A retrospective study comparing open and percutaneous trigger finger release in the Thai population

Saran Malisorn

doi:10.12688/f1000research.130915.1

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Research Article

A retrospective study comparing open and percutaneous trigger finger release in the Thai population

[version 1; peer review: 1 approved, 1 approved with reservations, 1 not approved]

Saran Malisorn

PUBLISHED 26 Jun 2023

Author details Author details

Department of Orthopedic, Faculty of Medicine, Naresuan University Hospital, Phitsanulok, Thailand

Saran Malisorn
Roles: Conceptualization, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

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Abstract

Background: Over the years, open surgery has been the primary treatment for trigger finger, a prevalent issue among hand illnesses. There has been some resistance to the technique's routine use, despite the fact that the percutaneous release of triggers provides a quicker recovery than surgery. As a result, the study proposed that the percutaneous release technique outperforms open surgery. The objective of this study was to compares the trigger finger surgery's open and percutaneous releases in terms of short-term results.
Methods: From 2014 to 2020, 166 patients who underwent open or percutaneous release surgery for the trigger finger at Naresuan University Hospital were the subjects of this retrospective analysis. For one, three, and six weeks, the initial characteristics and post-operative hemorrhage, digital nerve and artery injury, surgical site pain, inability to flex the finger, and other outcomes were compared. The visual analog scale (VAS) score and the impairments of the arm, shoulder, and hand (DASH) score were also compared between the two groups.
Results: The age, sex, and number of patients in both groups were statistically comparable. Before the procedure, there was no difference between the groups in terms of DASH and VAS scores for pain; however, at six weeks, the percutaneous release group showed a substantial difference and low VAS scores. There were no differences between the groups in terms of consequences, including wound pain, damage to digital nerves and arteries, and others.
Conclusion: Based on the patients' short-term outcomes, the study found that percutaneous release of the trigger finger is just as successful as traditional open surgery.

Keywords

Trigger fingers, open surgery, percutaneous release, DASH Score

Corresponding author: Saran Malisorn

Competing interests: No competing interests were disclosed.

Grant information: The author(s) declared that no grants were involved in supporting this work.

Copyright: © 2023 Malisorn S. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

How to cite: Malisorn S. A retrospective study comparing open and percutaneous trigger finger release in the Thai population [version 1; peer review: 1 approved, 1 approved with reservations, 1 not approved]. F1000Research 2023, 12:744 (https://doi.org/10.12688/f1000research.130915.1) First published: 26 Jun 2023, 12:744 (https://doi.org/10.12688/f1000research.130915.1) Latest published: 26 Jun 2023, 12:744 (https://doi.org/10.12688/f1000research.130915.1)

Introduction

Trigger finger, sometimes referred to as stenosing tenosynovitis, is a prevalent issue. Trigger finger is a common hand condition, characterized by the catching or locking of a finger in a bent position before it straightens out. This prevalence estimate is supported by several studies.¹^–⁴ It has been reported that trigger finger affects approximately 2% to 3% of the general population.¹^,²^,⁵ Daily tasks are hampered by the malformation, which causes pain, clicking, or a stumbling block when moving the fingers. Although the exact cause is uncertain, the inflammation and consequent constriction of the A1 pulley may be to blame for the flexor tendon’s reduced range of motion. An additional layer of a structure made up of chondroid metaplasia has been identified by a histological investigation, indicating that there are fibers forming on the tendon sheath’s surface.¹ Trigger fingers primarily affects adults in their 40s and 50s, and previous research indicates that women are approximately six times more likely than men to suffer from the condition.² Without treatment, the illness leads to significant long-term disability and ongoing pain. Consequently, the trigger finger needs to be treated by a doctor.

Depending on the stage, there are numerous ways to treat trigger fingers. Early-stage patients typically opt for conservative treatments such as night finger splints, physical therapy, painkillers, anti-inflammatory medicines, and steroid injections. Open or percutaneous surgery can be used to section the flexor tendon at the A1 pulley in more advanced stages.³ Open surgery has been used for a while and is up to 97% effective, but it can lead to post-operative pain, infection risk, longer recovery times for movements, nerve injury, and scarring.⁴^,⁶ Another well-liked alternative technique is the percutaneous release of the trigger finger, which has a success rate of 74 to 94%.⁷ Less stress and a quicker recovery are provided by the percutaneous approach, but there is also a risk of digital nerve and artery injury and incomplete surgery.⁸ In this regard, clinical research comparing the outcomes of various surgical procedures in patients is critical. It might aid the expert in selecting the best course of action.

Even while the results of open surgery and the percutaneous release approach have been previously reported after three months (short-term) and two years (long-term) of follow-up,⁵^,⁹ there are few studies that compared the results for patients in similar patient groups. This retrospective study compares the short-term outcomes of trigger finger percutaneous release vs routine open surgery with the expectation that the latter procedure will produce superior results.

Methods

Study design and population

The patients who underwent open surgery or percutaneous release of the trigger finger at Naresuan University Hospital between 2014 and 2020 were the participants of this retrospective cohort study. Adults over the age of 18 who scored between 2 and 5 on the modified Quinnel grading scale met the inclusion criteria.³ Patients with temporary trigger finger, prior steroid injection treatment, treatment received less than eight weeks prior to the study, surgery for the trigger finger, tendon injuries, fractures of the affected finger or palm, degenerative arthritis, finger gout, rheumatoid arthritis, connective tissue disease, and diabetes were all disqualified from participating in the study. Additionally, it was decided that patients with a history of allergies to non-steroidal anti-inflammatory medicines, stomach ulcers or gastrointestinal bleeding, asthma, chronic liver or biliary illness, and kidney disease were not acceptable. This study complied with the Declaration of Helsinki and was approved by the ethical committee of Naresuan University.

Sample size

As previously mentioned, the sample size was calculated by comparing the two independent proportions (two-tailed test).¹⁰ Kloeters et al. (2016) aimed to compare three different techniques of A1 pulley release in terms of scar tissue formation and postoperative rehabilitation.¹¹ The three techniques evaluated were open surgery, percutaneous release with a needle, and percutaneous release with a knife. Regarding the open surgery technique, the authors stated that open surgery was performed using a transverse incision over the A1 pulley in cases of severe contracture or a palpable nodule at the A1 pulley. In contrast, percutaneous techniques have been used in cases with a less severe degree of contracture.¹¹ The open surgery proportion (p=0.97) was taken into account from the previous study,¹¹ but the percutaneous release proportion (p2) was established at 0.84. The required sample size was 83 patients in each group, with a statistical power of 80% and an alpha-type error rate of 5%.

Surgical procedure

Both techniques for releasing the trigger finger were carried out in the hospital’s outpatient department while using conventional aseptic procedure. After identifying and marking the trigger location, 2 ml of 1% plain lidocaine hydrochloride was administered there to provide local anesthetic. When the flexor tendon at the A1 pulley was divided during open trigger finger release surgery, a 1 cm longitudinal incision was created. The release of triggering was then verified by stretching the finger. To stop infection, the wound was stitched and treated. The percutaneous release of the trigger digit was carried out as previously described on a different set of patients.¹² In order to allow blood vessels and nerves to fall laterally and bring the flexor tendon closer to the skin, the patient’s injured finger was stretched to its maximum extent. Then, at the A1 pulley, a perpendicular 18 gauze needle tip was introduced into the skin. To cut the tendon, the needle’s tip was positioned 5-8 mm from the predetermined border. The operation was finished when the grating feeling that was caused when the needle tip sliced through the transverse fibers vanished. Additionally, by passively moving the finger, the full release of the triggering was verified. The procedure was repeated, and gauze was applied to the wound when the triggering continued. After either surgical procedure, the patients were permitted to go home while receiving analgesics, antibiotics, and instructions on basic wound care. To evaluate the healing of the wound, postoperative pain, complications, recurrence, and the time required to return to daily activity, follow-up sessions were scheduled at 1, 3, and 6 weeks.

Data collection

The work involved gathering information from the patients’ medical records stored in the hospital computer system. The study was approved by the ethics committee of Naresuan University. The hospital provided consent after the study was approved by the ethics committee. The ethics committee waived the need for patient consent.

With consent from the hospital, information was gathered from the patients’ medical records and the hospital’s computer system. The results, including bleeding, injury to the digital nerve and artery, disability of the arm, shoulder, and hand (DASH) and visual analog scale (VAS) scores, were noted in the record book previously described.⁵

Statistical analysis

The terms frequency, proportion, mean, and standard deviation were used to describe descriptive data. The Chi-square test was used to evaluate categorical covariates, while the Mann-Whitney U test was used to compare the groups for continuous variables. Statistical significance was defined as a p-value 0.05. The analysis was conducted using SPSS version 17 (SPSS Inc., Chicago, IL, USA).

