Trigger digit release: rates of surgery and complications as indicated by a United States Medicare database

Comorbidities Associated With Increased Likelihood of Postoperative Surgical Site Infection in Patients Treated for Hand or Finger Fracture and/or Dislocations

BACKGROUND

We aimed to determine the relationship between common preoperative comorbidities and subsequent incidence of postoperative surgical site infections (SSIs) in hand and finger fractures and/or dislocations.

METHODS

We queried the American College of Surgeons National Safety and Quality Improvement Program from January 1, 2015 to December 31, 2019. Patients were included in our study if they were treated by open or percutaneous fixation for any hand or finger fracture and/or dislocation. Predictor variables were smoking status, diabetes mellitus status, and obesity (body mass index > 30) status. Primary outcome was incidence of postoperative SSI.

RESULTS

There were a total of 9245 patients included in our study, and 148 patients (1.6%) experienced postoperative SSI. Of these, 59 patients (39.9%) were only smokers, 7 patients (4.7%) only had diabetes mellitus, and 55 patients (37.2%) were only obese. Overall, patients experienced greater odds of sustaining a postoperative SSI if they were a smoker or diabetic compared to non-smokers and non-diabetics, respectively. Considering only open fixation modality, patients with comorbidities were not at significantly increased odds of sustaining postoperative SSI. Considering only percutaneous fixation modality, patients experienced significantly greater odds of sustaining postoperative SSI if they were a smoker compared to non-smoker.

CONCLUSIONS

Common preoperative comorbidities, including smoking status and diabetes mellitus, increase the likelihood of postoperative complication in patients with hand and finger fractures and/or dislocations undergoing surgical treatment. Further investigation into the different relationship of these comorbidities between open and closed fractures with larger sample sizes will be valuable.

Corticosteroid Injection in the Operative Hand Prior to a Trigger Finger or Carpal Tunnel Release: If It Is Not at the Surgical Site Then What Is the Big Deal?

BACKGROUND

Patients who have had a corticosteroid injection at the surgical site within 90 days of trigger finger release (TFR) or carpal tunnel release (CTR) have an elevated risk of postoperative infection. Currently, it remains unknown if a preoperative injection in proximity to the surgical site for a separate complaint alters the risk of a postoperative infection.

METHODS

A retrospective chart review was performed on all patients who underwent TFR or CTR between 2010 and 2022. Patients who had a corticosteroid injection at or near the surgical site within 90 days of surgery were included. Outcome measures included uncomplicated healing, superficial infection requiring antibiotics, and deep infection (DI) requiring surgical debridement.

RESULTS

There were 564 cases in which a corticosteroid injection was performed within 90 days of TFR or CTR. Superficial infections occurred in 12 (2.1%), and DIs occurred in 6 (1.1%) cases. There was no significant difference in infection rates between the two groups relative to the location of the injection nor timing of the injection (0-30, 31-60, or 61-90 days prior to surgery).

CONCLUSIONS

Patients who had an injection at the surgical site within 90 days of TFR or CTR had an elevated rate of postoperative infection compared with published rates in the literature. This study is unique in that preoperative injections at an adjacent site in the palm also correlated with an elevated rate of infection, similar to patients who had an injection at the surgical site.

LEVEL OF EVIDENCE

Level 4.

Effects of socioeconomic status on patient-reported outcome after surgically treated trigger finger: a retrospective national registry-based study

OBJECTIVES

To investigate if socioeconomic status impacts patient-reported outcomes after a surgically treated trigger finger (TF).

DESIGN AND SETTING

Data on patients with TF treated with surgery were collected from the Swedish National Quality Registry of Hand Surgery (HAKIR) 2010-2019 with an evaluation of symptoms and disability before surgery and at 3 and 12 months after surgery, using the short version of the Disabilities of Arm, Shoulder and Hand (QuickDASH) questionnaire.Data from HAKIR and the Swedish National Diabetes Registry (ndr.nu) were combined with socioeconomic data from Statistics Sweden (scb.sc), analysing the impact of marital status, education level, income, occupation, sickness benefits, days of unemployment, social assistance and migrant status on the outcome by a linear regression model.

PARTICIPANTS

In total, 5477 patients were operated on for primary TF during the study period, of whom 21% had diabetes, with a response rate of 35% preoperatively, 26% at 3 months and 25% at 12 months.

