Abstract
Purpose:
Trigger finger, also referred to as stenotic flexor tenosynovitis, is a common condition affecting the digits, with a lifetime incidence of 2.6% among the healthy population and up to 16.5% in diabetic patients. Diabetes mellitus is associated with multiple musculoskeletal conditions including trigger finger. In this study, we aimed to compare the functional outcome of trigger finger release in diabetic and nondiabetic patients to evaluate whether the management of trigger finger in diabetic patients should be the same as that in nondiabetic patients, or whether diabetic patients would benefit from a more tailored management plan to optimize results.
Methods:
A retrospective case–control study was performed at a single center among patients who underwent A1 pulley release from January 2013 to February 2017. Patients were diagnosed with trigger finger grades I to IV according to the Quinnell classification and assessed using the The Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire (Arabic version).
Results:
Sixty-nine patients, including 21 male (30.4%) and 48 female (69.6%), underwent A1 pulley release surgery. More than half of the participants included in this study were diabetic (n = 40, 58%) and 29 were nondiabetic (42%). The mean postoperative QuickDASH scores were 19.93 among diabetic patients and 17.15 among nondiabetic patients. There was no significant difference in the functional outcome between diabetic and nondiabetic (p = 0.6) patients.
Conclusions:
The postoperative functional outcomes are similar in diabetic and nondiabetic patients. Therefore, the management of trigger finger should be the same in both groups.
Introduction
Trigger finger is a common condition affecting the digits and is characterized by mechanical impingement secondary to stenotic tenosynovitis, 1,2 with a lifetime incidence of 2.6% in the healthy population and up to 10% in diabetic patients. 3 Medical treatment options include nonsteroidal anti-inflammatory drugs, splinting, and steroid injections, which are helpful in reducing pain and inflammation. Surgical options are of superior efficacy and include percutaneous and open surgical A1 pulley release. 1,4,5 Although surgical intervention is generally considered a simple low-risk procedure, it may result in complications such as persistence, recurrence, prolonged pain, infection, stiffness, flexion contracture, bowstringing, and digital nerve injury. 6,7 Radial extracorporeal shock wave therapy is a common method to treat soft tissue pathology, but the efficacy of this procedure for the treatment of trigger finger is limited. 2 Diabetes mellitus (DM) is an endocrine disease that can result in microvascular and macrovascular complications and is associated with multiple musculoskeletal conditions including trigger finger. Previous studies reported a prevalence of trigger finger in diabetic patients, ranging from 3.8% to 16.5%. 8 –10
Outcomes following surgical A1 pulley release of trigger finger have been previously discussed, with some studies citing the impact of diabetes on procedure outcomes. 11 –14 However, no study to date has directly compared the functional outcome of trigger finger release in diabetic and nondiabetic patients. Thus, in this study, we aimed to compare the functional outcome of surgical A1 pulley release between diabetic and nondiabetic patients to determine whether routine management of trigger finger is appropriate in diabetic patients, or whether they would benefit from a more tailored management approach in order to improve functional outcomes.
Materials and methods
A case–control retrospective study was conducted in the Department of Orthopedic Surgery at King Abdulaziz University Hospital, Jeddah, Saudi Arabia, between January 2013 and February 2017. Patients underwent open surgical A1 pulley release during that period. This study received ethical approval from the research and ethics committee of KAU-Faculty of Medicine, and all patients provided written informed consent preoperatively. Using mobile numbers provided in patients’ files, they were contacted via telephone after at least 3 months from the intervention and up to 54 months between May 27, 2017, and June 10, 2017. A short questionnaire was administered to gather information on demographic data, age, sex, work status, past medical history, and surgical history in addition to the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire (Arabic version). 15 Patient files were reviewed to assess previous symptoms and to grade disease severity based on the Quinnell classification system. 5,16 All patients who underwent open surgical A1 pulley release between January 2013 and February 2017 were included in this study. Patients were excluded if they did not answer the telephone call, refused to participate in the study, were deceased, or were non-Arabic speakers.
