Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis

Impact of Bad Ragaz ring in hot spring water on knee osteoarthritis: A prospective observational study

To evaluate the impact of the Bad Ragaz ring method (BRRM) in hot spring water for knee osteoarthritis (KOA), this prospective study enrolled KOA patients treated at the hospital between March 2020 and December 2020. The primary outcome was the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index score. A total of 60 patients were included, with 30 participants in the BRRM group and 30 patients in the non-BRRM group, respectively. The mean age was 56.4 ± 10.2 years (13 females), and the duration of disease was 5.0 ± 2.2 years in the BRRM group. The mean age was 56.0 ± 11.3 years (14 females), and the disease duration was 4.7 ± 2.1 years in the non-BRRM group. There were no differences between the 2 groups in the pain, stiffness, and function scores of the WOMAC (all P > .05) before treatment. The pre post difference in total WOMAC scores (56.57 ± 12.45 vs 36.81 ± 13.51, Cohen d = 1.52, P < .01) between the 2 groups was statistically significant. Compared with the non-BRRM group, the BRRM group showed lower scores for pain (6.5 ± 1.5 vs 8.1 ± 2.9, Cohen d = -0.69, P = .01), stiffness (2.7 ± 1.0 vs 5.0 ± 1.2, Cohen d = -1.93, P < .01), and function (14.8 ± 6.6 vs 26.7 ± 7.5, Cohen d = -1.68, P < .01) after treatment. In conclusion, the BRRM might improve the pain and function of patients with KOA.

Magnetic Nanoemulsions for the Intra-Articular Delivery of Ascorbic Acid and Dexamethasone

(1) Osteoarthritis (OA) is a progressive joint degenerative disease that currently has no cure. Limitations in the development of innovative disease modifying therapies are related to the complexity of the underlying pathogenic mechanisms. In addition, there is the unmet need for efficient drug delivery methods. Magnetic nanoparticles (MNPs) have been proposed as an efficient modality for the delivery of bioactive molecules within OA joints, limiting the side effects associated with systemic delivery. We previously demonstrated MNP's role in increasing cell proliferation and chondrogenesis. In the design of intra-articular therapies for OA, the combined NE-MNP delivery system could provide increased stability and biological effect. (2) Proprietary Fe3O4 MNPs formulated as oil-in-water (O/W) magneto nanoemulsions (MNEs) containing ascorbic acid and dexamethasone were tested for size, stability, magnetic properties, and in vitro biocompatibility with human primary adipose mesenchymal cells (ADSC), cell mobility, and chondrogenesis. In vivo biocompatibility was tested after systemic administration in mice. (3) We report high MNE colloidal stability, magnetic properties, and excellent in vitro and in vivo biocompatibility. By increasing ADSC migration potential and chondrogenesis, MNE carrying dexamethasone and ascorbic acid could reduce OA symptoms while protecting the cartilage layer.

Magnetic Nanoemulsions for the Intra-Articular Delivery of Ascorbic Acid and Dexamethasone

(1) Osteoarthritis (OA) is a progressive joint degenerative disease that currently has no cure. Limitations in the development of innovative disease modifying therapies are related to the complexity of the underlying pathogenic mechanisms. In addition, there is the unmet need for efficient drug delivery methods. Magnetic nanoparticles (MNPs) have been proposed as an efficient modality for the delivery of bioactive molecules within OA joints, limiting the side effects associated with systemic delivery. We previously demonstrated MNP’s role in increasing cell proliferation and chondrogenesis. In the design of intra-articular therapies for OA, the combined NE-MNP delivery system could provide increased stability and biological effect. (2) Proprietary Fe3O4 MNPs formulated as oil-in-water (O/W) magneto nanoemulsions (MNEs) containing ascorbic acid and dexamethasone were tested for size, stability, magnetic properties, and in vitro biocompatibility with human primary adipose mesenchymal cells (ADSC), cell mobility, and chondrogenesis. In vivo biocompatibility was tested after systemic administration in mice. (3) We report high MNE colloidal stability, magnetic properties, and excellent in vitro and in vivo biocompatibility. By increasing ADSC migration potential and chondrogenesis, MNE carrying dexamethasone and ascorbic acid could reduce OA symptoms while protecting the cartilage layer.

Reduction of systemic exposure and side effects by intra-articular injection of anti-inflammatory agents for osteoarthritis: what is the safer strategy?

Osteoarthritis (OA) is a chronic degenerative joint disease associated with pain, inflammation, and cartilage degradation. However, no current treatment can effectively halt the progression of the disease. Therefore, the use of NSAIDs and intra-articular corticosteroids is usually recommended as the primary treatment for OA-associated pain and inflammation. However, there is accumulating evidence that the long-term use of oral NSAIDs and intra-articular corticosteroids can lead to a myriad of negative side effects. Although numerous efforts have been made to develop intra-articular formulations for NSAIDs, the systemic exposure of intra-articular injection of NSAIDs and its potential side effects have not been explicitly investigated. To ascertain the evident and potential side effects of intra-articular injection of anti-inflammatory agents, we have summarised in this review the systemic exposure, local side effects, and systemic side effects of intra-articular injections of anti-inflammatory agents, including NSAIDs and corticosteroids. For developing a safer treatment to fulfil the unmet long-term use needs of patients, a new therapy, which combines the locally active drug and a sustained-release formulation, has been proposed in this review.

Accuracy of Intraarticular Injections: Blind vs. Image Guided Techniques-A Review of Literature

Intra-articular injections are widely used for diagnostic and therapeutic purposes of joint pathologies throughout the body. These injections can be performed blind by utilizing anatomical landmarks or with the use of imaging modalities to directly visualize the joint space during injections. This review of the literature aims to comprehensively identify differences in the accuracy of intra-articular injections via palpation vs. image guidance in the most commonly injected joints in the upper and lower extremities. To our knowledge, there are no such comprehensive reviews available. A narrative literature review was performed using PubMed and Google Scholar databases to identify studies focusing on the accuracy of blind or image-guided intra-articular injections for each joint. A total of 75 articles was included in this review, with blind and image-guided strategies being discussed for the most commonly injected joints of the upper and lower extremities. Varying ranges of accuracy with blind and image-guided modalities were found throughout the literature, though an improvement in accuracy was seen in nearly all joints when using image guidance. Differences are pronounced, particularly in deep joints such as the hip or in the small joints such as those in the hand or foot. Image guidance is a useful adjunct for most intra-articular injections, if available. Though there is an increase in accuracy in nearly all joints, minor differences in accuracy seen in large, easily accessed joints, such as the knee, may not warrant image guidance.

Histological features of knee osteoarthritis treated with triamcinolone acetonide and hyaluronic acid

Osteoarthritis (OA) is one of the most common degenerative joint diseases leading to disability in the end stage. Although intra-articular triamcinolone acetonide (TA) is one of the OA treatments that have been widely used, the side effects of such corticosteroids are still controversial. Intra-articular hyaluronic acid (HA) injection is another therapeutic option for patients with OA who do not want to use corticosteroids because of their side effects. However, the difference between the histological features associated with TA and HA in the treatment of OA remains unclear. Thus, the present study aimed to compare the histological effects of TA and HA on the cartilage of patients with knee OA. In the current study, 31 patients diagnosed with grade 3-4 knee OA on the Kellgren-Lawrence radiographic grading scale were separated into three groups: TA (n=12); HA (n=7) and untreated group (n=12). Histological examination of the whole articular cartilages of the patients was performed with hematoxylin and eosin and Alcian staining, as well as using a TUNEL assay. Clinical data such as cartilage thickness, structural and component deterioration, proteoglycan levels, apoptosis and empty lacunae were compared between the three groups. The results showed a high level of deterioration in both TA and HA groups but not in the untreated group, although the thickness of cartilage in the HA group was lower compared with that in the TA and untreated groups. The proteoglycan levels in the TA group were lower compared with those in the HA group. Moreover, the number of empty lacunae in the HA group was higher compared with that in the TA group, while no difference in apoptosis was found between TA and HA groups. A significant difference was not found in the histological staining between TA and HA groups. On the other hand, a significant difference was found in cartilage deterioration between the medial and lateral sides in these groups. TA and HA groups showed comparable histological results. TA injection is cheaper and easier but has more adverse effects for patients with knee OA than HA injection. Therefore, orthopaedists should select TA or HA based on the economic and specific needs of patients.

