The mechanism of action for hyaluronic acid treatment in the osteoarthritic knee: a systematic review

Study on the potential mechanism of anti-inflammatory activity of covalently immobilized hyaluronan and heparin

Inflammation and subsequent fibrotic encapsulation that occur after implantation of biomaterials are issues that fostered efforts in designing novel biocompatible materials to modulate the immune response. In this study, glycosaminoglycans (GAG) like hyaluronic acid (HA) and heparin (Hep) that possess anti-inflammatory activity were covalently bound to NH₂ -modified surfaces using EDC/NHS cross-linking chemistry. Immobilization and physical surface properties were characterized by atomic forces microscopy, water contact angle studies and streaming potential measurements demonstrating the presence of GAG on the surfaces that became more hydrophilic and negatively charged compared to NH₂ -modified. THP-1 derived macrophages were used here to study the mechanism of action of GAG to affect the inflammatory responses illuminated by studying macrophage adhesion, the formation of multinucleated giant cells (MNGCs) and IL-1β release that were reduced on GAG-modified surfaces. Detailed investigation of the signal transduction processes related to macrophage activation was performed by immunofluorescence staining of NF-κB (p65 subunit) together with immunoblotting. We studied also association and translocation of FITC-labeled GAG. The results show a significant decrease in NF-κB level as well as the ability of macrophages to associate with and take up HA and Hep. These results illustrate that the anti-inflammatory activity of GAG is not only related to making surfaces more hydrophilic, but also their active involvement in signal transduction processes related to inflammatory reactions, which may pave the way to design new anti-inflammatory surface coatings for implantable biomedical devices.

Rethinking Viscosupplementation: Ultrasound- Versus Landmark-Guided Injection for Knee Osteoarthritis

OBJECTIVES

Viscosupplementation, intra-articular injection of hyaluronic acid (HA), for knee osteoarthritis has fallen somewhat out of favor, with studies failing to show consistent benefits in pain reduction. Hyaluronic acid must enter the joint space to be beneficial; however, landmark-guided injection can be substantially inaccurate, especially in obese patients. We aimed to determine whether ultrasound (US) guidance to ensure needle placement for HA knee injection resulted in improved outcomes as reflected by surgery-free survival compared to landmark-guided HA knee injection.

METHODS

All community-dwelling patients in 6 contiguous surrounding counties receiving HA knee injection either by landmark guidance (n = 647) or by US guidance (n = 500) were analyzed for the degree of arthritis, body mass index, follow-up injection, and subsequent need for knee arthroplasty. A subgroup analysis of obese patients was also performed.

RESULTS

The US- and landmark-guided HA injection cohorts were similar with respect to sex, body mass index, and the degree of arthritis. Of 1147 patients receiving knee HA injection, 462 subsequently underwent knee arthroplasty. Significantly fewer patients in the US-guided HA injection cohort went to surgery (33.2%) compared to the landmark-guided cohort (45.8%; P < .001). The subgroup analysis for obese patients showed even larger differences (34.8% versus 51.8%; P < .001).

CONCLUSIONS

Knee osteoarthritis treatment by viscosupplementation can be optimized by US guidance, ensuring intra-articular needle placement. Using an objective surgical outcome, our study shows that rethinking viscosupplementation to ensure intra-articular delivery improves effectiveness. Patients receiving US-guided knee HA injection were significantly less likely to undergo subsequent knee arthroplasty than patients receiving landmark-guided HA injection.

A single intra-articular injection of 2.0% non-chemically modified sodium hyaluronate vs 0.8% hylan G-F 20 in the treatment of symptomatic knee osteoarthritis: A 6-month, multicenter, randomized, controlled non-inferiority trial

OBJECTIVES

The aim of the study was to demonstrate the non-inferiority of a single intra-articular injection of 2.0% non-chemically modified sodium hyaluronate (SH) vs 0.8% hylan G-F 20 (control) in symptomatic knee osteoarthritis.

DESIGN

This was a double-blind, randomized, controlled trial conducted in patients with painful tibiofemoral osteoarthritis (American College of Rheumatology criteria) with insufficient response or intolerance to first-line analgesics and regular non-steroidal anti-inflammatory drugs. Subjects received a single intra-articular injection of either SH or hylan G-F 20. The primary outcome was the 6-month change from baseline in the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale (WOMAC A), with a pre-specified lower margin for non-inferiority of 8 mm.

RESULTS

Of the 292 patients randomized (SH: 144), 288 received an injection (SH: 142), 266 completed the study (SH: 134). In the Per Protocol dataset (SH: 113, control: 112), the WOMAC A change at 6 months was -34.3 mm (95% confidence interval (CI): -37.8, -30.8) and -36.2 mm (95% CI: -40.3, -32.1) for the SH and hylan G-F 20 patients, respectively (P = 0.5). The intergroup difference was -1.9 mm (95% CI: -7.3, 3.5). Results were similar in the Full Analysis Set (SH: 139, control: 141) with a difference between the groups of -2.9 mm (95% CI: -7.9, 2.2). A total of 31.3% of the injected patients reported a treatment-emergent adverse event, including injection site reactions (pain, inflammation or effusion) which occurred in 8.5% of the SH patients vs 13.0% of the hylan G-F 20 patients. No serious reactions were reported.

CONCLUSIONS

This clinical trial demonstrated the non-inferiority of a single intra-articular injection of SH vs hylan G-F 20 on the WOMAC A change from baseline at 6 months.

Intra-Articular Hyaluronic Acid and Chondroitin Sulfate: Pharmacokinetic Investigation in Osteoarthritic Rat Models

Background

Viscosupplementation of synovial fluid with intra-articular (IA) injections of hyaluronic acid (HA) is widely used for symptomatic treatment of osteoarthritis (OA). Herein we present HCS, a new combination of chemicals, associating HA and chondroitin sulfate (CS), both members of the glycosaminoglycan (GAGs) family, which are major components of the joint. HA provides viscosity to the synovial fluid and CS provides elasticity to the cartilage. Reduced levels of HA and CS are observed in OA joints and are associated with progressive cartilage damage and loss.

Objective

The objective of the study was to evaluate the pharmacokinetic (PK) properties of both HA and CS after IA administration in a validated OA animal model.

Methods

Motion impairment measurements and histological examinations were used to validate the ability of an IA injection of mono-iodoacetate (MIA) in the knee of rats to induce OA symptoms. Then, the PK properties of HA and CS after IA administration were characterized and each active ingredient was independently profiled: HA was labeled with tritium (3H-HA) and CS was labeled with carbon 14. (14C-CS) The final radio-labeled solution reproduced the cold HCS formulation.

Results

Four male Sprague-Dawley rats received a 1 mg MIA injection on day 1, then motor impairment was monitored from day 4 to day 18. Chondrocyte necrosis, loss of GAGs and other cartilage damage were observed. Twelve other rats received a MIA IA injection on day 1 then a radio-labeled HCS IA injection (50 µL) on day 8. Plasma and knee cartilage were collected postadministration and the terminal half-life was similar in both matrices (about 5 days), for both 3H-HA and 14C-CS.

Conclusions

Despite differences in their molecular size, HA and CS showed PK behavior similarly characterized by prolonged residence inside the joint and slow release in plasma, favoring long-term beneficial effects. (Curr Ther Res Clin Exp. 2020; 92:XXX-XXX).

