Keywords trigger finger disorder - surveys and questionnaires - surgeons - expert testimony
- acquired hand deformities
Introduction
Stenosing tenosynovitis of the flexors, also called trigger finger, is usually an
idiopathic pathology in which a fibrocartilaginous metaplasia occurs at the level
of the flexor tendon sheath of the hand, generating impingement or entrapment of it
as it passes through the A1 pulley at the level of the metacarpal head.[1 ]
[2 ]
[3 ]
[4 ] It is estimated that this condition has a prevalence of 3% in the general population,
although in diabetics it can reach even 10 to 20%, and its usual presentation is often
described in women from the fifth decade of life onwards. The affection of the thumb,
ring finger, and middle finger is more common, although it can also occur in multiple
fingers simultaneously.[1 ]
[2 ]
[4 ]
[5 ]
[6 ]
[7 ] Clinically, it manifests as a triggering of the finger associated with hypersensitivity
at the level of the metacarpophalangeal or proximal interphalangeal joints, sometimes
with an evident palpable nodule at the level of the A1 pulley.[1 ]
[7 ]
[8 ] Likewise, it can cause chronic pain, deformity in the finger, rupture of the flexor
tendon, and a significant functional limitation, so the importance of its timely and
adequate management is clear.[1 ]
Currently, however, there is no consensus in the literature on the ideal approach
to this disease. Firstly, no clinical classification has proven to be superior in
defining severity and management, which also explains why different factors or characteristics
of patients are considered when choosing treatment, performing follow-up and predicting
outcomes[9 ]. On the other hand, the usefulness of non-invasive management is a matter of controversy,
so the preferred initial management tends to be corticosteroid injection, although
the course of action in the case of recurrence is not clear, and it is considered
that this can even vary depending on the duration of the condition[1 ]
[9 ]
[10 ]
[11 ]
[12 ]. Additionally, it is still necessary to establish in which cases the most favorable
initial management is surgical, as well as the ideal technique (open or percutaneous
release, transverse or longitudinal incision).[6 ]
Based on the aforementioned information and also considering that there tends to be
a delay in the adoption of available evidence, it is presumed that the current management
of patients is significantly influenced by the specialist's judgment.[13 ] Therefore, the objective of the present study is to characterize the perspectives
and preferences of hand surgeons in Colombia regarding the approach to trigger finger
in adults, aiming to clarify the landscape regarding the management of this condition
in the country.
Materials and Methods
A cross-sectional study was carried out, with the target population being all hand
surgeons who were members of Colombian Association of Hand Surgery (Asociación Colombiana
de Cirugía de la Mano, Asocimano, in Spanish) and/or the hand chapter of the Colombian
Society of Orthopedic Surgery and Traumatology (Sociedad Colombiana de Cirugía Ortopédica
y Traumatología, SCCOT, in Spanish) in the first half of 2021. A sample calculation
was not necessary, since the aim of the present study was to carry out a census.
To assess the perspectives of surgeons, a survey was developed based on the researchers'
experience and the available literature. Relevant demographic variables were collected,
including the first specialty pursued, years of experience, practice setting, and
frequency of treating patients with trigger finger. Additionally, surgeons' perspectives
on three relevant topics were evaluated: the approach (specifically, the relevance
of using classifications, considerations to direct management, outcomes to consider
in the evaluation, and the waiting time to consider referral or recurrence), non-surgical
treatment (opinions on the use of orthoses and physiotherapy, as well as on infiltration
in terms of its effectiveness, complications, number of injections to offer, choice
of corticosteroid, and approach to recurrence), and the surgical treatment (indications
for its selection as initial management, its use in diabetic patients, preference
for open or percutaneous technique, type of anesthesia, and perspective on the use
of orthoses during the postoperative period).
