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Systematic Review

Therapeutic interventions for osteoarthritis of the wrist: a systematic review and meta-analysis

[version 1; peer review: 3 approved]
PUBLISHED 18 Sep 2018
Author details Author details
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Abstract

Background: In order to evaluate the effectiveness of interventions for osteoarthritis of the wrist in adults we performed a systematic review and meta-analysis.
Methods: The MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO databases were searched from inception to 25th April  2018.All randomised controlled clinical trials (RCTs) and any prospective studies of adults with wrist osteoarthritis investigating any intervention with a comparator were included.  Data were extracted and checked for accuracy and completeness by pairs of reviewers. Primary outcomes were pain and function. Comparative treatment effects were analysed by random effects at all time points.
Results: Three RCTs were identified for inclusion after screening and all had a high risk of bias. Two compared proximal row carpectomy (PRC) with four corner fusion (4CF) for post-traumatic osteoarthritis, while the other compared leather with commercial wrist splints in patients with chronic wrist pain, of which a small group had wrist osteoarthritis. 
Conclusion: There is no prospective study comparing operative to non-operative treatment for wrist osteoarthritis, while there is a paucity of prospective studies assessing the effectiveness of both non-operative and operative interventions.  Further research is necessary in order to better define which patients benefit from which specific interventions.
Registration: The review protocol was registered with PROSPERO under the registration number CRD42018094799.

Keywords

wrist, osteoarthritis, ulnocarpal, radiocarpal, TFCC, review, intervention, surgery

Introduction

Osteoarthritis of the wrist is a diverse and poorly understood clinical condition, likely relating to the complexity of the anatomy and biomechanics of the human wrist joint1. Wrist pain is a relatively common clinical problem, accounting for an annual consultation prevalence rate of 58 in 10,000 patients in the UK2, which is around one-tenth the rate of consultation for back pain, the most common site of musculoskeletal pain. The prevalence of radiographic wrist osteoarthritis varies widely in the literature35, while there is a lack of epidemiological research relating pain to structural change in this condition.

Different anatomical areas of the wrist may be affected by osteoarthritis; the radiocarpal, the distal radioulnar, the ulnocarpal, the midcarpal (including the scaphotrapeziotrapzoid (STT)) and the pisotriquetral joint6. Further complexity is added by the variety of terms used to describe ulnocarpal osteoarthritis, such as ulnocarpal abutment and ulnocarpal impaction syndrome, while tears and/or degeneration of the triangular fibrocartilage complex (TFCC) are intimately involved in ulnocarpal osteoarthritis and distal radioulnar joint synovitis7. Osteoarthritis of the wrist may also occur after trauma, such as scaphoid non-union advanced collapse (SNAC), while the pattern of osteoarthritis seen in scapholunate advanced collapse (SLAC) may be post-traumatic or degenerative8.

Non-operative treatment includes activity modification, education, analgesia, physiotherapy, splintage and corticosteroid injections9. Operative treatment is reserved for patients who fail non-operative measures, the specifics of which are determined by the anatomical pattern of the osteoarthritis10. A wide array of operations are carried out on the wrist for osteoarthritis. Wrist arthroscopy has been increasingly performed in recent years, having both diagnostic and therapeutic components, including debridement and TFCC repair11. Other procedures include denervation, excision arthroplasty, partial and total arthroplasty, partial and total wrist fusion and osteotomies. There is a scarcity of published material relating to the number of elective surgical procedures carried out on the wrist. Melamed et al. have described trends in the US relating to total wrist fusion and wrist arthroplasty12. Jain et al. estimated that the number of wrist arthroscopies carried out per annum in the USA was approximately 25,000 in 2006, while the interest in and the number of surgeons performing wrist arthroscopy has been on the rise in recent years11.

Our aim was to perform a systematic review of the effectiveness of available interventions for osteoarthritis of the wrist in terms of patient-reported outcome measures and to assess the rates of adverse outcomes associated with these interventions.

Methods

The systematic review was developed in accordance with the PRISMA statement, using methodology described in the Cochrane Handbook for Systematic Reviews of Interventions. The protocol was developed prospectively and peer reviewed locally before registration on the PROSPERO database (CRD42018094799).

Data sources and searches

A comprehensive search strategy was created in collaboration with a research librarian (N.T.) and was designed to capture all relevant articles pertaining to inventions for osteoarthritis of the wrist (Supplementary Material 1). The full search strategy is detailed on the PROSPERO website. The search strategy was applied to the following bibliographic databases from database inception until 24th April 2018: MEDLINE and EMBASE via OVID, CINAHL and SPORTDiscus via EBSCO.