RESULTS

At all time points, being born in Sweden (preoperatively B-coefficient: -9.74 (95% CI -13.38 to -6.11), 3 months postoperatively -9.80 (95% CI -13.82 to -5.78) and 12 months postoperatively -8.28 (95% CI -12.51 to -4.05); all p<0.001) and high earnings (preoperatively -7.81 (95% CI -11.50 to -4.12), 3 months postoperatively -9.35 (95% CI -13.30 to -5.40) and 12 months postoperatively -10.25 (95% CI -14.37 to -6.13); all p<0.0001) predicted lower QuickDASH scores (ie, fewer symptoms and disability) in the linear regression models. More sick leave during the surgery year predicted higher QuickDASH scores (preoperatively 5.77 (95% CI 3.28 to 8.25; p<0.001), 3 months postoperatively 4.40 (95% CI 1.59 to 7.22; p<0.001) and 12 months postoperatively 4.38 (95% CI 1.35 to 7.40; p=0.005)). No socioeconomic factors impacted the change in QuickDASH score from preoperative to 12 months postoperatively in the fully adjusted model.

CONCLUSION

Individuals with low earnings, high sick leave the same year as the surgery and those born outside of Sweden reported more symptoms both before and after surgery, but the relative improvement was not affected by socioeconomic factors.

Social Disparities in the Management of Trigger Finger: An Analysis of 31 411 Cases

BACKGROUND

Cost and compliance are 2 factors that can significantly affect the outcomes of non-operative and operative treatment of trigger finger (TF) and both may be influenced by social factors. The purpose of this study was to investigate socioeconomic disparities in the surgical treatment for TF.

METHODS

Adult patients (≥18 years old) were identified using International Classification of Diseases 9 and 10 Clinical Modification diagnostic codes for TF and Current Procedural Terminology (CPT) procedural codes (CPT: 26055) in the New York Statewide Planning and Research Cooperative System database. Each diagnosis was linked to procedure data to determine which patients went on to have TF release. A multivariable logistic regression was performed to assess the likelihood of receiving surgery. The variables included in the analysis were age, sex, race, social deprivation index (SDI), Charlson Comorbidity Index, and primary insurance type. A P-value < .05 was considered significant.

RESULTS

Of the 31 411 TF patients analyzed, 8941 (28.5%) underwent surgery. Logistic regression analysis showed higher odds of receiving surgery in females (odds ratio [OR]: 1.108) and those with workers compensation (OR: 1.7). Hispanic (OR: 0.541), Asian (OR: 0.419), African American (OR: 0.455), and Other race (OR: 0.45) had decreased odds of surgery. Medicaid (OR: 0.773), Medicare (OR: 0.841), and self-pay (OR: 0.515) reimbursement methods had reduced odds of receiving surgery. Higher social deprivation was associated with decreased odds of surgery (OR: 0.988).

CONCLUSIONS

There are disparities in demographic characteristics among those who receive TF release for trigger finger related to race, primary insurance, and social deprivation.

HbA1c and Infection in Diabetic Elective Hand Surgery: A Veterans Affair Medical Center Experience 2012-2018

BACKGROUND

Hemoglobin A1c (HbA1c) is an indicator of glucose control over a 3-month period. The plastic surgery service began screening HbA1c levels prior to surgery when a trend in infectious complications was noted in diabetics. We made a cutoff value of < 8% for elective hand surgery.

METHODS

The institutional review board approved a 7-year retrospective chart review (#201900402) 2012 through 2018 of our elective diabetic hand surgery cases. Data collected included: surgery, HbA1c levels within 3 months before surgery, glucose finger sticks day of surgery, and infectious complications up to 30 days after surgery. A Fisher exact test using a P value of < .05 and a logistic regression analysis using a P value of < .05 were used to determine statistical significance between infectious complications and screening.

RESULTS

In all, 848 cases were recorded in the data base. Infection complication rates before and after screening were not statistically significant (P = .44). All major complications (3) requiring a return to the operating room involved surgery within the flexor sheath before screening was enforced. This was not statistically significant (P = .25). The relative risk of an infectious complication involving the flexor sheath in unscreened patients was 3.66. A logistic regression analysis found no correlation with infectious complications based on the 3 variables of screening time (P = .99), preoperative finger stick values (P = .12), or HbA1c levels (P = .29).

CONCLUSION

The data did not support our guidelines for enforcing HbA1c cutoff levels prior to elective hand surgery. Consider enforcing levels < 8% when the flexor sheath may be violated.