Therapeutic Perspectives for Inflammation and Senescence in Osteoarthritis Using Mesenchymal Stem Cells, Mesenchymal Stem Cell-Derived Extracellular Vesicles and Senolytic Agents

Osteoarthritis (OA) is the most common cause of disability worldwide among the elderly. Alarmingly, the incidence of OA in individuals less than 40 years of age is rising, likely due to the increase in obesity and post-traumatic osteoarthritis (PTOA). In recent years, due to a better understanding of the underlying pathophysiology of OA, several potential therapeutic approaches targeting specific molecular pathways have been identified. In particular, the role of inflammation and the immune system has been increasingly recognized as important in a variety of musculoskeletal diseases, including OA. Similarly, higher levels of host cellular senescence, characterized by cessation of cell division and the secretion of a senescence-associated secretory phenotype (SASP) within the local tissue microenvironments, have also been linked to OA and its progression. New advances in the field, including stem cell therapies and senolytics, are emerging with the goal of slowing disease progression. Mesenchymal stem/stromal cells (MSCs) are a subset of multipotent adult stem cells that have demonstrated the potential to modulate unchecked inflammation, reverse fibrosis, attenuate pain, and potentially treat patients with OA. Numerous studies have demonstrated the potential of MSC extracellular vesicles (EVs) as cell-free treatments that comply with FDA regulations. EVs, including exosomes and microvesicles, are released by numerous cell types and are increasingly recognized as playing a critical role in cell-cell communication in age-related diseases, including OA. Treatment strategies for OA are being developed that target senescent cells and the paracrine and autocrine secretions of SASP. This article highlights the encouraging potential for MSC or MSC-derived products alone or in combination with senolytics to control patient symptoms and potentially mitigate the progression of OA. We will also explore the application of genomic principles to the study of OA and the potential for the discovery of OA phenotypes that can motivate more precise patient-driven treatments.

Thermo-Responsive Hyaluronan-Based Hydrogels Combined with Allogeneic Cytotherapeutics for the Treatment of Osteoarthritis

Thermo-responsive hyaluronan-based hydrogels and FE002 human primary chondroprogenitor cell sources have both been previously proposed as modern therapeutic options for the management of osteoarthritis (OA). For the translational development of a potential orthopedic combination product based on both technologies, respective technical aspects required further optimization phases (e.g., hydrogel synthesis upscaling and sterilization, FE002 cytotherapeutic material stabilization). The first aim of the present study was to perform multi-step in vitro characterization of several combination product formulas throughout the established and the optimized manufacturing workflows, with a strong focus set on critical functional parameters. The second aim of the present study was to assess the applicability and the efficacy of the considered combination product prototypes in a rodent model of knee OA. Specific characterization results (i.e., spectral analysis, rheology, tribology, injectability, degradation assays, in vitro biocompatibility) of hyaluronan-based hydrogels modified with sulfo-dibenzocyclooctyne-PEG4-amine linkers and poly(N-isopropylacrylamide) (HA-L-PNIPAM) containing lyophilized FE002 human chondroprogenitors confirmed the suitability of the considered combination product components. Specifically, significantly enhanced resistance toward oxidative and enzymatic degradation was shown in vitro for the studied injectable combination product prototypes. Furthermore, extensive multi-parametric (i.e., tomography, histology, scoring) in vivo investigation of the effects of FE002 cell-laden HA-L-PNIPAM hydrogels in a rodent model revealed no general or local iatrogenic adverse effects, whereas it did reveal some beneficial trends against the development of knee OA. Overall, the present study addressed key aspects of the preclinical development process for novel biologically-based orthopedic combination products and shall serve as a robust methodological basis for further translational investigation and clinical work.

Review of cooled radiofrequency ablation utilization for the treatment of symptomatic advanced knee arthritis and total knee arthroplasty

Degenerative knee osteoarthritis is a progressive debilitating condition that affects millions of people worldwide. Most patients experience limited range of motion, inflammation, swelling, and pain. Management options can lead to short- and long-term pain relief. Short-term pain relief usually involves conservative medical treatments such as NSAIDs, weight loss, physical therapy, and corticosteroid injections. The ultimate long-term pain relief treatment method involves total knee arthroplasty. The treatment algorithm for knee OA also includes managing pain until a patient is eligible for arthroplasty. Furthermore, about 20% of patients experience chronic pain after TKA without complications such as hardware loosening and infection with limited treatment options. The pathophysiology of this is unknown. Cooled radiofrequency ablation has been demonstrated to be clinically effective by disrupting the integrity of deep sensory nerves and hence interfering with transmission of pain signal. The analgesic effect after c-RFA has been reported up to 24 months. Here, we present an overview of the clinical application of cooled radiofrequency ablation and a summary of its effectiveness in the treatment of pain in the setting of advanced OA and symptomatic TKA.

Pharmaceutical treatment of osteoarthritis

OBJECTIVE

To review the current state of pharmaceutical treatment recommendations for the management of osteoarthritis.

METHOD

A narrative review was drafted to describe treatment guidelines, mechanism of action, pharmacokinetics, and toxicity for nine classes of pharmaceuticals: 1) oral nonsteroidal anti-inflammatory drugs (NSAIDs), 2) topical NSAIDs, 3) COX-2 inhibitors, 4) duloxetine, 5) intra-articular corticosteroids, 6) intra-articular hyaluronic acid, 7) acetaminophen (paracetamol), 8) tramadol, and 9) capsaicin.

RESULTS

In general, oral and topical NSAIDs, including COX-2 inhibitors, are strongly recommended first-line treatments for osteoarthritis due to their ability to improve pain and function but are associated with increased risks in patients with certain comorbidities (e.g., heightened cardiovascular risks). Intra-articular corticosteroid injections are generally recommended for osteoarthritis management and have relatively minor adverse effects. Other treatments, such as capsaicin, tramadol, and acetaminophen, are more controversial, and many updated guidelines offer differing recommendations.

CONCLUSION

The pharmaceutical management of osteoarthritis is a constantly evolving field. Promising treatments are emerging, and medicines that were once considered conventional (e.g., acetaminophen) are gradually becoming less acceptable based on concerns with efficacy and safety. Clinicians need to consider the latest evidence and recommendations to make an informed decision with their patients about how to optimize treatment plans for patients with knee, hip, polyarticular, or hand osteoarthritis.

Comparison of Dextrose Prolotherapy and Triamcinolone Intraarticular Injection on Pain and Function in Patients with Knee Osteoarthritis - A Randomized Clinical Trial

Background

The present study was performed to assess the therapeutic effects of combined intra and extraarticular dextrose prolotherapy on knee osteoarthritis and its comparison with intra- articular triamcinolone injection.

Methods

In this study, 50 patients suffering from knee osteoarthritis were allocated into two groups as a double-blind randomized clinical trial. The first group received one session of dextrose prolotherapy as one intra-articular injection of 10cc dextrose 16% and periarticular intradermal injections of dextrose 12% at 4 points around the knee (2.5 cc at each point). The second group underwent therapy with one intra-articular injection of triamcinolone (40 mg).

Results

Compared to pretreatment, both interventions caused significant improvement in pain (evaluated by VAS) and WOMAC (all its components) in 1 and 3 months postintervention (all with P-value < 0.005). In the first month, pain reduction was significantly better in corticosteroid group (P-Value 0.002 and 0.048 respectively). In third month post intervention, improvements in VAS and WOMAC components were significantly greater in prolotherapy group.

Conclusions

Both methods of corticosteroid and dextrose prolotherapy (combined intra and extraarticular technique) are effective on pain and function of patients with knee osteoarthritis. Compared to corticosteroid, prolotherapy method was associated with less pain reduction in short- term, but its effects were more persistent and in midterm examinations (3 months), it was more effective than corticosteroid.

