JBJS -- Letters to the Editor for Rozental et al., 90 (8) 1665-1672

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Letters to the Editor to:

Scientific Articles:
Tamara D. Rozental, David Zurakowski, and Philip E. Blazar
Trigger Finger: Prognostic Indicators of Recurrence Following Corticosteroid Injection
J Bone Joint Surg Am 2008; 90: 1665-1672 [Abstract] [Full text] [PDF]

Letters to the Editor: Submit a response to this article

Electronic letters published:

Dr. Rozental and colleagues respond to Dr. Ring: Tamara D. Rozental, Philip E. Blazar (10 September 2008)

Triggering (objective) vs. Pain (subjective): David Ring (10 September 2008)

Dr. Rozental and colleagues respond to Dr. Ring 10 September 2008

Tamara D. Rozental
Harvard Medical School,
Philip E. Blazar
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Re: Dr. Rozental and colleagues respond to Dr. Ring

trozenta{at}bidmc.harvard.edu Tamara D. Rozental, et al.

We thank Dr. Ring for his comments. While "trigger finger" can present with pure locking, the vast majority of patients in our practices present for treatment of the pain associated with stenosing flexor tenosynovitis and not for the locking phenomenon or mild flexion contracture. The triggering is typically an inconvenience and, in our experience, a small minority would undergo an injection or a surgical procedure for isolated triggering. As such, we feel that our definition of "trigger finger" and our patient-centered definition of symptom recurrence more accurately reflect clinical practice. In contrast to Dr Ring�s statement that pain is a less significant or less relevant outcome variable for treatment of stenosing flexor tenosynovitis, we feel that it is the single most important variable of clinical success, albeit likely a less objective variable than triggering alone.
   The recurrence rate in this study closely parallels that previously reported in multiple studies in the literature and we do not believe that this has been over-estimated. Our study already notes that the choice of triamcinolone for injection was based on the investigators clinical practice. To date, no literature has proven the definitive advantage of one steroid preparation over another. The referenced randomized clinical trial demonstrated that the rates of triggering, surgical release and patient satisfaction were not statistically different in patients treated with triamcinolone or dexamethasone and that recurrence rates were similar to those reported in our study.

Triggering (objective) vs. Pain (subjective) 10 September 2008

David Ring,
Orthopaedic Hand Surgeon
Massachusetts General Hospital
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Re: Triggering (objective) vs. Pain (subjective)

dring{at}partners.org David Ring

To the Editor:
The study of Rozental and colleagues(1) is a prospective cohort study that addresses a question of interest to patients with trigger finger and the health providers that care for them. What struck me as I read the article was that the authors have converted one of the more objective diagnoses in hand surgery (either the finger triggers or it doesn�t) into a less precise and somewhat murky diagnosis. Specifically, their definitions of treatment, success, and recurrence are based largely on the presence or absence of pain rather than triggering. In my opinion, this is unwise as idiopathic finger pain and unexplained pain at the A1 pulley are quite common. Furthermore, even when a corticosteroid injection is successful, the pain, tendon nodule, and PIP flexion contracture may persist for months after the triggering has resolved.
In addition to using the symptom of pain to define a recurrence, their inclusion of patients with �recurrence� only 2 weeks after injection muddies the waters because corticosteroid injections can take months to be effective. Thus,the authors are probably just measuring patient misperception of a cure followed by disappointment when they discover they were wrong. Persistent flexion contracture is part of the illness and not a recurrence. I would not be surprised if these were experienced by patients as unmet expectations, but they are not true treatment failures or recurrences. The mind-body aspects of illness are pervasive and, in my opinion, underappreciated.
As a result of these shortcomings, I believe the authors have over- estimated the recurrence rate. I also suspect that triamcinolone likely has a higher recurrence rate than Dexamethasone based on suggestive data from a recent clinical trial comparing these two steroids. (2)
The consequence of overestimating recurrence rates is that patients and surgeons may favor operative over non-operative treatment when they otherwise might not. The consequence of accepting a subjective complaint such as pain as a measure of treatment success for an objectively verifiable diagnosis such as trigger finger is that the analysis becomes less objective and less scientific, which means that it is more prone to bias and misinterpretation. I would caution surgeons and patients not to over-interpret the findings of this study.
The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Commercial entities (Accumed, Small Bone Innovations, Smith and Nephew, Tournier, Wright Medical) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of their immediate families, are affiliated or associated.
References:
1.Tamara D. Rozental, David Zurakowski, and Philip E. Blazar Trigger Finger: Prognostic Indicators of Recurrence Following Corticosteroid Injection J Bone Joint Surg Am 2008; 90: 1665-1672
2. Ring D, Lozano-Calder�n S, Shin R, Bastian P, Mudgal C, Jupiter J. A prospective randomized controlled trial of injection of dexamethasone versus triamcinolone for idiopathic trigger finger. J Hand Surg [Am]. 2008 Apr;33(4):516-22; discussion 523-4.