A Prospective Randomized Trial Comparing the Effectiveness of One versus Two (Staged) Corticosteroid Injections for the Treatment of Stenosing Tenosynovitis

Abstract

Background Stenosing tenosynovitis or trigger finger is a common clinical condition regularly treated with steroid injections. Varied success is reported at early time points following injection. We present a prospective, randomized IRB-approved study to confirm these findings at a long-term follow-up. Methods Adult patients presenting with symptoms of stenosing tenosynovitis who agreed to participate were randomized into two groups. Group 1 received an initial injection of triamcinolone and local anesthetic mixture. Group 2 received the same initial injection and an additional staged injection at 6 weeks. The patients were then followed beyond 2 years. If Group 1 patients were still symptomatic at 6 weeks, another injection was given. An additional injection or surgery was defined as treatment failure. DASH scores were obtained at baseline, 3, 6, and 12 months.Results Ninety-seven patients (101 trigger digits) were enrolled in the prospective trial. Fifty-six digits were randomized to the one-injection group versus 45 digits randomized to the two-injection group ("intention to treat analysis"-ITT). After accounting for crossover between the groups, 42 patients received one-injection versus fifty-nine patients receiving two injections ("actual" analysis).Overall failure was the same between the two groups. However, a higher surgery rate was noted for patients having undergone two injections versus one injection [47 % versus 27 % (p<0.013), ITT]. Diabetes was associated with a higher surgery rate at 1 year within the group of overall failures [56 % versus 37 % (p=0.0505), ITT]. High baseline DASH score (>40) was associated with a median time of 10 months for failure and 6 months for surgery as per a Kaplan-Meier survival analysis (p<0.005 and p<0.001, respectively, ITT). Conclusions As overall failure of steroid injection for trigger finger is not improved with staged, two-injection treatment, we recommend a single injection initial treatment for trigger finger with a second injection given in cases of recurrence or failure. Diabetes was a risk factor for needing surgery if failure occurred within 1 year. The baseline DASH score is helpful in predicting which patients have a higher chance of failing as well as needing surgery.Level of evidence Prospective, randomized trial, level I.

Long-Term Effectiveness of Repeat Corticosteroid Injections for Trigger Finger

“…Factors documented to affect injection success include duration of symptoms < 4 months 3 and >6 months, 2 sex, 7,14 finger type, 7,9 nodular subtype, 8 presence of multiple trigger fingers, 2,9,13,14 younger patient age, 13 and history of upper extremity tendonopathies 13 . Diabetes has also been proposed as a factor related to ultimate need for surgical release, 13,15,16 though this may be partly confounded by an increased presence of multiple trigger fingers. We considered these potential predictors of injection success in our current study.…”

“…13,14 Factors impacting the outcome after initial trigger finger injection include symptom duration, 2,3 nodule type, 8 finger involved, 7,9 presence of multiple trigger fingers, 2,9,13,14 sex, 7,14 age, 13 comorbid upper extremity tendonopathies, 13 and diabetes. 15,16 …”

Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review

“…While surgical intervention had lower recurrence of symptoms long term, it is associated with longer-lasting pain after the intervention [70]. Disability of arm shoulder and hand (DASH) score may be useful in determining which patients may benefit from surgery [71]. Surgery is often indicated in situations of refractory stenosing tenosynovitis, as it is largely understood that serial corticosteroid injections demonstrate diminishing returns [72][73][74].…”

“…Single injection is considered to be the best method of care, as double injection does not further reduce symptoms [70,71]. In the event of full reduction of symptoms and then recurrence, a second injection may be used.…”

Acquired triggering of the fingers and thumb in adults

“…64 Early and late recurrent triggering can be controlled effectively with a further injection. 65 A second and even a third injection controls symptoms in 39% for more than one year 66 , and the authors state that further injections should not be withheld from patients who prefer non-surgical treatment. However, we would recommend referral to secondary care at this stage in keeping with recent guidelines from the British Society of Surgery of the Hand.…”