The resulting survey was subjected to a review by a focus group of five hand surgeons
affiliated to the organizations of interest, who were considered suitable given that
they met the eligibility criteria and because they presented heterogeneous characteristics
of the population spectrum, as they had different years of experience, work experience
in different regions of the country, and had completed different postgraduate degrees
(Orthopedics and Traumatology and Plastic Surgery). [Diagram 1 ] shows the general structure of the final tool, however, the complete version of
it is found in [Annex 1 ].
Diagram 1 Structure of the survey administered to affiliated Colombian hand surgeons.
With the appropriate authorization, the databases of the members of Asocimano and
the SCCOT were obtained to distribute the survey, and each of the surgeons was contacted
directly to inform them about the justification and objectives of the study and request
their participation with the aim of reducing non-response selection bias. On the other
hand, to avoid the Hawthorne effect, it was emphasized to the surgeons that what was
intended to be evaluated through the survey was their perception and preferences regarding
management, not their theoretical knowledge.
The survey was completed by the surgeons electronically on the REDCap platform. Measures
were taken to avoid duplicate responses and missing data, and the surgeons were given
three months to respond before completing data collection.
The analysis of the data obtained was carried out through the R and R studio programming
language using the pwr package (R Foundation for Statistical Computing, Vienna, Austria).
For the qualitative variables, calculations of absolute and relative frequencies were
performed, and for the continuous variables, measures of central tendency and variability
were used. Likewise, a differential analysis was carried out based on the length of
experience of the surgeons and the first specialty studied, and differences between
these two groups were calculated using the Chi-squared test for the qualitative variables
(evaluating differences in proportions) and, for the quantitative variables, the Shapiro-Wilk
normality test and subsequently the Wilcoxon test (for the comparison of means between
two groups), since no variable had a normal distribution. A significance level of
0.05 was considered beforehand.
The present study adhered to the principles outlined in the Declaration of Helsinki
and to the technical and scientific standards indicated by the Colombian Ministry
of Health for the conduction of studies. According to these standards, as the present
work was classified as “no risk,” it did not require a process of informed consent.
However, it did require obtaining authorization from the Ethics Committee atr Hospital
Universitario San Ignacio, in Bogota, Colombia.
Results
In 2021, 154 hand surgeons were affiliated in Colombia, so the present study managed
to include up to 81% of the expected census (125 surgeons). Additionally, it was considered
that the respondents were familiar with trigger finger management, since 86% reported
treating this condition at least once a week, and 14%, at least once a month. The
demographic characteristics of the evaluated population are described in [Table 1 ] and [Diagram 2 ].
Table 1
Absolute frequency and proportion
Median years of experience
Mixed practice (public health insurance system, occupational risk administrator, university,
and/or private)
Private practice
University practice
Hand surgeons
125 (100%)
11
74.4%
11.2%
14.4%
Orthopedists and traumatologists
100 (80%)
11
73%
13%
14%
Plastic surgeons
25 (20%)
10
80%
4%
16%
Diagram 2 Proportion of hand surgeons in each practice department.
The opinions regarding the three aspects of controversy in the literature are reported
below.
Perspectives regarding the evaluation of trigger finger
As evidenced in [Table 2 ], most surgeons (72%) consider it necessary to routinely use a clinical classification
to define the severity and treatment of trigger finger. Although the instrument of
choice is a matter of controversy, it is clear that the minimum aspects that are considered
include the severity of the condition (90%), the time of evolution (62%), the involvement
of multiple fingers (49%), and the presence of rheumatoid arthritis (44%), as these
are the most relevant factors for surgeons.
