Effect of percutaneous release versus steroid injection among adults with trigger fingers: a randomized clinical trial

Abstract

Background

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Trigger finger (TF) causes pain and impaired hand function. Percutaneous release of the A1 pulley demonstrates a better outcome than steroid injection in the treatment of TF; however, evidence remains limited. Therefore, this study aimed to compare the effect of percutaneous release of the A1 pulley compared to local steroid injection in the treatment of trigger fingers in Nepal.

Methods

A hospital-based randomized clinical trial among 92 patients aged 18 years and above suffering from trigger fingers that were unresponsive to conservative treatment was conducted to evaluate the effect of the percutaneous release of A1 pulley and steroid injection. Quinnell’s classification, visual analogue scale (VAS) scoring system and thickness of A1 pulley, as well as the flexor tendon in the affected site, were assessed before and after intervention at six months. Student’s t-test, Mann-Whitney U test and chi-square tests were performed to compare the effectiveness of both treatments.

Result

Percutaneous release of the A1 pulley showed better functional improvement than steroid injection, with a p-value of < 0.001 and medium effect size of 0.43. The pain score was also decreased more in the percutaneous release group than the steroid group (-5.1 ± 1.4 versus − 3.7 ± 1.8), with the group difference of 1.3 (95% CI: 0.6 to 2.0), with a p-value of < 0.001 and a large effect size of 0.87. Nevertheless, steroid injection decreased the thickness of A1 pulley than percutaneous release (-0.34 ± 0.24 versus − 0.21 ± 0.21), with a p-value of 0.011 and a large effect size of 0.5. Furthermore, tendon thickness was decreased more in the steroid group compared with the percutaneous release group (-1.12 ± 0.73 versus − 0.34 ± 0.41), with a p-value of < 0.001 and a huge effect size of 1.31.

Conclusion

Percutaneous release of A1 pulley illustrated greater improvement in functional mobility with a moderate effect size and pain with a large effect size compared to steroid injection in trigger fingers. A multicenter trial with a larger sample size and involving a diverse participant cohort may enhance the strength of the evidence.

Trial registration

NCT05383040, first registered on 17/05/2022 (https//clinicaltrials.gov/ct2/show/NCT05383040).

Background

Stenosing flexor tenosynovitis, commonly known as Trigger finger (TF) [1], presents the locking and clicking during flexion and extension of the involved digit. The trigger ring finger is the most common, followed by the trigger thumb [2, 3]. Prevalence of trigger finger is 2% among the general population, which is most common in women in the 5th or 6th decade of life [4]. The probability of having a trigger finger is 2–3% during lifetime, which increases up to 10% in diabetic patients [5]. The probable risk factors of Trigger fingers are repetitive finger movement, forceful hand activities, carpal tunnel syndrome and diabetes mellitus [6,7,8]. Trigger Thumb is caused by the thickening of the flexor tendon gliding at the tendon A1 pulley interface or thickening of the A1 pulley, which can be confirmed by a high-resolution ultrasonography with a high-frequency transducer [8] and it has been found that the cut-off for pathological findings is a 20% increase in tendon thickness compared to the contralateral tendon [9] (Fig. 1).

Fig. 1

Internal structure of A1 pulley

The treatment of trigger fingers includes splinting, oral medications, injection and surgical management (open release and percutaneous release) [10]. Even though the trigger finger is frequently seen in clinical settings, there is no well-established standard protocol for treatment in practice [11]. Recently, extra shock wave therapy (ESWT) has been widely considered as non-invasive treatment among those patients with chronic trigger fingers who are not getting better with other non-invasive interventions because ESWT promotes tendon healing through different biological mechanisms such as neovascularization induction, cellularity and extracellular matrix changes, metalloprotease and cytokine production and lubricin production [12, 13]. However, steroid injection has been serving as a traditional and first-line intervention for such condition due to its convenience and effectiveness which has an incidence of a success rate of 69% in the long term follow-up, even ESWT has shown better effects than steroid injection in improving hand function and quality of life among diabetic patients with chronic trigger fingers [14, 15]. It has been widely accepted as an initial treatment for trigger fingers, primarily due to its convenience to use within outpatient departments and its low complications rate [16]. According to Robert et al. (2014), 45% of patients exhibited sustained successful treatment following a solitary injection [17]. Similarly, another study reveals the success rate of corticosteroid injection as 84% while 16% of patients required surgical release of the A1 pulley, and 41% required a second injection among them [18]. Besides these, Castellanos et al. (2015) recommend that the efficacy of a third steroid injection be explored [14]. However, some authors consider that a third injection does not appreciably improve the efficacy of the treatment [14]. Findings reveal that the third attempt of steroid injection increases the efficacy by only 2%, hence decreasing the overall effectiveness [16, 19].

