Intra-articular corticosteroid injections to manage trapeziometacarpal osteoarthritis-a systematic review

Does the Number of Preoperative Corticosteroid Injections Affect Clinical and Radiographic Outcomes of Trapeziectomy and Suspensionplasty?

PURPOSE

This study aimed to determine whether an increasing number of preoperative corticosteroid injections is associated with greater radiographic subsidence of the thumb metacarpal at long-term follow-up after abductor pollicis longus suspensionplasty, secondary to steroid-induced pathologic weakening of capsuloligamentous restraints surrounding the thumb carpometacarpophalangeal joint and greater extension of the lunate, but neither affect patient-reported outcomes nor revision rates.

METHODS

A retrospective chart review was performed of patients who underwent primary trapeziectomy and abductor pollicis longus suspensionplasty by a single surgeon over a 10-year period. The number of preoperative corticosteroid injections in the trapeziometacarpal joint was documented, and patients were separated into 4 subgroups: 0, 1, 2, or 3 or more injections. Preoperative and final radiographs were evaluated for a change in the distance between the base of the thumb metacarpal and the distal pole of the scaphoid as a measure of thumb metacarpal subsidence and radiolunate angle as a measure of nondissociative carpal instability, which has been reported as a complication after basal joint arthroplasty. Additionally, the final patient-reported outcomes (Quick Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation) and revision rates were also assessed.

RESULTS

Of a total of 60 patients with an average age of 64 years that were included in the study, 16 (26.7%) received 0, 19 (31.7%) received 1, 12 (20%) received 2, and 13 (21.7%) received 3+ preoperative injections. The median postoperative follow-up was 92 months. The mean distance between the base of the thumb metacarpal and the distal pole of the scaphoid decreased by 2 mm, and the mean radiolunate angle increased by 4° across the entire cohort. When comparing subgroups, no differences were observed in either parameter or the final Patient-Rated Wrist Evaluation and Quick Disabilities of the Arm, Shoulder, and Hand scores.

CONCLUSIONS

This study demonstrates no apparent detrimental effect of an increased number of preoperative corticosteroid injections on radiographic thumb metacarpal subsidence, increase in extension of radiolunate angle (nondissociative carpal instability), patient-reported outcomes, or revision rates at an average of almost 8 years after trapeziectomy and abductor pollicis longus suspensionplasty.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Patient Perspectives on Cognitive Behavioral Therapy for Thumb, Hand, or Wrist Pain and Function: A Survey of 98 Patients

PURPOSE

Cognitive behavioral therapy (CBT) is an established option to improve pain and function for many orthopedic conditions. Our purpose was to obtain patient perspectives regarding CBT for thumb, hand, or wrist pain and function.

METHODS

Between March and April 2022, we distributed an electronic survey via email to patients in our institution's health system with a diagnosis of arthritic or non-specific thumb, hand, or wrist pain. The survey included the opening statement "Cognitive Behavioral Therapy (CBT) is a non-medication option to help manage pain and improve function" and up to 13 questions pertaining to patients' experiences and perceptions regarding CBT. The survey was anonymous and did not collect protected health information. We used descriptive statistics for the findings.

RESULTS

We distributed the survey to 327 patients, yielding a 30% response rate (98/327). Of the respondents, 17 reported already using CBT to specifically help with pain/function. Of these, 15 felt it was helpful and agreed it could help others. Of the subset that used CBT for arthritis, all felt it was helpful. Of the 75 respondents with no CBT experience, 42 indicated "I've never heard of it," 28 responded "I never had it recommended as an option," and 16 marked "I don't know enough about it." Small subsets noted potential personal barriers to CBT implementation, such as cost, time involved, or perceived lack of potential efficacy for themselves.

CONCLUSIONS

A small proportion of patients from our institution with thumb, hand, or wrist pain are utilizing CBT, and the majority finds it helpful.

CLINICAL RELEVANCE

While some patients are already substantially benefiting from CBT to improve their thumb, hand, or wrist pain or function, there is a notable opportunity for providers to increase awareness and recommendations for this option.

Effects of Premixing Betamethasone and Lidocaine on Chondrocyte Inflammation in an In Vitro Model

BACKGROUND

It is common practice for hand surgeons to premix corticosteroids with a local anesthetic and store the mixture in pre-loaded syringes for rapid use during clinic. However, any possible loss of efficacy with this practice has never been studied. The purpose of this study, therefore, is to determine whether premixing betamethasone sodium phosphate/betamethasone acetate (BSP) and lidocaine (L) at different time intervals from injection has diminishing anti-inflammatory effects on chondrocytes in vitro.

