Journal Club Article July 2018

July, 2018: Carpometacarpal joint arthritis: does non-operative intervention prevent surgery?

Tsehaie J et al: Outcome of a Hand Orthosis and Hand Therapy for Carpometacarpal Osteoarthritis in Daily Practice: A Prospective Cohort Study.  J Hand Surg Am.2018 May 15. [Epub ahead of print]  abstract

Rocchi L et al: Trapeziometacarpal joint arthritis: a prospective trial on two widespread conservative therapies. Muscles, Ligaments and Tendons Journal, 2017; 7:603-610  free full text

Two recent articles address the issue of non-operative management of osteoarthritis at the trapeziometacarpal joint. Reviewing the articles together adds perspective.

The first article by Tsehaie et al comes from the Netherlands. The investigators prospectively followed 809 patients for at least a year and measured visual analog pain scale scores and the Michigan Hand Questionnaire at 2, 4, 6, and 12 months. On entry into the study, each subject received a custom or prefabricated orthosis and was advised to wear it full time for 6 weeks. Some patients also received hand therapy twice weekly depending on patients’ insurance and work schedules. Therapy, when administered, consisted of position training and strengthening and was personalized by therapist and patient. Both the orthosis and the training were phased out between weeks 7 and 12.

After a mean follow-up of 2.2 +/- .9 years, 15% of all patients had received surgery. Those patients undergoing surgery had higher pain scale scores to begin with and the scores did not change significantly over 3 months. Surgery was performed at an average of 5 months after enrollment in the trial. For the 85% of patients not requiring surgery, their pain diminished significantly during the first 6 weeks and then remained stable over a year.

The second article by Rocchi et al comes from Italy. These researchers identified patients with stage 1 or 2 (early) osteoarthritis and invited them to participate in the study and to choose if they preferred one cortisone injection or 10 sessions of hand therapy. Both groups of 25 subjects received an orthosis. Both groups were assessed for pain, function and strength at 2, 6, and 12 months.

The measured parameters improved more quickly in the group receiving the injection, whereas the subjects receiving hand therapy showed a longer remission of pain. Functional evaluation scores at one year were were similar to the pre-treatment scores.

COMMENT: Both articles offer food for thought. The first study was poorly controlled by type of orthosis used and the type and extent of hand therapy applied. The authors note that in the future it would be helpful to study the effect of orthosis alone, therapy alone, or combined therapy and orthosis. The bottom line of the study is that 85% of patients were successfully treated without surgery.

In my experience, I think the success for non-operative treatment is closer to 95%, and that the benefit results from wearing a custom-orthosis for 6-8 weeks and just at night. I do not put much stock in the prefabricated orthoses. An article from 2009 indicates that night-splinting alone is not effective at one month but is effective at one year. I wish they had studied their patients at 3 and 6 months. Based on the experience of my own aching thumb, I know that it took me more than a year to break my lifelong pinch-posture habits, and once I did, my thumb osteoarthritic symptoms stabilized to an entirely tolerable level.

Can we identify the 15% who are going to need surgery? Are they more pain sensitive? Less patient? More aggressive pinchers? Unwilling to slow down? Intolerant of the concept of middle age and its attendant aches? Anatomically or physiologically different? Perhaps with more guidance and counseling, the size of this group could be diminished. Thoughts?

The second study parallels my experience and supports my reasoning for not giving patients a cortisone injection early on. It does make them feel good–so good that they go right on subconsciously with their abusive pinch habits. Also, it is my experience that the first injection works for many months, the second one for many weeks, and after that, not much at all. So I would rather start off by having them use a night brace, to become aware of how they use and abuse their thumb, and to modify their habits to avoid pinch postures that hurt. For most of my patients, that is all they need. For those who fail the orthosis, the injection may last longer or even be life-durable since they have also retrained themselves to some extent on pinch habits.

Let me know your thoughts. I am happy to share them with the readership.