Table 2
Approach: initial evaluation and follow-up
n = 125
Routine use of some classification
Yes
72%
No
28%
Conditions to consider in the therapeutic plan
Rheumatoid arthritis
44.40%
Multiple fingers affected
36.30%
Mellitus diabetes
34.70%
Patient occupation
33.10%
Association with carpal tunnel syndrome
28.20%
No condition
15.30%
Trigger thumb
8.90%
Initial management depends on the time of evolution
Yes
62.40%
No
37.60%
Initial management depends on the severity of the condition
Yes
90.40%
No
9.60%
Initial management changes if multiple fingers are affected
Yes
48.80%
No
51.20%
Outcomes to evaluate response to treatment
Patient satisfaction
27.77%
Resolution of finger locking
27.77%
Resolution of trigger finger
22.22%
Pain and hypersensitivity
12.69%
Functionality measured through the DASH
7.93%
Development of adverse events
1.58%
Procedure with the least amount of perceived adverse effects
Corticosteroid infiltration
48.80%
Open release
46.40%
Percutaneous release
4.80%
Time to consider remission
Minimum 2 weeks
2.50%
Minimum 4 weeks
9.10%
Minimum 6 weeks
6.60%
Minimum 8 weeks
14%
More than 6 months
67.80%
Additionally, there is no consensus on which outcomes should be considered to establish
the response or failure to management, which is reflected in the heterogeneous distribution
of the variables in [Table 2 ]. However, it is noteworthy that, for the general population, the development of
adverse events is the least important outcome, with corticosteroid injection being
perceived as the safest procedure, and percutaneous release, considered the most unsafe.
Likewise, it is worth highlighting the existence of a difference in the surgeons'
responses depending on their expertise, given that, while surgeons with more than
12 years of experience consider that patient satisfaction is the most important factor
to take into account, surgeons with less than 11 years of experience prioritize the
cessation of the finger block or fixed position of the finger if this was previously
present.
On the other hand, most surgeons (68%) wait a minimum follow-up time of 6 months to
consider disease remission, although 32% believe that a shorter follow-up may be sufficient.
At this point, there is a greater tendency among plastic surgeons to wait more than
6 months before considering remission compared to orthopedic surgeons (71% vs. 54%,
respectively).
Perspectives against conservative treatment
Conservative management of trigger finger includes therapy with nonsteroidal anti-inflammatory
drugs (NSAIDs), orthoses, shock waves, physical therapy, activity modification, and
local injection with corticosteroids. However, not all of these alternatives are well
accepted by Colombian surgeons, as shown in the [Table 3 ].
Table 3
Non-surgical management
n = 125
Use of orthoses in routine management
Yes
7.20%
No
92.80%
Orthosis use protocol
Does not indicate the use of orthoses
85.60%
Night
7.20%
Only when performing activities that cause triggering
3.20%
Day
3.20%
Patient preference
0.80%
Weeks to consider management failure with orthoses
Range
0–12
Median (interquartile range)
0 (0)
Mean(±standard deviation)
0.64(±1.99)
Use of physical therapy in the initial management
Occasionally
40.80%
Never
30.40%
Yes, to all or almost all patients
24.80%
When the condition is severe
4%
Initial management with corticosteroid infiltration
Always or almost always
60.80%
If the clinical case is severe
22.40%
Never or almost never
16.80%
Preferred medication for infiltration
Triamcinolone
56%
Betamethasone
22.40%
Indifferent
16.80%
Methylprednisolone
3.20%
Dexamethasone
1.60%
Perceived effectiveness of infiltration
< 50%
27.20%
50–75%
42.40%
> 75%
30.40%
Recurrence of corticosteroid infiltration
How many days do you wait to infiltrate again?
Range
0–180
Median (interquartile range)
0 (30)
Mean(±standard deviation)
17.37(±36.39)
How many infiltrations before operating
Range
0–3
Median (interquartile range)
1 (1)
Mean(±standard deviation)
1.34(±0.69)
If fewer than 6 months have passed since the infiltration
Recommends surgery
79.80%
Repeats infiltration
20.20%
If 6 to 12 months have passed since the infiltration
Recommends surgery
64.80%
Repeats infiltration
35.20%
If more than 12 months have passed since the infiltration
Recommends surgery
51.20%
Repeats infiltration
48.80%
For 93% of the respondents, orthoses have no clinical usefulness in patients with
trigger finger, and only 7% include them in the routine management, preferring a regimen
of nightly use for 1 to 12 weeks. Conversely, perspectives on physiotherapy vary:
30% do not consider it indicated at all, 41% occasionally recommend it as sufficient
initial management, and only 25% believe it should be part of the routine management.