Inclusion/exclusion criteria

The inclusion and exclusion criteria were defined prospectively during the protocol stage. All prospective studies relating to interventions for osteoarthritis of the wrist were included. Studies had to contain an intervention and a comparator (i.e. both non-randomised controlled trials, and randomised controlled trials, including semi/quasi randomised, cluster randomised trials and prospective comparative case series). Any therapeutic intervention or control treatments were included. We included ulnocarpal, distal radioulnar, radiocarpal, piso-triquetral, scaphotrapeziotrapezoid and midcarpal osteoarthritis. For the purposes of this review we have included all ulnocarpal disorders, such as ulnar abutment, ulnar impaction syndrome and triangular fibrocartilage complex degeneration, which is debatable but arguably fits within the most widely used definition of ‘osteoarthritis’13. Post-traumatic arthritis was also included (SLAC and SNAC). We excluded studies involving children and adolescents (age <18 years), and studies relating to inflammatory arthritis such as rheumatoid arthritis or psoriatic arthritis. Only studies published in a peer-reviewed English-language journal were included.

Selection of studies

Duplicates were removed and relevant studies identified from the search were imported into Covidence for screening. Studies were independently screened by title and abstract by two authors (B.J.F.D. and S.H.). This was followed by a full-text evaluation of the selected studies from the first selection step by these authors. Disagreement between the two reviewers was resolved by consensus involving a third author (N.R.)

Data extraction

Two reviewers (S.H. and B.J.F.D) independently extracted data. Data was extracted using a custom data extraction sheet in Covidence. Any inconsistencies between the two reviewers’ forms were resolved by consensus discussion. A third review (N.R.) was available for any disagreement that could not be resolved by this initial discussion.

If data was not available from full-text articles or trial registrations, authors were contacted to provide this information. If authors were not contactable for additional data, then this aspect of the study was excluded from the data synthesis. If contactable authors did not respond to initial requests, they were sent two subsequent reminders over a minimum of 6 weeks. If there was still no response for the additional data, then this aspect of the study was excluded from the data synthesis.

Risk of bias assessment

Included studies were assessed for risk of bias by two independent raters (B.J.F.D. and S.H.) using the Cochrane Collaboration’s tool for assessing risk of bias in randomised trials14. This followed the description in the Cochrane Handbook for Systematic Review of Interventions, version 5.1 (Part 2: 8.5.1)14. Any disagreements between ratings were resolved by discussion between the raters. A third party (N.R.) was available in any case where disagreements persisted after discussion.

Data analysis

Descriptive analysis was performed for all demographic, intervention and outcome data to facilitate narrative interpretation and comparison across studies. It was decided that a direct-comparison meta-analysis would only be performed if data was available for similar time-points, outcomes and interventions across two or more studies. As this was not possible with the identified studies, we conducted a narrative synthesis of the results based on the domains of interest.

Results

Studies identified

After duplicates were removed, 750 studies were identified by the search. After screening by full-text, three studies were identified as eligible for inclusion (Figure 1). These were all randomized controlled trials (RCTs). The number of studies identified and excluded at each stage is detailed in Figure 1.

d2eb5851-9270-49da-8785-a45d574f8387_figure1.gif

Figure 1. PRISMA flow diagram.

Study characteristics of the included trials including the interventions and comparators are provided in Table 1. Of the three included randomised controlled trials, two compared proximal row carpectomy with four corner fusion for post-traumatic osteoarthritis15,16, while the remaining RCT compared leather with commercial wrist splints in patients with chronic wrist pain, of which a small group had wrist osteoarthritis17. Table 2 details the basic demographics of the intervention and comparator groups, as well as the details about the outcome data provided. The full details of all included studies and the forest plots are included within the Supplementary Material 3–7.

Table 1. Study characteristics.

AuthorYearJournalSettingPopulationStudy
type
InterventionComparatorPrimary
outcome
OutcomesTime
points
Aita
et al.16
2016Rev Bras
Ortop
Hand surgery
unit, secondary
care
Adults with
SNAC stage
2
RCT,
parallel
group
Proximal row
carpectomy
Four corner
fusion
DASHVAS, Grip
strength,
range of
movemment
Baseline
and 74
month final
follow up
Bisneto
et al.15
2011ClinicsOrthopaedic
surgery unit,
secondary care
Adults with
grade 1 or 2
SNAC/SLAC
RCT,
parallel
group
Proximal row
carpectomy
Four corner
fusion
DASHVAS, Grip
strength,
range of
movemment,
Jebsen
Taylor
Baseline,
3 months,
6 months
and final
12 month
follow up
Thiele
et al.17
2009BMC
Musc Dis
Occupational
therapy
department,
secondary care
Chronic
wrist pain
RCT,
crossover
Leather
splint
Commercial
wrist splint
AUSCANCOPM, Grip
strength
Baseline
3 weeks and
6 weeks

SNAC, scaphoid non-union advanced collapse; RCT, randomised controlled trial; DASH, disabilities of arm, hand and shoulder; VAS, visual analogue score; SLAC, scapholunate advanced collapse; AUSCAN, Australian/Canadian Hand Osteoarthritis Index; COPM, Canadian Occupational Performance Measure.