Percutaneous release is another approach of treatment for trigger fingers, first performed in 1958, and one study reveals that it has a 100% success rate without any reported complications [20]. However, another study indicates a success rate of 87%, based on factors such as persistent pain or discomfort at follow-up, the need for revision through open release/percutaneous release or repeated steroid injections (three or more than three times) [21]. The percutaneous release approach has been the choice for those patients who do not respond to conservative treatment (local steroid injection) with a low complication rate [10, 22, 23]. This procedure has a shorter recovery time, avoidance of scar tenderness and can be applied in an outpatient setting without any special preparation [1]. There is a concern regarding percutaneous release in the thumb where the tendon sheath and neurovascular bundle are in close proximity [24]. Wang et al. (2013) found that patients treated with percutaneous release had a higher level of satisfaction than the patients treated with corticosteroid injections and also a higher success rate (97%) of percutaneous release [23]. The percutaneous release is quick, safe, effective and hence decreases rehabilitation time. It is considered an effective, reliable, time-saving, convenient and cost-effective field, therefore preferred an alternative to surgery [25, 26]. However, most hand surgeons hesitate to do a percutaneous release of the A1 pulley of the thumb due to the close proximity of the digital nerve [23]. The radial digital nerve of the thumb lies at the level of the metacarpophalangeal crease, which is only 1.15 mm anterior to the radial sesamoid bone and 2.19 mm below the dermis, which may act as a cutting board to transect the digital nerve [23]. Different studies in the Nepalese context revealed the overall efficiency of percutaneous release of the A1 pulley as approximately 95% [27, 28]. However, no studies were found regarding the comparison of percutaneous release with steroid injection in trigger fingers in Nepal. Besides these, some studies have reported the changes in the thickness of A1 pulley following steroid injection, but not in the case of percutaneous release of A1 pulley, even globally. Hence, the existing scenario emphasizes the need for an empirical study to evaluate the effectiveness of steroid injection and percutaneous release of the A1 pulley, which might be of clinical importance in the treatment of trigger fingers.

Methods

Aim of the study, study design and setting

This study aimed to compare the effect of percutaneous release of the A1 pulley with the steroid injection in the treatment of trigger fingers. It also aimed to find out the morphological changes in the percutaneous release of the A1 pulley in trigger fingers, which may be the pioneer study.

This study followed the Consolidated Standards of Reporting Trials (CONSORT) 2010 updated guidelines for reporting for RCTs [29, 30]. This study was a single-center, hospital-based, open-label, parallel-group randomized clinical trial to compare the effects of percutaneous release of A1 pulley with steroid injection in the treatment of Trigger fingers between January 2022 and August 2023. The study was conducted in the outpatient department of Nepal Orthopaedic Hospital, Kathmandu, Nepal. It is one of the excellent 100-bed autonomous, charitable, specialized center for orthopaedic and trauma care in Nepal, dedicated exclusively to orthopaedic treatment. It was established in 1998 under the Nepal Disabled Association of Nepal with the support of the Patan Rotary Club, Nepal, and different International Rotary Clubs [31]. The patients aged 18 years and above with a history of trigger fingers of three months or more, trigger finger types 1–4 based on Quinnell classification [32], mentally fit, and those patients who provided written informed consent were included in the study. Those patients were excluded who had prior treatment for trigger finger, trigger fingers in more than one digit, previous surgery, or any other hand pathology such as rheumatoid arthritis, osteoarthritis, Dupuytren’s contracture and diabetic mellitus.

Sample size determination

No previous studies have been conducted in Nepal on this topic. Therefore, we initiated a pilot study involving 10 patients. Based on the success rate observed in the pilot study, we calculated the minimum sample size required for this study. The sample size was calculated based on the pilot study in Nepal Orthopaedic Hospital with a trigger finger success rate for the patients in the steroid injection group versus percutaneous release group on the basis of the persistence of pain/discomfort or hand movement function, which was 83% versus 100% respectively. With an α level of significance at 5% and power of 80%, the sample size was calculated using a test comparing two independent proportions in Stata/MP version 14.1 (StataCorp LP, College Station, Texas). The calculated sample size is 84 (42 participants in each group). To take into account a 10% loss through follow-up and drop out, the total sample size was 92 (46 participants in the steroid injection group and 46 participants in the percutaneous release group).

