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Percutaneous Release, Open Surgery, or Corticosteroid Injection, Which Is the Best Treatment Method for Trigger Digits?

Wang, Jia MD, PhD1; Zhao, Jia-Guo MD2, a; Liang, Cong-Cong MD3

Author Information
Clinical Orthopaedics and Related Research: June 2013 - Volume 471 - Issue 6 - p 1879-1886
doi: 10.1007/s11999-012-2716-6
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Abstract

Introduction

Trigger digit is caused by a size mismatch between the volume of the flexor tendon sheath and its contents and may result in painful triggering, clicking with finger or thumb movement, and secondary contracture at the proximal interphalangeal joint. The goal of treatment consists of reestablishing an undisturbed, full ROM in the involved digits.

There are various methods for treatment of trigger digits including corticosteroid injections in or around the flexor tendon sheath [10], or percutaneous [17] or open surgical release [26] of the A1 pulley. Corticosteroid injections often are recommended as the first line of treatment [20]. However, injections can result in a 33% relapse within 1 year [1]. Open trigger surgery is the standard technique [26] and traditionally consists of open A1 pulley release in which the pulley is completely observed and dissected. The results of open A1 pulley release generally are excellent. Turowski et al. [30], in a group of 59 patients treated by various surgeons, reported 97% complete resolution of triggering with no complications such as infection, bowstringing, or digital nerve injury.

Lorthioir [17] first described a percutaneous method of trigger finger release using a fine tenotome in 1958. Since then, several percutaneous surgeries, using various instruments and methods have been described with good results and few complications [8, 13, 22, 23, 29, 32, 33]. Although the technique of percutaneous release surgery has become common in the last 20 years [7, 8, 13, 16, 18], the best treatment of trigger digit remains unknown.

In this meta-analysis, we sought to use evidence from randomized controlled trials (RCTs) to identify the risk ratio (RR) of treatment failure, the level of satisfaction, and the frequency of complications, comparing percutaneous release with open surgery or corticosteroid injections for adult patients with trigger digits.

Materials and Methods

We searched PubMed, Embase, and Cochrane library for literature published up to October 2012. The following key words were used in the searches: ((trigger finger) OR (trigger thumb) OR (trigger digit) OR (stenosing tenosynovitis)) AND ((percutaneous release) OR percutaneous OR (subcutaneous release) OR subcutaneous). No language restriction was applied. With use of our search strategy 199 titles were identified.

Two investigators (JW and CCL) independently reviewed all 199 titles, abstracts, and the full texts of articles. We included only RCTs or quasiRCTs, comparing percutaneous release surgery with open surgery or corticosteroid injections. QuasiRCTs are those in which randomization is inadequately concealed (ie, patients are allocated according to known characteristics such as date of birth, day of presentation, or hospital chart number). We excluded the following types of articles: letters, review articles, those including children, case reports, cadaveric studies, and other articles that were not relevant to the topic (Fig. 1). One study was excluded, as it was a brief citation from another included study in this meta-analysis [5]. Disagreement was resolved by consensus or a third author (JGZ). These exclusions left seven RCTs involving 676 patients included in this meta-analysis [2, 9, 12, 14, 19, 28, 34]. There were six RCTs [2, 9, 14, 19, 28, 34] and one quasiRCT [12]. Among the seven eligible trials, three [2, 12, 14] compared percutaneous release with open release surgery, and three [9, 19, 34] compared percutaneous release with corticosteroid injections. Sato et al. [28] compared the three approaches. The sample size across the studies ranged from 36 to 160 (Table 1).

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Fig. 1:
A flow diagram summarizes the selection of studies, including numbers and reasons for excluding certain studies. RCT = randomized controlled trial.
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Table 1:
Characteristics of included studies

The methodologic qualities of the included trials were assessed independently by two reviewers (JW and JGZ). Disagreements were resolved by discussions to achieve consensus. We used the quality scale described by Detsky et al. [11] for randomized controlled trials to assess the methodologic quality of the included trials. This scale is more suitable for evaluating the quality of reporting of surgical trials because it requires users to consider blinding of outcome assessors rather than blinding of those providing treatment or blinding of patients, both of whom are difficult to blind in most surgical trials [4]. The Detsky quality scale evaluates randomization, description of outcome measures, inclusion and exclusion criteria, and descriptions of therapies and statistics. The mean Detsky score was 14.9 across included trials (range, 13-18) (Table 2). Randomization and allocation concealment were considered adequate in four trials and were performed by means of sealed envelopes [9, 14, 28, 34]. The baselines were similar regarding the most important prognostic indicators in six trials [2, 9, 14, 19, 28, 34], and one trial [12] was unclear. Only one trial [34] reported that the outcome assessor was blinded to the intervention. Loss to followup rates ranged between 1.7% and 17%.