Preoperative A1c and Postoperative Infection in Elective Hand Surgery

Diabetes mellitus affects 10.5% of the US population. Numerous studies have documented increased risk of complications for patients with diabetes after different types of surgery, including hand surgery. By aiming for a preoperative target hemoglobin A1c (A1c), the risk of surgical complications following elective hand surgery may be reduced for patients with diabetes. This literature review was conducted to evaluate the association between diabetes mellitus and surgical site infections and, more specifically, to determine whether there is any association between preoperative A1c level and postoperative infections in hand surgery. The risk for surgical site infections and wound complications appears to be higher for patients with insulin-dependent diabetes mellitus, but not necessarily for patients with noninsulin-dependent diabetes mellitus, when compared with patients without diabetes. The role of prophylactic antibiotics for patients with diabetes undergoing elective hand surgery was also considered. Prophylactic antibiotics have not been shown to be beneficial for healthy patients undergoing clean, elective hand surgery. However, preoperative antibiotics may have a protective role for some patients with poorly controlled hyperglycemia.

Prognostic factors related to recurrence of trigger finger after open surgical release in adults

INTRODUCTION

Recurrent trigger finger after surgery is one of the major adverse events. However, studies to identify factors associated with recurrence after open surgical release in adult trigger finger patients are still limited.

PURPOSE

To identify factors associated with recurrent trigger finger after open surgical release.

METHODS

This 12-year retrospective observational study included 723 patients with 841 trigger fingers who underwent open A1 pulley release. Patients were categorized into 2 groups: those with recurrent trigger finger after surgery and those without. Associations between potential predictors including age, sex, duration of symptoms, occupation status, active smoker status, number of steroid injections before surgery, and types of comorbidities and the outcome of interest, recurrence of trigger finger, were examined using univariable and multivariable analyses. The results are presented as hazard ratios (HR) with a 95% confidence interval (95% CI).

RESULTS

The recurrence rate after trigger finger release was 2.39% (20 of 841 fingers). After adjusting for confounders, more than 3 steroid injections before surgery and manual labor were the independent predictors of recurrent trigger finger (HR = 4.87, 95%CI = 1.06-22.35 and HR = 3.43, 95%CI = 1.15-10.23, respectively).

CONCLUSIONS

More than 3 steroid injections before surgery and manual labor increase the risk of recurrent trigger finger after an open A1 pulley release. There may be limited benefit in administering a fourth steroid injection.

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.

Complications After Clinic-Based Wide Awake Local Anesthesia No Tourniquet Hand Surgery at a Single Private Practice

BACKGROUND

This study was designed to analyze the results of all wide awake local anesthesia no tourniquet (WALANT) procedures performed on the hand and wrist at a single practice hand surgery practice with a focus on quantifying and qualifying complications.

METHODS

This retrospective chart review included 424 patients who underwent WALANT hand procedures in the minor procedure room of our private practice between 2015 and 2017. Patients were divided into groups based on the type of procedure, including carpal tunnel release, A1 pulley release, first dorsal compartment release, extensor tendon repair, mass excision, and foreign body removal. Data pertaining to patient demographics and complications were recorded.

RESULTS

The overall complication rate for all procedures was 2.8% for 424 patients: A1 pulley release (n = 314, 2.5%), first dorsal compartment release (n = 11, 9%), extensor tendon repairs (5.5%), and mass excision (4%). The carpal tunnel release and foreign body removal groups experienced no complications. No adverse events (arrhythmias, vasovagal, etc.) were observed during the use of the WALANT technique.

CONCLUSIONS

Clinic-based WALANT hand surgery procedures are equally safe compared to the same procedures performed in the operating room at an ambulatory surgery center or hospital.

Patient Risk Factors Associated With Postoperative Complications After Common Hand Procedures

BACKGROUND

Carpal tunnel syndrome (CTS), trigger finger (TF), and De Quervain tenosynovitis (DQ) are 3 common pathologies of the hand often treated with relatively simple surgical procedures. However, outcomes from these procedures can be compromised by postoperative complications. The aim of this study was to evaluate the association between diabetes, tobacco use, and obesity and the incidence of postoperative complications.

METHODS

We reviewed 597 patients treated surgically for CTS, TF, or DQ from 2010 to 2015. We used bivariate and multivariate analyses to assess independent associations between diabetes, tobacco use, obesity, and surgical complications and compared the incidences with healthier patients without these comorbidities. We also looked at patients with overlapping diagnoses of these comorbidities.

RESULTS

Bivariate analysis showed that patients with diabetes and smokers were more likely to have a surgical complication. Multivariate analysis showed diabetes and tobacco use as independent predictors of complications. The disease states or combinations placing patients at the highest risk of a postoperative complication were the diabetic-smoker-obese, diabetic-smoker, diabetic-obese, diabetic, and smoker-obese groups. The diabetic-smoker-obese patient population had a 42.02% predicted rate of postoperative complications.

