Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis

Intra-Articular Viscosupplementation for Patients with Hip Osteoarthritis: A Meta-Analysis and Systematic Review

BACKGROUND The aim of this study was to review the efficacy and safety of intra-articular (IA) viscosupplementation (VS) for hip osteoarthritis (OA). MATERIAL AND METHODS We searched Medline, Clinical Trial Register Center, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) comparing VS with placebo injection for hip OA. We included suitable studies, assessed the quality of studies, and extracted data on pain reduction, function improvement at different time points, and safety profiles. The comparisons of pain and function outcome were performed by meta-analysis. RESULTS Five high-quality randomized controlled studies trials (RCTs) with 591 patients with hip OA were identified. Although several trials demonstrated a significant decline in pain in VS groups during follow-up compared to baseline, without severe adverse events, the pooled analysis did not show VS was superior to placebo at any time windows [7-14 days: standardized mean difference (SMD): -0.18; 95% CI, -0.47 to 0.10, p=0.21; 28-30 days: 0.02 (-0.15, 0.19), p=0.82; or at final visit: -0.14 (-0.46, 0.18), p=0.38]. Similar results were also observed in the combined data of functional results. CONCLUSIONS IA VS does not reduce pain or improve function significantly better than placebo in a short-term follow-up. The benefits and safety of VS should be further assessed by sufficiently-sized, methodologically sound studies with validated assessment of more clinically relevant end-points.

Impact of obesity, structural severity and their combination on the efficacy of viscosupplementation in patients with knee osteoarthritis

Background

Obesity and radiological severity have been identified to be independent predictors of a low rate of response to viscosupplementation (VS), in patients with knee osteoarthritis (OA). Is that enough to formally refute VS in such patients in whom surgery is sometimes contraindicated?

Objectives

To compare pain and function scores before and 6 months after knee VS, according to the weight status (obese versus non obese), the radiological severity (mild/moderate versus severe) and both combined.

Methods

Post-hoc analysis of a prospective, double blind, randomized, multicentre trial, comparing 2 viscosupplements, in patients with symptomatic knee OA. Patients were classified according to body mass index (BMI < or ≥ 30 kg.^− 2), OARSI radiological grade (1–2 versus 3) and OMERACT-OARSI response criteria (Yes/No). WOMAC between-group comparisons (obese versus non-obese, OARSI 1–2 versus 3, and both combined) in all patients and in OMERACT-OARSI Responders, were achieved using Mannn-Whitney U test.

Results

One-hundred and sixty-six patients were analyzed: 28.3% were obese, 44% were OARSI grade 3, 42,2% were neither obese nor OARSI 3, whereas 14.5% were obese and OARSI 3. At baseline WOMAC pain score did not differ according to the patients sub-groups (p > 0.05). Six months after VS, WOMAC pain decreased significantly in all patient sub-groups (all p < 0.01). At month 6, WOMAC pain sub-score was significantly lower in non-obese than in obese patients (4.9 ± 4.1 versus 7.1 ± 4.9; p = 0.008) and in patients OARSI 1–2 versus 3 (4.8 ± 4.3 versus 6.4 ± 4.5; p = 0.009). However, in responder patients there was no difference in pain score and pain decrease related to the weight status and the radiological score.

Conclusion

These results do not confirm our previous conclusions that recommended not performing VS in obese patients with severe knee OA. Although the chances of being a responder were much reduced in these patients, the benefit of patients who respond to treatment was similar to that of subjects with normal weight and mild/moderate OA. Different pain phenotypes, more than overweight and advanced disease, might be the main reason for the success or failure of VS.

Indications of the Neurotomy of Genicular Nerves by Radiofrequency for the Treatment of Knee Osteoarthritis: A Literature Review

Osteoarthritis (OA) is one of the most frequent and incapacitating pathologies today, especially of the knee. Among the possible approaches for knee OA, the neurotomy of the genicular nerves by radiofrequency (RF) has been gaining prominence. However, as this is a relatively new procedure, indications for its implementation are still unclear. The objective of the present review is to identify the main indications of the use of RF for the treatment of knee OA in the medical literature. A review of the literature was performed in January 2018 through a search in the PubMed, ClinicalKey and Google Scholar databases. After reviewing the main articles on the subject, it was concluded that the main indications of the use of RF for the treatment of knee OA were: OA Kellgren-Lawrence grades 3 and 4, with moderate to severe pain and failure of conservative treatment, mainly in elderly people; persistence of pain even after total knee arthroplasty (TKA); patients with an indication for TKA who refuse to undergo surgical treatment.

BRAZILIAN CONSENSUS STATEMENT ON VISCOSUPPLEMENTATION OF THE KNEE (COBRAVI)

Objective:

The aim of this consensus statement on viscosupplementation is to serve as a reference document based on relevant literature and clinical experience in the treatment of knee osteoarthritis using an intra-articular injection of hyaluronic acid, covering key aspects such as clinical indications, effectiveness, and tolerability.

Methods:

A multidisciplinary panel including two sports medicine physicians, six orthopedists, four physiatrists, and two rheumatologists were selected based on their clinical and academic experience of viscosupplementation. Sixteen statements were prepared and discussed, after which a vote was held. Each member of the panel gave a score between 0 and 10 on a Likert scale, specifying their level of agreement with the statement.

Results:

The panel reached a consensus on several issues. Specifically, the panel agreed that the best indication is for mild to moderate knee arthrosis; prior or concomitant use of intraarticular triamcinolone hexacetonide may optimize the effect of hyaluronic acid; viscosupplementation should not be performed as an isolated procedure but in conjunction with other rehabilitative and pharmacological measures; viscosupplementation has analgesic, anti-inflammatory, and chondroprotective effects; and viscosupplementation is cost-effective.

Conclusion:

This consensus statement provides clear information and guidance for both individuals and payers. Level of evidence V, Consensus statement.

Hyaluronan derivative HYMOVIS® increases cartilage volume and type ii collagen turnover in osteoarhritic knee: data from MOKHA study

BACKGROUND

The objective of this pilot study was to identify biological, clinical or structural biomarkers of an intra-articular hyaluronic acid injection efficacy (HYMOVIS®) for the design of a larger placebo-controlled clinical trial studying the disease-modifying activity of this treatment.

METHODS

Forty six patients with symptomatic knee Osteoarthritis (OA) were enrolled in this open-label, prospective, multicenter, pilot study. Patients received two treatment cycles of intra-articular injections (3 mL) of HYMOVIS® (8 mg/mL of hyaluronic acid hexadecylamide) at 6 months interval. Each treatment cycle involved two intra-articular injections 1 week apart. All patients had Magnetic Resonance Imaging (MRI) of the target knee at baseline and 1 year, and blood samples to assess joint biomarkers. The primary outcome was the change in type II collagen-specific biomarkers (Coll2-1, Coll2-1NO2 and CTX-II) after HYMOVIS® treatment versus baseline. Secondary endpoints included levels changes in aggrecan chondroitin sulfate 846 epitope (CS-846), Cartilage Oligomeric Matrix Protein (COMP), procollagen type II N-terminal propeptide (PIIANP), Matrix Metalloprotease (MMP)-3, Myeloperoxidase (MPO) and Interleukin (IL)-6 serum biomarkers, the ratio Coll2-1/PIIANP, CTX-II/PIIANP, variation of MRI cartilage volume, and Knee injury and Osteoarthritis Outcome Score (KOOS) index.

RESULTS

Coll2-1 serum levels significantly increased overtime while Coll2-1NO2 levels were only increased at D360. Serum PIIANP levels also progressively and significantly enhanced with time. In contrast, other serum biomarker levels including CTX-II, CS-846, COMP, MMP-3, MPO or IL-6 did not change significantly overtime. Interestingly, the ratios Coll2-1/PIIANP and CTX-II/PIIANP decreased, indicating a decrease of cartilage catabolism. Compared to baseline value, MRI cartilage volume and thickness increased in lateral femoral and lateral trochlea compartments and not in medial compartment. These results, in addition to an improvement of T2 mapping score suggest a positive structural effect of the product. Interestingly, WORMS effusion score, an indicator of synovitis, significantly decreased. Finally, global KOOS score and subscales significantly increased overtime while pain at rest, walking pain and patients or investigators global assessment of disease activity decreased. The safety profile was favorable with a low incidence of injection-site pain.

