Testosterone Replacement Therapy and Associated Rates of Trigger Finger, de Quervain Tenosynovitis, and Their Subsequent Management.

PURPOSE: Anabolic steroid therapy has been associated with tendon injury, but there is a paucity of evidence associating physiologic testosterone replacement therapy (TRT) with tenosynovitis of the hand, specifically trigger finger and de Quervain tenosynovitis. The purpose of this study was to evaluate the relationship between TRT and tenosynovitis of the hand. METHODS: This was a one-to-one exact matched retrospective cohort study using a large nationwide claims database. Records were queried between 2010 and 2019 for adult patients who filled a prescription for TRT for 3 consecutive months. Rates of new onset trigger finger and de Quervain tenosynovitis and subsequent steroid injection or surgery were identified using ICD-9, ICD-10, and Current Procedural Terminology billing codes. Single-variable chi-square analyses and multivariable logistic regression were used to compare rates in the TRT and control cohorts while controlling for potential confounding variables. Both unadjusted and adjusted odds ratios (OR) are reported for each comparison. RESULTS: In the adjusted analysis, patients undergoing TRT were more than twice as likely to develop trigger finger compared to their matched controls. TRT was also associated with an increased likelihood of experiencing de Quervain tenosynovitis. Of the patients diagnosed with either trigger finger or de Quervain tenosynovitis over the 2-year period, patients with prior TRT were roughly twice as likely to undergo steroid injections or surgical release for both trigger finger and de Quervain tenosynovitis compared to the controls. CONCLUSIONS: TRT is associated with an increased likelihood of both trigger finger and de Quervain tenosynovitis, and an increased likelihood of requiring surgical release for both conditions. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Effectiveness of high-intensity laser application combined with splinting and therapeutic exercise in subacute de Quervain's tenosynovitis: A pilot study.

The purpose of this study is to determine the additional effect of high-intensity laser therapy (HILT) when combined with therapeutic exercise and splinting in the treatment of patients diagnosed with de Quervain's tenosynovitis. Nineteen patients diagnosed with de Quervain's tenosynovitis were randomly divided into two groups: the HILT group and the sham HILT group. A total of 9 HILT or sham HILT sessions were administered, with 3 sessions per week for 3 consecutive weeks. Both groups received the thumb spica splint and therapeutic exercise. A comparison was conducted between the two groups, as well as pre- and post-treatment, focusing on the following outcomes: Visual Analog Scale (VAS) for pain, hand grip strength, and Thai version of Patient-Rated Wrist and Hand Evaluation (PRWHE-Thai) as a disability score. No significant differences were found between the HILT group and the sham group across all evaluated outcomes. However, when examining changes within each group over time, both the HILT and sham groups showed significant reductions in pain and improvements in disability score at the follow-up assessments compared to baseline. On the other hand, no statistically significant differences were observed in grip strength outcomes at any of the measured time points. The combination of HILT with a splint and exercise demonstrates effectiveness as a method for pain management and functional improvement in patients with subacute de Quervain's tenosynovitis. It is important to note that HILT does not offer any additional advantages when compared to the combined use of a splint and exercise.

Association of Patient-Reported Outcomes Measurement Information System Measures With Injection and Surgical Treatment Response in Patients With De Quervain Tenosynovitis.

PURPOSE: Treatment of de Quervain tenosynovitis is largely empiric. Patient-Reported Outcomes Management Information System (PROMIS) scores at the time of diagnosis might provide insights into the probability of success of nonsurgical management and predict the necessity for surgical treatment. We aimed to identify which, if any, of the PROMIS metrics may be used to identify patients who will opt for surgery or be managed with injection alone. METHODS: Patients presenting to a tertiary academic medical center from 2014 to 2019, with a sole diagnosis of de Quervain tenosynovitis, were identified and separated by initial and most invasive treatment of either injection or surgery. These groups were then dichotomized using cut points of more than one SD from the mean on the PROMIS physical function and pain interference scales, and a logistic regression model was used to determine the odds ratio of surgical intervention. RESULTS: Patients who had low physical function or high pain interference had significantly increased odds of ultimately undergoing surgery. Age ranging from 40 to 60 years and female sex were also associated with increased odds of undergoing surgery. CONCLUSIONS: Patients who scored lower than 40 for physical function or higher than 60 for pain interference had significantly increased odds of eventually undergoing surgical release for de Quervain tenosynovitis. PROMIS scores may identify patients who are likely to fail steroid injections as a sole nonsurgical intervention and inform an individualized discussion about surgical management of this condition. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Is a Steroid Injection in Both Compartments More Effective than an Injection in the Extensor Pollicis Brevis Subcompartment Alone in Patients with de Quervain Disease? A Randomized, Controlled Trial.

