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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. [ABSTRACT FROM AUTHOR]

Background: Cost and compliance are 2 factors that can significantly affect the outcomes of non-operative and operative treatment of trigger finger (TF) and both may be influenced by social factors. The purpose of this study was to investigate socioeconomic disparities in the surgical treatment for TF. Methods: Adult patients (≥18 years old) were identified using International Classification of Diseases 9 and 10 Clinical Modification diagnostic codes for TF and Current Procedural Terminology (CPT) procedural codes (CPT: 26055) in the New York Statewide Planning and Research Cooperative System database. Each diagnosis was linked to procedure data to determine which patients went on to have TF release. A multivariable logistic regression was performed to assess the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation index (SDI), Charlson Comorbidity Index, and primary insurance type. A P -value <.05 was considered significant. Results: Of the 31 411 TF patients analyzed, 8941 (28.5%) underwent surgery. Logistic regression analysis showed higher odds of receiving surgery in females (odds ratio [OR]: 1.108) and those with workers compensation (OR: 1.7). Hispanic (OR: 0.541), Asian (OR: 0.419), African American (OR: 0.455), and Other race (OR: 0.45) had decreased odds of surgery. Medicaid (OR: 0.773), Medicare (OR: 0.841), and self-pay (OR: 0.515) reimbursement methods had reduced odds of receiving surgery. Higher social deprivation was associated with decreased odds of surgery (OR: 0.988). Conclusions: There are disparities in demographic characteristics among those who receive TF release for trigger finger related to race, primary insurance, and social deprivation. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: This article compares the rates and time-to-development of new-onset Dupuytren disease in patients with trigger finger treated by steroid injection, surgical release, or both. Methods: PearlDiver's Mariner 30 database was queried to identify patients with trigger finger between January 2010 and June 2019. One-to-one exact matching based on baseline patient demographics allowed us to create 4 identical groups defined by the type of trigger finger intervention received. Results: The matched population analyzed in this study consisted of 85 944 patients who were equally represented in the steroid injection cohort (n = 21 486, 25.00%), surgical release cohort (n = 21 486, 25.00%), steroids prior to surgery cohort (n = 21 486, 25.00%), and no intervention (control) cohort (n = 21 486, 25.00%). A new Dupuytren diagnosis after trigger finger treatment occurred in 1 in 128 patients overall, 1 in 156 patients treated with steroid injection, and 1 in 126 patients treated with surgical release. Trigger fingers treated by steroid injection only had the lowest rates of Dupuytren disease overall (n = 137, 0.64%, P =.0424) and treatment with fasciectomy (n = 14, 0.07%, P <.0005). In all, 171 patients in the surgery cohort developed Dupuytren disease 1 year after undergoing surgical trigger finger release. Furthermore, this cohort had the highest rates of fasciectomy (n = 55, 0.26%, P <.0005) and the lowest rates of no intervention (n = 103, 0.48%, P =.0471). Trigger fingers managed by surgical release developed Dupuytren disease (mean, 56.11 days; SD, 80.93 days, log-rank P =.02) and underwent fasciectomy (mean, 49.74 days; SD, 62.27 days; log-rank P <.0005) more quickly than all other cohorts. Conclusions: Patients solely undergoing surgical release of their trigger finger had significantly higher odds and expedited rate of developing new-onset Dupuytren disease overall and undergoing subsequent treatment by fasciectomy compared with trigger fingers managed by other interventions. [ABSTRACT FROM AUTHOR]

This prospective randomized controlled study compared two injection techniques for trigger digit: either dorsal to the tendons in the proximal phalanx (PP group) or anterior to the tendons at the A1 pulley level (A1 group) in 106 patients. The primary outcome was the number of days to total relief of pain, stiffness and triggering, as recorded by the patients on visual analogue scales day-by-day for 6 weeks. The median number of days to complete symptom relief was 9 days in the PP group and 11 days in the A1 group for pain, 11 days and 15 days for stiffness and 21 and 20 days for triggering, respectively. Ninety-one per cent of all patients did not require any additional treatment, but 11 patients in both groups reported some remaining symptoms at 6 weeks. This study did not detect any significant difference between the two injection techniques, but provides detailed data of the rate and order of symptomatic relief after corticosteroid injection for this common condition. Level of evidence: I [ABSTRACT FROM AUTHOR]

We investigated the minimal clinically important difference (MCID) of the Michigan Hand Outcomes Questionnaire (MHQ) and the pain visual analogue scale (VAS-pain) after conservative treatment of trigger finger. This secondary analysis of a randomized controlled trial compared pain reduction, symptoms and functional improvement at 12 weeks. Patients included were at least 18 years old and able to complete MHQ and VAS-pain at enrolment and 12 weeks after treatment. The MCIDs of MHQ and VAS-pain were evaluated using a distribution-based, anchor-based and receiver operating characteristic (ROC) curve-based approach. Of the 117 patients, the MCIDs of MHQ and VAS-pain using a distribution-based approach were 5.3 and 0.6, respectively; applying ROC method were 23.5 and 2.5, respectively; and using anchor questions were 15 and 2, respectively. These MCID values by anchor-based method with a minimal difference of 15 for MHQ and 2 for VAS-pain are recommended as primary evidence to determine clinically significant improvement after conservative treatment of trigger finger. Level of evidence: I [ABSTRACT FROM AUTHOR]

This study aimed to identify the rates and risk factors for failure of percutaneous A1 pulley release. We retrospectively analysed patients who underwent percutaneous A1 pulley release between 2015 and 2019. We defined failure as (1) pain or discomfort at the final follow-up, (2) when open release or revision percutaneous release was performed, or (3) when steroid injections were administered three or more times for symptom control. A total of 331 digits from 251 patients were included. The mean follow-up duration was 47 months (minimum 24 months). Complete resolution was achieved in 287 cases (87%), but 21% required steroid injection before symptoms settled. There was failure in 44 cases (13%). Involvement of the index, middle and ring fingers was significantly different between the successful and failure groups. Percutaneous A1 pulley release has a long-term success rate of 87%. The failure rate was higher when the procedure was performed on the index, middle or ring fingers. Level of evidence: III [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

A retrospective study of patients with symptomatic trapeziometacarpal osteoarthritis was conducted to assess the prevalence of other disorders of the hand. Another disorder of the hand was associated in 49% of cases. A systematic clinical examination of the whole hand must be performed preoperatively. [ABSTRACT FROM AUTHOR]

