Percutaneous release of trigger thumb: do we really need steroid?

Comparative clinical study of ultrasound-guided A1 pulley release vs open surgical intervention in the treatment of trigger finger

AIM

To investigate the effectiveness of ultrasound-guided release of the first annular pulley and compare results with the conventional open operative technique.

METHODS

In this prospective randomized, single-center, clinical study, 32 patients with trigger finger or trigger thumb, grade II-IV according to Green classification system, were recruited. Two groups were formed; Group A (16 patients) was treated with an ultrasound-guided percutaneous release of the affected A1 pulley under local anesthesia. Group B (16 patients) underwent an open surgical release of the A1 pulley, through a 10-15 mm incision. Patients were assessed pre- and postoperatively (follow-up: 2, 4 and 12 wk) by physicians blinded to the procedures. Treatment of triggering (primary variable of interest) was expressed as the “success rate” per digit. The time for taking postoperative pain killers, range of motion recovery, QuickDASH test scores (Greek version), return to normal activities (including work), complications and cosmetic results were assessed.

RESULTS

The success rate in group A was 93.75% (15/16) and in group B 100% (16/16). Mean times in group A patients were 3.5 d for taking pain killers, 4.1 d for returning to normal activities, and 7.2 and 3.9 d for complete extension and flexion recovery, respectively. Mean QuickDASH scores in group A were 45.5 preoperatively and, 7.5, 0.5 and 0 after 2, 4, and 12 wk postoperatively. Mean times in group B patients were 2.9 d for taking pain killers, 17.8 d for returning to normal activities, and 5.6 and 3 d for complete extension and flexion recovery. Mean QuickDASH scores in group B were 43.2 preoperatively and, 8.2, 1.3 and 0 after 2, 4, and 12 wk postoperatively. The cosmetic results found excellent or good in 87.5% (14/16) of group A patients, while in 56.25% (9/16) of group B patients were evaluated as fair or poor.

CONCLUSION

Treatment of the trigger finger using ultrasonography resulted in fewer absence of work days, and better cosmetic results, in comparison with the open surgery technique. It is a promising method that represents excellent results without major complications, so that it could be possibly be established as a first-line treatment in the trigger finger’s disease.

Percutaneous first annular pulley release for trigger digits: a systematic review and meta-analysis of current evidence

PURPOSE

To determine the overall success rate and potential influencing factors within the current evidence for percutaneous first annular pulley release.

METHODS

We searched PubMed, EMBASE, and the Cochrane Library for all clinical studies of percutaneous release. The rates of successful procedure and complication were extracted and analyzed. We charted the overall success rate on a forest plot with 95% confidence intervals. Data of success rates were analyzed in 5- and 10-year intervals to determine whether the rate of success had increased chronologically. We then performed 3 subgroup analyses according to instrument type (needles vs knife blades), cortisone use (cortisone vs noncortisone), and sonography guidance (sonography vs non-sonography guidance). Pooled success rates were calculated in the subgroups and compared using chi-square test.

RESULTS

A total of 34 studies involving 2,114 percutaneous procedures were included in this systematic review and meta-analysis. The total success rate was 94%. There was a trend toward increasing number of publications in the past 20 years. We found a statistically significant trend showing that overall success rates had increased over time. Chi-square test revealed that percutaneous release with sonography guidance had a significantly higher success rate than non-sonography guidance. There were no significant differences in other subgroup analyses including instrument type and cortisone use.

CONCLUSIONS

Percutaneous release is an effective and safe procedure for the treatment of trigger digit. It has become progressively popular in recent years, with a trend toward increased overall success. Sonography might be a helpful tool for maximizing success. The success rates were not affected by instruments and cortisone use.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Percutaneous release, open surgery, or corticosteroid injection, which is the best treatment method for trigger digits?

BACKGROUND

Percutaneous A1 pulley release surgery for trigger digit (finger or thumb) has gained popularity in recent decades. Although many studies have reported the failure rate and complications of percutaneous release for trigger digit, the best treatment for trigger digit remains unclear.

QUESTIONS/PURPOSES

Our aim was to identify the relative risk of treatment failure, level of satisfaction, and frequency of complications, comparing percutaneous release with open surgery or corticosteroid injections for adult patients with trigger digits.

METHODS

We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials (RCTs), comparing percutaneous release with open surgery or corticosteroid injections. Seven RCTs involving 676 patients were identified. Methodologic quality was assessed by the Detsky quality scale. After data extraction, we compared results using a fixed meta-analysis model.

RESULTS

There were no differences in the failure rate (risk ratio [RR] = 0.93; 95% CI, 0.14-6.25) and complication frequency (RR = 0.83; 95% CI, 0.15-4.72) between patients undergoing percutaneous release and open surgery. Patients treated with percutaneous release had fewer failures (RR = 0.07; 95% CI, 0.02-0.21) and a greater level of satisfaction (RR = 2.01; 95% CI, 1.62-2.48) compared with the patients treated with corticosteroid injections. We found no difference in complication frequency between percutaneous release and corticosteroid injection (RR = 3.19; 95% CI, 0.51-19.91).

CONCLUSIONS

The frequencies of treatment failure and complications were no different between percutaneous release surgery and open surgery for trigger digit in adults. Patients treated with percutaneous releases were less likely to have treatment failure than patients treated with corticosteroid injections.

Conservative treatment of pediatric trigger thumb: follow-up for over 4 years

We analyzed the outcomes of our conservative treatment for pediatric trigger thumb. Since March 2004, we have used conservative treatment for all patients with pediatric trigger thumb. We prospectively analyzed 30 patients in whom 35 thumbs were affected (10 right, 15 left, 5 bilateral). The mean age at diagnosis was 28 (11-50) months. The treatment consisted of passive exercises performed by the children's mothers, 10-20 times daily. How reliably this was performed is unproven. Trigger thumb severity was graded as 0A (extension beyond 0°), 0B (extension to 0°), 1 (active extension with triggering), 2 (passive extension with triggering), and 3 (cannot extend either actively or passively i.e. locked). At diagnosis, six of the 35 thumbs (17%) were grade 1, 25 (71%) were grade 2, and four (11%) were grade 3. After a mean follow-up period of 63 (range, 49-73) months, 28 thumbs (80%) were grade 0A or 0B, 5 (14%) were grade 1 and 2 (6%) were grade 2. The bilateral cases and the patients who initially had grade 3 severity had significantly more unfavorable results than the other patients. This study suggests that conservative treatment for pediatric trigger thumb is a successful method, although cases that present with bilateral involvement or locking (grade 3) should be considered for early surgical release.