Network meta-analysis of management of trigger thumb in children

Abstract

To estimate and rank cure and recurrence rates between conservative and operative treatments for trigger thumb in children. A systematic review was conducted by searching PubMed and Scopus. Eligible criteria were comparative studies included non-syndromic trigger thumbs, aged up to 10 years, reported at least 20 thumbs and followed up at least 12 months. Two assessors independently extracted data and appraised for cure, recurrence rates among observation, stretching, splinting, open surgery, and percutaneous surgery. We assessed the risk of bias in non-randomized studies of interventions. A network meta-analysis, and probability of being the best outcomes were estimated with surface under the cumulative ranking curves (SUCRA). From 6853 searched articles, eight studies (799 children and 981 thumbs) were included. Mean age was 1.87-2.83 years and average followed up time was 1-5.7 years. Open surgery, percutaneous release, splinting, and stretching had higher cure rate than observation; pooled risk ratio (95% confidence interval) of 2. 06 (1.53-2.78), 1.79 (1.26-2.53), 1.76 (1.30-2.36), and 1.37 (0.93-2.03), respectively. Percutaneous release increased risk of recurrence 3.29 times (1.42-7.60) when compared with open surgery. The best cure rates were open surgery (SUCRA = 95) followed by splint (SUCRA = 63.4), and percutaneous technique (SUCRA= 62.8). The highest recurrence rates were percutaneous (SUCRA = 97.3), and open surgery (SUCRA = 62.4). Splint is the most appropriate intervention for pediatric trigger thumb. After failed conservative methods, open surgery is considered for operative treatment. Level of evidence: Therapeutic study level II-III.

Trends in the Management of Pediatric Trigger Thumb in the United States

“…The average age of children at the time of spontaneous resolution was 5.8 years, greater than the age of 3 years that were often supported by previous mentioned studies. 3,5,8 This suggests that spontaneous resolution of trigger thumb can occur at a later age than previously suspected, and that previous studies may have had a lower rate of spontaneous resolution due to inadequate length of observation time. 7,10 Although children treated with surgery were older than those who were observed in our study, showing a possible tendency to treat trigger thumb more conservatively in younger children, the age difference (3.6 ± 1.69 vs 3.3 ± 1.96) represents minimal clinical relevance.…”

“…A meta-analysis of studies of pediatric trigger thumb (n = 981) for the last 10 years concluded that surgery had the highest cure rate, whereas observation had the lowest. 8 However, the included studies varied in follow-up duration (1-5.7 years) and had a young mean age of patients (1.9-2.8 years). In the same study, patients who were observed initially had a mean age of 2.2 years, and 54% had resolution of trigger thumb after an average of 1.3 years and avoided an operation.…”

“…[1][2][3][4] The various approaches to managing pediatric trigger thumb, which include observation, splinting, stretching, or surgery, have shown various disadvantages and varying degrees of success. [5][6][7][8] Surgery for trigger thumb release is a simple procedure that provides a quick solution to parents and surgeons, with a high success rate of 95%. 9 Furthermore, when a pediatric patient presents with a painful trigger thumb, it can warrant earlier surgical treatment to relieve pain.…”

Pulgar en gatillo, pulgar en resorte, o tenosinovitis estenosante del pulgar pediátrico

“…El diagnóstico diferencial se establece con pulgar flexo aducto congénito, artrogriposis, parálisis cerebral, fracturas y luxaciones de la articulación interfalángica. 1,2,5 El tratamiento está determinado por la edad; entre 10-30% de los pacientes menores de 2 años puede curarse de forma espontánea, 15,16,2 incluso aumenta este valor a 60% si realizan ejercicios de extensión pasiva por los padres y la colocación de férulas en extensión. 6 En pacien-tes mayores de 2 años o con contractura fija en flexión se prefiere el tratamiento quirúrgico, pues ha demostrado excelentes resultados y pocas complicaciones, entre las que destacan la lesión del nervio digital y las infecciones.…”

Open Release of Pediatric Trigger Thumb

“…Although spontaneous resolution without surgery has been reported in 63% of cases 3 , patients with a flexion contracture of >30° showed spontaneous resolution in only 2.5% of cases 10 . Furthermore, the open surgical technique has been shown to have a lower rate of complications (around 3.4%) 11 compared with percutaneous techniques, which showed a 3.29 times increased risk of recurrence 12 and relevant injury to the neurovascular bundle 8 . If the A1 is fully divided, recurrence is highly unlikely.…”