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Percutaneous release is safe, effective for trigger thumb

By Maureen Leahy

Provides an alternative to cortisone injection as in-office procedure

Initial management of trigger thumb in the office setting typically involves either cortisone injection into the flexor tendon sheath or percutaneous release of the involved pulley. However, both procedures have shortcomings, as reported in the literature. According to Kevin Kang, MD, cortisone injections have only a 57-percent effective rate, while percutaneous release may result in injury to the radial digital nerve of the thumb, scoring of the tendon, or inadequate release.

Dr. Kang and his colleagues conducted a retrospective study to determine which of the two office procedures for trigger thumb yields better outcomes. The results of their study, which Dr. Kang presented at the 2011 annual meeting of the American Society for Surgery of the Hand, indicate that patients who received percutaneous release had superior and more predictable results than those who received cortisone injections.

Defining the cohorts
The researchers identified 120 patients who had undergone initial treatment for trigger thumb between January 2008 and December 2009. Only patients whose trigger thumbs exhibited clinical triggering on active flexion and extension—defined as Grade II (mechanical clicking) or Grade III (active or passive unlocking)—were included in the study. Patients with painful thumbs with tenosynovitis and thumbs locked in flexion or extension were excluded, as were patients with a history of diabetes, inflammatory joint diseases, or trauma, and those who had received prior treatment for trigger thumb.

The cortisone injection cohort consisted of 60 patients (16 males; 44 females), with a mean age of 57 years. Most patients (88 percent) had Grade II thumbs. Similarly, the percutaneous release cohort consisted of 60 patients (14 males; 46 females), with a mean age of 59 years; 85 percent had Grade II thumbs (Table 1). All patients were treated by a single physician.

Patients in the cortisone injection cohort were allowed a repeat injection for residual symptoms of pain and/or clicking. All patients were allowed four weeks of hand therapy after their initial procedure for stiffness and/or decreased range of motion (ROM).

Percutaneous release more successful than cortisone injection
One-year follow-up was obtained via either office visit or phone for 57 cortisone injection patients and 59 percutaneous release patients. Overall success in all patients was defined as negligible pain, absence of clicking symptoms, less than 15 degrees loss of ROM, and no complications such as nerve injury or infection.

Among the percutaneous release patients, the success rate was 95 percent, compared to 79 percent in the cortisone injection patients (P = 0.022), which was statistically significant, according to Dr. Kang. No cases of infection or nerve injury were reported in either group.

In the cortisone injection group, failures were due to isolated pain (two patients), isolated mechanical symptoms (three patients), and a combination of pain and mechanical symptoms (six patients). In addition, one patient required more than two injections, one patient experienced a flare reaction at the injection site that resolved within one week, and two patients required hand therapy.

“If the cortisone injection failed, most patients opted to undergo further treatment with surgical release, percutaneous release, or additional cortisone injections due to persistence of symptoms,” said Dr. Kang.

The three percutaneous release failures were all due to mechanical symptoms; one of the patients opted to undergo a second percutaneous release. Although five patients in this group required hand therapy versus three patients in the cortisone injection group, the difference was not statistically significant.

Limitations of the study, according to Dr. Kang, include its retrospective nature and the fact that patients were given a choice of procedures. The potential for reporting bias also existed because follow-up on some patients was obtained over the phone and not through a clinical exam.

“Despite the study’s limitations, we concluded that, when performed by an experienced surgeon, percutaneous release can be a safe and effective alternative to cortisone injection as an office procedure for trigger thumb,” he said.

Dr. Kang’s coauthors of “Comparison of Cortisone Injection and Percutaneous Release of Trigger Thumbs,” include Archit Patel, MD, and Mukund Patel, MD.

Disclosure information: The authors report no conflicts.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

  • This retrospective study reviewed two cohorts of patients who received in-office treatment by a single physician for trigger thumb. One group received cortisone injection; the other group underwent percutaneous release.
  • Patients received superior and more predictable results (less pain, no clicking, minimal ROM loss, few complications) with percutaneous release compared to cortisone injection.
  • Percutaneous release is a safe and effective alternative to cortisone injection as an office procedure for trigger thumb.

References

  1. Fleisch SB, Spindler KP, Lee DH. Corticosteroid injections in the treatment of trigger finger: a level I and II systematic review. J Am Acad Orthop Surg 2007;15:166-71.

AAOS Now
November 2011 Issue
http://www.aaos.org/news/aaosnow/nov11/clinical4.asp