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

Percutaneous Surgical Treatment of Trigger Finger

Objective  To evaluate the efficacy of percutaneous release therapy for patients with trigger finger. Methods  We obtained the hospital records of 120 patients who underwent percutaneous release, and their final status was evaluated by telephone. Results  The sample was composed of 84 (70%) female and 36 (30%) male patients, with a mean age of 55.4 (range: 30-79) years, and a mean follow-up of 28.6 (range: 6-74) months. Successful results were obtained in 118 (98.3%) patients. In the first week after the procedure, release was performed through the open surgical method in two patients who had complaints of re-entanglement in their fingers. No limitation to the joint range of motion was detected in any finger. Conclusions  Percutaneous release has advantages over the open surgery method in the surgical treatment of trigger finger, due to its low cost, ease of application, performance outside operating room conditions, and similar complication rates.

Percutaneous Surgery for Trigger Finger Treatment Using a Novel Surgical Device: An Experimental Study on Fresh Cadavers

Purpose

Trigger finger, a stenosing tenosynovitis of the flexor tendon at the A1 pulley, can cause pain and impair daily activities. Despite common surgical interventions, postsurgical complications are frequent, prompting the search for less invasive techniques.

Methods

An experimental study was conducted on fresh cadavers to compare three techniques: the first using a PulleyCut without ultrasound guidance, the second using a PulleyCut with ultrasound guidance, and the third using a percutaneous needle technique. The complete release of the A1 pulley, integrity of the A2 pulley, flexor tendons, and neurovascular bundles were assessed.

Results

The new device group and the ultrasound-guided group demonstrated 100% complete release of the A1 pulley, whereas the needle group achieved only 38% success. There were no A2 pulley injuries in any group. Flexor tendons were injured in 7% of cases in the new device group and 77% in the needle group. A neurovascular injury occurred in the needle group.

Conclusions

Compared with the percutaneous needle technique, the new device proved safe and effective for A1 pulley release, minimizing damage to flexor tendons and neurovascular structures. Ultrasound did not provide significant advantages, suggesting that the new device can be confidently used without ultrasound assistance. The PulleyCut represents a promising percutaneous technique for trigger finger treatment, demonstrating superiority over the needle technique in terms of efficacy and safety. These results encourage future clinical investigations to validate its practical application.

Type of study/level of evidence

Therapeutic IIc.

Open Versus Percutaneous Fixation of Trigger Finger: Meta-Analysis of Clinical Outcomes

PURPOSE

With variable and conflicting results to date, it remains unclear whether the percutaneous or open surgical A1 pulley release technique is superior regarding safety and efficacy. The goal of this meta-analysis was to compare the two techniques.

METHODS

PubMed, Cochrane, and Google Scholar (pages 1-20) were searched through August 2023. Eight randomized controlled trials met the inclusion criteria and were included in this meta-analysis.

RESULTS

Of the eight included studies and 548 total patients, there were 278 subjects in the percutaneous release group and 270 subjects in the open release group. There was no significant difference between the two surgical techniques in postoperative rates of revision, complications, or pain.

CONCLUSIONS

This meta-analysis found no significant difference between open and percutaneous techniques regarding the need for revision procedures, complications, or postoperative pain. Therefore, both open and percutaneous releases are appropriate.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic I.

Isolated A1 pulley release surgery for trigger finger leads to significant increase in tip-to-tip pinch strength

BACKGROUND

Even in the first application of patients with early complaints of trigger finger, pinch strength of the hand may be affected. Therefore, it is difficult to assess the change of strength as a result of treatment in this problem. In this study, we aimed to evaluate the change of strength taking into account both measured and expected pinch strengths before and after A1 pulley release surgery.

METHODS

Thirty fingers (9 thumbs, 12 middle, 8 ring and 1 index fingers) of 26 patients (17 women, 9 men) who underwent A1 pulley release were included into this study. The mean age of the patients was 53 (16-71). Tip-to-tip finger pinch strengths were measured pre-operatively and at 3 months postoperatively. The expected strengths were calculated using the values obtained from the healthy side and taking into account the dominance effect. In the analysis, pre-operative and postoperative measured strength/expected strength ratios were compared.

RESULTS

The mean of measured pinch strength/expected pinch strength ratio was 0.91 ± 0.3 pre-operatively and 1.14 ± 0.3 postoperatively (p < 0.05).

CONCLUSION

With the calculation method used in this study, it was found that there was a significant increase in the tip-to-tip pinch strength after surgical A1 pulley release for the trigger finger.

LEVEL OF EVIDENCE

III (Retrospective cohort study).

Organisational capabilities, outcomes, and benefits of trigger finger release surgery in primary care: a service evaluation study

BACKGROUND

Trigger finger is a common hand condition in which a finger is unable to fully extend owing to a thickening of the tendon and its sheath, causing the finger to lock in a bent position.

AIM

To assess the viability of carrying out trigger finger surgeries in NHS primary care in terms of clinician and patient acceptance, experience, and outcomes; and operational requirements of this service for wider application.

DESIGN & SETTING

A pilot study for a new service in primary care in Leicestershire, UK.

METHOD

A total of 214 trigger finger release surgery procedures were carried out between 22 August 2019 and 25 October 2022 by a single hand surgeon in a single primary care surgery. Data were analysed using information from SystmOne, which is a patient database linked with the NHS.

RESULTS

Thirty-two cases out of 214 (15.0%) experienced a wait time of <10 days from the GP referral to the first outpatient appointment (OPA). Out of 214 procedures, there were 26 (12.1%) postoperative complications that required follow-up action. Of the total number of cases where postoperative complications were identified, 13 cases required further follow-up action, while the remaining 13 did not have any identifiable further follow-up action and were regarded as closed cases thereafter.

CONCLUSION

Trigger finger release surgery in primary care offers an opportunity to reduce pressures on secondary care orthopaedic referrals, as well as offering patients faster and effective surgical treatment while utilising fewer NHS resources.

Prospective Randomized Controlled Trial Comparing Absorbable and Nonabsorbable Sutures in A1 Pulley Release

BACKGROUND

Both absorbable and nonabsorbable sutures are used to correct palmar incisions or lacerations. Nonabsorbable sutures have been used without complications but require removal at a follow-up appointment. Alternatively, the use of absorbable sutures has increased in popularity as postoperative suture removal is not required but is associated with local immunological and inflammatory responses. In this study, we compared the scar quality and outcomes of nonabsorbable and absorbable sutures in A1 pulley release.

METHODS

Patients who underwent A1 pulley release were randomized to 1 of 2 suture materials. The Patient Scar Assessment Scale, Observer Scar Assessment Scale, Visual Analogue Scale, and Disabilities of the Arm, Shoulder, and Hand scores were collected at 2, 6, and 12 weeks postoperatively. Among the 41 patients included in the study, 23 were randomized to the nonabsorbable suture group, and 18 to the absorbable suture group.

RESULTS

There were no significant differences between the two suture groups in the aforementioned assessments. Complication rates were higher in the nonabsorbable suture group, but the difference was not statistically significant. Notably, 1 case in the absorbable suture group had uncontrolled postoperative bleeding and required reoperation.

CONCLUSION

We found no significant difference between the two materials in terms of the Patient or Observer Scar Assessment Scales, overall complication rates, symptom scores, or pain scores. Therefore, the choice using absorbable or nonabsorbable can be guided by other factors such as physician or patient preference, availability, and cost.