Does Injection of Hyaluronic Acid Protect Against Early Cartilage Injury Seen After Marathon Running? A Randomized Controlled Trial Utilizing High-Field Magnetic Resonance Imaging

BACKGROUND

Previous studies have shown that runners demonstrate elevated T2 and T1ρ values on magnetic resonance imaging (MRI) after running a marathon, with the greatest changes in the patellofemoral and medial compartment, which can persist after 3 months of reduced activity. Additionally, marathon running has been shown to increase serum inflammatory markers. Hyaluronic acid (HA) purportedly improves viscoelasticity of synovial fluid, serving as a lubricant while also having chondroprotective and anti-inflammatory effects.

PURPOSE/HYPOTHESIS

The purpose was to investigate whether intra-articular HA injection can protect articular cartilage from injury attributed to marathon running. The hypothesis was that the addition of intra-articular HA 1 week before running a marathon would reduce the magnitude of early cartilage breakdown measured by MRI.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 2.

METHODS

After institutional review board approval, 20 runners were randomized into receiving an intra-articular injection of HA or normal saline (NS) 1 week before running a marathon. Exclusionary criteria included any prior knee injury or surgery and having run >3 prior marathons. Baseline 3-T knee MRI was obtained within 48 hours before the marathon (approximately 5 days after injection). Follow-up 3-T MRI scans of the same knee were obtained 48 to 72 hours and 3 months after the marathon. The T2 and T1ρ relaxation times of articular cartilage were measured in 8 locations-the medial and lateral compartments (including 2 areas of each femoral condyle) and the patellofemoral joint. The statistical analysis compared changes in T2 and T1ρ relaxation times (ms) from baseline to immediate and 3-month postmarathon scans between the HA and NS groups with repeated measures analysis of variance.

RESULTS

Fifteen runners completed the study: 6 women and 2 men in the HA group (mean age, 31 years; range, 23-50 years) and 6 women and 1 man in the NS group (mean age, 27 years; range, 20-49 years). There were no gross morphologic MRI changes after running the marathon. Postmarathon studies revealed no statistically significant changes between the HA and NS groups in all articular cartilage areas of the knee on both T2 and T1ρ relaxation times.

CONCLUSION

Increased T2 and T1ρ relaxation times have been observed in marathon runners, suggesting early cartilage injury. The addition of intra-articular HA did not significantly affect relaxation times in all areas of the knee when compared with an NS control.

Effect of high molecular weight hyaluronic acid in treatment of osteoarthritic temporomandibular joints of rats

OBJECTIVE

The aim of this study was to determine the histological and biochemical effects of high molecular weight hyaluronic acid on experimentally induced osteoarthritic changes in male rat temporomandibular joint (TMJ).

DESIGN

In this in-vivo study, 36 male albino rats were divided into 3 groups; control non-injected, disease and treatment group. Osteoarthritis was induced using a single intra-articular injection of Complete Freund's adjuvant (CFA) (50 μl). High molecular weight hyaluronic acid (HMWHA) was injected intra-articularly once a week, for a total of 3 injections. TMJ tissue samples were dissected from control, disease and treatment groups for biochemical analysis using ELISA test to detect the levels of matrix metalloproteinase-3 (MMP-3) on day 28. Histological examination was done using Hematoxylin &eosin, Mallory's trichrome and Alcian blue stains. Data was analyzed using Kruskal-Wallis test followed by Dunn-Sidek method, with a 5 % significance level.

RESULTS

Treatment group showed regaining of the normal histological features of the TMJ and decreased levels of MMP-3 when compared to disease group.

CONCLUSIONS

These findings may suggest that HMWHA plays a role in the management of CFA-induced osteoarthritic cartilage lesions.

Pharmacodynamics, efficacy, safety and administration of intra-articular therapies for knee osteoarthritis

Introduction: Osteoarthritis (OA) is the leading cause of disability in the elderly, usually presenting with mono-or oligo-arthritis where local drug delivery by intra-articular (IA) injection may be more effective in terms of increased bioavailability, less systemic exposure and reduced adverse events. Several intra-articular medications for symptomatic are available on the market while the new disease-modifying drugs (DMOADs) are progressing into phase 3 pipeline of drug development.Areas covered: This narrative review covered the pharmacokinetic and pharmacodynamics of clinically available IA drugs which include corticosteroids, hyaluronic acid as well as injection techniques, efficacy, adverse effects and contraindications. In addition, the authors briefly describe the newer disease-modifying OA drugs (DMOAD) which are undergoing phase 3 pipeline of development such as Fibroblast growth factor (FGF-18) and Wnt inhibitor.Expert opinion: This is a rapidly evolving area with both new products and new trials regularly emerging. It is also a critically important area in a disease field that lacks for safe and effective treatments, where intra-articular delivery may enhance both local efficacy and reduce systemic toxicity.

Is Intra-Articular Injection of Synvisc Associated with a Delay to Knee Arthroplasty in Patients with Knee Osteoarthritis?

OBJECTIVE

There is debate about the effectiveness of intra-articular (IA) hyaluronic acid (HA) injections. We asked the following questions: (1) What is the epidemiology of IA HA use in knee arthroplasty (KA) patients? (2) Is Synvisc associated with a delay to KA? (3) Is there a difference in the delay to KA with the number of HA courses?

DESIGN

The Optum Clinformatics data set (2006-June 2016) was used to identify patients with knee osteoarthritis (OA). Patients who did not receive IA HA were identified, along with those who received Synvisc or non-Synvisc HA. The median duration from knee OA to KA was compared using quantile regression modeling with propensity score weighting. The trend in time to KA with each HA course was evaluated.

RESULTS

Of 4,027,848 knee OA patients, 141,305 patients underwent KA. Overall median time from knee OA diagnosis to KA was 1.2 years (average: 1.9 ± 1.9 years; interquartile range of 0.4-2.8 years). HA patients had significantly longer adjusted median time to KA by at least 7 months (P < 0.001). After adjusting for the time to HA and number of injections, Synvisc patients had 1.7 months longer time to KA than non-Synvisc HA patients (P < 0.001). There was a trend toward longer time to KA with more HA courses.

CONCLUSIONS

Most KA patients did not use HA (73.7%) and when received, it was associated with a longer median time to KA by at least 7 months, though the cause and effect could not be examined. The delay to KA increased with more HA courses.

A Single Intra-Articular Injection of Gel-200 for Treatment of Symptomatic Osteoarthritis of the Knee Is More Effective than Phosphate Buffered Saline at 6 Months: A Subgroup Analysis of a Multicenter, Randomized Controlled Trial

OBJECTIVE

Many clinical trials of viscosupplementation have been conducted, although only the Gel-200 (primary) trial included a different patient population. A subgroup analysis of a multicenter, randomized controlled trial comparing the efficacy of single intra-articular injections of Gel-200 with phosphate buffered saline (PBS) was performed to demonstrate its benefit as treatment of osteoarthritis of the knee in a population similar to those of other reported trials of viscosupplementation.

DESIGN

The subgroup population was defined as patients in the intention-to-treat (ITT) population who met the specified criteria. Changes from baseline in Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores following treatment with Gel-200 or PBS were derived from a longitudinal model and treatment differences compared between groups at weeks 12 and 26, and over 26 weeks.

