Purpose:
To assess safety and search predictive factors of efficacy of a single intra-articular injection of a mannitol-modified hyaluronic acid (HA) viscosupplement, in patients having ...trapeziometacarpal (TMC) osteoarthritis (OA).
Methods:
Patients with symptomatic TMC OA, not adequately relieved by analgesic therapy and/or by the use of a thumb splint, were included in a 3-month prospective multicentre open-label trial. All underwent plain radiographs with the Kapandji incidences allowing the Dell radiological grade assessment (1-4). Primary end point was the variation between injection (D0) and day 90 (D90) of the thumb pain (11-point Likert scale). Treatment consisted in a single injection of 0.6 to 1 mL of a viscosupplement made of a cross-linked HA combined with mannitol. All injections were performed under imaging guidance. Predictive factors of pain decrease were studied in univariate and multivariate analysis.
Results:
A total of 122 patients (76% women, mean age 60, mean disease duration 36 months) were included and 120 (98%) were assessed at 3 months. The TMC OA was of Dell’s grade 1, 2, 3, and 4 in 23%, 36.8%, 36.8%, and 3.5% of cases, respectively. At D0, the average (SD) pain level was 6.5 ± 1.6 without significant difference between Dell groups (P = .21). At day 90, pain decreased from 6.5 ± 1.6 to 3.9 ± 2.5 (difference −2.7 ± 2.5; −42%; P < .0001) without significant difference between Dell grade (P = .055), despite a seemingly smaller number of responders in stage 2 patients. The average analgesic consumption decreased in more than 1 out of 2 patients. In multivariate analysis, no predictor of response was identified. There was no safety issue. All adverse events (11%) were transient increase in pain during or following HA administration and resolved without sequel within 1 to 7 days.
Conclusions:
This study suggests that a single course of HANOX-M-XL injection is effective in relieving pain in patients with TMC OA, without safety concern. Patients with advanced stage of OA benefit the treatment as much as those with mild or moderate OA.
Parce que l’administration intra-articulaire d’un médicament offre de nombreux avantages par rapport à la voie systémique, les infiltrations de corticoïdes ou d’acide hyaluronique occupent une place ...centrale dans la prise en charge de l’arthrose en pratique courante comme dans les récentes recommandations de la Société Française de Rhumatologie pour la prise en charge de la gonarthrose. Néanmoins, les recommandations internationales ne sont pas unanimes quant à leur utilisation au genou, à la hanche ou à la main. Cette discordance est liée aux résultats de méta-analyses d’essais randomisés contrôlés, montrant une taille d’effet souvent modeste et à la limite de la pertinence clinique. En effet, les essais cliniques ne tiennent pas compte de l’effet contextuel lié au geste de ponction-infiltration. Or, cet effet explique en partie l’effet placebo plus important pour un traitement administré par voie intra-articulaire que par voie orale ou topique, et la plus grande difficulté à démontrer un effet cliniquement pertinent d’un traitement actif intra-articulaire. Les infiltrations ont par ailleurs un profil de tolérance avantageux par rapport aux autres traitements disponibles pour soulager la douleur liée à l’arthrose. Une incertitude réside dans la tolérance à long terme des infiltrations de corticoïdes, suspectes de précipiter l’évolution structurale. Enfin, la place des infiltrations de plasma riche en plaquettes est encore incertaine, leur efficacité n’étant pas formellement démontrée. La littérature à ce sujet est particulièrement hétérogène et des essais randomisés contrôlés de bonne qualité méthodologique sont nécessaires pour mieux préciser leur efficacité et leur tolérance à court et à long terme.
Because the intra-articular administration of a drug offers many advantages over the systemic route, corticosteroids or hyaluronic acid intra-articular injections are routinely used in the management of osteoarthritis, and recommended in the recent guidelines of the French Society of Rheumatology for the management of knee osteoarthritis. Nevertheless, international guidelines are not unanimous as to their use in the knee, hip or hand osteoarthritis. This discrepancy is explained by the results of meta-analyses of randomized controlled trials, showing a modest effect size and a disputable clinical relevance. Indeed, clinical trials do not take into account the contextual effect associated with the intra-articular procedure. This effect contributes to the greater placebo effect observed with intra-articular therapies than with oral or transdermal treatments, and the difficulty in demonstrating a clinically relevant effect of intra-articular drugs. Intra-articular injections have an advantageous safety profile compared to other therapies available for the management of osteoarthritis pain. The long-term tolerance of intra-articular corticosteroids remains uncertain, as they have been associated with accelerated structural progression, especially if they are repeated multiple times. Finally, the efficacy of platelet-rich plasma is debated. The literature on this topic is particularly heterogeneous, and randomized controlled trials of good methodological quality are warranted to determine their efficacy and tolerance in the short and long term.
