OUTCOMES OF CORTICOSTEROID INJECTION AND PERCUTANEOUS RELEASE IN TREATMENT OF TRIGGER FINGER AT TERTIARY HOSPITAL OF EASTERN NEPAL

1* 1 1 Mithilesh Kumar Gupta , Ajay Chaudhary , Ajay Mahato Received : 28 January, 2021 Accepted : 05 July, 2021 Published : 04 November, 2021 ISSN: 2542-2758 (Print) 2542-2804 (Online) 1449 Birat Journal of Health Sciences Vol.6/No.2/Issue 15/May-Aug., 2021 Original Research Ar cle


Introduc on
Trigger finger or stenosing tenosynovi s is a common cause of painful fingers and thumb that result in painful triggering, snapping or locking of fingers on flexion and extension of involved digit. Available treatment op ons for this condi on are NSAID, splints, intralesional steroid injec on, percutaneous release and open release of tendon sheath.

Objec ves
To study the clinical and func onal outcomes and complica ons of cor costeroid injec on and percutaneous release in management of trigger finger.

Methodology
In this prospec ve study, sixty pa ents who presented with Grade 2 to Grade 3 trigger finger were placed into two groups. Group A(30 pa ents) were treated with intralesional steroid (40 mg of methylprednisolone) injec on. Group B (30 pa ents) underwent percutaneous surgical release of affected tendon sheath. Both group of pa ents were treated in outpa ent department. Pa ents of both groups were then asked to follow on scheduled me interval of twoweek, six-week, three-months and six-months of period and their progress were recorded.

Results
The baseline VAS score before interven on in group A (5.82) and group B (6.12) was sta s cally significant. In group B there was significant improvement of VAS score ll 6 months of follow up. However, in group A there was significant improvement of VAS score by 3 months of follow-up, but by end of 6 months it again raised to 2.14. Yet it was far be er than baseline VAS score.

Conclusion
In our study both cor costeroid injec on and percutaneous trigger finger release were found to be much effec ve in management of trigger finger.

KEY WORDS
Trigger finger, percutaneous release, cor costeroid injec on

INTRODUCTION
Entrapment of flexor tendon of fingers, also known as trigger finger or stenosing tenosynovi s is a common 1 tendinopathy and was first described by No a in 1851. This entrapment of flexor tendon is frequently associated with pain on movement and later results in triggering, snapping or locking of involved digit on finger flexion.
The flexor tendons of fingers are enveloped by a doublewalled connec ve ssue cylindrical sheath. These flexor tendon sheath are held in place around tendon by three cruciform (C1-C3) and five annular pulleys ( A1-A5).This triggering of finger is caused by mismatch between the size of tendon and its sheath, and is most probably due to 2 hypertrophy of the first annular pulley(A1).
This hypertrophied A1 pulley results in narrow fibro-osseous canal in which now flexor tendon excursion with difficulty and causes painful triggering in fingers. When con nued, the pa ent tends to avoid a painful trigger finger, resul ng in a development of secondary proximal interphalangeal 3 flexion contracture.
The life me prevalence of trigger finger among nondiabe cs is approximately 2.6%. It commonly affects digits of dominant hand. Middle aged women are most affected, and thumb followed by ring and middle fingers are most involved digits. Male to female ra o is 1:6 and right to le 4 ra o is about 3:2.
It has two incidence peaks in life. The first peak is among children less than 8 years age, and the second peak in the fi h and sixth decade of life. Trigger finger in children below 10 years old predominantly have changes in tendon itself as a nodule forma on whereas in adults it is the tendon sheath to be involved predominantly. In majority e ology of trigger finger are primary(idiopathic) whereas a small popula on has secondary cause where triggering is secondary to amyloidosis, rheumatoid arthri s, diabetes mellitus, direct 5 trauma to tendon or tendon sheath.
Various treatment methods are available including short term oral NSAIDs, various splints, intralesional steroid injec ons, percutaneous release and open release of tendon sheath. Oral NSAIDs and splints have high recurrence rates. Intralesional steroid injec ons has good results in single [6][7][8] digit and early involvement. Percutaneous release of A1 pulley can also be done safely with good outcomes for [9][10][11][12][13][14] fingers and thumb. Open surgical release of A1 pulley is indicated for failure of conserva ve treatments and for recurrent cases, but has high complica ons such as infec ons, s ffness, scar tenderness, digital (radial) nerve injury, [15][16][17] bowstringing.
As there are various treatment methods available, the aim of our study is to assess the clinical and func onal outcomes of intralesional cor costeroid injec ons and percutaneous release in trigger finger.

METHODOLOGY
This prospec ve study was carried out at the outpa ent department of orthopedics, at Birat medical college teaching hospital, Biratnagar, from February 2020 to January 2021. The study was approved by the ins tu onal ethical review commi ee. A clinical diagnosis of trigger finger was defined as a history of triggering or locking of a finger with or without pain and tenderness or swelling at the A1 pulley. Inclusion criteria were -any pa ent above 18 18 years of age, trigger finger with Quinnell grade 2-3, pa ent giving informed consent. Exclusion criteria were-age less than 18 years, uncontrolled diabetes mellitus, coagula on disorder, fixed flexion contracture, pa ent who received any form of treatment for trigger finger prior to par cipa on in this study. Table A: 18 Quinnell grading for trigger finger.
• Grade 0 Mild crepitus in non-triggering finger • Grade 1 No triggering but uneven finger movement • Grade 2 Triggering is ac vely correctable • Grade 3 Usually correctable passively by other hand • Grade 4 The finger is locked in flexion All pa ents with trigger finger fulfilling both inclusion and exclusion criteria, were included in our study un l the planned number of 60 pa ents were achieved. The sample size was obtained a er calcula ons, assuming alpha 0.05 and power 80 (beta 0.20). Those pa ents were divided into two groups. Group A included 30 pa ents who were treated with intralesional steroid injec on. Group B also included 30 pa ents and they were treated with percutaneous release of trigger finger. Before any interven on all pa ents were examined clinically for recording the number of digits involved, side, Quinnell grading and baseline visual analogue score (VAS). All pa ents included were also inves gated for complete hemogram, platelet counts, bleeding profile and random blood sugar. For intralesional injec on, the palmar skin surface was cleaned with povidone solu on and then wiped with methyl spirit. A 26-gauge needle was inserted directly into the flexor tendon at level of A1 pulley, confirmed by detec ng the movement of needle with flexion and extension of finger. The needle was then slightly withdrawn un l there was no movement of needle with finger flexion and extension. At this point 40 mg of methylprednisolone was injected. Percutaneous trigger finger release was done as described 19 20

