UTILITY OF ULTRASOUND IN HAND SURGERY PART II

General guidelines for ultrasound infiltration

Ultrasound-guided injections are performed in hand surgery practice. All the tendons, joints and many structures, can be identified by ultrasound. We can use ultrasound in a lot of pathologies such as trigger finger, De Quervain, Carpal tunnel syndrome …

The advantages of an ultrasound-guided infiltration are¹:

• Accurate needle placement and delivery of the drug into the joint or structure.
• Less uncomfortable for the patient.

The tips for an effective ultrasound-guided joint injections and tendon are¹:

• A full aseptic technique is required. You can use betadine gel instead of normal US-gel.
• Careful planning and positioning before needle insertion will make the procedure easier and safer.
• The needle path should be carefully chosen to avoid injury to vessels, nerves and tendons.
• Align your transducer along the chosen path. Angle your needle along the same path as the transducer.
• Anesthetizing the skin is optional.
• The depth of the joint will influence the angle of insertion of the needle and advance your needle slowly under ultrasound guidance.  Take your time to find the needle tip location.
• When the needle pierce the joint capsule, the patient may experience mild discomfort (a little amount of anesthetic can be injected to avoid pain).
• You can use an in-plane or out-of-plane approach.
• For an in-plane approach: the needle tip will lie along the line of the transducer allowing the whole needle track to be seen. This is the easier technique to learn.  
• The out-of-plane approach, where the needle is inserted at the side rather than at the end of the transducer. It is slightly more difficult to learn and perform but is useful in certain situations.

The surgeon must check in both planes, transverse and longitudinal, also called short and long axis, when performing an ultrasound infiltration, to be sure that the tip of the needle is in the right place.

• Once the needle tip is in a good position, the injected fluid should flow easily. Sometimes the needle is inside a tendon or against the bone. Just withdraw the needle slightly by 1 to 2 mm, recheck the position, and continue with the injection.
• For the hand, higher frequency transducer (12–18 MHz) or a small footprint hockeystick transducer is preferred. We recommend a 25G hypodermic needle for the smaller joints (wrist, hand), and a 28G hypodermic needle for the finger joints.

The technique is the same in procedures such trigger finger, De Quervain disease or Carpal tunnel syndrome. Only the anatomy will change but the procedure, as described above, will be similar.

Trigger finger

Trigger finger is a pathologic condition of the digital pulleys and flexor tendons. Lifetime occurrence rates of 2.6% in healthy individuals and 10% in diabetics². It affects women more than men (fifth and sixth decades)², involving the ring finger, middle finger, and thumb².

The diagnosis of trigger finger is based on the medical history and clinical findings: a transient blockage of the digit when it is flexed with subsequent painful snapping when it is extended. Trigger finger is typically due to thickening of the A1 pulley at the level of the metacarpophalangeal joint³. Thickening of the A1 pulley narrows the digital osseofibrous tunnel through which the flexor tendons run, impairing tendon gliding.

Clinically, this results in different stages of disease according to the classification of Green and Wolfe^3,6:

• Grade 1: they include local pain and a history of catching
• Grade 2: demonstrable catching with normal active extension
• Grade 3: demonstrable locking requiring passive extension
• Grade 4: fixed flexion deformity

Ultrasound (US) is a helpful guide for establishing the severity of the disease, identifying the underlying cause, and deciding the appropriate treatment options. These include conservative therapies, such as splinting, anti-inflammatory medications, ultrasound steroid injections, and ultrasound surgical pulley release^2,3,4,5.

Examination Technique, Normal US Appearance^2,3

For US examination, the dorsal surface of both hands resting on the exploration table. Fingers are kept in full extension.

The examination is best performed with high-resolution transducers working at 18 MHz and a large amount of coupling gel.

The annular pulleys can be visualized with US under healthy conditions:

• On transverse view or in the short axis, the central part of the annular pulleys appears as a fibrillar echoic structure that lies superficial to the flexor tendons. Their lateral bands are not perpendicular to the US beam and appear as hypoechoic bands at both tendon sides secondary to anisotropy.
• On longitudinal view or in the long axis, the annular pulleys appear as linear thickening of the flexor tendon sheath and often hypoechoic because of anisotropy.

