Shamma Ahmad Al-Nokhatha, MD^1,2,3*; Sinead Maguire, MD¹; Luke Corcoran, MD¹; Neil Mac Eoin, MD¹; Richard Conway, MB BCh BAO, PhD, CCD, FRCPI¹; Ciaran Johnson, MB, FFR RCSI, FRCR (UK)⁴

(1) Department of Rheumatology, St. James’s Hospital, Dublin, Ireland

(2) Department of Rheumatology, Tawam Hospital, Al Ain, United Arab Emirates

(3) College of Medicine and Health Sciences, UAE University, Al Ain, United Arab Emirates

(4) Department of Radiology, St. James’s Hospital, Dublin, Ireland

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Download article PDF – POCUS Journal 2023; 8(2):230-236.

DOI: https://doi.org/10.24908/pocus.v8i2.16594

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Abstract

Background: Osteoarthritis is a debilitating degenerative disease more pronounced in elderly affecting many joints. The first carpometacarpal joint (CMC1) is commonly affected. Pain is the major complaint, which can impact patient’s daily activities. Intra-articular glucocorticoid injection can be considered if conservative measures fail and ultrasound guided injection might be superior to the traditional anatomic landmark-guided technique. Objective: The aim of this study is to evaluate the effectiveness of ultrasound-guided versus landmark-based approach to intra-articular CMC1 injection using the Australian Canadian osteoarthritis hand index (AUSCAN). Methods: Adult patients diagnosed with symptomatic CMC1 osteoarthritis who failed conservative measures were enrolled. In this prospective observational cohort study, utilizing a convenience sample, intra-articular corticosteroid injection was administered either by ultrasound-guided technique or landmark-based approach. Pain, stiffness and function in 10-points scale at baseline, 6 and 12 weeks were collected and analyzed using descriptive analysis. Results: There were 33 patients enrolled. Mean age was 63 years, with females making up the majority of participants (n = 28, 84.8%). Mean duration of CMC1 pain was 10 months (SD=2.5) up to the point of receiving the injection.  Ultrasound guided injection was performed in 60.6% (n=20), while 39.4% (n=13) had the landmark approach. Both groups achieved a statistically and clinically significant level of change in AUSCAN score at week 6 (P≤ 0.05) but with a recurrence of symptoms at week 12 (P ≤ 0.05). At both intervals the AUSCAN scores were better than baseline (P ≤ 0.05). There was no difference between the two groups regarding baseline pain VAS score (mean ultrasound group= 6.6 vs landmark group= 7.5; P = 0.18). No significant differences were identified between two groups in terms of changes from baseline to 6, 12 and between 6 to 12 weeks in pain, stiffness and hand function (P > 0.05). Conclusion: No difference was found between the ultrasound-guided and landmark-based approaches for CMC1 injection on pain score, stiffness, or function.

Background

Osteoarthritis (OA) is a debilitating degenerative disease that affects many joints. The carpometacarpal is one of the commonly affected sites (Figure 1). Pain in particular is a major component and this can significantly impact patients’ activities of daily living [1]. The prevalence of symptomatic thumb OA as recorded by the Framingham study is 2.7% and 5% for males and females, respectively. More recent studies have reported a prevalence of erosive OA of the first CMC (CMC1) of 2.2% [2,3]. According to the recent 2019 American College of Rheumatology and Arthritis Foundation guidelines, in patients who fail non-pharmacological management, medication can be considered, among which intra-articular glucocorticoid injection is noted to be more efficacious in comparison to other compounds. Ultrasound (US) guidance can facilitate the accuracy at the target point, which may improve outcomes [4]. The aim of this study is to evaluate the effectiveness of ultrasound-guided compared to landmark-based intra-articular injection of CMC1.

Methods

A prospective, observational cohort study was conducted at St James’s hospital in Ireland between January and July 2021. The study employed a convenience sample, comprising patients from the dedicated patient lists of two expert doctors who routinely perform therapeutic injections. Ethical approval was obtained from the St James’ and Tallaght Hospital Joint Ethics Committee. To be included the following inclusion criteria was required of all participants: adults (aged ≥18 years) diagnosed with symptomatic first CMC osteoarthritis with Eaton-Littler stage 2 and greater [5] who had failed conservative measures such as anti-inflammatory treatment and occupational therapy, with or without splint usage). Those who had received a glucocorticoid injection in the past three months were excluded. All injections consisted of 20mg of depomedrone with a local anesthetic (0.5 ml 1% lidocaine). One of two techniques were performed: the landmark approach, which involved identifying the anatomical landmarks for the carpometacarpal joint, and the ultrasound-guided technique  (using GE Logiq P9 machine). Demographic, smoking history and employment data were collected at the time of injection. Participants completed the Visual Analogue Scale (VAS) for pain severity assessment (range: 0-10) and the Australian Canadian Osteoarthritis Hand Index (AUSCAN) questionnaire, which assessed hand pain, stiffness and function on a scale of 0 to 10. This questionnaire was completed by all participants at baseline, 6 weeks and 12 weeks, which aligns with the average duration of injection’s effect [6,7].

