Journal of Hand Surgery (British and European Volume) http://jhs.sagepub.

com/

Sonographically Assisted Percutaneous Release of the A1 Pulley: A New Surgical Technique for Treating Trigger Digit
I. M. JOU and T. C. CHERN J Hand Surg [Br] 2006 31: 191 DOI: 10.1016/J.JHSB.2005.11.003 The online version of this article can be found at: http://jhs.sagepub.com/content/31/2/191

Published by:
http://www.sagepublications.com

On behalf of:
British Society for Surgery of the Hand

Federation of the European Societies for Surgery of the Hand

Additional services and information for Journal of Hand Surgery (British and European Volume) can be found at: Email Alerts: http://jhs.sagepub.com/cgi/alerts Subscriptions: http://jhs.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav

>> Version of Record - Apr 1, 2006 What is This?

Downloaded from jhs.sagepub.com at HINARI on March 20, 2013

ARTICLE IN PRESS SONOGRAPHICALLY ASSISTED PERCUTANEOUS RELEASE OF THE A1 PULLEY: A NEW SURGICAL TECHNIQUE FOR TREATING TRIGGER DIGIT
I. M. JOU and T. C. CHERN From the Department of Orthopaedics, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan, and the Department of Orthopaedic Surgery, Ping-Tong Christian Hospital, Ping-Tong, Taiwan

This study introduces a sonographically assisted percutaneous technique for releasing trigger digits which provides direct visualization of the release and avoids the risks of incomplete release and injury to adjacent neurovascular structures associated with other percutaneous release techniques. The safe zone and an estimate of the size of the A1 pulley were determined in a separate cadaver study. We then used these landmarks in a prospective clinical study of 107 digits in 83 consecutive patients treated by this technique. During the follow-ups of between 9 and 15 months, we evaluated 104 digits in 80 patients. Pain was absent in 101 digits (97%) and considerably improved in the other three (3%). All mechanical problems had been resolved and none recurred during follow-up. This technique allows the surgeon to see and monitor, precisely, the percutaneous division of the A1 pulley without open surgery and, therefore, to avoid the inherent risks of percutaneous and open surgical release. Journal of Hand Surgery (British and European Volume, 2006) 31B: 2: 191199
Keywords: percutaneous release, trigger digit, sonography

INTRODUCTION Triggering of a digit cannot always be relieved by corticosteroid injection, the preferred initial form of treatment, or by other non-invasive modalities. When these conservative treatments fail, surgical release is generally recommended. Despite the popularity of open release of the A1 pulley, which is considered a simple, safe and effective procedure, reports of outcomes are, surprisingly, rare. The cure rate after open release varies from 60% to 97% in different reports (Panayotopoulos et al., 1992; Saldana, 2001), and the reported satisfaction rate is about 83% (Thorpe, 1988). Complications and postoperative morbidities include digital nerve transection, A2 pulley injury with subsequent bowstringing of the tendons, bothersome scars, recurrent symptoms, stiffness, weakness, infection and reex sympathetic dystrophy (Bonnici and Spencer, 1988; Panayotopoulos et al., 1992; Thorpe, 1988; Turowski et al., 1997). Percutaneous release of trigger digits has become popular (Bain et al., 1995; Blumberg et al., 2001; Carrozzella et al., 1989; Cihantimur et al., 1998; Dunn and Pess, 1999; Eastwood et al., 1992; Gilberts et al., 2001; Ha et al., 2001; Heithoff et al., 1988; Lorthioir Jr J, 1958; Lyu, 1992; Patel and Moradia, 1997; Pope and Wolfe, 1995; Tanaka et al. 1990; Stothard and Kumar, 1994; Wilhelmi et al., 2003), but its exact risk-benet compared with that of open release remains controversial (Lane, 1995). Because there is no open incision and exploration, percutaneous release has two inherent problems, viz. the potential for accidental injury to adjacent neurovascular bundles and difculty in determining the completeness of the release. Therefore, we
191

would not advocate widespread use of percutaneous release until intraoperative reliability has been improved. These considerations led us to develop a sonographically assisted percutaneous release technique for the A1 pulley. Before using the method clinically, we rst performed cadaver studies to dene several useful landmarks for our sonographic observations. We then developed a new technique that proved effective and safe in releasing the A1 pulley in cadavers (Chern et al., 2005). We present the instruments, surgical procedures and clinical results of a prospective study of the rst 107 trigger digits treated consecutively using our sonographically assisted, percutaneous release technique.

