A randomized controlled trial of real versus sham acupuncture for basal thumb joint arthritis.

We report a single-blinded randomized controlled trial comparing acupuncture to sham (non-penetrating) needling for relief of symptoms of basal thumb joint arthritis. Seventy acupuncture naive patients with basal thumb joint arthritis were randomized to receive true acupuncture or sham needling with 35 patients in each arm. Blinded baseline and post-treatment assessments included visual analogue pain scores for different grips and movement. Function was assessed using the Nelson questionnaire. Both groups showed statistically and clinically significant improvements in pain at week one post-treatment compared with baseline, but there was no difference between the treatment groups. The pain relief was comparable with published data for some standard treatments. Acupuncture did not perform better than sham needling in this study, indicating that pain relief may have been achieved through non-specific mechanisms. Level of evidence: I.

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.

OBJECTIVE: To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. METHODS: We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. RESULTS: Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. CONCLUSION: This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.

OBJECTIVE: To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. METHODS: We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. RESULTS: Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. CONCLUSION: This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

Thiemann disease and familial digital arthropathy - brachydactyly: two sides of the same coin?

BACKGROUND: Familial digital arthropathy-brachydactyly (FDAB) and Thiemann disease are non-inflammatory digital arthropathies with many phenotypic similarities. Thirty-three cases of Thiemann disease have been described so far (Mangat et al, Ann Rheum Dis 64:11-2, 2005; Ha et al, Thiemann's disease: a case Report, 2017) but no gene variants have been identified as causative to date. FDAB is reported in only a few patients and has been associated with three heterozygous missense variants in the Transient receptor potential vanilloid 4 (TRPV4) gene. We report a TRPV4 variant in a father and son referred with a diagnosis of Thiemann disease and compare the clinical and radiological features of Thiemann disease with Familial digital arthropathy-brachydactyly (FDAB). We hypothesize that these two entities may be one and the same. METHODS: We describe a father and son referred with a diagnosis of Thiemann disease who were subsequently identified with a heterozygous variant (c.809G > T) in TRPV4. The identical genetic variant was previously reported to cause FDAB. A PUBMED® database search was conducted to retrieve articles related to Thiemann disease and FDAB. We were able to review the clinical and radiological findings of nineteen individuals affected by Thiemann disease and compare them with three families affected by FDAB. RESULTS: Thiemann disease initially affects the proximal interphalangeal joints and primarily the middle phalangeal bases. In FDAB, the distal phalangeal joints are first affected with the middle phalangeal heads being the primary site of changes. Radial deviation has only been described in FDAB. Our analysis determined that 5 of 20 individuals affected by Thiemann disease have clinical and radiological findings that also fit well with FDAB. CONCLUSION: FDAB and Thiemann disease are non-inflammatory digital arthropathies with phenotypic overlap. Although more extensive joint involvement, a distal hand joint preponderance and brachydactyly are expected in FDAB, there are striking clinical and radiological similarities between the two entities. Our analysis suggests that these two phenotypes may represent phenotypic variability of the same entity. Despite many attempts to identify other reported patients affected by Thiemann disease, we were not able to procure DNA from any of the cases to verify our findings. Genetic testing of an affected individual will be crucial in order to provide accurate reproductive genetic counselling about the autosomal dominant nature of this condition.

Joint Mobilization of the Hands of Patients With Rheumatoid Arthritis: Results From an Assessor-Blinded, Randomized Crossover Trial.