Statistical analysis

Data were entered into JASP software and then were analyzed. The efficacy of the two methods were compared based on the pain severity, stiffness, and function of the patient using t-tests and ANOVA. The relation between qualitative variables was assessed using chi-squared tests.

Results

There were 33 patients enrolled in this study. The mean age was 63 years (SD = 9.5). There was a higher proportion of females (84.8%, n = 28) compared to males. At the time of injection majority (81.8%, n = 27) were unemployed, and (72.7%, n = 24) were non-smokers. One patient was left-handed (3%) while the rest were right-handed (n=32, 97%). The mean duration of CMC1 pain was 10 months (SD = 2.5). There was no difference in baseline pain VAS scores between the two groups (mean US group= 6.6 vs landmark group= 7.5; P = 0.18).

Over one third of the participants (36.4%, n = 12) did not use a hand splint and, 45.5% (n= 15) had a previous glucocorticoid injection to the joint of interest. The majority of patients (69.7%, n = 23) had a right CMC1 glucocorticoid injection. Overall, 60.6% (n= 20) had ultrasound-guided injection and 39.4% (n = 13) had a landmark-based injection.

Both groups achieved a statistically significant improvement in AUSCAN score at week 6 (P≤0.05) but with a recurrence of symptoms at week 12 (P ≤0.05), at both intervals the AUSCAN scores were better than baseline (P ≤0.05) (Figure 2). No significant differences were identified between two groups in terms of changes from baseline to 6, 12, and between 6 to 12 weeks in pain, stiffness and hand function. The US-guided injection group and the standard approach group had significant better results in pain score at rest, gripping, lifting, turning, squeezing, and stiffness in 6 weeks’ time as highlighted in Table 1. In the US-guided injection group hand function improved significantly at weeks 6 and 12 (P<0.05) in all aspects assessed apart from carrying a full pot with one hand (P= 0.06). While in the landmark-based approach group significant improvements were captured at week 6 (P <0.05) (Table 1). No injection side reactions or complications were reported during the duration of this study.

Table 1. Comparison changes between two groups (ultrasound-guided vs landmark-based approach) in CMC1 pain, stiffness and function.