METHODS

Human articular chondrocytes were partitioned into six groups: two controls and four experimental conditions. The negative control had growth media only. The positive control had growth media and inflammatory cytokines (interleukin-1β and oncostatin M). Experimental conditions were additionally treated with BSP alone or BSP mixed with lidocaine (BSP + L) at the time of treatment (0 hours), or at 4 or 24 hours prior. Relative expressions of inflammatory genes were measured.

RESULTS

Relative to the positive control, chondrocytes in all experimental conditions decreased expression of TNF-α, MMP-3, and ADAMTS-4. Chondrocytes exposed to BSP only or BSP + L at 4 hours or 24 hours prior to treatment decreased expression of IL-8. Chondrocytes exposed to BSP only or BSP + L at 0 hours or 4 hours prior to treatment decreased expression of MMP-1. There were no significant differences in expression of IL-6 or MMP-13.

CONCLUSIONS

Treatment with BSP + L prepared in pre-loaded syringes at varying time intervals up to 24 hours prior to injection does not significantly impact the ability of the mixture to reduce expression of certain key inflammatory mediators in vitro.

The Effect of Thumb Carpometacarpal Joint Corticosteroid Injections on Outcomes Following Arthroplasty

BACKGROUND

Prior studies suggest steroid injections may affect infection rates following thumb carpometacarpal joint (CMCJ) arthroplasty. However, it is unclear whether injections prior to CMCJ arthroplasty affect functional outcomes, primarily Quick Disabilities of the Arm, Shoulder, and Hand (qDASH).

METHODS

We retrospectively identified patients who underwent thumb CMCJ arthroplasty from 2015 to 2019. Patients who had qDASH scores reported preoperatively, and at 5 and 11 months postoperatively were included. Charts were reviewed for the presence or absence of prior corticosteroid injection to the CMCJ and complications. Delta qDASH was calculated by subtracting the patients' postoperative qDASH scores from the preoperative qDASH scores.

RESULTS

In all, 350 CMCJ arthroplasty patients were identified, 177 who had received at least 1 steroid injection and 173 who were steroid-naïve. No significant differences existed in delta qDASH scores postoperatively between the injection and naïve groups at 5 months (28.5 vs 28.6) or 11 months (31.2 vs 31.9). Whereas there were no significant differences in rates of major complications between the 2 groups, minor complications were higher in the injection group (16.4% vs 9.2%). Patients who received more than 3 injections did not have worse 5-month or 11-month delta qDASH scores or complication rates than those with fewer than 3.

CONCLUSIONS

Preoperative CMCJ steroid injection status does not affect major complication rates or functional outcomes following CMCJ arthroplasty. However, injections increase the rate of minor complications. The qDASH and complication rates following CMCJ arthroplasty are not affected by receiving greater than 3 injections preoperatively.

Transcatheter Arterial Embolization for Alleviating Chronic Musculoskeletal Pain and Improving Physical Function: A Narrative Review

Chronic musculoskeletal pain imposes immense suffering and diminishes the quality of life for millions of patients worldwide; the pain persists despite the use of standard conservative treatments. Increases in our understanding of the pathophysiological mechanisms underlying musculoskeletal disorders indicate the involvement of inappropriate angiogenesis. Accordingly, the resulting neovessels are the target of emerging treatments for chronic musculoskeletal pain, including transarterial embolization. The use of this noninvasive procedure to treat pain refractory to standard therapy in a variety of musculoskeletal conditions is the focus of numerous recent investigations. Here, we describe the pathophysiological indications for the use of transarterial embolization and summarize the findings of studies investigating its use in a variety of histopathological conditions and anatomical sites.

Evaluation of PROMIS Scores 6 Weeks after Conservative Management of Carpometacarpal Thumb Arthritis

Patient-reported outcome measures are being increasingly emphasized to assign value to care‚ given the current trend toward pay-for-performance healthcare. We sought to determine if the Patient-reported Outcomes Measurement Information System (PROMIS), a general questionnaire, is sensitive enough to detect improvement after corticosteroid injection or splinting/hand therapy for thumb carpometacarpal (CMC) arthritis.