RESULTS
In our study pa ents were in the age group of 29 years to 58 years of age group. Most of the pa ents affected were 41-50 years of age (33.3%), followed by 51-60 years of age (1.66%).
Group wise comparison of their distribu on was as shown in Figure 1.  Among all the involved pa ent's thumb was the most affected digit (36.66%), followed by ring finger (21.66%), Li le finer was least affected one (3.33%). Distribu on of involved digits in both groups were as shown in figure 4.
A er interven on of both groups there was significant improvement in VAS score in pa ents of group A as well as VAS score of Group B pa ents at every follow up ll 6 months of period (p< 0.001).    24,25 of triggering for more than 6 months prior to treatment. Open surgical release has a high success rate and low recurrence rate, thus also considered the standard of treatment for trigger finger. But it also has poten al complica ons such as painful scar, infec ons, bowstringing and neurovascular injuries. There are studies which have reported 26% of dissa sfac on rate with open surgical [15][16][17] treatment of trigger finger. Lorthior in 1958 first descried percutaneous release of trigger finger. In their study they good results in all 52 9 pa ents without any neurovascular complica on. Similarly, Leu in 1992 reported percutaneous release with a curved 26 knife in 16 trigger fingers with high success rate. Eastwood et. al in 1992 was the first to report the use of 21gauge needle instead of a knife for percutaneous release. He 10 had success rate of 94% in 35 trigger digits. Because of proximity of digital nerves to A1 pulley in thumb some authors recommended to avoid percutaneous release 19,20 in cases where thumb is involved. However, Cihan mur et. al and Gilberts et. al claimed 100% success rate with their 19,20 method of percutaneous release even in thumb. The decision of choice of treatment depends on the severity and dura on of trigger finger. Salanda first outlined 18 treatment of trigger fingers according to severity. It is widely accepted that Quinnell grade 0 and 1 responds well to physiotherapy, NSAIDs and splints, failure of this responds well to cor costeroid treatment. Quinnell grade 4 usually is resistant co conserva ve treatment and requires surgical release. Thus, the management of grade 2 and grade 3 are s ll subject for debate. Our study was a prospec ve study of two groups which had sta cally comparable baseline demographic features such as age, sex, side, digits involved, dura on of symptoms, grade of triggering. Our objec ve was to study the outcomes of both treatment modali es during and by the end of 6 months of dura on. The baseline VAS score before interven on in group A (5.82) and group B (6.12) was sta s cally comparable. In group B there was uniform fall in VAS score ll 6 months of follow up. However, in group A there was uniform fall of VAS score by 3 months of follow-up, but by end of 6 months it again raised to 2.14. Yet it was far be er than baseline VAS score. In the study by Zyluk A, 46 digits treated with percutaneous release and 47 digits treated with cor costeroid injec on had a similar fall in VAS, with mild be er response in percutaneous 22 group. In this study, VAS scores by the end of 6 months were far below the baseline in both groups with both grades with sta s cally significant be er outcome in group B compared to group A throughout all follow up visits. This is like study reported by Chao et al, where at the end of one month both treatments were equally effec ve but by the end of 6-month assessment, pa ents treated with percutaneous release had slight be er response, whereas those treated with steroid 22 injec on had slight deteriora on. In Group A 1(3.33%) pa ent had complain of hypopigmented th skin by the 6 week of injec on which did not required any interven on except reassurance of pa ent. In Group B three pa ents (10%) had mild skin inflamma on a er 2 days of percutaneous release, they were treated with oral Cefuroxime for five days, without any further complica ons. Saldana MJ, in their study of 31 pa ents treated with percutaneous release, reported similar condi on two pa ents, treated 18 with oral an bio cs. In group A total 5 pa ents (16.66%) had recurrence of triggering requiring repe on of intralesional steroid injec on at 3 months of follow up. No pa ent in group B had recurrence by the end of study. This contrasts with study by Zyluk et al, who reported 11% of recurrence rate in pa ents 22 treated by steroid injec on, by the end of 6 month follow up.

CONCLUSION
To conclude both cor costeroid injec on and percutaneous trigger finger release were found to be equally effec ve in management of trigger finger, but per cutaneous group has slight be er outcome in term of VAS by the end of 6 months of follow up.

RECOMMENDATION
Based on results of our study we recommend both intralesional steroid and per cutaneous release are useful and safe for treatment of trigger finger that can be performed as outpa ent department procedures. However, in terms of complica on and recurrence both treatment modali es has similar response.

LIMITITATION OF STUDY
This was a prospec ve study conducted at a single ter ary center. The results may also vary with longer periods of follow up.