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Jawanda H, Khan ZA, Warrier AA, Acuña AJ, Allahabadi S, Kaplan DJ, Ritz E, Jackson GR, Mameri ES, Batra A, Dornan G, Westrick J, Verma NN, Chahla J. Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis. Arthroscopy 2024; 40:1623-1636.e1. [PMID: 38331363 DOI: 10.1016/j.arthro.2024.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 01/23/2024] [Accepted: 01/28/2024] [Indexed: 02/10/2024]
Abstract
PURPOSE To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months. METHODS A literature search was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient-reported outcome scores for pain and function at baseline and at latest follow-up were extracted, and the change in scores was converted to uniform 0 to 100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function. RESULTS Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%), followed by placebo (26.2%), PRP (21.5%), CS (8.8%), and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared with placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared with placebo. Surface under the cumulative ranking curves (SUCRAs) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function, with overall SUCRA scores of 91.54, 76.46, and 53.12, respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70, respectively. CONCLUSIONS At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared with placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared with BMAC, HA, and CS. LEVEL OF EVIDENCE Level II, meta-analysis of Level I to II studies.
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Affiliation(s)
- Harkirat Jawanda
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Zeeshan A Khan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Alec A Warrier
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Alexander J Acuña
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Sachin Allahabadi
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Daniel J Kaplan
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Ethan Ritz
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Garrett R Jackson
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Enzo S Mameri
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A.; Instituto Brasil de Tecnologia de Saude, Rio de Janeiro, Brazil; Department of Orthopedics and Traumatology, Federal University of São Paulo (EPM-UNIFESP), São Paulo, Brazil
| | - Anjay Batra
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Grant Dornan
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Jennifer Westrick
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Jorge Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, U.S.A..
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Qiao X, Yan L, Feng Y, Li X, Zhang K, Lv Z, Xu C, Zhao S, Liu F, Yang X, Tian Z. Efficacy and safety of corticosteroids, hyaluronic acid, and PRP and combination therapy for knee osteoarthritis: a systematic review and network meta-analysis. BMC Musculoskelet Disord 2023; 24:926. [PMID: 38037038 PMCID: PMC10687893 DOI: 10.1186/s12891-023-06925-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/26/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVE There are many injectable treatments for knee osteoarthritis with different characteristics and effects, the aim is to understand which one can lead to better and safer results. METHODS The PRISMA principles were followed when doing the literature search. Web of Science databases, Embase, the Cochrane Library, PubMed, and the Wanfang database were searched to identified randomized controlled trials that assessed the efficacy of corticosteroids (CSC), platelet-rich plasma (PRP), hyaluronic acid (HA), and combination therapy in treating KOA. Risk of bias was assessed using the relevant Cochrane tools (version 1.0). The outcome measure included the visual analog scale (VAS) score, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, and treatment-related adverse events. The network meta-analysis was performed using STATA17 software and a Bayesian stratified random effects model. RESULTS Network meta-analysis using the Bayesian random-effects model revealed 35 studies with 3104 participants. PRP showed the best WOMAC score at a 3-month follow-up, followed by PRP + HA, HA, placebo, and CSC; PRP + HA scored the highest VAS, followed by PRP, CSC, HA, and placebo. PRP, CSC, HA, and placebo had the highest WOMAC scores six months following treatment; PRP + HA showed the best VAS scores. PRP showed the best WOMAC score at 12 months, followed by PRP + HA, HA, placebo, and CSC; The best VAS score was obtained with PRP, followed by PRP + HA, HA, and CSC. No therapy demonstrated a rise in adverse events linked to the treatment in terms of safety. CONCLUSIONS The current study found that PRP and PRP + HA were the most successful in improving function and alleviating pain after 3, 6, and 12 months of follow-up. CSC, HA, PRP, and combination therapy did not result in an increase in the incidence of treatment-related side events as compared to placebo.
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Affiliation(s)
- Xiaochen Qiao
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, JinZhong Hospital Affiliated to Shanxi Medical University, 689 Huitong South Road, Jinzhong, Shanxi, 030600, PR China
| | - Lei Yan
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
| | - Yi Feng
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
| | - Xiaoyan Li
- Xihua Yang Shanxi Province Cancer Hospital, Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, Shanxi, 030013, PR China
| | - Kun Zhang
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
| | - Zhi Lv
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
| | - Chaojian Xu
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
| | - Sen Zhao
- Taiyuan Hand Surgery Hospital, Taiyuan, Shanxi, 030001, PR China
| | - Fengrui Liu
- Orthopedics Department, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030001, PR China
| | - Xihua Yang
- Xihua Yang Shanxi Province Cancer Hospital, Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, Shanxi, 030013, PR China.
| | - Zhi Tian
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China.
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China.
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Anhesini M, Anzai A, Katayama H, Spir IAZ, Nery MM, Tiezzi OS, Otani P, Bernardo WM. Use of intra-articular hyaluronic acid in knee osteoarthritis or osteoarthritis. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023D698. [PMID: 37820190 PMCID: PMC10561918 DOI: 10.1590/1806-9282.2023d698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/19/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Mauricio Anhesini
- Brazilian Medical Association - Guideline Group - São Paulo (SP), Brazil
| | - Adriano Anzai
- Brazilian Medical Association - Guideline Group - São Paulo (SP), Brazil
| | - Haroldo Katayama
- Brazilian Medical Association - Guideline Group - São Paulo (SP), Brazil
| | | | - Mary Martins Nery
- Brazilian Medical Association - Guideline Group - São Paulo (SP), Brazil
| | | | - Pericles Otani
- Brazilian Medical Association - Guideline Group - São Paulo (SP), Brazil
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Wang CC, Hu TM, Chen CL, Hong CC, Chang YH, Kao CL. Concurrent Imaging and Clinical Study of the Efficacy of Hyaluronic Acid Injection for Knee Osteoarthritis: A Synovial Membrane Investigation with Ultrasound Imaging. Pharmaceuticals (Basel) 2023; 16:1186. [PMID: 37631101 PMCID: PMC10459875 DOI: 10.3390/ph16081186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Revised: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
We investigated whether hyaluronic acid (HA) injections can ameliorate ultrasound-detected synovitis in knee osteoarthritis (OA). We recruited 103 patients with symptomatic knee OA and ultrasound-detected synovitis and performed two ultrasound-guided fluid drainage procedures, followed by the administration of a low-molecular-weight HA injection (2.5 mL) in the subpatellar bursa, at a 2-week interval. Knee ultrasound imaging evaluations were performed before injection (baseline) and at 1 and 6 months after the second injection and included the measurements of synovial vascularity by using color Doppler ultrasound, synovial fluid depth over the suprapatellar bursa (SF), and synovial hypertrophy (SH). Initial clinical assessments included a visual analog scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). VAS scores decreased significantly at both 1-month and 6-month evaluations (p < 0.001). WOMAC scores also significantly decreased at 1 month (p < 0.001), but not at 6 months (p = 0.23). The ultrasound parameters did not significantly change, except color Doppler grading, which tended to decrease at the 6-month evaluation (p = 0.059). Our findings revealed that two ultrasound-guided HA injections following fluid drainage improved pain and knee function but did not considerably influence imaging-detected synovitis in patients with knee OA.
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Affiliation(s)
- Chien-Chih Wang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital Yuli Branch, Hualien 981002, Taiwan;
- Department of Physical Medicine and Rehabilitation, School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Tsung-Ming Hu
- Department of Psychiatry, Taipei Veterans General Hospital Yuli Branch, Hualien 981002, Taiwan;
- Department of Future Studies and LOHAS Industry, Fo Guang University, Yilan 262307, Taiwan
| | - Chien-Lung Chen
- Taipei Hospital, Ministry of Health and Welfare, New Taipei City 24213, Taiwan;
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
| | - Chung-Chih Hong
- Tri-Service General Hospital Songshan Branch, Taipei 10508, Taiwan;
| | - Yu-Hui Chang
- Department of Nursing, Taipei Veterans General Hospital, Taipei 11220, Taiwan;
| | - Chung-Lan Kao
- Department of Physical Medicine and Rehabilitation, School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Section 2, Shi-Pai Road, Taipei 11220, Taiwan
- Center for Intelligent Drug Systems and Smart Bio-Devices (IDS2B), National Chiao Tung University, Hsinchu 30010, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
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Yu SP, van Middelkoop M, Ferreira ML, Deveza L, Bierma-Zeinstra SM, Venkatesha V, Hunter DJ. The OA Trial Bank: Update of individual patient data meta-analysis of intra-articular glucocorticoids in persons with knee and hip osteoarthritis. OSTEOARTHRITIS AND CARTILAGE OPEN 2023; 5:100362. [PMID: 37284460 PMCID: PMC10239915 DOI: 10.1016/j.ocarto.2023.100362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 06/08/2023] Open
Abstract
Objective To evaluate the efficacy of intra--articular (IA) glucocorticoid for knee or hip osteoarthritis (OA) in specific subgroups of patients according to the baseline severity of pain and inflammatory signs using individual patient data (IPD) from existing trials. Furthermore, this study aims to assess if a baseline pain cut-off was associated with clinically important effectiveness of IA glucocorticoid. This is an update of an IA glucocorticoid IPD meta-analysis by the OA Trial Bank. Method Randomized trials evaluating one or more IA glucocorticoid preparations in hip and knee OA, published to May 2018 were selected. IPD of patient and disease characteristics and outcome measures were acquired. The primary outcome was pain severity at short-term follow-up (up to 4 weeks). Potential interaction effect of severe pain (≥70 points, 0-100 scale) and signs of inflammation at baseline were studied using a two-stage approach with general liner model followed by random effects model. Analysis of trend was conducted, assessing if a baseline pain cut-off was associated with the threshold for clinically important treatment effect of IA glucocorticoid compared to placebo. Results Four out of 16 eligible randomized clinical trials (n = 641) were combined with the existing OA Trial Bank studies (n = 620), yielding 1261 participants from eleven studies. Participants with severe baseline pain compared to those with less severe pain had greater pain reduction at mid-term (around 12 weeks) (mean reduction: -6.90 (95%CI -10.91; -2.90)), but not at short- and long-term. No interaction effects were found between inflammatory signs and IA glucocorticoid injections compared to placebo at all follow-up time-points. Analysis of trend demonstrated treatment response to IA glucocorticoid from baseline pain levels >50 (0-100 scale) and above. Conclusion This updated IPD meta-analysis demonstrated that participants with severe pain compared to those with less severe pain at baseline experienced significantly more pain relief with IA glucocorticoid compared with placebo at mid-term.
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Affiliation(s)
- Shirley P. Yu
- Department of Rheumatology, Royal North Shore Hospital, New South Wales, Australia
- Sydney Musculoskeletal Health, The Kolling Institute, School of Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Marienke van Middelkoop
- Erasmus MC Medical University Center Rotterdam, Department of General Practice, the Netherlands
| | - Manuela L. Ferreira
- Sydney Musculoskeletal Health, The Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Leticia Deveza
- Department of Rheumatology, Royal North Shore Hospital, New South Wales, Australia
- Sydney Musculoskeletal Health, The Kolling Institute, School of Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | | | - Venkatesha Venkatesha
- Sydney Musculoskeletal Health, The Kolling Institute, School of Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Northern Sydney Local Health District, Royal North Shore Hospital, New South Wales, Australia
| | - David J. Hunter
- Department of Rheumatology, Royal North Shore Hospital, New South Wales, Australia
- Sydney Musculoskeletal Health, The Kolling Institute, School of Medicine, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
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Blicharski T, Łukasik P, Plebanski R, Żęgota Z, Szuścik M, Moster E, Pavelka K, Jeon S, Park SL. Efficacy and Safety of Intra-Articular Cross-Linked Sodium Hyaluronate for the Treatment of Knee Osteoarthritis: A Prospective, Active-Controlled, Randomized, Parallel-Group, Double-Blind, Multicenter Study. J Clin Med 2023; 12:jcm12082982. [PMID: 37109318 PMCID: PMC10145240 DOI: 10.3390/jcm12082982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
The safety and efficacy of Hyruan ONE (test product), an intra-articular cross-linked sodium hyaluronate injection, to treat mild-to-moderate knee osteoarthritis was compared with that of Durolane (comparator) in a prospective, active-controlled, parallel-group, double-blind (masked-observed), multicenter non-inferiority study. European patients (n = 284) were randomized 1:1 (test product:comparator) and received one injection of cross-linked hyaluronic acid (60 mg/3 mL). In total, 280 patients completed the study. The primary endpoint of mean change in Western Ontario and McMaster University (WOMAC)-Likert Pain sub-scores from baseline at week 13 revealed changes of -5.59 and -5.54 for the test and comparator groups, respectively, demonstrating non-inferiority of the test product (difference, -0.05 [95% confidence interval, -0.838 to 0.729]). Secondary endpoint results, which included changes in WOMAC-Likert Pain sub-score from baseline to 26 weeks post-injection and changes in WOMAC-Likert Total score and Physical Function and Stiffness sub-scores, changes in patients' and investigators' global assessments, use of rescue medication, and responder rates at 13 and 26 weeks post-injection were similar between the groups. Incidence of adverse events was also similar. In both groups, most treatment-emergent adverse events were mild/moderate. Hyruan ONE was non-inferior to the comparator at 13 weeks post-injection in European patients with mild-to-moderate knee osteoarthritis.
