1 mm incision | Trigger digit | Hand Surgery | Dubai

ONE mm incision | Trigger Digits | Dubai | UAE

TD Trigger digit Hand Surgery Dubai UAE Dr. Jose Manuel Rojo-ManauteCarpal Tunnel Syndrome | Hand Surgery | Dubai | UAE | Dr. Jose Manuel Rojo-Manaute


“Ultra-MIS refers to those procedures performed thru a ONE millimeter skin incision”

Rojo-Manaute JM, J Ultrasound Med. 2013

Carpal Tunnel Syndrome | Hand Surgery | Dubai | UAE | Dr. Jose Manuel Rojo-Manaute

Dr. JOSE MANUEL ROJO- MANAUTE —— MD, PhD, FEBOT, EDHS/FESSH


Dr. Jose M. Rojo-Manaute MD, PhD, is a European Board Certified Orthopedic Surgeon (FEBOT) and a European Board Certified Hand Surgeon (EDHS/FESSH). He has proudly served patients since 1996



What is trigger digit?

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Stenosing tenosynovitis, commonly known as “trigger digit” (TD), “trigger finger” (or “trigger thumb”), involves the pulleys and tendons in the hand that bend the fingers. The tendons work like long ropes connecting the muscles of the forearm with the bones of the fingers and thumb. In the digits, the pulleys are a series of rings that form a tunnel through which the tendons must glide, much like the guides on a fishing rod through which the line (or tendon) must pass. These pulleys hold the tendons close against the bone (see Figure 1)1.

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Trigger digit | Hand Surgery | Dubai | UAE | Dr. Jose Manuel Rojo-Manaute

Trigger Digit | Jose Manuel Rojo Manaute, Hand Surgeon, Dubai-UAE (Image from the AAOS)

Figure 1: Normal anatomy flexor sheath showing pulley, tendon, and tenosynovium1.

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TD occurs when the pulley at the base of the finger (A1) becomes too thick and constricting around the tendon, making it hard for the tendon to move freely through the pulley. Sometimes the tendon develops a nodule (knot) or swelling of its lining. Because of the increased resistance to the gliding of the tendon through the pulley, one may feel pain, popping, or a catching feeling in the finger or thumb (see Figure 2). When the tendon catches, it produces irritation and more swelling of the pulley. This causes a vicious cycle of triggering and thickening of the pulley. Sometimes the finger becomes stuck or locked, and is hard to straighten or bend1.

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Trigger digit 2 | Hand Surgery | Dubai | UAE | Dr. Jose Manuel Rojo-Manaute

Trigger Digit | Jose Manuel Rojo Manaute, Hand Surgeon, Dubai-UAE (Image from the AAOS)

Figure 2: Abnormal anatomy showing tendon catching thick, tight pulley. Sometimes the tendon will be locally enlarged and thicker1.

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What conditions and diseases cause trigger digit?

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The cause of trigger digit is usually unknown. There are risk factors for developing it: TDs are more common in women than men, they occur most frequently in people who are between the ages of 40 and 60 years of age, they are more common in people with certain medical problems (e.g.: rheumatoid arthritis, gout, and diabetes) and they may occur after activities that strain the hand2.

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What are signs and symptoms of trigger digit?

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Trigger digit may start with discomfort felt at the base of the finger or thumb, where they join the palm. This area is often tender to local pressure. Symptoms may include: A tender lump in your palm, swelling, catching or popping sensation in your finger or thumb joints and pain when bending or straightening your finger. Stiffness and catching tend to be worse after inactivity, such as when you wake in the morning. Your fingers will often loosen up as you move them. In severe cases of TD, the finger cannot be straightened, even with help. Sometimes, one or more fingers are affected1,2.

Trigger digit can be classified into the following grades: Grade I (pretriggering), history of catching, but not demonstrable on physical examination; Grade II (active) Demonstrable catching, but the patient can actively extend the digit; Grade III (passive) Demonstrable catching requiring passive extension or inability to actively flex; Grade IV (contracture) catching with a fixed flexion contracture of the joint3.

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How is trigger digit diagnosed?

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Your doctor can diagnose the problem by talking with you and examining your hand and, for severe catching, it can be confirmed with a simple local anesthetic injection into the flexor sheath to unlock the digit. No other testing or x-rays are usually needed to diagnose TD2. When in doubt, thickening of the A1 pulley can also be identified on sonography as a thickening, with impingement of flexor tendon movement identified during active and passive movement4.