Randomization

Participants were randomized in a 1:1 ratio and assigned to either the steroid injection group or the percutaneous release of the A1 pulley group randomly (Fig. 2). Simple randomization, also known as complete randomization was performed in which a statistician constructed a computer-generated random number from 1 to 92 for participants using a Microsoft Excel sheet and coded steroid as “S” and percutaneous as “P”. Then, we developed 92 envelopes, and those random numbers 1–92 were put inside envelopes separately. We shuffled, sealed and obscured envelopes to ensure proper allocation concealment. Upon confirmation of a participant’s eligibility, the participants were asked to draw the envelope with the slips of paper marked as steroid or percutaneous. These procedures of the simple randomization method are mentioned in different studies [33,34,35,36,37]. The envelope was opened in the presence of the participant witness to ensure the allocation to the trial arm and to convince the participants of our trial protocol, and, of course, to reduce the selection bias from the study team members. The principal investigator was involved in the participant recruitment, and another research team members were involved in the treatment. The principal investigator assessed the outcomes in the follow-up. No blinding was applied in this study. Therefore, the patients, treating physicians and researchers were aware of group allocation.

Fig. 2

Flow chart of the study

Intervention

The participants with trigger fingers were diagnosed clinically by experienced orthopaedic surgeons. After obtaining informed consent from the patients, they were allocated either to the steroid group or the percutaneous group on the basis of randomization.

Percutaneous release of A1 pulley

Percutaneous release of A1 pulley was performed in the well-managed operation theatre set up with the preparation of skin and injection of 1 ml (2%) of plain lidocaine. After waiting a few minutes to attain a better anaesthetic effect, the proper location of the pulley was identified using surface landmarks in each digit with an 18-gauge needle. The needle was longitudinally moved by keeping the bevel of the needle parallel to achieve a tendon-grating sensation for the confirmation of the cut of the pulley. At last, a sterile dressing was applied [38].

Steroid injection

The skin was cleansed with alcohol over the A1 pulley region. A mixture of 1 ml of injection Depo-Medrol 40 mg (methylprednisolone) and 1 ml lignocaine (0.25%) in a 3 ml syringe was inserted into the flexor tendon sheath over A1 pulley at a slightly oblique angle through the palmar skin in the affected digit. Patients were asked to flex and extend their fingers while injecting. This procedure was also performed in the operating theatre for patient safety. These techniques have been mentioned in the previous studies [15, 22, 39].

The procedure was performed without ultrasound guidance due to the lack of such facilities at the research site institution. All patients were counselled to follow up in the next visit at six months. Information was again recorded at six months of follow-up [40].

Study variables

Outcome variables

The primary outcomes were the functional mobility and pain of the participants; the secondary outcome measure was the thickness of the A1 pulley and tendon. The functional mobility was assessed through Quinnell’s classification field [38] before intervention (baseline data) and after intervention at six months. The clinical severity of Trigger fingers was assessed using Quinnell’s grading system [41], wherein the categorizations include: ‘0’ indicating normal movement of the digit; ‘1’ for uneven movement; ‘2’ for actively correctable locking of the digit; ‘3’ for passively correctable locking; and ‘4’ for fixed deformity [42]. The severity of pain was assessed through the Visual Analogue Scale (VAS) score before and after intervention at six months. The VAS, first used by Hayes and Patterson in 1921, is a validated and subjective assessment which consists of a 10 cm straight line representing the self-reported intensity of pain from zero to 10, indicating that zero is “no pain at all” and 10 is “worst pain”. Patients were asked to reveal their intensity of pain in qualitative terms such as no pain, mild pain, moderate pain, severe pain, or worst pain, and they were further requested to quantify the scores from 0 to 10 for analysis by displaying the VAS scoring system in the pictorial form as explained in the studies [43, 44]. All of these parameters were assessed by the principal investigator. Another outcome was the thickness of the A1 pulley and tendon, which were assessed before intervention (baseline) and after intervention at six months through high-resolution ultrasonography (Ultrasound machine-SONOACE X7) by a trained radiologist. Bianchi et al. (2019) explore ultrasound as an effective and valuable tool for the assessment of trigger fingers that provides static and dynamic conditions, as well as a comparison with the adjacent normal digits [45]. The average width and thickness of the A1 pulley are 7.1 mm and less than 1 mm, respectively [1]. The thickening of the A1 pulley reaches the mean value of 1.8 mm (range 1.1–2.9 mm) in the trigger fingers [46]. The cut-off value for confirming the trigger finger was used if the thickness of the A1 pulley was more than 1.15 mm [47]. The thickness of the A1 pulley was measured longitudinally and proximally.