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Grants
- T.B., T.H., A.G., J.B., P.Ł., R.P., Z.Ż., M.S., E.M., K.P., and T.T. received a study grant from LG Chem, Ltd. S.J. and S.L.P. are full-time employees of LG Chem, Ltd LG Chem
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Affiliation(s)
- Tomasz Blicharski
- Clinic of Rehabilitation and Orthopedics, Medical University of Lublin, 20-090 Lublin, Poland
| | - Piotr Łukasik
- Trauma and Orthopedic Ward, NZOZ Medi-Spatz, 44-100 Gliwice, Poland
| | | | - Zbigniew Żęgota
- Specjalistyczny Osrodek Leczniczo Badawczy (Specialist Treatment and Research Center), 14-100 Ostroda, Poland
| | - Marek Szuścik
- Orthopedic Department, Rydygier's Hospital, 31-826 Krakow, Poland
| | - Erik Moster
- Rheumatic Center of Dr. Mostera, 61500 Brno, Czech Republic
| | - Karel Pavelka
- Institute of Rheumatology, 12850 Prague, Czech Republic
| | - Seonhui Jeon
- Life Sciences, LG Chem, Ltd., Seoul 07336, Republic of Korea
| | - So La Park
- Life Sciences, LG Chem, Ltd., Seoul 07336, Republic of Korea
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Is intraarticular enjections effective on pain management in patients with late stage primer gonarthrosis during COVID-19 pandemic? A single centre experience. JOURNAL OF CONTEMPORARY MEDICINE 2022. [DOI: 10.16899/jcm.1143442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Background: Primary gonarthrosis is a progressive disease that increases with age and leads to limitations in activities of daily living. Until surgery is performed, nonsteroidal anti-inflammatory drugs, intraarticular injections, and physical therapy methods are used.
Purpose: This study aims to compare the clinical outcomes of intra- articular corticosteroid (CCS) and hyaluro nic acid (HA) injections for pain relief in primary gonartrhosis in COVID -19 pandemic period.
Study Design: Retrospective Cohort Study.
Methods: In this study, 88 patients who underwent intra-articular CCS and HA injection between August 2020 and March 2021 due to Kellgren-Lawrence stage 2 and higher gonarthrosis were investigated. Patients were divided into two groups. Group I represents the patients who received HA injections, and group II represents the patients who received CCS injection. Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS) scores were used for the preoperative and postoperative functional evaluations of the patients.
Results: Group I included 40 patients and group II included 48 patients. The mean age was 59.4 ± 7.3 years, and the average follow-up period was 12 ± 2,6 months. The pre-intervention WOMAC scores were 13,5 in Group I and 13.6 in Group II, KSS scores were 26,5 in Group I and 25,2 in Group II. While there was a significant change in the control at month 1 in both groups, no difference was found between the groups. At the 6th month control, the improvement in group 1 continued at a significant level compared to the pre-injection period, while group 2 returned to the pre-injection level. (p
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Singh H, Knapik DM, Polce EM, Eikani CK, Bjornstad AH, Gursoy S, Perry AK, Westrick JC, Yanke AB, Verma NN, Cole BJ, Chahla JA. Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis: A Systematic Review and Network Meta-analysis. Am J Sports Med 2022; 50:3140-3148. [PMID: 34403285 DOI: 10.1177/03635465211029659] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND In younger patients and those without severe degenerative changes, the efficacy of intra-articular (IA) injections as a nonoperative modality for treating symptomatic knee osteoarthritis (OA)-related pain while maintaining function has become a subject of increasing interest. PURPOSE To assess and compare the efficacy of different IA injections used for the treatment of knee OA, including hyaluronic acid (HA), corticosteroids (CS), platelet-rich plasma (PRP), and plasma rich in growth factors (PRGF), with a minimum 6-month patient follow-up. STUDY DESIGN Meta-analysis of randomized controlled trials; Level of evidence, 1. METHODS A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Mean or mean change from baseline and standard deviation for outcome scores regarding pain and function were recorded at the 6-month follow-up and converted to either a 0 to 100 visual analog scale score for pain or a 0 to 100 Western Ontario and McMaster Universities Osteoarthritis Index score for function. A frequentist network meta-analysis model was developed to compare the effects of HA, CS, PRP, PRGF, and placebo on patient-reported outcomes. RESULTS All IA treatments except CS were found to result in a statistically significant improvement in outcomes when compared with placebo. PRP demonstrated a clinically meaningful difference in function-related improvement when compared with CS and placebo due to large effect sizes. Studies evaluating outcomes of PRGF reported significant improvement when compared with placebo due to large effect sizes, whereas a potential clinically significant difference was detected in the same comparison parameters in pain evaluation. With regard to improvements in pain, function, and both combined, PRP was found to possess the highest probability of efficacy, followed by PRGF, HA, CS, and placebo. CONCLUSION PRP yielded improved outcomes when compared with PRGF, HA, CS, and placebo for the treatment of symptomatic knee OA at a minimum 6-month follow-up. Further investigations evaluating different IA and other nonoperative treatment options for patients with knee OA are warranted to better understand the true clinical efficacy and long-term outcomes of nonsurgical OA management.
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Affiliation(s)
- Harsh Singh
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Derrick M Knapik
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Evan M Polce
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Carlo K Eikani
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Amanda H Bjornstad
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Safa Gursoy
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Allison K Perry
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jennifer C Westrick
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Adam B Yanke
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Nikhil N Verma
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Brian J Cole
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jorge A Chahla
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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9
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Ko PY, Li CY, Li CL, Kuo LC, Su WR, Jou IM, Wu PT. Single Injection of Cross-Linked Hyaluronate in Knee Osteoarthritis: A 52-Week Double-Blind Randomized Controlled Trial. Pharmaceutics 2022; 14:pharmaceutics14091783. [PMID: 36145530 PMCID: PMC9504468 DOI: 10.3390/pharmaceutics14091783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/13/2022] [Accepted: 08/22/2022] [Indexed: 11/16/2022] Open
Abstract
Background: to compare the 52-week effectiveness and safety between HYAJOINT Plus (HJP) and Durolane in knee osteoarthritis (OA) treatment. Methods: consecutive patients received a single injection of 3 mL HJP or Durolane. The primary outcome was a visual analog scale (VAS) pain measurement at 26 weeks post-injection. Secondary outcomes included other clinical, satisfaction, and safety assessments for 52 weeks. Results: 142 patients were equally randomized. At week 26, the HJP group had less VAS pain than the Durolane group (18.1 ± 9.5 versus 24.4 ± 14.0, p = 0.001). Both groups showed improvement in their VAS pain and stiffness scores, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and total scores for 52 weeks after injection (p < 0.001). However, the HJP group showed lower VAS pain and stiffness scores, reduced WOMAC pain and stiffness scores, a shorter Timed “Up & Go” (TUG) time, and a higher satisfaction score than the Durolane group for 39 weeks (p < 0.05). Only mild and self-limited adverse events occurred (40.8%). Conclusion: While a single injection of either HJP or Durolane is safe and effective for at least 52 weeks, HJP provided superior improvement in terms of VAS pain and stiffness scores, WOMAC pain and stiffness scores, and satisfaction score within 39 weeks of treatment.
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Affiliation(s)
- Po-Yen Ko
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan 701401, Taiwan
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
- Department of Public Health, College of Public Health, China Medical University, Taichung 404328, Taiwan
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung 413305, Taiwan
| | - Chia-Lung Li
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
- Department of Orthopedics, Tainan Hospital, Ministry of Health and Welfare, Tainan 700043, Taiwan
| | - Li-Chieh Kuo
- Department of Occupational Therapy, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
- Medical Device Innovation Center, National Cheng Kung University, Tainan 701401, Taiwan
| | - Wei-Ren Su
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
- Medical Device Innovation Center, National Cheng Kung University, Tainan 701401, Taiwan
- Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
| | - I-Ming Jou
- Department of Orthopedics, E-Da Hospital, Kaohsiung 824005, Taiwan
- School of Medicine, College of Medicine, I-Shou University, Kaohsiung 824005, Taiwan
- GEG Orthopedic Clinic, Tainan 701002, Taiwan
| | - Po-Ting Wu
- Department of Orthopedics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704302, Taiwan
- Department of Biomedical Engineering, National Cheng Kung University, Tainan 701401, Taiwan
- Medical Device Innovation Center, National Cheng Kung University, Tainan 701401, Taiwan
- Department of Orthopedics, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
- Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Tainan 701401, Taiwan
- Correspondence: ; Tel.: +886-6-276-6689
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10
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Emans P, Skaliczki G, Haverkamp D, Bentin J, Chausson M, Schifflers M, Hermitte L, Douette P. First-in-human Study to Evaluate a Single Injection of KiOmedine®CM-Chitosan for Treating Symptomatic Knee Osteoarthritis. Open Rheumatol J 2022. [DOI: 10.2174/18743129-v16-e2206100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:
Single-injection viscosupplementation is currently performed with cross-linked hyaluronan (e.g., Durolane®) for treating symptomatic knee osteoarthritis.
Objective:
This first-in-human study evaluated the safety and performance of single-injection treatment with non-crosslinked KiOmedine®CM-Chitosan.
Methods:
Patients with painful knee osteoarthritis were randomly assigned to the KiOmedine®CM-Chitosan (n=63) or Durolane® (n=32) group. Patients were blinded to treatment and followed up for 26 weeks. Durolane® was used as scientific control to ensure the validity of the study and reliability of results. No direct comparison was performed between the two groups. The primary objective was defined as an intra-group effect size of 0.8 at 13 weeks post-injection compared to baseline on WOMAC-A (pain). Secondary outcomes included self-reported knee stiffness and knee function, responder rate, quality-of-life questionnaires, and safety.
Results:
The primary objective for both the KiOmedine®CM-Chitosan and the Durolane® groups was met: mean pain reduction of 62.5% (effect size 2.08) for the KiOmedine®CM-Chitosan group and 62.4% (effect size 2.28) for the Durolane® group. Secondary performance outcomes showed all clinically relevant treatment effects over 26 weeks for both groups (p<0.05). Treatment-related adverse events were more often reported in the KiOmedine®CM-Chitosan than Durolane® group and were limited to local reactions. No serious treatment-related adverse events were reported.
Conclusion:
A single intra-articular injection of non-crosslinked KiOmedine®CM-Chitosan is safe and effective for treating symptomatic knee osteoarthritis with a high responder rate. Pain reduction is maintained for 6 months with a high responder rate.
The clinical trial registration number: NCT03679208.
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11
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Wang CP, Lee WC, Hsieh RL. Effects of Repeated Co-Injections of Corticosteroids and Hyaluronic Acid on Knee Osteoarthritis: A Prospective, Double-Blind Randomized Controlled Trial. Am J Med 2022; 135:641-649. [PMID: 34958762 DOI: 10.1016/j.amjmed.2021.11.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/05/2021] [Accepted: 11/13/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND We compared the effects of repeated co-injections of corticosteroids plus hyaluronic acid (HA) with the effects of HA injections alone in patients with knee osteoarthritis. METHODS A double-blind randomized controlled trial was conducted between October 2016 and July 2017 at a medical center. Patients (n = 57) who fulfilled the clinical and radiographic criteria for knee osteoarthritis established by the American College of Rheumatology with a Kellgren-Lawrence score of 2 or 3 were included. They were assigned to either the HA group (n = 29) or corticosteroids plus HA group (n = 28), and injections were administered under ultrasound guidance once a week for 3 consecutive weeks. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores were the primary outcomes. Physical functional performance (10-m fast walking and chair-rising time) and the Knee Injury and Osteoarthritis Outcome Score (KOOS) were secondary outcomes. The assessment was performed prior to injections, 1 week, and 1, 3, and 6 months after injections. Data were analyzed through repeated-measures analysis of covariance. RESULTS Both groups experienced decreased pain and improved physical function and physical functional performance over time. We found significant group × time interaction effects favoring the corticosteroids plus HA group in WOMAC-pain (P = .005) and physical function (P = .005), chair-rising time (P = .032), and KOOS-pain (P = .001). CONCLUSIONS Repeated co-injections of corticosteroids plus HA more effectively decreased pain and improved physical function and physical functional performance than injections of HA alone from 1 week through 6 months posttreatment.
