The efficacy of hyaluronic acid in the treatment of osteoarthritis of the trapeziometacarpal joint

Risk of Infection in Thumb Carpometacarpal Surgery After Corticosteroid Injection

PURPOSE

The purpose of this study was to determine whether patients who had an intra-articular corticosteroid injection into the thumb carpometacarpal (CMC) joint for the treatment of arthritis within the 3 months before CMC joint arthroplasty or arthrodesis were at increased risk for wound complication/infection and/or repeat surgery for wound complication/infection in comparison with patients who did not receive an injection within 6 months or who received an injection between 3 and 6 months before surgery.

METHODS

We identified 5,046 patients in the Humana claims database who underwent surgery for CMC joint arthritis. The patients were stratified into 3 groups: (1) no thumb injection within 6 months of CMC joint surgery, (2) thumb injection between 3 and 6 months before CMC joint surgery, and (3) thumb injection within 3 months before CMC joint surgery. The primary outcome was wound complication/infection within 90 days after surgery. The secondary outcome was repeat surgery for wound complication/infection within 90 days after surgery. Multivariable logistic regression was performed to assess the associations between the timing of injection and wound complication/infection and repeat surgery for wound complication/infection.

RESULTS

The rates of wound complication/infection within 90 days after surgery were similar among the 3 study groups. However, patients who received an intra-articular corticosteroid injection within 3 months before surgery had a 2.2 times greater likelihood of repeat surgery for a wound complication/infection compared with patients who did not have an injection within 6 months before surgery.

CONCLUSIONS

Patients who receive an intra-articular corticosteroid injection within the 3 months before surgery for CMC joint arthritis may be at increased risk of repeat surgery to treat a wound complication/infection in the 90-day postoperative period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

T2 mapping of the trapeziometacarpal joint and triangular fibrocartilage complex: a feasibility and reproducibility study at 1.5 T

PURPOSE

To assess the feasibility and reproducibility of T2 relaxation time measurements of the trapeziometacarpal joint (TM) and triangular fibrocartilage complex (TFCC) on healthy subjects at 1.5 T MR.

MATERIALS AND METHODS

Thirty-four healthy volunteers underwent an axial oblique multislice multiecho spin-echo sequence of the wrist at 1.5 T, with 10 of them having performed another MR scan on a different 1.5 T scanner. Regions of interest were independently manually drawn by two musculoskeletal radiologists to include the cartilaginous part of the TM and TFCC. Intra-observer, inter-observer and inter-scanner reproducibility of T2 relaxation time measurements was tested using the Bland-Altman method.

RESULTS

The mean T2 values obtained by the two radiologists were 29.9 ± 6.5 ms and 30.0 ± 6.1 ms in the TM and 24.5 ± 2.3 ms and 24.6 ± 2.8 ms in the TFCC, respectively. The mean values of the second series of T2 measurements obtained by the senior radiologist were 29.9 ± 6.5 ms and 30.0 ± 6.3 ms in the TM and 24.3 ± 2.9 ms in the TFCC. Inter-observer reproducibility in the TM and in the TFCC was 76% and 82%, respectively. Intra-observer reproducibility in the TM and TFCC was 71% and 76%, respectively. Inter-scanner reproducibility of T2 measurements was 36% in the TM and 85% in the TFCC, respectively.

CONCLUSION

The assessment of T2 relaxation time measurements of the cartilage of the TM and the TFCC seems to be feasible and reproducible, although the inter-scanner reproducibility of T2 measurements of the TM is suboptimal. Further studies including patients are warranted to prove the utility of this tool.

Upper Limb Interventions

Ultrasound has been reported to be a quick, cheap, and effective imaging modality to guide the interventional procedures in the musculoskeletal system. The use of ultrasound results in increased accuracy of needle placement associated with a reduction of complications. In the upper limb, ultrasound-guided procedures are applied to joints and soft tissues around the shoulder, elbow, wrist, and hand. This article reviews the clinical and technical aspects of the most common procedures performed in this anatomic area.

