The Association of Hemoglobin A1c With the Prevalence of Stenosing Flexor Tenosynovitis

doi:10.1016/j.jhsa.2012.06.007

The Journal of Hand Surgery

Volume 37, Issue 9, September 2012, Pages 1765-1769

https://doi.org/10.1016/j.jhsa.2012.06.007 Get rights and content

Purpose

Diabetic patients are susceptible to stenosing flexor tenosynovitis (FTS) and may have a diminished response to treatment. The purpose of this study was to determine whether elevated hemoglobin A1c (HbA1c) levels are associated with the development of FTS.

Methods

A review of our diabetic registry identified a cohort of patients with diabetes mellitus. We stratified this cohort to those with and without a diagnosis of FTS during 2008 based on International Classification of Diseases-9 coding (727.00-727.05J). We reviewed charts to confirm the diagnosis. For patients diagnosed with FTS, we used the HbA1c measurement made closest to the date of diagnosis for analysis. We assessed patients without FTS using an average of HbA1c measurements during the same time period and performed subgroup analysis based on specified HbA1c levels (group A, HbA1c level < 7.0%; group B, HbA1c 7.0% to 7.9%; group C, HbA1c 8.0% to 8.9%; group D, HbA1c ≥ 9.0%). Statistical testing consisted of chi-square analysis, odds ratios, and multivariate regression analysis.

Results

There were 259,927 patients in 2008 identified with diabetes mellitus, 3,952 of whom were diagnosed with FTS. The period prevalence of FTS in this diabetic population was 1.5%. Multivariate regression analysis revealed that HbA1c greater than 7% was an independent risk factor for FTS (odds ratio/confidence interval: group B, 1.31/1.20–1.42; group C, 1.35/1.21–1.51; group D, 1.23/1.10–1.38).

Conclusions

The prevalence of FTS in this diabetic population was considerably lower than expected and may represent a more accurate assessment given the power of this population-based study. In addition, the development of FTS appears to be associated with higher HbA1c levels. Although further study is necessary, this association may be relevant when evaluating and treating diabetic patients with trigger finger.

Type of study/level of evidence

Prognostic III.

Section snippets

Materials and Methods

We obtained institutional review board approval to search the Kaiser Permanente Southern California medical record and diabetic registry databases to identify patients age 18 years and older, with continuous active membership between January 1 and December 31, 2008, who were diagnosed with insulin-dependent or non–insulin-dependent diabetes mellitus before December 31, 2007. Kaiser Permanente Southern California is a not-for-profit community service health care organization providing care to

Results

We identified 259,927 patients with diabetes mellitus who met our inclusion criteria. Flexor tenosynovitis was diagnosed in 3,952 of these patients. From this, we calculated the period prevalence of FTS in the diabetic population to be 15.2/1,000 people (1.5%). Electronic records for the 2008 calendar year were available for 2,129,184 nondiabetic patients greater than 18 years of age. Review of ICD-9 coding identified 15,839 nondiabetic patients diagnosed with FTS. This yields a period

Discussion

Notta,¹⁷ a French physician, described stenosing FTS in 1850, and it remains a common tendinopathy of the hand regularly encountered by primary care physicians, general orthopedists, and hand surgeons. The etiology of trigger finger is multifactorial, with localized repetitive friction and systemic disease contributing to its development.1, 18, 19 A considerable body of literature has been published regarding the relationship between FTS and systemic disease, most of which concerns diabetes

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Cited by (27)