Background: Corticosteroid injections have proven benefit in the treatment of symptomatic trigger finger; however, the immune system and tissue repair modulating properties of corticosteroids justify further consideration in surgical candidates. The aim of this study was to assess the relationship between corticosteroid injections and postoperative infection in trigger finger release. Methods: A single-center retrospective review was conducted of patients seen from 2010 to 2019 to identify those who underwent trigger finger release with subsequent antibiotic prescription for chart-documented wound infection. A demographic matched cohort of 100 patients was identified for comparison. Preoperative corticosteroid injection history including timing, frequency, and dose was collected for all patients. Patient demographics, comorbidities, and presence of postoperative infection were collected from patient medical records. Superficial infection was defined as those requiring antibiotics for resolution without return to the operating room; deep infection was defined as infections that required irrigation and debridement. Results: Of 3234 patients who underwent trigger finger release, 58 (1.8%) were identified with postoperative infections, 6 (0.2%) of which were deep infections. History of corticosteroid injection was significantly more common in patients with postoperative infection. Compared with an age-matched, gender-matched, and body mass index–matched cohort, patients with postoperative infection had significantly increased rate of diabetes mellitus at 34.5% to 19% (P =.04) Conclusions: While corticosteroid injection in the preoperative period is associated with a higher rate of postoperative infection, the time before surgery and the corticosteroid dose do not appear to have an effect. [ABSTRACT FROM AUTHOR]

Background: The palmar aponeurosis or "A0 pulley" may play a role in trigger finger pathology. This study assesses the involvement of the A0 pulley in patients receiving trigger finger release. Methods: This single-surgeon, prospective, randomized clinical trial was conducted among consenting patients with symptomatic trigger finger. Intraoperative coin toss was used to randomize initial release of either the A0 or A1 pulley. Following release, active flexion and extension of the affected digit were examined. The remaining pulley was then released in sequence, and clinical trigger status was recorded. Results: Thirty fingers from 24 patients were released; 17 fingers received A0 release first, and 13 received A1 release. Following initial A0 release, 8 fingers (47%) demonstrated complete resolution of symptoms, 4 (24%) demonstrated improvement but incomplete resolution of triggering, and 5 (29.4%) demonstrated no improvement. Following initial A1 release, 6 fingers (46%) demonstrated complete resolution, 3 (23%) demonstrated improvement but incomplete resolution of triggering, and 4 (31%) demonstrated no improvement. All patients demonstrated complete resolution after surgical release of both sites. Neither initial A1 release nor initial A0 release was statistically associated with complete, incomplete, or failed symptom resolution. Conclusions: These data implicate the A0 pulley as the primary cause of 31% to 47% of trigger fingers in our study. Although larger trials are needed to validate these results, our study suggests that release of both A0 and A1 pulleys may offer greater symptom resolution than release of the A1 pulley alone. [ABSTRACT FROM AUTHOR]

Background: Trigger finger is a common hand complaint of the general population. Limited literature exists implicating a low-estrogen state in patients on aromatase inhibitor (AI) therapy for breast cancer who develop trigger finger. The authors' objective was to determine the incidence and treatment outcomes of this population. Methods: A single-center retrospective chart review was conducted on patients with a diagnosis of breast cancer on AI who developed trigger finger from 2010 to 2019. The total population of patients during this time served as our population, and patients with breast cancer not on AI with trigger finger served as our control. Primary outcomes included total number of injections and need for surgery. Secondary outcomes included risk factors for surgery. χ2 analysis and logistical regression model determined the significance of primary and secondary outcomes, respectively. Results: In all, 192 patients of a population size of 664 751 met our study group criteria. The study group showed a higher incidence of trigger finger (5.1% vs 1.3%; P <.001) compared with our population. Patients treated with AI for breast cancer had both higher incidence of trigger finger (5.1% vs 1.5%, P <.001) and injections (77.1% vs 66.5%, P <.001) compared with patients not on AI therapy. Independent risk factors requiring surgical treatment were found in patients with diabetes (odds ratio [OR], 3.54; P =.01) and in patients with concomitant radiation therapy (OR, 3.17; P =.02). Conclusions: This study demonstrates for the first time the incidence, treatment outcomes, and surgical risk factors of trigger finger in patients on AI therapy for breast cancer. [ABSTRACT FROM AUTHOR]

The aim of this prospective study of 55 patients was to analyse the cross-sectional and longitudinal relationship between disability and physical and psychological variables after conservative treatment of trigger finger and to determine the predictive factors for the post-treatment disability score and change in disability score. The primary outcome measure was the Disabilities of the Arm, Shoulder, and Hand questionnaire. Potential predictive factors included pain, number of triggering events, depression, anxiety and kinesiophobia. Disability correlated strongly with anxiety, moderately with pain and depression and weakly with triggering and kinesiophobia. The change in depression score correlated significantly with the change in disability score. Post-treatment pain and anxiety scores accounted for 47% of the explained variance in disability score. Improvement in depression after treatment accounted for 18% of the explained variance in disability change score. Psychological variables appear to be potential predictors of disability. Level of evidence: IV [ABSTRACT FROM AUTHOR]

Background: Traditional dogma regarding management of rheumatoid arthritis (RA) patients with trigger digit symptoms holds that A1 pulley release should be avoided. Surgical release was thought to further destabilize the metacarpophalangeal joint. Biologic disease modifying anti-rheumatic drugs (DMARDs) have limited the development of hand deformities. Despite advances in RA treatment, many textbooks continue to discourage release of the A1 pulley in RA patients. The aim of this study was to determine if this belief is consistent with current trends in surgical management of trigger digits in patients with RA. Methods: Active Members of the American Society for Surgery of the Hand (ASSH) were surveyed on their training and current practices as related to RA patients with trigger digits. Results: Five hundred three surveys were completed (16% response rate). During training, 55% of ASSH Members were taught to avoid releasing the A1 pulley in RA patients. Seventy-one percent of respondents currently release the A1 pulley in RA patients with no preexisting deformities, no tenosynovial thickening, or if tenosynovectomy and flexor digitorum superficialis slip excision fail to relieve triggering. Forty percent reported that their practice has evolved toward more frequent release of the A1 pulley in RA patients. Conclusion: The majority of ASSH Active Members were taught during training to avoid surgical release of the A1 pulley in RA patients to prevent acceleration of finger deformities. Indications and contraindications for A1 pulley release are evolving along with the improved natural history of RA associated with the use of biologic DMARDs. [ABSTRACT FROM AUTHOR]