Participant’s information

Age and sex of participants were recorded. Similarly, a clinical parameter such as plain radiographs of the affected hand was performed to find out the presence/absence of any other hand pathologies.

Safety issue

The side effects of the steroid injection may be local versus systemic or immediate versus delayed. Local side effects may be flare, skin hypopigmentation and atrophy, infection, tendon rupture, progression of osteoarthritis and osseous injury, while systemic side effects include adrenal suppression, facial flushing, hypertension, hyperglycemia and osteoporosis [14, 23, 48, 49]. Tendon, nerve, arterial injury, regional pain syndrome, hematoma and infection or any other condition that can be attributed to the intervention, were regarded as adverse events in the percutaneous release [50]. As in our study, the injection was locally applied directly into the flexor sheath just distal to A1 pulley as mentioned by [16], there were less chances of the systemic side effects of steroid injection, which are clinically insignificant [51]. However, we noticed whether the local or immediate effect occurred or not. It was evaluated by the treating team members. If complications occurred, the treating physicians managed symptomatically. For this, normal saline injection was considered a potent modality to treat if progressive cutaneous atrophy appeared [14]. We had a plan to manage the pain with oral NSAIDs and rest; infection with oral antibiotics; skin depigmentation with normal saline injection; and tendon rupture was supposed to be managed with surgical repair.

As this study was performed in a specialized orthopedic and trauma care hospital, there was no worry about the management if any immediate adverse reaction might have occurred. The principal author recorded all data about adverse effects found. Luckily, no participants had to face with such side effects. A review also did not find any side effects of steroid injection in trigger fingers [16].

Ethical consideration

Ethical clearance was obtained from the Ethical Review Board (ERB) of the Nepal Health Research Council (NHRC) (Reference number 442, issued on 26 August 2022). We constituted a Data and Safety Monitoring Board (DSMB) consisting of two orthopedic surgeons and one statistician as per the requirements set by NHRC for the ethical approval. The DSMB members prepared study-stopping rules and reviewed all the possible effects reported. Similarly, we prepared Standard Operating Procedure (SOP), Investigator Brochure and Case Report Form (CRP). Also, all of the investigators had Good Clinical Practice (GCP) certificates. Similarly, the clinical trial was registered to clinicaltrilregistry.gov (Identifier: NCT05383040, registered first on 17/05/2022). Formal permission was obtained from the Nepal Orthopaedic Hospital, Kathmandu, Nepal, to conduct the study at their site. The respondents were informed about the purpose of this study. Informed consent was obtained from eligible participants. Voluntary, informed participation and the freedom to refuse at any time during the study were strongly emphasized, allowing participants to withdraw from the study at any point without giving any reason and without fear. Privacy and confidentiality of collected information were ensured at all levels.

Statistical analysis

The collected data were entered in Epi-Data version 3.2 and transferred into SPSS version 20 for analysis. Socio-demographic data were analyzed using descriptive statistics. The mean and standard deviation were calculated for the numerical data, such as VAS score for pain, thickness of A1 pulley and thickness of flexor tendon sheath. The normality of distributed data was checked by the Kolmogorov-Smirnov test. Having confirmed the normality, analysis were made by comparing the means and standard deviation using the student’s two-sample t-test and Levene’s Test for equality of variance for measurement. Similarly, the qualitative data, such as functional movement measured with Quinnell’s grading system, were presented in frequency and percentage, and the Mann-Whitney U test was applied for the change in the qualitative ordinal data among both groups. Furthermore, the statistical analysis for categorical variables, such as the complications of treatment, was performed using the chi-square test. All probability values less than 0.05 were considered statistically significant.

Results

Participants’ clinical information

At baseline, a total of 92 participants were included in this study (46 participants in the steroid group and 46 in the percutaneous group). However, after six months of follow-up, a total of 91 participants completed the study (46 participants in the steroid group and 45 participants in the percutaneous group) (Fig. 2).