Proportion and distribution of upper extremity musculoskeletal disorders and its association with disability in type 2 diabetes mellitus
2022, Journal of Hand Therapy
Citation Excerpt :
Previous studies have demonstrated decreased hand function in diabetes participants15-17. This can be confirmed by other studies that show a higher prevalence of LJM18-20, Dupuytren's Contracture, FS, and CTS18,21,22 in diabetes participants. The presence of these disorders was found to influence upper extremity pain and disability23.
Cross-sectional
Globally, diabetes is a leading cause of disability with an increased prevalence rate in the past three decades. Chronic diabetes has been shown to affect collagenous tissue which often leads to subsequent musculoskeletal complications. Despite increasing prevalence of musculoskeletal disorders, the proportion and distribution of types of upper extremity musculoskeletal disorders resulting in disabilities is poorly understood.
This cross-sectional study aims to gather data on the prevalence, proportion and distribution of upper extremity musculoskeletal disorders among individuals with Type 2 Diabetes Mellitus. Further, this study examines the relationship between common upper extremity disorders and the resulting disability among individuals with Type 2 Diabetes Mellitus.
170 individuals diagnosed with Type 2 Diabetes Mellitus were recruited at a tertiary care hospital. Routine upper extremity assessments were performed to identify the presence of Frozen Shoulder (FS), Limited Joint Mobility (LJM), Trigger Finger, Carpal Tunnel Syndrome (CTS), and Dupuytren's Contracture. Disability was measured using the Disabilities of arm, shoulder, and hand (DASH) questionnaire. Descriptive statistics, one-way analysis of variance, Tukey's test, and Pearson's test were used to examine the prevalence, proportion and distribution of musculoskeletal disorders and disabilities among individuals with type 2 Diabetes Mellitus.
83(48.9%) participants had one or a combination of multiple musculoskeletal disorders of the upper extremity. The proportion of LJM, FS, CTS, Trigger Finger, and Dupuytren's Contracture were n = 46(27.1%); n = 43(25.3%); n = 16(9.4%); n = 8(4.7%); n = 5(2.9%) respectively. Disability scores on the DASH were 25.8 ± 14.5, 10.3 ± 11.9, and 10.6 ± 10.4 respectively for individuals with FS, LJM and Trigger Finger. DASH scores were highest in individuals with both CTS and FS, 29.8 ± 19.3. Duration of diabetes was significantly associated (r = 0 .19; P < .01) with the disability scores on DASH.
The prevalence of musculoskeletal disorders in people with type 2 Diabetes mellitus remains high despite advances in medical management over the last two decades. The overall prevalence of hand disorders (LJM, CTS, Dupuytren's contracture, Trigger Finger) was higher than shoulder disorders (FS), e.g. frozen shoulder. People with a diabetes that had a diagnosed upper extremity conditon had more upper extremity disability, than those with diabetes but no diagnosed hand condition, Disability was highest for frozen shoulder and lowest for Dupuytren's diagnoses. Carpal tunnel syndrome was the most disabling hand condition. People with diabetes should be screened for upper extremity diagnoses that could limit their function. Poeple with disability resulting from hand disorders was lower than the shoulder disorders. A combination of hand and shoulder disorders resulted in greater disability.
Predictive factors and clinical effects of diabetic hand: A prospective study with 1-year follow-up
2022, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
In this context, fibrous hypertrophy or sterile inflammatory changes in the flexor tendon synovium at the A1 pulley can lead to TF, while hypertrophy of the flexor tendon synovium at the wrist can lead to CTS.11 The prevalence of TF in the general population is only 1–2%, although it reaches 5–20% among patients with diabetes.12-14 Previous reports have suggested that age and diabetes duration are related to these changes in hand function,1,15 although the factors predicting the development of diabetic hand (DH) remain unclear.
Diabetes mellitus is considered an etiological factor for hand-related conditions that are grouped under the term “diabetic hand” (DH), which includes limited joint mobility, Dupuytren's contracture, carpal tunnel syndrome, and trigger finger. This study aimed to identify predictive factors and the clinical effects of DH development among patients with diabetes.
