Comparison of the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the A1 pulley in treating trigger finger

Abstract

OBJECTIVE:

To compare the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the A1 pulley in treating trigger finger.

METHODS:

A total of 60 patients with trigger finger were enrolled in this retrospective study. Among them, 30 patients were treated with ultrasound-guided needle release of the A1 pulley with corticosteroid injection (group A) and 30 patients were treated with single ultrasound-guided corticosteroids injection (group B). The following parameters were evaluated including clinical parameters (pain degree, function of joint, finger tendon function, postoperative satisfaction), and ultrasound parameter (thickness of A1 pulley).

RESULTS:

The postoperative visual analogue scale (VAS) and Quinnell scores in two groups were significantly lower than that before operation (p < 0.05). The postoperative Quinnell score of group A was significantly lower than that in group B (p < 0.05). The TAM results showed that the postoperative overall excellent and good rate of group A was significantly higher than that in group B (p < 0.05). The postoperative survey showed that more than 80% patients reported satisfaction in the two groups. The ultrasound imaging results showed that the postoperative thickness of A1 pulley in two groups were thinner than that before operation (p < 0.05). There were no adverse effects and complications in the two groups.

CONCLUSIONS:

Both approaches had treatment benefit in trigger finger. Ultrasound-guided needle release of the A1 pulley with corticosteroid injection had better treatment benefits than single ultrasound-guided corticosteroids injection in improving finger tendon function and joint function.

Keywords

Trigger finger ultrasound A1 pulley corticosteroid injection

1 Introduction

Stenosing flexor tenosynovitis, or “trigger finger”, is a chronic condition with lifetime occurrence rates of 2.6% in healthy individuals and 10% in diabetics [1]. It affects women more than men, mostly in the ages over 50 and 60 years old [2]. The cause for trigger finger is thickening of the A1 pulley due to excessive flexion and extension of digits, repeated friction between flexor tendon and tendon sheath, or failure in prompt treatment of palm skin injury [3]. The diagnosis of trigger finger is based on the clinical examination and medical history [4]. The typical symptoms are pain or tenderness at the base of the affected finger with snapping and/or complete locking [5]. With modern ultrasonographic equipment, the finger tendons and pulleys can be fully analyzed in their normal state and the pathologic anatomic structures involved in trigger finger can be clearly seen. The signs of trigger finger have been well described as hypoechogenic or even doppler hyperemic thickening of the A1 pulley with abnormal underlying flexor tendons (tendinosis, tenosynovitis, dark tendon sign) [6].

Generally, mild cases are first treated conservatively, with oral anti-inflammatory drugs, physical therapy, or corticosteroid injections; while severe cases are released surgically, which is successful in 60–97% of cases [7]. Local corticosteroid injection is a simple and quick method to treat trigger finger and is effective in reducing symptoms [8]. However, this intervention is often performed “blindly”, so the risk for damaging the median nerve and the surrounding structures such as tendons and vessels cannot be completely avoided [9]. Moreover, this “blind” intervention does not ensure the accurate placement of the injected steroid. Percutaneous A1 pulley release has many advantages, including avoidance of scar tenderness, shorter recovery time, and application in the outpatient setting [5,10,11 , 5,10,11]. However, there is still a potential risk of damage to the tendon and neurovascular structures [12-14]. As an inexpensive and largely available radiologic modality, ultrasound can provide direct visualization of the vascular and nerve structures during the procedure [15-17] and can also guide local steroid injections [18] and pulley release [19]. However, we find that the effect of ultrasound-guided acupuncture to release the A1 pulley is not ideal in the actual work. Therefore, we designed a procedure of ultrasonography guided percutaneous A1 pulley release combined with drug injection. In this study, we aimed to compare the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the A1 pulley in treating trigger finger.

