Elsevier

Joint Bone Spine

Volume 74, Issue 4, July 2007, Pages 368-372
Joint Bone Spine

Original article
Injection of intra-articular sodium hyaluronidate (Sinovial®) into the carpometacarpal joint of the thumb (CMC1) in osteoarthritis. A prospective evaluation of efficacy

https://doi.org/10.1016/j.jbspin.2006.08.008Get rights and content

Abstract

Objective

To compare the efficacy on pain relief and function of one, two or three injections of intra-articular hyaluronic acid in symptomatic osteoarthritis (OA) of the carpometacarpal joint of the thumb (CMCJ).

Methods

Among subjects with symptomatic OA of the CMCJ of the thumb referred to the Rheumatology Department of Nice, patients free of any joint injection in last 6 months with pain visual analogue score (VAS) >40 and with Kellgren and Lawrence score between 2 and 4 were included. Each subject was randomly allocated to receive, at weekly intervals, 1 (group 1) or 2 (group 2) or 3 injections (group 3) of 1 ml Sodium Hyaluronidate (Sinovial®). Injections were given under imaging control. Sociodemographic characteristics, VAS and functionality (Dreiser Functional Index) were assessed at baseline, at one month and at three months. An intention to treat analysis was performed.

Results

Forty two subjects were enrolled in the study. Their mean age was 64.8 (8.0) years, and 90.5% were women. Baseline pain VAS, and mean Dreiser functional index were respectively 57.7 (17.1) and 12.5 (5.8). A repeated measure analysis of variance (ANOVA) model was used to compare the time-course profile of the three treatment groups for VAS and Dreiser index. Due to statistically significant groups-time interaction the analyses were conducted at each evaluation time. No difference was found for VAS at 1 month (p = 0.075) and 3 months (p = 0.382). Intra group differences between baseline and three months was significant in groups 2 and 3 (p = 0.012 and p = 0.002).

Conclusion

No significant differences were found between each group over the study period for pain relief and function. But the intra groups analysis results show that intra-articular sodium hyaluronidate injections into the carpometacarpal joint of the thumb in osteoarthritis can be efficacious on pain and fuctionality. What is now needed is a controlled placebo randomised study with larger samples and longer term follow up of the achieved effects.

Introduction

Peripheral osteoarthritis (OA) often affects the hand, leading to an underestimated degree of disability, and potentially considerable negative effects on quality of life [1]. Estimates of the prevalence of OA of the hand vary widely. A recent survey based on radiographic data showing at least one affected joint put the figure at 67% of women and 54.8% of men [2].

The most commonly affected sites are: the distal interphalangeal joints (DIP), 47.3%; thumb base, 35.8%; proximal interphalangeal joints (PIP), 18.2%; and metacarpophalangeal joints (MCP), 8.2% [2].

In the absence of guidelines for the treatment of OA of the hand, most patients are managed using analgesics, slow-acting osteoarthritis drugs aimed at the relief of symptoms (SySADOA), slow disease-modifying osteoarthritis drugs (SMOAD), splints, and intra-articular steroid injections.

Intra-articular steroids are reported to be efficacious in knee OA [3], but a recent double-blind randomised controlled trial [4] failed to detect a clinical benefit in moderate to severe OA of the CMC1 compared with placebo injections and long terms benefits are not observed [5]. CMC1 intraarticular hyaluronic acid injections literature is scarce, two recent studies seem to show efficacy on pain and function [6], [7].

Viscosupplementation with hyaluronic acid injections seems to relieve pain and improve function in the management of OA in various joints, principally the knee [8]. The goal of the present prospective study was to investigate a difference of efficacy in pain relief of one, two or three injections of hyaluronic acid in OA of the CMC1. We studied the effect of injections all the study long and looked for a difference in efficacy at three months on pain and functionality.

Section snippets

Patients

Outpatients attending the Rheumatology Department of the University Hospital of Nice with symptomatic OA of the CMC1 joint (visual analogue scale [VAS] <40) and refractory to other therapeutic interventions were enrolled. Exclusion criteria included symptomatic OA in any other digit, use of steroid injection in the previous 6 months and previous use of sodium hyaluronidate injection. Subjects with blood coagulation abnormalities, infection, and hand trauma were also excluded. All subjects had

Results

Forty-two subjects were enrolled in the study between October 2003 and June 2005. Five patients were lost to follow up between one and three month (two each in groups 1 and 3, one in group 2). All five exhibited X-ray grade 3. The reasons for drop out were lack of efficacy (n = 3) and non-attendance to scheduled visits (n = 2). These patients did not differ significantly from the study population at baseline.

The mean age was 64.8 years (8.0), and 90.5% were women. With regard to professional status,

Discussion

The injections were performed easily and were well tolerated. No significant differences were found between each group all the study long for pain relief and function. Intra groups analyses showed significant improvements in both pain (VAS) and function (Dreiser test) in groups 2 and 3 but did not reach significance in group 1. Efficacy was reported as early as the first month and persisted at 3 months.

The literature regarding the use of hyaluronic acid injections in OA of the hand is scanty

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