CONCLUSION

HYMOVIS®, a well-tolerated intra-articular treatment, significantly enhanced type II collagen turnover as suggested by the increase in Coll2-1 and PIIANP levels and cartilage volume observed by MRI in lateral knee compartment. Importantly, this study provides critical information for the design of a larger phase III clinical trial investigating Disease Modifying effect of HYMOVIS®.

TRIAL REGISTRATION

http://www.isrctn.com/ISRCTN12227846 11/02/2015.

[The effectiveness of complex therapy using the injectable form of chondroitin sulfate and sodium hyaluronate with osteoarthritis of the knee joint]

AIM

The study on the effectiveness of complex therapy for osteoarthritis (OA) of the knee joint was conducted in real clinical practice.

MATERIALS AND METHODS

The survey involved 125 patients aged fr om 50 to 70 years (25 men and 100 women) with a diagnosis of knee joint OA (the III roentgenologic Kellgren-Lawrence stage).The average age of the patients was 62±3.21, the average duration of the disease - 9.4±2.8 years. Patients were randomly assigned to three groups of 35 people, the control group had 20 patients. Group 1 patients received non - steroidal anti - inflammatory drugs (NSAIDs) + Injectran(Chondroitin sulfate) 200 mg intramuscularly (I.M.) every other day No. 25.In group 2, patients received NSAIDs + Fermatron 1% 2 ml with an interval of 7 days intra - articularly (I.A.) No. 3. In group 3 - NSAIDs + Injectran 200 mg (I.M.) every other day No. 25 + Fermatron 1% 2 ml with an interval of 7 days (I.A.) No. 3. In the control group (20 people), patients received only NSAIDs. Evaluation of the symptoms was carried out using the WOMAC index before the start of thetherapy, after 8 and 12 weeks of treatment. The intensity of pain while walking was estimated on a visual analogue scale.

RESULTS

In the groups that received Injectran (I; group 1) or Fermatron (F; group 2), the dynamics of pain while walking reduction was comparable and had slightly more than 30% in both groups, the figures are reliable in comparison withinitial data (p.

Frictional characterization of injectable hyaluronic acids is more predictive of clinical outcomes than traditional rheological or viscoelastic characterization

Hyaluronic acid injections have been a mainstay of arthritis treatment for decades. However, much controversy remains about their clinical efficacy and their potential mechanism of action. This approach to arthritis therapy is often called viscosupplementation, a term which is rooted in the elevated viscosity of the injected solutions. This terminology also suggests a mechanical pathway of action and further implies that their efficacy is dependent on viscosity. Notably, previous studies of the relationship between viscous properties of hyaluronic acid solutions and their clinical efficacy have not been definitive. Recently we developed an experimental and analytical framework for studying cartilage lubrication that captures the Stribeck-like behavior of cartilage in an elastoviscous transition curve. Here we apply this framework to study the lubricating behavior of six hyaluronan products currently used for injectable arthritis therapy in the US. Despite the fact that the source and chemical modifications endow these products with a range of lubricating properties, we show that the lubricating effect of all of these materials can be described by this Stribeck-like elastoviscous transition. Fitting this data to the elastoviscous transition model enables the calculation of effective lubricating viscosities for each material, which differ substantially from the viscosities measured using standard rheometry. Further we show that while data from standard rheometry are poor predictors of clinical performance of these materials, measurements of friction coefficient and effective lubricating viscosity correlate well (R2 = 0.77; p < 0.005) with assessments of improved clinical function reported previously. This approach offers both a novel method that can be used to evaluate potential clinical efficacy of hyaluronic acid formulations and provide new insight on their mode of action.

Outcomes of hyaluronic acid injections for glenohumeral osteoarthritis: a systematic review and meta-analysis

BACKGROUND

Hyaluronic acid (HA) is an analgesic and chondroprotective agent often used for the nonoperative treatment of osteoarthritis (OA). The effects of HA injections are well studied in the treatment of knee OA, but the effects in glenohumeral OA remain unclear. This study evaluated the efficacy of HA to reduce pain in patients with glenohumeral OA.

METHODS

PubMed, MEDLINE, CENTRAL, and Embase were searched from the database inception date through January 16, 2018. Two reviewers independently screened articles for eligibility and extracted data for analysis. A methodological quality assessment was completed for all included studies, including assessment of risk of bias. The primary outcome was change in visual analog scale for pain. The secondary outcomes were functional outcome and adverse events.

RESULTS

In the HA arm, the reduction of visual analog scale pain score at 3 months was 26.2 mm (95% confidence interval, 22.0-30.3 mm; I² = 31%) and at 6 months was 29.5 mm (95% confidence interval, 25.5-33.4 mm; I² = 19%). All studies reported an improvement in functional outcome. Similar clinical improvements were reported in the intervention and control groups, suggesting that these improvements may not be directly related to HA. Commonly reported adverse events were rare and included swelling and mild pain at the injection site, local effusion, lethargy, and face rash.

CONCLUSION

Intra-articular HA injection is safe and improves pain for patients with glenohumeral OA. Pain improvements also reported in the control group suggest that a significant placebo effect may be present with respect to intra-articular shoulder injection. Further randomized controlled trials are necessary to evaluate the efficacy of HA and identify optimal dosing and route of administration.

A randomised pilot equivalence trial to evaluate diamagnetically enhanced transdermal delivery of key ground substance components in comparison to an established transdermal non-steroidal anti-inflammatory formulation in males with prior knee injury

Objective

This pilot study assessed the efficacy of a knee guard device, which used magnetophoresis to transdermally deliver Glucosamine, Chondroitin and Hyaluronic Acid in a cohort of individuals with prior knee injury. The aim was to determine if the change in physical function and pain with the knee guard device was equivalent to the change produced by an established topical NSAID formulation containing diclofenac sodium 1%.

Methods

A randomized, controlled, equivalence trial evaluated outcomes following treatment with the knee guard device or NSAID formulation. The study recruited 114 male participants (aged 40–55 years). Participants were randomly allocated to wear the knee guard device or to use a NSAID gel daily for two weeks. The primary outcomes were the knee injury osteoarthritis function score (KOOS-F) and an aggregated function score (AFS). The lower extremity functional scale (LEFS), pain numerical rating scale (PNRS), global rating of change (GROC) and other KOOS scores were also evaluated.

Results

Multiple linear regression analyses indicated that there were no significant differences between the interventions for changes in the primary outcomes of AFS and KOOS_F. The 95% confidence interval (-2.89 to 5.15) of the estimated treatment difference for KOOS-F was within the lower (-5.61) and upper (5.61) bounds of the 7% equivalence margin for that measure, The mean value for the AFS was within, but the 95% CI (-3.11 to 7.37) exceeded the 7% equivalence margin (-2.97 to 2.97) for that measure. There was a significant difference in PNRS, which favored the knee guard device.

Conclusion

The knee guard device demonstrated equivalence for the KOOS-F measure but not the AFS measure of function over the two week trial period when compared to a widely available NSAID gel that has been shown to be superior to placebo. The knee guard produced a greater reduction in pain report (p = 0.002) than the NSAID gel. Users of the knee guard device experienced more skin irritation than participants using the NSAID gel. Further research is required to fully evaluate the therapeutic potential of this innovative treatment approach.

Evaluating the use of intra-articular injections as a treatment for painful hip osteoarthritis: a randomized, double-blind, multicenter, parallel-group study comparing a single 6-mL injection of hylan G-F 20 with saline

OBJECTIVE

Hip osteoarthritis (OA) is difficult to treat. Steroid injections reduce pain with short duration. With widespread adoption of office-based, image-guided injections, hyaluronic acid is a potentially relevant therapy. In the largest clinical trial to-date, we compared safety/efficacy of a single, 6-mL image-guided injection of hylan G-F 20 to saline in painful hip OA.