Results

The majority (72.23%) of the 166 patients in the research were female. The quantity, sex, and percutaneous release method of patients who underwent open surgery were not statistically significant. The age of the patients who underwent an open release for the trigger fingers was statistically comparable to that of those who underwent a percutaneous release. Patients over 60 years old made up a smaller portion of both categories, nevertheless. In contrast to the finger triggering grade and the affected digit in the study groups, the hand side associated with the trigger digit was substantially different (p=0.01) between the two patient groups (Table 1).

Table 1. Baseline characteristics of the patients.

Variable	Open release	Percutaneous release	p-value
Sex			0.72
Male	24 (28.92)	22 (26.51)
Female	59 (71.08)	61 (73.49)
Age			0.48
<60	58 (69.88)	62 (74.70)
>60	25 (30.12)	21 (25.30)
Hand side			<0.01
Left	11 (13.25)	42 (50.60)
Right	72 (86.75)	41 (49.40)
Grade			0.36
3	39 (46.99)	31 (37.35)
4	26 (31.33)	26 (31.33)
5	10 (12.05)	18 (21.69)
6	8 (9.64)	8 (9.64)
Affected digit			0.71
Index finger	18 (21.69)	24 (28.92)
Middle finger	30 (36.14)	29 (34.94)
Ring finger	28 (33.73)	23 (27.71)
little finger	7 (8.43)	7 (8.43)

The baseline VAS score for pain among the patients in open and percutaneous release groups was insignificant (6.79±1.26 and 7.03±1.54; p=0.27) as shown in Table 2. both groups had comparable DASH scores and triggering grades. However, when measured using the faces rating scale, a significant difference between the two groups’ levels of pain prior to surgery was discovered.

Table 2. Summary of findings before the open and percutaneous release of the trigger finger.

Variables	Before		p-value
Variables	Open release	Percutaneous release	p-value
VAS score	6.79±1.26	7.03 ±1.54	0.27
Faces pain scale score	3.04±0.81	3.40±0.88	<0.01
Grade			0.70
1	40 (48.19)	41 (49.40)
2	34 (40.96)	30 (36.14)
3	9 (10.84)	12 (14.46)
DASH score	31.02±8.45	31.80±10.24	0.59

The trigger finger was fully released in each patient in both groups. However, a digital nerve lesion was documented in one patient who underwent open surgery. It was discovered during the study’s follow-up visits at one, three, and six weeks that the proportion of patients who experienced bleeding in the first week varied significantly across the groups (30.12% vs. 3.61%). Similarly, the open surgery group’s DASH score at the third post-operative visit was considerably higher than the percutaneous release groups. After the three-week follow-up, there were considerably more patients who underwent open surgery (28.92%) than underwent percutaneous release (8.43%), but none at six-weeks. In addition, as indicated in Table 3, the VAS score and face pain scale score in open surgery patients at six weeks following therapy were both considerably greater than those who had the percutaneous release of the triggers. Figure 1 depicts a graphic comparison of the DASH scores between the two groups of patients at one, three, and six weeks after surgery and before surgery. Similar to Figure 1, Figure 2 shows the variation in pain (measured as a VAS score) between patients before and after trigger finger release surgery, both open and percutaneous.

Table 3. Summary of the findings after the open and percutaneous release of triggering finger at one, three, and six weeks.

Variables	One week		Three weeks		Six weeks
Variables	Open surgery	Percutaneous release	Open surgery	Percutaneous release	Open surgery	Percutaneous release
Grade 0	83 (100)	83 (100)	83 (100)	83 (100)	83 (100)	83 (100)
Bleeding	25 (30.12)*	3 (3.61)*	0 (0)	0 (0)	0 (0)	0 (0)
Digital nerve injury	1 (1.20)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
Digital artery injury	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)	0 (0)
DASH score	8.3±8.26	8.63±10.01	0.74±0.33*	0 (0)*	0 (0)	0 (0)
Pain in surgical wound	83 (100)	80 (96.39)	0 (0)	0 (0)	0 (0)	0 (0)
Inability to flex the finger	8 (9.64)	4 (4.82)	24 (28.92)*	7 (8.43)*	0 (0)	0 (0)
VAS score					1.02±0.68*	0.43±0.56*
Face pain scale score					0.48±0.50*	0.13±0.34*

* Significant <0.05.

Figure 1. The comparison of DASH scores before surgery, and post-surgery at 1, 3, and 6 weeks between the two groups.

Figure 2. The difference in pain (VAS score) before and after the open and percutaneous release of trigger finger surgery.

Discussion

The results of the traditional open and percutaneous trigger finger release surgeries were compared in this retrospective analysis. The matched patients in the two groups (in terms of sex, gender, and age) are the study’s main selling point. In the patients who underwent either procedure, there was no bleeding, impairment of the arm, shoulder, or hand, pain in the surgical site, or difficulty to flex the fingers at the six-week follow-up. All patients who underwent percutaneous release without any issues experienced a full release of the triggers. The study concludes that open surgery is still the most effective and safest option for treating trigger fingers.

Our discovery that females have higher levels of trigger finger confirms the findings of other investigations.¹³^,¹⁴ The study’s inclusion of 72.28% individuals under the age of 60 furthered the claim that the condition is prevalent in people between the ages of 40 and 60.¹³ The relationship between the trigger finger and age and sex has not yet been thoroughly established. In general, fingers that are used repeatedly are more likely to develop deformities. In the study, the middle and ring fingers were affected in about 66% of the participants. The dominant hand is typically afflicted with trigger finger, and in the study, the majority of patients (68.07%) were right-handed. Similar results have already been published.¹⁴^,¹⁵ Overall, 73.48% of the patients in the study showed stages 3 and 4 of triggering, which meant that the patients had irregular finger movement and sporadic finger locking but that these symptoms were actively correctable.

Patients in the open surgery and percutaneous surgery groups had insignificant baseline VAS scores for pain. However, the percutaneous release group had a significantly lower post- surgery VAS score and facial pain rating scale score when compared between the two groups at six weeks of follow-up. It suggests that open surgery was less beneficial in the patients studied than the percutaneous release approach. A prior study showing improved short-term satisfaction in patients who had percutaneous release of the trigger finger supports this conclusion.¹⁶^,¹⁷ The subjective aspect of pain measurement, which depends on the patient’s age, literacy, cognitive ability, and other factors, may be the rationale for a significant difference in baseline pain scores between the groups using the faces pain scale but not the VAS score. It should be noted that VAS and face rating scales are both appropriate for assessing immediate postoperative pain.¹⁸

The open and percutaneous release methods did not result in significantly different DASH scores at baseline or at one week after surgery, however at three weeks, the score was statistically different and primarily declined from one week. Additionally, both groups’ DASH ratings decreased from baseline to one-, three-, and six-weeks following surgery.

This supports past reports’ findings that the trigger finger treatment for the patients in the study had a high rate of success when using the two procedures.⁴^,⁷ In a brief period of time following the procedure, the percutaneous approach achieved 100% release of the finger without any problems. According to another study, there were no differences between the patients who received percutaneous release and open surgery in terms of pain in the surgical wound, digital nerve injury, or artery injury.⁷

The results of this investigation supported the notion that less invasive treatment options exist for trigger finger. The author is aware of the limitations of the current study after mentioning them. First, the study’s retrospective design may have contributed to bias. Second, a small amount of the outcome factors was measured quickly after the study ended. Thirdly, because the thumb has the highest risk of sustaining a digital nerve injury, individuals with trigger thumb were excluded from the study.¹⁹ Therefore, to maximize the impact of such research findings, a comparison between the trigger thumb and finger patients would be essential.

Conclusion

Based on the patients’ short-term outcomes, the study found that percutaneous release of the trigger finger is just as successful as traditional open surgery. This data may be useful in determining that the percutaneous procedure is the best option for getting better results quickly and at low risk.

Data availability

Underlying data

Figshare: formatdata_trigger10.08-2565 Percutaneous (2).xlsx. figshare. Dataset. https://doi.org/10.6084/m9.figshare.21829032.v1.²⁰

Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).