Table 2. Details of study participants demographics, inclusion/exclusion criteria and whether data was provided.

AuthorYearInclusion
criteria
Exclusion
criteria
Intervention
group mean
age, years
(sd)
Comparator
group mean
age, years
(sd)
Intervention
group
numbers/sex
Comparator
group
numbers/sex
Data
comments
Aita et al.162016SNAC stage 2
and aged 18
to 60
Metabolic
bone disease,
bilateral
problems and
previous surgery
32.4 (9.4)40.4 (8.9)13/12M 1F14/12M 2FFull data
provided
Bisneto et al.152011SNAC/SLAC
grade 1 or 2
Inflammatory
arthritis,
midcarpal joint
disease, failure
to attend follow
up
43.4 (10.1)42 (10.6)Not statedNot statedIncomplete
data and
author did
not respond
to multiple
emails
Thiele et al.172009Chronic wrist
pain, mixed
population of
osteoarthritis
and
inflammatory
arthritis
Under 18 years of
age, no functional
impairment,
seeking
compensation,
significant
comorbidity
64 (range 18–82)25/12M 13FData set for
OA group not
published
and author
did not
respond
to multiple
emails

SNAC, scaphoid non-union advanced collapse; SLAC, scapholunate advanced collapse; OA, osteoarthritis.

The RCT by Aita et al. compared PRC (13 patients) with 4CF (14 patients) in adults with stage 2 SNAC. There were significant baseline differences between the two groups, the PRC group was significantly younger and had significantly greater range of movement pre-operatively. In terms of outcomes there was no observed difference in disabilities of arm, shoulder and hand (DASH), visual analogue score (VAS) pain and range of movement between PRC and 4CF, but a greater improvement in grip strength with PRC (SMD 0.61 95% CI 0.04-1.17) at final follow up.

Bisneto et al. showed similar outcomes in terms of DASH and VAS pain in an RCT comparing PRC with 4CF in patients with a diagnosis of either post-traumatic SNAC or SLAC (10 patients in each group). The 4CF group did have significantly greater grip strength than the PRC group on the affected side pre-operatively and this persisted post-operatively. Unfortunately, it was not possible to obtain further data from the authors to enable a more detailed analysis.

Thiele et al. conducted a single-blind crossover RCT comparing the use of leather and commercial wrist splints for treating chronic wrist pain in adults17. Of 25 included patients only six had the diagnosis of osteoarthritis, with the remaining 19 being inflammatory arthritis. Unfortunately, it was not possible to obtain the data pertaining to this osteoarthritis subgroup and further analysis was precluded.

Adverse events

Aita et al. reported one complication in each group16. One patient in the PRC group developed symptomatic radiocarpal osteoarthritis requiring total wrist arthrodesis, while one patient in the 4CF group developed a ‘pseudoarthrosis’ (non union of the intercarpal fusions) which did not require further intervention. Bisneto et al. reported one complication in the 4CF group (‘reflex sympathetic dystrophy’) and five complications in the PRC group (two cases of ‘reflex sympathetic dystrophy’ and three cases synovitis; none of these complications required further surgical intervention15.

Risk of bias

All criteria were judged as low, high or unclear risk of bias. Overall, all studies were deemed to be at a high risk of bias, particularly in terms of allocation concealment, incomplete outcome data and selecting reporting. Full risk of bias assessment is available in Figure 2 and Figure 3. Specifically the studies by Aita et al. and Bisneto et al. were both single-centre studies, did not specify a primary outcome measure and did not fully report outcome data. None of the three studies mentioned power calculations and all studies were relatively small in terms of participant numbers. All three studies used a random method of sequence generation. The studies by Aita et al. and Thiele et al. did blind the outcome assessors; however, the blinding of outcome assessment was not specified by Bisneto et al. Blinding of the participants was not possible in the study by Thiele et al., while it was not made clear in the studies by Aita et al. and Bisneto et al.

d2eb5851-9270-49da-8785-a45d574f8387_figure2.gif

Figure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

d2eb5851-9270-49da-8785-a45d574f8387_figure3.gif

Figure 3. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Meta analysis. As a result of the degree of heterogeneity in terms of study interventions and the incomplete outcome data, it was determined that a meta-analysis of the outcomes was not possible. We carried out a meta-analysis of adverse events for 4CF vs PRC, as these were reported by two trials15,16 and the forest plot of this data is shown in Figure 4. No significant difference was noted in the risk of adverse events between these two groups (risk ratio 3.08 95% CI 0.69-13.65).

d2eb5851-9270-49da-8785-a45d574f8387_figure4.gif

Figure 4. Forest plot of comparison: 1 Proximal row carpectomy vs Four corner fusion, outcome: adverse events.

