251
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Filardo G, Kon E, Buda R, Timoncini A, Di Martino A, Cenacchi A, Fornasari PM, Giannini S, Marcacci M. Platelet-rich plasma intra-articular knee injections for the treatment of degenerative cartilage lesions and osteoarthritis. Knee Surg Sports Traumatol Arthrosc 2011; 19:528-35. [PMID: 20740273 DOI: 10.1007/s00167-010-1238-6] [Citation(s) in RCA: 251] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Accepted: 07/27/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE Platelet-rich plasma (PRP) therapy is a simple, low-cost and minimally invasive method that provides a natural concentrate of autologous blood growth factors (GFs) that can be used to enhance tissue regeneration. In a previous analysis of a 12-month follow-up study, promising results were obtained when treating patients affected by knee degeneration with PRP intra-articular injections. The main purpose of this study was to investigate the persistence of the beneficial effects observed. METHODS Of the 91 patients evaluated in the previous 12-month follow-up study, 90 were available for the 2-year follow-up (24 patients presented a bilateral lesion, in a total of 114 knees treated). All of the patients presented a chronic knee degenerative condition and were treated with three intra-articular PRP injections. IKDC and EQ-VAS scores were used for clinical evaluation. Complications, adverse events and patient satisfaction were also recorded. RESULTS All of the evaluated parameters worsened at the 24-month follow-up: these parameters were at significantly lower levels with respect to the 12-month evaluation (the IKDC objective evaluation fell from 67 to 59% of normal and nearly normal knees; the IKDC subjective score fell from 60 to 51), even if they remained higher than the basal level. Further analysis showed better results in younger patients (P = 0.0001) and lower degrees of cartilage degeneration (P < 0.0005). The median duration of the clinical improvement was 9 months. CONCLUSIONS These findings indicate that treatment with PRP injections can reduce pain and improve knee function and quality of life with short-term efficacy. Further studies are needed to confirm these results and understand the mechanism of action, and to find other application modalities, with different platelet and GF concentrations and injection timing, which provide better and more durable results.
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Affiliation(s)
- Giuseppe Filardo
- Biomechanics Laboratory-III Clinic, Rizzoli Orthopaedic Institute, Via Di Barbiano 1/10, 40136, Bologna, Italy.
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252
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CT-guided sternoclavicular joint injections: description of the procedure, reliability of imaging diagnosis, and short-term patient responses. AJR Am J Roentgenol 2011; 195:W435-9. [PMID: 21098176 DOI: 10.2214/ajr.10.4501] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The purpose of this study was to evaluate pain relief 20 to 30 minutes after diagnostic or therapeutic injections into the sternoclavicular joint and to compare patient outcomes based on the CT diagnosis. MATERIALS AND METHODS Informed consent was obtained from each patient. Ethics approval was not required. Fifty patients who had CT-guided injections of corticosteroid and local anesthetic into their sternoclavicular joints were included in the study. Preinjection and 20- to 30-minute postinjection visual analog scale data were recorded and compared with the imaging findings agreed by consensus. Kappa statistics were calculated for the reliability of imaging diagnosis. The percentage of patients improving after joint injection was calculated, and the risk ratio comparing the response of patients with osteoarthritis to those without osteoarthritis was completed. The correlation between the severity of each patient's osteoarthritis and the pain response was calculated using Spearman's correlation coefficient. RESULTS Sixty-six percent of the patients reported clinically significant pain reduction at between 20 and 30 minutes after injection. The proportion of patients with osteoarthritis who had a clinically significant response was 67% compared with 64% for patients who did not have osteoarthritis. This difference was not statistically or clinically significant. There was no correlation between the severity of osteoarthritis and the amount of pain reduction (r = 0.03). The reliability of imaging diagnosis was substantial. CONCLUSION Two thirds of patients having sternoclavicular joint injections of corticosteroids and local anesthetics report clinically significant improvement regardless of the abnormalities detected on their CT images.
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253
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Iannitti T, Lodi D, Palmieri B. Intra-articular injections for the treatment of osteoarthritis: focus on the clinical use of hyaluronic acid. Drugs R D 2011; 11:13-27. [PMID: 21142290 PMCID: PMC3586124 DOI: 10.2165/11539760-000000000-00000] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Osteoarthritis (OA), also called degenerative joint disease, is the most frequently occurring chronic musculoskeletal disease, particularly affecting the aging population. The use of viscosupplementation, i.e. intra-articular (IA) hyaluronic acid (HA) drug therapy, to treat OA, is growing worldwide, due to important results obtained from several clinical trials, which reported IA HA-related improvements in functional activity and pain management. This review is an update of the IA use of this compound in the treatment of OA, with clinical evidence from the last few years being discussed and used to delineate new trends for the future.
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Affiliation(s)
- Tommaso Iannitti
- Department of Biological and Biomedical Sciences, Glasgow Caledonian University, Glasgow, UK.
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254
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Abstract
The management of osteoarthritis requires a careful combination of pharmacologic and nonpharmacologic therapies to effect improvements in pain and function. When choosing pharmacologic therapy, the potential toxicities must be considered relative to potential benefits. This review highlights commonly used medications and presents the evidence for their effectiveness as well as their toxicities. Acetaminophen and nonsteroidal antiinflammatory drugs are the mainstay of pharmacologic therapy, but there are numerous adjunctive or alternative medications that may provide some benefit to patients with osteoarthritis.
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255
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Farkas B, Kvell K, Czömpöly T, Illés T, Bárdos T. Increased chondrocyte death after steroid and local anesthetic combination. Clin Orthop Relat Res 2010; 468:3112-20. [PMID: 20700677 PMCID: PMC2947661 DOI: 10.1007/s11999-010-1443-0] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2009] [Accepted: 06/08/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hyaline articular cartilage has limited repair and regeneration capacity. Intraarticular administration of glucocorticoid and local anesthetic injections play an important role in the therapy of osteoarthritis. Glucocorticoids and anesthetics reportedly enhance apoptosis in chondrocytes, but effects of the combined use of glucocorticoids and local anesthetics are unknown. QUESTIONS/PURPOSES We asked whether glucocorticoid and local anesthetic agents combined had any synergistic effects on chondrocyte apoptosis. METHODS Cell viability and apoptosis/necrosis assessment of human articular chondrocytes were performed in vitro (chondrocyte cell cultures) and ex vivo (osteochondral specimens) using flow cytometry and TUNEL analysis, respectively. RESULTS Glucocorticoids and local anesthetics induce apoptosis in chondrocytes at various rates. When used in combination, the percentage of dead chondrocytes was increased in in vitro chondrocyte cell cultures and osteochondral ex vivo specimens. CONCLUSIONS We observed a time-dependent decrease in chondrocyte viability after concurrent steroid and local anesthetic exposure. CLINICAL RELEVANCE The combination of glucocorticoids and local anesthetics has an adverse effect on articular chondrocytes, and it raises a question regarding whether concomitant administration should be used in treating osteoarthritis.
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Affiliation(s)
- Boglárka Farkas
- Department of Orthopaedics, University of Pécs, Ifjúság u. 13, 7624 Pécs, Hungary ,Department of Anatomy, University of Pécs, Pécs, Hungary
| | - Krisztián Kvell
- Department of Immunology and Biotechnology, University of Pécs, Pécs, Hungary
| | - Tamás Czömpöly
- Department of Immunology and Biotechnology, University of Pécs, Pécs, Hungary
| | - Tamás Illés
- Department of Orthopaedics, University of Pécs, Ifjúság u. 13, 7624 Pécs, Hungary
| | - Tamás Bárdos
- Department of Orthopaedics, University of Pécs, Ifjúság u. 13, 7624 Pécs, Hungary
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256
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Edwards SHR. Intra-articular drug delivery: the challenge to extend drug residence time within the joint. Vet J 2010; 190:15-21. [PMID: 20947396 DOI: 10.1016/j.tvjl.2010.09.019] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 09/20/2010] [Accepted: 09/22/2010] [Indexed: 02/02/2023]
Abstract
The rationale behind developing sustained release microsphere formulations of non-steroidal anti-inflammatory drugs (NSAIDs) administered via the intra-articular (IA) route is to minimise the systemic bioavailability and attendant side-effects associated with oral drug administration. Overall dose is reduced whilst therapeutic benefit within the joint is maintained. The potential benefits of IA therapy for osteoarthritis (OA) are not achieved using currently available medications and delivery vehicles due to the rapid clearance of therapeutic substances from the synovial space. There is a need for sustained release delivery systems if the potential of IA drug administration is to be realised. Rationally designed microspheres taken up by synovial macrophages offer a strategy to sustain drug delivery within the joint, and to deliver NSAIDs directly to pivotal inflammatory cells. The efficacy of microsphere candidates may be evaluated in large animal models of OA. The principles of IA microsphere drug delivery may also be applicable to other classes of drugs.
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Affiliation(s)
- Scott H R Edwards
- School of Animal and Veterinary Sciences, Charles Sturt University, Wagga Wagga, New South Wales, Australia.