We dissected 192 fingers in 48 fresh cadaveric hands (23 right and 25 left hands from 26 female and 22 male donors) and analysed the incidence, location, length and structure of the five annular and three cruciform pulleys. No statistically significant differences were found between left and right or between male and female hands. The A1, A2 and A4 pulleys were present in all fingers, while the incidence of other pulleys varied. We found 32 different patterns of pulley combinations. The structure of the pulleys also varied. Most important was the variation of A1, which consisted of one to four separate rings. In 18% there was no gap between the A1 and A2 pulleys. A greater understanding of the anatomical variation of the pulley system is beneficial for hand surgeons performing open or percutaneous trigger finger releases and for radiologists examining the area sonographically. [ABSTRACT FROM AUTHOR]

Background: Trigger finger release (TFR) is one of the most commonly performed hand procedures and typically results in restoration of normal finger function. However, uncommon postoperative complications such as deep infection can have devastating consequences. The goal of this study was to evaluate the incidence, risk factors, and characteristics of infectious flexor tenosynovitis occurring after TFR. Methods: We searched billing records for the Current Procedural Terminology code for TFR to identify all adult patients who underwent TFR at our institution over a 10-year period. We defined infectious tenosynovitis as any case where the patient underwent tendon sheath drainage or postoperative wound debridement within 6 months of the index TFR procedure. Medical records were reviewed to obtain patient demographic information, body mass index (BMI), tobacco use, history of diabetes mellitus, surgical setting (clinic vs outpatient surgery center), and surgical digit for all patients. In those patients treated for infection, we recorded hospital length of stay, number of operative procedures, and any culture results. Results: We identified a total of 18 infections out of 2307 procedures (1827 patients), for an incidence of 0.99%. Current smokers had a significantly higher incidence of infection than nonsmokers (1.77% vs 0.29%). On univariate analysis, smoking was closely associated with infection (P ≤.05). All infections occurred in overweight or obese patients by BMI criteria, but there was no difference in average BMI between patients with and without infection. History of diabetes, in-office surgery, patient age, and patient sex were not associated with a higher incidence of infection. Patients with infections spent an average of 4.1 days in the hospital, and 40% required multiple surgical procedures. The most common infectious organism cultured was Staphylococcus aureus, which was present in 67% of infections. Patients with isolated methicillin-sensitive S aureus on culture showed signs of infection within 3 weeks of the index procedure, whereas polymicrobial, coagulase-negative staphylococci or beta hemolytic streptococci were identified in patients presenting with infectious symptoms later. Conclusion: Infections after TFR are uncommon but are more likely to occur in patients who are current smokers and overweight or obese by BMI criteria. Methicillin-sensitive S aureus is the most likely causative organism, especially in patients presenting during the early postoperative course. [ABSTRACT FROM AUTHOR]

This single-centre retrospective study reports our management of carpal tunnel syndrome in 52 children (103 hands) with mucopolysaccharidoses and mucolipidoses. All except one were bilateral. The median age at surgery was 4 years (range 1.5 to 12). The diagnosis of carpal tunnel syndrome was confirmed by an electromyogram (EMG) in all patients; 38% of these presented without any clinical signs. Surgical neurolysis was performed in all hands, combined with epineurotomy in 52 hands (50%) and flexor tenosynovectomy in 75 hands (73%). Surgery was bilateral in 98% of children (102 hands). The mean follow-up was 12 years (range 1 to 19) and the EMG was normalized in 78% of hands. Ten patients suffered recurrence, eight of whom required further surgery. Screening for carpal tunnel syndrome is essential for the management of children mucopolysaccharidoses and mucolipidoses. Surgical treatment should be carried out early with follow-up by EMG to detect recurrence. Level of evidence: IV [ABSTRACT FROM AUTHOR]

Background: Trigger finger has a prevalence of 2% to 3% in the general population. Although anecdotal evidence exists, there is a lack of conclusive data that prove a relationship between repetitive power grip and flexion with triggering. Ocean rowing is becoming a popular sport, with the race across the Atlantic alone attracting more than 100 participants annually. Anecdotal reports suggest ocean rowing may be a significant cause of trigger finger. We aimed to identify whether the sport causes an increased prevalence of triggering, whether there were any alleviating or compounding factors, and, finally, whether there was any effect on performance. Methods: A prospective observational study was carried out. A questionnaire was sent to all participants of the Talisker Whisky Atlantic Challenge 2018, which included a trigger finger self-scoring system and the Oslo Sports Trauma Center Overuse Injury Questionnaire. Results: Responses were received from 67 rowers (83% response rate). Age ranged from 21 to 62 years, with a mean of 40 years. In all, 49.3% had clinical triggering, with 79.3% reporting bilateral symptoms. The length of continuous rest time had a significant impact on the incidence of finger triggering and disease stage (P =.0275 and.0353, respectively; multivariate logistic regression). High-grade triggering had a more negative effect on rowing performance than low grade or no triggering (not significant). Conclusion: Ocean rowers suffered a 15-fold increase in trigger finger prevalence compared with the general population. This was increased in those who took shorter, more frequent rest periods. This study provides new conclusive evidence that the repetitive power grip and flexion involved in rowing increase the prevalence of trigger finger. [ABSTRACT FROM AUTHOR]

Paediatric trigger finger is a rare condition distinct from paediatric trigger thumb and adult trigger digits. We performed a systematic review of paediatric trigger finger presentation and aetiology in order to guide workup and management. Fifty-one studies with 193 patients and 398 trigger fingers were included. Most patients had a single, unilateral trigger finger (54%). Fifty-five patients (29%) had an underlying condition, such as mucopolysaccharidosis; these cases appeared to be associated with multiple or bilateral trigger fingers or with carpal tunnel syndrome. All patients with mucopolysaccharidosis were treated surgically. Conservative management was reported in 33% of all patients, and two-thirds of these did not need further intervention. Patients undergoing surgical release infrequently had recurrence of triggering (6%). We propose an algorithmic approach for patients presenting with paediatric trigger finger. Presence of bilateral or multiple trigger digits or concomitant carpal tunnel syndrome should raise suspicion for an atypical underlying pathology. [ABSTRACT FROM AUTHOR]

