Frequently Asked Questions and Technical Tips:
Responses are provided by Dr. Dale Dellacqua as a result of his experience with the Advansor TF™. Dr. Dellacqua is a founding partner of Del Palma Orthopedics and designer of the Advansor TF.
Why perform trigger finger release procedures in the office setting?
The primary reason trigger finger release is performed in the office is to benefit the patient with convenience and point of service care. This is a patient centered care (PCC) approach. Secondarily, the procedure is more cost effective to the patient and provides greater reimbursement to the surgeon (Win-Win).
How is the procedure worked into a busy office schedule?
The mechanics of working the in-office release into a busy office should be addressed by the surgeons and their staff. Dr. Dellacqua’s approach is as follows: A patient with a known locking digit who calls for an appointment is given the first or last appointment of the morning or afternoon. They are asked to report to the office prior to the scheduled appointment and placed into a cast room for the procedure. A new patient who presents with a locking digit and who wants to have a release that day is anesthetized with 1% plain lidocaine during the office visit. The patient is then moved to a cast room by office staff and prepped for the procedure. Once the patient is ready for the release (blood pressure cuff on the arm, prepped with duraprep and good lighting available), I am called to the room for the release. The release takes approximately 5-7 minutes from start to the application of the ace wrap.
How is the patient positioned?
The patient is typically lying down with the arm fully extended on an arm table. The arm is rotated with the palm facing up and a rolled towel is placed under the hand.
How much local anesthetic is used?
~ 4 cc of lidocaine without epinephrine is in injected working from proximal to distal
Is special equipment needed to perform the procedure in the physician office?
It is helpful to have an exam table for the patient to lie down, an arm table to perform the procedure, a tourniquet and a focused light.
Is a tourniquet used for the procedure?
A tourniquet or blood pressure cuff is typically used on the forearm as it is generally more easily tolerated by the patient, however, the brachium can be used.
Where is the incision made?
The incision is made approximately 2-3 mm proximal to the metacarpophalangeal flexion crease to allow visualization of the proximal extent of the A1 pulley.
Is there any dissection necessary?
A curved hemostat is provided with a retractor. The hemostat is first used to spread transversely over the flexor tendon and then in a distal direction elevating the palmar skin/ palmar fascia as one unit separating them from the underlying pulley.
Is the Palmar Aponeurosis Pulley released?
It can be visualized with the above-described incision and is routinely released.
If a volar retinacular cyst is encountered, can it be cut through with the Advansor TF or should it be excised?
I have encountered retinacular cysts during the release of trigger finger and I treat them as I would open. If encountered and the origin of the cyst is ruptured, I complete the operation. If the cyst was not ruptured and is present on the cut leaf of the A-1 pulley, I excise it.
How do you prevent cutting into A2?
The surgeon’s hand that is holding the retractor will rest at the digital palmar flexion crease and will feel the tip of the Advansor TF as it exits the distal extent of the A1 pulley. This will indicate that you have reached the distal extent of A1 and you are starting to enter A2. The knife will stop short of the tip, so if the distal tip of the finder is at A2, you will not cut into A2 or beyond.
What is a standard patient experience post-operatively?
Patients have universally accepted the in-office approach. The concern I have for controlling their costs resonates with them.
The typical patient leaves the office comfortable and as such does not always appreciate that they just had an operation. This can be good and bad. They are started on immediate unrestricted motion in an ace wrap. The wrap is removed at 48 hours. The hand is then used without restriction. The small scab in the palm heals over 5-7 days. All patients experience palmar pain and some experience pain at the PIP joint for weeks to months. This resolves and seems to be related to the manipulation of the flexor tendon at the time of release. All patients receive a follow-up phone call at 48 hours post release to encourage motion and respond to questions. No additional follow-up is scheduled. Patients are told to call if they experience increased pain or loss of motion. A minority of patients do have difficulty with PIP extension. This usually responds to verbal encouragement at finger straightening. Patients with grade 3 locked digits or thick palms have required hand therapy on occasion.
Can this device be used for trigger thumb?
The use of this device is contra-indicated for the thumb. Development efforts are currently underway for a device specific for treating trigger thumb.
Technical Tips:
Blade Deployment
It is important to push the button for blade deployment in a longitudinal direction, not down, to allow the blade to travel smoothly down the monorail track.
Technique modification for the thickened palm
Visualization of the proximal extent of the A-1 pulley is essential prior to insertion of the device. In some patients the palmar fascia is intimately adherent to the skin. In the thickened palm or nodular type hand, the hemostat should be used to elevate the skin from the underlying fascia in line with the flexor tendon sheath. This allows the dissector to smoothly pass, completely releasing the A-1 pulley.