The Effectiveness of Rehabilitation after Open Surgical Release for Trigger Finger: A Prospective, Randomized, Controlled Study

BACKGROUND

It is not clear whether rehabilitation after surgery for trigger finger is effective. The aim of this study was to reveal its effectiveness for trigger finger.

METHODS

This study was a randomized, controlled trial that included patients who underwent operations for trigger fingers. The patients in the rehabilitation group had postoperative occupational therapy (OT) for 3 months, while the patients in the control group were not referred for rehabilitation but received advice for a range of motion exercises. We evaluated the severity of trigger finger, Disability of Arm-Shoulder-Hand (DASH) score, pain-visual analogue scale (VAS), grip strength, whether they gained a full range of motion (ROM), and complications before and after surgery.

RESULTS

Finally, 29 and 28 patients were included in the control and rehabilitation groups, respectively. At final follow-up, the DASH score, grip strength, and ROM were significantly improved in the rehabilitation group compared to that preoperatively. At final follow-up, pain was significantly improved in both groups from that preoperatively. There were no significant differences in the results, including the DASH score, grip strength, ROM and pain-VAS between the control and rehabilitation groups at the final follow-up. Subgroup analysis showed that there is a significant difference in the DASH score of patients doing housework or light work and those with a duration of symptoms >12 months between the control and rehabilitation groups at the final follow-up.

Three-Month Complication Rate of Ultrasound-Guided Soft Tissue Surgical Procedures Across Six Sports Medicine Clinics

OBJECTIVES

To 1) determine the types and frequency of complications within 3 months following ultrasound-guided surgical procedures, and 2) identify any patient demographics, co-morbidities, or procedural characteristics that were associated with an increased risk of complications.

METHODS

A retrospective chart review was performed at six Sports Medicine clinics across the United States. The Clavien-Dindo classification was used to categorize procedural complications on a 5-point scale from 1, representing any deviation in post-procedure care without requiring pharmacological or invasive treatment to 5, representing death. Generalized Estimating Equations for binomial outcomes with a logit link were used to estimate the overall and procedure-specific 3-month complication rates.

RESULTS

Among 1902 patients, 8.1% (n = 154) had diabetes and 6.3% (n = 119) were current smokers. The analysis included 2,369 procedures, which were performed in either the upper extremity (44.1%, n = 1045) or lower extremity (55.2%, n = 1308) regions. The most common procedure was ultrasound-guided tenotomy (69.9%, n = 1655). Additional procedures included, trigger finger release (13.1%, n = 310), tendon scraping (8.0%, n = 189), carpal tunnel release (5.4%, n = 128), soft tissue release (2.1%, n = 50), and compartment fasciotomy (1.6%, n = 37). Overall, there was a complication rate of 1.2% (n = 29 complications; 95% CI: 0.8-1.7%). Individual procedures had complication rates that ranged from 0 to 2.7%. There were 13 Grade I complications in 13 patients, 12 Grade II complications in 10 patients, 4 Grade III complications in 4 patients, and 0 Grade IV or V complications. No associations between complication risk and any patient demographics (age, sex, BMI), co-morbidities (diabetes, smoker), or procedure characteristics (type, region) were identified.

CONCLUSION

This retrospective review provides an evidence-based estimate supporting the low level of risk associated with ultrasound-guided surgical procedures for patients from a variety of geographical settings who are seeking care at private and academic-affiliated clinics.

Does Surgical Experience Affect the Outcomes During Percutaneous Release of the Trigger Finger?

Background Trigger finger is a condition characterized by clicking or locking during finger movement, sometimes resulting in the freezing of a finger in flexion or extension. The aim of our retrospective study was to determine the effect of the surgeon's learning curve on clinical outcomes in percutaneous release of the trigger finger. In addition, we evaluated the effects of diabetes and local steroid injections on clinical outcomes. Methodology A total of 954 trigger fingers in 678 patients were reviewed from 2012 to 2022. All percutaneous release procedures were performed by a single surgeon in our institute under local anesthesia. The main outcome measures were recurrence and patient satisfaction. In addition, all patients were evaluated in terms of re-operation and complications. The mean follow-up period was 54.87 months. Results There was complete relief of symptoms in 636 (93.81%) patients, and 22 (3.24%) patients had mild pain but were satisfied. We found that the success rate increased over time. The success rate was 91.4% in the first three years and increased to 98.25% in the next seven years (p = 0.001). There was no statistically significant difference between the diabetic and non-diabetic groups in terms of recurrence, satisfaction rate, and complications (p > 0.05). There was no statistically significant difference in terms of recurrence, satisfaction rate, and complications between the groups that received and did not receive steroid injections (p > 0.05). Conclusions Percutaneous release is a safe and reliable procedure in the treatment of trigger fingers, and the success rate increases as the experience increases. Moreover, diabetes mellitus and steroid injections did not affect the clinical results.

Surgical Treatment of Stenosing Tenosynovitis: Early and Late Outcomes, Complications

Background. The thickening of A1 pulley of the tendon sheath limits the excursion of flexor tendon. Stenosing tenosynovitis causes finger movements dysfunction and pain. Objective. To analyze early and late outcomes of patients with stenosing tenosynovitis after surgical treatment – anulotomy. Methods. All patients had standard surgical procedure – open anulotomy of A1 pulley. Pain (verbal pain scale), hand and arm function (QuickDASH) and complications were recorded before surgery, after 1 week, 3 months and 6 months post surgery. Results. There were 45 patients, 29 (64%) female, 16 (36%) male. The highest pain score was recorded before surgery median 5 (IQR 5). The lowest pain score median 2 (IQR 2) was recorded after 6 months post surgery. The difference of the results after 1 week, 3 months and 6 months was statistically significant p < 0.001. The worst hand and arm function was before surgery and 1 week post surgery. Accordingly: medians 52 (IQR 33) and 52 (IQR 35). Full hand function recovery was noticed after 6 months post surgery median 0 (IQR 11). The difference is statistically significant p < 0.001. Conclusions. Surgical treatment, open anulotomy is one of the most effective methods for stenosing tenosynovitis. After this procedure pain and hand function improves greatly. However, for some patients it might cause discomfort of the hand because of the scar’s sensitivity and location.

National Benchmarks for the Efficacy of Trigger Finger and the Risk Factors Associated With Failure

BACKGROUND

The purpose of this study was to compare the efficacy of single and multiple corticosteroid injections used for symptomatic trigger finger. The rates of subsequent injections and the rate of tendon sheath release are reported along with the identification of risk factors correlated with failure of injection.

METHODS

A retrospective review of a national healthcare database was conducted identifying patients with a diagnosis of trigger finger or thumb. Inclusion required a tendon sheath injection on the same day or within six weeks of diagnosis. Patient cohorts were further stratified based on treatment success and those requiring additional injections within 6 months or surgery within 1 year of initial diagnosis.

RESULTS

Thirty-one thousand seven hundred fifty-one patients met inclusion criteria and underwent an initial injection within the study period. The efficacy of initial, second, and third injection was 66.3%, 79.4%, and 79.6%, respectively. Of the patients who failed an injection, 9.4% had tendon sheath release after a primary injection, 23.1% had surgery after a second injection, and 30.4% had surgery after a third injection. Only obesity (OR 1.2; P < 0.0001) and concomitant diagnosis of carpal tunnel syndrome (OR 1.4; P < 0.0001) were found to be significant for injection failure on multivariate logistic regression analysis.

