A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger

Establishing the Patient Acceptable Symptom State in a Nonshoulder Hand and Upper Extremity Population for the QuickDASH and PROMIS UE Computer Adaptive Tests

PURPOSE

It is unclear what score thresholds on patient-reported outcomes instruments reflect an acceptable level of upper extremity (UE) function from the perspective of patients undergoing hand surgery. The purpose of this study was to calculate the patient acceptable symptom state (PASS) for the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) and Patient-Reported Outcomes Measurement Information System (PROMIS) UE Computer Adaptive Test (CAT), version 2.0, in a population who underwent hand surgery.

METHODS

Adult patients who underwent hand surgery between February 2019 and December 2019 at a single academic tertiary institution were identified. QuickDASH and PROMIS UE CAT version 2.0 scores were collected 1 year after surgery, as were separate symptom- and function-specific anchor questions that queried the acceptability of patients' current state. Threshold values predictive of a patient reporting an acceptable symptom state (PASS[+]) were calculated for both instruments using the 75th percentile score for patients in the PASS(+) group and the Youden Index as determined by receiver operating curve (ROC) analysis.

RESULTS

A total of 222 patients were included. QuickDASH and PROMIS UE CAT scores differed significantly between the PASS(+) and PASS(-) groups. The 75th percentile method yielded PASS values of <16 for the QuickDASH and >43 for the PROMIS UE CAT for both anchor questions. The ROC analysis yielded PASS estimates of <15.9 to <20.5 for the QuickDASH and >38.1 to >46.2 for the PROMIS UE CAT, with ranges calculated from differing threshold values for each of the 2 anchor questions. The ROC-based estimates demonstrated high levels of model discrimination (area under the curve ≥ 0.80).

CONCLUSIONS

We propose PASS estimates obtained using the 75th percentile and ROC methods.

CLINICAL RELEVANCE

Specifically, PASS values in the range of 15.9-20.5 for the QuickDASH and 38.1-46.2 for the PROMIS UE CAT version 2.0 should be used when interpreting outcomes at a population level.

Are There Differences in Pain Reduction and Functional Improvement Among Splint Alone, Steroid Alone, and Combination for the Treatment of Adults With Trigger Finger?

BACKGROUND

Steroid injection and splinting, which are commonly recommended nonsurgical treatments in adults with trigger finger, have been demonstrated to effectively relieve pain and improve function. However, to our knowledge, there have been no direct comparisons of pain relief and function improvement with splinting alone, steroid injection alone, or a combination of splinting and steroid injection in patients with this diagnosis.

QUESTION/PURPOSE

Are there differences in pain reduction and functional improvement in adults with trigger finger treated with splinting alone, steroid injection alone, and a combination of splinting and steroid injection at 6, 12, and 52 weeks after the intervention?

METHODS

Between May 2021 and December 2021, we treated 165 adult patients for trigger finger at an academic university hospital. Based on prespecified criteria, all patients we saw during that period were eligible, but 27% (45 of 165) were excluded because they had received a previous local corticosteroid injection (n = 10) or they had concomitant carpal tunnel syndrome (n = 14), first carpometacarpal joint arthritis (n = 3), osteoarthritis of the hand (n = 6), de Quervain disease (n = 3), multiple-digit trigger finger (n = 6), or pregnancy during the study period (n = 3). After screening, 120 patients were randomized to receive either splinting (n = 43), steroid injection (n = 40), or splinting plus steroid injection (n = 37). Patients were randomly assigned to the different treatments using computer-generated block randomization (block of six). Sequentially numbered, opaque, sealed envelopes were used in the allocation concealment process. Both the allocator and the outcome assessor were blinded. Splinting involved the patient wearing a fixed metacarpophalangeal joint orthosis in the neutral position at least 8 hours per day for 6 consecutive weeks. Steroid injection was performed using 1 mL of 1% lidocaine without epinephrine and 1 mL of triamcinolone acetonide (10 mg/mL) injected directly into the flexor tendon sheath. No patients were lost to follow-up or had treatment failure (that is, the patient had persistent pain or triggering with the trigger finger treatment and requested additional medical management including additional splinting, steroid injection, or surgery) at 6 or 12 weeks after the intervention, and at 52 weeks, there was no difference in loss to follow-up among the treatment groups. An intention-to-treat analysis was performed with all 120 patients, and a per-protocol analysis was conducted with 86 patients after excluding patients who were lost to follow-up or had treatment failure. Primary outcomes evaluated were VAS pain reduction and improvement in Michigan Hand Outcomes Questionnaire (MHQ) scores at 6, 12, and 52 weeks after the intervention. The minimum clinically important difference (MCID) values were 1 and 10.9 for the VAS and MHQ, respectively.

RESULTS

There were no clinically important differences in VAS pain scores among the three treatment groups at any timepoint, in either the intention-to-treat or the per-protocol analyses. Likewise, there were no clinically important differences in MHQ scores at any timepoint in either the intention-to-treat or the per-protocol analyses.

CONCLUSION

Splinting alone is recommended as the initial treatment for adults with trigger finger because there were no clinically important differences between splinting alone and steroid injection alone in terms of pain reduction and symptom or functional improvement up to 1 year. The combination of steroid injection and splinting is disadvantageous because the benefits in terms of pain reduction and symptom or functional improvement are not different from those achieved with steroid injection or splinting alone.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Minimal clinically important difference of the Michigan Hand Outcomes Questionnaire score and the pain visual analogue scale in conservative treatment of trigger finger

We investigated the minimal clinically important difference (MCID) of the Michigan Hand Outcomes Questionnaire (MHQ) and the pain visual analogue scale (VAS-pain) after conservative treatment of trigger finger. This secondary analysis of a randomized controlled trial compared pain reduction, symptoms and functional improvement at 12 weeks. Patients included were at least 18 years old and able to complete MHQ and VAS-pain at enrolment and 12 weeks after treatment. The MCIDs of MHQ and VAS-pain were evaluated using a distribution-based, anchor-based and receiver operating characteristic (ROC) curve-based approach. Of the 117 patients, the MCIDs of MHQ and VAS-pain using a distribution-based approach were 5.3 and 0.6, respectively; applying ROC method were 23.5 and 2.5, respectively; and using anchor questions were 15 and 2, respectively. These MCID values by anchor-based method with a minimal difference of 15 for MHQ and 2 for VAS-pain are recommended as primary evidence to determine clinically significant improvement after conservative treatment of trigger finger.Level of evidence: I.

The management of trigger fingers: commentary and personal opinion

Trigger fingers are common. Although the options for management are well-described, including conservative measures such as steroid injection, or surgical options such as open or percutaneous release, there remains variations in the way these are administered. In addition, there is a recent emphasis on patient-reported outcome measures in this condition. The purpose of this further knowledge article is to look at three recently published articles to gather some evidence about best practice in the management of this painful but common condition.

Determining the Optimal Dosage of Corticosteroid Injection in Trigger Finger

BACKGROUND

Corticosteroid injection is the mainstay of nonoperative treatment for trigger finger (stenosing tenosynovitis), but despite substantial experience with this treatment, there is minimal available evidence as to the optimal corticosteroid dosing. The purpose of this study is to compare the efficacy of 3 different injection dosages of triamcinolone acetonide for the treatment of trigger finger.