In contrast, 70% of the surgeons support infiltration with corticosteroids as initial
management, and the perceived effectiveness of this intervention is greater than 50%
for more than half of those surveyed (72%). Additionally, the preferred corticosteroid
for infiltration is triamcinolone (56%), followed by betamethasone (22%), while 16%
of the surgeons are indifferent to the corticosteroid used.
However, in cases of recurrence, the surgeons consider on average that only 1 additional
infiltration should be administered, spaced apart from the first by at least 17 days.
Furthermore, when analyzing this opinion based on years of experience, surgeons who
have practiced for more than 12 years tend to wait less time to repeat the procedure
than those with less experience.
The opinion on the approach to take in the event of a recurrence also varies depending
on the time that has passed since the infiltration. Surgeons prefer the surgical procedure
to repeating the infiltration if the recurrence has occurred in fewer than 6 months
(80%). In contrast, if between 6 and 12 months have passed since the infiltration,
the consensus is lower, since only 65% propose surgery, and if more than a year has
passed, the number of surgeons offering surgery drops to 51%.
Perspectives on surgical treatment
Regardless of the technique, surgical management is the initial choice for surgeons
when the patient is diabetic (open release), if constant finger blockage occurs (61%),
when it is the patient's desire to undergo surgery (51%), when there are multiple
affected fingers (22%) or, for 12%, in the majority of patients regardless of their
conditions, as evidenced in [Table 4 ].
Table 4
Surgical approach
n = 125
Surgical release as initial management
When there is constant blocking of the finger
60.50%
By patient preference
50.80%
When multiple fingers are affected
21.80%
In most patients
12.10%
Hardly ever
11.30%
Ideal management in diabetics
Open release
88.80%
Corticosteroid infiltration
4.80%
Percutaneous release
4.00%
Use of orthoses
2.40%
Frequency of use of percutaneous release
Frequently (> 50% of the cases)
8.80%
Occasionally (10–50% of the cases)
16.80%
Never (< 10% of cases)
74.40%
Type of anesthesia
Walant local anesthesia
41.60%
Regional anesthesia with bloodless field
41.60%
Regional anesthesia
13.60%
General anesthesia
3.20%
Postoperative immobilization with orthoses
Yes
2.40%
*Fewer than 2 weeks
1.60%
*More than 4 weeks
0.80%
No
97.60%
Most surgeons prefer open release over percutaneous release (74% perform the latter
in less than 10% of their cases), and the anesthesia of choice is predominantly the
Walant technique or local anesthesia with a bloodless field.
Additionally, in accordance with what has been reported regarding the conservative
management, there is also homogeneity in the opinion of avoiding the use of orthoses
during the postoperative period (98% of the surgeons).
Discussion
Although trigger finger is a prevalent pathology in hand surgery consultations, there
is still no protocol that guides its approach and management. In the absence of a
consensus, the perspectives and preferences of hand surgeons significantly influence
the management offered, which is why the present study aimed to characterize them
in Colombia.
To achieve this objective, a survey was carried out to explore opinions regarding
the main controversies found in the literature. This instrument was evaluated by a
focus group representative of the population, and pertinent modifications were made
before its application. Although it was not possible to capture all the member surgeons,
a high response rate was obtained (81%) compared to previously published surveys that
have had lower response rates (42–53%).[14 ]
Although the surgeons' responses could have been affected by the Hawthorne effect,
we sought to partially control its presence, emphasizing to the participants that
we did not want to evaluate their knowledge of the available literature or directly
estimate their actions in the clinical practice, but rather, to measure their opinion
against the survey items. The heterogeneity of the responses is considered a reflection
of the degree of control that could be achieved over this bias.