Consecutive Japanese adults with diabetes were prospectively recruited at a single outpatient center. We assessed the presence of DH at baseline and at the 1-year follow-up, which was considered present if the patient exhibited one or more of the hand disorders at either examination.
The 590 eligible subjects had a mean age of 57 years and included 155 patients (26%) with DH. Binary logistic regression analysis revealed that DH was significantly associated with older age, longer diabetes duration, and higher body mass index. Patients with DH had significantly lower hand function and quality of life (QOL) scores. We assessed 476 patients at the 1-year follow-up, including 96 patients (20%) who had DH at baseline. Although 25 of the 96 patients (26%) experienced resolution of DH without specific treatment, 83 of 380 patients (22%) without DH at baseline had developed new DH-related conditions. At the 1-year follow-up, the group with DH was significantly older than that without DH.
Older age and prolonged duration of diabetes predicted the development of DH. Patients who are not old and do not have a prolonged duration of diabetes may experience DH resolution without specific treatment.
Management of Diabetic Trigger Finger
2019, Journal of Hand Surgery
Citation Excerpt :
Diabetics are more susceptible to developing trigger finger.1 Estimates of the prevalence of trigger finger in the diabetic population range from 5% to 20% compared with 1% to 2% in the general population.2,3 The lifetime incidence of trigger finger in the general population is between 2% and 3%, whereas that in the diabetic population is 10%.4
Diabetics have a much greater prevalence of trigger finger than nondiabetics and are more likely to have severe symptoms. Diabetic trigger finger may be more accurately described on a spectrum of diabetic hand pathology alongside carpal tunnel syndrome and cheiroarthropathy. Recent publications have called into question the current treatment algorithm for diabetic trigger finger. Although some evidence supports the use of corticosteroid injections, a recent cost analysis reported that immediate surgical release of the A1 pulley in the clinic is the most cost-effective management of diabetic trigger finger. In addition to traditional treatment with injection and open release, percutaneous release with or without simultaneous corticosteroid injection has shown promising results and may have a role in patient care. The appropriate treatment algorithm in terms of efficacy, safety, and cost remains controversial.
The incidence of trigger digit after carpal tunnel release in diabetic and nondiabetic patients
2014, Journal of Hand Surgery
Citation Excerpt :
For patients with DM, additional information regarding method of disease control (diet-controlled, oral medications, or insulin dependence) and disease severity (HbA1c level) was recorded. In accordance with the method employed by Vance et al,3 diabetic patients were further divided with respect to their HbA1c levels into 4 groups: less than 7.0%, 7.0% to 7.9%, 8.0% to 8.9%, or greater than 9.0%. We recorded HbA1c levels 3 months before and 3 months after CTR.
To determine whether patients with diabetes mellitus (DM) are at greater risk for developing postoperative trigger digits (TD) after carpal tunnel release (CTR) compared with patients without diabetes.
A retrospective review of our electronic medical records identified all patients who had undergone CTR by a single hand fellowship–trained surgeon from September 2007 through May 2012. For patients with DM, additional information regarding method of disease control and hemoglobin A1c (HbA1c) level was recorded. We recorded HbA1c levels 3 months before and 3 months after CTR. The location and time to development of postoperative, new-onset TD were recorded for each case. Statistical testing included chi-square or Student t test and multivariate logistic regression analysis.
Of the 1,217 CTRs, 214 had DM. Of the 1,003 CTRs in cases without DM, 3% developed TD within 6 months of CTR and 4% within 1 year of CTR, compared with 8% and 10%, respectively, for diabetic cases. A multivariate regression analysis revealed DM as a significant risk factor for developing TD after CTR at 6 and 12 months. We found no significant association between HbA1c level at the time of CTR and the likelihood of developing TD.
The incidence of TD after CTR was higher in the diabetic population compared with a nondiabetic cohort. The presence of DM rather than its severity was the most important factor for developing TD. Preoperative counseling for patients with DM undergoing CTR may alert them to the possibility of developing TD.