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Treatment of trigger digit

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The goal of treatment in TD is to eliminate the catching or locking and allow full movement of the finger or thumb without discomfort1.

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Nonsurgical Treatment

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Swelling around the flexor tendon and tendon sheath must be reduced to allow smooth gliding of the tendon. If symptoms are mild, the wearing of a splint, resting or taking over-the-counter pain medications (such as non-steroidal anti-inflammatory medicines or paracetamol) may be enough to resolve the problem 1,2.

Corticosteroid injections are widely accepted as the first choice for treating trigger digit and, at present, we indicate one injection prior to proceeding with surgery for grades I and II, with a high (61 to 84%) success rate3,5. Injections are less likely to provide permanent relief if you have had the triggering for a long time, or if you have an associated medical problem, like diabetes2. Splinting is also another alternative, but with lower success rates (55 to 66%)3,5.

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Surgical Treatment

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Trigger digit is not a dangerous condition. The decision to have surgery is a personal one, based on how severe your symptoms are and whether nonsurgical options have failed. I normally suggest proceeding directly with surgery to patients showing more than a grade II TD, because I believe that the symptoms are sufficiently annoying and the success rate of a second corticosteroid injection is low enough (around 20%) for the patient as to avoid more delays5. However, a second injection can also be indicated2. In addition, if your finger is stuck in a bent position, your doctor may recommend surgery to prevent permanent stiffness6.

Surgery is performed as an outpatient (you will not need to stay overnight at the hospital), usually with simple local anesthesia. The goal of surgery is to open the pulley at the base of the finger so that the tendon can glide more freely1,2. Active motion of the finger generally begins immediately after surgery. Normal use of the hand can usually be resumed once comfort permits.

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What is the risk/benefit for trigger digit Surgery?

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Surgery may be performed with four different techniques: Open, blind Percutaneous releases (e.g.: with a needle or a blade), Endoscopic and Ultra-Minimally Invasive Surgery. In all of them, the tendon sheath tunnel is cut. When it heals back together, the sheath is looser and the tendon has more room to move through it.

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Open TD Hand Surgery Dubai UAE Dr. Jose Manuel Rojo-Manaute

Trigger Digit, Classic Open Procedure | Jose Manuel Rojo Manaute, Hand Surgeon, UAE, Dubai (Image from ¨Your Hands, UK¨

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After surgery, most people are able to move their fingers immediately. It is common to have some soreness in your palm. Frequently raising your hand above your heart can help reduce swelling and pain2. As for the risks (theoretically for all the above mentioned techniques), some patients may feel tenderness, discomfort, and swelling about the area of their surgery longer than others. Recovery is usually complete within a few weeks, but it may take up to 6 months for all swelling and stiffness to go away. Occasionally, hand therapy is required after surgery to regain better use1. If your finger was quite stiff before surgery, physical therapy and finger exercises may help loosen it up, but sometimes some of this stiffness may remain if the finger was stuck in a bent position for a long time. The patient needs to know that complications may occur, including: Incomplete extension (due to persistent tightness of the tendon sheath beyond the part that was released); Persistent triggering (due to incomplete release of the first part of the sheath); Bowstringing (due to excessive release of the sheath); neurovascular damage and Infection2.

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What is there new for trigger digit surgery?: Ultra Minimally Invasive Surgery (Ultra-MIS).

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Trigger digit | Hand Surgery | Dubai | UAE | Dr. Jose Manuel Rojo-Manaute

Trigger Digit: Differences in the incision’s size between the one millimeter Ultra MIS (left) and the Classic/ traditional surgical procedure | Jose Manuel Rojo Manaute, Hand Surgeon, Dubai-UAE

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Even though the open classical incision (1 to 1.5 cm) is a simple procedure, follow-up series have documented poor results secondary to complications including complex regional pain syndrome, infection, stiffness, nerve injuries and dissatisfactions rates as high as 17% to 26%. As opposed to the open procedure, no major complications have been reported following a blind needle percutaneous release, with the exception to our knowledge of a case described in literature of a radial sensory deficit in a thumb and a case of persistent pain, however, the lack of a continuous intra-surgical visualization increases the difficulty for obtaining a complete release and puts at risk the surrounding anatomy at risk7. Recently, Rojo-Manaute and col. described in international scientific publications an ultra-minimally invasive procedure (or “Ultra-MIS”), with a very small incision (≤1 mm). This method has shown efficacy and safety. In his clinical report, Rojo-Manaute reported a 100% success rate with short mean times for recovery (patients need 1.9 days taking pain killers, 6.6 days for returning to normal activities, and 9.9 and 3.8 days for complete extension and flexion recovery, respectively). Radial digital nerve numbness developed in 1 finger, which disappeared by the third week. Two patients (with preoperative intense rigidity) had to follow different rehabilitation protocols for 6 months. All wounds were cosmetically excellent, and final satisfaction was excellent or good in 98%.