METHODS

Patients diagnosed with a trigger finger were prospectively enrolled and treated with an initial triamcinolone acetonide (Kenalog) injection of 5 mg, 10 mg, or 20 mg. Patients were followed longitudinally over a 6-month period. Patients were assessed for duration of clinical response, clinical failure, Visual Analog Scale (VAS) pain scores, and Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores.

RESULTS

A total of 146 patients (163 trigger fingers) were enrolled over a 26-month period. At 6-month follow-up, injections were still effective (without recurrence, secondary injection, or surgery) in 52% of the 5-mg group, 62% of the 10-mg group, and 79% of the 20-mg group. Visual Analog Scale at final follow-up improved by 2.2 in the 5-mg group, 2.7 in the 10-mg group, and 4.5 in the 20-mg group. The QuickDASH scores at final follow-up improved by 11.8 in the 5-mg group, 21.5 in the 10-mg group, and 28.9 in the 20-mg group.

CONCLUSIONS

Minimal evidence exists to guide the optimal dosing of steroid injection in trigger digits. When compared with 5-mg and 10-mg doses, a 20-mg dose was found to have a significantly higher rate of clinical effectiveness at 6-month follow-up. The VAS and QuickDASH scores were not significantly different between the 3 groups.

"Spin" in Plastic Surgery Randomized Controlled Trials with Statistically Nonsignificant Primary Outcomes: A Systematic Review

BACKGROUND

"Spin" refers to a manipulation of language that implies benefit for an intervention when none may exist. Randomized controlled trials (RCTs) in other fields have been demonstrated to employ spin, which can mislead clinicians to use ineffective or unsafe interventions. This study's objective was to determine the strategies, severity, and extent of spin in plastic surgery RCTs with nonsignificant primary outcomes.

METHODS

A literature search of the top 15 plastic surgery journals using MEDLINE was performed (2000 through 2020). Parallel 1:1 RCTs with a clearly identified primary outcome showing statistically nonsignificant results ( P > 0.05) were included. Screening, data extraction, and spin analysis were performed by two independent reviewers. The spin analysis was then independently assessed in duplicate by two plastic surgery residents with graduate-level training in clinical epidemiology.

RESULTS

From 3497 studies identified, 92 RCTs were included in this study. Spin strategies were identified in 78 RCTs (85%), including 64 abstracts (70%) and 77 main texts (84%). Severity of spin was rated moderate or high in 43 abstract conclusions (47%) and 42 main text conclusions (46%). The most identified spin strategy in the abstract was claiming equivalence for statistically nonsignificant results (26%); in the main text, focusing on another objective (24%).

CONCLUSIONS

This study suggests that 85% of statistically nonsignificant RCTs in plastic surgery employ spin. Readers of plastic surgery research should be aware of strategies, whether intentional or unintentional, used to manipulate language in reports of statistically nonsignificant RCTs when applying research findings to clinical practice.

Factors associated with conversion to surgical release after a steroid injection in patients with a trigger finger

AIMS

The aim of this retrospective study was to evaluate the rate of conversion to surgical release after a steroid injection in patients with a trigger finger, and to analyze which patient- and trigger finger-related factors affect the outcome of an injection.

METHODS

The medical records of 500 patients (754 fingers) treated for one or more trigger fingers with a steroid injection or with surgical release, between 1 January 2016 and 1 April 2020 with a follow-up of 12 months, were analyzed. Conversion to surgical release was recorded as an unsuccessful treatment after an injection. The effect of patient- and trigger finger-related characteristics on the outcome of an injection was assessed using stepwise manual backward multivariate logistic regression analysis.

RESULTS

Treatment with an injection was unsuccessful in 230 fingers (37.9%). Female sex (odds ratio (OR) 1.87 (95% confidence interval (CI) 1.21 to 2.88)), Quinnell stage IV (OR 16.01 (95% CI 1.66 to 154.0)), heavy physical work (OR 1.60 (95% CI 0.96 to 2.67)), a third steroid injection (OR 2.02 (95% CI 1.06 to 3.88)), and having carpal tunnel syndrome (OR 1.59 (95% CI 0.98 to 2.59)) were associated with a higher risk of conversion to surgical release. In contrast, an older age (OR 0.98 (95% CI 0.96 to 0.99)), smoking (OR 0.39 (95% CI 0.24 to 0.64)), and polypharmacy (OR 0.39, CI 0.12 to 1.12) were associated with a lower risk of conversion. The regression model predicted 15.6% of the variance found for the outcome of the injection treatment (R² > 0.25).

CONCLUSION

Factors associated with a worse outcome following a steroid injection were identified and should be considered when choosing the treatment of a trigger finger. In women with a trigger finger, the choice of treatment should take into account whether there are also one or more patient- or trigger-related factors that increase the risk of conversion to surgery.Cite this article: Bone Joint J 2022;104-B(10):1142-1147.

Comparison of Different Dosages and Volumes of Triamcinolone in the Treatment of Stenosing Tenosynovitis: A Prospective, Blinded, Randomized Trial

Background

Stenosing tenosynovitis is a condition due to a size mismatch between the flexor tendons and the first annular pulley. Corticosteroid injection is the mainstay treatment. The purpose of this study is to compare different dosages and volumes of triamcinolone in the treatment of primary stenosing tenosynovitis.

Methods

Patients with primary Quinnell grades 1 or 2 stenosing tenosynovitis were recruited in this prospective, blinded, randomized trial. Patients were randomized into 1 of 2 groups. Group A received 0.25 mL of triamcinolone 40 mg/mL, mixed with 0.25 mL of 1% lidocaine with epinephrine (10 mg of triamcinolone, 0.5 mL in total volume). Group B received 0.5 mL of triamcinolone 40 mg/mL, mixed with 0.5 mL of 1% lidocaine with epinephrine (20 mg of triamcinolone, 1 mL in total volume). Patients were assessed by a blinded hand therapist at 2 and 4 weeks, and by a blinded hand surgeon at 6 weeks. The primary outcome was complete symptom resolution at 6 weeks. Both per-protocol and intention-to-treat analyses were performed.

Results

One hundred ninety-one patients were recruited from 2009 to 2018. Eighty-two and 77 patients had complete data in group A and B, respectively. There was no difference in success rates in complete symptom resolution at 6 weeks between group A (59.8%) and group B (62.3%). The mean visual analogue pain scores on injection were 4.31 ± 2.11 for group A and 4.30 ± 2.09 for group B.

Conclusions

Triamcinolone 10 mg was as effective as 20 mg in the resolution of symptoms of Quinnell grade 1 or 2 stenosing tenosynovitis at 6 weeks.

Time to Improvement After Corticosteroid Injection for Trigger Finger

Purpose

Trigger finger is a commonly occurring hand condition that presents with symptoms of pain, clicking, locking, and catching of the finger. A common non-operative management option is corticosteroid injection. The purpose of this study was to evaluate the short-term patient response to corticosteroid injections for trigger finger. 

Methods

The patients of six fellowship-trained orthopedic hand surgeons who underwent a corticosteroid injection for trigger finger between June 2019 and October 2019 were invited to participate in this study. Patients were contacted by phone at one week, two weeks, and three weeks after the injection to complete a questionnaire regarding their pain and triggering symptoms. Medical records were also reviewed to collect basic demographic data.

Results

A total of 452 patients were included in the study. At the final follow-up, 82.4% of patients reported complete pain relief, 16.3% had partial relief, and 1.2% had no relief from their pain. For their triggering symptoms, 65.9% reported complete triggering relief, 30.4% had partial relief, and 3.5% had no triggering relief. It took an average of 6.6 days following injection for patients to experience complete pain relief, and an average of 8.1 days for patients to experience complete triggering relief.

