Validation of a novel smart drilling system to monitor bone impedance during transpedicular screw placement: a pilot study.

Transpedicular screw placement is a high-risk procedure routinely performed in spine surgery. To decrease the rate of complications, it is necessary to find innovative solutions to assist the surgeon during screw insertion so as to avoid the chance of mispositioning. In this study, we developed a new drilling system able to estimate the mechanical properties of drilled tissues. Several investigations show that cortical bone requires a high level of thrust force and torque during drilling compared to trabecular bone. To implement an algorithm for bony breakthrough detection, a new drilling system has been built together with a mechanical support to drill the pedicle along a pre-planned trajectory. The mechanical support is equipped with a smart rotative drill that embeds force and position sensors. Ten human vertebral segments have been used to test the surgical platform, for percutaneous bone drilling. 10 transpedicular holes from L1 to L5 have been performed bilaterally. The holes were further evaluated by computed tomographic scans to measure bone density in the cortical and in the trabecular layers. To compare bone density with the bony mechanical impedance two new parameters (DHU and DPAI) have been introduced. The results show that in 18 out of 20 cases the D values of bone density and mechanical impedance, related to the same bone transition, differ less than 10%. The proposed system is thus able to evaluate the variation of bone density of the cortical and the trabecular layer using impedance. Therefore, it is possible to use the described system to increase the accuracy of transpedicular screw placement.

Osseointegration for lower and upper-limb amputation a systematic review of clinical outcomes and complications.

The conventional use of prosthetic custom-design socket is affected by discomfort related to wellknown problems: sweating, sores or skin irritation, excessive weight and harness, impaired body image, that lead to a high rate of abandonment. Osseointegrated prosthetic implants for limb amputation are progressively evolving to overcome limitations of socket. The aim of this article is to present a systematic review of the use, safety in terms of rate of infection and complications, and reported outcomes of upper and lower limb osseointegrated prosthetic implants. A systematic search was carried out for studies that evaluated outcomes of osseointegration technique in case of upper and lower limb amputees according to the PRISMA guidelines with a PRISMA checklist and algorithm. MINORS score was used for methodologic assessment. 17 articles about the treatment of patients with upper or lower limb amputation treated with an osseointegrated prostesis were included. The overall rate of infections was 32%. All the clinical outcomes reported were related to lower limb. No clinical data for upper limb was found. The postoperative mean value of MCS and PCS SF-36 and Q-TFA was 55.1, 45.4 and 73.8 respectively, while six minute walk test (6MWT) and the timed up and go (TUG) test scored an average value of 388 meters and 11.5 seconds respectively. MINORS score ranged from 5 to 13, with a median of 11 [interquartile range (IQR), 9-11]. The osseointegration is associated to a high rate of postoperative complications but, significant improvement in clinical outcomes compared to preoperative time are shown. The data available from the literature are limited but suggest good clinical outcomes and significant survivorship of the implants. Further clinical studies are needed to establish which kind of implant is associated to higher clinical performance and lower rate of postoperative complications and infections.

Frailty of the elderly in orthopaedic surgery and body composition changes: the musculoskeletal crosstalk through irisin.

In recent years, scientific interest has been developed towards irisin, a novel molecule of the family of myokines, which is directly involved in body mass composition balance, chronic diseases susceptibility and physiologic resilience to stressful events, including surgery. In the context of musculoskeletal disease, the role of this molecule has been associated to the balance of lean and fatty mass, and the production of irisin is subordinated to a healthy lifestyle and exercise. The mechanism of action of irisin on tissues is complex, and several studies described the molecular pathways in animal model and human subjects. In particular, in adipose cells, the key-role of irisin is to stimulate the differentiation of white adipose tissue to brown adipose tissue, through the action on the uncoupling protein 1. Furthermore, in the bony tissue, irisin stimulates osteogenesis through expression of Sost and Opn genes. These features make irisin a suitable molecule to use as a biomarker of the overall musculoskeletal health of the elderly, before undergoing orthopaedic surgery. Further research on this topic should be carried out to highlight the possible clinical role and predictive value of irisin in a multidisciplinary approach to the elderly before musculoskeletal surgery.