METHOD

357 patients were enrolled in a multicenter, double-blind, randomized saline placebo- controlled trial. Subjects were ≥35 years of age, with painful (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]-A1:5.0-8.0; numeric rating scale [NRS]: 0-10) mild-to-moderate hip OA (Kellgren-Lawrence grade II/III) and minimal contralateral hip pain (WOMAC-A1 < 4). Outcome measures included "pain on walking" (WOMAC-A1 and -A), Patient Global Self-Assessment (PTGA), WOMAC-A1 responder rate (+≥2 points on NRS), and adverse events (AEs) over 26 weeks.

RESULTS

357 patients (hylan G-F 20 single:182; saline:175) were enrolled. Both groups demonstrated significant pain improvement from baseline over 26 weeks (P < 0.0001); saline-induced pain reduction was a remarkable 35%. WOMAC-A and PTGA scores also significantly improved (P < 0.0001). No statistically significant difference was observed between groups in WOMAC-A1 scores (hylan G-F 20 single:-2.19 ± 0.16; saline:-2.26 ± 0.17) or WOMAC-A1 responders (41-52%). Treatment-related AE rates at target hip were similar (hylan G-F 20 single:23 patients [12.8%]; saline:12 [7.0%]). Posthoc analysis found, despite protocol requirements, many patients had psychological (31%) or potential neuropathic pain (27.5%) conditions.

CONCLUSION

A single 6-mL hylan G-F 20 injection or saline for painful hip OA resulted in similar, statistically significant/clinically relevant pain and function improvements up to 6 months following injection; no differences between hylan G-F 20 and saline placebo were observed.

When is indicated viscosupplementation in hip osteoarthritis?

Background and aim: The incidence of hip osteoarthritis (OA) is increasing in parallel with the aging of the population. The aim of this study is to report the efficacy of an ultrasound-guided intra-articular (IA) hip injection of a single dose of high-weight hyaluronic acid (HA) (2500 kDa) at a follow-up of 12 months. Materials and Methods: 226 patients older than 40 years of age affected by painful hip OA (Kellgren-Lawrence stage 1-2-3) were treated from January 2012 to December 2015 with viscosupplementation. Patients were clinically evaluated before injection (T0) and after 3 months (T3), 6 months (T6) and 1 year (T3) through the WOMAC scale and Harris Hip Score (HHS). Results: During the follow-up period no patients underwent to hip surgery or need adjunctive IA injection of HA. No adverse effects were registered. An improvement in WOMAC and HHS was observed in all patients after treatment. Results showed that patients with grade 2 of osteoarthritis had the higher delta of change in the scores. Discussion: Ultrasound-guided with high weight IA HA injection could be a possibility of treatment in the symptomatic osteoarthritic hip. Subjects with a moderate grade of osteoarthritis (Kellgren-Lawrence stage 2) represent the group that could report the maximum benefits from viscosupplementation. (www.actabiomedica.it)

Viscosupplementation for knee osteoarthritis: a focus on Hylan G-F 20

Knee osteoarthritis is a chronic degenerative joint disease characterized by destruction of articular cartilage with resultant para-articular bone changes. It is a major cause of disability in older persons and is managed by surgical and nonsurgical interventions. Pharmacotherapy includes acetaminophen, nonsteroidal anti-inflammatory agents, and intra-articular steroids. Another treatment option is viscosupplementation with intra-articular injection of hyaluronan (HA). The full mechanism of action of exogenous HA is uncertain, but studies indicate that it may promote endogenous HA production, reduce inflammation, prevent degeneration of cartilage and promote cartilage regeneration. Clinically, HA may improve symptoms of osteoarthritis and delay time to total knee replacement surgery. However, clinical studies are heterogenous and of varying quality, and thus there is a need for more robust studies to determine the place of viscosupplementation in the management of knee osteoarthritis.

Knee osteoarthritis: pathophysiology and current treatment modalities

For decades, multiple attempts to fully understand knee osteoarthritis pathophysiology and natural history have been attempted. Despite the extensive amount of research regarding this topic, there are still marked controversies. This multifactorial condition gets influenced by local, systemic, and external factors and its progression and/or response to treatments widely varies from patient to patient. Multiple therapies have been studied in the past, low impact physical activity seems to be supported by all the current medical societies while other interventions have shown conflicting findings. Newer therapies and routes of administration are under investigation and some of them have shown promising preliminary reports. This review intends to give an overview of the current knowledge of pathophysiology and non-surgical therapies available for knee osteoarthritis.

Getting Better or Getting Well? The Patient Acceptable Symptom State (PASS) Better Predicts Patient's Satisfaction than the Decrease of Pain, in Knee Osteoarthritis Subjects Treated with Viscosupplementation

Background In the management of knee osteoarthritis (OA), patient-reported-outcomes (PROs) are being developed for relevant assessment of pain. The patient acceptable symptom state (PASS) is a relevant cutoff, which allows classifying patients as being in "an acceptable state" or not. Viscosupplementation is a therapeutic modality widely used in patients with knee OA that many patients are satisfied with despite meta-analyses give conflicting results. Objectives To compare, 6 months after knee viscosupplementation, the percentage of patients who reached the PASS threshold (PASS +) with that obtained from other PROs. Methods Data of 53 consecutive patients treated with viscosupplementation (HANOX-M-XL) and followed using a standardized procedure, were analyzed at baseline and month 6. The PROs were Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function, patient's global assessment of pain (PGAP), patient's self-assessment of satisfaction, PASS for WOMAC pain and PGAP. Results At baseline, WOMAC pain and PGAP (range 0-10) were 4.6 (1.1) and 6.0 (1.1). At month 6, they were 1.9 (1.2) and 3.1 (5) ( P < 0.0001). At 6 months, 83% of patients were "PASS + pain," 100% "PASS + function," 79% "PASS + PGAP," 79% were satisfied, and 73.6% experienced a ≥50% decrease in WOMAC pain. Among "PASS + pain" and "PASS + PGAP" subjects, 90% and 83.3% were satisfied with the treatment, respectively. Conclusion In daily practice, clinical response to viscosupplementation slightly varies according to PROs. "PASS + PGAP" was the most related to patient satisfaction.

Intra-articular, single-shot co-injection of hyaluronic acid and corticosteroids in knee osteoarthritis: A randomized controlled trial

The aim of the present study was to investigate whether the co-injection of hyaluronic acid (HA) and corticosteroids (CS) was superior to HA alone in the treatment of knee OA. A total of 120 participants with symptomatic knee OA were recruited and formed the intention-to-treat population for a 6-month follow-up. In the HA group, patients received a single-shot injection of 4 ml HA. In the HA&CS group, patients received a co-injection of 3 ml compound betamethasone solution and 4 ml HA. Visual analog scale (VAS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and knee flexion motion were assessed as primary outcomes. Patients in the HA&CS group exhibited better pain relief and knee function at the time points of week 1, month 1 and month 3 (P<0.05). For the last follow-up at month 6, the values did not differ significantly between these two groups. Patients in both groups exhibited improvement in pain, knee function, and range of motion following injection. For the final follow-up at month 6, the mean VAS score, WOMAC score and knee flexion motion were still superior to that prior to treatment, but the values did not differ significantly. The co-injection of HA and CS provided a rapid improvement in pain relief, knee function, and range of motion, but did not differ significantly from that of HA alone in the long term effect.

