Carpometacarpal osteoarthritis (CMC CA) is a very common problem among older women; approximately 75% of post-menopausal women have some evidence of joint destruction, with at least one third being symptomatic. Men are also affected, but less commonly. CMC CA leads to pain, deformity, instability and eventually loss of hand function. While surgery is effective for severe disease, there are a limited number of medical treatments for moderate pain and disability. Intra-articular corticosteroids are the mainstay for patients who have not responded to non-steroidal antiinflammatories or joint immobilization. However, there are no randomized, placebo-controlled trials evaluating this therapy. It is unknown what predicts response to corticosteroids, how long any benefit lasts, or if corticosteroids are any better than placebo injection. Recently, another intra-articular therapy, hyaluronan, (HA) has been introduced for osteoarthritis of the knee. Although HA therapy is gaining widespread use, its efficacy in treating knee CA is controversial due to weaknesses in study design and debatable data interpretation. There are also case reports of HA being used to treat CA of the temporomandibular and sacro-iliac joints, and HA will likely achieve more widespread use over time. However, HA is an expensive therapy, and should only be used if it has a demonstrable treatment benefit. We propose a randomized, placebo-controlled trial to compare intra-articular corticosteroids, intra-articular HA, and placebo injections in patients with CMC CA. We hope to avoid some of the efficacy controversies that have surrounded HA use in the knee with a rigorous, well-designed trial utilizing an intention-to-treat analysis plan. Through this trial we also hope to establish the efficacy of corticosteroids in CMC CA. This will fill a gap in the literature, and provide evidence-based data for intra-articular corticosteroids, the present use of which is based only on anecdotal and conventional practices.
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