Weil osteotomy for the treatment of grade III hallux rigidus: a case series.

Hallux rigidus (HR) is one of the most common pathologies of the forefoot. The conservative treatment is indicated for early stages, while surgical treatment is required for advanced osteoarthritis and rigidity. Surgical treatment of advanced stages of HR is still controversial and includes joint-destructive procedures such as arthrodesis and arthroplasty, Weil osteotomy for decompression of the joint space may be a safe and effective procedure for the treatment of grade III HR. Twenty-four patients that underwent Weil osteotomy for Grade III HR were retrospectively reviewed. American Orthopedic Foot and Ankle Score (AOFAS), ROM and a subjective 5-point satisfaction scale were evaluated preoperatively, at 1 year, and at a minimum follow-up of 2 years. Joint space width and metatarsal length were assessed through radiographic examination preoperatively, immediately postoperatively and at 2 years follow up. AOFAS score was 45.1±3.9 preoperatively, 84.9±6.4 at 1 year and 73.7±6.2 at two years of follow up. All patients were satisfied with the procedure at 2 years follow up. Mean ROM increased from 35.1° (range, 10°- 50°) preoperatively to 80.3° (range, 60°-90°) at 1 year. Mean dorsiflexion increased from 5° (range 0° to 10°) preoperatively to 15° (range 7° to 23°) at 1 year. Both total ROM and dorsiflexion values remained constant at 2 years. The joint space was 0.5±0.9 mm preoperatively, 2.0±1.9 mm at 1 year and 1.5±1.2 mm at 2 years. The average metatarsal shortening was 2±1.4 mm. Weil osteotomy alone can be beneficial for the treatment of patients affected by advanced HR. It can improve clinical and radiological outcomes at 2 years follow up in a series of patients affected by grade III HR. Therefore, the sliding oblique osteotomy represent a valid alternative to delay more aggressive procedures.

Adipose-derived stromal vascular fraction processed with different systems for the treatment of knee osteoarthritis: a pilot study on cell proliferation and clinical results.

In recent years, the interest in stromal vascular fraction (SVF) therapy for conservative treatment of osteoarthritis has grown significantly. This study aims to assess three different processing systems (micro-fragmentation, filtration, or slow centrifugation) in terms of cell proliferation in vitro and clinical results of intraarticular injections for the treatment of knee OA. From December 2017 to June 2018, 25 procedures were performed using three different systems. A considerable improvement of the clinical condition in almost all patients already one month after the treatment with a stable effect at 6 and 12 months was recorded. Patients treated with SVF, obtained by the micro-fragmentation system, had better outcomes one month after the treatment with a mean improvement of the symptomatology higher than that found in patients treated with the filtration or slow centrifugation system. The SVF product from the same system had a higher cell proliferation capacity in vitro.

Epidemiology of rotator cuff surgery in Italy: regional variation in access to health care. Results from a 14-year nationwide registry.

PURPOSE: Rotator cuff (RC) disease is frequent and represents a common source of shoulder pain. The aim of this study is to analyse geographical differences in RC surgeries from 2001 to 2014 in Italy, a country with universal and free health care for its population. METHODS: An analysis of the Italian National Hospital Discharge records from 2001 to 2014 was performed. These data are anonymous and include patient's age, sex, domicile, region of hospitalization, length of the hospitalization and type of reimbursement (public or private). National and regional population data were obtained from the National Institute for Statistics (ISTAT) for each year. RESULTS: During the 14-year study period, 390,001 RC repairs were performed in Italy, which represented a mean incidence of 62.1 RC procedures for every 100,000 Italian inhabitants. Nevertheless, the incidence was very different if every single regional population is considered individually. Lombardy resulted to have the highest number of surgeries during the 14-year study period, with 27.95% (108,954) of the total national procedures performed in the 2001-2014 time span. More than half the surgeries (52.00%) were performed in only 3 regions of the northern part of Italy. CONCLUSIONS: This study shows the existence of geographical disparities in access to RC surgery and patients' necessity to migrate among regions in order to obtain it. Southern regions of Italy are characterized by a lower number of surgeries compared to the northern part of Italy.

