Ultrasound-guided injection of a corticosteroid and hyaluronic acid: a potential new approach to the treatment of trigger finger

Leonardo Callegari, Emanuela Spanò, Amedeo Bini, Federico Valli, Eugenio Genovese, Carlo Fugazzola, Leonardo Callegari, Emanuela Spanò, Amedeo Bini, Federico Valli, Eugenio Genovese, Carlo Fugazzola

Abstract

Background and objectives: Stenosing tenosynovitis (trigger finger) is one of the most common causes of pain and disability in the hand, which may often require treatment with anti-inflammatory drugs, corticosteroid injection, or open surgery. However, there is still large room for improvement in the treatment of this condition by corticosteroid injection. The mechanical, visco-elastic, and antinociceptive properties of hyaluronic acid may potentially support the use of this molecule in association with corticosteroids for the treatment of trigger finger. This study examines the feasibility and safety of ultrasound-guided injection of a corticosteroid and hyaluronic acid compared, for the first time, with open surgery for the treatment of trigger finger.

Methods: This was a monocentric, open-label, randomized study. Consecutive patients aged between 35 and 70 years with ultrasound-confirmed diagnosis of trigger finger were included. Patients were randomly assigned to either ultrasound-guided injection of methylprednisolone acetate 40 mg/mL with 0.8 mL lidocaine into the flexor sheath plus injection of 1 mL hyaluronic acid 0.8% 10 days later (n = 15; group A), or to open surgical release of the first annular pulley (n = 15; group B). Clinical assessment of the digital articular chain was conducted prior to treatment and after 6 weeks, and 3, 6, and 12 months. The duration of abstention from work and/or sports activity, and any treatment complications or additional treatment requirements (e.g. physiotherapy, compression, medication) were also recorded.

Results: Fourteen patients (93.3%) in group A had complete symptom resolution at 6 months, which persisted for 12 months in 11 patients (73.3%), while three patients experienced recurrences and one experienced no symptom improvements. No patients in group A reported major or minor complications during or after corticosteroid injection, or required a compression bandage. All 15 patients in group B achieved complete resolution of articular impairment by 3 weeks after surgery, but ten patients were assigned to physiotherapy and local and/or oral analgesics for complete resolution of symptoms, which was approximately 30-40 days postsurgery. The mean duration of abstention from work and/or sport was 2-3 days in group A and 26 days in group B.

Conclusions: Although the limited sample size did not allow any statistical comparison between treatment groups, and therefore all the findings should be regarded as preliminary, the results of this explorative study suggest that ultrasound-guided injection of a corticosteroid and hyaluronic acid could be a safe and feasible approach for the treatment of trigger finger. It is also associated with a shorter recovery time than open surgery, which leads to a reduced abstention from sports and, in particular, work activities, and therefore may have some pharmacoeconomic implications, which may be further explored. In light of the promising results obtained in this investigation, further studies comparing ultrasound-guided injection of corticosteroid plus hyaluronic acid with corticosteroid alone are recommended in order to clarify the actual benefits attributable to hyaluronic acid.

Figures

Fig. 1
Fig. 1
Puncture: longitudinal scan of the flexor tendons of the fourth finger using a high frequency (17 Mhz) linear probe over the metacarpophalangeal joint. The 25 G needle is clearly displayed (empty white arrow) with its tip at the tendon sheath distal to the A1 pulley (full white arrow). The X and bar on the right are markers of focus in the US display (X is the center, and the bar is the range of focus). FPT = flexor profundus tendon; FST = flexor superficialis tendon; MCH = metacarpal head; PP = proximal phalange.
Fig. 2
Fig. 2
Corticosteroid injection: longitudinal scan of the flexor tendons of the fourth finger using a high frequency (17 Mhz) linear probe over the metacarpophalangeal joint. The 25 G needle is clearly displayed (empty white arrow) with its tip at the tendon sheath distal to the A1 pulley (full white arrow). The drug is injected into the proximal recess of the tendon sheath (empty arrowhead). The X and bar on the right are markers of focus in the US display (X is the center, and the bar is the range of focus). FPT = flexor profundus tendon; FST = flexor superficialis tendon; MCH = metacarpal head; PP = proximal phalange.
Fig. 3
Fig. 3
Hyaluronic acid injection: longitudinal scan over the flexor tendons of the fourth finger using a high frequency (17 Mhz) linear probe over the metacarpophalangeal joint. The 25 G needle is clearly displayed (empty white arrow) with its tip at the tendon sheath distal to the A1 pulley (full white arrow). Two weeks after corticosteroid injection, low-medium molecular weight hyaluronic acid is injected using the same technique into the synovial space (empty arrowheads) releasing the walls of the tendon sheath. The X and bar on the right are markers of focus in the US display (X is the center, and the bar is the range of focus). FPT = flexor profundus tendon; FST = flexor superficialis tendon; MCH = metacarpal head; PP = proximal phalange.
Table I
Table I
Duration of abstention from physical work/sport (P), office work (O), or normal household work (N) as a result of the treatment in group A (corticosteroid and hyaluronic acid injection) and group B (open surgery)
Table II
Table II
Mean scores (range) for disability (Disabilities of the Arm, Shoulder and Hand [DASH] questionnaire), patient satisfaction (Satisfaction Visual Analog Scale [SVAS]) and pain (visual analog scale [VAS]) in patients treated for trigger finger with ultrasound-guided injection of a corticosteroid and hyaluronic acid (group A) or open surgery (group B)

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