OBJECTIVE: The purpose of this study was to assess the clinical feasibility and effectiveness of manual mobilization of the hands of patients with rheumatoid arthritis (RA). METHODS: A total of 320 individual hand joints were evaluated after recruiting an experimental research group of 12 participants with RA and, for clinical comparability, 8 participants with hand osteoarthritis (OA). One hand per participant was randomized to receive weekly low-grade (I-II) Kaltenborn manual mobilization, using passive sustained stretch of the metacarpophalangeal (MCP) joints II to V by licensed manual therapists. After 2 weeks, the randomized treated hand was crossed over to control (untreated) during weeks 3 to 4 and vice versa. Final assessment was at 2 months, which was 1 month after the last treatment at week 4. Primary hand outcomes included pain by visual analog scale, tender or swollen joint count, and presence of Doppler signal or synovial fluid and radiographic joint space by musculoskeletal ultrasound. RESULTS: In the RA group, both the initially randomized treated hand and the contralateral hand improved significantly from baseline to crossover to follow-up at 2 months (pain outcomes and Doppler signal, P < .050; synovial fluid and MCP joint space, P ≤ .001). Hand pain and MCP joint space also improved significantly in OA. There were no dropouts or reported adverse events in either the RA or OA group. CONCLUSION: In this study, manual mobilization of the hands of patients with RA was shown to be feasible, safe, and effective to integrate into specialized healthcare.

Effect of flaxseed poultice compress application on pain and hand functions of patients with hand osteoarthritis.

INTRODUCTION/OBJECTIVES: This randomized controlled intervention study investigated the effect of flaxseed poultice compress application on pain and hand functions in patients with primary interphalangeal hand osteoarthritis (OA). METHOD: The study sample consisted of 82 patients who met the inclusion criteria in the Rheumatology Outpatient Clinic at a University Hospital between January 15, 2017, and May 15, 2018. Patients included in the sample groups were selected randomly. Three sample groups were formed: intervention group I (flaxseed poultice compress) (n = 33), intervention group II (hot compress) (n = 29), and control group (n = 20). The interventions were applied once a day for 7 days in a row. These patients also continued their routine pharmacological treatment. descriptive characteristics identification form, visual analog scale (VAS), Australian-Canadian (AUSCAN) Osteoarthritis (OA) Hand Index, and side effect evaluation form were used as data collection tools. RESULTS: The means of VAS scores of patients in the intervention group I were 6.03 ± 0.25 on day 0, 2.2 ± 0.30 on day 8, and 3.39 ± 0.32 on day 15. The means of AUSCAN total scores of patients in the intervention group I were 40.84 ± 1.76 on day 0, 14.03 ± 1.66 on day 8, and 15.78 ± 1.66 on day 15. The present study showed that pain significantly decreased and the hand function efficiency increased in patients treated with flaxseed poultice compress compared with the hot compress and control groups. CONCLUSIONS: In addition to pharmacological treatment, flaxseed poultice compress intervention is recommended to be used as a nursing intervention for reducing pain and increasing hand functions for patients with hand OA in cooperation with the physicians and other health professionals.

Wide-Awake Wrist and Small Joints Arthroscopy of the Hand.

The minimally invasive nature of wrist and small joint arthroscopy renders it particularly suitable for the application of the wide-awake local anesthesia no tourniquet (WALANT) technique. The application of WALANT wrist and small joint arthroscopy has given surgeons the ability to visualize both static and dynamic movements of a joint, to show the pathology and discuss with the patient, and to visualize a patient's repaired structures. This reinforces confidence in surgeons and encourages patients to comply with postoperative rehabilitation.

Effects of a massage-like essential oil application procedure using Copaiba and Deep Blue oils in individuals with hand arthritis.

BACKGROUND AND PURPOSE: Existing research suggests that both massage and essential oils may have analgesic and anti-inflammatory benefits. We investigate the benefits of the AromaTouch Hand Technique® (ATHT), a procedure that combines a moderate pressure touch with the application of essential oils to the hand, in individuals with hand arthritis. METHODS AND MATERIALS: Thirty-six participants with rheumatoid arthritis, osteoarthritis, and/or chronic inflammation received ATHTs with either a 50/50 preparation of Deep Blue® and Copaiba oil or a coconut oil placebo twice daily for 5 consecutive days. Changes in maximum flexion in finger and thumb joints, items from the Arthritis Hand Function Test, and hand pain scores were evaluated. RESULTS: Participants treated with the essential oil preparation required significantly less time to complete dexterity tasks and showed about 50% decrease in pain scores, increased finger strength, and significantly increased angle of maximum flexion compared to subjects treated with coconut oil. CONCLUSION: The ATHT with Copaiba and Deep Blue may have ameliorative effects on hand arthritis.

