Pain, function, and radiographic disease in trapeziometacarpal osteoarthritis.

INTRODUCTION: Trapeziometacarpal joint osteoarthritis (OA) produces significant functional impairment due to pain and loss of strength in both power and precision grips, but few studies have related radiographic scores to functional and pain-based measures. PURPOSE: To investigate the association between markers of radiographic disease and outcomes for symptomatic and functional disease. STUDY DESIGN: This study in an exploratory analysis of baseline data from the first 100 participants in a clinical trial evaluating the efficacy of combined conservative therapies for base of thumb OA (COMBO). METHODS: Functional Index for Hand Osteoarthritis (FIHOA) scores and Visual Analogue Scale (VAS) scores for pain were recorded for the index hand. Bilateral isometric grip and tip-pinch strength measurements were taken, as well as posteroanterior and Eaton stress-view hand radiographs. Generalized estimating equations (GEEs), univariate, and multivariate analyses were used according to whether the data were bilateral or unilateral. RESULTS: A total of 79 females and 21 males were included, with a median Kellgren-Lawrence (KL) grade of 3 in the index hand. Higher KL and Eaton grades were associated with lower grip strength in the GEE analysis (B-coefficients of -1.25 and -1.16, and P-values of .002 and .010, respectively). Higher KL grade was also associated with poorer function and higher pain levels in the multivariable analysis (B-coefficients of 1.029 and 3.681, and P-values of .021 and .047, respectively). Lower radial subluxation ratios were associated with lower grip strength in the GEE analysis, and higher pain scores in the multivariable analysis (B-coefficients of 2.06 and -42.1, and P-values of .006 and .031, respectively). Greater pain scores were also associated with poorer function (B-coefficient 0.082, P-value .001). CONCLUSION: More advanced radiographic trapeziometacarpal OA severity is associated with lower grip strength and poorer self-reported functional outcomes. Lower subluxation ratios were associated with higher pain scores and lower grip strength.

High baseline pain is associated with treatment adherence in persons diagnosed with thumb base osteoarthritis: An observational study.

BACKGROUND: Thumb osteoarthritis (OA) is a common and disabling condition. Adherence to prescribed conservative interventions may affect outcomes of thumb OA trials. PURPOSE: The aim of the study was to determine whether baseline pain and hand function is associated with treatment adherence over 12 weeks in participants with thumb base OA. STUDY DESIGN: Observational cohort study nested within a randomized-controlled trial. METHODS: Ninety-four participants from the intervention group were included in the analysis. Baseline pain and function were assessed using a 100 mm Visual Analogue Scale and the Functional Index for Hand Osteoarthritis questionnaire (0-30), respectively. Participants received a combination of treatments including education, orthosis, hand exercises, and topical anti-inflammatory gel. Adherence was measured using a daily self-reported diary. Participants were classified as non-adherent, partially adherent or fully adherent if they completed none, 1 and/or 2 or all 3 of the interventions as prescribed. Ordinal logistic regression modelling was performed. RESULTS: At 12-week follow-up, half of the participants were fully adherent to the treatments (n = 46, 48.9%), 30.9% of participants were partially adherent (n = 29) and 20.2% were non-adherent (n = 19, 20.2%). High baseline pain was a significantly associated with better adherence in the unadjusted model [OR = 3.15, 95% CI (1.18, 8.42)] and adjusted model [OR = 3.20, 95% CI (1.13, 8.20)]. Baseline function was not associated with adherence [OR = 1.03, 95% CI (0.47, 2.23)]. CONCLUSION: High baseline pain was associated with better adherence in participants with thumb base OA. Higher baseline functional impairment was not associated with better adherence.

Efficacy of a Combination of Conservative Therapies vs an Education Comparator on Clinical Outcomes in Thumb Base Osteoarthritis: A Randomized Clinical Trial.