RESULTS

The subgroup included 311 subjects (152 Gel-200; 159 PBS). Mean improvements from baseline in WOMAC pain subscores in the Gel-200 over PBS groups were statistically significant at week 12 (P = 0.031) and week 26 (P = 0.019). Treatment group differences in WOMAC stiffness and total scores were statistically significant at week 26 (P = 0.023 and P = 0.036, respectively).

CONCLUSIONS

The efficacy of Gel-200 following a single injection for knee osteoarthritis was demonstrated in WOMAC pain, stiffness, and total scores as well as clinically important improvements in pain at 26 weeks in this subset of patients with comparable characteristics to populations evaluated in other viscosupplementation treatment trials.

Single- and double-dose of platelet-rich plasma versus hyaluronic acid for treatment of knee osteoarthritis: A randomized controlled trial

BACKGROUND

Platelet-rich plasma (PRP) and hyaluronic acid have been shown to be useful in the treatment of knee osteoarthritis. However, investigations comparing the efficacy of these two drugs together are insufficient.

AIM

To compare the outcomes of PRP vs hyaluronic acid injections in three groups of patients with bilateral knee osteoarthritis.

METHODS

This randomized controlled trial study involved 95 patients. Thirty-one subjects received a single injection of PRP (group PRP-1), 33 subjects received two injections of PRP at an interval of 3 wk (group PRP-2) and 31 subjects received three injections of hyaluronic acid at 1-wk intervals (group hyaluronic acid). The patients were investigated prospectively at the enrollment and at 4-, 8- and 12-wk follow-up with the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Visual Analogue Scale questionnaires.

RESULTS

Percentages of patients experiencing at least a 30% decrease in the total score for the WOMAC pain subscale from baseline to wk 12 of the intervention were 86%, 100% and 0% in the groups PRP-1, PRP-2 and hyaluronic acid, respectively (P < 0.001). The mean total WOMAC scores for groups PRP-1, PRP-2 and hyaluronic acid at baseline were 63.71, 61.57 and 63.11, respectively. The WOMAC scores were significantly improved at final follow-up to 42.5, 35.32 and 57.26, respectively. The highest efficacy of PRP was observed in both groups at wk 4 with about 50% decrease in the symptoms compared with about 25% decrease for hyaluronic acid. Group PRP-2 had higher efficacy than group PRP-1. No major adverse effects were found during the study.

CONCLUSION

PRP is a safe and efficient therapeutic option for treatment of knee osteoarthritis. It was demonstrated to be significantly better than hyaluronic acid. We also found that the efficacy of PRP increases after multiple injections.

Efficacy of intra-articular hyaluronic acid injections in the rehabilitation programme of Knee Osteoarthritis

Abstract Knee osteoarthritis (KOA) is a disease of wear and tear, leading to disability and ultimate surgical treatment. KOA has multiple etiologies and is considered a disorder of physiological processes that is manifested by progressive lesions of articular cartilage caused by chondrolysis, synovial membrane inflammation and subchondral osteophytes production. Modalities that limit the progression of the KOA and rehabilitation are a constant interest for clinicians and medical researchers. Various physical therapies and pharmacological strategies are currently used for pain management, with no clear benefit in terms of inhibiting disease progression. In this context, the use of exogenous hyaluronic acid (HA) (that is a vital component of the synovial fluid and involved in lubricating all synovial joints) has been explored as viable alternative to alleviate knee pain and temporarily restore knee function. In the following, we will review the use of HA injections associated with the physiotherapeutic recovery plan in the treatment of KOA. The therapeutic effects of the HA is still a matter of debate in the field, with no consensus being reached so far and thus, difficult to evaluate. However, much research has to be done to understand the therapeutic efficacy of HA alone or in combination with physical therapies and the role that other factors may play in unraveling its beneficial effects on the KOA. Key words: knee, osteoarthritis, hyaluronic acid, physiotherapy, rehabilitation,

pH-responsive poly(lactide-co-glycolide) nanoparticles containing near-infrared dye for visualization and hyaluronic acid for treatment of osteoarthritis

This study focuses on intra-articular (IA) drug delivery system for the treatment of knee osteoarthritis (OA). In osteoarthritic condition the synovial fluid presents pockets with lower pH environment. To take advantage of these pH differences, poly(lactic-co-glycolic acid (PLGA) nanoparticles (NPs) and pH- responsive PLGA NPs encapsulated with ammonium bicarbonate (NH₄HCO₃) were generated. The nanoparticles were loaded with hyaluronic acid (HA) as a possible model drug for OA and with near-infrared dye (NIR) that was used to visualize the NPs with molecular imaging techniques. These NPs were characterized by dynamic light scattering, transmission electron microscopy and compared in in vitro, in vivo and ex vivo experiments in the treatment of OA. The results indicate that the NPs were sufficiently small, displayed a uniform size distribution and were non-toxic both in vitro and in vivo. Both NPs treatment seem to induced a reduction in OA progression, with pH- responsive NPs showing the more pronounced effect. This is probably because the pockets of low pH environment in the synovial fluid trigger a burst release of the pH-responsive NPs. This result is corroborated by in vitro experiments since the pH- responsive NPs showed an extracellular burst release behavior and higher chondrocyte vitality than non-responsive NPs. This study demonstrates that PLGA NPs containing HA and NH₄HCO₃ are candidates for the treatment of knee OA.

N-acetyl glucosamine and proteoglycan containing supplement improves the locomotor functions of subjects with knee pain

The aim of this study was to investigate the effect of N-acetyl glucosamine and proteoglycan-containing supplement (NGPS) on knee pain and locomotor functions in middle-aged and elderly persons with knee pain. An open trial was conducted on 19 subjects suffering from knee pain. The subjects, aged (55.6 ± 6.9) years, were given the NGPS tablets, which they must take 3 times per day, that contain 526.5 mg of N-acetyl glucosamine (GlcNAc) and 33.6 mg of proteoglycan for 12 weeks. Subjective pain was evaluated using the Visual Analog Scale (VAS), while the function of the knee with regard to daily operation was evaluated using the Japanese Knee Osteoarthritis Score (JKOM). Walking, stair-climbing and swelling were evaluated using the Japanese Orthopedic Association Score (JOA). These items were evaluated at a baseline, and after 4, 8, and 12 weeks of NGPS treatment. The VAS scores at 8 (p = 0.004) and 12 (p < 0.001) weeks were significantly lower than that at the baseline. The JKOM total score was significantly lower at 8 and 12 weeks (p = 0.001) than that at the baseline. The JOA score in the more painful side of the leg was significantly higher at 12 weeks (p = 0.002) than that at the baseline. The present study reveals that intake of NGPS is effective for relieving knee pain and improving knee function when walking or climbing stairs, swelling and bending or stretching.

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.

