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Reviews: Review Article

Current Concepts in the Management of Trigger Finger in Adults

Gil, Joseph A. MD; Hresko, Andrew M. MD; Weiss, Arnold-Peter C. MD

Author Information
Journal of the American Academy of Orthopaedic Surgeons: August 1, 2020 - Volume 28 - Issue 15 - p e642-e650
doi: 10.5435/JAAOS-D-19-00614
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Abstract

Trigger finger (TF), also known as stenosing tenosynovitis, is one of the most common causes of hand disability.1,2 TF most commonly presents in a bimodal distribution in patients younger than eight years and in adults in their fifth and sixth decades. In the adult population, the lifetime prevalence of TF is 2% to 3% and the annual incidence is 28 per 100,000.2,3 TF more commonly presents in women and in the long and ring fingers of the dominant hand.3 Systemic conditions that predispose patients to a higher incidence and increased severity of TF include endocrine disorders (eg, diabetes mellitus, hypothyroidism, and mucopolysaccharidosis) and various inflammatory arthropathies.2,4 Patients with diabetes have a predisposition to developing more frequent and more severe TF. Prevalence in diabetic patients is between 5% and 20%, at least 2-fold higher than the general population.4

Conservative treatment modalities for TF include activity modification, orthotic immobilization, hand therapy exercise protocols, nonsteroidal anti-inflammatory medications, and steroid injections. Surgical management includes open or percutaneous surgical release of the A1 pulley. The severity of TF has been correlated with the success of conservative management and time to recovery after open release.5,6 The objective of this review is to provide a summary of the most recent literature regarding the etiology of adult TF and the efficacy of conservative and surgical treatment modalities.

Pathoanatomy

Although the precise etiology for TF in most cases remains elusive, risk factors associated with TF include genetic predisposition, presence of a systemic metabolic condition (eg, diabetes mellitus), and an inciting mechanical irritation of the tendon-A1 pulley interface (eg, repetitive power gripping activities).2,3 TF is caused by thickening of the A1 pulley or flexor tendon that disturbs the flexor tendon gliding at the tendon-A1 pulley interface.3 Although some studies have suggested that the onset of TF could be caused by performing ipsilateral carpal tunnel release, recent evidence refutes this.7 Zhang et al7 conducted a retrospective review of 1,386 hands that underwent carpal tunnel release. They found no difference in the onset of new TF before or after CTR, with TF seen in 10.6% of patients within 1 year before CTR and 5.8% of patients within 1 year after CTR.

Schreck et al8 demonstrated the utility of an animation glove for assessing how TF affects the dynamic hand function. This comparison of dynamic measurements in healthy fingers and those with known TF showed joint velocity to be a reliable parameter for assessment of TF. They found that normal peak extension and flexion velocity of the index and long fingers was highest at the metacarpophalangeal (MCP) joint and slowest at the distal interphalangeal joint. Patients with TF had a notable decrease in the maximum velocity of the proximal interphalangeal (PIP) joint in both flexion and extension.

The efficacy of surgery relies on the precise knowledge and anticipation of anatomy based on the surface landmarks (Figure 1). Fiorini et al1 sought to define an optimal incision for predictably allowing access to the proximal edge of the A1 pulley. They conducted a cadaveric study of 280 fingers and found that the distance between the digital-palmar and PIP creases corresponds with the distance between the digital palmar crease and the proximal edge of the A1 pulley in the palm. They concluded that this should be used as a surface landmark intraoperatively. Gnanasekaran et al9 conducted an anatomic study to identify palmar surface landmarks that could help locate the A1, A2, oblique, and variable annular (Av) pulleys of the thumb. The Av pulley is found between A1 and the oblique pulley. Names were assigned to the palmar thumb creases (ie, proximal palmar crease [PPC] at the MCP joint, the distal palmar crease over the middle of the proximal phalanx, and the distal crease at the interphalangeal joint). They reported that the proximal edge of the A1 pulley was 2 mm proximal to the PPC, and the distal edge of the A1 pulley was 3 mm distal to the PPC. The proximal Av and oblique pulleys were 8 and 16 mm distal to the PPC, respectively. The proximal edge of the A2 pulley was 3 mm proximal to distal crease. Precise placement of the incision over the A1 pulley of the thumb and careful technique are critical to avoid injury to the radial digital nerve, which may pass obliquely beneath the incision (Figure 2).

