Wrist & Hand

Base of thumb arthritis – steroids not a waste of time

Should we inject arthritic joints with steroid? It seems that almost all joints that can, are injected. The injection itself cannot, however, change the pathology and rescue the joint. On the other hand, steroids can, and do, reduce the inflammation associated with flare-ups of the disease. Anecdotally, patients often find the injection helps, at least for a while, and they often come back for another. In a disease process like trapeziometacarpal arthritis where the disease is known to burn out, perhaps the key question is whether for some patients the injection will remove the need for surgery by controlling the symptoms in the meantime. A team from Derby (UK) have undertaken a thorough systematic review with the aim of answering just this question.¹ Following a comprehensive search, 118 publications were initially identified, of which just nine papers fulfilled the authors’ inclusion criteria. These were all prospective studies, with four RCTs and five prospective case series; the quality of the evidence on which this review is based is surprisingly good. Despite a range of disparities in study design, outcome reporting and methods, the majority of studies found a transient benefit for intra-articular steroid injection into the TMJ. Having reviewed all the indexed studies on injecting this joint, the authors found that it does help for at least one to three months.

De Quervain’s tenosynovitis and steroids

While on the topic of steroid injections, we here at 360 are never ones to shy away from controversy. Local steroid injection in de Quervain’s tenosynovitis is a well-used and accepted technique, but is it any good? With this very painful condition, patients will often find therapy alternatives such as ultrasound and massage to be just too painful, so the question is, do local steroid injections offer a conservative option for those not wishing to undergo (or who are not suitable for) release?² A prospective study reported by researchers in Boston (USA) was designed to establish the efficacy of local anaesthetic and triamcinolone injections in de Quervain’s. Their study reports the outcomes of a consecutive series of 50 patients, all treated with steroid injections for isolated primary de Quervain’s. Outcomes were assessed at regular intervals up to a year following injection, and the authors reported their results using Kaplan-Meier survival analysis. These authors report that in 82% of patients, symptoms had resolved by six weeks, but that the symptoms recurred in 48%. Interestingly, if symptoms had not recurred within six months then these authors report that they are unlikely to recur at all. The evidence presented does suggest that de Quervain's may be treated effectively in the majority of cases with steroid injection.

Use your therapy time wisely!

Hand surgeons regard their hand therapist as one of the cornerstones of successful practice, but while the value of hand therapy in general is without doubt, precious little data exist on who precisely will benefit. Surely it is better to use their time for those who really need it when problems such as unexpected stiffness are likely to emerge? A group from Clarks Summit in Pennsylvania (USA) set out to evaluate the benefit of hand therapy interventions in patients post-distal radial fracture fixation. The study team randomly allocated 50 consecutive patients with a surgically treated distal radial fracture to either a hand therapy programme administered by a therapist twice a week, or to perform the same programme of exercises at home without supervision. Outcomes were assessed primarily using the Patient Reported Wrist and Hand Evaluation (PRWHE). Outcomes including PRWHE, composite motion arcs and grip strengths were measured at three and six months.³ In short, the study team were unable to find any difference in outcome, however, it is important to remember that those with problems could revert to hand therapist supervision.

Excision osteotomy for the carpometacarpal joint?

Trapeziectomy is the earliest described, and probably the most widely used, operation for thumb base arthritis. While the outcome is usually acceptable and durable, concern about the effect of losing thumb ray length and stability, with consequent loss of pinch, has prompted the use of several implants, suspensions and other modifications. Not all have fared well, and for most clinicians, the trapeziectomy remains the technique of choice.⁴ A group from Pittsburgh (USA) remind us in their retrospective series that a simple extension osteotomy should be seriously considered in suitable patients as an alternative. Their study of just 13 patients, all of whom underwent metacarpal excision osteotomy for early carpometacarpal joint (CMCJ) OA, reports results at an impressive ten years of mean follow-up. The authors were able to report equal grip strength compared with the contralateral side, low pain scores and equal mobility to the non-operative side. All in all, good results are reported here, admittedly in a small group of patients, but with long-term follow-up. It is good to remember that other techniques can preserve thumb length and stability without the uncertainty of replacement or excision.