Hyaluronic Acid (HA), Platelet-Rich Plasm and Extracorporeal Shock Wave Therapy (ESWT) promote human chondrocyte regeneration in vitro and ESWT-mediated increase of CD44 expression enhances their susceptibility to HA treatment

Novel strategies have been proposed for articular cartilage damage occurring during osteoarthritis (OA) and -among these- Extracorporeal Shock Wave Therapy (ESWT), intra-articular injections of Platelet-Rich Plasma (PRP) or Hyaluronic Acid (HA) revealed encouraging results. To investigate the possible mechanisms responsible for those clinical benefits, we established primary cultures of human chondrocytes derived from cartilage explants and measured the in vitro effects of ESW, PRP and HA therapies. After molecular/morphological cell characterization, we assessed those effects on the functional activities of the chondrocyte cell cultures, at the protein and molecular levels. ESWT significantly prevented the progressive dedifferentiation that spontaneously occurs during prolonged chondrocyte culture. We then attested the efficiency of all such treatments to stimulate the expression of markers of chondrogenic potential such as SOX9 and COL2A, to increase the Ki67 proliferation index as well as to antagonize the traditional marker of chondrosenescence p16INK4a (known as Cdkn2a). Furthermore, all our samples showed an ESW- and HA-mediated enhancement of migratory and anti-inflammatory activity onto the cytokine-rich environment characterizing OA. Taken together, those results suggest a regenerative effect of such therapies on primary human chondrocytes in vitro. Moreover, we also show for the first time that ESW treatment induces the surface expression of major hyaluronan cell receptor CD44 allowing the increase of COL2A/COL1A ratio upon HA administration. Therefore, this work suggests that ESW-induced CD44 overexpression enhances the in vitro cell susceptibility of human chondrocytes to HA, presumably favouring the repair of degenerated cartilage.

Combined intra-articular injection of corticosteroid and hyaluronic acid reduces pain compared to hyaluronic acid alone in the treatment of knee osteoarthritis

PURPOSE

Intra-articular injections of corticosteroid (CS) and hyaluronic acid (HA) have individually demonstrated efficacy for knee osteoarthritis (OA); however, both treatments are limited by the trajectory of symptom relief. The combination of CS and HA in the management of knee OA may provide improved symptomatic relief for patients who are candidates for intra-articular therapies.

METHODS

Electronic databases Medline, EMBASE and Cochrane Library were used to identify relevant publications. Randomized controlled trials (RCT) that evaluated intra-articular injections of combined CS and HA in comparison to HA alone were included. Outcomes eligible for meta-analysis were WOMAC pain, WOMAC total, OMERACT-OARSI responder rate, and treatment-related adverse events. Standardized mean differences (SMD) were calculated for continuous outcomes using an inverse variance method and a random-effects model. Odds ratios (OR) were calculated for dichotomous outcomes using the Mantel-Haenszel method and a random-effects model. Heterogeneity was assessed using the I² statistic.

RESULTS

Eight trials (n = 751 patients) were included. Reduction in WOMAC pain scores at 2-4 weeks favoured the combined CS and HA group compared to HA alone [SMD 0.60, 95% CI (0.23, 0.97); p = 0.002, I² = 75%]. Longer term improvements at 24-26 and 52 weeks WOMAC pain scores also favoured the combined CS and HA group {[SMD 0.25, 95% CI (0.09, 0.41); p = 0.002, I² = 0%] and [SMD 0.39, 95% CI (0.01, 0.77); p = 0.05, I² = 0%]} compared to HA alone, respectively. There were no significant differences in WOMAC total scores, OMERACT-OARSI responder rate, or treatment-related adverse events.

CONCLUSION

Combined intra-articular injections of CS and HA led to reductions in pain at 2-4, 24-26 and 52 weeks compared to HA injections alone.

LEVEL OF EVIDENCE

Level II-meta-analysis.

Efficiency of intra-articular hyaluronic acid therapy in patients with osteoarthritis

Osteoarthritis (OA) is the most common disease of the musculoskeletal system, which is characterized by persistent pain, joint dysfunction, and early disability. The incidence of OA has now increased, and, according to the data obtained by the V.A. Nasonova Research Institute of Rheumatology, amounts to about 13%, which is 5 times higher than official statistics. The major goals of OA treatment are aimed at reducing pain, improving the functional state of the joint, preventing the development of joint deformity, improving the quality of life of patients, and minimizing the side effects of pharmacotherapy. Intra-articular hyaluronic acid (HA) injections have been long used as a synovial fluid prosthesis; however, recently published studies have provided new data on the mechanisms of action of these drugs and the role of this method in the treatment of patients with OA. Numerous meta-analyses have shown that HA therapy does not substantially differ from placebo in tolerance, thereby ensuring significantly reduced pain and improved joint function. This review deals with some issues of intra-articular HA administration in patients with OA, with the mechanisms of action of HA preparations, with the problems of choosing a drug according to its source, molecular weight, administration methods, and the efficiency of the therapy compared to other drugs.

The synovial fluid neuropeptide PACAP may act as a protective factor during disease progression of primary knee osteoarthritis and is increased following hyaluronic acid injection

The correlation of serum and synovial fluid (SF) pituitary adenylate cyclase-activating polypeptide (PACAP) levels with disease progression of primary knee osteoarthritis (OA) was explored. Radiographic severity of OA was determined by Kellgren-Lawrence (K-L) grades. PACAP levels were measured by ELISA before treatment, and 4 and 8 wk following hyaluronic acid (HA) injection. Levels of IL-1β and MMP-3 were also detected. The numeric pain scale (NPS), revised Oxford Knee Score (OKS), and American Knee Society Score (AKSS) were employed to evaluate to symptomatic severity. Receiver-operating-characteristic (ROC) curve analysis was carried out to compare the diagnostic value of PACAP, IL-1β, and MMP-3 for the K-L grade. PACAP concentrations in SF but not serum were significantly lower in OA patients compared with controls. SF PACAP levels were negatively associated with K-L grades and higher NPS as well as worse AKSS and OKS. Further analysis demonstrated that PACAP concentration in SF was negatively correlated with expressions of IL-1β as well as MMP-3 and may act as a marker for radiographic progression along with MMP-3. Last, we found SF PACAP levels exhibited an incremental trend after HA injection. These findings confirmed the crucial role of PACAP deficiency in the development of primary knee OA.

Supartz (Sodium Hyaluronate) for the Treatment of Knee Osteoarthritis: A Review of Efficacy and Safety

As concerns about the safety of systemic oral pharmacologic treatments for knee osteoarthritis (OA) mount, clinicians have increased the use of intra-articular hyaluronic acid (IA-HA) in managing mild-to-moderate knee OA. Supartz (sodium hyaluronate; Seikagaku Corporation, Tokyo, Japan) is the first IA-HA product to be approved in the world and has the longest history of global use. In this review, we summarize evidence supporting Supartz efficacy and safety, including data from pivotal clinical trials that resulted in approval of Supartz in the United States and Japan, the safety of single and repeated courses of Supartz, and Supartz efficacy using objective outcomes and in special populations. There is strong evidence that single 5-week courses of Supartz provide clinically meaningful reductions in pain and improved function for up to 6 months without risk of serious side effects or complications. Repeated courses of Supartz are as safe as single courses and have an extremely low risk of infection. Findings from promising initial studies, which suggest that Supartz may improve muscle strength, gait pattern, and balance, should be confirmed in randomized controlled trials.