Figure 1
Figure 1:
A, Illustration showing the anatomic and surface landmarks for surgical exposure. B, Photograph of three incision techniques for trigger finger release: longitudinal (left), oblique (middle), and transverse (right). A, Reproduced with permission from Smith AA, Zidel P. Tendinopathies, in Weiss APC, Goldfarb CA, Hentz VR, Raven RB, Slutsky DJ, Steinmann SP, eds. Textbook of Hand & Upper Extremity Surgery. Chicago, IL, American Society for Surgery of the Hand, 2013, pp 670-705. B, Courtesy of Arnold-Peter C. Weiss, MD, Providence, RI.
Figure 2
Figure 2:
Illustration showing the vulnerability of the digital nerves of the thumb during incision of the A1 pulley. (Reproduced with permission from Smith AA, Zidel P. Tendinopathies, in Weiss APC, Goldfarb CA, Hentz VR, Raven RB, Slutsky DJ, Steinmann SP, eds. Textbook of Hand & Upper Extremity Surgery. Chicago, IL, American Society for Surgery of the Hand, 2013, pp 670-705.)

Diagnosis

Diagnosis of TF is primarily made based on history and physical examination. Patients with TF often present with pain or clicking at the level of the metacarpal head that causes limitation in grasping and holding objects.3 In more advanced cases, patients report locking or catching of the digit in addition to loss of motion at the MCP joint and the PIP joint.3 Patients with early TF may have only swelling and tenderness to palpation of the A1 pulley, whereas those presenting later may have a palpable nodule and palpable clicking that is reproduced with flexion and extension of the involved digit and is exacerbated with simultaneous compression of the A1 pulley.3 In early trigger thumb, symptoms are often reported at the interphalangeal joint. Pathology at the tendon-pulley interface can be demonstrated with ultrasonography evaluation if needed to confirm the diagnosis.10

Conservative Management

Multiple conservative modalities have been reported for TF including corticosteroid injection, oral or injectable nonsteroidal anti-inflammatory medications, and immobilization using a variety of orthoses.3 Lunsford et al3 conducted a systematic review of evidence supporting or refuting the utility of NSAIDs, orthoses, and steroid injection. They recommended that a single joint be immobilized for 6 weeks initially and then up to 12 weeks if symptoms fail to resolve at the 6-week follow-up.

Little has been known regarding the natural history of TF until recently. McKee et al6 conducted a retrospective case series analysis of 343 patients with TF who were managed with observation alone (ie, no splinting or steroid injections). Loss to follow-up occurred in less than 1% of this cohort. They reported that 6% of patients had spontaneous resolution of symptoms occurring during the 6 to 8 week interval between symptom onset and presentation for evaluation. Overall, 52% of the patients had complete spontaneous resolution of symptoms. Of those with spontaneous resolution, 50% had resolution by 8 months and 90% had complete resolution within one year of initial consultation.

Splinting

Immobilization of TF with single joint orthoses can effectively relieve pain and improve function.3 Teo et al11 conduced a randomized comparison of Green grade 2 or 3 TF (Table 1) managed with either a PIP joint blocking orthosis or MCP joint blocking orthosis. At the 2 month follow-up, a greater degree of pain reduction was observed in the PIP blocking orthosis group. The authors reported improvement by at least a single grade in 48% of patients in the PIP blocking orthosis group and 40% in the MCP blocking orthosis group. There was notable improvement in the Quick Disability of the Arm, Shoulder and Hand Score (DASH) and markedly longer duration of orthosis wear for the PIP blocking orthosis group. The authors concluded that while both effectively reduce the severity of TF, the PIP blocking orthosis is associated with superior cosmesis and functional outcomes.