	Group	Mean difference	Std. deviation	P value	P value (US vs landmark)
Pain at rest (Vas score)	US	3.5	0.599	<0.001	0.094
Change after 6 weeks	Landmark	2.5	0.879	0.047
Change after 12 weeks	US	1.55	0.599	0.084
	Landmark	0.115	0.879	0.896
Change between 6-12 weeks	US	-1.95	0.599	0.020
	Landmark	-2.385	0.743	0.021
Pain in gripping	US	4.8	0.547	<0.001	0.373
Change after 6 weeks	Landmark	4.23	0.678	<0.001
Change after 12 weeks	US	2.5	0.547	<0.001
	Landmark	1.92	0.678	0.037
Change between 6-12 weeks	US	-2.3	0.547	<0.001
	Landmark	-2.3	0.678	0.008
Pain in lifting	US	4.65	0.542	<0.001	0.109
Change after 6 weeks	Landmark	4.462	0.673	<0.001
Change after 12 weeks	US	2.95	0.542	<0.001
	Landmark	2.077	0.673	0.018
Change between 6-12 weeks	US	-1.7	0.542	0.018
	Landmark	-2.385	0.673	0.006
Pain in turning	US	4.75	0.607	<0.001	0.197
Change after 6 weeks	Landmark	3.923	0.753	<0.001
Change after 12 weeks	US	2.95	0.607	<0.001
	Landmark	1.615	0.753	0.214
Change between 6-12 weeks	US	-1.8	0.607	0.03
	Landmark	-2.308	0.753	0.026
Pain in squeezing	US	4.65	0.615	<0.001	0.153
Change after 6 weeks	Landmark	4.154	0.762	<0.001
Change after 12 weeks	US	2.550	0.6159	0.001
	Landmark	2.077	0.762	0.059
Change between 6-12 weeks	US	-2.1	0.615	0.009
	Landmark	-2.077	0.762	0.059
Stiffness	US	2.95	0.581	<0.001	0.124
Change after 6 weeks	Landmark	3.462	0.721	<0.001
Change after 12 weeks	US	1.6	0.581	0.070
	Landmark	0.8467	0.721	1
Change between 6-12 weeks	US	-1.350	0.581	0.188
	Landmark	-2.615	0.721	0.007
Turning taps/faucets on	US	4.2	0.538	<0.001	0.751
Change after 6 weeks	Landmark	2.615	0.667	0.003
Change after 12 weeks	US	2.5	4.651	<0.001
	Landmark	0.769	0.667	0.759
Change between 6-12 weeks	US	-1.7	0.538	0.024
	Landmark	-1.846	0.667	0.067
Turning around doorknob or handle	US	3.85	0.576	<0.001	0.964
Change after 6 weeks	Landmark	3.692	0.715	<0.001
Change after 12 weeks	US	2	0.576	0.01
	Landmark	1.615	0.715	0.192
Change between 6-12 weeks	US	-1.85	0.576	0.021
	Landmark	-2.077	0.715	0.046
Doing up buttons	US	4.05	0.651	<0.001	0.742
Change after 6 weeks	Landmark	3.154	0.808	0.003
Change after 12 weeks	US	2.15	0.651	0.018
	Landmark	1.077	0.808	0.822
Change between 6-12 weeks	US	-1.9	0.651	0.049
	Landmark	-2.077	0.808	0.113
Fastening jewellery	US	4	0.557	<0.001	0.947
Change after 6 weeks	Landmark	4.602	0.691	<0.001
Change after 12 weeks	US	2.050	0.557	0.005
	Landmark	2.296	0.891	0.074
Change between 6-12 weeks	US	-1.95	0.557	0.008
	Landmark	-2	0.691	0.042
Opening a new jar	US	4.55	0.603	<0.001	0.691
Change after 6 weeks	Landmark	4.308	0.748	<0.001
Change after 12 weeks	US	2.35	0.603	0.003
	Landmark	2.077	0.748	0.044
Change between 6-12 weeks	US	-2.200	0.603	0.005
	Landmark	-2.231	0.748	0.033
Carrying a full pot with one hand	US	3.85	0.651	<0.001
Change after 6 weeks	Landmark	4.154	0.808	<0.001
Change after 12 weeks	US	1.8	0.651	0.06
	Landmark	1.692	0.808	0.241
Change between 6-12 weeks	US	-2.05	0.651	0.028
	Landmark	-2.462	0.808	0.034
Peeling vegetables/fruits	US	4.7	0.633	<0.001	0.607
Change after 6 weeks	Landmark	3.769	0.785	<0.001
Change after 12 weeks	US	2.8	0.633	<0.001
	Landmark	2	0.785	0.082
Change between 6-12 weeks	US	-1.9	0.633	0.039
	Landmark	-1.769	0.785	0.139
Picking up large heavy objects	US	3.95	0.615	<0.001	0.879
Change after 6 weeks	Landmark	4	0.762	<0.001
Change after 12 weeks	US	2	0.615	0.02
	Landmark	1.538	0.762	0.239
Change between 6-12 weeks	US	-1.95	0.615	0.021
	Landmark	-2.462	0.762	0.02
Wringing out wash cloths	US	3.8	0.611	<0.001	0.645
Change after 6 weeks	Landmark	3.462	0.757	<0.001
Change after 12 weeks	US	1.75	0.611	0.051
	Landmark	1.154	0.757	0.664
Change between 6-12 weeks	US	-2.050	0.611	0.015
	Landmark	-2.308	0.757	0.034

Discussion

Osteoarthritis involving the first CMC is a degenerative joint condition for which patients seek intervention to alleviate pain and improve hand function. In this study, 33 participants with symptomatic CMC1 arthritis were prospectively evaluated for response to either ultrasound-guided or landmark-based joint injection. Both cohorts were predominantly female, with a median age of 65 years consistent with baseline demographics of previous studies [4,6,8]. Previous research has shown that intra-articular corticosteroid injections can improve hand pain and function regardless of osteoarthritis stages. However, they have also been shown to be more efficacious for longer durations (beyond 3 months) for early (Eaton 1-2) than late (Eaton 3-4) osteoarthritis stages [8,9], similar to the outcome of using hand splint [10].

In addition, a case series of 43 patients with grade 2 or higher Eaton classification were assessed following ultrasound-guided injection to the CMC1 and a strong correlation was found between patients who had persistent pain following glucocorticoid and local anesthesia injection at one week and the progression to surgery, (odd ratio 3.1) [11]. Factors influencing the likelihood of a repeat injection or surgical intervention are beyond the scope of this study.

Several studies have been done comparing use of ultrasound-guided  versus landmark-based approach in small joint or structures [12-14]. To et al. performed a similar study on cadavers, they found that the success rate by injection site was higher for ultrasound-guided participants than for non-ultrasound participants for thumb CMC arthrosis (72% vs. 38%), which was confirmed by fluoroscopy and later by dissection and localizing the blue dye mix in the cadavers [12]. On the other hand, Derian et al. found no statistically significant difference in accuracy between the two methods (ultrasound vs. landmark approach) in cadaver investigations [15], although no clinical conclusion could be drawn from these studies.