Ultrasound Appearance of Trigger Finger^2,6

On US imaging, of trigger finger, there is a global or nodular hypoechoic thickening of the involved A1 pulley. It is best assessed on transverse scans in comparison with the normal pulley of the adjacent unaffected digit.

The US measured thickness of the A1 pulley has shown a strong correlation with that assessed intraoperatively.  A cutoff value of 0.62 mm has been recently described to discern the A1 pulley thickness of trigger digits from that of healthy digits in adults, regardless of age, sex, height, and body mass index^2,4.

Thickening of the A1 pulley is greater in patients with proximal interphalangeal joints contracture of the thumb or other fingers, as compared with patients without any contracture^2,4,6.

On Doppler imaging, hyperemia of the affected A1 pulley has been seen in 91% of cases⁶.

Secondary causes of trigger finger, such as an exostosis can be identified with US⁶.

The underlying flexor tendons often become swollen, and on a transverse scan, their cross-sectional area is rounder and thicker.  The superficial flexor tendon is first involved, as it impinges on the inferior aspect of the A1 pulley during finger flexion. Flexor tendon thickness under the A1 pulley depends on the severity of triggering. In the acute stages, synovial sheath effusion develops and is more evident proximal to the thickened pulley.

Technique of ultrasound percutaneous trigger finger release^2,4,5

We perform these procedures using a high-frequency transducer (18 MHz).

The patient was positioned supine with the hand placed flat on a table. A sterile working area is prepared and using a sterile probe cover and US gel or betadine gel. We use an extra gel heaped on the finger between the transducer and skin, to make it easier to locate the needle.

First, a local anesthetic is inserted with a 25-mm long, 25-gauge needle. The needle’s entry point is in the proximal third of the proximal phalanx and the needle is directed towards the distal part of the A1 pulley.

Two cubic centimeters of Lidocaine 1% adrenaline 1/100000 is injected along the needle’s path and into the synovial sheath of the flexor tendons.

Next, the base of a 50-mm long, 21-gauge needle is manually curved to a 140° angle so that its bevel faces laterally. This curvature had two effects: it places the needle in a completely horizontal position and made it possible to determine the bevel’s orientation even when it is fully inserted.

Once the 21-gauge needle was in the desired location, the surgeon slid it back and forth horizontally, parallel to the long axis of flexor tendons along the trajectory of the A1 pulley, several times. You can feel the typical slight resistance of the structure being cut (A1 pulley).

During the release, continuous US monitoring of the position of the needle is performed in the long axis, also checking the position of the needle in the short axis of the tendon. A centrally located needle, ensures that we are far away from the interdigital neurovascular bundle and that the release will be more effective.

Once these back-and-forth movements with the needle are completed, the needle is removed, and the patient asked to active flex and extend the treated finger. If the triggering has disappeared, the procedure is considered complete. If moderate triggering remains, the 21-gauge needle is reinserted and the back and forth movements repeated several times.

Performance of US-guided release in the thumb is technically more difficult than in the long fingers. A continuous monitoring in both, the short and the long axis will prevent any damage of the tendon or neurovascular structures.

After the procedure, a rest period of 8-10 hours may be advisable and avoiding weightlifting with that hand for several days to avoid pain and edema.

The results of ultrasound percutaneous trigger finger release has been shown: Rajeswaran⁷ with a follow-up of 6 months in 35 cases, show that the trigger finger was completely resolved in 91% (32 of 35) of cases and no complications were observed. Jou⁸ et al conducted a larger study (104 fingers) where a specially designed hook (2.5 mm), used during the US-guided release; patients were seen again 9 to 15 months later; the mechanical problem had resolved in 100% of cases and the pain had disappeared in 97% (101 of 104) of cases. Sometimes there is a persistence of isolated, nonspecific, nondisabling pain in 3% of fingers. Jou⁸ found the same in his study. 

