背景:骨性关节炎(OA)影响第一掌趾关节(hallux硬体)是常见且疼痛的。已经提出了几种非手术治疗方法;然而,很少有人经过充分评估。自2010年最初的审查以来,已经发表了几项研究,需要进行此更新。
目的:确定非手术治疗大脚趾OA的益处和危害。
方法:我们使用标准,广泛的Cochrane搜索方法。最新的搜索是2023年2月。
方法:我们纳入了随机试验,比较了任何类型的非手术治疗与安慰剂(或假手术),没有治疗(如观望)或其他治疗。
方法:我们使用标准Cochrane方法。主要结果是疼痛,函数,生活质量,射线照相连接结构,不良事件和因不良事件而退出。主要时间点是12周。我们使用等级来评估证据的确定性。
结果:本次更新包括6项试验(547名参与者)。参与者的平均年龄为32至62岁。试验持续时间为4至52周。在单个试验中比较了以下治疗方法:足弓轮廓足部矫形器与假插入物;鞋子加固插入物与假插入物;关节内注射透明质酸与生理盐水(安慰剂)注射;足弓轮廓足部矫形器与摇臂鞋底鞋;骨盆疗法与石蜡疗法;和芝麻样动员,长屈肌强化和步态训练加物理治疗与单纯物理治疗。证据的确定性受到偏见和不精确风险的限制。由于干预措施的异质性,未进行Meta分析。我们报告了使用安慰剂/假对照组的三项试验的12周时间点的数值数据。一项试验(88名参与者)显示足弓矫形器可能导致疼痛差异很小或没有差异,函数,或与假插入相比的生活质量(中度确定性)。平均疼痛(0-10量表,0无疼痛)的假插入物为3.9分,而足弓矫形器为3.5分;差异为0.4分(95%(CI)0.5至1.3更好)。平均函数(0-100量表,100个最佳功能)的假插入物为73.3分,而足弓轮廓足矫形器为65.5分;差异差7.8分(95%CI17.8更差至2.2更好)。平均生活质量(-0.04-100量表,假插入物的100分最佳分数)为0.8分,而足弓轮廓足矫形器组的0.8分(95%CI从0.1差到0.1好)。与假插入物相比,足弓轮廓矫形器可能在不良事件和由于不良事件引起的退缩方面表现出很小或没有差异(确定性低)。不良事件(主要是足部疼痛)在41名假插入者中的6名和47名有足弓轮廓足部矫形器者中的4名报告(RR0.58,95%CI0.18至1.92)。据报道,41名假插入物患者中有0名因不良事件而戒断,47名因足弓矫形器患者中有1名患者因不良事件而戒断(PetoOR6.58,95%CI0.13至331)。强化鞋垫与假鞋垫一项试验(100名参与者)表明,强化鞋垫可能导致很少或没有疼痛差异,函数,或生活质量与假插入相比(中度确定性)。平均疼痛(0-100量表,0无疼痛)的假插入物为63.8分,而鞋子加固插入物为70.1分;差异为6.3分(95%CI0.5更差至13.1更好)。平均函数(0-100量表,100个最佳功能)的假插入物为81.0分,而鞋子加固插入物为84.9分;差异为3.9分(95%CI3.3更差至11.1更好)。平均生活质量(0-100量表,假插入物的100分最佳分数)为53.2分,而鞋子加固插入物的53.3分;差异为0.1分(95%CI从3.7恶化到3.9更好)。由于不良事件,鞋加固插入件在不良事件和退出方面可能表现出很小或没有差异,与假插入相比(低确定性)。不良事件(主要是脚痛,水泡,和脊柱/髋部疼痛)在51人中有31人使用假插入物,在49人中有29人使用鞋子加固插入物(RR0.94,95%CI0.42至2.08)。据报道,51人中有1人使用假插入物,49人中有2人因不良事件而退出(PetoOR2.08,95%CI0.19至22.23)。透明质酸与安慰剂一项试验(151名参与者)表明,与安慰剂相比,单次关节内注射透明质酸可能导致疼痛或功能的差异很小或没有差异(中度确定性)。平均疼痛(0-100量表,0无疼痛)安慰剂为72.5分,透明质酸为68.2分;差异为4.3分(95%CI2.1更差至10.7更好)。平均函数(0-100量表,100最佳功能)安慰剂为83.4分,透明质酸为85.0分;差异为1.6分(95%CI4.6更差至7.8更好)。透明质酸可能在生活质量方面几乎没有差异(0-100量表,100分),安慰剂为79.9分,透明质酸为82.9分;差异为3.0更好(95%CI1.4更差至7.4更好;确定性低)。与安慰剂相比,透明质酸的不良事件可能更少。76名安慰剂患者中有43名报告了不良事件(主要是注射部位疼痛),而75名透明质酸患者中有27名报告了不良事件(RR0.64,95%CI0.44至0.91;确定性低)。没有参与者因不良事件退出两组。在任何研究中都没有报道对射线照相关节结构的影响。
结论:关于大趾OA非手术治疗的益处和危害的现有证据是有限的。有中等确定性的证据,基于三项单一安慰剂/假对照试验,足弓矫形器没有临床上重要的好处,加强鞋垫,或单次关节内注射透明质酸。需要进一步的安慰剂对照试验来评估大脚趾OA非手术治疗的有效性。
Osteoarthritis (OA) affecting the first metatarsophalangeal joint (hallux rigidus) is common and painful. Several non-surgical treatments have been proposed; however, few have been adequately evaluated. Since the original 2010 review, several studies have been published necessitating this update.
To determine the benefits and harms of non-surgical treatments for big toe OA.