DISCUSSION

Overall corticosteroid injections were effective in greater than 65% of patients. This information may help guide treatment practice because there seems to be continued additional benefit to repeat corticosteroid injections after injection failure.

Mast cell presence in tendon sheaths of trigger fingers: implications on pathogenesis and clinical presentation

Trigger finger is a common hand disorder; however, its pathogenesis remains unknown. In this study, we aimed to investigate mast cells, fibroblast activators that synthesize collagen, in the tendon sheaths of trigger fingers. We investigated the presence of mast cells and their association with changes in the collagen content of the tendon sheath and clinical data. We performed a multicenter prospective study of 77 adult patients with trigger finger who had undergone resection of the first annular pulley between August 2012 and January 2020. The tendon sheath was immunostained with an anti-tryptase antibody to confirm mast cell presence. The percentage of collagen in the tendon sheath was determined by picrosirius red staining observed through a polarization microscope. The clinical data, including the duration from symptom onset to surgery, severity, pain numerical rating scale, and Hand20 scores, were evaluated. Tryptase-positive mast cells were recognized in 83.5% of all specimens. The mast cell presence group (Group P) had a significantly higher percentage of type-3 collagen in the tendon sheath than the non-mast cell presence group (Group N) (Group P, 15.6%; Group N, 12.7%; p = 0.03). Moreover, Group P had significantly higher pain numerical rating scale (Group P; 5, Group N; 3, p = 0.04) and Hand20 (Group P; 35.5, Group N; 13.0, p = 0.01) scores than Group N. These findings suggest that mast cell presence in the tendon sheath of the trigger finger is related to the pathology and clinical symptoms of trigger finger.

Acupotomy in the treatment of tenosynovitis of hand flexor tendons: A systematic review and meta-analysis

BACKGROUND

Acupotomy was used to treat tenosynovitis of hand flexor tendons (THFT) in China. But it's uncertain about the efficacy of acupotomy for THFT. We plan to evaluate the efficacy and safety about acupotomy therapy in the treatment of THFT through this review.

METHODS

The protocol about this review was registered in PROSPERO (registration number: CRD42022330568). We searched 6 databases from their respective inception dates to January 11, 2022. Studies searched was screened by our reviewers, and then the raw data was filtered out. We used RevMan 5.3 software to perform statistical analysis.

RESULTS

11 studies involving 828 patients were shortlisted. The experimental group showed obvious advantages compared with the control group, such as effective rate (odds ratio [OR] = 6.77, 95% CI [confidence intervals] = [3.89, 11.77], P < .00001), cure rate (OR = 3.32, 95% CI = [1.81, 6.11], P = .0001) and Vas score (MD = -1.21, 95% CI = [-2.00, -0.42], Z = 3.01, P < .003).

CONCLUSIONS

According to the above results, Acupotomy is an effective and safe treatment for THFT. So it should be recommended for the treatment of THFT patients.

Temporal Relationship of Corticosteroid Injection and Open Release for Trigger Finger and Correlation With Postoperative Deep Infections

PURPOSE

Previous single-institution studies have shown a relationship between corticosteroid injection and infection after surgery if open trigger release occurs within 90 days. We queried an insurance claims database to evaluate the temporal relationship between a corticosteroid injection and the development of a surgical site infection requiring secondary surgery in patients undergoing trigger release.

METHODS

The PearlDiver database was queried for adults who underwent unilateral trigger finger release surgery from 2012 to 2018. The total number of injections, time from last injection to surgery, and preoperative antibiotic use were determined, in addition to the rates of postoperative administration of antibiotics and deep infection requiring surgery at 30, 60, and 90 days after surgery. Logistic regression analysis was used to evaluate the odds of deep infection at 30, 60, and 90 days.

RESULTS

A total of 14,686 patients were included; at least 1 corticosteroid injection was administered to 5,173 patients prior to surgery. When grouped based on whether a corticosteroid injection was administered prior to surgery, the postoperative infection rates between the groups were similar at 30, 60, and 90 days. When surgery was performed within 1 month of injection, increased odds of deep infection requiring irrigation and debridement were seen at 60 (odds ratio 2.92 [1.01-7.52]) and 90 days (odds ratio 3.01 [1.13-7.25]). Postoperative antibiotic use in the groups with and without a preoperative injection was similar at all queried time points, but patients who underwent open trigger finger release within 1 month of a prior injection had significantly increased odds (odds ratio 5.77 [1.41-22.06]) of using antibiotics after surgery. Male sex, a higher Elixhauser comorbidity index, and rheumatoid arthritis were additional independent risk factors for a deep infection.

CONCLUSIONS

Patients who undergo open trigger release within 1 month of a corticosteroid injection are at increased odds of developing a postoperative infection requiring surgical debridement.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Complications and Functional Outcomes following Trigger Finger Release: A Cohort Study of 1879 Patients

BACKGROUND

Although trigger finger release is considered a safe procedure, large cohort studies reporting consistent complication rates and functional outcomes are scarce. Further insight into outcomes of this commonly performed procedure is essential for adequate treatment evaluation and patient counseling. Therefore, the aim of this study was to assess the complication rates and functional outcomes following trigger finger release.

METHODS

This is an observational multicenter cohort study of patients undergoing trigger finger release. The primary outcome included the occurrence of complications. The secondary outcome was change in hand function (Michigan Hand outcomes Questionnaire) from baseline to 3 months postoperatively.

RESULTS

Complications were observed in 17.1 percent of 1879 patients. Most complications were minor, requiring hand therapy or analgesics (7.0 percent of all patients), antibiotics, or steroid injections (7.8 percent). However, 2.1 percent required surgical treatment and 0.2 percent developed complex regional pain syndrome. The Michigan Hand Outcomes Questionnaire total score improved from baseline to 3 months postoperatively with 12.7 points, although the authors found considerable variation in outcomes with less improvement in patients with better baseline scores.

CONCLUSIONS

This study demonstrates that trigger finger release results in improved hand function, although complications occur in 17 percent. Most complications are minor and can be treated with nonsurgical therapy, resulting in improved hand function as well. However, additional surgical treatment is required in 2 percent of patients. In addition, the authors found that change in hand function depends on the baseline score, with less improvement in patients with better baseline scores. Future studies should investigate factors that contribute to the variability in treatment outcomes following trigger finger release.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Nonpalmar Endoscopic versus Open Trigger Finger Release: Results from a Prospective Trial

The most common complaint after open surgical release for trigger finger is of pain and scarring at the surgical site. We hypothesized that use of a new nonpalmar endoscopic approach for release of the A1 pulley through an incision at the proximal digital crease would result in decreased scarring and faster recovery compared to those treated with standard open release.

Methods

Patients with trigger finger were prospectively enrolled and treated with a nonpalmar endoscopic versus open surgical technique. Outcome measures included scar assessment based on the Patient and Observer Scar Assessment Scale (POSAS) administered 1 week, 1 month, and 6 months postoperatively, time before return to work, occupational therapy visits, and overall satisfaction. Additional outcomes included pain medication use, operative time, and complication and recurrence rates.