2 Methods

2.1 Patients

A total of 60 patients were enrolled in this retrospective study from June 2017 to May 2019. Among these patents, there were 6 males and 54 females. The mean age was 57.37±8.60 years (range, 37–73 years). The mean duration of disease was 8.12±4.29 months (range, 2-18 months). Among these patients, 30 patients were treated with ultrasound-guided needle release of the A1 pulley with corticosteroid injection (group A) and 30 patients were treated with single ultrasound-guided corticosteroids injection (group B). The baseline characteristics of two groups were shown in Table 1.

Table 1
Baseline characteristics in 2 groups

Characteristic Group A Group B p

Cases (n) 30 30

Age (years), Mean±SD 56.90±8.94 57.83±8.38 0.678

Sex (n) 0.389

Male 2 4

Female 28 26

BMI (kg/m²) 21.47±2.32 21.43±1.69 0.946

Duration of disease (months), Mean±SD 8.23±4.54 8.00±4.11 0.835

Lesion site 0.347

Right 25 22

Left 5 8

Characteristic	Group A	Group B	p
Cases (n)	30	30
Age (years), Mean±SD	56.90±8.94	57.83±8.38	0.678
Sex (n)			0.389
Male	2	4
Female	28	26
BMI (kg/m²)	21.47±2.32	21.43±1.69	0.946
Duration of disease (months), Mean±SD	8.23±4.54	8.00±4.11	0.835
Lesion site			0.347
Right	25	22
Left	5	8

Group A, ultrasound-guided needle release of the A1 pulley with corticosteroid injection; Group B, single ultrasound-guided corticosteroids injection; BMI, body mass index.

The inclusion criteria were as follows: 1) patients who presented with typical symptoms of pain or tenderness at the base of the affected finger with snapping and/or complete locking were clinically diagnosed with trigger finger; 2) patient received no other treatment. The exclusion criteria were as follows: 1) patients with mental disorders; 2) there were skin lesions or acute inflammation around the puncture point; 3) congenital deformity of the thumb; 4) patients who were contraindicated for corticosteroid drugs or sensitive to drug injections; 5) patients with poor general conditions (such as severe cardiovascular and cerebrovascular diseases, diabetes, coagulation dysfunction, etc.). This study was approved by the ethic committee of Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital and conducted in accordance with the Helsinki Declaration.

2.2 Procedures

Preoperative ultrasonography was performed in all 60 patients. All Ultrasonography were performed by a senior radiologist (more than 5 years of experience) using a high-frequency (5–12 MHz) line array probe (Philips Elite Ultrasound Diagnostic Instrument) and Philips Elite scanner (Philips Healthcare Solutions).

The patient was placed in the sitting position with their forearm and fingers resting on a table and the palm facing upwards. The transducer of the ultrasound scanner was enclosed in a sterilized covering, a surgical glove, and a length of stockinette. A standard acoustic coupling agent (Ambi-tion TC, Chongqing, People’s Republic of China) was applied to the inside of the glove before insertion of the transducer. The probe was placed at the metacarpophalangeal joint of the thumb, and the flexor tendon was longitudinally cut and the first pulley thickness was measured (Fig. 1A). The needle entry point was selected at 1 cm from the distal end of the first pulley. After wiping the skin with ethyl alcohol, 1.0 mL local anesthetic (2% lidocaine) was injected around the needle entry point. Once the local anesthetic has taken effect, a 22-gauge hypodermic needle (Becton Dickinson S.A.) with 0.5 mL of compound betamethasone injection (Schering-Plough labo N.V. Belgium) was advanced at a 15–20° slope angle to imaging plane. Once the needle tip reaches the A1 pulley, the needle was used to repeatedly puncture the A1 pulley from the distal to the proximal ends under continuous ultrasound guidance (Fig. 1B). Then the drug was injected (Fig. 1C). Finally, the needle was withdrawn, and the needle entry point was pressed for 3–5 min, and a small adhesive bandage was placed over the needle entry point. The wound had to be free from water contact for 48 h in order to prevent infection (Fig. 1D).