BACKGROUND: Ultrasonography (US)-guided steroid injections can improve the accuracy of injection in patients with de Quervain disease, especially in those with an intracompartmental septum. Although the main lesion of de Quervain disease in patients with a septum is a stenosing tenosynovitis of the extensor pollicis brevis (EPB), no report we know of has compared injection into the EPB subcompartment with an injection into both the abductor pollicis longus (APL) and EPB subcompartments. In this randomized trial, we compared the results of US-guided steroid injections targeting both subcompartments and the EPB subcompartment alone in patients with de Quervain disease. QUESTIONS/PURPOSES: (1) Do patients who receive a steroid injection in the EPB subcompartment alone have lower pain scores at 6 weeks and at 3 months after US-guided injection compared with patients who receive an injection in both subcompartments? (2) Do patients who receive a steroid injection in the EPB subcompartment alone experience fewer steroid injection-related complications than patients who receive an injection in both subcompartments? METHODS: A randomized controlled study was performed at a single center between August 2018 and March 2021. Patients with a diagnosis of de Quervain disease and with a complete intracompartmental septum between the APL and the EPB tendons were included. In total, 112 patients had a diagnosis of de Quervain disease during the study period. Definite, complete subcompartmentalization was seen in 50 patients. Patients were randomly assigned to US-guided injections targeting both subcompartments (n = 25) or the EPB subcompartment alone (n = 25). There were no between-group differences in age, gender, affected wrist, or disease duration, and all patients had US evidence of tendinosis of the EPB, with or without tendinosis of the APL. Although 33% of patients (16 of 48) showed tendinosis of the APL, no patient showed tendinosis of the APL alone. In all patients, a dorsal-to-palmar side injection of 0.5 mL of 2% lidocaine and 0.5 mL of triamcinolone acetonide (40 mg/mL) was administered by two experienced hand surgeons. In the both-subcompartments group, US-guided injections were performed in each of the APL and EPB subcompartments. In the EPB subcompartment group, US-guided injections were administered in the EPB subcompartment only. All patients underwent the same protocol after the procedure. Four percent (n = 2, 1 in each group) of patients were excluded after randomization because their pain level was not registered. Pre- and postinjection clinical outcome assessments were completed by orthopaedic surgery residents not involved in patient management. Patients were regularly examined at baseline, 6 weeks, and 3 months to evaluate the intensity of pain. We assessed pain by the VAS score, where 0 indicated no pain and 100 the most pain. At baseline, the VAS score was 67 ± 14 in the both-subcompartment group and 67 ± 16 in the EPB subcompartment group (mean difference 0.17 [95% CI -8.45 to 8.82]; p = 0.97). Complications related to the steroid injection, including numbness, tendon rupture, and skin hypopigmentation, were also recorded at final follow-up examinations. To determine statistical power, the VAS score for pain at 6 weeks after the injection was used as the primary outcome variable. The minimum clinically important difference for the VAS score was deemed to be 20 mm, and we estimated an SD of 23. A sample size calculation indicated that a sample of 21 patients per group would provide 80% power to detect an effect of this size between the groups at the p = 0.05 level using a t-test. RESULTS: There were no differences in the VAS scores between the both-subcompartment group and the EPB group at 6 weeks (10 ± 6 versus 10 ± 7, mean difference -0.08 [95% CI -4.08 to 3.91]; p = 0.97). The same was true at 12 weeks (12 ± 13 versus 11 ± 15, mean difference 0.38 [95% CI -7.74 to 8.49]; p = 0.09). No adverse events related to treatment (such as tendon rupture, infections, and numbness) occurred in either group. However, skin hypopigmentation occurred at the final follow-up examination in both groups. The proportion of patients experiencing skin hypopigmentation in the EPB subcompartment group was lower than in the both-subcompartment group (33% [8 of 24] versus 67% [16 of 24]; odds ratio 0.25 [95% CI 0.08 to 0.83]; p = 0.02). CONCLUSION: Our data suggest that a US-guided steroid injection targeting the EPB subcompartment alone is as effective in terms of pain reduction as targeting both subcompartments in patients with de Quervain disease who have complete septation. Furthermore, an injection targeting the EPB subcompartment alone can reduce the dose of steroids used, perhaps thereby decreasing complications related to steroid injections. We recommend using only single-compartment injections in this context, even among patients with an intracompartmental septum. LEVEL OF EVIDENCE: Level I, therapeutic study.

