The Outcomes of 2,154 Endoscopic Trigger Finger Releases

BACKGROUND

Trigger finger is one of the most frequent causes of hand pain and disability. Recently, an endoscopic trigger finger release technique was developed, but outcomes have rarely been reported. Here, we present the outcomes of 2154 endoscopic trigger finger release procedures in a single center.

METHODS

In this retrospective study, 2154 endoscopic trigger finger release procedures were performed on 2034 patients. Outcome assessment at 90 days after surgery was classified as excellent, good, fair or poor according to a combination of patient satisfaction with the scar and pain at rest or under load on a numeric rating scale.

RESULTS

The therapeutic outcomes were: 1027 excellent, 607 good, 400 fair, and none poor. No major surgical complications were observed. Minor complications occurred in 231 fingers (10.7%).

CONCLUSIONS

All patients were satisfied with their outcome after endoscopic trigger finger release. Endoscopic release can be an effective and efficient therapeutic method for the treatment of trigger finger.

Flexor Tenosynovial Fistula as a Complication after Endoscopic Trigger Finger Release: A Case Report

OBJECTIVE

We report a rare case of flexor tenosynovial fistula secondary to endoscopic release of the A1 pulley for treatment of trigger finger.

CASE PRESENTATION

A 72-year-old woman underwent endoscopic release of the A1 pulleys of her left ring and right middle fingers. Nine days after surgery, the wound at the base of the proximal phalanx of the ring finger (distal portal) remained open and a clear liquid discharge was seen. The volume of discharge increased with active finger motion. However, there was no evidence of infection. The patient was diagnosed with tenosynovial fistula as a complication of endoscopic release of the A1 pulley. At day 30, the fistula and drainage persisted and the condition was managed by surgical excision of the fistula and primary closure. The wound then healed completely.

CONCLUSION

Our report alerts hand surgeons to the potential development of flexor tenosynovial fistula as a very rare complication following endoscopic release of the A1 pulley for the treatment of trigger finger.

Organisational capabilities, outcomes, and benefits of trigger finger release surgery in primary care: a service evaluation study

BACKGROUND

Trigger finger is a common hand condition in which a finger is unable to fully extend owing to a thickening of the tendon and its sheath, causing the finger to lock in a bent position.

AIM

To assess the viability of carrying out trigger finger surgeries in NHS primary care in terms of clinician and patient acceptance, experience, and outcomes; and operational requirements of this service for wider application.

DESIGN & SETTING

A pilot study for a new service in primary care in Leicestershire, UK.

METHOD

A total of 214 trigger finger release surgery procedures were carried out between 22 August 2019 and 25 October 2022 by a single hand surgeon in a single primary care surgery. Data were analysed using information from SystmOne, which is a patient database linked with the NHS.

RESULTS

Thirty-two cases out of 214 (15.0%) experienced a wait time of <10 days from the GP referral to the first outpatient appointment (OPA). Out of 214 procedures, there were 26 (12.1%) postoperative complications that required follow-up action. Of the total number of cases where postoperative complications were identified, 13 cases required further follow-up action, while the remaining 13 did not have any identifiable further follow-up action and were regarded as closed cases thereafter.

CONCLUSION

Trigger finger release surgery in primary care offers an opportunity to reduce pressures on secondary care orthopaedic referrals, as well as offering patients faster and effective surgical treatment while utilising fewer NHS resources.

Complications Following Endoscopic and Open Trigger Finger Release: A Retrospective Comparative Study

BACKGROUND

Open trigger finger release (OTFR) and endoscopic trigger finger release (ETFR) are effective methods in treating stenosing tenosynovitis. However, a paucity of literature exists comparing the techniques. This study describes and compares postoperative complications following OTFR and ETFR at a single institution.

METHODS

Patients undergoing trigger finger release between 2018 and 2020 within a single institution were identified. Electronic medical records were reviewed for patient demographics, surgical history, surgical characteristics, and clinical outcomes. Major and minor postoperative complications were assessed. Secondary outcome measures included tourniquet time and procedure time. Statistical analysis evaluated associations between postoperative complications, surgical technique, patient demographics, and surgical characteristics.

RESULTS

In total, 57 patients (80 digits) were included in the study: 42 digits treated with OTFR and 38 digits treated with ETFR. Mean follow-up time was 57.6 ± 69.0 days (range, 7-307 days) for ETFR and 34.2 ± 26.3 days (range, 6-120 days) for OTFR. Overall, major, and minor complication rates for the cohort were 8.8%, 1.8% and 7.0%, respectively. There were no major complications following ETFR and 1 following OTFR (4%), the isolated case being postoperative Chronic regional pain syndrome. Minor complication rates were similar following OTFR (8%) and ETFR (6%). Persistent digit stiffness and swelling were found to be the most prevalent minor complications (n = 2, respectively), followed by wound dehiscence (n = 1). Female patients were significantly more likely to experience postoperative complications.

