What is the step-by-step procedure for a trigger finger operation?

Trigger Finger Operation: Step-by-Step Surgical Procedure

The open surgical release of the A1 pulley is the gold standard treatment for trigger finger when conservative measures have failed, offering a 98-100% success rate with minimal recurrence risk compared to steroid injections.

Indications for Surgery

• Persistent triggering after failed conservative treatment (steroid injections)
• Severe triggering with locking of the digit
• Symptoms lasting more than 4 months
• Significant pain and functional limitation

Surgical Approaches

Two main surgical approaches are available:

1. Open Surgical Release (Gold Standard)
2. Percutaneous Release (Alternative minimally invasive option)

Open Surgical Release Procedure

Preoperative Preparation

• Obtain informed consent
• Mark the affected digit and A1 pulley location
• Position patient supine with hand on arm table
• Prepare and drape the hand using standard aseptic technique
• Apply local anesthesia (1-2% lidocaine with epinephrine)

Step-by-Step Surgical Technique

1. Incision

   • Make a 1-2 cm transverse or longitudinal incision over the A1 pulley at the level of the metacarpophalangeal joint crease
   • Transverse incisions in the distal palmar crease provide good cosmetic results 1

2. Exposure

   • Carefully dissect through subcutaneous tissue using blunt dissection
   • Identify and protect the digital neurovascular bundles (located on either side of the tendon)
   • Expose the A1 pulley (thickened fibrous tissue over the flexor tendon)

3. Release

   • Identify the proximal edge of the A1 pulley
   • Make a longitudinal incision through the entire A1 pulley using a scalpel or scissors
   • Confirm complete release by observing free tendon gliding without catching
   • Check for triggering by passively flexing and extending the digit

4. Closure

   • Achieve hemostasis
   • Close the skin with 4-0 or 5-0 non-absorbable sutures
   • Apply sterile dressing

Percutaneous Release Technique

This alternative technique uses an 18-21 gauge needle or specialized minimally invasive knife under ultrasound guidance 2, 3:

1. Identify the A1 pulley with palpation or ultrasound
2. Insert needle or specialized knife at the level of the A1 pulley
3. Position the bevel parallel to the longitudinal axis of the tendon
4. Use a sweeping motion to cut the A1 pulley
5. Confirm release with active finger movement

Postoperative Care

• Early active range of motion exercises immediately after surgery
• Suture removal at 10-14 days
• Gradual return to normal activities as tolerated
• Complete recovery typically within 2-4 weeks

Outcomes and Complications

Outcomes

• Success rate of 97-100% for open release 4
• Low recurrence rate (0-3%) compared to steroid injections (38.5%) 5

Potential Complications

• Digital nerve injury (rare with proper technique)
• Infection (uncommon)
• Incomplete release leading to persistent symptoms
• Bowstringing of the flexor tendon (rare)
• Scar tenderness

Special Considerations

• Diabetic patients may have higher recurrence rates
• Multiple digit involvement may require staged procedures
• Thumb trigger finger may require more extensive release due to the sesamoid bones

The open surgical approach remains the most reliable method for trigger finger release with excellent outcomes and minimal complications when performed correctly 5. Percutaneous techniques offer a less invasive alternative with comparable success rates in experienced hands 2, 6.