Effect of platelet-rich plasma versus steroid injection in plantar fasciitis: a randomized clinical trial

BACKGROUND

Plantar fasciitis (PF) is a common orthopaedic problem, with heel pain worsening the quality of life. Although steroid injection is often used if the conservative treatment fails, Platelet-Rich Plasma (PRP) injection is gaining popularity due to its safety and long-lasting effect. However, the effect of PRP versus steroid injection in PF has not been studied yet in Nepal. Therefore, this study aimed to assess the effect of PRP compared with steroid injection in the treatment of PF.

METHODS

This study was a single-center, hospital-based, open-label, parallel-group randomized clinical trial to compare the effect of PRP injection with steroid injection in plantar fasciitis between August 2020 and March 2022. A total of 90 randomly selected participants aged 18 to 60 years suffering from plantar fasciitis with failed conservative treatment were intervened. The American Orthopaedic Foot and Ankle Society (AOFAS) and the Visual Analog Scale (VAS) scoring system were used to evaluate functional mobility and pain before and after the intervention for three and six months, respectively. Statistical analyses were performed using a Student's two-sample t-test. P-value < 0.05 was considered statistically significant.

RESULTS

The PRP injection showed a better outcome than the steroid injection in six months follow-up. The mean (± SD) VAS score was significantly decreased in the PRP group (1.97 + 1.13) than in the steroid group (2.71 ± 0.94) with the group difference of -0.73 (95% CI: -1.18 to -0.28) at six months. Similarly, there was a significant increase in the AOFAS scores in the PRP group (86.04 ± 7.45) compared to the steroid group (81.23 ± 9.60) at six months of follow-up with a group difference of 4.80 (95% CI: 1.15 to 8.45). There was also a significant reduction of plantar fascia thickness in the PRP group compared to that of the steroid group (3.53 ± 0.81 versus 4.58 ± 1.02) at six months of follow-up with the group difference of -1.04 (95% CI: -1.44 to -0.65).

CONCLUSION

The PRP injection showed better outcomes than steroid injection in plantar fasciitis treatment over the course of six months. Further research with a larger population and longer follow-up than six months is needed to generalize the findings and their long-term efficacy.

TRIAL REGISTRATION

NCT04985396. First registered on 02 August 2021. ( https://clinicaltrials.gov/ct2/show/NCT04985396 ).

The use of platelet-rich plasma in studies with early knee osteoarthritis versus advanced stages of the disease: a systematic review and meta-analysis of 31 randomized clinical trials

INTRODUCTION

Reports have concluded that platelet-rich plasma (PRP) is an effective and safe biological approach to treating knee osteoarthritis (OA). However, the effectiveness of PRP in advanced stages of the disease is not entirely clear. The purpose of this study was to evaluate whether the use of PRP would be as effective in studies with early-moderate knee OA patients compared to studies including patients with end-stage OA, based on the Kellgren-Lawrence classification.

MATERIALS AND METHODS

A comprehensive search in MEDLINE, EMBASE, Scopus, and Web of Science databases was conducted to identify randomized controlled trials (RCTs) comparing the effect of PRP injections versus other intra-articular treatments on pain and functionality. A meta-analysis was conducted using a random-effects model and the generic inverse variance method.

RESULTS

We included 31 clinical trials that reported data of 2705 subjects. Meta-analysis revealed an overall significant improvement of both pain [MD, - 1.05 (95% CI - 1.41 to - 0.68); I² = 86%; P ≤ 0.00001] and function [SMD, - 1.00 (95% CI - 1.33, to - 0.66); I² = 94%; P ≤ 0.00001], favoring PRP. Subanalysis for pain and functional improvement showed a significant pain relief in studies with 1-3 and 1-4 Kellgren-Lawrence OA stages and a significant functional improvement in studies with 1-2, 1-3 and 1-4 knee OA stages, favoring PRP.

CONCLUSION

Our results indicate that including patients with advanced knee OA does not seem to affect the outcomes of clinical trials in which the effectiveness of the PRP in knee OA is assessed.

Intra-Articular Collagen Injections for Osteoarthritis: A Narrative Review

Osteoarthritis (OA) is the most frequent degenerative progressive joint disease worldwide, with the hand, hip, and knee being the most-affected joints. Actually, no treatment can alter the course of OA, and therapy is directed at reducing pain and improving function. The exogenous administration of collagen has been investigated as a possible symptomatic adjuvant or stand-alone treatment for OA. The aim of this review is to assess if intra-articular collagen administration can be considered as a valid and safe therapeutic option for OA. A search in the main scientific electronic databases to identify the available scientific articles about the effects of intra-articular collagen as an OA treatment was performed. The results of the seven included studies showed that the intra-articular administration of collagen may stimulate chondrocytes to produce hyaline cartilage and hinder the normal inflammatory response leading to fibrous tissue formation, reducing symptoms, and improving functionality. The use of type-I collagen as an intra-articular treatment for knee OA was found not only to be effective, but also safe with negligible side effects. The reported findings are strongly promising, highlighting the need for further high-quality research to confirm the consistency of these findings.

New insights in osteoarthritis diagnosis and treatment: Nano-strategies for an improved disease management

Osteoarthritis (OA) is a common chronic joint pathology that has become a predominant cause of disability worldwide. Even though the origin and evolution of OA rely on different factors that are not yet elucidated nor understood, the development of novel strategies to treat OA has emerged in the last years. Cartilage degradation is the main hallmark of the pathology though alterations in bone and synovial inflammation, among other comorbidities, are also involved during OA progression. From a molecular point of view, a vast amount of signaling pathways are implicated in the progression of the disease, opening up a wide plethora of targets to attenuate or even halt OA. The main purpose of this review is to shed light on the recent strategies published based on nanotechnology for the early diagnosis of the disease as well as the most promising nano-enabling therapeutic approaches validated in preclinical models. To address the clinical issue, the key pathways involved in OA initiation and progression are described as the main potential targets for OA prevention and early treatment. Furthermore, an overview of current therapeutic strategies is depicted. Finally, to solve the drawbacks of current treatments, nanobiomedicine has shown demonstrated benefits when using drug delivery systems compared with the administration of the equivalent doses of the free drugs and the potential of disease-modifying OA drugs when using nanosystems. We anticipate that the development of smart and specific bioresponsive and biocompatible nanosystems will provide a solid and promising basis for effective OA early diagnosis and treatment. This article is categorized under: Diagnostic Tools > In Vivo Nanodiagnostics and Imaging Implantable Materials and Surgical Technologies > Nanotechnology in Tissue Repair and Replacement.

Intra-articular platelet-rich plasma vs. corticosteroid injections efficacy in knee osteoarthritis treatment: a systematic review

Osteoarthritis (OA) affects the entire joint structure. The most injured joints are the hands, knees, and hips. OA is a common disease all over the world, and a cause of disability in the elderly; hence, medicine is facing a steady challenge to find effective therapeutics to relieve the pain, improving symptoms for a better quality of life for patients.

Purpose

To compare the results, in the recent literature, of intra-articular injection of platelet-rich plasma (PRP) and corticosteroids (CSs) in osteoarthritic knees at early and mid-term postinjection.

Methods

A PubMed and CENTRAL (Cochrane Central Register of Controlled Trials) database search was performed. Initial screening yielded 108 randomized controlled trials, 17 results, and 17 others were added after updates. The final review includes nine randomized control trials, with outcome evaluating of knee OA by Western Ontario and McMaster Universities Arthritis Osteoarthritis Index, Knee Injury and Osteoarthritis Outcome Scale Index, and Visual Analog Scale.

Results

PRP and CS intra-articular injections both are safe and effective treatments in knee OA for alleviating pain, and improving symptoms. It seems that PRP injections have prolonged and shown better improvement in some studies. However, the results do not prefer one method over the other.

Conclusion

Up till now, it is not easy to draw firm conclusions about prioritizing PRP or CS injections for knee OA treatment due to the limitation of this review.

Cost-utility analysis and net monetary benefit of Platelet Rich Plasma (PRP), intra-articular injections in compared to Plasma Rich in Growth Factors (PRGF), Hyaluronic Acid (HA) and ozone in knee osteoarthritis in Iran

PURPOSE

To evaluate the cost-effectiveness of Platelet Rich Plasma (PRP), Plasma Rich in Growth Factors (PRGF), Hyaluronic Acid (HA) and ozone as effective treatment approaches in knee osteoarthritis management from Iran Health care perspective.

