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Advance Access publication 29 October 2011 Treatment of trigger finger: randomized clinical trialcomparing the methods of corticosteroid injection,percutaneous release and open surgery Edson S. Sato1, Joa˜o B. Gomes dos Santos1, Joa˜o C. Belloti1,Walter M. Albertoni1 and Flavio Faloppa1 Objective. The aim of this study is to evaluate the effectiveness of CS injection, percutaneous pulleyrelease and conventional open surgery for treating trigger finger in terms of cure, relapse and complication Methods. One hundred and thirty-seven patients with a total of 150 fingers were randomly assigned andallocated into one of the treatment groups, with treatments allocated into 150 opaque and sealed enve-lopes. We included patients >15 years of age with a trigger on any finger of the hand (Types II–IV) andused a minimum follow-up time of 6 months. The primary outcome measures were cures, relapses andfailures.
Results. Forty-nine patients were assigned to the conservative group to undergo CS injections, whereas45 and 56 were assigned to undergo percutaneous release and outpatient open surgery, respectively. Thetrigger cure rate for patients in the injection method group was 57%, and wherever necessary, twoinjections were administered, which increased the cure rate to 86%. For the percutaneous and open release methods, remission of the trigger was achieved in all cases.
Conclusions. The percutaneous and open surgery methods displayed similar effectiveness and provedsuperior to the conservative CS method regarding the trigger cure and relapse rates.
Trial registration. Current Controlled Trials, http://www.controlled-trials.com/, ISRCTN19255926.
Key words: trigger finger disorder, tendon entrapment, stenosing tenosynovitis, trigger digits, snappingfinger, trigger thumb, randomized controlled trial, controlled clinical trial, operative surgical procedure,tendon release identified as triggering factors, there is no consensus inthe literature about its true cause and its aetiology remains Trigger finger is a condition that occurs when the gliding unknown Notta described trigger finger as a con- movement of the tendon is blocked by the osteofibrous dition caused by changes to the flexor tendon and its canal of the A1 pulley, preventing the tendon from natur- sheath. Hueston and Wilson demonstrated in an ana- ally extending and returning to its initial position. Although tomical study that the spiral arrangement of the architec- synovial proliferation and fibrosis flexor sheath are ture of the intratendon fibres leads to the formation ofnodules that form distally to the A1 pulley.
This pathology is more common in women, on the dom- Department of Orthopedics and Traumatology, Discipline of Hand and Upper Limb Surgery, UNIFESP – Federal University of Sa˜o Paulo, inant side, and in the sixth decade of life. The most af- Sa˜o Paulo City, Sa˜o Paulo, Brazil.
fected finger is the thumb; however, the occurrence of the Submitted 3 June 2011; revised version accepted 5 August 2011.
trigger is also common in the other fingers The symp- Correspondence to: Edson S. Sato, Department of Orthopedics and toms vary from a slight local discomfort to the formation of Traumatology, Discipline of Hand and Upper Limb Surgery, UNIFESP – a tendon blockage, experienced principally in the morn- Federal University of Sa˜o Paulo, Sa˜o Paulo City, Sa˜o Paulo, Brazil.
E-mail: edsonsasahara@ig.com.br ing, which leads to a deficit in actively extending the ! The Author 2011. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com finger, which remains fixed in a flexed position Trigger they were discharged from the study. For the injection finger also appears to be linked to other diseases, such as group, those that received a second injection were fol- RA, gout, CTS, De Quervain’s disease and diabetes lowed for 6 months starting from the second intervention.
