A prospective randomized trial comparing the effectiveness of one versus two (staged) corticosteroid injections for the treatment of stenosing tenosynovitis

Abstract

Background: Stenosing tenosynovitis or trigger finger is a common clinical condition regularly treated with steroid injections. Varied success is reported at early time points following injection. We present a prospective, randomized IRB-approved study to confirm these findings at a long-term follow-up.

Methods: Adult patients presenting with symptoms of stenosing tenosynovitis who agreed to participate were randomized into two groups. Group 1 received an initial injection of triamcinolone and local anesthetic mixture. Group 2 received the same initial injection and an additional staged injection at 6 weeks. The patients were then followed beyond 2 years. If Group 1 patients were still symptomatic at 6 weeks, another injection was given. An additional injection or surgery was defined as treatment failure. DASH scores were obtained at baseline, 3, 6, and 12 months.

Results: Ninety-seven patients (101 trigger digits) were enrolled in the prospective trial. Fifty-six digits were randomized to the one-injection group versus 45 digits randomized to the two-injection group ("intention to treat analysis"-ITT). After accounting for crossover between the groups, 42 patients received one-injection versus fifty-nine patients receiving two injections ("actual" analysis). Overall failure was the same between the two groups. However, a higher surgery rate was noted for patients having undergone two injections versus one injection [47 % versus 27 % (p < 0.013), ITT]. Diabetes was associated with a higher surgery rate at 1 year within the group of overall failures [56 % versus 37 % (p = 0.0505), ITT]. High baseline DASH score (>40) was associated with a median time of 10 months for failure and 6 months for surgery as per a Kaplan-Meier survival analysis (p < 0.005 and p < 0.001, respectively, ITT).

Conclusions: As overall failure of steroid injection for trigger finger is not improved with staged, two-injection treatment, we recommend a single injection initial treatment for trigger finger with a second injection given in cases of recurrence or failure. Diabetes was a risk factor for needing surgery if failure occurred within 1 year. The baseline DASH score is helpful in predicting which patients have a higher chance of failing as well as needing surgery. Level of evidence Prospective, randomized trial, level I.

Keywords: Cortisone injection; DASH; Stenosing tenosynovitis; Trigger finger.

Fig. 1

Age distribution of patients

Fig. 2

Kaplan–Meier survival: overall failure vs. initial DASH score (p < 0.005) (X-axis: months after first injection; Y-axis: percentage survival-patients without failure)

Fig. 3

Kaplan–Meier Survival: Surgery outcome vs. Injection Treatment Group (p < 0.013) (X-axis: months after first injection; Y-axis: percentage survival-patients without surgery)

Fig. 4

Kaplan–Meier survival: surgery outcome vs. initial DASH score (p < 0.001) (X-axis: months after first injection; Y-axis: percentage survival-patients without surgery)