METHODS

A decision tree model was conducted to assess the cost-effectiveness of four common intra-articular treatment approaches in patients with mild and moderate knee osteoarthritis. The data on clinical effectiveness was obtained from a randomized controlled trial (RCT) conducted in Iran and used to estimate utility values. The direct medical costs were estimated according to tariffs for public medical centers and hospitals, approved by the Iran Ministry of Health and Medical Education in 2021. The incremental cost-effectiveness ratio (ICER) and the net monetary benefit (NMB) were used to evaluate the cost-utility analysis. Deterministic and probabilistic sensitivity analyses are performed to investigate the robustness of the results and account for the different sources of uncertainty.

RESULTS

In this study, HA intra-articular injection-related costs ($581.67/patient) were defined as the highest cost, followed by PRGF ($328.10/patient), PRP (318.58/patient), and Ozone (103.20/patient). According to the utility value, PRP and PRGF (0.68) have the same and the most utility among Intra-articular injections in knee osteoarthritis management. However, the PRP injection method was identified as the most cost-effective intervention due to its high NMB and ICER estimates. Based on the Monte Carlo Simulation, PR intervention, compared to other ones, was introduced as the dominant strategy regarding knee OA management, with a WTP of $10,000 for 100% of cases.

CONCLUSION

The study result demonstrated that intra-articular injection of PRP, compare to other injections, is a cost-effective treatment option for patients with mild and moderate knee osteoarthritis. In addition, intra-articular injection of PRP was identified as the best injection, with the highest level of net monetary benefit, for knee OA management.

Platelet-Rich Plasma for Intra-articular Injections: Preclinical and Clinical Evidence

The use of platelet-rich plasma (PRP) has been supported by encouraging data from in vitro and preclinical in vivo studies, both in terms of safety and efficacy. This led to the wide use of PRP injections in the clinical practice, with promising results especially as a minimally invasive treatment for cartilage degeneration and osteoarthritis (OA). While many controversies remain on the best PRP formulation, the overall available clinical studies support the benefits of PRP, with functional improvement and reduction of pain-related symptoms up to 12 months, especially in young patients and early OA stages.

An update on the effect of intra-articular intervention strategies using nanomaterials in osteoarthritis: Possible clinical application

Osteoarthritis (OA) is the most common progressive condition affecting joints. It mainly affects the knees and hips as predominant weight-bearing joints. Knee osteoarthritis (KOA) accounts for a large proportion of osteoarthritis and presents numerous symptoms that impair quality of life, such as stiffness, pain, dysfunction, and even deformity. For more than two decades, intra-articular (IA) treatment options for managing knee osteoarthritis have included analgesics, hyaluronic acid (HA), corticosteroids, and some unproven alternative therapies. Before effective disease-modifying treatments for knee osteoarthritis, treatments are primarily symptomatic, mainly including intra-articular corticosteroids and hyaluronic acid, so these agents represent the most frequently used class of drugs for managing knee osteoarthritis. But research suggests other factors, such as the placebo effect, have an essential role in the effectiveness of these drugs. Several novel intra-articular therapies are currently in the clinical trial processes, such as biological therapies, gene and cell therapies. Besides, it has been shown that the development of novel drug nanocarriers and delivery systems could improve the effectiveness of therapeutic agents in osteoarthritis. This review discusses the various treatment methods and delivery systems for knee osteoarthritis and the new agents that have been introduced or are in development.

Effect of temperature-responsive hydrogel on femoral and sciatic nerve blocks using bupivacaine in Beagle dogs

OBJECTIVES

To compare the duration of regional anesthesia of the pelvic limb using bupivacaine with and without a temperature-responsive hydrogel (TRH) in dogs.

METHODS

Under anesthesia using medetomidine (10 μg·kg^-1 ), alfaxalone (2 mg·kg^-1 ), and isoflurane, seven healthy male Beagles received four injections of 0.5% bupivacaine (1 mg·kg^-1 with 5 μg·ml^-1 epinephrine) to block the femoral and sciatic nerves bilaterally via ultrasound with nerve stimulation guidance. Bupivacaine was used on one pelvic limb (Bup treatment), and bupivacaine with TRH was used on the contralateral limb (Bup-TRH treatment). The nerve block was considered successful upon the absence of responses to pinching the digital pads and mid-tibial skin of both pelvic limbs with mosquito forceps; the pinch, proprioception, and locomotion tests were performed before (baseline) and at each hour after the nerve block until sensory and motor functions returned to baseline. The effect of TRH on nerve blocks was analyzed using a linear mixed model.

RESULTS

The duration of the sensory nerve block at the digital pads and mid-tibial skin was longer with Bup-TRH (8.0 ± 1.6 h and 10.9 ± 1.6 h, respectively) than with Bup treatment (3.7 ± 2.0 h and 8.0 ± 1.6 h, respectively). Motor block times of proprioception and locomotion were longer with Bup-TRH (9.3 ± 1.6 and 12.7 ± 1.5 h, respectively) than with Bup treatment (4.6 ± 1.9 and 9.6 ± 1.5 h, respectively). No complications were observed.

CLINICAL SIGNIFICANCE

TRH extended the duration of regional anesthesia of the pelvic limb using bupivacaine.

A Combination of Surgical and Chemical Induction in a Rabbit Model for Osteoarthritis of the Knee

BACKGROUND

Appropriate animal models of osteoarthritis (OA) are essential to develop new treatment modalities for OA. A combination of surgical and chemical induction could be appropriate for OA models.

METHODS

Rabbit knee OA models developed by surgical induction (anterior cruciate ligament transection [ACLT]), chemical induction (monosodium iodoacetate [MIA] injection), and a combination of both were compared to assess compositional and structural destruction of the knee joint. Twenty-one New Zealand white rabbits were randomly divided into 3 groups to induce OA (group 1: ACLT, n = 3; group 2: MIA [3, 6, 9 mg] injection, n = 9; group 3: ACLT + MIA [3, 6, 9 mg] injection, n = 9).

RESULTS

In all groups, the Modified Mankin score was significantly higher in the osteoarthritis-induced knee than in the control. Modified Mankin scores were compared by category. The ACLT group was observed to score high in cartilage structure. In the MIA group, chondrocytes and matrix staining showed higher scores, and the ACLT+MIA group scored higher in all categories for cartilage structure, chondrocytes, matrix staining, and tidemark integrity. The ACLT + 3 mg MIA showed definite OA characteristics such as cartilage surface destruction and degeneration of cartilage layers, and the ACLT + 6 mg MIA and ACLT + 9 mg MIA showed more prominent OA characteristics such as cartilage surface destruction, matrix disorganization, and osteophyte formation.

CONCLUSION

The combination of MIA injection and ACLT could be an appropriate method for OA induction in rabbit models.

Interventional Therapies for Osteoarthritis: An Update

Osteoarthritis (OA) is one of the most common diseases worldwide and is expected to increase in incidence as the age of the general population rises. Both oral medications, such as NSAIDs, and surgical treatments used for OA management have limitations. Demand is rising for minimally invasive techniques such as intraarticular injections and percutaneous interventions for use in place of or in conjunction with oral medications and surgical therapies, and the past 2 decades have seen a rapid expanse in both pharmacologic and nonpharmacologic minimally invasive OA treatments. Image guidance with fluoroscopy, CT, or ultrasound is often used in conjunction with these procedures to achieve precise treatment localization to achieve maximal therapeutic effect. The choice of modality used for image guidance is often influenced by clinician experience, patient characteristics, and equipment availability. This article reviews the mechanisms of action, contraindications, complications, and efficacy of conventional and developing minimally invasive OA treatments. The minimally invasive treatment options described in this Review include therapeutic injections such as antiinflammatory agents, viscosupplements, and biologics, as well as nonpharmacologic treatments of subchondroplasty, nerve ablation, genicular artery embolization, intraarticular pulsed radiofrequency therapy, and MRI-guided focused ultrasound therapy.

