Risk Factors
Diabetes, tobacco use, type of incision, and number of digits treated were assessed as risk factors for complications after trigger finger surgery. Nicotine is widely accepted as increasing the risk for wound complications.8 Almost 20% of the U.S. population smokes, compared with 22% of the VA population and 32% of active-duty military personnel.9 One in 4 veterans has been diagnosed with diabetes, a well-known predisposing factor in delayed wound healing and infection.10,11 No prior studies were found comparing type of incision or multiple digits treated as complications risk factors.
There is also a well-known association between trigger finger and diabetes. Chronic hyperglycemia results in the accumulation of collagen within tendon sheaths due to impairment of collagen breakdown. Patients with diabetes tend to present with multiple digit involvement and respond less favorably to steroid injections compared with patients without diabetes.12 Wound healing is also impaired in patients with diabetes. All 6 wound infections in this study were in patients with diabetes. Proposed etiologies for wound-healing complications include pathologic angiogenesis, impaired fibroblast proliferation and migration, impaired circulation, decreased oxygenation, and a defective immune response to the injured site.13
Trigger finger may develop in multiple digits. Once surgery has been planned for 1 digit, patients may request surgery on another digit on the same hand that has not had an attempt at nonoperative intervention. The NFSGVHS plastic surgeons have raised the threshold to offer multiple surgical procedures on the same hand at the same operative visit to minimize recovery time and number of visits, particularly when patients are travelling long distances. This may be less convenient; however, the overall cost to the patient and the health care system in the event of a complication is significant. Plastic surgery providers also run an alcohol prep pad over the incision site to prevent inoculation of the flexor sheath during suture removal.
Current recommendations to ameliorate the postoperative risks to the patient and costs to the system include endorsing a more conservative approach to treating trigger finger than was previously practiced at NFSGVHS. The known, less favorable response of patients with diabetes to steroid injections plus their elevated risk of postoperative infection create a catch-22 for the treatment plan. Given the low risk of a single steroid injection to the flexor sheath, this procedure is still recommended as a first-line treatment.
Related: Experience Tells in Hip Arthroplasty
During the 5-year study there was a lower threshold for surgical management and for treatment of multiple digits during the same surgery than the one currently practiced, with an overall consensus of the hospital’s HCPs. The authors recommend that all patients start with a steroid injection before committing to surgery. Patients with diabetes are informed that the injection will cause a temporary rise in their blood glucose.14 If they are resistant to the injection, high-dose oral nonsteroidal anti-inflammatory drugs and/or proximal interphalangeal joint splinting is ordered.
Verification of A1C values showing better chronic management of blood sugar is a procedure HCPs from the NFSGVHS will begin to follow. Preoperative A1C values between 6.5% and 8% in patients known to have diabetes has been recommended.15 A1C values > 7% have been found to be an independent risk factor for stenosing tenosynovitis.16 The total number of trigger finger surgeries may drop with the benefit of improved utilization of resources.
Conclusion
The authors found a statistically significant association between postoperative infection and 2 patient populations: patients with diabetes (P = .002) and patients having > 1 digit released during the same surgery (P = .027). This outcome suggests using caution when offering A1 pulley release in select patient populations.
Acknowledgement
Justine Pierson, BS, research coordinator at University of Florida, for statistical analysis. Funding is through salary.
Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.