CONCLUSIONS

Diabetes and tobacco use are independent risk factors for complications after operative treatment of CTS, TF, and DQ. Obesity when coexisting with diabetes mellitus (DM) and/or tobacco use increased the risk of complications. When the 3 patient factors evaluated, DM, obesity, and tobacco use, were present, the rate of complications was 42.02%. Careful assessment and discussion should occur before proceeding with operative treatment for simple hand conditions in patients with the risk factors studied.

Association between diabetes mellitus and risk of infection after trigger finger release: a systematic review and meta-analysis

PURPOSE

To investigate the association between diabetes mellitus and risk of infection after trigger finger release.

METHODS

Reports of adult trigger finger patients who had undergone trigger finger release that included details of patient diabetic status and post-surgery infections were included in the study. Reports of congenital trigger finger release and incomplete data on either diabetic status or infection after surgery were excluded. Search engines were PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Web of Science from inception to third December 2021. The risk of infection after trigger finger release was compared between diabetic and non-diabetic patients by evaluating the pooled risk ratio (RR) with a 95% confident interval (CI) under random effects modeling. Risk of bias in each study was assessed using Newcastle-Ottawa Scale (NOS).

RESULTS

A total of 213,071 trigger finger patients described in seven studies were identified. Overall, patients with diabetes mellitus had a 65% higher risk of infection after trigger finger release compared to non-diabetic patients (RR 1.65; 95% CI, 1.39-1.95). Diabetes mellitus increased the risk of infection following trigger finger surgery in both young and old age groups as well as obese and non-obese patients who underwent open release surgery. The risk of bias in each of the included studies was estimated as moderate to high.

CONCLUSION

Meta-analysis results demonstrated that diabetes mellitus increases the risk of infection after trigger finger release. Glycemic control and percutaneous rather than open surgery might be strategies to the reduce risk of infection after trigger finger release in diabetic patients.

Infectious Flexor Tenosynovitis Following Trigger Finger Release: Incidence and Risk Factors

Background: Trigger finger release (TFR) is one of the most commonly performed hand procedures and typically results in restoration of normal finger function. However, uncommon postoperative complications such as deep infection can have devastating consequences. The goal of this study was to evaluate the incidence, risk factors, and characteristics of infectious flexor tenosynovitis occurring after TFR. Methods: We searched billing records for the Current Procedural Terminology code for TFR to identify all adult patients who underwent TFR at our institution over a 10-year period. We defined infectious tenosynovitis as any case where the patient underwent tendon sheath drainage or postoperative wound debridement within 6 months of the index TFR procedure. Medical records were reviewed to obtain patient demographic information, body mass index (BMI), tobacco use, history of diabetes mellitus, surgical setting (clinic vs outpatient surgery center), and surgical digit for all patients. In those patients treated for infection, we recorded hospital length of stay, number of operative procedures, and any culture results. Results: We identified a total of 18 infections out of 2307 procedures (1827 patients), for an incidence of 0.99%. Current smokers had a significantly higher incidence of infection than nonsmokers (1.77% vs 0.29%). On univariate analysis, smoking was closely associated with infection (P ≤ .05). All infections occurred in overweight or obese patients by BMI criteria, but there was no difference in average BMI between patients with and without infection. History of diabetes, in-office surgery, patient age, and patient sex were not associated with a higher incidence of infection. Patients with infections spent an average of 4.1 days in the hospital, and 40% required multiple surgical procedures. The most common infectious organism cultured was Staphylococcus aureus, which was present in 67% of infections. Patients with isolated methicillin-sensitive S aureus on culture showed signs of infection within 3 weeks of the index procedure, whereas polymicrobial, coagulase-negative staphylococci or beta hemolytic streptococci were identified in patients presenting with infectious symptoms later. Conclusion: Infections after TFR are uncommon but are more likely to occur in patients who are current smokers and overweight or obese by BMI criteria. Methicillin-sensitive S aureus is the most likely causative organism, especially in patients presenting during the early postoperative course.

The Prevalence and Risk Factors for Trigger Digits in a Random Sampling of a Japanese Population Registry between 50 and 89 Years of Age

Background: Trigger digit(s) (TD) is one of the most common disorders of the hand in the elderly population. The aim of this study is to determine the prevalence and identify the risk factors for TD in an elderly Japanese population. Methods: We randomly sampled 1,297 subjects between the ages of 50 and 89 years from the population registry of a town in Japan. About 413 subjects agreed to participate in the study, and all were examined for the presence of TD. Subjects were divided into three groups namely history of treatment for TD in the past (PTD), current evidence of TD (CTD) or both (BTD). The prevalence of TD was weighted by age according to the composition of the Japanese population. Age, female gender, obesity, hard manual work, exposure to vibration tools, sports activity, smoking, alcohol, wrist fracture, hypertension, hypothyroidism, diabetes mellitus, rheumatoid arthritis and carpal tunnel syndrome were assessed as risk factors for TD using univariate and multivariate logistic regression analysis. Results: Forty subjects had TD. This included 18, 19 and 3 subjects with PTD, CTD and BTD, respectively. The weighted prevalence of TD was 9.7% (female, 14.3%; male, 4.4%) in the Japanese population aged 50-89 years. Age 70-79 and female gender were identified as risk factors for TD. Conclusions: The random sampling of a Japanese population registry between the ages of 50 and 89 years revealed the prevalence of TD as 9.7% and identified age between 70 and 79 and female gender as risk factors for developing TD. Level of Evidence: Level II (Therapeutic).