Quinnell classified the trigger finger using five typesduring flexion and extension: normal movement (Type 0), uneven movement (Type I), actively correctable (Type II), The patients were initially treated by outpatient hand sur- passively correctable (Type III) and fixed deformity (Type IV).
gery in the Discipline of Hand and Upper Limb Surgery, Although some patients may experience a spontaneous Department of Orthopedics and Traumatology, Paulista cure or a disappearance of the symptoms by means of the Medical School – Federal University of Sa˜o Paulo treatment strategies of immobilization or CS injections, (UNIFESP) – Brazil. Treatment was started for a group of many may require surgery for release of the A1 pulley 137 patients presenting 150 cases of trigger finger. The , –Some authors support a conservative treat- patients were treated by resident physicians, assistant ment based on steroid injection, whereas others advocate physicians and the author of this article according to the A CS in conjunction with anaesthesia may be adminis- The study participants and each finger submitted to tered to the flexor muscle sheath, and this strategy has treatment were grouped and numbered chronologically.
been demonstrated to produce good results – In cases in which the patient presented with two trigger However, that technique can result in a relapse rate of up fingers, each finger received its own order number regard- less of whether the fingers were on the same or different Release through open surgery has a high rate of suc- cess with minimal morbidity and recurrence, although In the study, 12 patients had a trigger on more than one they do occur, principally in cases of long-standing illness finger of a hand. Each trigger finger received an order and in which there was a failure of a conservative remedy; number. Eleven patients participated in the study on two however, accounts of complications do exist, such as occasions, and one participated on three occasions.
painful scarring, infections and nerve damage, in addition Calculation of the size of the study sample was based on the primary outcome of the differences in cure rates In 1958, Lorthioir described a treatment method for among the different proposed treatment techniques, with trigger finger consisting of a delicate tenotomy. Other au- the sample being considered dichotomically and categor- thors have also reported good results by using percutan- ically variable. The difference in cure rates was originally determined to be $25%. Each group finally consisted of We developed this randomized prospective study with 50 fingers, after 43 were calculated per group with a the objective of verifying the most effective treatment b-value of 80% and an a statistical significance of 5%.
method for this pathology by comparing the techniques For the purposes of randomization, we used a six-sided of CS injection, percutaneous release of the A1 pulley and die, with the treatment method selection depending on the conventional open surgery in terms of their rates of cure, result obtained. When sides one and six were scored, the selected method was injection, surgical release was se-lected when sides three and four were scored and percu- taneous release was selected when sides five and sixwere scored, resulting in three study groups. The draw was conducted before the study by a person independent The study compared the rates of cure, relapse and com- of the research. There were 150 draws conducted. As the plications of treatments for trigger finger based on CS in- methods were drawn, each result was placed in an jection, percutaneous release and open release of the A1 opaque envelope, which was then sealed; envelopes pulley as realized in the period from November 2002 to were numbered from 1 to 150. None of the project par- March 2007. The research project was analysed and ticipants had prior access to the envelope contents.
approved by the Ethics Research Committee of the Before treatment, the envelope was opened and the paper, with either one, two or three methods to be used, (CEP No. 0349/03 on 23 May 2003). Written informed con- was read by the assistant physician. The patient was in- sent was obtained from all the participants.
formed of the type of treatment he or she would receive For both genders, the inclusion criteria were 515 years and was led to the operating theatre. In this manner, each of age and symptomatologies of trigger finger movement patient received treatment according to his or her number blockage on either hand in subjects who had not under- (e.g. the first patient received the treatment indicated gone previous treatment of any type and were classified as Quinnell Types II—IV We excluded individuals with Type I trigger fingers, which are considered congenitaland secondary to the partial lesion to the tendon.
