Abstract
Background:
Trigger finger is thought to be caused by aseptic inflammation of the A1 pulley and subsequent thickening and narrowing of the fibrous sheath. Acupotomy has been an important treatment for trigger finger. But an updated systematic review about this issue has not yet been released. This systematic review protocol is aimed at providing a higher quality method used to evaluate the efficacy and safety of acupotomy treatment for trigger finger.
Methods:
The following databases will be searched from the study inception to July 2019: the Cochrane Central Register of Controlled Trials (Cochrane Library), MEDLINE, EMBASE, PubMed, China National Knowledge Infrastructure, Wan-Fang Data, and Chinese Biomedical Literature Database. All English or Chinese randomized controlled trials related to acupotomy for trigger finger will be included. Two reviewers will independently perform the processes of study inclusion, data extraction, and quality assessment. The primary outcome will be assessed by improvement of the pain symptoms and finger activity. Secondary outcomes will be assessed through Safety assessment. Meta-analysis will be completed by RevMan V.5.3 software.
Results:
This systematic review will provide an assessment of the current state of acupotomy for trigger finger, aiming to show the efficacy and safety of treatment.
Conclusion:
This systematic review will re-evaluate a higher-quality systematic review to obtain a relatively convincing conclusion that finds acupotomy to be a better choice for trigger finger patients.
PROSPERO registration number:
CRD42018118663
Keywords: acupotomy, protocol, systematic review, trigger finger
1. Introduction
Trigger finger, also known as stenosing flexor tenosynovitis, is a mechanical problem. It is thought to be caused by aseptic inflammation of the A1 pulley and subsequent thickening and narrowing of the fibrous sheath. When the flexor tendon passes the tendon sheath at the metacarpal head, this abnormal structure can lead to restricted movement of the tendon. Trigger finger has been a common hand disease that often requires surgery, and it has numerous etiological factors as possible causes. The thumb, long finger, and ring finger are most commonly affected. The condition often occurs in manual laborers, such as tilers, fitters, and housewives. Primary trigger finger is more common in patients between the ages of 50 and 60 years, and it is more prevalent in women than men.[1] The diagnosis is mainly based on clinical symptoms presenting during examination. The condition is characterized by pain, clicking, and loss of motion in the affected finger. Sometimes a pea-sized induration can be felt near the metacarpophalangeal joint where the popping is generated. There is no role for x-rays in diagnosis if patients have no experience of inflammatory disease or trauma.[2]
Trigger finger can be treated nonsurgically by using splinting and corticosteroid injections. Surgery is not the first option unless patients continue to be symptomatic after conservative treatment. Surgery treatment options most often include percutaneous A1 pulley release and open A1 pulley release.[3,4] In addition, acupotomy therapy is commonly used in clinical treatment in China.[5–7]
Acupotomy treatment uses a needle knife as the main treatment tool, which has a needle body with a knife tip. It is a new procedure that combines traditional Chinese acupuncture treatment with modern surgical principles. Acupotomy theory supposes that disorders of soft tissue structures are the risk factors for chronic soft tissue injury, which includes adhesion, contracture, scar formation, and blockage.[8] Acupotomy treatment for trigger finger has its unique advantages, such as a small wound size, high efficacy rate, and low recurrence rate. An increasing number of clinical studies have reported that acupotomy is effective for the treatment of trigger finger. It has been one of the most important treatments for trigger finger in China.
The mechanism of acupotomy therapy is not yet clear. It works effectively for chronic soft tissue injury by peeling the adhesion, releasing the contracture, and clearing the blockage.[8] The mechanism to treat trigger finger using acupotomy is similar to percutaneous A1 pulley release. Some literature sources[9–12] have reported that acupotomy can effectively release the thickened tendon sheath, relieve the pressure of the flexor tendon, and help the recovery of the normal metacarpophalangeal joint structure.
The applied value of acupotomy in treating trigger finger is obvious. However, the safety of this operation is often questioned owing to its closed surgery approach, which is mostly performed by relying on hand sensations. Tendons, blood vessels, and nerves may get damaged during treatment.[13] Until now, only 1 systematic review of acupotomy for trigger finger has been published.[14] The conclusion of literature published in 2016 only assessed acupotomy as being superior to steroid injection based on the efficacy rate, and there were no significant differences in adverse reactions. However, 3 years have passed since the publication of the 2016 evaluation, and many new experiments in the field have been published during this time.[15–18] Ultrasound guidance technology is also gradually being applied.[17,18] What's important is that our latest anatomy test has confirmed the efficacy and safety of acupotomy treatment. However, an updated systematic review or research program on this issue has not yet been released. Therefore, it is important to re-evaluate a higher-quality systematic review to obtain a relatively convincing conclusion that finds acupotomy to be a better choice for trigger finger patients.