Functional outcomes of trigger finger release in non-diabetic and diabetic patients

We compared the functional outcomes, health-related quality of life, and satisfaction in diabetic and non-diabetic patients undergoing A1 pulley release for trigger finger in 192 patients. Preoperative and postoperative Quick Disabilities of the Arm, Shoulder and Hand questionnaire (Quick DASH), EuroQol-5 dimensions, and satisfaction scores were collected prospectively over a 6-year period. These patients had a mean follow-up of 14 months (range 11-40) after surgery. There were 143 patients (143 trigger fingers) without diabetes and 49 patients (49 trigger fingers) with diabetes. We found overall QuickDASH improvement was the same in both groups (-4.5 points). Patient satisfaction rates were comparable in both groups (90% versus 96%), and no significant difference in postoperative health-related quality of life was observed. No complications were reported in either group. We conclude from this study that A1 pulley release leads to similar functional improvement and high patient satisfaction at one year postoperatively in diabetic and non-diabetic patients.Level of evidence: III.

Comparison of Safety and Insurance Payments for Minor Hand Procedures Across Operative Settings

IMPORTANCE

Surgical procedures can be performed in different settings, but the association between the operative setting and patient safety and cost to the patient and payer is unknown.

OBJECTIVE

To examine differences in complications, total payments, and out-of-pocket (OOP) spending for minor hand surgical procedures performed in office, ambulatory surgery center (ASC), and hospital outpatient department (HOPD) operative settings.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective, population-based cohort study was conducted using deidentified claims data from private employer-sponsored health insurance from January 1, 2009, to December 31, 2017. Patients aged 18 years or older undergoing carpal tunnel release, trigger finger release, excision of wrist ganglion, and excision of small hand masses (N = 468 365) were included.

EXPOSURES

Operative setting, defined as procedures performed in the clinic setting, ASC, and HOPD.

MAIN OUTCOMES AND MEASURES

Complications during the 90-day postoperative period, total payments (total facility and payer reimbursement), and OOP spending.

RESULTS

Of the 468 365 patients, 296 378 women (63.3%) and 171 987 men (36.7%) underwent minor hand surgical procedures from 2009 to 2017, with 284 889 procedures (60.8%) performed in HOPDs, 158 659 procedures (33.9%) performed in ASCs, and 24 817 procedures (5.3%) performed in the office setting. Ninety-day complications occurred in 3.4% of procedures performed in HOPDs, 3.3% in ASCs, and 2.9% in office settings (P < .001). After controlling for patient characteristics, procedures performed outside of the office had higher odds of complications (HOPDs: odds ratio [OR], 1.32; 95% CI, 1.22-1.43; ASCs: OR, 1.24; 95% CI, 1.14-1.34). Compared with the office setting, procedures performed in HOPDs incurred an extra $1216 in total payments (95% CI, $1184-$1248) and $115 in OOP expenses (95% CI, $109-$121). Procedures performed in ASCs cost an additional $709 (95% CI, $676-$741) and $140 in OOP expenses (95% CI, $134-$146). Transitioning ASC and HOPD procedures to the office setting could have saved an estimated $6 million annually in OOP expenses during the study period.

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that minor hand surgery performed in the office setting is safe and less costly compared with ambulatory and hospital-based operations. Shifting minor surgical procedures to the office setting may lead to substantial cost savings for payers and patients without compromising care quality.

A Cost-Effectiveness Analysis of Corticosteroid Injections and Open Surgical Release for Trigger Finger

PURPOSE

To evaluate the cost-effectiveness of corticosteroid injection(s) versus open surgical release for the treatment of trigger finger.

METHODS

Using a US health care payer perspective, we created a decision tree model to estimate the costs and outcomes associated with 4 treatment strategies for trigger finger: offering up to 3 steroid injections before to surgery or immediate open surgical release. Costs were obtained from a large administrative claims database. We calculated expected quality-adjusted life-years for each treatment strategy, which were compared using incremental cost-effectiveness ratios. Separate analyses were performed for commercially insured and Medicare Advantage patients. We performed a probabilistic sensitivity analysis using 10,000 second-order Monte Carlo simulations that simultaneously sampled from the uncertainty distributions of all model inputs.