Results

POSAS scores were better in the endoscopic treatment group than in the open group at all time points with a statistically significant difference seen at 1 week and 1 month postoperatively. The endoscopic group returned to work sooner, required fewer occupational therapy visits, and had better overall satisfaction compared to the open group, but the differences were not statistically significant. Complication and recurrence rates did not differ significantly between groups.

Conclusions

Patients treated for trigger finger with a nonpalmar endoscopic release through an incision at the proximal digital crease demonstrate significantly better scarring in the early postoperative period compared to patients treated with the open surgical approach. Treatment for trigger finger with this technique is as effective as the standard open technique.

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.

Prevalence and Risk Factors for Postoperative Complications Following Open A1 Pulley Release for a Trigger Finger or Thumb

PURPOSE

Although A1 pulley release is an effective treatment to reduce pain and improve hand function, complications may occur. More insight into risk factors for complications is essential to improve patient counseling and potentially target modifiable risk factors. This study aimed to identify factors associated with complications following A1 pulley release.

METHODS

Patients completed baseline questionnaires, including patient characteristics, clinical characteristics, and the Michigan Hand outcomes Questionnaire. We retrospectively reviewed medical records to identify complications classified using the International Consortium for Health Outcome Measurement Complications in Hand and Wrist conditions tool. Grade 1 complications comprise treatment with additional hand therapy, splinting, or analgesics, grade 2 treatment with antibiotics or steroid injections, grade 3A minor surgical treatment, grade 3B major surgical treatment, and grade 3C complex regional pain syndrome. Logistic regression analyses were performed to examine the contribution of patient characteristics, clinical characteristics, and patient-reported outcome measurement scores to complications.

RESULTS

Of the included 3,428 patients, 16% incurred a complication. The majority comprised milder grades 1 (6%) and 2 (7%) complications, followed by more severe grades 3B (2%), 3C (0.1%), and 3A (0.1%) complications. A longer symptom duration (standardized odds ratio [SOR], 1.09), ≥3 preoperative steroid injections (SOR, 3.22), a steroid injection within 3 months before surgery (SOR, 2.02), and treatment of the dominant hand (SOR, 1.34), index finger (SOR, 1.65), and middle finger (SOR, 2.01) were associated with a higher complication rate.

CONCLUSION

This study demonstrates that ≥3 preoperative steroid injections and a steroid injection within 3 months before surgery were the most influential factors contributing to complications. These findings can assist clinicians during patient counseling and may guide preoperative treatment. We recommend that clinicians should consider avoiding steroid injections within 3 months before surgery and to be reluctant to perform >2 steroid injections.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Corticosteroid Injection for the Treatment of Trigger Finger: A Meta-Analysis of Randomised Control Trials

Background: The purpose of this meta-analysis is to provide an evidence-based overview of the effectiveness of corticosteroid injection for the treatment of stenosing tenosynovitis (trigger digits). We have analysed only randomised control trials (RCTs) which compared the effectiveness of corticosteroid injections with control injections. Methods: The Cochrane Library, PubMed, Medline, Web of Science and Scopus were searched to identify relevant studies. The keywords for search in the database were ('stenosing tenosynovitis' OR 'trigger finger') AND injections. After screening titles and abstracts of these studies, full-text articles of studies that fulfilled the selection criteria were obtained. For the meta-analysis, we determined the pooled mean failure rate, odds ratio (OR), relative risk (RR) and 95% confidence intervals (CI) for the risk of failure rate between the corticosteroid injection group and the control group through the random-effects model. Results: Six RCTs were found that involved 368 participants. The corticosteroid injection group included 190 patients and 178 patients were included in the control group. The pooled estimate of successful treatment in the corticosteroid injections group was 63.68 ± 5.32% and that in the control group was 27.53 ± 11.52%. The pooled RR of treatment failure between the corticosteroid injection group and the control group was 0.49 (95% CI 0.40-0.60). The pooled OR of treatment failure between the corticosteroid injection group and the control group was 0.18 (95% CI 0.08-0.44). All the included studies reported either mild or no complications with corticosteroids or placebo injections. Conclusions: In the treatment of stenosing tenosynovitis, the corticosteroid injections have better outcomes compared to the control injections and this meta-analysis provides significant evidence of the effectiveness of corticosteroid injection for stenosing tenosynovitis with minimal adverse effects. Level of Evidence: Level II (Therapeutic).

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.

Current Concepts in the Management of Advanced Trigger Finger: A Critical Analysis Review

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While the majority of patients with trigger finger obtain excellent outcomes from nonoperative treatment or release of the A1 pulley, a subset of patients with advanced trigger finger, defined as trigger finger with loss of active or passive range of motion, may have incomplete symptom relief and warrant specific attention.

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Advanced trigger finger is more refractory to complete symptom resolution from corticosteroid injection, and particular attention should be paid to incomplete improvement of flexion contractures.

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Unlike simple trigger finger, the pathology in advanced trigger finger involves not only the A1 pulley but also the flexor tendon, including thickening and degeneration.

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Progression toward surgical intervention should not be delayed when nonoperative measures fail, and specific attention should be paid to persistent inability to achieve full extension following A1 pulley release.

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Facing substantial residual flexion contracture, reduction flexor tenoplasty and partial or complete resection of the superficialis tendon followed by hand therapy and splinting may be needed to allow patients to regain reliable full range of motion.

[Tendinopathies - Common Diagnoses in Hand Surgery]

Tendinopathies - Common Diagnoses in Hand Surgery Abstract. Tendinopathies are among the most frequent reasons for consulting a hand surgeon. The diagnosis can usually be made clinically. A supplementary ultrasound examination helps to visualize the pathology. Most of these diseases respond to non-surgical treatment. If surgical treatment is necessary, it can usually be performed as an outpatient procedure under local anesthesia. This article provides an overview of the most common tendinopathies of the hand and wrist, their diagnosis and treatment.

Multi-site evaluation of advanced practice hand therapy clinics for the management of patients with trigger digit

STUDY DESIGN

Prospective cohort design.

BACKGROUND

Patient time on Australian public hospital surgical outpatient department (SOPD) waitlists often exceeds clinical recommendations for chronic hand conditions. Diversion to allied health is an alternative option, however evidence regarding patient and organizational outcomes in hand therapy is lacking.

PURPOSE OF THE STUDY

To evaluate clinical and organizational efficacy, patient outcomes and satisfaction of diversion of referrals for patients with trigger digit (TD) from SOPD waitlists to Advanced Practice Hand Therapy (APHT) at 3 Australian hospitals.

METHODS

Data was collected from eligible patients with TD through chart reviews and telephone satisfaction surveys. Data included number of patients requiring SOPD review, repeat referral to SOPD in the 12 months following APHT discharge, patient-rated outcomes, satisfaction scores, wait times to SOPD review and conversion to surgery-rates. Mann Whitney-U, t-test, Pearson's chi-squared test and a Binary Logistic Regression analysis were performed.

RESULTS

104 patients completed APHT treatment. Seventy patients (67%) did not require return to the SOPD waitlist. Repeat referral to SOPD within 12 months of APHT discharge occurred for only 1 patient. Patients requiring SOPD review after APHT treatment were seen within target time frames and demonstrated 88% conversion to surgery-rates. Michigan Hand Outcome Questionnaire scores showed greater improvement in those not requiring SOPD review (P< .001~25.9 vs 4.2). Regression analysis identified a negative association between initial total Michigan Hand Outcome Questionnaire scores and unfavorable discharge outcomes (OR 0.96, P= .007). Most (81%-93%) patients indicated satisfaction with the APHT service.