Fig. 1

Ultrasound-guided needle release of the A1 pulley with corticosteroid injection. A, Preoperative thickened A1 pulley (Arrow, preoperative A1 pulley; A, flexor tendon; P, proximal; D, distal). B, The needle was advanced at a 15–20° slope angle to imaging plane. Once the needle tip reaches the A1 pulley, the needle was used to repeatedly puncture the A1 pulley (Arrow, A1 pulley; B, needle). C, Ultrasound-guided corticosteroid injection in group A (Arrow, the drug diffused in A1 pulley; Group A, ultrasound-guided needle release of the A1 pulley with corticosteroid injection). D, Ultrasound-guided corticosteroid injection in group B (Arrow, the drug diffused in A1 pulley; Group B, single ultrasound-guided corticosteroids injection).

Fig. 2

The postoperative thickness of A1 pulley in two groups was significantly thinner. A, Group A. B, Group B. Group A, ultrasound-guided needle release of the A1 pulley with corticosteroid injection; Group B, single ultrasound-guided corticosteroids injection; A, flexor tendon; arrow, postoperative A1 pulley; P, proximal; D, distal.

The same procedures were performed in the group B. In group B, only the drug was injected into the A1 pulley sheath without release of A1 pulley.

2.3 Clinical evaluation

Patients were followed up and asked to return to our hospital 2 weeks after the operation. Patients were asked to rate pain using a ten-inch visual analog scale (VAS) ruler immediately after injection [20]. The scale had marking every inch from 0 to 10 and the patients were told that a pain score of 0 represented no pain and 10 represented extreme pain. The function of joint was assessed using the Quinnell grading system [21]. Grade 0 represented mild crepitus in a non-triggering finger. Grade I represented a vague sense of tightness and tenderness around the MP joint, without triggering. Grade II represented intermittent triggering, which was actively correctable. Grade III represented continuous triggering, which is usually correctable by manipulation with the other hand. Grade IV represented a locked digit. The VAS and Quinnell scores were recorded preoperatively and 2 weeks postoperatively.

The function of finger tendon was assessed using the total active movement (TAM) scoring system [22] of the American Society for Surgery of the Hand 2 weeks postoperatively. Forearm circumference, hand circumference, R/C joint (dorsal and palmar flexion, radial and ulnar inclination), flexion and extension in MCP joints PIP joints and DIP joints were recorded. Flexion and extension of each joint were measured using a manual goniometry and the flexion and extension deficits were recorded. TAM was defined as the sum of the DIP, PIP and MP flexion minus the sum of the DIP, PIP, and MP extension deficits. The TAM results were divided into four grades: complete relief from symptoms was graded excellent; the finger tendon function had regained more than 75% was graded good; the finger tendon function had regained more than 50% was graded medium; the finger tendon function had regained less than 50% was graded poor.

The patient was also asked to state he or she was “very satisfied”, “satisfied”, “general”, “dissatisfied” or “very dissatisfied” with the care of their trigger finger 2 weeks postoperatively. All of the assessments were performed by an experienced attending doctor and an assistant.

2.4 Ultrasound evaluation

Ultrasound examination was performed using a color Doppler US device (Philips Elite Ultrasound Diagnostic Instrument, Philips, Best, The Netherlands) with a probe frequency of 5 to 12 MHz. The patients received ultrasound examine preoperatively and 2 weeks postoperatively. Patients sat on the chair with palmup on the bed. The probe was placed on the metacarpophalangeal joints. The short and longitudinal axes were observed along the tender point and/or painful nodules. The dynamic examine was carried out as the flexion and extension of finger. The thickness of A1 pulley was measured and marked by ultrasound. The therapeutic effect was evaluated based on the thickness of A1 pulley. If the thickness of A1 pulley was reduced, the therapeutic effect was effective. Ultrasound evaluations were conducted by the two senior operators with more than 5 years of experience in sonography. Each measurement was repeated three times, and the mean value was quantified. Finally, any potential complications such as infection or nerve damage were all recorded.