References

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2. Giugale JM, Fowler JR: Trigger Finger: Adult and Pediatric Treatment Strategies. Orthop. Clin. North Am. 2015 Oct; 46(4): 561–569. Publisher Full Text
3. Quinnell RC: Conservative management of trigger finger. Practitioner. 1980; 224(1340): 187–190. PubMed Abstract
4. Pavlicný R: Percutaneous release in the treatment of trigger digits. Acta Chir. Orthop. Traumatol. Cechoslov. 2010 Feb; 77(1): 46–51. PubMed Abstract
5. Ho SWL, Chia CY, Rajaratnam V: Characteristics and Clinical Outcomes of Open Surgery for Trigger Digits in Diabetes. J. Hand Microsurg. 2019 Aug; 11(2): 80–83. PubMed Abstract | Publisher Full Text
6. Moriya K, Uchiyama T, Kawaji Y: Comparison of the surgical outcomes for trigger finger and trigger thumb: preliminary results. Hand Surg. 2005 Jul; 10(1): 83–86. Publisher Full Text
7. Fiorini HJ, Tamaoki MJ, Lenza M, et al.: Surgery for trigger finger. Cochrane Database Syst. Rev. 2018 Feb 20; 2018. Publisher Full Text
8. Dierks U, Hoffmann R, Meek MF: Open versus percutaneous release of the A1-pulley for stenosing tendovaginitis: a prospective randomized trial. Tech. Hand Up. Extrem. Surg. 2008 Sep; 12(3): 183–187. Publisher Full Text
9. Cebesoy O, Kose KC, Baltaci ET, et al.: Percutaneous release of the trigger thumb: is it safe, cheap and effective?. Int. Orthop. 2007 Jun; 31(3): 345–349. PubMed Abstract | Publisher Full Text | Free Full Text
10. Bernard R: Fundamentals of Biostatistics. 5th ed.Duxbery: Thomson Learning; 2000.
11. Kloeters O, Ulrich DJO, Bloemsma G, et al.: Comparison of three different incision techniques in A1 pulleyrelease on scar tissue formation and postoperative rehabilitation. Arch. Orthop. Trauma Surg. 2016; 136: 731–737. Publisher Full Text
12. Uçar BY: Percutaneous Surgery: A Safe Procedure for Trigger Finger? N. Am. J. Med. Sci. 2012 Sep; 4(9): 401–403. Publisher Full Text
13. Brozovich N, Agrawal D, Reddy G: A Critical Appraisal of Adult Trigger Finger: Pathophysiology, Treatment, and Future Outlook. Plast. Reconstr. Surg. Glob. Open. 2019 Aug 8; 7(8): e2360. PubMed Abstract | Publisher Full Text | Free Full Text
14. Leung LTF, Hill M: Comparison of Different Dosages and Volumes of Triamcinolone in the Treatment of Stenosing Tenosynovitis: A Prospective, Blinded, Randomized Trial. Plast. Surg (Oakv). 2021 Nov; 29(4): 265–271. PubMed Abstract | Publisher Full Text | Free Full Text
15. Brown AM, Tanabe KL, DellaMaggiora RJ, et al.: Nonpalmar Endoscopic versus Open Trigger Finger Release: Results from a Prospective Trial. Plast. Reconstr. Surg. Glob. Open. 2022 Oct 7; 10(10). Publisher Full Text
16. Huang HK, Wang JP, Lin CJ, et al.: Short-term Versus Long-term Outcomes After Open or Percutaneous Release for Trigger Thumb. Orthopedics. 2017 Jan 1; 40(1): e131–e135. PubMed Abstract | Publisher Full Text
17. Giugale JM, Fowler JR: Trigger Finger: Adult and Pediatric Treatment Strategies. Orthop. Clin. North Am. 2015 Oct; 46(4): 561–569. Publisher Full Text
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20. Malisorn S: formatdata_trigger10.08-2565 Percutaneous (2).xlsx. [Dataset]. figshare. 2023. Publisher Full Text

Comments on this article Comments (0)

Version 1

VERSION 1 PUBLISHED 26 Jun 2023

Author details Author details

Department of Orthopedic, Faculty of Medicine, Naresuan University Hospital, Phitsanulok, Thailand

Saran Malisorn
Roles: Conceptualization, Investigation, Methodology, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing

Competing interests

No competing interests were disclosed.

Grant information

The author(s) declared that no grants were involved in supporting this work.

Article Versions (1)

version 1

Published: 26 Jun 2023, 12:744

https://doi.org/10.12688/f1000research.130915.1

© 2023 Malisorn S. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Malisorn S. A retrospective study comparing open and percutaneous trigger finger release in the Thai population [version 1; peer review: 1 approved, 1 approved with reservations, 1 not approved]. F1000Research 2023, 12:744 (https://doi.org/10.12688/f1000research.130915.1)

NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.

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ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions

Version 1

VERSION 1

PUBLISHED 26 Jun 2023

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Reviewer Report 12 Aug 2024

Mohamed Abdel-Wahed, Cairo University, Giza, Giza Governorate, Egypt; Orthopedic surgery department, Cairo University, Giza, Cairo Governorate, Egypt

Not Approved

https://doi.org/10.5256/f1000research.143712.r294082

The article is a comparative study between two methods for treatment of trigger finger. There is a good effort done for data collection, tabulation, and extraction of the results. There is some ambiguous points that should be cleared however:

1- There is more than one type for percutaneous release. the author used the needle percutaneous release. This should be mentioned cleary in the abstract section and also the title section

2- The author excluded the thumb from the study. this was mentioned only once at the end of the research. I prefer it to be mentioned in the abstract and in the methods section

3- The surgical procedure should be mentioned with more details. Antibiotic used? tourniquet used? sedation used? how did the surgeon noticed to ensure full release? who did the surgeries?? was this a single surgeon experience?

4- Again, the surgical procedure section: the landmark of skin incision for open release should be mentioned in an anatomic way.

5- Again, the surgical procedure section: I can't understand this phrase: ((To stop infection, the wound was stitched and treated))

6- Again, the surgical procedure section: The author mentioned: ((To cut the tendon, the needle’s tip was positioned 5-8 mm from the predetermined border))
are we going to cut the tendon??
and what is the predetermined border

7- In the results section: the author present data and percentages of both groups without referring which is group 1 and which is group 2

8- Again, the results section: ((After the three-week follow-up, there were considerably more patients who underwent open surgery (28.92%) than underwent percutaneous release (8.43%), but none at six-weeks))
This text is missing the comparative parameter and i had to refer to the table to get that the author was talking about inability to flex the finger. this should be mentioned in the text

9- Did the author noticed any tendon rupture with either procedures?

10- What was done for the case of digital nerve injury complicated in open release?

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Hand and upper limb surgery, Microsurgery, Congenital hand lesions, Trauma and Orthopedic surgery, Limb reconstruction and Orthoplastic surgeries

I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above.

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Author Response 16 Jan 2025

Saran Malisorn, Department of Orthopedic, Faculty of Medicine, Naresuan University Hospital, Phitsanulok, Thailand

16 Jan 2025

Author Response
1. There is more than one type for percutaneous release. The author used the needle percutaneous release. This should be mentioned clearly in the abstract section and the title section.
... Continue reading
1. There is more than one type for percutaneous release. The author used the needle percutaneous release. This should be mentioned clearly in the abstract section and the title section.
Response:
Thank you for this observation. We will revise the title and abstract to specify that the percutaneous release was performed using a needle technique.

Revised Title:
"A Retrospective Study Comparing Open and Needle Percutaneous Trigger Finger Release in the Thai Population."

Abstract Revision:
"The objective of this study was to compare the short-term outcomes of open surgery and needle percutaneous release for the treatment of trigger finger."

2. The author excluded the thumb from the study. This was mentioned only once at the end of the research. I prefer it to be mentioned in the abstract and the methods section.
Response:
We agree that this important exclusion should be highlighted.

Abstract Revision:
"Patients with trigger thumb were excluded from the study to focus on fingers with different anatomical and procedural considerations."

Methods Section Addition:
"Patients with trigger thumb were excluded due to the unique anatomy and higher risk of digital nerve injury associated with this condition."

3. The surgical procedure should be mentioned with more details: the antibiotic used, the tourniquet used, the sedation used, how the surgeon ensured full release, who performed the surgeries, and whether it was a single-surgeon experience.
Response:
We will expand the Surgical Procedure section to address these points.

Revision:
"Both procedures were performed under local anesthesia using 2 ml of 1% plain lidocaine hydrochloride. No sedation or tourniquet was used. Prophylactic antibiotics were not routinely administered. The release of the A1 pulley was verified intraoperatively by passively moving the finger to confirm the absence of triggering. All surgeries were performed by a single senior hand surgeon with extensive experience in both techniques to ensure consistency."

4. The landmark of skin incision for open release should be mentioned in an anatomic way.
Response:
We will clarify the anatomical landmarks for the incision in the Surgical Procedure section.

Revision:
"For the open release, a 1 cm longitudinal incision was made at the level of the distal palmar crease, directly over the A1 pulley. Care was taken to avoid injury to adjacent neurovascular structures."

5. The phrase ‘To stop infection, the wound was stitched and treated’ is unclear.
Response:
We will rephrase this sentence for clarity.