First Carpometacarpal Joint Denervation: A Systematic Review

PURPOSE

The first carpometacarpal (CMC) joint is a frequent location of osteoarthritis in the hand. The denervation of the first CMC joint has gained traction as a viable treatment for CMC arthritis. This study reviewed literature on CMC denervation for first CMC arthritis.

METHODS

A systematic review of papers and abstracts was conducted. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Articles including the results of CMC denervation were included. We compiled data on patient demographics, preoperative testing, intraoperative technique, and postoperative outcomes. Anatomic literature was also reviewed to assess agreement on the innervation of the first CMC joint.

RESULTS

Six anatomic studies and 9 clinical studies were included in this systematic review. Pinch strength, grip strength, and Kapandji scores increased on average in patients. Pain relief was noted on average in patients in 5 studies that reported pain outcomes. In studies that reported postoperative complications, the most frequent complications were radial paresthesias, hypoesthesia dorsal and/or distal to the surgical site, and wound infection.

CONCLUSIONS

The innervation of the CMC joint is controversial. This is reflected in clinical practice, wherein varied surgical approaches are used. Carpometacarpal denervation shows promise as an option to treat patients with CMC arthritis without joint instability, but its results vary. Additional clinical studies with longer-term follow-up and control groups are necessary to better determine its longevity and efficacy.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic V.

Surgical management of osteoarthritis of the hand and wrist

Osteoarthritis of the hand and wrist is common; varying disease manifestations and a spectrum of symptoms make it imperative to approach treatment strategies in an individualized fashion. In this review, attention is focused upon site specific diagnoses and indications for various surgical treatment strategies.

The Efficacy of Intra-Articular Versus Extra-Articular Corticosteroid Injections in the Thumb Carpometacarpal Joint

Purpose

This study evaluated whether the location of steroid deposition (intra-articular vs extra-articular) for thumb carpometacarpal (CMC) joint arthritis affects clinical outcomes.

Methods

We prospectively enrolled 102 hands (82 patients) with thumb CMC joint arthritis. Patients received a CMC joint injection with Triamcinolone and radiopaque contrast. Wrist radiographs were used to visualize the injection location. Patients completed Disabilities of the Arm, Shoulder, and Hand Questionnaire (DASH) questionnaires and visual analog scale (VAS; scale, 1-100) pain scores before injection and then at 1 week and 1, 3, and 6 months after injection. Generalized linear regression models were constructed to identify variables associated with clinical outcomes.

Results

The rate of intra-articular injection was 80%. No differences were found between the 2 groups in preinjection DASH or VAS scores. After 1 week, both the intra-articular and extra-articular groups showed improvements of DASH (14.2 and 11.2, respectively) and VAS (15.5 and 15.0, respectively) scores. Although both groups were worse at 3 months, the intra-articular group had significantly lower DASH (26.7 vs 37.5, respectively) and VAS (26.5 vs 39.0, respectively) scores than the extra-articular group. There were no differences between the intra-articular and extra-articular groups for DASH (33.8 vs 42.5, respectively) or VAS scores at 6 months. The intra-articular group maintained significant improvements in outcomes for up to 6 months, while the extra-articular group only maintained them for up to 1 month. The Eaton-Littler classification was found to be a predictor of DASH and VAS scores at 3 and 6 months.

Conclusions

Intra-articular injection in the thumb CMC joint provides significantly greater pain relief and functional improvement compared to extra-articular injection at 3 months. Inadvertent extra-articular injection is common and appears to provide short-term pain relief and functional improvement. Some patients receiving intra-articular injections continue experiencing relief for up to 6 months.

Type of study/level of evidence

Therapeutic II.

The Effect of Acupuncture on Hand and Wrist Pain Intensity, Functional Status, and Quality of Life in Adults: A Systematic Review