Importance: A combination of conservative treatments is commonly used in clinical practice for thumb base osteoarthritis despite limited evidence for this approach. Objective: To determine the efficacy of a 6-week combination of conservative treatments compared with an education comparator. Design, Setting, and Participants: Randomized, parallel trial with 1:1 allocation ratio among people aged 40 years and older with symptomatic and radiographic thumb base osteoarthritis in a community setting in Australia. Interventions: The intervention group (n = 102) received education on self-management and ergonomic principles, a base-of-thumb splint, hand exercises, and diclofenac sodium, 1%, gel. The comparator group (n = 102) received education on self-management and ergonomic principles alone. Intervention use was at participants' discretion from 6 to 12 weeks. Main Outcomes and Measures: Hand function (Functional Index for Hand Osteoarthritis; 0-30) and pain (visual analog scale; 0-100 mm) were measured at week 6 (primary time point) and week 12. An α of .027 was used at week 6 to account for co-primary outcomes. Results: Of the 204 participants randomized, 195 (96%) and 194 (95%) completed follow-ups at 6 and 12 weeks, respectively; the mean (SD) age of the population was 65.6 (8.1) years, and 155 (76.0%) were female. At week 6, hand function improved significantly more in the intervention group than the comparator (between-group difference, -1.7 units; 97.3% CI, -2.9 to -0.5; P = .002). This trend was sustained at 12 weeks (-2.4 units; 95% CI, -3.5 to -1.3; P < .001). Pain scores improved similarly at week 6 (between-group difference, -4.2 mm; 97.3% CI, -11.3 to 3.0; P = .19). At week 12, pain reduction was significantly greater in the intervention group (-8.6 mm; 95% CI, -15.2 to -2.0; P = .01). There were 34 nonserious adverse events, all in the intervention group-mostly skin reactions and exercise-related pain exacerbations. Conclusions and Relevance: In this randomized clinical trial of people with thumb base osteoarthritis, combined treatments provided small to medium and potentially clinically beneficial effects on hand function but not pain. Trial Registration: Australian New Zealand Clinical Trials Registry Identifier: ACTRN12616000353493.

Carpometacarpal and metacarpophalangeal joint collapse is associated with increased pain but not functional impairment in persons with thumb carpometacarpal osteoarthritis.

INTRODUCTION: Due to the complex shape of the carpometacarpal (CMC) joint, a fixed joint collapse deformity of the thumb CMC (CMC1) and metacarpophalangeal (MCP1) joint can present in advanced stages of CMC1 osteoarthritis (OA), resulting in adduction of the first metacarpal (MC1) and hyperextension of the MCP1. PURPOSE OF THE STUDY: To determine whether joint collapse deformity is associated with worse pain and/or functional impairment. STUDY DESIGN: Cross-sectional. METHODS: This study used the baseline data from 140 patients enrolled in a longitudinal study of treatment for CMC1 OA. (efficacy of combined conservative therapies on clinical outcomes in patients with CMC1 OA). Joint collapse was determined at baseline using a pinch gauge. Pain was assessed on a visual analog scale (0-100) and function was assessed using the Functional Index for Hand Osteoarthritis questionnaire (0-30). Pain and function and the presence of joint collapse were entered in a univariate logistic regression. The final adjusted model for pain and joint collapse included age and sex. The final adjusted model for function and joint collapse included Kellgren Lawrence grade and grip strength. RESULTS: About 20% of participants demonstrated joint collapse on the tip-pinch test. The presence of joint collapse was associated with increased pain in the unadjusted [P = .047, OR = 2.45, 95% CI (1.01, 5.910)] and adjusted model [P = .049, OR = 2.45, 95% CI (1.00, 5.98)]. CONCLUSION: CMC1 patients with joint collapse reported increased pain compared with those without joint collapse. Future studies should determine the relationship between thumb hypermobility and joint collapse and how to manage these conditions effectively.

Association of Comorbid Interphalangeal Joint Pain and Erosive Osteoarthritis With Worse Hand Function in Individuals With Symptomatic Thumb Base Osteoarthritis.