De Quervain´s disease

De Quervain’s disease (DQd), is a common differential diagnosis within radial wrist pain. Ultrasound may help to confirm the clinical diagnosis ^9,10 the detection of anatomical variants and the presence of alterations that represent a prognostic factor in the evolution of the process.

Regarding treatment, the introduction of the ultrasound guide allows to increase the precision and efficiency of the infiltrations.

Choi¹¹ compared the result of the ultrasound study with the intraoperative findings, establishing a diagnostic sensitivity of 100%.

The diagnosis of Quervain’s disease is defined by the following US criteria ^12,13:

1. Hypoechoic thickening of the extensor retinaculum of the first extensor tunnel.

2. Increased Doppler signal.

3. Thickening of the tendons distal to the retinaculum (adductor pollicis longus and extensor pollicis brevis).

4. Peritendinous effusion.

5. Absence of findings suggestive of intersection syndrome, CTS or radiocarpal arthropathy.

Of all these findings, the thickness of the retinaculum is probably the most important one¹².

Recent studies determine that ultrasound has a sensitivity of 97.9% and a specificity of 91.6% to identify the presence of subcompartments^14,15,16. False positives have been identified in previously infiltrated patients where the crystallization of corticoid derivatives, can generate hypoechoic images in the tendon sheath that simulate septation¹⁴.

Volpe^16, proposed a differentiation into two types of De Quervain´s disease based on ultrasound findings:

Type I: thickening of the entire retinaculum that surrounds the APL and EPB.

Type II: selective thickening of the Retinaculum at the level of the EPB.

The only difference observed between groups was that in type I the patients were older, so we did not consider the utility classification as we can´t establish prognostic factors.

The treatment of De Quervain´s disease, includes conservative therapies, such as splinting, anti-inflammatory medications, ultrasound steroid injections, and surgery when these conservative treatment fails.

There is level I evidence that glucocorticoid infiltration associated or not with splint immobilization is superior to isolated immobilization, making it the recommended initial option for the treatment of DQd with resolution rates between 62% and 100%^17,18,19,20.

Cadaveric studies have shown an ultrasound-guided infiltration accuracy of 93.3% even in the presence of septa¹⁸. On the contrary, the technique based on anatomical references presents an overall precision of 40% and only 16.7% in wrists with sub-compartments^19,20.

McDermott¹⁹ describes symptomatic improvement at 6 weeks in 97% of cases and resolution (improvement of at least 80%) in 92% of cases. At the end of the follow-up, the mean score on the DASH and VAS scales was 18.39 and 2.2, respectively, with a recurrence of symptoms in only 14% 7. These results are slightly higher than the series of infiltrations without the use of ultrasound¹⁹.

A clinical trial carried out by Kume²⁰ demonstrates the superiority of ultrasound-guided infiltration to techniques based on anatomical landmarks in cases with intracompartmental septa.  

CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome (CTS) is the most frequently diagnosed nerve entrapment syndrome (3.8 cases for every 1000 individuals in the general population)^21,22,23.

It affects from 1 to 2/1000 men and 4 to 5/1000 women, being more frequent in patients between 40 and 60 years of age. ²¹ CTS occurs in 14% of diabetic who do not have polyneuropathy versus 30% of those with clinical polyneuropathy²³. The incidence of carpal tunnel syndrome during pregnancy varies from 7 to 62% according to the study, and in most of the cases it regresses after giving birth²³.

When medical treatment fails, or in severe cases, surgical treatment becomes a necessity.

Surgical intervention generally resolves the symptoms, or at least prevents further clinical deterioration and the development of a motor deficit.

Surgical treatment of the carpal tunnel is one of the most frequently performed procedures. The number of interventions to release the median nerve in the carpal tunnel has increased considerably since the early 1990s.

There are presently two main surgical techniques^24,25,26,27: open surgery (referred to as conventional or mini-open) and endoscopic treatment. While the rate of major complications is low irrespective of the surgical technique that is used, return to work times are shorter after endoscopic treatment than with open surgery²⁴.

