Scar-less Day Surgery for Trigger Digits
List of contents on this page
What is spring toe?
Spring Finger is a tendonitis of the flexor tendons of the fingers that causes a symptom called "spring phenomenon," in which the fingers become bent and do not extend, or extended and difficult to bend. Symptoms are especially intense and painful in the morning or at the beginning of movement. It is a common upper extremity surgical condition. It is mainly seen in middle-aged and elderly women and postpartum women, but is also seen in men.
Spring toe has a classification of progression: progression 1: stage of pain only, progression 2: finger hooks that return automatically, progression 3: finger hooks that do not return on their own, and progression 4: hooks that do not return or do not bend to the point of hooking.
Surgery is recommended at approximately the stage of progression 3 to 4. Compared to conventional surgery, the fingers can be used immediately after the surgery, so early surgery is considered an option for those who have been suffering from pain and difficulty using the fingers for a long time.
Why can surgery be performed without cutting?
The "no-cut" spring toe surgery is a minimally invasive procedure that uses echo to improve the condition by incising the targeted tissue using only a needle. By using echo, it is now possible to target tissues in the body that could not be done before without cutting.
Echo-guided minimally invasive surgery is still performed only in a few medical institutions in Japan and abroad. Although there are technical difficulties, the reality is that few orthopedic surgeries using echo as a guide have yet been introduced. Our clinic hopes to be of service to patients as a local clinic that can provide state-of-the-art treatment by physicians with clinical experience abroad.
The "no-cut" spring finger surgery is a unique technique developed at our clinic. As a pioneer clinic in Japan that introduced this technique early on, we have evolved the safety and certainty of the procedure by reducing the risk of leftover tendon sheath cuts and neurovascular injuries with a delicate and precise method that is not available at other clinics.
Minimally invasive day surgery with no incision, water available from the day of surgery
High-definition echocardiography (ultrasound) is used during the initial consultation to reliably diagnose the condition and determine whether surgery is indicated. Palpation alone does not reveal the degree of thickening of the tendon sheath or the state of tendon sliding, and may misdiagnose the evaluation of ganglion or adhesions. Preoperative diagnosis is very important for the success of non-surgical spring toe. For this reason, our clinic always performs an imaging evaluation with ultrasound at the initial visit.
The actual surgery is performed under echo-guided (ultrasound-guided) conditions, using an injection needle.Non-ablative spring surgery (echo-guided percutaneous flexor tendon sheath incision)The wound size is much smaller and the postoperative pain is less than that of the conventional method. The wounds are much smaller than those of the conventional method, and there is less postoperative pain. In both cases, stitches are not required,on the day ofWater is available.The following is a list of the most common problems with the
- Characteristics of non-surgical spring finger surgery
- day trip
- Less pain
- Leaves no scars
- Less bleeding.
- Low risk of infection
- You can take a bath from that day
- No need for postoperative disinfection visits
- Can be treated before it gets worse.
- Safe for monitoring by echo
- You can use your fingers from day one.
- Get back into sports faster.
Echo-guided, "no-cut" day surgery performed by hand surgeons
In the past, a 2 cm incision was made and the tendon sheath was removed under direct vision, requiring stitches to be removed and water work to be avoided for about a week.
At our clinic, a hand surgeon, a specialist in diseases of the upper limb, performs spring toe surgery percutaneously using only a needle under ultra-high definition echo-guided (ultrasound-guided) conditions. The only wound is the needle hole, so you can start working with water on the same day. The safety is also higher than before because the tendon sheath is securely incised using high-definition echo. Furthermore, postoperative pain can be significantly reduced compared to the conventional method.
Unfortunately, it is approximately0.1In about % of cases, the tendon sheath is too thick or the incision cannot be completed by needle alone.It is said that there are cases ofOur clinic has developed a proprietary method that reduces the probability of leftover tendon sheath cuts to almost 0%.I am doing it.
There are also cases in which minimally invasive surgery is difficult due to the presence of adhesions or ganglions, such as in cases of revision surgery. In such cases, an additional incision of about 1 cm is made to safely and reliably incise the tendon sheath.
Non-surgical spring finger surgery is a delicate procedure. It is important to have it performed by a hand surgeon as much as possible.