The combined use of platelet rich plasma and hyaluronic acid: prospective results for the treatment of knee osteoarthritis.

Osteoarthritis represents an important social economic burden with a high incidence worldwide. Conservative management of knee OA consists in several therapeutic options: pharmacologic therapy such as analgesics, non-steroid and steroid anti-inflammatory drugs, physical therapy, and injective therapy with hyaluronic acid (HA) and platelet-rich plasma injections (PRP). The aim of our study is to evaluate the effect of combined autologous PRP and HHA (Hybrid Hyaluronic Acid) viscosupplementation on clinical outcomes of patients with knee OA, by assessing the subjects before and after injective treatment. The study was conducted on 60 patients with an age between 40 and 70 years old affected by unilateral symptomatic knee osteoarthritis (stage II and III of Kellgren-Lawrence scale) nonresponsive to pharmacologic and rehab treatment. We divided the patients in two groups, and we treated the group A with injection of HHA and group B with HHA+PRP. Each patient received 3 injections at an interval of 1 week for 3 consecutive weeks. The patients were evaluated by the Knee Injury and Osteroartrhitis Outcome Score (KOOS) and Visual Analog Scale (VAS) at 3, 6 and 12 months after treatment. Statistical comparison between groups showed a significantly better result for the group B concerning the KOOS value, at 3 months and at 6 months. This difference, although clinically relevant, lost the statistical significance at 12 months. The VAS trend differently showed a significant difference at 3 and 12 months, while at 6 months the superiority of group B did not achieve statistical significance. Few studies investigated the effects of HA+PRP combined treatment for knee OA. Numerous studies demonstrated the efficacy of HA injection therapy in knee OA for a clinical point of view, reducing the pain and improving the quality of life. PRP preparations also improved functional outcome scores compared to hyaluronic acid and placebo in patients affected by knee OA. Based on our results we can conclude that the combined PRP and HHA treatment is not only a safe and efficacious procedure which can provide functional benefit but is also significantly better than HHA injective therapy alone, as demonstrated by the comparison within our cohort.

Sport activity as risk factor for early knee osteoarthritis.

There is wide discussion about the association between sport activity and musculoskeletal disorders, as sports-related joint loading increases the risk of osteoarthritis (OA). The present article reviews the current available literature on the connections between participation in several sports and athletic activities and prevalence of knee OA, especially focusing on early knee OA. The study was based on an electronic search through web databases including Medline, Cochrane and Google Scholar. Articles were retrieved and evaluated, and case series, retrospective studies, case-control studies, prospective cohort studies and randomized controlled trials were considered for inclusion. The main data were extracted and summarized in tables and text. Athletic individuals do show an increased prevalence of knee OA, especially for professional athletes when compared to general population or non-professional athletes. Furthermore, several features related to sport activity were associated to increased risk of early knee OA, such as knee ligamentous injury, concussion, high-impact sports and different team roles. Methodology and results of the included studies are barely comparable, thus preventing the authors to carry out an accurate and systematic comparison of the results of the included studies. Only low level evidence studies are available, and better designed studies, with radiological and functional evaluation of the knee based on internationally validated measures, should be planned. Also, follow-up of patients during and after their life-period of sport involvement should be considered.

Advances in management of periprosthetic joint infections: an historical prospective study.