2.5 Statistical analysis

All statistical analyses were performed by using SPSS version 19.0 (SPSS Institute. IL.USA). Quantitative data were expressed as means±standard deviations (SD) and were compared using Student’s t-test. Qualitative data were expressed as number and percentage and were compared using χ² test. Statistical significance was set at p < 0.05.

3 Results

3.1 Baseline characteristics

A total of 60 patients were enrolled in this study from June 2017 to May 2019. Among these patents, there were 6 males and 54 females. The mean age was 57.37±8.60 years (range, 37–73 years). The mean duration of disease was 8.12±4.29 months (range, 2–18 months). Among these patients, 30 patients were treated with ultrasound-guided needle release of the A1 pulley with corticosteroid injection (group A) and 30 patients were treated with single ultrasound-guided corticosteroids injection (group B). The baseline characteristics of two groups were shown in Table 1.

3.2 Clinical evaluation outcomes

The clinical evaluation results showed that the VAS and Quinnell scores 2 weeks postoperatively in two groups were significantly lower than that before operation (all p < 0.05), suggesting the effectiveness of these two treatment methods (Table 2). In addition, the Quinnell score of group A 2 weeks postoperatively was significantly lower than that in group B (p < 0.05), suggesting the superiority of ultrasound-guided needle release of the A1 pulley with corticosteroid injection than single ultrasound-guided corticosteroids injection in improving joint function.

Table 2
The VAS and Quinnell scores preoperatively and 2 weeks postoperatively in two groups

Group A Group B

Preoperative Postoperative Preoperative Postoperative

VAS score 4.80±2.28 1.80±0.85^a 4.70±2.12^b 1.83±0.87^a,b

Quinnell score 2.03±1.13 0.70±0.60^a 1.93±1.01^b 1.10±0.76^a,b *

	Group A	Group B
VAS score	4.80±2.28	1.80±0.85^a	4.70±2.12^b	1.83±0.87^a,b
Quinnell score	2.03±1.13	0.70±0.60^a	1.93±1.01^b	1.10±0.76^a,b *

^avs. preoperative, p < 0.05; ^bvs. group A, p > 0.05; ^b *vs. group A, p < 0.05; Group A, ultrasound-guided needle release of the A1 pulley with corticosteroid injection; Group B, single ultrasound-guided corticosteroids injection; VAS, visual analogue scale.

The TAM results showed that the overall excellent and good rate of group A 2 weeks postoperatively was significantly higher than that in group B (p < 0.05) (Table 3). This suggested that ultrasound-guided needle release of the A1 pulley with corticosteroid injection had better treatment benefits than single ultrasound-guided corticosteroids injection in improving finger tendon function.

Table 3

The postoperative TAM score in two groups

	Excellent	Good	Medium	Poor	Excellent and good rate
Group A (n, %)	13 (43.3)	12 (40.0)	3 (10.0)	2 (6.7)	25 (83.3)
Group B (n, %)	9 (30.0)	8 (26.7)	10 (33.3)	3 (10.0)	17 (56.7)^a

^avs. group A, p < 0.05; Group A, ultrasound-guided needle release of the A1 pulley with corticosteroid injection; Group B, single ultrasound-guided corticosteroids injection; TAM, total active movement.

The postoperative satisfaction survey results showed that the patients in the two groups were all satisfied with more than 80%, suggesting the effectiveness of these two treatment methods (Table 4).

Table 4

The postoperative satisfaction survey in two groups

	Very satisfied	Satisfied	General	Dissatisfied	Very dissatisfied	Satisfaction
Group A (n, %)	14 (46.7)	12 (40.0)	3 (10.0)	1 (3.3)	0 (0.0)	26 (86.7)
Group B (n, %)	11 (36.7)	13 (43.3)	4 (13.3)	1 (3.3)	1 (3.3)	24 (80.0)^a

^avs. group A, p > 0.05; Group A, ultrasound-guided needle release of the A1 pulley with corticosteroid injection; Group B, single ultrasound-guided corticosteroids injection.