*Spring toe surgery that does not involve cutting isSelf-funded treatment (not covered by insurance)becomes
The "non-surgical" spring finger surgery is suitable for the following people
Most patients with spring toe are middle-aged or older and are in their prime socially. What about "non-surgical" spring toe surgery?Return to daily life immediately without having to miss work.Therefore, it is suitable for the following
(1) Those who have difficulty taking time off work* (can return to work early)
(2) Those who work with water, housewives (ready access to water)
(iii) Those who play sports that use their arms* (can move them earlier)
(4) Those who are sensitive to pain (scarring is less likely to be painful)
(5) Those who do not want to leave scars (no scarring)
(6) Those who wish to reduce the number of hospital visits (no need for stitches)
The probe used is a high-resolution 24 MHz high-frequency probe
In order to confirm the position and direction of the special scalpel used, the patient is not provided with the standard echo used in orthopedic surgery, but with a high-resolution echo manufactured by Canon, which is known for its image resolution and specializes in high-resolution imaging of the body surface area.24 MHz very high frequency probe*.(The higher the frequency, the higher the resolution, which is suitable for shallow images of the hand, etc.). (The higher the frequency, the better the echo is suited to rendering shallow images of the hand and other parts of the body, and the higher the resolution.) The images appear more delicate than normal echoes, making the surgery safer and more reliable.
* 24Mhz very high frequency probehas been introduced only at the university hospital level, and only a few medical institutions nationwide use the probe.
Standard resolution echo commonly used in orthopedics
Differences from "echo-free" non-surgical procedures
Surgery without cutting is actually1958It has been performed since 1949. However, because the tendon sheath was incised blindly without looking inside with an echo, the movement of the needle tip could not be confirmed, resulting in damage to nerves and tendons, and the procedure did not become widely used. At our clinic, we have solved this disadvantage by carefully incising the tendon sheath while checking the needle tip using ultra-high definition echo, and we are now able to provide patients with the advantage of minimally invasive surgery.
Comparison of spring toe by each surgical technique
| Normal incision. surgery to do | No echo." MINIMALLY INVASIVE SURGERY | Using echoes." MINIMALLY INVASIVE SURGERY |
|---|---|---|---|
Wound size | 2-3 cm | 1mm | 1mm |
pain | strong | few | few |
Skin and subcutaneous damage | ant | Almost never | Almost never |
safety (Less nerve/tendon damage) | ◯ | ✖️ | 'good work' (equiv. of silver star awarded to children at school) |
certainty (Less leftover/overcutting) | 'good work' (equiv. of silver star awarded to children at school) | ✖️ | 'good work' (equiv. of silver star awarded to children at school) |
Response to additional tendon sheath incision | Incision needs to be enlarged | Impossible to judge in the first place. | Possible from the same puncture site |
Bathing on the day of surgery | ✖️ | ◯ | ◯ |
Confirmation of tendon sheath sliding | under one's direct observation | impossible | sub-echo |
Preoperative, intraoperative, and postoperative tendonitis Pathological condition check of | ✖️ | ✖️ | 'good work' (equiv. of silver star awarded to children at school) |
Are there any disadvantages?
It was said that "no incision" spring finger surgery was less reliable than direct visualization. This is because percutaneous (no incision) spring finger surgery was usually performed in a way that did not look inside. Without an incision, it is feared that there is a possibility of damaging internal invisible tissues (nerves, blood vessels, etc.).
At our clinic, we have developed a reliable method of performing this procedure under echo-guidance. When we look inside with the echo, we can see the inserted needle, nerves, and blood vessels. It is now possible to cut the tendon sheath more safely than with an incision. Still, it is not the same as the 18 used in regular orthopedic surgery.MHzThe resolution was not sufficient with the probe of a "1" and in about 5% of cases, complete release of the tendon sheath could not be achieved. Therefore, our clinic, which incorporates orthopedic ultrasound diagnostic treatment24MhzThe 24Mhz ultra-high definition probe is only available at the university hospital level, and our clinic is one of the few institutions in Marugame City and Kagawa Prefecture that uses this probe. Our clinic is one of the few medical institutions in Marugame, and even in Kagawa Prefecture, that use this probe.
If there is an incision left over, an additional injection procedure can be performed to obtain complete liberation. Even in cases where additional injections are required, the introduction of high-definition echocardiography has largely eliminated them.