RESULTS

Offering 3 steroid injections before surgery was the optimal strategy for both commercially insured and Medicare Advantage patients. The probabilistic sensitivity analysis showed that this strategy was cost-effective 67% and 59% of the time for commercially insured and Medicare Advantage patients, respectively. Our results were sensitive to the probability of injection site fat necrosis, success rate of steroid injections, time to symptom relief after a steroid injection, and cost of treatment. Immediate surgical release became cost-effective when the cost of surgery was below $902 or $853 for commercially insured and Medicare Advantage patients, respectively.

CONCLUSIONS

Multiple treatment strategies exist for treating trigger finger, and our cost-effectiveness analysis helps define the relative value of different approaches. From a health care payer perspective, offering 3 steroid injections before surgery is a cost-effective strategy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Economic and Decision Analyses II.

Steroid Injection and Open Trigger Finger Release Outcomes: A Retrospective Review of 999 Digits

Background: Open surgical release of the A1 pulley is the definitive treatment for the common hand condition of trigger finger, or inflammatory stenosing tenosynovitis. Anecdotal evidence among hand surgeons has questioned whether or not recent steroid injection may be related to complications following open trigger finger release, particularly wound infection, but no studies have primarily studied this connection to date. We aimed to determine whether recent steroid injection was associated with postoperative surgical infections. Methods: We performed a retrospective chart review of 780 adult patients who had undergone open trigger finger release of 999 digits by 6 fellowship-trained hand surgeons at three affiliated hospital settings from January 1, 2014, to January 1, 2016. Data on timing of steroid injections relative to surgery, number of steroid injections, concomitant conditions, use of antibiotics, and postoperative complications including infections were gathered. Results: Steroid injection timing relative to subsequent operative intervention correlated with postoperative surgical site infection in trigger finger release. Older age and decreasing days between steroid injection and surgery correlated with infection rates. Other factors found to be associated with infection rates included smoking, use of preoperative antibiotics, and use of lidocaine with epinephrine. The other factors examined did not correlate with infection rates. Conclusions: Steroid injection, smoking, increasing age, lesser number of days between steroid injection and surgery, and use of lidocaine with epinephrine are risk factors for postoperative trigger surgical infections. We recommend careful preoperative counseling regarding higher wound healing risks for smokers, avoidance of steroid injections immediately prior to an operative date, and scheduling operative dates that tend to be greater than 80 days from the date of last steroid injection. We also recommend avoidance of epinephrine in the local anesthetic solution, as this may minimize surgical site infection risks.

Preoperative PROMIS Scores Predict Postoperative PROMIS Score Improvement for Patients Undergoing Hand Surgery

Background: Patient-Reported Outcomes Measurement Information System (PROMIS) can be used alongside preoperative patient characteristics to set postsurgery expectations. This study aimed to analyze whether preoperative scores can predict significant postoperative PROMIS score improvement. Methods: Patients undergoing hand and wrist surgery with initial and greater than 6-month follow-up PROMIS scores were assigned to derivation or validation cohorts, separating trauma and nontrauma conditions. Receiver operating characteristic curves were calculated for the derivation cohort to determine whether preoperative PROMIS scores could predict postoperative PROMIS score improvement utilizing minimal clinically important difference principles. Results: In the nontrauma sample, patients with baseline Physical Function (PF) scores below 31.0 and Pain Interference (PI) and Depression scores above 68.2 and 62.2, respectively, improved their postoperative PROMIS scores with 95%, 96%, and 94% specificity. Patients with baseline PF scores above 52.1 and PI and Depression scores below 49.5 and 39.5, respectively, did not substantially improve their postoperative PROMIS scores with 94%, 93%, and 96% sensitivity. In the trauma sample, patients with baseline PF scores below 34.8 and PI and Depression scores above 69.2 and 62.2, respectively, each improved their postoperative PROMIS scores with 95% specificity. Patients with baseline PF scores above 52.1 and PI and Depression scores below 46.6 and 44.0, respectively, did not substantially improve their postoperative scores with 95%, 94%, and 95% sensitivity. Conclusions: Preoperative PROMIS PF, PI, and Depression scores can predict postoperative PROMIS score improvement for a select group of patients, which may help in setting expectations. Future work can help determine the level of true clinical improvement these findings represent.