OBJECTIVE: Hand osteoarthritis (OA) trials often target exclusively the thumb base joint, although concomitant widespread interphalangeal (IP) joint involvement is frequent. We aimed to compare hand strength and function between individuals with isolated thumb base OA and those with coexistent IP joint pain and erosive OA. METHODS: Baseline data from a thumb base OA trial were analyzed (n = 204). Participants were age ≥40 years with symptomatic and radiographic thumb base OA. Only the index hand was included. Self-reported IP joint pain (in any proximal, distal, or thumb IP joint), hand function score (Functional Index for Hand Osteoarthritis questionnaire [range 0-30]), and hand grip and tip-pinch strength test results were obtained at baseline. Radiographs were scored for OA severity at each joint (Kellgren/Lawrence grade) and for the presence of erosive OA at the thumb base or IP joints. Multiple linear regression was used adjusting for age, sex, body mass index, and radiographic thumb base OA severity. RESULTS: Compared to individuals with isolated thumb base OA (62%), those with concomitant IP joint pain (17%) and erosive OA (21%) had significantly worse hand function (ß = 1.82 [95% confidence interval (95% CI) 0.36, 3.28] and ß = 1.47 [95% CI 0.74, 2.88], respectively). In addition, coexistence of erosive OA was independently associated with lower grip and tip-pinch strength (ß = -5.14 [95% CI -7.58, -2.70] and ß = -0.61 [95% CI -1.05, -0.17], respectively). CONCLUSION: Concomitant IP joint pain and erosive OA are associated with worse hand function in individuals with thumb base OA. Patient stratification based on these characteristics may improve the design of future thumb base OA trials.

Pain in the Post-Operative Week Predicts Pain and Hand Use Twelve Weeks after Proximal Phalangeal Fracture Fixation.

Background: The purpose of this study was to determine whether baseline characteristics predict outcomes twelve weeks after open reduction and internal fixation of proximal phalangeal fracture. Methods: A cohort of patients (n = 48, mean 35 years; SD 11) commencing outpatient rehabilitation within one week of surgery were reviewed. Outcomes of interest were active PIP extension; active total range of motion; pain at rest; comprehensive pain; strength; and hand use (reported difficulty performing specific activities such as turning a door handle, as well as usual activities including housework and recreation) at twelve weeks. Possible predictors included which finger is injured, whether the fracture is intra or extra-articular, whether the dominant or non-dominant hand is injured and/or how much pain is experienced in the first post-operative week. Multiple linear regression was performed to produce a model of the prediction for each outcome of interest at Week 1 (baseline). Results: Results from multivariate linear regression analyses suggest that pain at rest at baseline was significantly predictive of pain at rest (OR = 1.25, 95% CI = 1.06-1.47), p = 0.01), comprehensive pain (OR = 3.18, 95% CI = 1.47-6.84, p = 0.01), and hand use (OR = 2.38, 95% CI = 1.18-4.80, p = 0.02) twelve weeks after open reduction and internal fixation of proximal phalangeal fracture. The turning point on the receiver-operator characteristic curve of false versus true risk (AUC = 0.94, p = 0.04) indicated that at least a score of 4.5 on the 10 cm visual analogue scale for baseline resting pain was needed for significant likelihood of reduced hand use. Which finger was injured, location of fracture and side of injury were not predictive of any outcomes. Conclusions: Moderate to high levels of resting pain in the week following surgery for proximal phalangeal fracture is predictive of pain and hand use at twelve weeks. Moderate to high levels of resting pain should be recognised as unusual, and could be targeted in rehabilitation. Further prospective studies are needed to determine whether early identification and targeted intervention to reduce pain improves outcomes at 12 weeks.

The effectiveness of physical therapies for patients with base of thumb osteoarthritis: Systematic review and meta-analysis.