We used standard, extensive Cochrane search methods. The latest search was February 2023.
We included randomised trials that compared any type of non-surgical treatment versus placebo (or sham), no treatment (such as wait-and-see) or other treatment.
We used standard Cochrane methods. The major outcomes were pain, function, quality of life, radiographic joint structure, adverse events and withdrawals due to adverse events. The primary time point was 12 weeks. We used GRADE to assess the certainty of evidence.
This update includes six trials (547 participants). The mean age of participants ranged from 32 to 62 years. Trial durations ranged from 4 to 52 weeks. Treatments were compared in single trials as follows: arch-contouring foot orthoses versus sham inserts; shoe-stiffening inserts versus sham inserts; intra-articular injection of hyaluronic acid versus saline (placebo) injection; arch-contouring foot orthoses versus rocker-sole footwear; peloid therapy versus paraffin therapy; and sesamoid mobilisation, flexor hallucis longus strengthening and gait training plus physical therapy versus physical therapy alone. Certainty of the evidence was limited by the risk of bias and imprecision. Meta-analysis was not performed due to the heterogeneity of interventions. We reported numerical data for the 12-week time point for the three trials that used a placebo/sham control group. Arch-contouring foot orthoses versus sham inserts One trial (88 participants) showed that arch-contouring foot orthoses probably lead to little or no difference in pain, function, or quality of life compared to sham inserts (moderate certainty). Mean pain (0-10 scale, 0 no pain) with sham inserts was 3.9 points compared to 3.5 points with arch-contouring foot orthoses; a difference of 0.4 points better (95% (CI) 0.5 worse to 1.3 better). Mean function (0-100 scale, 100 best function) with sham inserts was 73.3 points compared to 65.5 points with arch-contouring foot orthoses; a difference of 7.8 points worse (95% CI 17.8 worse to 2.2 better). Mean quality of life (-0.04-100 scale, 100 best score) with sham inserts was 0.8 points compared to 0.8 points with arch-contouring foot orthoses group (95% CI 0.1 worse to 0.1 better). Arch-contouring foot orthoses may show little or no difference in adverse events and withdrawal due to adverse events compared to sham inserts (low certainty). Adverse events (mostly foot pain) were reported in 6 out of 41 people with sham inserts and 4 out of 47 people with arch-contouring foot orthoses (RR 0.58, 95% CI 0.18 to 1.92). Withdrawals due to adverse events were reported in 0 out of 41 people with sham inserts and 1 out of 47 people with arch-contouring foot orthoses (Peto OR 6.58, 95% CI 0.13 to 331). Shoe-stiffening inserts versus sham inserts One trial (100 participants) showed that shoe-stiffening inserts probably lead to little or no difference in pain, function, or quality of life when compared to sham inserts (moderate certainty). Mean pain (0-100 scale, 0 no pain) with sham inserts was 63.8 points compared to 70.1 points with shoe-stiffening inserts; a difference of 6.3 points better (95% CI 0.5 worse to 13.1 better). Mean function (0-100 scale, 100 best function) with sham inserts was 81.0 points compared to 84.9 points with shoe-stiffening inserts; a difference of 3.9 points better (95% CI 3.3 worse to 11.1 better). Mean quality of life (0-100 scale, 100 best score) with sham inserts was 53.2 points compared to 53.3 points with shoe-stiffening inserts; a difference of 0.1 points better (95% CI 3.7 worse to 3.9 better). Shoe-stiffening inserts may show little or no difference in adverse events and withdrawal due to adverse events, compared to sham inserts (low certainty). Adverse events (mostly foot pain, blisters, and spine/hip pain) were reported in 31 out of 51 people with sham inserts and 29 out of 49 people with shoe-stiffening inserts (RR 0.94, 95% CI 0.42 to 2.08). Withdrawals due to adverse events were reported in 1 out of 51 people with sham inserts and 2 out of 49 people with shoe-stiffening inserts (Peto OR 2.08, 95% CI 0.19 to 22.23). Hyaluronic acid versus placebo One trial (151 participants) showed that a single intra-articular injection of hyaluronic acid probably leads to little or no difference in pain or function compared to placebo (moderate certainty). Mean pain (0-100 scale, 0 no pain) with placebo was 72.5 points compared to 68.2 points with hyaluronic acid; a difference of 4.3 points better (95% CI 2.1 worse to 10.7 better). Mean function (0-100 scale, 100 best function) was 83.4 points with placebo compared to 85.0 points with hyaluronic acid; a difference of 1.6 points better (95% CI 4.6 worse to 7.8 better). Hyaluronic acid may provide little or no difference in quality of life (0-100 scale, 100 best score) which was 79.9 points with placebo compared to 82.9 points with hyaluronic acid; a difference of 3.0 better (95% CI 1.4 worse to 7.4 better; low certainty). There may be fewer adverse events with hyaluronic acid compared to placebo. Adverse events (mostly pain at the injection site) were reported in 43 out of 76 people with placebo compared with 27 out of 75 people with hyaluronic acid (RR 0.64, 95% CI 0.44 to 0.91; low certainty). No participants withdrew from either group due to adverse events. The effects on radiographic joint structure were not reported in any study.
The existing evidence regarding the benefits and harms of non-surgical treatments for big toe OA is limited. There is moderate-certainty evidence, based upon three single placebo/sham-controlled trials, that there are no clinically important benefits of arch-contouring foot orthoses, shoe-stiffening inserts, or a single intra-articular injection of hyaluronic acid. Further placebo-controlled trials are needed to evaluate the effectiveness of non-surgical treatments for big toe OA.