03.05.2016

Need for surgery high if steroid injections repeated within 6 months

by Nancy Walsh
Senior Staff Writer, MedPage Today

ORLANDO — Patients with the hand ailment stenosing tenosynovitis — “trigger finger” — who need more than one corticosteroid injection within 6 months are likely to need early surgery and to develop the condition in additional fingers, a retrospective study suggested.

Among patients who required a second injection within 6 months, 34% underwent surgery less than 6 months later and 60% required surgery within a year, according to Charles Ekstein, MD, an orthopedic surgeon in Brooklyn, N.Y.

In contrast, for those who had an interval between steroid injections longer than 6 months, only 15% had surgery during the subsequent 6 months and 40% within a year, he reported at the annual meeting of the American Academy of Orthopaedic Surgeons here.

“This is relevant because for patients who’ve been given an injection and return to the office within 6 months, you can counsel them that they have a 60% chance of needing surgery on that finger,” he said.

Trigger finger is one of the most common hand conditions. In the general population, lifetime risk is 2% to 3%, rising to 10% for individuals with diabetes.

Corticosteroid injections are the usual initial treatment and can alleviate inflammation and allow the tendon to glide smoothly.

If the first injection fails, the current recommendation is to repeat the injection, but success rates decline dramatically, Ekstein explained. A second injection may only have a 30% to 35% success rate, and a third injection works less than 5% of the time.

There currently is no consensus on how many injections to give before surgery and what characteristics are associated with increased failure rates.

Accordingly, Ekstein and his colleagues reviewed the electronic medical records of their center, identifying 250 patients who had two or more injections in a single finger during the years 2007 to 2014.

The analysis included 349 fingers, with a mean time of 5.5 months between injections. A total of 106 fingers ultimately required surgical release.

Among those who had two injections in the same finger within 6 months, 14% developed triggering in another finger in the following year and 39% did so within 2 years. For those whose injections were spaced more than 6 months apart, 8% had another trigger within a year as did 24% within 2 years.

The differences between the groups were all statistically significant, he noted.

“There is a subset of patients to whom you might offer earlier surgery if they understand that their eventual need for surgery is high. This way they can forego the repeated pain and cost of a second injection,” he concluded.