Comblike Ionic Complexes of Hyaluronic Acid and Alkanoylcholine Surfactants as a Platform for Drug Delivery Systems

Nontoxic alkanoylcholine soaps ( nACh) were synthesized from choline and fatty acids with numbers of carbons n equal to 12, 14, 16, and 18, the latter including both saturated and 9- cis unsaturated alkanoyl chains. Coupling of nACh with hyaluronic acid (HyA) rendered comblike ionic complexes nACh·HyA that were non-water-soluble. The complexes were thermally stable up to temperatures above 200 °C but readily degraded by water, in particular when hyaluronidases were present in the aqueous medium. In the solid state, these complexes were self-assembled in a biphasic layered structure in which the surfactant and the polysaccharide phases were alternating regularly with a periodicity dependent on the length of the alkanoyl chain. The paraffinic phase was found to be crystallized in saturated complexes with n ≥ 14, but only 18ACh·HyA showed reversible melting crystallization when subjected to cyclic heating-cooling treatment. Nanoparticles with diameters in the 50-150 nm range were prepared by ionotropic gelation from unbalanced 18ACh·HyA complexes with surfactant:HyA ratios of 0.5 and 0.25. These nanoparticles were also structured in layers, swelled slowly in water, and shown to be noncytotoxic in in vitro assays against macrophages cells. It was also shown that the anticancer drug doxorubicin was efficiently encapsulated in both films and NPs of 18ACh·HyA, and its release was shown to be almost linear and complete after one day of incubation in physiological medium. The nACh·HyA complexes constitute a highly promising biocompatible/biodegradable platform for the design of systems suitable for drug transport and targeting delivery in anticancer chemotherapy.

Current Concepts and Future Directions of Minimally Invasive Treatment for Knee Pain

PURPOSE OF REVIEW

The purpose of this paper is to review the percutaneous interventions available for the treatment of osteoarthrosis of the knee that address pain and prolong the time to arthroplasty.

RECENT FINDINGS

Corticosteroid injection and viscosupplementation have been the most studied, but there is still no consensus about their value. Thermal nerve ablation, including both radiofrequency ablation and cryoneurolysis, is a promising new modality of therapy that may increase in clinical use given current data showing favorable outcomes. Of the future therapies that are currently under investigation, synovial embolization via the geniculate arteries represents an exciting new approach that may soon be available clinically. There are various percutaneous interventions available for the treatment of osteoarthrosis of the knee that address pain and prolong the time to arthroplasty.

Decision Algorithms for the Retreatment with Viscosupplementation in Patients Suffering from Knee Osteoarthritis: Recommendations from the EUROpean VIScosupplementation COnsensus Group (EUROVISCO)

Background Viscosupplementation (VS) is a symptomatic treatment of knee osteoarthritis. Although systematic reviews of its repeat use showed favorable benefit/risk ratio, no study has focused on the indication of retreatment. Methods A task force was created to look at issues regarding retreatment with VS in knee osteoarthritis. An attempt was made to reach consensus on several issues: (1) to define treatment "success" and "failure," (2) to determine when to retreat patients successfully treated by a previous VS, (3) to determine how to retreat patients in whom VS failed, (4) to define what to do in case of adverse reaction following previous VS, and (5) to examine the interests of soluble biomarkers to manage retreatment. After debate and review of literature the working group voted on 88 issues. Two "decision trees" were built based on the results of the votes. Results In case of failure, the authors draw attention to the need of a rigorous clinical and radiological analysis, and consider evidence-based medicine. When VS was previously successful, retreatment can be considered after recurrence or increase in pain. However, in subjects with high risk of disease progression, in young patients, and in professional sportsmen, retreatment could be considered systematically, because of the probability of hyaluronic acid to slow osteoarthritis progression. Evidence on soluble biomarkers was not considered as enough strong to support their use as decision tools for patient retreatment. Conclusion The decision algorithms are intended to facilitate consideration of the therapeutic options, in patients with knee osteoarthritis previously treated with VS.

Safety and Predictive Factors of Short-Term Efficacy of a Single Injection of Mannitol-Modified Cross-Linked Hyaluronic Acid in Patients with Trapeziometacarpal Osteoarthritis. Results of a Multicentre Prospective Open-Label Pilot Study (INSTINCT Trial)

Purpose:

To assess safety and search predictive factors of efficacy of a single intra-articular injection of a mannitol-modified hyaluronic acid (HA) viscosupplement, in patients having trapeziometacarpal (TMC) osteoarthritis (OA).

Methods:

Patients with symptomatic TMC OA, not adequately relieved by analgesic therapy and/or by the use of a thumb splint, were included in a 3-month prospective multicentre open-label trial. All underwent plain radiographs with the Kapandji incidences allowing the Dell radiological grade assessment (1-4). Primary end point was the variation between injection (D0) and day 90 (D90) of the thumb pain (11-point Likert scale). Treatment consisted in a single injection of 0.6 to 1 mL of a viscosupplement made of a cross-linked HA combined with mannitol. All injections were performed under imaging guidance. Predictive factors of pain decrease were studied in univariate and multivariate analysis.

Results:

A total of 122 patients (76% women, mean age 60, mean disease duration 36 months) were included and 120 (98%) were assessed at 3 months. The TMC OA was of Dell’s grade 1, 2, 3, and 4 in 23%, 36.8%, 36.8%, and 3.5% of cases, respectively. At D0, the average (SD) pain level was 6.5 ± 1.6 without significant difference between Dell groups (P = .21). At day 90, pain decreased from 6.5 ± 1.6 to 3.9 ± 2.5 (difference −2.7 ± 2.5; −42%; P < .0001) without significant difference between Dell grade (P = .055), despite a seemingly smaller number of responders in stage 2 patients. The average analgesic consumption decreased in more than 1 out of 2 patients. In multivariate analysis, no predictor of response was identified. There was no safety issue. All adverse events (11%) were transient increase in pain during or following HA administration and resolved without sequel within 1 to 7 days.

Conclusions:

This study suggests that a single course of HANOX-M-XL injection is effective in relieving pain in patients with TMC OA, without safety concern. Patients with advanced stage of OA benefit the treatment as much as those with mild or moderate OA.

Notochordal cell matrix as a bioactive lubricant for the osteoarthritic joint

Notochordal cell derived matrix (NCM) can induce regenerative effects on nucleus pulposus cells and may exert such effects on chondrocytes as well. Furthermore, when dissolved at low concentrations, NCM forms a viscous fluid with potential lubricating properties. Therefore, this study tests the feasibility of the use of NCM as a regenerative lubricant for the osteoarthritic joint. Chondrocyte-seeded alginate beads were cultured in base medium (BM), BM with NCM (NCM), or BM with TGF-β1 (TGF), as well as BM and NCM treated with IL-1β. NCM increased GAG deposition and cell proliferation (stronger than TGF), and GAG/DNA ratio and hydroxyproline content (similar to TGF). These effects were maintained in the presence of IL-1β. Moreover, NCM mitigated expression of IL-1β-induced IL-6, IL-8, ADAMTS-5 and MMP-13. Reciprocating sliding friction tests of cartilage on glass were performed to test NCM's lubricating properties relative to hyaluronic acid (HA), and showed a dose-dependent reduction in coefficient of friction with NCM, similar to HA. NCM has anabolic and anti-inflammatory effects on chondrocytes, as well as lubricating properties. Therefore, intra-articular NCM injection may have potential as a treatment to minimize pain while restoring the affected cartilage tissue in the osteoarthritic joint.