Comparison of the effect of ketorolac versus triamcinolone acetonide injections for the treatment of de Quervain's tenosynovitis: a double-blind randomized controlled trial.

BACKGROUND: De Quervain's disease is tenosynovitis of the first dorsal compartment causing severely painful radial-side wrist pain and impaired function. Steroids are effective in treating this condition due to their anti-inflammatory properties. However, this drug causes problems such as hypopigmentation, and is contradicted in diabetes mellitus patients. Non-steroidal anti-inflammatory drug (NSAID) which are efficacious in shoulder pathology and not contraindicated in diabetics and can be used to avoid the local effects of steroids could be beneficial for some patients. The present study was a randomized controlled trial to examine the differences in pain scores and functional response to local injections of a corticosteroid and the NSAID ketorolac. METHODS: Sixty-four patients with radial styloid tenosynovitis were randomized using a computer-generated random number table into two groups receiving either a ketorolac injection or a triamcinolone injection. We evaluated post-injection pain intensity using a verbal numerical rating scale (VNRS), functional outcomes using the Thai Disabilities of the Arm, Shoulder and Hand (DASH) scale, and evaluated grip and pinch strengths, recorded at baseline and 6 weeks after the injection. RESULTS: Thirty-one participants in the ketorolac group and 29 participants in the triamcinolone group completed the study and were included in the analysis. There were no significant differences in the assessments at baseline. At the 6-week conclusion of the study, patients in the triamcinolone group had a statistically lower average pain score than in the ketorolac group (0.7 ± 2.0 vs 5.3 ± 3.2, P < 0.001), higher DASH functional score (4.4 ± 6.5 vs 34.1 ± 20.2, P < 0.001), higher right grip strength (60.8 ± 16.8 vs 49.2 ± 18.6, P < 0.015), and higher left grip strength (59.8 ± 18.1 vs 50.3 ± 18.0, P < 0.04). However, there was no difference in pinch strength. CONCLUSIONS: Our study found that ketorolac injections resulted in inferior pain reduction, functional score and grip improvement than triamcinolone injection in patients with radial styloid tenosynovitis. Future studies are required to examine the effects of ketorolac in larger group and with longer follow-up periods to further elucidate the findings of this study. TRIAL REGISTRATION: The study was registered at Clinicaltrials.in.th (TCTR20200909006).

Effectiveness of Corticosteroid Injections in Diabetic Patients With De Quervain Tenosynovitis.

PURPOSE: We sought to determine the effectiveness of corticosteroid injections (CSIs) for de Quervain tenosynovitis in patients with diabetes mellitus. METHODS: We retrospectively identified all patients with diabetes receiving a CSI for de Quervain tenosynovitis by 16 surgeons over a 2-year period. Data collected included demographic information, medical comorbidities, number and timing of CSIs, and first dorsal compartment release. Success was defined as not undergoing an additional CSI or surgical intervention. The mixture of a corticosteroid and local anesthetic provided in each injection was at the discretion of each individual surgeon. RESULTS: Corticosteroid injections were given to 169 wrists in 169 patients with diabetes. Out of 169 patients, 83 (49%) had success following the initial CSI, 44 (66%) following a second CSI, and 6 (67%) following a third CSI. A statistically significant difference was identified in the success rates between the first and second CSIs. Ultimately, 36 of 169 wrists (21%) underwent a first dorsal compartment release. CONCLUSIONS: Patients with diabetes mellitus have a decreased probability of success following a single CSI for de Quervain tenosynovitis in comparison to nondiabetic patients, as described in the literature. However, the effectiveness of each additional CSI does not appear to diminish. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Effects of local anaesthetics (neural therapy) on pain and hand functions in patients with De Quervain tenosynovitis: A prospective randomised controlled study.