So far, we have not experienced any cases where incisionless surgery was not successful and incisions had to be made.100We believe that this is a safe treatment with less pain and scarring, with results comparable to surgery that involves incisions, although we cannot say that it is the best treatment.
Some people worry about the possibility of damaging tissues such as nerves and blood vessels, but in echo-guided surgery, both nerves and blood vessels are visible by echo, so it is unlikely that they will be damaged. In fact, the risk is considered to be higher with regular surgery, where the surgeon cannot see until he or she cuts and opens. At present, we have not experienced any cases of damage to nerves or blood vessels, so we would like to reassure our patients that they can receive treatment with confidence.
Also, if you have inflammation or adhesions to begin with, simply opening the tendon sheath will not immediately improve the inflammation or adhesions. It improves slowly, and the inflammation swelling, swelling, and pain may continue for some time. The presence of inflammation can be determined by echo before the surgery, and will be explained in detail during the consultation.
Finally, because any surgery or procedure is invasive to the body, there is a risk of complications. Specifically, there are the following risks: (1) allergies due to drugs; (2) complications due to swelling, bleeding, or hematoma; (3) infection; (4) nerve or blood vessel damage; (5) pain or resulting movement disorders; (6) thrombosis or embolism; (7) skin scars, keloids, or wound pain; (8) joint contracture or joint instability (when joints are manipulated); (9) other complications (CRPS) and other unforeseen complications (e.g., problems not only in the affected area but in other parts of the body as well). Since the future can be unpredictable, we will take the best possible measures (administration of drugs, additional surgical procedures, additional treatment, resuscitation, emergency medical care, etc.) depending on the situation. In case of emergency, we may perform the surgery without your consent, but we ask that you understand this before accepting the surgery.
Advantages of non-surgical Spring Finger Surgery
Downward risk | Advantages |
|---|---|
Hemorrhage/hematoma | Improved safety (protects nerves and blood vessels) |
infection | Less pain from anesthesia injections |
Swelling, edema | No need to wear a painful tourniquet |
Anesthesia solution volume | No need for disinfection visits |
drug allergy | No stitches required |
neurovascular injury | Leaves no scarring |
pain | Bathing is possible on the day of surgery |
CRPS | Short operating time |
No need to extend the incision when making additional A2 tendon sheath incisions |
For those with symptoms of inability to extend the second joint
If the spring finger is left untreated for a long period of time, the second joint becomes difficult to extend. This is especially likely to occur in the middle finger, but can also be seen occasionally in the ring and index fingers. If the tendon sheath is severely constricted and its gliding is restricted, synovitis may occur, and the tendon itself may become swollen and thickened, resulting in the tendon sheath of the third joint (Fig. 3).A1tendon sheath) as well as the tendon sheath in front of the second joint (A2(tendon sheath) because it also causes the tendon to slip. This condition is not well known, but in our clinic, where we observe a lot of echoes, we have come to understand the pathophysiology so that we can diagnose it before surgery. Many cases areA1As the tendon sheath is loosened, the synovitis gradually improves and the tendon swelling goes down,A2Although the snagging at the tendon sheath improves, some people have intractable tendon sheaths. In that case.A2The procedure loosens the tendon sheath by about half. However, if loosened too muchA2Bowstringing (lifting of the tendon in the tendon sheath) occurs and bending strength is reduced. As much as possibleA2but only for those with poor growth or refractory cases that have been neglected for quite a long time,A2We try to make a partial incision in the tendon sheath.
The method of spring toe without cutting isA2Also useful in procedures to loosen tendon sheaths, which usually require a wider incision to loosen.A2However, it can be done simply by advancing the needle tip to the back, so no additional incision is necessary. Also, even if you have a problem with a joint that does not extend after the surgery, you can do it later without making an incision.A2A procedure to loosen the tendon sheath is possible.
normal
Spring toe in which the second joint is not fully extended
A1Spring toe after tendon sheath incision
About tendonitis with preoperative inflammation
At our clinic, we always perform a preoperative ultrasoundMicrovascular blood flow assessment (SMI)to confirm the degree of "tendonitis". Tendonitis implies dilation of inflammatory blood vessels. Recently, this inflammatory vessels have beenmoyamoya vesselsand has been shown to cause prolonged pain.