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Affiliation(s)
- Chun-Ping Wang
- Department of Physical Medicine and Rehabilitation, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Wen-Chung Lee
- College of Public Health, Institute of Epidemiology and Preventive Medicine, National Taiwan University, Taipei, Taiwan
| | - Ru-Lan Hsieh
- Department of Physical Medicine and Rehabilitation, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan; Department of Physical Medicine and Rehabilitation, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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12
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Dilley JE, Everhart JS, Klitzman RG. Hyaluronic acid as an adjunct to microfracture in the treatment of osteochondral lesions of the talus: a systematic review of randomized controlled trials. BMC Musculoskelet Disord 2022; 23:313. [PMID: 35366851 PMCID: PMC8976295 DOI: 10.1186/s12891-022-05236-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/16/2022] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Osteochondral lesions of the talus (OLT) are common after ankle trauma. Studies have shown that bioactive substances, such as hyaluronic acid (HA), alone, or in combination, with surgical treatment could improve cartilage regeneration and repair, but the effect of HA on patient reported outcomes is unclear. METHODS Literature searches were performed across four databases (PubMed, SPORTDiscus, Scopus, and The Cochrane Library) for randomized controlled trials in which at least one treatment arm involved use of HA as an adjunct to microfracture to treat patients with OLT. Primary outcomes included the American Orthopaedic Foot and Ankle Society scores (AOFAS), and the Visual Analog Scale (VAS) for pain. The level of evidence and methodological quality were evaluated using the Modified Coleman Methodology Score (MCMS). RESULTS Three randomized studies were eligible for review with a total of 132 patients (35, 40, 57 patients, respectively) and follow-up ranged from 10.5 to 25 months. Utilization of HA at the time of microfracture resulted in greater improvement in AOFAS scores compared to microfracture alone. The pooled effect size was moderate (Standardized Mean Difference [SMD] 0.45, 95% Confidence Interval [CI] 0.06, 0.84; P = .02) and between-study heterogeneity was low (I-squared = 0%). Utilization of HA during microfracture also led to greater improvement in VAS-pain scores compared to microfracture alone. The pooled effect size was very large (SMD -3.86, 95% CI -4.75, - 2.97; P < .001) and heterogeneity was moderate (I-squared = 69%). CONCLUSION Hyaluronic acid injection as an adjunct to arthroscopic MF in OLT provides clinically important improvements in function and pain at short-term follow-up compared to MF alone. Future longer-term follow-up studies are warranted to investigate the durability of MF with HA for treatment of OLT.
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Affiliation(s)
- Julian E Dilley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Joshua S Everhart
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Robert G Klitzman
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA.
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13
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Lim WB, Al-Dadah O. Conservative treatment of knee osteoarthritis: A review of the literature. World J Orthop 2022; 13:212-229. [PMID: 35317254 PMCID: PMC8935331 DOI: 10.5312/wjo.v13.i3.212] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/29/2021] [Accepted: 01/29/2022] [Indexed: 02/06/2023] Open
Abstract
Knee osteoarthritis (KOA) is a common chronic debilitating disease with an estimated prevalence of 23.9% in the general adult population. The condition is characterised by joint pain, functional impairment and significant reduction in quality of life. Management for KOA can generally be divided into conservative (non-operative) and surgical (operative) measures. Conservative management broadly compromises pharmacological and non-pharmacological options and is conventionally the first line treatment to avoid or delay the need for surgical management. The aim of this study is to provide an overview of the current recommendations, efficacy and safety profile of different conservative treatments through a review of the literature.
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Affiliation(s)
- Wei Boon Lim
- The Medical School, Newcastle University, Newcastle-upon-Tyne NE2 4HH, United Kingdom
| | - Oday Al-Dadah
- Department of Trauma and Orthopaedic Surgery, South Tyneside District Hospital, South Tyneside NE34 0PL, United Kingdom
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle-upon-Tyne NE2 4HH, United Kingdom
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14
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Recent Developments in Hyaluronic Acid-Based Hydrogels for Cartilage Tissue Engineering Applications. Polymers (Basel) 2022; 14:polym14040839. [PMID: 35215752 PMCID: PMC8963043 DOI: 10.3390/polym14040839] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 02/18/2022] [Accepted: 02/19/2022] [Indexed: 01/27/2023] Open
Abstract
Articular cartilage lesions resulting from injurious impact, recurring loading, joint malalignment, etc., are very common and encompass the risk of evolving to serious cartilage diseases such as osteoarthritis. To date, cartilage injuries are typically treated via operative procedures such as autologous chondrocyte implantation (ACI), matrix-associated autologous chondrocyte implantation (MACI) and microfracture, which are characterized by low patient compliance. Accordingly, cartilage tissue engineering (CTE) has received a lot of interest. Cell-laden hydrogels are favorable candidates for cartilage repair since they resemble the native tissue environment and promote the formation of extracellular matrix. Various types of hydrogels have been developed so far for CTE applications based on both natural and synthetic biomaterials. Among these materials, hyaluronic acid (HA), a principal component of the cartilage tissue which can be easily modified and biofunctionalized, has been favored for the development of hydrogels since it interacts with cell surface receptors, supports the growth of chondrocytes and promotes the differentiation of mesenchymal stem cells to chondrocytes. The present work reviews the various types of HA-based hydrogels (e.g., in situ forming hydrogels, cryogels, microgels and three-dimensional (3D)-bioprinted hydrogel constructs) that have been used for cartilage repair, specially focusing on the results of their preclinical and clinical assessment.
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15
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Liepe K. Radiosynovectomy of large joint arthritis. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00024-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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16
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Vincent P. Acide hyaluronique intra-articulaire dans la gonarthrose: résultats cliniques d'une famille de produits (ARTHRUM), avec méta-analyses comparatives. Curr Ther Res Clin Exp 2021; 95:100652. [PMID: 34868410 PMCID: PMC8626835 DOI: 10.1016/j.curtheres.2021.100652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 10/29/2021] [Indexed: 11/15/2022] Open
Abstract
Introduction La viscosupplémentation est largement pratiquée, pour réduire la douleur dans l'arthrose (OA), par des injections intra articulaires (IA) d'acide hyaluronique (AH). En Europe, ces produits sont des dispositifs médicaux de classe III, pour lesquels la réglementation Medical Device Regulation (MDR) impose une évaluation clinique, basée sur des études spécifiques et/ou une revue bibliographique des dispositifs équivalents. L'objet de cet article est de présenter une revue comparative entre une famille de dispositifs (ARTHRUM, de LCA Pharmaceuticals, Chartres, France) et un groupe important de dispositifs AH IA présumés équivalents dont les résultats et ceux de leurs contrôles, ont fait l'objet de publications dans des journaux scientifiques. Méthodes Pour rejoindre les critères utilisés dans la plupart des études ARTHRUM, les sous-scores de l'indice Western Ontario and McMaster Universities ont été sélectionnés pour la douleur (WOMAC A), la raideur (WOMAC B) et la fonction (WOMAC C). Le critère principal était la variation du score WOMAC A depuis T0 (date d'inclusion) jusqu'à T6 (6 mois). Les autres critères WOMAC ont été évalués à T1, T3, T6 et complétés par les taux de répondeurs au traitement selon OMERACT-OARSI. Cinquante articles ont été sélectionnés, incluant des résultats portant sur plus de 12.000 patients. Ceux-ci ont été répartis en trois groupes: ARTHRUM, EQUIVALENTS et CONTROLES. Pour obtenir des comparaisons quantitatives, des méta-analyses furent réalisées pour chaque critère individuel. Les intervalles de confiance (CI) à 95% de chaque variation par rapport à l'inclusion, ont permis d'évaluer la pertinence clinique en se référant à un minimum validé dans la littérature de l'OA. L'investigation a été complétée par des comparaisons entre groupes et par l'évaluation de la tolérance. Résultats Pour les scores WOMAC A, B et C, l'intégralité de CI 95% était toujours supérieure à l'amélioration minimale cliniquement perceptible (MPCI), pour les groupes ARTHRUM et EQUIVALENTS, ce qui n'a pas été observé pour la totalité des critères, avec le groupe CONTROLES. Dans les comparaisons, les groupes ARTHRUM et EQUIVALENTS ont été significativement meilleurs que le groupe CONTROLES pour chaque critère. La taille de l'effet (ES) sur la douleur, pour les groupes ARTHRUM et EQUIVALENTS, a varié de 0,28 à 0,56 et de 0,23 to 0,27, respectivement. Globalement, ARTHRUM a toujours été évalué non-inférieur aux EQUIVALENTS, et parfois statistiquement et cliniquement supérieur. Conclusions La comparaison des études cliniques ARTHRUM, avec les études tirées de la recherche bibliographique, permet de conclure que l'efficacité clinique des dispositifs médicaux ARTHRUM, pour réduire la douleur et améliorer la fonction dans la gonarthrose, sur une période de six mois, est au moins aussi élevée que celle des dispositifs équivalents. Avec un bon profil de tolérance (taux plus faible d'effets indésirables, et aucun sévère), le rapport risque-bénéfice est en faveur de la viscosupplémentation avec ARTHRUM.
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Affiliation(s)
- Patrice Vincent
- Directeur R&D, LCA Pharmaceutical, 9 allée Prométhée, 28000 Chartres, France
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17
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Webner D, Huang Y, Hummer CD. Intraarticular Hyaluronic Acid Preparations for Knee Osteoarthritis: Are Some Better Than Others? Cartilage 2021; 13:1619S-1636S. [PMID: 34044600 PMCID: PMC8808930 DOI: 10.1177/19476035211017320] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This literature review summarizes evidence on the safety and efficacy of intraarticular hyaluronic acid (IAHA) preparations approved in the United States for the treatment of osteoarthritis of the knee. DESIGN A systematic literature search was performed in PubMed, Ovid MEDLINE, and SCOPUS databases. Only studies in which clinical outcomes of individual IAHA preparations alone could be assessed when compared to placebo, no treatment, other standard knee osteoarthritis treatments, and IAHA head-to-head studies were selected. RESULTS One hundred nine articles meeting our inclusion criteria were identified, including 59 randomized and 50 observational studies. Hylan G-F 20 has been the most extensively studied preparation, with consistent results confirming efficacy in placebo-controlled studies. Efficacy is also consistently reported for Supartz, Monovisc, and Euflexxa, but not for Hyalgan, Orthovisc, and Durolane. In the head-to-head trials, high-molecular-weight (MW) Hylan G-F 20 was consistently superior to low MW sodium hyaluronate preparations (Hyalgan, Supartz) up to 20 weeks, whereas one study reported that Durolane was noninferior to Supartz. Head-to-head trials comparing high versus medium MW preparations all used Hylan G-F 20 as the high MW preparation. Of the IAHA preparations with strong evidence of efficacy in placebo-controlled studies, Euflexxa was found to be noninferior to Hylan G-F 20. There are no direct comparisons to Monovisc. One additional IAHA preparation (ie, Synovial), which has not been assessed in placebo-controlled studies, was also noninferior to Hylan G-F 20. CONCLUSION IAHA efficacy varies widely across preparations. High-quality studies are required to assess and compare the safety and efficacy of IAHA preparations.
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Affiliation(s)
- David Webner
- Crozer-Keystone Health System,
Springfield, PA, USA,David Webner, Crozer-Keystone Health
System, 196 W. Sproul Road, Suite 110, Springfield, PA 19064, USA.
| | - Yili Huang
- Northwell Health, Zucker School of
Medicine at Hofstra/Northwell, Hempstead, NY, USA
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18
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Heidt C, Grueberger N, Grisch D, Righini-Grunder F, Rueger M, Ramseier L. The Assessment of Steroid Injections as a Potential Risk Factor for Osteochondral Lesions in Children with Juvenile Idiopathic Arthritis. Cartilage 2021; 13:894S-899S. [PMID: 32985233 PMCID: PMC8808797 DOI: 10.1177/1947603520961173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Intra-articular corticosteroid injections (IACIs) are frequently used to suppress local inflammation, that is, in children with juvenile idiopathic arthritis (JIA). While systemic high-dosage corticosteroids are known to trigger osteonecrosis and result in osteochondral (OC) lesions, the effect of IACIs on joint cartilage and subchondral bone remains unclear. This study was conceived to analyze the coincidence of IACI and the subsequent manifestation of osteochondral lesions in a large cohort of pediatric JIA patients. DESIGN Retrospective data assessment and comparative analysis of skeletally immature JIA patients treated with IACIs between 1993 and 2017. RESULTS A total of 280 JIA patients were included in the analysis, the majority were girls (64%). Osteochondral lesions were present in 16 patients (5.7%) at a mean age of 10.7 years (range 4-14 years) and appeared on average after 63-month duration of disease. The majority was present at atypical locations such as the lateral femoral condyle. Multivariable analysis using cox regression showed that steroid injections were a risk factor to develop an OC lesion (hazard ratio [95%CI] for number of steroid injections per year, 8.20 [3.18, 21.16]). CONCLUSIONS Pediatric patients with JIA show a relatively high incidence of osteochondritic lesions, which present at an early age and in rather atypical locations and repetitive steroid injection need to be considered an associated risk factor.