In the past several years, ultrasound -guided release has assumed an increasingly prominent role in the treatment^25,26,27,28 and in the investigation of secondary etiologies,

The first applications of ultrasound surgery for carpal tunnel syndrome was described by Nakamichi, more than 30 years ago. Since then, several studies have highlighted the potential of an ultra-minimally invasive technique with ultrasound guidance to transect the flexor retinaculum^28,29,30.

Diagnosis of CTS

Carpal tunnel syndrome²² is diagnosed clinically.

An electromyogram (EMG) is a useful procedure, although it is not indispensable for the diagnosis²¹. A comparison of ultrasonography and EMG indicates that, depending on the study, they are largely identical in terms of sensitivity and specificity, although ultrasonography has the advantage of being a procedure that allows the anatomical structures and the nerve itself to be analyzed²¹. Ultrasonography is tolerated better, and it costs less than an electromyogram²¹.

On the other hand, ultrasonography does not allow for evaluation of the nature of the functional impact on the nerve (sensory or motor).

MacDonagh²⁵ recently highlighted a new role for ultrasonography in the diagnosis and treatment of the carpal canal. They investigated multiple ultrasound parameters, of which bulging of the FR, thickening of the retinaculum, and alteration of the echogenicity of the median nerve are deemed to be the most relevant²⁵.

The increase in the cross-sectional area of the median nerve at the level of the proximal carpal tunnel (scaphoid-pisiform plane) is the most conventional parameter, and it varies from 6.5 mm2 to 13 mm2 depending on the study²⁶. However, there is a lack of consensus regarding the limiting values to be assigned to it. More specific parameters have also been described, such as the difference or ratio of the cross-sectional area of the median nerve at the proximal carpal tunnel and the distal third of the forearm (at the pronator muscle). Klauser ²⁶ recently evaluated the relevance of these two measurements for predicting the severity of carpal tunnel syndrome in a population for whom the diagnosis had been confirmed clinically and by EMG.

However, the diversity of the ultrasonography criteria used in these studies limits the comparison, and the latest validated criteria that appear to be the most sensitive and specific have not yet been used.

Lastly, at the therapeutic level, interventional ultrasonography provides guidance for carpal tunnel injections that makes the procedure safer and avoids complications due to intraneural injection²⁵. The benefit of ultrasound guidance on the efficacy of injections has not been shown, however.

Ultrasonography has become a readily accessible low-cost procedure that is an immediate extension of the clinical examination. The carpal tunnel is studied using a lineal probe and allows for its visualization by sweeping the probe over the trajectory of the median nerve.

In an axial view^25,26,29, the nerve presents as an oval shaped fascicled structure; the nerve bundles are hypoechogenic regardless of the orientation of the ultrasound beam to the bundle. This helps with differentiation of the nerve from the tendons that surround it, with fibrillar structure alternating from hypo to hyperechogenic according to the orientation of the probe.

Inside the tunnel, one tip to find the median nerve is look for the flexor carpi radialis (FCR) tendon over the scaphoid and de flexor pollicis longus (FPL) tendon. The median nerve is always superficial and ulnar to the FPL and ulnar to the FCR.

In a longitudinal view^,25,26,29, the median nerve presents as hypoechogenic strips that run parallel to each other. Its diameter is constant or decreases slightly and progressively along its intracanal trajectory. The nerve runs between the flexor retinaculum (FR) and the superficial flexor tendons of the second and third digits. 

Several anatomical layers of the FR have been described. The more superficial layer is continuous with the antebrachial fascia and can be its reinforcement, while deeper layer is akin to a ligament (the transverse carpal ligament).

Surgical treatment

Surgical treatment²⁹ is based on fully opening the FR to decompress the nerve. However, selective transection of the deep layer may allow the mechanical functions of the FR to be preserved and the highly innervated layers to be spared.