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257
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Boon AJ, Smith J, Dahm DL, Sorenson EJ, Larson DR, Fitz-Gibbon PD, Dykstra DD, Singh JA. Efficacy of intra-articular botulinum toxin type A in painful knee osteoarthritis: a pilot study. PM R 2010; 2:268-76. [PMID: 20430328 DOI: 10.1016/j.pmrj.2010.02.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2009] [Revised: 02/17/2010] [Accepted: 02/23/2010] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To evaluate the efficacy and safety of botulinum toxin type A (BoNT-A) injected intra-articularly in 60 subjects with moderate pain and functional impairment secondary to knee osteoarthritis. The study investigators hypothesized that intra-articular BoNT-A would result in statistically significant improvements in pain and function at 8 weeks. DESIGN Double-blind, randomized, single tertiary care academic medical center trial with 6-month follow-up. PATIENTS Sixty patients aged 40 years or older with painful osteoarthritis of the knee who had failed physical therapy, medications, and/or injection therapy presenting to the musculoskeletal or orthopedic outpatient clinics at a large tertiary care medical institution. All 60 patients completed 8-week follow-up, but only 32 patients completed the 26-week follow-up. METHODS Subjects were randomized to receive a single injection of corticosteroid, low-dose BoNT-A (100 units), or high-dose BoNT-A (200 units). Outcome measures were compared at baseline, 4, 8, 12, and 26 weeks after injection. MAIN OUTCOME MEASUREMENTS The primary outcome measure was pain visual analog scale (VAS) at 8 weeks. Secondary outcome measures included Western Ontario McMaster Arthritis Index, Short Form-36 scores, patient global assessment, 40-meter timed walk, and adverse effects. RESULTS The primary end point was pain VAS score at 8 weeks, which decreased within each group but only reached statistical significance in the low-dose BoNT-A group. In the intra-articular corticosteroid group, VAS decreased from 6.4 +/- 1.8 to 5.4 +/- 2.3 (P = .15); for low-dose BoNT-A, from 6.6. +/- 1.9 to 4.5 +/- 2.2 (P = .01); and for high-dose BoNT-A, from 6.6 +/- 1.4 to 5.9 +/- 2.4 (P = .15). All groups showed statistically significant improvements in Western Ontario McMaster Arthritis Index scores (pain, stiffness, function) at 8 weeks. No serious adverse events were noted in any group. CONCLUSIONS This pilot study supports a possible role for BoNT-A as a treatment option for symptomatic knee osteoarthritis; however, larger double-blind randomized studies are needed to determine whether BoNT-A is more effective than placebo in this patient population.
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Affiliation(s)
- Andrea J Boon
- Department of Physical Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA.
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258
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Injections for trapeziometacarpal osteoarthrosis. J Hand Surg Am 2010; 35:1007-9. [PMID: 20513580 DOI: 10.1016/j.jhsa.2010.03.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2010] [Revised: 03/26/2010] [Accepted: 03/26/2010] [Indexed: 02/02/2023]
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259
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Abstract
Musculoskeletal system complaints are one of the most common reasons that patients seek medical care. A significant number of these patients use complementary and alternative medicine. This article discusses the most common musculoskeletal problems for which patients present to a physician's office. These include osteoarthritis, rheumatoid arthritis, low back pain, neck pain, and myofascial pain syndrome.
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Affiliation(s)
- Kim Edward LeBlanc
- Department of Family Medicine, Louisiana State University Health Sciences Center School of Medicine, 1542 Tulane Avenue, Room 123, T1-8, New Orleans, LA 70112, USA.
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260
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Goldberg VM, Goldberg L. Intra-articular hyaluronans: the treatment of knee pain in osteoarthritis. J Pain Res 2010; 3:51-6. [PMID: 21197309 PMCID: PMC3004653 DOI: 10.2147/jpr.s4733] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Indexed: 11/23/2022] Open
Abstract
The etiology of pain in osteoarthritis is multifactoral, and includes mechanical and inflammatory processes. Intra-articular injections of hyaluronans (HAs) are indicated when non-pharmacological and simple analgesics have failed to relieve symptoms. The HAs appear to reduce pain by restoring both mechanical and biomechanical homeostasis in the joint. There are five FDA-approved injectable preparations of HAs: Hyalgan®, Synvisc®, Supartz®, Orthovisc® and Euflexxa®. They all appear to relieve pain from 4 to 14 weeks after injection and may have disease-modification properties. Although several randomized controlled trials have established the efficacy of this treatment modality, additional high quality randomized control studies with appropriate comparison are still required to clearly define the role of intra-articular HA injections in the treatment of osteoarthritis.
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Affiliation(s)
- Victor M Goldberg
- Department of Orthopaedics, Case Medical Center, Cleveland, Ohio, USA
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261
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Zhang W, Nuki G, Moskowitz RW, Abramson S, Altman RD, Arden NK, Bierma-Zeinstra S, Brandt KD, Croft P, Doherty M, Dougados M, Hochberg M, Hunter DJ, Kwoh K, Lohmander LS, Tugwell P. OARSI recommendations for the management of hip and knee osteoarthritis: part III: Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage 2010; 18:476-99. [PMID: 20170770 DOI: 10.1016/j.joca.2010.01.013] [Citation(s) in RCA: 1056] [Impact Index Per Article: 75.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 01/26/2010] [Accepted: 01/26/2010] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To update evidence for available therapies in the treatment of hip and knee osteoarthritis (OA) and to examine whether research evidence has changed from 31 January 2006 to 31 January 2009. METHODS A systematic literature search was undertaken using MEDLINE, EMBASE, CINAHL, AMED, Science Citation Index and the Cochrane Library. The quality of studies was assessed. Effect sizes (ESs) and numbers needed to treat were calculated for efficacy. Relative risks, hazard ratios (HRs) or odds ratios were estimated for side effects. Publication bias and heterogeneity were examined. Sensitivity analysis was undertaken to compare the evidence pooled in different years and different qualities. Cumulative meta-analysis was used to examine the stability of evidence. RESULTS Sixty-four systematic reviews, 266 randomised controlled trials (RCTs) and 21 new economic evaluations (EEs) were published between 2006 and 2009. Of 51 treatment modalities, new data on efficacy have been published for more than half (26/39, 67%) of those for which research evidence was available in 2006. Among non-pharmacological therapies, ES for pain relief was unchanged for self-management, education, exercise and acupuncture. However, with new evidence the ES for pain relief for weight reduction reached statistical significance, increasing from 0.13 [95% confidence interval (CI) -0.12, 0.36] in 2006 to 0.20 (95% CI 0.00, 0.39) in 2009. By contrast, the ES for electromagnetic therapy which was large in 2006 (ES=0.77, 95% CI 0.36, 1.17) was no longer significant (ES=0.16, 95% CI -0.08, 0.39). Among pharmacological therapies, the cumulative evidence for the benefits and harms of oral and topical non-steroidal anti-inflammatory drugs, diacerhein and intra-articular (IA) corticosteroid was not greatly changed. The ES for pain relief with acetaminophen diminished numerically, but not significantly, from 0.21 (0.02, 0.41) to 0.14 (0.05, 0.22) and was no longer significant when analysis was restricted to high quality trials (ES=0.10, 95% CI -0.0, 0.23). New evidence for increased risks of hospitalisation due to perforation, peptic ulceration and bleeding with acetaminophen >3g/day have been published (HR=1.20, 95% CI 1.03, 1.40). ES for pain relief from IA hyaluronic acid, glucosamine sulphate, chondroitin sulphate and avocado soybean unsponifiables also diminished and there was greater heterogeneity of outcomes and more evidence of publication bias. Among surgical treatments further negative RCTs of lavage/debridement were published and the pooled results demonstrated that benefits from this modality of therapy were no greater than those obtained from placebo. CONCLUSION Publication of a large amount of new research evidence has resulted in changes in the calculated risk-benefit ratio for some treatments for OA. Regular updating of research evidence can help to guide best clinical practice.
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Affiliation(s)
- W Zhang
- Nottingham City Hospital, University of Nottingham, Nottingham, UK.
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262
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Singh JA. Botulinum toxin therapy for osteoarticular pain: an evidence-based review. Ther Adv Musculoskelet Dis 2010; 2:105-118. [PMID: 21304830 PMCID: PMC3034142 DOI: 10.1177/1759720x09357113] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Botulinum (BoNT) toxin has been used for its muscle-paralyzing action in conditions such as treatment of wrinkles, cervical dystonia and blephrospasm. There is preclinical and emerging clinical evidence of another mechanism of action of BoNT, namely, an antinociceptive action. In this review, we provide an evidence-based review of clinical studies of BoNT in osteoarticular conditions, such as osteoarthritis, tennis elbow, low back pain, and hand pain. Many randomized controlled trials (RCTs) found evidence of short-term efficacy of an injection of BoNT in relief of pain, and in some cases, improvement of function and quality of life. However, more clinical trials are needed to better define the clinical use of BoNT for treatment of refractory osteoarticular pain.
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Affiliation(s)
- Jasvinder A. Singh
- Minneapolis VA Medical
Center, Rheumatology [111R], One Veteran's Drive, Minneapolis, MN 55417,
USA
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263
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Michael JWP, Schlüter-Brust KU, Eysel P. The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. DEUTSCHES ARZTEBLATT INTERNATIONAL 2010; 107:152-62. [PMID: 20305774 PMCID: PMC2841860 DOI: 10.3238/arztebl.2010.0152] [Citation(s) in RCA: 211] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Accepted: 12/21/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Osteoarthritis is the most common joint disease of adults worldwide. Its incidence rises with age. Both intrinsic and extrinsic risk factors promote its development. In men aged 60 to 64, the right knee is more commonly affected; in women, the right and left knees are affected with nearly equal frequency. METHODS The PubMed, Medline, Embase and Cochrane Library databases were selectively searched for current studies (up to September 2009; case reports excluded) on the epidemiology, etiology, diagnosis, staging, and treatment of osteoarthritis of the knee. The search terms were "gonarthrosis," "prevention," "conservative treatment," "joint preservation," "physical activity," "arthroscopy," "osteotomy," "braces," "orthoses," and "osteoarthritis knee joint." RESULTS AND CONCLUSION Osteoarthritis is not yet a curable disease, and its pathogenesis remains unclear. The best treatment for osteoarthritis of the knee is prevention. The goal of therapy is to alleviate clinical manifestations. The therapeutic spectrum ranges from physiotherapy and orthopedic aids to pharmacotherapy and surgery.
