Rationale

Initial nonsurgical treatment of patients with thumb CMC OA typically involves joint injections and splinting. Intra‐articular injections are a common presurgical intervention aimed mainly at pain relief. It is unclear which conservative measures, if any, are most effective.

Clinical comment

Intra‐articular corticosteroid injections are thought to decrease pain and inflammation associated with osteoarthritis. Alternatively, intra‐articular hyaluronic acid injections aim to supplement and increase the viscoelasticity of synovial fluid.

Available literature and quality of the evidence

The best evidence to answer this question comes from a recent systematic review that included meta‐analyses of six randomized controlled trials (RCTs).¹–⁷ The majority of the studies were not of high methodological quality and many sources of heterogeneity were present. This is level II evidence.

Findings

Pooled meta‐analysis was performed on three sets of data: corticosteroid injection versus placebo, hyaluronic acid injection versus placebo, and corticosteroid versus hyaluronic acid. Analysis of corticosteroid injection versus placebo showed that individual study findings were mixed. Pooled analysis, with 82 patients in each arm, showed no difference between corticosteroid injection and placebo at 24 weeks post injection (Standardized response means [SRM]: −1.20; 95% confidence interval [CI]: −3.69 to 1.29). Earlier time points were unable to be pooled for analysis. Pooled analysis of hyaluronic acid versus placebo, with 74 patients in each arm, showed improvement in functional capacity in the hyaluronic acid group (SRM: −1.14 [−1.69 to −0.60]) at 12 weeks, but no difference in pain (SRM: −0.95 [−3.87 to 1.97]). Results at 24 weeks were unable to be pooled. Pooled analysis between corticosteroid and hyaluronic acid did not yield significant results at four and 12 weeks; however, differences were apparent at 24 weeks. Hyaluronic acid appeared superior on pulp pinch force (SRM: −1.66 [−0.75 to −2.57]), and corticosteroid superior for pain (SRM 1.44 [0.17–2.74]); however, the authors commented that the results at 24 weeks were almost entirely driven by one strongly positive study, while the other studies showed no effect.

Resolution of clinical scenario

• In patients with thumb CMC OA, there is weak evidence to support the use of corticosteroid and hyaluronic acid injections for relief of pain and improvement in function.
  
• Studies comparing the two forms of injection suggest that corticosteroid may be better for pain relief, whereas hyaluronic acid may be more useful for increasing functional capacity.

Rationale

Use of an orthosis is a common nonoperative treatment prescribed by family physicians, sports medicine physicians, and hand and wrist surgeons. Orthoses vary in their size, rigidity, and method of manufacture. Despite widespread use, optimal type and duration of use of splinting is unclear.

Clinical comment

Orthoses are prescribed to immobilize the first CMC joint in order to decrease pain and perhaps improve function.

Available literature and quality of the evidence

The current best evidence comes from a systematic review of 10 RCTs studying the effects of orthoses in patients with symptomatic thumb CMC OA.⁸ This is level I evidence.

Findings

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