Thermosensitive In Situ Gels for Joint Disorders: Pharmaceutical Considerations in Intra-Articular Delivery

The intra-articular administration of conventional drug solutions or dispersions in joint diseases such as osteoarthritis has a relatively short retention time and, therefore, limited therapeutic effect. Thermosensitive polymer solutions that exhibit a sol-gel phase transition near body temperature after injection can prolong drug retention by providing a depot from which the drug release is sustained while relieving inflammation and preventing degradation of the joint complex. Thermosensitive hydrogels have in recent times garnered considerable attention in the intra-articular therapeutics of joint diseases such as osteoarthritis. Among the stimuli-responsive gelling systems, most research has focused on thermosensitive hydrogels. These gels are preferred over other stimuli-sensitive hydrogels since they have well-controlled in situ gelling properties and are also easier to load with drugs. Temperature-sensitive polymers, such as block copolymers or poloxamers, are frequently used to modify their gelation properties, usually in combination with other polymers. They are compatible with most drugs but may pose formulation challenges in terms of their low-response time, highly fragile nature, and low biocompatibility. The stability and biodegradability of implant hydrogels can control the drug release rate and treatment efficacy. This review stresses the application of thermosensitive gels in joint disorders and summarizes recent developments for intra-articular application, including the incorporation of nanoparticles. The hydrogel composition, drug release mechanisms, and the challenges involved in their formulation and storage are also discussed.

At the Edge of Orthopaedics: Initial Experience with Transarterial Periarticular Embolization for Knee Osteoarthritis in a Romanian Population

BACKGROUND

Transarterial embolization (TAE) of genicular artery branches is a relatively new technique that has emerged as a promising method for delaying invasive knee surgery in patients suffering from degenerative knee osteoarthritis (OA). In mild to moderate OA, invasive major surgery can be safely postponed, and patients with major risk factors now have an alternative. Our aim was to examine the impact of TAE on clinical outcomes in individuals with degenerative knee OA over a 12-month period.

METHODS

A case series of 17 patients diagnosed with knee OA and treated with TAE was included in the study. Every patient was clinically evaluated at different timeframes according to the Western Ontario and McMaster Universities' arthritis index, knee injury, and osteoarthritis outcome scores, and the 36-item short-form survey (WOMAC, KOOS, and SF-36).

RESULTS

At the first follow-up (1 month), KOOS and WOMAC improved from 46.6 ± 13.2 (range 27.3-78.2) to 56.5 ± 13.9 (range 32.3-78.4; p = 0.023) and 49.5 ± 13.2 (range 29.3-82.3) to 59.8 ± 12.6 (range 39.3-83.5, p = 0.018), respectively. Physical SF-36 improved significantly from 42.1 ± 7.75 (range 30.3-57.3) to 50.5 ± 9.9 (range 35.6-67.9; p = 0.032). No significant changes in scores were observed at three, six, or twelve months after TAE.

CONCLUSIONS

TAE provided early pain reduction and considerable improvement in quality of life without complications for a consecutive sample of Romanian patients with mild to severe knee OA.

Efficacy of Ultrasound-Guided Glenohumeral Joint Injections of Leukocyte-Poor Platelet-Rich Plasma Versus Hyaluronic Acid in the Treatment of Glenohumeral Osteoarthritis: A Randomized, Double-Blind Controlled Trial

OBJECTIVE

To compare the efficacy of ultrasound-guided hyaluronic acid (HA) versus leukocyte-poor platelet-rich plasma (LP-PRP) injection in the treatment of glenohumeral osteoarthritis.

DESIGN

Double-blind randomized controlled trial.

SETTING

Academic institution.

PATIENTS

Seventy patients with chronic glenohumeral osteoarthritis were randomly assigned to receive a single injection of HA (n = 36) or LP-PRP (n = 34).

INTERVENTIONS

Leukocyte-poor platelet-rich plasma was processed using Harvest/TerumoBCT Clear PRP kits. Ultrasound-guided injections of 6 mL HA or 6 mL LP-PRP into the glenohumeral joint were performed. Patients, the injecting physician, and outcomes assessor were blinded to treatment assignments.

MAIN OUTCOME MEASURES

Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) score, current/average numerical rating scale (NRS) pain scores, satisfaction, and side effects were assessed at the 5 follow-up time points over 12 months.

RESULTS

Baseline characteristics were similar between groups. There were no significant between-group differences regarding SPADI, ASES, and current/average NRS pain scores at any time point up to 12 months postinjection ( P > 0.05). However, significant improvements in SPADI, ASES, and current/average NRS pain scores were observed in both groups starting at 1 or 2 months ( P < 0.01, P < 0.01, P < 0.001, and P < 0.01, respectively). These improvements were observed regardless of osteoarthritis severity. For patients who received LP-PRP, there was no effect of platelet yield on outcomes. Side effect and satisfaction rates were similar between groups.

CONCLUSIONS

There were no differences in pain and functional outcomes after a single injection of LP-PRP versus HA. However, significant improvements in pain and function were observed after both treatments in patients with glenohumeral osteoarthritis.

Influence of hyaluronic acid on intra-articular friction - a biomechanical study in whole animal joints

BACKGROUND

Cartilage is a mechanically highly stressed tissue in the human body and an important part of synovial joints. The joint cartilage is lubricated by synovial fluid with hyaluronic acid (HA) as main component. However, in joints with osteoarthritis HA has a lower concentration and molecular weight compared to healthy joints. In recent years, the intra-articular injection of therapeutic HA lubricant, has become a popular therapy. The effect of HA application on the friction of a complete joint with physiological movement needs to be further determined.

METHODS

The aim of the present study was to evaluate the lubrication effect of the joint by three lubricants (NaCl, fetal calf serum (FCS) and HA) and their effect on the friction in nine complete ovine carpo-metacarpal joints. The joints were mounted on a material testing machine and a physiological movement with 10° rotation was simulated with ascending axial load (100 - 400 N). Specimens were tested native, with cartilage damage caused by drying out and relubricated. Dissipated energy (DE) as a measure of friction was recorded and compared.

RESULTS

Investigating the effect of axial load, we found significant differences in DE between all axial load steps (p < .001), however, only for the defect cartilage. Furthermore, we could document an increase in DE from native (Mean: 15.0 mJ/cycle, SD: 8.98) to cartilage damage (M: 74.4 mJ/cycle, SD: 79.02) and a decrease after relubrication to 23.6 mJ/cycle (SD: 18.47). Finally, we compared the DE values for NaCl, FCS and HA. The highest values were detected for NaCl (M_Norm = 16.4 mJ/cycle, SD: 19.14). HA achieved the lowest value (M_Norm = 4.3 mJ/cycle, SD: 4.31), although the gap to FCS (M_Norm = 5.1 mJ/cycle, SD: 7.07) was small.

CONCLUSIONS

We were able to elucidate three effects in joints with cartilage damage. First, the friction in damaged joints increases significantly compared to native joints. Second, especially in damaged joints, the friction increases significantly more with increased axial load compared to native or relubricated joints. Third, lubricants can achieve an enormous decrease in friction. Comparing different lubricants, our results indicate the highest decrease in friction for HA.

Double-Blind Randomized Controlled Trial Comparing Platelet-Rich Plasma With Intra-Articular Corticosteroid Injections in Patients With Bilateral Knee Osteoarthritis

Introduction

Platelet-rich plasma (PRP) intra-articular injections have gained popularity and are suggested to be more effective and longer lasting than corticosteroid or visco-supplementation therapy. There are few studies comparing PRP with corticosteroid injections and none comparing PRP in patients with bilateral knee osteoarthritis with the patient acting as their own control.

Methods

We performed a double-blind randomized controlled trial including 29 patients (58 knees) with radiologically confirmed mild-to-moderate bilateral knee osteoarthritis. They were randomized to receive an intra-articular PRP injection into one knee and a methylprednisolone injection with a local anesthetic into the contralateral knee. The primary outcome was measured using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) before the treatment and at six weeks, three months, and six months. Secondary outcome was measured pain with the visual numerical pain rating scale (VNS).

Results

Corticosteroids and PRP were both effective in improving pain, stiffness, and function at all time points, with maximal improvements at six weeks and three months. PRP scored slightly better than steroid injections at six months; nevertheless, there was no statistically significant difference between corticosteroids and PRP injections (F_2,139=0.173, p=0.84). The secondary outcome also delivered the same result with improvement at all time points but no statistically significant difference (F_2,139=0.168, p=0.85).