OBJECTIVE: De Quervain tenosynovitis is the most common cause of lateral wrist pain. The diagnosis can be made with the Finkelstein test when pain is provoked with wrist ulnar deviation. Conservative treatment including rest, non-steroidal anti-inflammatory medication and physical therapy is applied first, then there may be a need for corticosteroid injections, and in resistant cases, surgery. The aim of this study was to evaluate the effectiveness of neural therapy (NT) on pain and hand functions in patients with De Quervain tenosynovitis. METHODS: A total of 36 patients admitted between May 2019 and March 2020 were randomly assigned to neural therapy (NT) and control groups. Hand rest and thumb spica splint were applied to all the patients, and NT interventions to the NT group only. A visual analogue scale (VAS) and the Duruöz Hand index (DHI) were used to measure pain and functionality at baseline, then at 1 and 12 months after the end of the treatment. RESULTS: The NT and control groups both showed improvements in VAS and DHI scores at 1 and 12 months compared with baseline (P < .001) according to within group comparisons. The VAS scores were significantly lower at both 1 and 12 months compared with baseline in the NT group (P < .001, P = .002 respectively). The DHI scores were lower in the NT group at 1 month (P = .009), and at 12 months there was no significant difference between the two groups (P = .252). No adverse effects were seen in any patient. CONCLUSION: NT seems to be effective in reducing pain and improving hand functions in patients with De Quervain tenosynovitis.

Methylprednisolone acetate injection with casting versus casting alone for the treatment of De-Quervain's Tenosynovitis: a randomized controlled trial.

OBJECTIVE: To compare the success of treatment between thumb spica cast with "methylprednisolone acetate injection" versus thumb spica cast alone for the treatment of de Quervain's disease as functional outcomes, complications and patient compliance. METHODS: A single blinded randomized controlled trial using a probability sampling technique was conducted from January 2014 to h February 2017at the Orthopaedic Unit II, King Edward Medical University / Mayo Hospital, Lahore. A total of 134 patients of both genders, between 30-60 years of age presented with wrist pain and diagnosed de Quervain's disease, were included in the study. Patients were randomly divided into two group by the computer allocation method. Patients in Group-A received thumb spica cast with methylprednisolone acetate and xylocaine injection while patients in Group-B were treated with thumb spica cast alone. The outcome variable was frequency of successful treatment which was noted and compared among the groups. RESULTS: Amongst the total 134 patients, the age of the patients ranged from 30 to 60 years with a mean of 37.16±5.15 years. Most of the patients were aged between 30 40 years (78.8%) followed by 41-50 years (21.2%). There were 38 (28.4%) male and 96 (71.6%) female patients in the study group with a male to female ratio of 1:2.5. In group-A mean VAS and Quick DASH score before treatment and after the treatment was statistically significant (p-value <0.001). In group-B mean VAS and Quick DASH score before and after the treatment was also significant (p-value <0.001) ( Table-2). CONCLUSIONS: The effectiveness of treatment was significantly higher in patients treated with thumb spica cast with methylprednisolone acetate injection as compared to thumb spica cast alone.

US-guided percutaneous release of the first extensor tendon compartment using a 21-gauge needle in de Quervain's disease: a prospective study of 35 cases.

PURPOSE: To evaluate the efficacy of ultrasonography-guided percutaneous treatment of de Quervain tenosynovitis with the combination of a corticosteroid injection and release of the retinaculum of the first extensor compartment tendons with a 21-gauge needle. MATERIALS AND METHODS: The first part of our study consisted of ten procedures on cadaver wrists followed by dissection to analyse the effectiveness of the retinaculum release and detect any collateral damage. The second part was a prospective clinical study of 35 procedures. Outcomes were evaluated through a 6-month clinical follow-up and telephone interview at the end of the study. The following parameters were monitored over time: pain level on a visual analogue scale, the QuickDASH and the PRWE. Patient satisfaction questionnaires were also administered. RESULTS: No complications were found during the cadaver study. However, the release was confirmed as 'partial' in all wrists. In the clinical portion of this study, significant improvement was observed in 91.4 % of cases (32/35) within 1 month and the results were stable until the end of the study; all of these patients avoided surgery. The release procedure failed in three patients who eventually required surgical treatment. CONCLUSION: US-guided partial release and simultaneous corticosteroid injection for treatment of de Quervain's disease using a 21-gauge needle is feasible in current practice, with minimal complications. KEY POINTS: • Ultrasound-guided treatment of de Quervain's disease is feasible with a 21G needle. • There was notable regression of clinical signs in 91.4 % of cases. • The procedure is very safe, no iatrogenic neurovascular or tendinous injuries occurred. • Our procedure requires only one session and 3 days away from work.

Psychologic Factors Do Not Affect Placebo Responses After Upper Extremity Injections: A Randomized Trial.