Ultrasound-guided intra-articular injection of hyaluronic acid and ketorolac for osteoarthritis of the carpometacarpal joint of the thumb: A retrospective comparative study

Intra-articular hyaluronic acid (HA) is widely used to treat symptomatic osteoarthritis (OA) in the carpometacarpal joint (CMCJ) of the thumb. However, although apparently effective and relatively safe, intra-articular HA injections act relatively slowly. Therefore, a nonsteroidal anti-inflammatory drug could be added for more prompt pain relief. The aim of this study was to compare the efficacy and safety of ultrasound (US)-guided intra-articular injection of HA and ketorolac with that of HA alone in patients with OA of the CMCJ of the thumb.Seventy-four patients identified by chart review to have a diagnosis of OA of the CMCJ of the thumb received either a US-guided intra-articular injection of 0.5 mL of sodium hyaluronate and 0.5 mL of ketorolac (n = 38) or 0.5 mL of sodium hyaluronate and 0.5 mL of saline (n = 36). Disabilities of the arm, shoulder, and hand (DASH) and verbal numeric scale (VNS) pain scores were recorded before and 1, 3, and 6 months after injection. Univariable analyses (using the chi-squared test) and multiple logistic regression analysis were performed to evaluate the relationship between potential predictors of the outcome (treatment allocation, patient age and sex, duration of pain, and Eaton-Littler classification) and therapeutic effects.The DASH and VNS scores were improved at 1, 3, and 6 months postinjection in both groups. The onset of pain relief was significantly more rapid (at 1 month) after the injection containing HA and ketorolac than after the injection containing HA alone. In 55.3% of cases, pain and function were improved postinjection compared with baseline and remained so for up to 6 months. The success rate was not significantly different between the assessments at 1, 3, and 6 months, and the univariable analyses did not identify any statistically significant potential predictors of the outcome. Multiple logistic regression analysis did not identify any independent predictors of a successful outcome at midterm follow-up.The onset of analgesic action was more rapid after an injection containing HA and ketorolac than after 1 containing HA alone in patients with OA of the CMCJ of the thumb. There were no serious complications.

Corticosteroid or hyaluronic acid injections to the carpometacarpal joint of the thumb joint are associated with early complications after subsequent surgery

Truven MarketScan® Databases were used to identify patients with thumb carpometacarpal arthritis who underwent surgical treatment. Pre-operative corticosteroid or hyaluronic acid injections were identified, as were post-operative complications. Multivariable regressions assessed the relationship between injections and complications. Of 16,268 patients, 4462 had steroid injections and 252 received hyaluronic acid injections. Twenty-one per cent (3381 patients) had post-operative complications. Diabetes and smoking increased the odds of complications in all models. Odds of any complication, most notably infectious complications, were increased 20% by corticosteroids (OR 1.2; 95% CI: 1.1 to 1.3). More than three injections increased the odds of a complication by 70% (OR 1.7; 95% CI: 1.3 to 2.1). Hyaluronic acid increased the odds of wound-healing complications by 110% (OR 2.1; 95% CI: 1.3 to 3.4). Corticosteroid and hyaluronic acid injections for thumb carpometacarpal arthritis increase the odds of post-operative complications. Level of evidence: IV.

PANLAR Consensus Recommendations for the Management in Osteoarthritis of Hand, Hip, and Knee

OBJECTIVE

The objective of this consensus is to update the recommendations for the treatment of hand, hip, and knee osteoarthritis (OA) by agreeing on key propositions relating to the management of hand, hip, and knee OA, by identifying and critically appraising research evidence for the effectiveness of the treatments and by generating recommendations based on a combination of the available evidence and expert opinion of 18 countries of America.

METHODS

Recommendations were developed by a group of 48 specialists of rheumatologists, members of other medical disciplines (orthopedics and physiatrists), and three patients, one for each location of OA. A systematic review of existing articles, meta-analyses, and guidelines for the management of hand, hip, and knee OA published between 2008 and January 2014 was undertaken. The scores for Level of Evidence and Grade of Recommendation were proposed and fully consented within the committee based on The American Heart Association Evidence-Based Scoring System. The level of agreement was established through a variation of Delphi technique.

RESULTS

Both "strong" and "conditional" recommendations are given for management of hand, hip, and knee OA and nonpharmacological, pharmacological, and surgical modalities of treatment are presented according to the different levels of agreement.