Most of the participants were female (approx. 85%), and they were proportionally comparable in both groups. A slightly higher proportion of males were in the steroid group (17%) versus 13% in the percutaneous group. Similarly, regarding the age group, both groups had comparable percentages of participants in the age group. In addition to these, both groups had a similar proportion of affected trigger thumb (first digit), but the steroid group had more participants having 3rd and 4th digit trigger fingers (Table 1).

Table 1 Baseline characteristics of participants

Primary outcomes

The primary outcome was the functional movements, which were measured with Quinnell’s grading system, and baseline data were found to be comparable. At baseline, 33% respondents in the steroid group and 22% respondents in the percutaneous group had Grade-2 trigger fingers. They were found to be improved more in percutaneous release than the steroid group at six months. There were 49% and 15% patients with Grade 0 in the percutaneous release group and steroid group, respectively, with the p-value of < 0.001 and medium effect size (r value = 0.43). Similarly, another primary outcome was the pain which was measured with the VAS scoring system, and this was also found to be more decreased in the percutaneous release group than that of the steroid group (−5.1 ± 1.4 versus − 3.7 ± 1.8), with a p-value of < 0.001 and large effect size of a d-value = 0.87 (Table 2).

Table 2 Comparison of pain, A1 pulley thickness and tendon thickness between the steroid group and percutaneous release group

The secondary outcome was the change in the thickness of A1 pulley, and it was found to be more subsided in the steroid group than the percutaneous release group (−0.34 ± 0.24 versus − 0.21 ± 0.21), with a p-value of 0.011 and a strong effect size of d value of 0.5. Similarly, another secondary outcome was the change in the tendon’s thickness. It was found to be substantially decreased in the steroid group compared with the percutaneous release group (−1.12 ± 0.73 versus − 0.34 ± 0.41), with a p-value of < 0.001 and a huge effect size of d value = 1.31 (Table 2).

Regarding the complication of the treatment, seven patients of the steroid group showed the failure of treatment and they needed the re-intervention, which is significant with a p-value of 0.001 and a small effect size of φ-value of 0.29 (Table 3).

Table 3 Comparison of functional movement measured with Quinnel’s grading system between the steroid group and percutaneous release group

Discussion

This study aimed to compare the effect of percutaneous release of the A1 pulley with steroid injection in trigger fingers.

This study found better results in functional movement in the percutaneous release treatment arm than that of the steroid injection group, measured with Quinnell’s classification approach, which is consistent with the findings of this study [52]. Steroid injection in the trigger finger gives relief faster for the first 1 to 4 weeks, but does not remain effective in the mid or long term [11]. It is due to the fact that steroid has anti-inflammatory action; the mechanism of anti-inflammatory action of steroid injection is mentioned in the study of Sharma et al., 2023 [53]. Of course, the trigger finger is the inflammation and subsequent narrowing of the A1 pulley [54]. On the other hand, the percutaneous release of A1 pulley has a similar outcome compared to the surgical release of A1 pulley, which is considered the gold standard method for trigger fingers [55]. Panghate et al., 2021 have found that 96.25% patients have improved to Grade 0 at six-month follow-up [3]. Therefore, percutaneous release is considered to be an ideal alternative to steroid injection because steroid injection provides short-term relief from pain [23]. The procedure of percutaneous follows the complete release of the pulley until the grating sound disappears, and hence, the range of motion (ROM) can be achieved [56]. In fact, it is considered the better choice if severe triggering cannot be managed with steroid injection [57].

Another primary outcome was to measure the improvement in pain in both groups and found that percutaneous release has a greater reduction of pain than that of steroid injection, consistent with several studies [22, 24, 58]. The previous study showed a decrease in VAS scores from 8.0 ± 0.9 to 1.7 ± 0.6 in percutaneous release at six months [3]. On the other hand, [59] have compiled the findings of various studies that report a decrease in VAS score ranging from 3.3 to 6.8 following steroid injection. Steroid injection alters the action of cytokines involved in inflammation and reduces inflammation and pain in the affected joints and tissues; however, most of the steroid medicines have a half-life of less than seven days, and hence, the effects of steroids are decreased in the long term [60].