Objective: This systematic review examined the effects of acupuncture on hand-and-wrist pain intensity, functional status, quality of life, and incidence of adverse effects in adults. Methods: Searches of 6 databases and previous reviews for randomized controlled trials (RCTs) were performed. Each outcome was analyzed for participant conditions, interventions, controls, and follow-up times determined a priori. Active controls were excluded. Follow-up periods were based on Cochrane 5.1.0 guidelines. The results were tabulated and described narratively. Results: In the 10 included RCTs (622 participants), 6 had a low risk of bias. For cryotherapy-induced pain, 1 trial showed significant pain reduction post treatment. For rheumatoid arthritis, 1 trial shown significant pain reduction and function improvements post treatment and short-term. For carpal tunnel syndrome, 1 trial showed significant pain reduction and functional improvements intermediate-term, while 3 trials suggested no significant difference. For tenosynovitis, 1 trial showed significant pain reduction and function improvements short-term. For poststroke impairments, 1 trial showed significant function improvements post treatment and at short-term, while another trial suggested no significant difference. No significant improvements were noted for trapezio-metacarpal joint osteoarthritis. In 2 trials, adverse effects occurred in patients with carpal tunnel syndrome; yet acupuncture appeared to be relatively safe. Conclusions: Acupuncture may be effective and safe for short-term pain reduction and functional improvement in hand-and-wrist conditions. Clinicians should interpret the results with caution due to small sample sizes and clinical heterogeneity. Future research is warranted.

Intra-articular methylprednisolone and bupivacaine for treatment of sesamoid disease in dogs

INTRODUCTION

The sesamoid disease is a cause of lameness in dogs, and there is limited literature relating to diagnosis, treatment and outcome of treatment in dogs with the sesamoid disease. Our aim was to compare the efficacy of intra-articular metacarpophalangeal/metatarsophalangeal joint injection with methylprednisolone and bupivacaine (IMPB) or conservative management with nonsteroidal anti-inflammatories and rest (CMNR) for treatment of this disease.

MATERIALS AND METHODS

We conducted a retrospective survey of dogs treated for the sesamoid disease with IMPB or CMNR. The medical records of all dogs that received IMPB or were recommended CMNR for treatment of sesamoid pain were reviewed, and a client questionnaire was delivered to owners. Response to treatment, rapidity of response, length of resolution and recurrence of clinical signs associated with the sesamoid disease were assessed.

RESULTS

A total of 78 dogs were included in the study. One week after IMPB, 52/58 (89.7%) dogs demonstrated resolution of lameness compared with 1 week of CMNR, 0/18 (P < 0.001). There was limited statistical evidence in client satisfaction between treatment groups, IMPB 36/53 (67.9%) and CMNR 16/17 (94%) (P = 0.052). Dogs presenting with the sesamoid disease had comorbidities in 51/78 (65.4%) of cases. Elbow disease was the most common comorbidity 29/78 (37.2%).

CONCLUSION

Our results support the use of IMPB for short-term (1 week) resolution of lameness associated with sesamoid disease in dogs. Dogs treated with CMNR had slower improvement; however, there was no difference in lameness or client satisfaction between treatment groups at long-term follow-up (12 months).

Intra-Arterial Infusion of Imipenem/Cilastatin Sodium through a Needle Inserted into the Radial Artery as a New Treatment for Refractory Trapeziometacarpal Osteoarthritis

PURPOSE

To evaluate the efficacy and safety of intra-arterial infusion of temporary embolic material with/without radiographic monitoring via a needle placed into the radial artery to occlude abnormal neovessels for trapeziometacarpal osteoarthritis.

MATERIALS AND METHODS

Thirty-one patients having Eaton stage II or III osteoarthritis, with a symptom duration longer than 6 months, resistant to conservative therapy for at least 3 months were prospectively enrolled. All procedures were performed by infusing imipenem/cilastatin sodium through a 24-gauge needle that was percutaneously inserted into the radial artery. Seven patients underwent the procedure with fluoroscopy, and 21 patients underwent the procedure without fluoroscopy. The mean Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score, numerical rating scale (NRS), and Patient Global Impression of Change (PGIC) scale were evaluated before and at 2, 6, and 24 months after the first procedure.

RESULTS

Technical success was 100%. The mean procedure time (from the beginning of local anesthesia to the removal of needle) was 2.9 minutes ± 1.6. The QuickDASH score improved from the baseline to 2, 6, and 24 months (49.2 ± 11.2 vs 22.1 ± 11.2, 20.9 ± 16.6, and 19.5 ± 16.1, respectively, all P <.001). The NRS improved from the baseline to 2, 6, and 24 months (7.2 ± 1.1 vs 3.1 ± 1.8, 2.8 ± 2, and 2.5 ± 2.1, respectively, all P <.001). Improvement on PGIC was observed in 84%, 81%, and 77% of patients at 2, 6, and 24 months, respectively. No major adverse events were encountered.