Hyaluronic Acid Dictates Chondrocyte Morphology and Migration in Composite Gels

Tissue equivalent collagen-hyaluronic acid-based hydrogels are widely used for cartilage tissue engineering; however, not much importance has been given to investigate how cellular responses are altered with varying concentrations of hyaluronic acid in gels. In this study, different concentrations of hyaluronic acid dialdehyde (HAD) were combined with collagen to fabricate collagen-HAD composite (CH) gels, and the influence of HAD on cell shape, migration, viability, cytoskeletal organization, and gel contraction was examined. The microstructure and the mechanical strength of the composite gels were altered by varying HAD concentrations. Morphology of chondrocytes cultured on CH gels showed a significant increase in their aspect ratio and decrease in number of cell protrusions with increase in concentration of HAD. The organization of the cytoskeleton at the cellular protrusions was vimentin localized at the base, microtubules at the tip, and actin localized throughout the cell body. Changes in HAD concentrations altered hydrogel mechanical strength, cytoskeletal organization, and formation of cellular protrusions, all of which contributed to changes in cell morphology and migration. These changes were more evident in 3D cell-encapsulated gels than chondrocytes cultured over the 2D gels. However, viability of cells and matrix contraction, staining for adhesion protein vinculin, and hyaluronic acid receptor CD44 remained similar in all CH compositions. The changes in cell responses further influenced extracellular matrix deposition during in vitro culture. Cell responses in low HAD gels mimic the cellular behavior in damaged cartilage, whereas those in high HAD gels resembled the behavior in healthy cartilage tissue. Our study illustrates the importance of careful formulations of hydrogel compositions in designing biomimetic matrices that are used as in vitro models to study chondrocyte behavior.

Efficacy of a single intra-articular injection of ultra-high molecular weight hyaluronic acid for hip osteoarthritis: a randomized controlled study

BACKGROUND

Viscosupplementation with hyaluronic acid (HA) is increasingly used for the treatment of hip osteoarthritis (OA). The purpose of this study was to compare the efficacy of intra-articular injections of an ultra-high molecular weight viscosupplement (UHMW-HA, Fermathron S) with a medium molecular weight hyaluronan (MMW-HA, Hyalubrix 60) in hip OA.

METHODS

Fifty-four patients with hip OA grade 3 on the Kellgren/Lawrence scale were randomized. All infiltrations were performed under ultrasound guidance. Evaluation was performed preoperatively and at 1, 3, 6 and 12 months after infiltration. Patients were clinically evaluated using Lequesne index, VAS and WOMAC score.

RESULTS

Fifty patients, including 27 in the MMW-HA group and 23 in the UHMW-HA group, completed the follow-up. No significant difference was found between the two groups in terms of VAS, WOMAC or Lequesne index preoperatively or at 1, 3, 6 and 12 months after viscosupplementation. A stratified analysis was performed to study the development over time of Lequesne index of patients aged ≤ 55 years, > 55 and, ≤ 70 years and > 70 years and Lequesne index was different between the three age-stratified subgroups only in the MMW-HA group. The subgroup of older patients showed a higher Lequesne index than the subgroups of younger patients (p < 0.05).

CONCLUSIONS

UHMW-HA is a safe and effective treatment for hip osteoarthritis. A single dose of UHMW-HA was as effective as two doses of MMW-HA resulting in similar reductions of pain and disability.

STUDY DESIGN

Multicenter, independent, prospective, randomized controlled trial with level of evidence 1.

Do intra-articular hyaluronic acid injections delay total knee replacement in patients with osteoarthritis - A Cox model analysis

Due to the growing worldwide prevalence of knee osteoarthritis, the optimal management of this issue is critical for reducing its burden.

Can hybrid hyaluronic acid represent a valid approach to treat rizoarthrosis? A retrospective comparative study

BACKGROUND

Osteoarthritis (OA) of the trapeziometacarpal joint (TMJ) is a disabling condition with a significant impact on quality of life. The optimal management of hand OA requires a combination of non-pharmacological and pharmacological treatments that include intra-articular (i.a.) therapy. EULAR experts recommend corticosteroid injections in TMJ OA and underline the usefulness of hyaluronic acid (HA). The aim of this study was the assessment of the efficacy and tolerability of i.a. injections of a hybrid formulation of HA (Sinovial H-L®) in comparison to triamcinolone in patients with TMJ OA.

METHODS

This 6-months observational comparative study, retrospective analyzed the medical records of 100 patients with monolateral or bilateral TMJ OA, treated with two injections of Sinovial H-L® (Sinovial H-L Group) or of triamcinolone acetonide (Triamcinolone Group). Clinical assessments were recorded at the time of the first and second injection and after one, 3 and 6 months. The primary outcomes were the change in global pain on a Visual Analogue Scale (VAS) and in hand function evaluated by the Functional Index for Hand OA (FIHOA) from baseline to month 6. Secondary outcomes were the improvement of the duration of morning stiffness, Health Assessment Questionnaire (HAQ) and the Medical Outcomes Study 36-Item Short Form (SF-36). The comparison between the two groups of treatment were performed with the Wilcoxon rank-sum test for continuous variables and with chi-square or Fisher exact test for categorical variables. Statistical significance was set at p < 0.05.

RESULTS

Both therapies provided effective pain relief and joint function improvement, but the benefits achieved were statistically significantly superior in the Sinovial H-L Group than the Triamcinolone Group after one month (p < 0.01) from the beginning of the therapy and during the 6-months follow-up (p < 0.001). Furthermore, Sinovial H-L® was associated with a significant decrease in the duration of morning stiffness and with a significant improvement in the HAQ score and physical component summary (PCS)-SF-36.

CONCLUSIONS

Our results suggested that the hybrid formulation of HA may be more effective than triamcinolone in pain relief and joint function improvement with a rapid and persistent effect, resulting a valid alternative to steroid in the management of TMJ OA.

TRIAL REGISTRATION

ClinicalTrials.gov, date of registration: June 14, 2017, NCT03200886 . The present trial was retrospectively registered.

Intra-articular therapy in hip osteoarthritis

Several therapeutic options have been used in the past for treatment of patients with hip osteoarthritis (HO). In recent years we have witnessed to the introduction of the intra-articular injection (IA) of hyaluronic acid (HA) in clinical practice. This technique was initially used to treat knee arthritis, for which was actually introduced, but hip anatomy itself (deeper joint structure) and technical features (different methods) pose more challenges. However, results look promising in terms of symptoms improvement and delaying prosthetic surgery. Indeed, it does appear mandatory to increase pool of available data with further studies in order to refine techniques, make them more effective, and target patients who could potentially benefit more than others from treatment.

Obesity and radiological severity are associated with viscosupplementation failure in patients with knee osteoarthritis

Viscosupplementation (VS) is still controversial. One of the key points is the lack of well-identified factors of response. We aimed to identify clinical and radiological factors associated with lack of relevant response after intra-articular (IA) hyaluronic acid (HA) injections in symptomatic knee osteoarthritis patients. A post hoc analysis of the HAV-2012 trial, a controlled, multicentre, double-blind, randomized, non-inferiority trial comparing 3 weekly IA injections of HA (HAnox-M or BioHA) for symptomatic tibiofemoral OA was performed. At inclusion, demographic, anthropometric, clinical data (WOMAC score, patient global assessment, presence of knee effusion), and radiological data (OARSI grade, patello-femoral involvement) were recorded. VS response was defined according to OMERACT-OARSI response criteria at month 6. Predictors of response were investigated in univariate then in multivariate analysis. One hundred and sixty-six patients with full available data were included. As baseline characteristics and treatment effectiveness were similar between the 2 HA groups, their data were pooled. The mean age was 65.2 [63.7-66.8] years; 101 (60.8%) were women; 73 (44.0%) had severe TF space narrowing. At 6 months, 113 patients (68.1%) were responders. Multivariate analysis showed that obesity (BMI ≥30 kg/m²⁾ and radiological severity (OARSI grade 3) were significantly associated with VS failure (p = 0.001 and p = 0.008, respectively). Moreover, the association of obesity and severe TF space narrowing significantly increased the risk of VS failure. Baseline pain intensity and functional impairment were not associated with VS response. Consequently, IA injection of HA for knee OA should mainly be considered in subjects with low BMI and mild TF space narrowing. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:2269-2274, 2017.

