Ultrasound-guided intra-articular injection of hyaluronic acid and ketorolac for osteoarthritis of the carpometacarpal joint of the thumb: A retrospective comparative study

Sung Hoon Koh, Sang Chul Lee, Woo Yong Lee, Jongwoo Kim, Yongbum Park, Sung Hoon Koh, Sang Chul Lee, Woo Yong Lee, Jongwoo Kim, Yongbum Park

Abstract

Intra-articular hyaluronic acid (HA) is widely used to treat symptomatic osteoarthritis (OA) in the carpometacarpal joint (CMCJ) of the thumb. However, although apparently effective and relatively safe, intra-articular HA injections act relatively slowly. Therefore, a nonsteroidal anti-inflammatory drug could be added for more prompt pain relief. The aim of this study was to compare the efficacy and safety of ultrasound (US)-guided intra-articular injection of HA and ketorolac with that of HA alone in patients with OA of the CMCJ of the thumb.Seventy-four patients identified by chart review to have a diagnosis of OA of the CMCJ of the thumb received either a US-guided intra-articular injection of 0.5 mL of sodium hyaluronate and 0.5 mL of ketorolac (n = 38) or 0.5 mL of sodium hyaluronate and 0.5 mL of saline (n = 36). Disabilities of the arm, shoulder, and hand (DASH) and verbal numeric scale (VNS) pain scores were recorded before and 1, 3, and 6 months after injection. Univariable analyses (using the chi-squared test) and multiple logistic regression analysis were performed to evaluate the relationship between potential predictors of the outcome (treatment allocation, patient age and sex, duration of pain, and Eaton-Littler classification) and therapeutic effects.The DASH and VNS scores were improved at 1, 3, and 6 months postinjection in both groups. The onset of pain relief was significantly more rapid (at 1 month) after the injection containing HA and ketorolac than after the injection containing HA alone. In 55.3% of cases, pain and function were improved postinjection compared with baseline and remained so for up to 6 months. The success rate was not significantly different between the assessments at 1, 3, and 6 months, and the univariable analyses did not identify any statistically significant potential predictors of the outcome. Multiple logistic regression analysis did not identify any independent predictors of a successful outcome at midterm follow-up.The onset of analgesic action was more rapid after an injection containing HA and ketorolac than after 1 containing HA alone in patients with OA of the CMCJ of the thumb. There were no serious complications.

Conflict of interest statement

The authors have no funding and conflicts of interest to disclose.

Figures

Figure 1
Figure 1
Ultrasound-guided CMCJ intra-articular injection. (A) The needle tip (arrows) was observed within CMCJ space. (B) Color Doppler image showing accurate intra-articular injection (arrows). CMCJ = carpometacarpal joint.
Figure 2
Figure 2
Flow diagram indicating progress of patients through the study. HA = hyaluronic acid.
Figure 3
Figure 3
Illustration of significant pain relief (≥50% reduction in verbal numerical scale from baseline). A group: sodium hyaluronate (0.5 mL) with ketorolac; B group: sodium hyaluronate (0.5 mL) with saline (0.5 mL).