Ultrasound surgery of the carpal tunnel

Technological advances have led to the use of ultrasound guidance to improve CTS treatment. Ultrasonographic determination of the relative position of the retinaculum with the neural and vascular structures in relation to the bony landmarks correlates well with the actual anatomy^{27,28,29,30,31,32,33,34,35,36,37,38,39}.

In 1997, Nakamichi²⁸ proposed making use of ultrasound guidance during the conventional surgical intervention. This first description was more an ultrasound assisted surgery than an ultrasound-guided surgery. Over time, several studies were able to demonstrate that it is possible to perform the whole procedure guided by ultrasound^{30,31,32,33,34,35,37,38}.

The location of a “safe-zone” between the median nerve and the ulnar artery for the transection, has been clearly demonstrated by Nakamichi²⁹.

Echographic localization of the target structures facilitates safe and efficacious resection of the FR. Recent anatomical and clinical studies suggest that complete release of the nerve is possible by transection of only the deep fibers of the FR without cutting the superficial fibers^29,36. The superficial layer is more richly innervated and sparing it by not transecting it, should allow local postoperative pain to be avoided.

The foremost justification for the development of this new technique is its minimally invasive nature. An open surgery or limited approach requires an opening of more than 4–5 cm, mini-open surgery involves an incision of 2 cm, and endoscopic treatment employs an opening of 1 to 2 cm³¹. Ultrasound surgery allows for an incision that is up to ten times smaller, ranging from 0.1 to 0.5 cm with continuous vision of the nerve and surrounding structures ^30,31,32.

Comparison of surgical procedures in terms of the size of the approach route indicates that, the smaller the incision the shorter the return time to work. Not surprisingly, the esthetic and functional consequences of the surgical scar are also more limited with a smaller incision^{31,32,33,34,35,37}.

Indeed, Jugovac³⁶observed that compared to a conventional open approach, a mini-open incision decreased the return to work time by half (i.e. 15 days versus 30 days). Ultrasound surgery therefore appears to combine a decrease in size of the incision with an excellent surgical field of view by continuous image-based guidance.

The surgical technique for ultra-minimally invasive ultrasound surgery can be performed as an outpatient procedure, and it can be done outside the operating theatre such as in an interventional radiology room or in an office, as previously reported.^{31,32,33,34,35,36,37,38,39,40,41.} We prefer to do this technique in the operating room.

We presented our technique in AAOS (Orlando 2016)³⁰ using a systematic approach useful for other ultrasound-guided surgeries.

The patient is placed lying down in a supine position, without a tourniquet, under strict antiseptic conditions³⁰.

We use a 25G and then a 21G needle, a V shaped curette of two sizes as well and an Acufex 3.0 mm hook knife with a retrograde blade (010600; Smith & Nephew PLC, London, England). We only perform a local anesthesia of the median nerve with lidocaine 1% adrenaline 1:100000³⁰.

First, an ultrasound is carried out so as to locate the safe zone between the ulnar artery and the median nerve as described by Nakamichi²⁸. The possibility of a variant of the thenar motor branch needs to be systematically checked with the ultrasound. Certain variants originating from the ulnar nerve or with a trajectory that perforates the retinaculum, are more at risk of iatrogenic lesion. The position of the vascular arch is also ascertained^29,30.

A first subcutaneous anesthetic is given at the proximal crease of the wrist, while a second deeper one with 10 cm3 of lidocaine 1% adrenaline 1/100000 allows for a hydrodissection of the carpal tunnel^30.

A small curette is used over the needle to penetrate the antebrachial fascia and later allow the hook blade to enter in the fascia and retinaculum. The hook blade must be placed under the junction of the antebrachial fascia and the retinaculum. The blade is steadily advanced under the FR with continuous ultrasound monitoring, with the blade facing to the ulnar artery, while taking care to avoid the median nerve and the origins of the sensory branches, as well as the Berrettini branch. The hook is advanced until 2-3 mm from the palmar arch, then turned vertical. A back and forth movement allows the tip of the hook-knive to perforate the fibers of the retinaculum. Then, the retinaculum is transected in a retrograde manner with continuous ultrasound monitoring. It has been shown that complete relief of carpal tunnel syndrome is not achieved until joint release of the transverse carpal ligament and the distal part of the deepest fibrous layer^{39,30,31,32,33,38}.