Revision:
"The wound was closed with interrupted sutures, and sterile dressing was applied to reduce the risk of infection."

6. The phrase ‘To cut the tendon, the needle’s tip was positioned 5-8 mm from the predetermined border’ needs clarification: Are we cutting the tendon? What is the predetermined border?
Response:
Thank you for highlighting this. The intention was to cut the A1 pulley, not the tendon.

Revision:
"To release the trigger, the needle’s tip was positioned 5-8 mm from the proximal edge of the A1 pulley. Care was taken to divide only the A1 pulley fibers without damaging the flexor tendon."

7. In the results section, the author presents data and percentages of both groups without referring to which is group 1 and which is group 2.
Response:
We will ensure that groups are clearly identified throughout the results section.

Revision:
"The proportion of patients who experienced bleeding was higher in the open surgery group (30.12%) compared to the percutaneous release group (3.61%)."

8. The results section mentions: ‘After the three-week follow-up, there were considerably more patients who underwent open surgery (28.92%) than underwent percutaneous release (8.43%), but none at six weeks.’ This text is unclear without mentioning the parameter (inability to flex the finger).
Response:
We will specify the parameter directly in the text.

Revision:
"After the three-week follow-up, the inability to flex the finger was reported in 28.92% of patients in the open surgery group compared to 8.43% in the percutaneous release group. By six weeks, no patients in either group experienced this complication."

9. Did the author notice any tendon rupture with either procedure?
Response:
No tendon ruptures were observed during the study. This will be explicitly mentioned in the results section.

10. What was done for the case of digital nerve injury complicated in open release?
Response:
The digital nerve injury was managed conservatively with close follow-up. This information will be added to the results section.
1. There is more than one type for percutaneous release. The author used the needle percutaneous release. This should be mentioned clearly in the abstract section and the title section.
Response:
Thank you for this observation. We will revise the title and abstract to specify that the percutaneous release was performed using a needle technique.

Revised Title:
"A Retrospective Study Comparing Open and Needle Percutaneous Trigger Finger Release in the Thai Population."

Abstract Revision:
"The objective of this study was to compare the short-term outcomes of open surgery and needle percutaneous release for the treatment of trigger finger."

2. The author excluded the thumb from the study. This was mentioned only once at the end of the research. I prefer it to be mentioned in the abstract and the methods section.
Response:
We agree that this important exclusion should be highlighted.

Abstract Revision:
"Patients with trigger thumb were excluded from the study to focus on fingers with different anatomical and procedural considerations."

Methods Section Addition:
"Patients with trigger thumb were excluded due to the unique anatomy and higher risk of digital nerve injury associated with this condition."

3. The surgical procedure should be mentioned with more details: the antibiotic used, the tourniquet used, the sedation used, how the surgeon ensured full release, who performed the surgeries, and whether it was a single-surgeon experience.
Response:
We will expand the Surgical Procedure section to address these points.

Revision:
"Both procedures were performed under local anesthesia using 2 ml of 1% plain lidocaine hydrochloride. No sedation or tourniquet was used. Prophylactic antibiotics were not routinely administered. The release of the A1 pulley was verified intraoperatively by passively moving the finger to confirm the absence of triggering. All surgeries were performed by a single senior hand surgeon with extensive experience in both techniques to ensure consistency."

4. The landmark of skin incision for open release should be mentioned in an anatomic way.
Response:
We will clarify the anatomical landmarks for the incision in the Surgical Procedure section.

Revision:
"For the open release, a 1 cm longitudinal incision was made at the level of the distal palmar crease, directly over the A1 pulley. Care was taken to avoid injury to adjacent neurovascular structures."

5. The phrase ‘To stop infection, the wound was stitched and treated’ is unclear.
Response:
We will rephrase this sentence for clarity.

Revision:
"The wound was closed with interrupted sutures, and sterile dressing was applied to reduce the risk of infection."

6. The phrase ‘To cut the tendon, the needle’s tip was positioned 5-8 mm from the predetermined border’ needs clarification: Are we cutting the tendon? What is the predetermined border?
Response:
Thank you for highlighting this. The intention was to cut the A1 pulley, not the tendon.

Revision:
"To release the trigger, the needle’s tip was positioned 5-8 mm from the proximal edge of the A1 pulley. Care was taken to divide only the A1 pulley fibers without damaging the flexor tendon."

7. In the results section, the author presents data and percentages of both groups without referring to which is group 1 and which is group 2.
Response:
We will ensure that groups are clearly identified throughout the results section.

Revision:
"The proportion of patients who experienced bleeding was higher in the open surgery group (30.12%) compared to the percutaneous release group (3.61%)."

8. The results section mentions: ‘After the three-week follow-up, there were considerably more patients who underwent open surgery (28.92%) than underwent percutaneous release (8.43%), but none at six weeks.’ This text is unclear without mentioning the parameter (inability to flex the finger).
Response:
We will specify the parameter directly in the text.

Revision:
"After the three-week follow-up, the inability to flex the finger was reported in 28.92% of patients in the open surgery group compared to 8.43% in the percutaneous release group. By six weeks, no patients in either group experienced this complication."

9. Did the author notice any tendon rupture with either procedure?
Response:
No tendon ruptures were observed during the study. This will be explicitly mentioned in the results section.

10. What was done for the case of digital nerve injury complicated in open release?
Response:
The digital nerve injury was managed conservatively with close follow-up. This information will be added to the results section.
Competing Interests: No competing interests were disclosed. Close
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COMMENTS ON THIS REPORT

Author Response 16 Jan 2025

Saran Malisorn, Department of Orthopedic, Faculty of Medicine, Naresuan University Hospital, Phitsanulok, Thailand

16 Jan 2025

Author Response
1. There is more than one type for percutaneous release. The author used the needle percutaneous release. This should be mentioned clearly in the abstract section and the title section.
... Continue reading
1. There is more than one type for percutaneous release. The author used the needle percutaneous release. This should be mentioned clearly in the abstract section and the title section.
Response:
Thank you for this observation. We will revise the title and abstract to specify that the percutaneous release was performed using a needle technique.

Revised Title:
"A Retrospective Study Comparing Open and Needle Percutaneous Trigger Finger Release in the Thai Population."

Abstract Revision:
"The objective of this study was to compare the short-term outcomes of open surgery and needle percutaneous release for the treatment of trigger finger."

2. The author excluded the thumb from the study. This was mentioned only once at the end of the research. I prefer it to be mentioned in the abstract and the methods section.
Response:
We agree that this important exclusion should be highlighted.

Abstract Revision:
"Patients with trigger thumb were excluded from the study to focus on fingers with different anatomical and procedural considerations."

Methods Section Addition:
"Patients with trigger thumb were excluded due to the unique anatomy and higher risk of digital nerve injury associated with this condition."

3. The surgical procedure should be mentioned with more details: the antibiotic used, the tourniquet used, the sedation used, how the surgeon ensured full release, who performed the surgeries, and whether it was a single-surgeon experience.
Response:
We will expand the Surgical Procedure section to address these points.

Revision:
"Both procedures were performed under local anesthesia using 2 ml of 1% plain lidocaine hydrochloride. No sedation or tourniquet was used. Prophylactic antibiotics were not routinely administered. The release of the A1 pulley was verified intraoperatively by passively moving the finger to confirm the absence of triggering. All surgeries were performed by a single senior hand surgeon with extensive experience in both techniques to ensure consistency."

4. The landmark of skin incision for open release should be mentioned in an anatomic way.
Response:
We will clarify the anatomical landmarks for the incision in the Surgical Procedure section.

Revision:
"For the open release, a 1 cm longitudinal incision was made at the level of the distal palmar crease, directly over the A1 pulley. Care was taken to avoid injury to adjacent neurovascular structures."

5. The phrase ‘To stop infection, the wound was stitched and treated’ is unclear.
Response:
We will rephrase this sentence for clarity.

Revision:
"The wound was closed with interrupted sutures, and sterile dressing was applied to reduce the risk of infection."

6. The phrase ‘To cut the tendon, the needle’s tip was positioned 5-8 mm from the predetermined border’ needs clarification: Are we cutting the tendon? What is the predetermined border?
Response:
Thank you for highlighting this. The intention was to cut the A1 pulley, not the tendon.

Revision:
"To release the trigger, the needle’s tip was positioned 5-8 mm from the proximal edge of the A1 pulley. Care was taken to divide only the A1 pulley fibers without damaging the flexor tendon."

7. In the results section, the author presents data and percentages of both groups without referring to which is group 1 and which is group 2.
Response:
We will ensure that groups are clearly identified throughout the results section.

Revision:
"The proportion of patients who experienced bleeding was higher in the open surgery group (30.12%) compared to the percutaneous release group (3.61%)."