Thermosensitive hybrid hyaluronan/p(HPMAm-lac)-PEG hydrogels enhance cartilage regeneration in a mouse model of osteoarthritis

Osteoarthritis (OA), due to cartilage degeneration, is one of the leading causes of disability worldwide. Currently, there are not efficacious therapies to reverse cartilage degeneration. In this study we evaluated the potential of hybrid hydrogels, composed of a biodegradable and thermosensitive triblock copolymer cross-linked via Michael addition to thiolated hyaluronic acid, in contrasting inflammatory processes underlying OA. Hydrogels composed of different w/w % concentrations of hyaluronan were investigated for their degradation behavior and capacity to release the polysaccharide in a sustained fashion. It was found that hyaluronic acid was controllably released during network degradation with a zero-order release kinetics, and the release rate depended on cross-link density and degradation kinetics of the hydrogels. When locally administered in vivo in an OA mouse model, the hydrogels demonstrated the ability to restore, to some extent, bone remineralization, proteoglycan production, levels of Sox-9 and Runx-2. Furthermore, the downregulation of proinflammatory mediators, such as TNF-α, NFkB, and RANKL and proinflammatory cytokines was observed. In summary, the investigated hydrogel technology represents an ideal candidate for the potential encapsulation and release of drugs relevant in the field of OA. In this context, the hydrogel matrix could act in synergy with the drug, in reversing phenomena of inflammation, cartilage disruption, and bone demineralization associated with OA.

Drug-loaded hyaluronic acid hydrogel as a sustained-release regimen with dual effects in early intervention of tendinopathy

Resulting from accumulative microtrauma, impaired healing and oxidative stress, tendinopathy is a debilitating and relentlessly deteriorating disease that greatly affects daily function and quality of life. Current therapy usually provides symptomatic relief only. Sufferers undergo repetitive and protracted treatment courses that rarely alter the disease process. We aim to develop a sustained-release regimen with an intrinsic therapeutic effect in tendinopathy treatment, using oxidised hyaluronic acid/adipic acid dihydrazide hydrogel (HA hydrogel) as both the drug carrier and a mitigating agent of symptoms. We show that HA hydrogel can mitigate tendinopathy changes both in vitro (mechanically induced tendinopathy model) and in vivo (collagenase-induced tendinopathy model). A potent anti-oxidative (pigallocatechin gallate) incorporated into HA hydrogel conferred an additional protective effect in both models. The results indicate that when administered early, combined medications targeting different pathogenesis pathways can resolve tendinopathy. Although facilitating the healing process and mitigating oxidative stress are promising therapeutic strategies, the most effective regimen for tendinopathy treatment has to be determined yet. The established experimental model and drug carrier system provide a platform for exploring new therapeutics against this debilitating disease.

An exploratory comparison of single intra-articular injection of platelet-rich plasma vs hyaluronic acid in treatment of haemophilic arthropathy of the knee

INTRODUCTION

Intra-articular platelet-rich plasma (PRP) injection therapy has been extensively applied in clinical practice to treat musculoskeletal disorders such as osteoarthritis, but the treatment for haemophilic arthropathy is rarely reported.

AIMS

This study aimed to compare the efficacy of intra-articular PRP vs hyaluronic acid (HA) injections in treating haemophilic arthropathy of knee joints.

PATIENTS

Twenty-two haemophilia patients (mean age, 41.1 ± 1.7 [range, 20-50] years) with painful haemophilic arthropathy of the knee were enrolled for this open-label and observer-blind study.

METHODS

Eleven patients were treated with a single intra-articular injection of PRP and the other 11 received five consecutively weekly intra-articular injections of HA. Outcome assessment included pain by visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Chinese Version and synovial change determined by ultrasonography.

RESULTS

Platelet-rich plasma and HA intra-articular injection showed statistically significant reduction in VAS, WOMAC total score and hyperaemia score from baseline to 6-month post-treatment. Inter-group comparison showed statistically significant difference in the change in VAS score, WOMAC pain score, physical function score and total score at 6 months, wherein PRP group showed sustained beneficial effect than HA group at 6 months.

CONCLUSION

Our study demonstrates that, in comparison with five weekly injections of HA, a single PRP injection resulted in better improvement in pain relief and knee joint function, and greater reduction in synovial hyperaemia for up to 6 months. Our results suggest that PRP may be practical and effective for haemophilic knee arthropathy, and further investigation is warranted.

The Role of Orthobiologics in the Management of Osteoarthritis and Focal Cartilage Defects

Individuals with osteoarthritis have a diminished quality of life, and the condition is a major cause of disability. Newer biologic treatments have been developed that are believed to modify disease progression. These predominantly include hyaluronic acid, platelet-rich plasma, bone marrow aspirate concentrate, and adipose-derived mesenchymal stem cells. There is conflicting evidence regarding the use of orthobiologics for osteoarthritis and for focal chondral defects, although most studies indicate that injections of biologics are safe and without significant adverse effects. [Orthopedics. 2019; 42(2):66-73.].

Active viscosupplements for osteoarthritis treatment

OBJECTIVE

Osteoarthritis is a chronic, painful and disabling disease which prevalence is increasing in developing countries. Patients with osteoarthritis present a reduced synovial fluid viscoelasticity due to a reduction in concentration and molecular weight of hyaluronic acid. Currently, the main treatment used to restore the compromised rheological properties of synovial fluid is the viscosupplementation by hyaluronic acid injections that can be combined with oral anti-inflammatory drugs for pain relief. Combination of viscosupplements with chemical agents or drugs is emerging as a new strategy to provide a double action of synovial fluid viscoelasticity recovery and the therapeutic effect of the bioactive principle.

METHODS

In this review, we present the latest research on the combination of viscosupplements with active molecules. We conducted a literature review of articles published in different web search engines and categorized according to the active molecule introduced into the viscosupplement.

RESULTS

Generally, the introduction of anti-inflammatory molecules have shown to improve pain relief although some cytotoxicity has been demonstrated especially for non-steroidal anti-inflammatory drugs. Other molecules such as antioxidant or disease modifying osteoarthritis drugs have been reported to improve viscosupplementation action. Drug delivery systems combined with hyaluronic acid could enhance the activity of the encapsulated molecules and provide better control over the drug release. Finally, biological approaches such as the use of stem cells or platelet-rich plasma seem to be the most promising strategies for cartilage recovery.

CONCLUSIONS

Combination therapy of viscosupplements with therapeutic agents, drug delivery systems or regenerative therapies can improve viscosupplementation outcome in terms of pain relief and joint functionality. However, further research is needed in order to reach more conclusive results.

Evaluation of pharmacokinetics and pharmaco-dynamics of sinomenine-hyaluronic acid conjugate after intra-articular administration for osteoarthritis treatment

Objectives

Intra-articular injection of sinomenine (SN) is an effective treatment method for knee osteoarthritis (OA), however, SN could be eliminated quickly in vivo. To extend the residence time of SN in the joint cavity, the SN-hyaluronic acid (HA) conjugate was prepared previously. This study was performed to evaluate the pharmacokinetics and pharmacodynamics of SN-HA conjugate after intra-articular administration for the treatment of OA.

Methods

A high performance liquid chromatography-mass spectrometry (HPLC-MS/MS) method was established to determine the SN content in rat synovial fluid. One hundred and twenty rats were randomly divided into two groups, the SN-HA group and SN group. The concentration of SN in articular cavity washings was determined by HPLC-MS/MS. The protective effect on the cartilage was evaluated by histological evaluation in a model of papain induced rabbit knee osteoarthritis.