MATERIALS AND METHODS The study group consisted of 107 consecutive primary sonographically assisted percutaneous releases performed on 83 patients (49 females and 34 males; age range 1584 years; average age 52.6713.2 years) at two hospitals from September 2001 until October 2002. The entry criterion for inclusion in this study was idiopathic trigger digit. Patients with rheumatoid arthritis, trauma and a previous history of open release were excluded. All patients had had typical symptoms of painful triggering for at least 3 (range 360; average 10.2) months and 85 digits (79%) had been treated by steroid injection at least once before sonographically assisted, percutaneous release. The surgical indications included grade III or IV triggering (see below) (Froimson, 1999) or, in grade I or II cases, ongoing symptoms for 3

Downloaded from jhs.sagepub.com at HINARI on March 20, 2013

ARTICLE IN PRESS
192 THE JOURNAL OF HAND SURGERY VOL. 31B No. 2 APRIL 2006

months with a poor response to conservative treatments, including avoidance of overuse, oral analgesic, physical therapy and local steroid injection. There were 54 thumbs, 13 index ngers, 24 long ngers, 15 ring ngers and one little nger. A single digit was involved in 65 patients, two in 14 patients and three or more in four patients. Multiple involved digits on the same hand were always released on the same occasion. Patients with locked digits on both hands returned for a second procedure on the second hand, 4 to 6 weeks after the rst procedure. The mechanical symptoms of triggering of the digit were graded according to a system suggested by Froimson (1999): Grade I Pre-triggering-pain; tenderness over the A1 pulley; history of catching but not demonstrable on physical examination. Grade II Triggering, active; demonstrable catching, patient can actively extend. Grade III Triggering, passive; demonstrable catching requiring passive extension (IIIA) or inability to actively ex (IIIB). Grade IV Contracture; demonstrable catching, with a xed exion PIP joint contracture. Eighteen (17%) of the digits in this series were grade II, 44 (41%) were grade IIIA, 42 (39%) were grade IIIB and 3 (3%) were grade IV. Instruments and Operative Technique Linear-array transducers were used with a variety of sonography scanners (ATL HDI 5000; 7.512 MHz; Advanced Technology Laboratories, Bothell, WA; or SonoSite, 510 MHz; Inc., Bothell, WA). Standard 21and 18-gauge needles (Becton, Dickinson and Co., Franklin Lakes, NJ) were used for the inltration of anaesthesia and preparation of the puncture inlet for the introduction of (i) a specially designed probe, easily fashioned from a 2.5 mm (diameter) K-wire (Hall Surgical, FL, USA) to the diameter of the hook knife, with an electric grindstone and (ii) a custom-made hook knife (#1: ECTRA; Smith & Nephew (Dyonics), Andover, MA; or #2: Arthroknife; Stryker Howmedica Osteonics, Allendale, NJ) (Fig 1A). The patient was placed in a supine position with the affected hand and wrist sterilized and draped. The scan head of the sonographic unit was enclosed in a sterile covering, a surgical glove and a length of stockinette. A standard acoustic coupling gel (Surgilube; E. Fougera and Co., Melville, NY) was applied to the inside of the glove before scan-head insertion. The transducer was held in contact with the metacarpophalangeal joint of the involved nger with aseptic gel to eliminate artefacts. This joint is located at the level of the distal palmar crease for the last three digits, at the level of the proximal palmar crease for the index nger and 0.5 cm proximal to the proximal thumb crease for the thumb