8. The results section mentions: ‘After the three-week follow-up, there were considerably more patients who underwent open surgery (28.92%) than underwent percutaneous release (8.43%), but none at six weeks.’ This text is unclear without mentioning the parameter (inability to flex the finger).
Response:
We will specify the parameter directly in the text.

Revision:
"After the three-week follow-up, the inability to flex the finger was reported in 28.92% of patients in the open surgery group compared to 8.43% in the percutaneous release group. By six weeks, no patients in either group experienced this complication."

9. Did the author notice any tendon rupture with either procedure?
Response:
No tendon ruptures were observed during the study. This will be explicitly mentioned in the results section.

10. What was done for the case of digital nerve injury complicated in open release?
Response:
The digital nerve injury was managed conservatively with close follow-up. This information will be added to the results section.
1. There is more than one type for percutaneous release. The author used the needle percutaneous release. This should be mentioned clearly in the abstract section and the title section.
Response:
Thank you for this observation. We will revise the title and abstract to specify that the percutaneous release was performed using a needle technique.

Revised Title:
"A Retrospective Study Comparing Open and Needle Percutaneous Trigger Finger Release in the Thai Population."

Abstract Revision:
"The objective of this study was to compare the short-term outcomes of open surgery and needle percutaneous release for the treatment of trigger finger."

2. The author excluded the thumb from the study. This was mentioned only once at the end of the research. I prefer it to be mentioned in the abstract and the methods section.
Response:
We agree that this important exclusion should be highlighted.

Abstract Revision:
"Patients with trigger thumb were excluded from the study to focus on fingers with different anatomical and procedural considerations."

Methods Section Addition:
"Patients with trigger thumb were excluded due to the unique anatomy and higher risk of digital nerve injury associated with this condition."

3. The surgical procedure should be mentioned with more details: the antibiotic used, the tourniquet used, the sedation used, how the surgeon ensured full release, who performed the surgeries, and whether it was a single-surgeon experience.
Response:
We will expand the Surgical Procedure section to address these points.

Revision:
"Both procedures were performed under local anesthesia using 2 ml of 1% plain lidocaine hydrochloride. No sedation or tourniquet was used. Prophylactic antibiotics were not routinely administered. The release of the A1 pulley was verified intraoperatively by passively moving the finger to confirm the absence of triggering. All surgeries were performed by a single senior hand surgeon with extensive experience in both techniques to ensure consistency."

4. The landmark of skin incision for open release should be mentioned in an anatomic way.
Response:
We will clarify the anatomical landmarks for the incision in the Surgical Procedure section.

Revision:
"For the open release, a 1 cm longitudinal incision was made at the level of the distal palmar crease, directly over the A1 pulley. Care was taken to avoid injury to adjacent neurovascular structures."

5. The phrase ‘To stop infection, the wound was stitched and treated’ is unclear.
Response:
We will rephrase this sentence for clarity.

Revision:
"The wound was closed with interrupted sutures, and sterile dressing was applied to reduce the risk of infection."

6. The phrase ‘To cut the tendon, the needle’s tip was positioned 5-8 mm from the predetermined border’ needs clarification: Are we cutting the tendon? What is the predetermined border?
Response:
Thank you for highlighting this. The intention was to cut the A1 pulley, not the tendon.

Revision:
"To release the trigger, the needle’s tip was positioned 5-8 mm from the proximal edge of the A1 pulley. Care was taken to divide only the A1 pulley fibers without damaging the flexor tendon."

7. In the results section, the author presents data and percentages of both groups without referring to which is group 1 and which is group 2.
Response:
We will ensure that groups are clearly identified throughout the results section.

Revision:
"The proportion of patients who experienced bleeding was higher in the open surgery group (30.12%) compared to the percutaneous release group (3.61%)."

8. The results section mentions: ‘After the three-week follow-up, there were considerably more patients who underwent open surgery (28.92%) than underwent percutaneous release (8.43%), but none at six weeks.’ This text is unclear without mentioning the parameter (inability to flex the finger).
Response:
We will specify the parameter directly in the text.

Revision:
"After the three-week follow-up, the inability to flex the finger was reported in 28.92% of patients in the open surgery group compared to 8.43% in the percutaneous release group. By six weeks, no patients in either group experienced this complication."

9. Did the author notice any tendon rupture with either procedure?
Response:
No tendon ruptures were observed during the study. This will be explicitly mentioned in the results section.

10. What was done for the case of digital nerve injury complicated in open release?
Response:
The digital nerve injury was managed conservatively with close follow-up. This information will be added to the results section.
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 06 Aug 2024

Takafumi Hosokawa, Tone Chuo Hospital, Numasu-machi, Japan

Approved with Reservations

https://doi.org/10.5256/f1000research.143712.r310330

Reviewer comments:
・The authors retrospectively compared 83 percutaneous and 83 open surgeries for trigger fingers. The study topic is very interesting with the large number of patients.
・Although this study was defined retrospective, authors calculated the sample size, and 83 patients were studied in each of the percutaneous and open surgeries. How in the world did authors allocate these two groups? Is this not a prospective study with arbitrary selection?
・Methods: I would like a brief explanation of Quinnel grading.
・Sample size: I did not understand how to calculate the sample size.
・Surgical procedure: 18 gauge instead of 18 gauze?

・Discussion:
・The authors predicted in the introduction that open surgery would be superior, but there is no discussion of this prediction.
・In the Abstract, the authors state "the study found that percutaneous release of the trigger finger is just as successful as traditional open surgery. In the Discussion, the authors state "The study concludes that open surgery is still the most effective and safest option for treating trigger fingers. In the Conclusion, it is stated that "the percutaneous procedure is the best option for getting better results quickly and at low risk.” After all, I'm not sure what is the point.

・In Table 1, Grade 3,4,5,6 are correct?

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: hand surgery, distal radius fracture

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

CITE

Report a concern

Author Response 16 Jan 2025

Saran Malisorn, Department of Orthopedic, Faculty of Medicine, Naresuan University Hospital, Phitsanulok, Thailand

16 Jan 2025

Author Response

1. "Although this study was defined as retrospective, authors calculated the sample size, and 83 patients were studied in each of the percutaneous and open surgeries. How in the world ... Continue reading 1. "Although this study was defined as retrospective, authors calculated the sample size, and 83 patients were studied in each of the percutaneous and open surgeries. How in the world did authors allocate these two groups? Is this not a prospective study with arbitrary selection?"
Response: Thank you for your observation. This study is indeed a retrospective cohort analysis. The allocation to the groups was not prospective or arbitrary. Instead, the grouping was based on the surgical records retrieved from the hospital database during the specified period (2014–2020). Patients were categorized into the percutaneous or open surgery groups according to the procedure they underwent, as recorded in their medical history. The calculation of sample size was done retrospectively to ensure that the statistical power of the study would be sufficient to detect differences between the two groups. I will clarify this point in the Methods section.

2. "Methods: I would like a brief explanation of Quinnel grading."
Response: I appreciate this request and will include a brief explanation of the Quinnell grading system in the Methods section. Here is the proposed addition:
"The Quinnell grading system is used to classify the severity of trigger finger:
Grade 1: Pre-triggering, with pain or clicking but no locking. Grade 2: Active triggering, with locking that is actively correctable. Grade 3: Passive triggering, with locking that requires passive correction. Grade 4: Fixed deformity, with joint contractures. Grades 2–5 were included in this study to focus on moderate to severe cases requiring surgical intervention.

3. "Sample size: I did not understand how to calculate the sample size."
Response: Thank you for pointing this out. The sample size was calculated retrospectively using the formula for comparing two proportions in a two-tailed test. Based on a previous study (Kloeters et al., 2016), the success rate of open surgery was set at 97%, while the success rate for percutaneous release was set at 84%. Using a statistical power of 80% and an alpha error of 5%, the minimum required sample size was calculated as 83 patients per group. This calculation ensures adequate power to detect significant differences between the two techniques. We will include this explanation in the Sample Size section.

4. "Surgical procedure: 18 gauge instead of 18 gauze?"
Response: Thank you for catching this error. The correct term is "18-gauge needle," not "18 gauze." This will be corrected throughout the manuscript.

5. Discussion: "The authors predicted in the introduction that open surgery would be superior, but there is no discussion of this prediction."
Response: Thank you for highlighting this inconsistency. In the Discussion section, we will address the initial prediction and explain the results more clearly. Here is the proposed addition:
"In the Introduction, it was hypothesized that open surgery would be superior due to its established effectiveness and precision. However, the results demonstrated that percutaneous release achieved similar short-term outcomes with faster recovery times and comparable complication rates. This finding suggests that while open surgery remains a reliable and effective option, percutaneous release may be preferable for patients prioritizing quicker recovery and minimal invasiveness. Further studies comparing long-term outcomes are needed to refine these conclusions."

