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Current Management of Trigger Digit in RA Patients: A Survey of ASSH Members
Rebecca Bickham, MD, James Butterfield, Logan Carr, MD, Alexander Payatakes, MD.
Penn State Hershey Medical Center, Hershey, PA, USA.

BACKGROUND: Traditional teaching regarding rheumatoid arthritis (RA) patients with trigger digit symptoms held that A1 pulley release was to be avoided. Surgical release of the A1 pulley in these patients was thought to further destabilize the metacarpophalangeal joint predisposing patients to ulnar deviation and volar subluxation. Biologic disease modifying anti-rheumatic drugs (DMARDs) have significantly altered the natural course of RA and slowed the onset of debilitating hand deformities. Despite these advances in RA treatment, many recent textbooks continue to discourage release of the A1 pulley in RA patients. The aim of this study was to determine if this dogma is consistent with current trends in surgical treatment of trigger digits in patients with RA. METHODS: Members of the American Society for Surgery of the Hand (ASSH) were surveyed as to how they were trained in the treatment of RA patients and how their practice has changed since completion of their training. RESULTS: Five hundred three surveys were completed for a response rate of 13% of active ASSH members. Sixty-four percent have completed an orthopedic hand surgery fellowship. Fifty-eight percent report that their practice is almost exclusively (>95%) hand surgery. The majority work in a private group practice (54%). Approximately 60% of respondents have been in practice for more than 15 years. During training, 12% percent were taught never to release the A1 pulley in RA patients, whereas an additional 43% were taught to avoid releasing it. Only 12% have ever seen a patient develop ulnar deviation attributable to A1 pulley release. Seventy-one percent of respondents will release the A1 pulley in patients with RA if they have no pre-existing deformities, no tenosynovial thickening, or if previous tenosynovectomy and FDS slip excision were insufficient to relieve triggering. Forty percent report that their practice has evolved towards more frequent release of the A1 pulley in RA patients. CONCLUSIONS:
Most ASSH members were taught during training to avoid surgical release of the A1 pulley in RA patients to prevent acceleration of joint deformities. Indications and contraindications for A1 pulley release are evolving along with the improved natural history of RA associated with the use of biologic DMARDs.


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