title: A prospective randomized trial comparing the effectiveness of one versus two (staged) corticosteroid injections for the treatment of stenosing tenosynovitis.
abstract: BACKGROUND
  Stenosing tenosynovitis or trigger finger is a common clinical condition regularly treated with steroid injections. Varied success is reported at early time points following injection. We present a prospective, randomized IRB-approved study to confirm these findings at a long-term follow-up.
  
  
  METHODS
  Adult patients presenting with symptoms of stenosing tenosynovitis who agreed to participate were randomized into two groups. Group 1 received an initial injection of triamcinolone and local anesthetic mixture. Group 2 received the same initial injection and an additional staged injection at 6 weeks. The patients were then followed beyond 2 years. If Group 1 patients were still symptomatic at 6 weeks, another injection was given. An additional injection or surgery was defined as treatment failure. DASH scores were obtained at baseline, 3, 6, and 12 months.
  
  
  RESULTS
  Ninety-seven patients (101 trigger digits) were enrolled in the prospective trial. Fifty-six digits were randomized to the one-injection group versus 45 digits randomized to the two-injection group ("intention to treat analysis"-ITT). After accounting for crossover between the groups, 42 patients received one-injection versus fifty-nine patients receiving two injections ("actual" analysis). Overall failure was the same between the two groups. However, a higher surgery rate was noted for patients having undergone two injections versus one injection [47 % versus 27 % (p < 0.013), ITT]. Diabetes was associated with a higher surgery rate at 1 year within the group of overall failures [56 % versus 37 % (p = 0.0505), ITT]. High baseline DASH score (>40) was associated with a median time of 10 months for failure and 6 months for surgery as per a Kaplan-Meier survival analysis (p < 0.005 and p < 0.001, respectively, ITT).
  
  
  CONCLUSIONS
  As overall failure of steroid injection for trigger finger is not improved with staged, two-injection treatment, we recommend a single injection initial treatment for trigger finger with a second injection given in cases of recurrence or failure. Diabetes was a risk factor for needing surgery if failure occurred within 1 year. The baseline DASH score is helpful in predicting which patients have a higher chance of failing as well as needing surgery. Level of evidence Prospective, randomized trial, level I.
authors.affiliation: 201 Route 17 North 11th Floor, Rutherford, NJ 07070 USA.
authors.forename: Emran
authors.initials: E
authors.lastname: Sheikh
authors.affiliation: Jefferson Medical College, 103 Fairway Dr, Clarks Summit, PA 18411 USA.
authors.forename: John D
authors.initials: JD
authors.lastname: Peters
authors.affiliation: Department of Orthopedics, Thomas Jefferson University Hospital, 1015 Walnut St. Curtis Building, Rm 801, Philadelphia, PA 19107 USA.
authors.forename: Will
authors.initials: W
authors.lastname: Sayde
authors.affiliation: Statistics, Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107 USA.
authors.forename: Mitchell
authors.initials: M
authors.lastname: Maltenfort
authors.affiliation: Orthopaedics, Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107 USA.
authors.forename: Charles
authors.initials: C
authors.lastname: Leinberry
keywords: Cortisone injection; DASH; Stenosing tenosynovitis; Trigger finger