Zusammenfassung
In einer offenen prospektiven Studie an 20 Patienten mit einer
röntgenologisch gesicherten Daumensattelgelenkarthrose erwies sich
intra-artikuläre Hyaluronsäure aus Fermentation (zwei bis drei
Injektionen in wöchentlichen Abständen) als zuverlässig wirksam
und gut verträglich. Besonders bemerkenswert ist eine die Behandlung
überdauernde Wirkung (carry-over-Effekt) dieses bislang nicht
beschriebenen Verfahrens. Drei Monate nach der letzten Injektion zeigten die
Parameter Schmerz (VAS) sowie Kraftgewinn beim Spitzgriff und
Schlüsselgriff noch eine statistisch signifikante Besserung
(p < 0,001; Friedman Test). Die Beweglichkeit des betroffenen
Gelenks und eine tastbare Krepitation besserten sich ebenfalls rasch und
anhaltend. Untersucher und Patienten schätzten den erzielten
Behandlungserfolg in 19 von 20 Fällen als ausgezeichnet bis
zufriedenstellend ein.
Abstract
Osteoarthritis (OA) of the carpometacarpal (CMC) joint is a very
common problem in elderly patients. In a survey, 30 % out of
25 000 patients suffering from OA reported problems located in the CMC
joint while, in an epidemiological study, 53 % of women between 75 and
79 years of age showed signs of OA of the CMC joint. Pain and degeneration of
joint structures may adversely affect joint function and the quality of life in
such patients. Current conservative treatment includes physiotherapy followed
by the topical and oral administration of analgesics and non-steroidal
antirheumatic drugs and intra-articular (i.a.) glucocorticoids respectively.
This is the first report on the safety and efficacy of i.a. exogenous
Hyaluronic acid (HA) in patients with OA of the CMC joint. Endogenous HA, a
biopolymer made up of repeating sequences of N-acetylglucosamine and glucuronic
acid, plays a crucial role in the structure, function and pathology of synovial
joints: HA forms part of the cartilage matrix. It also coats the surface of the
cartilage and the synovial membrane and confers viscoelasticity to the synovial
fluid. In OA, the quality and quantity of endogenous HA in the joint is reduced
and numerous clinical studies have shown the therapeutic value of using
exogenous HA in OA of bigger joints, such as the knee joint. Twenty patients
suffering from severe pain due to radiologically ascertained OA of the CMC
joint, were included in an open, prospective clinical study. Treatment
consisted of two to three i.a. injections of 10 mg/1 ml HA,
obtained by fermentation (Ostenil mini, a presentation specifically developed
for treatment of smaller joints), which were administered at weekly intervals.
The efficacy parameters were pain, assessed using a Huskisson Visual Analogue
Scale (VAS), grip strength (pulp pinch and lateral pinch) assessed using an
intrinsicmeter, joint mobility, crepitation during passive movement of the
joint and the global clinical impression of investigator and patients. Safety
was assessed by the documentation of clinically evident adverse events. The
time sequence of the assessments, with a final evaluation of all patients three
months after the end of the i.a. treatment, allowed to differentiate between
the immediate( effects and the carry over( effects of i.a. HA. A marked
reduction of pain (from 63.95 ± 11.06 to
39.30 ± 13.24 mm VAS, -38.55 %) and an
increase in grip strength (pulp pinch: 1.48 ± 0.52 to
2.09 ± 0.90 grades, ± 37.84 %;
lateral pinch: 2.10 ± 0.74 to
2.87 ± 1.01 grades, 36.67 %) was observed when the
pre-treatment values were compared to those obtained at the end of the
observation period. These differences reached statistical significance
(p < 0.001, Friedman test). Crepitation persisted in
only three out of eleven patients while joint mobility on radial and palmar
abduction also showed a marked improvement. In 19 out of the 20 cases, the
investigator and patients were satisfied with the improvements in signs and
symptoms achieved in this study. Considering that no adverse effects were
reported, the benefit -risk-evaluation favours the use of i.a. HA in this
indication. It can be concluded that i.a. HA is a promising new option in the
treatment of OA of the CMC joint. The findings of this study should be
confirmed in controlled clinical studies with a longer observation period.