CONCLUSION

Diversion of referrals for TD from SOPD to APHT is an effective waitlist management strategy, with the propensity to reduce waiting times, improve patient flow, whilst resulting in favorable clinical and patient-rated outcomes and satisfaction.

A cadaveric assessment of percutaneous trigger finger release with 15° stab knife: its effectiveness and complications

Percutaneous release of the A1 pulley has been introduced as a therapeutic approach for trigger fingers and is suggested as an effective and safe alternative, where conservative treatments fail. The aim of the current study was to determine if percutaneous release with a 15° stab knife can effectively result in acceptable efficacy and lower complication rate.

METHODS

In the present study, the percutaneous release of the A1 pulley was evaluated by percutaneous release using a 15° stab knife in 20 fresh-frozen cadaver hands (10 cadavers). One hundred fingers were finally included in the present study. The success rate of A1 pulley release as well as the complications of this method including digital vascular injury, A2 pulley injury, and superficial flexor tendon injury was evaluated, and finally, the data were analyzed by the SPSS software.

RESULTS

The results showed a success rate of 75% for A1 pulley release in four fingers, followed by eleven fingers (90%) and eighty-five fingers (100%). Therefore, the A1 pulley was found to be completely released in eighty-five fingers (100%). Overall, the mean of A1 pulley release for these fingers was determined as 97.9%, indicating that percutaneous trigger finger release can be an effective technique using a 15° stab knife. Furthermore, our findings revealed no significant difference in the amount of A1 pulley release in each of the fingers in the right and left hands. Additionally, 17 fingers developed superficial scrape in flexor tendons, while 83 fingers showed no flexor tendons injuries and no other injuries (i.e., vascular, digital nerve, and A2 pulley injuries).

CONCLUSIONS

Percutaneous release of the A1 pulley using a 15° stab knife was contributed to acceptable efficacy and a relatively good safety in the cadaveric model.

Diagnosis and Treatment of Trigger Finger in Brazil - A Cross-Sectional Study

Objective  The present paper aims to evaluate the therapeutic planning for trigger finger by Brazilian orthopedists. Methods  This is a cross-sectional study with a population composed of participants from the 2018 Brazilian Congress on Orthopedics and Traumatology (CBOT-2018, in the Portuguese acronym), who answered a questionnaire about the conduct adopted for trigger finger diagnosis and treatment. Results  A total of 243 participants were analyzed, with an average age of 37.46 years old; most participants were male (88%), with at least 1 year of experience (55.6%) and from Southeast Brazil (68.3%). Questionnaire analysis revealed a consensus on the following issues: diagnosis based on physical examination alone (73.3%), use of the Quinnell classification modified by Green (58.4%), initial nonsurgical treatment (91.4%), infiltration of steroids combined with an anesthetic agent (61.7%), nonsurgical treatment time ranging from 1 to 3 months (52.3%), surgical treatment using the open approach (84.4%), mainly the transverse open approach (51%), triggering recurrence as the main nonsurgical complication (58%), and open surgery success in > 90% of the cases (63%), with healing intercurrences (54%) as the main complication. There was no consensus on the remaining variables. Orthopedists with different practicing times disagree on treatment duration ( p  = 0.013) and on the complication rate of open surgery ( p  = 0.010). Conclusions  Brazilian orthopedists prefer to diagnose trigger finger with physical examination alone, to classify it according to the Quinnell method modified by Green, to institute an initial nonsurgical treatment, to perform infiltrations with steroids and local anesthetic agents, to sustain the nonsurgical treatment for 1 to 3 months, and to perform the surgical treatment using a transverse open approach; in addition, they state that the main nonsurgical complication was triggering recurrence, and report open surgery success in > 90% of the cases, with healing intercurrences as the main complication.

Assessment of short-term response and review of technique of ultrasound-guided percutaneous A1 pulley release for the treatment of trigger finger

INTRODUCTION

Ultrasound-guided percutaneous first annular pulley (A1) release is a non-surgical management for the treatment of trigger finger, also known as stenosing tenosynovitis. Trigger finger occurs secondary to inflammation and retinacular sheath hypertrophy with subsequent restriction of the flexor tendons. Trigger finger can have a marked functional impact, with current conservative measures including steroids and/or splinting, and surgical therapy involving open release.

METHODS

A population of 20 adult patients with ultrasound proven trigger finger underwent percutaneous release with refined technique. Patients with additional ultrasound proven tenosynovitis received steroid injection.

RESULTS

Of the 20 cases, 18 cases involved the fingers, 2 cases involved the thumb and 14 cases had additional tenosynovitis. All procedures involving the fingers were well tolerated with initial symptomatic and functional relief. At 1-week post-intervention, 2 finger cases without concurrent steroid injection represented with pain but not triggering. Cases which did not receive concurrent steroid injection described post-procedural pain requiring oral analgesia. One case involving the thumb was complicated by no relief with a mild radial digital nerve neuropraxia, with near complete resolution at 6 weeks. The second thumb case reported only partial relief of triggering.

CONCLUSION

US-guided percutaneous release of the A1 pulley is an effective procedure in achieving at least short-term resolution of trigger finger. It is best reserved for fingers due to the challenging anatomy of the thumb.

Trigger Finger Treatment

Trigger finger is a frequent condition. Although tenosynovitis and the alteration of pulley A1 are identified as triggering factors, there is no consensus on the true cause in the literature, and its true etiology remains unknown. The diagnosis is purely clinical most of the time. It depends solely on the existence of finger locking during active bending movement. Trigger finger treatment usually begins with nonsurgical interventions that are instituted for at least 3 months. In patients with initial presentation with flexion deformity or inability to flex the finger, there may be earlier indication of surgical treatment due to pain intensity and functional disability. In the present review article, we will present the modalities and our algorithm for the treatment of trigger finger.

Effectiveness of Amniotic Fluid Injection in the Treatment of Trigger Finger: A Pilot Study

Purpose

To assess the efficacy and safety of amniotic fluid therapy injections in patients with mild to moderate trigger finger.

Methods

All participants received 1 mL of amniotic fluid injected into the tendon sheath of the affected tendon. Pretreatment and posttreatment data were collected for triggering frequency, Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire scores, and numerical pain rating scale scores.

Results

Of 111 digits from 96 patients, 51% experienced clinically notable improvement and did not receive an alternative treatment. Average length of follow-up was 11 months. From baseline to end of follow-up, average pain score (0–10) decreased from 5.19 to 1.19 (P < .001), median triggering per day decreased from 5 to 0 (P < .001), and median DASH score (1–100) decreased from 20 to 6.03 (P < .001). There was a 50% success rate in patients with diabetes and a 52.6% success rate in digits diagnosed with concomitant Dupuytren contracture in the same hand.

Conclusions

Amniotic fluid therapy injections may offer a biologic alternative for conservative treatment of trigger finger, particularly for patients with diabetes. Decreased pain, decreased triggering, and improved DASH scores offer preliminary evidence supporting the use of amniotic injections for stenosing tenosynovitis.