Inflammation can occur in the following ways The tendon sheath becomes too narrow and the tendon or tendon sheath is scraped by rubbing as the tendon passes through it. To repair itimmunoreactionThis leads to vasodilatation of the nourishing blood vessels, which in turn leads to synovitis. Inflammation leads to edema and further swelling of the tendon sheath and tendon, creating a vicious cycle that makes it difficult for the tendon to pass through.
This inflammation gradually improves after surgery to open the tendon sheath, as friction is reduced, but in some cases the inflammation may persist and swelling of the finger may continue after surgery.
The clinic has reviewed past cases,(1) Chronic cases that are more than 6 months old, ,(2) Middle fingertendovaginitis, ,(iii) Before the surgery, the first2Joints not fully extended, ,(4) Inability to flex completely before surgeryInflammation tends to be prolonged when any one of the following is met (intractable tenosynovitis).
When prolonged inflammation (refractory tendonitis) occurs
If the tendon snagging has improved but the patient still experiences lingering tendonitis after surgery (refractory tendonitis), two options are available.
(i)steroid injection: Anti-inflammatory steroids are injected into the affected area. Caution should be exercised because of side effects such as tendon rupture, infection, and worsening of diabetes mellitus. If the disease recurs when the effect of steroids wears off, treatment (2) should be considered.
(2)Embolization of Abnormal Blood Vessels: This is a treatment that embolizes (packs) the inflamed blood vessels and eliminates the blood vessels altogether. It is highly effective, more durable than steroids, and safer than steroids because it does not cause tendon rupture, a side effect of steroids. This treatment is not covered by Japanese insurance and must be paid for by the patient.
Specifically, the arteries of the elbow and hand are injected with a chemical solution containing microparticles that have the property of embolizing only in the inflamed vessels, eliminating the inflamed vessels in the hand.
If the patient is diagnosed with high inflammation before surgery, the tendon is in poor condition and prolonged gliding problems can be expected. In our clinic, when prolonged inflammation is expected in this way, inflammatory vascular treatment is performed simultaneously with surgery(non-surgical spring surgery + inflammatory vascular treatment)to improve their performance.
To avoid prolonged inflammation
After a tenotomy, the tendon sheath is partiallyCeiling deficientI will do so. With the current echocardiographicTendon sheath regeneratesIt is known that it will be In order to regenerate1~ (after a number N)2About a monthBecause it takes a lot of time1~ (after a number N)2It is safe to avoid finger flexion and extension exercises for a month. Although non-surgical surgery has no scar, too much finger movement in the early postoperative period can lead to prolonged inflammation, as in intractable tendonitis.
About the cost of treatment
Surgery for non-surgical spring toe is not covered by insurance.Treatment costs are as follows
(1) Normal spring toe:
55,000 yen (excluding tax) per finger (60,500 yen including tax)
2 (ii)After the second run (only on the same side):14 for each additional bottle5,000Additional yen(Excluding tax) (Tax included) 49,500(Yen)
(Surgical fees include all anesthesia, costs, pre- and post-operative medications, surgical drugs, and surgical technique fees.)
Although we have introduced this treatment in order to reduce the pain and burden of surgery on patients, there are some aspects of treatment using advanced and sophisticated treatment equipment that are not fully covered by the current Japanese insurance system. We explain to our patients that they should choose this treatment with the understanding that the quality and content of the treatment can be limited by the current insurance coverage in Japan.
When patients are asked to choose whether to receive treatment covered by insurance or at their own expense, we explain the advantages and disadvantages of these treatments to them and let them make their own choice. We will then do our best to provide the treatment that the patient chooses. We believe that a relationship of trust with our patients is of utmost importance. We cannot provide treatment without mutual trust. Please feel free to contact us if you have any questions.
[On the cost of self-funded treatment.
Self-funded treatment not covered by insurance may not be covered by life insurance or accident insurance benefits. In addition, benefits from workers' compensation insurance, liability insurance, and various public subsidies are also not available.
However, since it is a medical expense, it is deductible.
Finally.
When providing treatment, we try to suggest treatments that patients would want to receive if they were their own family members.If you have any questions, please feel free to ask them during the consultation. We believe that it is important for you to be satisfied with your treatment so that you can undergo the surgery. We will provide you with thorough explanations as needed so that you can undergo the surgery with as little anxiety and peace of mind as possible.
Responsibility: Dr. Yuki Toya, Orthopedic Surgeon, Hand Surgery Specialist/Supervisor
日本語 
English 