Background: The aim of this preliminary study was to evaluate the effectiveness of a J-tip needle-free injection system (JNFS) to reduce pain associated with corticosteroid injection of the tendon sheath for treatment of trigger finger. Methods: Thirty-four consecutive trigger fingers occurring in 28 unique patients who met inclusion/exclusion criteria were consented and enrolled into this double-blind randomized controlled study. Patients were randomly assigned to the control (JNFS loaded with sterile normal saline) or treatment group (JNFS loaded with buffered 1% lidocaine). Both the fellowship-trained hand surgeon and patient were blinded to the allocation group. Prior to each trigger finger injection, each patient rated pain associated with stubbing toe and papercut on the visual analog scale (VAS), in addition to a postprocedure VAS pain score. Results: A total of 28 patients and 34 digits were enrolled in this study. There was no difference in patient demographics or preintervention pain perception between the control and treatment groups. The use of JNFS demonstrated lower mean pain VAS score when comparing the control group (n = 17) with the treatment group (n = 17), with VAS pain scores of 49 (SD = 31) and 39 (SD = 36), respectively. However, this difference was not statistically significant (P =.389). Conclusions: The use of JNFS loaded with 1% buffered lidocaine may reduce pain associated with trigger finger injections, although our results did not find a statistically significant difference. We hypothesize that the pain caused by the acidity of lidocaine is the primary driver of pain and discomfort during injection, and the pain from the needle stick is secondary. As a result, any pain reduction from JNFS is masked by the most painful part of injection—the delivery of injectate. Based on the findings and experience obtained from this study, we hypothesize that a follow-up study using buffered lidocaine may be able to better reveal the benefits of JNFS. [ABSTRACT FROM AUTHOR]

We performed a detailed dynamic high-resolution ultrasound examination of the flexor tendons in trigger fingers and compared this with normal contralateral digits. There was a loss of defined linear tendon margins and/or traction of the flexor tendons on the surrounding soft tissue during passive flexion of the distal interphalangeal joint in 17 out of 20 trigger fingers, which indicated adherence to the surrounding tissues. The differential motion between the flexor digitorum profundus tendon and the flexor digitorum superficialis tendons was also lost in ten trigger fingers, which suggested adherence between the tendons. No signs of peritendinous or intertendinous adhesions were found in the healthy control fingers. We conclude that tendon adhesions are present in the majority of trigger fingers. We could not determine a relationship between the severity of triggering and the presence of adherence due to limited sample size. Level of evidence: II [ABSTRACT FROM AUTHOR]

Background: Trigger finger release (TFR) is a commonly performed procedure. However, there is great variation in the setting, care pathway, anesthetic, and cost. We compared the institutional cost for isolated TFR before and after redesigning our clinical care pathway. Methods: Total direct cost to the health system (excluding the surgeon and anesthesiology costs) and time spent by the patient at the surgery center were collected for 1 hand surgeon's procedures at an ambulatory surgery center over a 3-year period. We implemented a redesigned pathway that altered phases of care and anesthetic use by transitioning from intravenous (IV) sedation to wide awake local anesthesia with no tourniquet. Cost data were reported as percentage change in the median and compared both pre- to post-implementation and with 2 control surgeons using the traditional pathway within the same center. Power analysis was based on prior work on a carpal tunnel pathway. Significance was defined by a P -value <.05. Results: Ten TFRs (90% local with IV sedation) and 44 TFRs (89% local alone) were performed pre- and post-implementation, respectively. From pre- to post-implementation, the study surgeon's total direct cost decreased by 18%, while the control surgeons decreased by 2%. Median time spent at the surgery center decreased by 41 minutes post-implementation with significantly shorter setup time in the operating room (OR), total time in the OR, and time spent in recovery prior to discharge. Conclusions: Redesigning the care pathway for TFR led to a decrease in institutional cost and patient time spent at the surgery center. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to identify the main diseases related to trigger finger. Methods: A retrospective, observational study was performed with data obtained through a computerized record of 75 patients with trigger finger diagnosis between July 2011 and October 2015. The diagnosis of metabolic syndrome was performed following National Cholesterol Education Program Adult Treatment Panel III (2001). Results: Patients' ages ranged from 50 to 84 years, with a mean age of 63 years. The ring finger was the most affected, followed by the middle finger, index finger, and little finger. Most had a grade 2 trigger finger classified by Green; the right hand involvement was more prevalent, as was the dominant hand. The incidence in women was twice as high as in men. Arterial hypertension, diabetes mellitus, and dyslipidemia were shown to be important associated diseases, but metabolic syndrome was the main association found. Conclusions: Metabolic syndrome in the group of patients studied in this scientific article seems to be the main associated disease. [ABSTRACT FROM AUTHOR]

Background: Many techniques for injection of trigger fingers exist. The purpose of this study was to determine whether the type of steroid or technique used for trigger finger injection altered clinical outcomes. Methods: Six hand surgeons at a single institution were surveyed regarding their injection technique, preferred steroid used, and protocol for repeat injection or indication for surgery for symptomatic trigger finger. A retrospective chart review of patients who underwent trigger finger injections was performed by randomly selecting 35 patients for each surgeon between January 2013 and December 2015. Demographic data at the time of presentation were collected. Outcome data during follow-up appointments were also recorded. Results: A total of 210 patient charts were reviewed. Demographic data and initial presenting grade of triggering were similar among all groups. There was no significant difference in clinical course or eventual outcomes noted with injection technique. There were 70 patients in each steroid cohort. Patients receiving triamcinolone required additional injections compared with those receiving methylprednisolone and dexamethasone. Eventual surgical intervention was significantly higher in those patients receiving methylprednisolone. The methylprednisolone group also underwent operative release significantly earlier. Conclusions: Trigger finger injections with triamcinolone demonstrate a higher rate of additional injections when compared with dexamethasone and methylprednisolone. Patients who underwent methylprednisolone injection had surgical release performed earlier and more frequently than the other 2 groups. The choice of corticosteroid significantly affected clinical outcome in this study population. Clinicians performing steroid injections for trigger finger may wish to consider these results when selecting a specific agent. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The United Kingdom National Institute for Health and Care Excellence considers a procedure to be cost-effective if the cost per quality-adjusted life year gained falls below a threshold of £20,000–£30,000 (€22,600–33,900; US$24,600–$36,900). This study used cost per quality-adjusted life year methodology to determine the cost-utility ratio of A1 pulley release. Pre- and postoperative EuroQol 5 Dimensions 5 Likert scores were collected prospectively over 6 years from 192 patients. The median pre- and postoperative indices derived from the EuroQol 5 Dimensions 5 Likert scores were significantly different at 0.77 and 0.80. The mean life expectancy was 21 years. The mean number of quality-adjusted life years gained was 1 per patient. The mean cost-utility ratio per patient was £32,308 (€36,508; US$39,730) and £16,154 (€18,254; US$19,869) at 1 and 2 years, respectively. Provided the benefit of surgery was maintained over the remaining life expectancy, the cost-utility ratio decreased to £1537 (€1737; US$1891) per patient. A1 pulley release is cost-effective provided the benefit is maintained for 2 years. The procedure is also associated with a statistically significant improvement in quality of life. Level of evidence: III [ABSTRACT FROM AUTHOR]