The full procedure can be carried out in 15 to 20 minutes,. A preventative compression bandage is applied, rest is recommended, and simple analgesics on request are recommended, although not systematically. The patient can return to home within an hour of the procedure. The compression bandage is removed 24-48 hours after the surgery. No sutures are needed at the end of the procedure³⁰.

Comparison of the techniques

Surgical advances have allowed for a progressive decrease in the size of the approach (conventional open surgery in the order of 5 cm, mini-open in the order of 2 cm, and endoscopy in the order of 1.5 cm). Percutaneous or ultrasound-guided surgeries allow for an approach that is 10 times smaller, in the order of 1 to 2 mm³².

Numerous studies comparing endoscopy with “open” surgery have shown that minor incisions allow for a reduction in complications and a faster recovery. Hamedcompared a double-incision technique (limited palmar and mini-open at the distal antebrachial crease) versus the conventional open method. They showed that there was a very significant reduction in postoperative pain such as pillar pain and scar sensitivity (48% versus 14.7% and 57.1 versus 21%, respectively) ^32,33,34.

The development of percutaneous ultrasound surgery, which involves a smaller incision, appears to allow for a faster recovery, and the care after the surgery is more straightforward.

Comparative studies are, however, rare and this technique is not used uniformly between teams.

Mc Shane³² performed a complete release of the carpal tunnel under ultrasound guidance with the bevel of a needle. This is the less invasive surgical approach described so far, as he only used the bevel of a needle, but the author termed it percutaneous.

Rojo^35,36,37,38 performed a similar procedure with the use of a hook-knive. After piercing the skin and superficial fascia with an abbocath, he inserted a retrograde hook-knive with a 3 mm section to make the transection of the ligament. However, the elasticity of the skin makes the final wound to be 1-2 mm. The entire procedure was done with ultrasound monitoring. Despite a larger incision than that of McShane³² he first used the term “ultra-minimally invasive surgery”. They also compared ultrasound-guided surgery, with a portal of 1 mm, to mini-open surgery with a portal of 20 mm in 129 patients^35,37. The functional score (QuickDash), the grip strength, the lack of paresthesia, and the resumption of everyday activities and at work were evaluated. The functional score improved significantly faster for the group that had undergone ultrasound surgery than for the one treated by mini-open surgery. It was therefore two times less severe after only 1 week (23.6 vs. 52.6), and 3.3 times less severe at six months after the intervention (4.9 vs. 13.0). On average, the resumption of daily activities occurred significantly earlier for the group treated by ultrasound surgery (after only 4.9 days versus 25.4 days on average after mini-open surgery) ^35,37,38.

Chern^39,40obtained satisfactory results in 91 patients with retrograde transection of the FR involving ultrasound guidance, although this was by a superficial approach above the retinaculum.

DUPUYTREN´S DISEASE

Palmar fibromatosis, also known as Dupuytren disease, is a benign fibroproliferative disorder in which subcutaneous fibrous nodules arise within the palmar fascia of the hand, eventually forming cordlike attachments with the adjacent flexor tendons^42,43,44,45. Progressive shortening of these cordlike attachments ultimately results in flexion contractures of the fingers.

Dupuytren contracture,  most commonly affect the fourth digit, followed by the third, fifth, second, and first digits in decreasing order of frequency. Affect  20% of people older than 65 years. It is associated with diabetes mellitus types 1 and 2, alcoholism, and epilepsy. Although an underlying genetic predisposition and a propensity for palmar fibromatosis to affect white people of Northern European descent is supported by twin and family studies, a multifactorial etiology is suggested by additional studies implicating trauma, microvascular injury, and immunologic processes^42,43,44_.

Ultrasound may be used to confirm palmar fibromatosis and for imaging‐guided treatment^46,47,48.

