The Clinical Anatomy Study Of A1 Pulley Percutaneously Released By Needle Knife Under Ultrasound Guidance

[Background]Stenotic flexor tenosynovitis,also known as trigger finger(TF),is a common and frequently occurring disease in orthopedics.TF is aseptic inflammation of the flexor digital tendon.Most of the lesions were located at the beginning of the fiber sheath of flexor tendon,and most of the lesions were located at the A1 pulley,which was also the target of clinical treatment.The percutaneous A1 pulley release was first reported in 1958,and has become the first choice for the patients with TF who have no effect on conservative treatment.There are a lot of medical devices for percutaneous release,and the needle knife also belongs to one of them.At present,the operation of needle knife loosening A1 pulley is mostly performed under blind vision,which has obvious defects because it is not visible.In recent years,ultrasound-guided technology has been widely used in the field of invasive treatment,which makes a lot of percutaneous invasive treatment technology significantly improved.At present,ultrasound-guided percutaneous A1 pulley release by needle-knife has been used in the treatment of TF,but its related anatomical research has not been reported,which is not conducive to the clinical promotion of the technology.this study was carried out for clarify the anatomical basis of ultrasound-guided percutaneous release of A1 trochlea,and make it a scientific,accurate,safe and reliable clinical treatment technology for TF.[Objectives]To simulate the operation of percutaneous A1 pulley release by needle-knife in the treatment of stenosing flexor tenosynovitis on human specimens by clinical anatomy,and compare the safety and accuracy with ultrasound-guide,non-ultrasound-guide and classical acupotomy treatment.Observe the puncture path of percutaneous A1 pulley release and its adjacent nerve and blood vessel tissues,and provide anatomic basis for the treatment of stenosing flexor tenosynovitis with ultrasound-guided percutaneous A1 pulley release by needle-knife.[Methods]A total of 84 human upper limb specimens with 10%formalin-preserved(54 males,30 females,40 left-handed and 44 right-handed),with an average age of 82.60±12.46 years were obtained.The specimens were derived from the Donor Center of School of Basic Medical Sciences,Peking University,study started from November 2018 to May 2019.The specimens were divided into three groups(group U:ultrasound-guided needle-knife pushing group,group N,non-ultrasound-guided needle-knife pushing group,group T,classical acupotomy operation puncture group).Three methods were used to release the A1 pulley by needle-knife.After the acupotomy release operation was completed,dissected the soft tissue layer by layer from shallow to deep to expose the A1 pulley,and the acupotomy and surrounding anatomical structures were observed and compared with the ultrasound image.And then,observed the injury condition and measure the relevant anatomical data,and finally perform data analysis.(1)Safety evaluation:Perform operational safety assessments for the U,N and T groups,and compare the safety indicators of the three groups.The safety indicators are as follows:?The injury of the proper digital nerve and blood vessel:visually observe whether there are cutting marks on the proper digital nerve and blood vessel.?The injury of the A2 and PA pulley:visually observe whether there are cutting marks on the A2 and PA pulley.?The injury of the flexor digital tendon:The flexor tendons were inspected to evaluate for any injury.Tendon injuries were classified as no injury,mild injury(indentation into the tendon substance),moderate injury(interruption of one edge of the tendon with the tendon continuity maintained),severe injury(tendon continuity interrupted).?Calculation of injury rate:calculate the injury rate of nerve,blood vessel,A2 and PA pulley,and tendon respectively.Injury rate(%)= number of injury cases÷total cases× 100%.(2)Accuracy evaluation:visually observe whether the incision of the needle-knife is located on the A1 pulley,use the electronic vernier caliper to measure the length of the needle-knife push mark(L1)and the length of the A1 pulley(L2),and then calculate the effective rate.Effective rate(%)=release length of A1 pulley÷total length of A1 pulley × 100%.(3)Measurement of anatomical data:use an electronic vernier caliper to measure the length of the following anatomical structure and the distance:the width of A1 pulley(W),the distance between the proximal end of A1 pulley and the transverse line of metacarpophalangeal joint(D1),the distance between the proximal end of A1 pulley and the transverse stria of the palm(D2,the thumb is not included,the index finger is based on the middle transverse stria of palm,the middle finger,ring finger and little finger are based on the distal transverse stria of palm),the distance between the projection line of A1 pulley midline on finger surface and the radial side of the proper digital nerve(D3),the distance between the projection line of A1 pulley midline on finger surface and the ulnar side of the proper digital nerve(D4).[Results]The high-frequency ultrasound probe can better display the anatomy of the A1 pulley,and it is easier to operate by placing the probe long in a longitudinal position over the MP joint and inserting the needle-knife in the plane.