Original Research

Percutaneous Release of Trigger Digits

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Stenosing flexor tenosynovitis, or trigger finger, has been treated with open, endoscopic, and percutaneous tendon sheath incisions. A comparison of techniques highlights increased cost, procedure time, and postoperative recovery associated with open surgical treatment.

We conducted a study of the efficacy of percutaneous tendon sheath incision as a treatment for trigger digit. Using percutaneous tendon sheath incisions, a single surgeon treated 596 trigger digits (429 patients) over a 10-year period. Successful release was defined as symptom relief on follow-up, or patient request for no further treatment. There were 537 successful releases (90.1%). Of the 59 failures, 17 underwent another percutaneous procedure (15 successful) and 40 underwent open surgical release (100% successful); 2 patients requested no further treatment. There were no significant differences in digit success rates and no complications. The success rate of this method was comparable to rates reported for open surgical procedures, but there were no instances of infection, chronic pain, or tendon or neurovascular damage. Percutaneous release is a safe, effective, and economical treatment option for trigger digits.


 

References

Take-Home Points

  • The author had a 90% success rate with no complications in treating almost 600 trigger digits.
  • All digits can be safely treated, including multiple fingers on one hand, all in an office setting.
  • Percutaneous trigger release appears to be a safe and reliable alternative to open surgery.
  • Success rate, discomfort, and cost may make a percutaneous trigger release preferable to even a trial of corticosteroid injection.
  • A failed percutaneous release can be successfully treated with an open release, if needed.

Trigger finger, or stenosing flexor tenosynovitis, is a condition characterized by clicking or locking during finger movement, sometimes resulting in the freezing of a digit in flexion or extension 1 (Figure 1 ).

Figure 1.
Tendon inflammation is thought to cause constriction of the tendon sheath and bunching of the fibrous bundles of the first annular (A1) pulley, often creating a palpable nodule at the base of the digit. 2,3 Many patients experience intermittent joint pain and swelling, which may progress to triggering or complete locking of the digit. 1 One of the most common conditions treated by hand surgeons, trigger finger is most often reported in the dominant hand of women in their sixth decade of life and has been associated with several conditions, including diabetes and rheumatoid arthritis. 4-6 Other researchers have indicated the thumb and ring finger are most commonly affected, though all fingers can potentially trigger. 7,8

Initial treatment often involves injecting corticosteroid into the flexor tendon sheath, at or proximal to the annular pulley system, to reduce inflammation and the fibrous nodule. 3 Another injection study found an initial success rate of 57% with a single injection, and 86% with a second injection, but patients were monitored for only 6 months, a period that may have been too short for symptom recurrence. 7

On failure of steroid injections, patients typically are treated with open tendon sheath incision. 9 This procedure, usually performed in a hospital or outpatient surgery setting, requires postoperative wound care, including dressing changes, suture removal, possible hand therapy, and follow-up physician visits. Operative treatment involves making a 1-cm to 2-cm incision, releasing the A1 pulley, and skin suturing. 7,8,10 The most common postoperative complaint is incisional tenderness, though long-term scar pain, infection, nerve injury, and disease recurrence have been reported.8 Overall, the procedure is very successful, providing up to 100% symptom relief. 7,8,10

Endoscopic release of trigger finger has also been described as an effective operative treatment. This technique involves passing a small cannula through a palmar incision—using an endoscope and retrograde knife within this 2.7-mm tunnel. 10 With this treatment, reduced visibility may increase the risk of nerve injury. 10 Although generally successful, endoscopic release requires anesthesia and expensive instruments and has a significant learning curve. 8,10

More recently, percutaneous release of trigger finger has been described as a definitive, in-office treatment. 5,6,11,12 Percutaneous release has the obvious advantages of no open incision, less scarring, less discomfort, and shorter recovery. Several studies have found comparable success rates for open and percutaneous procedures but consistently shorter recovery with the percutaneous technique. 7,8,12 Given its lower recurrence rate (vs steroid injections) and shorter recovery and lower cost (vs a surgical procedure), percutaneous treatment of stenosing tenosynovitis appears to be a safe, highly successful, and minimally invasive treatment method. 8 This study represents a single surgeon’s experience with percutaneous tendon sheath incision over a 10-year period.

Methods

Patients presented with symptoms of stenosing flexor tenosynovitis with severity ranging from intermittent triggering to frank locking of the digit. Most patients underwent prior conservative treatment, including corticosteroid injections and hand therapy. With each patient, the senior author discussed the pathophysiology of trigger digit; treatment options, including observation, hand therapy, corticosteroid injection, percutaneous release, and open release; and potential risks and complications. The treatment path—initial corticosteroid injection, percutaneous release, or open release—was left up to the patient. The only exclusion criterion was prior surgery to the involved digit, and there was no discrimination by finger, symptomatic period, or severity. Each released digit was recorded independently. In no case was anticoagulant therapy discontinued.
A complete medical history was obtained for each patient.

Over a 10-year period (March 2003-December 2013), percutaneous release was performed on 596 trigger fingers in 429 patients, 18 years old or older. Of these patients, 279 were female. Mean age was 62 years (range, 26-97 years). Of the 531 releases with handedness recorded, 56.3% were performed on trigger digits on dominant hands ( Table 1 ).

Table 1.
Mean duration of

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