Assistive devices: an effective strategy in non-pharmacological treatment for hand osteoarthritis-randomized clinical trial.

This study aims to evaluate the use of assistive devices as a strategy in non-pharmacological treatment for hand osteoarthritis (HOA). This is a randomized, prospective, parallel, assessor-blinded clinical trial, in which patients with a diagnosis of HOA were randomly allocated to an intervention group (IG), where they received assistive devices for daily life activities, or to a control group (CG), where they received a guideline leaflet with information on joint protection and disease features. The primary outcomes considered were occupational performance, measured by the Canadian Occupational Performance Measure (COPM), and hand function was evaluated through the Score for the Assessment and Quantification of Chronic Rheumatoid Affections of the Hands (SACRAH). The secondary outcomes were pain, measured by the visual analog scale (VAS), and quality of life, measured by the World Health Organization Quality of Life Instrument, Short Form (WHOQOL-BREF). We compared both outcomes before and after interventions and outcomes between groups. Participants from the two groups were assessed at the time of inclusion in the study, 30, and 90 days after initial evaluation. Out of the 39 patients included, 19 were allocated to the IG and 20 to the CG. Only two patients from the CG did not complete the follow-up period. The patients' hand function and occupational performance improved after intervention (30 days-SACRAH-p < 0.05; COPM-p < 0.05; VAS-p < 0.05). When comparing results between the groups, there was a statistical difference in COPM (performance-p < 0.001; and satisfaction-p < 0.001), in the first reevaluation carried out. The use of assistive devices has proved to be an effective alternative in non-pharmacological treatment for HOA. CLINICAL TRIAL REGISTRATION: NCT02667145.

[Row acupuncture at the gaps between phalanges for dorsal stretch of fingers after cerebral infarction].

OBJECTIVE: To compare the effect differences between row acupuncture at the gaps between phalanges and physical therapy for the dorsal stretch of fingers after cerebral infarction. METHODS: Seven-one cases were randomized into a row acupuncture at the gaps between phalanges group (group A, 37 cases) and a physical therapy group (group B, 34 cases). Body acupuncture was applied in the two groups. Row acupuncture at the 1st, 2nd, and 3rd gaps between phalanges was used in the group A, with continuous wave of electroacupuncture. The two electrodes of nerve injury therapeutic apparatus were put in the muscle belly center of extensor digitorum of forearm in the group B. All the treatments were given for 30 min in the two groups, once a day and 10 times as one course. Three courses were required with 3 d at the interval. The dorsal stretch of metacarpophalangeal joints and the muscle force of common extensor of fingers were compared between the two groups before and after treatment. RESULTS: Compared with those before treatment, the dorsal stretch of metacarpophalangeal joints and the muscle force of common extensor of fingers were improved after treatment in the two groups (all P<0.05). There existed better effects in the group A on the dorsal stretch of the forefinger, middle finger and ring finger of metacarpophalangeal joints, as well as the muscle force of common extensor of fingers (all P<0.05). CONCLUSIONS: Row acupuncture at the gaps between phalanges achieves better effect than physical therapy for the dorsal stretch of fingers after cerebral infarction, based on body acupuncture.

Effects of rumenic acid rich conjugated linoleic acid supplementation on cognitive function and handgrip performance in older men and women.