BACKGROUND: Studies on how psychologic factors influence the placebo effect have shown conflicting results in an experimental setting. Pessimists are more likely to experience a nocebo effect (feel worse after an inert intervention), whereas other studies suggest that patients with more symptoms of depression or anxiety or greater neuroticism have a greater response to a placebo. This is important because treatment benefits are potentiated by placebo effects, and optimal utilization of this phenomenon may improve clinical outcomes. QUESTIONS/PURPOSES: (1) What psychologic factors are associated with a decrease in magnitude of limitations (Disabilities of the Arm, Shoulder and Hand [DASH] score) and pain intensity (visual analog scale [VAS] for pain) after placebo injections for the treatment of painful nontraumatic upper extremity conditions? (2) What psychologic factors are associated with achieving a minimum clinically important difference (MCID) in disability and pain intensity? METHODS: We performed a secondary analysis of data acquired in two prospective, double-blind, randomized controlled trials of patients with lateral elbow pain, trapeziometacarpal arthrosis, and de Quervain tendinopathy who received a single injection of dexamethasone and lidocaine or lidocaine alone (placebo). One hundred six patients were included between June 2003 and February 2008. Sixty-three patients (59%) received dexamethasone and lidocaine, and we analyzed the subset of 43 patients (41%) who received lidocaine alone. The primary outcomes of interest were the DASH questionnaire and the VAS for pain measured three times: when they received the injection, between 1 and 3 months after the injection, and between 5 and 8 months after the injection. Seven patients missed the first followup visit and 14 patients missed the second visit. Based on previous research, we chose a MCID threshold of 10 for the DASH and a threshold of 1.0 for the VAS score. In bivariate analysis, we accounted for sex, race, marital status, degree, education, work status, pretreatment pain, diagnosis, symptoms of depression (Center of Epidemiologic Studies-Depression Scale), coping strategies in response to nociception (Pain Catastrophizing Scale), and personality traits (measured with the Multidimensional Health Locus of Control scale and the Eysenck Personality Questionnaire-Revised score). Variables with p values < 0.10 in bivariate analysis were included in the multivariable regression models. An a priori power analysis showed that a sample of 43 participants provides 80% statistical power, with α set at 0.05, for a regression with five predictors if the depression score would account for 15% or more of the variability in pain score. We used multiple imputations (imputations = 50) for a total of 66 (8.5%) missing or incomplete questionnaires. RESULTS: In the final multivariable models, no psychologic factors were associated with a change in DASH score between injection and followup, and no factors were associated with greater decrease in pain intensity. After injection, no psychologic factors were independently associated with achieving a MCID in the DASH and VAS. CONCLUSIONS: Our study confirms that patient factors are less important mediators of the placebo effect than clinician factors. In other words, clinician warmth and competence can help diminish symptoms and limitations of people in various states of mind, even when using inert or ineffective treatments. LEVEL OF EVIDENCE: Level II, therapeutic study.

Ultrasound-guided steroid injection for the treatment of de Quervain's disease: an anatomy-based approach.

OBJECTIVE: To suggest different ultrasound-guided steroid injection (USI) techniques based on anatomical variations of the first extensor compartment (FEC), and to evaluate the usefulness of it, in patients with de Quervain's disease. MATERIALS AND METHODS: Twenty-eight patients who underwent USI for de Quervain's disease were included. Anatomical variations were classified into complete sub-compartmentalization (n = 11), distal incomplete sub-compartmentalization (n = 5), and no sub-compartmentalization (n = 12) on ultrasound. Involved sub-compartments were recorded in patients with complete sub-compartmentalization. USIs were performed based on the anatomical variations: in both sub-compartments (n = 2) or only in the affected sub-compartment (n = 9) depending on the location of tenosynovitis involvement, in patients with complete sub-compartmentalization; in proximal FEC in patients with distal incomplete sub-compartmentalization (n = 5); in the common compartment in patients with no sub-compartmentalization (n = 12). Medical charts were retrospectively reviewed for evaluation of clinical outcome at follow-up visits. RESULTS: Twenty-three out of 28 patients were followed up with a mean period of 31.2 days after injection (6~87 days). Mean VAS was 7.96 before injection (range: 4 to 10), which was significantly reduced to 0.65 at rest and 1.57 during activity at follow-up visits (p < 0.05). Twenty-two out of 23 patients were satisfied with the results. The mean proportion of subjective pain reduction was 82.0% (median 95%). CONCLUSION: Ultrasound-guided steroid injections using different injection techniques based on the anatomical variations of the FEC have shown to be beneficial in the management of de Quervain's disease.