One hundred and sixty patients were enrolled in a prospective randomized controlled trial to assess whether a steroid injection through the dorsal web space was less painful than the palmar midline technique in the treatment of trigger digits and whether they were equally effective. There were 116 women and 44 men with a mean age of 60 years. The mean visual analogue score for pain during the injection was 3.6 in the dorsal web space group and 5.4 in the palmar midline group on a scale of 0–10. The overall success of treatment in the dorsal group was 67%, whereas it was 56% in the palmar group. No complications were noted. We concluded from this study that the dorsal web space technique is less painful and at least as effective as the palmar midline technique. Level of evidence: I [ABSTRACT FROM AUTHOR]

We compared the functional outcomes, health-related quality of life, and satisfaction in diabetic and non-diabetic patients undergoing A1 pulley release for trigger finger in 192 patients. Preoperative and postoperative Quick Disabilities of the Arm, Shoulder and Hand questionnaire (Quick DASH), EuroQol-5 dimensions, and satisfaction scores were collected prospectively over a 6-year period. These patients had a mean follow-up of 14 months (range 11–40) after surgery. There were 143 patients (143 trigger fingers) without diabetes and 49 patients (49 trigger fingers) with diabetes. We found overall QuickDASH improvement was the same in both groups (–4.5 points). Patient satisfaction rates were comparable in both groups (90% versus 96%), and no significant difference in postoperative health-related quality of life was observed. No complications were reported in either group. We conclude from this study that A1 pulley release leads to similar functional improvement and high patient satisfaction at one year postoperatively in diabetic and non-diabetic patients. Level of evidence : III [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Open surgical release of the A1 pulley is the definitive treatment for the common hand condition of trigger finger, or inflammatory stenosing tenosynovitis. Anecdotal evidence among hand surgeons has questioned whether or not recent steroid injection may be related to complications following open trigger finger release, particularly wound infection, but no studies have primarily studied this connection to date. We aimed to determine whether recent steroid injection was associated with postoperative surgical infections. Methods: We performed a retrospective chart review of 780 adult patients who had undergone open trigger finger release of 999 digits by 6 fellowship-trained hand surgeons at three affiliated hospital settings from January 1, 2014, to January 1, 2016. Data on timing of steroid injections relative to surgery, number of steroid injections, concomitant conditions, use of antibiotics, and postoperative complications including infections were gathered. Results: Steroid injection timing relative to subsequent operative intervention correlated with postoperative surgical site infection in trigger finger release. Older age and decreasing days between steroid injection and surgery correlated with infection rates. Other factors found to be associated with infection rates included smoking, use of preoperative antibiotics, and use of lidocaine with epinephrine. The other factors examined did not correlate with infection rates. Conclusions: Steroid injection, smoking, increasing age, lesser number of days between steroid injection and surgery, and use of lidocaine with epinephrine are risk factors for postoperative trigger surgical infections. We recommend careful preoperative counseling regarding higher wound healing risks for smokers, avoidance of steroid injections immediately prior to an operative date, and scheduling operative dates that tend to be greater than 80 days from the date of last steroid injection. We also recommend avoidance of epinephrine in the local anesthetic solution, as this may minimize surgical site infection risks. [ABSTRACT FROM AUTHOR]

The purpose of this study was to test the hypothesis that an improved outcome can be achieved by employing simultaneous steroid injection after percutaneous A1 pulley release. One hundred and twelve digits were randomized to either percutaneous A1 pulley release alone or release of the A1 pulley with a steroid injection. The visual analogue scale score for pain, modified patient global impression of improvement and modified Quinnell grade were assessed at 3 weeks and 3 months after surgery. At 3 weeks, subjective improvement in the group with simultaneous steroid injection was significantly superior. At 3 months, pain score in the patients without a steroid injection was significantly better. No significant differences were found in the modified Quinnell grade. We conclude from this study that the simultaneous steroid injection at the time of surgical release decreases pain and improves subjective outcomes during the early postoperative period after percutaneous trigger finger release.Level of evidence: I [ABSTRACT FROM AUTHOR]

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 [ABSTRACT FROM AUTHOR]

The Friends and Family Test, a variant of the Net Promoter Score, was adapted for the National Health Service to evaluate overall patient satisfaction and how likely patients are to recommend an intervention. It ranges from −100 to 100. Positive scores indicate good performance. This study quantifies the scores in 810 patients at a mean of 14 months following four common procedures. The score was 83 for trigger finger release (n = 103), 68 for carpal tunnel decompression (n = 467), 62 for surgery for Dupuytren's disease (n = 224) and 44 for ganglia excision (n = 16). Our study indicates that these procedures are highly valued and are recommended by patients according to the Friends and Family Test. The results of the Friends and Family Test correlated well with postoperative functional improvement and satisfaction. We conclude from this study that a compound score based on the Friends and Family Test is a useful addition to traditional measures of patient satisfaction.Level of evidence: II [ABSTRACT FROM AUTHOR]

