JOURNAL OF PHARMACEUTICAL AND BIOMEDICAL SCIENCES

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1 JOURNAL OF PHARMACEUTICAL AND BIOMEDICAL SCIENCES. Revision Surgery after percutaneous release of the A1 pulley for surgical treatment of trigger finger: An unusual case and brief review of literature. Journal of pharmaceutical and biomedical sciences (J Pharm Biomed Sci.) 2013 December; 37(37): The online version of this article, along with updated information and services, is located on the World Wide Web at: Journal of Pharmaceutical and Biomedical Sciences (J Pharm Biomed Sci.), Member journal. Committee of Publication ethics (COPE) and Journal donation project (JDP).

2 Case report and literature review Revision Surgery after percutaneous release of the A1 pulley for surgical treatment of trigger finger: An unusual case and brief review of literature Ahmet Aslan 1,*,Mehmet Nuri Konya 1, Serdar Sargın 2 Affiliation:- 1 MD, Orthopaedics Surgeon; Afyonkarahisar State Hospital, Departmants of Orthopaedics and Traumatology. 2 MD, Orthopaedics Surgeon; Balıkesir Universty, Medicine Faculty, Departmants of Orthopaedics and Traumatology. Balıkesir/TURKEY. The name of the department(s) and institution(s) to which the work should be attributed: Afyonkarahisar State Hospital, Departmants of Orthopaedics and Traumatology. *Corresponding author:- Ahmet Aslan: MD, Orthopaedics Surgeon; Afyonkarahisar State Hospital, Departmants of Orthopaedics and Traumatology. Tel: Abstract: Percutaneous trigger finger releasing has been reported as a safe, effective and quick procedure, but most surgeons convert percutaneous releasing to an opened method because of residual triggering. In this article, we aimed to present an unusual case with trigger finger who underwent percutaneous releasing and afterwards opened revision surgery because of recurrence, in INTRODUCTION rigger Finger is a tenosynovitis and tendon dysfunction, depending on flourishing the flexor tendons, under pulley A1 flexor. This disease also called stenozan tenosynovitis.flexor tendons, at the level of the metacarpal heads under A1 pulley, is compressed due to inflammation caused by fibrocartilaginous metaplasia. Under Al pulley, tendons acting in conjunction with thickening of the synovial tissue and can be palpated as hard nodules. Thickening of the pulley prevents flexion and extension movements of the tendon 1,2. Endocrinological diseases such as diabetes may be accompanied by. attribution to current literature. The patient was a 51 year-old diabetic female with pain in the middle finger of right hand and had trigger finger. Percutaneous releasing was performed by using the tip of a 18-gauge needle at the outpatient room under local anaesthesia. Theree months after percuteneous surgery, the patient reapplied to the hospital because of recurrent triggering of the finger. A secondary procedure by using opened releasing surgery method with A1 pulley was performed to fix the residual or recurrent triggering occured after the initial percutaneous surgical procedure. The patient recovered completely after the second surgery and turned back to her normal life. No complications were observed at 6 month- follow-up examinations. In patients with trigger finger, opened revision surgery is needed when the triggering relapse after percutaneous releasing. The ganglion involvement should always be kept in mind because the ganglion at the level of the metacarpal head of the flexor tendon under A1 pulley can be trapped and this is one of the very rare cause of trigger finger as it is in this case. Key words: Trigger; Finger; Digits; Treatment; Surgical; Release; Percutaneous. In treatment of Trigger finger, conservative methods are preferred. In cases where conservative treatment is not successful, at the level of the metacarpal head, the A1 pulley released by percutaneous or opened surgery is recommended 1-4. In surgery, percutaneous releasing is easy to applicate, has low cost and has gained popularity because of its low complication rates 5,6. However in percutaneous pulley releasing, the flexor tendons cannot be achieved completely and damage of this tendons is noted 7,8. Opened surgery is recommended when percutaneous releasing has not been achieved 7,9. In this article, 1960

