Local Steroid Injection Versus Surgical Release for Treatment of Persistent De Quervain's Stenosing Tenosynovitis (DQST)

A Prospective Comparative Study

Ibrahim Mazrou, MBBCH; Mohamed Ramadan, MD; Ashraf Atef, MD; Ahmed El Elemy, MD

Disclosures

Curr Orthop Pract. 2022;33(1):27-31. 

In This Article

Materials and Methods

Ethical Review and Study Design

After approval of the ethical research committee of Tanta University under code 33519, 30 patients with 31 hands were enrolled in this prospective study that was conducted in Tanta University Hospital during 2020. Informed consent was obtained from all patients before participation. Every patient was given a code number, and anonymity was preserved by omitting personal data.

Patient Selection

Patients who were included were between the ages of 18 and 50 yr old with no concomitant medical problems who had persistent symptoms that had lasted for at least 2 mo despite medication, physical therapy, and activity restriction. Patients were excluded if they had a positive medical history for diabetes mellitus, rheumatoid arthritis, or other immunological disease, local skin problems such as eczema, recurrence following previous injection or surgical release, and other causes of radial-side wrist pain such as scaphoid fracture or trapeziometacarpal arthritis and intersection syndrome.

Data Collection

After exclusion of patients who were not compliant with the selected treatment, patients were randomly classified into two groups based on a closed envelope method (envelopes were provided by an orthopaedic resident who was not involved in the study to avoid bias). Group A included 15 patients who had steroid injections, one of whom was affected bilaterally, and group B included 15 patients who underwent surgical release. All patients completed at least a 3-month follow-up after undergoing the methods of injection or surgical release described below. Informed consent was obtained from each patient before any intervention and inclusion in this study. There were 27 women and 3 men with mean ages of 35.1±9.7 yr in group A and 35.7±9.2 yr in group B. Dominant hands were affected in 18 patients, nondominant hands were affected in 11 patients, and only one patient was affected bilaterally. Patient demographics are shown in Table 1.

Method of Injection. All patients were seated with the wrist in a vertical position with the radial side up. After sterilization of the surgical field, a mixture of 1 ml of corticosteroid (triamcinolone acetonide) and 1 ml of local anesthetic (lidocaine 1%) was used. The precise entry point was detected by drawing a line over the radial styloid that extended between Lister's tubercle dorsally and scaphoid tubercle on the volar side. The APL tendon could be palpated halfway between these two points, especially with thumb abduction (Figure 1A). A 22-gauge needle was inserted for 0.5 inch after bending at about 120 degrees, and then the mixture was injected after entering longitudinally in the sheath parallel to the EPB and APL tendon from distal to proximal (Figure 1B). The injection was repeated if needed with at least 1 mo between injections and a maximum of three injections. Patients were advised to avoid heavy work for 2 wk after injections.

Figure 1.

(A and B) The injection method and the precise point of entry.

Method of Surgical Release. All patients were operated under general anesthesia and without tourniquet use. Patients were laid supine over a surgical table with the wrist in a vertical position with the radial side up, and a towel was rolled below the wrist to facilitate the procedure (Figure 2A). After sterilization of the surgical field, a 2-cm transverse skin incision was made over the first dorsal compartment about 1 cm proximal to the tip of the radial styloid process (Figure 2B). Blunt longitudinal dissection of loose subdermal layers was performed to define and protect important structures such as the superficial branch of the radial nerve and cephalic vein to reach the extensor retinaculum (Figure 2C), then the extensor retinaculum was incised longitudinally along its dorsal margin with scissors, leaving a flap from the volar sheath to prevent future volar subluxation (Figure 2D). The APL tendon was retracted and followed by exploration for separate compartments and division of any intervening septa. There were separate compartments in 11 of 15 surgical patients (73.33%). Nine patients had only one additional compartment, and two patients had two additional compartments. The tendons were lifted by blunt retractors out of the tunnel to ensure complete decompression from their musculotendinous junctions to a point at least 1cm distal to the retinacular sheath (Figure 2E). If the septa and tenosynovial tissues were thick and bulky, surgical debulking was performed to prevent recurrence. The tendons were replaced, and the thumb was moved to ensure free and independent movement of the APL and EPB. The wound was closed by single subcuticle suture using Vicryl 3–0 (Ethicon, Inc., West Somerville, NJ) sutures.

Figure 2.

(A) The affected portion of the wrist during surgical release. (B) The surgical incision. (C) The superficial branch of the radial nerve detection. (D) The incision of extensor retinaculum with scissors. (E) The first compartment tendons were lifted by blunt retractors out of the tunnel to ensure complete release.

Postoperative Protocol. A bulky dressing was applied during the initial postoperative days. Patients were prescribed antiedematous, analgesic, and antibiotic medications for 1 wk. Patients were advised to wear a splint until removal of sutures after 2 wk. Grip-strengthening exercises were started at approximately 3 wk and progressed gradually to reach full activity at 6 wk.

Patient Evaluation. Clinical assessment of all patients was done every 2 wk for 3 mo using a functional De Quervain's score (See PDF, Supplemental Digital Content 1, http://links.lww.com/COP/A55, which is the scoring tool) modified after the Disabilities of the Arm, Shoulder and Hand Score and Michigan Hand Outcome Questionnaire.

Statistical Analysis

Statistical analysis was done using statistical programs for social science (IBM SPSS software package version 20.0, IBM Corp, Armonk, New York). Quantitative data were expressed as mean±standard deviation (±SD). The Kolmogorov-Smirnov test was used to verify the normality of distribution of variables, Comparisons between groups for categorical variables were assessed using the Chi-square test (Fisher or Monte Carlo). Student t-test was used to compare two groups for normally distributed quantitative variables while the Mann Whitney test was used to compare between two groups for quantitative variables that were not normally distributed. A P value less than 0.05 was considered significant. Power analysis and sample size resulted in a sample of 12 or more with a confidence level of 95% and margin of error of 5% with a standard deviation of 0.5.

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