CONCLUSIONS

Major complications following trigger finger release are unlikely; however, minor complications are prominent. Patients treated with OTFR and ETFR showed similar postoperative complication rates. Continued investigations into the benefits of ETFR are warranted.

Responsiveness of PROMIS Instruments for Trigger Digit After Corticosteroid Injection or A1 Pulley Release

PURPOSE

The purpose of the study was to determine if the patient-reported outcomes measurement information system (PROMIS) is sufficiently sensitive to detect improvement after 2 common treatments of trigger finger: corticosteroid injection or A1 pulley release.

METHODS

This retrospective cohort study included 72 patients in the injection group and 51 in the A1 pulley release group. PROMIS physical function (PF), pain interference (PI), and upper extremity (UE) scores were collected at baseline and 6 weeks after injection for the injection group and at baseline, and 1 week, 6 weeks, and 3 months after surgery for A1 pulley release patients. Descriptive statistics and paired t tests were used to compare PROMIS scores within each cohort. Standardized response means (SRMs) were calculated for each PROMIS domain to gauge instrument responsiveness.

RESULTS

Average age was 62 years, 65% were female patients, and 86% were White for the steroid injection cohort, compared to 60 years, 71%, and 88%, respectively, for the A1 pulley release cohort. For the steroid injection group, mean PROMIS PI scores (-4.0 points; SRM = -0.6) and PROMIS UE scores (+3.3 points; SRM = 0.5) improved significantly at 6 weeks after injection compared to baseline. Meanwhile, A1 pulley release patients improved significantly in mean PI scores (-3.7 points; SRM = -0.5) and in UE scores (+4.9 points; SRM = 0.7) at 3 months after surgery compared to baseline.

CONCLUSIONS

Clinical improvements after trigger digit treatments are reflected in improved PROMIS PI and UE scores that reach previously accepted minimum clinically important difference values for hand patients. PROMIS PI and UE also are more responsive than PROMIS PF in capturing improvement for trigger digit treatments.

CLINICAL RELEVANCE

As health care payers continue to emphasize patient-reported outcomes to determine treatment value and set reimbursement rates, this study helps establish that clinical improvement after trigger digit treatments are reflected in PROMIS PI and UE domains by reaching previously established minimum clinically important difference values for hand patients.

Prognostic factors related to recurrence of trigger finger after open surgical release in adults

INTRODUCTION

Recurrent trigger finger after surgery is one of the major adverse events. However, studies to identify factors associated with recurrence after open surgical release in adult trigger finger patients are still limited.

PURPOSE

To identify factors associated with recurrent trigger finger after open surgical release.

METHODS

This 12-year retrospective observational study included 723 patients with 841 trigger fingers who underwent open A1 pulley release. Patients were categorized into 2 groups: those with recurrent trigger finger after surgery and those without. Associations between potential predictors including age, sex, duration of symptoms, occupation status, active smoker status, number of steroid injections before surgery, and types of comorbidities and the outcome of interest, recurrence of trigger finger, were examined using univariable and multivariable analyses. The results are presented as hazard ratios (HR) with a 95% confidence interval (95% CI).

RESULTS

The recurrence rate after trigger finger release was 2.39% (20 of 841 fingers). After adjusting for confounders, more than 3 steroid injections before surgery and manual labor were the independent predictors of recurrent trigger finger (HR = 4.87, 95%CI = 1.06-22.35 and HR = 3.43, 95%CI = 1.15-10.23, respectively).

CONCLUSIONS

More than 3 steroid injections before surgery and manual labor increase the risk of recurrent trigger finger after an open A1 pulley release. There may be limited benefit in administering a fourth steroid injection.

Single-Portal Antegrade Endoscopic Trigger Finger Release: Cadaveric and Clinical Outcomes

BACKGROUND

This study aimed to examine the relationship between anatomical surface landmarks in fresh frozen cadavers as related to in vivo endoscopic trigger finger release (ETFR) and present clinical outcomes after a single-portal antegrade ETFR technique.

METHODS

Endoscopic trigger finger release was performed on 40 cadaveric digits. Each digit was dissected and the following measurements were recorded: distance from palmar digital crease and A1 pulley, length of the A1 pulley, percentage of A1 pulley released, and injury to vulnerable anatomy. A retrospective chart review was performed on 48 patients (62 digits) treated with ETFR. Outcome measures included grip and pinch strength, range of motion, Disability of Arm, Shoulder, and Hand (DASH) questionnaires, and Visual Analog Scale (VAS) pain scores.