Results

The method was validated with respect to sensitivity, specificity, linearity, precision, accuracy and especially the stability of analytes under various conditions, and was successfully applied in evaluating the pharmacokinetic profiles of SN in the joint cavity. Compared to the SN injection, the drug exposure in joint cavity was significantly increased following SN-HA injection administration, and AUC(0-12h) was 2.9 times of SN injection, mean residence time (MRT) was 1.88 times of SN injection. In the pharmacodynamic study, there was no significant difference between the SN-HA twice-treated group and SH/HA five-times mixture-treated group.

Conclusion

The local bioavailability of SN in joint cavity was improved significantly after conjugated with HA. The SN-HA conjugate showed good synergism effect of OA inhibition. The results indicated that the SN-HA conjugate seemed to be an effective therapeutic means for the treatment of OA.

Lower range of molecular weight of xanthan gum inhibits apoptosis of chondrocytes through MAPK signaling pathways

LRWXG has previously been reported to have a protective effect on chondrocytes, preventing apoptosis induced by oxidative stress. In this study, we were aimed at determining whether LRWXG exerts its anti-apoptotic activity through the MAPK signaling pathways in chondrocytes. Our results show that, at the cellular level, apoptosis of chondrocytes in the groups treated by LRWXG decreases compared with groups treated by inhibitors alone and model group under conditions of oxidative stress in a dose-dependent manner. Mechanistically at the molecular level, LRWXG regulates the MAPK pathway induced by oxidative stress: The levels of phosphorylation of JNK and p38 proteins in the groups treated by LRWXG are lower than model group, while compared with corresponding groups of inhibitors, there are no significant difference; For other related proteins, LRWXG reduces the levels of the apoptosis-related proteins BAX and cleaved caspase-3, and increases the level of anti-apoptotic protein BCL2. In addition, LRWXG can significantly reduce the levels of inflammatory-related factors such as COX2, PEG2, TNFα and IL1β, and inhibits the expression of MMPs, increasing the content of type II collagen. The results of this research strongly suggest that LRWXG exerts its anti-apoptotic activity via regulating the MAPK signaling pathways in vitro.

Antinociceptive effects of hyaluronic acid on monoiodoacetate-induced ankle osteoarthritis in rats

Purpose

Ankle osteoarthritis (OA) causes significant pain and debilitation; yet, its underlying mechanisms remain unclear. Clinically, hyaluronic acid (HA) is widely used to treat OA. The present study aimed to investigate the roles of HA in pain-related behavior, joint function, swelling, and pathological changes in cartilage in a rat model of monoiodoacetate (MIA)-induced ankle OA.

Materials and methods

Male Sprague Dawley rats were assigned to three experimental groups as follows: 1) MIA rats injected with 1 mg MIA in the right tibiotarsal joint for two consecutive days; 2) sham rats injected with saline instead of MIA; and 3) MIA-HA rats injected with HA in the tibiotarsal joint at 7, 14, and 21 days after MIA injection. Joint swelling, range of motion (ROM), and pain-related behavior were evaluated 1 day before and on the 7th, 14th, 21st, and 28th day after MIA or saline injection. Pathological changes in the ankle joint were assessed 28 days after MIA or saline injection.

Results

No significant difference in the degree of ankle swelling or ROM reduction was observed between MIA rats and MIA-HA rats. However, compared with those in MIA rats, mechanical and thermal hypersensitivity was significantly reduced and stride length significantly improved in MIA-HA rats. Histologic analysis revealed that cartilage degeneration was significantly suppressed in MIA-HA rats compared with that in MIA rats, reflecting the chondroprotective effects of HA.

Conclusion

HA improved pain-related behavior and stride length and suppressed MIA-induced cartilage degeneration. HA may thus inhibit OA progression and suppress peripheral and/or central sensitization.

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.

Anti-Inflammatory Effects of Intra-Articular Hyaluronic Acid: A Systematic Review

OBJECTIVE

Osteoarthritis (OA) is one of the leading causes of disability in the adult population. Common nonoperative treatment options include nonsteroidal anti-inflammatory drugs (NSAIDs), intra-articular corticosteroids, and intra-articular injections of hyaluronic acid (HA). HA is found intrinsically within the knee joint providing viscoelastic properties to the synovial fluid. HA therapy provides anti-inflammatory relief through a number of different pathways, including the suppression of pro-inflammatory cytokines and chemokines.

METHODS

We conducted a systematic review to summarize the published literature on the anti-inflammatory properties of hyaluronic acid in osteoarthritis. Included articles were categorized based on the primary anti-inflammatory responses described within them, by the immediate cell surface receptor protein assessed within the article, or based on the primary theme of the article. Key findings aimed to describe the macromolecules and inflammatory-mediated responses associated with the cell transmembrane receptors.

RESULTS

Forty-eight articles were included in this systematic review that focused on the general anti-inflammatory effects of HA in knee OA, mediated through receptor-binding relationships with cluster determinant 44 (CD44), toll-like receptor 2 (TLR-2) and 4 (TLR-4), intercellular adhesion molecule-1 (ICAM-1), and layilin (LAYN) cell surface receptors. Higher molecular weight HA (HMWHA) promotes anti-inflammatory responses, whereas short HA oligosaccharides produce inflammatory reactions.

CONCLUSIONS

Intra-articular HA is a viable therapeutic option in treating knee OA and suppressing inflammatory responses. HMWHA is effective in suppressing the key macromolecules that elicit the inflammatory response by short HA oligosaccharides.

Transplanting human umbilical cord mesenchymal stem cells and hyaluronate hydrogel repairs cartilage of osteoarthritis in the minipig model

OBJECTIVES

Osteoarthritis (OA) is a chronic disease of degenerative joints. Mesenchymal stem cells (MSCs) have been used for cartilage regeneration in OA. We investigated the therapeutic potential of human umbilical cord-derived MSCs (HUCMSCs) with hyaluronic acid (HA) hydrogel transplanted into a porcine OA preclinical model.

MATERIALS AND METHODS

The HUCMSCs were characterized with respect to morphology, surface markers, and differentiation capabilities. Quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) was used to examine gene expressions in a HUCMSC-HA coculture. Two healthy female minipigs weighing 30-40 kg and aged approximately 4 months were used in this large animal study. A full-thickness chondral injury was created in the trochlear groove of each of the pig's rear knees. After 3 weeks, a second osteochondral defect was created. Then, 1.5 mL of a HUCMSC (5 × 106 cells) and HA composite (4%) was transplanted into the chondral-injured area in the right knee of each pig. Using the same surgical process, an osteochondral defect (untreated) was created in the left knee as a control. The pigs were sacrificed 12 weeks after transplantation. Macroscopic and microscopic histologies, qRT-PCR, and immunostaining evaluated the degree of chondral degradation.

RESULTS

The HUCMSCs exhibited typical MSC characteristics, including spindle morphology, expression of surface markers (positive for CD29, CD4, CD73, CD90, and human leukocyte antigen [HLA]-ABC; negative for CD34, CD45, and HLA-DR), and multipotent differentiation (adipogenesis, osteogenesis, and chondrogenesis). More extensive proliferation of HUCMSCs was noted with 4% and 25% of HA than without HA. Expression of COL2A1 and aggrecan in the HUCMSC-derived chondrocytes was increased when HA was included. The treated knees showed significant gross and histological improvements in hyaline cartilage regeneration when compared to the control knees. The International Cartilage Repair Society histological score was higher for the treated knees than the control knees.