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Affiliation(s)
- Christoph Heidt
- University Children’s Hospital Basel,
Basel, Switzerland,University Children’s Hospital Zurich,
Zurich, Switzerland,Christoph Heidt, University Children’s
Hospital Basel, Spitalstrasse 33, 4056 Basel, 4056, Switzerland.
| | | | - Domenic Grisch
- University Children’s Hospital Zurich,
Zurich, Switzerland
| | | | | | - Leonhard Ramseier
- University Children’s Hospital Zurich,
Zurich, Switzerland,Ortho Clinic Zurich, Zurich,
Switzerland
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19
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Vincent P. Intra-articular hyaluronic acid in knee osteoarthritis: clinical data for a product family (ARTHRUM), with comparative meta-analyses. Curr Ther Res Clin Exp 2021; 95:100637. [PMID: 34712370 PMCID: PMC8529397 DOI: 10.1016/j.curtheres.2021.100637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/29/2021] [Indexed: 01/02/2023] Open
Abstract
Introduction Viscosupplementation is widely practiced, to reduce pain in osteoarthritis (OA), using intra articular (IA) injections of hyaluronic acid (HA). In Europe, these products are class III medical devices, for which the Medical Device Regulation (MDR) requires clinical assessment, based on specific studies and/or a bibliographical review of equivalent devices. The purpose of this article is to present a comparative review between a family of devices (ARTHRUM, from LCA Pharmaceuticals, Chartres, France) and an extensive group of presumed equivalent IA HA devices or their controls, whose results have been published in Scientific journals. Methods To meet the criteria used in most ARTHRUM studies, the Western Ontario and McMaster Universities’ index sub-scores were selected for pain (WOMAC A), stiffness (WOMAC B) and function (WOMAC C). The main criterion was the variation of the WOMAC A score from T0 (date of inclusion) to T6 (6 months). The other WOMAC criteria were assessed at T1, T3, T6 and complemented by OMERACT-OARSI rates of responders to the treatment. Fifty articles were selected, containing treatment details on more than 12,000 patients. These were divided into three groups: ARTHRUM, EQUIVALENTS and CONTROLS. To get quantitative comparisons, meta-analyses were performed for each criterion individually. The 95% confidence interval of each difference from baseline, was used to assess the clinical relevance, with reference to a minimum validated in OA literature. Comparisons between groups and tolerance assessment completed the investigation. Results For the WOMAC A, B and C scores, the full 95% CI was always above the minimal perceptible clinical improvement (MPCI), in the ARTHRUM and EQUIVALENTS groups, but not for all criteria in the CONTROLS group. In the comparisons, both ARTHRUM and EQUIVALENTS groups were significantly better than the CONTROLS group for each criterion. The effect size (ES) on pain, for the ARTHRUM and EQUIVALENTS groups, varied from 0.28 to 0.56 and from 0.23 to 0.27, respectively. Overall, ARTHRUM was estimated always non-inferior to EQUIVALENTS, and sometimes statistically and clinically superior. Conclusions The comparison of ARTHRUM clinical studies, with studies selected through bibliographic research, leads to the conclusion that the clinical efficacy of the ARTHRUM medical devices, to reduce pain and improve the function in knee OA, during a six-month period, is at least as great as those of equivalent products. With good tolerance results (lowest rate of adverse events, and none of them serious), the risk benefit ratio favours using viscosupplementation with ARTHRUM.
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Key Words
- AE, adverse event
- CD, Cohen's D (effect size)
- CI, confidence interval (with probability %)
- CS, chondroitin sulfate
- ES, effect size
- GAG, glycosaminoglycan
- HA, hyaluronic acid (sodium hyaluronate)
- IA, intra-articular
- KL, Kellgren-Lawrence (radiological OA severity scale)
- MD, mean difference
- MDR, Medical Device Regulation
- MPCI, minimal perceptible clinical improvement
- MSC, mesenchymal cells
- Mw, molecular weight (average in weight)
- NSAID, non-steroidal anti-inflammatory drug
- OA, osteoarthritis
- OARSI, Osteoarthritis Research Society International
- OMERACT, Outcomes Measurements in Rheumatology (international network)
- PRP, platelet rich plasma
- SAE, serious adverse event
- SD, standard deviation
- SE, standard error
- SF, synovial fluid
- SSD, smallest detectable difference
- WOMAC, Western Ontario & Mac Master Universities (OA index)
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Affiliation(s)
- Patrice Vincent
- R&D manager, LCA Pharmaceutical, 9 allée Prométhée, 28000 Chartres, France
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20
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Al-Sobayil F, Sadan MA, El-Shafaey EA, Allouch J. Intra-articular injection in the hind limb joints of dromedary camels ( Camelus dromedarius) using anatomical and arthrographic-guided landmarks. Vet World 2021; 14:2055-2063. [PMID: 34566321 PMCID: PMC8448646 DOI: 10.14202/vetworld.2021.2055-2063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2021] [Accepted: 06/11/2021] [Indexed: 12/02/2022] Open
Abstract
Background and Aim: A healthy joint is an important structure for the proper movement of the camel limb. Intra-articular (IA) injection is frequently used in veterinary practice for diagnostic and therapeutic purposes of joint injuries. Thus, the current study aimed to describe the injection of the hindlimb joints in dromedary camels based on the anatomical and arthrographic-guided landmarks. Materials and Methods: Eighteen orthopedically sound adult camels (mean±standard deviation age: 78±12 months) of both sexes were included in this study. Three camels were euthanized to identify anatomical features in the hindlimb joints and related structures. IA injections were performed in the hindlimbs of 5 camel cadavers to evaluate the optimal IA injection site, which was confirmed by arthrography. The optimized IA injection technique was applied in 10 live camels and confirmed by arthrocentesis and arthrography. For each joint, injection criteria (number of attempts, difficulty of injection, and successful injection) were assessed, scored, and statistically compared to the other joints. Results: The summation of IA injection criteria scores was significantly higher (p<0.05) in the femorotibial, femoropatellar, tibiotarsal, fetlock, pastern, and coffin joints in comparison to the hip joint. Conclusion: Anatomical and arthrographic-guided techniques offer considerable advantages for the characterization of anatomical landmarks and selection of the appropriate IA injection site in the hindlimb in dromedary camels. Furthermore, a reference approach for camels was established that is different from the approach for cattle and horses.
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Affiliation(s)
- Fahd Al-Sobayil
- Department of Veterinary Medicine, College of Agriculture and Veterinary Medicine, Qassim University, Qassim, Saudi Arabia
| | - Madeh A Sadan
- Department of Veterinary Medicine, College of Agriculture and Veterinary Medicine, Qassim University, Qassim, Saudi Arabia.,Department of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine, South Valley University, Qena 83523, Egypt
| | - Elsayed A El-Shafaey
- Department of Veterinary Medicine, College of Agriculture and Veterinary Medicine, Qassim University, Qassim, Saudi Arabia.,Department of Surgery, Anesthesiology and Radiology, Faculty of Veterinary Medicine, Mansoura University, Mansoura 35516, Egypt
| | - Jamal Allouch
- Department of Veterinary Medicine, College of Agriculture and Veterinary Medicine, Qassim University, Qassim, Saudi Arabia.,Department of Anatomy, AL-Baath University, Syria
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21
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Carney G, Harrison A, Fitzpatrick J. Long-Term Outcome Measures of Repeated Non-Animal Stabilized Hyaluronic Acid (Durolane) Injections in Osteoarthritis: A 6-Year Cohort Study with 623 Consecutive Patients. Open Access Rheumatol 2021; 13:285-292. [PMID: 34566438 PMCID: PMC8457651 DOI: 10.2147/oarrr.s331562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/03/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine the duration of symptom relief following repeated administration of hyaluronic acid injections for osteoarthritis. Patients and Methods This was a 6-year observational study with 623 consecutive patients who had received hyaluronic acid injections. The primary outcome measure was the mean time between injections measured in days. Classical one-sample 2-sided t-tests, one-way analysis of variances and post-hoc analyses were performed to determine if there were statistically significant differences between age, gender, radiographic severity and the type of joints injected. All patients were invited to complete an online post-treatment experience and satisfaction survey. Results The analysis included 727 joints (mean Kellgren-Lawrence grade, 2.9 ± 0.8 (range 2–4)) in 623 patients (297 (47.7%) male; mean age at first injection, 57.8 ± 12.7 years (range 21.2–92.1)). Patients ranged from having 1–8 injections per joint. The mean time between injections in days was 466.8 ± 321.7 (2nd injection, 157 joints), 400.5 ± 164.7 (3rd injection, 58 joints), 378.2 ± 223.1 (4th injection, 27 joints), 405.3 ± 216.3 (5th injection, 7 joints), 268.4 ± 104.4 (6th injection, 5 joints), 289.8 ± 99.4 (7th injection, 4 joints), and 272.5 ± 33.2 (8th injection, 2 joints). Patients with grades 2 and 3 compared to grade 4 osteoarthritis experienced a longer time between injections (F (2, 154) = 3.53, p = 0.0316). No statistically significant differences were observed between age, gender, or joint groups. The survey included 233 participants (109 (46.8% male)). A total of 144 respondents (64.9%) recommended hyaluronic acid injections for osteoarthritis. Conclusion Pain relief from hyaluronic acid injections was sustained for on average 466.8 days post initial treatment. Patients who received subsequent 3rd, 4th, and 5th injections also experienced extended duration of benefit. Patients with grades 2 or 3 osteoarthritis are more likely to experience a longer duration of relief.
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Affiliation(s)
- Georgia Carney
- Joint Health Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | | | - Jane Fitzpatrick
- Joint Health Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Australasian College of Sport and Exercise Physicians, Melbourne, Victoria, Australia
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Comparison between intra-articular infiltrations of placebo, steroids, hyaluronic and PRP for knee osteoarthritis: a Bayesian network meta-analysis. Arch Orthop Trauma Surg 2021; 141:1473-1490. [PMID: 32725315 DOI: 10.1007/s00402-020-03551-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 07/15/2020] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Regarding the efficacy of intra-articular injections of platelet-rich plasma, hyaluronic acid and corticosteroids, current evidence is controversial. The superiority of one technique over another is questioned and debates are ongoing. The purpose of the present study was to compare and investigate the efficacy of these intra-articular infiltrations in patients with knee osteoarthritis (OA). A Bayesian network meta-analysis of randomized clinical trials (RCTs) was conducted comparing patient outcomes at 3, 6 and 12-months of follow-up. MATERIALS AND METHODS This Bayesian network meta-analysis was conducted according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health care interventions. All the RCTs comparing the outcomes of two or more intra-articular infiltrations of interest for knee OA were considered for inclusion. The outcomes of interest were the WOMAC and VAS scores. The network meta-analyses were performed using the STATA routine for Bayesian hierarchical random-effects models. RESULTS Data from 30 RCTs (3463 patients) were collected. At 3-months follow-up, PRP showed the best WOMAC scores, followed by the Placebo, CCS and HA. At 6-months follow-up, PRP showed the best WOMAC scores, followed by HA, CCS and Placebo. At 12-months follow-up, PRP showed the best WOMAC scores, followed by the Placebo, HA and CCS. At 3-months follow-up, the PRP showed the best VAS scores, followed by CCS, HA and Placebo. At 6-months follow-up, PRP showed the best VAS scores, followed by CCS, Placebo and HA. At 12-months follow-up, the PRP showed the best VAS scores, followed by CCS, Placebo and HA. CONCLUSION Intra-articular injections of PRP demonstrated the best overall outcome compared to steroids, hyaluronic acid and placebo for patients with knee osteoarthrosis at 3, 6 and 12-months follow-up. Among CCS, hyaluronic acid and placebo, no discrepancies were detected. LEVEL OF EVIDENCE I, Bayesian network meta-analysis of RCTs.
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23
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Ayub S, Kaur J, Hui M, Espahbodi S, Hall M, Doherty M, Zhang W. Efficacy and safety of multiple intra-articular corticosteroid injections for osteoarthritis-a systematic review and meta-analysis of randomized controlled trials and observational studies. Rheumatology (Oxford) 2021; 60:1629-1639. [PMID: 33432345 DOI: 10.1093/rheumatology/keaa808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/30/2020] [Accepted: 10/19/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To investigate the efficacy and safety of multiple intra-articular corticosteroid (IACS) injections for the treatment of OA. METHODS We conducted electronic searches of several databases for randomized controlled trials (RCTs) and observational studies. Standard mean difference was calculated for efficacy, whereas hazard ratio (HR) was used for adverse effects. Results were combined using the random effects model. Heterogeneity was measured using I2 statistics. RESULTS Six RCTs were included for efficacy assessment. The use of multiple IACS appeared to be better than comparator (standard mean difference for pain -0.47, 95% CI -0.62, 0.31). However, there was considerable heterogeneity (I2 92.6%) and subgroup analysis by comparator showed no separation of regular IACS from placebo, though timing of pain assessments was questionable. Fourteen RCTs and two observational studies were assessed for the safety of multiple IACS. Minor local adverse events were similar in both groups. One RCT found that regular IACS every 3 months for 2 years caused greater cartilage loss compared with saline injection (-0.21 vs 0.10 mm). One cohort study found that multiple IACS injections associated with worsening of joint space narrowing (HR 3.02, 95% CI 2.25, 4.05) and increased risk of joint replacement (HR 2.54, 95% CI 1.81, 3.57). CONCLUSION Multiple IACS injections are no better than placebo for OA pain according to current evidence. The preliminary finding of a detrimental effect on structural OA progression warrants further investigation. Efficacy and safety of multiple IACS reflecting recommended best practice has yet to be assessed.
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Affiliation(s)
- Shazeen Ayub
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK.,Rheumatology Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Jaspreet Kaur
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michelle Hui
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK.,Rheumatology Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Shima Espahbodi
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michelle Hall
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Michael Doherty
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Weiya Zhang
- Academic Rheumatology, School of Medicine, University of Nottingham, Nottingham, UK
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Najm A, Alunno A, Gwinnutt JM, Weill C, Berenbaum F. Efficacy of intra-articular corticosteroid injections in knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Joint Bone Spine 2021; 88:105198. [PMID: 33901659 DOI: 10.1016/j.jbspin.2021.105198] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 04/05/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Knee osteoarthritis (OA) is a frequent degenerative disease representing an important health and economic burden. Symptomatic medical treatments available include intra-articular (IA) injections of corticosteroids (GC) but their efficacy and safety profile are debated. METHODS We performed a systematic literature review (SLR) and a meta-analysis (MA) of randomized controlled trials (RCTs) assessing the effect of IA GC injections for knee OA. The effect of the interventions on pain and function was extracted from the single studies and pooled. Standardized mean differences (SMD) are reported. RESULTS Of 520 studies screened, 23 were included in the SLR and 15 subsequently included in the MA. IA GC showed a trend towards a superior effect compared to control on both pain (SMD -0.61 (95% CI: -1.25, 0.03)) and function (SMD -1.02 (95% CI: -2.14, 0.10)) in short term follow-up (≤6 weeks), while long term follow-up (≥24 weeks) analysis showed a trend towards superiority of controls (IA HA, IA NSAID, physiotherapy) for pain (SMD 0.68 (95% CI: -0.11, 1.47)) and function (SMD 0.88 (95% CI: -0.36, 2.12). There were no differences between interventions in medium term (>6 weeks &<24 weeks). CONCLUSION In this work, IA GC injections reduced pain and improved function early after administration (≤6 weeks) compared to placebo; while this result was no longer statistically significant with other comparators (IA hyaluronic acid or physiotherapy). Other interventions seem to be more efficient in the long term (≥24 weeks) but this effect was largely driven by single studies with large effect sizes.