3.3 Ultrasound evaluation outcomes

Table 5
Ultrasound evaluation outcomes preoperatively and 2 weeks postoperatively in two groups

Group A Group B

Preoperative Postoperative Preoperative Postoperative

A1 pulley thickness (mm) 1.72±0.53 0.59±0.23^a 1.59±0.44 0.66±0.32^a,b

	Group A	Group B
A1 pulley thickness (mm)	1.72±0.53	0.59±0.23^a	1.59±0.44	0.66±0.32^a,b

^avs. preoperative, p < 0.05; ^b vs. group A, p > 0.05; Group A, ultrasound-guided needle release of the A1 pulley with corticosteroid injection; Group B, single ultrasound-guided corticosteroids injection.

4 Discussion

Trigger finger is a chronic condition caused by inflammation, swelling, and nodule formation within the digital flexor tendon sheath [23]. Corticosteroid injections have been widely used in the clinical medicine, particularly in the field of pain management. Previous studies have shown that ultrasound-guided corticosteroid injection is better than blind administration and reduces the time to symptom resolution [24, 25]. In addition, some scholars demonstrated that percutaneous A1 pulley release has a significant effect on the treatment of trigger finger, and ultrasound-guided acupuncture release has a higher success rate [3 , 26]. However, we find that the effect of ultrasound-guided needle release of the A1 pulley is not ideal in the actual work. Therefore, we designed a procedure of ultrasonography guided needle release of the A1 pulley with corticosteroid injection.

In this study, we compared the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the A1 pulley in treating trigger finger. The results showed that the VAS and Quinnell scores 2 weeks postoperatively in two groups were significantly lower than that before operation (all p < 0.05), suggesting the effectiveness of these two treatment methods. There was no significant difference in postoperative VAS scores between the two groups. The possible reasons were as follows. The basic pathological changes of stenosing tenosynovitis were hyperemia, edema and exudation, then chronic proliferation of fibroblasts, and finally myxoid degeneration and calcification. This kind of dropsy exudates and the aggregation of inflammatory medium caused an increase in pressure within the tendon sheath, which increased the stimulation of the nerve and caused pain. The clinical effectiveness of corticosteroid injection for trigger finger may be attributable to its anti-inflammatory potential [27]. Patients in both groups received corticosteroid injections, resulting in significant relief of pain symptoms. In this study, we first evacuated the effusion in the tendon sheath to relieve pain symptoms in 2 patients with peritendinous effusion. However, the amount of effusion in fingers was less and it was difficult to pump blindly, while ultrasound guidance showed its advantages. In this study, we also found that ultrasound-guided needle release of the A1 pulley with corticosteroid injection had better treatment benefits than single ultrasound-guided corticosteroids injection in improving finger tendon function and joint function. Percutaneous A1 pulley release could separate adhesion tendon sheath tissue and loosen the scar to achieve the purpose of opening the channel, so that the tendon could pass the narrow tendon sheath and restore the normal function of the finger. Therefore, combined therapy showed obvious advantages in functional recovery [28].

The ultrasound results showed that the thickness of A1 pulley 2 weeks postoperatively in two groups were thinner than that before operation (all p < 0.05), suggesting the effectiveness of these two treatment methods. However, there was no significant difference between the two groups. It may be related to the dominant role of corticosteroids in inflammation control. Of the 60 patients, 9 had preoperatively thickened flexor tendon. In 3 cases, the tendon became thinner 2 weeks postoperatively, which was related to the opening of the channel after treatment; In 6 cases, the tendons were still thick 2 weeks postoperatively, but most of the functions were improved effectively, which may be related to the long repair period of the tendons.