Conclusions

This analysis found that most patients experience relief of pain and triggering at three weeks following corticosteroid injection. The majority of patients experienced some pain relief within the first week following corticosteroid injection, while improvement in triggering appeared to lag behind pain relief.

Out-of-sheath corticosteroid injections through the dorsal webspace for trigger finger and trigger thumb. A prospective cohort study

BACKGROUND AND OBJECTIVE

Steroid injections are effective in the treatment of trigger digits but the pain during the injection is an always-present accompanying effect. The aim of this study was to assess the effectiveness and perceived pain during an out-of-sheath corticosteroid injection through the dorsal webspace in the treatment of trigger digits.

MATERIAL AND METHOD

A total of 126 consecutive patients were included. A subcutaneous (out-of-sheath) corticosteroid injection was performed through the dorsal webspace in all digits. In cases where signs or symptoms persisted, a second injection was offered. Visual analog scale for pain during the injection, DASH questionnaire, success rate and complications were collected.

RESULTS

There were 86 women and 40 men with a mean age of 61 years. The mean visual analog scale for pain during the injection was 3.8. Twelve patients were lost to follow-up. The overall success was 68% and success after a single injection was 54%. The best result was achieved on the ring finger. Patients who were not previously operated on carpal tunnel syndrome responded better. No complications were noted.

CONCLUSIONS

The extra-sheath corticosteroid injection through the dorsal webspace is effective and safe. It seems to be less painful than the reported scores for the palmar midline technique although it should be assessed in a comparative study.

AHAF, R. GVG, da Silveira DCEC, B. PN, Almeida SF. Epidemiology of Trigger Finger: Metabolic Syndrome as a New Perspective of Associated Disease

Objective: The aim of this study was to identify the main diseases related to trigger finger. Methods: A retrospective, observational study was performed with data obtained through a computerized record of 75 patients with trigger finger diagnosis between July 2011 and October 2015. The diagnosis of metabolic syndrome was performed following National Cholesterol Education Program Adult Treatment Panel III (2001). Results: Patients' ages ranged from 50 to 84 years, with a mean age of 63 years. The ring finger was the most affected, followed by the middle finger, index finger, and little finger. Most had a grade 2 trigger finger classified by Green; the right hand involvement was more prevalent, as was the dominant hand. The incidence in women was twice as high as in men. Arterial hypertension, diabetes mellitus, and dyslipidemia were shown to be important associated diseases, but metabolic syndrome was the main association found. Conclusions: Metabolic syndrome in the group of patients studied in this scientific article seems to be the main associated disease.

Choice of Corticosteroid Solution and Outcome After Injection for Trigger Finger

Background: Many techniques for injection of trigger fingers exist. The purpose of this study was to determine whether the type of steroid or technique used for trigger finger injection altered clinical outcomes. Methods: Six hand surgeons at a single institution were surveyed regarding their injection technique, preferred steroid used, and protocol for repeat injection or indication for surgery for symptomatic trigger finger. A retrospective chart review of patients who underwent trigger finger injections was performed by randomly selecting 35 patients for each surgeon between January 2013 and December 2015. Demographic data at the time of presentation were collected. Outcome data during follow-up appointments were also recorded. Results: A total of 210 patient charts were reviewed. Demographic data and initial presenting grade of triggering were similar among all groups. There was no significant difference in clinical course or eventual outcomes noted with injection technique. There were 70 patients in each steroid cohort. Patients receiving triamcinolone required additional injections compared with those receiving methylprednisolone and dexamethasone. Eventual surgical intervention was significantly higher in those patients receiving methylprednisolone. The methylprednisolone group also underwent operative release significantly earlier. Conclusions: Trigger finger injections with triamcinolone demonstrate a higher rate of additional injections when compared with dexamethasone and methylprednisolone. Patients who underwent methylprednisolone injection had surgical release performed earlier and more frequently than the other 2 groups. The choice of corticosteroid significantly affected clinical outcome in this study population. Clinicians performing steroid injections for trigger finger may wish to consider these results when selecting a specific agent.

Efficacy Comparison of Hyaluronic Acid and Corticosteroid Injection in Treatment of Trigger Digits: A Randomized Controlled Trial

Background: Although the current nonsurgical treatment for trigger digits is corticosteroid (CS) injection, it often comes with adverse effects that may cause some limitations. Currently, Hyaluronic acid (HA) has been successfully used in tendinopathy and may be used in stenosing tenosynovitis. The aim of this study is to compare the efficacy of ultrasound-guided injection between the HA and CS in trigger digits treatment. Methods: Double-blind randomized controlled trial was conducted. Fifty patients with 66 trigger digits were randomly assigned into an intervention group (1 ml of low-molecular weight HA) and a control group (1 ml of 10mg/ml triamcinolone acetate). The ultrasound-guided injection and local anesthesia (0.5 ml of 1% lidocaine without adrenaline) were used. The Quinnell grading, Visual Analog Scale (VAS) score of pain, Disabilities of the Arm, Shoulder and Hand (DASH) score and complications were collected at 1-, 3-and 6-month follow-up. Results: The mean age of HA group (33 digits) and CS group (33 digits) were 58.3 years and 54.7 years respectively. Nine patients were loss of follow-up (7 in HA group and 2 in CS group). The Quinnell grades have shown an improvement in both group. The CS group had a significant better improvement at 1-month (p-value < 0.001) and there was no significant difference at 3-and 6-month follow-up between the two groups. The median of VAS and DASH score were significantly improved by time in both groups (p-value < 0.01). The CS group showed a better significant improvement in early period of follow-up (p-value < 0.05). However, there was no significant difference between the two groups in the last follow-up. Conclusions: HA and CS injection has a comparable therapeutic effect in treatment of trigger digits. However, CS injection has higher efficacy of pain and inflammation reduction in the early phase of the disease.

Outcomes of Corticosteroid Treatment for Trigger Finger by Stage

BACKGROUND

Although steroid injection remains a common first-line treatment of trigger finger, clinical experience suggests that not all cases of trigger finger respond the same. The purpose of this study was to use a classification system for trigger finger that is simple and reproducible, and produces clearly definable, clinically relevant cutoff points to determine whether responsiveness to steroid injection correlates to clinical staging.

METHODS

The authors conducted a prospectively collected longitudinal study of trigger finger patients separated into four stages of severity. Each subject received a single injection of 6 mg of dexamethasone acetate. One-month outcomes were analyzed to evaluate the efficacy of steroid injection. These outcomes were further stratified based on baseline characteristics and stage of triggering.

RESULTS

A total of 99 digits and 69 subjects were included. Two variables were found to be significant in predicting response to initial injection: (1) multiple affected digits and (2) stage severity. Patients with multiple involved fingers were 5.8 times more likely to have no resolution of symptoms compared with those with a single affected finger. For every level of stage increase, the odds doubled for having no resolution of symptoms.

CONCLUSIONS

Steroid injection remains a viable first-line option for patients presenting with mild triggering (stage 1 and 2). For more severe triggering (stage 3 and 4) or multiple affected digits, the success of steroid injection is significantly lower at 1 month. For the latter patients, surgery may be a more reasonable initial treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Different Dosages of Triamcinolone Acetonide Injection for the Treatment of Trigger Finger and Thumb: A Randomized Controlled Trial

BACKGROUND

This study was designed to compare the efficacy and complications between 3 different dosages of triamcinolone acetonide for the treatment of trigger finger.