What Patient-related Factors are Associated with an Increased Risk of Surgery in Patients with Stenosing Tenosynovitis? A Prospective Study

BACKGROUND

Numerous patient-related risk factors have been identified as contributors to patient progression to operative treatment of stenosing tenosynovitis (STS). Identifying patients most at risk of undergoing surgery after receiving a corticosteroid injection would enable health care providers to identify patients most likely to benefit from nonsurgical treatment.

QUESTIONS/PURPOSES

(1) What proportion of prospectively enrolled patients with a new diagnosis of STS did not require further intervention after a first, second, or third injection when offered up to three corticosteroid injections? (2) Which identifiable risk factors present at the initial evaluation in patients with STS are associated with the patient opting for surgical release after a trial of one, two, or three corticosteroid injections?

METHODS

One hundred ninety-six patients with a presumed diagnosis of STS were evaluated between March 2014 and June 2015, and 160 patients with 186 affected fingers were prospectively enrolled after a new diagnosis of STS was made during the study period. STS was diagnosed by assessing for tenderness at the A1 pulley, passive or active triggering, and the absence of other confounding diagnoses. Only the affected finger received a corticosteroid injection, and these patients were followed up during the study period. Patients were followed for 2 years, and 135 of the 160 patients (84%) completed the final followup. Patients with recurrent symptoms were treated with up to three corticosteroid injections before undergoing A1 pulley release, although patients could elect to undergo surgery at any time. Bivariate comparisons and a multivariate logistic regression analysis were used for independent fingers (one per participant) to identify independent variables associated with progression to surgery after injection. The time between treatments (between injection and subsequent injection or between injection and surgery) for those with recurrent symptoms was also calculated. Information collected from the last time the patient could be contacted was carried forward in the analysis for all 160 patients.

RESULTS

No further treatment was sought after the first, second, and third injections by 81 of 160 (51%), 16 of 45 (37%), and three of 10 patients (30%), respectively; 100 of 160 patients (63%) did not pursue further intervention. After the first, second, and third injections, 36 of 160 patients (23%), 17 of 43 patients (40%), and seven of 10 of patients, respectively, did not respond to treatment. After controlling for 21 potentially confounding patient- and disease-related variables, we found that only two risk factors at the initial presentation were protective against eventual progression to surgery: osteoarthritis in the fingers (odds ratio [OR], 0.26 [95% CI, 0.085-0.786]; p = 0.017) and a longer duration of symptoms (OR, 0.58 [95% CI, 0.38-0.89]; p = 0.012). There was no association between progression to surgery and hand dominance, finger type (thumb or other), whether the patient had diabetes, or whether the affected finger was one of multiple affected fingers. Patients who presented again for intervention (injection or surgery) did so at a mean of 153 ± 94 days.

CONCLUSIONS

Although patients should be counseled that their risk of progressing to surgery after an initial corticosteroid injection is lower than for subsequently administered injections for recurrent symptoms, nonoperative treatment should not be bypassed for patients with any of the studied risk factors.

LEVEL OF EVIDENCE

Level II, therapeutic study.

The Use of Preoperative Antibiotics in Elective Soft-Tissue Procedures in the Hand: A Critical Analysis Review

» The use of preoperative antibiotic prophylaxis is not supported for elective cases of patients undergoing soft-tissue hand procedures that are ≤2 hours in length.

» The use of preoperative antibiotic prophylaxis is not supported for patients with diabetes undergoing elective, soft-tissue hand surgical procedures.

» There is a paucity of literature evaluating the use of preoperative antibiotic prophylaxis in patients with rheumatoid arthritis, those with cardiac valves, and those taking corticosteroids; because of this, there is no evidence to vary from our general recommendations.

Which Stitch? Replacing Anecdote with Evidence in Minor Hand Surgery

There is currently no consensus on the optimal suture type for palmar skin closure following open carpal tunnel release and trigger finger release. We performed a retrospective analysis of patients in the Palo Alto Veterans Affairs (PAVA) Health Care System who underwent these procedures over a 2-year period to compare 30-day wound outcomes following closure with poliglecaprone 25 (Monocryl), nylon, and chromic gut suture. Out of 312 PAVA cases (133 carpal tunnel release, 179 trigger finger release), incisions closed with Monocryl were significantly less likely to develop dehiscence (Monocryl 2.1%, nylon 10.5%, chromic 10.3%; P = 0.006) and infection (Monocryl 1.6%, nylon 7.4%, chromic 13.8%; P = 0.003), or lead to additional wound-related encounters (Monocryl 8.0%, nylon 16.8%, chromic 24.1%; P = 0.012). On multivariable logistic regression, suture type and diabetes were independent predictors of 30-day wound complications and extra encounters. At PAVA, compared with Monocryl, closures with nylon and chromic were significantly more likely to dehisce and/or become infected [nylon: odds ratio (OR), 5.0; 95% CI, 1.9–13.3 and chromic: OR, 9.3; 95% CI, 2.7–32.4; P = 0.002], and to be associated with an additional encounter (nylon: OR, 2.4; 95% CI, 1.1–5.3 and chromic: OR, 4.5; 95% CI, 1.6–12.9; P = 0.007). This has led to using Monocryl as the standard closure for these cases at PAVA.

