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• W3010446631 abstract "Sir: We would like to thank Dr. Reissis and Dr. Gardiner for their thoughtful review and critique1 of our publication “Autologous Fat Transfer for Thumb Carpometacarpal Joint Osteoarthritis: A Prospective Study.”2 Our article describes a new technique of autologous intraarticular fat transfer for thumb carpometacarpal joint osteoarthritis. The technique of autologous intraarticular fat transfer is currently advocated by other hand surgeons (as noted by the Journal’s associated commentary,3 and a recent Epub ahead of print publication in Plastic and Reconstructive Surgery4). Applying the Idea, Development, Exploration, Assessment, Long-term study framework, our surgical innovation can be grouped as phase 2b exploration, characterized by a stable technique replicated by others. Our reporting focused on potential benefits, such as reduction in pain and functional improvement. Characterization and analysis of Eaton-Glickel stages help to define pertinent quality parameters and aid in identifying patients for further assessment as they relate to Idea, Development, Exploration, Assessment, Long-term study phase 3. From a practical perspective, the development of a comprehensive, randomized, controlled trial for carpometacarpal osteoarthritis remains particularly challenging. Each Eaton-Glickel stage would likely require a unique randomized controlled trial. The question and associated logistics of whether autologous fat transfer for thumb carpometacarpal osteoarthritis should be tested against placebo or against current best practice would have to be addressed. For the control group, the former study would require a sham liposuction and injection of saline procedure, raising ethical and practical concerns of feasibility. Joint arthroscopy at the time of injection and again after 1 year is similarly practically problematic and ethically concerning to justify. A study approach with comparison against current best practice would require a consensus on the optimal treatment for Eaton-Glickel stages 2 and 3, a consensus that to date does not really exist. Numerous techniques are currently advocated, such as simple trapeziectomy; Epping, Lindborg, and Beckenbaugh-Lindscheid procedures and their many variations; and partial resections and the adjunctive use of prosthetics.5 Of particular note, it would be extremely challenging to convince patients who present with painful carpometacarpal joint osteoarthritis and are randomized to the nonintervention control group to merely “wait and see” as suggested by Dr. Reissis and Dr. Gardiner. Patients in our study provided informed consent according to the recommendations and direction of our ethical committee. The definitive mode of action of intraarticular fat grafting remains incompletely understood. The hypothesis that fat might behave as a functional spacer certainly focuses on potential mechanical contributions. We agree with Dr. Reissis and Dr. Gardiner that long-term survival of the injected fat restraining intraarticular pressure requires future critical evaluation. The antiinflammatory effects of adipose tissue and mesenchymal stem cells in alleviating or modulating inflammation has increasingly been described for disease states such as colitis, stroke, neuropathic pain, and scars.6–8 These cell types have also been noted to play a beneficial role in the prevention of secondary necrosis and apoptosis,9 pathophysiologic mechanisms well established in carpometacarpal joint osteoarthritis. Differentiation of adipose-derived stem cells from injected crude fat in new cartilage remains intriguing; however, at present, this remains hypothetical in concept for observed results.10 Dr. Reissis and Dr. Gardiner suggested that outcome should be monitored by the Australian/Canadian Score. A recent review of the literature notes that the Disabilities of the Arm, Shoulder, and Hand scoring system remains the most commonly used scoring system in the field of hand surgery and in studies on carpometacarpal joint osteoarthritis. In these referenced reports11,12 both Disabilities of the Arm, Shoulder, and Hand and Australian/Canadian scores were considered comparable, with no advantage of the Australian/Canadian Score over the Disabilities of the Arm, Shoulder, and Hand questionnaire. After more than 400 treatments to date with a clinically convincing effect, we do think that there is robust clinical evidence of efficacy. Further experimental studies to elucidate the mechanism of action are certainly advocated. A multicenter controlled clinical trial seems warranted and would require a priori established consensus among hand surgeons as to the appropriate comparator. DISCLOSURE The authors declare that they have no conflicts of interest. Christian Herold, M.D.HPC OldenburgOldenburg, GermanyDIAKO BremenBremen, Germany Robert Groddeck, M.D.Klinik für Kinder- und Jugendpsychiatrie/Psychosomatik und PsychotherapieKlinikum OldenburgOldenburg, Germany Sixtus Allert, M.D.Department of Plastic and Aesthetic Surgery, HandsurgerySana Klinikum Hameln PyrmontHameln, Germany Hans-Oliver Rennekampff, M.D.Plastic and Aesthetic SurgeryDepartment of Orthopaedic, Trauma, Hand, and Reconstructive SurgeryKlinikum LeverkusenLeverkusen, Germany" @default.
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• W3010446631 date "2018-03-01" @default.
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• W3010446631 title "Reply: Autologous Fat Transfer for Thumb Carpometacarpal Joint Osteoarthritis: A Prospective Study" @default.
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