Treatment of Trigger finger by ultrasound-guided needle release of a1 pulley: A series of 105 cases.

INTRODUCTION: We aimed to evaluate the efficacy and tolerance of A1 pulley release using the needle technique, under ultrasound guidance, in patients with symptomatic trigger finger. METHODS: All patients with symptomatic trigger finger underwent A1 pulley release using an intramuscular 21 gauge (G) needle. Quinnell grade (I-IV), Quick Disabilities of Arm, Shoulder & Hand (QuickDASH) score (0-100) and pain score on a visual analog scale (VAS: 0-10mm) were recorded at inclusion. The primary endpoint was complete resolution of the trigger finger at 6 months. RESULTS: Eighty-four patients totaling 105 treated digits were included. Mean age was 63.3±10.7 years. Prior to treatment, mean VAS pain score was 5.8±2.6mm, and mean QuickDASH score was 44.3±19.1. At 6 months, disappearance of symptoms was achieved in 85 of 91 digits with follow-up (93.4%), and in 85.7% at 12 months. The absolute reduction in VAS pain and QuickDASH scores at 6 months was respectively 4.1±3.1 (P<0.001) and 36.1±20.7 (P<0.001), and 90% of patients reported being satisfied or very satisfied at 6 months. Long duration of symptoms was significantly associated with persistent trigger finger at 6 months after intervention. Complications were rare and minor. Tenosynovitis occurred in 5.7% of cases, for which a corticosteroid injection into the tendon sheath rapidly led to favorable resolution. CONCLUSION: Treatment of trigger finger by release of the A1 pulley under ultrasound guidance using the needle technique is a mildly invasive technique that yields rapid and effective symptom resolution with good tolerance up to 12 months.

Recommendations of the French Society of Rheumatology on pharmacological treatment of knee osteoarthritis.

OBJECTIVES: To establish recommendations for pharmacological treatment of knee osteoarthritis specific to France. METHODS: On behalf of the French Society of Rheumatology (SFR), a bibliography group analyzed the literature on the efficacy and safety of each pharmacological treatment for knee osteoarthritis. This group joined a multidisciplinary working group to draw up recommendations. Strength of recommendation and quality of evidence level were assigned to each recommendation. A review committee gave its level of agreement. RESULTS: Five general principles were established: 1) need to combine pharmacological and non-pharmacological treatments, 2) personalization of treatment, 3) symptomatic and/or functional aim of pharmacological treatments, 4) need to regularly re-assess the treatments and 5) discussion about arthroplasty if medical treatment fails. Six recommendations involved oral treatments: 1) paracetamol should not necessarily be prescribed systematically and/or continuously, 2) NSAIDs, possibly as first-line, 3) weak opioids, 4) strong opioids, 5) symptomatic slow-acting drugs of osteoarthritis, and 6) duloxetine (off-label use). Two recommendations involved topical agents (NSAIDs and capsaicin<1%). Three recommendations involved intra-articular treatments: corticosteroid or hyaluronic acid injections that can be proposed to patients. The experts did not draw a conclusion about the benefits of platelet-rich plasma injections. CONCLUSION: These are the first recommendations of the SFR on the pharmacological treatment of knee osteoarthritis.

Safety and Predictive Factors of Short-Term Efficacy of a Single Injection of Mannitol-Modified Cross-Linked Hyaluronic Acid in Patients with Trapeziometacarpal Osteoarthritis. Results of a Multicentre Prospective Open-Label Pilot Study (INSTINCT Trial).