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Affiliation(s)
- Aurélie Najm
- Institute of Infection, Immunity and Inflammation, College of Medical Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.
| | - Alessia Alunno
- Rheumatology Unit, Department of Medicine, University of Perugia, Perugia, Italy
| | - James M Gwinnutt
- Centre for Epidemiology Versus Arthritis, Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, School of Biological Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Catherine Weill
- Bibliothèque interuniversitaire de Santé, Paris Descartes University, Paris, France
| | - Francis Berenbaum
- Sorbonne Université, INSERM CRSA Saint-Antoine, Department of Rheumatology, AP-HP, Saint Antoine Hospital, Paris, France
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Russu OM, Pop TS, Feier AM, Trâmbițaș C, Incze-Bartha Z, Borodi PG, Gergely I, Zuh SG. Treatment Efficacy with a Novel Hyaluronic Acid-Based Hydrogel for Osteoarthritis of the Knee. J Pers Med 2021; 11:jpm11040303. [PMID: 33920879 PMCID: PMC8071312 DOI: 10.3390/jpm11040303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 04/10/2021] [Accepted: 04/12/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Prior trials investigating the treatment of symptomatic osteoarthritis (OA) with hyaluronic-acid-derived products injections have provided optimistic results. The study was directed to assess the effectiveness of an innovative hyaluronic-acid-based hydrogel (Hymovis®) in the treatment of symptomatic knee OA. Methods: A prospective, single-center, clinical trial was performed. Thirty-five patients with degenerative knee OA were included. Inclusion criteria were: age between 45–80, radiographic Kellgren grade II or III osteoarthritis, minimum 35 mm score on the Visual Analogue Scale (VAS), pain for at least 6 months and agreement to participate in the study. Patients received two injections at a one-week interval. The evaluator assessed the patients using the Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and VAS. Evaluation was performed before, at 2 and 6 months after the injections. Results: A significant improvement on the WOMAC Index pain subscale was observed at 6 months after the injection. At two months, pain subscale score decreased from 10.34 to 9.34. At six months, a significant decrement in pain parameters compared to baseline was observed (from 10.34 to 7.72; p = 0.0004). Median points on VAS significantly ameliorated after 6 months (from 74.2 to 57.3 cm; p < 0.0001). Regarding physical function, a statistically significant difference compared to baseline was observed at the end of the study (from 29.74 to 25.18; p = 0.0025). WOMAC Index stiffness component did not differ from baseline at any time during follow-up. Conclusions: Pain relief installed with a delayed on-set but had a prolonged duration. The novel hyaluronic acid-based hydrogel (Hymovis®) had effective results, particularly after six months post-injections and offers a therapeutic advancement in the treatment of moderate to severe osteoarthritis.
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Affiliation(s)
- Octav Marius Russu
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (C.T.); (Z.I.-B.); (I.G.); (S.-G.Z.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
| | - Tudor Sorin Pop
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (C.T.); (Z.I.-B.); (I.G.); (S.-G.Z.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
| | - Andrei Marian Feier
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (C.T.); (Z.I.-B.); (I.G.); (S.-G.Z.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
- Correspondence: ; Tel.: +40-2652-13720
| | - Cristian Trâmbițaș
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (C.T.); (Z.I.-B.); (I.G.); (S.-G.Z.)
- Department of Anatomy and Embriology, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania
| | - Zsuzsanna Incze-Bartha
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (C.T.); (Z.I.-B.); (I.G.); (S.-G.Z.)
- Department of Anatomy and Embriology, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania
| | - Paul Gabriel Borodi
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
| | - István Gergely
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (C.T.); (Z.I.-B.); (I.G.); (S.-G.Z.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
| | - Sándor-György Zuh
- Department of Orthopaedics and Traumatology, Clinical County Hospital, 540139 Tîrgu Mureș, Romania; (O.M.R.); (T.S.P.); (C.T.); (Z.I.-B.); (I.G.); (S.-G.Z.)
- Faculty of General Medicine, University of Medicine, Pharmacy, Sciences and Technology, 540139 Tîrgu Mureș, Romania;
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Intra-Articular Injections of Hyaluronic Acid or Steroids Associated With Better Outcomes Than Platelet-Rich Plasma, Adipose Mesenchymal Stromal Cells, or Placebo in Knee Osteoarthritis: A Network Meta-analysis. Arthroscopy 2021; 37:292-306. [PMID: 32305424 DOI: 10.1016/j.arthro.2020.03.041] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 03/26/2020] [Accepted: 03/29/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the clinical effects of hyaluronic acid (HA), steroids, platelet-rich plasma (PRP), or adipose mesenchymal stromal cell (MSC) injections in the treatment of knee osteoarthritis (OA). METHODS Randomized controlled trials with OA of the knee that compared HA, steroids, PRP, adipose MSC, or their combination with placebo or in head-to-head combination were identified from the MEDLINE, EMBASE, Cochrane Library, Web of Science, and SCOPUS databases up to June 30, 2019. We performed a network meta-analysis of the relevant literature to determine whether there was benefit from HA, steroids, PRP, or adipose MSC treatment as compared with placebo. RESULTS A total of 43 trials covering 5554 patients were included. Steroids were ranked most likely to be effective for the management of pain or function, with adipose MSC and multiple PRP appearing least likely to be effective. Although no significant difference was observed among the 6 interventions, except for single PRP with respect to adverse effects, steroids and HA exhibited a lower rate of AEs compared with the placebo. In view of severe adverse effects, only single PRP was superior to placebo. Direct pairwise meta-analysis for pain relief showed that HA was superior to placebo or single PRP, but steroids had a significantly worse effect than single PRP. In addition, direct pairwise meta-analysis for adverse effects favored steroids in comparison to HA. CONCLUSIONS The ranking statistics like surface under the cumulative ranking curve values of our network meta-analysis support the use of steroids and HA for appropriate patients with knee OA. For pain relief and AEs, steroids are most likely the best treatment, followed by HA. Single PRP, multiple PRP, and adipose MSC interventions do not result in a relevant reduction of joint pain nor improvement of joint function compared with placebo. However, treatment effect differences were small and potentially not clinically meaningful, indicating that other factors, such as cost and patient preferences, may be more important in patients with knee OA. LEVEL OF EVIDENCE meta-analysis of non-homogenous randomized controlled trials, Level II.
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27
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Chevalier X, Sheehan B, Whittington C, Pourrahmat MM, Duarte L, Ngai W, de Campos GC. Efficacy and Safety of Hylan G-F 20 Versus Intra-Articular Corticosteroids in People with Knee Osteoarthritis: A Systematic Review and Network Meta-Analysis. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2020; 13:1179544120967370. [PMID: 33281462 PMCID: PMC7691947 DOI: 10.1177/1179544120967370] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 09/22/2020] [Indexed: 12/11/2022]
Abstract
Background: Direct injection of corticosteroids into the joint is a standard treatment
for knee osteoarthritis (OA). However, the treatment is somewhat
controversial with regard to the benefit of both single and repeated
injections; evidence that they are beneficial comes from small studies that
show only modest improvements. The aim of this study was to estimate the
short- and long-term clinical efficacy and safety of hylan G-F 20 versus
intra-articular corticosteroids (IACS) for the treatment of pain in knee OA
using Bayesian network meta-analysis. Methods: Based on a pre-specified protocol, MEDLINE, Embase, and CENTRAL were searched
from inception to June 2018 to identify randomized controlled trials. The
Cochrane Collaboration’s tool for assessing risk of bias in randomized
trials was used to assess the included studies. Hylan G-F 20 and IACS were
compared using Bayesian network meta-analysis. Efficacy was evaluated at 1,
3, and 6 months, and at the final follow-up for safety outcomes. A pain
hierarchy was used to select 1 pain outcome per study. Results: Forty-two trials were included for analysis. The network meta-analysis of
pain showed that hylan G-F 20 may be equivalent to IACS in the short-term,
but by 6 months the benefit relative to IACS was statistically significant,
standardized mean difference (95% credible interval): –0.13 (–0.26, –0.01).
There were no statistical differences in adverse events. Conclusions: Hylan G-F 20 may perform better in relieving pain at 6 months post-injection
compared to IACS. Both agents were relatively well tolerated, with no clear
differences in safety.
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Affiliation(s)
- Xavier Chevalier
- Department of Rheumatology, Hôpital Henri-Mondor, Paris University XII (UPEC), Créteil, France
| | - Brendan Sheehan
- Division of Orthopaedic Surgery, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Craig Whittington
- Doctor Evidence, Santa Monica, CA, USA.,Sanofi, Global Medical, Bridgewater, NJ, USA
| | | | | | - Wilson Ngai
- Sanofi, Global Medical, Bridgewater, NJ, USA
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Sellam J, Courties A, Eymard F, Ferrero S, Latourte A, Ornetti P, Bannwarth B, Baumann L, Berenbaum F, Chevalier X, Ea HK, Fabre MC, Forestier R, Grange L, Lellouche H, Maillet J, Mainard D, Perrot S, Rannou F, Rat AC, Roux CH, Senbel E, Richette P. Recommendations of the French Society of Rheumatology on pharmacological treatment of knee osteoarthritis. Joint Bone Spine 2020; 87:548-555. [PMID: 32931933 DOI: 10.1016/j.jbspin.2020.09.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To establish recommendations for pharmacological treatment of knee osteoarthritis specific to France. METHODS On behalf of the French Society of Rheumatology (SFR), a bibliography group analyzed the literature on the efficacy and safety of each pharmacological treatment for knee osteoarthritis. This group joined a multidisciplinary working group to draw up recommendations. Strength of recommendation and quality of evidence level were assigned to each recommendation. A review committee gave its level of agreement. RESULTS Five general principles were established: 1) need to combine pharmacological and non-pharmacological treatments, 2) personalization of treatment, 3) symptomatic and/or functional aim of pharmacological treatments, 4) need to regularly re-assess the treatments and 5) discussion about arthroplasty if medical treatment fails. Six recommendations involved oral treatments: 1) paracetamol should not necessarily be prescribed systematically and/or continuously, 2) NSAIDs, possibly as first-line, 3) weak opioids, 4) strong opioids, 5) symptomatic slow-acting drugs of osteoarthritis, and 6) duloxetine (off-label use). Two recommendations involved topical agents (NSAIDs and capsaicin<1%). Three recommendations involved intra-articular treatments: corticosteroid or hyaluronic acid injections that can be proposed to patients. The experts did not draw a conclusion about the benefits of platelet-rich plasma injections. CONCLUSION These are the first recommendations of the SFR on the pharmacological treatment of knee osteoarthritis.