(Chern et al., 2005; Eastwood et al., 1992; Ha et al., 2001; Lorthioir, 1959; Patel and Moradia, 1997) (Fig 1B). For continuous and steady images, the transducer was positioned and remained at the centre of the metacarpophalangeal joint and along the mid-line of the exor tendon during the procedure (Fig 1CF). A 10-ml syringe lled with 3 ml of 1% lidocaine without epinephrine (Xylocaine; Fujisawa Pharmaceutical Co Ltd, Osaka, Japan) with a standard 21-gauge, 1.5-in needle was bent at the base of the needle at about a 251 to 301 angle (Fig 2A). The needle was inserted 1 cm distal to the proximal crease of the thumb, and at the basal crease of the ngers. One millilitre of lidocaine was inltrated subcutaneously and the hole made by the needle was used as the insertion point for introducing the probe and the hook knife (Figs 1B,C and 2A). The needle was advanced through the space between the exor tendon and subcutaneous tissue along the midline of the exor tendon under continuous sonographic guidance and the lidocaine was inltrated along this space until the tip of the needle was 5 mm proximal to the junction of the head and neck of the metacarpal. Using the sonographic images, we were able to observe the local anaesthetic ll and expand the space (Fig 2B and C). Usually less than 3 ml was required to achieve this. This procedure facilitated introducing the probe in the optimal position. After enlarging the inlet (insertion point) to 2 mm using an 18-gauge needle (Fig 2DF), a specially designed probe was then pushed along the same route, now well-anaesthetized, to prepare the track for the hook knife (Fig 3AC). Finally, a custom-made hook knife (Smith & Nephew, Cambridge, England) was inserted easily along the previous track. When the hook knife was 5 mm proximal to the junction of the head and neck of the metacarpal and directly on top of the midline of the exor tendon, the blade was hooked around the A1 pulley (Fig 3DF) and the pulley was sectioned by moving the knife from proximal to distal. The cut stopped 5 mm distal to the junction of the base and shaft of the proximal phalanx. All these steps were easily monitored using sonography. Adequate release was shown by observing, sonographically, the unhindered movement of the probe from the subcutaneous space (Fig 4AC) into the space between the skin and the exor tendons (Fig 4DF) and by the disappearance of triggering upon active movement of the digit by the patient, who was asked to ex and extend the digit a number of times. This conrmed complete release of the A1 pulley. A transverse sonographic examination can also be used to demonstrate the A1 pulley release (Fig 5AF). If any suggestion of incomplete release persisted, the cutting procedure was performed again. Because the repeated sections were sonographically monitored, they caused no additional risk to the patients. Therefore, an initial failure did not necessitate open release. After the operation, the small puncture wound of the inlet was covered with a dry dressing. This was removed

Downloaded from jhs.sagepub.com at HINARI on March 20, 2013

ARTICLE IN PRESS
PERCUTANEOUS RELEASE OF THE A1 PULLEY 193

Fig 1 (A) Instruments used for sonographically assisted percutaneous release of the A1 pulley: 10-ml syringe with 21-gauge needle, 18-gauge needle, custom-made probe and two different hook knives. (B,C) Position of transducer (B) and inlet (insertion point) (C) for the hook knife. (DF) Drawing (D) and sonograms ((E) longitudinal section; (F) transverse section) of step (1) of sonographically assisted, percutaneous release: initial localization of guiding landmarks: midline of the exor tendon and the metacarpophalangeal joint.

the following day. Neither suturing nor immobilization was necessary and patients were encouraged to engage in all of their normal life and work activities the following day. Patients were followed prospectively and asked to return to our hospital 1 week after the operation and, again, at least 6 months after surgery for a nal assessment, which consisted of an interview and a clinical examination. In addition, on ve occasions 1 day, 2 to 4 and 6 weeks post-surgery patients were contacted by telephone and asked to answer our standardized telephone questionnaires. Patients were asked, specically, about their current pain and tenderness during movement compared with their pain and tenderness before surgery and this was assessed as one of four grades: none, mild, moderate, and severe. They were asked whether they required an oral analgesic and

whether they were experiencing pain and tenderness with their routine daily activities or work. They were asked about the range of movement of the treated digit(s) and this was assessed as one of three categories: (a) full movement; (b) minor limitation unable to ex or extend the digit fully because of pain, with either a mild limitation in the range of motion of the digit or the patient felt that the range of motion was worse than preoperatively but that it did not interfere with daily life and working and (c) signicant limitation stiffness and marked limitation of the range of motion of the digit, interfering with daily life and work. Patients were also asked to describe any uneven movements, triggering or locking. The result of this nal evaluation was graded as satisfactory (cured or minimal symptoms that did not bother the patient) or unsatisfactory (the patient was

Downloaded from jhs.sagepub.com at HINARI on March 20, 2013

ARTICLE IN PRESS
194 THE JOURNAL OF HAND SURGERY VOL. 31B No. 2 APRIL 2006

Fig 2 (AC) Drawings and sonograms of step (2) of sonographically assisted, percutaneous release: insertion of the needle for anaesthesia inltration. The dotted line in (B) shows the position of the transverse section in (C). (DF) Drawings and sonograms of step (3) of sonographically assisted, percutaneous release: insertion of an 18-gauge needle for creating the inlet (insertion point). The dotted line in (E) shows the position of the transverse section in (F).

troubled by signicant symptoms and/or needed analgesic for pain and/or needed further surgery for persistent, or residual, mechanical problems postoperatively). This grading is modied from Patel and Bassini (1992).

