Randomized and double-blinded controlled trial: percutaneous trigger finger release concomitant steroid injection versus percutaneous trigger finger release alone

INTRODUCTION

Trigger finger is a prevalent orthopedic condition. The condition causes pain and limited finger motion, significantly affecting quality of life. Corticosteroid injections are commonly used as first-line treatment, reducing inflammation and pain effectively.^1,2 However, recurrent cases often require surgical intervention.

Open A1 pulley release is the conventional surgical approach, demonstrating excellent outcomes.^3,4 However, concerns regarding cost and scar-related complications have led to interest in alternative treatments.⁵ Percutaneous A1 pulley release offers a simpler, cost-effective alternative with comparable results and minimal scarring.^6-8 However, studies indicate that postoperative pain scores for this method are similar to those of open A1 pulley release.^9,10

While combining percutaneous A1 release with corticosteroid injection has shown favorable results, early postoperative pain which emphasized the benefit of minimal invasive procedure has not been specifically studied.^11,12 This study addressed this gap by evaluating early postoperative pain outcomes in patients undergoing percutaneous A1 pulley release with and without corticosteroid injection.

METHODS

This study was a prospective, randomized, double-blinded clinical trial conducted at the orthopedic outpatient department, Police General Hospital, Bangkok, Thailand, between September 2023 and October 2024. The study protocol was approved by the Institutional Review Board of Police General Hospital (IRB No. Dh059-66).

Study population

Eligible participants included adult patients aged 18 years or older, clinically diagnosed with trigger finger grades 2-4 according to Quinell’s classification (Table 1). Exclusion criteria comprised prior hand surgery, presence of Dupuytren’s contracture, type 1 diabetes mellitus, corticosteroid injection within the past 3 months, and autoimmune disorders.

Randomization and blinding

Participants were randomly assigned to either the treatment or control group using computer-generated random numbers sealed in opaque envelopes to ensure allocation concealment. Syringes were prepared by an independent nurse to appear identical in volume and color, maintaining blinding of both patients and clinicians.

Group A: 1% lidocaine (1 ml) + triamcinolone acetonide 40 mg/ml (1 ml). Group B: 1% lidocaine (2 ml)

The operating surgeon and outcome assessors remained blinded to group assignments throughout the study period.

Surgical technique

All procedures employed the Eastwood percutaneous A1 pulley release technique, performed under local anesthesia (1% lidocaine) with the hand in a supinated position. A 19-gauge needle or fine scalpel blade was inserted percutaneously at the A1 pulley. A sweeping motion was used to release the pulley while preserving adjacent neurovascular structures. Completeness of release was confirmed intraoperatively via active flexion and extension by the patient. No sutures were applied; only a sterile dressing was used postoperatively.

Postoperative protocol

All patients were encouraged to begin immediate active range-of-motion exercises to prevent joint stiffness. Postoperative care, medication regimens, and rehabilitation instructions were standardized across both groups.

Outcome measures

Primary Outcomes were pain assessment using the visual analog scale (VAS). Secondary Outcomes were patient-reported quality of life using the QuickDASH score, satisfaction level, and occurrence of surgical complications.

Follow-up evaluations were conducted via telephone (postoperative days 1-6) and in-person clinic visits (weeks 1, 2, and months 1-2).

Statistical analysis

All statistical analyses were performed using Stata version 14.0 (StataCorp LLC, College Station, TX, USA). Descriptive data were expressed as means with standard deviations or medians with interquartile ranges, as appropriate. Comparative analyses between groups were performed using chi-square, t-tests, or Mann-Whitney U tests depending on variable distribution. A p value of <0.05 was considered statistically significant.

RESULTS

Seventy-six patients were enrolled: 36 in group A and 40 in group B. No significant differences in gender, age, or BMI were observed between the groups. Hypertension was the most common comorbidity.

Pain scores (VAS) from postoperative day 1 to day 3 showed no significant difference between the groups (p>0.05). However, from day 4 onward, group A demonstrated significantly lower pain scores than group B (p<0.05). This trend persisted through the second month (Table 2).

Values are expressed as mean±SD unless otherwise indicated. Group A: percutaneous A1 pulley release with steroid injection. Group B: percutaneous A1 pulley release alone.

Values are expressed as mean±SD unless otherwise indicated. Abbreviation VA: visual analog scale. Group A: percutaneous A1 pulley release with steroid injection. Group B: percutaneous A1 pulley release alone.

Values are expressed as mean±SD unless otherwise indicated. Abbreviation QuickDASH: quick disabilities of arm, shoulder and hand scale. Group A: percutaneous A1 pulley release with steriod injection. Group B: percutaneous A1 pulley release alone.

Although qDASH scores suggested a slight quality of life improvement in group A, the difference was not statistically significant. Patient satisfaction was consistently higher in group A, but without statistical significance. No major complications (e.g., infection, nerve injury, tendon rupture) were reported in either group. (Table 4).

DISCUSSION

This study represents the first double-blind (patient and assessor-blind) randomized controlled trial comparing percutaneous A1 pulley release alone

versus percutaneous A1 pulley release with corticosteroid injection. The results emphasize that corticosteroid injection significantly improves early postoperative pain control without affecting functional outcomes or overall patient satisfaction.

Demographically, our patient cohort aligns with previous studies, confirming the broader applicability of our findings.^13,14 The effectiveness of percutaneous A1 release is consistent with prior research.^15-19 The observed reduction in early postoperative pain in the corticosteroid group (group A) supports the hypothesis that corticosteroids reduce prostaglandin activity, mitigating inflammation and pain.^20-22 Mechanistically, corticosteroid injection decreases inflammation around the flexor tendon sheath, reducing swelling and enhancing tendon gliding, thereby alleviating pain and triggering sensations. Some patients reported symptom relief as early as three days, consistent with previous literature.²³

Clinically, the significant reduction in early postoperative pain suggests that patients receiving corticosteroid injections may experience a shorter recovery period and a faster return to daily activities. The ability of corticosteroids to minimize early postoperative discomfort could enhance patient mobility, potentially facilitating rehabilitation and preventing stiffness. The observed improvement in pain control may contribute to reduced reliance on postoperative analgesics, a factor that warrants further investigation.

The absence of major complications, along with similar functional outcomes and patient satisfaction between groups, may be attributed to the relatively small sample size, which could have limited the statistical power to detect differences. Additionally, the minimally invasive nature of the procedure and its inherently low discomfort likely contributed to the comparable results. Although the study’s short follow-up duration limits the assessment of long-term recurrence and re-operation rates, these findings provide valuable insights into optimizing early postoperative pain management and recovery. Future research with larger, multicenter cohorts and extended follow-up is essential to further validate these findings and refine clinical guidelines.

CONCLUSION

While both techniques offer effective symptom relief, the addition of corticosteroid may benefit patients seeking enhanced postoperative comfort. Further large-scale studies are recommended to strengthen these findings and establish their long-term impact on recurrence and functional outcomes.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee of Police General Hospital (IRB No. Dh059-66)

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