Aims. The paediatric trigger thumb is a distinct clinical entity with unique anatomical abnormalities. The aim of this study was to present the long-term outcomes of A1 pulley release in idiopathic paediatric trigger thumbs based on established patient-reported outcome measures. Methods. This study was a cross-sectional, questionnaire-based study conducted at a tertiary care orthopaedic centre. All cases of idiopathic paediatric trigger thumbs which underwent A1 pulley release between 2004 and 2011 and had a minimum follow-up period of ten years were included in the study. The abbreviated version of the Disabilities of Arm, Shoulder and Hand questionnaire (QuickDASH) was administered as an online survey, and ipsi- and contralateral thumb motion was assessed. Results. A total of 67 patients completed the survey, of whom 63 (94%) had full interphalangeal joint extension or hyperextension. Severe metacarpophalangeal joint hyperextension (> 40°) was documented in 15 cases (22%). The median QuickDASH score was 0 (0 to 61), indicating excellent function at a median follow-up of 15 years (10 to 19). Overall satisfaction was high, with 56 patients (84%) reporting the maximal satisfaction score of 5. Among 37 patients who underwent surgery at age ≤ two years, 34 (92%) reported the largest satisfaction, whereas this was the case for 22 of 30 patients (73%) with surgery at aged > two years (p = 0.053). Notta’s nodule resolved in 49 patients (73%) at final follow-up. No residual triggering or revision surgery was observed. Conclusion. Surgical release of A1 pulley in paediatric trigger thumb is an acceptable procedure with excellent functional long-term outcomes. There was a trend towards higher satisfaction with earlier surgery among the patients. Cite this article: Bone Jt Open 2024;5(9):736–741

Aim: To assess the efficacy of percutaneous needle bursting and limited percutaneous pulley division in the treatment of seed ganglia.

Methods: A prospective cohort study was run. All patients in the study had ganglia bursting by lignocaine injection. If this failed a limited percutaneous release was performed as at open release for trigger finger.

Results: There were 52 patients treated over a four-year period. 31 were female and 21 male with an average age of 37 years. The fingers involved were: index (6), middle (21), ring (19), little (5) and thumb (1)

Complications were 3 patients with mild stiffness at review (6 months, 1year and 2years), and one digital nerve injury.

Conclusions: Burst alone works in 50% of patients. Percutaneous release is effective in 69% of patients. It appears to be a safe and reliable alternative to open surgery, especially if restricted to midline lesions.

Introduction: The open approach for releasing the A1 pulley shows high dissatisfaction rates. Percutaneous blind release is as an alternative achieving similar effectiveness and better results but the lack of visualization puts at risk the adjacent anatomy and its indicated only for the 3rd and 4th fingers. Recently, an effective percutaneous method for releasing A1 in every finger has been described assisted by the visualization with ultrasounds (US). Despite the reported safety, this US-technique poses a risk to the adjacent anatomy due the orientation of the blade. Our purposes were to develop a new percutaneous US-guided A1 release (USGAR) that lessens the risk to adjacent anatomic structures and to determine the precision, safety and efficacy of our USGAR.

Methods: To determine how to lessen the risk to adjacent structures, a descriptive study with a power-Doppler US (Logiq Book XP Pro 5–11 MHz, GE) was done in 100 fingers from 10 volunteers (3 females and 7 males; mean age 29,8 years, range 25–49 years). Measurements, on a transverse section of A1, included: lateral vascular angle (LVA), medial vascular angle (MVA), distance to lateral artery (DLA), distance to medial artery (DMA), lateral latitude (LL), medial latitude (ML), pulley thickness (PT) and synovial space width (SW).

A descriptive study was developed in 5 formaldehyde preserved cadavers, 50 fingers (3 men and 2 women, average age at time of death 60,6 years, range 52–81). US identification of topographic markings was followed by USGAR and open dissection. Measurements included real (RL) and US (UL) A1 length and distances from: markers to proximal (MP) and distal A1 edges (MD); markers to A2 (MA) and neurovascular (NV) bundles (MN); and from the surgical release to A2 (SA) and NV (SN). The length of any incomplete release (IR) and damage to adjacent structures were recorded. Mean values, Standard deviation and range were gathered. ANOVA was used to analyze differences (significant at p < 0.05).