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Affiliation(s)
- Joern W-P Michael
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universität Köln, Köln, Germany.
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264
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Abstract
Osteoarthritis (OA) is the most common form of arthritis and the leading cause of chronic disability among older people. The burden of the disease is expected to rise with an aging population and the increasing prevalence of obesity. Despite this, there is as yet no cure for OA. However, in recent years, a number of potential therapeutic advances have been made, in part due to improved understanding of the underlying pathophysiology. This review provides the current evidence for symptomatic management of OA including nonpharmacological, pharmacological and surgical approaches. The current state of evidence for disease-modifying therapy in OA is also reviewed.
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Affiliation(s)
- Ananthila Anandacoomarasamy
- Institute of Bone and Joint Research, Royal North Shore Hospital, University of Sydney, Australia
- Department of Rheumatology, Concord Hospital Sydney, Australia
| | - Lyn March
- Institute of Bone and Joint Research, Royal North Shore Hospital, University of Sydney Sydney, Australia
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265
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Williams NH, Amoakwa E, Burton K, Hendry M, Lewis R, Jones J, Bennett P, Neal RD, Andrew G, Wilkinson C. The Hip and Knee Book: developing an active management booklet for hip and knee osteoarthritis. Br J Gen Pract 2010; 60:64-82. [PMID: 20132695 PMCID: PMC2814291 DOI: 10.3399/bjgp10x483166] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2009] [Revised: 06/23/2009] [Accepted: 07/14/2009] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The pain and disability of hip and knee osteoarthritis can be improved by exercise, but the best method of encouraging this is not known. AIM To develop an evidence-based booklet for patients with hip or knee osteoarthritis, offering information and advice on maintaining activity. DESIGN OF STUDY Systematic review of reviews and guidelines, then focus groups. SETTING Four general practices in North East Wales. METHOD Evidence-based messages were developed from a systematic review, synthesised into patient-centred messages, and then incorporated into a narrative. A draft booklet was examined by three focus groups to improve the phrasing of its messages and discuss its usefulness. The final draft was examined in a fourth focus group. RESULTS Six evidence-based guidelines and 54 systematic reviews were identified. The focus groups found the draft booklet to be informative and easy to read. They reported a lack of clarity about the cause of osteoarthritis and were surprised that the pain could improve. The value of exercise and weight loss beliefs was accepted and reinforced, but there was a perceived contradiction about heavy physical work being causative, while moderate exercise was beneficial. There was a fear of dependency on analgesia and misinterpretation of the message on hyaluranon injections. The information on joint replacement empowered patients to discuss referral with their GP. The text was revised to accommodate these issues. CONCLUSION The booklet was readable, credible, and useful to end-users. A randomised controlled trial is planned, to test whether the booklet influences beliefs about osteoarthritis and exercise.
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Affiliation(s)
- Nefyn H Williams
- Department of Primary Care and Public Health, Cardiff University, School of Medicine, North West Wales Clinical School, Wrexham.
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266
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Chao J, Wu C, Sun B, Hose MK, Quan A, Hughes TH, Boyle D, Kalunian KC. Inflammatory characteristics on ultrasound predict poorer longterm response to intraarticular corticosteroid injections in knee osteoarthritis. J Rheumatol 2010; 37:650-5. [PMID: 20080918 DOI: 10.3899/jrheum.090575] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess whether inflammation on ultrasound is predictive of clinical response to intraarticular (IA) corticosteroid injections in patients with knee osteoarthritis (OA). METHODS Patients with symptomatic knee OA were randomized to receive either an IA injection of 40 mg triamcinolone acetonide in the treatment group or 1 cc 0.9% saline in the placebo group. Clinical response was assessed by changes in baseline Western Ontario and McMaster Universities (WOMAC) index scores and physician global assessment at 4 and 12 weeks. Ultrasounds were performed at each visit. Patients and assessors were blinded to treatment status. RESULTS Seventy-nine patients were enrolled into the study. Four-week data were available for 67 patients in the primary analysis comparing change in WOMAC pain score from baseline to 4 weeks. There was almost no change in the WOMAC pain subscale score from baseline to 4 weeks in the control group, but there was a significant improvement in WOMAC pain subscale score from 10.8 (SD +/- 3.2) at baseline to 8.75 (SD +/- 4.0) at 4 weeks in the treatment group (adjusted p = 0.001). Of the 34 patients in the treatment group; 16 (47%) had inflammatory disease and 18 (53%) had noninflammatory disease as determined by ultrasound. There was no difference in the change in WOMAC pain score between the inflammatory and noninflammatory patients in the treatment group at 4 weeks. There was a statistically significant greater improvement in pain subscale scores among noninflammatory patients than among inflammatory patients at 12 weeks. CONCLUSION Intraarticular corticosteroid injections are an effective short-term treatment for symptomatic knee OA compared to placebo. Patients with noninflammatory characteristics on ultrasound had a more prolonged benefit from IA corticosteroids compared to inflammatory patients.
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Affiliation(s)
- Jeannie Chao
- University of California San Diego School of Medicine, 9350 Campus Point Drive, La Jolla, CA 92037, USA.
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267
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The use of hyaluronan after arthroscopic surgery of the knee. Arthroscopy 2010; 26:105-11. [PMID: 20117634 DOI: 10.1016/j.arthro.2009.05.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 05/27/2009] [Accepted: 05/27/2009] [Indexed: 02/02/2023]
Abstract
Viscosupplementation is defined as the use of intra-articular hyaluronan therapy for symptomatic osteoarthritis (OA). Originally used for the treatment of ophthalmic disorders, viscosupplementation has been available for over a decade in the United States for the treatment of pain secondary to OA of the knee in patients who have not responded adequately to conservative oral pharmaceuticals including nonsteroidal anti-inflammatories and simple analgesics. The majority of patients with symptomatic knee OA will have evidence of meniscal and/or articular surface pathology, and most orthopaedic surgeons include arthroscopic surgery as a possible treatment modality for the symptomatic patient. Although arthroscopic meniscectomy is the most commonly performed orthopaedic procedure in the United States, in patients with concomitant OA, disease-related pain can persist after arthroscopic surgery. This article reviews some of the more recent evidence recommending the use of viscosupplementation for the management of symptomatic knee OA and pain relief after arthroscopy.
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268
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Peterson C, Hodler J. Evidence-based radiology (part 2): Is there sufficient research to support the use of therapeutic injections into the peripheral joints? Skeletal Radiol 2010; 39:11-8. [PMID: 19727709 DOI: 10.1007/s00256-009-0784-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2009] [Revised: 08/14/2009] [Accepted: 08/17/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This review article addresses the best evidence currently available for the effectiveness of injection therapy for musculoskeletal conditions involving the peripheral joints. The research is presented by anatomical region and areas of controversy and the need for additional research are identified. DISCUSSION Randomized controlled trials, meta-analyses and systematic reviews are lacking that address the effectiveness of therapeutic injections to the sternoclavicular, acromioclavicular, ankle and foot joints. No research studies of any kind have been reported for therapeutic injections of the sternoclavicular joint. With the exception of the knee, possibly the hip and patients with inflammatory arthropathies, research does not unequivocally support the use of therapeutic joint injections for most of the peripheral joints, including the shoulder. Additionally, controversy exists in some areas as to whether or not corticosteroids provide better outcomes compared to local anesthetic injections alone. CONCLUSION When viscosupplementation injections are compared to corticosteroids in patients with osteoarthritis of the knee, the evidence supports the use of viscosupplementation for more prolonged improvement in outcomes, with corticosteroids being good for short-term relief.
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Affiliation(s)
- Cynthia Peterson
- Radiology, Orthopaedic University Hospital of Balgrist, Forchstrasse 340, 8008, Zürich, Switzerland.
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Migliore A, Massafra U, Bizzi E, Vacca F, Martin-Martin S, Granata M, Alimonti A, Tormenta S. Comparative, double-blind, controlled study of intra-articular hyaluronic acid (Hyalubrix) injections versus local anesthetic in osteoarthritis of the hip. Arthritis Res Ther 2009; 11:R183. [PMID: 20003205 PMCID: PMC3003515 DOI: 10.1186/ar2875] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Revised: 09/11/2009] [Accepted: 12/09/2009] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Comparison of intra-articular bacterial-derived hyaluronic acid (Hyalubrix) (HA) with local analgesia (mepivacaine) for osteoarthritis (OA) of the hip. METHODS A pilot prospective, double-blind, 6-month randomized trial of 42 patients with hip OA. HA or mepivacaine was administered twice (once a month) under ultrasound guidance. Efficacy measurements included the Lequesne's algofunctional index, a visual analog scale for pain, concomitant use of analgesia, patient and physician global measurement, and safety. RESULTS Patients in the HA group exhibited a significantly reduced Lequesne's algofunctional index 3 and 6 months after treatment (P < 0.001) and significantly reduced visual analog scale pain scores 3 and 6 months after treatment (P < 0.05) compared with the local anesthetic group. All primary and secondary measures were significantly improved versus baseline, but other than the above were not different from each other at 3 or 6 months. Adverse effects were minimal. CONCLUSIONS This comparative study suggests a beneficial effect and safety of intra-articular HA in the management of hip OA. TRIAL REGISTRATION NUMBER ISRCTN39397064.
