title: Efficacy of intra-articular hyaluronan (Synvisc(R)) for the treatment of osteoarthritis affecting the first metatarsophalangeal joint of the foot (hallux limitus): study protocol for a randomised placebo controlled trial.
abstract: BACKGROUND
  Osteoarthritis of the first metatarsophalangeal joint (MPJ) of the foot, termed hallux limitus, is common and painful. Numerous non-surgical interventions have been proposed for this disorder, however there is limited evidence for their efficacy. Intra-articular injections of hyaluronan have shown beneficial effects in case-series and clinical trials for the treatment of osteoarthritis of the first metatarsophalangeal joint. However, no study has evaluated the efficacy of this form of treatment using a randomised placebo controlled trial. This article describes the design of a randomised placebo controlled trial to evaluate the efficacy of intra-articular hyaluronan (Synvisc(R)) to reduce pain and improve function in people with hallux limitus.
  
  
  METHODS
  One hundred and fifty community-dwelling men and women aged 18 years and over with hallux limitus (who satisfy inclusion and exclusion criteria) will be recruited.Participants will be randomised, using a computer-generated random number sequence, to receive a single intra-articular injection of up to 1 ml hyaluronan (Synvisc(R)) or sterile saline (placebo) into the first MPJ. The injections will be performed by an interventional radiologist using fluoroscopy to ensure accurate deposition of the hyaluronan in the joint. Participants will be given the option of a second and final intra-articular injection (of Synvisc(R) or sterile saline according to the treatment group they are in) either 1 or 3 months post-treatment if there is no improvement in pain and the participant has not experienced severe adverse effects after the first injection. The primary outcome measures will be the pain and function subscales of the Foot Health Status Questionnaire. The secondary outcome measures will be pain at the first MPJ (during walking and at rest), stiffness at the first MPJ, passive non-weightbearing dorsiflexion of the first MPJ, plantar flexion strength of the toe-flexors of the hallux, global satisfaction with the treatment, health-related quality of life (assessed using the Short-Form-36 version two questionnaire), magnitude of symptom change, use of pain-relieving medication and changes in dynamic plantar pressure distribution (maximum force and peak pressure) during walking. Data will be collected at baseline, then 1, 3 and 6 months post-treatment. Data will be analysed using the intention to treat principle.
  
  
  CONCLUSIONS
  This study is the first randomised placebo controlled trial to evaluate the efficacy of intra-articular hyaluronan (Synvisc(R)) for the treatment of osteoarthritis of the first MPJ (hallux limitus). The study has been pragmatically designed to ensure that the study findings can be implemented into clinical practice if this form of treatment is found to be an effective treatment strategy.
  
  
  BACKGROUND
  Australian New Zealand Clinical Trials Registry: ACTRN12607000654459.
authors.affiliation: Musculoskeletal Research Centre, Faculty of Health Sciences, La Trobe University, Bundoora 3086, Victoria, Australia. s.munteanu@latrobe.edu.au.
authors.forename: Shannon E
authors.initials: SE
authors.lastname: Munteanu
authors.forename: Hylton B
authors.initials: HB
authors.lastname: Menz
authors.forename: Gerard V
authors.initials: GV
authors.lastname: Zammit
authors.forename: Karl B
authors.initials: KB
authors.lastname: Landorf
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Handley
authors.forename: Ayman
authors.initials: A
authors.lastname: Elzarka
authors.forename: Jason
authors.initials: J
authors.lastname: Deluca