6. "In the Abstract, the authors state, 'the study found that percutaneous release of the trigger finger is just as successful as traditional open surgery.' In the Discussion, the authors state, 'The study concludes that open surgery is still the most effective and safest option for treating trigger fingers.' In the Conclusion, it is stated that 'the percutaneous procedure is the best option for getting better results quickly and at low risk.' After all, I'm not sure what is the point."
Response: Thank you for pointing out these inconsistencies. We will revise these sections for clarity and consistency. Here is the revised text:
Abstract: "The study found that percutaneous release of the trigger finger achieved similar short-term outcomes to traditional open surgery, with advantages in quicker recovery and comparable safety." Discussion: "While open surgery remains a reliable and effective option, percutaneous release may be preferred for its minimally invasive nature and faster recovery, especially for short-term outcomes." Conclusion: "Percutaneous release is a viable alternative to open surgery, offering comparable success with the advantage of faster recovery and lower invasiveness. However, the choice of procedure should be tailored to individual patient needs and long-term goals."
This ensures consistency across all sections.

7. "In Table 1, Grades 3, 4, 5, and 6 are correct?"
Response: Thank you for pointing this out. In Table 1, the grades refer to the severity of the triggering based on the Quinnell grading system. Grades 3, 4, 5, and 6 are typographical errors, and we will correct them to Grades 2, 3, 4, and 5. Additionally, I will verify all table data to ensure accuracy before resubmission.
1. "Although this study was defined as retrospective, authors calculated the sample size, and 83 patients were studied in each of the percutaneous and open surgeries. How in the world did authors allocate these two groups? Is this not a prospective study with arbitrary selection?"
Response: Thank you for your observation. This study is indeed a retrospective cohort analysis. The allocation to the groups was not prospective or arbitrary. Instead, the grouping was based on the surgical records retrieved from the hospital database during the specified period (2014–2020). Patients were categorized into the percutaneous or open surgery groups according to the procedure they underwent, as recorded in their medical history. The calculation of sample size was done retrospectively to ensure that the statistical power of the study would be sufficient to detect differences between the two groups. I will clarify this point in the Methods section.

2. "Methods: I would like a brief explanation of Quinnel grading."
Response: I appreciate this request and will include a brief explanation of the Quinnell grading system in the Methods section. Here is the proposed addition:
"The Quinnell grading system is used to classify the severity of trigger finger:
Grade 1: Pre-triggering, with pain or clicking but no locking. Grade 2: Active triggering, with locking that is actively correctable. Grade 3: Passive triggering, with locking that requires passive correction. Grade 4: Fixed deformity, with joint contractures. Grades 2–5 were included in this study to focus on moderate to severe cases requiring surgical intervention.

3. "Sample size: I did not understand how to calculate the sample size."
Response: Thank you for pointing this out. The sample size was calculated retrospectively using the formula for comparing two proportions in a two-tailed test. Based on a previous study (Kloeters et al., 2016), the success rate of open surgery was set at 97%, while the success rate for percutaneous release was set at 84%. Using a statistical power of 80% and an alpha error of 5%, the minimum required sample size was calculated as 83 patients per group. This calculation ensures adequate power to detect significant differences between the two techniques. We will include this explanation in the Sample Size section.

4. "Surgical procedure: 18 gauge instead of 18 gauze?"
Response: Thank you for catching this error. The correct term is "18-gauge needle," not "18 gauze." This will be corrected throughout the manuscript.

5. Discussion: "The authors predicted in the introduction that open surgery would be superior, but there is no discussion of this prediction."
Response: Thank you for highlighting this inconsistency. In the Discussion section, we will address the initial prediction and explain the results more clearly. Here is the proposed addition:
"In the Introduction, it was hypothesized that open surgery would be superior due to its established effectiveness and precision. However, the results demonstrated that percutaneous release achieved similar short-term outcomes with faster recovery times and comparable complication rates. This finding suggests that while open surgery remains a reliable and effective option, percutaneous release may be preferable for patients prioritizing quicker recovery and minimal invasiveness. Further studies comparing long-term outcomes are needed to refine these conclusions."

6. "In the Abstract, the authors state, 'the study found that percutaneous release of the trigger finger is just as successful as traditional open surgery.' In the Discussion, the authors state, 'The study concludes that open surgery is still the most effective and safest option for treating trigger fingers.' In the Conclusion, it is stated that 'the percutaneous procedure is the best option for getting better results quickly and at low risk.' After all, I'm not sure what is the point."
Response: Thank you for pointing out these inconsistencies. We will revise these sections for clarity and consistency. Here is the revised text:
Abstract: "The study found that percutaneous release of the trigger finger achieved similar short-term outcomes to traditional open surgery, with advantages in quicker recovery and comparable safety." Discussion: "While open surgery remains a reliable and effective option, percutaneous release may be preferred for its minimally invasive nature and faster recovery, especially for short-term outcomes." Conclusion: "Percutaneous release is a viable alternative to open surgery, offering comparable success with the advantage of faster recovery and lower invasiveness. However, the choice of procedure should be tailored to individual patient needs and long-term goals."
This ensures consistency across all sections.

7. "In Table 1, Grades 3, 4, 5, and 6 are correct?"
Response: Thank you for pointing this out. In Table 1, the grades refer to the severity of the triggering based on the Quinnell grading system. Grades 3, 4, 5, and 6 are typographical errors, and we will correct them to Grades 2, 3, 4, and 5. Additionally, I will verify all table data to ensure accuracy before resubmission.
Competing Interests: No competing interests were disclosed. Close
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Respond or Comment

COMMENTS ON THIS REPORT

Author Response 16 Jan 2025

Saran Malisorn, Department of Orthopedic, Faculty of Medicine, Naresuan University Hospital, Phitsanulok, Thailand

16 Jan 2025

Author Response

1. "Although this study was defined as retrospective, authors calculated the sample size, and 83 patients were studied in each of the percutaneous and open surgeries. How in the world ... Continue reading 1. "Although this study was defined as retrospective, authors calculated the sample size, and 83 patients were studied in each of the percutaneous and open surgeries. How in the world did authors allocate these two groups? Is this not a prospective study with arbitrary selection?"
Response: Thank you for your observation. This study is indeed a retrospective cohort analysis. The allocation to the groups was not prospective or arbitrary. Instead, the grouping was based on the surgical records retrieved from the hospital database during the specified period (2014–2020). Patients were categorized into the percutaneous or open surgery groups according to the procedure they underwent, as recorded in their medical history. The calculation of sample size was done retrospectively to ensure that the statistical power of the study would be sufficient to detect differences between the two groups. I will clarify this point in the Methods section.

2. "Methods: I would like a brief explanation of Quinnel grading."
Response: I appreciate this request and will include a brief explanation of the Quinnell grading system in the Methods section. Here is the proposed addition:
"The Quinnell grading system is used to classify the severity of trigger finger:
Grade 1: Pre-triggering, with pain or clicking but no locking. Grade 2: Active triggering, with locking that is actively correctable. Grade 3: Passive triggering, with locking that requires passive correction. Grade 4: Fixed deformity, with joint contractures. Grades 2–5 were included in this study to focus on moderate to severe cases requiring surgical intervention.

3. "Sample size: I did not understand how to calculate the sample size."
Response: Thank you for pointing this out. The sample size was calculated retrospectively using the formula for comparing two proportions in a two-tailed test. Based on a previous study (Kloeters et al., 2016), the success rate of open surgery was set at 97%, while the success rate for percutaneous release was set at 84%. Using a statistical power of 80% and an alpha error of 5%, the minimum required sample size was calculated as 83 patients per group. This calculation ensures adequate power to detect significant differences between the two techniques. We will include this explanation in the Sample Size section.

4. "Surgical procedure: 18 gauge instead of 18 gauze?"
Response: Thank you for catching this error. The correct term is "18-gauge needle," not "18 gauze." This will be corrected throughout the manuscript.

5. Discussion: "The authors predicted in the introduction that open surgery would be superior, but there is no discussion of this prediction."
Response: Thank you for highlighting this inconsistency. In the Discussion section, we will address the initial prediction and explain the results more clearly. Here is the proposed addition:
"In the Introduction, it was hypothesized that open surgery would be superior due to its established effectiveness and precision. However, the results demonstrated that percutaneous release achieved similar short-term outcomes with faster recovery times and comparable complication rates. This finding suggests that while open surgery remains a reliable and effective option, percutaneous release may be preferable for patients prioritizing quicker recovery and minimal invasiveness. Further studies comparing long-term outcomes are needed to refine these conclusions."

