be categorized into a severer grade and into the group with a shorter symptom duration (P < .01 for both).

CONCLUSIONS

Hypervascularization of the A1 pulley tended to appear in an earlier period after the patients had become aware of symptoms, as frequently as their symptoms became severe, in conjunction with higher pain scores. Doppler imaging of the A1 pulley might help in better understanding patients' conditions.

Percutaneous A1 Pulley Release Combined with Finger Splint for Trigger Finger with Proximal Interphalangeal Joint Flexion Contracture

Background: Long-standing trigger finger can lead to proximal interphalangeal (PIP) joint flexion contracture. In the present study, we present the clinical outcome of percutaneous release with finger splinting for trigger finger with PIP joint flexion contracture prospectively. Methods: We compared outcomes in patients with trigger fingers combined with proximal interphalangeal joint flexion contracture treated by percutaneous release therapy regimen alone (group I) or percutaneous trigger finger release combined with finger splint (group II) during January 2011 and May 2016 with 6 months follow up. Results: Sixty-five patients were randomly allocated to group I (35 patients) or group II (30 patients). Symptoms of locking sensation and pain over the A1 pulley were improved in all patients. The patients in group II showed significantly greater improvements in the flexion contracture angles of proximal interphalangeal joint at post-operative 3 months later (group I, 9.4° ± 4.1°; group II, 27.8° ± 4.6°) and at 6 months later (group I, 15.1° ± 5.2°; group II, 35.7° ± 5.3°) relative to group I. In group II, 25 fingers achieved near full extension (< 10° contracture) after 6 months. Conclusions: Percutaneous release combined with finger splint is regarded as a useful therapy to speed recovery of trigger finger with proximal interphalangeal joint flexion contracture.

Clinical significance of proximal interphalangeal joint pain in patients with trigger fingers

We investigated incidence, clinical features and surgical outcomes of trigger finger accompanied by proximal interphalangeal joint pain. One-hundred and seventy-nine consecutive patients with trigger finger who had A1 pulley release were recruited. Forty-two patients (24%) complained of proximal interphalangeal joint pain at the time of surgery. Symptom duration was investigated, and tenderness at the proximal interphalangeal joint was palpated. Range of motion and pain score of the affected finger were measured pre- and post-operatively. Bone scan was performed to identify joint lesions. A comparison of the results between the proximal interphalangeal joint pain group and the non-proximal interphalangeal joint pain group shows that the proximal interphalangeal joint pain seemed to result from long symptom duration and consequent joint pathology. The proximal interphalangeal joint pain was incompletely resolved after A1 pulley release. Thus, the surgical outcomes might be worse than expected in spite of resolution of painful clicking, especially when there was additional joint tenderness on palpation. Level of evidence: IV.

Factors Causing Prolonged Postoperative Symptoms Despite Absence of Complications After A1 Pulley Release for Trigger Finger

PURPOSE

This study aimed to investigate the incidence and prognostic factors for prolonged postoperative symptoms after open A1 pulley release in patients with trigger finger, despite absence of any complications.

METHODS

We reviewed 109 patients (78 single-finger involvement, 31 multiple-finger involvement) who underwent open A1 pulley release for trigger finger from 2010 to 2016, with 8 weeks or longer postsurgical follow-up and without postoperative complications. The group had 16 men and 93 women, with mean age of 56 years (range, 21-81 years), and average follow-up period of 24.8 weeks (range, 8.0-127.4 weeks). Prolonged postoperative symptoms were defined as symptoms persisting for longer than 8 weeks after surgery. Factors analyzed for delay in recovery included duration of preoperative symptoms; number of preoperative local corticosteroid injections; preoperative flexion contracture of proximal interphalangeal (PIP) joint; multiplicity of trigger finger lesions; occupation; presence of type 2 diabetes mellitus, other hand disorders like carpal tunnel syndrome, de Quervain disease, or Dupuytren contracture; and fraying or partial tear of the flexor tendon.

RESULTS

Twenty-six fingers (19.3%) showed prolonged postoperative symptoms, with mean time until complete relief being 14.0 ± 6.4 weeks (range, 9-34 weeks). Risk factors associated with prolonged postoperative symptoms included duration of preoperative symptoms, preoperative flexion contracture of the PIP joint, and fraying or partial tear of the flexor tendon.