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Affiliation(s)
- Alberto Migliore
- Operative Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, via Cassia 600, 00189 Rome, Italy
| | - Umberto Massafra
- Operative Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, via Cassia 600, 00189 Rome, Italy
| | - Emanuele Bizzi
- Operative Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, via Cassia 600, 00189 Rome, Italy
| | - Francesca Vacca
- Operative Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, via Cassia 600, 00189 Rome, Italy
| | - Severino Martin-Martin
- Department of Internal Medicine, Regina Apostolorum Hospital, via San Francesco 50, 00041 Albano Laziale, Rome, Italy
| | - Mauro Granata
- Operative Unit of Rheumatology, San Filippo Neri Hospital, via Giovanni Martinotti 20, 00135 Rome, Italy
| | - Andrea Alimonti
- Operative Unit of Rheumatology, San Pietro Fatebenefratelli Hospital, via Cassia 600, 00189 Rome, Italy
| | - Sandro Tormenta
- Department of Radiology, San Pietro Fatebenefratelli Hospital, via Cassia 600, 00189 Rome, Italy
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270
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Panusa A, Orioli M, Aldini G, Carini M. A rapid and sensitive LC-ESI-MS/MS method for detection and quantitation of methylprednisolone and methylprednisolone acetate in rat plasma after intra-articular administration. J Pharm Biomed Anal 2009; 51:691-7. [PMID: 19875262 DOI: 10.1016/j.jpba.2009.09.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2009] [Revised: 09/18/2009] [Accepted: 09/24/2009] [Indexed: 10/20/2022]
Abstract
A rapid, sensitive and specific liquid chromatography-electrospray-tandem mass spectrometric (LC-ESI-MS/MS) method for the simultaneous detection and quantitation of methylprednisolone acetate (MPA) and methylprednisolone (MP) in rat plasma, using a triple-stage quadrupole, has been developed and validated. MP-D(2) was used as internal standard (IS) and acetonitrile was added to plasma samples for protein precipitation. After extraction with dichloromethane, the analytes were separated on a C-12 reversed-phase column by isocratic elution (6min at a flow rate 0.2mLmin(-1)) with water containing 0.01% formic acid (A) and acetonitrile (B) (50:50, v/v). Quantitation was performed in positive ion multiple reaction monitoring (MRM) mode by applying the following precursor-to-product ion transitions: MPA m/z 417-->135+161+253; MP m/z 375-->135+161+253; IS m/z 377-->135+161+253. The method, validated over the concentration range 6-600ngmL(-1), has been shown to meet the current requirements of bioananalytical validation, providing satisfactory results in terms of linearity, recovery, intra-day and inter-day precision and accuracy. The lower limit of quantitation (LLOQ) was 6ngmL(-1) for both the analytes (0.080 and 0.072pmol injected for MP and MPA, respectively). The method was successfully applied to monitor the plasma levels of MPA and MP following intra-articular (IA) injections of a low MPA (Depo-Medrol((R))) dose in rats.
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Affiliation(s)
- Alessia Panusa
- Dipartimento di Scienze Farmaceutiche P. Pratesi, Universita' degli Studi di Milano, 20133 Milan, Italy
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271
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Mandl LA, Hotchkiss RN, Adler RS, Lyman S, Daluiski A, Wolfe SW, Katz JN. Injectable hyaluronan for the treatment of carpometacarpal osteoarthritis: open label pilot trial. Curr Med Res Opin 2009; 25:2103-8. [PMID: 19601706 PMCID: PMC2761209 DOI: 10.1185/03007990903084016] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Carpometacarpal osteoarthritis (CMC OA) is highly prevalent in older adults, and is often unresponsive to medical treatment. Intra-articular Hylan G-F 20 has been shown to improve pain and function in patients with knee OA; however, its effectiveness in CMC OA is less clear. METHODS 32 patients with CMC OA were injected with Hylan G-F 20, once weekly for three consecutive weeks. Patients were assessed 4, 12, 20 and 26 weeks after the first injection. A last-value carried forward analysis was performed. RESULTS Average age was 64 years, (range 46-79), 69% were female and 97% Caucasian. Fifty-three percent had at least one previous corticosteroid injection in the affected CMC joint. At 26 weeks, mean visual analogue scale (VAS) for pain had improved significantly (15.2 mm; p-value = 0.006). Disabilities of the arm, shoulder and hand questionnaire (DASH) scores also improved significantly (12.6; p-value < 0.001). A DASH change of 10-14 is considered clinically meaningful. Neither key strength nor opposition grip strength improved. VAS scores for pain at 26 weeks showed good correlation with patient satisfaction (Spearman r = 0.52, p-value < 0.01). Adverse events potentially related to the injections included three episodes of post-injection pain and swelling, and one case of crystal proven pseudogout. CONCLUSION Intra-articular Hylan G-F 20 injections reduced pain and improved function in patients with CMC OA at 26 weeks in this small open label study. Limitations of this study include its small, open label design. Larger randomized controlled trials are needed to confirm these results, and to determine predictors of response to treatment. CLINICAL TRIAL REGISTRATION This study was approved by the Institutional Review Board at the Hospital for Special Surgery, New York, NY, USA and registered at (www.ClinicalTrials.Gov)# NCT00198029.
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Affiliation(s)
- Lisa A Mandl
- Hospital for Special Surgery, New York, NY 10021, USA.
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272
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Abstract
Patients commonly present to primary care physicians with musculoskeletal symptoms. Clinicians certified in internal medicine must be knowledgeable about the diagnosis and management of musculoskeletal diseases, yet they often receive inadequate postgraduate training on this topic. The musculoskeletal problems most frequently encountered in our busy injection practice involve, in decreasing order, the knees, trochanteric bursae, and glenohumeral joints. This article reviews the clinical presentations of these problems. It also discusses musculoskeletal injections for these problems in terms of medications, indications, injection technique, and supporting evidence from the literature. Experience with joint injection and the pharmacological principles described in this article should allow primary care physicians to become comfortable and proficient with musculoskeletal injections.
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Affiliation(s)
| | | | | | - Thomas J. Beckman
- Individual reprints of this article are not available. Address correspondence to Thomas J. Beckman, MD, Division of General Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ().
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273
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Richmond J, Hunter D, Irrgang J, Jones MH, Levy B, Marx R, Snyder-Mackler L, Watters WC, Haralson RH, Turkelson CM, Wies JL, Boyer KM, Anderson S, St Andre J, Sluka P, McGowan R. Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg 2009; 17:591-600. [PMID: 19726743 PMCID: PMC3170838 DOI: 10.5435/00124635-200909000-00006] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The clinical practice guideline was explicitly developed to include only treatments less invasive than knee replacement (ie, arthroplasty). Patients with symptomatic osteoarthritis of the knee are to be encouraged to participate in self-management educational programs and to engage in self-care, as well as to lose weight and engage in exercise and quadriceps strengthening. The guideline recommends taping for short-term relief of pain as well as analgesics and intra-articular corticosteroids, but not glucosamine and/or chondroitin. Patients need not undergo needle lavage or arthroscopy with débridement or lavage. Patients may consider partial meniscectomy or loose body removal or realignment osteotomy, as conditions warrant. Use of a free-floating interpositional device should not be considered for symptomatic unicompartmental osteoarthritis of the knee. Lateral heel wedges should not be prescribed for patients with symptomatic medial compartmental osteoarthritis of the knee. The work group was unable either to recommend or not recommend the use of braces with either valgus- or varus-directing forces for patients with medial unicompartmental osteoarthritis; the use of acupuncture or of hyaluronic acid; or osteotomy of the tibial tubercle for isolated symptomatic patellofemoral osteoarthritis.
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Affiliation(s)
- John Richmond
- Department of Orthopaedic Surgery, New England Baptist Hospital, Boston, MA, USA
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274
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Khan M, Waseem M, Raza A, Derham D. Quantitative Assessment of Improvement with Single Corticosteroid Injection in Thumb CMC Joint Osteoarthritis? Open Orthop J 2009; 3:48-51. [PMID: 19572034 PMCID: PMC2703835 DOI: 10.2174/1874325000903010048] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Revised: 05/13/2009] [Accepted: 05/20/2009] [Indexed: 11/22/2022] Open
Abstract
We present a unique prospective study to estimate the median sustained stage-related improvement in pain and hand function in patients with trapezio-metacarpal joint osteoarthritis after administration of a single corticosteroid injection. Response to the corticosteroid injection was assessed using Disability of Arm Shoulder and Hand (DASH) and Visual Analogue Scale (VAS) pain scores. Self assessment scores revealed a reduction in pain and improvement in hand function. All patients reported a significant improvement in pain and hand function (p </= 0.05), regardless of the disease stage. Additionally, we observed a marked difference in the duration of improvement in hand function between early and late stages of the disease (p = 0.0046). In conclusion, it is possible to predict the period of symptomatic improvement at each of the four radiological stages of the disease. This would allow the treating clinician to judge the outcome of treatment with reasonable accuracy.