Ultrasound appearance of Dupuytren disease

On US, the lesions are typically located directly superficial to the flexor tendons (93%) with their epicenter in the region of the distal metacarpal (89%).  Dupuytren lesions are characteristically hypoechoic (98%) and noncompressible (95%). ⁴⁶

Sometimes we can find atypical features: intralesional calcification (2%), compressibility (5%), and hyperemia on color Doppler images (6%)⁴⁶.

Also, we can find lesions more distally than what was typical, in the region of the metacarpophalangeal joint and the proximal phalanx. Less frequent the lesions can be located superficial but lateral to the flexor tendons, rather than directly superficial to them⁴⁶.

Several benign and malignant lesions in the hand may simulate palmar fibromatosis: epithelioid sarcomas, giant cell tumors of the tendon sheath, ganglion cysts, inclusion cysts, stenosing tenosynovitis without triggering, edematous changes of the hand, and thickening and callus formation related to occupational activity⁴⁴. Familiarity with the imaging features of palmar fibromatosis can aid in distinguishing this disease from these entities.

Ultrasound guidance is used for collagenase injection therapy or surgical procedures to avoid complications of tendons and neurovascular structures⁴⁸.

During the past 10 years, the complications and long-term postoperative recovery associated with Limited Fasciectomy (LF) have led to the use of minimally invasive techniques, including collagenase injections and percutaneous needle aponeurotomy (PNA) ^{46,47,48,49,50,51,52,53}.

A systematic review of the literature demonstrates an overall complication rate below 4% with Percutaneous needle aponeurotomy (PNA). The most common complication is skin tears, which may occur in 4% to 16% of cases, with tendon damage or complex regional pain syndrome being exceptional. Complication rate may be lower in non-advanced forms and when the surgeons are expert in the technique^{49,50,51,52,53,54,55,56,57,58,59,60}.

Most authors do not use ultrasound due to the cord must be palpable as a pre-requisite before blind techniques are applied. Joint contracture is considered a relative limitation for needle aponeurotomy, as it is the presence of a palpable cord^49,50,51,60.

We have recently described the technique and results of ultrasound-guided aponeurotomy (USGA) and interphalangeal capsule release in patients with Dupuytren’s disease^47,48. Ultrasound allows direct visualization of the cords and control of the flexor tendons and neurovascular bundle. Even in cases with interphalangeal joint contracture we can release the capsule while preserving these structures.

Surgical procedure of Dupuytren disease^47,48

The instrument set included a series of needles (22G, 21G, 18G, and 16G), a V-shaped straight curette, a blunt dissector, and an ultrasound device with a 10- to 17-Mhz linear transducer. Hockey stick may be recommended for contractures over 80º, as normal lineal probes may be difficult to adapt. The patient is placed in the supine position with the hand resting on an arm board and facing upward. It is not necessary to apply a tourniquet. We do not use a malleable hand retractor, since we perform the procedure with two surgeons, as with the other ultrasound-guided procedures we perform^47,48.

The cords are palpated and then identified with the probe in both the transverse plane and the longitudinal plane. We mark the tract of the cord and select several entry points, from proximal to distal, between the metacarpal zone and the interphalangeal zone. Skin areas without severe retraction are preferred.

The portals are chosen on the ulnar side of the ray with the probe over the cord. 

The tendons, nerves, and vessels are always under direct control of the surgeons.

The needle and the syringe loaded with anesthetic (lidocaine 1% adrenaline 1/100000) are used as a scalpel.  First in the selected portal we insert a little of anesthetic close to the cord.

With the probe in the transverse plane, we insert the needle under direct visualization from a lateral (ulnar) entry point, rather than making multiple and blind perpendicular punctures as is the case in non–ultrasound-guided aponeurotomy.  We make several portals starting proximal and moving distal, towards the fingers.

The movement of the needle is monitored. The procedure can be performed with needles of different thicknesses. The needle is inserted from ulnar to radial at the point selected, with the transducer in the same plane as the needle along the short axis or the axis that is transverse to the cords. Multiple perforations are made from ulnar to radial and from deep to superficial at all selected points until the cord is released.

