EVIDENCE-BASED MEDICINE

Percutaneous Trigger Finger Release

Evidence-Based Medicine
John R. Fowler, MD, Mark E. Baratz, MD

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David Ring, MD, has no relevant conflicts of interest to disclose.
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Learning Objectives
ASSH Disclaimer: The material presented in this CME activity is made available by the ASSH
• Review the literature regarding open trigger finger release.
for educational purposes only. This material is not intended to represent the only methods or
• Appraise the evidence regarding percutaneous trigger finger release.
the best procedures appropriate for the medical situation(s) discussed, but rather it is
• Discuss the safety of percutaneous trigger finger release.
intended to present an approach, view, statement, or opinion of the authors that may be
• Describe the efficacy of percutaneous trigger finger release.
helpful, or of interest, to other practitioners. Examinees agree to participate in this medical
• Propose indications for both open and percutaneous methods of treatment.
education activity, sponsored by the ASSH, with full knowledge and awareness that they
waive any claim they may have against the ASSH for reliance on any information presented. Deadline: Each examination purchased in 2013 must be completed by January 31, 2014, to
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educational activity may not yet have received FDA approval. Copyright © 2013 by the American Society for Surgery of the Hand. All rights reserved.

THE PATIENT trigger finger release and wants to know if percutaneous

A 60-year-old man returns to the office complaining of release is a good option.
recurrent locking and triggering of his right ring finger
after 2 prior corticosteroid injections. The symptoms THE QUESTION
have been present for approximately 6 months. On Is percutaneous trigger finger release as safe and effec-
physical examination, he has a painful nodule at the tive as open release?
level of the A1 pulley, moderate triggering with active
finger motion, and a slight flexion contracture at the CURRENT OPINION
proximal interphalangeal joint. He is not diabetic and Open trigger release has a high success rate with
has no other medical comorbidities. He is interested in low morbidity and is considered the standard op

FromtheDepartmentofOrthopaedics,UniversityofPittsburgh;andOrthopaedicSpecialists–University Corresponding author: John R. Fowler, MD, 1205 Joseph Court, Gibsonia, PA 15044; e-mail:
of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. [email protected].
Received for publication February 26, 2013; accepted in revised form March 3, 2013. 0363-5023/13/38A10-0023$36.00/0
http://dx.doi.org/10.1016/j.jhsa.2013.03.001
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article.

©  ASSH 䉬 Published by Elsevier, Inc. All rights reserved. 䉬 2005

 2006 PERCUTANEOUS TRIGGER FINGER RELEASE

erative treatment.1 Percutaneous trigger release, in 43 patients who underwent percutaneous A1 pulley
Evidence-Based Medicine