BACKGROUND: Trapeziometacarpal osteoarthritis (known as base of thumb OA) is a common condition causing pain and disability worldwide. OBJECTIVE: The purpose of this review was to evaluate the effectiveness of multimodal and unimodal physical therapies for base of thumb osteoarthritis (OA) compared with usual care, placebo or sham interventions. DESIGN: Systematic review and meta-analysis. METHOD: We searched MEDLINE (PubMed), CINAHL, Embase, AMED, PEDro, Cochrane Database of Systematic Review, Cochrane Register of Controlled Trials (CENTRAL) from inception to May 2017. Randomized controlled trials involving adults comparing physical therapy treatment for base of thumb OA with an inactive control (placebo or sham treatment) and reported pain, strength or functional outcomes were included. Meta-analyses were performed where possible. Methodological risk of bias was assessed with the Cochrane Risk of Bias tool. RESULTS: Five papers with low risk of bias were included. Meta-analyses of mean differences (MD) with 95% confidence intervals (95% CI), were calculated for between-group differences in point estimates at 4 weeks post-intervention. Multimodal and unimodal physical therapies resulted in clinically worthwhile improvements in pain intensity (MD 2.9 [95% CI 2.8 to 3.0]; MD 3.1 [95% CI 2.5 to 3.8] on a 0-10 scale, respectively). Hand function improved following unimodal treatments (MD 6.8 points [95% CI 1.7 to 11.9)] on a 0-100 scale) and after a multimodal treatment (MD 20.5 (95%CI -0.7 to 41.7). CONCLUSIONS: High quality evidence shows unimodal and multimodal physical therapy treatments can result in clinically worthwhile improvements in pain and function for patients with base of thumb OA.

WITHDRAWN: Surgery for thumb (trapeziometacarpal joint) osteoarthritis.

BACKGROUND: Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005. OBJECTIVES: To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis. SEARCH METHODS: We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013). SELECTION CRITERIA: Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events. MAIN RESULTS: We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement). We did not find any studies that compared surgery with sham surgery or surgery with non-surgical interventions.Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone. AUTHORS' CONCLUSIONS: We did not identify any studies that compared surgery to sham surgery or to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

Efficacy of combined conservative therapies on clinical outcomes in patients with thumb base osteoarthritis: protocol for a randomised, controlled trial (COMBO).

INTRODUCTION: Management of thumb base osteoarthritis (OA) using a combination of therapies is common in clinical practice; however, evidence for the efficacy of this approach is lacking. The aim of this study is to determine the effect of a combination of conservative therapies for the treatment of thumb base OA compared with an education control group. METHODS AND ANALYSIS: This is a randomised, controlled, single-centre, two-arm superiority trial with 1:1 allocation ratio; with assessor and statistician blinded. Participants are blinded to the trial's hypothesis and to the interventions received by the opposite group. A total of 204 participants will be recruited from the community and randomised using a computer-generated schedule. The intervention group will receive education for joint protection and OA, a splint for the base of the thumb, hand exercises and topical diclofenac sodium 1% gel over 6 weeks. The control group will receive education for joint protection and OA alone. Main inclusion criteria are pain ≥40 mm (Visual Analogue Scale, 0-100) at the base of the thumb, impairment in hand function ≥6 (Functional Index for Hand Osteoarthritis, 0-30) and radiographic thumb base OA (Kellgren Lawrence grade ≥2). Participants currently receiving any of the intervention components will be excluded. Outcomes will be measured at 2, 6 and 12 weeks. The primary outcome is change in pain and hand function from baseline to 6 weeks. Other outcomes include changes in grip and pinch strength, quality of life, presence of joint swelling and tenderness, duration of joint stiffness, patient's global assessment and use of rescue medication. Analysis will be performed according to the intention-to-treat principle. Adverse events will be monitored throughout the study. ETHICS AND DISSEMINATION: This protocol is approved by the local ethics committee (HREC/15/HAWKE/479). Dissemination will occur through presentations at international conferences and publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: ACTRN12616000353493; Pre-results.