La synoviorthèse radio-isotopique ou « radiosynoviorthèse » a pour but de réaliser une synovectomie par atrophie ou nécrose des villosités synoviales hypertrophiques au cours de la synovite des ...rhumatismes inflammatoires chroniques. Ce traitement local a aussi sa place dans les arthropathies hémophiliques ou des synovites villonodulaires en ajout du traitement chirurgical, en particulier au genou. Son indication thérapeutique dans l’arthrose des doigts et du poignet est beaucoup plus discutée. Elle est effectuée en collaboration entre un service de médecine nucléaire et un service de rhumatologie. Sa réalisation impose une technique rigoureuse, en particulier pour la position intra-articulaire de l’aiguille. Les radiopharmaceutiques sont préparés extemporanément et le choix d’isotope et du volume à injecter dépendent de la taille de l’articulation. Les seules contre-indications sont la grossesse et l’allaitement. Les complications de la radiosynoviorthèse sont celles de toute infiltration guidée.
Radioisotopic synoviorthesis or “radiosynoviorthesis” aims to achieve synovectomy by atrophy or necrosis of hypertrophic synovial villi during synovitis in chronic inflammatory arthritis. This local treatment also has its place in hemophilic arthropathies or villonodular synovitis in addition to surgical treatment, particularly in the knee. Its therapeutic indication in osteoarthritis of the finger and wrist joints is much more controversial. It is carried out in collaboration between a nuclear medicine department and a rheumatology department. It requires a rigorous technique, particularly for achieving the intra-articular position of the needle. Radiopharmaceuticals are prepared extemporaneously and the choice of radioisotope and the volume to be injected depends on the size of the joint. The only contraindications are pregnancy and breastfeeding. Complications are those of radioguided infiltration.
La prise en charge de la maladie de Dupuytren a évolué depuis 30 ans. L’aponévrotomie à l’aiguille semble avoir trouvé sa place, notamment dans les formes palmaires et dans les formes digitales avant ...le blocage articulaire. Cette technique ne ferme pas la porte à une chirurgie traditionnelle qui peut être proposée dans un second temps en cas d’échec ou de récidives trop fréquentes. Les dernières publications concernant les autres traitements percutanés comme la collagénase n’ont montré aucune supériorité par rapport à l’aponévrotomie percutanée pratiquée selon la technique de l’Unité rhumatologique des affections de la main (URAM) de l’hôpital Lariboisière. Les rhumatologues interventionnels doivent développer et transmettre cette technique qui peut être pratiquée en consultation.
The management of Dupuytren's disease has evolved over the past 30 years. Needle aponevrotomy seems to have found its place, particularly in palm and digital forms before joint blockage. This technique does not close the door to traditional surgery, which can be offered in a second one in the event of failure or too frequent recurrences. The latest publications concerning other percutaneous treatments such as collagenase have shown no superiority over percutaneous aponevrotomy performed using the technique of the Lariboisière Hand Impairment Unit. Interventional rheumatologists must develop and transmit this technique, which can be practiced in consultation.
La coxarthrose est responsable de douleurs et de raideur articulaire à l’origine d’un handicap fonctionnel important. Le seul traitement curatif à ce jour est chirurgical et consiste en la mise en ...place d’une prothèse totale de hanche. Néanmoins, cette option thérapeutique n’est utilisée qu’en dernier recours, après avoir épuisé les autres thérapeutiques disponibles, notamment médicales. Parmi l’arsenal thérapeutique dont dispose le clinicien, le geste intra articulaire occupe une place de choix. Plusieurs agents thérapeutiques injectables ont été évalués ; parmi ceux-ci, les plus couramment utilisés sont les corticoïdes et les acides hyaluroniques. L’infiltration intra articulaire de dérivés cortisonés apporte un bénéfice modeste sur la douleur et uniquement à court terme. La visco-supplémentation de la hanche n’a pas prouvé sa supériorité par rapport au placebo dans la coxarthrose, mais les études ayant évalué son efficacité manquent de puissance. Son intérêt pourra être rediscuté avec les résultats d’essais thérapeutiques complémentaires et mieux conçus.