first described by Lorthioir in 1958,2 has become release using a hypodermic needle. At 6-month follow-
increasingly popular in recent years as an alterna- up, there were no recurrences.
tive to open release. Proponents point to the ease Ragoowansi et al6 used a “lift and cut” percutaneous
of the procedure, decreased pain, faster recovery, technique in 180 patients with a recurrence rate of 5%
absence of a painful palmar scar, and the flexibility and no nerve or tendon injuries. Ha et al18 used a
to perform the procedure in the office with reduced specially designed hooked knife to perform percutane-
costs.3,4 Hypodermic needles are usually used for ous release in 185 trigger fingers and achieved satisfac-
percutaneous release,4 – 8 but the use of blades or tory results in 94%.
specially designed scalpels has also been re- Calleja et al3 performed percutaneous release of 25
ported.2,9 –11 trigger fingers using a 19-gauge needle, then performed
an open trigger release and found that only 6 of 25
THE EVIDENCE (24%) achieved a complete A1 pulley release. Superfi-
Open A1 pulley release cial tendon abrasions were noted in 15 fingers (60%).
Turowski et al12 reviewed 59 patients who underwent Habbu et al19 used a no. 15 blade scalpel to perform
open trigger release and reported a 97% rate of resolu- percutaneous release in 54 fresh frozen cadaver fingers
tion of symptoms with no adverse events such as infec- and noted complete release in 72% of fingers. Longi-
tion, nerve injury, or bowstringing. tudinal scoring of the tendons occurred in 20%, but no
Bruijnzeel et al13 retrospectively reviewed 1598 neurovascular injuries were found.
open A1 pulley releases in 984 patients and found Cebesoy20 described 25 trigger thumb releases in 21
recurrence in 4 patients (0.3%) and persistent triggering patients using an 18-gauge needle, followed by corticoste-
in 10 patients (0.6%). The authors reported an overall roid injection. Four patients had an incomplete release and
adverse event rate of 5%, with over half of these ad- then underwent open pulley release. Three of the 4 patients
verse events related to slow recovery of motion. Wound had superficial tendon lacerations noted at the time of open
complications, including suture abscess, superficial in- surgery. Percutaneous release on thumbs is generally con-
fection, and wound separation occurred in 30 patients sidered more dangerous because the radial digital nerve
(2%). There were no nerve or tendon injuries in this crosses at the level of the A1 pulley.
large series. Jou and Chern21 used ultrasound-guided percutane-
Lange-Riess et al14 reviewed 254 digits that under- ous trigger release on 104 digits in 80 patients. At final
went open A1 pulley release at average follow-up of 14 evaluation an average of 15 months later, 97% of pa-
years and found complete resolution of triggering tients experienced relief of pain and none had mechan-
symptoms in 100% of patients. Adverse events were ical recurrence. Rajeswaran et al22 performed ultra-
noted in 9 fingers (3.5%), including 2 superficial wound sound-guided percutaneous release in 35 fingers, with
infections and 6 transient digital neurapraxias. Lim et complete resolution of symptoms in 91%. Pegoli et al23
al15 reported no recurrences in 373 patients who under- compared open with endoscopic trigger in 200 patients
went open A1 pulley release, and an adverse event rate and found equivalent results.
of less than 1%.
In contrast, Will and Lubahn16 reported a 30% ad- Randomized trials comparing open to percutaneous
verse event rate in 78 open trigger finger releases. The A1 pulley release
authors classified most of these as minor adverse events, Dierks et al11 randomized 36 patients to either
including decreased range of motion, wound infection, traditional open pulley release or percutaneous re-
wound separation, swelling, and pain. Thorpe17 reviewed lease with a no. 15 blade scalpel. The authors
53 open A1 pulley releases performed by house officers in found greater range of motion at 1 week in the
43 patients and reported successful release in only 60% of percutaneous group, but equivalent pain and grip
patients at an average follow-up of 47 months. Recurrence strength at 1 week and 12 weeks and equivalent
developed in 6 digits (11%). Nerve laceration occurred in range of motion at 12 weeks. Mean surgical time in
2 digits (3.8%) and neurapraxia in 2 digits (3.8%). the percutaneous group was 26 seconds, compared
with 10 minutes in the open group.
Percutaneous A1 pulley release Gilberts et al24 randomized 100 patients to tradi-
Eastwood et al4 performed percutaneous release using a tional open trigger release or percutaneous trigger re-
21-gauge needle on 35 fingers with resolution of trig- lease using an 18-gauge needle. With respect to post-
gering in 94%. Zyluk and Jagielski8 reviewed 46 digits operative duration of pain, the open group reported

JHS 䉬 Vol A, October 

 PERCUTANEOUS TRIGGER FINGER RELEASE 2007

postoperative pain for an average of 5.7 days compared lease requires further study and longer-term fol-
with 3.1 days in the percutaneous group. The percuta- low-up with respect to recurrence and range of
neous group returned to work at 3.9 days compared motion. The value of various approaches should be