RESULTS All patients tolerated the operation, demonstrated resolution of the trigger phenomenon after the operation and no patient needed open release of the A1 pulley. The follow-up ranged from 9 to 15 months, with an average of 12.5 months. Three patients with three digits released were followed up by telephone interview only, during which all afrmed that they had no difculty moving the treated digit and felt no difference between

it and their normal digits. Excluding these three digits, 101 of 104 digits (97%) manifested no pain, abnormal movement or interference with regular daily activities or work. The remaining three digits (3%) had signicantly improved and exhibited only minor pain and tenderness during movement. They required no further treatment. The telephone interviews indicated that most postoperative tenderness and pain had disappeared within 1 week, although, at this stage, 15 (14%) of the patients still complained of moderate pain and 89 (86%) of mild pain. However, none needed medication. Four weeks after surgery, 96 (92%) of the digits had no pain (Table 1). Although seven of the digits (7%) could not be moved through their full range of motion initially because of postoperative pain, all had been restored to a full range of motion within 4 weeks (Table 2).

Downloaded from jhs.sagepub.com at HINARI on March 20, 2013

ARTICLE IN PRESS
PERCUTANEOUS RELEASE OF THE A1 PULLEY 195

Fig 3 (AC) Drawings and sonograms of step (4) of sonographically assisted percutaneous release: subcutaneous insertion of the probe to create a correct track for introduction of the cutting device: hook knife. The dotted line in (B) shows the position of the transverse section in (C). (DF) Drawings and sonograms of step (5) of sonographically assisted percutaneous release: advancement of the hook knife and cutting of the A1 pulley by backward withdrawal of the hook knife from 3 to 5 mm proximal to the metacarpal head-neck junction to 2 to 3 mm distal to the proximal phalangeal base shown in sonography, which can be monitored continuously. The dotted line in (E) shows the position of the transverse section in (F).

Wound healing was uneventful within a few days in all patients and all of the wounds eventually became invisible. There was no skin thickening or other cosmetic problem. Three thumbs (3%) in three patients developed radial digital nerve numbness immediately after the operation. There were no Tinels signs or abnormal ndings on static and dynamic two-point discrimination testing or SemmesWeinstein monolament testing at 1 week after the operations. In all three thumbs, the numbness resolved spontaneously after 2 weeks. There were no supercial, or tendon-sheath, infections, digital nerve injuries, bowstringing of the exor tendon or reex sympathetic dystrophy. Therefore, none of the sonographically assisted, percutaneous releases was rated unsatisfactory.

DISCUSSION The use of sonography to guide the sampling of small tumours or cysts is a common technique whose value is generally accepted. A few studies report that sonography could be a useful adjunct for intraoperative monitoring of orthopaedic procedures such as fracture reduction (Chern et al., 2002; Grechenig et al., 1998; Mahaisavariya et al., 1991; Vincent et al., 1989) and spinal-lesion evaluation (Rubin and Chandler, 1987). Assisting percutaneous release of trigger digits with greater safety and success is a further, and logical, use of sonography. Division of the A1 pulley remains a necessity for trigger digits refractory to conservative measures

Downloaded from jhs.sagepub.com at HINARI on March 20, 2013

ARTICLE IN PRESS
196 THE JOURNAL OF HAND SURGERY VOL. 31B No. 2 APRIL 2006

Fig 4 (AC) Drawings and sonograms of step (5) of sonographically assisted percutaneous release: after cutting, the probe can easily be moved across the A1 pulley, upward from the subcutaneous space. (DF) The probe can easily be moved downward to the undersurface of the exor tendons.