No difference between two types of exercise after proximal phalangeal fracture fixation: a randomised trial.

QUESTION: Are 6 weeks of synergistic wrist and finger exercises with the metacarpophalangeal joint constrained in an orthosis (constrained exercises) more effective than traditional finger exercises with the metacarpophalangeal joint unconstrained (unconstrained exercises) after open reduction and internal fixation of a proximal phalangeal fracture in terms of impairment, activity limitation and participation restriction at 6 and 12 weeks? DESIGN: Randomised, parallel-group trial with concealed allocation, intention-to-treat analysis and blinded outcome assessors. PARTICIPANTS: Sixty-six participants within 1 week of open reduction and internal fixation of proximal phalangeal fractures. INTERVENTION: The experimental group carried out 6 weeks of synergistic wrist and finger exercises with the metacarpophalangeal joint constrained, whilst the control group carried out finger exercises with the metacarpophalangeal joint unconstrained, as part of a comprehensive rehabilitation program. OUTCOME MEASURES: The primary outcomes were: active proximal interphalangeal joint extension of the injured finger, total active range of motion, and strength. Secondary outcomes were: pain, difficulty with specific hand activity and difficulty with usual hand activity. A blinded assessor measured outcomes at Weeks 1, 6 and 12. RESULTS: By Week 6, there were no significant between-group differences in improvement for: active proximal interphalangeal joint extension (MD 2 deg, 95% CI -3 to 7); total active finger range of motion (MD 0 deg, 95% CI -21 to 22); strength (MD -2kg, 95% CI -8 to 4); pain (MD 1/50, 95% CI -3 to 5); difficulty with specific hand activity (MD 2/60, 95% CI -3 to 8); or difficulty with usual hand activity (MD 0/40, 95% CI -4 to 3). By Week 12, there were also no significant between-group differences in any outcome. CONCLUSIONS: Constrained and unconstrained exercises has similar effects after open reduction and internal fixation of proximal phalangeal fracture. REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12610000294055).

Surgery for thumb (trapeziometacarpal joint) osteoarthritis.