Patient- and Disease-Specific Factors Associated With Operative Management of de Quervain Tendinopathy.

PURPOSE: It remains unclear which factors, patient- or disease-specific, are associated with electing to undergo operative management for de Quervain tendinopathy. Our null hypothesis was that no patient- or disease-specific factors would be associated with the choice of surgical treatment of de Quervain tendinopathy. METHODS: We performed a retrospective review of consecutive patients diagnosed with de Quervain tendinopathy over 3 years by 1 of 3 fellowship-trained hand surgeons at an urban academic institution. Descriptive statistics were calculated for patient baseline and disease-specific characteristics. Cohorts were compared using bivariate analysis for all collected variables. Binary logistic regression with backward stepwise term selection was performed including independent predictors identified by bivariate analysis. RESULTS: A total of 200 patients were identified for inclusion. Bivariate analysis revealed that surgically treated patients were significantly more likely to have Medicaid insurance, psychiatric illness history, and disabled work status. Regression analysis revealed an association between surgical treatment and 2 of the factors evaluated: Medicaid insurance status and psychiatric illness history. CONCLUSIONS: Psychiatric illness and Medicaid insurance status are associated with undergoing surgical release of the first dorsal compartment. These findings support the use of a biopsychosocial framework when treating patients with de Quervain tendinopathy. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Ultrasound-guided injection for De Quervain's disease: Accuracy and its influenceable anatomical variances in first extensor compartment of fresh cadaver wrists.

BACKGROUND: This study was designed to evaluate the accuracy of ultrasound-guided injection targeting EPB tendon sheath and influenceable anatomical variances to the accuracy in the first extensor compartment of fresh cadaver wrists. METHODS: Thirty wrists of 15 cadavers were used. The wrists were divided into right-sided wrists (control group) and left-sided wrists (group A) to compare the accuracy of the manual injection technique (control group) and ultrasound-guided injection technique (group A) targeting EPB tendon sheath. To estimate the influence of anatomical variances within first extensor compartment to the accuracy of each injection techniques, control group (manual injection group) was divided into Control group I (right-sided wrists without septum) and II (right-sided wrists with septum) and group A (ultrasound-guided injection group) was also divided into group AI (left-sided wrists without septum) and group AII (left-sided wrists with septum), respectively. After the methylene blue dye injection, the location of methylene blue dye and anatomical variances in the first extensor compartment was identified by dissection. RESULTS: The accuracy was higher in the group A (93.3%) than in control group (40.0%, p < 0.05). The accuracy in control group I (55.6%) was higher than in control group II (16.7%, p < 0.05). The accuracy between group AI (100%) and group AII (85.7%) was not significantly different (p > 0.05). Wrists with more EPB or APL tendon slips showed a tendency not to have septum and all intratendinous injections was occurred in the wrist with 1 EPB tendon slip or 1 or 2 APL tendon slip. CONCLUSIONS: Ultrasound-guided injection targeting EPB tendon ensures correct needle placement through the visualization of compartmental anatomy and improves accuracy of injection though the septum in first extensor compartment encourage inaccurate injections.

National Utilization Patterns of Steroid Injection and Operative Intervention for Treatment of Common Hand Conditions.

PURPOSE: To conduct a population-level analysis of practice trends and probability of surgery based on the number of steroid injections for common hand conditions. METHODS: Patients aged at least 18 years receiving injection or surgery for carpal tunnel syndrome (CTS), trigger finger (TF), or de Quervain tenovaginitis (DQ) were identified for inclusion using the 2009 to 2013 Truven MarketScan databases. The researchers counted the number of injections performed and calculated the time between injection and operation for patients receiving both treatments. A multivariable logistic regression model was created to evaluate the odds of undergoing surgery based on the number of injections performed, controlling for patient age, sex, comorbidities, and insurance type. RESULTS: The study sample included 251,030 patients who underwent steroid injection or operative release for CTS (n = 129,917), TF (n = 102,778), and DQ (n = 18,335). Most patients with CTS were managed with immediate surgery (71%), whereas most patients with TF and DQ were managed initially with injection (74% and 84%, respectively). Among patients receiving both an injection and an operation, a single injection was the most common practice before surgery (69%, 58%, and 67% of patients with CTS, TF, and DQ, respectively). Multiple injections for DQ and TF were associated with relatively low predicted probability of surgery (17% and 26%, respectively, after 2 injections). However, the predicted probability of surgery after 2 injections was higher in patients with CTS (44%). CONCLUSIONS: Given the associated probability of surgery after multiple injections for the 3 hand conditions examined, the practice of repeat injections should be critically examined to determine whether underuse or overuse is present and whether efficiency and use of resources can be improved upon. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Ultrasound-guided percutaneous injection to treat de Quervain's disease using three different techniques: a randomized controlled trial.