2. Methods
2.1. Inclusion criteria for study selection
2.1.1. Types of studies
Randomized controlled trials (RCTs) of acupotomy for patients with trigger finger will be included without restrictions on language and publication status. Nonrandomized studies will be excluded for further data syntheses while the data of the acupotomy group will be extracted for a safety assessment.
2.1.2. Types of patients
Trials must include participants who meet diagnostic criteria.[1,19,20] Participants with trigger finger, regardless of age, gender, race, educational status, and symptom stage, will be included. Trials involving study participants who are not eligible for acupotomy treatment owing to pre-existing conditions, such as fractures, dislocations, tumors, and other serious illnesses, will be excluded.
2.1.3. Types of interventions
2.1.3.1. Experimental interventions
The treatment group will receive acupotomy therapy without any limits to the needle shape, material, or treatment process.
2.1.3.2. Control interventions
The control group without acupotomy interventions will receive either acupuncture, sham acupotomy, placebo control, steroid injection therapy, massage, or other conventional therapies. This review will also include an evaluation of acupotomy combined with another treatment modality and compared with the same treatment alone.[21,22] Trials that compare different needle insertions or different forms of needle knives will be excluded.
2.1.4. Types of outcome measures
2.1.4.1. Primary outcomes
The primary outcome will be improvement of the pain symptoms and finger activity. This will be assessed through validated questionnaires such as Quinnell Grade 1,[23] diagnostic efficacy of standard TCM syndrome,[19] and visual analog scale. Trials with nonvalidated questionnaires or no clear descriptions of evaluation methods will be excluded.
2.1.4.2. Secondary outcomes
Secondary outcomes will include a safety assessment, as judged by incidence rate and severity of adverse effects (eg, pain or limited activity), and a quality of life assessment based on the recurrence rate after at least 3 months of treatment.[7]
2.2. Search methods for the identification of studies
Regardless of the publication status, the following databases will be searched electronically from study inception to July 2019: the Cochrane Central Register of Controlled Trials (Cochrane Library), EMBASE, PubMed, MEDLINE, China National Knowledge Infrastructure, Wan-Fang Data, and Chinese Biomedical Literature Database. The databases will be searched for acupotomy RCTs of trigger finger. The search strategy will be created according to the Cochrane handbook guidelines. Search terms will be as follows: Acupotomy therapy, acupotomy, the needle knife, trigger finger, tenosynovitis of hand flexor tendons, flexor tendon stenosis tenosynovitis, flexor muscle tenosynovitis, randomized controlled trials, random trials, and clinical trials. The trials included will not be restricted by language and publication status. For Chinese databases, the search terms will be accurately translated. The search strategies for PubMed are summarized in Table 1.
Table 1.
Search strategy used in PubMed.
2.2.1. Searching other resources
We will search potential eligible trials through scanning the reference lists of identified publications. In addition, we will search other electronic sources, including the Cochrane Library and Turning Research Into Practice databases, for existing systematic reviews to select as relevant references to be cited in the study. Conference proceedings and unpublished literature will also be included.
2.3. Data collection and analysis
2.3.1. Selection of studies
Each reviewer will receive training to ensure a full understanding of the purpose and process of the review. Reviewers will use Endnote X7 software to manage the trials that have been searched and remove duplicates. Two reviewers will independently review the titles, abstracts, and keywords of all the potentially eligible references to decide which trials will satisfy the inclusion criteria. The results of the selection process will be cross-checked by 2 reviewers. A trial will be excluded if both reviewers agree that it does not meet eligibility criteria. Any disagreements will be resolved with a senior reviewer through a group discussion. The selection procedure for the study is shown in Figure 1.
Figure 1.
Flow diagram of the study selection process.
2.3.2. Data extraction and management
The data extraction for the selected reports or studies will be completed by 2 authors independently via data forms. Any differences or uncertainties found during the check will be resolved through discussion and recommendations with a senior reviewer. The data extraction forms will include the following: author's information, time of publication, characteristics of participants, method of randomization, blinding, interventions, treatment course, evaluation index, outcomes, and adverse events. When the details are not granted explicitly in an article, the authors will be contacted.
2.3.3. Assessment of risk of bias in included studies
Two reviewers will evaluate the risk of bias based on the Cochrane Collaboration's tool.[24] We will evaluate the following 7 domains: random sequence generation, allocation hiding, blinding of participants, people and results, incomplete results data, selective reporting, and other biases. The risk of bias will be classified as low, unclear, and high. When the details are not granted explicitly in an article, the authors will be contacted.
2.3.4. Measures of treatment effect
As for dichotomous data analysis, risk ratios with 95% confidence intervals (CIs) will be used. Mean difference with 95% CIs will be used for continuous data analysis. If scales are the same, weighted mean differences will be used for the data measured. Otherwise, standardized mean differences will be used.