OBJECTIVE: The purpose of our study is to assess the incidence of prosthetic joint infection (PJI) after total Knee arthroplasty (TKA), total Hip arthroplasty (THA) and total Shoulder arthroplasty (TSA), to identify risk factors, determine the microbial spectrum and management's outcome. PATIENTS AND METHODS: A case-control, retrospective observational study was performed analyzing patients who developed a PJI after TKA, THA, and TSA from 2000 to 2017 at our hospital. The patient's risk profile was defined extracting from clinical records the following data: sex, age, BMI, type of implant, comorbidity, year of surgery, year of infection, previous intra-articular injection, microbial isolation, medical and surgical management outcome. We include in the "control group" for each "case" at least 3 patients who didn't have a PJI after TJA. RESULTS: 28 patients met all inclusion and exclusion criteria. Comparing the "cases" with "controls" demographics parameters, medical comorbidities and previous intra-articular injection were not associated with an increased risk of PJI. Comparing the "early/delayed group" with "late group", BMI was associated with an increased risk of early/delayed PJI, while demographics parameters, medical comorbidities, and previous intra-articular injection did not significantly increase the risk of PJI. Logistic regression showed that for each BMI unit there was a 20-fold increased risk of early prosthetic infection (OR 1.19, IC 1.03-1.38, p=0.01). Staphylococci were isolated most frequently from pre-operative and intra-operative cultures. Two-stage arthroplasty exchange and surgical debridement resulted in the most performed surgical treatment with a success rate of 88 and 87%. CONCLUSIONS: Obesity is a risk factor for "early/delayed infection" of TJA. Two-stage arthroplasty exchange, debridement, antibiotics, and implant retention in patients are treatments with a high rate of success in terms of reinfection.

Infection after spinal surgery and procedures.

Postoperative infections after spinal surgery are a challenging issue, difficult to diagnose and treat, that requires prolonged medical therapy and even surgery. In this paper, we aim to review the current standards in the diagnosis and treatment of post-procedural Spondylodiscitis (SD). We performed a review of the available literature focusing on diagnostic and therapeutic standards of post-procedural SD, both after minimally invasive procedures and open surgery. Spinal infections can occur in less invasive procedures with an incidence ranging from 0.26% to 2.75%. Post-surgical spinal infections range from 2.1% to 8.5% for instrumented surgery, whereas these are less than 1% in open surgery without instrumentation. MRI is currently the most sensitive and specific technique to diagnose postoperative SD. CT guided aspiration culture should be performed in all patients with deep-seated infections with negative blood cultures. Early infections start with wound healing problems within a few weeks from surgery, and the occurrence of fever and an increase in serum markers of inflammation. Late infections often cause chronic pain, implant failure, non-union or wound dehiscence even a long time after surgery. The onset of the infection differentiates the specific treatment. Indeed, in the early postoperative period spinal fusion is not appropriate yet, and the stability of the fusion site only relies on the instrumentation. Therefore, even when suitable, implant removal may lead to undesirable consequences. In chronic infections, on the other hand, implant removal is unlikely to determine instability since the fusion has already been accomplished.

Outcomes of neck modularity in total hip arthroplasty: an Italian perspective.

BACKGROUND: The aim of this study is to conduct a systematic review of clinical outcomes and complications of modular neck THA among Italian cohorts. METHODS: Only reviewed publications focused on Italian cohort patients in English language were considered for inclusion. Studies were included if they involved patients who underwent total hip replacement surgery with modular necks, and reported aetiology or survival rate or bone stability or clinical scores or complications. RESULTS: The studies included in our search reported data on 3714 patients and 3856 hips. Most of the studies were from high-volume surgery centres. The most frequent diagnosis was osteoarthritis that occurred in 2910 cases (75.9%). The average survival rate and average bone stability were 97.20% and 99.37%, respectively. The average HHS improved from 42.1 prior to surgery to 89.52 after surgery. Studies included in our search reported 40 complications. The most frequently reported complication was dislocation (40%). CONCLUSION: This review showed excellent survival rate and bone stability and good clinical outcomes in Italian cohort patients treated with modular neck THA, and these clinical results are comparable with international cohort rates. This review suggests that modular implants represent a very satisfying choice when practised by expert orthopaedic joint surgeons.