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Trigger Digit Surgery Video


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Summary for our patients concerned about a possible Trigger Digit

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Trigger digit is a frequent condition that occurs at the thumb and fingers due to tendon entrapment at a digit’s pulley (A1). It is normally felt as catching. Sometimes the finger becomes stuck. TD is not a dangerous condition. The decision to have surgery is a personal one, based on how severe your symptoms are, however, your doctor may recommend you surgery to prevent permanent stiffness if your finger is stuck in a bent position. One or two (maximum) corticosteroid injections are widely accepted as the first choice for treating Trigger digit. Splinting is also another alternative. Surgery is performed as an outpatient, usually with simple local anesthesia. The Ultra-MIS skin incision (≤1 mm) for TD have shown a quick functional and pain recovery, with a cosmetically excellent wound and final good or excellent satisfaction in most of our patients.

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REFERENCES:

  1. ASSH. Public Education Committee. Trigger Finger. In: American Society for Surgery of the Hand http://wwwasshorg/Public/HandConditions/Pages/TriggerFingeraspx; 2012.
  2. Orthoinfo. Trigger Finger. In: American Academy of Orthopaedic Surgeons http://orthoinfoaaosorg/topiccfm?topic=a00024; 2010.
  3. Wolfe SW. Tenosynovitis. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, eds. Green’s operative hand surgery. 5th ed. Philadelphia Churchill Livingstone; 2005 2137–54.
  4. Rajeswaran G, Lee JC, Eckersley R, Katsarma E, Healy JC. Ultrasound-guided percutaneous release of the annular pulley in trigger digit. Eur Radiol 2009;19:2232-7.
  5. Rojo-Manaute JM, Capa-Grasa A, Cerro-Gutierrez MD, Martinez MV, Chana-Rodriguez F, Vaquero Martín J. Sonographically guided intrasheath percutaneous release of the first annular pulley for trigger digits, part 2: randomized comparative study of the economic impact of 3 surgical models. J Ultrasound Med 2012;31:427-38.
  6. AAOS. American Academy of Orthopaedic Surgeons Clinical Guidelines on the Treatment of Carpal Tunnel Syndrome. Summary of Recommendations. http://www.aaos.org/news/aaosnow/oct08/clinical3.asp. 2014.
  7. Rojo-Manaute JM, Soto VL, De las Heras Sanchez-Heredero J, Del Valle-Soto M, Del Cerro-Gutierez M, Vaquero-Martin J. Percutaneous intrasheath ultrasonographically guided first annular pulley release: anatomic study of a new technique. J Ultrasound Med 2010;29:1517-29.

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FULL DETAILED DESCRIPTION OF THE TECHNIQUE CAN BE FOUND AT:

 

Rojo-Manaute JM, Soto VL, De las Heras Sanchez-Heredero J, Del Valle-Soto M, Del Cerro-Gutierez M, Vaquero-Martin J. Percutaneous intrasheath ultrasonographically guided first annular pulley release: anatomic study of a new technique. J Ultrasound Med 2010;29:1517-29.

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Trigger digit 1 Hand Surgery Dubai UAE Dr. Jose Manuel Rojo-Manaute

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Rojo Manaute JM, Rodríguez Maruri GE, Capa Grasa A, Chana Rodríguez F, Del Valle Soto M, Vaquero Martín J. Ultrasound assisted intrasheath percutaneous release of the A1 pulley for trigger digits. Part I: Clinical efficacy and safety. J Ultrasound Med. 2012; 31(3):417-24.

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Trigger digit 2 Hand Surgery Dubai UAE Dr. Jose Manuel Rojo-Manaute

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Rojo-Manaute JM, Capa-Grasa A, Cerro-Gutierrez MD, Martinez MV, Chana-Rodriguez F, Vaquero Martín J. Sonographically guided intrasheath percutaneous release of the first annular pulley for trigger digits, part 2: randomized comparative study of the economic impact of 3 surgical models. J Ultrasound Med 2012;31:427-38.

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Trigger digit 3 Hand Surgery Dubai UAE Dr. Jose Manuel Rojo-Manaute

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