Results: In our volunteers, we obtained the following values (degrees or mm): LVA, 20,9 +/− 14,03 (0/83,7); MVA, 23,3 +/−13,06 (0/61,5); DLA, 8,96 +/−3,08 (3,5/20,6); DMA, 7,59 +/−2,56 (3,7/16,8); LL, 2,38 +/−1,53 (−1/6,5); ML,: 2,56 +/−1,84 (0/10,8); PT, 0,79 +/−0,22 (0,2/1,5); SW, 0,33 +/−0,19 (0,1/0,9). Differences were not significant among fingers. In our group of cadavers our findings (mm) were: RL, 10,1 +/−1,36 (8/13); UL, 10,84 +/−1,38 (8/14); MP, −0,56 +/−1,3 (−5/2); MD, −0,19 +/−0,95 (−4/2); MA, 4,56 +/−1,64 (1/9); MN, 18,78 +/−4,11 (11/27); SA −1,08 +/−1,67 (−5/2); SN −13,17 +/−3,55 (−22/−6). There was a 1 mm IR in 2 fingers and minor puncture-like erosions in 6.

Conclussion: Our new method for USGAR minimizes the risk of accidental damage to adjacent anatomic structures. The method is precise, effective and safe in cadavers. This has set the bases for a clinical phase at our Institution.

Introduction and Objective. Zone 2 flexor tendon injuries are still one of the challenges for hand surgeons. It is not always possible to achieve perfect results in hand functions after these injuries. There is no consensus in the literature regarding the treatment of zone 2 flexor tendon injuries, tendon repair and surgical technique to be applied to the A2 pulley. The narrow fibro-osseous canal structure in zone 2 can cause adhesions and loss of motion due to the increase in tendon volume due to surgical repair. Different surgical techniques have been defined to prevent this situation. In our study, in the treatment of zone 2 flexor tendon injuries; Among the surgical techniques to be performed in addition to FDP tendon repair; We aimed to compare the biomechanical results of single FDS slip repair, A2 pulley release and two different pulley plasty methods (Kapandji and V-Y pulley plasty). Materials and Methods. In our study, 12 human upper extremity cadavers preserved with modified Larssen solution (MLS) and amputated at the mid ½ level of the arm were used. A total of 36 fingers (second, third and the fourth fingers were used for each cadaver) were divided into four groups and 9 fingers were used for each group. With the finger fully flexed, the FDS and FDP tendons were cut right in the middle of the A2 pulley and repaired with the cruciate four-strand technique. The surgical techniques described above were applied to the groups. Photographs of fingers with different loads (50 – 700 gr) were taken before and after the application. Proximal interphalangeal (PIP) joint angle, PIP joint maximum flexion angle and bowstring distance were measured. The gliding coefficient was calculated by applying the PIP joint angle to the single-phase exponential association equation. Results. Gliding coefficient after repair increased by %21.46 ± 44.41, %62.71 ± 116.9, %26.8 ± 35.35 and %20.39 ± 28.78 in single FDS slip repair, A2 pulley release, V-Y pulley plasty and Kapandji plasty respectively. The gliding coefficient increased significantly in all groups after surgical applications (p<0.05). PIP joint maximum flexion angle decreased by %3.17 ± 7.92, %12.82 ± 10.94, %8.33 ± 3.29 and %7.35 ± 5.02 in single FDS slip repair, A2 pulley release, V-Y pulley plasty and Kapandji plasty respectively. PIP joint maximum flexion angle decreased significantly after surgery in all groups (p<0.05). However, there was no statistically significant difference between surgical techniques for gliding coefficient and PIP joint maximum flexion angle. Bowstring distance between single FDS slip repair, kapandji pulley plasty and V-Y pulley plasty showed no significant difference in most loads (p>0.05). Bowstring distance was significantly increased in the A2 pulley release group compared to the other three groups (p<0.05). Conclusion. Digital motion was negatively affected after flexor tendon repair. Similar results were found in terms of gliding coefficient and maximum flexion angle among different surgical methods. As single FDS slipe repair preserves the anatomical structure of the A2 pulley therefore we prefer it as an ideal method for zone 2 flexor tendon repair. However, resection of FDS slip may jeopardizes nutrition to the flexor digitorum profundus tendon which weakens the repair site. Therefore the results must be confirmed by an in vivo study before a clinical recommendation can be made. Keywords: Flexor tendon; injury; pulley plasty; cadaver;