PURPOSE: To compare the six-month outcome of three different ultrasound-guided treatments for de Quervain's disease (DQD). METHODS: We prospectively treated 75 consecutive patients (51 females, 24 males, mean age ± standard deviation = 45.3 ± 9.8 years) with DQD. Patients' features (hand dominance, intraretinaculum septum, accessory tendons) were recorded. Visual analogue scale (VAS), reduced disability (quickDASH) score, and retinaculum thickness were evaluated at baseline and after one (excluding retinaculum thickness), three, and six months. Patients were randomized into three groups of 25 patients each treated under ultrasound guidance: Group A (1 ml methylprednisolone acetate; mean baseline thickness = 1.6 mm; mean baseline VAS = 6; mean baseline quickDASH = 55); Group B (1 ml methylprednisolone acetate +15-day delayed 2 ml saline 0.9 %; 1.4; 6; 56); Group C (1 ml methylprednisolone acetate +15-day delayed 2 ml low molecular weight hyaluronic acid; 1.7; 6; 55). RESULTS: After one month results were: Group A mean VAS = 2; mean quickDASH = 23; Group B 2; 22; Group C 2; 21. After three months results were: Group A retinaculum thickness = 0.7 mm; 3; 27); Group B 0.8 mm; 1; 25; Group C 0.5 mm; 1; 23. After six months results were: Group A 1.5 mm; 3; 51; Group B 1 mm; 2; 51; Group C 0.7 mm; 1; 26 (P < 0.001 for all vs. baseline). Patients' age, sex, hand dominance, presence of subcompartment dividing septum, and supernumerary tendons had no influence on outcome (P ≥ 0.177). CONCLUSION: Addition of hyaluronic acid to ultrasound-guided injections of steroids to treat DQD seems to improve the outcome and to reduce the recurrence rate. KEY POINTS: • Ultrasound guidance allows for safe injection procedures to treat de Quervains' disease • Steroid injections allow prompt recovery in de Quervain's disease with short-term recurrence • Addition of hyaluronic acid allows recurrence rate reduction compared to simple steroid injections.

De Quervain tendinopathy: survivorship and prognostic indicators of recurrence following a single corticosteroid injection.

PURPOSE: To determine short- and long-term success rates of a single corticosteroid injection for de Quervain tendinopathy while identifying prognostic indicators for symptom recurrence and repeat intervention. METHODS: Fifty consecutive patients with de Quervain tendinopathy treated with corticosteroid injections (lidocaine plus triamcinolone acetonide or dexamethasone) were prospectively enrolled. Patients with inflammatory arthritis, carpometacarpal osteoarthritis, or a previous distal radius fracture affecting the symptomatic wrist were excluded. Demographic data and information on existing comorbidities were recorded. Patients were seen in clinic at 6 weeks after injection and contacted at 3, 6, 9, and 12 months following injection to determine symptom recurrence and further intervention. Medical records were also reviewed for this purpose. Kaplan-Meier survival analysis and Cox regression modeling were used to estimate recurrence rates and identify predictors of symptom recurrence and repeat intervention. RESULTS: Fifty wrists in 50 patients (average age, 49 y) were included. One patient was lost to follow-up. Eighty-two percent of patients had resolved symptoms 6 weeks after a steroid injection. Twenty-four patients had a recurrence of symptoms at a median of 84 days after the injection. Eleven patients underwent additional intervention (7 surgical releases and 4 repeat injections) at a median of 129 days (range, 42-365) after the injection. Estimated freedom from symptom recurrence was 52% at 6 and 12 months. Estimated freedom from repeat intervention was 81% at 6 months and 77% at 12 months. Two of 3 patients with a history of trigger finger required subsequent de Quervain surgery. CONCLUSIONS: We demonstrated that a single cortisone injection was effective in alleviating symptoms of de Quervain tendinopathy in 82% of patients and that over half remained symptom-free for at least 12 months. All patients with recurring symptoms developed them within the first 6 months. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Blood glucose levels in diabetic patients following corticosteroid injections into the hand and wrist.