METHODS

Ninety-three patients with a total of 120 trigger digits were included in the study. The involved digits were randomized to 3 groups. Each group received treatment consisting of injection with 5, 10 or 20 mg triamcinolone acetonide. The clinical response to the steroid was evaluated during the first six weeks after injection. The success rate was determined at 3, 6, 9 and 12 months after injection.

RESULTS

After the injections, pain and triggering improved gradually and nearly resolved completely at 6 weeks in all dosages. A dose related pattern was found at 3 and 6 months after the injection. The 20 mg group had a significant higher success rate when compared to the 5 and 10 mg at 3 and 6 months. The 10 mg group has significant higher success rate when compare to 5 mg at 3 months. There were no differences of success rate between groups at 9 and 12 months. At 12 months, 7 of 40 digits (17.5%) in the 5 mg group, 7 of 40 digits (17.5%) in the 10 mg group, and 9 of 40 digit (22.5%) in the 20 mg group were without triggering (p = 0.806).

CONCLUSIONS

A dose-response characteristic was demonstrated in the treatment of trigger finger with triamcinolone acetonide. Triamcinolone acetonide 5 mg seems to have the lowest success rate.

Treatment of paediatric trigger finger: a systematic review and treatment algorithm

PURPOSE

Paediatric trigger finger (PTF) is a rare condition as seen by the lack of studies published about paediatric populations. Due to this general lack of information, the steps to employ to correct this disorder, whether surgically or non-surgically, have not yet reached consensus status. The objective of this study is to review the published literature regarding treatment options for PTF in order to develop a proposed step-wise treatment algorithm for children presenting with trigger finger.

METHODS

A systematic review of the literature was conducted on PubMed to locate English language studies reporting on treatment interventions of PTF. Data was collected on number of patients/fingers seen in the study, the category of the fingers involved, the number of patients/fingers undergoing each intervention and reported outcomes.

RESULTS

Seven articles reporting on 118 trigger fingers were identified. In all, 64 fingers were treated non-surgically, with 57.8% (37/64) resolving. In all, 54 fingers were initially surgically treated, with 87% (47/54) resolving. In total, 34 fingers did not have resolution of symptoms following primary treatment, and 27 fingers received follow-up treatment, with 92.6% (25/27) resolving. Overall, 92.4% (109/118) of fingers achieved resolution of symptoms after all treatments were completed.

CONCLUSION

Limitations for this study included few prospective studies and small sample sizes. This is likely due to the rarity of PTF. This review of the literature indicated that a step-wise approach, including non-operative and surgical techniques, should be employed in the management of PTF.

LEVEL OF EVIDENCE III

This work meets the requirements of the PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

The Effect of Trigger Finger Injection Site on Injection-Related Pain

BACKGROUND

Stenosing tenosynovitis, or trigger digit, is a common condition for which patients often seek relief. Corticosteroid injections have been shown to provide relief in many cases, and several different approaches for delivering the injection have been described in the literature. We compared patients' perception of pain following each of 3 accepted injection methods, namely, palmar proximal, palmar distal, and webspace approaches.

METHODS

We prospectively followed 38 patients with 39 symptomatic digits in this trial, with varying severities of trigger finger as graded by the Patel and Moradia classification. The patients were divided into 3 groups representing the 3 approaches without randomization, based upon the treating surgeons' preference. Disabilities of the Arm, Shoulder and Hand and visual analog scale (VAS) pain scores were calculated pre-injection and at 4-week and 8-week follow-up visits.

RESULTS

No statistically significant differences in age, sex, affected extremity, grade, or duration of symptoms were observed among the 3 approaches. No statistically significant differences in VAS score were found between the palmar proximal (mean = 6.6, SD = 2.6), palmar distal (mean = 6.0, SD = 2.8), and webspace (mean = 6.8, SD = 1.8) approaches.

CONCLUSION

Our data suggest that injection approach does not affect patient pain perception scores or outcomes. We recommend that the technique that is most comfortable to the surgeon be utilized, with the understanding that one injection alone has a low likelihood of relieving symptoms.

Surgery for trigger finger

BACKGROUND

Trigger finger is a common clinical disorder, characterised by pain and catching as the patient flexes and extends digits because of disproportion between the diameter of flexor tendons and the A1 pulley. The treatment approach may include non-surgical or surgical treatments. Currently there is no consensus about the best surgical treatment approach (open, percutaneous or endoscopic approaches).

OBJECTIVES

To evaluate the effectiveness and safety of different methods of surgical treatment for trigger finger (open, percutaneous or endoscopic approaches) in adults at any stage of the disease.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase and LILACS up to August 2017.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that assessed adults with trigger finger and compared any type of surgical treatment with each other or with any other non-surgical intervention. The major outcomes were the resolution of trigger finger, pain, hand function, participant-reported treatment success or satisfaction, recurrence of triggering, adverse events and neurovascular injury.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trial reports, extracted the data and assessed the risk of bias. Measures of treatment effect for dichotomous outcomes calculated risk ratios (RRs), and mean differences (MDs) or standardised mean differences (SMD) for continuous outcomes, with 95% confidence intervals (CIs). When possible, the data were pooled into meta-analysis using the random-effects model. GRADE was used to assess the quality of evidence for each outcome.

MAIN RESULTS

Fourteen trials were included, totalling 1260 participants, with 1361 trigger fingers. The age of participants included in the studies ranged from 16 to 88 years; and the majority of participants were women (approximately 70%). The average duration of symptoms ranged from three to 15 months, and the follow-up after the procedure ranged from eight weeks to 23 months.The studies reported nine types of comparisons: open surgery versus steroid injections (two studies); percutaneous surgery versus steroid injection (five studies); open surgery versus steroid injection plus ultrasound-guided hyaluronic acid injection (one study); percutaneous surgery plus steroid injection versus steroid injection (one study); percutaneous surgery versus open surgery (five studies); endoscopic surgery versus open surgery (one study); and three comparisons of types of incision for open surgery (transverse incision of the skin in the distal palmar crease, transverse incision of the skin about 2-3 mm distally from distal palmar crease, and longitudinal incision of the skin) (one study).Most studies had significant methodological flaws and were considered at high or unclear risk of selection bias, performance bias, detection bias and reporting bias. The primary comparison was open surgery versus steroid injections, because open surgery is the oldest and the most widely used treatment method and considered as standard surgery, whereas steroid injection is the least invasive control treatment method as reported in the studies in this review and is often used as first-line treatment in clinical practice.Compared with steroid injection, there was low-quality evidence that open surgery provides benefits with respect to less triggering recurrence, although it has the disadvantage of being more painful. Evidence was downgraded due to study design flaws and imprecision.Based on two trials (270 participants) from six up to 12 months, 50/130 (or 385 per 1000) individuals had recurrence of trigger finger in the steroid injection group compared with 8/140 (or 65 per 1000; range 35 to 127) in the open surgery group, RR 0.17 (95% CI 0.09 to 0.33), for an absolute risk difference that 29% fewer people had recurrence of symptoms with open surgery (60% fewer to 3% more individuals); relative change translates to improvement of 83% in the open surgery group (67% to 91% better).At one week, 9/49 (184 per 1000) people had pain on the palm of the hand in the steroid injection group compared with 38/56 (or 678 per 1000; ranging from 366 to 1000) in the open surgery group, RR 3.69 (95% CI 1.99 to 6.85), for an absolute risk difference that 49% more had pain with open surgery (33% to 66% more); relative change translates to worsening of 269% (585% to 99% worse) (one trial, 105 participants).Because of very low quality evidence from two trials we are uncertain whether open surgery improve resolution of trigger finger in the follow-up at six to 12 months, when compared with steroid injection (131/140 observed in the open surgery group compared with 80/130 in the control group; RR 1.48, 95% CI 0.79 to 2.76); evidence was downgraded due to study design flaws, inconsistency and imprecision. Low-quality evidence from two trials and few event rates (270 participants) from six up to 12 months of follow-up, we are uncertain whether open surgery increased the risk of adverse events (incidence of infection, tendon injury, flare, cutaneous discomfort and fat necrosis) (18/140 observed in the open surgery group compared with 17/130 in the control group; RR 1.02, 95% CI 0.57 to 1.84) and neurovascular injury (9/140 observed in the open surgery group compared with 4/130 in the control group; RR 2.17, 95% CI 0.7 to 6.77). Twelve participants (8 versus 4) did not complete the follow-up, and it was considered that they did not have a positive outcome in the data analysis. We are uncertain whether open surgery was more effective than steroid injection in improving hand function or participant satisfaction as studies did not report these outcomes.

