Corticosteroid injection therapy for trigger finger or thumb: a retrospective review of 577 digits

Background

Stenosing flexor tenosynovitis of the digital flexor tendon (trigger digit) is a common condition encountered by hand surgeons. Our purpose was to determine the efficacy of corticosteroid injections and review the demographic profile of patients with trigger digits.

Methods

We reviewed the records of 362 patients (577 trigger digits) treated with steroid injections (8 mg of triamcinolone acetonide in 1 % lidocaine) from 1998 through 2011. Follow-up (intervention to last visit) averaged 66.4 months. We assessed patient demographics (e.g., gender, age, diabetes mellitus, hand dominance, trigger digit distribution) and determined recurrence rate and injection duration of efficacy. If one injection failed, additional injections or surgical A1 pulley release were offered. Results were analyzed with Student''s t test or Fisher''s exact test (significance, p < 0.05).

Results

Women (258, 71.3 %) were affected significantly (p < 0.001) more frequently than men (104, 28.7 %) and at a significantly (p < 0.001) younger age (average, 58.3 versus 62.1 years, respectively). Eighty patients (22.1 %) were diabetic. We observed no correlation between trigger digit and hand dominance. The two most commonly affected digits were the right long finger (17.8 %) and right thumb (17.7 %). For 721 injections, the recurrence rate was 20.3 %; there were no major complications. For recurrences, the injection efficacy averaged 315 days. Surgery was required for 117 patients.

Conclusions

Injection therapy is safe and highly effective (79.7 %). Women were affected by trigger digits more often than men and at a younger age. Surgical release provides a definitive therapeutic option if corticosteroid injection fails.     

Musculoskeletal corticosteroid injections: Recommendations of the French Society for Rheumatology (SFR)

Musculoskeletal corticosteroid injections are widely performed, although the exact practice varies greatly due to advances in knowledge and techniques. This justifies updating and drawing up good practice recommendations. Using a consensus model formalized by the French National Authority for Health (HAS) and based on a literature review that resulted in a “white book”, 13 recommendations were developed by a group of experts. These recommendations were then sent online to 48 specialists for evaluation, 27 of whom were rheumatologists and 15 of whom were general practitioners. These recommendations were also presented at the 34th annual meeting of the French Society for Rheumatology (SFR) (Paris, December 2021) at a symposium attended by a hundred or so rheumatologists, who voted on these recommendations in person. The results are presented as an overall score out of 10, a median out of 10 and as tertiles. The agreement was excellent for 10 of these 13 recommendations, with mean values of 8.5 to 9.1 out of 10, median values of 9 or 10 out of 10 and agreement of 91.7% to 97.9%, which corresponds to a consensus. The 3 other recommendations were broadly supported but were the subject of more debate. One relates to patient information (mean 7.3/10, median 8/10, upper tertile 72.9%) with discussion about the waiting period. Another related to the summary report (mean 8.4/10, median 9, upper tertile 91.7%) with discussions about its content and the need to specify the lot number of the injected product. The last one related to periprosthetic injections and the need to consult and get approval from a specialist (mean 8.0/10, median 8, upper tertile 83.3%) with mostly the general practitioners having reservations. In all, there is a very strong consensus among the musculoskeletal corticosteroid injection experts and specialists consulted, which justifies them being taken into consideration to improve our daily practice.     

Open versus percutaneous release of the A1-pulley for stenosing tendovaginitis: a prospective randomized trial

A prospective randomized trial for release of the first annular pulley (A-1 pulley) in trigger fingers with a percutaneous technique versus the open surgical technique is presented. Thirty-six patients were randomized to either open (n = 16) or percutaneous (#15 blade; n = 20) release of the A-1 pulley. All patients were evaluated for grip strength, active range of motion of the proximal interphalangeal joint, and residual pain at 1 and 12 weeks after release. Furthermore, the operation time was assessed, and the costs were calculated. Overall, 100% success in terms of grip strength, active range of motion of the proximal interphalangeal joint, and residual pain was obtained in both groups. Mean operation time was significantly longer with the open technique. Because of lower costs and quicker procedure with equal functional outcome when compared with open surgery, we recommend the percutaneous technique using a #15 blade for trigger finger release.     

Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial

PURPOSE: Conservative, nonsurgical therapies for basal joint osteoarthritis, such as thumb spica splinting and intra-articular corticosteroid injections, remain the mainstays for symptomatic treatment. This study compares intra-articular hylan, corticosteroid, and placebo injections with regard to pain relief, strength, symptom improvement, and metrics of manual function in a randomized, controlled, double-blinded study. METHODS: Sixty patients with basal joint arthritis were randomized to receive 2 intra-articular hylan injections 1 week apart, 1 placebo injection followed by 1 corticosteroid injection 1 week later, or 2 placebo injections 1 week apart. Patients were evaluated at 2, 4, 12, and 26 weeks and assessed with Visual Analog Scale pain scores, strength measures, difference scores, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and range of motion measurements. RESULTS: All groups reported pain relief at 2 weeks. The steroid and placebo groups had significantly less pain at week 4 compared with baseline, but this effect disappeared by week 12. Only hylan injections continued to provide pain relief at 12 and 26 weeks compared with baseline. There were no significant differences in pain between groups at any time. At 12 and 26 weeks, the hylan group had improved grip strength compared with baseline, whereas the steroid and placebo groups were weaker. At 4 weeks, the steroid group reported in the difference score a greater improvement in symptoms (68%) compared with the hylan (44%) and placebo (50%) groups. Whereas at 26 weeks the hylan group reported the largest improvement in symptoms (68%), this was not statistically different from the placebo (47%) and steroid (58%) groups. There were no significant differences in Disabilities of the Arm, Shoulder, and Hand scores or range of motion among the groups. There were no complications from any injection. CONCLUSIONS: There were no statistically significant differences among hylan, steroid, and placebo injections for most of the outcome measures at any of the follow-up time points. However, based on the durable relief of pain, improved grip strength, and the long-term improvement in symptoms compared with preinjection values, hylan injections should be considered in the management of basal joint arthritis of the thumb. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.     

A randomized trial comparing two corticosteroid regimens combined with mycophenolate mofetil and cyclosporine for prevention of acute renal allograft rejection

INTRODUCTION: The launching of mycophenolate mofetil (MMF) has reduced the incidence of acute rejection episodes. We sought to evaluate the efficacy of decreasing the steroid dose. MATERIALS AND METHODS: This was a quasiexperimental, randomized, prospective trial. We enrolled 150 patients who received de novo renal transplantations from living or cadaveric donors, fulfilling the screening criteria. Patients were randomized to one of the following two arms: (A) MMF at a 2 g/d dose, cyclosporine (CsA) at a dose necessary to achieve target levels, and corticosteroids at the usual doses; (B) MMF at a 2 g/d dose, CsA at a dose necessary to achieve target levels, and corticosteroids at doses 50% lower than those of group A. RESULTS: Group A included 72 (48%) and group B, 78 patients (52%). There were no differences among the variables: leukopenia occurred in 11 patients in group A, and five patients in group B. Complications occurred in 67.4% (56) of group A, but only 32.6% (27) were related to infections. One case of urinary infection occurred in group B, while six occurred in group A. There was one case of acute rejection in group A, and none in group B. One graft loss occurred in group A. There were no differences in the remaining variables under study. DISCUSSION: The results showed an increased complication rate related to receiving usual steroid doses. There was no increase in acute rejection episodes among patients receiving 50% of the usual steroid dose.     

Corticosteroid compared with hyaluronic acid injections for the treatment of osteoarthritis of the knee. A prospective,randomized trial

BACKGROUND: Although both corticosteroid and hyaluronic acid injections are widely used to palliate the symptoms of knee osteoarthritis, little research involving a comparison of the two interventions has been done. We tested the hypothesis that there are no significant differences between Hylan G-F 20 (Synvisc) and the corticosteroid betamethasone sodium phosphate-betamethasone acetate (Celestone Soluspan) in terms of pain relief or improvement in function, as determined by validated scoring instruments. METHODS: One hundred patients with knee osteoarthritis were randomized to receive intra-articular injection of either Hylan G-F 20 or the corticosteroid, and they were followed for six months. The patients treated with Hylan G-F 20 received one course of three weekly injections. The patients treated with the corticosteroid received one injection at the time of enrollment in the study, and they could request one more injection any time during the study. An independent, blinded evaluator assessed the patients with the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), a modification of the Knee Society rating system, and the visual analog pain scale. RESULTS: Both the group treated with the corticosteroid and the group treated with Hylan G-F 20 demonstrated improvements from baseline WOMAC scores (a median decrease from 55 to 40 points and from 54 to 44 points, respectively; p < 0.01 for both). The scores according to the Knee Society system did not significantly improve for the patients who received the corticosteroid (median, 58 to 70 points; p = 0.06) or for those who received Hylan G-F 20 (median, 58 to 68 points; p = 0.15). The scores on the visual analog scale improved for patients receiving Hylan G-F 20 (median, 70 to 52 mm; p < 0.01) but not for the patients who received the corticosteroid (median, 64 to 52 mm; p = 0.28). However, no significant differences between the two treatment groups were found with respect to the WOMAC, Knee Society system, or visual analog scale results. Women demonstrated a significant improvement in only one of the six possible outcome-treatment combinations (the WOMAC scale), whereas men demonstrated significant improvements in five of the six outcomes (all measures except the Knee Society rating system). CONCLUSIONS: No differences were detected between patients treated with intra-articular injections of Hylan G-F 20 and those treated with the corticosteroid with respect to pain relief or function at six months of follow-up. Women demonstrated significantly less response to treatment than men did for both treatments on all three outcome scales. Such significant gender-related differences warrant further investigation.     