(Gilberts et al., 2001; Patel and Bassini, 1992; Saldana, 2001; Turowski et al., 1997). Several percutaneous techniques have been introduced to provide similar relief of symptoms with fewer complications and less disability time than usually generated by conventional open release (Bain et al., 1995; Cihantimur et al., 1998; Dunn and Pess, 1999; Eastwood et al., 1992; Ha et al., 2001; Lorthioir, 1959; Lyu, 1992; Patel and Moradia, 1997; Pope and Wolfe, 1995; Stothard and Kumar, 1994; Tanaka et al., 1990). Whether using a needle (Bain et al., 1995; Blumberg et al., 2001; Cihantimur et al., 1998; Eastwood et al., 1992; Gilberts et al., 2001; Patel and Moradia, 1997; Pope and Wolfe, 1995; Stothard and Kumar, 1994; Tanaka et al., 1990; Wilhelmi et al., 2003) or various custom-made (Lorthioir, 1959; Lyu, 1992) or specially designed knives (Dunn and Pess, 1999; Ha et al., 2001), all percutaneous techniques lack complete visualization of the cutting process and depend, mainly, on skin landmarks, which have been shown to be inaccurate (Bain et al., 1995; Dunn and

Pess, 1999; Wilhelmi et al., 2003). These techniques, therefore, are not completely without risk of injury to adjacent vital structures. Unlike open release, percutaneous release using a perpendicular needle was thought to be safe because the needle is inserted and moved between the two digital nerves (Patel and Moradia, 1997). However, because the neurovascular bundles are close to the A1 pulley, especially in the little nger, and, because the radial digital nerve passes diagonally across the exor pollicis longus tendon from the ulnar to the radial side very close to the A1 pulley, the risk of injury to these vital structures can never be overemphasized (Bain et al., 1995; Chern et al., 2005; Eastwood et al., 1992; Pope and Wolfe, 1995). Bain et al. (1995) concluded that the close proximity of the digital nerve makes percutaneous release potentially hazardous in the thumb and little nger and Pope and Wolfe (1995) found that the potential risk of injury in the index nger was signicant. We agree with the assessments of these two cadaveric studies. The clinical work by Eastwood et

Downloaded from jhs.sagepub.com at HINARI on March 20, 2013

ARTICLE IN PRESS
PERCUTANEOUS RELEASE OF THE A1 PULLEY 197

Fig 5 (A,B) Clinical picture (A) and transverse sections of sonograms (B) of the long nger with grade IV trigger digit before the procedure. (C,D) Clinical picture (C) and transverse sections of sonograms (D) of the long nger with grade IV trigger digit after the procedure.

Table 1Results of sonographically assisted, percutaneous release on grade of pain Pain Pre-operative 1 day None Mild Moderate Severe 0 93 (89%) 8 (8%) 3 (3%) 0 16 (15%) 81 (78%) 7 (7%) 1 week 0 89 (86%) 15 (14%) 0 2 weeks 0 97 (93%) 7 (7%) 0 Postoperative 3 weeks 34 (33%) 69 (66%) 4 (4%) 0 4 weeks 96 (92%) 8 (8%) 0 0 6 weeks 101 (97%) 3 (3%) 0 0 Final exam 101 (97%) 3 (3%) 0 0

Table 2Results of sonographically assisted, percutaneous release on the range of motion after operation Movement 1 day Full Minor limited Signicant limited 101 (97%) 7 (7%) 0 1 week 101 (97%) 7 (7%) 0 2 weeks 101 (97%) 3 (3%) 0 Postoperative 3 weeks 101 (97%) 3 (3%) 0 4 weeks 104 (100%) 0 0 6 weeks 104 (100%) 0 0 Final exam 104 (100%) 0 0

al. (1992) concluded that percutaneous release in the thumb was unsafe, although Tanaka et al. (1990) reported no thumb injuries in their large study. These reports, at least, indicate that the published percutaneous release techniques are not suitable for all digits. Moreover, they imply that there are potential risks, which using skin landmarks, or palpable nodules, cannot resolve.

Because most of these complications may not be recognized at the time of surgery, any measure endoscopic, radiological, or sonographic which increases the safety and the success rate of percutaneous release techniques should be supported. Sonographic monitoring with a special cutting instrument, kept deadcentre over the exor tendon sheath (Ha et al., 2001; Lyu, 1992) and performed with a custom-made needle