Conclusions

Both corticosteroids and PRP interventions are effective in improving pain, stiffness, and function in patients with bilateral knee osteoarthritis up to six months with no statistically significant difference between the two.

Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis: A Systematic Review and Network Meta-analysis

BACKGROUND

In younger patients and those without severe degenerative changes, the efficacy of intra-articular (IA) injections as a nonoperative modality for treating symptomatic knee osteoarthritis (OA)-related pain while maintaining function has become a subject of increasing interest.

PURPOSE

To assess and compare the efficacy of different IA injections used for the treatment of knee OA, including hyaluronic acid (HA), corticosteroids (CS), platelet-rich plasma (PRP), and plasma rich in growth factors (PRGF), with a minimum 6-month patient follow-up.

STUDY DESIGN

Meta-analysis of randomized controlled trials; Level of evidence, 1.

METHODS

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Mean or mean change from baseline and standard deviation for outcome scores regarding pain and function were recorded at the 6-month follow-up and converted to either a 0 to 100 visual analog scale score for pain or a 0 to 100 Western Ontario and McMaster Universities Osteoarthritis Index score for function. A frequentist network meta-analysis model was developed to compare the effects of HA, CS, PRP, PRGF, and placebo on patient-reported outcomes.

RESULTS

All IA treatments except CS were found to result in a statistically significant improvement in outcomes when compared with placebo. PRP demonstrated a clinically meaningful difference in function-related improvement when compared with CS and placebo due to large effect sizes. Studies evaluating outcomes of PRGF reported significant improvement when compared with placebo due to large effect sizes, whereas a potential clinically significant difference was detected in the same comparison parameters in pain evaluation. With regard to improvements in pain, function, and both combined, PRP was found to possess the highest probability of efficacy, followed by PRGF, HA, CS, and placebo.

CONCLUSION

PRP yielded improved outcomes when compared with PRGF, HA, CS, and placebo for the treatment of symptomatic knee OA at a minimum 6-month follow-up. Further investigations evaluating different IA and other nonoperative treatment options for patients with knee OA are warranted to better understand the true clinical efficacy and long-term outcomes of nonsurgical OA management.

Omega-3 Fatty Acids for the Management of Osteoarthritis: A Narrative Review

Osteoarthritis (OA) is a disease which results in degeneration of cartilage within joints and affects approximately 13.6% of adults over 20 years of age in Canada and the United States of America. OA is characterized by a state of low-grade inflammation which leads to a greater state of cellular catabolism disrupting the homeostasis of cartilage synthesis and degradation. Omega-3 polyunsaturated fatty acids (PUFAs) have been postulated as a potential therapeutic treatment option for individuals with OA. Omega-3 PUFAs are recognized for their anti-inflammatory properties, which could be beneficial in the context of OA to moderate pro-inflammatory markers and cartilage loss. The purpose of this narrative review is to outline recent pre-clinical and clinical evidence for the use of omega-3 in the management of OA.

Shape-specific microfabricated particles for biomedical applications: a review

The storied history of controlled the release systems has evolved over time; from degradable drug-loaded sutures to monolithic zero-ordered release devices and nano-sized drug delivery formulations. Scientists have tuned the physico-chemical properties of these drug carriers to optimize their performance in biomedical/pharmaceutical applications. In particular, particle drug delivery systems at the micron size regime have been used since the 1980s. Recent advances in micro and nanofabrication techniques have enabled precise control of particle size and geometry-here we review the utility of microplates and discoidal polymeric particles for a range of pharmaceutical applications. Microplates are defined as micrometer scale polymeric local depot devices in cuboid form, while discoidal polymeric nanoconstructs are disk-shaped polymeric particles having a cross-sectional diameter in the micrometer range and a thickness in the hundreds of nanometer range. These versatile particles can be used to treat several pathologies such as cancer, inflammatory diseases and vascular diseases, by leveraging their size, shape, physical properties (e.g., stiffness), and component materials, to tune their functionality. This review highlights design and fabrication strategies for these particles, discusses their applications, and elaborates on emerging trends for their use in formulations.

Increased Chondroprotective Effect of Combining Hyaluronic Acid with a Glucocorticoid Compared to Separate Administration on Cytokine-Treated Osteoarthritic Chondrocytes in a 2D Culture

Intra-articular injections of glucocorticoids (GC) or hyaluronic acid (HA) are commonly used interventions for patients suffering from knee osteoarthritis (OA). Both substances are combined to achieve a chondroprotective and anti-inflammatory effect. Clinical studies have shown benefits, but data on the cellular level are still lacking. This study aimed to investigate the effect of the GC triamcinolone hexacetonide, HA, and a mix of both substances on cytokine-treated chondrocytes in vitro. Chondrocytes isolated from human articular cartilage were seeded on 6- and 24-well plates. Mimicking OA’s inflammatory state, cells were treated with IL-1β and IL-17 for six days, whereby, after three days, test substances (10%) were added to the culture medium. Chondrocytes were analyzed on days three and six concerning their actin polymerization, expression of anabolic and catabolic genes, metabolic activity, cytokine release, and reactive oxygen species (ROS). Adding HA or GC/HA to the inflammatory culture medium increased the metabolic activity of chondrocytes, while groups containing GC reduced catabolic gene expression and the release of TNF-α. In addition, enhanced F-actin content was shown supplementing HA or GC/HA to the culture medium. Supplementing GC with HA leads to an anti-inflammatory and chondroprotective effect by diminishing the side effects of GC supplementation alone.

Vitamin D status is associated with inflammatory biomarkers and clinical symptoms in patients with knee osteoarthritis

BACKGROUND AND AIM

The association between vitamin D status and osteoarthritis (OA) and bone remodeling has been shown previously. The present study was conducted to determine the association between vitamin D status and inflammatory biomarkers and clinical symptoms in patients with knee OA.

METHODS

This case-control study was performed on 124 subjects with mild to moderate knee OA and 65 healthy controls. Demographic data was collected from all participants at baseline. We used Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC Index) for evaluating the severity of clinical symptoms in these patients. Serum levels of vitamin D as well as markers of inflammation including interleukin 1-β (IL-1β), interleukin 6 (IL-6), interleukin 10 (IL-10), tumor necrosis factor-alpha (TNF-α), high-sensitivity C-reactive protein (hs-CRP), and nuclear factor k-B (NF-κB) p65 were evaluated for each participant.

RESULTS

The results of the present study showed that patients with knee OA had lower levels of vitamin D and higher levels of IL-1β, TNF-α, hs-CRP, and NF-кB p65 compared with healthy controls (P < 0.0001). The levels of IL-1β, TNF-α, and NF-кB p65 in knee OA patients with vitamin D insufficiency were significantly higher compared with the knee OA patients with sufficient vitamin D (P < 0.05). Based on the linear regression analysis, serum vitamin D levels were inversely correlated with IL-1β, TNF-α, hs-CRP, and NF-кB p65 levels (P < 0.0001). Patients with sufficient vitamin D levels had lower total and physical function WOMAC scores compared with patients with vitamin D insufficiency (P = 0.011 and P = 0.010, respectively).

CONCLUSION

The results suggest a strong link between vitamin D deficiency and increased inflammatory biomarkers as well as increased severity of clinical symptoms in knee OA patients.

Cumulative Intraarticular Injections Are Not a Risk Factor for Periprosthetic Joint Infection Following total Knee Arthroplasty

BACKGROUND

While injections within 90 days prior to total knee arthroplasty (TKA) are associated with an increased risk of periprosthetic joint infection (PJI), there is a paucity of literature regarding the impact of cumulative injections on PJI risk. This study was conducted to assess the association between cumulative corticosteroid and hyaluronic acid (HA) injections and PJI risk following TKA.

METHODS

This retrospective study using an injection database included patients undergoing TKA with a minimum 1-year follow-up from 2015 to 2020. Patients with injections within 90 days prior to surgery were excluded. The sum of corticosteroid and HA injections within five years prior to TKA was recorded. The primary outcome was PJI within 90 days following TKA. Area under the curve (AUC) values were calculated for a cumulative number of injections.