The purpose of this study was to investigate the effects of 8weeks at 6g per day of RAR CLA versus placebo on cognitive function and handgrip performance in older men and women. Sixty-five (43 women, 22 men) participants (mean±SD; age=72.4±5.9yrs; BMI=26.6±4.2kg·m-2) were randomly assigned to a RAR CLA (n=30: 10 men, 20 women) or placebo (PLA; high oleic sunflower oil; n=35: 12 men, 23 women) group in double-blind fashion and consumed 6g·d-1 of their allocated supplement for 8weeks. Before (Visit 1) and after supplementation (Visit 2), subjects completed the Serial Sevens Subtraction Test (S7), Trail Making Test Part A (TMA) and Part B (TMB), and Rey's Auditory Verbal Learning Test (RAVLT) to measure cognitive function. The RAVLT included 5, 15-item auditory word recalls (R1-5), an interference word recall (RB), a 6th word recall (R6), and a 15-item visual word recognition trial (RR). For handgrip performance, subjects completed maximal voluntary isometric handgrip strength (MVIC) testing before (MVICPRE) and after (MVICPOST) a handgrip fatigue test at 50% MVICPRE. Hand joint discomfort was measured during MVICPRE, MVICPOST, and the handgrip fatigue test. There were no treatment differences (p>0.05) for handgrip strength, handgrip fatigue, or cognitive function as measured by the Trail Making Test and Serial Seven's Subtraction Test in men or women. However, RAR CLA supplementation improved cognitive function as indicated by the RAVLT R5 in men. A qualitative examination of the mean change scores suggested that, compared to PLA, RAR CLA supplementation was associated with a small improvement in joint discomfort in both men and women. Longer-term studies are needed to more fully understand the potential impact of RAR CLA on cognitive function and hand joint discomfort in older adults, particularly in those with lower cognitive function.

Methotrexate Dosage Reduction Upon Adalimumab Initiation: Clinical and Ultrasonographic Outcomes from the Randomized Noninferiority MUSICA Trial.

OBJECTIVE: To examine the clinical and ultrasonographic (US) outcomes of reducing methotrexate (MTX) dosage upon initiating adalimumab (ADA) in MTX-inadequate responders with moderately to severely active rheumatoid arthritis (RA). METHODS: MUSICA (NCT01185288) was a double-blind, randomized, parallel-arm study of 309 patients with RA receiving MTX ≥ 15 mg/week for ≥ 12 weeks before screening. Patients were randomized to high dosage (20 mg/week) or low dosage (7.5 mg/week) MTX; all patients received 40 mg open-label ADA every other week for 24 weeks. The primary endpoint was Week 24 mean 28-joint Disease Activity Score based on C-reactive protein (DAS28-CRP) to test for noninferiority of low-dosage MTX using a 15% margin. US images were scored using a 10-joint semiquantitative system incorporating OMERACT definitions for pathology, assessing synovial hypertrophy, vascularity, and bony erosions. RESULTS: Rapid improvement in clinical indices was observed in both groups after addition of ADA. The difference in mean DAS28-CRP (0.37, 95% CI 0.07-0.66) comparing low-dosage (4.12, 95% CI 3.88-4.34) versus high-dosage MTX (3.75, 95% CI 3.52-3.97) was statistically significant and non-inferiority was not met. Statistically significant differences were not detected for most clinical, functional, and US outcomes. Pharmacokinetic and safety profiles were similar. CONCLUSION: In MUSICA, Week 24 mean DAS28-CRP, the primary endpoint, did not meet non-inferiority for the low-dosage MTX group. Although the differences between the 2 MTX dosage groups were small, our study findings did not support routine MTX reduction in MTX inadequate responders initiating ADA.

Positive effects of low level laser therapy (LLLT) on Bouchard's and Heberden's osteoarthritis.

BACKGROUND AND OBJECTIVE: Osteoarthritis (OA) is a common chronic disorder. While research usually focuses on OA of the large joints, OA of the hand receives relatively little attention resulting in a lack of a therapeutic gold standard. Low level laser therapy (LLLT)/photobiomodulation therapy has been successfully used to treat a variety of medical conditions. Nevertheless, its merits in the treatment of (hand) OA remain controversial. The aim of the present study was to examine the longitudinal effect of LLLT on the three major hand OA symptoms-pain, swelling, reduced joint mobility-in patients suffering from Bouchard's and Heberden's OA. STUDY DESIGN/MATERIALS AND METHODS: Thirty-four patients (32 females) aged 61.21 ± 2.13 years were administered 5-10 LLLT sessions to 85 joints (47 proximal and 38 distal interphalangeal joints). Therapy took place twice a week. Pain (Visual Analogue Scale), ring size (perimeter in mm), and range of motion (extension/flexion) were measured at baseline and after five treatments for all patients, and additionally after seven sessions and 8 weeks after treatment ended for patients who received more than five and seven treatments, respectively. Eighteen patients (37 joints) received only five treatments, 10 patients (29 joints) were administered seven treatments, and six patients (19 joints) were administered 10 LLLT sessions. RESULTS: LLLT significantly reduced pain and ring size and increased range of motion after five and seven treatments (all P's < 0.001). The effects were very large (all η(2) 's > 0.14). No further significant change occurred between 7 and 10 treatments. The effects achieved after seven sessions persisted for 8 weeks. CONCLUSIONS: LLLT is a safe, non-invasive, efficient and efficacious means to reduce pain and swelling and to increase joint mobility in patients suffering from Heberden's and Bourchard's OA. Further randomized controlled studies are needed to examine medium- to long-term effects as well as the ideal LLLT parameters. Lasers Surg. Med. 48:498-504, 2016. © 2016 Wiley Periodicals, Inc.