Table 1 - Common Classifications of Trigger Finger Severity
Grade Clinical Findings
Green classification
 I (Pretriggering) Pain; tenderness over A1 pulley; reported history of catching
 II (Active) Demonstrable catching on physical examination with preserved active extension
 III (Passive) IIIA: Catching requiring passive extension to release
IIIB: Loss of active flexion
 IV (Contracture) Fixed flexion contracture at the PIP joint
Quinnell grading
 0 Mild crepitus in a non-triggering finger
 I No triggering, uneven movement
 II Triggering is actively correctable
 III Usually correctable by the other hand
 IV The digit is locked
Source for Green classification: Wolfe SW: Tendinopathy, in Wolfe SW, Hotchkiss RN, Pederson WC, Kozin SH, Cohen MS, eds.: Green's Operative Hand Surgery, 7th Ed. Philadelphia: Elsevier, 2017; pp. 1903-1925.
Source for Quinnell grading: Quinnell RC. Conservative management of trigger finger. Practitioner 1980;224(1340):187-190.

Drijkoningen et al12 assessed the effectiveness of nighttime splinting in patients with acute onset (<3 months) of TF. Thirty-four patients wore a MCP blocking splint at night for 6 weeks. Patients completed the short version of the DASH questionnaire and a numerical rating scale for pain at the initial visit, at 6 to 8 weeks, and after 3 months. They found that at the final follow-up, 18 patients (55%) had complete resolution of symptoms.

Injection

Steroid injections are an effective method for resolving signs and symptoms of TF, with the reported response rates between 45% and 80%.13 NSAID injections have also been studied as an alternative for patients who cannot tolerate steroids but have been found to be less effective. Shakeel and Ahmad14 designed a double-blinded RCT comparing diclofenac injection with triamcinolone and found that at the final follow-up 70% of patients in the steroid group had complete resolution of symptoms compared with 53% in the NSAIDs group. In addition, they found that patients in the steroid group had better Quinnell scores (Table 1) at the short-term (3 weeks) follow-up. More recently, Leow et al13 repeated this study comparing triamcinolone with ketorolac injections and found similar results. At 3, 6, and 12 weeks, a higher percentage of patients in the steroid group had a complete resolution of symptoms. However, at the 24-week follow-up, no difference was noted in pain between the groups. The authors acknowledged that the resolution of symptoms in the ketorolac group at 24 weeks could be related to spontaneous resolution of TF.

Steroid injections improve TF by reducing flexor tendon and A1 pulley size. Takahashi et al10 conducted a prospective study to determine if high resolution ultrasonography could detect differences in volumes of the tendon and pulley after steroid injection. They performed axial scans prior to and an average 30 days after an intrasynovial steroid injection in 23 digits. Participants in the study group improved by at least a single grade, and the transverse diameter and cross-sectional area of the tendon and the thickness of the pulley markedly decreased.

The efficacy of steroid injections for TF varies based on the number of affected digits and the clinical severity.5 Using a prospective cohort of 99 digits, Shultz et al5 found that multiple affected digits and stage severity were predictive of patient response to a steroid injection. Patients with multiple affected fingers were 5.8 times more likely not to have a response to steroid compared with those with a single affected digit. For every stage increase in severity, the odds of having no symptom resolution doubled.

Dardas et al15 conducted a retrospective case series analysis to quantify the long-term success of repeat steroid injections in patients with TF and to identify patient characteristics that are predictive of treatment outcomes. They included 292 repeat injections in their analysis. Second injection provided long-term success, defined as no need for additional injection or surgical release of the A1 pulley, in 111 patients (39%). Eighty-six (86) patients (30%) required an additional injection, and 108 (38%) underwent surgical release. Of patients receiving a third injection, 39% (24 of 62) had long-term success, 35% received a fourth injection, and 27% underwent surgical release. Sex, TF grade, presence of multiple TFs, and diabetes status were not associated with the success of second or third injections. Although most patients ultimately required a surgical release, 50% of patients who had a repeat injection had at least a year of symptomatic relief. Sobel et al16 prospectively followed 160 patients with 186 trigger digits after first, second, and third injection and similarly found that 81 of 160 (51%), 16 of 45 (37%) and 3 of 10 (30%), respectively, did not require any additional intervention. Therefore, repeat injections should be offered to patients who prefer a nonsurgical option.