AUTHORS' CONCLUSIONS

Low-quality evidence indicates that, compared with steroid injection, open surgical treatment in people with trigger finger, may result in a less recurrence rate from six up to 12 months following the treatment, although it increases the incidence of pain during the first follow-up week. We are uncertain about the effect of open surgery with regard to the resolution rate in follow-up at six to 12 months, compared with steroid injections, due high heterogeneity and few events occurred in the trials; we are uncertain too about the risk of adverse events and neurovascular injury because of a few events occurred in the studies. Hand function or participant satisfaction were not reported.

Effectiveness of Corticosteroid Injections for Treatment of de Quervain's Tenosynovitis

BACKGROUND

Although surgery can provide definitive treatment for de Quervain's tenosynovitis, nonoperative treatment could be preferable if symptoms are predictably relieved. We sought to determine the effectiveness of corticosteroid injections as treatment for de Quervain's tenosynovitis and to evaluate patient characteristics as predictors of treatment outcome.

METHODS

A retrospective study was conducted using our institutional database International Classification of Disease, version 9 (ICD-9) code list for de Quervain's tenosynovitis. Treatment success was defined as relief of symptoms after 1 or 2 injections. Relief was defined as resolution or improvement to the extent that the patient did not seek further intervention. Failure was defined as a subsequent surgical release or a third injection. Logistic regression analyses were performed to look for univariate associations between patient demographics/comorbidities and risk of treatment failure.

RESULTS

The treatment outcome of 222 limbs from 199 patients was studied. Of the 222 limbs, 73.4% (95% confidence interval [CI], 66.9%-79.1%) experienced treatment success within 2 injections, and 51.8% (95% CI, 45.0%-58.6%) experienced success after 1 injection. Body mass index (BMI) >30 and female sex were found to be significantly associated with treatment failure, with a 2.4-fold increase (95% CI, 1.02%-5.72%) in odds and 3.23 times greater (95% CI, 1.08%-9.67%) odds of failure, respectively. Although not reaching statistical significance, African American race, hypothyroidism, and carpal tunnel syndrome suggested increased odds of failure.

CONCLUSIONS

This study indicates that corticosteroid injections are a useful treatment for de Quervain's tenosynovitis, leading to treatment success 73.4% of the time within 2 injections. This study also suggests that female sex and BMI >30 are associated with increased treatment failure.

Open Surgery Versus Ultrasound-Guided Corticosteroid Injection for Trigger Finger: A Randomized Controlled Trial With 1-Year Follow-up

PURPOSE

Trigger finger is a common condition with a lifetime prevalence of 2%. Corticosteroid injection is a treatment often considered as a first-line intervention with reported cure rates between 60% and 90% in observational cohorts. Nevertheless, open surgery remains the most effective treatment with reported cure rates near 100%. Head-to-head trials on these treatments are limited. We investigated the efficacy of open surgery compared with ultrasound-guided corticosteroid injections.

METHODS

The study was performed as a single-center, randomized, controlled trial with a 1-year follow-up. A total of 165 patients received either open surgery (n = 81) or ultrasound-guided corticosteroid injection (n = 84). Follow-up was conducted at 3 and 12 months. If the finger had normal movement or normal movement with discomfort at latest follow-up, the outcome was considered a success. Secondary outcomes were postprocedural pain and complications.

RESULTS

The groups were similar at baseline except for lower alcohol consumption in the open surgery group. At 3 months, 86% and 99% were successfully treated after corticosteroid injection and open surgery, respectively. At 12 months, 49% and 99% were considered successfully treated after corticosteroid injection and open surgery, respectively. The pain score at latest follow-up was significantly higher in the corticosteroid injection group. Complications after open surgery were more severe and included 3 superficial infections and 1 iatrogenic nerve lesion. After corticosteroid injection 11 patients experienced a steroid flare and 2 had fat necrosis at the site of injection.

CONCLUSIONS

Open surgery is superior to ultrasound-guided corticosteroid injections. Complications after open surgery are more severe; this must be taken into account when advising patients with regard to treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies

INTRODUCTION

local glucocorticoids injections are widely administered for the treatment of tendinopathies. positive results have been observed in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures has been reported. the characteristics of the tendinopathies, the clinical peculiarities of the patient, and the technique used to administer glucocorticoids, can influence the therapeutic response. Areas covered: After reviewing the pertinent literature on the clinical results, basic information, both on the pathogenesis of tendinopathies and the effects of glucocorticoids on tendons, is reported. The pharmacological properties of glucocorticoids are useful to counteract some pathogenetic mechanisms of tendinopathies. However, several experimental studies suggest that the direct action of glucocorticoids on tendons is detrimental. Loss of collagen organization, impaired viability of fibroblasts, depletion of stem cells pool, and reduced mechanical properties have been observed. Expert opinion: Drawbacks of local glucocorticoids injections could be predicted on an individual basis, after a careful appraisal of patient characteristics and concomitant medications, along with the specific stage of tendon disease.

Effect of Metabolic Syndrome on the Outcome of Corticosteroid Injection for Trigger Finger: Matched Case-Control Study

PURPOSE

To compare the efficacy of corticosteroid injections in treating trigger finger in patients with and without metabolic syndrome (MS).

METHODS

Fifty-one patients with trigger finger and MS were matched for age and sex with 52 control patients without MS. All patients were treated with a single corticosteroid injection. The response to treatment, including objective triggering, tenderness at the A1 pulley, and Quick Disabilities of the Arm, Shoulder, and Hand score (QuickDASH) were assessed at 6, 12, and 24 weeks' follow-up. Before the 24-week evaluation, 7 in the MS group and 10 in the control group were lost to follow-up.

RESULTS

Prior to treatment, patients with MS had Quinnell grades and initial mean QuickDASH scores similar to those in the control group. The proportion of treatment failure for the MS group (49%) was significantly higher than that of control group (19%) after 6 months' follow-up. Unresolved triggering was more prevalent in patients in the MS group at the 12- and 24-week follow-ups. Local tenderness was more persistent in the MS group than in the control group throughout the 24 weeks of follow-up. After 24 weeks of follow-up, 14 patients (27%) in the MS group and 6 (12%) in the control group underwent surgical release. QuickDASH scores of the MS group were worse than those of the control group at the 12- and 24-week follow-ups.