The survey was structured around three aspects: the approach to the pathology, controversies
about conservative management, and controversies about surgical management, considering
that there could be divergence in medical judgment regarding these three topics.
First, the perception of the usefulness of clinical classifications as a standardization
method and approach guide was evaluated. Although most surgeons reported the favorability
of their use, previous surveys[9 ] have shown that the actual rate of implementation of these instruments is of only
30%. This is explained because although up to five tools have been described in the
literature,[4 ]
[9 ] the superiority of one of them has not yet been defined according to their predictive
value.
On the other hand, these tools do not include all the variables that have been identified
in the literature as important or predictive. These include baseline patient characteristics
(such as the presence of diabetes mellitus and occupation), as well as findings from
the physical examination indicating the severity of the condition (such as involvement
of the thumb, deformity in flexion of the proximal interphalangeal joint, and flexor
tendon injury), and the course of the clinical condition (such as symptoms lasting
more than two years or requiring more than two or three injections).[15 ]
[16 ] Likewise, they do not consider other additional variables that, under the criteria
of Colombian surgeons, should be taken into account, such as the presence of rheumatoid
arthritis, the condition of multiple fingers or the association with carpal tunnel
syndrome.
Once management is established, most surgeons consider it necessary to wait at least
6 months to consider that there is remission of the trigger finger; however, there
is no consensus in the literature that establishes the most important variables to
define whether there is a favorable response to treatment or not. This explains why
none of the proposed outcomes have a percentage of acceptance higher than 30% among
surgeons, although a tendency is observed to prioritize patient satisfaction and the
resolution of factors that indicate clinical severity, such as finger blockage.
Regarding the conservative treatment, the literature does not support monotherapy
with NSAIDs or physical therapy to resolve trigger finger, which aligns with the low
favorability of Colombian surgeons towards these approaches.[9 ]
[17 ] Additionally, although orthoses are preferred by patients over invasive treatments,[18 ] their usefulness lacks sufficient evidence. While some studies[1 ]
[9 ]
[19 ]
[20 ]
[21 ]
[22 ] support their use, ensuring a success rate between 53% and 88%, other studies[9 ]
[23 ] refute their effect on outcomes. Consequently, most hand surgeons, regardless of
their years of experience or primary specialty, consider orthoses to have no clinical
usefulness for this condition, regardless of their regimen of use.
Within the initial conservative management, infiltration with corticosteroids is the
most accepted. Specifically, 83% of the respondents supported its use, primarily with
triamcinolone. Although this percentage of acceptance is close to that reported by
other hand surgery societies, the literature is still divergent regarding the usefulness
of infiltration.[14 ] Although in 2009 the Cochrane collaboration reported moderate evidence to support
corticosteroid infiltrations, arguing greater effectiveness than the use of placebo
or anesthetic monotherapy, these conclusions were obtained only from two randomized
clinical experiments with questionable methodology and that evaluated the therapy
essentially in the short term.[4 ]
[17 ] Additionally, a meta-analysis[10 ] conducted in 10 clinical experiments in 2019 compared corticosteroid therapy against
the rest of the therapeutic alternatives (surgical and conservative managements),
concluding that both groups presented comparable improvement in symptoms and complications,
although the recurrence rate was significantly higher in those patients managed with
corticosteroid infiltration (relative risk [RR]: 19.53; 95% confidence interval [95%CI]:
6.23–61.19; p = 0.000).
The popularity of infiltrations may be explained by the fact that most surgeons estimate
a success rate of more than 50% with this intervention; however, in a previous study,[24 ] recurrence was reported 12 months after infiltration in 48 to 65% of the patients,
of whom up to 18% ultimately required surgical release.