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Affiliation(s)
- Jérémie Sellam
- Service de rhumatologie, Assistance Publique-Hôpitaux de Paris (AP-HP), hôpital Saint-Antoine, Sorbonne Université, Inserm UMRS_938, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France.
| | - Alice Courties
- Service de rhumatologie, Assistance Publique-Hôpitaux de Paris (AP-HP), hôpital Saint-Antoine, Sorbonne Université, Inserm UMRS_938, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Florent Eymard
- Service de rhumatologie, Hôpital Henri Mondor, AP-HP, 94000 Créteil, France
| | - Stéphanie Ferrero
- Service de rhumatologie, LAMHESS, université Cote d'Azur, CHU de Nice, 06000 Nice, France
| | - Augustin Latourte
- Service de rhumatologie, hôpital Lariboisière, AP-HP, 75010 Paris, France
| | - Paul Ornetti
- Service de rhumatologie, CHU de Dijon, 21000 Dijon, France
| | | | | | - Francis Berenbaum
- Service de rhumatologie, Assistance Publique-Hôpitaux de Paris (AP-HP), hôpital Saint-Antoine, Sorbonne Université, Inserm UMRS_938, 184, rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Xavier Chevalier
- Service de rhumatologie, Hôpital Henri Mondor, AP-HP, 94000 Créteil, France
| | - Hang Korng Ea
- Service de rhumatologie, hôpital Lariboisière, AP-HP, 75010 Paris, France
| | | | - Romain Forestier
- Centre de recherche rhumatologique et thermale, 73100 Aix-les-Bains, France
| | - Laurent Grange
- Service de rhumatologie, AFLAR, CHU de Grenoble-Alpes, 38000 Grenoble/Paris, France
| | - Henri Lellouche
- Cabinet libéral et service de rhumatologie, hôpital Lariboisière, AP-HP, 75010 Paris, France
| | - Jérémy Maillet
- Service de rhumatologie, hôpital Lariboisière, AP-HP, 75010 Paris, France
| | - Didier Mainard
- Service de chirurgie orthopédique, CHU de Nancy, 54000 Nancy, France
| | - Serge Perrot
- Centre d'évaluation et traitement de la douleur, hôpital Cochin, AP-HP, 75014 Paris, France
| | - François Rannou
- Service de rééducation et de réadaptation de l'appareil locomoteur et des pathologies du Rachis, centre-université de Paris, hôpital Cochin, université de Paris, AP-HP, 75014 Paris, France
| | | | - Christian H Roux
- Service de rhumatologie, LAMHESS, université Cote d'Azur, CHU de Nice, 06000 Nice, France
| | - Eric Senbel
- Cabinet libéral et service de rhumatologie, Hôpital Sainte-Marguerite, 13000, Marseille, France
| | - Pascal Richette
- Service de rhumatologie, hôpital Lariboisière, AP-HP, 75010 Paris, France
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- Faculté de santé, UFR médecine de Paris-Centre, 75006 Paris, France
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Saltzman BM, Frank RM, Davey A, Cotter EJ, Redondo ML, Naveen N, Wang KC, Cole BJ. Lack of standardization among clinical trials of injection therapies for knee osteoarthritis: a systematic review. PHYSICIAN SPORTSMED 2020; 48:266-289. [PMID: 32027200 DOI: 10.1080/00913847.2020.1726716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Purpose: Osteoarthritis (OA) of the knee is a debilitating, expensive, and prevalent disease, and interest in the non-surgical management of knee OA has grown recently. Our objective was to systematically assess the level of heterogeneity among all clinical trials and published studies regarding injections for knee osteoarthritis, in terms of treatment of interest, outcomes evaluated, and time points of outcome assessment. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to review all published studies and publically available clinical trials from 1 January 2013 to 3 May 2019evaluating intra-articular injections to treat knee OA. Their treatment group and specifics of methodology were scrutinized and compared. Results: 84 published studies and 114 clinical trials were included. Within the 84 published studies, the most common injection treatment studied was hyaluronic acid [N = 22; 26.2%]. In total, 29 different injection treatment groups were utilized. The most common time point for patient evaluation post-injection was 6 months (N = 33 studies; 50.0%), and ranged from 1 week (N = 9 studies; 13.6%) to 7 years (N = 1 study; 1.5%). The most common patient-reported outcome (PRO) measure assessed in the included studies was Western Ontario and McMaster's University Osteoarthritis Index (WOMAC) [N = 44 studies; 66.7%]. For the 114 clinical trials identified, the most common injection treatment studied is platelet-rich plasma in isolation (N = 19; 16.7%). Forty-two different injection treatment types/groups are utilized. The most common PRO measure assessed was WOMAC (N = 77 trials; 67.5%). Overall there were 34 different patient-reported outcome measures used. Conclusions: Research efforts to find the most effective injection therapy for knee OA continue with a tremendous number of injection therapies still being evaluated. Substantial heterogeneity exists in these completed and ongoing trials in terms of patient demographics, OA grades, outcome scores and relatively short-term timing of assessments, with no clear standardization of testing protocol despite proposing to answer the same clinical question. We recommend that studies of this genre going forward be standardized in terms of outcome measures and longer-term follow-up time points, and should incorporate functional assessment evaluations and imaging studies.
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Affiliation(s)
- Bryan M Saltzman
- Orthopaedic Surgery, Rush University Medical Center , Chicago, IL, USA
| | - Rachel M Frank
- Orthopaedic Surgery, Rush University Medical Center , Chicago, IL, USA
| | - Annabelle Davey
- Orthopaedic Surgery, Rush University Medical Center , Chicago, IL, USA
| | - Eric J Cotter
- Orthopaedic Surgery, Rush University Medical Center , Chicago, IL, USA
| | - Michael L Redondo
- Orthopaedic Surgery, Rush University Medical Center , Chicago, IL, USA
| | - Neal Naveen
- Orthopaedic Surgery, Rush University Medical Center , Chicago, IL, USA
| | - Kevin C Wang
- Orthopaedic Surgery, Rush University Medical Center , Chicago, IL, USA
| | - Brian J Cole
- Orthopaedic Surgery, Rush University Medical Center , Chicago, IL, USA
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30
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Zhang Y, Chen X, Tong Y, Luo J, Bi Q. Development and Prospect of Intra-Articular Injection in the Treatment of Osteoarthritis: A Review. J Pain Res 2020; 13:1941-1955. [PMID: 32801850 PMCID: PMC7414982 DOI: 10.2147/jpr.s260878] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Accepted: 06/15/2020] [Indexed: 12/19/2022] Open
Abstract
Osteoarthritis (OA) is a common degenerative disease that affects the vast majority of the elderly and may eventually embark on the road of the total knee arthroplasty (TKA), although controversy still exists in the medical community about the best therapies for osteoarthritis. Compared with physical therapy, oral analgesics and other non-operative treatments, intra-articular injection is more safe and effective. Moreover, intra-articular injection is much less invasive and has fewer adverse reactions than surgical treatment. This article reviews mechanism, benefits and adverse reactions of corticosteroids (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), mesenchymal stem cell (MSCs), stromal vascular fraction (SVF) and other new therapies (for example: gene therapy). The application prospect of intra-articular injection was analyzed according to the recent progress in drug research.
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Affiliation(s)
- Yin Zhang
- Department of Orthopedic Surgery, Zhejiang Provincial People's Hospital and People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang 310014, People's Republic of China.,The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui 233004, People's Republic of China
| | - Xinji Chen
- Department of Orthopedic Surgery, Zhejiang Provincial People's Hospital and People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang 310014, People's Republic of China
| | - Yu Tong
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, People's Republic of China
| | - Junchao Luo
- The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, People's Republic of China
| | - Qing Bi
- Department of Orthopedic Surgery, Zhejiang Provincial People's Hospital and People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang 310014, People's Republic of China.,The First Affiliated Hospital of Bengbu Medical University, Bengbu, Anhui 233004, People's Republic of China
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31
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Garza JR, Campbell RE, Tjoumakaris FP, Freedman KB, Miller LS, Santa Maria D, Tucker BS. Clinical Efficacy of Intra-articular Mesenchymal Stromal Cells for the Treatment of Knee Osteoarthritis: A Double-Blinded Prospective Randomized Controlled Clinical Trial. Am J Sports Med 2020; 48:588-598. [PMID: 32109160 DOI: 10.1177/0363546519899923] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Currently, there are limited nonoperative treatment options available for knee osteoarthritis (OA). Cell-based therapies have emerged as promising treatments for knee OA. Autologous stromal vascular fraction (SVF) has been identified as an efficient medium for intra-articular administration of progenitor cells and mesenchymal stem cells derived from adipose tissue. HYPOTHESIS Patients receiving intra-articular SVF would show significantly greater improvement than patients receiving placebo injections, and this improvement would be dose dependent. STUDY DESIGN Randomized controlled trial; Level of evidence, 1. METHODS This was a multisite prospective double-blinded randomized placebo-controlled clinical trial. Adult patients with symptomatic knee OA were eligible. Thirty-nine patients were randomized to high-dose SVF, low-dose SVF, or placebo (1:1:1). SVF was obtained via liposuction, processed to create the cellular implant, and injected during the same clinical visit. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and magnetic resonance images were obtained preoperatively and at 6 and 12 months after injection. The Wilcoxon rank sum nonparametric test was utilized to assess statistical significance, and the Hodges-Lehmann location shift was used to assess superiority. RESULTS The median percentage change in WOMAC score at 6 months after injection for the high-dose, low-dose, and placebo groups was 83.9%, 51.5%, and 25.0%, respectively. The high- and low-dose groups had statistically significant changes in WOMAC scores when compared with the placebo group (high dose, P = .04; low dose, P = .02). The improvements were dose dependent. The median percentage change in WOMAC score from baseline to 1 year after injection for the high-dose, low-dose, and placebo groups was 89.5%, 68.2%, and 0%, respectively. The high- and low-dose groups displayed a greater percentage change at 12 months when compared with the placebo group (high dose, P = .006; low dose, P = .009). Magnetic resonance image review revealed no changes in cartilage thickness after treatment. No serious adverse events were reported. CONCLUSION Intra-articular SVF injections can significantly decrease knee OA symptoms and pain for at least 12 months. The efficacy and safety demonstrated in this placebo-controlled trial support its implementation as a treatment option for symptomatic knee OA. REGISTRATION NCT02726945 (ClinicalTrials.gov identifier).
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Affiliation(s)
- Jaime R Garza
- School of Medicine, Tulane University, New Orleans, Louisiana, USA
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32
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Simental-Mendía M, Lozano-Sepúlveda SA, Pérez-Silos V, Fuentes-Mera L, Martínez-Rodríguez HG, Acosta-Olivo CA, Peña-Martínez VM, Vilchez-Cavazos F. Anti‑inflammatory and anti‑catabolic effect of non‑animal stabilized hyaluronic acid and mesenchymal stem cell‑conditioned medium in an osteoarthritis coculture model. Mol Med Rep 2020; 21:2243-2250. [PMID: 32323772 DOI: 10.3892/mmr.2020.11004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 02/03/2020] [Indexed: 01/15/2023] Open
Abstract
Previous clinical studies have reported the clinical effectiveness of non‑animal stabilized hyaluronic acid (NASHA) and adipose‑derived mesenchymal stromal/stem cells (MSC) in the treatment of knee osteoarthritis (OA). Unlike MSC secreted mediators, in vitro anti‑inflammatory effects of NASHA have not been evaluated. We aimed to evaluate and compare the anti‑inflammatory effect of NASHA and MSC conditioned medium (stem cell‑conditioned medium; SC‑CM), in an explant‑based coculture model of OA. Cartilage and synovial membrane from seven patients undergoing total knee arthroplasty were used to create a coculture system. Recombinant IL‑1β was added to the cocultures to induce inflammation. Four experimental groups were generated: i) Basal; ii) IL‑1β; iii) NASHA (NASHA + IL‑1β); and iv) SC‑CM (SC‑CM + IL‑1β). Glycosaminoglycans (GAG) released in the culture medium and of nitric oxide (NO) production were quantified. Gene expression in cartilage and synovium of IL‑1β, matrix metallopeptidase 13 (MMP13), ADAM metallopeptidase with thrombospondin type 1 motif 5 (ADAMTS5) and tissue inhibitor of metalloproteinases 1 (TIMP1) was measured by reverse transcription‑quantitative PCR. Media GAG concentration was decreased in cocultures with NASHA and SC‑CM (48 h, P<0.05; 72 h, P<0.01) compared with IL‑1β. Production of NO was significantly lower only in SC‑CM after 72 h (P<0.01). In cartilage, SC‑CM inhibited the expression of IL‑1β, MMP13 and ADAMTS5, while NASHA had this effect only in MMP13 and ADAMTS5. In synovium, SC‑CM decreased the expression level of MMP13 and ADAMTS5, while NASHA only decreased ADAMTS5 expression. Both NASHA and SC‑CM increased TIMP1 expression in cartilage and synovium. Treatments with NASHA and SC‑CM were shown to be a therapeutic option that may help counteract the catabolism produced by the inflammatory state in knee OA. The anti‑inflammatory mediators produced by MSC promote a lower expression of inflammatory targets in our study model.
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Affiliation(s)
- Mario Simental-Mendía
- Orthopedics and Traumatology Service, School of Medicine and University Hospital 'Dr. José Eleuterio González', Universidad Autonoma de Nuevo León, Monterrey, Nuevo León 64460, México
| | - Sonia Amelia Lozano-Sepúlveda
- Department of Biochemistry and Molecular Medicine, School of Medicine, Universidad Autonoma de Nuevo León, Monterrey, Nuevo León 64460, México
| | - Vanessa Pérez-Silos
- Department of Biochemistry and Molecular Medicine, School of Medicine, Universidad Autonoma de Nuevo León, Monterrey, Nuevo León 64460, México
| | - Lizeth Fuentes-Mera
- Department of Biochemistry and Molecular Medicine, School of Medicine, Universidad Autonoma de Nuevo León, Monterrey, Nuevo León 64460, México
| | | | - Carlos Alberto Acosta-Olivo
- Orthopedics and Traumatology Service, School of Medicine and University Hospital 'Dr. José Eleuterio González', Universidad Autonoma de Nuevo León, Monterrey, Nuevo León 64460, México
| | - Víctor Manuel Peña-Martínez
- Orthopedics and Traumatology Service, School of Medicine and University Hospital 'Dr. José Eleuterio González', Universidad Autonoma de Nuevo León, Monterrey, Nuevo León 64460, México
| | - Félix Vilchez-Cavazos
- Orthopedics and Traumatology Service, School of Medicine and University Hospital 'Dr. José Eleuterio González', Universidad Autonoma de Nuevo León, Monterrey, Nuevo León 64460, México
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Siu WS, Shum WT, Cheng W, Wong CW, Shiu HT, Ko CH, Leung PC, Lam CWK, Wong CK. Topical application of Chinese herbal medicine DAEP relieves the osteoarthritic knee pain in rats. Chin Med 2019; 14:55. [PMID: 31827595 PMCID: PMC6902578 DOI: 10.1186/s13020-019-0278-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Accepted: 12/03/2019] [Indexed: 12/26/2022] Open
Abstract
Background The potential adverse effects of conventional oral pharmacotherapy of osteoarthritis (OA) restrict their long-term use. Topical application of a Chinese herbal paste for relieving OA knee pain can be effective and safe. However, evidence-based scientific research is insufficient to support its application worldwide. The aim of this study was to investigate the in vivo efficacy of a topical Chinese herbal paste on relieving OA knee pain and its underlying mechanism. Methods An OA rat model was developed by anterior cruciate ligament transection (ACLT) followed by treadmill running. A herbal paste including Dipsaci Radix, Achyranthis Bidentatae Radix, Eucommiae Cortex and Psoraleae Fructus, named as DAEP, was applied topically on the knee joint of the rats (DAEP). The rats without DAEP treatment served as Control. Rats with surgery but without ACLT, treadmill running and DAEP treatment acted as Sham. The morphologic change of the knee joint was observed radiographically. Nociception from the knee of the rats was assessed using Incapacitent test and CatWalk gait system. The therapeutic mechanism was investigated by analyzing the gene and protein expression of inflammatory markers via qPCR and Western blot, respectively. Results Radiographic images showed less destruction at the posterior tibial plateau of the DAEP group compared with the Control after 2 weeks of treatment. The static weight ratio and the gait parameters of the Control were reduced significantly via Incapacitance test and CatWalk gait analysis, respectively. DAEP treatment increased the Print Area and Maximum Intensity significantly compared with the Control. DAEP significantly suppressed the upregulation of gene expression of interleukin (IL)-6, tumor necrosis factor (TNF)-α, and inducible nitric oxide synthase (iNOS). Conclusions DAEP exhibited its effect via the nuclear factor (NF)-κB pathway by suppressing the phosphorylation of IκB kinase αβ (p-IKKαβ) and cyclooxygenase-2 (COX-2) protein expression. This study provides scientific evidence to support the clinical application of the Chinese herbal paste on reliving OA pain.
