The relationship between surgical site infection and preoperative corticosteroid injection for various procedures, findings on the long-term effectiveness of corticosteroid injection versus carpal tunnel release in the treatment of carpal tunnel syndrome, and other topics of interest are presented in the new JBJS Guest Editorial “What’s New in Hand and Wrist Surgery.” Here, we highlight the most impactful studies, as selected by author Deborah C. Bohn, MD.
Carpal Tunnel Syndrome
Researchers observed the long-term outcomes of corticosteroid injection vs. carpal tunnel release (CTR) in the treatment of carpal tunnel syndrome in patients originally enrolled in a randomized clinical trial (RCT). Ninety percent of the original cohort was available at a mean follow-up of 6.3 years. The incidence of therapeutic failure, defined as the need for any new treatment on the involved wrist, was greater in the injection group (41.6%) than in the CTR group (11.6%). Nonetheless, 58% of patients in the injection group did not need additional treatment in the 6 years following treatment1.
Dupuytren Disease
In a Level I RCT of 156 patients with Dupuytren disease, researchers found similar outcomes at 5 years for patients treated with collagenase Clostridium histolyticum (CCH) injection vs. those treated with percutaneous needle fasciotomy2. As Guest Editorial author Dr. Bohn notes, this study contributes to recent literature that has shown that CCH “provides little to no benefit over percutaneous needle fasciotomy in terms of recurrence or reintervention but is much more expensive.”
Trauma
A recent study compared the outcomes of patients with zone-I flexor digitorum profundus (FDP) tendon laceration who were treated with either acute primary repair or non-repair (with or without tendon debridement). The nonrepair group (11 patients) had better objective outcomes and lower cost and fewer complications and therapy visits than the repair group (15 patients), and the groups had similar patient-reported outcomes3. Dr. Bohn notes that, “at the very least, this suggests that non-repair of an isolated FDP injury is not inferior to acute repair, which may help in counseling patients with delayed presentation.”
Infection
There is substantial empirical support for the use of corticosteroid injections in trigger finger, carpal tunnel syndrome, and thumb carpometacarpal joint (CMCJ) arthritis. However, recent literature on the relationship between surgical site infection (SSI) and corticosteroid injection for these conditions leads Dr. Bohn to conclude that “strong consideration should be given to avoiding ipsilateral hand surgery within 90 days after corticosteroid injection.” In one study, corticosteroid injection to the surgical site within 90 days prior to CMCJ arthroplasty was associated with a higher rate of SSI and wound complication4. In another investigation, preoperative corticosteroid injection (mean, 55 days) was associated with a higher infection rate after CTR5. Other studies found that corticosteroid injection within 30 days prior to trigger finger release was associated with an elevated risk of deep infection necessitating surgical debridement and that, within 90 days prior to trigger finger release, it increased the risk of SSI of any type6,7.
Pediatrics
Pediatric patients with 100% displaced distal radial fractures who were treated with closed reduction and casting were found to have significantly worse angulation at final follow-up and higher emergency-department costs compared with a historical cohort who had been treated with in situ casting. Additionally, of the 50 patients in the reduction group, 36 (72%) had unacceptable alignment at some point in their follow-up8.
“What’s New in Hand and Wrist Surgery” is freely available at JBJS.org.
What’s New by Subspecialty
Each month, JBJS publishes a review of the most pertinent studies from the orthopaedic literature in a select subspecialty. To read the reports, visit the “What’s New by Subspecialty” collection at JBJS.org.
Recent OrthoBuzz posts include: “What’s New in Pediatric Orthopaedics,” “What’s New in Adult Reconstructive Knee Surgery,” and “What’s New in Musculoskeletal Tumor Surgery.”
References
- Ly-Pen D, Andreu JL, Millán I, de Blas G, Sánchez-Olaso A. Long-term outcome of local steroid injections versus surgery in carpal tunnel syndrome: observational extension of a randomized clinical trial. Hand (N Y). 2022 Jul;17(4):639-45.
- Byström M, Ibsen Sörensen A, Samuelsson K, Fridén JO, Strömberg J. Five-year results of a randomized, controlled trial of collagenase treatment compared with needle fasciotomy for Dupuytren contracture. J Hand Surg Am. 2022 Mar;47(3):211-7.
- Compton J, Wall LB, Romans S, Goldfarb CA. Outcomes of acute repair versus nonrepair of zone I flexor digitorum profundus tendon injuries. J Hand Surg Am. 2022 Apr 9:S0363-5023(22)00120-4.
- Qin MM, Qin CD, Johnson DJ, Kalainov DM. Risk of infection in thumb carpometacarpal surgery after corticosteroid injection. J Hand Surg Am. 2021 Sep;46(9):765-771.e2.
- Kirby D, Donnelly M, Buchalter D, Gonzalez M, Catalano L, Hacquebord J. Influence of corticosteroid injections on postoperative infections in carpal tunnel release. J Hand Surg Am. 2021 Dec;46(12):1088-93.
- Straszewski AJ, Lee CS, Dickherber JL, Wolf JM. Temporal relationship of corticosteroid injection and open release for trigger finger and correlation with postoperative deep infections. J Hand Surg Am. 2022 Nov;47(11):1116.e1-11.
- Koopman JE, Zweedijk BE, Hundepool CA, Duraku LS, Smit J, Wouters RM, Selles RW, Zuidam JM; Hand-Wrist Study Group. Prevalence and risk factors for postoperative complications following open A1 pulley release for a trigger finger or thumb. J Hand Surg Am. 2022 Sep;47(9):823-33.
- Bradley H, Hartman CA, Crawford SE, Ramo BA. Outcomes and cost of reduction of overriding pediatric distal radius fractures. J Pediatr Orthop. 2022 Jul 1;42(6):307-13.
The lessons from Reference 1 and 5 shows that you can’t have your cake and eat it.
Despite the well-known fact that steriod injection in carpal tunnel can have a good long-lasting symptomatic relief, many patients, their primary care physicians and even the surgeons themselves, believe that a surgical release is better as a “permanent” solution, despite its known complications of wound healing, scar formation, pillar pain and relapse rate of at least 10%. While the steriod injection with associated relatively low infection and other complication rate have up to 42% relapse rate, but as pointed out by the study authors, and Dr Bohn herself, this still means 58% of those who have the injection still has lasting relief from this relatively simple and highly accessible interventional procedure.
In a public hospital system, there are more than a few patients would elect for a carpal tunnel release but also demands a steroid injection at the same time while waiting for their name to come up in a public surgical wait list.
This review of evidence vindicates current practice of offering either the surgical release or steriod injection but not both together. Carpal tunnel release, being an elective procedure, should only be performed when risks are optimised as low as practical, whereas the wound infection from a carpal tunnel operation can be disastrous if associated with wound dehiscence.