CS injection consisted of an injection of 2 ml of methyl- Outpatient follow-up was conducted over a minimum prednisolone acetate 40 mg/ml at the site corresponding period of 6 months. The patients were prospectively as- to the A1 pulley, attempting to inject the solution within the sessed after 1, 2 weeks, 1, 2, 4 and 6 months, after which osteofibrous canal Percutaneous release consisted of release of the A1 pulley with a 40 Â 12 needle, using 6 months after the treatment. Complications, including longitudinal movements, in the direction of the axis of those linked to the treatment methods used, infection, the flexor tendon, and this release was introduced at total lesion of the flexor tendon and lesion of the digital Conventional open surgery consisted of an incision of2 cm in the skin transverse to the axis of the finger at the palmar skin fold, followed by subcutaneous dissection Analysis of variance (ANOVA) was used to compare the and longitudinal opening of the A1 pulley averages of the numerical variables. For the categoricalvariables, we used the Pearson’s chi-square test. For all tests, an a-value of 5% was used, with P < 0.05 indicating statistical significance. All analyses were performed using Cure of the trigger was considered as the remission of the trigger, cessation of blockage (bending) of the finger, and We analysed the homogeneity among participants of the free flow of its movement. Patients were deemed the study according to their gender, the onset of diabetes, cured if they maintained remission of the ‘trigger’ for age and duration of disease at the date they committed to 6 months of follow-up. Relapse of the trigger was classi- the protocol. The Pearson’s chi-square test was used to fied as the relapse or return of blockage of the finger verify the existence of the link among the categorical vari- within the 6 months of post-study follow-up. With respect ables, gender and onset of diabetes. ANOVA was used to to percutaneous release and open release, we classified make comparisons among the averages of the numeric as failures those fingers that relapsed or in which block- variables, gender and duration of disease at the date of age of the finger was maintained after treatment. For the committing to the protocol. We used Pearson’s chi- purposes of the injection, we considered as failures those square test for the statistical analysis of the frequency of fingers that relapsed or in which blockage of the finger complaints regarding pain subsequent to the treatments, was maintained after the second injection.
both at the site of the procedure as well as at the IP jointsof the digits. We used ANOVA for the statistical analysis of the variation of movement of the fingers before and Topical pain was defined as pain at the site of the pro- after the treatments. Pearson’s chi-square test was used cedure 1 and 2 weeks and 1, 2, 4 and 6 months after the for statistical comparisons among the cure rates for the procedure. Articular pain was defined as pain at the IP injection, percutaneous and open methods.
joint of the thumb and at the PIP joint of the fingers 1 and 2 weeks and 1, 2, 4 and 6 months after the procedure.
For the purposes of assessing the active movement of thefingers, we used the total active motion (TAM) method as advocated by the Committee for Tendon Lesions of the The three groups were homogeneous in terms of age, International Federation of Societies of Hand Surgery comorbidity, gender, time of onset of trigger finger and To calculate the TAM value, we added the degree of flex- classification (and The data pertaining to ure of the joints of the fingers with active flexure and sub- the analysis of the rates of cure, relapse and failure tracted the loss of extension as measured with the finger observed among the injection, percutaneous and open in active extension. The measurements were collected using a goniometer in the dorsal region of the fingers. Themeasurements were taken before and 1, 2, 4 and TABLE 1 Epidemiological data: gender, onset of diabetes,age in years and disease time in months *Chi-square test. n: number of patients per group.
The injection group presented a rate of trigger finger relapse of 12.5%. All relapses received a second injection.
The open and percutaneous methods resulted in signifi- The group that received two injections presented a re- cantly higher rates of cure of trigger finger than the injec- lapse rate of 18%. No relapse was observed in the groups treated by percutaneous release and open surgery.
There were seven failures in the injection method groupafter the second injection: four occurred as a result of the TABLE 2 Distribution of patients by classification persistence of the trigger and three occurred as a result ofrelapse. There were no failures in the percutaneous and open surgery groups. The results of the interventions aresummarized in The percentage of patients experiencing topical pain in the injection group was statistically lower than those inthe percutaneous and open surgery groups after 1 week *Chi-square test. n: number of patients per group.
(P = 0.000), 2 weeks (P = 0.000) and 1 month (P = 0.008) offollow-up. After 2, 4, and 6 months of follow-up, the per-centage of patients experiencing topical pain was similar TABLE 3 Distribution of results with grouping by method: The percentage of patients complaining of articular pain in the injection group was statistically lower than those in the percutaneous and open surgery groups after 1 week(P = 0.014), 2 weeks (P = 0.023) and 1 month (P = 0.029) of follow-up. After 2, 4 and 6 months of follow-up, the percentage of patients complaining about pain was similar There was no difference in the TAM values among the injection, percutaneous release and open surgery groups in the pre-treatment period and 6 months after treatment.
FIG. 2 Flowchart of the intervention results.