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Affiliation(s)
- Wing Sum Siu
- 1Institute of Chinese Medicine, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China.,2State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China
| | - Wai Ting Shum
- 1Institute of Chinese Medicine, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China.,2State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China
| | - Wen Cheng
- 1Institute of Chinese Medicine, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China.,2State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China
| | - Chun Wai Wong
- 1Institute of Chinese Medicine, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China.,2State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China
| | - Hoi Ting Shiu
- 1Institute of Chinese Medicine, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China
| | - Chun Hay Ko
- 1Institute of Chinese Medicine, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China
| | - Ping Chung Leung
- 1Institute of Chinese Medicine, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China.,2State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China
| | - Christopher Wai Kei Lam
- Faculty of Medicine and State Key Laboratory of Quality Research in Chinese Medicines, Macau University of Science and Technology, Macau, China
| | - Chun Kwok Wong
- 1Institute of Chinese Medicine, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China.,2State Key Laboratory of Research on Bioactivities and Clinical Applications of Medicinal Plants, The Chinese University of Hong Kong, Shatin, NT Hong Kong SAR, China.,Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT Hong Kong SAR, China.,5Li Dak Sum Yip Yio Chin R & D Centre for Chinese Medicine, The Chinese University of Hong Kong, Hong Kong, China
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Vincent P. Injections intra articulaires (IA) d'acide hyaluronique (AH) dans le traitement symptomatique de la gonarthrose : une méta-analyse des injections uniques (mono-injections). Curr Ther Res Clin Exp 2019; 91:52-65. [PMID: 31871509 PMCID: PMC6911907 DOI: 10.1016/j.curtheres.2019.100569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 10/09/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction La viscosupplémentation du liquide synovial par injections intra articulaires (IA) d'acide hyaluronique (AH), est un traitement symptomatique bien connu dans la gonarthrose. La question se pose de savoir si les traitements par injection unique (mono-injection) peuvent présenter autant d'efficacité que les multi-injections (3 à 5). Méthodes Une méta-analyse des résultats publiés pour les essais de mono-injections IA de AH a été réalisée. Le critère d'efficacité retenu a été le sous-score douleur de l'indice Western Ontario and MacMaster universities (WOMAC A). Toutes les conceptions d'études ont été admises, depuis les essais randomisés contrôlés jusqu'aux études observationnelles ouvertes à simple bras. Une recherche extensive a été effectuée à partir de PubMed, Google, Google Scholar, et des listes de références trouvées dans les méta-analyses récentes, pour obtenir tous les articles publiés avant fin avril 2018. Les profils des populations furent analysés en termes d'âge, de sexe, d'indice de masse corporelle (IMC) et de stade radiologique selon Kellgren-Lawrence (KL). Les résultats d'injection IA unique de placebo, ont été pris en compte pour créer une base permettant des comparaisons post-hoc. Chaque bras AH IA étudié a été comparé à un bras placebo IA (seul ou mixé), de manière à présenter un profil KL similaire, contrôlé à l'aide du test Chi2. Les tailles de l'effet (ES) avec intervalles de confiance (IC 95%) et p-valeurs furent calculées et synthétisées pour chacune des visites de contrôle à 1, 2, 3 et 6 mois. En parallèle, une approche globale a été utilisée afin de représenter les variations par rapport à la baseline, pour chacun des sous-groupes étudiés. Résultats En partant de 1 547 citations, 28 études ont été incluses dans la méta-analyse, décrivant 4 129 patients traités par mono-injection: 3 360 ont reçu de l'AH IA et 769 patients ont reçu du placebo IA. Le patient moyen (SD) traité par AH IA était âgé de 61,2 (9,6) ans dont 63% de femmes, avec un IMC de 28,0 (4,1) kg/m2, et un stade radiologique à 47% KL III pour 3% KL IV. Un bon appariement du profil KL a été obtenu pour 26 des 31 bras AH IA. Sur l'ensemble de la population AH IA, ES = 0,30 (0,25; 0,35) à 3 mois et ES = 0,39 (0,33; 0,44) à 6 mois. Dans une analyse restreinte, après élimination des cas aberrants, des KL mal appariés et des bras actifs < 30 patients, les résultats sont restés inchangés, ES = 0,29 (0,23; 0,34) et ES = 0,40 (0,34; 0,45) à 3 et 6 mois respectivement, tandis que l'hétérogénéité était améliorée. Discussion Il existe certainement des limites à la méthode de comparaison post-hoc versus placebo, appliquée à des essais individuels. Mais pour chaque synthèse par sous-groupe ou groupe, les résultats ont été confirmés en utilisant plusieurs approches statistiques et différentes méthodes de pondération. Cette méta-analyse suggère que les résultats des mono-injections sont similaires à ceux des multi-injections d'acide hyaluronique intra articulaire en termes de soulagement de la douleur, dans le traitement de la gonarthrose.
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Key Words
- AH, Acide Hyaluronique (ou hyaluronate de sodium)
- ES, Taille d'effet (« d » de Cohen)
- IA, Intra articulaire
- IC, Intervalle de Confiance
- IMC, Indice de Masse Corporelle (Kg/m2)
- KL, Kellgren-Lawrence (Echelle radiologique de l'arthrose)
- La viscosupplémentation
- MCID, Différence Minimale Cliniquement Importante
- MD, Différence Moyenne
- MSC, Cellules Souche Mésenchymateuses
- NA, Non disponible (donnée manquante)
- NS, Non significatif
- OA, Ostéoarthrose
- PRGF, Plasma Riche en Facteurs de Croissance
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- PRP, Plasma Riche en Plaquettes
- RCT, Essai Contrôlé Randomisé
- SD, Ecart-type
- SDD, Plus Petite Différence Détectable
- SE, Erreur-type
- SMD, Différence Moyenne Standardisée
- UE, Union Européenne
- VS, Viscosupplémentation
- WOMAC, Western Ontario & McMaster universities
- la gonarthrose
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Affiliation(s)
- Patrice Vincent
- Correspondence to: Patrice Vincent, 9 allée Prométhée, 28000 Chartres, France
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35
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Richardson C, Plaas A, Block JA. Intra-articular Hyaluronan Therapy for Symptomatic Knee Osteoarthritis. Rheum Dis Clin North Am 2019; 45:439-451. [DOI: 10.1016/j.rdc.2019.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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McKee MD, Litchfield R, Hall JA, Wester T, Jones J, Harrison AJ. NASHA hyaluronic acid for the treatment of shoulder osteoarthritis: a prospective, single-arm clinical trial. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2019; 12:227-234. [PMID: 31354368 PMCID: PMC6573776 DOI: 10.2147/mder.s189522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 03/14/2019] [Indexed: 01/22/2023] Open
Abstract
Background: Osteoarthritis of the shoulder or glenohumeral joint is a painful condition that can be debilitating. Intra-articular injection with hyaluronic acid should be considered for patients not responding adequately to physical therapy or anti-inflammatory medication. Methods: This was a single-arm, open-label, prospective study of a single intra-articular injection of NASHA (non-animal hyaluronic acid) in patients with symptomatic glenohumeral osteoarthritis. Patients were followed up for 26 weeks post-treatment, during which time rescue medication with acetaminophen was permissible. The study objective was to demonstrate that a single injection of NASHA is well tolerated with an over-6-month 25% reduction in shoulder pain on movement, assessed using a 100-mm visual analog scale. Results: Forty-one patients were enrolled, all of whom received study treatment. The mean decrease in shoulder pain on movement score over the 6-month study period was −20.1 mm (95% CI: −25.2, −15.0 mm), corresponding to a mean reduction of 29.5% (22.0, 37.0%). Statistically significant improvements were also observed in shoulder pain at night and patient global assessment. There was no clear change over time in the percentage of patients using rescue medication and mean weekly doses were below 3500 mg. Seventeen patients (41.5%) experienced adverse events, all of which were mild or moderate. Two adverse events (both shoulder pain) were deemed related to study treatment. Conclusion: This study provides preliminary evidence that a single injection of NASHA may be efficacious over 6 months and well tolerated in patients with symptomatic glenohumeral osteoarthritis. Larger studies are needed for confirmation.
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Affiliation(s)
- Michael D McKee
- Department of Orthopaedic Surgery, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Robert Litchfield
- Department of Surgery, Fowler Kennedy Sport Medicine Clinical, London, ON, Canada
| | - Jeremy A Hall
- Department of Surgery, St Michael's Hospital, Toronto, ON, Canada
| | - Tawana Wester
- Research and Development, Bioventus LLC, Durham, NC 27703, USA
| | - John Jones
- Research and Development, Bioventus LLC, Durham, NC 27703, USA
| | - Andrew J Harrison
- Research and Development, Bioventus Cooperatief UA, Hoofddorp, Netherlands
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37
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Hayes AJ, Melrose J. Glycosaminoglycan and Proteoglycan Biotherapeutics in Articular Cartilage Protection and Repair Strategies: Novel Approaches to Visco‐supplementation in Orthobiologics. ADVANCED THERAPEUTICS 2019. [DOI: 10.1002/adtp.201900034] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Anthony J. Hayes
- Bioimaging Research HubCardiff School of BiosciencesCardiff University Cardiff CF10 3AX Wales UK
| | - James Melrose
- Graduate School of Biomedical EngineeringUNSW Sydney Sydney NSW 2052 Australia
- Raymond Purves Bone and Joint Research LaboratoriesKolling Institute of Medical ResearchRoyal North Shore Hospital and The Faculty of Medicine and HealthUniversity of Sydney St. Leonards NSW 2065 Australia
- Sydney Medical SchoolNorthernRoyal North Shore HospitalSydney University St. Leonards NSW 2065 Australia
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38
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Younger ASE, Penner M, Wing K, Veljkovic A, Nacht J, Wang Z, Wester T, Harrison A. Nonanimal Hyaluronic Acid for the Treatment of Ankle Osteoarthritis: AProspective, Single-Arm Cohort Study. J Foot Ankle Surg 2019; 58:514-518. [PMID: 30910489 DOI: 10.1053/j.jfas.2018.10.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Indexed: 02/03/2023]
Abstract
Ankle osteoarthritis (OA) can cause disabling symptoms, and some patients prefer to be treated with minimally invasive procedures. Nonanimal hyaluronic acid (NASHA) is a cross-linked hyaluronic acid product that has a prolonged intra-articular residence time. The authors report the first study of NASHA for the treatment of ankle OA. Thirty-seven patients with Kellgren-Lawrence grade II or III ankle OA received an intra-articular injection of NASHA (1 mL). Outcomes included visual analogue scale (VAS) scores for pain and disability. At baseline, the mean VAS pain score was 50.1 ± 14.5mm. During the 26-week follow-up period, the least squares (LS) mean change from baseline in the ankle OA VAS pain score was -20.5mm (95% confidence interval [CI] -25.5 to -15.6 mm), an LS mean percentage reduction of 40.0% (95% CI 30.2% to 49.9%). The LS mean change from baseline in the VAS disability score during 26 weeks was -19.2mm (95% CI -24.8 to -13.6 mm), a percentage reduction of 34% (95% CI 22.3% to 45.7%). Five participants experienced a total of 7 adverse events considered to be related to study treatment (injection site pain, n = 3; injection site joint pain, n = 3; plantar fasciitis, n = 1). This study shows promise for viscosupplementation with NASHA in the treatment of ankle OA. A single injection was associated with clinically meaningful reductions in pain and disability during a 26-week period and, in general, was well tolerated.