Minimally invasive thread trigger digit release: a preliminary report on 34 digits of the adult hands

The trigger finger release was performed in 34 digits (11 thumbs and 23 fingers) of 24 patients through the thread transecting technique with the tip-to-tip approach, in which a 22-gauge needle inserts into a 18-gauge needle when both needles are inside the hand, guiding the 22-gauge needle to exit the hand at the same access point of 18-gauge needle. We prospectively evaluated the effectiveness and functional recovery of these patients. In all 34 digits, triggering and locking were resolved, and complete extension and flexion occurred immediately following the release. There were no complications, such as incomplete release, neurovascular or flexor tendon or A2 pulley injury, infection, or tendon bow-stringing. Patients did not require prescription pain medications. Most patients used their hands to meet their basic living needs the same day of the procedure. The hand function evaluated with the Quick Disabilities of the Arm, Shoulder and Hand questionnaire, and scored 4 within 3 months. Level of evidence: II.

Preoperative Hypoglycemia Increases Infection Risk After Trigger Finger Injection and Release

BACKGROUND

Diabetes mellitus is a well-known risk factor for infection after trigger finger (TF) injection and/or release. However, the effect of preoperative hypoglycemia before TF injection or release is currently unknown. The purpose of this study is to determine the effects of preoperative hypoglycemia on infection incidence after TF injection or release.

METHODOLOGY

A retrospective cohort review between 2007 and 2015 was conducted using a national private payer database within the PearlDiver Supercomputer. Preoperative, fasting, glucose levels were collected for each patient, and these ranged from 20 to 219 mg/dL. Surgical site infection (SSI) rates were determined using International Classification of Diseases, Ninth Revision codes.

RESULTS

The query of the PearlDiver database returned 153,479 TF injections, of which 3479 (2.27%) and 6276 (4.09%) had infections within 90 days and 1 year after procedure, respectively. There were 70,290 TF releases identified, with 1887 (2.68%) SSIs captured within 3 months after surgery and 3144 (4.47%) within 1 year after surgery. There was a statistically significant increase in SSI rates in patients with hypoglycemia within 90-day (P = 0.006) and 1-year (P < 0.001) time intervals post-TF injection. Likewise, a statistically significant increase in SSI rate in patients with hypoglycemia undergoing TF release within 1 year after release was seen (P = 0.003).

CONCLUSIONS

Hypoglycemia before TF injection or release increases the risk for SSI. Tight glycemic control may be warranted to mitigate this risk. Further studies are needed to investigate the effect of hypoglycemia as an independent risk factor for SSI.

Thirty-Day Reoperation and/or Admission After Elective Hand Surgery in Adults: A 10-Year Review

PURPOSE

Whereas acute complications following elective hand surgery have been assumed to be rare, the incidence of 30-day unplanned reoperation and/or admission for the most common elective procedures has not been well described. Our goal was to calculate the incidence and identify the risk factors associated with these complications in a busy academic practice.

METHODS

Our institution's quality assurance database was examined retrospectively for unplanned reoperations and/or admissions within 30 days in adults undergoing elective procedures with 2 senior attending surgeons from February 2006 to January 2016. Each event was categorized by causative factor and charts were reviewed to establish risk factors and cultured organisms. Our billing database was examined for the concomitant procedural volume.

RESULTS

In our cohort of 18,081 surgeries (57.6% carpal tunnel or trigger digit releases), 27 patients had an unplanned reoperation and/or admission within 30 days (0.15% total incidence; including carpal tunnel release, 0.10%; trigger digit release, 0.09%; major wrist surgery, 0.74%) including 17 infections (0.09%). These were unevenly distributed over time after surgery with 29.6% occurring within 7 days, 59.2% in 8 to 14 days, 11.1% in 15 to 21 days, and none between 22 and 30 days.

CONCLUSIONS

Reoperations and/or unplanned admission within 30 days after elective hand surgery are infrequent (15 per 10,000 cases) and are most commonly related to infections (63.0%). More invasive surgeries are associated with a higher incidence than simpler procedures, and these complications are most likely to occur within 3 weeks after surgery. These data in elective patients do not cover certain clinically relevant outcomes, such as chronic pain or limited function, and may not be generalizable to all practices.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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.