From the Guidelines
Hyaluronic acid injections are conditionally recommended against in patients with first CMC joint OA due to limited evidence of benefit and potential harm. The 2020 American College of Rheumatology guideline for the management of osteoarthritis of the hand, hip, and knee states that intraarticular hyaluronic acid injections are conditionally recommended against in patients with knee and/or first CMC joint OA 1. This recommendation is based on the finding that the apparent benefits of hyaluronic acid injections in OA are restricted to studies with higher risk of bias, and when limited to trials with low risk of bias, the effect size of hyaluronic acid injections compared to saline injections approaches zero.
Key Points to Consider
- The evidence for hyaluronic acid injections in treating osteoarthritis of the first CMCJ is limited and suggests that the benefits may be restricted to studies with higher risk of bias 1.
- The guideline recommends against the use of hyaluronic acid injections in patients with first CMC joint OA, but acknowledges that some providers may still consider using them in certain clinical scenarios, such as when other interventions have failed to adequately control local joint symptoms 1.
- The procedure is generally well-tolerated with minimal side effects, but patients should be informed that multiple treatment sessions may be needed, effects are temporary, and individual responses vary considerably.
Clinical Implications
- Hyaluronic acid injections should only be considered as part of a comprehensive treatment approach that includes activity modification, splinting, and appropriate analgesics.
- Patients should be fully informed of the limited evidence of benefit and potential harm associated with hyaluronic acid injections, and the decision to use them should be made on a case-by-case basis, taking into account the individual patient's needs and preferences 1.
From the Research
Evidence for Hyaluronic Acid Injections in 1st CMCJ OA
- The use of hyaluronic acid (HA) in osteoarthritis (OA) is based on its role in maintaining the viscoelasticity of the synovial fluid and its potential to influence the disease by interacting with components of the synovial fluid 2.
- A pilot study published in 2006 found that intra-articular HA injections significantly reduced pain and improved joint function in patients with OA of the 1st carpometacarpal joint (CMCJ) 2.
- Another study published in 2009 found that a single ultrasound-guided injection of HA improved pain and function in patients with CMC-OA, with significant reductions in pain at rest and during activities, as well as improvements in grip and pinch strengths 3.
- A retrospective comparative study published in 2019 found that the onset of pain relief was more rapid after an injection containing HA and ketorolac than after an injection containing HA alone in patients with OA of the CMCJ of the thumb 4.
- A prospective evaluation of efficacy published in 2007 found that intra-articular sodium hyaluronidate injections into the CMCJ of the thumb in osteoarthritis can be efficacious on pain and functionality, although no significant differences were found between different treatment groups 5.
- It is worth noting that while these studies provide evidence for the use of HA injections in 1st CMCJ OA, other treatments such as arthroscopy have also been explored, with some studies suggesting that arthroscopic techniques involving trapeziectomy may be more effective at lowering pain scores compared to techniques involving debridement alone 6.
Key Findings
- HA injections can reduce pain and improve joint function in patients with OA of the 1st CMCJ 2, 3, 4, 5.
- The onset of pain relief can be more rapid when HA is combined with ketorolac 4.
- Arthroscopic techniques may also be effective in managing 1st CMCJ OA, with trapeziectomy and interposition/suspension techniques showing promise 6.
Study Limitations
- Many of the studies had small sample sizes and short follow-up periods, highlighting the need for larger, longer-term studies to fully evaluate the efficacy and safety of HA injections in 1st CMCJ OA 2, 3, 4, 5.
- More research is needed to compare the effectiveness of different treatment approaches, including HA injections and arthroscopic techniques, in managing 1st CMCJ OA 6.