3 we presented an unusual trigger finger case, treated with percutaneous surgery and revised with opened surgery, as a review in current literature. CASE PRESENTATION A 51-year-old female patient was administered to our outpatient clinic with the complaints of triggering and pain in the third digit of the right hand. The patient had been previously treated conservatively with local steroid injections and non steroidal anti inflammatory drugs (NSAIDs) therapy. However no response was seen and all complaints were continued. In the clinical examination, a nodule was palpated over the A1 pulley of the third finger. There was also pain and triggering of the finger during flexion. Our diagnose was trigger finger so we offered percutaneous release. Informed consent was obtained from the patient. After antisepsis and local anesthesia of the hand, percutaneous release was performed with 18 gauge injector needle in the outpatient clinic room. On the control examination, the patient expressed relief of all complaints. After three months, the patient was called back for control. Patient s complaints were relapsed more than before. On clinical examination, a giant nodule was palpated over the A1 pulley so surgical treatment was suggested. After the patient was hospitalized, an informed consent was obtained from the patient. Firstly the hand of the patient was cleaned with antiseptic solution and wrapped sterile. 10 cc prilocaine was administered over the A1 pulley on the volar surface of the hand. We made a-2-centimeter skin incision and explored the A1 Pulley. We determined a ganglion cyst that constricts the third flexor tendon. Ganglion cyst was excized and A1 pulley was released. Histopathological examination showed dense fibrous tissue, with no synovial or epithelial lining and confirmed the diagnosis of ganglion cyst. In the control examination after surgery, the patient had no complaints and there was no triggering and pain over her finger. The range of motion of the finger was full. Six months after the second operation, the patient was asymptomatic with no complication and recurrence of triggering. There are figures of this case below (Figure 1 and 2). Fig. 1 A schematic view of percutaneous and open surgical release at the A1 pulley. Fig. 2 During revision open surgery of the case, the appearance of ganglion cyst. DISCUSSION Trigger finger disorder is more commonly encountered in women older than 45 years old and some other conditions such as diabetes can accompany with it. Patients mostly admit to the clinics with flexion pain, stifness and click sound during hperflexion movement complains. This movement is especially painful in new cases. Thickening of the sheath interfere with the flexion and extension movements. The finger can be 1961

4 locked in flexion, extension or middle positions 1-5,10. Our case was a woman at 51 and she has had the same findings during the first and second visits to the clinics. Thus, this condition has confirmed the literature knowledge. On the other hand, Yalçınkaya et al. 1 have reported that ganglion cysts could also be associated with this disoerder. However, we could not find any related case about ganglion cyst in the literature. Ganglion cysts are cystic formations located in joint or tendon sheats, which is formed as a result of synovial herniation and it is more common in female gender and in wrist. In ethiopathogenesis, it is considered that micro traumas constitute an important factor 11. In our case, we think that a possible traumatic insult in tendon sheath occured during the percutaneous A1 pulley release operation might have caused ganglion cyst, which in turn gave rise to a relapse in trigger finger condition. In treatment of trigger finger, surgical release of A1 pulley at metacarpal head level is recommended in such cases in which various conservative modalities including tension and other physiotherapy methods, non-steroidal antiinflammatory drug (NSAID) administration and steroid injeciton to joint are failed in disease management. Moreover, in more recent past, it can be obviously seen that percutaneous release appoach has gained more widespread application field as it is an easy-to-make and cost-effective surgical operation with less complicaiton ratios, which can be applied under polyclinic conditions. However, it has also been reported that percutaneous release can lead to abrasion type damage in flexor tendon and the possibility that % part of the distal pulley remained uncut 1,7-9. In a retrospective study conducted by Pavlicný 12, it has been reported that a total of 100 trigger fingers of 88 patients have been treated with percutaneous release operation and considerable amelioration in symptoms and full finger movement funcitonality have been established in 95 cases. The same author has also reported that he has performed revision surgery to five fingers, of which three were percutaneous release and two were open surgery during two months follow-up period. Dahabra and Sawaqed 13 have treated the A1 pulleys of the 42 patients with trigger finger disorder by making reselase with 18 gauge of injector needle and have reported full remission in 39 patients and relapse in three cases. Ragoowansi et al. 14 have performed release operation to 240 trigger fingers of 180 patients and reported a 94 % management rate during three months follow-up. Kılıç et al. 7 have reported that they have released 25 trigger fingers of 22 patients with percutaneous method and they have also stated that open surgery has been applied to 10 cases during 24 months of follow-up and superficial abrasions were observed. In a randomized prospective study, Sato et al. 10 have reported that results gathered from percutaneous and open surgery are similiar and better than those established from corticosteroid injection. Gilberts et al. 15 have reported in their prospective randomized and controlled study that percutaneous surgery is superior to open surgery approach by means of operation duration, postoperative pain and improvement in motor functions. Fu et al. 9 have applied percutaneous surgery to 31 cases and have reported that full remission was achieved in 28 cases whereas relapse of the symptoms observed in three cases during 12 weeks of follow-up. The authors have also mentioned that percutaneous surgery is a reliable, effective and rapid approach, however open surgery is applied to the relapsed trigger finger cases. We also perform percutaneous release surgery in cases in which conservative treatment is noneffective and apply open surgery in relapsed cases. Our case was a diabetic patient and she has told that her complains remained unchanged despite conservative treatment. During her first admittance to our clinics, we have treated our patient with percutaneous release operation performed by using 18 gauge injector needle under local anesthesia. After three months, on her second visit, we have revised the condition by open surgical approach. In this case, we think that inadequate release of percutaneous surgery and abrasion damage of the flexor tendon have played role together in development of the ganglion cyst and relapse of the trigger finger condition. CONCLUSION As a result, open surgery is required in cases with exacerbated clinical findings which were formerly treated with percutaneous release. It may also be beneficial to keep in mind that some very rare conditions such as fibrocartilaginous metaplasia of the pulley could be responsible for the scratch of the flexor tendons under the A1 pulley at metacarpal head level, just as in our case in which ganglion cyst caused such condition. 1962