In this study, we found that the effect of intra-articular corticosteroid injection is satisfactory but transient for both ultrasound-guided and landmark based CMC1 injection

Limitations

Our study had limitations, including a small sample size, convenience sample of doctor’s own patients, lack of blinding, and two experts performing the injection in both arms.

Conclusion

In a small study of ultrasound versus landmark based CMC1 injection for OA, both techniques provided similar transient pain relief.

Ethics approval and consent to participate

 Ethical approval was obtained from the St James’ and Tallaght Hospital Joint Ethics Committee, Written informed consent was obtained from all individual patients included in the study.

Availability of data and material

The data supporting the study’s findings are available from the corresponding author upon a reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

No author received funding for this study.

Authors’ contributions

SAA: data collection, data analysis, manuscript writing. SM: data collection and manuscript writing. LC and NME: data collection. RC and CJ: manuscript writing/editing. All authors read and approved the final manuscript.

References

1. Firestein, G., Gabriel, S., Mcinnes, I. and O’Dell, J., 2017. Kelley And Firestein’s Textbook Of Rheumatology Volumes I And II. Philadelphia, PA: Elsevier.

2. Niu J. Symmetry and clustering of symptomatic hand osteoarthritis in elderly men and women: the Framingham Study. Rheumatology. 2003;42(2):343-348.

3. Kwok WY, Kloppenburg M, Marshall M, Nicholls E, Rosendaal FR, Peat G. The prevalence of erosive osteoarthritis in carpometacarpal joints and its clinical burden in symptomatic community-dwelling adults. Osteoarthritis Cartilage. 2014;22(6):756-763.

4. Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis & Rheumatology. 2020;72(2):220-233.

5. Kennedy CD, Manske MC, Huang JI. Classifications in Brief: The Eaton-Littler Classification of Thumb Carpometacarpal Joint Arthrosis. Clin Orthop Relat Res. 2016;474(12):2729-2733. doi:10.1007/s11999-016-4864-6

6. Day CS, Gelberman R, Patel AA, Vogt MT, Ditsios K, Boyer MI. Basal joint osteoarthritis of the thumb: a prospective trial of steroid injection and splinting. J Hand Surg Am. 2004;29(2):247-251. 

7. Yavuz U, Sökücü S, Albayrak A, Oztürk K. Efficacy comparisons of the intraarticular steroidal agents in the patients with knee osteoarthritis. Rheumatol Int. 2012;32(11):3391-3396. doi:10.1007/s00296-011-2188-0

8. Ostergaard PJ, Hall MJ, Dowlatshahi AS, Harper CM, Rozental TD. Thumb Carpometacarpal Arthritis: Prognostic Indicators and Timing of Further Intervention Following Corticosteroid Injection. J Hand Surg Am. 2020;45(10):986.e1-986.e9. doi:10.1016/j.jhsa.2020.03.025

9. Khan M, Waseem M, Raza A, Derham D. Quantitative Assessment of Improvement with Single Corticosteroid Injection in Thumb CMC Joint Osteoarthritis?. Open Orthop J. 2009;3:48-51. Published 2009 Jun 19. doi:10.2174/1874325000903010048

10. Kumar N, Newman RJ. Complications of intra- and peri-articular steroid injections. Br J Gen Pract. 1999;49(443):465-466.

11. McCann P, Wakeley C, Amirfeyz R. THE EFFECT OF ULTRASOUND GUIDED STEROID INJECTION ON PROGRESSION TO SURGERY IN THUMB CMC ARTHRITIS. Hand Surgery. 2014;19(01):49-52.

12. To P, McClary KN, Sinclair MK, et al. The Accuracy of Common Hand Injections With and Without Ultrasound: An Anatomical Study. Hand (N Y). 2017;12(6):591-596. doi:10.1177/1558944717692086

13. Karaahmet ÖZ, Gürçay E, Kara M, Serçe A, Kıraç Ünal Z, Çakcı A. Comparing the effectiveness of ultrasound-guided versus blind steroid injection in the treatment of severe carpal tunnel syndrome. Turk J Med Sci. 2017;47(6):1785-1790. Published 2017 Dec 19. doi:10.3906/sag-1704-97

14. Gutierrez M, Di Matteo A, Rosemffet M, et al. Short-term efficacy to conventional blind injection versus ultrasound-guided injection of local corticosteroids in tenosynovitis in patients with inflammatory chronic arthritis: A randomized comparative study. Joint Bone Spine. 2016;83(2):161-166. doi:10.1016/j.jbspin.2015.04.017

15. Derian A, Amundson J, Abi-Aad K, Vasquez-Duarte R, Johnson-Greene D. Accuracy of ultrasound-guided versus palpation-based carpometacarpal joint injections: A randomized pilot study in cadavers. Ultrasound. 2018;26(4):245-250. doi:10.1177/1742271X18789711