CONCLUSIONS

Physicians should consider the duration of preoperative symptoms and preoperative flexion contracture of the PIP joint when deciding timing of surgery for trigger finger patients. In addition, they should explain to patients with a positive history of these factors and in whom flexor tendon injury is found during surgery about the possibility of prolonged postoperative symptoms.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Case of Trigger Finger Related to an Intertendinous Connection between the Flexor Tendons

We report a rare cause of trigger finger related to an anatomical variation of an intertendinous connection between the flexor digitorum superficialis and flexor digitorum profundus tendons in the palmar region.

Tendinopathies of the Hand and Wrist

Tendinopathies involving the hand and wrist are common. Many are diagnosed easily, and in many cases, the management is straightforward, provided the pathology and principles are understood. Common conditions involving the tendons of the hand and wrist include trigger finger, tenosynovitis of the first through sixth dorsal extensor compartments, and flexor carpi radialis tendonitis. Management strategies include nonsurgical treatments, such as splinting, injection, or therapy, and surgical techniques such as tendon release.

Trigger Finger: Adult and Pediatric Treatment Strategies

Trigger fingers are common tendinopathies representing a stenosing flexor tenosynovitis of the fingers. Adult trigger finger can be treated nonsurgically using activity modification, splinting, and/or corticosteroid injections. Surgical treatment options include percutaneous A1 pulley release and open A1 pulley release. Excision of a slip of the flexor digitorum superficialis is reserved for patients with persistent triggering despite A1 release or patients with persistent flexion contracture. Pediatric trigger thumb is treated with open A1 pulley release. Pediatric trigger finger is treated with release of the A1 pulley with excision of a slip or all of the flexor digitorum superficialis if triggering persists.

Biomechanical analyses of the human flexor tendon adhesion models in the hand: A cadaveric study

Patients with longstanding trigger finger may develop flexion contracture at the proximal interphalangeal (PIP) joint that persists even after division of the A1 pulley. The purpose of this study was to explore the hypothesis that flexion deformity of the PIP joint in advanced trigger finger is caused by severe adhesion between the flexor digitorum superficialis (FDS) and the flexor digitorum profundus (FDP) tendons. Ten freshly frozen cadaveric hands were used in the experiments. After preparation of the extrinsic flexor, extrinsic extensor, and intrinsic muscle tendons, we applied weights to the flexor tendons and minimal tension to the extrinsic extensor and intrinsic muscle tendons. We then measured the initial flexion angles of the metacarpophalangeal (MCP) and PIP joints. Next, we measured the flexion angles of the MCP and PIP joints as increasing tension was applied to the extrinsic extensor and intrinsic muscle tendons, respectively. We repeated these experiments after constructing flexor tendon adhesion model. The initial flexion angles of the MCP and PIP joints were greater in the adhesion model, as were the average tensions required for full extension of these joints. Our results suggest that adhesion between two flexor tendons contributes to progression of flexion deformity in the PIP joint.

Sonographic analyses of pulley and flexor tendon in idiopathic trigger finger with interphalangeal joint contracture

This study investigated the sonographic appearance of the pulley and flexor tendon in idiopathic trigger finger in correlation with the contracture of the interphalangeal (IP) joint in the thumb or proximal IP (PIP) joint in the other digits. Sonographic measurements using axial images were performed in 177 affected digits including 17 thumbs and 34 other digits judged to have IP or PIP joint contracture and 77 contralateral control digits. The A1 pulley of the contracture group was significantly thicker than that of the non-contracture group in all digits, whereas the flexor tendon was thicker only in digits other than the thumb. In the analysis using calculated cut-off values, A1 pulley thickening in the thumb and A1 pulley and flexor tendon thickening in the other digits showed statistically significant correlations with IP or PIP joint contracture. This study sonographically confirmed previous reports showing that enlargement of the flexor tendons contribute to the pathogenesis of PIP joint contracture.

Primary ulnar superficial slip resection in complicated trigger finger

Long standing trigger finger, often present for 6 months to years before consulting, can result in a lack of extension, which is often painful and may persist after section of the A1 pulley. The ulnar superficial slip resection (USSR) was introduced by Le Viet to address this problem. It is hypothesised that primary section of the A1 pulley with USSR resolves both extension lack and pain in longstanding trigger fingers with a painful extension lack. This retrospective study reviewed the results of primary USSR for longstanding trigger fingers (6 months or more) with painful extension lack in 18 patients. Locking was resolved and full extension was acquired in all cases (100%). Satisfaction rate was high (89%) and disability returned to normal after surgery. In two patients, satisfaction was low due to residual loss of flexion as a result of osteoarthritis and cold intolerance in another. It is concluded that the USSR procedure is a valuable primary surgical option in complicated trigger finger with painful extension lack caused by flexor tendon tendinosis.