RESULTS

648 knees with no injections and 672 knees with injections prior to TKA were included, among whom 243 received corticosteroids, 151 received HA, and 278 received both. No significant differences in early PJI rates existed between patients who received injections (0.60%) or not (0.93%) (P = .541). No significant differences existed in early PJI rates between patients injected with corticosteroids (0.82%), HA (0.66%), or both (0.36%) (P = .832). No cutoff number of injections was predictive for PJI.

DISCUSSION

A cumulative amount of steroid or HA injections, if given more than 90 days prior to TKA, does not appear to increase the risk of PJI within 90 days postoperatively. Multiple intraarticular corticosteroid injections and HA injections may be safely administered before TKA, without increased risk for early PJI.

Intra-articular Injectates: What to Use and Why

Intra-articular injections are a nonsurgical treatment modality that can be used to manage osteoarthritis, naturally occurring or surgically induced acute synovitis, and intra-articular ligamentous or tendon injury. This option may be assistive for patients in which other conservative modalities are ineffective, or in conjunction with other forms of treatment. It may also be used as the primary treatment. Injectates labeled for use in companion animal joints include corticosteroids and viscosupplements. Additional injectates, that are not specifically approved for use in companion animals are but are reported in the literature, include orthobiologics and a radioisotope of Tin-117m.

The Role of Mechanically-Activated Ion Channels Piezo1, Piezo2, and TRPV4 in Chondrocyte Mechanotransduction and Mechano-Therapeutics for Osteoarthritis

Mechanical factors play critical roles in the pathogenesis of joint disorders like osteoarthritis (OA), a prevalent progressive degenerative joint disease that causes debilitating pain. Chondrocytes in the cartilage are responsible for extracellular matrix (ECM) turnover, and mechanical stimuli heavily influence cartilage maintenance, degeneration, and regeneration via mechanotransduction of chondrocytes. Thus, understanding the disease-associated mechanotransduction mechanisms can shed light on developing effective therapeutic strategies for OA through targeting mechanotransducers to halt progressive cartilage degeneration. Mechanosensitive Ca2+-permeating channels are robustly expressed in primary articular chondrocytes and trigger force-dependent cartilage remodeling and injury responses. This review discusses the current understanding of the roles of Piezo1, Piezo2, and TRPV4 mechanosensitive ion channels in cartilage health and disease with a highlight on the potential mechanotheraputic strategies to target these channels and prevent cartilage degeneration associated with OA.

Adductor canal block versus intra-articular steroid and lidocaine injection for knee osteoarthritis: a randomized controlled study

Background

This study aimed to assess the efficacy of the adductor canal block (ACB) in comparison to intra-articular steroid-lidocaine injection (IASLI) to control chronic knee osteoarthritis (KOA) pain.

Methods

A randomized, single-blinded trial in an outpatient rehabilitation clinic recruiting chronic KOA with pain ≥ 6 months over one year. Following randomization, subjects received either a single ACB or IASLI under ultrasound guidance. Numerical rating scale (NRS) scores for pain, and Knee Injury and Osteoarthritis Outcome Scores (KOOS) were recorded at baseline, 1 hour, 1 month, and 3 months post-injection.

Results

Sixty-six knees were recruited; 2 were lost to follow-up. Age was normally distributed (P = 0.463), with more female subjects in both arms (P = 0.564). NRS scores improved significantly for both arms at 1 hour, with better pain scores for the IASLI arm (P = 0.416) at 1st month and ACB arm at 3rd month (P = 0.077) with larger effect size (Cohen’s d = 1.085). Lower limb function improved significantly in the IASLI arm at 1 month; the ACB subjects showed greater functional improvement at 3 months (Cohen’s d = 0.3, P = 0.346). Quality of life (QoL) improvement mirrored the functional scores whereby the IASLI group fared better at the 1st month (P = 0.071) but at the 3rd month the ACB group scored better (Cohen’s d = 0.08, P = 0.710).

Conclusions

ACB provides longer lasting analgesia which improves function and QoL in chronic KOA patients up to 3 months without any significant side effects.

Ultrasound guided anterior approach to intra-articular injection of the knee

In this clinical practice article, we describe a novel, anterior, approach for therapeutic intra-articular injection of the knee under ultrasound guidance. The benefits of this approach are improved accuracy in knees that do not have an effusion, simplified sonoanatomy for learners, and easy localization in patients with enlarged body habitus or altered anatomy. This article describes the positioning, sonographic anatomy, risks, and technical considerations for this anterior approach.

Leukocyte-Rich versus Leukocyte-Poor Platelet-Rich Plasma for the Treatment of Knee Osteoarthritis: A Double-Blind Randomized Trial

BACKGROUND

Platelet-rich plasma (PRP) is gaining large interest in clinical practice as a minimally invasive injective treatment for knee osteoarthritis (OA). Different preparation methods are available, and the presence of leukocytes, deemed detrimental in some preclinical studies, is one of the most debated aspects regarding PRP efficacy.

PURPOSE

To compare the safety and effectiveness of leukocyte-rich PRP (LR-PRP) and leukocyte-poor PRP (LP-PRP) for the treatment of knee OA.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 192 patients with symptomatic knee OA (Kellgren-Lawrence grade 1-3) were randomly allocated to 3 weekly injections of LR-PRP or LP-PRP. LP-PRP was obtained with a filter for leukodepletion. LR-PRP and LP-PRP were divided into aliquots of 5 mL, with a mean platelet concentration of 1146.8 × 10⁹/L and 1074.9 × 10⁹/L and a mean leukocyte concentration of 7991.4 × 10⁶/L and 0.1 × 10⁶/L, respectively. Patients were evaluated at baseline and thereafter at 2, 6, and 12 months for the primary outcome, the International Knee Documentation Committee (IKDC) subjective score; and for secondary outcomes, the Knee injury and Osteoarthritis Outcome Score (KOOS) subscales, EuroQol-visual analog scale (EQ-VAS), and Tegner score.

RESULTS

No differences between groups were observed in terms of absolute values or improvement of the clinical scores across all follow-up intervals. The mean IKDC subjective score at baseline and 12 months improved from 45.6 to 60.7 in the LR-PRP group as compared with 46.8 to 62.9 in the LP-PRP group (P = .626). No severe adverse events were described in either group, although 15 mild adverse events (knee pain or swelling) were reported: 12.2% for LR-PRP and 4.7% for LP-PRP (P = .101). No statistically significant difference was also found between LR-PRP and LP-PRP in terms of failures (7.8% vs 3.5%, P = .331).

CONCLUSION

This double-blind randomized trial showed that 3 intra-articular LR-PRP or LP-PRP injections produced similar clinical improvement in the 12 months of follow-up in patients with symptomatic knee OA. Both treatment groups reported a low number of adverse events, without intergroup differences. The presence of leukocytes did not significantly affect the clinical results of PRP injections.

REGISTRATION

NCT02923700 (ClinicalTrials.gov identifier).

Peroperative Intra-Articular Infiltration of Tranexamic Acid and Ropivacaine Cocktail in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial

Background Total knee arthroplasty (TKA) is a procedure that has improved the quality of life of patients with knee arthritis. Postoperative pain and blood loss are the two major drawbacks of TKA which affect patient satisfaction and delay recovery and rehabilitation. Local infiltration analgesia has shown better results in controlling immediate postoperative pain, thus enabling early rehabilitation and mobilization, while local infiltration of antifibrinolytic agents has shown impressive results in controlling blood loss. In this study, we evaluate the effect of a combination of intra-articular infiltration of ropivacaine cocktail along with intra-articular instillation of tranexamic acid in reducing patient-reported postoperative pain and the level of blood loss control after TKA. Methodology Patients presenting with high-grade osteoarthritis and undergoing TKA were included and randomly allocated to two groups: one receiving the intra-articular infiltration (group A), and the other not receiving any infiltration (group B). Postoperative pain was measured through the Visual Analog Scale (VAS) every three hours for the first 24 hours, and then at 48 hours and 72 hours postoperatively. The need for additional analgesia, in the form of a slow epidural infusion, in patients experiencing severe postoperative pain was evaluated in both groups. Postoperative blood loss was assessed by measuring total drain output (in mL) and by comparing preoperative and postoperative (at 24 hours) hemoglobin, hematocrit drift, and blood transfusion rates. The duration of the postoperative hospital stay and the time taken to start postoperative knee mobilization exercises and weight-bearing were noted to assess the recovery and rehabilitation of the patients in the two groups. Results The study included 42 patients (group A, 22 patients; group B, 20 patients) with 28 knees in each group. Patients with intra-articular infiltration using ropivacaine cocktail with tranexamic acid showed excellent pain control compared to the non-infiltrated patients in the early 48 hours postoperatively. There was a significant drop in postoperative hemoglobin and hematocrit values in the non-infiltrated patients compared to the other group. Further, the intra-articular infiltration-instillation significantly reduced blood loss through the drain, the requirement of postoperative blood transfusions, and the duration of hospital stay. Conclusions It can be safely concluded that ropivacaine cocktail and tranexamic acid instillation postoperatively in knee arthroplasty patients is a very useful and effective technique to reduce postoperative pain and blood loss.