(1)Safety:In group U,29 cases were injured,the injury rate was 20.71%.Among them,25(17.86%)cases were flexor digital tendon injury(21 cases were mild injury,4 cases were moderate injury),2(1.43%)cases were A2 and PA pulley injury,2(1.43%)cases were proper digital nerve injury,and no blood vessel injury was found.In group N,36 cases were injured,the injury rate was 25.71%.Among them,23(16.43%)cases were flexor digital tendon injury(22 cases were mild injury,one case was moderate injury),11(7.86%)cases were A2 and PA pulley injury,1(0.71%)case was proper digital nerve injury,and 1(0.71%)case was blood vessel injury.In group T,28 cases were injured,and the injury rate was 20.00%.Among them,20(14.29%)cases were flexor digital tendon injury(19 cases were mild injury,1 case was moderate injury),4(2.86%)cases were A2 and PA pulley injury,3(2.14%)cases were proper digital nerve injury,and 1(0.71%)case was blood vessel injury.The total injury rate of three groups was compared:group N>group U>group T.Chi-square test was used to compare the each two groups,and no significant difference was found between the each two groups.(2)Accuracy:In group U:8(5.71%)cases had a missed release.The average actual length of A1 pulley was 7.76±3.13 mm.The average release length was 5.71 ±2.50 mm.The effective rate was 79.90%.In group N:4(2.86%)cases had a missed release.The average actual length of A1 pulley was 8.14± 1.93 mm.The average release length was 5.24±1.60 mm.The effective rate was 67.19%.In group T:13(9.29%)cases had a missed release.The average actual length of A1 pulley was 7.69±2.66 mm.The average release length was 4.65±2.50 mm.The effective rate was 64.66%.The missed release rate of three groups was compared:group T>group U>group N.Chi-square test was used to compare the each two groups.Only group T was significantly higher than that in group U(P2=0.023<0.05).The actual length of A1 pulley of three groups was compared:group N>group U>group T.The independent sample t-test was used to compare the each two groups,and no significant difference was found between the each two groups(P>0.05).The release length of A1 pulley of three groups was compared:group U>group N>group T.The independent sample t-test was used to compare the each two groups.The release length of A1 pulley in group U was significantly higher than group N(P1=0.031<0.05)and group T(P2=0.0002<0.05).The release length of A1 pulley in group N was significantly higher than group T(P3=0.009<0.05).The release effective rate of three groups was compared:group U>group N>group T.Chi-square test was used to compare the each two groups.The release effective rate in group U was significantly higher than that in group N(Pi=0.042<0.05)and group T(P2=0.16<0.05).There is no significant difference between group N and group T(P3=0.766>0.05).(3)Measurement of anatomical data:The average length(L)of A1 pulley was 7.86±2.62 mm.There was no significant difference between male and female.Only the left index finger A1 pulley was significantly longer than the right index finger in the comparative.analysis(P<0.05);the average width(W)of A1 pulley was 5.59±1.47 mm.The width of male A1 pulley was significantly larger than that of female(P<0.05)and the width of A1 pulley on the right side was significantly larger than that on the left side(P<0.05);the average distance between the proximal end of A1 pulley and the transverse line of metacarpophalangeal joint(Di)was 0.21 ±0.83 mm,and that of the other four fingers was 9.35±3.62 mm,and there was no significant difference between male and female,left and right;the average distance between the proximal end of A1 pulley and the transverse stria of the palm(D2)was 7.59±2.88 mm,and that of middle finger,ring finger and little finger was 8.07±3.34 mm.There was no significant difference between male and female.Only the left index finger was significantly longer than the right index finger in the comparative analysis(P<0.05);the average distance between the projection line of A1 pulley midline on finger surface and the radial side of the proper digital nerve(D3)was 5.11±1.39 mm;and the average distance between the projection line of A1 pulley midline on finger surface and the ulnar side of the proper digital nerve(D4)was 5.47± 1.64 mm.[Conclusion]In this study,clinical anatomy was used to observe the safety and accuracy of the treatment of Stenotic flexor tenosynovitis with percutaneous A1 pulley release by needle-knife under ultrasound guidance,non-ultrasound guidance and classical acupotomy operation.The results show that the ultrasound-guided percutaneous A1 pulley release by needle-knife has higher accuracy.Ultrasound guidance can accurately identify the location of A1 pulley,accurately identify the anatomical relationship of pulley,tendon and blood vessel,reduce the damage to tendon and neurovascular during operation,which can improve the safety and efficiency of acupotomy treatment.At the same time,the ultrasound guidance method can achieve pre-operative examination and location,intraoperative real-time guidance and postoperative reexamination,which is more suitable for clinical beginners.In addition,ultrasound-guided percutaneous A1 pulley release by needle-knife can also reduce the tension of patients and improve the medical experience of patients.It is a widely welcomed and promising medical technology,which is worthy of extensive clinical promotion.