Frozen shoulder or shoulder stiffness from Parkinson disease?

PURPOSE: To understand the role of camptocormia (increased kyphosis) and postural alteration in Parkinson's disease in the development of shoulder pathology, with a special concern for adhesive capsulitis and shoulder stiffness. METHODS: A preliminary online search was carried out, with combination of keywords including "Parkinson," "Shoulder stiffness," "Frozen shoulder," "Adhesive capsulitis," "Postural alteration," "Camptocormia". The retrieved papers were screened by title and abstract and those considered relevant to the aim of the review were read in full text and included. Relevant information were extracted and reported into text. RESULTS: Due to a severe impairment of posture, patients affected by PD show an increased thoracic kyphosis (camptocormia) and decreased mobility of the trunk that can yield a humeroacromial impingement syndrome and capsulitis, resulting in inflammation of the bursa, shoulder pain and reduction of movement. Furthermore, kinematic of the shoulder is allowed by the combined movement of the humerus, the scapula, the clavicle, the thoracic wall and thoracic spine. The thoracic spine and wall mobility are severely impaired in the parkinsonian patient, thus limiting the shoulder motion. CONCLUSION: The postural alteration observed in PD is the primum movens for shoulder pathology, since anterior tilt of the scapula, which occurs with the increment of thoracic kyphosis, yields to a subacromial impingement. A closed loop is then created, as the rigidity of the shoulder causes further alteration in the posture, which worsens the impingement syndrome and so on.

Targeting VEGF-A in cartilage repair and regeneration: state of the art and perspectives.

Osteoarthritis (OA) is the most common joint disorders in western populations, and is characterized by a progressive degradation of articular cartilage (AC) leading to loss of joint function. Methods to cure, delay or prevent the onset of OA and/or improve AC repair strategies have high clinical and socioeconomic impact. Possible innovative strategies envisioned for early OA treatments or cartilage repair include the implantation/injection of mesenchymal progenitors (MPs)-based constructs or cell-free bioactive scaffolds/hydrogel coupled with the controlled recruitment and instruction of resident MPs or AC. However, these tissue engineering-based strategies still suffer from unreliable outcomes with poor fibro-cartilaginous repair and blood vessel invasion. In such conditions Vascular Endothelial Growth Factor (VEGF) family has been shown to play a key role in controlling AC catabolism on one hand and angiogenesis on the other as a crucial step for endochondral ossification of MPs, ultimately leading to progressive breakdown of the neo-formed matrix. This review aims to provide a summary of relevant relationships between impaired angiogenesis, OA and cartilage regeneration highlighting how VEGF might play a paramount role in the pathophysiology of cartilage aging or degeneration as well as in cartilage repair.

Failed back surgery syndrome: a new strategy by the epidural injection of MESNA.

PURPOSE: Evaluate the efficacy and safety of MESNA (sodium 2-mercaptoethanesulfonate) injection into the epidural space in the FBSS. METHODS: We designed a prospective phase II longitudinal study. Six consecutive patients were enrolled. Patients underwent one peridural injection per week for 3 weeks. NRS and ODI were investigated before and 48 h after injections, and at 1 week, 1 month and 2 months after the last procedures. Opioids intake is investigated before procedures and 1 week, 1 month and 3 months after the last procedures. Lumbosacral MRI is performed before the first procedure, at the end and 3 months after the last procedures. RESULTS: From baseline, at 3 months, NRS in standing, sitting and lying position improved, respectively, of 34.29, 30.56 and 26.47%; ODI improved of 20.3%; the average decrease in morphine intake was 20.54%. No difference in MR images was found. Conclusions Our preliminary results suggest that MESNA might be an efficacy alternative to common practice.

