Dev Joshi
October 28, 2008
Recurrence of the trigger finger
Fingers have the smallest bone joints in orthopedics. One of the most common finger deformities is “Trigger Finger” (TF). Trigger finger is painful. Very painful. And it is marked by a snapping of the tendons. Trigger Finger’s cause is unclear and symptoms can appear seemingly out of nowhere and on multiple fingers. But the physiological manifestations are obvious—in most cases the tissues that hold the tendon in place thicken and thereby narrowing the opening of the snug tunnel through which the tendons pass. Ultimately patients find it difficult to extend the finger or the finger locks. Trigger finger is denoted by ICD-9-D-727.03 and it represents the third most common hand and finger diagnoses in the PearlDiver Patient Records Database (PRD).
Trigger finger problems are more common in patients who have certain other medical problems—especially diabetes and rheumatoid arthritis. According to a PearlDiver study, almost 4.5% of these patients also are coded for diabetes and from 7% to 8% of the patients have rheumatoid arthritis. Twenty percent of these patients were also diagnosed with carpal tunnel syndrome. While carpal tunnel syndrome and trigger finger are but distantly related—the causes are different—the occurrence together may not be mere coincidence. Both conditions are associated with the ailments of rheumatoid arthritis and diabetes.
Trigger finger is more common in women than in men, with women being diagnosed twice as often as men. According to our PRD database, which does not include MEDPAR data, more than 80% of patients with this finger disorder are over the age of 40. Nationally over 70% of the patients who have trigger finger are over the age of 40, according to Ortho Fact Book and as reported by the Agency for Healthcare and Research Quality based in Rockville, Maryland. The PearlDiver database indicates that over 30,000 patients are diagnosed with this finger diagnoses annually which represent about 3% to 5% of the national estimates.
Like most extremity related treatments, this finger disorder is treated most often in an outpatient setting. Excluding therapeutical and radiological procedures, an injection of the tendon sheath or ligament is the most common procedure doctors and surgeons recommend for treating trigger finger. The following Chart 1 illustrates the principal procedures used for treating this finger deformity according to the PRD database.
Chart 1: Most Common Procedures For Trigger Finger
Source: PearlDiver Patient Records Database January 2004 – June 2007
Even though corticosteroid injection is one of the primary treatments for trigger finger disorder, the chances of the problem recurring are high. Injection is believed to be necessary in the initial stage, though the effects are often temporary and more than one injection may be needed. If the trigger finger disorder has been present for a long time and if diabetes is one of the associated ailments then the disorder is likely to recur. Tendon sheath incision, neuroplasty, or transpositions are the next possible treatments for this finger deformity. The following study is a trigger finger recurrence study presented at American Society for Surgery of the Hand (ASSH).
Reoccurrence of Trigger Finger (Clinical Paper Presented at ASSH)
At the 63rd annual meeting of the ASSH, one of the clinical papers discussed was number 61 titled “Trigger Finger: Prognostic Indicators of Recurrence Following Corticosteroid Injection” presented by Tamara D. Rozental, M.D., David Zurakowski, Ph.D. and Philip E. Blazar, M.D. from Boston, Massachusetts.
In this paper Dr. Rozental and her associates report that in a one-year follow up after corticosteroid injection there was a 57% chance of recurrence of trigger finger. The study shows that symptoms tend to reoccur several months after the injection. Dr. Rozental states that even though the chances of developing trigger finger again are high after the injection, the corticosteroid injection is still the first line of treatment unless the patient has IDDM (Insulin-Dependent Diabetes Mellitus). This is especially true for younger patients. To read more about this, visit “The Journal of Bone and Joint Surgery”.
Interview With Dr. Andrew J. Weiland
Dr. Andrew Weiland is the past President of the American Society for Surgery of the Hand (1995) and of the American Society for Reconstructive Microsurgery (1991). He is also the former Treasurer for the American Academy of Orthopedic Surgeons. He spent half of his career as Chief of Hand Surgery at John Hopkins Hospital and is currently an orthopedist at the Hospital for Special Surgery specializing in hand and trauma surgery.
According to Dr. Weiland, the study done by Dr. Tamara D. Rozental is reflective of his own experience. Dr. Weiland informs his patients that there is a 50/50 chance that the treatment will be successful. His primary treatment is a corticosteroid injection, followed by splicing, and anti-inflammatory medications. Only if they fail, does he recommend surgical release. There is a two week rehabilitation period after surgery.
Dr. Weiland also noted that rheumatoid arthritis and, more especially, diabetes play a significant role in developing trigger finger. Smoking does not appear to be a factor.
The ASSH has recently announced the creation of the Weiland Medal in honor of Dr. Andrew Weiland and his contribution to orthopedics. It will be awarded annually to a mid-career researcher dedicated to advancing patient care in the field of hand surgery. For more information, click here.
PearlDiver Study on Recurrence of Trigger Finger
After reviewing these studies, we at PearlDiver did our own follow-up study on the recurrence rate and the kinds of treatments that followed after injection for trigger finger. Within our PRD database, which runs from January 2004 through June 2007, there are over 90,000 patients who were diagnosed with this finger deformity. Our database also indicates that from those 90,000 or more patients, more than 50,000 were treated with injections; a combination of CPT-20526 which represents “Injection, therapeutic, corticosteroid” and also codes 20550, 20551, 20605 and 20600, which are explained in Chart 1. Table 1 shows which procedures followed the injections; within six months and then after six months.
Table 1: Follow-Up Treatment for Trigger Finger After Injections
Source: PearlDiver Patient Record Database January 2004 – June 2007
Based on Dr. Rozental’s study, we did an analysis on just the corticosteroid injection (CPT-20526) and out of the 2,300 patients that received this procedure for trigger finger; more than 60% of the patients followed up with additional treatment—the tendon sheath incision and neuroplasty and/or transposition.
Conclusion
Reoccurrence of the diagnoses in trigger finger is common and doctors and surgeons believe injection is a necessary step to determine exactly how bad the condition is. A 50/50 success ratio with corticosteroid and other injections makes it still a good measure for treating this disorder. However, when the trigger finger is permanent and the injection fails to heal the finger, tendon sheath incision for the surgical release is the next best alternative treatment. PearlDiver research shows the average charges for the surgical release treatment or the tendon sheath incision procedure is between $1,500 to $2,000 per procedure compared to the corticosteroid or other injections which average from $150 to $200 per procedure.