Type of study/level of evidence

Therapeutic IV.

Comparative effectiveness of various treatment strategies for trigger finger by pairwise meta-analysis

OBJECTIVE

To compare the efficacy of various strategies in the treatment of trigger finger.

DATA SOURCES

A systematic literature search for randomized controlled trials to compare treatments for trigger finger was conducted through three online databases, Pubmed, Embase and Cochrane Library, from their inception dates to 22 May 2020.

METHODS

Relative risk (RR) with 95% confidence interval (CI) was used to evaluate the effect sizes in success rate for included articles.

RESULTS

Sixteen articles (n = 1185) were included in our meta-analysis. The results showed that the efficacy of steroid injection was significantly better than the placebo group at short-term follow-ups (RR = 19.00, 95% CI = 1.17-309.77 for one-week; RR = 3.70, 95% CI = 3.70, 95% CI = 1.61-8.53 for one-month), and then became non-significant at four months (RR = 3.21, 95% CI = 0.88-11.79). There was no significant difference in success rate between steroid injection and nonsteroidal anti-inflammatory drug injection, and between open surgery and percutaneous release at all the follow-ups. Only surgical treatment had significantly better efficacy in success rate than steroid injection at all follow-ups (RR = 0.48, 95% CI = 0.34-0.66 for one-month; RR = 0.87, 95% CI = 0.80-0.96 for three-month; RR = 0.58, 95% CI = 0.48-0.68 for six-month; RR = 0.38, 95% CI = 0.20-0.72 for 12-month).

CONCLUSION

There were no differences in efficacy between steroid injection and shockwave or nonsteroidal anti-inflammatory drug injection. The surgical treatments had the best efficacy among these treatments.

Assessment of Surgeon Variation in Adherence to Evidence-Based Recommendations for Treatment of Trigger Finger

IMPORTANCE

Stenosing tenosynovitis (trigger finger) affects approximately 2% of the population. Given the prevalence of trigger finger and rising health care costs, adherence to the cost-effective and evidence-based treatment algorithm will permit better outcomes and allocation of resources.

OBJECTIVES

To examine treatment patterns for trigger finger and to determine surgeon-level and patient-level factors that influence adherence to evidence-based treatment.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study examined deidentified claims for treatment of trigger finger from a national insurance provider using the Clinformatics Data Mart database. Patients were included if they were 18 years or older and treated from January 1, 2002, through December 31, 2016 (excluding a washout period from July 1, 2008, until June 30, 2010), with a new diagnosis of single-digit trigger finger. Data were analyzed from December 21, 2018, through April 28, 2019.

EXPOSURES

Cost-effective and evidence-based research published in July 2009 for the treatment of trigger finger.

MAIN OUTCOMES AND MEASURES

After excluding the 1-year washout period on either side of July 1, 2009, adherence to the recommended treatment algorithm of 2 corticosteroid injections before surgical release of trigger finger was compared with practice before publication of research supporting this cost-effective and evidence-based approach.

RESULTS

In this analysis of 83 667 patients with trigger finger, 52 698 (63.0%) were women, and 20 045 (24.0%) had type 1 or 2 diabetes. Mean (SD) age was 61 (13) years. From 2002 to 2016, an overall increasing trend in adherence to the cost-effective and evidence-based approach to treatment was noted, with no significant increase in adherence in the postpublication era (67.5% vs 73.3%; P = .27). Substantial variation in adherence was observed at the surgeon level (intraclass correlation, 33%). Plastic surgeons had no change in adherence over time compared with orthopedic surgeons (odds ratio [OR], 1.00; 95% CI, 0.98-1.02; P = .90), whereas general surgeons had increased adherence (OR, 1.04; 95% CI, 1.02-1.06; P < .001). Higher-volume surgeons were also more adherent to these evidence-based recommendations (OR, 1.59; 95% CI, 1.53-1.65; P < .001).

CONCLUSIONS AND RELEVANCE

This study found substantial surgeon-level variation in adherence to evidence-based treatment of trigger finger. Surgeon specialty and volume were associated with differences in adherence. Efforts to understand surgeon barriers to implementation, regardless of physician specialty, appear to be necessary, and better implementation strategies may permit increased uptake of evidence-based treatment of trigger finger.

A prospective, randomized clinical trial of transverse versus longitudinal incisions for trigger finger release

We investigated whether incision type affects scar quality or outcome following trigger finger release. Our primary and secondary hypotheses were that transverse and longitudinal incision types yield similar scar quality and functional improvement. Digits undergoing trigger finger release at the participating hospitals were randomized to receive transverse or longitudinal incisions. The Patient Scar Assessment Scale, Observer Scar Assessment Scale, and the Disabilities of the Arm, Shoulder and Hand score were collected at 8 and 54 weeks postoperatively. Of 86 randomized patients, 67 patients (71%) had followed-up at 54 weeks postoperatively. We found no significant differences in above three assessments between the incisions at either time-point. Among patients receiving both incision types for multiple simultaneous trigger finger release, there were no significant differences in Patient Scar Assessment Scale or Observer Scar Assessment Scale scores. We found no significant difference in the scar quality and improvement in patient-reported disability with transverse or longitudinal incisions for trigger finger release. Level of evidence: II.

Acupotomy for patients with trigger finger: A systematic review protocol

BACKGROUND

Trigger finger is thought to be caused by aseptic inflammation of the A1 pulley and subsequent thickening and narrowing of the fibrous sheath. Acupotomy has been an important treatment for trigger finger. But an updated systematic review about this issue has not yet been released. This systematic review protocol is aimed at providing a higher quality method used to evaluate the efficacy and safety of acupotomy treatment for trigger finger.

METHODS

The following databases will be searched from the study inception to July 2019: the Cochrane Central Register of Controlled Trials (Cochrane Library), MEDLINE, EMBASE, PubMed, China National Knowledge Infrastructure, Wan-Fang Data, and Chinese Biomedical Literature Database. All English or Chinese randomized controlled trials related to acupotomy for trigger finger will be included. Two reviewers will independently perform the processes of study inclusion, data extraction, and quality assessment. The primary outcome will be assessed by improvement of the pain symptoms and finger activity. Secondary outcomes will be assessed through Safety assessment. Meta-analysis will be completed by RevMan V.5.3 software.

RESULTS

This systematic review will provide an assessment of the current state of acupotomy for trigger finger, aiming to show the efficacy and safety of treatment.

CONCLUSION

This systematic review will re-evaluate a higher-quality systematic review to obtain a relatively convincing conclusion that finds acupotomy to be a better choice for trigger finger patients.

PROSPERO REGISTRATION NUMBER

CRD42018118663.

