Comparison of postoperative outcomes between open surgical release and ultrasound guided percutaneous release of trigger finger: a systematic review and meta-analysis

INTRODUCTION

Trigger finger, or stenosing tenosynovitis, is characterised by thickening of the flexor tendon sheath resulting in pain, clicking, and locking of the affected hand finger.¹ If the A1 pulley is inflamed or contracted, it restricts tendon gliding and causes mechanical obstruction.^2,3 For refractory cases, treatment options run from conservative methods of stretching, corticosteroid injections to surgical procedures.^4-6 Two main approaches are used for surgical release of the A1 pulley, which continues to be the definitive treatment for chronic symptoms: open surgical release and US-guided percutaneous release.⁶ Though they seek to free the fingers for normal use and relief of pain, the methods vary in their strategy, complications, and likelihood of improvement.⁶ Following trigger finger release, postoperative results are usually evaluated using many clinical criteria. These are range of motion (ROM); the disability of arm-shoulder-hand (DASH) score; pain-VAS; time to functional recovery; grip strength; pain relief and occurrence of complications, including stiffness, infection, or nerve damage.^7,8 Satisfaction and return to normal activities among patient-reported results are also very important measures of surgical success outcomes.⁷ Though open release is generally considered reasonable, it does require cuts that might raise the risk of scarring, infection, and delayed healing.⁸ Conversely, guided percutaneous release done under US guidance is a minimally invasive approach designed to reduce tissue trauma and speed healing.⁹

US guidance in trigger finger release represents a promising alternative to regular open surgery.⁹ US-guided release offers exact A1 pulley targeting by giving real-time visualisation of the tendon and neighbouring structures while also lowering the chances of accidental nerve or tendon damage.¹⁰ Furthermore, this method is typically related to smaller surgical scars, less postoperative discomfort, and swifter recovery.¹⁰ Still, worries about its long-term effectiveness, learning curve, and possibility of incomplete release exist, hence more comparison studies of these two methods are required.¹⁰

This systematic review seeks to assess and compare the post-operative outcomes of US-aided trigger finger release with those from open surgery by evaluating clinical parameters including overall functional recovery, ROM, pain levels, and complication rates. Knowing the benefits and constraints of both techniques will help surgeons choose the most suitable treatment depending on individual patient considerations, thereby ideally improving surgical results for trigger finger patients.

METHODS

Registration and reporting

This systematic review has been registered in the international prospective register of systematic reviews (PROSPERO) (ID: CRD420251152764). It is being reported according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement.

Literature search strategy

A comprehensive literature search was conducted in the PubMed database and Cochrane library, with no timeline restrictions applied. The search strategy combined medical subject headings (MeSH) and free text words related to the concepts of "trigger finger", tendon "stenosing tenosynovitis”, surgical management terms like surgery, release, "trigger finger release", TFR, "A1 pulley release", and outcomes related terms like "outcomes", "complications."

An example search strategy for PubMed is provided: ("trigger finger" OR "stenosing tenosynovitis") AND (Surgery OR release OR "trigger finger release" OR TFR OR "A1 pulley release") AND (Outcomes OR Complication).

Screening and selection of studies

Search results were uploaded into the Rayyan.ai software to facilitate screening. Initially, six independent reviewers blindly screened all titles and abstracts, with conflicts resolved by a seventh reviewer. Full texts of all potentially eligible studies were then retrieved and independently assessed for eligibility by the same six reviewers, with two authors independently and blindly assessing each paper. Reasons for excluding studies during the full-text review phase were documented. Any duplicate studies identified were removed using the deduplication feature in Rayyan.ai. The complete study selection process was summarised using a PRISMA flow diagram (Figure 1).

Study eligibility criteria

This review included randomised controlled trials, cohort studies, case-control studies, and prospective or retrospective observational studies published in the English language, without any time restrictions, that reported on adult human participants diagnosed with trigger finger and management surgically with post operative outcomes reported, including assessment tools, assessment timeframes, duration of follow up and the report of any complications.

Studies were excluded if they involved patients under 18 years of age, did not report outcomes relevant to our objectives, or focused on conservatively managed trigger fingers. Additionally, review articles, case reports, editorials, commentaries, and letters; studies published in languages other than English; research involving traumatic injuries, cadaveric specimens, or animal models; and duplicate publications of the same study were also excluded.

