ABSTRACT
Introduction
To investigate the effects of two different treatment methods on the recurrence rates within one year and on clinical and functional outcomes in patients with trigger finger (TF) complaints.
Methods
The files of 137 patients diagnosed with TF at our clinic between 2018 and 2022, who received two different treatments administered by two different physicians, were retrospectively reviewed. After applying the exclusion criteria, the study included 111 patients, of whom 66 underwent surgical release and were designated as group I, and 55 received steroid injections and were designated as group II. The Wolfe grading system was used to evaluate the severity of TF, and the Visual Analog Scale was employed to measure pain levels. Clinical and functional outcomes were assessed at the third and sixth months, and one year after treatment to evaluate the effect of each procedure on the development of recurrence.
Results
In group II, the distribution of grade II and grade IIIa recurrence in the first three and six months was found to be statistically significantly higher than in group I (p=0.005 and p=0.045, respectively). In the first year, the distribution of grade II, grade IIIa, and grade IIIb recurrences in group II was also significantly higher statistically compared to group I (p=0.007). No statistically significant difference was observed between group I and group II in terms of the distribution of improvement from baseline to the third and sixth months after treatment (p=0.295 and p=0.118, respectively). All patients in both group I and group II who experienced recurrence were treated surgically.
Conclusion
Although the ease of application and rapid effectiveness of steroid injection may appear advantageous compared to surgical methods in the treatment of TF, the high recurrence rates after the first six months negatively affect the potential for sustained success with steroid injection treatment.
Introduction
Trigger finger (TF), also known as stenosing tenosynovitis, is one of the most common hand disorders, affecting approximately 2-3% of the global population. Its annual incidence in the general population is 30 cases per 100,000, and its lifetime prevalence is 2.8%, with a particular frequency among women in their 50s and 60s (1, 2). It is more commonly observed in the dominant hand, predominantly affecting the thumb, third, and fourth digits. Fibrous bands called pulleys, located along the flexor tendon sheath in the hand, anchor the flexor tendons tightly to the phalanges during finger flexion and extension movements (2). Each finger has five distinct pulley regions extending distally from the metacarpophalangeal (MP) joint level on the palmar surface. TF develops as a result of stenosis caused by inflammation of the A1 pulley located at the MP joint level. This condition arises due to the disparity between the thickened and narrowed sheath and the flexor tendon. There is non-specific causative agent in the etiology of TF. Multiple etiological factors are considered to play a role.
Risk factors for TF include diabetes, rheumatoid arthritis, strenuous hand activities, and female sex. It is observed with up to six times the frequency in women, and is most common during the fifth and sixth decades of life (3, 4). In the pathophysiology of TF, the tendon experiences friction due to the significant degeneration of the fibrocartilaginous surface within the stenotic A1 pulley, which impedes tendon gliding. This friction leads to nodular changes in the tendon and inflammation manifested as hypervascularity in the flexor tendon (3-5). Over time, smooth motion of the flexor tendon within the A1 pulley becomes increasingly difficult. When the finger is flexed and the thickened nodule passes through the tight pulley, a catching or snapping sensation occurs, which is often painful. In severe cases of TF, the finger may become locked in a flexed position. Patients may occasionally need to use their other hand to manually extend the affected finger or thumb (5, 6). Treatment options range from conservative methods such as splinting to corticosteroid injections: percutaneous release, or open surgical release. There is no definitive guideline for the treatment algorithm. The classic presentation of TF with clicking and locking is usually sufficient for diagnosis, however, patients may present with pain and swelling over the affected flexor sheath due to the acute symptom onset and avoidance of finger movement. Imaging plays no role in diagnosis (6-8).
In this study, we aimed to investigate the effect of two different treatment methods on recurrence development within one year in patients with TF complaints, based on clinical and functional outcome evaluations.
Methods
A retrospective review was conducted on the medical records of 137 patients diagnosed with TF who presented to our clinic between 2018 and 2022. The study was approved by the Sakarya University Non‑Interventional Ethics Committee (approval number: E-71522473-050.01.04-216230-23, date: 31.01.2023). Patients who did not attend regular follow-ups, those with renal failure undergoing dialysis, those receiving oncological treatment, and those with coexisting Dupuytren’s contracture in the hand were excluded from the study. Following the application of exclusion criteria, 111 patients were included in the analysis. Two treatment methods were applied by two physicians. A total of 66 patients who underwent surgical release under local anesthesia were designated as group I, and 55 patients who received a steroid injection (methylprednisolone acetate) into the A1 pulley were designated as group II. The severity of TF in patients was categorized using the Wolfe grading system.