Osteoarthritis is responsible for pain and joint stiffness that cause significant functional impairment. To date, the only curative treatment is the surgery with total hip prosthesis. Nevertheless, this therapeutic option is only used in last course, when all of the other available therapies have been exhausted, including medical ones. The intra articular injection is often used to treat osteoarthritis. Several injectable therapeutic agents have been evaluated; the most commonly used are corticosteroids and hyaluronic acids. Intra-articular infiltration of corticoids provides a modest benefit on pain and only in the short term. Visco-supplementation at the hip is not superior to placebo in hip osteoarthritis, but studies evaluating its efficacy lacked of power. Its interest can be reconsidered with the results of complementary and better-designed therapeutic trials.
•Trigger finger is a common and frequent pathology.•Ultrasound guided pulley release is fast and efficient.•This technique makes it possible to avoid a surgery.
We aimed to evaluate the efficacy and ...tolerance of A1 pulley release using the needle technique, under ultrasound guidance, in patients with symptomatic trigger finger.
All patients with symptomatic trigger finger underwent A1 pulley release using an intramuscular 21 gauge (G) needle. Quinnell grade (I-IV), Quick Disabilities of Arm, Shoulder & Hand (QuickDASH) score (0–100) and pain score on a visual analog scale (VAS: 0–10mm) were recorded at inclusion. The primary endpoint was complete resolution of the trigger finger at 6 months.
Eighty-four patients totaling 105 treated digits were included. Mean age was 63.3±10.7 years. Prior to treatment, mean VAS pain score was 5.8±2.6mm, and mean QuickDASH score was 44.3±19.1. At 6 months, disappearance of symptoms was achieved in 85 of 91 digits with follow-up (93.4%), and in 85.7% at 12 months. The absolute reduction in VAS pain and QuickDASH scores at 6 months was respectively 4.1±3.1 (P<0.001) and 36.1±20.7 (P<0.001), and 90% of patients reported being satisfied or very satisfied at 6 months. Long duration of symptoms was significantly associated with persistent trigger finger at 6 months after intervention. Complications were rare and minor. Tenosynovitis occurred in 5.7% of cases, for which a corticosteroid injection into the tendon sheath rapidly led to favorable resolution.
Treatment of trigger finger by release of the A1 pulley under ultrasound guidance using the needle technique is a mildly invasive technique that yields rapid and effective symptom resolution with good tolerance up to 12 months.
To establish recommendations for pharmacological treatment of knee osteoarthritis specific to France.
On behalf of the French Society of Rheumatology (SFR), a bibliography group analyzed the ...literature on the efficacy and safety of each pharmacological treatment for knee osteoarthritis. This group joined a multidisciplinary working group to draw up recommendations. Strength of recommendation and quality of evidence level were assigned to each recommendation. A review committee gave its level of agreement.
Five general principles were established: 1) need to combine pharmacological and non-pharmacological treatments, 2) personalization of treatment, 3) symptomatic and/or functional aim of pharmacological treatments, 4) need to regularly re-assess the treatments and 5) discussion about arthroplasty if medical treatment fails.
Six recommendations involved oral treatments: 1) paracetamol should not necessarily be prescribed systematically and/or continuously, 2) NSAIDs, possibly as first-line, 3) weak opioids, 4) strong opioids, 5) symptomatic slow-acting drugs of osteoarthritis, and 6) duloxetine (off-label use). Two recommendations involved topical agents (NSAIDs and capsaicin<1%). Three recommendations involved intra-articular treatments: corticosteroid or hyaluronic acid injections that can be proposed to patients. The experts did not draw a conclusion about the benefits of platelet-rich plasma injections.
These are the first recommendations of the SFR on the pharmacological treatment of knee osteoarthritis.
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