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

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.

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.

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 osteoarthritis^15,16, 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.

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.

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

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 trials^15,16 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). It is important to note that the way in which ‘adverse events’ were defined by these two studies was unclear and may have been significantly different. This result should therefore be interpreted with caution.

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