CONCLUSIONS

Trigger finger patients with MS are at risk of poorer functional outcomes and treatment failure after a single corticosteroid injection than age- and sex-matched controls.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Early Patient Satisfaction with Different Treatment Pathways for Trigger Finger and Thumb

Little is known about factors related to patient satisfaction with treatment for trigger digits. This study tested the null hypothesis that there are no factors associated with treatment satisfaction 2 months after completion of treatment (absence of triggering) or 4 months after the last visit for patients with a trigger thumb or finger. Secondary null hypotheses were: 1) There are no factors associated with a change in patients' preferred treatment before and after consultation with a hand surgeon; and 2) Initial treatment provided is not different from final received treatment. In an observational study, 63 English-speaking adult patients were enrolled after being diagnosed with one or more new idiopathic trigger digits by one of two hand surgeons, but before the hand surgeon discussed treatment options. Patients were asked to fill out questionnaires at enrollment. Final evaluation was by phone. Satisfaction with treatment was not related to the initial treatment or other patient or disease factors. Twenty-three patients (37 %) had a different preference for treatment after talking with a hand surgeon. Involvement of the long and ring fingers were the only factors associated with staying with pre-visit treatment preferences. There was a significant difference in proportions of the various treatments provided at enrollment and final treatment recorded at the final phone evaluation, 14 patients (22 %) had a subsequent alternative form of treatment. Patients' preferences for trigger finger treatment often change after consulting with a hand surgeon and during treatment, but these choices do not affect treatment satisfaction.

Prognostic Indicators for Recurrent Symptoms After a Single Corticosteroid Injection for Carpal Tunnel Syndrome

BACKGROUND

Corticosteroid injections are commonly used in the treatment of carpal tunnel syndrome in adults. This study sought to determine success rates early on and at one year postoperatively of a single corticosteroid injection while identifying prognostic indicators for symptom recurrence and repeat intervention.

METHODS

Fifty-four consecutive wrists in forty-nine patients with carpal tunnel syndrome treated with a single corticosteroid injection were prospectively enrolled. Demographic data and information on comorbidities were identified with a study-specific questionnaire. The Boston Carpal Tunnel Questionnaire was administered prior to injection. Patients returned to clinic at six weeks and were contacted at three, six, nine, and twelve months post-injection to determine symptom and intervention status. Kaplan-Meier analysis and Cox regression modeling were used to estimate recurrence rates and to identify predictors of symptom recurrence and repeat intervention.

RESULTS

Fifty-four symptomatic wrists in forty-nine patients with a mean age of fifty-three years were included. Two patients (two wrists) were lost to follow-up. Patients reported symptom recurrence in thirty-one wrists at a median duration of 155 days post-injection. Nineteen wrists underwent carpal tunnel release at a median time of 181 days after the injection. No patient underwent a repeat injection. In our study, diabetic patients were at a 2.6-fold greater risk of reporting recurring symptoms within a one-year follow-up period. Survivorship free from symptom recurrence was 53% at six months and 31% at twelve months; survivorship from repeat intervention was 81% at six months and 66% at twelve months.

CONCLUSIONS

A single injection achieved symptom relief in 79% of patients at six weeks; these results were maintained in 31% of patients at twelve months. Diabetic patients were at higher risk of symptom recurrence.

Trigger Finger: Adult and Pediatric Treatment Strategies

Trigger fingers are common tendinopathies representing a stenosing flexor tenosynovitis of the fingers. Adult trigger finger can be treated nonsurgically using activity modification, splinting, and/or corticosteroid injections. Surgical treatment options include percutaneous A1 pulley release and open A1 pulley release. Excision of a slip of the flexor digitorum superficialis is reserved for patients with persistent triggering despite A1 release or patients with persistent flexion contracture. Pediatric trigger thumb is treated with open A1 pulley release. Pediatric trigger finger is treated with release of the A1 pulley with excision of a slip or all of the flexor digitorum superficialis if triggering persists.

Ultrasound-Guided Hyaluronic Acid Injections for Trigger Finger: A Double-Blinded, Randomized Controlled Trial

OBJECTIVES

To investigate the effects of ultrasound-guided injections of hyaluronic acid (HA) versus steroid for trigger fingers in adults.

DESIGN

Prospective, double-blinded, randomized controlled study.

SETTING

Tertiary care center.

PARTICIPANTS

Subjects with a diagnosis of trigger finger (N=36; 39 affected digits) received treatment and were evaluated.

INTERVENTIONS

Subjects were randomly assigned to HA and steroid injection groups. Both study medications were injected separately via ultrasound guidance with 1 injection.

MAIN OUTCOME MEASURES

The classification of trigger grading, pain, functional disability, and patient satisfaction were evaluated before the injection and 3 weeks and 3 months after the injection.

RESULTS

At 3 months, 12 patients (66.7%) in the HA group and 17 patients (89.5%) in the steroid group exhibited no triggering of the affected fingers (P=.124). The treatment results at 3 weeks and 3 months showed similar changes in the Quinnell scale (P=.057 and .931, respectively). A statistically significant interaction effect between group and time was found for visual analog scale (VAS) and Michigan Hand Outcome Questionnaire (MHQ) evaluation (P<.05). The steroid group had a lower VAS at 3 months after injection (steroid 0.5±1.1 vs HA 2.7±2.4; P<.001). The HA group demonstrated continuing significant improvement in MHQ at 3 months (change from 3wk: steroid -2.6±14.1 vs HA 19.1±37.0; P=.023; d=.78).

CONCLUSIONS

Ultrasound-guided injection of HA demonstrated promising results for the treatment of trigger fingers. The optimal frequency, dosage, and molecular weight of HA injections for trigger fingers deserve further investigation for future clinical applications.

A scoping review of disabilities of the arm, shoulder, and hand scores for hand and wrist conditions

PURPOSE

To evaluate the variability of reported baseline Disabilities of the Arm, Shoulder, and Hand (DASH) scores for non-acute hand and wrist conditions. We hypothesized that DASH scores for evaluation of hand and wrist pathology would provide a map of scores that would correspond to severity. In addition to providing a catalog of DASH scores for various upper extremity pathologies, we hypothesized that this review would support the validity of the DASH instrument.

METHODS

A literature search was performed using 3 databases (MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials) from the earliest available date through January 1, 2013. Search terms included "DASH" and "hand" and combinations of conditions found in the initial search. The search was restricted to studies with baseline DASH scores and DASH scores for isolated conditions, and written in the English language.

RESULTS

Our search identified 1,770 citations; 136 full-text articles were reviewed and 85 studies were included in the scoping review. This provided 100 DASH scores mapped for 24 different diagnoses. Most articles (67%) included chronic conditions for inflammatory or degenerative pathologies rather than posttraumatic disorders. Posttraumatic DASH score reporting ranged from 4 months to 11 years after injury, and final outcome scores varied among studies assessing the same pathology. The greatest variation and highest scores were for de Quervain tendinitis (range, 29-93) and scapholunate advance collapse (range, 17-89). These scores indicated higher disability in de Quervain tendinitis and wrist osteoarthritis compared with conditions such as thumb amputation and upper extremity replantation.