CONCLUSIONS

Intra-arterial infusion of temporary embolic material is a feasible treatment option for trapeziometacarpal osteoarthritis.

Low rate of subsequent surgery and serious complications following intra-articular steroid injection for base of thumb osteoarthritis: national cohort analysis

Objectives

Intra-articular steroid injection is commonly used to treat base of thumb osteoarthritis (BTOA), despite a lack of large-scale data on safety and effectiveness. We estimate the incidence of serious complications and further procedures following BTOA injection, including the risk of post-operative serious surgical site infection for subsequent operative intervention.

Methods

Hospital Episode Statistics data linked to mortality records from 1 April 1998 to 31 March 2017 were used to identify all BTOA injections undertaken in adults in the National Health Service secondary care in England. Patients were followed up longitudinally until death or 31 March 2017. A multivariable regression with a Fine and Gray model adjusting for the competing risk of mortality in addition to age, sex and socioeconomic deprivation was used to identify factors associated with progression to further procedure. Secondary outcomes included serious complications after injection and subsequent surgical site infection.

Results

A total of 19 120 primary injections were performed during the 19-year period in 18 356 patients. Of these 76.5% were female; mean age 62 years (s.d. 10.6); 50.48% underwent further procedure; 22.40% underwent surgery. Median time to further intervention was 412 days (IQR 110–1945). Female sex was associated with increased risk of proceeding to surgery. Serious complication rate following injection was 0.04% (0.01–0.08) within 90 days. Of those proceeding to surgery 0.16% (0.06–0.34) presented with a wound infection within 30 days and 90 days, compared with an overall post-operative wound infection rate of 0.03% (0.02–0.05).

Conclusions

Very low rates of serious complications were identified following BTOA injections performed in secondary care; only one in five patients proceeded to subsequent surgery.

Clinical trial registration

clinicaltrials.gov, https://www.clinicaltrials.gov, NCT03573765

Efficacy of hydroxychloroquine in hand osteoarthritis: A protocol for systematic review and meta-analysis of randomized clinical trial

BACKGROUND

Symptoms of hand osteoarthritis result in activity limitations and lower quality of life. Hydroxychloroquine, which has been used successfully in the treatment of many autoimmune diseases, can suppress inflammation and might also be beneficial in hand osteoarthritis.

METHODS

We plan to perform a systematic review and meta-analysis of randomized clinical trial to determine the symptom-modifying effect of hydroxychloroquine in hand osteoarthritis. We will search PubMed, EMBASE, Cochrane Library, and Web of Science using a comprehensive strategy. The related conference proceedings and reference lists of the included studies will also be checked to identify additional studies. Two reviewers will screen retrieved records, extract information and assess the risk of bias independently. Stata v15.1 software will be used to conduct data synthesis.

RESULTS

This study will be submitted to a peer-reviewed journal for publication.

CONCLUSION

We hope it will provide a relatively comprehensive reference for clinical practice and future relevant clinical trials.

INPLASY REGISTRATION NUMBER

INPLASY2020110005.

Thumb Carpometacarpal Arthritis: Prognostic Indicators and Timing of Further Intervention Following Corticosteroid Injection

PURPOSE

Corticosteroid injections are commonly used to treat thumb carpometacarpal arthritis in adults. We aimed to define the timing of surgery following an initial corticosteroid injection and identify patient-specific factors that influence the likelihood of repeat injection or surgery.

METHODS

We performed a retrospective analysis of all patients who underwent a first-time corticosteroid injection for carpometacarpal arthritis between 2009 and 2017. Demographic information, radiographic classification, additional nonsurgical therapies, complications, and outcomes were collected. Primary outcomes were repeat injection and surgical reconstruction. Kaplan-Meier survival analysis was used to characterize the timing of surgical intervention and Cox regression modeling was used to identify predictors of subsequent intervention.

RESULTS

Two-hundred thirty-nine patients (average age, 62.9 years) were identified, of which 141 (59.0%) had a repeat injection and 90 (37.6%) underwent surgery. There were no patient-specific characteristics associated with repeat injection. Eaton stage III/IV arthritis at initial presentation, current smoking status, and prior ipsilateral hand surgery were associated with an increased likelihood of surgery. By Kaplan-Meier analyses, 87.7% of patients who presented with Eaton III/IV arthritis did not have surgery within a year and 66.7% of these patients did not have surgery within 5 years.