Dataset 1.Extracted study data, available as a RevMan 5 file.
RevMan 5 can be downloaded from: https://community.cochrane.org/help/tools-and-software/revman-5/revman-5-download.

Discussion

Based on this systematic review of the published literature, we have identified that there is no prospective study comparing operative to non-operative treatment for wrist osteoarthritis, while there is a paucity of prospective studies comparing the effectiveness of both non-operative and operative interventions. All three included studies were at high risk of bias, especially regarding reporting and blinding, and had other significant methodological weaknesses. In our opinion, the available evidence to inform treatment choices for this common clinical condition is surprisingly limited.

The manner in which this lack of evidence results in a difficulty managing patients is saliently demonstrated by the example of the choice between PRC or 4CF for the treatment of SLAC or SNAC. Mulford et al. reviewed the literature in this area and remarked at the highly biased nature of the evidence base, the vast majority of which was retrospective case series18. Of the three studies included in this review, two compared PRC with 4CF; however, the biased and small nature of these studies means that these studies do not substantially aid clinicians in making an evidence based decision in managing this group of patients.

The management of many other relatively common subtypes of wrist osteoarthritis is similarly hampered by a lack of high-quality evidence. This is demonstrated in the case of degenerative ulnocarpal disorders, which may also referred to as ulnar abutment, or ulnar impaction syndrome where the available evidence base consists exclusively of low-quality and highly biased retrospective case series, which invariably demonstrate no meaningful difference in outcome between different surgical interventions1922. Not only are there no prospective studies, but to our knowledge no study has compared non-operative with operative intervention. This leaves both patients and clinicians with a dilemma in which the evidence base makes it very hard to decisively support any specific intervention.

The prevalence of radiographic wrist osteoarthritis varies widely in the literature. The seminal epidemiological study by Kellgren and Lawrence demonstrated a prevalence of radiographic wrist osteoarthritis of approximately 10% in men and 5% in women, notably this was in the 55 to 64 age bracket4. Van Saase et al. demonstrated a prevalence of 9.1% and 12.4% in the 55–59 and the 60–64 year old age groups respectively5. A much lower prevalence was reported in the Framingham study of between 1% and 2% in a group of mean age 58.9 years3. Katayama reported a prevalence of radiographic ulnar sided wrist osteoarthritis in 12.8% of patients presenting to their orthopaedic wrist service with a mean age of 53.8 years; however, this study did not investigate the relationship between radiographic change and symptoms23. There is also a paucity of high quality epidemiological evidence relating to the association between radiological changes and patient reported symptoms such as pain and dysfunction. The only studies which have investigated how radiological changes may relate to wrist pain have been conducted in young gymnastic populations24.

The absence of high quality evidence presents a challenge to clinicians treating wrist osteoarthritis. Although wrist osteoarthritis is more heterogeneous and less common than osteoarthritis affecting other joints such as the hip and knee, this should not mean that prospective evidence is perpetually absent. Whether in the form of prospective case series, cohort studies or randomised clinical trials, it is clear that higher-quality evidence is needed to guide practice in the management of wrist osteoarthritis. This may relate to simple non-operative interventions such as splintage, all the way up to the more invasive procedures such as total wrist arthroplasty and total wrist arthrodesis.

Conclusions

There is no prospective study comparing operative and non-operative treatment for wrist osteoarthritis, and an overall paucity of prospective studies comparing the effectiveness of both non-operative and operative interventions. Further research is necessary in order to better define which patients benefit from which specific interventions.

Data availability

Dataset 1. Extracted study data, available as a RevMan 5 file. RevMan 5 can be downloaded from: https://community.cochrane.org/help/tools-and-software/revman-5/revman-5-download. DOI: https://doi.org/10.5256/f1000research.16218.d21762525.

Comments on this article Comments (1)

Version 2
VERSION 2 PUBLISHED 10 Dec 2018
Revised
Version 1
VERSION 1 PUBLISHED 18 Sep 2018
Discussion is closed on this version, please comment on the latest version above.
  • Reader Comment 18 Sep 2018
    saeed shahabi, Iran University of Medical Sciences, Iran
    18 Sep 2018
    Reader Comment
    In the introduction, previous systematic review or narrative review studies have not been made.