Background: The aim of the present study is to determine whether an animation glove can be utilized to provide a reliable and reproducible assessment of dynamic hand function and whether this assessment is altered in the setting of hand pathology. Methods: Ten subjects without known hand pathology and 11 subjects with known stenosing tenosynovitis were assessed on tasks involving hand function at varied speeds, including forceful and gradual making of a fist and the quick and slow grip of a baseball using an animation glove to record range of motion and measures of velocity (CyberGlove II). Results: In normal subjects, peak extension and flexion velocity of the index and middle finger was highest in the metacarpophalangeal and lowest in the distal interphalangeal; however, the converse was true in the ring finger. In those subjects with stenosing tenosynovitis, the animation glove was able to detect a triggering event during assessment. Furthermore, there was a significant decrease in the maximum velocity of the proximal interphalangeal joint observed with the slow fist task in both flexion and extension (55%, P < .01) in the affected hand when compared with the unaffected hand. Conclusions: The CyberGlove II can be utilized in the dynamic functional analysis of the hand and is able to detect a triggering event in subjects with known stenosing tenosynovitis. Those subjects demonstrate a significant decrease in maximum velocity in slow fist tasks, highlighting the need for comprehensive assessment to ascertain the full extent of functional limitations that can occur in the setting of hand pathology. [ABSTRACT FROM AUTHOR]

We assessed the efficacy of ketorolac trometamol injections compared with triamcinolone acetonide injections in trigger digits. Patients with trigger digits were randomized to receive either ketorolac or triamcinolone. They were followed up at 3, 6, 12 and 24 weeks, and monitored for resolution of triggering, pain and total active motion. One hundred and twenty-one patients with single trigger digits were recruited (59 ketorolac, 62 triamcinolone). At 6 weeks, 54% of patients in the triamcinolone group had complete resolution of trigger, whereas no patients in the ketorolac group had resolution. At 12 weeks, 58% of patients in the triamcinolone group had complete resolution of trigger compared with 6.7% in the ketorolac group. At 24 weeks, both groups had comparable rates of resolution at 26% and 25%, respectively. Patients in the triamcinolone group had significantly better resolution of pain at 3, 6 and 12 weeks. But at 24 weeks, there was no significant difference in pain between both groups. Significantly less flexion deformity was reported at 3 weeks and 6 weeks in the triamcinolone group. In the short term, ketorolac was less effective in relieving symptoms of trigger digit than triamcinolone.Level of evidence: I [ABSTRACT FROM AUTHOR]

Background: This study assessed nighttime splinting for 6 weeks as treatment for recent onset idiopathic trigger fingers. Methods: Patients over 18 years with a Quinnell grade 1 or 2, idiopathic trigger finger or thumb causing symptoms for less than 3 months were eligible for a custom-made hand-based orthoplast night orthotic. Improvement of symptoms and/or resolution of triggering were recorded. Patients also completed the short version of the Disabilities of the Arm, Shoulder and Hand and a numerical rating scale for pain at the initial visit, after 6 to 8 weeks, and after 3 months. Results: Thirty-four patients wore a night orthotic for at least 6 weeks. At final evaluation, there was a substantial reduction in disability and pain. Symptoms of triggering resolved completely in 18 patients (55%). Sixteen patients did not resolve their triggering after splinting and therefore underwent a steroid injection. Conclusion: Night splinting is a noninvasive treatment option for idiopathic trigger fingers/thumb with symptoms for less than 3 months. [ABSTRACT FROM AUTHOR]

Purpose Paediatric trigger finger (PTF) is a rare condition as seen by the lack of studies published about paediatric populations. Due to this general lack of information, the steps to employ to correct this disorder, whether surgically or non-surgically, have not yet reached consensus status. The objective of this study is to review the published literature regarding treatment options for PTF in order to develop a proposed step-wise treatment algorithm for children presenting with trigger finger. Methods A systematic review of the literature was conducted on PubMed to locate English language studies reporting on treatment interventions of PTF. Data was collected on number of patients/fingers seen in the study, the category of the fingers involved, the number of patients/fingers undergoing each intervention and reported outcomes. Results Seven articles reporting on 118 trigger fingers were identified. In all, 64 fingers were treated non-surgically, with 57.8% (37/64) resolving. In all, 54 fingers were initially surgically treated, with 87% (47/54) resolving. In total, 34 fingers did not have resolution of symptoms following primary treatment, and 27 fingers received follow-up treatment, with 92.6% (25/27) resolving. Overall, 92.4% (109/118) of fingers achieved resolution of symptoms after all treatments were completed. Conclusion Limitations for this study included few prospective studies and small sample sizes. This is likely due to the rarity of PTF. This review of the literature indicated that a step- wise approach, including non-operative and surgical techniques, should be employed in the management of PTF. [ABSTRACT FROM AUTHOR]

Background: Stenosing tenosynovitis, or trigger digit, is a common condition for which patients often seek relief. Corticosteroid injections have been shown to provide relief in many cases, and several different approaches for delivering the injection have been described in the literature. We compared patients’ perception of pain following each of 3 accepted injection methods, namely, palmar proximal, palmar distal, and webspace approaches. Methods: We prospectively followed 38 patients with 39 symptomatic digits in this trial, with varying severities of trigger finger as graded by the Patel and Moradia classification. The patients were divided into 3 groups representing the 3 approaches without randomization, based upon the treating surgeons’ preference. Disabilities of the Arm, Shoulder and Hand and visual analog scale (VAS) pain scores were calculated pre-injection and at 4-week and 8-week follow-up visits. Results: No statistically significant differences in age, sex, affected extremity, grade, or duration of symptoms were observed among the 3 approaches. No statistically significant differences in VAS score were found between the palmar proximal (mean = 6.6, SD = 2.6), palmar distal (mean = 6.0, SD = 2.8), and webspace (mean = 6.8, SD = 1.8) approaches. Conclusion: Our data suggest that injection approach does not affect patient pain perception scores or outcomes. We recommend that the technique that is most comfortable to the surgeon be utilized, with the understanding that one injection alone has a low likelihood of relieving symptoms. [ABSTRACT FROM AUTHOR]

The aim of this systematic review was to develop an evidence-based guideline to assist clinicians in the treatment of adult trigger digits. There is moderate evidence to suggest that local corticosteroid injection is a safe and effective short-term treatment and it may, therefore, be recommended as an initial treatment for this condition. However, when compared with surgery, there is strong evidence that corticosteroid injection is associated with increased rates of ongoing or recurrent symptoms at 6 months after intervention. There is strong evidence suggesting that trigger digit can be managed safely by surgical release. There is weak evidence to support the use of splinting or other non-operative modalities. Hence a single corticosteroid injection may be offered as the first line in treatment of adult trigger digits, but percutaneous release is a safe alternative. Surgery should be the next line if the injection fails, symptoms recur or the patient chooses.Level of evidence: I [ABSTRACT FROM AUTHOR]