Early Efficacy of Intra-Articular HYADD® 4 (Hymovis®) Injections for Symptomatic Knee Osteoarthritis

Purpose  The aim of the study was to evaluate the clinical effects of HYADD® 4, an hydrogel based on a hyaluronic acid derivative, in patients with symptomatic knee osteoarthritis, on symptoms, and joint function. Methods  This retrospective study of patients with Kellgren-Lawrence grade II to IV knee osteoarthritis (American College of Rheumatology criteria) enrolled patients who had received two infiltrations of HYADD® 4, (24 mg/3 mL) 1 week apart, and evaluated: pain at rest, pain with movement, change in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score; change in nonsteroidal anti-inflammatory drugs (NSAIDs)/acetaminophen use; satisfaction with therapy; tolerability. Study duration was 6 months for all predefined endpoints, with a 6-month extension for pain symptoms only. Results  After 6 months, all predefined endpoints were evaluable in 698 of 937 enrolled patients (74.5%). Mean WOMAC scores were reduced by 56.3% from baseline ( p  < 0.05). NSAIDs/acetaminophen use ≥2 times/week (48.8% of patients at baseline) was substantially reduced after 1 month and was 19.6% after 6 months. After 6 months, 85.6% of patients were satisfied about efficacy. There were no significant adverse effects. The effect on resting pain was rapid, strong, and lasting: reduction from baseline was 45.1% at 1 month ( p  < 0.05), 56.8% at 6 months ( p  < 0.05), and 53.6% at 12 months ( p  < 0.05). Pain on moving was reduced by 47.4% after 6 months ( p  < 0.05) and 46.0% after 12 months ( p  < 0.05), results at 6 and 12 months were similar. Conclusion  HYADD® 4 is a new-generation hyaluronic acid with distinctive viscoelastic and rheological properties. In patients with mild-to-severe knee OA (Kellgren-Lawrence grades II-IV), two consecutive infiltrations 1 week apart reduced WOMAC scores and NSAIDs/acetaminophen consumption for at least 6 months. In a subpopulation ( n  = 106), efficacy on pain lasted approximately 12 months. Adverse events were reported in 11.2% of patients; the most frequent were arthralgias. No cases of allergic reactions or systemic effects were recorded. Level of Evidence  Level IV, retrospective case series.

Appropriate Use Criteria for Hyaluronic Acid in the Treatment of Knee Osteoarthritis in the United States

OBJECTIVE

A workgroup of clinical experts has developed an Appropriate Use Criteria (AUC) for the use of hyaluronic acid (HA) in the treatment of osteoarthritis (OA) of the knee. The increasingly broad and varied use of HA injections, lack of published clinical guidance, and limited coverage for their use has created the imperative to establish appropriateness criteria.

METHODS

The experts of this workgroup represent rheumatology, orthopedic surgery, physiatry, sports medicine, and nursing clinicians with substantive knowledge of intra-articular HA therapy. This workgroup utilized the results of a systematic review of evidence, expert clinical opinion, and current evidence-based clinical practice guidelines to develop appropriateness criteria for the use of intra-articular HA for knee OA in 17 real-world clinical scenarios.

RESULTS

The workgroup scored the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as appropriate (7-9), uncertain (4-6), or inappropriate (1-3). Six scenarios were scored as appropriate, 10 scenarios were scored as uncertain, and 1 scenario was scored as inappropriate.

CONCLUSION

This article can assist clinicians in shared decision-making by providing best practices in considering HA injections for knee OA treatment. Moreover, this AUC article can aid payers and policy makers in determining reimbursement and preauthorization policies and more appropriately managing health care resources. It is clear that further research is still necessary-particularly in patient populations differentiated by OA severity-that may benefit the greatest from the use of HA injections for the treatment of knee OA.

Reduction of the Serum Levels of a Specific Biomarker of Cartilage Degradation (Coll2-1) by Hyaluronic Acid (KARTILAGE® CROSS) Compared to Placebo in Painful Knee Osteoarthritis Patients: the EPIKART Study, a Pilot Prospective Comparative Randomized Double Blind Trial

Background

Viscosupplementation is a symptomatic treatment of the knee osteoarthritis based on the intra-articular injection of hyaluronic acid (IAHA). Although many studies have investigated its effect on symptoms, few clinical studies have focused on its effects on biologicals markers of cartilage metabolism. In this study, we assessed the effect of an intra-articular injection of a reticulated hyaluronic acid compound on the level of a specific biomarker of type II collagen degradation.

Methods

Eighty one patients with symptomatic knee osteoarthritis were included in this randomized placebo controlled trial testing a reticulated hyaluronic acid (HA) with mannitol (KARTILAGE® CROSS, 16 mg/ml, one single injection of 2.2 mL; IAHA) versus saline solution. Primary outcome was the percentage of patients with a reduction of at least 10 nmol/l of serum Coll2-1 between baseline and day 90 (D90, 3 months after injection). Secondary outcomes concerned clinical evaluation and tolerance to the study product.

Results

A significant effect of IAHA was revealed by the sensitivity analysis of the decrease in cartilage marker. In the intention-to-treat population, the percentage of patients showing a decrease in the levels of serum Coll2-1 between inclusion and D90 showed was higher in HA (56.8%) than in placebo group (28.6%; P = 0.01). The same significant difference was observed between groups in the per protocol population (57.1% vs 29.0%; P = 0.02) corresponding to all patients having received the intra-articular injection (IA), being evaluated for the primary outcome on D-10 and D90, and with no major defined deviation. No significant differences between groups were observed on the changes in function (Lequesne index) or pain and on the number of adverse events.

Conclusions

This is the first randomized double-blind placebo controlled trial showing that IA injection of reticulated HA with mannitol in knee osteoarthritis patients can reduce the serum levels of Coll2-1, a marker specific of type II collagen degradation. This finding suggests that IAHA may have a beneficial effect on cartilage degradation and that Coll2-1 could be used for the assessment of a single intra-articular treatment in clinical trials.

Trial registration

NCT02951585; clinicaltrial.gov. Retrospectively registered on October 28, 2016.

Nonoperative Options for Management of Articular Cartilage Disease

Nonoperative options for articular cartilage injury are pervasive but have not shown to be curative. Recommendations for low-impact exercise and weight loss provide benefit and are a foundation for the treatment of osteoarthritis. Judicious use of NSAIDs and acetaminophen can be appropriate for pain management. Topical NSAIDs may be a treatment option with fewer side effects than its oral counterpart. Additionally, viscosupplementation injections are useful for mild to moderate knee osteoarthritis, whereas short-term pain relief is provided by intra-articular corticosteroid injections. Future studies to individualize treatment options based on patient phenotype and genotype may hold promise.

Chondroprotective activity of N-acetyl phenylalanine glucosamine derivative on knee joint structure and inflammation in a murine model of osteoarthritis

OBJECTIVE

Osteoarthritis (OA), the most common chronic degenerative joint disease, is characterized by joint structure changes and inflammation, both mediated by the IκB kinase (IKK) signalosome complex. The ability of N-acetyl phenylalanine derivative (NAPA) to increase cartilage matrix components and to reduce inflammatory cytokines, inhibiting IKKα kinase activity, has been observed in vitro. The present study aims to further clarify the effect of NAPA in counteracting OA progression, in an in vivo mouse model after destabilization of the medial meniscus (DMM).

DESIGN

26 mice were divided into three groups: (1) DMM surgery without treatment; (2) DMM surgery treated after 2 weeks with one intra-articular injection of NAPA (2.5 mM) and (3) no DMM surgery. At the end of experimental times, both knee joints of the animals were analyzed through histology, histomorphometry, immunohistochemistry and microhardness of subchondral bone (SB) tests.

RESULTS

The injection of NAPA significantly improved cartilage thickness (CT) and reduced Chambers and Mankin modified scores and fibrillation index (FI), with weaker MMP13, ADAMTS5, MMP10 and IKKα staining. The microhardness measurements did not shown statistically significant differences between the different groups.

CONCLUSIONS

NAPA markedly improved the physical structure of articular cartilage while reducing catabolic enzymes, extracellular matrix (ECM) remodeling and IKKα expression, showing to be able to exert a chondroprotective activity in vivo.