CORDLESS at five years?

x-ref Research

There is a mantra that the best surgeons try to avoid surgery. Collagenase has emerged over the past five years as an effective way of reducing cords of Dupuytren’s disease, with early outcomes reported as similar to surgery and needle fasciotomy. The concern lurking at the back of clinicians’ minds has always been recurrence. The drug dissolves a segment of disease but does not usually remove the whole cord, nor the cells that produce the contracting matrix. CORDLESS is a longitudinal study originating in Michigan (USA), examining the natural history of Dupuytren’s disease treated with collagenase. With the five-year outcomes report, some answers are at last available. The study reports the outcomes of 644 patients (from a possible 950 patients) enrolled in the original efficacy trials, which led to licensing of collagenase as an intervention for Dupuytren’s. The present report concerns an interval review after at least five years of follow-up. Patients were all reviewed annually as part of the safety and efficacy monitoring.⁵ As perhaps could be expected, 39% of metacarpophalangeal cords and 66% of p roximal interphalangeal cords recurred within the five-year follow-up of the study. While this study reports a rather high recurrence rate, here at 360 we would venture that this may be expected in the context of the ease of both the original procedure and any subsequent interventions.

Arthroscopy again of no benefit?

x-ref Trauma

It seems that, whatever the discipline - knee, shoulder, wrist or hip - there has been a spate of papers recently undermining the clinical benefit of a huge range of treatments, many of them (as in the case of subacromial decompression) from large-scale randomised controlled trials and concerning widely accepted treatments. Researchers from Matsumoto (Japan) present another poke in the eye for arthroscopists, and wrist arthroscopists in particular. In what may prove to be an important paper both for fracture surgeons and hand surgeons alike, their randomised controlled trial addresses the question of arthroscopic assistance in fixation of unstable wrist fractures.⁶ The study reports the outcomes of 74 wrists, all with AO Type C unstable fractures. Arguing that the benefits or otherwise of arthroscopic assisted fixation are yet to be proven, the authors of this trial randomised participants to receive arthroscopic and fluoroscopic assessment and reduction, or fluoroscopic alone in conjunction with volar plate fixation. Outcomes were assessed with a combination of DASH scores, grip strength (assessed at 48 weeks) and radiologic parameters (assessed using CT at 12 weeks). In short, like so many studies, there were no differences in any outcome measures reported or recorded. Fluoroscopy represents the widely accepted current standard across the world, and it is always troubling when a group proposes a more complex technique, potentially changing practice without evidence. It is heartening to see these authors trial such a complex technique, allaying any doubt or medicolegal concerns over those choosing to use the tried and tested fluoroscopic approach.

Distal radius stirring up trouble again!

x-ref Trauma

As we all (surgeons, politicians and patients alike) ‘go for gold’ in the constant battle for a perfectly reproducible perfect outcome, increasingly interventional treatments have been chosen over conservative options. In many injuries the discernible benefit is a quicker return to function, but with increasing operative and metalwork-related complications as a drawback.⁷ Clinical trialists from Oslo (Norway) have been following up their randomised controlled trial of ‘external fixation’ which, in their hands, included K-wires versus volar plating for over five years, and have now reported the mid-term results. Their study included the outcomes of over 100 patients randomised to each treatment, with 91 patients available for five-year review. At the five-year point there were no differences in QuickDASH outcomes, although subjective measures (including a range of motion and radiological parameters) favour the volar locking plate. For the moment, at least, it seems all treatments are equal in the eyes of the DASH score!

Scaphoid arthroscopy under the spotlight

In a bumper month for the arthroscopic-assisted hand and wrist trauma RCTs, here at 360 our beady eyes were caught by another such RCT with long-term follow-up. Industrious surgeons in Lund (Sweden) report their own randomised study designed to evaluate the efficacy of conservative treatment versus arthroscopic-assisted scaphoid fixation. The study cohort consisted of 35 patients, all presenting with minimally displaced or undisplaced fractures of the scaphoid. Curiously for a randomised trial, there was a complete failure of randomisation with 21 conservatively treated patients and 14 treated with arthroscopic screw fixation.⁸ Outcomes were assessed at a minimum of four years follow-up, including radiographic and range of motion measurements. The fixation group had a slightly better outcome at 14 weeks, but by 26 weeks the conservative group had overtaken the fixation group. By one year post-injury, there were no differences in range of motion or nonunion rate but there was a slight increase in radiographic arthrosis in the surgical group. So for this initial faster recovery, there is a payback of marginally higher arthroses rates. The cynically minded reader may wonder, with just 14 patients in one group and a clear failure of randomisation, if indeed anything can be drawn from this study at all?