A prospective randomized controlled trial comparing night splinting with no splinting after treatment of mallet finger

Background

The effectiveness of night splinting after treatment of mallet finger is unknown. We tested the hypothesis that there is no difference in extensor lag between patients with mallet finger that wear a night splint for an additional month after 6 to 8 weeks of continuous splinting and patients that do not wear a night splint.

Methods

Fifty-one patients were enrolled in this randomized controlled trial. At enrollment, range of motion was measured for the injured and contralateral uninjured finger. The follow-up was conducted approximately 4 weeks later in person (41 patients) or by phone (10 patients). Analysis was by intention to treat.

Results

There were no significant differences in final extensor lag between patients that did and did not receive a night splint. Among the 41 patients with a final in-person evaluation, the final average extensor lag was 14°, and 34 % (14 of 41 patients) had a lag of 20° or greater. Final extensor lag correlated significantly with age, enrollment distal interphalangeal joint (DIP) flexion and extensor lag, and final DIP flexion, with the latter two accounting for 28 % of the variation in final lag in the final multivariable model (p < 0.001). There were no differences in disability (p = 0.67) or treatment satisfaction (p = 0.48) between patients that did and did not use night splints.

Conclusions

Supplemental night splinting does not improve the outcome of mallet finger in terms of extensor lag, disability, or satisfaction with treatment. Patients with worse initial extensor lags should expect worse final lags; residual lags of 20° or greater are commonplace.     

Comparing effectiveness of polydeoxyribonucleotide injection and corticosteroid injection in plantar fasciitis treatment: A prospective randomized clinical study

BackgroundThis study aimed to compare the efficacy and safety of polydeoxyribonucleotide (PDRN) injection and corticosteroid injection for plantar fasciitis.MethodsThis study included 44 patients with plantar fasciitis, randomly allocated to the PDRN and corticosteroid groups. Evaluation using the visual analogue scale (VAS) pain score and Manchester-Oxford foot questionnaire (MOXFQ) was conducted at baseline, 1, 2, 6 weeks and 6 months. The thickness and echogenicity of the plantar fascia in ultrasonography and complications were recorded.ResultsCorticosteroid injection elicited more pain relief than did PDRN injection at 2 (p = 0.010) and 6 weeks (p = 0.016); however, it showed no superiority at 6 months (p = 0.523). MOXFQ showed similar outcomes. The thickness and echogenicity did not differ between groups and no complications were reported in either group.ConclusionsWe demonstrated that PDRN injection could be an effective and safe option for plantar fasciitis and was comparable to corticosteroid injection after 6 months follow up.Level of evidenceII, comparative study.     

A prospective randomized trial comparing the efficacy of tacrolimus versus cyclosporine in black recipients of primary cadaveric renal transplants.

BACKGROUND: We performed a prospective randomized trial to compare the efficacy and safety of tacrolimus (FK506) versus cyclosporine (CSA) in black primary cadaveric renal transplant (CRT) recipients. METHODS: Between December 1994 and February 1997, 35 black primary CRT recipients were enrolled in this trial. All patients received 7 days of induction therapy with OKT3. Fourteen patients received FK506 and prednisone only. Twenty-one patients received CSA, azathioprine, and prednisone. The two groups were comparable in terms of age, gender, plasma renin activity, human leukocyte antigen mismatches, and cause of renal failure. RESULTS: Patient and graft survival were 12 of 14 (86%) for the FK506 group and 20 of 21 (95%) for the CSA group (P = 0.71). Three patients died owing to cardiac events with functioning grafts. Acute rejection was 2 of 14 (14%) for the FK506 and 8 of 21 (38%) for the CSA group (P = 0.25). Two other patients on CSA were converted to FK506 as rescue for OKT3-resistant rejection. Mean serum cholesterol at 1 year was 198 +/- 45 mg/dL for the FK506 group and 244 +/- 49 mg/dL for the CSA group (P = 0.03). Mean serum creatinine at 1 year was 1.39 +/- 0.38 mg/dL for the FK506 group and 1.94 +/- 0.64 mg/dL for the CSA group (P = 0.02). CONCLUSION: Patient and graft survival were similar in both groups at 1 year posttransplant. Although statistically not significant, the incidence of acute rejection was lower in the FK506 group. Furthermore, FK506-treated patients had significantly lower serum creatinine and cholesterol levels at 1 year posttransplant.