No difference in outcomes has been demonstrated between steroid injections given subcutaneously (extrasheath) versus within-the-flexor tendon sheath (intrasheath). Mardani-Kivi et al randomized 180 patients to receive either an intrasheath or extrasheath injection under ultrasonography guidance. They found no difference in the rate of TF resolution at one year, reinjection rate, or the final Quinnell grade between the techniques.17

Steroid injection may increase the risk of postoperative infection in subsequent open TF release. Ng et al18 retrospectively reviewed the effect of steroid injection on the outcomes of 999 open TF releases, aiming to identify the risk factors for postoperative infections. They found that older age and decreasing days between injection and surgery correlated with infection rates. Patients without infection had a mean 260 days between injection and surgery compared with 79 days in those who had a postoperative infection. Lutsky et al19 used retrospectively matched cohorts to investigate the risk of surgical site infection after steroid injection given intraoperatively during another soft-tissue hand procedure. They found that injections ipsilateral to the surgical procedure markedly increased the infection risk. The authors concluded that injections should not be provided intraoperatively during other procedures on the ipsilateral hand. Flexor tendon rupture after corticosteroid injection has been reported, although this complication is rare.20

Efficacy of Single and Repeat Injection in Diabetic Patients

Historically, the literature has suggested that steroid injections are less effective in patients with diabetes compared with those without, with success rates in diabetic patients reported to be between 32% and 66%.4,21 Most notably, a prospective randomized trial conducted by Baumgarten et al21 in 2007 revealed that steroid injections were markedly more effective in nondiabetic patients (86% effective) than in diabetic patients (63%). However, more recently, Castellanos et al22 conducted a long-term follow-up of steroid injections in patients with TF and demonstrated no difference in success between injections in patients with diabetes (57%) and without diabetes (72%). Similarly, Dardas et al15 found no difference between the efficacy of second or third repeat injection in diabetic patients and nondiabetics. Corticosteroid injections for TF have been noted to cause transient hyperglycemia in diabetic patients, but this risk is considered acceptable given their efficacy.4

Cost Effectiveness of Injection

Halim et al23 recently conducted a cost analysis on a prospectively collected cohort of patients with TF to identify a cost effective treatment strategy. Costs reflected reimbursements for all care related to the TF, and cost savings were calculated by comparing actual cost incurred to theoretical cost of performing TF release instead of a second or third steroid injection. They included 88 digits that had at least a single steroid injection. Offering up to three injections resulted in a potential cost savings of $72,730. Of the patients who underwent more than one injection, a second injection resulted in a potential cost savings of $15,956 and a third injection resulted in a potential cost savings of $1,986. They concluded that from a cost stand point, up to three injections should be offered before surgical release.

Surgical Management

Open Release

Open surgical release of the A1 pulley effectively alleviates the subjective and objective manifestations of TF when conservative interventions are unsuccessful. Open release currently remains the benchmark operation for addressing TF. Success rates of open A1 pulley release are reported between 90 and 100%, and the procedure is associated with a complication rate between 5% and 12%.24,25 Recently however, Baek et al recognized that although open A1 pulley release is an effective procedure, a cohort of patients experience prolonged postoperative symptoms. In their review of 109 patients who underwent open A1 pulley release, 19% were found to have snapping, locking, and/or pain for longer than 8 weeks after surgery.26 Risk factors for prolonged postoperative symptoms included duration of preoperative symptoms, flexion contracture at the PIP joint, and intraoperative identification of fraying or partial flexor tendon tear.

Persistent triggering after isolated A1 pulley release is infrequent but requires additional subsequent releases.27 Structures that cause persistent triggering include the palmar aponeurosis pulley, A2 pulley, and constrictive FDS tendon (Figure 3). Although palmar aponeurosis pulley release and a single slip or complete release of the FDS have been demonstrated to be inconsequential, complete release of the A2 pulley has been previously avoided because of fears of bowstringing.27 However, Tanaka et al demonstrated that at least partial A2 release may be acceptable. In a cadaveric study, they found that releasing up to 50% of the A2 pulley did not reduce the breaking strength of the residual pulley, suggesting preservation of pulley biomechanics with partial A2 release.28 More recently, Strigelli et al performed a complete A2 release in a cohort of 169 patients with TF who underwent A1 pulley release and had persistent triggering intraoperatively. Postoperatively, they did not find any bowstringing or flexion contracture at the PIP joint.27 They attributed this biomechanical preservation to the surgical and postoperative bandaging technique in which soft bandages were applied to create a functional dressing that blocked the MCP joints in extension while allowing PIP and distal interphalangeal joint flexion with 10° of wrist extension. Patients remained in this functional dressing for 21 days after combined A1-A2 release and were instructed to avoid strenuous manual activity for two months. Therefore, in rare cases where triggering persists after A1 pulley release and more traditional release of the palmar aponeurosis and resection of slips of the FDS tendon, partial sectioning of the A2 pulley may be considered.