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Affiliation(s)
- Munir Khan
- Macclesfield General Hospital, Victoria Road, Macclesfield SK10 3BL, UK
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275
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Altman RD, Rosen JE, Bloch DA, Hatoum HT, Korner P. A double-blind, randomized, saline-controlled study of the efficacy and safety of EUFLEXXA for treatment of painful osteoarthritis of the knee, with an open-label safety extension (the FLEXX trial). Semin Arthritis Rheum 2009; 39:1-9. [PMID: 19539353 DOI: 10.1016/j.semarthrit.2009.04.001] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2009] [Revised: 04/05/2009] [Accepted: 04/11/2009] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the FLEXX trial, the first well-controlled study assessing the safety and efficacy of Euflexxa (1% sodium hyaluronate; IA-BioHA) therapy for knee osteoarthritis (OA) at 26 weeks. METHODS This was a randomized, double-blind, multicenter, saline-controlled study. Subjects with chronic knee OA were randomized to 3 weekly intra-articular (IA) injections of either buffered saline (IA-SA) or IA-BioHA (20 mg/2 ml). The primary efficacy outcome was subject recorded difference in least-squares means between IA-BioHA and IA-SA in subjects' change from baseline to week 26 following a 50-foot walk test, measured via 100-mm visual analog scale (VAS). Secondary outcome measures included Osteoarthritis Research Society International responder index, Western Ontario McMaster University Osteoarthritis Index VA 3.1 subscales, patient global assessment, rescue medication, and health-related quality of life (HRQoL) by the SF-36. Safety was assessed by monitoring and reporting vital signs, physical examination of the target knee following injection, adverse events, and concomitant medications. RESULTS Five hundred eighty-eight subjects were randomized to either IA-BioHA (n = 293) or IA-SA (n = 295), with an 88% 26 week completion rate. No statistical differences were noted between the treatment groups at baseline. In the IA-BioHA group, mean VAS scores decreased by 25.7 mm, compared with 18.5 mm in the IA-SA group. This corresponded to a median reduction of 53% from baseline for IA-BioHA and a 38% reduction for IA-SA. The difference in least-squares means was -6.6 mm (P = 0.002). Secondary outcome measures were consistent with significant improvement in Osteoarthritis Research Society International responder index, HRQoL, and function. Both IA-SA and IA-BioHA injections were well tolerated, with a low incidence of adverse events that were equally distributed between groups. Injection-site reactions were reported by 1 (<1%) subject in the IA-SA group and 2 (1%) in the IA-BioHA group. CONCLUSIONS IA-BioHA therapy resulted in significant OA knee pain relief at 26 weeks compared with IA-SA. Subjects treated with IA-BioHA also experienced significant improvements in joint function, treatment satisfaction, and HRQoL.
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Affiliation(s)
- Roy D Altman
- Division of Rheumatology and Immunology, University of California Los Angeles, Los Angeles, CA 90095, USA.
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276
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277
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Gomis A, Miralles A, Schmidt RF, Belmonte C. Intra-articular injections of hyaluronan solutions of different elastoviscosity reduce nociceptive nerve activity in a model of osteoarthritic knee joint of the guinea pig. Osteoarthritis Cartilage 2009; 17:798-804. [PMID: 19103502 DOI: 10.1016/j.joca.2008.11.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Accepted: 11/20/2008] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To study in guinea pigs knee joints the effects of intra-articular injection of HYADD 4-G (Fidia-Farmaceutici), a novel hyaluronan (HA)-derived elastoviscous material and of Hyalgan (Fidia-Farmaceutici), a HA product with very low viscoelasticity, on movement-evoked nociceptor impulse activity from normal and inflamed knee joints. DESIGN Nociceptor impulse activity was recorded from single Adelta and C fibers of the medial articular nerve either under control conditions or after induction of an experimental knee joint osteoarthritis (OA) by partial medial menisectomy and transection of the anterior cruciate ligament (PMM-TACL). The stimuli consisted of standardized innocuous and noxious inward and outward rotations of the tibia against the femur of 50s duration, repeated every 5min for 1.5h. RESULTS The number of movement-evoked impulses was significantly augmented 1 day and 1 week after PMM-TACL compared with intact knee joint. The enhanced impulse response to joint movements 1 week following surgery was attenuated by repeated intra-articular injection of HYADD 4-G and even more prominently by Hyalgan. CONCLUSIONS HA products have a reducing action on joint nociceptor discharges that appears to depend predominantly on their role as an elastoviscous filter associated with their rheological properties, but also on a chemical effect on sensitized nociceptive terminals of inflamed joint tissues, possibly linked to the HA concentration.
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Affiliation(s)
- A Gomis
- Instituto de Neurociencias de Alicante, Universidad Miguel Hernández-CSIC, San Juan de Alicante 03550, Spain.
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278
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Rasheed Z, Anbazhagan AN, Akhtar N, Ramamurthy S, Voss FR, Haqqi TM. Green tea polyphenol epigallocatechin-3-gallate inhibits advanced glycation end product-induced expression of tumor necrosis factor-alpha and matrix metalloproteinase-13 in human chondrocytes. Arthritis Res Ther 2009; 11:R71. [PMID: 19445683 PMCID: PMC2714117 DOI: 10.1186/ar2700] [Citation(s) in RCA: 88] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 04/29/2009] [Accepted: 05/15/2009] [Indexed: 11/15/2022] Open
Abstract
Introduction The major risk factor for osteoarthritis (OA) is aging, but the mechanisms underlying this risk are only partly understood. Age-related accumulation of advanced glycation end products (AGEs) can activate chondrocytes and induce the production of proinflammatory cytokines and matrix metalloproteinases (MMPs). In the present study, we examined the effect of epigallocatechin-3-gallate (EGCG) on AGE-modified-BSA (AGE-BSA)-induced activation and production of TNFα and MMP-13 in human OA chondrocytes. Methods Human chondrocytes were derived from OA cartilage by enzymatic digestion and stimulated with in vitro-generated AGE-BSA. Gene expression of TNFα and MMP-13 was measured by quantitative RT-PCR. TNFα protein in culture medium was determined using cytokine-specific ELISA. Western immunoblotting was used to analyze the MMP-13 production in the culture medium, phosphorylation of mitogen-activated protein kinases (MAPKs), and the activation of NF-κB. DNA binding activity of NF-κB p65 was determined using a highly sensitive and specific ELISA. IκB kinase (IKK) activity was determined using an in vitro kinase activity assay. MMP-13 activity in the culture medium was assayed by gelatin zymography. Results EGCG significantly decreased AGE-stimulated gene expression and production of TNFα and MMP-13 in human chondrocytes. The inhibitory effect of EGCG on the AGE-BSA-induced expression of TNFα and MMP-13 was mediated at least in part via suppression of p38-MAPK and JNK activation. In addition, EGCG inhibited the phosphorylating activity of IKKβ kinase in an in vitro activity assay and EGCG inhibited the AGE-mediated activation and DNA binding activity of NF-κB by suppressing the degradation of its inhibitory protein IκBα in the cytoplasm. Conclusions These novel pharmacological actions of EGCG on AGE-BSA-stimulated human OA chondrocytes provide new suggestions that EGCG or EGCG-derived compounds may inhibit cartilage degradation by suppressing AGE-mediated activation and the catabolic response in human chondrocytes.
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Affiliation(s)
- Zafar Rasheed
- Department of Pathology, School of Medicine, University of South Carolina, Columbia, SC 29209, USA.
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279
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Liberopoulos G, Trikalinos NA, Ioannidis JPA. The elderly were under-represented in osteoarthritis clinical trials. J Clin Epidemiol 2009; 62:1218-23. [PMID: 19356899 DOI: 10.1016/j.jclinepi.2008.12.009] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2008] [Revised: 12/03/2008] [Accepted: 12/16/2008] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Osteoarthritis is the most common disease affecting joints in the elderly. We aimed to evaluate if elderly patients are properly represented in clinical trials of diverse osteoarthritis interventions. STUDY DESIGN AND SETTING Clinical trials of osteoarthritis interventions were retrieved from Cochrane Library systematic reviews (2006, issue 2). We examined the age distribution of the trial participants and eligibility criteria. RESULTS We analyzed data from 219 eligible trials from 18 systematic reviews. The average mean age of the participants was 63 years. Only 13 trials (6.4%) had a mean age between 71 and 80 years and only one trial had a mean age exceeding 80 years. Among trials where the age range of participants was available or could be approximately inferred, we estimated that 66 (38%) trials had not included any patients over 80 years old. Only 23 trials specifically excluded patients over 70 based on reported eligibility criteria, but 168 trials excluded patients with various comorbidities and 142 trials excluded patients receiving other specific treatments. CONCLUSIONS Elderly patients are considerably under-represented in clinical trials of osteoarthritis. This causes an important deficit in the utility, relevance, and generalizability of trial results for this very common condition.
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Affiliation(s)
- George Liberopoulos
- Clinical and Molecular Epidemiology Unit, Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
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280
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Willick S, Akau CK, Harrast MA, Storm SA, Finnoff JT. Sports and Performing Arts Medicine: 5. Special Populations. PM R 2009; 1:S78-82. [DOI: 10.1016/j.pmrj.2009.01.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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281
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[Appropriate use of non-steroidal anti-inflammatory drugs in rheumatology: guidelines from the Spanish Society of Rheumatology and the Mexican College of Rheumatology]. ACTA ACUST UNITED AC 2009; 5:3-12. [PMID: 21794567 DOI: 10.1016/s1699-258x(09)70197-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2008] [Accepted: 07/04/2008] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To develop guidelines for the appropriate use of NSAIDs in rheumatology. METHODS We used a methodology modified from the one developed by RAND/UCLA. Two groups of panellists were selected, one by the CMR and another by the SER. Recommendations were proposed from nominal groups and the agreement to them was tested among rheumatologists from both societies by a tworound Delphi survey. The analysis of the second Delphi round supported the generation of the final set of recommendations and the assignment of a level of agreement to each of them. Systematic reviews of five recommendations in which the agreement was low or was divided were also carried out. RESULTS Here we present recommendations for the safe use of NSAIDs in rheumatic diseases, based on the best available evidence, expert opinion, the agreement among rheumatologists, and literature review. The trend is to reduce the frequency, duration and dose of NSAIDs in favour of non-pharmacological measures, analgesic drugs or disease modifying drugs. In addition, the recommendations help to identify profiles for increased toxicity, with an emphasis on gastrointestinal and cardiovascular risks. The recommendations deal with the course of action and monitoring in different risk groups and in patients using antiplatelet or anticoagulant drugs. The overall level of agreement is high. CONCLUSIONS The NSAIDs are safe and effective drugs for the treatment of rheumatic diseases. However, it is necessary to individualize its use according to their risk profile.