Prognostic IV.
Association between multiple trigger fingers, systemic diseases and carpal tunnel syndrome: A multivariate analysis
2019, Revista Espanola de Cirugia Ortopedica y Traumatologia
El dedo en resorte (DR) es una patología frecuente de etiología multifactorial. El objetivo de este estudio fue valorar la relación entre la aparición de DR múltiple y patologías sistémicas o musculoesqueléticas en una muestra de pacientes jóvenes en edad laboral.
Se analizaron retrospectivamente todos los pacientes con DR intervenidos en nuestro hospital entre 2011 y 2015. Se recogió la existencia de DR múltiple o único y patologías como diabetes mellitus (DM), disfuncionalidad tiroidea, síndrome del túnel carpiano (STC), epicondilalgia o enfermedad de DeQuervain. Los resultados estadísticos incluyen un análisis bivariante y una regresión logística multivariante.
Se incluyeron 279 pacientes, con una edad media de 48,45 ± 9,01 años. La mano dominante estuvo afectada en 217 casos. Hubo 59 pacientes con DR múltiple, 21 con DM, 55 STC, 16 epicondilalgia y 14 DeQuervain. La prevalencia de STC fue del 19,7%, significativamente superior a la media poblacional (2-4%). No se hallaron diferencias en cuanto a edad media, sexo, hipotiroidismo, epincondilitis o DeQuervain en DR único o múltiple. El análisis bivariante detectó que la proporción de DM (20,3%) y STC (32,2%) en el grupo de DR múltiple fue significativamente mayor que en el grupo de DR único (DM: 4,1%, p = 0,007; STC: 16,4%, p < 0,01). El DR múltiple también fue más frecuente en mano dominante (93,2%; p < 0,01). La regresión logística multivariante confirmó los hallazgos, mostrando asociación estadísticamente significativa entre el grupo de DR múltiple y DM (OR: 4,98, p < 0,01), STC (OR: 2,09, p = 0,037) y la mano dominante (OR: 3,76, p = 0,016).
La DM, el STC y la mano dominante se relacionan de forma independiente con la aparición de DR múltiples en pacientes jóvenes en edad laboral.
Trigger finger (TF) is a frequent pathology depending on several factors. The objective of this study was to assess the relationship between multiple TF and systemic or musculoskeletal disorders in a sample of young patients.
A retrospective study was performed of all patients with TF operated in our hospital between 2011 and 2015. Multiple or single TF diagnosis and pathologies such as diabetes mellitus (DM), thyroid dysfunction, carpal tunnel syndrome (CTS), epicondylalgia or DeQuervain's disease were collected. Statistical results included a bivariate analysis and a multiple logistic regression.
Two hundred and seventy-nine patients with a mean age of 48.45 years were included. The dominant hand was affected in 217 cases. There were 59 patients with multiple TF, 21 DM, 55 STC, 16 epicondylalgia and 14 DeQuervains. Prevalence of CTS was 19.7%, significantly higher than the general population (2%-4%). No statistical differences were found in age, sex, hypothyroidism, epicondylalgia or DeQuervain in the multiple TF group. Bivariate analysis detected that DM and CTS patients in the multiple TF group was significantly higher than in the single TF group (P = .007, P < .01). Multiple TF was also more frequent on the dominant side (P < .01). Multivariate logistic regression confirmed these findings, showing a statistically significant association between the multiple TF group and DM (OR: 4.98, P < .01), STC (OR: 2.09, P = .037) and dominant side (OR: 3.76, P = .016).
Diabetes, CTS and dominant side are independently associated with multiple TF in young patients.
Incidence, Prevalence, and Outcomes of Hand Manifestations in Patients With Diabetes Mellitus: A Comprehensive Literature Review
2024, Hand

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: The authors acknowledge Tony S. Yiu and Su-Jau Yang for their contribution to data collection and statistical analysis.

: N.G.H. received support from Kaiser Foundation Healthplans.

: No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

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Scientific articleThe Association of Hemoglobin A1c With the Prevalence of Stenosing Flexor Tenosynovitis

Purpose

Methods

Results

Conclusions

Type of study/level of evidence

Section snippets

Materials and Methods

Results

Discussion

J Hand Surg

J Hand Surg

J Hand Surg

Am J Med

J Hand Surg

J Diabetes Complications

J Hand Surg

J Hand Surg

Hand

Eur J Intern Med

Trigger digits: diagnosis and treatment

J Am Acad Orthop Surg

Scientific article
The Association of Hemoglobin A1c With the Prevalence of Stenosing Flexor Tenosynovitis