CONCLUSIONS

In this retrospective observational cohort study with 10-year follow-up from a 4-surgeon practice, advanced radiographic arthritis, current smoking status, and a history of ipsilateral hand surgery were patient-specific factors that predicted progression to surgery following injection. Of patients who presented with advanced radiographic arthritis, one-third underwent surgery within 5 years of initial injection. Although injection efficacy and causality cannot be inferred based on an observational longitudinal analysis, these data identify patient-specific factors that may have an impact on surgical decision-making and a potential timeframe for future intervention.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Efficacy of conservative treatments for hand osteoarthritis : An umbrella review of interventional studies

BACKGROUND

Hand osteoarthritis (OA) is common, but the efficacy/safety of treatment interventions aimed to improve health outcomes in this population are not well understood. Therefore, the aim of this study was to map and grade the effect of interventions for health outcomes in hand OA.

METHODS

Umbrella review of systematic reviews with meta-analyses of randomized controlled trials (RCTs) using placebo/no intervention as control group. For outcomes with a p-value <0.05, the certainty of the evidence was evaluated using the grading of recommendations assessment, development and evaluation (GRADE) assessment.

RESULTS

From 189 abstracts, 9 meta-analyses (24 outcomes) were included, with 8 reporting significant summary results. The use of splints was associated with reduced pain at medium term in thumb carpometacarpal OA (standardized mean difference [SMD] = -0.70; 95% confidence intervals [95% CI]: -1.05 to -0.35; low certainty), reduced pain in long follow-up RCTs in symptomatic hand OA (SMD = -0.80; 95% CI: -1.16; -0.45; moderate certainty), and better function (SMD = 0.42; 95% CI: 0.08; 0.70; low certainty). The use of resistance training (SMD = -0.27; 95% CI: -0.47; -0.07) or physical exercise (SMD = -0.23; 95% CI: -0.42; -0.04) in improving hand pain and in improving finger joint stiffness (SMD = -0.36; 95%CI: -0.58; -0.15) was supported by a moderate certainty of evidence. The use of intra-articular hyaluronic acid in improving function (MD = 1.12; 95% CI: 0.61; 1.64; moderate certainty of evidence) was the only statistically significant pharmacological intervention.

CONCLUSION

Only some non-pharmacological interventions are effective in improving health outcomes in hand OA and this evidence is supported by a moderate/low certainty, indicating the necessity of further interventional research.

Trapeziometacarpal total joint replacement as an alternative to trapeziectomy depends on trapezium height: Retrospective study of 67 patients

Surgical indications for trapeziometacarpal (TMC) total joint replacement for thumb basal joint osteoarthritis (OA) are increasing. However, complications following this procedure are not insignificant. To avoid complications, preoperative planning with measurement of trapezium height is indicated to ensure a cup is not implanted in the trapezium if its height is less than 8 millimeters. The objective of our study was to analyze a series of preoperative radiographs of patients managed by trapeziectomy and suspensionplasty in our department, and to assess the possibility of a surgical alternative-total joint replacement-based on the trapezium's height. We also wanted to determine whether radiological height was influenced by the radiological progression of the thumb OA. A single-center retrospective study based on available medical records was conducted. The patients included had TMC OA refractory to conservative treatment and were managed surgically by trapeziectomy and suspensionplasty between 2012 and 2018. Sixty-seven patients were eligible. Based on the Eaton-Littler classification of radiological TMC OA, our case series had 0% (n=0) stage I, 36% (n=24) stage II, 42% (n=28) stage III and 22% (n=15) stage IV findings. We measured the radiological trapezium height on AP and lateral views as described by Kapandji. These were 10.6mm and 10.8mm for stage II, 9.6mm and 8.9mm for stage III, 8.6mm and 7.8mm for stage IV, respectively. Eighty-six percent of patients had a trapezium height suitable for total joint replacement. The radiological height decreased significantly with the OA stage. At stage IV, the average height fell below the 8-mm threshold, compromising the surgical indication for total arthroplasty.

Injection therapy for base of thumb osteoarthritis: a systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness of injection-based therapy in base of thumb osteoarthritis.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO were searched from inception to 22 May 2018.

STUDY SELECTION

Randomised controlled trials (RCTs) and non-RCTs of adults with base of thumb osteoarthritis investigating an injection-based intervention with any comparator/s.