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

Background: The trigger finger is characterized by the painful blocking of finger flexor tendons of the hand, while crossing the A1 pulley. It is a rare disease in children and, when present, is usually located in the thumb, and does not have any defined cause. Methods: We report 2 pediatric trigger finger cases affecting the long digits of the hand that were caused by an osteochondroma located at the proximal phalanx. Both children held the diagnosis of juvenile multiple osteochondromatosis. They had presented at the initial visit with a painful finger blocking. Surgical approach was decided with wide regional exposure, as compared with the trigger finger traditional surgical techniques, with the opening of the A1 pulley and the initial portion of the A2 pulley, along with bone tumor resection. Results: Patients evolved uneventfully, and recovered the affected finger motion. Conclusion: It is important to highlight that pediatric trigger finger is a distinct ailment from the adult trigger finger, and also in children is important to differentiate whenever the disease either affects the thumb or the long fingers. A secondary cause shall be sought whenever the long fingers are affected by a trigger finger. [ABSTRACT FROM AUTHOR]

A United States insurance database was examined for trigger digit release using International Classification of Diseases, 9th Revision diagnoses and procedures or Current Procedural Terminology codes. Complications after trigger digit release, including stiffness, infection and revision surgery, were assessed. A total of 209,634 patients who underwent trigger digit release were included. The rate of trigger digit release increased significantly from 2005 to 2012, with the middle finger the most frequently released. The rate of postoperative stiffness was low, ranging from 0.8% to 1.6% depending on the operated digit. The rate of postoperative infection was lower, ranging from 0.5% to 0.6%. The need for revision within 3 years of initial trigger digit release was also low, ranging from 0.3% to 0.8%. Complications, including infection, stiffness and revision surgery, occur infrequently, but certain factors, including diabetes, Dupuytren’s disease, smoking, rheumatoid arthritis, obesity and age, increase risk.Level of Evidence: Therapeutic Level III, Retrospective comparative study [ABSTRACT FROM AUTHOR]

Background: Local anesthetics are routinely used in hand surgery for procedures such as trigger finger releases (TFRs). However, little is known as to the difference in efficacy and patient experience with various local anesthetics. We prospectively evaluated the efficacy of Lidocaine (L), Marcaine (M), and Exparel (E) to elucidate differences in pain scores and opioid consumption between these groups. Methods: All consecutive TFR performed over a 6-month period in 2014 at our institution were divided to receive Lidocaine, Marcaine, or Marcaine with postoperative Exparel. Pain levels, daily opioid consumption, and adverse reactions were recorded and analyzed for postoperative day (POD) 0-3. Results: A total of 154 patients were enrolled (L:53, M:50, E:51). The Lidocaine group reported the highest pain levels for POD 0-1. Marcaine pain levels were similar to Exparel on POD 0 but higher on POD 1. Opioid consumption on POD 0-1 was significantly different with E:27%, M:58% and L:59% as was the number of pills consumed (E:0.70, M: 1.08 and L:1.62). In addition, 50% of Exparel patients required no pain medications and experienced significantly less adverse reactions (E:4%, M:10%, L:13%). By POD 2-3, there were no statistical differences between the 3 groups. Conclusions: Patients treated with Marcaine attain better pain control than Lidocaine on POD 0-1but only patients who received Exparel maintained the lowest pain levels through POD 0-3 while using little-to-no opioid medications and with less adverse reactions than Lidocaine or Marcaine alone. [ABSTRACT FROM AUTHOR]

We aimed to investigate the relationship between the pulley-tendon complexes and the severity of trigger finger. The thickness of the A1 and A2 pulleys, and the cross-sectional area of the flexor tendon under the pulleys, were prospectively assessed using 17 MHz high-resolution ultrasonography, in 20 patients with trigger finger (31 fingers). A control group comprised 15 asymptomatic fingers. The thickness of the A1 pulley and the proximal part of the A2 pulley, and the cross-sectional area of the flexor tendon under the A2 pulley, were significantly increased in the patient group. Clinical grade was significantly correlated with the thickness of the A1 pulley, the thickness of the proximal part of the A2 pulley, and the cross-sectional area of the flexor tendon under the proximal part of the A2 pulley. This study confirmed that the thickness of the A2 pulley and flexor tendon under the A2 pulley seems to be related to the severity of trigger finger.Level of evidences: Level III [ABSTRACT FROM AUTHOR]

Trigger fingers with proximal interphalangeal joint flexion contracture are suggested to have a poorer response to corticosteroid injection than those without contracture, though this has not been proven scientifically. We compared the clinical response to corticosteroid injection between trigger fingers with and without proximal interphalangeal joint contracture, and investigated the influence of the injection on the A1 pulley and flexor digitorum tendons using ultrasonography. One month after injection, pain was significantly reduced in the no contracture group, and 56% of trigger fingers with proximal interphalangeal joint contracture resolved. Before injection, relative thickening of the A1 pulley and flexor digitorum tendons, and a partial hypoechoic lesion of the flexor digitorum superficialis tendon were observed in the contracture group. One month after injection, the thickening of the tendons and the A1 pulley was reduced, but the partial hypoechoic lesion was still observed in significant numbers. We have demonstrated that the presence of a proximal interphalangeal joint contracture was associated with a reduced clinical response to corticosteroid injection, and we suggest that the pathologic change in the flexor digitorum superficialis tendon, represented by the partial hypoechoic lesion, contributed to corticosteroid injection resistance.Level of evidence: IV [ABSTRACT FROM AUTHOR]

We compared the short-term (3 months) and long-term (2 years) outcomes and complications of percutaneous release of 187 trigger digits of 154 patients treated between 2009 and 2012, all treated by a single surgeon. The 154 patients included 48 patients with diabetes mellitus and 106 non-diabetic patients. The only short-term complication was pain, occurring in three digits (5%) in the diabetic patients and six digits (5%) in the non-diabetic patients. The long-term complications were pain in 15 digits (25%) in the diabetic patients and 18 digits (14%) in the non-diabetic patients. This was not significant (p = 0.058). Recurrent triggering occurred in nine digits (15%) in the diabetic patients, which was significantly greater than the six digits (5%) in the non-diabetic patients (p = 0.013). The non-diabetic patients were significantly more satisfied.Level of Evidence: level III [ABSTRACT FROM AUTHOR]