TABLE 4 Distribution of topical and joint pain frequency TABLE 5 Distribution of the average measurements of movement of the fingers by active movement (TAM values) by method before and 1, 2, 4 and6 months after treatment *ANOVA. **Statistically significant (P < 0.05). Before: TAM indicated for Type I due to the need for active demonstra- tion of the flexion–extension activity of the finger for that procedure. With Type I, the trigger occurs sporadically at the time of surgery and a blockage may not occur, which would give an erroneous impression of remission.
The open and percutaneous surgery methods proved similar and superior to injection in terms of cure and re-lapse rates. In the injection group, a 57% cure rate of the trigger was achieved with CS injection. The cases of fail- ure of relapse were submitted to a second injection; in thismanner, the cure rate increased to 86% over a 6-monthfollow-up period. A third injection was not offered, and No differences were observed after 1, 2 and 4 months of the relapses were considered failures, which were then follow-up between the injection and percutaneous release treated by means of open or percutaneous release. The groups. Lower values were observed in the open surgery results for those patients were computed in the initially group than in the injection and percutaneous release randomized group, in line with the principle of intent of groups after 1 (P = 0.012), 2 (P = 0.048) and 4 months treatment. Of the cases in which there were failures in the remission of the trigger, six were initially classified asType II, and one was classified as Type III. We did not find any studies related to the percentage of cure by injection We did not record any complications such as infection in conjunction with the type of trigger in the literature. The and total lesion of the flexor tendon or digital nerve patients in the percutaneous and open release groups had among the three groups receiving CS injections, percu- remission rates of 100%, similar to the results presented taneous release or conventional open surgery.
by Gilberts et al. in a randomized prospective studycomparing the percutaneous method with the open method, in which they reported remission rates of 98%with the open surgery method and 100% with the percu- The treatment approach to trigger finger can be conser- vative, such as the method of CS injection, or can be The patients in the injection group experienced a lower surgical, such as open surgical and percutaneous release incidence of pain in the first month of follow-up compared methods. Conclusive evidence regarding the best treat- with those of the open and percutaneous groups, which ment option is lacking. We consequently developed this had similar incidences. Authors such as Chao et al. randomized-format study based on a homogeneous popu- compared the percutaneous and injection methods and lation to test the effectiveness of the three methods.
reported that the group given injections also presented a We included patients >15 years of age with a trigger on lower incidence of patients with pain in the first month any finger, although authors such as Bain et al. [have after the procedure than patients submitted to percutan- indicated that a greater risk of lesion to the neurovascular sheath exists with the percutaneous release of the thumb For all three groups, TAM values in the sixth month of and small finger. With respect to the stage of disease, follow-up were greater than the values observed before we included Types II–IV triggers because in a previous treatment, similar to the findings of Marcus et al. [The study we observed that the percutaneous method is not open group had lower TAM values than the injection and percutaneous groups after 1, 2 and 4 months of follow-up, 10 Rhoades CE, Gelberman RH, Manjarris JF. Stenosing which may be explained by the greater morbidity of the tenosynovitis of the fingers and thumb. Clin Orthop Relat We did not observe any lesion of the digital nerve 11 Marks MR, Gunther SF. Efficacy of cortisone injection in among the three treatment groups, which would be a dis- treatment of trigger fingers and thumbs. J Hand Surg Am tressing factor, principally for the percutaneous method group. We believe that the demarcation of the longitudinal 12 Newport ML, Lane LB, Stuchin SA. Treatment of trigger axis of the tendon in the percutaneous technique and pre- finger by steroid injection. J Hand Surg Am 1990;15: cise anatomical knowledge of the pulleys are important factors for preventing complications, which is similar to 13 Benson LS, Ptaszek AJ. Injection versus surgery in the the conclusion reached in anatomical studies treatment of trigger finger. J Hand Surg Am 1997;22:138–44.
14 Ring D, Lozano-Caldero´n S, Shin R et al. A prospective randomized controlled trial of injection of dexamethasone The levels of effectiveness of open surgical and percutan- versus triamcinolone for idiopathic trigger finger. J Hand eous methods were superior to the conservative method of using CSs based on the cure and reappearance rates of 15 Turowski GA, Zdankiewicz PD, Thomson JG. The results of surgical treatment of trigger finger. J Hand Surg Br1997;22:145–9.