A new surgical positioning system for robotic assisted minimally invasive spine surgery and transpedicular approach to the disc.

Minimally Invasive Spine Surgery (MISS) procedures for the treatment of spinal pathologies have experienced exponential growth due to improved techniques and decreased trauma to the patient. Several MISS procedures that require the use of a trans-pedicular cannula as a guiding tool for pedicle screw placement, delivery of biomaterials to the vertebral body or injection of biologics to the disc space have been described. Although these are clear advantages of MISS, the limited dissection and exposure may reduce the accuracy and stability of operation and make spine surgeons rely heavily on intraoperative fluoroscopy, raising concerns over the level of radiation exposure. Robot-assisted minimal invasive surgery has aroused more attention for its high precision and stability, minimizing risks of damage to neurovascular structures and diminishing harmful exposure to ionizing radiation. The aim of this paper is to describe and characterize a new surgical positioning system for for robotic assisted MISS. The system is conceived to be integrated in a surgical platform capable of supporting the surgeon in a new procedure to treat degenerative intervertebral disc disease. For this purpose, it is necessary to orientate a cannula in order to guide the bone drill along a planned route, to access the intervertebral disc through the pedicle and endplate. In particular, we describe a mechanism that percutaneously guides a cannula towards the intervertebral disc based on the acquisition of few fluoroscopic images. The design of the positioning system, with its features and constrains imposed by the presence of instrumentation and medical staff in the operating room, as well as the software for trajectory planning during surgery, are here described.

Posterolateral bundle reconstruction of the anterior cruciate ligament to restore rotational stability of the knee.

Only 5-10% of partial tears of the anterior cruciate ligament (ACL) are symptomatic, especially in high demand individuals or in patients practicing sports requiring rotational motions.. A certain preoperative diagnosis of this condition is challenging and often needs the combination of clinical examination, magnetic resonance imaging (MRI) and knee-laxity tool measurements. However, the arthroscopic examination of the torn ACL bundle is the most important factor in decision-making. Evidence in various studies have shown that the preservation of the ACL remnant and its surgical augmentation can bring important advantages in terms of vascularity and proprioception, resulting in better outcomes. The purpose of our paper was to describe the surgical technique of arthroscopic posterolateral (PL) bundle reconstruction with the preservation of the anteromedial (AM) bundle for ACL partial tears. Moreover, we reported the current knowledge about rationale, diagnosis and treatment of partial tears of ACL.

Targeted muscle reinnervation for improved control of myoelectric upper limb prostheses.

Targeted muscle reinnervation (TMR) is a novel surgical technique developed to improve the control of myoelectric upper limb prostheses. Nerves transected by the amputation, which retain their original motor pathways even after being severed, are redirected to residual denervated muscles that serve as target for consequent reinnervation. Once the process is complete, reinnervated muscles will contract upon voluntary activation of transferred nerves while attempting to move missing regions of the amputated limb, generating EMG signals that can be recorded and used to control a prosthetic device. This allows creating new control sites that can overcome major drawbacks of conventional myoelectric prostheses by offering a more natural and intuitive control of prosthetic arms. TMR has been widely performed in individuals who underwent shoulder disarticulation amputation and transhumeral amputation since proximal amputations do not leave enough functional muscles exploitable to control independent degree of freedoms of multi-articulated prostheses. TMR application is currently under investigation in patients suffering further distal amputations, as well as for treating and preventing painful post-amputation neuromas. The purpose of this paper is to describe the physiologic basis and the surgical technique of TMR, reporting current knowledge on the clinical results.

The use of hyaluronic acid in the treatment of shoulder capsulitis: a systematic review.