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Table 2:
Methodologic quality of included studies

The following data were extracted: participant characteristics, number of trigger fingers or thumbs, inclusion and exclusion criteria, intervention details, and followup time. Although we extracted the data of a single injection for the corticosteroid injection group, a few patients with a second injection in trials also were included. The primary outcomes were number of posttreatment failures, patient satisfaction rate, and complications. Failure was defined as recurrence of symptoms or minimal improvement in symptoms requiring further surgeries or injections. Information regarding complications was extracted, including infection, vascular injury, flexor tendon injury, digital nerve injury, excessive release or adhesions-related reduction of flexion, and hematomas. Incomplete trigger release requiring further treatment was considered a failed procedure rather than a complication in this meta-analysis. Other outcomes, such as the pain scores, grip strength, active ROM, operative time, and cost were omitted because they were not consistently available in the source studies. In addition, we extracted only the data within 6 months from the time of treatment to ensure a similar time of outcome assessment.

Dichotomous variables were presented as risk ratios (RR) with 95% CI. If considered appropriate, results of comparable groups of trials will be pooled. Initially, we used a fixed-effect model and 95% CI with the significance level set at p = 0.05. Homogeneity across the studies was assessed with the I2 test. Heterogeneity was considered present if the I2 value was greater than 50%. We then used a random-effects Mantel-Haenszel model when there was statistical or graphic evidence of heterogeneity. RevMan 5.1 software (Cochrane IMS, Oxford, UK) was used for data analysis.

Percutaneous release was compared with open surgery in four studies [2, 12, 14, 28]. Of the 397 patients from these four studies, 199 were randomly assigned to the percutaneous release group, and 198 were assigned to the open surgery group. The followups across the studies ranged from 2 to 6 months. Three trials [2, 14, 28] reported the failed procedure occurred in one of 179 patients (0.56%) with percutaneous release and in one of 182 patients (0.55%) with open surgery. Four trials [2, 12, 14, 28] reported the complications occurred in two of 199 patients (1.0%) with percutaneous release and in two of 198 patients (1.0%) with open surgery.

Four trials [9, 19, 28, 34] compared percutaneous release with corticosteroid injections, and enrolled 417 patients; 202 of the patients were assigned to the percutaneous release group and 215 were assigned to the corticosteroid injection group. Three trials [19, 28, 34] reported the failed procedure occurred in two of 156 patients (1.28%) in the percutaneous release group, while also occurring in 45 of 168 patients (26.8%) in the corticosteroid injection group. Postoperative satisfaction rate was reported in two trials [8, 18]; the rates were 91.89% (102 of 111) in the percutaneous release group and 45.79% (49 of 107) in the corticosteroid injection group. The complication rates were 1.5% (three of 202) in the percutaneous release group and 0% (0 of 215) in the corticosteroid injection group [9, 19, 28, 34].

Results

There were no differences in the frequency of treatment failure (RR = 0.93; 95% CI, 0.14-6.25; p = 0.94) (Fig. 2) or complications (RR = 0.83; 95% CI, 0.15-4.72; p = 0.84) (Fig. 3) between patients undergoing percutaneous release and open surgery.

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Fig. 2:
The results show that there is no great difference in the failed procedure between percutaneous release and open surgery. PR = percutaneous release; OS = open surgery; Z = p value of weighted test for the overall effect; df = degrees of freedom; I2 = test statistic.
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Fig. 3:
The results show that there is no great difference in complications between percutaneous release and open surgery. PR = percutaneous release; OS = open surgery; Z = p value of weighted test for the overall effect; df = degrees of freedom; I2 = test statistic.

Fewer patients who underwent percutaneous release experienced treatment failure compared with patients who received corticosteroid injections (RR = 0.07; 95% CI, 0.02-0.21; p < 0.001) (Fig. 4). The test for heterogeneity showed that no important heterogeneity existed across the four studies (p = 0.64; I2 = 0%). Patient satisfaction was higher in the percutaneous release group than in the corticosteroid injection group (RR = 2.01; 95% CI, 1.62-2.48; p < 0.001) (Fig. 5). There was little heterogeneity on that endpoint as well (p = 0.74; I2 = 0%). We identified no significant difference in the complication rates of the two procedures (RR = 3.19; 95% CI 0.51-19.91; p = 0.21) (Fig. 6). A summary of the meta-analyses is detailed in Table 3.