The value of high-frequency ultrasonographic imaging for quantifying trigger digits: a correlative study with clinical findings in patients with different severity grading

Trigger digit is recognized as thickening and constriction of the flexor tendon sheath at the base of digits. This study investigates the correlation between the severity grading of trigger digits and clinical findings from high-frequency ultrasonography. We measured and compared thicknesses, areas and pathological changes of the flexor digit tendons among total, contracture and noncontracture trigger digits and noninvolved contralateral digits. Forty-seven patients with 55 idiopathic trigger digits (36 contracture and 19 noncontracture) and 55 noninvolved contralateral digits were examined using high-frequency ultrasonography. The thickness of the flexor tendons was measured in a longitudinal plane at the A1 pulley: Inlet (metacarpal head-neck junction), Outlet (proximal phalangeal base-shaft junction) and Interpulley (middle of Inlet and Outlet). The cross-sectional and extratendinous tissue areas of the flexor tendons in a transverse plane at the point of Interpulley were measured. Pathological changes including irregular internal echotextures, fluid collection, dominant A1 pulley and abnormal metacarpophalangeal joint were analyzed. All thicknesses and areas of total and contracture trigger digits were significantly greater than those of noninvolved contralateral digits (p < 0.05), whereas no significant difference was observed in noncontracture trigger digits. The pathological changes were all significantly different from noninvolved contralateral digits in total, contracture and noncontracture trigger digits (p < 0.05). In contracture and noncontracture trigger digits, there were significant differences only in the thickness of the Inlet and the pathological change of the dominant A1 pulley (p < 0.05). In conclusion, the results of the ultrasonographic measurements and findings provided evidence of Notta's node and correlated with clinical findings and severity grades.

Resection of the flexor digitorum superficialis for trigger finger with proximal interphalangeal joint positional contracture

PURPOSE

Open release of the A1 pulley is a widely known procedure for the treatment of trigger finger. A subset of patients presents with both trigger finger and a positional contracture of the proximal interphalangeal (PIP) joint. These patients usually have a long history of trigger finger or have already undergone a surgical release of the annular pulley. This study is a retrospective review of the outcomes of resection of the flexor digitorum superficialis (FDS) for patients whose trigger finger was associated with a positional contracture of the PIP joint.

METHODS

Thirty-six patients (39 fingers) were treated by resection of the FDS after section of the A1 pulley. The mean age of the patients was 63 years (range, 45-90 y). Seven patients (19 %) had previously undergone an open release of the A1 pulley and had developed a positional contracture of the PIP joint 2 to 5 months afterward. We performed a retrospective review with a mean follow-up of 30 months (range, 12-60 mo). No patient was lost to follow-up. The active range of motion was recorded at the PIP joint before and after surgery.

RESULTS

The mean preoperative positional contracture of the PIP joint was 24° (range, 15°-30°). The mean postoperative positional contracture of the PIP joint was 4° (range, 0°-10°). The most commonly affected digit was the middle finger (26 fingers, 67%). In 28 fingers (72%), full extension was achieved following only the surgical procedure. The remaining 11 fingers (28%) had a postoperative residual positional contracture (range, 5°-10°). However, all fingers achieved a full range of motion after physical therapy and an injection of betamethasone. All of the resected tendons had histological damage.

CONCLUSIONS

This technique is a useful treatment for selected patients whose trigger finger is associated with a positional contracture.

A COMPARISON OF ENDOSCOPIC AND OPEN TRIGGER FINGER RELEASE

The main complaint of the patients after an open trigger finger release is a discomfort at the incision site. In this prospective study, we compared the two consecutive groups of patients with trigger fingers. One was treated by an open approach and the other by the endoscopic release of the A1 pulley. Pre- and post-operative evaluation at seven, 30 and 90 days showed a faster recovery from the discomfort with a faster return to daily and working activities, after the endoscopic procedure.

[Trigger digits]

Trigger finger is an entity seen commonly by hand surgeons. It is produced by a size mismatch between the flexor tendon and the A1 pulley, which causes pain, clicking, catching, and loss of motion of the affected finger. The diagnosis is usually easy but other pathological processes (extensor apparatus instability, locked metacarpo-phalangeal joint) must be excluded. Treatment modalities in trigger finger include splinting, corticosteroid injection and/or surgery. Indication depends on the clinical form of trigger finger.