Downloaded from jhs.sagepub.com at HINARI on March 20, 2013

ARTICLE IN PRESS
198 THE JOURNAL OF HAND SURGERY VOL. 31B No. 2 APRIL 2006

moved exactly along the route of the tendon (Cihantimur et al., 1998; Patel and Moradia, 1997; Tanaka et al., 1990) allowed observation during the division. Our ndings, in this prospective study of 107 digits in 83 patients with chronic triggering of digits, illustrates that sonographic monitoring provides continuous and direct visualization to guide, and permit, an effective and safe percutaneous release of trigger digits. All 107 digits were successfully treated, postoperative recovery was uneventful and there were no recurrences during an average 12.5 month follow-up. Sonography was able to show the several landmarks for the division procedure and depict the instruments and the target structures simultaneously during the operation for our cadaver study (Chern et al., 2005) and this clinical study. The safety of sonographically assisted, percutaneous release has been demonstrated by the absence of iatrogenic digital nerve injury in any of these digits. One practical problem with sonographically assisted, percutaneous release of the A1 pulley is clear delineation of the target structure. If advances in technology lead to higher resolution images, this difculty may be overcome. However, the structures underlying the A1 pulley have strong echogenic patterns on sonographic examination which are not difcult to observe, even with conventional, low-frequency sonography (Fornage and Rifkin, 1986; Fornage et al., 1985). Our cadaveric study (Chern et al., 2005), on the correlation of the A1 pulley with those echogenic structures, demonstrated a consistent and close relationship between the actual location of the A1 pulley and the sonographically visible landmarks. Sonographically assisted, percutaneous release is technically demanding: the surgeons non-dominant hand must control the transducer while the dominant hand manipulates the cutting device. We, therefore, recommend that surgeons observe sonographic images of their own hands, train themselves to hold and manipulate the transducer steadily and skilfully with their non-dominant hand and interpret the images precisely. The next step of training should be performing sonographically assisted, percutaneous release in all digits on several cadaver specimens. This should include actual cutting of the A1 pulley, followed by open conrmation of the completeness of the release and the absence of injury to the vital structures. Consistent successful application of the technique on cadavers will provide a safe transition to use of the technique on patients. The cost of sonographically assisted, percutaneous release is another shortcoming. Sonography systems come in a variety of congurations. A refurbished, greyscale system may be as low as h3319/US$4000, but new, and more sophisticated systems will cost more. This equipment is, almost always, available for general surgery, or obstetric and gynaecological purposes, in operating rooms and hospital clinics. The equipment found in most modern hospital operating rooms and

clinics is adequate for the task of performing sonographically assisted, percutaneous release. The cutting device is cheap (h12.5/US$15). However, the savings realized by reduced time in the operating room and the elimination of the cost of draping may make this technique cheaper or equal in cost to, the open method.

References
Bain GI, Turnbull J, Charles MN, Roth JH, Richards RS (1995). Percutaneous Al pulley release: a cadaveric study. Journal of Hand Surgery, 20A: 781784. Blumberg N, Arbel R, Dekel S (2001). Percutaneous release of trigger digits. Journal of Hand Surgery, 26B: 256257. Bonnici AV, Spencer JD (1988). A survey of trigger nger in adults. Journal of Hand Surgery, 13B: 202203. Carrozzella J, Stern PJ, Von Kuster LC (1989). Transection of radial digital nerve of the thumb during trigger release. Journal of Hand Surgery, 14A (Part 1): 198200. Chern TC, Jou IM, Lai KA, Yang CY, Yeh SH, Cheng SC (2002). Sonography for monitoring closed reduction of displaced extraarticular distal radius fracture. Journal of Bone and Joint Surgery, 84A: 194203. Chern TC, Jou IM, Yen SH, Lai KA, Shao CJ (2005). Cadaveric study of sonographically assisted percutaneous release (SAPR) of the A1 pulley. Plastic and Reconstructive Surgery, 115: 811822. Cihantimur B, Akin S, Ozcan M (1998). Percutaneous treatment of trigger nger: 34 ngers followed 0.52 years. Acta Orthopaedica Scandinavica, 69: 167168. Dunn MJ, Pess GM (1999). Percutaneous trigger nger release: a comparison of new push knife and a 19-gauge needle in a cadaveric model. Journal of Hand Surgery, 24A: 860865. Eastwood DM, Gupta KJ, Johnson DP (1992). Percutaneous release of the trigger nger: an ofce procedure. Journal of Hand Surgery, 17A: 114117. Fornage BD, Rifkin MD (1986). Ultrasound examination of the hand. Radiology, 160: 853854. Fornage BD, Schernberg FL, Rifkin MD (1985). Ultrasound examination of the hand. Radiology, 155: 785788. Froimson AI. Tenosynovitis and tennis elbow, 19892006. In: Green DP, Hotchkiss RN, Pederson WC, Lampert R (Eds) Greens operative hand surgery, 4th Edn., Philadelphia, Churchill Livingstone, 1999, Vol. 2: 1993. Gilberts EC, Beekman WH, Stevens HJ, Wereldsma JC (2001). Prospective randomized trial of open versus percutaneous surgery for trigger digits. Journal of Hand Surgery, 26A: 497500. Grechenig W, Clement HG, Fellinger M, Seggl W (1998). Scope and limitations of ultrasonography in the documentation of fractures an experimental study. Archives of Orthopaedic and Trauma Surgery, 117: 368371. Ha KI, Park MJ, Ha CW (2001). Percutaneous release of trigger digits: a technique and results using a specially designed knife. Journal of Bone and Joint Surgery, 83B: 7577. Heithoff SJ, Millender LH, Helman J (1988). Bowstringing as a complication of trigger nger release. Journal of Hand Surgery, 13A: 567570. Lane LB (1995). Percutaneous release of the rst annular pulley. Journal of Hand Surgery, 20A: 785786. Lorthioir J (1959). Surgical treatment of trigger nger by a subcutaneous method. Journal of Bone and Joint Surgery, 40A: 793795. Lyu SR (1992). Closed division of the exor tendon sheath for trigger nger. Journal of Bone and Joint Surgery, 74B: 418420. Mahaisavariya B, Suibnugarn C, Mairiang E, Saengnipanthkul S, Laupattarakasem W, Kosuwon W (1991). Ultrasound for closed femoral nailing. Journal of Clinical Ultrasound, 19: 393397.