Data extraction

A standardised data extraction sheet was used by the reviewers to independently extract relevant data from the included studies. Data from each article has been extracted by two independent reviewers, any discrepancies during the data extraction process were resolved through discussion with a third reviewer. Data items extracted included study characteristics (authors, year of publication, country, study design, sample size, study period), patient characteristics (age, sex, comorbidities), classification/grade of severity of triggering if applicable, management approaches (open surgical release, percutaneous US guided release), reported outcomes (pain scores, functional outcomes, ROM, patient satisfaction), statistical methods used for data analysis, reported effect estimates with confidence intervals, study conclusions, limitations, as well as recommendations provided by the authors.

Quality assessment and risk of bias

For observational studies, the Newcastle-Ottawa scale (NOS) was utilised by two independent reviewers to evaluate the risk of bias across four domains: selection of study groups, comparability of groups, ascertainment of exposure/outcome, and outcome assessment. Studies were categorised as low quality (0-3), moderate quality (4-6), or high quality (7-9) based on their NOS scores (Supplementary Table 1). For randomised controlled trials, the ROB II tool was utilised to evaluate the risk of bias across five domains: bias arising from the randomisation process, bias due to deviations from intended intervention, bias due to missing outcome data, bias in measurement of the outcome, bias on selection of the reported result (Figure 1). Any disagreements between reviewers during the quality assessment process were resolved through discussion with a third reviewer to reach a consensus rating.

Statistical analysis

Cochrane review manager 5.3 was used to perform a meta-analysis of the selected studies. For dichotomous outcomes, the pooled OR with 95% CI is given among groups. While mean difference (MD) was used for continuous outcomes. Random mode was used to reduce heterogeneity. The heterogeneity assumption was checked using the I2 test. A leave-one-out sensitivity test was applied to solve any resulting heterogeneity. In terms of values, we interpreted the I-square as follows: not significant for 0-40%, moderate heterogeneity for 30-60%, and substantial heterogeneity for 50-90%, following the Cochrane handbook chapter nine.

*The diagram outlines the number of records identified, screened, excluded, assessed for eligibility, and included.

RESULTS

Characteristics of included studies

Eleven articles comparing the efficacy and safety of open classic versus USG guide release were included in our study. The summary characteristics and baseline features of the included studies are listed in supplementary (Table 2 and 3).

Clinical outcomes

VAS score

The mean difference in VAS score has been investigated between open classic versus percutaneous Ultrasonography guide release across 6 studies. The pooled mean difference indicated Ultrasonography guide release had a higher VAS score compared to open classic release [MD: 0.04 (-0.27, 0.34) with 95% CI] in which the results were not statistically significant (p=0.80) (Figure 2). The sensitivity analysis revealed significant heterogeneity (I2=74%, p=0.002) that is not resolved and only decreased after omitting Lee et al by the leave-one-out test (I2=70%) with no statistically significant difference [MD: -0.07 (-0.37, 0.23) with 95% CI, p=0.66] (Figure 3).

The funnel plot of VAS score appeared relatively symmetrical with no major signs of publication bias, but the number of studies is small to make definitive conclusions. The studies are clustered near the pooled effect size, suggesting consistent findings (Figure 4).

Q-DASH score

Mean difference in Q-DASH score has been investigated between open classic versus USG guide release across 3 studies. Pooled mean difference indicated open classic release had lower Q-DASH score compared to USG guide release [MD: -0.06 (-2.24, 2.13) with 95% CI] in which the results were not statistically significant (p=0.96) (Figure 5). Sensitivity analysis revealed significant heterogeneity (I2=79%, p=0.008) that is resolved after omitting Yavari et al by the leave-one-out test (I2=0%) with no statistically significant difference [MD: -2.35 (-1.02, 0.30) with 95% CI, p=0.13] (Figure 6).¹¹ The funnel plot of Q-DASH score did not demonstrate obvious asymmetry, though the small number and low precision of included studies limit acute assessment of publication bias (Figure 7).