CONCLUSIONS

Substantial variation in the DASH scores and methodology was found and indicates a need for further study of the DASH to allow for standardized interpretation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

PROSPECTIVE STUDY ON THE MANAGEMENT OF TRIGGER FINGER

Trigger finger is one of the very common conditions encountered in hand surgery. Currently, the treatment modes we offer in our clinics are combination therapy of topical NSAIDS, occupational therapy and splinting or invasive modes involving corticosteroid injections and trigger finger release.

This is a prospective review looking at the outcomes of the various initial treatment modules currently used for treating trigger fingers and the rate of surgery following non-surgical treatment.

From our study we have noted that 26% of the digits which were subjected to combination therapy eventually underwent surgery whereas 60% of digits which received corticosteroid injections underwent surgery. Even though our results comparing operation rates are not statistically significant, they appear to show that combination therapy was more effective in avoiding surgery than corticosteroid injection in lower grades of trigger.

Temporary inductions of matrix metalloprotease-3 (MMP-3) expression and cell apoptosis are associated with tendon degeneration or rupture after corticosteroid injection

Corticosteroid injections are widely used to treat enthesopathy and tendinitis, but are also associated with possible side effects, such as tendon degeneration or rupture. However, the mechanism of tendon degeneration or rupture after corticosteroid injection remains controversial. The purpose of this study was to reveal the mechanism of tendon degeneration or rupture after injection of triamcinolone acetonide (TA) or prednisolone (PSL). Forty-two rats were divided into 3 groups: A normal saline injection group (control group), a TA injection group, and a PSL injection group; the normal saline or corticosteroid was injected around the Achilles tendon. One or 3 weeks after injection, the tendons were subjected to biomechanical testing and histological analysis. At 1 week, the biomechanical strength was significantly lower in the corticosteroid groups. Histological analysis, at 1-week post-injection, showed collagen attenuation, increased expression of MMP-3 and apoptotic cells in the corticosteroid groups. The histological changes and biomechanical weaknesses of the tendon were not seen at 3 weeks. These alterations appeared to be involved in tendon degeneration or rupture after corticosteroid injection.

Percutaneous release of trigger fingers

Open surgery has been indicated as the surgical treatment for trigger finger for many years; however, minimally invasive techniques are replacing conventional methods. Minimally invasive techniques enable early recovery of the patient with minimal damage to soft tissues. The authors’ study showed that levels of effectiveness of open surgical and percutaneous methods were superior to those of the conservative method using corticosteroid based on the cure and reappearance rates of the trigger. Percutaneous pulley release for treating trigger finger is a safe, effective, and minimally invasive surgical alternative.

Corticosteroid injection therapy for trigger finger or thumb: a retrospective review of 577 digits

BACKGROUND

Stenosing flexor tenosynovitis of the digital flexor tendon (trigger digit) is a common condition encountered by hand surgeons. Our purpose was to determine the efficacy of corticosteroid injections and review the demographic profile of patients with trigger digits.

METHODS

We reviewed the records of 362 patients (577 trigger digits) treated with steroid injections (8 mg of triamcinolone acetonide in 1 % lidocaine) from 1998 through 2011. Follow-up (intervention to last visit) averaged 66.4 months. We assessed patient demographics (e.g., gender, age, diabetes mellitus, hand dominance, trigger digit distribution) and determined recurrence rate and injection duration of efficacy. If one injection failed, additional injections or surgical A1 pulley release were offered. Results were analyzed with Student's t test or Fisher's exact test (significance, p < 0.05).

RESULTS

Women (258, 71.3 %) were affected significantly (p < 0.001) more frequently than men (104, 28.7 %) and at a significantly (p < 0.001) younger age (average, 58.3 versus 62.1 years, respectively). Eighty patients (22.1 %) were diabetic. We observed no correlation between trigger digit and hand dominance. The two most commonly affected digits were the right long finger (17.8 %) and right thumb (17.7 %). For 721 injections, the recurrence rate was 20.3 %; there were no major complications. For recurrences, the injection efficacy averaged 315 days. Surgery was required for 117 patients.

CONCLUSIONS

Injection therapy is safe and highly effective (79.7 %). Women were affected by trigger digits more often than men and at a younger age. Surgical release provides a definitive therapeutic option if corticosteroid injection fails.

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.

Resolution and recurrence rates of idiopathic trigger finger after corticosteroid injection

BACKGROUND

This study addresses factors associated with apparent resolution and recurrence of triggering using data from providers with various treatment strategies.

METHODS

A retrospective review identified 878 adult patients with 1,210 Quinnell grade 2 or 3 trigger fingers that had one or more corticosteroid injections by one of three surgeons between 2001 and 2011. Two surgeons injected dexamethasone, but one had patients return 1 month after injection and was quick to recommend surgery (strategy A) and the other had patients return 2 months after injection, offered another injection or surgery, and followed the patient's preference. One surgeon used triamcinolone, had patients return only if the injection did not work, and waited at least 3 months to offer surgery. Factors associated with apparent resolution and recurrence of triggering were sought in bivariable and multivariable statistical analysis.

RESULTS

Triamcinolone injection was associated with more frequent apparent resolution (83 %), than dexamethasone injection (30 %). Apparent resolution of triggering was also associated with a delayed surgery treatment strategy (B and C) and the affected finger (long and ring fingers were less likely to resolve). Return with triggering after documented or presumed resolution occurred in 188 fingers (33 %) and was associated with triamcinolone injection, index, long and ring finger, and orally treated non-insulin-dependent diabetes mellitus. Strategy A had the lowest initial apparent resolution rate, the highest proportion of patients having surgery, and the lowest final triggering rate of 10 %.

CONCLUSION

Both treatment strategy and type of corticosteroid determine apparent resolution and recurrence rates.

Compound f: the history of hydrocortisone and hand surgery

Hydrocortisone (cortisol) is used daily in the practice of medicine and hand surgery. It has an effective use in a number of orthopedic conditions, including tendinitis, tenovaginitis, bursitis, carpal tunnel syndrome, and joint inflammation. But are surgeons aware of how this important pharmaceutical agent was discovered and prepared for clinical trial and who was responsible for its first clinical application? How did medical doctors determine that, like penicillin, cortisone and its derivative hydrocortisone would have such a life-changing effect on certain medical conditions? The purpose of this review is to relate the story of the development of cortisone (Compound E) and hydrocortisone (Compound F) and how both influenced the practice of hand surgeons in the treatment of rheumatoid arthritis and related inflammatory conditions. This history of cortisone and hydrocortisone also relates to the importance of partnership between physician and research scientist and of the principle at Mayo Clinic that the only concern--or the first concern--is the concern for the patient.

A retrospective review to determine the long-term efficacy of orthotic devices for trigger finger

PURPOSE

To evaluate the use of orthotic devices (splints) in an attempt to resolve trigger finger.

METHODS

Data were extracted from 46 charts during a five-year period from January 2005 to December 2010. At ten weeks, patients were seen for follow-up assessment of pain and stage of stenosing tenosynovitis (SST). One-year follow-up was performed to determine if the patients required further surgical intervention or steroid injection. The data were analyzed to determine the efficacy of orthosis intervention.

RESULTS

Mean pain score preorthotic is 5.63 and postorthotic is 1.20. Mean SST score preorthotic is 3.93 and postorthotic is 1.21. There was an 87% (40 patients) success rate with the orthotic intervention; 4.3% (two patients) had surgery and 8.5% (four patients) received a steroid injection in the year after orthotic application.