DATA EXTRACTION AND ANALYSIS

Data were extracted and checked for accuracy and completeness by pairs of reviewers. Primary outcomes were pain and function. Comparative treatment effects were analysed by random-effects model for short-term and medium-term follow-up.

RESULTS

In total, 9 RCTs involving 504 patients were identified for inclusion. All compared different injection-based therapies with each other, no studies compared an injection-based therapy with a non-injection-based intervention. Twenty injection-based intervention groups were present within these nine trials, consisting of hyaluronic acid (n=9), corticosteroid (n=7), saline placebo (n=3) and dextrose (n=1). Limited meta-analysis was possible due to the heterogeneity in the injections and outcomes used, as well as incomplete outcome data. Meta-analysis of two RCTs (92 patients) demonstrated reduced Visual Analogue Scale pain on activity with corticosteroid versus hyaluronic acid (mean difference (MD) -1.32, 95% CI -2.23 to -0.41) in the medium term, but no differences in other measures of pain or function in the short term and medium term. Overall, the available evidence does not suggest that any of the commonly used injection therapies are superior to placebo, one another or a non-injection-based comparator.

CONCLUSION

Current evidence is equivocal regarding the use of injection therapy in base of thumb osteoarthritis, both in terms of which injection-based therapy is the most effective and in terms of whether any injection-based therapy is more effective than other non-injection-based interventions. Given limited understanding of both the short-term and long-term effects, there is a need for a large, methodologically robust RCT investigating the commonly used injection therapies and comparing them with other therapeutic options and placebo.

PROSPERO REGISTRATION NUMBER

CRD42018095384.

Thumb Basal Joint Arthritis

The thumb basal joint is the second most common site of osteoarthritis in the hand, and osteoarthritis of this joint can contribute to painful movement and debilitating function. To achieve a high degree of prehensile and manipulative function, this highly mobile joint is constrained by both the saddle morphology of the trapezium and a stout complement of ligamentous constraints. The disease proceeds progressively with several wear patterns. Substantial new biomechanical and longitudinal clinical studies have changed some of the prevailing opinions on the process of serial degenerative changes. Diagnosis is made with a thorough clinical examination and radiographic staging, as described by Eaton and Littler. Thumb basal joint arthritis can be initially managed with medications, orthoses, and steroid injections; however, it frequently progresses despite these interventions. Surgical management commonly consists of trapeziectomy with or without interposition or suspension, arthroplasty with implant, volar ligament reconstruction, osteotomy, or arthrodesis; none of these techniques has been proved to be superior to the others.

Safety and Predictive Factors of Short-Term Efficacy of a Single Injection of Mannitol-Modified Cross-Linked Hyaluronic Acid in Patients with Trapeziometacarpal Osteoarthritis. Results of a Multicentre Prospective Open-Label Pilot Study (INSTINCT Trial)

Purpose:

To assess safety and search predictive factors of efficacy of a single intra-articular injection of a mannitol-modified hyaluronic acid (HA) viscosupplement, in patients having trapeziometacarpal (TMC) osteoarthritis (OA).

Methods:

Patients with symptomatic TMC OA, not adequately relieved by analgesic therapy and/or by the use of a thumb splint, were included in a 3-month prospective multicentre open-label trial. All underwent plain radiographs with the Kapandji incidences allowing the Dell radiological grade assessment (1-4). Primary end point was the variation between injection (D0) and day 90 (D90) of the thumb pain (11-point Likert scale). Treatment consisted in a single injection of 0.6 to 1 mL of a viscosupplement made of a cross-linked HA combined with mannitol. All injections were performed under imaging guidance. Predictive factors of pain decrease were studied in univariate and multivariate analysis.

Results:

A total of 122 patients (76% women, mean age 60, mean disease duration 36 months) were included and 120 (98%) were assessed at 3 months. The TMC OA was of Dell’s grade 1, 2, 3, and 4 in 23%, 36.8%, 36.8%, and 3.5% of cases, respectively. At D0, the average (SD) pain level was 6.5 ± 1.6 without significant difference between Dell groups (P = .21). At day 90, pain decreased from 6.5 ± 1.6 to 3.9 ± 2.5 (difference −2.7 ± 2.5; −42%; P < .0001) without significant difference between Dell grade (P = .055), despite a seemingly smaller number of responders in stage 2 patients. The average analgesic consumption decreased in more than 1 out of 2 patients. In multivariate analysis, no predictor of response was identified. There was no safety issue. All adverse events (11%) were transient increase in pain during or following HA administration and resolved without sequel within 1 to 7 days.