RESULTS

Release of the A1 pulley was achieved in 33 of the 40 cadaveric digits (83%) with an A2 pulley laceration rate of 25%. No flexor tendon or neurovascular injuries occurred. Gross grasp, lateral pinch, 3-jaw chuck, and precision pinch strength had 85%, 90%, 82%, and 90% recovery, respectively. At the final follow-up, average metacarpophalangeal joint, proximal interphalangeal joint, and distal interphalangeal joint range of motion were within the normal limits. Mean VAS scores decreased from 5.7 preoperatively to 1.0 postoperatively and mean DASH score at the final follow-up was 4.8.

CONCLUSIONS

With the use of anatomical surface landmarks, ETFR may be performed in an efficient and reproducible manner. Patients treated with ETFR had low complication rates, good functional recovery, and improved pain at short-term follow-up. Further study of long-term outcomes and cost-effectiveness of ETFR is warranted.

Complications and Functional Outcomes following Trigger Finger Release: A Cohort Study of 1879 Patients

BACKGROUND

Although trigger finger release is considered a safe procedure, large cohort studies reporting consistent complication rates and functional outcomes are scarce. Further insight into outcomes of this commonly performed procedure is essential for adequate treatment evaluation and patient counseling. Therefore, the aim of this study was to assess the complication rates and functional outcomes following trigger finger release.

METHODS

This is an observational multicenter cohort study of patients undergoing trigger finger release. The primary outcome included the occurrence of complications. The secondary outcome was change in hand function (Michigan Hand outcomes Questionnaire) from baseline to 3 months postoperatively.

RESULTS

Complications were observed in 17.1 percent of 1879 patients. Most complications were minor, requiring hand therapy or analgesics (7.0 percent of all patients), antibiotics, or steroid injections (7.8 percent). However, 2.1 percent required surgical treatment and 0.2 percent developed complex regional pain syndrome. The Michigan Hand Outcomes Questionnaire total score improved from baseline to 3 months postoperatively with 12.7 points, although the authors found considerable variation in outcomes with less improvement in patients with better baseline scores.

CONCLUSIONS

This study demonstrates that trigger finger release results in improved hand function, although complications occur in 17 percent. Most complications are minor and can be treated with nonsurgical therapy, resulting in improved hand function as well. However, additional surgical treatment is required in 2 percent of patients. In addition, the authors found that change in hand function depends on the baseline score, with less improvement in patients with better baseline scores. Future studies should investigate factors that contribute to the variability in treatment outcomes following trigger finger release.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Nonpalmar Endoscopic versus Open Trigger Finger Release: Results from a Prospective Trial

The most common complaint after open surgical release for trigger finger is of pain and scarring at the surgical site. We hypothesized that use of a new nonpalmar endoscopic approach for release of the A1 pulley through an incision at the proximal digital crease would result in decreased scarring and faster recovery compared to those treated with standard open release.

Methods

Patients with trigger finger were prospectively enrolled and treated with a nonpalmar endoscopic versus open surgical technique. Outcome measures included scar assessment based on the Patient and Observer Scar Assessment Scale (POSAS) administered 1 week, 1 month, and 6 months postoperatively, time before return to work, occupational therapy visits, and overall satisfaction. Additional outcomes included pain medication use, operative time, and complication and recurrence rates.

Results

POSAS scores were better in the endoscopic treatment group than in the open group at all time points with a statistically significant difference seen at 1 week and 1 month postoperatively. The endoscopic group returned to work sooner, required fewer occupational therapy visits, and had better overall satisfaction compared to the open group, but the differences were not statistically significant. Complication and recurrence rates did not differ significantly between groups.

Conclusions

Patients treated for trigger finger with a nonpalmar endoscopic release through an incision at the proximal digital crease demonstrate significantly better scarring in the early postoperative period compared to patients treated with the open surgical approach. Treatment for trigger finger with this technique is as effective as the standard open technique.

Endoscopic Retrograde Approach for Trigger Finger Release: A Cadaver Study

Trigger finger is one of the most common causes of disability and pain in the hand. Current surgical techniques for trigger finger release fall short in that they are performed blindly with trauma to, or require incision of, the palmar fascia, which can be a source of significant and long-lasting morbidity. Retrograde endoscopic release of the A1 pulley was performed through a single incision at the proximal digital crease in cadaveric specimens. The fingers were then dissected to assess for completeness of release and inspected for injury to nearby structures. Complete release of the A1 pulley was noted in 16 of 16 fingers. No significant injuries to the A2 pulley and flexor tendon were found, and no injuries to the digital nerves or vasculature occurred. The described technique, as demonstrated in cadaveric specimens, is a feasible alternative approach in the treatment of trigger finger. The technique allows complete visualization of A1 pulley release through a single palmar fascia sparing incision.