CONCLUSION

Our findings suggest that cartilage regeneration using a mixture of HUCMSCs and HA in a large animal model may be an effective treatment for OA, and this study is a stepping stone toward the future clinical trials.

Does Hyaluronan improve pain or function following Arthroscopic Subacromial decompression (ASD) surgery of Shoulder? Results of a level 1 RCT

BACKGROUND

Sodium hyaluronate (hyaluronan) can be used as a synovial fluid substitute following arthroscopic surgery. In this study, we examined its effect on pain and function following arthroscopic subacromial arthroscopic decompression (ASAD).

METHODOLOGY

A prospective, randomized, and single-blinded design was used (13/LO0427) to compare the effect of a single postprocedure subacromial instillation of 10 ml hyaluronan, against 10 ml saline control. All patients had interscalene block along with general anesthesia and followed standard postoperative rehabilitation protocol. A power calculation for a 6-point difference in Oxford Shoulder Score (OSS) indicated a minimum sample size of 44. Participants were assessed preoperatively, and at 12 weeks using the following outcome measures -Oxford Shoulder Score (OSS), visual analog score (VAS), European quality of life score (EUROQOL), and Disability of the arm, shoulder, and hand (DASH) scores.

RESULTS

46 patients were included for analysis. Both groups showed a mean improvement in OSS of 9 points (P = 0.0001), DASH (10 points, P < 0.05), and EUROQOL (0.13, P < 0.05). No significant difference was observed between groups in any of the recorded outcomes. Apart from one case of frozen shoulder in each group, no other complications were noted.

CONCLUSION

While both groups showed improved pain and function scores after ASAD, no significant difference was seen between groups receiving placebo or hyaluronan. The intervention is safe but, in this study, has not been shown to improve postoperative pain or function over ASAD alone. Level of evidence: I.

Image guided injection therapies in athletes-Do they work and what should we be using?

In the modern management of the injured elite athlete, the goals of guided injection therapies have extended beyond simple reduction of pain to enhancement of tissue healing and accelerated return to competition, faster than natural healing can allow. This article will review the injection therapies which are frequently used in elite sports injury management and describe other less commonly used injection therapies that are available to the treating clinician and athlete. The evidence base, where available, for each treatment option will be summarised.

High molecular weight hyaluronan protects cartilage from degradation by inhibiting aggrecanase expression

Hyaluronan (HA) is an extracellular matrix (ECM) component of articular cartilage and has been used to treat patients with osteoarthritis (OA). A disintegrin and metalloproteinases with thrombospondin motifs (ADAMTSs) play an important role in cartilage degradation in OA. We have previously reported that ADAMTS4 and ADAMTS9 were induced by cytokine stimulation. However, the effect of HA on the cytokine-inducible ADAMTS9 has never been investigated. Moreover, it is unclear whether HA protects cartilage by suppressing aggrecan degradation. Here, we examined the effects of HA on ADAMTS expression in vitro and on cartilage degradation in vivo. ADAMTS9 expression was higher than that of the other aggrecanases (ADAMTS4 and 5) in human chondrocytes, chondrocytic cells, and rat cartilage. ADAMTS4 and 9 mRNA levels were upregulated in cytokine-stimulated chondrocytes and chondrocytic cells. Pre-incubation with HA significantly inhibited ADAMTS9 mRNA expression in cytokine-stimulated cells. In a rat OA model, Adamts5 and 9 mRNA levels were transiently increased after surgery; intra-articular HA injections attenuated the induction of Adamts5 and 9 mRNA. HA also blocked aggrecan cleavage by aggrecanase in OA rats in a molecular size-dependent manner. These results demonstrate that HA attenuates induced aggrecanases expression in OA and thereby protects articular cartilage degradation by this enzyme. Our findings provide insight into the molecular basis for the beneficial effects of HA in OA. © 2018 The Authors. Journal of Orthopaedic Research® Published by Wiley Periodicals, Inc. on behalf of Orthopaedic Research Society. J Orthop Res 36:3247-3255, 2018.

Worsen depression after viscosupplementation treatment for geriatric people with knee osteoarthritis?

Background/objective: Knee osteoarthritis (OA) in older people may result in psychological impairment, including anxiety and depression. This study investigates the effect of intraarticular hyaluronic acid injection (IAHA) on geriatric patients with OA. Method: A total of 102 geriatric patients with knee OA undergoing IAHA were prospectively enrolled in this study. Geriatric Depression Scale (GDS), State-Trait Anxiety Inventory (STAI), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and the International Knee Documentation Committee Subjective Knee Evaluation Form (IKDC), and Visual Analogue Scale (VAS) for pain were recorded. All outcomes were measured at baseline before injection and during two, four, and six month follow-ups. Results: IAHA had a significant short-term effect, relieving pain at the two month follow-up, but the effect was weaker at the four month follow-up. Both IKDC and WOMAC scores were significantly improved at the two month follow-up. Viscosupplementation did not improve STAI. GDS exhibited significant deterioration at the four month follow-up. Conclusions: Although IAHA for the treatment of OA provided short-term efficiency, it had no effects on anxiety and increased depression of geriatric people. Health education should be provided with caution before viscosupplementation treatment to manage expectations of the efficacy of treatment for geriatric OA patients.

Efficacy of viscosupplementation with hyaluronic acid in temporomandibular disorders: A systematic review

OBJECTIVE

To perform a systematic review of the viscosupplementation effectiveness with hyaluronic acid (HA) in the articular Temporomandibular Dysfunctions (TMDs) clinical management.

METHOD

Electronic searches were performed in the following databases: MEDLINE (via PubMed), Scopus, Web of Science, Cochrane Library, EMBASE, LILACS, BBO, SIGLE (System for Information on Grey Literature in Europe), ClinicalTrials.gov, and the Brazilian Clinical Trials Registry (ReBec). Only randomized clinical trials that evaluated the intra-articular administration of HA or its derivatives in osteoarthritis and/or anterior displacement of the temporomandibular joint (TMJ) disc were included. The primary outcomes evaluated were patients' self-report of pain and/or discomfort in the TMJ. Each study was assessed for the risk of bias, using the Cochrane collaboration's risk of bias tool.

RESULTS

A total of 640 studies were obtained in the electronic search. After the application of the eligibility criteria, manual search, and duplicate removal, 21 articles were included. Five articles classified their volunteers with internal derangements of the TMJ, in 4 articles the treatment was directed to participants with disc displacement with reduction and the other articles evaluated HA therapy in osteoarthritis. The protocols presented heterogeneity, varying in the form of application, associated or not with arthrocentesis, number of applications, molecular weight, dose and concentration. Nine studies presented high risk of bias.

CONCLUSION

Due to the heterogeneity and methodological inconsistencies of the studies evaluated, it was not possible to establish the efficacy of HA in articular TMDs.