Evidence-Based Medicine
with 7.5 days in the open group. There were no revision investigated because percutaneous release done in
surgeries in the percutaneous group, but 1 revision the office seems much more economical.
surgery in the open group.
Sato et al7 randomized 150 trigger fingers to corti- OUR CURRENT CONCEPTS FOR THIS PATIENT
costeroid injection, percutaneous release, or open trig- We usually offer patients like the one presented (per-
ger release. The authors noted 100% relief of triggering sistent triggering after corticosteroid injection) an open
in both the percutaneous and the open groups and A1 pulley release. We sometimes offer percutaneous
reported no complications. release as initial treatment for patients who are unlikely
Wang et al25 performed a meta-analysis using these to respond to corticosteroid injection (eg, patients with
randomized trials. The authors found no differences in type 1 diabetes mellitus).
the failure rate or complication rate between open and After local anesthesia, the metacarpophalangeal joint
percutaneous techniques. However, there was signifi- is hyperextended and an 18-gauge needle with the bevel
cant heterogeneity between the studies. oriented in line with the long axis of the metacarpal is
introduced at the proximal margin of the A1 pulley,
SHORTCOMINGS OF THE EVIDENCE lifted with the operator’s index finger positioned be-
The published series for percutaneous release are neath the needle to catch and cut the pulley. The release
much smaller than those for open release, gener- can be felt and heard. The needle is advanced several
ally fewer than 100 patients. The published pro- millimeters distally and the process is repeated. The
spective randomized trials are too small to identify release can usually be accomplished with about 3
differences in infrequent adverse events such as passes of the needle. The patient is asked to move the
incomplete release and nerve or tendon injury. The digit. If trigger persists, the process is repeated. Expe-
definition of an adverse event varies widely among rience with percutaneous release in the operating room,
studies. For instance, Will and Lubahn16 included followed by open inspection, has taught us that trigger-
postoperative pain and swelling as a complication ing may abate even in the face of what appears to be an
and documented an adverse event rate of 30% of incomplete release.
the patients in their series, whereas Turkowski et
REFERENCES
al12 defined an adverse event as neurapraxia, ten-
1. Ryzewicz M, Wolf JM. Trigger digits: principles, management, and
don bowstringing, or ulnar deviation of the finger,
complications. J Hand Surg Am. 2006;31(1):135–146.
and reported an adverse event in 8%. 2. Lorthioir J Jr. Surgical treatment of trigger-finger by a subcutaneous
method. J Bone Joint Surg Am. 1958;40(4):793–795.
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outcome of percutaneous release among patients with trigger finger.
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homogenous groups of patients would help deter- 4. Eastwood DM, Gupta KJ, Johnson DP. Percutaneous release of the
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relief of symptoms and adverse events between 5. Maneerit J, Sriworakun C, Budhraja N, Nagavajara P. Trigger
open and percutaneous release. With relief of thumb: results of a prospective randomised study of percutaneous
release with steroid injection versus steroid injection alone. J Hand
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Surg Br. 2003;28(6):586 –589.
less of the technique, it would require 350 patients 6. Ragoowansi R, Acornley A, Khoo CT. Percutaneous trigger finger
per group to detect a 5% difference assuming an release: the “lift-cut” technique. Br J Plast Surg. 2005;58(6):817–
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7. Sato ES, Gomes Dos Santos JB, Belloti JC, Albertoni WM, Faloppa
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needed to determine whether there is a benefit over open surgery. Rheumatology (Oxford). 2012;51(1):93–99.
8. Zyluk A, Jagielski G. Percutaneous A1 pulley release vs steroid
blind release. Randomized trials comparing differ- injection for trigger digit: the results of a prospective, randomized
ent percutaneous release devices (eg, hypodermic trial. J Hand Surg Eur Vol. 2011;36(1):53–56.
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pulley release in trigger digits. J Med Assoc Thai. 2010;93(2):199 –204.
vantages and disadvantages of specific devices.
10. Chao M, Wu S, Yan T. The effect of miniscalpel-needle versus
The significance of incomplete release and super- steroid injection for trigger thumb release. J Hand Surg Eur Vol.
ficial flexor tendon injuries with percutaneous re- 2009;34(4):522–525.

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11. Dierks U, Hoffmann R, Meek MF. Open versus percutaneous release 19. Habbu R, Putnam MD, Adams JE. Percutaneous release of the A1
Evidence-Based Medicine

of the A1-pulley for stenosing tendovaginitis: a prospective random- pulley: a cadaver study. J Hand Surg Am. 2012;37(11):2273–2277.
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JOURNAL CME QUESTIONS

Percutaneous Trigger Finger Release a. The open and percutaneous groups experience
similar postoperative pain at 3 days
Studies have shown that what rate of pain relief b. Residual triggering and complications are ex-
and recurrence or persistent triggering is pected to be greater for the open group
expected following open release?
c. Both groups are expected to have a high rate of
a. Pain relief of 50% and residual triggering of 10% residual triggering and revision surgery
b. Pain relief of 77% and residual triggering of 17% d. Greater range of motion at 1 week in the percu-
c. Pain relief of 80% and residual triggering of 15% taneous group, but an equivalent range of motion
d. Pain relief of 97% and residual triggering of 1% at 12 weeks
e. Pain relief of 100% and residual triggering of 0% e. Equal range of motion at 1 week in the percuta-
neous group, but less range of motion at 12 weeks
According to comparative studies, which of the in the open group
following outcome is expected following
percutaneous or open trigger finger release?

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JHS 䉬 Vol A, October 