Satisfaction rate

The pooled results indicated that patients in open classic release group had a lower odd of satisfaction compared to the USG guide release group [OR: 0.44 (0.10, 1.84) with 95% CI]. However, the results were not statistically significant (p=0.26) (Figure 8). The sensitivity analysis revealed moderate heterogeneity (I2=60%, p=0.01) that decreased after omitting Nikolaou et al by the leave-one-out test (I2=0%) with statistically significant difference [OR: 0.23(0.08, 0.64) with 95% CI, p=0.005] (Figure 9).¹⁰ The funnel plot of satisfaction rate is showed some asymmetry, with more studies clustered on the left side of the null line. However, the limited number and low precision of included studies restrict reliable assessment of publication bias (Figure 10).

DISCUSSION

In this study, we pool eleven articles comparing the outcomes of trigger finger release by open classic release versus US guided release. VAS was analyzed through 6 of the included studies as a tool of post-operative pain measuring scale. The analysis showed that patients who underwent US-guided release scored higher than those who underwent open classic release, yet these results were statistically insignificant (p=0.80), with significant heterogeneity. One of the most recent included studies for this analysis by Yavari et al explained that pain severity immediately postoperatively was not of a significant difference between both groups, yet after a one-month follow-up, a significant difference was noticed with less pain among the US guided group.¹¹ In the same study, they also denoted that the duration of needing analgesia postoperatively was much less in patients who underwent US-guided compared to the other group which supports the argument whether a noticeable difference was noticed when it comes to pain after the procedure. Almost all the studies included agreed that there was no significant difference or supported the same observation of pain improvement. Across the eleven included studies, three of them assessed functionality post-procedure using the Q-DASH score. In comparison between both groups, the analysis showed that although the open surgical release had better functionality post-procedure, as Q-DASH score was lower compared with the US-guided release, it is not of a much statistically significant (p=0.96). One of the largest studies that was included in this analysis included 111 patients with a total of 138 operated fingers showed that in comparison to blinded release, US-guided dose did not have a statistically significant difference.¹² The same result was supported by Yavari et al as well, where they compared US-guided release to open surgical release.¹¹

Another important factor to consider is patient satisfaction, but as it does not have a unified measuring tool, statistically, there was not much of a significant difference as per our analysis of 8 of the included studies. However, individually, most of these studies did report better patient satisfaction, favoring US-guided release over the open classic surgical release.^10-13 Across the literature, even those papers that studied the satisfaction post-blind percutaneous release had better satisfaction rates.¹³ This considers thinking about the similarities between both approaches, which both are following minimally invasive rather than the classic surgical release with incision.

Nevertheless, sensitivity analysis indicated variability in certain results, especially Q-DASH scores, which was addressed by excluding a particular study. Notably, satisfaction rates initially displayed no substantial difference; however, following sensitivity analysis, US-guided release correlated with increased patient satisfaction. These results indicate that although both methods yield similar results, patient preference and experience might lean towards US guidance in specific situations. Additional high-quality research is necessary to verify these trends and inform clinical decision-making.

Limitations

This review has several limitations. First, study designs were heterogeneous, including RCTs and observational studies, as RCTs alone did not provide sufficient data for all outcomes. Second, trigger finger severity/ grade was inconsistently reported, preventing stratified analysis based on condition severity. Third, postoperative outcome assessment time points and follow up intervals were often unspecified, which may affect the accuracy and comparability of the results.

CONCLUSION

This systematic review aimed to assess the efficacy and safety of open classic release in comparison to ultrasound-guided release across multiple studies, focusing on VAS scores, Q-DASH scores, and patient satisfaction rates. The results showed no statistical significance differences between the two techniques when reviewing the VAS scores and Q-DASH scores. Even though the pooled results for VAS scores favoured ultrasound-guided release and the Q-DASH scores marginally favoured open classic release, neither result showed any statistical significance. Persisting after sensitivity analysis, both analyses exhibited substantial heterogeneity; however, some reduction was observed when specific studies were omitted. When reviewing the pooled analysis for patient satisfaction rates, it initially showed no statistically significant difference between the two techniques. However, after omitting one study, (Nikolaou et al), sensitivity analysis revealed a statistically significant difference emerged, favouring US-guided release. All in all, despite this review highlighting potential trends favouring US-guided release in certain outcomes, lack of consistent statistically significant results and presence of heterogeneity limits the ability to draw conclusive outcomes.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

REFERENCES

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APPENDIX