16 Thorpe AP. Results of surgery for trigger finger. J Hand . Trigger finger should be treated first by steroid 17 Lorthioir J. Surgical treatment of trigger-finger by a subcutaneous method. J Bone Joint Surg Am 1958;40: . Trigger finger treatment by percutaneous pulley release and open surgery showed similar levels ofpain.
18 Tanaka J, Muraji M, Negoro H et al. Subcutaneous release . Steroid injection is a less painful method than of trigger thumb and fingers in 210 fingers. J Hand Surg Br surgery for treating trigger finger.
19 Lyu SR. Closed division of the flexor tendon sheath for trigger finger. J Bone Joint Surg Br 1992;74:418–20.
Disclosure statement: The authors have declared no 20 Cohen TJ. Percutaneous treatment of trigger finger. Rev 21 Nagoshi M, Hashizume H, Nishida K et al. Percutaneous release for trigger finger in idiopathic and hemodialysis patients. Acta Med Okayama 1997;51:155–8.
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Notta A. Research on a particular condition of tendon 23 Blumberg N, Arbel R, Dekel S. Percutaneous release of sheaths of the hand, characterized by the development of trigger digits. J Hand Surg Br 2001;26:256–7.
a nodule in the path of flexor tendons and blocking their 24 Ragoowansi R, Acornley A, Khoo CT. Percutaneous trig- movements. Arch Ge´n Med 1850;24:142–61.
ger finger release: the ‘lift-cut’ technique. Br J Plast Surg Hueston JT, Wilson WF. The aetiology of trigger finger.
25 Wang HC, Lin GT. Retrospective study of open versus Weilby A. Trigger finger. Incidence in children and adults percutaneous trigger thumb in children. Plast Reconstr and the possibility of a predisposition in certain age groups. Acta Orthop Scand 1970;41:419–27.
26 Fu YC, Huang PJ, Tien YC et al. Revision of incompletely Eastwood DM, Gupta KJ, Johnson DP. Percutaneous released trigger fingers by percutaneous release: results release of the trigger finger: an office procedure. J Hand and complications. J Hand Surg Am 2006;31:1288–91.
27 Sato ES, Albertoni WM, Leite VM et al. Trigger finger: a Freiberg A, Mulholland RS, Levine R. Nonoperative treat- prospective analysis of 76 fingers treated surgically by ment of trigger fingers and thumbs. J Hand Surg Am 1989; percutaneous release. Rev Bras Ortop 2004;396:309–22.
28 Kleinert HE, Verdan C. Report of the Committee Ryzewicz M, Wolf JM. Trigger digits: principles, on Tendon Injuries (International Federation of Societies management, and complications. J Hand Surg Am 2006; for Surgery of the Hand). J Hand Surg Am 1983;8:794–8.
29 Bain GI, Turnbull J, Charles MN et al. Percutaneous A1 Patel MR, Bassini L. Trigger fingers and thumb: when to pulley release: a cadaveric study. J Hand Surg Am 1995; splint, inject, or operate. J.Hand Surg Am 1992;17:110–3.
Kolind-Sorensen V. Treatment of trigger fingers. Acta 30 Gilberts EC, Beekman WH, Stevens HJ et al.
Prospective randomized trial of open versus percutaneous surgery for trigger digits. J Hand Surg Am 2001;26: 33 Wilhelmi BJ, Mowlavi A, Neumeister MW et al. Safe treatment of trigger finger with longitudinal and transverse 31 Chao M, Wu S, Yan T. The effect of miniscalpel-needle landmarks: an anatomic study of the border fingers for versus steroid injection for trigger thumb release. J Hand percutaneous release. Plast Reconstr Surg 2003;112: 32 Marcus AM, Culver JE Jr, Hunt TR 3rd. Treating trigger 34 Fiorini HJ, Santos JB, Hirakawa CK et al. Anatomical finger in diabetics using excision of the ulnar slip of the study of the A1 pulley: length and location by means of flexor digitorum superficialis with or without A1 pulley cutaneous landmarks on the palmar surface. J Hand Surg

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