LETTER TO THE EDITOR

Year : 2015  |  Volume : 29  |  Issue : 1  |  Page : 55-56

Corticosteroid injection versus percutaneous release surgery in the treatment of trigger fingers

Upadhyay Sachin¹, Thakur Dileep Singh², Chansoria Mayank^3
1 Department of Orthopaedics, Traumatology and Rehabilitation, N.S.C.B Medical College, Jabalpur, Madhya Pradesh, India
² Department of Surgery, N.S.C.B Medical College, Jabalpur, Madhya Pradesh, India
³ Department of Anaesthesiology, N.S.C.B Medical College, Jabalpur, Madhya Pradesh, India

Correspondence Address:
Upadhyay Sachin
622, Poonam Sneh Nagar, State Bank Colony, Jabalpur - 482 002, Madhya Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0970-5333.145950

1. What are the methods in the present study ^[1] for comparing primary and secondary outcomes? When the author was considered a "trigger" to be cured (remission) or relapsed?
2. The authors ^[1] articulated that "in both the groups, a significant improvement in pain occurred in the first 2 weeks, but a better improvement of pain and triggering was observed in the corticosteroid group after 2 weeks." Did the authors mean that both groups showed significant improvement in pain from their baseline parameter; if yes then what are the baseline parameters? Furthermore, author stated "better improvement of pain and triggering was observed in the corticosteroid group after 2 weeks" here what does the word "better" signifies? The readers think it to be "better but not significant."
3. A research should be large enough to have a chance of detecting a statistically significant, worthwhile outcome if it exists. The current ^[1] small sample sizes research with short follow-up (6 weeks) prevents the generalization of the finding and typically lead to type-II errors - the mistaken conclusion that an intervention has no effect. ^[2]
4. Did the authors use any scale for assessing the active movement of the fingers following procedures? For assessing the active movement of the fingers, we used the total active motion ^[3] method as advocated by the Committee for Tendon Lesions of the International Federation of Societies of Hand Surgery. We would like to have a comment from the authors regarding this issue.
5. In the present study, ^[1] none of the patient in the corticosteroid group opted for a second injection during the course of the study. Is this is a pure coincidence or author's objective was to compare the efficacy of single steroid injection? We believe that if the cases of failure were submitted to a second injection, the improvement rate would be increased? Management of trigger finger with 2 steroid injections before surgery is the cost effective strategy. ^[4] We would appreciate their comment regarding this critical concern.
6. Study shows that the open surgical and percutaneous methods were superior to the conservative method of using corticosteroid injection in term of cure and relapse/recurrence rate. ^[5] We would like to know from the authors of the present study about the factors that favor steroid injection over percutaneous release.
7. In the present study, the authors found a higher rate of complication with percutaneous release. Is this higher rate of complication is attributable to surgical error? We believe that the precise anatomical knowledge of the pulleys and proper demarcation of the longitudinal axis of the tendon during the procedure are the key factors preventing complications. ^[6],[7]
8. Peer review evidence ^[8],[9] found "steroid injection showed increased efficacy for treating the thumb compared with other digits." This could be attributed to the anatomical difference in its flexor tendon pulley system. In our setup, we used steroid injection as the first line of intervention for trigger thumb too.
9. The conclusion of the present study ^[1] is perplexing. The authors articulated that both the procedures give similar outcome, but one shows better (but not significant) result than other. What is author's take home message; whether they recommend steroid injection or percutaneous release? Also what are absolute indications for either procedure?
10. We believe that steroid injection (at least two) should be the first-line therapy for trigger finger and cases not responding (with recurrent symptoms/relapse or failure) to steroids/conservative modality will then treated by means of open or percutaneous release.

Acknowledgment

References

1.	Amiri AH, Shirani F, Kariminasab MH. Corticosteroid injection versus percutaneous release surgery in treatment of trigger fingers. Indian J Pain 2014;28:173-6.
2.	Greenhalgh T. Assessing the methodological quality of published papers. BMJ 1997;315:305-8.
3.	Kleinert HE, Verdan C. Report of the committee on tendon injuries (International Federation of Societies for Surgery of the Hand). J Hand Surg Am 1983;8:794-8.
4.	Kerrigan CL, Stanwix MG. Using evidence to minimize the cost of trigger finger care. J Hand Surg Am 2009;34:997-1005.
5.	Sato ES, Gomes Dos Santos JB, Belloti JC, Albertoni WM, Faloppa F. Treatment of trigger finger: Randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery. Rheumatology (Oxford) 2012;51:93-9.
6.	Wilhelmi BJ, Mowlavi A, Neumeister MW, Bueno R, Lee WP. Safe treatment of trigger finger with longitudinal and transverse landmarks: An anatomic study of the border fingers for percutaneous release. Plast Reconstr Surg 2003;112:993-9.
7.	Fiorini HJ, Santos JB, Hirakawa CK, Sato ES, Faloppa F, Albertoni WM. Anatomical study of the A1 pulley: Length and location by means of cutaneous landmarks on the palmar surface. J Hand Surg Am 2011;36:464-8.
8.	Dala-Ali BM, Nakhdjevani A, Lloyd MA, Schreuder FB. The efficacy of steroid injection in the treatment of trigger finger. Clin Orthop Surg 2012;4:263-8.
9.	Marks MR, Gunther SF. Efficacy of cortisone injection in treatment of trigger fingers and thumbs. J Hand Surg Am 1989;14:722-7.