Downloaded from jhs.sagepub.com at HINARI on March 20, 2013

ARTICLE IN PRESS
PERCUTANEOUS RELEASE OF THE A1 PULLEY 199

Panayotopoulos E, Fortis AP, Armoni A, Dimakopoulos P, Lambiris E (1992). Trigger digit: the needle or the knife? Journal of Hand Surgery, 17B: 239240. Patel MR, Bassini L (1992). Trigger nger and thumb: when to splint, inject, or operate. Journal of Hand Surgery, 17A: 110113. Patel MR, Moradia VJ (1997). Percutaneous release of trigger digit with and without cortisone injection. Journal of Hand Surgery, 22A: 150155. Pope DF, Wolfe SW (1995). Safety and efcacy of percutaneous trigger nger release. Journal of Hand Surgery, 20A: 280283. Rubin JM, Chandler WF (1987). The use of ultrasound during spinal cord surgery. World Journal of Surgery, 11: 570578. Saldana MJ (2001). Trigger digits: diagnosis and treatment. Journal of the American Academy of Orthopaedic Surgeons, 9: 246252. Stothard J, Kumar A (1994). A safe percutaneous procedure for trigger nger release. Journal of the Royal College of Surgeons of Edinburgh, 39: 116117. Tanaka J, Muraji M, Negoro H, Yamashita H, Nakano T, Nakano K (1990). Subcutaneous release of trigger thumb and ngers in 210 ngers. Journal of Hand Surgery, 15B: 463465. Thorpe AP (1988). Results of surgery for trigger nger. Journal of Hand Surgery, 13B: 199201.

Turowski GA, Zdankiewicz PD, Thomson JG (1997). The results of surgical treatment of trigger nger. Journal of Hand Surgery, 22A: 145149. Vincent KA, Benson DR, McGahan JP (1989). Intraoperative ultrasonography for reduction of thoracolumbar burst fractures. Spine, 14: 387390. Wilhelmi BJ, Mowlavi A, Neumeister MW, Bueno R, Ketchum J, Lee WP (2003). Surface landmarks to locate the thenar branch of the median nerve: an anatomical study. Plastic and Reconstructive Surgery, 111: 16121615.
Received: 17 February 2005 Accepted after revision: 1 November 2005 Corresponding author. Dr I. M. Jou, MD, PhD, Department of Orthopaedics, College of Medicine, National Cheng Kung University, 138 Sheng-Li Road, Tainan 70428, Taiwan. Tel.: +886 6 276 6689; fax: +886 6 276 6189. E-mail: jming@mail.ncku.edu.tw We received no nancial support from any source for this study. r 2005 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2005.11.003 available online at http://www.sciencedirect.com

Downloaded from jhs.sagepub.com at HINARI on March 20, 2013