Intra articular hyaluronic acid in the management of knee osteoarthritis: Pharmaco-economic study from the perspective of the national health insurance system

Introduction

Pharmaco-economic data on the management of knee osteoarthritis (OA) with intra articular hyaluronic acid (IA HA) viscosupplementation is limited. We contrasted IA HA with non-steroidal anti-inflammatory drugs (NSAIDs).

Methods

Observational, prospective and multicenter study comparing treatments of knee OA costs and efficacy with either NSAIDs alone, or hyaluronic acid (Arthrum H 2%^®), during a 6-month follow-up period. The investigators were pharmacists who recorded data on disease, drug consumption and healthcare circuit. Retrospectively, the 6-month period preceding inclusion was also studied, to ensure the comparability of groups.

Results

199 patients were analyzed in a NSAIDs group and 202 in an IA HA group. Any of the WOMAC sub-scores and the EQ-5D Quality of Life index were significantly improved in the IA HA group (p<0.0001) at 3 and 6 months. Clinical results were therefore in favor of the IA HA group. The total drug expenses per 6-month period were comparable before and after inclusion, €96 and €98 for NSAIDs group vs €94 and €101 for IA HA group, which indicates no evidence of additional cost from IA HA. For the active part of the population, the incidence of sick leave was lower in the IA HA group, indicating a better maintenance of patient activity. The overall expense on 12 months (6 months before and 6 months after inclusion) for the national health insurance system was comparable for NSAIDs and IA HA groups: €528 and €526, respectively. The number of patients taking NSAIDs significantly decreased in IA HA group (from 100% at inclusion to 66% at 1–3 months and 44% at 4–6 months), but remained unchanged (100%) during the follow-up period, in NSAIDs group.

Conclusion

Treatment with IA HA did not generate additional cost for the national health insurance and was associated with a functional improvement of knee osteoarthritis and Quality of Life. The cost-utility analysis was in favor of IA HA, with a gain of QALY equivalent to half a month, after the 6-month follow-up period comparing both treatments. The NSAIDs consumption was decreased in the IA HA group, resulting in an improved estimated benefit/risk ratio.

Efficacy and safety study on a new compound associating low and high molecular weight hyaluronic acid in the treatment of hip osteoarthritis

The combined use of low and high molecular weight hyaluronic acid (HA) has never been reported in the treatment of osteoarthritis (OA). The aim of this paper was to evaluate the efficacy of a new hybrid association of both preparations in patients suffering from hip OA and to compare the results with those obtained retrospectively from a cohort of patients treated with high molecular weight HA.

Twenty patients with moderate-severe hip OA (grade II–IV according to Kellgren-Lawrence score) were enrolled in the study group. After clinical and functional evaluation (Visual Analogue Scale [VAS] for pain, Lequesne Index, Harris Hip Score), each participant received an intra-articular ultrasound-guided injection of the new HA compound at baseline and after 40 days. The measures were repeated at three and six months. The data collected were retrospectively compared with those obtained in a cohort of 20 patients, matched for sex, age, and severity of hip OA, treated with high molecular weight hyaluronic acid.

The intra-group comparison showed a significant improvement in clinical and functional outcomes at three and six months in both cohorts, while the infra-group comparison showed better results in the patients treated with the study compound at six months (VAS at rest, P <0.04; VAS during activities, P <0.02; Harris Hip Score, P <0.001).

The present study is the first which demonstrates that a combination of low and high molecular weight HA is effective and safe in the management of patients suffering from hip OA and provides better therapeutic results in comparison to high molecular weight HA. We may infer that both HA preparations work synergically, enhancing their positive activities.

Prospective Evaluation of Intra-Articular Sodium Hyaluronate Injection in the Ankle

Viscosupplementation by injection of hyaluronic acid into the ankle can be used to provide pain relief and to delay the need for surgery in patients with osteoarthritis of the ankle. In the present investigation, we prospectively evaluated 50 consecutive patients (25 males and 25 females) undergoing a 3-injection protocol of sodium hyaluronate viscosupplementation in the ankle from January 2014 to January 2015. The Foot and Ankle Outcomes Score was used to compare the patients' pre- and post-treatment opinions about their ankle problems. The mean pretreatment Foot and Ankle Outcomes Score was 48 ± 6.3 (range 25 to 84) and the 6-month post-treatment score was 78 ± 5.8 (range 48 to 100). This difference was statistically significant (p = .003). From our findings in the present prospective cohort study, we have concluded that intra-articular injection of sodium hyaluronate viscosupplementation is a useful conservative therapy for osteoarthritis of the ankle.

Predictors of response to viscosupplementation in patients with hip osteoarthritis: results of a prospective, observational, multicentre, open-label, pilot study

Background

To identify predictive factors of response to viscosupplementation (VS) in patients with hip osteoarthritis (HOA).

Methods

Prospective, multicentre, open-label trial, achieved in daily practice conditions. Patients with HOA were treated with a single intra-articular injection of a cross-linked hyaluronic acid combined with mannitol (HAnox-M-XL), using imaging guidance. WOMAC pain and function scores and patient global assessment (PGA) were assessed at baseline and day 90. Improvement, satisfaction and efficacy were self-assessed at day 90.

Hip radiographs at baseline were scored using Kellgren-Lawrence grade and Osteoarthritis Research Society International (OARSI) score. Associations between clinical and radiological features and response to VS (pain improvement > 50% at day 90) were assessed in univariate analysis, and then using logistic regression, adjusted for confounding factors.

Results

The intent-to-treat (ITT) population included 97 patients (57 females, mean age 63). Ninety completed the follow-up and 80 had full clinical and radiological data. Response to VS was achieved in 47.8% of patients. In univariate analysis, the only clinical outcome statistically and negatively related to response was PGA at baseline (p = 0.047). Radiologically, response to VS was negatively correlated with joint space narrowing (JSN) score (JSN < 2 vs. JSN ≥ 2, p = 0.01) and was related to the patterns of femoral head migration (p = 0.008). In multivariate analysis, only JSN grade (p = 0.03) remained significantly related to a poor response.

Conclusion

This pilot study, which needs further confirmation by larger scale trials, suggests that radiological features might be of importance for the decision of VS in patients with HOA.

Trial registration number

ID RCB N°2013-A00165-40. Registered 31 January 2013.

An in vivo cross-linkable hyaluronan gel with inherent anti-inflammatory properties reduces OA cartilage destruction in female mice subjected to cruciate ligament transection

OBJECTIVE

To explore the possibility of cartilage protection in osteoarthritis (OA) by intraarticular injection of a chemically modified hyaluronan (HA) gel and investigate whether the chemical modifications provide intrinsic anti-inflammatory activity.

METHOD

OA was induced in C57BL/6 mice by anterior cruciate ligament transection (ACLT) and HA gel or carbazate-modified component was injected intra-articularly. Assessment of cartilage rescue was performed by histology, immunohistochemistry and TUNEL analysis. Serum levels of proinflammatory cytokines were evaluated with cytometric bead array, measuring IL-1β, TNF, IFN-γ, KC/CXCL1 and MCP-1.

RESULTS

Intraarticular injection of the HA gel showed significantly reduced cartilage destruction and decreased osteophyte formation. Besides the biological and biomechanical effects of HA, we investigated lipid peroxidation products as an alternative inflammatory and potential mechanism contributing to OA. To address this, injection of the carbazate-modified component alone was performed, which also demonstrated a cartilage-saving effect. Besides the cartilage amelioration effects, decreased apoptosis, 4-hydroxynonenal (4-HNE) and MHC class II staining was recorded. No changes in serum levels of proinflammatory cytokines were detected.

CONCLUSION

We have shown that the HA gel has an anti-destructive effect on articular cartilage (AC). Our results demonstrated that the carbazate-modified component could suppress apoptotic events, potentially by quenching of ROS/LPO products such as 4-HNE in OA joints. Modification of the HA molecule offers opportunities to introduce (covalent) coupling of additional molecules to the gel, with controlled retention and subsequent release in the joint.