Comparative effectiveness of various treatment strategies for trigger finger by pairwise meta-analysis

OBJECTIVE

To compare the efficacy of various strategies in the treatment of trigger finger.

DATA SOURCES

A systematic literature search for randomized controlled trials to compare treatments for trigger finger was conducted through three online databases, Pubmed, Embase and Cochrane Library, from their inception dates to 22 May 2020.

METHODS

Relative risk (RR) with 95% confidence interval (CI) was used to evaluate the effect sizes in success rate for included articles.

RESULTS

Sixteen articles (n = 1185) were included in our meta-analysis. The results showed that the efficacy of steroid injection was significantly better than the placebo group at short-term follow-ups (RR = 19.00, 95% CI = 1.17-309.77 for one-week; RR = 3.70, 95% CI = 3.70, 95% CI = 1.61-8.53 for one-month), and then became non-significant at four months (RR = 3.21, 95% CI = 0.88-11.79). There was no significant difference in success rate between steroid injection and nonsteroidal anti-inflammatory drug injection, and between open surgery and percutaneous release at all the follow-ups. Only surgical treatment had significantly better efficacy in success rate than steroid injection at all follow-ups (RR = 0.48, 95% CI = 0.34-0.66 for one-month; RR = 0.87, 95% CI = 0.80-0.96 for three-month; RR = 0.58, 95% CI = 0.48-0.68 for six-month; RR = 0.38, 95% CI = 0.20-0.72 for 12-month).

CONCLUSION

There were no differences in efficacy between steroid injection and shockwave or nonsteroidal anti-inflammatory drug injection. The surgical treatments had the best efficacy among these treatments.

Trigger finger: An overview of the treatment options

Stenosing flexor tenosynovitis, more commonly known as trigger finger, is one of the most common causes of hand pain and dysfunction. Clinicians must be able to identify the disorder, know the broad range of treatment options, and counsel patients on the treatment best suited for their condition. Awareness of the economic burden each option entails is central to optimizing treatment outcomes and patient satisfaction.

Endoscopic Trigger Finger Release: Surgical Technique

Numerous surgical approaches have been described for treating patients suffering with stenosing tenosynovitis. The usual surgical descriptions differ mainly by the type of skin incision utilized. The goal of surgery is to completely release the A1 pulley, thereby allowing unimpeded motion of the flexor tendons. We describe a minimally invasive endoscopic technique to address this condition in the fingers.

Surgery for trigger finger

BACKGROUND

Trigger finger is a common clinical disorder, characterised by pain and catching as the patient flexes and extends digits because of disproportion between the diameter of flexor tendons and the A1 pulley. The treatment approach may include non-surgical or surgical treatments. Currently there is no consensus about the best surgical treatment approach (open, percutaneous or endoscopic approaches).

OBJECTIVES

To evaluate the effectiveness and safety of different methods of surgical treatment for trigger finger (open, percutaneous or endoscopic approaches) in adults at any stage of the disease.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and LILACS up to August 2017.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that assessed adults with trigger finger and compared any type of surgical treatment with each other or with any other non-surgical intervention. The major outcomes were the resolution of trigger finger, pain, hand function, participant-reported treatment success or satisfaction, recurrence of triggering, adverse events and neurovascular injury.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trial reports, extracted the data and assessed the risk of bias. Measures of treatment effect for dichotomous outcomes calculated risk ratios (RRs), and mean differences (MDs) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CIs). When possible, the data were pooled into meta-analysis using the random-effects model. GRADE was used to assess the quality of evidence for each outcome.