Intra-Articular Therapies in the Treatment of Hand Osteoarthritis: A Systematic Literature Review.

BACKGROUND: Local treatments to alleviate symptoms in hand osteoarthritis (OA) are preferred, especially in elderly patients with comorbidities. Therefore, we have summarized the benefits and harms of intra-articular (IA) therapies. METHODS: We conducted a systematic literature review until May 2015, including all controlled trials investigating efficacy or safety of any IA therapy in carpometacarpal (CMC) and interphalangeal (IP) OA compared with placebo or other treatments. Two authors independently selected trials and assessed risk of bias using the Cochrane tool. The main efficacy outcome was pain. We performed meta-analysis where appropriate. RESULTS: A total of 13 trials (864 patients) studying CMC (n = 11) and IP OA (n = 2) were included, comparing corticosteroids or hyaluronic acid (HA) versus placebo (n = 4 and n = 3), and corticosteroids versus HA (n = 6). Single studies investigated infliximab, dextrose, and different HAs. The overall risk of bias was unclear or high in most trials. Meta-analysis of two trials comparing corticosteroids with placebo in CMC OA showed no improvement in pain [mean difference -3.56, 95 % confidence interval (CI) -13.87 to 6.75, scale 0-100). HA also appeared not efficacious compared with placebo in CMC OA. One trial comparing corticosteroids with placebo in IP OA demonstrated significantly improved pain during movement. No convincing evidence for efficacy of corticosteroids or HA over the other or alternative therapies was found. Only local adverse events were reported. No specific IA therapy appeared more harmful than another. CONCLUSION: Despite a beneficial short-term safety profile, IA corticosteroids or HA do not appear more effective than placebo in CMC OA. The suggestion that IA corticosteroids might be efficacious in IP OA requires confirmation.

Osteoarthritis year in review 2015: rehabilitation and outcomes.

OBJECTIVE: The purpose of this narrative review was to highlight recent research in the rehabilitation of people with osteoarthritis (OA) by summarizing findings from selected key systematic reviews and randomized controlled trials (RCTs). METHODS: A systematic search was conducted using the PubMed, Physiotherapy Evidence Database (PEDro) and Cochrane databases from April 1st 2014 to March 31st 2015. A selection of these is discussed based on study quality, relevance, contribution to new knowledge or controversial findings. Methodological quality of RCTs was assessed using guidelines from PEDro. RESULTS: From 274 articles, 74 were deemed to meet the eligibility criteria including 24 systematic reviews and 50 studies reporting on findings from RCTs. Overall the methodological quality of the RCTs was moderate. The studies were grouped into several themes covering; evidence of rehabilitation outcomes in less studied joints including the hand and hip; new insights into exercise in knee OA; effects of biomechanical treatments on symptoms and structure in knee OA; and effects of acupuncture. CONCLUSIONS: Exercise was the most common treatment evaluated. Although little evidence supported benefit of exercise for hand OA, exercise has positive effects for hip and knee OA symptoms and these benefits may depend upon patient phenotypes. The first evidence that a brace can influence knee joint structure emerged. The latest evidence suggests that acupuncture has, at best, small treatment effects on knee OA pain of unlikely clinical relevance.