The postoperative satisfaction survey results showed that the patients in the two groups were all satisfied with more than 80%, suggesting the effectiveness of these two treatment methods. The main reason for the dissatisfaction of the patients was that the improvement of symptoms did not achieve the expected effect, and some of them were satisfied after the second treatment. The patients with general evaluation were not satisfied with medical attitude, medical environment and long appointment time.

Attentions should be paid to the following points during our procedure: 1) Strict aseptic operation to avoid postoperative infection. 2) The surgeon should be familiar with the anatomical structure of the finger, control the depth and direction of the puncture needle, and try to place the puncture point and injection plane in the middle of the palmar face to avoid damage to the bilateral digital arteries. 3) In the process of acupuncture, the depth of needle tip must reach between tendon and A1 pulley. If it was too shallow, it cannot be completely released; if it was too deep, it would damage the tendon. 4) When a feeling of falling out occurred during acupuncture, the pulley may have released. The patient may be asked to do a finger flexion and extension activity to understand the degree of release. If the activity was normal and the sound disappeared, it means the A1 pulley had been completely released. Then the drug was injected.

There were several limitations in the current study. First, this study was a retrospective study conducted at a single institute which had certain limitations in clinical application. Second, the follow-up period was somewhat short. In the future, the follow-up time should be increased to observe the long-term effect and recurrence. Third, preoperative classification regarding disease severity was not performed. Therefore, future studies should be conducted to investigate the optimal populations of this procedure.

5 Conclusions

Declaration of conflicting interests

The authors declare that they have no conflict of interest.

Funding

None.

Footnotes

Acknowledgment

None.

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	Group A		Group B
	Preoperative	Postoperative	Preoperative	Postoperative
VAS score	4.80±2.28	1.80±0.85^a	4.70±2.12^b	1.83±0.87^a,b
Quinnell score	2.03±1.13	0.70±0.60^a	1.93±1.01^b	1.10±0.76^a,b *

Comparison of the clinical effectiveness of ultrasound-guided corticosteroid injection with and without needle release of the A1 pulley in treating trigger finger

Abstract

OBJECTIVE:

METHODS:

RESULTS:

CONCLUSIONS:

Keywords

1 Introduction

2 Methods

2.1 Patients

2.4 Ultrasound evaluation

2.5 Statistical analysis

3 Results

3.1 Baseline characteristics

3.2 Clinical evaluation outcomes

Table 2 The VAS and Quinnell scores preoperatively and 2 weeks postoperatively in two groups Group A Group B Preoperative Postoperative Preoperative Postoperative VAS score 4.80±2.28 1.80±0.85a 4.70±2.12b 1.83±0.87a,b Quinnell score 2.03±1.13 0.70±0.60a 1.93±1.01b 1.10±0.76a,b *

Table 5 Ultrasound evaluation outcomes preoperatively and 2 weeks postoperatively in two groups Group A Group B Preoperative Postoperative Preoperative Postoperative A1 pulley thickness (mm) 1.72±0.53 0.59±0.23a 1.59±0.44 0.66±0.32a,b

5 Conclusions

Declaration of conflicting interests

Funding

Footnotes

Acknowledgment

References

Table 2
The VAS and Quinnell scores preoperatively and 2 weeks postoperatively in two groups

Group A Group B

Preoperative Postoperative Preoperative Postoperative

VAS score 4.80±2.28 1.80±0.85^a 4.70±2.12^b 1.83±0.87^a,b

Quinnell score 2.03±1.13 0.70±0.60^a 1.93±1.01^b 1.10±0.76^a,b *

Table 5
Ultrasound evaluation outcomes preoperatively and 2 weeks postoperatively in two groups

Group A Group B

Preoperative Postoperative Preoperative Postoperative

A1 pulley thickness (mm) 1.72±0.53 0.59±0.23^a 1.59±0.44 0.66±0.32^a,b