Current Concepts in the Management of Trigger Finger in Adults

Joseph A. Gil, MD; Andrew M. Hresko, MD; Arnold-Peter C. Weiss, MD

Disclosures

J Am Acad Orthop Surg. 2020;28(15):e642-e650. 

In This Article

Surgical Management

Open Release

Open surgical release of the A1 pulley effectively alleviates the subjective and objective manifestations of TF when conservative interventions are unsuccessful. Open release currently remains the benchmark operation for addressing TF. Success rates of open A1 pulley release are reported between 90 and 100%, and the procedure is associated with a complication rate between 5% and 12%.[24,25] Recently however, Baek et al recognized that although open A1 pulley release is an effective procedure, a cohort of patients experience prolonged postoperative symptoms. In their review of 109 patients who underwent open A1 pulley release, 19% were found to have snapping, locking, and/or pain for longer than 8 weeks after surgery.[26] Risk factors for prolonged postoperative symptoms included duration of preoperative symptoms, flexion contracture at the PIP joint, and intraoperative identification of fraying or partial flexor tendon tear.

Persistent triggering after isolated A1 pulley release is infrequent but requires additional subsequent releases.[27] Structures that cause persistent triggering include the palmar aponeurosis pulley, A2 pulley, and constrictive FDS tendon (Figure 3). Although palmar aponeurosis pulley release and a single slip or complete release of the FDS have been demonstrated to be inconsequential, complete release of the A2 pulley has been previously avoided because of fears of bowstringing.[27] However, Tanaka et al demonstrated that at least partial A2 release may be acceptable. In a cadaveric study, they found that releasing up to 50% of the A2 pulley did not reduce the breaking strength of the residual pulley, suggesting preservation of pulley biomechanics with partial A2 release.[28] More recently, Strigelli et al performed a complete A2 release in a cohort of 169 patients with TF who underwent A1 pulley release and had persistent triggering intraoperatively. Postoperatively, they did not find any bowstringing or flexion contracture at the PIP joint.[27] They attributed this biomechanical preservation to the surgical and postoperative bandaging technique in which soft bandages were applied to create a functional dressing that blocked the MCP joints in extension while allowing PIP and distal interphalangeal joint flexion with 10° of wrist extension. Patients remained in this functional dressing for 21 days after combined A1-A2 release and were instructed to avoid strenuous manual activity for two months. Therefore, in rare cases where triggering persists after A1 pulley release and more traditional release of the palmar aponeurosis and resection of slips of the FDS tendon, partial sectioning of the A2 pulley may be considered.

Figure 3.

Photograph of palmar aponeurosis pulley (black arrow) visualized proximal to the cut A1 pulley. (Courtesy of Arnold-Peter C. Weiss, MD, Providence, RI.)

Percutaneous

The literature supporting the safety and efficacy of percutaneous A1 pulley release (Figure 4) is growing.[29,30] Guo et al demonstrated the efficacy of a percutaneous ultrasonography-guided thread technique. Although they reported a near-perfect result with their technique, they acknowledged that previous reports found percutaneous techniques to occasionally result in digital nerve injury, incomplete release, and tendon injury.[30] The study of percutaneous trigger release by Gulabi et al[29] reported 90% complete symptom resolution and 10% persistent triggering. Complications included insufficient release, scar sensitivity, transient hypoesthesia, and tendon lacerations. More recently, Xie et al randomized 76 patients with 89 TF into an open or percutaneous release. They found no difference in the VAS, DASH, Quinnell grade, finger range of motion, or symptom recurrence rate, concluding that the percutaneous method is a safe and effective alternative to open release.[31]

Figure 4.

Illustration showing the percutaneous release of the flexor tendon first annular (A1) pulley by using a backward-and-forward movement. (Reproduced with permission from Smith AA, Zidel P. Tendinopathies, in Weiss APC, Goldfarb CA, Hentz VR, Raven RB, Slutsky DJ, Steinmann SP, eds. Textbook of Hand & Upper Extremity Surgery, Chicago, IL, American Society for Surgery of the Hand, 2013:670–705.)

Jegal et al conducted a randomized trial to determine if adding a steroid injection after percutaneous TF release would improve outcomes. They found that augmenting percutaneous release with steroid injection decreases pain and improves subjective outcomes in the early postoperative course (ie, 3 weeks); however, this effect does not persist at 3 months.[32]

Although several studies have suggested that a percutaneous approach may result in improved outcomes, the technique demands a learning curve that may predispose patients to higher risk of procedure-related complications. At present, many hand surgery training programs do not provide routine exposure to percutaneous TF release. Surgeons not extensively trained in a percutaneous technique should consider pursuing additional education to achieve competency before changing practice to reduce the risk of iatrogenic injuries.