PURPOSE: To quantify diabetic patients' change in blood glucose levels after corticosteroid injection for common hand diseases and to assess which patient-level risk factors may predict an increase in blood glucose levels. METHODS: Patients were recruited for this case-crossover study in the clinic of fellowship-trained hand surgeons at a tertiary care center. Patients with diabetes mellitus type 1 or 2, who received a corticosteroid injection, recorded the morning fasting blood glucose levels for 14 days after the injection. Fasting glucose levels on days 1 to 7 after injection qualified as case data; levels on days 10 to 14 provided control data. A mixed model with a priori contrasts was used to compare postinjection blood glucose levels with baseline levels. We used a linear regression model to determine patient predictors of a postinjection rise in blood glucose levels. RESULTS: Of 67 patients recruited for the study returned, 40 (60%) completed blood glucose logs. There was a significant increase in fasting blood glucose levels after injection limited to postinjection days 1 and 2. Among patient risk factors in the linear regression model, type 1 diabetes and use of insulin each predicted a postinjection increase in blood glucose levels from baseline, whereas higher glycated hemoglobin levels did not predict increases. CONCLUSIONS: Corticosteroid injections in the hand transiently increase blood glucose levels in diabetic patients. Patients with type 1 diabetes and insulin-dependent diabetics are more likely to experience this transient rise in blood glucose levels. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Systematic review and meta-analysis on steroid injection therapy for de Quervain's tenosynovitis in adults.

BACKGROUND: de Quervain's tenosynovitis is a painful condition of the wrist which leads to difficulties in performing activities of daily living. AIMS: This systematic review was conducted to examine the effectiveness of steroid injection therapy as compared to splinting for treatment of de Quervain's tenosynovitis in adults. METHODS: The following databases were searched for relevant studies, MEDLINE, EMBASE, CINAHL, AMED and PsycINFO (via NHS Evidence), and Cochrane Library (via Cochrane Collaboration). Synonyms and free texts were used to locate studies. The reference lists of articles were checked for related papers. Hand searching was performed for important relevant journals. All searches found 89 studies, out of which 14 were relevant. Two studies were selected according to the inclusion criteria of the systematic review. Data were extracted and analysed for the two selected randomised trials using a fixed effect model at 95 % confidence intervals. RESULTS: The meta-analysis demonstrated that the total effect estimate was 3 with a narrow 95 % confidence interval (1.89, 4.77). z score for overall effect was 4.66 which was highly significant (p < 0.01). Moderate heterogeneity with I-square test was found to be 64 % but was not significant (p > 0.05). Number needed to treat was 2, which showed that for every two persons treated with steroid injections, one person gets the benefit. CONCLUSION: Steroid injection is an effective form of conservative management for de Quervain's disease although more research is needed to establish the full benefits of the treatment.

Corticosteroid injection versus immobilisation for the treatment of De Quervain's tenosynovitis: A systematic review and meta-analysis.

OBJECTIVE: De Quervain's tenosynovitis causes pain and impairment of thumb function. Conservative treatments comprise corticosteroid injection and immobilization, and it is unclear which offers greater efficacy. Previous reviews were limited by the small number of included studies; thus an updated review and meta-analysis is warranted. METHODS: A systematic review of the PubMed, Embase, and Web of Science databases was conducted. Randomized control trials comparing corticosteroid injection to immobilization were included. Two authors screened articles, extracted data, and assessed the risk of bias of included studies. Meta-analyses using the random-effects model were conducted, calculating pooled relative risks and mean differences with 95% confidence intervals. RESULTS: 16 studies comprising 1206 patients were included. Corticosteroid injection showed greater treatment success than immobilization (relative risk: 1.61; 95% confidence interval: 1.21-2.15). Combining treatments demonstrated greater efficacy than immobilization (relative risk: 2.15; 95% confidence interval: 1.77-2.62) or injection alone (relative risk: 1.23; 95% confidence interval: 1.12-1.34). Pain and disability scores were lower with injection than immobilization and with combined treatment than with either alone. CONCLUSION: Corticosteroid injection is more effective than immobilization for De Quervain's tenosynovitis, and combining the two treatments provides additional benefit. We recommend corticosteroid injection in first line treatment and immobilization as adjuvant therapy. Further research is required regarding optimal corticosteroid and local anesthetic formulations.