Intra-artikuläre Hyaluronsäure bei der Arthrose des Daumensattelgelenks

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.

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