MAIN RESULTS

Fourteen trials were included, totalling 1260 participants, with 1361 trigger fingers. The age of participants included in the studies ranged from 16 to 88 years; and the majority of participants were women (approximately 70%). The average duration of symptoms ranged from three to 15 months, and the follow-up after the procedure ranged from eight weeks to 23 months.The studies reported nine types of comparisons: open surgery versus steroid injections (two studies); percutaneous surgery versus steroid injection (five studies); open surgery versus steroid injection plus ultrasound-guided hyaluronic acid injection (one study); percutaneous surgery plus steroid injection versus steroid injection (one study); percutaneous surgery versus open surgery (five studies); endoscopic surgery versus open surgery (one study); and three comparisons of types of incision for open surgery (transverse incision of the skin in the distal palmar crease, transverse incision of the skin about 2-3 mm distally from distal palmar crease, and longitudinal incision of the skin) (one study).Most studies had significant methodological flaws and were considered at high or unclear risk of selection bias, performance bias, detection bias and reporting bias. The primary comparison was open surgery versus steroid injections, because open surgery is the oldest and the most widely used treatment method and considered as standard surgery, whereas steroid injection is the least invasive control treatment method as reported in the studies in this review and is often used as first-line treatment in clinical practice.Compared with steroid injection, there was low-quality evidence that open surgery provides benefits with respect to less triggering recurrence, although it has the disadvantage of being more painful. Evidence was downgraded due to study design flaws and imprecision.Based on two trials (270 participants) from six up to 12 months, 50/130 (or 385 per 1000) individuals had recurrence of trigger finger in the steroid injection group compared with 8/140 (or 65 per 1000; range 35 to 127) in the open surgery group, RR 0.17 (95% CI 0.09 to 0.33), for an absolute risk difference that 29% fewer people had recurrence of symptoms with open surgery (60% fewer to 3% more individuals); relative change translates to improvement of 83% in the open surgery group (67% to 91% better).At one week, 9/49 (184 per 1000) people had pain on the palm of the hand in the steroid injection group compared with 38/56 (or 678 per 1000; ranging from 366 to 1000) in the open surgery group, RR 3.69 (95% CI 1.99 to 6.85), for an absolute risk difference that 49% more had pain with open surgery (33% to 66% more); relative change translates to worsening of 269% (585% to 99% worse) (one trial, 105 participants).Because of very low quality evidence from two trials we are uncertain whether open surgery improve resolution of trigger finger in the follow-up at six to 12 months, when compared with steroid injection (131/140 observed in the open surgery group compared with 80/130 in the control group; RR 1.48, 95% CI 0.79 to 2.76); evidence was downgraded due to study design flaws, inconsistency and imprecision. Low-quality evidence from two trials and few event rates (270 participants) from six up to 12 months of follow-up, we are uncertain whether open surgery increased the risk of adverse events (incidence of infection, tendon injury, flare, cutaneous discomfort and fat necrosis) (18/140 observed in the open surgery group compared with 17/130 in the control group; RR 1.02, 95% CI 0.57 to 1.84) and neurovascular injury (9/140 observed in the open surgery group compared with 4/130 in the control group; RR 2.17, 95% CI 0.7 to 6.77). Twelve participants (8 versus 4) did not complete the follow-up, and it was considered that they did not have a positive outcome in the data analysis. We are uncertain whether open surgery was more effective than steroid injection in improving hand function or participant satisfaction as studies did not report these outcomes.

AUTHORS' CONCLUSIONS

Low-quality evidence indicates that, compared with steroid injection, open surgical treatment in people with trigger finger, may result in a less recurrence rate from six up to 12 months following the treatment, although it increases the incidence of pain during the first follow-up week. We are uncertain about the effect of open surgery with regard to the resolution rate in follow-up at six to 12 months, compared with steroid injections, due high heterogeneity and few events occurred in the trials; we are uncertain too about the risk of adverse events and neurovascular injury because of a few events occurred in the studies. Hand function or participant satisfaction were not reported.

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.

Percutaneous release of the A1 pulley using a modified Kirschner wire: a cadaveric study

PURPOSE. To evaluate the outcome of percutaneous release of the A1 pulley in 40 cadaveric fingers using a modified Kirschner wire. METHODS. A 2.5-mm-diameter Kirschner wire measuring >12 cm in length was used. One end of the wire was sharpened into a 'J' shape using a grinder. The J-shaped tip featured a blunt, elongated lower tip, a sharp J-shaped curve, and a blunt upper tip. Completeness of A1 pulley release and injuries to the A2 pulley, flexor tendon, and neurovascular structures were evaluated in 40 cadaveric fingers. RESULTS. Complete release of the A1 pulley was achieved in 8 index, 7 middle, 8 ring, and 8 little fingers, whereas incomplete release of the distal part was noted in 2 index, 2 middle, 2 ring, and one little fingers; release was missed in one middle and one little fingers. Injury to the A2 pulley was noted in 2 index fingers; the injury was minimal and limited to the proximal 2 mm of the A2 pulley. There was no flexor tendon or digital nerve injury in any finger. CONCLUSION. Percutaneous release of the A1 pulley using a modified Kirschner wire achieved complete release in 78% of cadaveric fingers, which is comparable to that using a specially manufactured push knife.

[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.