CONCLUSIONS

These recommendations are based on the consensus of clinical experts from a wide range of disciplines taking available evidence into account while balancing the benefits and risks of nonpharmacological, pharmacological, and surgical treatment modalities, and incorporating their preferences and values. Different backgrounds in terms of patient education or drug availability in different countries were not evaluated but will be important.

Current review of trapeziometacarpal osteoarthritis (rhizarthrosis)

Trapeziometacarpal (TMC) joint is the secondly affected joint for osteoarthritis in the hand. TMC joint arthritis affects most commonly postmenopausal women after the fifth decade of life, due to hormonal and structural factors. Rhizarthrosis may lead to a clinical spectrum from subtle symptoms to advanced symptoms such as; severe pain, limitation of range of motion, muscular weakness, bony deformities, and end up ultimately with disability. Regardless of the etiopathogenesis; a variety of non-surgical and surgical methods have been used for the treatment of rhizarthrosis, depending on the age of the patient, symptomatology and the stage of the disease. The main goals of the treatments are as follows; relief of pain, conservation or restoration the stability and mobility of the TMC joint with the optimal preservation of the strength of surrounding musculature. In this article, the current methods, which have been used for the treatment of TMC joint osteoarthritis, will be mainly reviewed, together with concise up-to-date information on both its diagnosis and the anatomy of the TMC joint.

Power Doppler sonography and clinical monitoring for hyaluronic Acid treatment of rhizarthrosis: a pilot study

Trapeziometacarpal (TMC) joint osteoarthritis (OA) is a common disabling condition in which the impact of visco-supplementation has to be ascertained. We aim to evaluate the efficacy of high molecular weight hyaluronic acid (HA) ultrasound (US)-guided intra-articular injection of TMC joints in OA. 32 TMC joints of 16 patients with symptomatic thumb base OA were treated with three injections of high molecular weight HA at 1-week intervals. Before injection, at week 0, 1, 2, and 24 all patients underwent clinical and US examination. A significant clinical improvement was obtained by the decrease in visual analog scale for pain after 2 weeks of treatment (p = 0.0003) and this result is maintained at week 24 (p = 0.009). The Dreiser's index also decreased after week 2 and remain stable after 6 months. Power Doppler signal significantly decreased after 2 weeks of treatment (p = 0.02), even if this result was not maintained at week 24. No significant decrease in the synovial hypertrophy score was observed during the study. Our preliminary study suggests that US-guided TMC injections by high molecular weight HA may be effective in decreasing local inflammation and pain.

Viscosupplementation in the management of ankle osteoarthritis: a review

INTRODUCTION

Osteoarthritis (OA) is a disease of synovial joints and is the most common cause of chronic pain. Viscosupplementation (VS) with hyaluronic acid (HA) is largely used for knee osteoarthritis therapy but the evidence for its usefulness in ankle osteoarthritis is limited. The objective of this review is to assess the efficacy of viscosupplementation treatment of ankle osteoarthritis in the current literature.

METHODS

The following databases were searched: Medline (period 2006-2008), Database of Abstract on Reviews and Effectiveness and Cochrane Database of Systematic Reviews. Reference lists of relevant articles were controlled for additional references. The search terms Review, Viscosupplementation (VS), Osteoarthritis (OA), Hyaluronic acid (HA), Hyaluronan, Sodium hyaluronate, Ankle OA, Ankle joint were used to identify all studies relating to the use of VS therapy for the ankle OA. Methodological quality of included studies was assessed by assigning level of evidence as previously defined by the Centre for Evidence Based Medicine (CEBM).

RESULT

Seven articles concerning the efficacy of a total of 275 patients undergoing VS treatment for ankle OA were included. One European study, one Taiwanese study, one Italian study, one Turkish study and three American studies with level of evidence ranging from I to IV evaluated the following products: Hyalgan, Synvisc, Supartz, Adant.

CONCLUSION

Viscosupplementation is used widely in knee OA and is included in the professional guidelines for treatment of the disease in this joint. The potential for treating osteoarthritis of the ankle joint by viscosupplementation has been suggested in the literature, however, no dosing studies have been published to date, and dosing in the ankle joint remains an area for discussion. Viscosupplementation could potentially provide an useful alternative in treating such patients with painful ankle OA.