Trapeziometacarpal Osteoarthritis


154 Trapeziometacarpal Osteoarthritis


Jeremiah D. Johnson MD1, Jennifer M. Brewer BA1, and Jennifer Moriatis Wolf MD2


1 Department of Orthopaedic Surgery, University of Connecticut, Farmington, CT, USA


2 Department of Orthopaedic Surgery, University of Chicago, Chicago, IL, USA


Clinical scenario



  • A 61‐year‐old, right‐hand‐dominant female presents with three years of progressive right base of thumb pain unrelated to any injury. She reports her pain is provoked by activities such as opening jars.
  • On exam, she is tender over the trapeziometacarpal (TM) joint and pain is elicited with axial loading and extension of the joint.
  • Her radiographs show narrowing of the TM joint with cystic changes and subchondral sclerosis, and small loose bodies.

Top three questions



  1. In a patient who presents with symptomatic TM arthritis, what nonoperative intervention is most effective in relieving symptoms compared to placebo?
  2. In a patient with TM osteoarthritis, which arthroplasty procedures have been shown to result in improved patient outcomes with the fewest complications?
  3. In a patient who presents with symptomatic TM osteoarthritis, does implant arthroplasty or arthrodesis offer any advantages over trapeziectomy with or without ligament reconstruction and tendon interposition (LRTI)?

Question 1: In a patient who presents with symptomatic TM arthritis, what nonoperative intervention is most effective in relieving symptoms compared to placebo?


Rationale


There are many nonoperative treatments for TM arthritis. Treating physicians optimally want an effective intervention to relieve symptoms and maximize function for one of the most common joints affected by osteoarthritis.


Clinical comment


Conservative treatment of TM arthritis includes: therapy, orthoses (splinting), and corticosteroid injections. Hyaluronate injections have been described but are less commonly used. These treatments can be used in combination. It is essential to determine which conservative interventions provide patients with the best outcomes in order to guide treatment and manage symptoms long term.


Available literature and quality of the evidence



  • Level I: 9 studies.
  • Level II: 1 meta‐analysis and 2 systematic reviews.

Findings


Corticosteroid and hyaluronate injections


A randomized controlled trial (RCT) comparing functional outcomes after intra‐articular hyaluronic acid (HA) injections of the TM joint in 29 patients to saline placebo in 29 patients. The authors reported HA reduced pain Visual Analog Scale (VAS) scores and improved function (Dreiser’s Functional Index) from baseline values, but did not reach a significant difference compared with controls at six months.1 A meta‐analysis compared HA injections in 169 patients and an unspecified placebo in 74 patients. The authors reported HA marginally improved functional capacity (standardized response means [SRM] −1.14; 95% confidence interval [CI]: −1.59 to −0.60) at 12 weeks, but provided no difference in unspecified pain scores.2 The meta‐analysis also compared corticosteroids injections in 147 patients and unspecified placebo injections in 74 patients. The authors reported no difference in pain scores at 24 weeks (SRM −1.20; 95% CI: −3.69 to 1.29). A RCT of 40 patients comparing hyaluronate and corticosteroids injections found corticosteroids was superior in reducing pain (4.9 mm ± 2.0 vs 5.7 mm ± 2.2) and improving hand function (Duruoz Hand Index [DHI]: 12.0 pts ± 8.7 vs 22.1 pts ± 12.5) for up to six months, but other studies have failed to replicate corticosteroid’s superiority.3 Two RCTs found no difference in pain and functional outcome scores up to six months after treatment between hyaluronate or steroid injections.4,5 In a cohort of 80 patients, Heyworth et al. compared the two types of injections with saline placebo and reported no difference in VAS or Disabilities of the Arm, Shoulder, and Hand (DASH) scores between the three groups.4 Stahl et al. found no difference in 50 patients treated with hyaluronate or corticosteroids but reported a significant reduction between baseline and six‐month pain VAS for both groups at rest (−2.2 mm ± 2.0, −2.2 mm ± 2.1) and after activity (−2.7 mm ± 2.2, 2.2 mm ± 1.9).5 Two review articles concluded there was no difference in various pain or functional outcomes scores between hyaluronic and steroid injections.6,7 A meta‐analysis comparing HA and corticosteroids reported corticosteroid was superior in reducing pain measurements compared to HA (SRM 1.44; 95% CI: 0.14–2.74) but was heavily influenced by one RCT.2


Orthoses


An RCT compared custom neoprene orthoses (n = 57) with standard care at the discretion of their physician (n = 55), and reported a reduction in pain VAS with orthoses for up to 12 months (−22.2 mm ± 3.2 vs −7.9 mm ± 3.5).8 Several RCTs compared types of orthoses in patients with TM OA.8–12 Two studies compared prefabricated orthoses to custom orthoses. Weiss et al. found patients with prefabricated splints had better VAS pain (2.29, standard error of the mean [SEM]: 0.44 vs 3.59, SEM: 0.33) and satisfaction scores (7.5, SEM: 0.45 vs 4.9, SEM: 0.43) in a randomized, cross‐over study of 25 patients.10 Another randomized, crossover study of 63 patients demonstrated no difference in pain, but the Push Ortho Thumb Brace had higher satisfaction on the D‐QUEST questionnaire (30.6, standard deviation [SD]: 3.9) versus a custom brace likely due to less interference with key grip (26.9, SD 4.9).9 Spaans et al. reviewed 10 RCTs utilizing various orthoses and reported evidence for improved pain control but no improvement regarding function or strength.7


Hand therapy


Spaans et al. reviewed six RCTs comparing various hand therapy techniques with nontherapeutic ultrasound as a control and reported all four techniques provided some reduction in pain without any notable improvement in function.7 Unfortunately, all six studies had limited follow‐up, ranging from two weeks to three months. One RCT (n = 40) comparing splinting to exercise therapy reported no significant differences between groups in VAS pain or Sollerman Test of Hand Function scores at six weeks.13


Resolution of clinical scenario



  • Multiple RCTs have reported that corticosteroids and HA injections reduce patient’s TM pain compared with baseline values; however, neither steroid nor hyaluronate showed superiority in pain relief or functional outcomes when compared with placebo for either intervention.
  • There is growing evidence supporting bracing with custom or prefabricated splints as a method of providing long‐term pain relief.
  • There is no strong evidence supporting any specific orthosis as superior in terms of pain relief. However, some studies have suggested higher patient satisfaction with smaller, less bulky splints.
  • There is no strong evidence that hand therapy provides long‐term pain relief for symptomatic TM arthritis and only low‐quality evidence therapy provides short‐term pain relief.

Question 2: In a patient with TM osteoarthritis, which arthroplasty procedures have been shown to result in improved patient outcomes with the fewest complications?


Rationale


Multiple arthroplasty techniques are currently employed to treat TM osteoarthritis, and understanding the possible risks and benefits of different procedures will help guide surgical decisions.

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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Trapeziometacarpal Osteoarthritis

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