BACKGROUND: Surgery is used to treat persistent pain and dysfunction at the base of the thumb when conservative management, such as splinting, or medical management, such as oral analgesics, is no longer adequate in reducing disability and pain. This is an update of a Cochrane Review first published in 2005. OBJECTIVES: To assess the effects of different surgical techniques for trapeziometacarpal (thumb) osteoarthritis. SEARCH METHODS: We searched the following sources up to 08 August 2013: CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to August 2013), EMBASE (1974 to August 2013), CINAHL (1982 to August 2013), Clinicaltrials.gov (to August 2013) and World Health Organization (WHO) Clinical Trials Portal (to August 2013). SELECTION CRITERIA: Randomised controlled trials (RCTs) or quasi-RCTs where the intervention was surgery for people with thumb osteoarthritis. Outcomes were pain, physical function, quality of life, patient global assessment, adverse events, treatment failure or trapeziometacarpal joint imaging. We excluded trials that compared non-surgical interventions with surgery. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by the Cochrane Collaboration. Two review authors independently screened and included studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse events. MAIN RESULTS: We included 11 studies with 670 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty (IA), Artelon joint resurfacing, arthrodesis and Swanson joint replacement).Most included studies had an unclear risk of most biases which raises doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, quality of life, patient global assessment, adverse events, treatment failure (re-operation) or trapeziometacarpal joint imaging. One study demonstrated a difference in adverse events (mild-moderate swelling) between Artelon joint replacement and trapeziectomy with tendon interposition. However, the quality of evidence was very low due to a high risk of bias and imprecision of results.Low quality evidence suggests trapeziectomy with LRTI may not provide additional benefits or result in more adverse events over trapeziectomy alone. Mean pain (three studies, 162 participants) was 26 mm on a 0 to 100 mm VAS (0 is no pain) for trapeziectomy alone, trapeziectomy with LRTI reduced pain by a mean of 2.8 mm (95% confidence interval (CI) -9.8 to 4.2) or an absolute reduction of 3% (-10% to 4%). Mean physical function (three studies, 211 participants) was 31.1 points on a 0 to 100 point scale (0 is best physical function, or no disability) with trapeziectomy alone, trapeziectomy with LRTI resulted in sightly lower function scores (standardised mean difference 0.1, 95% CI -0.30 to 0.32), an equivalent to a worsening of 0.2 points (95% CI -5.8 to 6.1) on a 0 to 100 point scale (absolute decrease in function 0.03% (-0.83% to 0.88%)). Low quality evidence from four studies (328 participants) indicates that the mean number of adverse events was 10 per 100 participants for trapeziectomy alone, and 19 events per 100 participants for trapeziectomy with LRTI (RR 1.89, 95% CI 0.96 to 3.73) or an absolute risk increase of 9% (95% CI 0% to 28%). Low quality evidence from one study (42 participants) indicates that the mean scapho-metacarpal distance was 2.3 mm for the trapeziectomy alone group, trapeziectomy with LRTI resulted in a mean of 0.1 mm less distance (95% CI -0.81 to 0.61). None of the included trials reported global assessment, quality of life, and revision or re-operation rates.Low-quality evidence from two small studies (51 participants) indicated that trapeziectomy with LRTI may not improve function or slow joint degeneration, or produce additional adverse events over trapeziectomy and ligament reconstruction.We are uncertain of the benefits or harms of other surgical techniques due to the mostly low quality evidence from single studies and the low reporting rates of key outcomes. There was insufficient evidence to assess if trapeziectomy with LRTI had additional benefit over arthrodesis or trapeziectomy with IA. There was also insufficient evidence to assess if trapeziectomy with IA had any additional benefit over the Artelon joint implant, the Swanson joint replacement or trapeziectomy alone.We did not find any studies that compared any other combination of the other techniques mentioned above or any other techniques including a sham procedure. AUTHORS' CONCLUSIONS: We did not identify any studies that compared surgery to sham surgery and we excluded studies that compared surgery to non-operative treatments. We were unable to demonstrate that any technique confers a benefit over another technique in terms of pain and physical function. Furthermore, the included studies were not of high enough quality to provide conclusive evidence that the compared techniques provided equivalent outcomes.

Surgery for thumb (trapeziometacarpal joint) osteoarthritis.

BACKGROUND: This is an update of a Cochrane Review first published in 2005. Surgery has been used to treat persistent pain and dysfunction at the base of the thumb. However, there is no evidence to suggest that any one surgical procedure is superior to another. OBJECTIVES: To compare the effect of different surgical techniques in reducing pain and improving physical function, patient global assessment, range of motion and strength in people with trapeziometacarpal osteoarthritis at 12 months. Additionally, to investigate whether there was any improvement or deterioration in outcomes between the 12-month review and five year follow up. SEARCH STRATEGY: We searched:(CENTRAL) (The Cochrane Library 2008, issue 1), MEDLINE (1950 to Dec 2008), CINAHL (1982 to Dec 2008), AMED (1985 to Dec 2008) and EMBASE (1974 to Dec 2008), and performed handsearching of conference proceedings and reference lists from reviews and papers. SELECTION CRITERIA: Randomised or quasi-randomised trials where the intervention was surgery and pain, physical function, patient global assessment, range of motion or strength was measured as an outcome. DATA COLLECTION AND ANALYSIS: Two review authors independently selected studies according to the inclusion criteria, assessed the risk of bias and extracted data, including adverse effects. We contacted trial authors for missing information. MAIN RESULTS: We included nine studies involving 477 participants. Seven surgical procedures were identified (trapeziectomy with ligament reconstruction and tendon interposition (LRTI), trapeziectomy, trapeziectomy with ligament reconstruction, trapeziectomy with interpositional arthroplasty, Artelon joint resurfacing, arthrodesis and joint replacement). Studies reported results of a mixed group of participants with Stage II-IV osteoarthritis, with a range of improvement for pain and physical function. The majority of studies included in this review had an unclear risk of bias which raises some doubt about the results. No procedure demonstrated any superiority over another in terms of pain, physical function, patient global assessment or range of motion. Of participants who underwent trapeziectomy with ligament reconstruction and tendon interposition, 22% had adverse effects (including scar tenderness, tendon adhesion or rupture, sensory change, or Complex Regional Pain Syndrome (Type 1)) compared to 10% who underwent trapeziectomy. Trapeziectomy with ligament reconstruction and tendon interposition is therefore associated with 12% more adverse effects (RR = 2.21, 95% CI 1.18 to 4.15). AUTHORS' CONCLUSIONS: Although it appears that no one procedure produces greater benefit in terms of pain and physical function, there was insufficient evidence to be conclusive. Trapeziectomy has fewer complications than trapeziectomy with LRTI.