    In the search section, you could use Scopus and Pedro databases.

    For grey literature, trying to find it? ... Continue reading
  • Discussion is closed on this version, please comment on the latest version above.
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Dean B, Henari S, Thurley N et al. Therapeutic interventions for osteoarthritis of the wrist: a systematic review and meta-analysis [version 1; peer review: 3 approved]. F1000Research 2018, 7:1484 (https://doi.org/10.12688/f1000research.16218.1)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 1
VERSION 1
PUBLISHED 18 Sep 2018
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Reviewer Report 03 Dec 2018
Katie Smith, Derby Hospitals NHS Foundation Trust, Derby, UK 
Benjamin E. Smith, Physiotherapy Department, London Road Community Hospital, Derby Hospitals NHS Foundation Trust, Derby, UK;  University of Nottingham, Notttingham, UK 
Approved
VIEWS 15
This is an interesting, well written, and well conducted systematic review highlighting the lack of prospective studies comparing operative and non-operative treatment for wrist osteoarthritis, and lack of evidence evaluating the effectiveness of any intervention for osteoarthritis of the wrist.
 
... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Smith K and Smith BE. Reviewer Report For: Therapeutic interventions for osteoarthritis of the wrist: a systematic review and meta-analysis [version 1; peer review: 3 approved]. F1000Research 2018, 7:1484 (https://doi.org/10.5256/f1000research.17709.r40811)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 10 Dec 2018
    Benjamin Dean, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, OX3 7LD, UK
    10 Dec 2018
    Author Response
    Many thanks for taking the time to review the manuscript.

    We have changed the erroneous '>' on Prospero to '<'.

    In terms of review agreement - this is not recorded on Covidence ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 10 Dec 2018
    Benjamin Dean, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, OX3 7LD, UK
    10 Dec 2018
    Author Response
    Many thanks for taking the time to review the manuscript.

    We have changed the erroneous '>' on Prospero to '<'.

    In terms of review agreement - this is not recorded on Covidence ... Continue reading
Views
12
Cite
Reviewer Report 03 Dec 2018
Kirsty Challen, Emergency Department, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK 
Approved
VIEWS 12
This is a well presented systematic review of the published literature on operative and non-operative interventions for wrist osteoarthritis. It could be strengthened with inclusion of grey literature (eg. searches of clinicaltrials.gov).

I am not sure that ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Challen K. Reviewer Report For: Therapeutic interventions for osteoarthritis of the wrist: a systematic review and meta-analysis [version 1; peer review: 3 approved]. F1000Research 2018, 7:1484 (https://doi.org/10.5256/f1000research.17709.r40020)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 10 Dec 2018
    Benjamin Dean, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, OX3 7LD, UK
    10 Dec 2018
    Author Response
    Many thanks for taking the time to review our manuscript.

    The point regarding the meta-analysis is valid and we shall update the manuscript to include a description of this ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 10 Dec 2018
    Benjamin Dean, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, OX3 7LD, UK
    10 Dec 2018
    Author Response
    Many thanks for taking the time to review our manuscript.

    The point regarding the meta-analysis is valid and we shall update the manuscript to include a description of this ... Continue reading
Views
14
Cite
Reviewer Report 08 Oct 2018
Anju Jaggi, Royal National Orthopaedic Hospital (RNOH), Stanmore, UK 
Approved
VIEWS 14
This is a well presented systematic review paper representing selection criteria, data for analysis, risk of bias very well diagrammatically.

The interpretation and conclusion is clear and justified in light of the results, there is a lack of evidence ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Jaggi A. Reviewer Report For: Therapeutic interventions for osteoarthritis of the wrist: a systematic review and meta-analysis [version 1; peer review: 3 approved]. F1000Research 2018, 7:1484 (https://doi.org/10.5256/f1000research.17709.r38438)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.

Comments on this article Comments (1)

Version 2
VERSION 2 PUBLISHED 10 Dec 2018
Revised
Version 1
VERSION 1 PUBLISHED 18 Sep 2018
Discussion is closed on this version, please comment on the latest version above.
  • Reader Comment 18 Sep 2018
    saeed shahabi, Iran University of Medical Sciences, Iran
    18 Sep 2018
    Reader Comment
    In the introduction, previous systematic review or narrative review studies have not been made.

    In the search section, you could use Scopus and Pedro databases.

    For grey literature, trying to find it? ... Continue reading
  • Discussion is closed on this version, please comment on the latest version above.
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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