Trigger finger is a common condition of the hand that affects up to 2.6% of the adult
population over the course of their lifetimes. This prevalence is even higher in patients
with diabetes affecting 5-20% of people. The condition is caused by the thickening of the
A1 pulley or flexor tendon that alters the way in which the flexor tendon glides within
the tendon sheath. While first-line therapy for this condition is conservative treatment
through activity modification, bracing, and corticosteroid injections, this fails a
reported 20-50% of the time. In cases in which conservative management failure occurs,
surgery is the next line of treatment. The purpose of this study is to evaluate the
efficacy of excision versus incision of the A1 pulley for the trigger finger. The
research team hypothesizes that excision of the A1 pulley would result in lower trigger
finger recurrence rates, better pain relief, reduced soreness & stiffness as well as
higher final PROMs.
Surgery can be performed either percutaneously or open. Rates of persistent triggering in
the percutaneous release group range from 7 to 9%. Additionally, even with open
procedures, there is some risk of persistent triggering or symptom recurrence. A study by
Everding et al. reported a recurrent triggering rate of 2.6% in their cohort of 795
patients who underwent open trigger finger release. A review of 209,634 patients who
underwent trigger digit release from the PearlDiver Database reported a revision rate of
0.4% at 1 year and 0.64% at 3 years. Finally, a retrospective study by Bruijnzeel et al.
demonstrated a 0.6% risk of persistent triggering and a 0.3% risk of recurrence in their
sample of 1,598 patients. Risk factors for revision include Dupuytren's disease,
rheumatoid arthritis, liver, disease, obesity, tobacco use, peripheral vascular disease,
diabetes mellitus, and age under 65 years. In cases of recurrence, the procedure can be
repeated to release any remaining portion of the A1 pulley, partial release of the A2, or
release of the ulnar slip of flexor digitorum superficialis. Two biomechanical studies
have demonstrated that the entire A1 pulley and up to 50% of the A2 pulley can be
released with minimal risk for bowstringing.
There have also been studies assessing the use of different incision types for open
procedures and their effects on scar formation. Kazmers et al. compared scar formation
from trigger finger release through a transverse skin incision versus a longitudinal
incision and found no difference in DASH scores, complication rates, or scar quality
metrics in the 61 patients studied. Additionally, a study comparing a transverse incision
at the distal palmar crease, a transverse incision 2-3 mm distal to the distal palmar
crease, and a longitudinal incision at the level of the A1 pulley demonstrated similar
results between the longitudinal incision and the incision 2-3 mm distal to the distal
palmar crease with no difference in scar volume as measured by ultrasound. There have
been no studies to date assessing the effect of complete A1 pulley resection in
comparison to longitudinal release of the A1 pulley. Theoretically, resection of the A1
pulley should reduce the rate of persistent triggering and recurrence and thus result in
superior patient outcomes; however, this has yet to be determined.