The secondary outcome was to find out the changes in the thickness of the A1 pulley and its tendon. Both the A1 pulley and the tendon thickness decreased more in steroid injection treatment than in percutaneous release treatment, especially massively decreased in the case of the tendon sheath. Kim et al. (2015) mention about its reason that inflammatory changes are localized specifically to the tendon sheath [61]. Different studies reveal a decrease in A1 pulley thickness and tendon sheath thickness with steroid injection [62]. The mechanism of decrease of thickness is mentioned by the fact that steroid injection reduces the synthesis of collagen type I and proteoglycans but increases the synthesis of MMP-1 and MMP-13, which ultimately leads to further cleavage of collagen type I [41]. Even the thickness of A1 pulley decreases more with steroid injection than that of percutaneous release of A1 pulley, the clinical outcomes are better in percutaneous release. Chopin et al., 2022, also found that the clinical outcome at six-month follow-up is not related to the thickness of the A1 pulley in univariate analysis [63]. Sato et al., 2014 also did not find any significant correlation between the thickness of the proximal A2 pulley and A1 pulley with the severity of trigger fingers [64]. The plausible reason behind this can be explained through a surgical procedure. Like open surgical release of trigger fingers, where incision of A1 pulley is performed to widen the space through which the flexor tendon passes, percutaneous release considers a similar process of cutting the A1 pulley but through the percutaneous insertion of small instruments [65]. No studies are available about the change in thickness of A1 pulley with percutaneous release treatment. Therefore, it has to be explored more in this regard.

This study found that seven patients faced with no improvement in steroid group and they needed re-intervention while all of the patients got improved well and no one needed re-intervention in percutaneous release group. Benan et al. 2012 have revealed the success rate of steroid injection is about 66 to 68% [16]. On the other hand, percutaneous release of A1 pulley in trigger fingers was found to be a100% success rate in one study [66]. Our findings are consistent with these studies.

This study has some limitations. First, although the measurements were standardized and performed by the principal investigator, the lack of blinding during outcome assessment could introduce potential observer bias. Second, while the study included a moderate sample size of 92 participants, the findings may not be generalizable to broader populations due to its single-center design. Third, the six-month follow-up period may not fully capture long-term structural or functional changes in the A1 pulley and tendon sheath. Fourth, the use of ultrasonography, though non-invasive and practical, may be subject to inter-operator variability.

Finally, the study was conducted at a super-specialty hospital, where most patients were either referral cases or self-referred cases, and some may have already received treatment with various non-invasive methods, which could affect the outcome. However, we tried to find out whether they had previous treatment or not on the basis of the patient record. If we found such cases, we excluded them. We could not evaluate pain, activity level and patient satisfaction at six months as performed by [67]. The steroid has a better outcome for the thickness decrement of the A1 pulley than that of percutaneous release. Brozovich et al. (2019) reveal that corticosteroids have an immediate effect on the A1 pulley rather than the tendon due to differences in tissue density [41]. It can be explained in the way that steroids reduce the synthesis of collagen type I and proteoglycans and decrease tenocyte proliferation, differentiation, viability, and metabolism, which induces the tendinopathies [9]. Moreover, we performed the intervention in both groups without ultrasound guidance due to the current institutional setup, which may lead to iatrogenic injury in the case of an abnormally located tendon sheath, and it is believed that it affects the outcomes. Lee et al., 2011 found that sonographically guided injections are more accurate and may be potentially safer than without ultrasound guidance [68]. However, there is no significant difference in the VAS score of steroid injection at six months between the ultrasound-guided and non-ultrasound-guided techniques [69]. Besides these, we could not follow blinding for participants as well as for the clinicians to prevent bias due to the nature of the study.

This study has some specific strengths. First, we assessed the thickness of the A1 pulley and tendon both before the intervention (baseline) and at a six-month follow-up, an approach not reported in previous studies. To our knowledge, this is the first study to compare the effects of percutaneous A1 pulley release and steroid injection on changes in the thickness of the A1 pulley and tendon sheath as post-treatment outcomes. Second, all interventions were performed by pre-assigned orthopedic surgeons, and evaluations were conducted solely by the principal investigator, which likely helped minimize measurement and performance bias.

Conclusion

Percutaneous release of A1 pulley illustrated greater improvement in functional mobility with a moderate effect and pain reduction with a large effect compared to steroid injection. Likewise, all participants in the percutaneous release group showed symptomatic improvements, whereas approximately 15% of those in the steroid group needed re-intervention. The steroid injection group exhibited a greater reduction in the thickness of the A1 pulley and tendon sheath than the percutaneous A1 pulley release group, suggesting that the pulley thickness may not be directly related to clinical outcome. Further multi-center trials with larger sample sizes and diverse participant populations are recommended to strengthen the evidence in this area.