Differential Pulley Release in Trigger Finger: A Prospective Randomized Clinical Trial
Robin Wu, BS1; Yuen Jong Liu, MD2; Peter Hetzler, BS2; John Smetona, MD2; Scott Persing, MD2; J. Grant Thomson, MD3
1Section of Plastic Surgery, Yale University School of Medicine, New Haven, CT, 2Yale University School of Medicine, New Haven, CT, 3Section of Plastic and Reconstructive Surgery, Yale University School of Medicine, New Haven, CT
Purpose: Though trigger finger is traditionally associated with A1 pulley constriction, the A0 pulley, customarily known as the palmar aponeurosis, has been observed to be responsible for trigger finger pathology. This study attempts to outline the clinical prevalence and patient factors related to A0 pulley trigger finger in surgical patients.
Methods: This was a prospective IRB approved randomized clinical trial. Patient demographics, medical history, and trigger finger history/symptoms were documented prior to trigger finger release. Intra-operatively, initial relase of A0 or A1 pulley was randomized by coin toss. Following release, the patient was asked to flex/extend the fingers under careful examination and documentation. The remaining pulley was then released and clinical trigger status was recorded. The A0 pulley was deemed responsible if the initial release of A1 failed, but following release of A0 successfully resolved triggering. The A0 pulley was deemed at least partially involved if the initial A0 release completely or incompletely resolved the trigger status of the patient. Statistic analysis was performed with Chi square and multivariate regressions.
Results: To date, twenty-six fingers belonging to eighteen patients (61% right handed, 39% left handed; average age 56 yrs; 44% female) have been released. Of the 26 fingers, 31% showed complete resolution of symptoms following the initial release of A0, and 15% had improvement of symptoms, requiring an A1 release for complete resolution. 15% had failed A1 release with complete resolution after subsequent A0 release. Neither initial A1 or A0 release was significantly associated with complete release, incomplete release, or release failure. Multivariate regression revealed that diabetes status(p<0.001), occupation requiring manual labor(p=0.002), presence of past hand procedures(p=0.003), increased pain level at baseline(p=0.020), and absence of a palpable nodule(p=0.009) predicted incomplete resolution at first release. Incomplete release was independent of A1 or A0 release, age, sex, finger, smoking status, or steroid injections.
Conclusions: Our preliminary data suggest that 31-46% of trigger fingers may be primarily caused by the A0 pulley. Furthermore, the data suggest that up to 61% of trigger fingers may involve the A0 pulley system. While literature documented factors such as diabetes status and past hand pathology appropriately predicted poor results from initial release, the actual pulley released was independent. This implicates both pulleys in trigger finger and suggests that release of both the A1 and A0 may be necessary for comprehensive treatment. As our sample size increases, the true prevalence of A0 trigger finger may be elucidated.
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