Reducing the tension of the cords at several points minimizes skin complications when the fingers are extended. The depth of the needle and its position with respect to arteries and nerves can be controlled using ultrasound in two planes.

Skin retractions into the subcutaneous tissue are released by severing the diseased fibers that insert into the dermis by moving the needle or the curette following a horizontal windshield wiper motion in the plane just below the skin.

After a first phase of multiple horizontal perforations from ulnar to radial, we start making a levering movement from deep to superficial, and the sharp bevel of this needle cuts the cord like a knife. It is very important to maintain the position of the needle and the probe and the cord under tension in the same plane while making the perforations, because if the tension is released, the plane the needle was originally in will be lost, possibly rendering the aponeurotomy more difficult⁴⁶.

Interphalangeal contracture is a problematic issue with blind surgery. Ultrasound-guided surgery enables the contracture to be released with direct control of the nerves and vessels, by staying immediately beneath them. For this surgical gesture, we prefer 22 G and 18 G needles^46,60.

When we feel that the cord is sufficiently loose at several points or if we can pass the needle through it, we extend the finger and break the cord. The surgeon can feel the release of the cord like a snap. We complete the proximal cuts by flexing the fingers and extending the metacarpophalangeal joint, thus reducing skin tension. We complete the distal cuts by flexing the wrist and metacarpophalangeal joint and extending the finger⁴⁶.

We can then check the final result and ask the patient to flex and extend his/her hand.

The patient can move the hand immediately after the procedure. No sutures are required. We use adhesive strips and an elastic bandage.

We have treated almost 100 patients with excellent results, and we have already reported our results with the first 70 patients⁴⁷_.

We can do bilateral cases with this technique at the same time⁴⁶. We can do this technique in the OR and recently we started to do it in the office. It is reliable and safe technique.

Results

In our series recently publicated⁴⁶, the contractures were Tubiana stage I in 15 cases, stage II in 41 and stage III in 14 cases.  In 21% of cases the digits had isolated metacarpophalangeal joint contractures. Two cases (3%) involved an isolated proximal interphalangeal joint contracture (Stage II). The remainder (fifty-three fingers, 76%) involved contractures of both the metacarpophalangeal and proximal interphalangeal joints.

Proximal interphalangeal capsule release was performed in 15 cases with digital deformity (11 cases with Tubiana stage III and 4 patients with Tubiana stage II). Preoperative mean contracture was 70° (35-115º). Pre-operative metacarpophalangeal joint contracture means 39° (range, 25-65°), and that of proximal interphalangeal contracture mean 40° (range, 15-70°) (excluding the 15 cases with isolated metacarpophalangeal deformity).  

The improvement after surgery means 67º, which represents 95% of the contracture.

Residual contractures mean 4º (0-15º). Metacarpophalangeal joint contractures were corrected a mean of 95% (37º) and proximal interphalangeal joint contractures a mean of 94.5% (38º) immediately after surgery (excluding the 15 cases with isolated metacarpophalangeal deformity). 

At 1 and 2 years of follow-up, the correction mean 63º, which represents 90% of the initial global contracture. At 1 and 2 years of follow-up, the correction for metacarpophalangeal joint contracture mean 35.3º (91.4 %), and the correction for proximal interphalangeal joint contracture (excluding the cases with isolated MCP deformity) mean 35º, which represents a correction of 88% of the initial contracture.

All patients were satisfied at 3 months of follow-up, 1 and 2 years of follow-up, with a rate of 9 on the visual analogue scale (0-10).

Conclusions

Ultrasound is a well-established imaging modality for both diagnostic and therapeutic uses in hand surgery, in the office and in the operating room.

It helps us to perform ultrasound guided procedures such carpal tunnel syndrome, trigger finger or Dupuytren disease. With these techniques, we minimize the morbidity in hand surgery procedures, allowing the patient for an early recovery.

Ultrasound-guided surgery may help to reduce complications, fasten recovery and improve results. It may also become the gold-standard form of surgery for certain pathologies in the near future.  

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