6. "In the Abstract, the authors state, 'the study found that percutaneous release of the trigger finger is just as successful as traditional open surgery.' In the Discussion, the authors state, 'The study concludes that open surgery is still the most effective and safest option for treating trigger fingers.' In the Conclusion, it is stated that 'the percutaneous procedure is the best option for getting better results quickly and at low risk.' After all, I'm not sure what is the point."
Response: Thank you for pointing out these inconsistencies. We will revise these sections for clarity and consistency. Here is the revised text:
Abstract: "The study found that percutaneous release of the trigger finger achieved similar short-term outcomes to traditional open surgery, with advantages in quicker recovery and comparable safety." Discussion: "While open surgery remains a reliable and effective option, percutaneous release may be preferred for its minimally invasive nature and faster recovery, especially for short-term outcomes." Conclusion: "Percutaneous release is a viable alternative to open surgery, offering comparable success with the advantage of faster recovery and lower invasiveness. However, the choice of procedure should be tailored to individual patient needs and long-term goals."
This ensures consistency across all sections.

7. "In Table 1, Grades 3, 4, 5, and 6 are correct?"
Response: Thank you for pointing this out. In Table 1, the grades refer to the severity of the triggering based on the Quinnell grading system. Grades 3, 4, 5, and 6 are typographical errors, and we will correct them to Grades 2, 3, 4, and 5. Additionally, I will verify all table data to ensure accuracy before resubmission.
1. "Although this study was defined as retrospective, authors calculated the sample size, and 83 patients were studied in each of the percutaneous and open surgeries. How in the world did authors allocate these two groups? Is this not a prospective study with arbitrary selection?"
Response: Thank you for your observation. This study is indeed a retrospective cohort analysis. The allocation to the groups was not prospective or arbitrary. Instead, the grouping was based on the surgical records retrieved from the hospital database during the specified period (2014–2020). Patients were categorized into the percutaneous or open surgery groups according to the procedure they underwent, as recorded in their medical history. The calculation of sample size was done retrospectively to ensure that the statistical power of the study would be sufficient to detect differences between the two groups. I will clarify this point in the Methods section.

2. "Methods: I would like a brief explanation of Quinnel grading."
Response: I appreciate this request and will include a brief explanation of the Quinnell grading system in the Methods section. Here is the proposed addition:
"The Quinnell grading system is used to classify the severity of trigger finger:
Grade 1: Pre-triggering, with pain or clicking but no locking. Grade 2: Active triggering, with locking that is actively correctable. Grade 3: Passive triggering, with locking that requires passive correction. Grade 4: Fixed deformity, with joint contractures. Grades 2–5 were included in this study to focus on moderate to severe cases requiring surgical intervention.

3. "Sample size: I did not understand how to calculate the sample size."
Response: Thank you for pointing this out. The sample size was calculated retrospectively using the formula for comparing two proportions in a two-tailed test. Based on a previous study (Kloeters et al., 2016), the success rate of open surgery was set at 97%, while the success rate for percutaneous release was set at 84%. Using a statistical power of 80% and an alpha error of 5%, the minimum required sample size was calculated as 83 patients per group. This calculation ensures adequate power to detect significant differences between the two techniques. We will include this explanation in the Sample Size section.

4. "Surgical procedure: 18 gauge instead of 18 gauze?"
Response: Thank you for catching this error. The correct term is "18-gauge needle," not "18 gauze." This will be corrected throughout the manuscript.

5. Discussion: "The authors predicted in the introduction that open surgery would be superior, but there is no discussion of this prediction."
Response: Thank you for highlighting this inconsistency. In the Discussion section, we will address the initial prediction and explain the results more clearly. Here is the proposed addition:
"In the Introduction, it was hypothesized that open surgery would be superior due to its established effectiveness and precision. However, the results demonstrated that percutaneous release achieved similar short-term outcomes with faster recovery times and comparable complication rates. This finding suggests that while open surgery remains a reliable and effective option, percutaneous release may be preferable for patients prioritizing quicker recovery and minimal invasiveness. Further studies comparing long-term outcomes are needed to refine these conclusions."

6. "In the Abstract, the authors state, 'the study found that percutaneous release of the trigger finger is just as successful as traditional open surgery.' In the Discussion, the authors state, 'The study concludes that open surgery is still the most effective and safest option for treating trigger fingers.' In the Conclusion, it is stated that 'the percutaneous procedure is the best option for getting better results quickly and at low risk.' After all, I'm not sure what is the point."
Response: Thank you for pointing out these inconsistencies. We will revise these sections for clarity and consistency. Here is the revised text:
Abstract: "The study found that percutaneous release of the trigger finger achieved similar short-term outcomes to traditional open surgery, with advantages in quicker recovery and comparable safety." Discussion: "While open surgery remains a reliable and effective option, percutaneous release may be preferred for its minimally invasive nature and faster recovery, especially for short-term outcomes." Conclusion: "Percutaneous release is a viable alternative to open surgery, offering comparable success with the advantage of faster recovery and lower invasiveness. However, the choice of procedure should be tailored to individual patient needs and long-term goals."
This ensures consistency across all sections.

7. "In Table 1, Grades 3, 4, 5, and 6 are correct?"
Response: Thank you for pointing this out. In Table 1, the grades refer to the severity of the triggering based on the Quinnell grading system. Grades 3, 4, 5, and 6 are typographical errors, and we will correct them to Grades 2, 3, 4, and 5. Additionally, I will verify all table data to ensure accuracy before resubmission.
Competing Interests: No competing interests were disclosed. Close
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Reviewer Report 25 Jul 2024

Grigorios Kastanis, Venizelio General Hospital of Heraklion, Heraklion, Greece

Approved

https://doi.org/10.5256/f1000research.143712.r305752

The article is a comparative study between two surgical techniques for the surgical treatment of trigger finger . The author thoroughly analyzes the two techniques and their results with a statistical study comparing them based on pain and functional recovery of the patients. In my opinion:
1. Author must refer the technique of subcutaneous release( Surgical Procedure line 6)
2. Author no refer which group presented with bleeding? because in section of Result line 13 presented statistic results?
3.There are manuscripts in the literature comparing subcutaneous release of A1 pulley with ultrasound guidance, could the author cite them in Section of Discussion comparing his results with those of other works.
After these corrections are made the article should be indexed.

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests: No competing interests were disclosed.

Reviewer Expertise: Hand, Wrist, Trauma, Geriatric, Foot

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

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Version 1

VERSION 1 PUBLISHED 26 Jun 2023

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Grigorios Kastanis, Venizelio General Hospital of Heraklion, Heraklion, Greece
Takafumi Hosokawa, Tone Chuo Hospital, Numasu-machi, Japan
Mohamed Abdel-Wahed, Cairo University, Giza, Egypt; Cairo University, Giza, Egypt

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Reviewer Report

9 Views

12 Aug 2024 | for Version 1

Mohamed Abdel-Wahed, Cairo University, Giza, Giza Governorate, Egypt; Orthopedic surgery department, Cairo University, Giza, Cairo Governorate, Egypt

9 Views Cite this report Responses(1)

Not Approved

Is the work clearly and accurately presented and does it cite the current literature?

Partly
Is the study design appropriate and is the work technically sound?

Partly
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Partly

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Hand and upper limb surgery, Microsurgery, Congenital hand lesions, Trauma and Orthopedic surgery, Limb reconstruction and Orthoplastic surgeries

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Author Response

16 Jan 2025

Saran Malisorn, Department of Orthopedic, Faculty of Medicine, Naresuan University Hospital, Phitsanulok, Thailand

1. There is more than one type for percutaneous release. The author used the needle percutaneous release. This should be mentioned clearly in the abstract section and the title section.
Response:
Thank you for this observation. We will revise the title and abstract to specify that the percutaneous release was performed using a needle technique.

Revised Title:
"A Retrospective Study Comparing Open and Needle Percutaneous Trigger Finger Release in the Thai Population."
Abstract Revision:
"The objective of this study was to compare the short-term outcomes of open surgery and needle percutaneous release for the treatment of trigger finger."

2. The author excluded the thumb from the study. This was mentioned only once at the end of the research. I prefer it to be mentioned in the abstract and the methods section.
Response:
We agree that this important exclusion should be highlighted.

Abstract Revision:
"Patients with trigger thumb were excluded from the study to focus on fingers with different anatomical and procedural considerations."
Methods Section Addition:
"Patients with trigger thumb were excluded due to the unique anatomy and higher risk of digital nerve injury associated with this condition."

3. The surgical procedure should be mentioned with more details: the antibiotic used, the tourniquet used, the sedation used, how the surgeon ensured full release, who performed the surgeries, and whether it was a single-surgeon experience.
Response:
We will expand the Surgical Procedure section to address these points.