References

    1. Bagis S, Sahin G, Yapici Y, et al. The effect of hand osteoarthritis on grip and pinch strength and hand function in postmenopausal women. Clin Rheumatol 2003;22:420–4.
    1. Spaans AJ, van Minnen LP, Kon M, et al. Conservative treatment of thumb base osteoarthritis: a systematic review. J Hand Surg Am 2015;40:16–21.
    1. Gillis J, Calder K, Williams J. Review of thumb carpometacarpal arthritis classification, treatment and outcomes. Can J Plast Surg 2011;19:134–8.
    1. Bakri K, Moran SL. Thumb carpometacarpal arthritis. Plast Reconstr Surg 2015;135:508–20.
    1. Van Heest AE, Kallemeier P. Thumb carpal metacarpal arthritis. J Am Acad Orthop Surg 2008;16:140–51.
    1. Tehranzadeh J, Booya F, Root J. Cartilage metabolism in osteoarthritis and the influence of viscosupplementation and steroid: a review. Acta Radiol 2005;46:288–96.
    1. Bahadir C, Onal B, Dayan VY, et al. Comparison of therapeutic effects of sodium hyaluronate and corticosteroid injections on trapeziometacarpal joint osteoarthritis. Clin Rheumatol 2009;28:529–33.
    1. Zhang W, Doherty M, Leeb BF, et al. EULAR evidence based recommendations for the management of hand osteoarthritis: report of a task force of the EULAR standing committee for international clinical studies including therapeutics (ESCISIT). Ann Rheum Dis 2007;66:377–88.
    1. Stahl S, Karsh-Zafrir I, Ratzon N, et al. Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints. J Clin Rheumatol 2005;11:299–302.
    1. Figen Ayhan F, Ustün N. The evaluation of efficacy and tolerability of Hylan G-F 20 in bilateral thumb base osteoarthritis: 6 months follow-up. Clin Rheumatol 2009;28:535–41.
    1. Fuchs S, Monikes R, Wohlmeiner A, et al. Intraarticular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis. Osteoarthr Cartil 2006;14:82–8.
    1. Unlu Z, Ay K, Tuzun C. Comparison of intra-articular tenoxicam and oral tenoxicam for pain and physical functioning in osteoarthritis of the knee. Clin Rheumatol 2006;25:54–61.
    1. Shapiro PS, Rohde RS, Froimson MI, et al. The effect of local corticosteroid or ketorolac exposure on histologic and biomechanical properties of rabbit tendon and cartilage. Hand (N Y) 2007;2:165–72.
    1. Riggin CN, Tucker JJ, Soslowsky LJ, et al. Intra-articular tibiofemoral injection of a nonsteroidal anti-inflammatory drug has no detrimental effects on joint mechanics in a rat model. J Orthop Res 2014;32:1512–9.
    1. Galán-Herrera JF, Poo JL, Maya-Barrios JA, et al. Bioavailability of two sublingual formulations of ketorolac tromethamine 30 mg: a randomized, open-label, single-dose, two-period crossover comparison in healthy Mexican adult volunteers. Clin Ther 2008;30:1667–74.
    1. Park KD, Kim TK, Bae BW, et al. Ultrasound guided intra-articular ketorolac versus corticosteroid injection in osteoarthritis of the hip: a retrospective comparative study. Skeletal Radiol 2015;44:1333–40.
    1. Altman RD, Alarcon G, Appelrouth D, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hand. Arthritis Rheum 1990;33:1601–10.
    1. Eaton R, Littler JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Joint Surg 1973;55A:1655–66.
    1. Umphrey GL, Brault JS, Hurdle MF, et al. Ultrasound-guided intra-articular injection of the trapeziometacarpal joint: description of technique. Arch Phys Med Rehabil 2008;89:153–6.
    1. Gummesson C, Atroshi I, Ekdahl C. The disabilities of the arm, shoulder and hand (DASH) outcome questionnaire: longitudinal construct validity and measuring self-rated health change after surgery. BMC Musculoskelet Disord 2003;4:11.
    1. Beaton DE, Katz JN, Fossel AH, et al. Measuring the whole or the parts? Validity, reliability, and responsiveness of the disabilities of the arm, shoulder and hand outcome measure in different regions of the upper extremity. J Hand Ther 2001;14:128–46.
    1. Hartrick CT, Kovan JP, Shapiro S. The numeric rating scale for clinical pain measurement: a ratio measure? Pain Pract 2003;3:310–6.
    1. Keen HI, Lavie F, Wakefield RJ, et al. The development of a preliminary ultrasonographic scoring system for features of hand osteoarthritis. Ann Rheum Dis 2008;67:651–5.
    1. Fam H, Bryant JT, Kontopoulou M. Rheological properties of synovial fluids. Biorheology 2007;44:59–74.
    1. Moran SL, Duymaz A, Karabekmez FE. The efficacy of hyaluronic acid in the treatment of osteoarthritis of the trapeziometacarpal joint. J Hand Surg Am 2009;34:942–4.
    1. Heyworth BE, Lee JH, Kim PD, et al. Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial. J Hand Surg Am 2008;33:40–8.
    1. Lee SC, Rha DW, Chang WH. Rapid analgesic onset of intra-articular hyaluronic acid with ketorolac in osteoarthritis of the knee. J Back Musculoskelet Rehabil 2011;24:31–8.
    1. Fraser JR, Kimpton WG, Pierscionek BK, et al. The kinetics of hyaluronan in normal and acutely inflamed synovial joints: observations with experimental arthritis in sheep. Semin Arthritis Rheum 1993;22:9–17.
    1. Grecomore G, Piccione F, Letizia G. Therapeutic synergism between hyaluronic acid and dexamethasone in the intraarticular treatment of osteoarthritis of the knee: a preliminary open study. Curr Med Res Opin 1992;13:49–55.
    1. Hameed F, Ihm J. Injectable medications for osteoarthritis. PM R 2012;4suppl:S75–81.
    1. Reuben SS, Connelly NR. Postoperative analgesia for outpatient arthroscopic knee surgery with intraarticular bupivacaine and ketorolac. Anesth Analg 1995;80:1154–7.
    1. Mallinson PI, Tun JK, Farnell RD, et al. Osteoarthritis of the thumb carpometacarpal joint: correlation of ultrasound appearances to disability and treatment response. Clin Radiol 2013;68:461–5.
    1. Dekker J, Boot B, van der Woude LH, et al. Pain and disability in osteoarthritis: a review of biobehavioral mechanisms. J Behav Med 1992;15:189–214.
    1. Day CS, Gelberman R, Patel AA, et al. Basal joint osteoarthritis of the thumb: a prospective trial of steroid injection and splinting. J Hand Surg 2004;29:247–51.
    1. Khan M, Waseem M, Raza A, et al. Quantitative assessment of improvement with ingle corticosteroid injection in thumb CMC joint osteoarthritis? Open Orthop J 2009;3:48–51.
    1. Sawyer GA, Anderson BC, Raukar NP, et al. Intramuscular ketorolac injections in the athlete. Sports Health 2012;4:319–27.
    1. Douketis JD, Berger PB, Dunn AS, et al. The perioperative management of antithrombotic therapy: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest 2008;133suppl:299S–339S.
    1. Feldman HI, Kinman JL, Berlin JA, et al. Parenteral ketorolac: the risk for acute renal failure. Ann Intern Med 1997;126:193–9.
    1. Strom BL, Berlin JA, Kinman JL, et al. Parenteral ketorolac and risk of gastrointestinal and operative site bleeding: a post marketing surveillance study. JAMA 1996;275:376–82.
    1. Roux C, Fontas E, Breuil V, et al. Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb (CMC1) in osteoarthritis. A prospective evaluation of efficacy. Joint Bone Spine 2007;74:368–72.

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