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Fig. 4:
The results show that there is substantial difference in the failed procedure between percutaneous release and corticosteroid injection. PR = percutaneous release; Z = p value of weighted test for overall effect; RR = risk ratios; df = degrees of freedom; I2 = test statistic.
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Fig. 5:
The results show that there is substantial difference in patient satisfaction between percutaneous release and corticosteroid injection. PR = percutaneous release; Z = p value of weighted test for overall effect; RR = risk ratios; df = degrees of freedom; I2 = test statistic.
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Fig. 6:
The results show that the difference of complication rate is trivial between percutaneous release and corticosteroid injection. PR = percutaneous release; Z = p value of weighted test for overall effect; RR = risk ratios; df = degrees of freedom; I2 = test statistic.
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Table 3:
Summary of the meta-analyses

Discussion

Several instruments have been advocated for the percutaneous procedure, including the hypodermic needle [13, 19, 23, 28, 34], tenotome [17], blade [12], and specially designed knives and needle-knives [2, 9, 32]. Although all of these techniques produce good functional outcomes, the best treatment of trigger digit remains unknown. In this context, we therefore performed a meta-analysis of RCTs comparing percutaneous release with open surgery or corticosteroid injections to compare the risk of treatment failure, the levels of patient satisfaction, and the frequency of complications.

We acknowledge limitations of our meta-analysis. First, although only RCTs and quasiRCTs were considered for inclusion, study quality varied among the studies that met our inclusion criteria. Potential sources of bias in these trials included inadequate methods to conceal random allocation, lack of blinding, and an unclear loss of followup. Second, patients with trigger fingers and thumbs were included in this meta-analysis. Two trials [9, 19] studied only patients with trigger thumb, and the risk of operative complications, however, may be different among fingers and thumbs. The thumb is at highest risk for digital nerve injury because the radial digital nerve courses subcutaneously over the A1 pulley [6, 15], although there were no digital nerve injuries in any of the included studies. Third, Maneerit et al. [19] compared percutaneous release and steroid injection with steroid injection, which could augment the efficacy of percutaneous release [31]. Fourth, we extracted the outcomes after a single injection for the corticosteroid injection group. Ten patients underwent second injections 1 week after the first injections [9], which could have modified the total results. Fifth, the indications for treatment, an actual instrument type of percutaneous release and the drug type of steroid injection, varied. The percutaneous release instruments included a blade, needle, miniscalpel needle, and a full-handle knife at 45°, and the steroid injection drugs involved triamcinolone, betamethasone, and methylprednisolone. Some differences may exist among those instruments and/or steroids [25]. We did not assess the relative outcomes in subgroups for a stratified analysis.

Open surgical release of the A1 pulley has been performed for more than 100 years. It has a high rate of success with minimal morbidity and recurrence and therefore is considered the gold standard [26]. Even so, there is a relative paucity of published data regarding the success of open surgical release, with success being achieved, variably, in 60% to 97% of patients treated with that approach [21, 27, 30]. Furthermore, open trigger finger release is thought to be a low-risk procedure by many practitioners. For the percutaneous technique, a potential disadvantage is the limited visibility, as one could cause damage to either nerve or tendon. Many hand surgeons are hesitant to release the A1 pulley of digits percutaneously owing to its close proximity to the digital nerve [31]. That is why many surgeons choose open surgery or steroid injections alone for trigger digits. Carrozzella et al. [6] reported that the radial digital nerve of the thumb at the level of the metacarpophalangeal crease is only 1.15 mm anterior to the radial sesamoid bone and 2.19 mm below the dermis, which can act as a cutting board to transect the digital nerve. Our meta-analysis identified four RCTs that compared percutaneous release and open surgery for trigger digits. The data suggest open methods of A1 pulley release are similar to percutaneous release in terms of failure rate and frequency of complications. Percutaneous release may offer advantages in terms of operative time and expense, although these endpoints were beyond the scope of this study.

Steroid injection with local anesthetics into the flexor tendon sheath is commonly offered to patients with trigger finger as a first-line treatment [20]. Various injection techniques have been used to treat trigger finger [26]; however, a diminished response to injection has been associated consistently with an increased duration of symptoms, usually more than 4 to 6 months, and an increasing number of injections [24]. In addition, there is a 33% risk of recurrence within 1 year [1]. Benson and Ptaszek [3] reported 60% of patients achieved pain relief from one injection. Of those treated with a second injection, 36% were asymptomatic at 3 months. Six patients were injected a third time, none of whom had long-term relief. Our meta-analysis of RCTs suggests percutaneous release is a reasonable alternative for patients with trigger digits when compared with one injection of corticosteroid, as it appears to have a lower failure rate without an increased risk of complications.

Future research in this area should include RCTs performed with appropriate methods to limit bias, including concealed randomization, larger sample sizes, objective outcome measures, and blinded outcome assessments.

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