2.3.5. Dealing with missing data
We will try to request additional information from the corresponding authors of the original trials to provide missing or incomplete trial data if possible. If we are unable to obtain the missing data, a reliable analysis will be performed based on the available data and tested by a sensitive analysis. Otherwise, we will synthesize the rest of the available data. The possible impact of missing data will be discussed if necessary.
2.3.6. Assessment of heterogeneity
A standard χ2 test will be completed for the detection of heterogeneity. The I2 statistic is going to be used to quantify inconsistencies among the studies. An I2 value of 50% or more will be considered to have substantial heterogeneity.
2.3.7. Assessment of reporting bias
When the trials included are more than 10, funnel plots will be generated to detect the reporting bias. We will perform the Egger regression test to assess plots visually.
2.3.8. Data synthesis
Data synthesis will be performed using RevMan V.5.3 software from the Cochrane Collaboration. Based on the results of χ2 and I2, we will choose to use either fixed-effects or random-effects models. The heterogeneity of each trial will not be considered if the I2 value is less than 50%, and the fixed effects model will be used for combined data. If substantial statistical heterogeneity is found, a random-effects model will be chosen. If significant clinical heterogeneity is found, we will perform a subgroup analysis, or analyze the characteristics and differences of the included studies.
2.3.9. Subgroup analysis
To explain the heterogeneity, we will conduct a subgroup analysis depending on the specific situation. The premise is that we must get complete data. Factors such as subgroups of different acupotomy types and interventions will be taken into account.
2.3.10. Sensitivity analysis
We will conduct a sensitivity analysis to guarantee the robustness of the review conclusions, methodological quality, sample size, and the effect of missing data. The studies of lower quality will be excluded. The analysis will then be discussed and repeated.
2.3.11. Grading the quality of evidence
The quality of evidence for all outcomes will be judged through the grading of recommendations assessment, development, and evaluation. The assessments will be divided into 4 levels: high, moderate, low, or very low.[25]
3. Discussion
This systematic review will provide an assessment of the current state of acupotomy for trigger finger, aiming to show the efficacy and safety of treatment. The analysis of this systematic review will be divided into 4 parts: identification, study inclusion, data extraction, and data synthesis. Conclusions generated from this review may benefit clinicians, policymakers, and patients with trigger finger. On the other hand, there are some potential limitations that must be addressed in this review. The first concern is that high heterogeneity may arise from the various criteria for efficacy evaluation and different forms of acupotomy. Different operating methods may also cause this problem. The second issue is that the quality of included reports may be irregular, which will limit the ability to draw a conclusion based on high confidence. Presently, the effective treatment choices for patients with trigger finger are various; however, there is no clear and unified treatment protocol. Therefore, we will do our best to improve the methods of this comprehensive systematic review and draw convincing conclusions. Researchers and clinicians will formulate the most appropriate treatment plans for different degrees of patients based on these results.
Author contributions
Conceptualization: Yan Jia, Zuyun Qiu.
Data curation: Yan Jia, Zuyun Qiu.
Formal analysis: Yan Jia, Zuyun Qiu, Yifeng Shen, Qiaoyin Zhou.
Methodology: Yan Jia, Zuyun Qiu.
Project administration: Yan Jia, Zuyun Qiu.
Resources: Yan Jia, Zuyun Qiu, Xiaojie Sun.
Software: Yan Jia, Zuyun Qiu, Yifeng Shen, Qiaoyin Zhou.
Supervision: Shiliang Li.
Writing – original draft: Yan Jia, Zuyun Qiu.
Writing – review and editing: Yan Jia, Zuyun Qiu, Shiliang Li.
Footnotes
Abbreviations: 95% CI = 95% confidence interval, RCTs = randomized controlled trials.
How to cite this article: Jia Y, Qiu Z, Sun X, Shen Y, Zhou Q, Li S. Acupotomy for patients with trigger finger. Medicine. 2019;98:42(e17402).
YJ and ZQ contributed equally to this work and are co-first authors.
Ethics approval is not required because individual patient data and privacy were not involved in this study.
This work is supported by China-Japan Friendship Hospital 2010 Research Fund projects (No. 2010-MS-38).
The authors have no conflicts of interest to disclose.