CONCLUSION

This study demonstrated the efficacy of orthoses for the reduction of pain and SST score for patients who have trigger finger.

LEVEL OF EVIDENCE

3.

Ultrasound-guided injection of a corticosteroid and hyaluronic acid: a potential new approach to the treatment of trigger finger

Background and Objectives: Stenosing tenosynovitis (trigger finger) is one of the most common causes of pain and disability in the hand, which may often require treatment with anti-inflammatory drugs, corticosteroid injection, or open surgery. However, there is still large room for improvement in the treatment of this condition by corticosteroid injection. The mechanical, viscoelastic, and antinociceptive properties of hyaluronic acid may potentially support the use of this molecule in association with corticosteroids for the treatment of trigger finger. This study examines the feasibility and safety of ultrasound-guided injection of a corticosteroid and hyaluronic acid compared, for the first time, with open surgery for the treatment of trigger finger.

Methods: This was a monocentric, open-label, randomized study. Consecutive patients aged between 35 and 70 years with ultrasound-confirmed diagnosis of trigger finger were included. Patients were randomly assigned to either ultrasound-guided injection of methylprednisolone acetate 40 mg/mL with 0.8mL lidocaine into the flexor sheath plus injection of 1mL hyaluronic acid 0.8% 10 days later (n = 15; group A), or to open surgical release of the first annular pulley (n = 15; group B). Clinical assessment of the digital articular chain was conducted prior to treatment and after 6 weeks, and 3, 6, and 12 months. The duration of abstention from work and/or sports activity, and any treatment complications or additional treatment requirements (e.g. physiotherapy, compression, medication) were also recorded.

Results: Fourteen patients (93.3%) in group A had complete symptom resolution at 6 months, which persisted for 12 months in 11 patients (73.3%), while three patients experienced recurrences and one experienced no symptom improvements. No patients in group A reported major or minor complications during or after corticosteroid injection, or required a compression bandage. All 15 patients in group B achieved complete resolution of articular impairment by 3 weeks after surgery, but ten patients were assigned to physiotherapy and local and/or oral analgesics for complete resolution of symptoms, which was approximately 30–40 days postsurgery. The mean duration of abstention from work and/or sport was 2–3 days in group A and 26 days in group B.

Conclusions: Although the limited sample size did not allow any statistical comparison between treatment groups, and therefore all the findings should be regarded as preliminary, the results of this explorative study suggest that ultrasound-guided injection of a corticosteroid and hyaluronic acid could be a safe and feasible approach for the treatment of trigger finger. It is also associated with a shorter recovery time than open surgery, which leads to a reduced abstention from sports and, in particular, work activities, and therefore may have some pharmacoeconomic implications, which may be further explored. In light of the promising results obtained in this investigation, further studies comparing ultrasound-guided injection of corticosteroid plus hyaluronic acid with corticosteroid alone are recommended in order to clarify the actual benefits attributable to hyaluronic acid.

Proximal phalanx injection for trigger finger: randomized controlled trial

Trigger finger is one of the most common upper extremity problems in the outpatient department. Conservative treatment is the mainstay for management of trigger digits especially steroid injection with highly satisfactory outcome and minimal complication. Conventional injection technique (CI) that approaches flexor tendon sheath over metacarpal head directly causes pain for most patients. The proximal phalanx injection technique (P1I) at palmar surface of midproximal phalanx is simple and less painful for the patients. We compared pain result and effectiveness between these two methods. Forty patients with primary trigger fingers were placed in a prospective randomized study to receive steroid injection with either the CI or P1I techniques. Demographic data were recorded. Immediately after the injection, pain score was recorded for each patient using the pain visual analog scale. The patients were followed every month for three months to determine recurrent symptoms. Student's t-test, chi-square and Fisher's exact test were used for data analysis. The mean pain VAS scores immediately post-injection were 7.3 ± 1.3 and 3.2 ± 2.2 in the CI and P1I techniques, respectively. The P1I technique group had a significantly lower pain score than CI technique group (p < 0.001). The recurrence rate was 15% in the CI technique when compared to 25% in the P1I technique which was not significant (p = 0.685). We concluded that the P1I technique is less painful than the CI technique without any significant difference in recurrence rate between the two groups at three months follow-up.

Predictors of pain during and the day after corticosteroid injection for idiopathic trigger finger

PURPOSE

Some patients report a transient increase in pain the day after a corticosteroid injection. We investigated factors associated with greater pain during and the day after a corticosteroid injection for idiopathic trigger finger.

METHODS

A total of 100 patients with trigger finger completed questionnaires measuring heightened illness concern, catastrophic thinking, depression, perceived health, expected pain, pain with injection, and pain the day after injection. We performed bivariate analysis to determine variables associated with pain with injection, next-day pain, and next-day pain greater than 4 points on an 11-point ordinal scale. We entered variables with a significant correlation into multivariable linear regression models.

RESULTS

The average pain with injection and the day after injection were 4.3 (SD 2.8) and 1.8 (SD 2.0), respectively. Expected pain, heightened illness concern, catastrophic thinking, depression, physician, and gender correlated with pain with injection. A multivariable regression model conducted in backward stepwise fashion demonstrated that physician, depression, expected pain, and female gender explained 28% of the variance in pain with injection. Pain with injection was the only significant predictor of next-day pain and pain greater than 4 points the day after injection.

CONCLUSIONS

Our data suggest that psychosocial factors are the strongest correlates of pain with corticosteroid injection, but a large portion of the variability remains unexplained. Future research will investigate cognitive/behavioral methods for decreasing pain with injection.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Treatment of trigger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery

OBJECTIVE

The aim of this study is to evaluate the effectiveness of CS injection, percutaneous pulley release and conventional open surgery for treating trigger finger in terms of cure, relapse and complication rates.

METHODS

One hundred and thirty-seven patients with a total of 150 fingers were randomly assigned and allocated into one of the treatment groups, with treatments allocated into 150 opaque and sealed envelopes. We included patients >15 years of age with a trigger on any finger of the hand (Types II-IV) and used a minimum follow-up time of 6 months. The primary outcome measures were cures, relapses and failures.

RESULTS

Forty-nine patients were assigned to the conservative group to undergo CS injections, whereas 45 and 56 were assigned to undergo percutaneous release and outpatient open surgery, respectively. The trigger cure rate for patients in the injection method group was 57%, and wherever necessary, two injections were administered, which increased the cure rate to 86%. For the percutaneous and open release methods, remission of the trigger was achieved in all cases.

CONCLUSIONS

The percutaneous and open surgery methods displayed similar effectiveness and proved superior to the conservative CS method regarding the trigger cure and relapse rates. Trial registration. Current Controlled Trials, http://www.controlled-trials.com/, ISRCTN19255926.

Tendon disorders of the hand and wrist

The terminology used to describe most common tendon disorders in the hand and wrist suggests that they are inflammatory in nature, although current evidence indicates that mechanical and degenerative factors are more important. Corticosteroid injections provide relief in 60% or more of cases; however, the duration of their effectiveness remains uncertain. Surgical release of the stenotic pulley or sheath is curative in well over 90% of cases; complications of surgery are rare, and relief is long-lasting. Enlightened management of these common problems demands evidence-based guidelines defining indications for surgery that will maximize outcomes and minimize costs.