Intervention
A1 pulley open surgical release was immediately performed or after one to two corticosteroid injections in all patients in the operation room under local anesthesia. 4,17,18
Assessment
Functional outcome was measured using the QuickDASH questionnaire. 19,20 This questionnaire was developed by the Institute for Work and Health and the American Academy of Orthopedic Surgeons in the early 1990s to describe the disability experienced by people with upper limb disorders and to monitor changes in symptoms and function over time. The QuickDASH is an 11-item shortened version of the DASH questionnaire, and it relates to physical function, social function, and different symptoms, all assessed on a scale of 1–5. Each item has five response options. The scores for all items are then used to calculate a scale score ranging from 0 (no disability) to 100 (most severe disability). There are separate parts (two additional parts that relate to sports, music, and work) with separate scores that were not included in this study. 15,21 The Quinnel classification system is used to grade the patients based on their symptoms at presentation. The four grades of this classification system are grade I pain and tenderness at the A1 pulley; II catching of the digit; III locking of the digit, passively correctable; and IV fixed, locked digit. 5,16
Data processing and statistical analysis
Data were analyzed using the statistical packaging for social science (SPSS) version 23. Descriptive statistics were used. Qualitative variables are presented as frequencies and percentages. Quantitative variables are presented as measurements of central tendency (mean, SD, maximum (max) and minimum (min) values). The independent t test was used to test significant differences.
Results
Sixty-nine patients underwent trigger finger release surgery, comprising 21 male (30.4%) and 48 female (69.6%) patients (Table 1). The mean age at the time of surgery was 55.26 years (min: 29, max: 75). The average time from onset of symptoms to treatment was 15.04 months (min: 1, max: 120).
Patient characteristics and grading of triggering (Green classification).
More than half of all patients included in this study were diabetic (n = 40, 58%), compared to 29 nondiabetic patients (42%) (Table 1). To assess the preoperative severity of trigger finger, the Quinnell classification system was used. The number of patients within the grades I, II, III, and IV categories of the Quinnell classification were 1 (1.4%), 22 (31.9%), 40 (58%), and 6 (8.7%), respectively (Table 1).
Overall, the mean QuickDASH score for the outcome of trigger finger release surgery was 18.76. The mean score among diabetic patients was 19.93 (22.54 SD) compared to 17.15 among nondiabetic patients, with no significant difference between groups (p = 0.6) (Table 2). When comparing the outcome of trigger finger release in patients who were employed to those who were unemployed or retired, we found a significantly better outcome among employed patients (p < 0.05).
Mean scores’ difference between groups.
There were 10 (14.5%) documented complications in 69 patients. The most common complications involved persistent pain, swelling, or stiffness (7 patients, 10.1%). Other complications included persistent or recurrent triggering (2 patients, 2.9%) and wound infection (1 patient, 1.4%). The complication rate among diabetic patients was 20% (8 of 40) and among nondiabetic was 6.8% (2 of 29). Only 1 patient (1.4%) was treated operatively with revision release.
Discussion
This study evaluated functional outcomes after open surgical A1 pulley release in diabetic and nondiabetic patients. Most patients included in the study were female (69.6%); this gender distribution is similar to that cited in a previous study. 7 DM is a well-known risk factor for musculoskeletal conditions including trigger finger, but in one study, this condition also affected 58% of nondiabetic patients. 8 In a study by Stahl et al, 12 which assessed surgical outcomes of diabetic and nondiabetic patients, as reported by the patients themselves, the authors found that 77% of diabetic patients responded to treatment compared with 94% of nondiabetic patients. 12 By contrast, in our study, we found no significant difference between the two groups. This finding has important implications for orthopedic surgeons, as it suggests that diabetic patients do not require special surgical considerations compared to nondiabetic patients. Interestingly, we found that when the preoperative severity of trigger finger was assessed using the Quinnell classification system, only 1.4% of patients had grade I disease. This may be because patients were satisfied with the nonsurgical management of their disease, or their disease progressed, and they were classified as Quinnell grades II, III, or IV. Overall, the mean QuickDASH score, which represents functional outcome of surgical release, was 18.76. A previous study, which used the QuickDASH to compare ultrasound-guided A1 pulley release versus open surgical intervention in the treatment of trigger finger, found that 3 months after either treatment, the QuickDASH scores approached 0. However, the aforementioned study included a limited number of patients (16 per group). 1 In our study, we found that QuickDASH scores differed significantly between patients who were employed compared to those who were unemployed or retired (p < .05). This finding suggests that people who actively exercise their hands showed improved outcomes; however, this hypothesis was not formally investigated in this study and should be further evaluated in future work.
Limitations
This study has several limitations worth noting. For better estimation of outcomes, we should apply the QuickDASH routinely in the clinic for these patients before treating them as it is comparable with pre- and posttreatment QuickDASH scores. However, this limitation should be considered. Second, we did not clarify the nature of the work, including the amount of manual work performed by the participants in this study, and this should be addressed in future studies.
Conclusions
Postoperative outcomes following open surgical A1 pulley release for trigger finger are similar among diabetic and nondiabetic patients. Therefore, the surgical management of trigger finger does not need to be modified for diabetic patients.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
