Between October 2003 and May 2009, we evaluated 33 patients (3 men and 30 women) who were treated with surgical treatment for refractory de Quervain's disease. The medical records of these patients were retrospectively reviewed. All patients presented with clinical signs and symptoms of de Quervain's disease, which included positive Finkelstein tests, localized tenderness over the first dorsal compartment, and positive sign on active EPB extension test. In this active EPB extension test, the patient was asked to abduct the thumb and extend the metacarpophalangeal joint, and induction or aggravation of pain over the first compartment was determined as positive.

We defined the disease refractory when symptoms persisted for longer than 3 months after injection of 0.1mL betamethasone and 0.4 mL 1% (w/v) lidocaine once or twice, or when symptoms recurred after repeated injection more than three times.

Of the 33 patients, 31 had unilateral and 2 had bilateral de Quervain's disease. The mean age of the patients included in this study was 37.6 years (range, 26 to 44 years) for men and 51.6 years (range, 30 to 67 years) for women. Four patients had associated diseases in the same upper extremity, which are one carpal tunnel syndrome, two cubital tunnel syndromes and one lateral epicondylitis. However de Quervain's disease at those cases was developed after the other diseases were cured. The mean duration of follow-up was 28.4 months (range, 18 to 39.5 months). All operations were performed by a single senior surgeon and intra-operative findings were recorded. We collected clinical data of Finkelstein test, DASH score,10) and overall and night visual analogue scale (VAS) pain score before operation and at the final follow-up.

All operations were performed in the day surgery unit, under local anesthesia using intravenous midazolam and pethidine. A mixture of 0.1% (w/v) lidocaine and 0.25% (w/v) bicarbonate was injected into the area of skin incision and a pneumatic tourniquet was inflated. A 2-cm long transverse skin incision was made over the first extensor compartment of the radial styloid process. Great care was taken to identify and retract the radial sensory nerve branches. The EPB tendon was exposed and identified just distal to the first extensor compartment. After lifting the EPB tendon, the extensor retinaculum covering the EPB subcompartment was incised longitudinally along the EPB tendon (Fig. 1) on its dorsal side. If there was a septum between the EPB and APL tendons, the septum was incised longitudinally. Any entanglement was double-checked by pulling and lifting up the tendon distally (Fig. 2). When we found a ganglion from the tendon sheath, we removed the mass from the tendon sheath without excision of the tendon sheath. After meticulous hemostat control, the skin was closed and a compressive dressing was applied. No immobilization was performed.

Paired t-test was used to compare the preoperative and postoperative clinical examination parameters with SPSS ver. 17.0 (SPSS Inc., Chicago, IL, USA). A p-value of < 0.05 was considered to be statistically significant.

In 18 patients (55%), the EPB tendon compartment was separated from the APL compartment. A thick retinaculum and neovascularization of the tendon sheath were noted. The EPB tendon was easily identified by its dorsal location to the APL tendon and relatively distal musculotendinous junction compared to that of the APL tendon. We also identified small ganglia from the tendon sheaths of eight patients (Fig. 3). These ganglia were removed from the sheath at the time of release. The diseases were treated by operation before the index surgery.

Only one patient showed a positive sign of Finkelstein test at the last follow-up. However, this patient reported that the symptom severity decreased after surgery. Although the patient had mild pain, the hand functioned normally. All returned to normal daily activities.

We found that the average VAS pain score significantly decreased, from 7.42 before surgery to 1.33 at the final follow-up (p < 0.05). Individuals with pain during night showed a decrease in VAS score from 5 preoperatively to 0.15 postoperatively (p < 0.05) (Fig. 4). The DASH score also decreased from 53.2 to 3.45 (p < 0.05) (Fig. 5).

There was no postoperative infection or subluxation of the tendon of the first extensor compartment when an active thumb extension or flexion was tested. No injury to the sensory branch of the radial nerve, adhesion between sensory branches and the fascia, scar hypertrophy or wound dehiscence was noted.