Literatur
-
1
Balasz E A, Denlinger J C.
Viscosupplementation: A New Concept in the Treatment of
Osteoarthritis.
J Rheumatol.
1993;
20
3-9
-
2
Dreiser R L, Gersberg M, Thomas F, Courcier S.
Ibuprofen 800 mg in the treatment of arthrosis of the
fingers or rhizarthrosis.
Rev Rhum Ed Fr.
1993;
60
836-841
-
3
Gotoh S, Miyazaki J, Onaya J. et al .
Experimental Models of Knee Pain in Rats and the Analgesic
Effects of Sodium Hyaluronate.
Folia Pharmacol Japon.
1988;
92
17-27
-
4
Gotoh S, Onaya JJ, Abe M. et al .
Effects of the molecular weight of hyaluronic acid and its
action mechanism on experimental joint pain in rats.
Ann Rheum Dis.
1993;
52
817-822
-
5
Kopp S, Carlsson GE, Haraldson T, Wenneberg B.
Long-term effect of intra-articular injections of sodium
hyaluronate and corticosteroid on temporomandibular joint pain and
dysfunction.
Oral Maxillofac Surg.
1987;
45
929-935
-
6 Mitgliederbefragung 2000 - Ergebnisse Arthrose-Info,
Offizielles Organ der Deutschen Arthrose-Hilfe e. V. 2000 1: 16
-
7
Pendleton E, Arden N, Dougados M. et al .
EULAR-Recommendations for the management of osteoarthritis:
report of a task force of the Standing Committee for International Clinical
Studies Including Therapeutic Trials (ESCIST).
Ann Rheum Dis.
2000;
59
936-944
-
8
Recommendations for the Medical Management of
Osteoarthritis of the Hip and Knee .
American College of Rheumatology.
Arthritis and Rheumatism.
2000;
43
1905-1915
-
9
Reeves K D, Hassanein K.
Randomized, prospective, placebo-controlled double-blind
study of dextrose prolotherapy for osteoarthritic thumb and f inger (DIP, PIP,
and trazepziometacarpal) joints; evidence of clinical efficacy.
J Altern Complement Med.
2000;
6
311-320
-
10
van Saase J LCM, van Romunde L KJ, Cats A. et al .
Epidemiology of osteoarthritis: Zoetermeer Survey. Comparison
of radiological osteoarthritis in a Dutch population with that in 10 other
populations.
Ann Rheum Dis.
1989;
48
271-280
-
11
Sato S, Oguri S, Yamaguchi K. et al .
Pumping injection of sodium hyaluronate for patients with
non-reducing disc displacement of the temporomandibular joint: two year
follow-up.
J Maxillofac Surg.
2001;
29
89-93
-
12
Smith M M, Ghosh P.
The synthesis of hyaluronic acid by human synovial
fibroblasts is influenced by the nature of the hyaluronate in the extracellular
environment.
Rheumatol Int.
1987;
7
113-122
-
13
Talke M.
Die intraartikuläre Therapie mit Superoxid-Dismutase
(Orgotein) oder Kortison bei rheumatoiden und arthrotisch-entzündlichen
Fingergelenksveränderungen.
Handchirurgie, Mikrochirurgie, Plastische Chirurgie.
1984;
1
59-63
-
14 Talke M. Die konservative Therapie der
Daumensattelgelenksarthrose. In: Buck-Gramcko D, Helbig B (Hrsg) Daumensattelgelenksarthrose. Stuttgart; Hippokrates Verlag 1994: 179-183
Dr. med. M. Talke
Arzt für Orthopädie, Rheumatologie, Physikalische
Therapie, Sportmedizin
Klosterstraße 34-35 · 13581 Berlin