Surgical procedures were performed under operating room conditions without the use of a tourniquet. After the subcutaneous administration of a local anesthetic (prilocaine hydrochloride) to the incision site, a 2-cm transverse incision was made, using the midpoint of the pulley as a reference. Care was taken to preserve vascular structures as the incision was deepened subcutaneously to reach the pulley. The pulley was released with a longitudinal incision extending proximally, and distally. Following the release, the tendons were assessed for any residual catching by performing flexion and extension movements of the finger (Figure 1). Upon confirmation of adequate release, and absence of locking, the anatomical layers were closed, and an elastic bandage was applied. Postoperatively, patients received a one-week course of oral antibiotics and non-steroidal anti-inflammatory drug therapy. Passive exercises were initiated during the first postoperative week, followed by active exercises over the next two weeks. Sutures were removed on postoperative day 15.
In the steroid injection procedure, a mixture of 1 cc of long-acting steroid (methylprednisolone acetate) and 1 cc of local anesthetic, was administered over the pulley and tendon sheath. The steroid injection was administered only once by two physicians using a similar technique. No ultrasound or similar devices were used during the procedure; instead, an insulin injection was administered manually, using the midline of the pulley. These procedures were carried out under outpatient clinic conditions. Following both treatment modalities, the Wolfe grading system was used to assess the severity of TF based on flexion-extension movements of the fingers, while the Visual Analog Scale (VAS) was employed to evaluate pain levels. Clinical and functional outcomes were assessed at the third and sixth months, and one year after treatment in order to investigate the effect of the intervention on recurrence.
Statistical Analysis
In this study, statistical analyses were performed using the Number Cruncher Statistical System (NCSS) 2007 Statistical Software (Utah, USA) package. In the evaluation of data, descriptive statistical methods (mean ± standard deviation) were used, and the distribution of variables was assessed using the Shapiro-Wilk normality test. For variables with a normal distribution, comparisons between two groups were made using the Independent Samples t-test. For the comparison of categorical data, the chi-square test and Fisher’s exact test were used. Results were considered statistically significant at a p-value of <0.05.
Results
The mean age was 55.32±8.96 years for group I and 57.64±9.34 years for group II. The mean follow-up durations were 17.42±4.14 months for group I and 16.80±4.35 months for group II. Group I consisted of 66 patients (12 males and 54 females). In this group, 35 procedures were performed on the right extremity and 31 on the left. Group II included 55 patients, of whom 7 were male and 48 were female. In this group, 35 interventions were performed on the right side and 20 on the left (Table 1). In group I, 51 patients (77.27%) presented with TF in the first digit, while in group II, 43 patients (78.18%) had TF in the first digit. No statistically significant differences were observed between group I and group II in terms of mean age and sex distribution (p=0.167 and p=0.412, respectively). Similarly, no statistically significant differences were identified in laterality or affected finger distribution between the groups (p=0.239 and p=0.920, respectively). The presence of comorbidities such as hypertension, vascular disease, chronic obstructive pulmonary disease, renal failure, heart disease, or rheumatoid arthritis showed no statistically significant differences between groups (p>0.05).
No statistically significant difference was observed between the groups in terms of the distribution of TF severity according to the Wolfe classification (p=0.965). However, in group II, the presence of grade II and grade IIIa recurrences at three and six months was significantly higher than in group I (p=0.005 and p=0.045, respectively). Similarly, during the first year, the distributions of grade II, grade IIIa, and grade IIIb recurrence in group II were significantly higher than in group I (p=0.007) (Table 2).
In group II, 8 patients (14.55%) showed no change and 4 patients (7.27%) had clinical worsening from pre-treatment to the one-year follow-up. These distributions were significantly higher than those in group I (p=0.001). No statistically significant difference was found between the groups regarding the distribution of clinical improvement from pre-treatment to the third and sixth months (p=0.295 and p=0.118, respectively). However, the number of patients with no change (n=8, 14.55%) or worsening (n=4, 7.27%) at the one-year mark was again significantly higher in group II than in group I (p=0.001) (Figure 2). All patients in both groups who experienced recurrence underwent surgical release (Table 3).
No statistically significant difference was found between the pre-treatment mean VAS scores of the groups (p=0.273). At the third month after treatment, the mean VAS score in group I was significantly higher than in group II (p=0.001). However, at six months, group I had significantly lower VAS scores than group II (p=0.001), and at one year, group I showed significantly lower VAS scores (p=0.0001) (Table 4).
A statistically significant change was observed between pre-treatment and post-treatment three-month, six-month, and one-year mean VAS scores in group I (p=0.0001). Pre-treatment VAS scores were significantly higher than scores at all post-treatment timepoints (p=0.0001). Three-month VAS scores were significantly lower than both six-month and one-year scores (p=0.0001). Six-month scores were significantly higher than one-year scores (p=0.0001). Similarly, a statistically significant change was observed among all follow-up timepoints in group II (p=0.0001). Pre-treatment VAS scores were significantly higher than those at all post-treatment times (p=0.0001). While three-month scores were significantly lower than one-year scores (p=0.0001), there was no statistically significant difference between three-month and six-month scores (p=0.619). However, six-month scores were significantly lower than one-year scores (p=0.0001, Table 5).