Characteristics and Clinical Outcomes of Open Surgery for Trigger Digits in Diabetes

Introduction Trigger digit is a common condition of the hand. Diabetes has a known association with the development of trigger digit. It is thought to influence the clinical presentation and efficacy of open surgical release. This study aimed to assess the differential characteristics of trigger digits and the clinical outcomes of open surgery for trigger digits in diabetics. Materials and Methods This was a retrospective study of all patients who underwent open surgical release of trigger digits in a single institution from 2012 to 2013. Patients were divided into two groups with group 1 consisting of all patients with a history of diabetes. Group 2 consisted of all patients without diabetes. Demographics and clinical presentation were reviewed. All patients were reviewed via a telephone questionnaire at least 2 years after the initial surgery and were assessed for patient-reported outcomes. Results There were 201 patients who met the inclusion criteria, of which 191 patients were recruited. This included 87 (45.5%) males and 104 (54.5%) females. A total of 260 open releases were performed. Sixty-one (31.9%) patients were diabetic, and 130 (68.1%) patients were nondiabetic. The diabetic group was significantly older than the nondiabetic group ( p = 0.002). The dominant hand was not significantly more affected than the nondominant hand ( p = 0.51). The middle finger was most commonly involved (43.5%), and the little finger was the least commonly involved (1.2%). There was no significant increase in multiple-digit presentation in the diabetic population when compared with the nondiabetic population ( p = 0.52). There was a low complication rate and a high rate of postoperative satisfaction after open surgery in both groups. Conclusion Diabetes does not predispose patients to increased rates of multiple trigger digit presentation or increased clinical severity on presentation. Open surgery for trigger digit is an effective and safe treatment modality for diabetics.

A Critical Appraisal of Adult Trigger Finger: Pathophysiology, Treatment, and Future Outlook

Trigger finger (TF) is a common referral to a hand surgeon, with people with diabetess being the most at-risk population. Abnormal thickening, scarring, and inflammation occur at the A1 pulley and flexor tendon, and histological changes correlate well with the clinical severity of TF. Corticosteroid injections decrease the thickness of the A1 pulley and are considered a first-line treatment. However, corticosteroids are only moderately effective, especially for people with diabetes. Patients may elect for surgery if nonoperative treatments prove ineffective; some may choose immediate surgical release instead. To release the A1 pulley, patients have the option of an open or percutaneous approach. The open approach has a greater risk of infection and scar tissue formation in the short run but an overall superior long-term outcome compared with the percutaneous approach.

METHODS

We critically reviewed the efficacy and cost-effectiveness of the treatment methods for TF through a comprehensive search of the PubMed Database from 2003 to 2019.

RESULTS

To reduce costs, while still delivering the best possible care, it is critical to consider the likelihood of success for each treatment method in each subpopulation. Furthermore, some patients may need to return to work promptly, which ultimately may influence their desired treatment method.

CONCLUSIONS

Currently, there is no universal treatment algorithm for TF. From a purely financial standpoint, women without diabetes presenting with a single triggering thumb should attempt 2 corticosteroid trials before percutaneous release. It is the most cost-effective for all other subpopulations to elect for immediate percutaneous release.

The Net Promoter Scores with Friends and Family Test after four hand surgery procedures

The Friends and Family Test, a variant of the Net Promoter Score, was adapted for the National Health Service to evaluate overall patient satisfaction and how likely patients are to recommend an intervention. It ranges from -100 to 100. Positive scores indicate good performance. This study quantifies the scores in 810 patients at a mean of 14 months following four common procedures. The score was 83 for trigger finger release ( n = 103), 68 for carpal tunnel decompression ( n = 467), 62 for surgery for Dupuytren's disease ( n = 224) and 44 for ganglia excision ( n = 16). Our study indicates that these procedures are highly valued and are recommended by patients according to the Friends and Family Test. The results of the Friends and Family Test correlated well with postoperative functional improvement and satisfaction. We conclude from this study that a compound score based on the Friends and Family Test is a useful addition to traditional measures of patient satisfaction. Level of evidence: II.

Tenosynovitis of the Hand and Wrist: A Critical Analysis Review

Trigger FingerTrigger finger is common in patients with diabetes.Corticosteroid injections are effective in about 60% to 92% of cases.Proximal interphalangeal joint contracture may occur in long-standing cases.The outcomes of open and percutaneous releases are similar; however, surgeons are split on preferences. Intersection SyndromeThe classic finding is crepitus with wrist motion at the distal one-third of the radial aspect of the forearm. Extensor Pollicis Longus (EPL) TenosynovitisCorticosteroid injections should be used with caution because of the potential for rupture.EPL tenosynovitis is very rare. de Quervain DisorderThis condition is common in postpartum women.A positive Finkelstein test is considered to be pathognomonic of de Quervain disorder, but care should be taken to differentiate this condition from thumb carpometacarpal arthritis.Corticosteroid injections are effective in about 80% of cases.Patients in whom corticosteroid injections fail to provide relief of symptoms frequently have a separate extensor pollicis brevis (EPB) compartment.The abductor pollicis longus (APL) tendon has multiple slips; care should be taken not to confuse one of these slips as the EPB.Traction on the APL pulls up the thumb metacarpal but not the thumb tip.Traction on the EPB extends the thumb metacarpophalangeal joint.Care should be taken to avoid injury to the sensory branch of the radial nerve. Fourth Compartment TenosynovitisThis uncommon condition is most often seen in patients with rheumatoid arthritis.The condition involves a large diffuse area, as opposed to the compact dorsal ganglion cyst.

Does Bowstringing Affect Hand Function in Patients Treated With A1 Pulley Release for Trigger Fingers?: Comparison Between Percutaneous Versus Open Technique

We aimed to inspect bowstringing after percutaneous and open release of the A1 pulley for trigger digits and its influence on hand function. Sixty-two patients with a resistant trigger digit were randomized to undergo either open release or percutaneous release of the A1 pulley. We quantified bowstringing of the digit using ultrasonography preoperatively and at 12 and 24 weeks after surgery. Pain on a visual analog scale; Disabilities of the Arm, Shoulder, and Hand questionnaire; pinch power; and grip strength were assessed. Bowstringing was significantly increased at 12 weeks after surgery in both groups, and the mean value of the open release group was significantly greater than that of the percutaneous group (2.30 ± 0.58 mm vs 1.46 ± 0.51 mm, respectively; P = 0.035). However, the bowstringing was decreased at 24 weeks without showing significant difference between the 2 groups. The clinical outcomes of each cohort improved significantly, with no difference between the groups at final follow-up. No association was found between bowstringing and any clinical outcome measure. Bowstringing occurred by A1 pulley release with either the percutaneous or open technique does not affect clinical hand function in patients with trigger fingers.

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.

Intra-sheath versus extra-sheath ultrasound guided corticosteroid injection for trigger finger: a triple blinded randomized clinical trial

OBJECTIVE

The aim of this study is to compare clinical results of ultrasound-guided corticosteroid injection, intra-sheath versus extra-sheath of the finger flexor tendon.

METHODS

A total of 166 patients with trigger finger were evaluated in a triple blind randomized clinical trial study. All the patients were injected with 1ml of 40mg/ml methyl prednisolone acetate, under the guidance of ultrasound. Half the patients were injected extra sheath, while the other half were injected intra sheath at the level of first annular pulley.

RESULTS

The two groups were comparable in baseline characteristics (age, gender, dominant hand, involved hand and finger, and the symptoms duration). No significant difference was observed in the two groups with regards to Quinnell grading. In the final visit, 94% of patients from each group were symptom free.

CONCLUSION

Results of corticosteroid injection intra-sheath or extra-sheath of the finger flexor tendon under ultrasound guidance in patients with trigger finger are comparably alike. Extra-sheath injection at the level of A1 pulley is as effective as an Intra-sheath administration.