References
- [1].Makkouk AH, Oetgen ME, Swigart CR, et al. Trigger finger: etiology, evaluation, and treatment. Curr Rev Musculoskelet Med 2008;1:92–6.. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [2].Sato ES, Gomes Dos Santos JB, Belloti JC, et al. Treatment of trigger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery. Rheumatology (Oxford, England) 2012;51:93–9.. [DOI] [PubMed] [Google Scholar]
- [3].Giugale JM, Fowler JR. Trigger finger: adult and pediatric treatment strategies. Orthop Clin North Am 2015;46:561–9.. [DOI] [PubMed] [Google Scholar]
- [4].Ryzewicz M, Wolf JM. Trigger digits: principles, management, and complications. J Hand Surg A 2006;31:135–46.. [DOI] [PubMed] [Google Scholar]
- [5].Zhu GW, Jin J, Lu Y, et al. Advances in diagnosis and treatment of flexor tendon stenosis tenosynovitis. J Tradit Chin Orthoped Traumatol 2008;20:70–2.. [Google Scholar]
- [6].Huang ZB, Li ZJ, Li SW, et al. Therapeutic effect of four methods on treatment of flexor tendon tenosynovitis. J Liaoning Univ Tradit Chin Med 2012;11:166–8.. [Google Scholar]
- [7].Wang HM, Cai TL, Zeng HB, et al. The effect of percutaneous minimally invasive acupotomy combined with hormone blocking for trigger finger. Guangdong Med J 2012;33:2994–7.. [Google Scholar]
- [8].Guo CQ, Liu FS, Ma HF, et al. Effect of acupotomy intervention on cervicomuscular apoptosis in cervical spondylosis rabbits. Acupunct Res 2014;39:68–72.. [PubMed] [Google Scholar]
- [9].Ge ZH, Zhu YC. Report of 152 cases of flexor tendonitis release with acupotomy. J Cervicodynia Lumbodynia 2006;27:150–150.. [Google Scholar]
- [10].Zhou GT, Yang Y. Comparative observation on curative effects of stenosing tenovaginitis of flexor digitorum treated with acupuncture knife therapy and blocking therapy. Chin Acupunct Moxibust 2011;31:840–2.. [PubMed] [Google Scholar]
- [11].Yao XM, et al. Curving Acupotomy for Trigger Finger. Zhejiang J Integrated Tradit Chin Western Med 2009;12. [Google Scholar]
- [12].Cao YF, Li H, Yu WJ, et al. Acupotomy treatment for flexor tendon stenosis tenosynovitis. J Tradit Chin Orthop Traumatol 2015;9:15–7.. [Google Scholar]
- [13].Ouyang J, Li YK, Yue YB. The research for damage of local anatomical structure of the finger palm side caused by acupotmy operation methods for trigger finger. Chin J Rehabil Med 2010;256:523–6.. [Google Scholar]
- [14].Xie H, Pan JK, Hong KH, et al. Acupotomyfor trigger finger: a systematic review. Liaoning J Tradit Chin Med 2016;3. [Google Scholar]
- [15].Liu MX, Tan W, Ni SS. Therapeutic effect of acupotomy treatment for thumb tenosynovitis. China's Naturopathy 2016;24:35–6.. [Google Scholar]
- [16].Liu L, Liu ZY. Therapeutic effect of minimally invasive acupotomy treatment for tenosynovitis of hand flexor tendons. Zhejiang J Integrated Tradit Chin Western Med 2016;7:641–3.. [Google Scholar]
- [17].Pan M, Yang H, Xie TX, et al. Value of ultrasound-guided acupotomy treatment for trigger finger. Chin J Ultrasound Med 2018;4:372–5.. [Google Scholar]
- [18].Geng Y, Li JL, Liu XL. Application value of high-frequency ultrasound in the acupotomy treatment for thumb trigger finger. Guide China Med 2017;25:69–70.. [Google Scholar]
- [19].State Administration of Traditional Chinese Medicine. The Diagnostic Efficacy of Standard TCM Syndrome. 1994;Beijing: People's Medical Publishing House, 198–199. [Google Scholar]
- [20].Sun K, Tang X. A prospective study of the clinical treatment for stenosing tenosynovitis. Orthop J China 1999;7:490–2.. [Google Scholar]
- [21].Peng L, Wang WW. Therapeutic effect of intrathecal injection plus acupotomy for treatment for trigger finger. Guiding J Tradit Chin Med Pharm 2009;15:29–129.. [Google Scholar]
- [22].Zhu JT, Chen JH, Huang JF, et al. Clinical observation for 30 cases of needle knife combined with manual release for stenosing flexor tenosynovitis. Rheumatism Arthritis 2018;2:19–21.. [Google Scholar]
- [23].Maneerit J, Sriworakun C, Budhraja N, et al. Trigger thumb: results of a prospective randomised study of percutaneous release with steroid injection versus steroid injection alone. J Hand Surg 2003;28:586–9.. [DOI] [PubMed] [Google Scholar]
- [24].Higgins JPT, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [25].Guyatt GH, Oxman AD, Schünemann, et al. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol 2011;64:0–382.. [DOI] [PubMed] [Google Scholar]