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282
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Ackerman IN, Dieppe PA, March LM, Roos EM, Nilsdotter AK, Brown GC, Sloan KE, Osborne RH. Variation in age and physical status prior to total knee and hip replacement surgery: A comparison of centers in Australia and Europe. ACTA ACUST UNITED AC 2009; 61:166-73. [DOI: 10.1002/art.24215] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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283
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Birchall D, Ismail AM, Peat G. Clinical outcomes from a physiotherapist-led intra-articular hyaluronic acid injection clinic. Musculoskeletal Care 2009; 6:135-49. [PMID: 18729065 DOI: 10.1002/msc.130] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To describe the clinical course of knee osteoarthritis following a single course of intra-articular hyaluronic acid (HA) injection clinic, and specifically to explore treatment withdrawal. DESIGN Prospective consecutive case series with follow-up, set in an innovative physiotherapist-led clinic, based in a hospital orthopaedic surgery department. PARTICIPANTS A total of 100 patients with knee osteoarthritis referred to the clinic received a single course of five injections of Hyalgan. Patients were followed up in clinic at five, 13, 26 and 52 weeks. The primary outcome measures were Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) Likert 3.0 pain (0-20) and physical function (0-68) scores. In addition, at 13 and 26 weeks, patients were reviewed independently by an orthopaedic surgeon, with the option of withdrawing for alternative management those patients who had not responded. RESULTS Ninety (90%) patients were successfully followed to study endpoint. Improvements were seen at five weeks and, to a lesser extent, at 13 weeks (mean reduction in WOMAC pain at 13 weeks = 1.3; 95% confidence interval [CI] 0.5, 2.0; mean reduction in WOMAC Physical Function at 13 weeks = 5.6; 95% CI 3.0, 8.1). Of 34 treatment withdrawals, most had returned to baseline levels by 13 weeks. The remaining 56 patients maintained improvements up to 52 weeks, although the pattern of outcome was highly variable between individuals. Withdrawals and non-responders had higher initial pain severity. CONCLUSIONS Physiotherapist-led intra-articular HA clinics are feasible. Clinical outcomes for individual patients are highly heterogeneous up to one year after injections. Patients with initially high levels of pain may be less likely to benefit.
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Affiliation(s)
- Dolina Birchall
- Department of Physiotherapy, Trafford General Hospital, Moorside Road, Manchester, England. [corrected]
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284
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Harvey WF, Hunter DJ. The role of analgesics and intra-articular injections in disease management. Med Clin North Am 2009; 93:201-11, xii. [PMID: 19059029 DOI: 10.1016/j.mcna.2008.07.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The most important goals of therapy in patients with osteoarthritis are pain management, improvement in function and disability, and, ultimately, disease modification. This review discusses the current pharmacologic regimen available to address these goals. Specific attention is paid to current trends and controversies related to pharmacologic management, including the use of oral, topical, and injectable agents.
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Affiliation(s)
- William F Harvey
- Division of Rheumatology, Tufts Medical Center, 800 Washington Street, Box 406, Boston, MA 02111, USA.
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285
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Abstract
There is an increasing incidence in osteoarthritis, particularly following the 5th life-decade. However, also young people may suffer from severe osteoarthritis, which is estimated to be the most common cause of disability in adults resulting in substantial economic burden. To this end, effective therapies are needed. Therapeutic options are very comprehensive, which are presented in this review as non-pharmacological, pharmacological and surgical treatment modalities. Treatment efficacy will be discussed with regard to alleviation of symptoms and potential prevention of disease progression according to the given evidence.
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Affiliation(s)
- P Härle
- Klinik und Poliklinik für Innere Medizin I, Universität Regensburg, Regensburg, Deutschland.
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286
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The Role of Analgesics and Intra-articular Injections in Disease Management. Rheum Dis Clin North Am 2008; 34:777-88. [DOI: 10.1016/j.rdc.2008.05.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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287
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van den Bekerom MPJ, Lamme B, Sermon A, Mulier M. What is the evidence for viscosupplementation in the treatment of patients with hip osteoarthritis? Systematic review of the literature. Arch Orthop Trauma Surg 2008; 128:815-23. [PMID: 17874246 DOI: 10.1007/s00402-007-0447-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2007] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Osteoarthritis (OA) is a disease of the synovial joints and is the most common cause of chronic pain in the elderly. One of the treatment modalities for OA of the hip is viscosupplementation (VS). Today there are several different formulations of viscosupplements produced by different manufactures of different molecular weights. The objective of this review is to asses the efficacy of VS treatment of hip OA osteoarthritis in the current literature. MATERIAL AND METHODS The following databases were searched: Medline (period 1966 to November 2006), Cochrane Database of Systematic Reviews (1988 to November 2006), Cochrane Clinical Trial Register (1988 to November 2006), Database of Abstracts on Reviews and Effectiveness, Current Controlled Trials, National Research Register and Embase (January 1988 to November 2006). The search terms [osteoarthritis, hip (joint), viscosupplementation, hyaluronic acid, hyaluronan, sodium hyaluronate and trade names] were applied to identify all studies relating to the use of VS therapy for OA of the hip joint. RESULTS Sixteen articles concerning the efficacy of a total of 509 patients undergoing VS treatment for hip OA were included. Twelve European studies, three Turkish studies and one American study with Levels of Evidence ranging from I to IV evaluated the following products: Hylan G-F 20, Hyalgan, Ostenil, Durolane, Fermatron and Orthovisc. Heterogeneity of included studies did not allow pooled analysis of data. DISCUSSION Despite the relatively low Level of Evidence of the included studies, VS performed under fluoroscopic or ultrasound guidance seems an effective treatment and may be an alternative treatment of hip OA. Intra-articular injection of (derivatives of) HA into the hip joint appears to be safe and well tolerated. However, VS cannot be recommended as standard therapy in hip OA for wider populations, and therefore the indications remain a highly individualised matter.
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288
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Scanzello CR, Moskowitz NK, Gibofsky A. The Post-NSAID Era: What to use now for the pharmacologic treatment of pain and inflammation in osteoarthritis. Curr Rheumatol Rep 2008; 10:49-56. [DOI: 10.1007/s11926-008-0009-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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289
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Numbers needed to treat calculated from responder rates give a better indication of efficacy in osteoarthritis trials than mean pain scores. Arthritis Res Ther 2008; 10:R39. [PMID: 18384679 PMCID: PMC2453757 DOI: 10.1186/ar2394] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 03/27/2008] [Accepted: 04/02/2008] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Osteoarthritis trials usually report average changes in visual analogue scale (VAS) pain, and examine the difference between treatment and placebo. We investigated whether dichotomous responder analysis provides a more informative interpretation of drug efficacy. METHODS Merck supplied the number of patients who, by 6 weeks, had achieved pain relief compared with a baseline of 0% or more, 10% or more, 20% or more, and so on at equal intervals up to 90% or more. These different levels of pain relief were used to distinguish different definitions of responders, for example at least 50% pain relief from baseline. Numbers and percentages of patients achieving each level were identified. Information was sought from a dose-response trial over 6 weeks in osteoarthritis using placebo and using etoricoxib at 5, 10, 30 and 60 mg daily. RESULTS With placebo, the proportions of patients achieving at least 20%, 50% and 70% pain relief over baseline at 6 weeks were 30%, 11% and 2%. With 60 mg etoricoxib the equivalent percentages were 74%, 49% and 29%. The numbers needed to treat for 30 mg and 60 mg etoricoxib to produce at least 50% pain relief at 6 weeks compared with placebo were 4.2 (95% confidence interval 3.8 to 8.6) and 2.6 (2.0 to 3.9), respectively. Levels of pain relief of 50% and above discriminated best between different doses of etoricoxib. CONCLUSION Responder analysis seemed to be more sensitive than examination of average changes in VAS pain scores. Validation would require calculations to be performed on a set of trials using individual patient data not available in publications.
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Abstract
The majority of patients with osteoarthritis present to orthopaedic surgeons seeking relief of pain and associated restoration of function. Although our understanding of the physiology of pain has improved greatly over the last 25 years there remain a number of unexplained pain-related observations in patients with osteoarthritis. The understanding of pain in osteoarthritis, its modulation and treatment is central to orthopaedic clinical practice and in this annotation we explore some of the current concepts applicable. We also introduce the concept of the ‘phantom joint’ as a cause for persistent pain after joint replacement.
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Affiliation(s)
- S. E. Gwilym
- Nuffield Department of Orthopaedic Surgery, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK
| | - T. C. B. Pollard
- Nuffield Department of Orthopaedic Surgery, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK
| | - A. J. Carr
- Nuffield Department of Orthopaedic Surgery, University of Oxford, Nuffield Orthopaedic Centre, Windmill Road, Headington, Oxford OX3 7LD, UK
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Kristensen KD, Stoustrup P, Küseler A, Pedersen TK, Nyengaard JR, Hauge EM, Herlin T. Quantitative histological changes of repeated antigen-induced arthritis in the temporomandibular joints of rabbits treated with intra-articular corticosteroid. J Oral Pathol Med 2008; 37:437-44. [PMID: 18266658 DOI: 10.1111/j.1600-0714.2007.00630.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND To compare the inflammatory changes of antigen-induced temporomandibular joint (TMJ) arthritis in rabbits by different histological methods and to evaluate the immunomodulatory effect of intra-articular corticosteroid injections histologically. METHODS 35 rabbits (10 weeks old) pre-sensibilized with ovalbumin were divided into three groups: a placebo group of five (saline), an arthritis group of 15 (ovalbumin) and a steroid-treated group of 15 (ovalbumin + corticosteroid). Additionally, a group of seven rabbits receiving no sensibilization with ovalbumin and no intra-articular injections served as controls. Histomorphometry of the inflammatory changes in the subsynovial connective tissue (SSCT) of the TMJ included: (i) semi-quantitative (S-Q) scoring of inflammation and synovial proliferation, (ii) thickness measurements and fractional surface and (iii) stereological quantitative assessment of volume and plasma cells in thick sections of the SSCT by an optical fractionator. RESULTS The histomorphometry showed synovial proliferation in both the arthritis and the steroid groups. The plasma cell count obtained by the optical fractionator was significantly reduced when treating the TMJ with corticosteroids. However, the thickness of the synovial lining and volume of the SSCT as well as S-Q scoring of inflammation showed no difference between the arthritis and the steroid-treated groups. The optical fractionator proved a superior tool compared to S-Q assessments. CONCLUSION Counting of plasma cells in the SSCT showed that corticosteroids reduced the inflammation, but did not eliminate it. Semiquantitative scoring of synovial proliferation and inflammation demonstrated low sensitivity regarding changes in immunomodulation in antigen-induced arthritis compared to stereological quantitative estimations using an optical fractionator.