PURPOSE: To assess safety and search predictive factors of efficacy of a single intra-articular injection of a mannitol-modified hyaluronic acid (HA) viscosupplement, in patients having trapeziometacarpal (TMC) osteoarthritis (OA). METHODS: Patients with symptomatic TMC OA, not adequately relieved by analgesic therapy and/or by the use of a thumb splint, were included in a 3-month prospective multicentre open-label trial. All underwent plain radiographs with the Kapandji incidences allowing the Dell radiological grade assessment (1-4). Primary end point was the variation between injection (D0) and day 90 (D90) of the thumb pain (11-point Likert scale). Treatment consisted in a single injection of 0.6 to 1 mL of a viscosupplement made of a cross-linked HA combined with mannitol. All injections were performed under imaging guidance. Predictive factors of pain decrease were studied in univariate and multivariate analysis. RESULTS: A total of 122 patients (76% women, mean age 60, mean disease duration 36 months) were included and 120 (98%) were assessed at 3 months. The TMC OA was of Dell's grade 1, 2, 3, and 4 in 23%, 36.8%, 36.8%, and 3.5% of cases, respectively. At D0, the average (SD) pain level was 6.5 ± 1.6 without significant difference between Dell groups (P = .21). At day 90, pain decreased from 6.5 ± 1.6 to 3.9 ± 2.5 (difference -2.7 ± 2.5; -42%; P < .0001) without significant difference between Dell grade (P = .055), despite a seemingly smaller number of responders in stage 2 patients. The average analgesic consumption decreased in more than 1 out of 2 patients. In multivariate analysis, no predictor of response was identified. There was no safety issue. All adverse events (11%) were transient increase in pain during or following HA administration and resolved without sequel within 1 to 7 days. CONCLUSIONS: This study suggests that a single course of HANOX-M-XL injection is effective in relieving pain in patients with TMC OA, without safety concern. Patients with advanced stage of OA benefit the treatment as much as those with mild or moderate OA.

Hip Inflammation MRI Scoring System (HIMRISS) to predict response to hyaluronic acid injection in hip osteoarthritis.

OBJECTIVE: To assess predictors of response, according to hip MRI inflammatory scoring system (HIMRISS), in a sample of patients with hip osteoarthritis (OA) treated by hyaluronic acid (HA) injection. METHOD: Sixty patients with hip OA were included. Clinical outcomes were assessed at baseline and three months after HA injection by WOMAC. On hip MRI performed before HA injection, bone marrow lesion (BML) and synovitis were assessed by HIMRISS by four readers. The inter-reader reliability of HIMRISS was for HIMRISS total, acetabular BML, femoral BML and synovitis-effusion respectively 0.86, 0.64, 0.83 and 0.78. Associations between MRI features and clinical data were assessed. Logistic regression (univariate and multivariate) was used to explore associations between MRI features and response to HA injection, according to WOMAC50 response at three months. RESULTS: In total, 45.5% of patients met WOMAC50 response. Five adverse events were reported. At baseline, WOMAC function correlated significantly to HIMRISS synovitis-effusion (r=0.27, P=0.03). In univariate analysis, BML femoral according to binary assessment (P=0.025), HIMRISS BML femoral (P=0.0038), HIMRISS BML acetabular (P=0.042), HIMRISS total (P=0.0092) were associated negatively with WOMAC50 response. In multivariate analysis, adjusted for age and BMI, HIMRISS femoral BML (P=0.02) and HIMRISS total (P=0.016) were negatively associated with response. At a HIMRISS threshold of<15, 82% of patients were responders, with specificity SP=0.97, sensitivity SN=0.39, and positive and negative predictive values of 0.91 and 0.64, respectively. CONCLUSION: HIMRISS is reliable for total scores and sub-domains. It permits identification of responders to HA injection in hip OA patients.

Predictors of response to viscosupplementation in patients with hip osteoarthritis: results of a prospective, observational, multicentre, open-label, pilot study.

BACKGROUND: To identify predictive factors of response to viscosupplementation (VS) in patients with hip osteoarthritis (HOA). METHODS: Prospective, multicentre, open-label trial, achieved in daily practice conditions. Patients with HOA were treated with a single intra-articular injection of a cross-linked hyaluronic acid combined with mannitol (HAnox-M-XL), using imaging guidance. WOMAC pain and function scores and patient global assessment (PGA) were assessed at baseline and day 90. Improvement, satisfaction and efficacy were self-assessed at day 90. Hip radiographs at baseline were scored using Kellgren-Lawrence grade and Osteoarthritis Research Society International (OARSI) score. Associations between clinical and radiological features and response to VS (pain improvement > 50% at day 90) were assessed in univariate analysis, and then using logistic regression, adjusted for confounding factors. RESULTS: The intent-to-treat (ITT) population included 97 patients (57 females, mean age 63). Ninety completed the follow-up and 80 had full clinical and radiological data. Response to VS was achieved in 47.8% of patients. In univariate analysis, the only clinical outcome statistically and negatively related to response was PGA at baseline (p = 0.047). Radiologically, response to VS was negatively correlated with joint space narrowing (JSN) score (JSN < 2 vs. JSN ≥ 2, p = 0.01) and was related to the patterns of femoral head migration (p = 0.008). In multivariate analysis, only JSN grade (p = 0.03) remained significantly related to a poor response. CONCLUSION: This pilot study, which needs further confirmation by larger scale trials, suggests that radiological features might be of importance for the decision of VS in patients with HOA. TRIAL REGISTRATION NUMBER: ID RCB N°2013-A00165-40. Registered 31 January 2013.