Is there a role for Digital X-ray Radiogrammetry as surrogate marker for radiological progression and imaging of structural integrity in rheumatoid arthritis?

INTRODUCTION: The established scoring techniques based on radiographs present limitations in the evaluation of structural integrity due to high effectiveness of innovative therapeutic strategies. The aim of this study was to evaluate the periarticular mineralisation as detected by Digital X-ray Radiogrammetry (DXR) as surrogate marker for structural integrity during the course of rheumatoid arthritis (RA). METHODS: 11 centers throughout Germany contributed data of 94 patients with verified RA. The patients were treated with leflunomide or methotrexate during a mean observation period of 22 months. All patients underwent complete computerized calculations of bone mineral density (BMD) and metacarpal index (MCI) by DXR using digitized hand radiographs. The radiological assessment of disease progression was estimated by the Sharp Score. RESULTS: The Sharp Score revealed no significant change during the study period. DXR-BMD revealed minimal decrease of -1.4 % (leflunomide group) versus a higher reduction of -4.3 % (methotrexate group). Regarding DXR-MCI, a reduction of -2.2 % (leflunomide group) and -4.9 % (methotrexate group) was observed. CONCLUSION: Quantitative data of hand bone mass estimated by the presented DXR-technique may be a complementary precise tool in the identification of RA-related radiographic changes and in the assessment of structural integrity.

Effect of Time Interval Between Tumescent Local Anesthesia Infiltration and Start of Surgery on Operative Field Visibility in Hand Surgery Without Tourniquet.

PURPOSE: To determine the optimal time interval between tumescent local anesthesia infiltration and the start of hand surgery without a tourniquet for improved operative field visibility. METHODS: Patients aged 16 to 60 years who needed contracture release and tendon repair in the hand were enrolled from the outpatient clinic. Patients were randomized to 10-, 15-, or 25-minute intervals between tumescent anesthetic solution infiltration (0.18% lidocaine and 1:221,000 epinephrine) and the start of surgery. The end point of tumescence anesthetic infiltration was pale and firm skin. The surgical team was blinded to the time of anesthetic infiltration. At the completion of the procedure, the surgeon and the first assistant rated the operative field visibility as excellent, fair, or poor. We used logistic regression models without and with adjustment for confounding variables. RESULTS: Of the 75 patients enrolled in the study, 59 (79%) were males, 7 were randomized to 10-minute time intervals (further randomization was stopped after interim analysis found consistently poor operative field visibility), and 34 were randomized to the each of the 15- and 25-minute groups. Patients who were randomized to the 25-minute delay group had 29 times higher odds of having an excellent operative visual field than those randomized to the 15-minute delay group. After adjusting for age, sex, amount of tumescent solution infiltration, and duration of operation, the odds ratio remained highly significant. CONCLUSIONS: We found that an interval of 25 minutes provides vastly superior operative field visibility; 10-minute delay had the poorest results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Effects of mud-bath therapy in psoriatic arthritis patients treated with TNF inhibitors. Clinical evaluation and assessment of synovial inflammation by contrast-enhanced ultrasound (CEUS).

OBJECTIVES: Despite the efficacy of TNF inhibitors, most patients with psoriatic arthritis maintain a residual synovial inflammation. The main aim of the study was to evaluate the effects of mud-bath therapy on clinical picture of PsA patients treated with TNF inhibitors. The secondary outcome was to assess synovial inflammation in hand joints detected by contrast-enhanced ultrasound. Other aims were to verify the risk of arthritis flare and to evaluate the effects of spa treatment on functional ability and on quality of life. METHODS: Thirty-six patients with psoriatic arthritis, treated in the last 6 months with TNF inhibitors, were enrolled. After 1:1 randomisation, 18 patients (group A) underwent mud-bath therapy (12 mudpacks and 12 thermal baths), maintaining treatment with TNF inhibitors; 18 patients (group B) continued pharmacological therapy alone. CRP, PASI, DAS28, swollen and tender joint count, VAS pain, HAQ and SF-36 were evaluated at baseline (T0) and after 45 days (T1). Synovial inflammation detected by contrast-enhanced ultrasound, analysed by a software system, was also assessed. RESULTS: A significant improvement in PASI (P<0.005), DAS28 (P<0.05), swollen joint count and tender joint count (P<0.001), and HAQ (P<0.001) between T0 and T1 was observed in group A. No patient underwent a flare-up of arthritis. Ultrasound videos demonstrated a significant appearance delay (P<0.05) and faster washout (P<0.02) of contrast dye in group A patients with respect to group B. CONCLUSIONS: These data suggest a decrease of residual synovial inflammation and a beneficial clinical effect of spa therapy in psoriatic arthritis patients treated with TNF inhibitors.