Analysis of the Cost and Efficacy of Intra-Articular Knee Injections

INTRODUCTION

Intra-articular joint injections have been used with the goal of providing patients with symptomatic relief. Recently, however, the efficacy of corticosteroid (CS) and hyaluronic acid (HA) injections in the management of knee osteoarthritis (OA) is questionable. In this analysis, we investigated the costs associated with injections by assessing overall use, conversion and average time to total knee arthroplasty (TKA), and reimbursement.

METHODS

Patients aged 50 to 70 years with a knee-related diagnosis of pain, effusion, or OA were identified in the Humana insurance national data set. Patients who received intra-articular injections were stratified by the type and number of injection(s) received. The subsequent rates of TKA were compared with Kaplan-Meier curves for patients who underwent CS injections, HA injections, and a benchmarking cohort of patients with OA and no history of knee injections in the medical record. Average time to TKA was determined from index diagnosis, and total cost was compared using Wilcoxon rank sum analyses.

RESULTS

A total of 778,686 patients were identified. Of these, 637,112 had no knee injection history, while 124,129 received CS and 17,445 received HA injections. The 10-year conversion to TKA was highest in HA cohort (31.6%), followed by the CS cohort (24.0%) and the noninjection cohort (7.3%) (P < 0.001). Time to TKA increased with number of injections for both injection types. For patients who underwent TKA, median cost was greater in HA ($16,687) and CS ($15,563) cohorts relative to noninjection cohort ($14,733) (P < 0.001).

DISCUSSION

Compared with the noninjection cohort, both HA and CS cohorts experienced increased costs and increased time to TKA. However, while the cost incurred in HA cohort was greater than that in CS cohort, no appreciable benefit was demonstrated for conversion or time to TKA. Therefore, if intra-articular knee injections are indicated for the nonsurgical management of knee OA, the results of this study support CS over HA.

Osteoarthritis, Corticosteroids and Role of CYP Genes in COVID-19 Patients: A Mini Review

Objectives of this review is to evaluate the role of cytochrome P450 gene polymorphisms in COVID-19 infected patients with pre-existing OA on corticosteroids. The purpose of this review is to analyze whether polymorphisms of Cytochrome p450 isoforms (CYP2C9 and CYP3A4) affect the dosage of steroids in OA patients in COVID-19 infected patients. This review may provide more therapeutic options; suggest a few guidelines which may be useful in managing COVID-19 patients with pre-existing osteoarthritis. The important role of corticosteroids in treating patients infected with COVID-19 with preexisting osteoarthritis, its influence on incidence of mortality or morbidity may be highlighted. The influence of CYP enzymes and their polymorphisms suggest safety of treatments as well as the possible need for the dosage adjustment or their discontinuation.

Structural origins of cartilage shear mechanics

Articular cartilage is a remarkable material able to sustain millions of loading cycles over decades of use outperforming any synthetic substitute. Crucially, how extracellular matrix constituents alter mechanical performance, particularly in shear, remains poorly understood. Here, we present experiments and theory in support of a rigidity percolation framework that quantitatively describes the structural origins of cartilage's shear properties and how they arise from the mechanical interdependence of the collagen and aggrecan networks making up its extracellular matrix. This framework explains that near the cartilage surface, where the collagen network is sparse and close to the rigidity threshold, slight changes in either collagen or aggrecan concentrations, common in early stages of cartilage disease, create a marked weakening in modulus that can lead to tissue collapse. More broadly, this framework provides a map for understanding how changes in composition throughout the tissue alter its shear properties and ultimate in vivo function.

Combined Mesenchymal Stem Cells and Cartilage Acellular Matrix Injection Therapy for Osteoarthritis in Goats

BACKGROUND

Human umbilical cord blood-derived MSCs (hUCB-MSCs) have been studied in osteoarthritis (OA) and cartilage regeneration. Our previous study demonstrated that hUCB-MSCs combined with cartilage acellular matrix injection (CAM Inj.) represent potential therapeutic agents for structural improvement and anti-inflammatory effects in a rabbit model of OA.

METHODS

Based on a previous study, this study has evaluated the safety and efficacy of hUCB-MSCs combined with CAM Inj. in an anterior cruciate ligament transection (ACLT) with medial meniscectomy (MMx) in a goat model. In this study, 27 goats were divided into 5 groups: normal (n = 3), OA (n = 6), OA + CAM Inj. (n = 6), OA + hUCB-MSCs (n = 6), and OA + hUCB-MSCs + CAM Inj. (n = 6). Lameness and radiographic parameters were assessed 6 months after administration, and macroscopic and histological evaluations of the goat articular cartilage were performed 6 months after intervention.

RESULTS

The results showed significant improvement in lameness score only in the OA + hUCB-MSCs group at 5 months after treatment (*p < 0.05), whereas the K&L score showed significant improvement only in the OA + hUCB-MSCs + CAM Inj. group 6 months after intervention (*p < 0.05). In addition, the gross findings showed significance in OA + CAM Inj. and OA + hUCB-MSCs + CAM Inj. groups 6 months after treatment (*p < 0.05 and **p < 0.01).

CONCLUSION

In conclusion, treatment with a combination of hUCB-MSCs and CAM Inj. reduced OA symptoms and induced effective cartilage tissue repair in a goat model. We suggest the combination of hUCB-MSCs and CAM Inj. as an alternative therapy for OA.

The Incorporation of Etanercept into a Porous Tri-Layer Scaffold for Restoring and Repairing Cartilage Tissue

Cartilage diseases currently affect a high percentage of the world’s population. Almost all of these diseases, such as osteoarthritis (OA), cause inflammation of this soft tissue. However, this could be controlled with biomaterials that act as an anti-inflammatory delivery system, capable of dosing these drugs over time in a specific area. The objective of this study was to incorporate etanercept (ETA) into porous three-layer scaffolds to decrease the inflammatory process in this soft tissue. ETA is a blocker of pro-inflammatory cytokines, such as tumour necrosis factor alpha (TNF-α) and interleukin 6 (IL-6). For this reason, the scaffold was built based on natural polymers, including chitosan and type I collagen. The scaffold was grafted next to subchondral bone using hydroxyapatite as filler. One of the biomaterials obtained was also crosslinked to compare its mechanical properties with the non-treated one. Both samples’ physicochemical properties were studied with SEM, micro-CT and photoacoustic imaging, and their rheological properties were also compared. The cell viability and proliferation of the human chondrocyte C28/I2 cell line were studied in vitro. An in vitro and in vivo controlled release study was evaluated in both specimens. The ETA anti-inflammatory effect was also studied by in vitro TNF-α and IL-6 production. The crosslinked and non-treated scaffolds had rheological properties suitable for this application. They were non-cytotoxic and favoured the in vitro growth of chondrocytes. The in vitro and in vivo ETA release showed desirable results for a drug delivery system. The TNF-α and IL-6 production assay showed that this drug was effective as an anti-inflammatory agent. In an in vivo OA mice model, safranin-O and fast green staining was carried out. The OA cartilage tissue improved when the scaffold with ETA was grafted in the damaged area. These results demonstrate that this type of biomaterial has high potential for clinical applications in tissue engineering and as a controlled drug delivery system in OA articular cartilage.