Conclusions:

This study suggests that a single course of HANOX-M-XL injection is effective in relieving pain in patients with TMC OA, without safety concern. Patients with advanced stage of OA benefit the treatment as much as those with mild or moderate OA.

Can hybrid hyaluronic acid represent a valid approach to treat rizoarthrosis? A retrospective comparative study

BACKGROUND

Osteoarthritis (OA) of the trapeziometacarpal joint (TMJ) is a disabling condition with a significant impact on quality of life. The optimal management of hand OA requires a combination of non-pharmacological and pharmacological treatments that include intra-articular (i.a.) therapy. EULAR experts recommend corticosteroid injections in TMJ OA and underline the usefulness of hyaluronic acid (HA). The aim of this study was the assessment of the efficacy and tolerability of i.a. injections of a hybrid formulation of HA (Sinovial H-L®) in comparison to triamcinolone in patients with TMJ OA.

METHODS

This 6-months observational comparative study, retrospective analyzed the medical records of 100 patients with monolateral or bilateral TMJ OA, treated with two injections of Sinovial H-L® (Sinovial H-L Group) or of triamcinolone acetonide (Triamcinolone Group). Clinical assessments were recorded at the time of the first and second injection and after one, 3 and 6 months. The primary outcomes were the change in global pain on a Visual Analogue Scale (VAS) and in hand function evaluated by the Functional Index for Hand OA (FIHOA) from baseline to month 6. Secondary outcomes were the improvement of the duration of morning stiffness, Health Assessment Questionnaire (HAQ) and the Medical Outcomes Study 36-Item Short Form (SF-36). The comparison between the two groups of treatment were performed with the Wilcoxon rank-sum test for continuous variables and with chi-square or Fisher exact test for categorical variables. Statistical significance was set at p < 0.05.

RESULTS

Both therapies provided effective pain relief and joint function improvement, but the benefits achieved were statistically significantly superior in the Sinovial H-L Group than the Triamcinolone Group after one month (p < 0.01) from the beginning of the therapy and during the 6-months follow-up (p < 0.001). Furthermore, Sinovial H-L® was associated with a significant decrease in the duration of morning stiffness and with a significant improvement in the HAQ score and physical component summary (PCS)-SF-36.

CONCLUSIONS

Our results suggested that the hybrid formulation of HA may be more effective than triamcinolone in pain relief and joint function improvement with a rapid and persistent effect, resulting a valid alternative to steroid in the management of TMJ OA.

TRIAL REGISTRATION

ClinicalTrials.gov, date of registration: June 14, 2017, NCT03200886 . The present trial was retrospectively registered.

Development and Validation of a Disease-Specific Questionnaire for Basal Joint Arthritis

Background The Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire is the most commonly used instrument to assess outcomes of basal joint arthritis (BJA). However, the DASH is subject to influence by the entire upper extremity. Purpose This study aims to develop and validate a disease-specific questionnaire for BJA that would be more sensitive to changes in thumb function and pain, and correlate better with objective and subjective metrics. Patients and Methods The thumb disability examination (TDX) was developed and 80 patients presenting with BJA at one of the two hospital-based hand clinics were enrolled in the validation study. At enrollment, subjects were given the TDX, DASH, and visual analog pain scale with activity (A-VAS) surveys. The strength was assessed. Patients receiving corticosteroid injection were seen for follow-up at 6 weeks and those who underwent surgery were seen between 3 and 6 months postoperatively. Both the groups were given the TDX, DASH, and A-VAS scales at follow-up. Results In total, 65 subjects were included in the analysis. Average TDX completion time was 134.3 seconds. The TDX correlated more strongly with A-VAS scores at baseline than the DASH, but less strongly with tip-pinch measures. The TDX was more responsive to injection and surgical treatments for BJA than the DASH, yielding a larger effect size and standardized response mean, and was the only instrument to significantly correlate with changes in A-VAS. Conclusion The TDX is a reliable instrument for assessing BJA treatment outcomes. It bears less of a burden on patients, is more responsive to symptomatic changes, and correlates better with most objective and subjective measures than the DASH. Level of Evidence II, diagnostic.