Intra-articular injection in carpometacarpal joint for arthritis may provide pain relief
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Published results showed intra-articular injection provided significantly greater pain relief and functional improvement of thumb carpometacarpal joint arthritis at 3 months compared with extra-articular injection.
“A steroid injection given into the [carpometacarpal] CMC joint of the thumb will provide, on average, longer lasting relief than when it is given outside of the joint,” Brian M. Katt, MD, told Healio.
Katt and colleagues used wrist radiographs to visualize location of the CMC joint injection with triamcinolone and radiopaque contrast among 102 hands with thumb CMC joint arthritis. Researchers collected DASH questionnaires and VAS pain scores before injection and at 1 week and 1, 3 and 6 months after injection. Researchers constructed generalized linear regression models to identify variables associated with clinical outcomes.
Results showed an intra-articular injection rate of 80%, with no differences found in pre-injection DASH or VAS scores between patients who received either an intra-articular injection or extra-articular injection.
Researchers found improvements in DASH and VAS scores after 1 week in both the intra-articular injection group and extra-articular injection group. Although both groups reported worse DASH and VAS scores at 3 months, researchers noted significantly lower DASH and VAS scores among patients in the intra-articular group. The intra-articular injection group and extra-articular injection group had no differences in DASH and VAS scores at 6 months, according to results. While significant improvements in outcomes were maintained in the intra-articular group for up to 6 months, researchers found improvements were only maintained in the extra-articular group for up to 1 month.
Researchers noted the Eaton-Littler classification was a predictor of DASH and VAS scores at 3 and 6 months.
“Providers should understand the implications of the study, which document the benefit of placing the steroid in a specific locale to maximize the change of short-term pain relief,” Katt said.
Perspective
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The study by Brian M. Katt, MD, and colleagues comparing the efficacy of intra-articular and extra-articular injections for thumb carpometacarpal arthritis is well done and has some interesting findings with practical relevance to many of our practices. It is somewhat surprising that the accuracy of non-image-guided intra-articular injections is only 20%, even in the hands of experienced hand surgeons. Considering that many of these injections are performed by trainees and physician extenders, it is conceivable that the accuracy rate at large is lower.
The salient finding of this study is that extra-articular injections provide similar pain relief to intra-articular injections at 1 month, but intra-articular injections provide better relief by 3 months, and often provide relief for up to 6 months. Possible reasons for this finding include the patulous nature of the joint capsule from laxity at the joint, which could allow some extra-articular cortisone to enter the joint, and the local effect of cortisone on the capsule and surrounding soft tissues when there is concomitant pathology, such as DeQuervain’s tendinitis. Injections were also noted to be less effective, even when intra-articular, in advanced stages of arthritis. These findings can be used to counsel patients appropriately and also to make the case for the use of image guidance when performing these common injections.
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