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Re: Gulabi D, Cecen GS, Bekler HI, Saglam F and Tanju N. A study of 60 patients with percutaneous trigger finger releases: clinical and ultrasonographic findings. J Hand Surg Eur. 2014, 39: 699–703

We read with interest Gulabi et al.’s study investigating the safety of percutaneous trigger finger release and the role of ultrasound (USS) in the assessment of trigger finger. We were surprised at the author’s conclusion that stated ‘their study confirmed the efficacy and safety of percutaneous trigger release but no clinical advantage in using preor postoperative USS.’ Their conclusion is not supported by their results, which show that percutaneous trigger release is not safe in more severe forms of triggering (Grade 3 or 4) and trigger thumb. Six trigger thumb cases had incomplete release of the A1 pulley identified on USS and three trigger thumbs had nerve hypoaesthesia, which recovered. The nerve hypoaesthesia seen in the trigger thumb is most likely down to the difficulty in determining the position of the neurovascular bundles in the thumb in comparison to the fingers. Performing the trigger release not under direct visualization, such as in the standard approach, increases the risk of nerve injury. USS may have some clinical advantage in determining the thickness of the A1 pulley and possibly the severity of the triggering. Those with thicker pulleys would be more difficult to release percutaneously and one could hypothesize that there would be more chance of incomplete release, tendon laceration and possible laceration of the digital nerves. USS could thus determine which patients are better candidates for percutaneous release. The 13% tendon laceration is also a concern and there are no long-term assessments on these patients. The small sample size of the study does make one question the efficacy of percutaneous release when there is a 10% incomplete A1 pulley release in their series. We would also be interested if the authors had any data from this series demonstrating how quickly patients go back to work or normal activities, as this is not mentioned in their article. To truly convince the reader that percutaneous release offers a significant clinical advantage over standard open release, a well-designed randomized trial is needed with comparable groups at baseline. Furthermore, patient satisfaction in each group should be assessed. Although standard open release is not office based, it is much safer and reliable, as the entire A1 pulley can be visualized distally and proximally under Loupe magnification. Furthermore, adhesions between the flexor tendons can be released, this is particularly important in more severe triggering (Grades 3 and 4).