Does the location of incision over A-1 pulley matter?
Laxminarayan Bhandari, MD; Christine M Kleinert Institute, Louisville, KY; Huey Y. Tien, MD; Christine M. Kleinert Institute for Hand and Microsurgery, Louisville, KY
Background: Surgical management of trigger finger involves release of A-1 pulley. It is theorized that loss of A-1 pulley can lead to bowstringing or progressive ulnar subluxation which can be prevented by incising A-1 radially. However there is no evidence in literature on whether location of incision on A-1 pulley has any effect on outcome.
Material and Methods: In order to find out the difference between incising the A-1 radially or ulnarly, the study was conducted in 12 cadaver upper limb specimens. After placing vertical skin incision, the A1 pulleys of 48 fingers were divided at radial (24 fingers) or ulnar (24 fingers) location. Volar distal forearm was opened and 20lb traction force was applied on flexor tendons. The process was repeated ten times and any subluxation or bowstringing was noted. This was followed by serial release of A2- initially 25% followed by 50% and 100%. Force application and measurements were repeated (Fig 1).
Results: There was no bowstringing or subluxation when only A-1 pulley was released or when A-1 with 25% A2 pulley was released. When A 1 and 50% A2 pulley was released, bowstringing was seen in 3/48 fingers. When A1 and 100% A2 was released, bowstringing occurred in all cases and subluxation occurred in 42/48 fingers. The subluxation was seen equally in radial (21/24) incision and Ulnar Incision (21/24).
Conclusion: The location of incision for release of A-1 has no effect on bowstringing or tendon subluxation. Up to 25% of A2 can be released without any bowstringing or subluxation. Bowstringing and subluxation are result of greater than 50% release of A2 rather than location of incision on A-1.
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