Work-related thumb pain in physiotherapists is associated with thumb alignment during performance of PA pressures.

Pain is common in the thumbs of physiotherapists. The purpose of this observational study was to investigate whether there is an association between the alignment of the thumb during performance of postero-anterior (PA) pressures and the presence of thumb pain. One hundred and twenty-nine physiotherapists who attended the Musculoskeletal Physiotherapy Association Conference (2003) participated. After providing a history of any work-related thumb pain, participants applied a PA pressure mimicking the technique they would use on a cervical spine, while the position of their metacarpophalangeal (MP) and interphalangeal (IP) joints was photographed. There was an association (p<0.05) between work-related thumb pain and alignment of the thumb during performance of PA pressures: participants who were able to maintain their MP and IP joints in extension were less likely to report pain. These findings serve as a guide to the safe performance of mobilization techniques, both for beginning practitioners and for experienced therapists complaining of thumb pain.

No difference between two splint and exercise regimens for people with osteoarthritis of the thumb: a randomised controlled trial.

The purpose of this study was to compare the effects of two 6-week splint and exercise regimens for patients with trapeziometacarpal osteoarthritis. Forty participants were enrolled in a randomised, controlled clinical trial. The experimental group received a newly designed thumb strap splint and an abduction exercise regimen, whereas the control group received current clinical practice consisting of a short opponens splint and a pinch exercise regimen. Outcome measures included pain (VAS at rest in cm), strength (tip pinch in kg), and hand function (Sollerman Test of Hand Function scored out of 80), measured by a blinded assessor at Weeks 0, 2, and 6. By Week 6 there was no significant difference in the extent of mean improvement between the groups in: pain, 0.5 cm (95% CI -1.1 to 2.1); strength, 0.1 kg (95% CI -0.8 to 0.9); or hand function, 0.7 points (95% CI -3.6 to 5.0). While both groups improved, neither regimen is superior to the other in patients with trapeziometacarpal osteoarthritis.

Prevalence of thumb pain in physical therapists practicing spinal manipulative therapy.

Thumb pain is a common complaint of physical therapists. The purpose of this study was to investigate the prevalence, presentation, and techniques associated with aggravation of thumb pain in physical therapists practicing spinal manipulative therapy and the management strategies used to deal with pain. A survey was sent to members of Musculoskeletal Physiotherapy Australia. Data were collected from subjects who had completed postgraduate study in manipulative physical therapy. Of the 155 subjects who responded, 83% complained of pain in their thumbs aggravated by performing manipulative therapy techniques in the preceding year (2000). The most common presentation of pain included mild pain (3.8/10) at the metacarpophalangeal joint, with multiple, short-lived episodes. Techniques most commonly responsible for aggravation of symptoms were unilateral (87%) and central posteroanterior glides (85%). Most subjects (74%) changed their choice of treatment technique to alleviate symptoms. Suggestions are made about the safe alignment of the thumb during performance of spinal manipulative therapy techniques.