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292
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OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008; 16:137-62. [PMID: 18279766 DOI: 10.1016/j.joca.2007.12.013] [Citation(s) in RCA: 1789] [Impact Index Per Article: 111.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 12/20/2007] [Indexed: 02/02/2023]
Abstract
PURPOSE To develop concise, patient-focussed, up to date, evidence-based, expert consensus recommendations for the management of hip and knee osteoarthritis (OA), which are adaptable and designed to assist physicians and allied health care professionals in general and specialist practise throughout the world. METHODS Sixteen experts from four medical disciplines (primary care, rheumatology, orthopaedics and evidence-based medicine), two continents and six countries (USA, UK, France, Netherlands, Sweden and Canada) formed the guidelines development team. A systematic review of existing guidelines for the management of hip and knee OA published between 1945 and January 2006 was undertaken using the validated appraisal of guidelines research and evaluation (AGREE) instrument. A core set of management modalities was generated based on the agreement between guidelines. Evidence before 2002 was based on a systematic review conducted by European League Against Rheumatism and evidence after 2002 was updated using MEDLINE, EMBASE, CINAHL, AMED, the Cochrane Library and HTA reports. The quality of evidence was evaluated, and where possible, effect size (ES), number needed to treat, relative risk or odds ratio and cost per quality-adjusted life years gained were estimated. Consensus recommendations were produced following a Delphi exercise and the strength of recommendation (SOR) for propositions relating to each modality was determined using a visual analogue scale. RESULTS Twenty-three treatment guidelines for the management of hip and knee OA were identified from the literature search, including six opinion-based, five evidence-based and 12 based on both expert opinion and research evidence. Twenty out of 51 treatment modalities addressed by these guidelines were universally recommended. ES for pain relief varied from treatment to treatment. Overall there was no statistically significant difference between non-pharmacological therapies [0.25, 95% confidence interval (CI) 0.16, 0.34] and pharmacological therapies (ES=0.39, 95% CI 0.31, 0.47). Following feedback from Osteoarthritis Research International members on the draft guidelines and six Delphi rounds consensus was reached on 25 carefully worded recommendations. Optimal management of patients with OA hip or knee requires a combination of non-pharmacological and pharmacological modalities of therapy. Recommendations cover the use of 12 non-pharmacological modalities: education and self-management, regular telephone contact, referral to a physical therapist, aerobic, muscle strengthening and water-based exercises, weight reduction, walking aids, knee braces, footwear and insoles, thermal modalities, transcutaneous electrical nerve stimulation and acupuncture. Eight recommendations cover pharmacological modalities of treatment including acetaminophen, cyclooxygenase-2 (COX-2) non-selective and selective oral non-steroidal anti-inflammatory drugs (NSAIDs), topical NSAIDs and capsaicin, intra-articular injections of corticosteroids and hyaluronates, glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects and the use of opioid analgesics for the treatment of refractory pain. There are recommendations covering five surgical modalities: total joint replacements, unicompartmental knee replacement, osteotomy and joint preserving surgical procedures; joint lavage and arthroscopic debridement in knee OA, and joint fusion as a salvage procedure when joint replacement had failed. Strengths of recommendation and 95% CIs are provided. CONCLUSION Twenty-five carefully worded recommendations have been generated based on a critical appraisal of existing guidelines, a systematic review of research evidence and the consensus opinions of an international, multidisciplinary group of experts. The recommendations may be adapted for use in different countries or regions according to the availability of treatment modalities and SOR for each modality of therapy. These recommendations will be revised regularly following systematic review of new research evidence as this becomes available.
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293
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Huskin JP, Vandekerckhove B, Delincé P, Verdonk R, Dubuc JE, Willems S, Hardy P, Blanco FJ, Charrois O, Handelberg F. Multicentre, prospective, open study to evaluate the safety and efficacy of hylan G-F 20 in knee osteoarthritis subjects presenting with pain following arthroscopic meniscectomy. Knee Surg Sports Traumatol Arthrosc 2008; 16:747-52. [PMID: 18536906 PMCID: PMC2516182 DOI: 10.1007/s00167-008-0556-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2008] [Accepted: 04/14/2008] [Indexed: 12/15/2022]
Abstract
The aim of the study was to evaluate the safety and efficacy of viscosupplementation with hylan G-F 20 in patients with mild to moderate osteoarthritis (OA) presenting with persistent knee pain 4-12 weeks after arthroscopic meniscectomy. A prospective, multi-centre, open study was carried out in patients with pain due to OA of the knee, not resolved by simple analgesics, 4-12 weeks after undergoing arthroscopic meniscectomy. To be eligible, patients had to score > or =50 mm and < or =90 mm on both walking pain and patient global assessment visual analogue scales (VAS; 0-100 mm) at baseline and be radiologically diagnosed pre-operatively with OA grade I or II on the Kellgren-Lawrence scale, with <50% joint space narrowing. Patients received three intra-articular, 2 ml injections of hylan G-F 20 in the target knee with an interval of 1 week between injections, and were followed for 52 weeks. The primary efficacy endpoint was the change from baseline in the walking pain VAS score at 26 weeks. Secondary outcome measures were the walking pain VAS scores at all other time points, the WOMAC Index at all time points, and patient and physician global assessment at all time points. The safety of the treatment was assessed using adverse event (AE) reports. A total of 62 patients (mean age 55.4 years, 52% male) were enrolled. The mean walking pain VAS score decreased by 36.8 mm from baseline at 26 weeks (P < 0.0001), and also showed statistically significant decreases (P < 0.0001) at all other time points. The change in WOMAC total and subscale scores from baseline were statistically significant (P < 0.0001) at all time points, as were the decreases in the physician and patient global assessment VAS scores. There were 18 target knee AEs (mostly pain and/or swelling and/or effusion) in 12 patients (19%) considered to be at least possibly related to treatment. The majority of these (78%) were mild or moderate in intensity. One patient (1.6%) experienced a serious adverse event (synovitis) in the target knee that was considered possibly related to study treatment. Hylan G-F 20 provides effective pain relief and improves stiffness and physical function in patients with mild to moderate OA presenting with persistent osteoarthritic pain 4-12 weeks after arthroscopic meniscectomy. Symptomatic efficacy was maximised at 12 weeks and maintained at 26 and 52 weeks. The type (pain and/or swelling and/or effusion) and the intensity (mostly mild/moderate) of AEs reported in this study are similar to those reported in other trials in different patient populations, but the incidence was higher (19%). The risk/benefit of hylan G-F 20 in this particular population of patients is favourable.
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Affiliation(s)
- J. P. Huskin
- CHU Liège Sart-Tilman, Sce Orthopédie, B.35, 4000 Liege 1, Belgium
| | | | - P. Delincé
- CHU St-Pierre, 290 rue Haute, 1000 Brussels, Belgium
| | - R. Verdonk
- U.Z. Gent, 185 De Pintelaan, 9000 Ghent, Belgium
| | - J.-E. Dubuc
- Cliniques Universitaires Saint-Luc, Avenue Hippocrate 10, 1200 Brussels, Belgium
| | - S. Willems
- Clinique St Joseph Espérance, 75 Rue de Hesbaye, 4000 Liege, Belgium
| | - P. Hardy
- Dpt Orthopédie, Hôpital Ambroise-Paré, 9 Avenue Charles de Gaulle, 92100 Boulogne Billancourt, France
| | - F. J. Blanco
- Dpto de Reumatologia, Hospital Juan Canalejo, Xubias de Arriba 84, 15006 A Coruna, Spain
| | - O. Charrois
- Dpt Orthopédie, Clinique Geoffroy St-Hilaire, 59 Rue Geoffroy St-Hilaire, 75005 Paris, France
| | - F. Handelberg
- Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium ,Dienst Orthopedie-Traumatologie, Afdelingshoofd Schouderpathologie-Sporttraumatologie, Laarbeeklaan 101, 1090 Brussels, Belgium
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294
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Scanzello CR, Moskowitz NK, Gibofsky A. The post-NSAID era: What to use now for the pharmacologic treatment of pain and inflammation in osteoarthritis. Curr Pain Headache Rep 2007; 11:415-22. [DOI: 10.1007/s11916-007-0227-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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295
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Review of Upper and Lower Extremity Musculoskeletal Pain Problems. Phys Med Rehabil Clin N Am 2007; 18:747-60, vi-vii. [DOI: 10.1016/j.pmr.2007.07.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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296
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Medicoeconomic evaluation of hyaluronic acid for knee osteoarthritis in everyday practice: the MESSAGE study. Joint Bone Spine 2007; 74:453-60. [PMID: 17921022 DOI: 10.1016/j.jbspin.2007.01.037] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2006] [Accepted: 01/15/2007] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Medicoeconomic data on treatments for osteoarthritis are scant. We investigated the impact of hyaluronic acid therapy on the cost of management of knee osteoarthritis. Our primary objective was to compare medical costs (admissions, outpatient visits, investigations, and treatments) and non-medical costs (sick leaves and transportation) from the perspective of the national health insurance system during the 3 months before and the 6 months after three intraarticular injections of hyaluronic acid. Our secondary objective was to evaluate treatment benefits in terms of pain, function, and quality of life. METHODS Observational, multicenter, longitudinal, before-after study of the medical and economic effects of hyaluronic acid therapy for symptomatic knee osteoarthritis. RESULTS Of the 296 assessable patients (mean age, 69 years; 30% with obesity; 65% women), only 5% of patients were withdrawn prematurely from the study. Significant improvements in the Lequesne index were found 3 and 6 months after treatment; the improvement was greater than 50% in over half the patients. Pain and quality-of-life scores improved significantly. Total cost of the disease decreased from 334 euros for the 3 pretreatment months to 295 euros and 233 euros for posttreatment months 1-3 and 4-6, respectively. CONCLUSION The costs of knee osteoarthritis decreased during the 6 months after Suplasyn therapy, indicating that the cost of the medication was more than offset by the decreased need for other treatments. Concomitantly, clinical benefits were obtained. Under the conditions of everyday practice, hyaluronic acid may provide medical benefits at an acceptable cost.