Figure 3
Figure 3:
Photograph of palmar aponeurosis pulley (black arrow) visualized proximal to the cut A1 pulley. (Courtesy of Arnold-Peter C. Weiss, MD, Providence, RI.)

Percutaneous

The literature supporting the safety and efficacy of percutaneous A1 pulley release (Figure 4) is growing.29,30 Guo et al demonstrated the efficacy of a percutaneous ultrasonography-guided thread technique. Although they reported a near-perfect result with their technique, they acknowledged that previous reports found percutaneous techniques to occasionally result in digital nerve injury, incomplete release, and tendon injury.30 The study of percutaneous trigger release by Gulabi et al29 reported 90% complete symptom resolution and 10% persistent triggering. Complications included insufficient release, scar sensitivity, transient hypoesthesia, and tendon lacerations. More recently, Xie et al randomized 76 patients with 89 TF into an open or percutaneous release. They found no difference in the VAS, DASH, Quinnell grade, finger range of motion, or symptom recurrence rate, concluding that the percutaneous method is a safe and effective alternative to open release.31

Figure 4
Figure 4:
Illustration showing the percutaneous release of the flexor tendon first annular (A1) pulley by using a backward-and-forward movement. (Reproduced with permission from Smith AA, Zidel P. Tendinopathies, in Weiss APC, Goldfarb CA, Hentz VR, Raven RB, Slutsky DJ, Steinmann SP, eds. Textbook of Hand & Upper Extremity Surgery, Chicago, IL, American Society for Surgery of the Hand, 2013:670-705.)

Jegal et al conducted a randomized trial to determine if adding a steroid injection after percutaneous TF release would improve outcomes. They found that augmenting percutaneous release with steroid injection decreases pain and improves subjective outcomes in the early postoperative course (ie, 3 weeks); however, this effect does not persist at 3 months.32

Although several studies have suggested that a percutaneous approach may result in improved outcomes, the technique demands a learning curve that may predispose patients to higher risk of procedure-related complications. At present, many hand surgery training programs do not provide routine exposure to percutaneous TF release. Surgeons not extensively trained in a percutaneous technique should consider pursuing additional education to achieve competency before changing practice to reduce the risk of iatrogenic injuries.

Impact of Diabetes on Surgical Outcomes

Although patients with diabetes have a predisposition to developing more severe TF, diabetic status does not appear to compromise the outcomes of open release.4 Although previous studies suggested that the outcomes of both open and percutaneous A1 release are less favorable in patients with diabetes, more recent studies have demonstrated no notable difference in functional and subjective outcomes between diabetic and nondiabetic patients.4

Although the effect of diabetes on the outcomes of TF release has been thoroughly studied, the effect of hypoglycemia in various surgical procedures had not been examined until recently.33 Buchanan et al33 conducted a retrospective review of a cohort of patients with TF using a national private payer database to determine if preoperative hypoglycemia predisposed patients to infection after surgical release. The authors identified 70,290 TF releases and found markedly higher surgical site infection rate within 1 year after release in patients with preoperative hypoglycemia.

Role of Perioperative Antibiotics

The literature does not support routine use of perioperative antibiotics in soft-tissue procedures of the hand. A retrospective review of 8,850 elective hand surgery procedures at a single center revealed no notable difference in surgical site infections between patients who received preoperative antibiotics (0.54%) and those who did not (0.26%).34

Given the overall low incidence of surgical site infection after soft-tissue procedures of the hand, previous studies are limited by being inadequately powered to detect the small treatment effect of prophylaxis.35 Li et al35 conducted a retrospective analysis of an administrative insurance claims database to maximize their sample size to reassess the effect of prophylactic antibiotic administration before soft-tissue procedures of the hand. Of the 516,986 patients identified, 58,201 received antibiotic prophylaxis. They assessed the remainder cohort with propensity score matching to control for multiple confounding variables. They found no difference in surgical site infection between patients who received antibiotics (1.4%) and those who did not (1.4%). Therefore, there is no role for preoperative antibiotics in patients who undergo elective soft-tissue procedures of the hand.