Intermediate Molecular Mass Hyaluronan and CD44 Receptor Interactions Enhance Neutrophil Phagocytosis and IL-8 Production via p38- and ERK1/2-MAPK Signalling Pathways

CD44 is a common leukocyte adhesion molecule expressed on the surface of various cells. Hyaluronan (HA), the natural ligand of CD44, is a simple repeated disaccharide with variable molecular mass that is widely distributed on cell surfaces and the connective tissue matrix. The binding of small molecular mass HA (SMM-HA, MW < 80 kDa) to CD44 on immune-related cells elicits cell proliferation, differentiation, and cytokine production. However, the effects and molecular basis of intermediate molecular mass HA (IMM-HA, MW ≈ 500 kDa)-CD44 interactions on polymorphonuclear neutrophil (PMN) functions have not been elucidated. We hypothesised that IMM-HA would potentiate immune functions as well as SMM-HA. In the present study, we demonstrated IMM-HA and CD44 interactions enhanced normal PMN phagocytosis and IL-8 production compared to those with LPS or anti-CD45 treatment via F-actin cytoskeleton polymerization and subsequent ERK1/2- and p38-MAPK phosphorylation. Antibody-based inhibition of CD44 did not affect PMN function; however, F-actin aggregation was induced without MAPK phosphorylation. Enhanced PMN function via IMM-HA was determined to be CD44-dependent since this effect was abolished in DMSO-induced CD44(-) PMN-like cells obtained from HL-60 cells. In conclusion, we demonstrated that IMM-HA and CD44 interactions on PMNs potently elicit F-actin cytoskeleton polymerization and p38- and ERK1/2-MAPK phosphorylation to enhance PMN function.

Hyaluronic Acid-Based Optical Probe for the Diagnosis of Human Osteoarthritic Cartilage

Osteoarthritis is typically caused by cartilage injury, followed by localized inflammatory responses and tissue deterioration. Early treatment of osteoarthritis is often impossible due to the lack of diagnostic options. Recent studies have supported that different imaging probes can be used for arthritis detection in mice. However, none of these diagnostic tools have been tested on human articular cartilage. To fill this gap, an optical imaging probe was developed to target activated macrophages and the accumulation of imaging probes on tissue was used to assess the severity of human osteoarthritis. Methods: The probe was fabricated using hyaluronic acid (HA) particles conjugated with near-infrared dye and folic acid (FA). The ability of the FA-HA probes to detect activated macrophages and quantify cartilage injury was evaluated using a cell culture model in vitro and human osteoarthritic cartilage explants ex vivo. Results: Our cell study results supported that the FA-HA probes are cell compatible (up to 0.5mg/mL) and can detect activated macrophages in 30 minutes. Using human articular cartilage, we verified the existence of activated macrophages on osteoarthritic cartilage with highly up-regulated expression of folate receptors (~13 folds by comparison with healthy control). In addition, we found that FA-HA probes had higher binding amounts (~3 folds) to osteoarthritic tissue than healthy ones. Histological analyses confirmed that there was a strong linear relationship (R=0.933) between the fluorescent intensity of tissue-associated probe and the extent of folate receptors on osteoarthritic cartilage. Finally, the co-localization of the imaging probe, folate receptors and cartilage degeneration on the tissue sections indicated the extraordinary accuracy and efficiency of this osteoarthritis diagnostic probe. Conclusions: Our results support the probe as an effective diagnostic tool to detect the area and severity of osteoarthritic human articular cartilage.

Clinical therapy of hyaluronic acid combined with platelet-rich plasma for the treatment of knee osteoarthritis

Knee osteoarthritis is the most common degenerative disease of the joints caused by articular cartilage injury, degradation of the joint edge and subchondral bone hyperplasia. Various treatments are used to alleviate the symptoms of patients with knee osteoarthritis, including analgesics and intra-articular injections. Platelet-rich plasma (PRP) is an autologous and multifunctional platelet concentrate of the blood, which stimulates the cartilage healing process and improves the damage caused by articular disease. Hyaluronic acid (HA) is an effective treatment for patients with knee osteoarthritis. In the current study, the effectiveness of PRP and HA combination therapy administered via intra-articular injections for patients with knee osteoarthritis was analyzed. A total of 360 patients with knee osteoarthritis were randomized into four different treatment groups as follows: Double-blind treatment with PRP (2-14 ml); double-blind treatment with HA (0.1-0.3 mg); combination therapy of PRP and HA; and placebo groups. Following treatment, all patients were evaluated using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Common Toxicity Criteria. The most common treatment-emergent adverse events were hypertension and proteinuria. The current study demonstrated that PRP and HA treatment significantly improved arthralgia, and PRP treatment was determined to be significantly more effective than HA treatment using the WOMAC pain score (P<0.05). PRP and HA combination treatment significantly improved arthralgia, reduced humoral and cellular immune responses and promoted angiogenesis, which improved the patients' histological parameters compared with PRP or HA treatment alone. These results suggested that PRP and HA combination treatment may be a potential treatment option for patients with knee osteoarthritis in the future.

Pooled Platelet-Rich Plasma Lysate Therapy Increases Synoviocyte Proliferation and Hyaluronic Acid Production While Protecting Chondrocytes From Synoviocyte-Derived Inflammatory Mediators

Platelet-rich plasma (PRP) preparations are being used with moderate success to treat osteoarthritis (OA) in humans and in veterinary species. Such preparations are hindered, however, by being autologous in nature and subject to tremendous patient and processing variability. For this reason, there has been increasing interest in the use of platelet lysate preparations instead of traditional PRP. Platelet lysate preparations are acellular, thereby reducing concerns over immunogenicity, and contain high concentrations of growth factors and cytokines. In addition, platelet lysate preparations can be stored frozen for readily available use. The purpose of this study was to evaluate the effects of a pooled allogeneic platelet-rich plasma lysate (PRP-L) preparation on equine synoviocytes and chondrocytes challenged with inflammatory mediators in-vitro to mimic the OA joint environment. Our hypothesis was that PRP-L treatment of inflamed synoviocytes would protect chondrocytes challenged with synoviocyte conditioned media by reducing synoviocyte pro-inflammatory cytokine production while increasing synoviocyte anti-inflammatory cytokine production. Synoviocytes were stimulated with either interleukin-1β (IL-1β) or lipopolysaccharide (LPS) for 24 h followed by no treatment or treatment with platelet-poor plasma lysate (PPP-L) or PRP-L for 48 h. Synoviocyte growth was evaluated at the end of the treatment period and synoviocyte conditioned media was assessed for concentrations of hyaluronic acid (HA), IL-1β, tumor necrosis factor alpha (TNF-α), and interleukin-6 (IL-6). Chondrocytes were then challenged for 48 h with synoviocyte conditioned media from each stimulation and treatment group and examined for gene expression of collagen types I (COL1A1), II (COL2A1), and III (COL3A1), aggrecan (ACAN), lubricin (PRG4), and matrix metallopeptidase 3 (MMP-3) and 13 (MMP-13). Treatment of inflamed synoviocytes with PRP-L resulted in increased synoviocyte growth and increased synoviocyte HA and IL-6 production. Challenge of chondrocytes with conditioned media from PRP-L treated synoviocytes resulted in increased collagen type II and aggrecan gene expression as well as decreased MMP-13 gene expression. The results of this study support continued investigation into the use of pooled PRP-L for the treatment of osteoarthritis and warrant further in-vitro studies to discern the mechanisms of action of PRP-L.

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.