Background: Open trigger finger release is generally considered a simple low-risk procedure. Reported complication rates vary widely from 1 to 43 %, mostly based on small studies. Our goal was to determine the incidence of complications in a large consecutive series, while also identifying potential risk factors. Methods: All open trigger finger releases performed from 2006 to 2009 by four fellowship-trained hand surgeons at a single institution were retrospectively reviewed. There were 795 digits released in 543 patients. Complications were defined as signs or symptoms requiring further treatment and/or considered unresolved by 1 month postoperatively. Complications requiring operative intervention were regarded as major. Multivariable analysis was performed to determine possible risk factors for complications. Results: There were 95 documented complications among 795 digits (12 %). The most common complications involved persistent pain, stiffness, or swelling, persistent or recurrent triggering, or superficial infection. Most were treated nonoperatively with observation, therapy, steroid injection, or oral antibiotics. There were 19 reoperations (2.4 %), mostly including revision release, tenosynovectomy, and irrigation and debridement. Male gender, sedation, and general anesthesia were independently associated with complications, while age, diabetes, hypothyroidism, recent injection, and concurrent procedures were not associated. Conclusions: Open trigger finger release is generally a low-risk procedure, although there is potential for complications, some requiring reoperation. Male gender, sedation, and general anesthesia may be associated with greater risk. Surgeons should be careful to thoroughly discuss the risk of both major and minor complications when counseling patients. [ABSTRACT FROM AUTHOR]

Background: Trigger digit is a common pathology encountered by hand surgeons, but there is a lack of evidence-based guidelines. We investigated the treatment preferences of hand surgeons and explored whether geographic location, type of residency training, or clinical experience is associated with differences in practice. Methods: An online survey was distributed via email by the American Association for Hand Surgery to 615 members. The survey consisted of 17 questions related to conservative and operative management of trigger digits. Results: One hundred thirty-nine unique responses were received (22.6 %). Geographic distribution of respondents encompassed the entire USA and was not associated with variations in practice. Of the respondents, 56.8 % were trained in orthopedic surgery while 37.4 % had plastic surgery training. In regards to duration of practice, 8.6 % were in practice for up to 5 years, 29.5 % for 6-15 years, 33.8 % for 16-25 years, and 28.1 % for more than 25 years. Notably, the great majority of respondents preferred corticosteroid injections for initial treatment. Those who were willing to give three or more injections prior to surgery were more likely to be plastic surgeons in practice for 16 years or more. A large minority of surgeons utilized splinting in their conservative management. Orthopedic surgeons were more likely to perform tenolysis during pulley release and more likely to use monitored anesthesia care. Conclusions: Variation exists between the treatment algorithms of hand surgeons when managing a trigger digit. Some of these differences may be attributable to the type of training or the duration of clinical practice. [ABSTRACT FROM AUTHOR]

Background: Stenosing tenosynovitis or trigger finger is a common clinical condition regularly treated with steroid injections. Varied success is reported at early time points following injection. We present a prospective, randomized IRB-approved study to confirm these findings at a long-term follow-up. Methods: Adult patients presenting with symptoms of stenosing tenosynovitis who agreed to participate were randomized into two groups. Group 1 received an initial injection of triamcinolone and local anesthetic mixture. Group 2 received the same initial injection and an additional staged injection at 6 weeks. The patients were then followed beyond 2 years. If Group 1 patients were still symptomatic at 6 weeks, another injection was given. An additional injection or surgery was defined as treatment failure. DASH scores were obtained at baseline, 3, 6, and 12 months. Results: Ninety-seven patients (101 trigger digits) were enrolled in the prospective trial. Fifty-six digits were randomized to the one-injection group versus 45 digits randomized to the two-injection group ('intention to treat analysis'-ITT). After accounting for crossover between the groups, 42 patients received one-injection versus fifty-nine patients receiving two injections ('actual' analysis). Overall failure was the same between the two groups. However, a higher surgery rate was noted for patients having undergone two injections versus one injection [47 % versus 27 % ( p < 0.013), ITT]. Diabetes was associated with a higher surgery rate at 1 year within the group of overall failures [56 % versus 37 % ( p = 0.0505), ITT]. High baseline DASH score (>40) was associated with a median time of 10 months for failure and 6 months for surgery as per a Kaplan-Meier survival analysis ( p < 0.005 and p < 0.001, respectively, ITT). Conclusions: As overall failure of steroid injection for trigger finger is not improved with staged, two-injection treatment, we recommend a single injection initial treatment for trigger finger with a second injection given in cases of recurrence or failure. Diabetes was a risk factor for needing surgery if failure occurred within 1 year. The baseline DASH score is helpful in predicting which patients have a higher chance of failing as well as needing surgery. Level of evidence Prospective, randomized trial, level I. [ABSTRACT FROM AUTHOR]

It has been suggested that the increased frequency of trigger finger (TF) after carpal tunnel release (CTR) may be caused by the volar migration of the flexor tendons at the wrist altering the tendon biomechanics at the A1 pulley. This hypothesis has not been validated. We performed pre- and post-operative ultrasonography (USG) on the affected wrists of 92 patients who underwent CTR. Pre-operative USG was performed in neutral with no tendon loading; post-operative USG was performed in neutral unloaded and in various positions of wrist flexion whilst loading the flexor tendons with gripping.The mean volar migration of the flexor tendons after CTR was 2.2 (SD 0.4) mm in the unloaded neutral position. It was 1.8 (SD 0.4) mm in patients who did not develop TF and 2.5 (SD 0.5) mm in those who did (p = 0.0067). In loaded wrist flexion, the mean volar migration of flexor tendons after CTR in patients who did not develop TF and those who did was 2.1 and 3.0 mm in 0° flexion; 3.2 and 3.9 mm in 15° flexion; 4.3 and 5.1 mm in 30° flexion; and 4.9 and 5.8 mm in 45° flexion, respectively. There were significant differences between patients with and without TF at each flexion angle.Our data indicate that patients with greater volar migration of the flexor tendons after CTR are more likely to develop TF. This conclusion supports the hypothesis that the occurrence of TF after CTR may be caused by the bowstringing effects of the flexor tendons. [ABSTRACT FROM PUBLISHER]