Impact of Diabetes on Surgical Outcomes

Although patients with diabetes have a predisposition to developing more severe TF, diabetic status does not appear to compromise the outcomes of open release.[4] Although previous studies suggested that the outcomes of both open and percutaneous A1 release are less favorable in patients with diabetes, more recent studies have demonstrated no notable difference in functional and subjective outcomes between diabetic and nondiabetic patients.[4]

Although the effect of diabetes on the outcomes of TF release has been thoroughly studied, the effect of hypoglycemia in various surgical procedures had not been examined until recently.[33] Buchanan et al[33] conducted a retrospective review of a cohort of patients with TF using a national private payer database to determine if preoperative hypoglycemia predisposed patients to infection after surgical release. The authors identified 70,290 TF releases and found markedly higher surgical site infection rate within 1 year after release in patients with preoperative hypoglycemia.

Role of Perioperative Antibiotics

The literature does not support routine use of perioperative antibiotics in soft-tissue procedures of the hand. A retrospective review of 8,850 elective hand surgery procedures at a single center revealed no notable difference in surgical site infections between patients who received preoperative antibiotics (0.54%) and those who did not (0.26%).[34]

Given the overall low incidence of surgical site infection after soft-tissue procedures of the hand, previous studies are limited by being inadequately powered to detect the small treatment effect of prophylaxis.[35] Li et al[35] conducted a retrospective analysis of an administrative insurance claims database to maximize their sample size to reassess the effect of prophylactic antibiotic administration before soft-tissue procedures of the hand. Of the 516,986 patients identified, 58,201 received antibiotic prophylaxis. They assessed the remainder cohort with propensity score matching to control for multiple confounding variables. They found no difference in surgical site infection between patients who received antibiotics (1.4%) and those who did not (1.4%). Therefore, there is no role for preoperative antibiotics in patients who undergo elective soft-tissue procedures of the hand.

Although consensus guidelines advise against the routine use of prophylactic antibiotics before clean soft-tissue hand surgery, current practice does not adhere to these guidelines.[36] Johnson et al[36] examined insurance claims from the Truven MarketScan Databases to determine the rate and trend of prophylactic antibiotic use in patients undergoing one of the five outpatient hand surgery procedures, including open and endoscopic carpal tunnel release, TF release, De Quervain's release, and wrist ganglion excision. They found a 72.5% increase in administration from 2009 (10.6%) to 2015 (18.3%).

Role of Anesthesia Type

Several anesthetic modalities have been used to facilitate surgical release of TF including local, MAC local, regional, and general. Wide Awake Local Anesthesia No Tourniquet (WALANT) has gained popularity because it has been associated with improved patient outcomes and a clear cost savings.[37] Gunasagarn et al randomized 40 patients who were indicated for TF release, carpal tunnel release, or ganglion excision to undergo either WALANT or local anesthesia with tourniquet.[38] They reported better patient comfort in WALANT cohort. Not surprisingly, in the absence of intravenous sedation, patients were primarily dissatisfied with the discomfort that was caused by the tourniquet. Rhee et al conduced a prospective cohort study to examine the cost and patient experience of the first 100 clinic-based WALANT hand surgery procedures at a military medical center. They reported 70% cost savings and that 94% percent of patients would choose WALANT if they were to have the procedure again.[37] However, despite the increasingly apparent value of WALANT, the studies in support of WALANT are often limited by setting the inclusion criteria to include patients who are screened to tolerate this method of anesthesia.

Postoperative Pain Management

Increased awareness of the opioid epidemic in the United States has prompted investigations to examine the opioid prescribing practices of hand surgeons and to study various strategies for minimizing opioid consumption after hand cases. Weinheimer et al[39] designed a double-blinded randomized controlled trial comparing pain intensity after elective soft-tissue procedures in patients who received acetaminophen/hydrocodone (opioid) compared with those who received acetaminophen/ibuprofen (nonopioid). They found no difference in the pain intensity postoperatively between the two groups. However, patients in the opioid group (23%) were markedly more likely to experience adverse effects compared with the nonopioid group (3%). They concluded that hand surgeons should prescribe an opioid-free regimen after soft-tissue procedures.

Multiple studies have demonstrated that a low number of opioids are consumed after soft-tissue hand surgery. Stepan et al[40] conducted a prospective cohort study of postoperative NSAID and opioid use in 123 patients who underwent either mass excision or carpal tunnel, De Quervain, or TF release. They found that only 4 to 10 tablets of hydrocodone/acetaminophen were required to control postoperative pain in most patients, regardless of the concomitant NSAID use. Based on these recent findings, routine prescription of opioids after TF release is not necessary.

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