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Evaluation of Percutaneous First Annular Pulley Release: Efficacy and Complications in a Perfused Cadaveric Study
Don Hoang, MD, MHS1; Ann C. Lin, BS1; Anthony Essilfie, MD1; Alidad Ghiassi, MD1; Stuart Kuschner, MD2; Joseph Carey, MD1
1USC Keck School of Medicine, Los Angeles, CA; 2Cedars Sinai Medical Center, Los Angeles, CA

Background: Trigger finger is the most common entrapment tendinopathy, with lifetime-risks of 2-3 percent (diabetics ~10%). Open tenovaginotomy is standard therapy associated with high success rates. Despite percutaneous trigger finger release (PFTR) success rates over 94%, controversy remains over its use due to fear of digital neurovascular injury. This study aimed to assess the safety of blind versus sonographically-guided (US) first annular (A1) pulley releases performed on a perfused cadaveric model (fig.1).
Methods: 155 (124 fingers and 31 thumbs) percutaneous A1 pulley releases were performed on un-embalmed cadavers (65 female, 90 male fingers) with restored perfusion (fig.2) and an 18-gauge needle. 45 fingers and thumbs were completed with US while 110 were completed without US. Each digit was dissected and assessed for A1 pulley release completeness as well as neurovascular, flexor tendon, and A2 pulley injury (fig.3).
Results: Overall, 114 (74%) A1 finger and thumb pulleys were effectively released. There were 38 (24%) partial releases and only three digits were completely missed (2%) (fig.3). Thumbs had 28 complete (90%) and 3 partial releases (10%). Index fingers had 23 complete (74%), and 8 partial releases (26%); long fingers had 23 complete (74%), 3 partial (23%), and 1 missed release (3%); ring fingers had 15 complete (48%), 15 partial (48%), 1 missed release (3%); while little fingers had 25 complete (81%), 5 partial (16%), and 1 missed release (3%) (fig.1). Average percent of A1 pulley length released for all fingers was 93%. No significant flexor tendon injury (partial or complete lacerations) was seen in any digit, although longitudinal scoring was found in 35 fingers (23% overall; total of 9 ring fingers, 8 thumbs, 6 index, 6 middle, 6 little fingers). No digital, radial or ulnar, nerves was found to be injured (fig.5). Only one ulnar middle finger digital artery was lacerated (1%) in a finger with a partial flexion contracture. The ultrasound-guided PTFR technique was not more likely to result in a complete pulley release compared to the blind needle technique (80% versus 72%; P < 0.26).
Conclusion: Both blind and ultrasound-assisted percutaneous releases of the A1 pulley can be performed safely and effectively for all fingers including the thumb. Perfusion of cadaver digits enhances surgical simulation for PTFR training, especially for in-vivo identification of structures by US with doppler-flow. Our cadaveric data support published clinical investigations recommending percutaneous A1 pulley release in the management of trigger finger.

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