In any case, if this management is chosen and a recurrence occurs, the surgeons surveyed
consider on average that only a single repetition should be performed, and that the
minimum waiting time before injecting corticosteroid again should be an average of
17 days. However, it is necessary to mention that this decision varies depending on
the time elapsed between treatment and recurrence, since a greater preference for
surgical intervention is reported if the recurrence has occurred in fewer than 6 months,
while it is almost comparable if more than a year has passed after infiltration (49%
and 51%, respectively).
Although there are no studies evaluating outcomes based on the number of injections
administered, the temporal spacing between them, their method of administration (which
can be subcutaneous or within the tendon sheath), nor have detailed considerations
been established to discontinue therapy and intervene surgically in a patient, the
European consensus suggests performing up to three injections, while North American
surgeons report a preference for up to two injections before considering refractoriness.[9 ]
[17 ]
[24 ]
[25 ]
In general, this could be an alternative as the initial management, except in diabetic
patients, who tend to present a lower response rate, so surgical intervention is preferred
as the first line of management.[1 ]
[24 ]
[26 ]
[27 ] Other predictors of recurrence to take into account should be early presentation,
the presence of multiple trigger fingers, diabetes mellitus, and other tendinopathies
of the upper extremity.[24 ]
Regarding surgical management, although it can present a cure rate of up to 97%, it
is not usually the first line of choice, as it entails high costs, prolongs the time
of return to activities, and can result in complications inherent to any invasive
management.[4 ]
[6 ]
[9 ] However, 60% of the surgeons consider that this should be the initial intervention
when there is constant blockage of the finger or if the patient is diabetic (89%).
Specifically, there are two surgical modalities, with open release being preferred
in Colombia over percutaneous release, which is considered riskier. This perception
corresponds to the review carried out in 2018 by Cochrane,[6 ] in which it was concluded that management with open surgery generated an absolute
reduction in the risk of recurrence in the medium and long terms of 29% compared to
injection with corticosteroids, while percutaneous surgery did not offer any benefit
in terms of resolution and recurrence of trigger finger when compared with infiltration.
With the information available, however, it was not possible to conclude which intervention
presented a lower rate of adverse events, so it is necessary to keep in mind that,
although the percutaneous technique implies a shorter surgical time and a faster return
of the patient to their activities (due to a lower risk of infection of the surgical
site, hypertrophic scar, and prolonged pain), one cannot ignore the potential risk
of injury to the adjacent structures by not enabling direct visualization, as in the
open release.[6 ]
[7 ]
[9 ]
Considering the aforementioned explanations, studies are still required to guide the
approach to trigger finger and to standardize its management to a greater extent so
that it does not only depend on the surgeon's beliefs but also relies on evidence-based
medicine. In this way, the present survey made it clear that studies are required
to evaluate the predictive value of existing classifications, as well as to validate
new instruments that consider not only the findings of the physical examination, but
also clinical factors inherent to the patient's clinical condition that are relevant
for surgeons.
On the other hand, regarding treatment, it is necessary to evaluate the effectiveness
of triamcinolone compared to other medications and define what is the maximum number
of infiltrations that is appropriate to offer to a patient with trigger finger, how
far apart the infiltrations should be, and what is the influence of the outcomes on
the time elapsed since the initial intervention.
Finally, it is also considered necessary to characterize the preferences of patients
in Colombia regarding the conservative and surgical managements, considering that
these opinions constitute a pillar to be taken into account in the construction of
a management guide.
Conclusion
Although trigger finger is a common condition in hand surgery consultations, currently
there is no clinical practice guideline that generates consensus regarding its management
and follow-up. Therefore, it is estimated that the approach Colombian patients receive
depends largely on the perspectives of hand surgeons. The divergence in the perspectives
of surgeons expressed here is mainly explained by the lack of consensus regarding
the available evidence. Therefore, studies are needed to unify the perspectives of
hand surgeons regarding the management algorithm of trigger finger, without neglecting
the importance of individualizing management according to the severity of the clinical
condition, duration of the disease, previous treatments administered, and, overall,
the surgeon's experience and the patient's personal preferences.[9 ]
[18 ]