Adhesive capsulitis (AC) is a common pathological condition of the shoulder characterized by painful restriction of range of motion (ROM) of the glenohumeral joint. Currently, no consensus has been reached regarding the best treatment. Hyaluronic acid (HA) injection is a safe procedure that can result in significant improvement in active and passive ROM, alleviating pain and improving shoulder function. We systematically reviewed current literature in order to evaluate the best evidence about the effectiveness of intra-articular HA injection for the treatment of primary AC. We searched Medline, CINAHL, Embase, Google Scholar and Cochrane Library. We selected studies comparing clinical outcomes of patients treated with HA in association or not with conventional therapy. Seven studies were evaluated: 2 uncontrolled randomized studies and 5 prospective randomized clinical trials with level of evidence I. Clinical outcome measures used included, among other, ROM, Visual Analogic Scale (VAS) pain scores, Constant score, Activity of daily living, Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) and Japanese Orthopedic Association Score (JOA score). Improvement was noted in terms of ROM, constant scores and pain in patients affected by AC treated with intra-articular HA injections. When compared with cortisone intra-articular injection, HA has equivalent clinical outcomes and ROM. The heterogeneity of treatments used in the studies reviewed, makes it difficult to draw a definite conclusion on the subject. HA injections do not seem to determine the final outcomes directly compared with conventional treatments. However, they could play an important role for early mobilization in the initial stages, during which, due to pain and inflammation, the patient keeps the shoulder immobilized for a long time, determining the direct cause of AC. Numerous variables, including use of lidocaine, different HA and AC stages, could influence the results and deserve to be accounted for in future investigations.

Meniscal extrusion as booster of osteoarthritis.

Meniscal extrusion (ME) has shown to play a critical but still unclear role in osteoarthritis (OA) development. ME has been described as an important risk factor in the progression of knee OA, as it is involved in the thinning of articular cartilage, joint space narrowing, spontaneous osteonecrosis of the knee and subchondral bone marrow lesions. Meniscal damage of any degree of severity could cause ME in both compartments, but it is commonly associated with severe meniscal tears or root tears mainly in the medial meniscus. Magnetic resonance imaging is the most commonly used imaging modality in the assessment of ME, while ultrasonography may represent a valid alternative with high sensitivity and specificity. Conservative treatment for ME includes physical therapy and rehabilitation to maintain range of motion, corticosteroid injections and intra-articular injections of hyaluronic acid to provide short-term relief of knee pain. The goal of this study is to review standards of current diagnosis and treatment of ME and its relationship to knee OA.

Intrarticular injections of hyaluronic acid for trapezio-metacarpal osteoarthritis: a systematic review.

Osteoarthritis (OA) of the base of the thumb, also known as Trapezio-Metacarpal (TM) OA, is a disabling condition, which mainly affects women and manual workers. When TM OA is not adequately treated, patients develop deformity and loss of function of the thumb. The surgical approach is a widespread strategy to treat this condition, but there is still no consensus on the most effective procedure. Therefore, several conservative strategies are commonly used, such as nonsteroidal anti-inflammatory drugs (NSAIDs) administration, thumb strengthening exercise, splinting, steroid (CS) and hyaluronic acid (HA) intrarticular injections. The present review of the literature aims to summarize the available scientific evidence on the treatment of TM OA with injections of HA. Thirteen studies were included: 7 randomized controlled trials, 5 case series and a case-control study. Among these, 5 studies compared HA versus CS injection. Results from most of them reported better outcomes with HA injections in terms of function (strength) and joint motion, while CS injections had greater effect on pain; moreover, CS action was faster but shorter, while HA required more time to obtain a therapeutic benefit and lasted longer. In non-comparative articles, this trend was also confirmed. Indeed, the authors reported an improvement in pain relief up to six months. Similarly, all studies indicated hand function improvement over time, measured though DASH score, pincher and grip strength tests. Available data from included studies show that there is no clear evidence to suggest a treatment with HA injections as the best advisable non-operative treatment for TM OA. However, promising potentials were shown by the randomized controlled trials, suggesting that there is some benefit and less comorbidities with the administration of HA. Further research, such as trials evaluating larger cohorts with validated scores for long-term follow-up, is still necessary.