Imaging Guidance Improves the Results of Viscosupplementation with HANOX-M-XL in Patients with Ankle Osteoarthritis: Results of a Clinical Survey in 50 Patients Treated in Daily Practice

BACKGROUND

The objective of this survey was to assess retrospectively the interest of performing viscosupplementation using imaging guidance in patients suffering from ankle osteoarthritis (OA).

PATIENTS AND METHODS

This is a multicenter retrospective survey using a standardized questionnaire. Fifty patients suffering from ankle OA and treated, in daily clinical practice, with a single intra-articular injection of a novel viscosupplement made of a combination of a non-animal cross-linked hyaluronan and mannitol, HANOX M-XL, were included in the survey. The injection procedure (imaging or landmark guidance), demographic data, patient’s self-evaluation of pain, satisfaction, treatment efficacy, and tolerability were collected. Predictive factors of both efficacy and patient’s satisfaction were investigated.

RESULTS

The percentages of patients very satisfied/satisfied and not really satisfied/dissatisfied with the treatment were 68% and 32%, respectively. Efficacy was rated as very good, good, moderate, and poor by 38%, 30%, 12%, and 20% of the cases, respectively. Efficacy was unrelated to gender and age and was highly correlated with pain score (P < 0.0001). In satisfied patients, the decrease in consumption of analgesics/non-steroidal anti-inflammatory drugs was >75% in 64% of the cases. Efficacy was significantly different with regard to imaging guidance. There was a statistically significant difference in efficacy and satisfaction between landmark-guided and imaging-guided injections (P = 0.02). The success rate was 2.3 times higher in the imaging-guided group than in the landmark-guided group. No significant difference was found between patients injected under fluoroscopy or ultrasound guidance, despite a trend favoring ultrasound (P = 0.09). Tolerability was rated as very good/good in 47 patients, moderate in two, and poor in one and was unrelated to the type of guidance.

CONCLUSION

This preliminary study suggests that the use of imaging guidance significantly optimizes the success rate of ankle viscosupplementation. No safety concern was observed.

LEVEL OF EVIDENCE

III.

Early Viscosupplementation After Anterior Cruciate Ligament Reconstruction: A Randomized Controlled Trial

BACKGROUND

Hyaluronic acid (HA) has been widely used to treat osteoarthritis given its biological and mechanical properties. Because HA is an "intra-articular" treatment approach that affects the joints, it could be used in the management of acute conditions, such as during the early postsurgical phase, to reduce inflammatory stress and improve articular function.

PURPOSE

The aim of the present double-blind, randomized controlled trial was to evaluate pain control and functional recovery provided by a single injection of HA performed the day after anterior cruciate ligament (ACL) reconstruction.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

The study enrolled 60 patients affected by primary, chronic, and symptomatic ACL tear requiring surgical reconstruction. All patients were treated with the same reconstructive technique and rehabilitation protocol. Exclusion criteria were (1) concurrent articular lesion requiring surgical treatment, (2) axial malalignment in the index limb, and (3) functional limitation or pain in the contralateral knee. The day after the procedure, the patients were randomized to receive a single injection of 3 mL HA or 3 mL saline solution after surgical drains were removed. All patients were evaluated at baseline and at 15, 30, 60, and 180 days and 12 months after surgery by use of the following tools: Short Form-36 Health Survey (SF-36), International Knee Documentation Committee (IKDC) subjective score, visual analog scale (VAS) for pain, VAS for general health status, and Tegner score. At each follow-up evaluation, the transpatellar circumference and active and passive range of motion (ROM) of both knees were recorded.

RESULTS

No severe adverse events were documented after early viscosupplementation. A significant improvement was documented in both treatment groups. Significant differences were documented in the transpatellar circumference at 60 days and in active ROM at 30 days postoperatively; patients who received HA had better values compared with the placebo group (P = .022 and .027, respectively). No statistically relevant intergroup differences were found in the clinical scores.

CONCLUSION

The study documented no adverse events and had some positive findings in terms of active ROM recovery and transpatellar circumference reduction. However, the early postoperative application of viscosupplementation did not lead to significant improvement in clinical scores after ACL reconstruction.

REGISTRATION

NCT02630407 (ClinicalTrials.gov identifier).

Standardized Follow-up of Patients with Symptomatic Knee Osteoarthritis Treated with a Single Intra-articular Injection of a Combination of Cross-Linked Hyaluronic Acid and Mannitol

OBJECTIVES

The objective of this study is to obtain pilot data from daily practice conditions of a viscosupplement made of a cross-linked high-molecular-weight hyaluronic acid (HA) combined with mannitol in patients with knee osteoarthritis (KOA).

METHODS

The data of 40 consecutive patients, 29 women and 11 men, who were prospectively followed up for 6 months, using a standardized procedure, were retrospectively analyzed. All patients have received a single intra-articular injection of HAnox-M-XL (4.4 mL), viscosupplement made of a cross-linked HA (16 mg/mL) + mannitol (35 mg/mL), in the target knee. The primary outcome was safety. The secondary end points included 3- and 6-month change in the WOMAC pain (0–50) and WOMAC total (0–240) and patient’s global assessment (PGA). Patient’s self-assessment of treatment efficacy (0–3) and analgesic consumption were obtained at months 3 and 6. An intent-to-treat analysis was performed.

RESULTS

Mean (SD) age was 60.7 (13.9) years, and mean BMI was 28.6 (5.0). Kellgren–Lawrence radiological grade was I/II and III/IV in 13 and 27 of the subjects, respectively. The average WOMAC pain and WOMAC total scores at baseline were 21.5 (9.8) and 89.9 (42.8), respectively. Thirty-nine patients completed the follow-up. HAnox-M-XL was well tolerated; two patients experienced knee pain after injection, which resolved within three days. No treatment-related severe adverse event was reported. Mean (SD) variations in WOMAC pain and WOMAC total scores were −8.2 (8.9) and −38.4 (35.6), respectively, at month 6 (P = 0.001). PGA decreased from 5.5 (2.0) to 3.0 (2.2) (P = 0.006). Efficacy was rated as good or very good in 76.9% of the cases. Most of the regular analgesics users decreased their consumption.

CONCLUSION

Treatment with one injection of 4.4 mL HAnox-M-XL is effective to alleviate KOA symptoms over six months, without safety concern. Controlled trials are needed to confirm these pilot data.

Identifying the procedural gap and improved methods for maintaining accuracy during total hip arthroplasty

Osteoarthritis is a ubiquitous condition, affecting 26 million Americans each year, with up to 17% of adults over age 75 suffering from one variation of arthritis. The hip is one of the most commonly affected joints and while there are conservative options for treatment, as symptoms progress, many patients eventually turn to surgery to manage their pain and dysfunction. Early surgical options such as osteotomy or arthroscopy are reserved for younger, more active patients with less severe disease and symptoms. Total hip arthroplasty offers a viable solution for patients with severe degenerative changes; however, post-surgical discrepancies in leg length, offset and component malposition are common and cause significant complications. Such discrepancies are associated with consequences such as low back pain, neurological deficits, instability and overall patient dissatisfaction. Current methods for managing leg length and offset during hip arthroplasty are either inaccurate and susceptible to error or are cumbersome, expensive and lengthen surgical time. There is currently no viable option that provides accurate, real-time data to surgeons regarding leg length, offset and cup position in a cost-effective manner. As such, we hypothesize that a procedural gap exists in hip arthroplasty, a gap into which fall a large majority of arthroplasty patients who are at increased risk of complications following surgery. These complications and associated treatments place significant stress on the healthcare system. The costs associated with addressing leg length and offset discrepancies can be minor, requiring only heel lifts and short-term rehabilitation, but can also be substantial, with revision hip arthroplasty costs of up to $54,000 per procedure. The need for a cost-effective, simple to use and unobtrusive technology to address this procedural gap in hip arthroplasty and improve patient outcomes is of increasing importance. Given the aging of the population, the projected increases in the volume of procedures over the coming decades and the economic pressures associated with downward pricing pressure and bundled payments, the need to address this gap is underscored.