Percutaneous intrasheath ultrasonographically guided first annular pulley release: anatomic study of a new technique.
OBJECTIVE
The purpose of this study was to define in volunteers a safe area for performing a percutaneous intrasheath first annular (A1) pulley release under ultrasonographic guidance in cadavers for the treatment of trigger fingers.


METHODS
First, in 100 fingers of 10 volunteers, we used Doppler ultrasonography to determine the limits of the sectors enclosing structures at risk (arteries and tendons). From the synovial sheath's most volar point, we determined the relative position of the arterial walls and the distance to the flexor tendons. A scatterplot overlay of the arterial positions was digitally analyzed for determining the limits of the safe area. Second, we released the A1 pulley in 46 fingers from 5 cadavers, directing the edge of the cutting device toward our safe area from an intrasheath instrument position. The precision, safety, and efficacy of the release were evaluated by surgical exposure of the A1 and A2 pulleys and the neurovascular bundles.


RESULTS
In our volunteers, we observed a volar safe area from +6.1° to +180°. Surgical precision was good in the cadavers, with no injuries to adjacent structures, a complete release in 44 fingers (95.7%), and an incomplete release of less than 1.6 mm in 2 fingers.


CONCLUSIONS
This study determined a safe volar area for aiming surgical instruments from an intrasheath position for percutaneous ultrasonographically guided A1 pulley release. The technique can be performed safely in all fingers, but we suggest being cautious in the thumb and converting the surgery to an open procedure if ultrasonographic visualization is not optimal.
Department of Orthopedic Surgery, Hospital Gregorio Marañón, Calle del Doctor Esquerdo 46, Madrid, Spain. k2rojo@yahoo.com
Jose Manuel
JM
Rojo-Manaute
Victor Lopez
VL
Soto
Julio
J
De las Heras Sánchez-Heredero
Miguel
M
Del Valle Soto
Miguel
M
Del Cerro-Gutiérez
Javier Vaquero
JV
Martín
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000704:Analysis of Variance; D002102:Cadaver; D005260:Female; D005385:Fingers / Q000033:anatomy & histology* / Q000000981:diagnostic imaging* / Q000601:surgery; D006801:Humans; D007091:Image Processing, Computer-Assisted; D008297:Male; D008875:Middle Aged; D016896:Treatment Outcome; D052582:Trigger Finger Disorder / Q000000981:diagnostic imaging / Q000601:surgery*; D018608:Ultrasonography, Doppler; D018084:Ultrasonography, Interventional