Needle aponeurotomy in Dupuytren's disease.

Needle aponeurotomy (NA) is recommended as a nonsurgical treatment for Dupuytren's disease. The aim of the procedure is to cut the Dupuytren's cord by use of the bevel of a needle and to restore full extension of the metacarpophalageal or proximal interphalangeal joints. According to Lermusiaux's standard, NA is performed in an outpatient setting, with the patient under local anesthesia. It entails the use of a 25-gauge, 16 mm-long needle and an anesthetic mixture of lidocaine and acetate of prednisolone. Various modifications have been proposed since the description of Lermusiaux's standard. Lermusiaux's and modified standards demonstrated structural efficacy in Dupuytren's disease. Clinical studies indicate that the mean rate of good structural results of NA is 80% at short-term assessment and 69% at 5-year assessment. Most of the studies are case series and only one is a randomized trial. Better results are demonstrated in early stages of the disease. NA also reduces disability and patients are highly satisfied. The short-term results with Lermusiaux's standard do not appear to be impaired in digital involvement. This is not the case for modified standards providing better results with palmar involvement. Lermusiaux's standard appears to provide less recurrences and less adverse events. In the largest study, skin fissure was observed in 8% of hands, transient dysesthesia in 3%, local infection in 0.7%, and flexor tendon rupture in 0.2%. Values were lower if related to NA sessions or NAs during each session. We therefore recommend Lermusiaux's standard for safe and effective NA in patients with Dupuytren's disease.

Multi-needle aponeurotomy for advanced Dupuytren's disease: preliminary results of safety and efficacy (MNA 1 study).

AIM: To assess the safety and efficacy of multi-needle aponeurotomy (MNA) for advanced Duputren's disease. METHODS: This prospective study included patients with age more than 17 years, Dupuytren's contracture with palmo-digital or poly-digital involvement, presumed NA number needed to treat>4, and availability for at least 1-month follow-up after MNA. Outcome measures were Tubiana score and passive extension deficit, after MNA and at 1 and 6 months; self-assessed disability and satisfaction at 1 and 6 months; and adverse events (AEs). RESULTS: Thirty patients were included. MNA was performed on 37 hands and 99 rays. Among 25 assessed MNA sessions for treatment-related discomfort, patients considered 22 (88%) not at all to moderately painful. Six minor AEs, representing 2 for every 100 NAs, were reported. Tubiana scores at baseline (5.3±2.3, n=35) were improved after treatment (1.7±1.8, n=32, P<0.0001), at 1 month (2.2±1.4, n=26, P<0.0001) and at 6 months (2.8±2.7, n=19, P<0.01). Passive extension deficit was greatly reduced after treatment and persisted at follow-up. Disability scores at baseline (27.6±26.9, n=37) were reduced at 1 month (13.2±19.5, n=26, P=0.02) and at 6 months (5.2±11.6, n=20, P<0.001). Patients were highly satisfied at 1 month (100%, n=25) and 6 months (95%, n=19). CONCLUSION: MNA appears safe and effective for advanced Dupuytren's disease. It could become a treatment of reference and contribute to reducing the need for surgery in this indication.

[Dupuytren's contracture: surgery is no longer necessary]. / Maladie de Dupuytren: la chirurgie n'est plus obligatoire.

Dupuytren contracture or disease of the hand is the retraction of the palmar aponeurosis. Its course is progressive and leads to an irreducible flexion deformity of one or more fingers. Early diagnosis is necessary for the table test, which determines the need for treatment. Needle aponeurotomy should be the first option treatment. This minimally invasive outpatient procedure minimizes sick leave and does not require immobilization or physical therapy. Several studies confirmed the short- and intermediate-term effectiveness of this treatment and the minimal side effects when performed by experienced operators. Multiple procedures for extensive disease (several knots) can be performed in the hospital. Close medical and surgical collaboration is necessary for treatment of severe forms, treatment failures, and multiple recurrences.