The difference in VAS scores between pre-treatment and the three-month follow-up in group I was significantly lower than in group II (p=0.012). No statistically significant difference was found between the groups regarding the change in VAS scores from pre-treatment to the six-month follow-up (p=0.414) (Figure 3). However, the change from pre-treatment to the one-year follow-up was significantly greater in group I than in group II (p=0.0001) (Table 6).
Discussion
TF is a condition characterized by painful locking or catching of the fingers due to inflammation of the flexor tendon sheath, caused by various factors (9). During flexion and extension movements, the gliding motion of the flexor tendon becomes obstructed. TF has a prevalence of approximately 2.8% in the general population and up to 12% among patients with diabetes (9, 10). Although it may be perceived as a simple condition, it can significantly impact daily life and functional capacity. Histological evaluation of the affected tissues suggests fibrocartilaginous metaplasia of the tendon sheath and the A1 pulley as a secondary response to inflammation. There are multiple treatment options for TF; however, determining the method that offers the highest clinical success and lowest recurrence rate remains a subject of debate (10, 11). In our study, which examined the effect of two different treatment modalities on recurrence rates within one year, we observed that both methods yielded comparable clinical and functional outcomes at three and six months, with no significant difference in recurrence rates during this period. Nevertheless, after the six-month mark and within the first year, patients treated with steroid injections demonstrated a significant decline in clinical and functional outcomes, along with a notable increase in recurrence rates compared to the surgical group. We therefore conclude that surgical intervention should be the preferred method to achieve a durable and effective outcome in the treatment of TF.
Guillén Astete et al. (12) reported that steroid injections in grade II and III TF cases, achieved clinical and functional success rates of up to 70% in the early months, but recurrence rates increased significantly after 12 months. Emphasizing the importance of appropriate patient selection, the authors advocated for prompt surgical release in advanced-stage cases. In another study, Patrinely et al. (13) highlighted that the mixture of local anesthetic with steroid provided a painless and comfortable treatment option for TF, with high success rates. Gil et al. (14) stated that releasing the A1 pulley effectively reduced both the subjective and objective findings of TF and remains the reference procedure in its treatment. In addition, they reported that prophylactic antibiotic use in elective hand surgery cases was unnecessary. In our study, however, patients who underwent surgery were prescribed a one-week course of oral antibiotics.
Mirza et al. (15) compared postoperative complications of open and endoscopic release techniques in TF surgery and found that both methods were effective, with comparable rates of minor postoperative complications. Pompeu et al. (16) concluded that in advanced cases of TF, steroid injections did not yield satisfactory clinical or functional outcomes and were ineffective against flexion contractures. They recommended prompt release of the A1 pulley in such cases and drew attention to the risk of permanent extension deficits after release. Effendi et al. (17) reported that while major complications after release surgery were rare, patients with poorly controlled diabetes might experience higher postoperative infection rates, which could potentially lead to severe wound complications and necrosis. In our study, no serious complications such as wound issues, infections, necrosis, or flexor tendon rupture were observed in diabetic patients. Notably, we observed that patients receiving steroid injections experienced less relief after six months, and their symptoms approached their pre-treatment levels. In a study involving 192 patients with and without diabetes, Stirling et al. (18) reported a high rate of patient satisfaction (96%) with surgical treatment for TF, and found comparable improvements in both groups. In another study, Koopman et al. (19) found a complication rate as high as 17% following surgical release for TF, but noted that it was clinically insignificant. Despite the complication rate, the authors emphasized that surgery should be the primary treatment choice due to its effectiveness in reducing recurrence. Çimen and Nami (20) stated that percutaneous release was a safe and successful method in TF surgery and that neither diabetes nor prior steroid injections affected clinical outcomes. In a study on the management of TF by orthopedic surgeons in Brazil, Silva et al. (21) found that steroid injections and non-steroidal anti-inflammatory drug therapy were typically used within the first month to three months. However, for persistent or recurrent cases after the third month, surgical release was preferred. Roberts et al. (22) investigated the efficacy of different steroid preparations in TF cases and found that patients treated with methylprednisolone required surgical release more frequently and earlier than those treated with triamcinolone or dexamethasone.
Study Limitations
This study has several limitations. First, the retrospective design and lack of randomization prior to treatment may limit the generalizability of the findings. Second, the subjective assessment of TF severity through physical examination introduces the possibility of measurement error. Third, the sample size may be insufficient to draw definitive conclusions. Therefore, future prospective studies involving a larger number of patients and a broader spectrum of comorbidities are warranted to address these limitations.
Conclusion
Although the simplicity and rapid effectiveness of steroid injection may provide clinical and functional results comparable to surgery in the first six months, the markedly higher recurrence rates beyond six months negatively affect the long-term and permanent success of this treatment method. Our study demonstrates that surgical treatment of TF results in significantly lower recurrence rates within the first year compared to treatment with steroid injection. We emphasize that surgical intervention should be considered a primary treatment option to achieve lasting and effective outcomes in TF management. We hope that this study will contribute to future research in the treatment of this condition, and believe that further studies including a greater number of patients and more variables are needed.