5 ACKNOWLEDGEMENT We would like to thank for their contribution Dr.Şule Yağcı, Dr. Ahmet Koçak and Dr. Aziz Atik. REFERENCES 1. Yalçınkaya M, Dogan A, Üzümcügil O, Yetiş M, Kabukçuoglu YS.[Our Results in Surgery Treatment oftrigger Finger Disease]. [Article in Turkish] Istanbul Med J 2008; 9(1): Ertem K, İnan M, Coşkun H, Bora A. [The Results of Treatment of Patients with Trigger Finger Released by Minimal Open Surgery]. [Article in Turkish] Journal of Turgut Ozal Medical Center 2003;10(1): Dierks U, Hoffmann R, Meek MF.Open versus percutaneous release of the A1-pulley for stenosing tendovaginitis: a prospective randomized trial. Tech Hand Up Extrem Surg. 2008;12(3): Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg Am. 2006;31(1): Eastwood DM, Gupta KJ, Johnson D P. Percutaneous release of the trigger finger: an office procedure. J Hand Surg 1992; 17A: Ha KI, Park MJ, Ha CW. Percutaneous release of trigger digits. J Bone Joint Surg Br ;83(1): Kılıç BA, Kiter AE, Selçuk Y. The effect of percutaneous trigger finger release on normal anatomic structures and long-term results of the procedure. Acta Orthop Traumatol Turc. 2002;36(3): Slesarenko YA, Mallo G, Hurst LC, Sampson SP, Serra-Hsu F. Percutaneous release of A1 pulley. Tech Hand Up Extrem Surg. 2006;10(1): Fu YC, Huang PJ, Tien YC, Lu YM, Fu HH, Lin GT. Revision of incompletely released trigger fingers by percutaneous release: results and complications. J Hand Surg Am ;31(8): Sato ES, Dos Santos JB, Belloti JC, Albertoni WM, Faloppa F. Percutaneous release of trigger fingers. Hand Clin. 2014;30(1): Aslan A, Atay T, Baykal YB, Kırdemir V, Konya MN, Sofu H, Baydar ML. Giant ganglion cyst at the posterior thigh. Diagnostic and Therapeutic Study 2013;2(3): Pavlicný R. Percutaneous release in the treatment of trigger digits]. [Article in Czech] Acta Chir Orthop Traumatol Cech. 2010;77(1): Dahabra IA, Sawaqed IS. Percutaneous trigger finger release with 18-gauge needle. Saudi Med J. 2007;28(7): Ragoowansi R, Acornley A, Khoo CT. Percutaneous trigger finger release: the 'lift-cut' technique. Br J Plast Surg. 2005;58(6): Gilberts EC, Beekman WH, Stevens HJ, Wereldsma JCProspective randomized trial of open versus percutaneous surgery for trigger digits. J Hand Surg Am. 2001;26(3): Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript. Source of support: Nil Article citation: Ahmet Aslan,Mehmet Nuri Konya,Serdar Sargın. Revision Surgery after percutaneous release of the A1 pulley for surgical treatment of trigger finger: An unusual case and brief review of literature. Journal of pharmaceutical and biomedical sciences (J Pharm Biomed Sci.) 2013 December 37(37): Available at Copyright 2013 Ahmet Aslan,Mehmet Nuri Konya,Serdar Sargın. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1963