Although consensus guidelines advise against the routine use of prophylactic antibiotics before clean soft-tissue hand surgery, current practice does not adhere to these guidelines.36 Johnson et al36 examined insurance claims from the Truven MarketScan Databases to determine the rate and trend of prophylactic antibiotic use in patients undergoing one of the five outpatient hand surgery procedures, including open and endoscopic carpal tunnel release, TF release, De Quervain's release, and wrist ganglion excision. They found a 72.5% increase in administration from 2009 (10.6%) to 2015 (18.3%).

Role of Anesthesia Type

Several anesthetic modalities have been used to facilitate surgical release of TF including local, MAC local, regional, and general. Wide Awake Local Anesthesia No Tourniquet (WALANT) has gained popularity because it has been associated with improved patient outcomes and a clear cost savings.37 Gunasagarn et al randomized 40 patients who were indicated for TF release, carpal tunnel release, or ganglion excision to undergo either WALANT or local anesthesia with tourniquet.38 They reported better patient comfort in WALANT cohort. Not surprisingly, in the absence of intravenous sedation, patients were primarily dissatisfied with the discomfort that was caused by the tourniquet. Rhee et al conduced a prospective cohort study to examine the cost and patient experience of the first 100 clinic-based WALANT hand surgery procedures at a military medical center. They reported 70% cost savings and that 94% percent of patients would choose WALANT if they were to have the procedure again.37 However, despite the increasingly apparent value of WALANT, the studies in support of WALANT are often limited by setting the inclusion criteria to include patients who are screened to tolerate this method of anesthesia.

Postoperative Pain Management

Increased awareness of the opioid epidemic in the United States has prompted investigations to examine the opioid prescribing practices of hand surgeons and to study various strategies for minimizing opioid consumption after hand cases. Weinheimer et al39 designed a double-blinded randomized controlled trial comparing pain intensity after elective soft-tissue procedures in patients who received acetaminophen/hydrocodone (opioid) compared with those who received acetaminophen/ibuprofen (nonopioid). They found no difference in the pain intensity postoperatively between the two groups. However, patients in the opioid group (23%) were markedly more likely to experience adverse effects compared with the nonopioid group (3%). They concluded that hand surgeons should prescribe an opioid-free regimen after soft-tissue procedures.

Multiple studies have demonstrated that a low number of opioids are consumed after soft-tissue hand surgery. Stepan et al40 conducted a prospective cohort study of postoperative NSAID and opioid use in 123 patients who underwent either mass excision or carpal tunnel, De Quervain, or TF release. They found that only 4 to 10 tablets of hydrocodone/acetaminophen were required to control postoperative pain in most patients, regardless of the concomitant NSAID use. Based on these recent findings, routine prescription of opioids after TF release is not necessary.

Treatment Algorithm Based on Current Concepts

We propose a treatment algorithm based on our review of the current evidence. Immobilization of TF can effectively relieve pain and improve function. Patients with acute onset (<3 months) of TF can be prescribed a nighttime PIP or MCP joint blocking orthosis for up to 6 to 8 weeks.11,12 If splinting fails to resolve the symptoms, at least one corticosteroid injection should be offered to all patients, irrespective of the comorbidities (including diabetes) as long as the patient can tolerate the steroid or the injection procedure. Steroid injections have been demonstrated to be both clinically effective and cost effective and can be offered up to three times. If the patient fails splinting and injections, surgical release should be offered. Open release of the A1 pulley effectively alleviates the subjective and objective manifestations of TF and remains the benchmark operation. However, a percutaneous release can be effective if performed by a surgeon who has additional training to become proficient with a percutaneous technique and overcome the initial learning curve that may predispose patients to higher risk of procedure-related complications. There is no role for preoperative antibiotics in patients who undergo elective soft-tissue procedures of the hand. WALANT anesthesia has been demonstrated to be a cost-effective option for patients who prefer to be awake for their procedure. Postoperatively, pain can be adequately controlled with a nonopioid regimen.

References

References printed in bold type are those published within the past 5 years.

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34. Bykowski MR, Sivak WN, Cray J, Buterbaugh G, Imbriglia JE, Lee WPA: Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: A single-center, retrospective review of 8,850 cases. J Hand Surg Am 2011;36:1741-1747.
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