Joint protection and hand exercises for hand osteoarthritis: an economic evaluation comparing methods for the analysis of factorial trials.

OBJECTIVES: Evidence regarding the cost-effectiveness of joint protection and hand exercises for the management of hand OA is not well established. The primary aim of this study is to assess the cost-effectiveness (cost-utility) of these management options. In addition, given the absence of consensus regarding the conduct of economic evaluation alongside factorial trials, we compare different analytical methodologies. METHODS: A trial-based economic evaluation to assess the cost-utility of joint protection only, hand exercises only and joint protection plus hand exercises compared with leaflet and advice was undertaken over a 12 month period from a UK National Health Service perspective. Patient-level mean costs and mean quality-adjusted life years (QALYs) were calculated for each trial arm. Incremental cost-effectiveness ratios (ICERs) were estimated and cost-effectiveness acceptability curves were constructed. The base case analysis used a within-the-table analysis methodology. Two further methods were explored: the at-the-margins approach and a regression-based approach with or without an interaction term. RESULTS: Mean costs (QALYs) were £58.46 (s.d. 0.662) for leaflet and advice, £92.12 (s.d. 0.659) for joint protection, £64.51 (s.d. 0.681) for hand exercises and £112.38 (s.d. 0.658) for joint protection plus hand exercises. In the base case, hand exercises were the cost-effective option, with an ICER of £318 per QALY gained. Hand exercises remained the most cost-effective management strategy when adopting alternative methodological approaches. CONCLUSION: This is the first trial evaluating the cost-effectiveness of occupational therapy-supported approaches to self-management for hand OA. Our findings showed that hand exercises were the most cost-effective option.

Ultrasound imaging of the trapeziometacarpal articular cavity to investigate the presence of intraarticular gas bubbles after chiropractic manipulation.

OBJECTIVE: The purpose of this study was to investigate the presence of intraarticular gas bubbles in the trapeziometacarpal joint cavity after chiropractic manipulation with audible cavitation and to assess the state of the gas bubbles after a 20-minute refractory period. METHODS: This investigation included 18 asymptomatic male and female participants between the ages of 21 and 26 years. High-resolution (15 MHz) sonograms of the trapeziometacarpal articular cavity were obtained by an experienced musculoskeletal ultrasonographer at 3 intervals: premanipulation, within 30 seconds postmanipulation, and at 20 minutes postmanipulation. The sonograms were saved as digital copies for subsequent reports that were correlated with reports compiled during dynamic visualization of the articular cavity. Data were extracted from the reports for analysis. RESULTS: The premanipulative sonograms showed that 27.78% of joints contained minute gas bubbles, also known as microcavities, within the synovial fluid before the joint was manipulated. The remaining 72.22% of joints contained no intraarticular microcavities. All of the postmanipulative sonograms revealed numerous large conspicuous gas bubbles within the synovial fluid. The postrefractory sonograms showed that, in 66.66% of the synovial fluid, gas bubbles were still visible, whereas the remaining 33.34% had no presence of gas bubbles or microcavities, and the synovial fluid had returned to its premanipulative state. CONCLUSION: The findings of this study suggest that synovial fluid may contain intraarticular microcavities even before a manipulation is performed. Numerous large intraarticular gas bubbles are formed during manipulation due to cavitation of the synovial fluid and were observed in the absence of an axial distractive load at the time of imaging. In most cases, these gas bubbles remained within the joint for longer than 20 minutes.