Tendon disorders of the hand and wrist

The terminology used to describe most common tendon disorders in the hand and wrist suggests that they are inflammatory in nature, although current evidence indicates that mechanical and degenerative factors are more important. Corticosteroid injections provide relief in 60% or more of cases; however, the duration of their effectiveness remains uncertain. Surgical release of the stenotic pulley or sheath is curative in well over 90% of cases; complications of surgery are rare, and relief is long-lasting. Enlightened management of these common problems demands evidence-based guidelines defining indications for surgery that will maximize outcomes and minimize costs.

Chronic granulomatous tenosynovitis treated with ulnar superficialis slip resection

Ulnar superficialis slip resection is a procedure initially performed to treat flexor tenosynovitis in the rheumatoid finger. It was first described for treating trigger digits of children with mucopolysaccharide storage disorders and for more complex trigger digits in children. The procedure for adults with trigger finger was described for triggering with flexion contracture at the proximal interphalangeal joint level persisting after release of the A1 pulley and for trigger finger in diabetic patients.This article describes a case of chronic flexor tenosynovitis treated with ulnar superficialis slip resection. The patient was injured by the needle of a water pressure gauge. He developed chronic flexor tenosynovitis, and 1 year after the initial injury, surgery was performed due to a severe limitation of passive and active proximal interphalangeal joint flexion. Synovectomy was performed first, then the A1 pulley was divided. Passive finger flexion and extension was simulated and failed to reproduce full range of motion (ROM). The A3 pulley was then divided and still failed to reproduce full ROM. The ulnar slip of the flexor digitorum superficialis tendon was then resected from the distal margin of the carpal tunnel to the distal edge of the A3 pulley. The tendons could now move smoothly, and full passive ROM was achieved.Surgery consisting of synovectomy alone with or without resection of the A1 pulley without achieving full intraoperative ROM will likely lead to a poor result. We believe that cases like ours should be addressed with an "à la carte" procedure, starting with synovectomy and followed by A1 resection, A3 resection, and finally ulnar superficialis slip resection for achieving full intraoperative ROM.

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 degrees . 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 degrees , and PIP extension deficit averaged less than 5 degrees . 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.

Trigger fingers requiring simultaneous division of the A1 pulley and the proximal part of the A2 pulley

In a prospective study of 50 adult patients with primary idiopathic trigger finger, four patients (8%) required simultaneous division of the proximal 3 to 4mm of the A2 pulley as well as the A1 pulley in order to completely resolve the triggering. At final follow up at 6 to 12 months, all patients were symptom-free with a full range of motion of the fingers. This entity is discussed.

Triggering at the distal A2 pulley

We report two cases with triggering at the distal end of the A2 pulley. One was caused by enlargement of the flexor digitorum profundus (FDP) tendon and the other by enlargement of both slips of the flexor digitorum superficialis (FDS) tendon. Both were relieved by reduction tenoplasty and short releases, or venting, of the distal A2 pulley.

Trigger digits: principles, management, and complications

Stenosing tenosynovitis, or trigger finger, is an entity seen commonly by hand surgeons. This problem generally is caused by a size mismatch between the flexor tendon and the first annular (A-1) pulley. Conservative management includes splinting, corticosteroid injection, and other adjuvant modalities. Surgical treatment consists of release of the A-1 pulley by open or percutaneous techniques. Complications are rare but include bowstringing, digital nerve injury, and continued triggering. Some patients require more extensive procedures to reduce the size of the flexor tendon. Comorbid conditions affect how trigger finger is treated. Patients with rheumatoid arthritis require tenosynovectomy instead of A-1 pulley release. In children trigger thumb resolves reliably with A-1 pulley release but other digits may require more extensive surgery. In diabetic patients trigger finger often is less responsive to conservative measures. An understanding of the pathomechanics, risk factors, and varied treatments for trigger finger is essential for appropriate care.

Optimization of flexor tenolysis using a suture

In zone 2, complete release of all the peritendinous adhesions is almost impossible because of the complexity of the two tendons' three-dimensional arrangement under the pulleys. Resection of one slip of the flexor digitorum superficialis (FDS) changes this complex arrangement into a two parallel tendons pattern, which makes it much easier, particularly when using the suture technique.