National Utilization Patterns of Steroid Injection and Operative Intervention for Treatment of Common Hand Conditions

Abstract

Purpose To conduct a population-level analysis of practice trends and probability of surgery based on the number of steroid injections for common hand conditions. Methods Patients at least 18 years old receiving injection or surgery for carpal tunnel syndrome (CTS), trigger finger (TF), or De Quervain tenovaginitis (DQ) were identified for inclusion using the 2009–2013 Truven MarketScan databases. The number of injections performed was counted, and time between injection and operation was calculated for patients receiving both treatments. A multivariable logistic regression model was created to evaluate the odds of undergoing surgery based on the number of injections performed, controlling for patient age, sex, comorbidities, and insurance type. Results The study sample included 251,030 patients who underwent steroid injection or operative release for CTS (n=129,917), TF (n=102,778), and DQ (n=18,335). The majority of CTS patients were managed with immediate surgery (71%), whereas most patients with TF and DQ were managed initially with injection (74% and 84%, respectively). Among patients receiving both an injection and an operation, a single injection was the most common practice prior to surgery (69%, 58%, and 67% of patients with CTS, TF, and DQ, respectively). Multiple injections for DQ and TF were associated with relatively low predicted probability of surgery (17% and 26%, respectively, after 2 injections). However, the predicted probability of surgery after two injections was higher in patients with CTS (44%). Conclusions Given the associated probability of surgery after multiple injections for the three hand conditions examined, the practice of repeat injections should be critically examined to determine whether underuse or overuse is present and whether efficiency and resource utilization can be improved upon. Level of Evidence Level II (retrospective prognostic study)

Long-Term Effectiveness of Repeat Corticosteroid Injections for Trigger Finger

“…19 This was consistent with a national database study assessing 102,778 records for treatments of trigger fingers finding that only 16% of which received at least 3 injections. 20 Based on a presumed minimal chance of third injection to prevent surgery, a cost-minimization analysis by Kerrigan et al determined that the optimal treatment strategy for recurrent trigger finger was two steroid injections followed by surgery. 21 This same analysis found that the third injections would have to provide ≥9% of patients with long term relief to be the most cost-effective treatment.…”

Predictors of Recurrence After Corticosteroid Injection for Trigger Digits

“…Of patients that received 2 corticosteroid injections, 26% required surgery, compared with 16% in our series. 16 Previous studies of nodular versus synovitic variants of trigger digit indicated increased injection efficacy with corticosteroid for nodular trigger digits. 3 Other studies have failed to demonstrate a difference.…”

Proximal Linear Extension of Skin Hypopigmentation After Ultrasound‐Guided Corticosteroid Injection for de Quervain Tenosynovitis: A Case Presentation

“…Thus, these studies suggest that if noninvasive treatments including splinting, physical therapy, oral medications, and topical medications fail to resolve symptoms, a single peri‐tendinous injection with corticosteroid may provide benefit. Although no studies exist to clearly characterize practice patterns of CSI versus noninjection therapy for de Quervain tenosynovitis in the United States, the treatment is common, and one review has suggested that patients who receive CSI therapy have only 12% odds of undergoing subsequent surgical intervention [24]. Ultrasound‐guided injection may improve identification of clinically meaningful anatomic variants of the APL and EPB extensor tendon sheath [25] and may improve placement of injectate [24] during treatment of de Quervain tenosynovitis.…”

“…Although no studies exist to clearly characterize practice patterns of CSI versus noninjection therapy for de Quervain tenosynovitis in the United States, the treatment is common, and one review has suggested that patients who receive CSI therapy have only 12% odds of undergoing subsequent surgical intervention [24]. Ultrasound‐guided injection may improve identification of clinically meaningful anatomic variants of the APL and EPB extensor tendon sheath [25] and may improve placement of injectate [24] during treatment of de Quervain tenosynovitis. The current case, however, suggests that dermal complications of CSIs are still a notable risk despite visual image guidance with verification of nondermal and non−intra‐articular placement of the injectate.…”