Revision:
"Both procedures were performed under local anesthesia using 2 ml of 1% plain lidocaine hydrochloride. No sedation or tourniquet was used. Prophylactic antibiotics were not routinely administered. The release of the A1 pulley was verified intraoperatively by passively moving the finger to confirm the absence of triggering. All surgeries were performed by a single senior hand surgeon with extensive experience in both techniques to ensure consistency."

4. The landmark of skin incision for open release should be mentioned in an anatomic way.
Response:
We will clarify the anatomical landmarks for the incision in the Surgical Procedure section.

Revision:
"For the open release, a 1 cm longitudinal incision was made at the level of the distal palmar crease, directly over the A1 pulley. Care was taken to avoid injury to adjacent neurovascular structures."

5. The phrase ‘To stop infection, the wound was stitched and treated’ is unclear.
Response:
We will rephrase this sentence for clarity.

Revision:
"The wound was closed with interrupted sutures, and sterile dressing was applied to reduce the risk of infection."

6. The phrase ‘To cut the tendon, the needle’s tip was positioned 5-8 mm from the predetermined border’ needs clarification: Are we cutting the tendon? What is the predetermined border?
Response:
Thank you for highlighting this. The intention was to cut the A1 pulley, not the tendon.

Revision:
"To release the trigger, the needle’s tip was positioned 5-8 mm from the proximal edge of the A1 pulley. Care was taken to divide only the A1 pulley fibers without damaging the flexor tendon."

7. In the results section, the author presents data and percentages of both groups without referring to which is group 1 and which is group 2.
Response:
We will ensure that groups are clearly identified throughout the results section.

Revision:
"The proportion of patients who experienced bleeding was higher in the open surgery group (30.12%) compared to the percutaneous release group (3.61%)."

8. The results section mentions: ‘After the three-week follow-up, there were considerably more patients who underwent open surgery (28.92%) than underwent percutaneous release (8.43%), but none at six weeks.’ This text is unclear without mentioning the parameter (inability to flex the finger).
Response:
We will specify the parameter directly in the text.

Revision:
"After the three-week follow-up, the inability to flex the finger was reported in 28.92% of patients in the open surgery group compared to 8.43% in the percutaneous release group. By six weeks, no patients in either group experienced this complication."

9. Did the author notice any tendon rupture with either procedure?
Response:
No tendon ruptures were observed during the study. This will be explicitly mentioned in the results section.

10. What was done for the case of digital nerve injury complicated in open release?
Response:
The digital nerve injury was managed conservatively with close follow-up. This information will be added to the results section.

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No competing interests were disclosed.

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Reviewer Report

13 Views

06 Aug 2024 | for Version 1

Takafumi Hosokawa, Tone Chuo Hospital, Numasu-machi, Japan

13 Views Cite this report Responses(1)

Approved With Reservations

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

No
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

I cannot comment. A qualified statistician is required.
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

No

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

hand surgery, distal radius fracture

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Responses (1)

Author Response

16 Jan 2025

Saran Malisorn, Department of Orthopedic, Faculty of Medicine, Naresuan University Hospital, Phitsanulok, Thailand

1. "Although this study was defined as retrospective, authors calculated the sample size, and 83 patients were studied in each of the percutaneous and open surgeries. How in the world did authors allocate these two groups? Is this not a prospective study with arbitrary selection?"
Response: Thank you for your observation. This study is indeed a retrospective cohort analysis. The allocation to the groups was not prospective or arbitrary. Instead, the grouping was based on the surgical records retrieved from the hospital database during the specified period (2014–2020). Patients were categorized into the percutaneous or open surgery groups according to the procedure they underwent, as recorded in their medical history. The calculation of sample size was done retrospectively to ensure that the statistical power of the study would be sufficient to detect differences between the two groups. I will clarify this point in the Methods section.

2. "Methods: I would like a brief explanation of Quinnel grading."
Response: I appreciate this request and will include a brief explanation of the Quinnell grading system in the Methods section. Here is the proposed addition:
"The Quinnell grading system is used to classify the severity of trigger finger:
Grade 1: Pre-triggering, with pain or clicking but no locking. Grade 2: Active triggering, with locking that is actively correctable. Grade 3: Passive triggering, with locking that requires passive correction. Grade 4: Fixed deformity, with joint contractures. Grades 2–5 were included in this study to focus on moderate to severe cases requiring surgical intervention.

3. "Sample size: I did not understand how to calculate the sample size."
Response: Thank you for pointing this out. The sample size was calculated retrospectively using the formula for comparing two proportions in a two-tailed test. Based on a previous study (Kloeters et al., 2016), the success rate of open surgery was set at 97%, while the success rate for percutaneous release was set at 84%. Using a statistical power of 80% and an alpha error of 5%, the minimum required sample size was calculated as 83 patients per group. This calculation ensures adequate power to detect significant differences between the two techniques. We will include this explanation in the Sample Size section.

4. "Surgical procedure: 18 gauge instead of 18 gauze?"
Response: Thank you for catching this error. The correct term is "18-gauge needle," not "18 gauze." This will be corrected throughout the manuscript.

5. Discussion: "The authors predicted in the introduction that open surgery would be superior, but there is no discussion of this prediction."
Response: Thank you for highlighting this inconsistency. In the Discussion section, we will address the initial prediction and explain the results more clearly. Here is the proposed addition:
"In the Introduction, it was hypothesized that open surgery would be superior due to its established effectiveness and precision. However, the results demonstrated that percutaneous release achieved similar short-term outcomes with faster recovery times and comparable complication rates. This finding suggests that while open surgery remains a reliable and effective option, percutaneous release may be preferable for patients prioritizing quicker recovery and minimal invasiveness. Further studies comparing long-term outcomes are needed to refine these conclusions."

6. "In the Abstract, the authors state, 'the study found that percutaneous release of the trigger finger is just as successful as traditional open surgery.' In the Discussion, the authors state, 'The study concludes that open surgery is still the most effective and safest option for treating trigger fingers.' In the Conclusion, it is stated that 'the percutaneous procedure is the best option for getting better results quickly and at low risk.' After all, I'm not sure what is the point."
Response: Thank you for pointing out these inconsistencies. We will revise these sections for clarity and consistency. Here is the revised text:
Abstract: "The study found that percutaneous release of the trigger finger achieved similar short-term outcomes to traditional open surgery, with advantages in quicker recovery and comparable safety." Discussion: "While open surgery remains a reliable and effective option, percutaneous release may be preferred for its minimally invasive nature and faster recovery, especially for short-term outcomes." Conclusion: "Percutaneous release is a viable alternative to open surgery, offering comparable success with the advantage of faster recovery and lower invasiveness. However, the choice of procedure should be tailored to individual patient needs and long-term goals."
This ensures consistency across all sections.

7. "In Table 1, Grades 3, 4, 5, and 6 are correct?"
Response: Thank you for pointing this out. In Table 1, the grades refer to the severity of the triggering based on the Quinnell grading system. Grades 3, 4, 5, and 6 are typographical errors, and we will correct them to Grades 2, 3, 4, and 5. Additionally, I will verify all table data to ensure accuracy before resubmission.

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Competing Interests

No competing interests were disclosed.

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Reviewer Report

17 Views

25 Jul 2024 | for Version 1

Grigorios Kastanis, Venizelio General Hospital of Heraklion, Heraklion, Greece

17 Views Cite this report Responses(0)

Approved

Is the work clearly and accurately presented and does it cite the current literature?

Yes
Is the study design appropriate and is the work technically sound?

Yes
Are sufficient details of methods and analysis provided to allow replication by others?

Partly
If applicable, is the statistical analysis and its interpretation appropriate?

Yes
Are all the source data underlying the results available to ensure full reproducibility?

Yes
Are the conclusions drawn adequately supported by the results?

Yes

Competing Interests

No competing interests were disclosed.

Reviewer Expertise

Hand, Wrist, Trauma, Geriatric, Foot

I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.

Respond to this report

Responses (0)

Alongside their report, reviewers assign a status to the article:

Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested

Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.

Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions

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A retrospective study comparing open and percutaneous trigger finger release in the Thai population

Abstract

Keywords

Introduction

Methods

Study design and population

Sample size

Surgical procedure

Data collection

Statistical analysis

Results

Table 1. Baseline characteristics of the patients.

Table 2. Summary of findings before the open and percutaneous release of the trigger finger.

Table 3. Summary of the findings after the open and percutaneous release of triggering finger at one, three, and six weeks.

Figure 1. The comparison of DASH scores before surgery, and post-surgery at 1, 3, and 6 weeks between the two groups.

Figure 2. The difference in pain (VAS score) before and after the open and percutaneous release of trigger finger surgery.

Discussion

Conclusion

Data availability

Underlying data

References

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