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297
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Abstract
A number of imaging modalities are available for the assessment of soft tissue complaints. The strengths and advantages of each modality must be seen in the context of any corresponding weakness or disadvantage. The sensitivity and specificity of the imaging technique must also be understood. In this article, each main radiological technique will be considered in turn. Fundamental technical aspects and common variations of the basic imaging theme will be explained and their relative strengths and limitations will be explored. Typical common clinical uses in the context of soft-tissue complaints will be considered.
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Affiliation(s)
- Philip W P Bearcroft
- Department of Radiology, Box 219, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge CB2 0QQ, UK.
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298
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Pettitt RA, Clements DN, Guilliard MJ. Stabilisation of medial shoulder instability by imbrication of the subscapularis muscle tendon of insertion. J Small Anim Pract 2007; 48:626-31. [PMID: 17608658 DOI: 10.1111/j.1748-5827.2007.00340.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the efficacy of subscapularis muscle tendon of insertion imbrication as a treatment for medial shoulder instability. METHODS Medial shoulder instability was diagnosed in five dogs. Initial management with medical or arthroscopic treatment failed to fully resolve lameness in four of the cases. Each case was treated by subscapularis muscle tendon of insertion imbrication. An anatomical model of medial shoulder instability was used to assess the effect of subscapularis muscle tendon of insertion imbrication on the angle of abduction of the shoulder. RESULTS In clinical study, subscapularis muscle tendon of insertion imbrication was performed in five cases. Lameness resolved fully in three cases and partially in two cases. In cadaver study, transection of either the subscapularis muscle tendon of insertion or the subscapularis muscle tendon of insertion and medial glenohumeral ligament significantly increased the angle of abduction. Imbrication of the subscapularis muscle tendon of insertion significantly reduced the angle of abduction. No significant differences were noted between the angle of abduction of normal shoulder and the shoulder with medial shoulder instability treated by subscapularis muscle tendon of insertion imbrication. CLINICAL SIGNIFICANCE Subscapularis muscle tendon of insertion imbrication is a moderately effective procedure for the management of medial shoulder instability unresponsive to medical and/or arthroscopic management. The angle of abduction of the shoulder was returned to normal in model of medial shoulder instability, following subscapularis muscle tendon of insertion. Subscapularis muscle tendon of insertion imbrication provides a relatively simple method of treating medial shoulder instability in dogs.
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Affiliation(s)
- R A Pettitt
- Small Animal Teaching Hospital, University of Liverpool, Crown Street, Liverpool L7 7EX, UK
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Bjordal JM, Johnson MI, Lopes-Martins RAB, Bogen B, Chow R, Ljunggren AE. Short-term efficacy of physical interventions in osteoarthritic knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord 2007; 8:51. [PMID: 17587446 PMCID: PMC1931596 DOI: 10.1186/1471-2474-8-51] [Citation(s) in RCA: 213] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2006] [Accepted: 06/22/2007] [Indexed: 12/27/2022] Open
Abstract
Background Treatment efficacy of physical agents in osteoarthritis of the knee (OAK) pain has been largely unknown, and this systematic review was aimed at assessing their short-term efficacies for pain relief. Methods Systematic review with meta-analysis of efficacy within 1–4 weeks and at follow up at 1–12 weeks after the end of treament. Results 36 randomised placebo-controlled trials (RCTs) were identified with 2434 patients where 1391 patients received active treatment. 33 trials satisfied three or more out of five methodological criteria (Jadad scale). The patient sample had a mean age of 65.1 years and mean baseline pain of 62.9 mm on a 100 mm visual analogue scale (VAS). Within 4 weeks of the commencement of treatment manual acupuncture, static magnets and ultrasound therapies did not offer statistically significant short-term pain relief over placebo. Pulsed electromagnetic fields offered a small reduction in pain of 6.9 mm [95% CI: 2.2 to 11.6] (n = 487). Transcutaneous electrical nerve stimulation (TENS, including interferential currents), electro-acupuncture (EA) and low level laser therapy (LLLT) offered clinically relevant pain relieving effects of 18.8 mm [95% CI: 9.6 to 28.1] (n = 414), 21.9 mm [95% CI: 17.3 to 26.5] (n = 73) and 17.7 mm [95% CI: 8.1 to 27.3] (n = 343) on VAS respectively versus placebo control. In a subgroup analysis of trials with assumed optimal doses, short-term efficacy increased to 22.2 mm [95% CI: 18.1 to 26.3] for TENS, and 24.2 mm [95% CI: 17.3 to 31.3] for LLLT on VAS. Follow-up data up to 12 weeks were sparse, but positive effects seemed to persist for at least 4 weeks after the course of LLLT, EA and TENS treatment was stopped. Conclusion TENS, EA and LLLT administered with optimal doses in an intensive 2–4 week treatment regimen, seem to offer clinically relevant short-term pain relief for OAK.
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Affiliation(s)
- Jan M Bjordal
- Faculty of Health and Social Sciences, Institute of Physiotherapy, Bergen University College, Moellendalsvn. 6, 5009 Bergen Norway
- Department of Public Health and Primary Health Care, Section of Physiotherapy Science University of Bergen, Kalfarveien 31, 5018 Bergen, Norway
| | - Mark I Johnson
- Faculty of Health, Leeds Metropolitan University, Civic Quarter, Leeds, LS1 3HE, UK
| | - Rodrigo AB Lopes-Martins
- Department of Pharmacology, Institute of Biomedical Sciences, University of São Paulo. Av. Prof. Lineu Prestes, 1524, Butantan, 05508-900São Paulo – SP, Brazil
| | - Bård Bogen
- Haraldsplass Deaconal Hospital, Physiotherapy Unit, Ulriksdal 10, 5009 Bergen, Norway
| | - Roberta Chow
- Castle Hill Medical Center, 103 Malton Rd, Beecroft, New South Wales, 2119 Australia
| | - Anne E Ljunggren
- Department of Public Health and Primary Health Care, Section of Physiotherapy Science University of Bergen, Kalfarveien 31, 5018 Bergen, Norway
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Fayad F, Lefevre-Colau MM, Rannou F, Quintero N, Nys A, Macé Y, Poiraudeau S, Drapé JL, Revel M. Relation of inflammatory modic changes to intradiscal steroid injection outcome in chronic low back pain. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2007; 16:925-31. [PMID: 17216228 PMCID: PMC2219668 DOI: 10.1007/s00586-006-0301-y] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2006] [Revised: 11/13/2006] [Accepted: 12/19/2006] [Indexed: 12/19/2022]
Abstract
The purpose of this study was to analyze the association between the severity of inflammatory endplate changes (Modic) on MRI and the clinical response to intradiscal injection of corticosteroids (IDIC) in chronic low back pain (LBP). A total of 74 patients with LBP and inflammatory Modic changes who showed no response to 3-month conservative treatment received lumbar IDIC. Two spine specialists and a radiologist assessed independently the endplate marrow changes of the injected discs. We classified patients with a pure edema endplate changes on MRI as Modic type I (n = 37); those with a mixture of Modic type I and type II changes but predominantly edema changes as Modic I-2 (n = 25) and those with predominantly fatty changes as Modic II-1 (n = 12). The primary outcome was the change in LBP intensity between baseline and 1 month after IDIC, as measured on a visual analog scale (range 0-100 mm). At 1 month, reduction in pain score was significantly higher in the Modic I and Modic I-2 groups than in the Modic II-1 group (30.2 +/- 26.6 and 29.4 +/- 21.5 vs 5.3 +/- 25.5; P = 0.009 and P = 0.017, respectively). At 3 and 6 months, IDIC tended to be more effective in the Modic I and Modic I-2 groups but not significantly. No complications such as infection or hematoma were reported. IDIC could be a short-term efficient treatment for patients with chronic LBP and predominantly inflammatory endplate changes when conservative treatments have failed.
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Affiliation(s)
- Fouad Fayad
- Service de Rééducation et de Réadaptation de l'Appareil Locomoteur et des Pathologies du Rachis, Hôpital Cochin (AP-HP), Université Paris 5, 75014 Paris, France.
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