It is well recognised that patients with diabetes mellitus have a predisposition towards stenosing flexor tenosynovitis (FTS). However, recent research has suggested an association between the development of FTS and haemoglobin A1c (HbA1c) level which is used as a marker of glycaemic control. National guidelines on management of diabetes suggest treatment should aim to maintain HbA1c at <6.5%. The aim of our study is to quantify glycaemic control in patients undergoing surgical A1 pulley release. We retrospectively reviewed the blood results of 78 patients who underwent FTS surgery. 27 of these had an HbA1c checked within 6 months of their surgery and we therefore presumed these patients were diabetic. For diabetic patients the average HbA1c was 7.9% (range 5.3–11.4) and only 7 of the 27 patients had an HbA1c within the recommended range. In this cohort 33% of patients were presumed diabetic and 74% of these had a documented HbA1c above the national target suggesting a significant number presenting for surgery have poor glycaemic control. Therefore it may be of benefit to screen for this in patients undergoing FTS surgery

Percutaneous A1 pulley release is being increasingly used as an alternative to open surgical release and injection of local steroids for the treatment of the trigger digit. We treated 43 patients, average age 57 years (range12-78). All trigger digits were grade III-IV (Quinnell classification). A mean duration of pre-operative symptoms was 7.3 months (range 2-13 months). A percutaneous release was performed with a 19-gauge hypodermic needle under local anaesthesia in the outpatient setting. All patients were evaluated with respect to clinical resolution of symptoms and general satisfaction. We report a 97% successful release and only one case of incomplete release. A result in terms of abolishing triggering was immediate and patient acceptance was excellent. By two weeks, all the patients had no pain at the operative site. After a mean follow-up of 30.2 months (range12-50), there had been no recurrences. There were no digital nerve injuries, flexor tendon injuries, and infections. The percutaneous release is a safe and effective technique, which provides significant cost savings. The time from onset of symptoms and grading prognostically is significant and affects the treatment outcome. We recommend the percutaneous technique for typical cases of trigger finger with a palpable nodule and reproducible mechanical triggering. This technique can be the treatment of choice for the established trigger finger (grade III and IV) with symptoms of more than few months' duration. The open technique is reserved for complicated cases such as florid tenosynovitis, locked digit, failed percutaneous release or those involving the thumb

Introduction: Common pathologies seen in hand clinics include Dupuytren’s contracture, ganglia and trigger digits. Some patients can be treated in the out patient department by percutaneous fasciotomy, aspiration, or percutaneous A1 pulley release. The effectiveness and safety of these procedures has been documented in the literature. There are no studies investigating the cost effectiveness these of treatments. Aim: Our aim was to compare the cost of treatment of Dupuytren’s contracture, ganglia and trigger digits in the out-patient department with the operating theatre. Methods: All patients seen in a new patient hand clinic with a diagnosis of Dupuytren’s contracture, trigger digit or ganglion of the wrist or hand were prospectively identified over a 6 month period.. The number undergoing a procedure in the out-patient clinic or theatre was recorded. Costings of theatre time and out-patient time were obtained from the hospital management. Results: 80, 26, and 52 patients were treated with regard to Dupuytrens contracture, ganglia, and trigger digits respectively over the 6-month period. Of these, 37, 23, and 44 were treated by an out patient procedure, and 43, 3 and 8 underwent a formal operation. Based on a cost of £216 per out-patient clinic session, the cost of the out-patient procedures was calculated at £1872 over 6 months, or £3744 per annum. Based on a theatre cost of £1785 per session, to perform all the clinic procedures as formal operations would have cost £60,690 over 6 months, or £121380 per annum. The cost savings were therefore £117636 per annum. Discussion: We conclude that outpatient interventions for dupuytrens disease, ganglions and trigger digits results in significant cost savings over formal surgical treatment

The October 2014 Children’s orthopaedics Roundup³⁶⁰ looks at: spondylolisthesis management strategies; not all cervical collars are even; quality of life with Legg-Calve-Perthe’s disease; femoral shaft fractures in children; percutaneous trigger thumb release – avoid at all costs in children; predicting repeat surgical intervention in acute osteomyelitis; and C-Arm position inconsequential in radiation exposure