Efficacy of Corticosteroid Injection for Treatment of Trigger Finger: A Meta-Analysis of Randomized Controlled Trials

Purpose: To determine the efficacy and safety of corticosteroid injection for trigger finger by performing a meta-analysis of all relevant studies. Methods: PubMed, EMBASE, and Cochrane Library databases were searched for randomized controlled trials (RCTs) comparing corticosteroid injection with other treatments for trigger finger. Pooled summary estimates for outcomes, including success rate, relapse rate, visual analogue score (VAS) and complications, were calculated as standardized mean difference (SMD) or relative risk (RR) either on a fixed- or random-effect model via Stata 12.0 software. Results: Ten literatures involving 806 patients (387 in corticosteroid injection group and 419 in control group) were included. Pooled analysis showed there were no differences in the success rate, VAS and complications between patients undergoing corticosteroid injection and others. However, the relapse rate was significantly higher in patients treated with corticosteroid injection than that of other treatments (RR = 19.53, 95% CI = 6.23-61.19). Subgroup analysis indicated the efficacy of corticosteroid injection was superior to other non-surgical treatments (success rate: RR = 1.54, 95% CI = 1.01-2.35), but inferior to surgery (success rate: RR = 0.55, 95% CI = 0.48-0.63; relapse rate: RR = 21.15, 95% CI = 6.06-73.85; VAS: SMD = 3.49, 95% CI = 2.84-4.14). Conclusions: Corticosteroid injection may be an effective strategy for management of trigger finger, although surgery may be needed for some patients due to recurrence.

The Safety of Percutaneous Trigger Digit Release Increased by Neurovascular Displacement with Local Hydraulic Dilatation: An Anatomical and Clinical Study

Background

Although percutaneous trigger digit release is common, controversy exists regarding its safety. The purpose of this study was to evaluate the feasibility and safety of the neurovascular displacement by local hydraulic dilatation (LHD) during percutaneous trigger digit release.

Material/Methods

Ten cadaver hands with 50 digits were dissected in this anatomical study. The distance between bilateral neurovascular bundles in each digit was measured before LHD and after LHD. The difference between the measured data before LHD and those after LHD in the same digit was compared to assess the feasibility of the neurovascular displacement by LHD. A further 81 patients with 106 trigger digits were treated by percutaneous release with neurovascular displacement by LHD in our clinical series. All patients were followed for 12 months. During the follow-up period, the presence of any postoperative complication and patient satisfaction were recorded.

Results

In our anatomical study, there was a statistically significant difference (p<0.05) comparing the average distance of bilateral neurovascular bundles before LHD with that after LHD. In the current series, no complications, such as digital neurovascular injury or recurrence of trigger, were encountered. On subjective assessment, 80/81 patients (98.8%) with 105/106 digits (99.1%) were graded as satisfactory with complete resolution of symptoms by percutaneous release under LHD.

Conclusions

Based on our study anatomical and clinical results, the neurovascular displacement by LHD may be a feasible adjunctive technique that may play a role in increasing the safety of percutaneous trigger digit release.

Evidence-based management of adult trigger digits

The aim of this systematic review was to develop an evidence-based guideline to assist clinicians in the treatment of adult trigger digits. There is moderate evidence to suggest that local corticosteroid injection is a safe and effective short-term treatment and it may, therefore, be recommended as an initial treatment for this condition. However, when compared with surgery, there is strong evidence that corticosteroid injection is associated with increased rates of ongoing or recurrent symptoms at 6 months after intervention. There is strong evidence suggesting that trigger digit can be managed safely by surgical release. There is weak evidence to support the use of splinting or other non-operative modalities. Hence a single corticosteroid injection may be offered as the first line in treatment of adult trigger digits, but percutaneous release is a safe alternative. Surgery should be the next line if the injection fails, symptoms recur or the patient chooses.

LEVEL OF EVIDENCE

I.

Trigger Finger: An Atraumatic Medical Phenomenon

Trigger finger is a mechanical problem with many etiological factors as possible causes, such as diabetes mellitus, carpal tunnel syndrome and repetitive finger movements. Although it can afflict anyone, it is much commoner in middle-aged women than men and the most commonly involved digit is reported to be the thumb. The diagnosis is mainly based on clinical symptoms during examination and first-line treatment is conservative with splinting and corticosteroid injections. Surgical open release is the “gold standard” of trigger finger treatment because it allows more careful inspection of the surgical area and is highly effective with low complication rates.

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.

Long-Term Effectiveness of Repeat Corticosteroid Injections for Trigger Finger

PURPOSE

To quantify the long-term success of repeat injections for trigger fingers and to identify predictors of treatment outcomes.

METHODS

This retrospective case series analyzed 292 repeat corticosteroid injections for trigger fingers administered by hand surgeons at a single tertiary center between January 2010 and January 2013. One hundred eighty-seven patients (64%) were female, 139 patients (48%) had multiple trigger fingers, and 63 patients (22%) were diabetic. The primary outcome, treatment failure, was defined as receiving a subsequent injection or surgical treatment. Patients without either documented failure or a return office visit in 2015 or 2016 were surveyed by telephone to determine if they had required subsequent treatment. Kaplan-Meier analyses with log-rank testing assessed the median time to treatment failure and the effect of demographic and disease-specific characteristics on injection success rate and predictors of injection outcome (success vs failure) were assessed with multivariable logistic regression.

RESULTS

Second injections provided long-term treatment success in 39% (111 of 285) of trigger fingers with 86 receiving an additional injection and 108 ultimately undergoing surgical release. Thirty-nine percent (24 of 62) of third injections resulted in long-term success, with 22 receiving an additional injection, and 23 ultimately undergoing surgery. Median times-to-failure for second and third injections were 371 and 407 days, respectively. Success curves did not differ significantly according to any patient or disease factor. Logistic regression identified that advancing patient age and injection for trigger thumb were associated with success of second injections.

CONCLUSIONS

Thirty-nine percent of second and third corticosteroid injections for trigger finger yield long-term relief. Although most patients ultimately require surgical release, 50% of patients receiving repeat trigger injections realize 1 year or more of symptomatic relief. Repeat injections of trigger fingers should be considered in patients who prefer nonsurgical treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Outpatient Percutaneous Release of Trigger Finger: A Cost Effective and Safe Procedure

INTRODUCTION

Trigger finger is a common cause of pain and disability of the hand. Percutaneous release results in earlier functional recovery and patient satisfaction. This is a rapid and cost-effective method which saves a surgical procedure and results in better functional outcome.

MATERIALS AND METHODS

This is a prospective observational study conducted on fifty-two fingers and thumbs in 52 patients treated from 1st July 2014 till 31st December 2014, in the Orthopaedic Section, Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan. All the baseline characteristics of the patients, like demographics, symptoms, Quinell's criteria and functional outcome were recorded. The patients were treated at our hospital with trigger finger, managed with percutaneous release using an 18 gauge needle and followed up for a minimum period of three months. The follow-up information included range of motion scoring, patient satisfaction and overall outcome of the procedure in terms of patient acceptance. The data was analyzed to determine the functional outcome at three months.

RESULTS

There was complete release of A1 pulleys in 52 out of 52 digits (100%) in the patients undergoing percutaneous release and significant patient satisfaction. No recurrence was observed.

CONCLUSION

Percutaneous release of trigger finger with needle was not only associated with excellent functional outcome and recovery in terms of patient satisfaction and range of finger motion three months post-procedure but also was found to be cost effective.

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.