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Affiliation(s)
- Alastair S E Younger
- Professor, Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Murray Penner
- Clinical Professor, Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Kevin Wing
- Clinical Professor, Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Andrea Veljkovic
- Associate Clinical Professor, Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Jeff Nacht
- Clinical Associate Professor, Department of Orthopaedics, University of British Columbia, Vancouver, Canada
| | - Zhe Wang
- Statistical Analyst, Bioventus LLC, Durham, NC
| | - Tawana Wester
- Manager for Clinical Affairs, Bioventus LLC, Durham, NC
| | - Andrew Harrison
- Director of Research, Research & Development, Bioventus Cooperatief UA, Hoofddorp, The Netherlands.
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Intra-articular injection of methylprednisolone for reducing pain in knee osteoarthritis: A systematic review and meta-analysis: Retraction. Medicine (Baltimore) 2019; 98:e15902. [PMID: 31124986 PMCID: PMC6571430 DOI: 10.1097/md.0000000000015902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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40
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Vincent P. Intra-Articular Hyaluronic Acid in the Symptomatic Treatment of Knee Osteoarthritis: A Meta-Analysis of Single-Injection Products. Curr Ther Res Clin Exp 2019; 90:39-51. [PMID: 31289603 PMCID: PMC6591794 DOI: 10.1016/j.curtheres.2019.02.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/25/2019] [Indexed: 01/06/2023] Open
Abstract
Background Viscosupplementation of the synovial fluid with intra-articular hyaluronic acid (IA HA) is a well-known symptomatic treatment of knee osteoarthritis. The question arises whether a monoinjection (ie, single injection) could be as efficient as multi-injection (ie, 3-5 injections) regimens. Methods A meta-analysis of published studies relating to IA HA monoinjection trials was performed. The efficacy criterion was the Western Ontario and MacMaster Universities pain subscore. Any study design was accepted, from randomized control trials to single-arm observational open-label studies. An extensive search was performed using PubMed, Google, Google Scholar, and references found in recent meta-analyses, for all articles published before end of April 2018. Population profiles were analyzed in terms of age, sex, body mass index (BMI), and Kellgren-Lawrence (KL) radiology grades. Results of intra-articular single injection of placebo were collected to create a database allowing post hoc comparisons. Each IA HA study arm was compared to an IA placebo arm (either pooled or not), to present a similar KL profile controlled with the χ2 test. The effect size (ES) (95% CI) and P values were calculated and synthesized for each follow-up visit at 1, 2, 3, and 6 months. In parallel, a global approach was used to represent the variations from baseline for each group or subgroup studied. Results From 1547 citations, 28 studies were included in the meta-analysis, representing 4129 patients treated with monoinjection: 3360 received IA HA and 769 patients received IA placebo. The mean (SD) IA HA patient was 61.2 (9.6) years, 63% women, BMI 28.0 (4.1), 47% KL III, and 3% KL IV. A good placebo KL profile matching was obtained for 26 of the 31 IA HA arms. For the whole IA HA population, ES = 0.30 (95% CI, 0.25-0.35) at 3 months and ES = 0.39 (95% CI, 0.33-0.44) at 6 months. In a restricted analysis, after removal of outliers, poorly KL matched and active arms <30 patients, results remained unchanged, ES = 0.29 (95% CI, 0.23-0.34) and ES = 0.40 (95% CI, 0.34-0.45) at 3 and 6 months respectively, whilst heterogeneity was improved. Conclusions There are certainly limits to the post hoc placebo comparison method, for individual studies. But for each synthesis per subgroup or group, the results were properly confirmed using multiple statistical approaches and weighing methods. This meta-analysis suggests that monoinjections produce results similar to multi-injections of IA HA in terms of pain relief in the treatment of knee osteoarthritis. (Curr Ther Res Clin Exp. 2019; 80:XXX-XXX).
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Affiliation(s)
- Patrice Vincent
- LCA Pharmaceutical, 9 allée Prométhée, 28000 Chartres, France
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Maia PAV, Cossich VRA, Salles-Neto JI, Aguiar DP, de Sousa EB. Viscosupplementation improves pain, function and muscle strength, but not proprioception, in patients with knee osteoarthritis: a prospective randomized trial. Clinics (Sao Paulo) 2019; 74:e1207. [PMID: 31778431 PMCID: PMC6844143 DOI: 10.6061/clinics/2019/e1207] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 09/15/2019] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES This study aimed to evaluate the clinical outcomes of intra-articular infiltration with hyaluronic acid and dexamethasone alone and in combination in the treatment of knee osteoarthritis (OA). METHOD This prospective randomized trial evaluated 44 patients undergoing treatment for OA. Patients were selected through clinical and radiological analysis using the American College of Rheumatology criteria. We included patients aged between 50 and 70 years who presented with K-L stage ≤2 knee OA and normal limb alignment. Patients with a previous history of knee injury (ligamentous, meniscal or traumatic), infection, patellofemoral OA or chondroprotective drug use in the previous year were excluded. Participants were randomized into 3 groups and underwent treatment with viscosupplementation (VS, n=16), viscosupplementation plus dexamethasone (VD, n=16) or dexamethasone (DX, n=12). All patients were evaluated before and 6 weeks, 3 months and 6 months after infiltration. Analysis included a physical examination, the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire (total score and domain subscores) and an evaluation of knee extensor and flexor strength and proprioception using an isokinetic dynamometer. RESULTS VS significantly improved the WOMAC total score and subscores for pain, stiffness and function for up to 6 months after infiltration. It also improved knee extensor and flexor strength during the same period. Proprioception was not affected by any of the treatments. CONCLUSIONS VS alone improved pain, stiffness and function according to the WOMAC total score and subscores and improved knee extensor and flexor strength, but not proprioception, for up to six months after infiltration. These findings suggest that VS has a positive effect on quadriceps arthrogenic inhibition.
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Affiliation(s)
| | | | | | - Diego Pinheiro Aguiar
- Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, BR
| | - Eduardo Branco de Sousa
- Instituto Nacional de Traumatologia e Ortopedia Jamil Haddad, Rio de Janeiro, RJ, BR
- *Corresponding author. E-mail:
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Issın A, Koçkara N, Çamurcu İY. Diz osteoartriti olan hastalarda eklem içi poliakrilamid hidrojel ve metilprednizolon asetatın etkinliğinin karşılaştırılması. CUKUROVA MEDICAL JOURNAL 2018. [DOI: 10.17826/cumj.403372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Matas J, Orrego M, Amenabar D, Infante C, Tapia-Limonchi R, Cadiz MI, Alcayaga-Miranda F, González PL, Muse E, Khoury M, Figueroa FE, Espinoza F. Umbilical Cord-Derived Mesenchymal Stromal Cells (MSCs) for Knee Osteoarthritis: Repeated MSC Dosing Is Superior to a Single MSC Dose and to Hyaluronic Acid in a Controlled Randomized Phase I/II Trial. Stem Cells Transl Med 2018; 8:215-224. [PMID: 30592390 PMCID: PMC6392367 DOI: 10.1002/sctm.18-0053] [Citation(s) in RCA: 191] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 10/20/2018] [Indexed: 12/18/2022] Open
Abstract
Knee osteoarthritis (OA) is a leading cause of pain and disability. Although conventional treatments show modest benefits, pilot and phase I/II trials with bone marrow (BM) and adipose‐derived (AD) mesenchymal stromal cells (MSCs) point to the feasibility, safety, and occurrence of clinical and structural improvement in focal or diffuse disease. This study aimed to assess the safety and efficacy of the intra‐articular injection of single or repeated umbilical cord‐derived (UC) MSCs in knee OA. UC‐MSCs were cultured in an International Organization for Standardization 9001:2015 certified Good Manufacturing Practice‐type Laboratory. Patients with symptomatic knee OA were randomized to receive hyaluronic acid at baseline and 6 months (HA, n = 8), single‐dose (20 × 106) UC‐MSC at baseline (MSC‐1, n = 9), or repeated UC‐MSC doses at baseline and 6 months (20 × 106 × 2; MSC‐2, n = 9). Clinical scores and magnetic resonance images (MRIs) were assessed throughout the 12 months follow‐up. No severe adverse events were reported. Only MSC‐treated patients experienced significant pain and function improvements from baseline (p = .001). At 12 months, Western Ontario and Mc Master Universities Arthritis Index (WOMAC‐A; pain subscale) reached significantly lower levels of pain in the MSC‐2‐treated group (1.1 ± 1.3) as compared with the HA group (4.3 ± 3.5; p = .04). Pain Visual Analog scale was significantly lower in the MSC‐2 group versus the HA group (2.4 ± 2.1 vs. 22.1 ± 9.8, p = .03) at 12 months. For total WOMAC, MSC‐2 had lower scores than HA at 12 months (4.2 ± 3.9 vs. 15.2 ± 11, p = .05). No differences in MRI scores were detected. In a phase I/II trial (NCT02580695), repeated UC‐MSC treatment is safe and superior to active comparator in knee OA at 1‐year follow‐up. stem cells translational medicine2019;8:215&224
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Affiliation(s)
- Jose Matas
- Department of Orthopedic Surgery, Universidad de los Andes, Santiago, Chile
| | - Mario Orrego
- Department of Orthopedic Surgery, Universidad de los Andes, Santiago, Chile
| | - Diego Amenabar
- Department of Orthopedic Surgery, Universidad de los Andes, Santiago, Chile
| | | | - Rafael Tapia-Limonchi
- Cells for Cells & Consorcio Regenero, Santiago, Chile.,Program for Translational Research in Cell Therapy, Universidad de los Andes, Santiago, Chile
| | | | - Francisca Alcayaga-Miranda
- Cells for Cells & Consorcio Regenero, Santiago, Chile.,Program for Translational Research in Cell Therapy, Universidad de los Andes, Santiago, Chile.,Laboratory of Nano-Regenerative Medicine, Universidad de los Andes, Santiago, Chile
| | - Paz L González
- Laboratory of Nano-Regenerative Medicine, Universidad de los Andes, Santiago, Chile
| | - Emilio Muse
- Department of Radiology, Clínica Universidad de los Andes, Santiago, Chile
| | - Maroun Khoury
- Cells for Cells & Consorcio Regenero, Santiago, Chile.,Program for Translational Research in Cell Therapy, Universidad de los Andes, Santiago, Chile.,Laboratory of Nano-Regenerative Medicine, Universidad de los Andes, Santiago, Chile
| | - Fernando E Figueroa
- Program for Translational Research in Cell Therapy, Universidad de los Andes, Santiago, Chile.,Laboratory of Nano-Regenerative Medicine, Universidad de los Andes, Santiago, Chile.,Department of Rheumatology, Universidad de los Andes, Santiago, Chile
| | - Francisco Espinoza
- Cells for Cells & Consorcio Regenero, Santiago, Chile.,Program for Translational Research in Cell Therapy, Universidad de los Andes, Santiago, Chile.,Department of Rheumatology, Universidad de los Andes, Santiago, Chile
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Gregori D, Giacovelli G, Minto C, Barbetta B, Gualtieri F, Azzolina D, Vaghi P, Rovati LC. Association of Pharmacological Treatments With Long-term Pain Control in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis. JAMA 2018; 320:2564-2579. [PMID: 30575881 PMCID: PMC6583519 DOI: 10.1001/jama.2018.19319] [Citation(s) in RCA: 186] [Impact Index Per Article: 31.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
IMPORTANCE Even though osteoarthritis is a chronic and progressive disease, pharmacological agents are mainly studied over short-term periods, resulting in unclear recommendations for long-term disease management. OBJECTIVE To search, review, and analyze long-term (≥12 months) outcomes (symptoms, joint structure) from randomized clinical trials (RCTs) of medications for knee osteoarthritis. DATA SOURCES AND STUDY SELECTION The databases of MEDLINE, Scopus, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials were searched until June 30, 2018 (MEDLINE alerts through August 31, 2018) for RCTs of patients with knee osteoarthritis that had treatment and follow-up lasting 1 year or longer. DATA EXTRACTION AND SYNTHESIS Data at baseline and at the longest available treatment and follow-up of 12 months' duration or longer (or the change from baseline) were extracted. A Bayesian random-effects network meta-analysis was performed. MAIN OUTCOMES AND MEASURES The primary outcome was the mean change from baseline in knee pain. Secondary outcomes were physical function and joint structure (the latter was measured radiologically as joint space narrowing). Standardized mean differences (SMDs) and mean differences with 95% credibility intervals (95% CrIs) were calculated. Findings were interpreted as associations when the 95% CrIs excluded the null value. RESULTS Forty-seven RCTs (22 037 patients; mean age range, mostly 55-70 years; and a higher mean proportion of women than men, around 70%) included the following medication categories: analgesics; antioxidants; bone-acting agents such as bisphosphonates and strontium ranelate; nonsteroidal anti-inflammatory drugs; intra-articular injection medications such as hyaluronic acid and corticosteroids; symptomatic slow-acting drugs in osteoarthritis such as glucosamine and chondroitin sulfate; and putative disease-modifying agents such as cindunistat and sprifermin. Thirty-one interventions were studied for pain, 13 for physical function, and 16 for joint structure. Trial duration ranged from 1 to 4 years. Associations with decreases in pain were found for the nonsteroidal anti-inflammatory drug celecoxib (SMD, -0.18 [95% CrI, -0.35 to -0.01]) and the symptomatic slow-acting drug in osteoarthritis glucosamine sulfate (SMD, -0.29 [95% CrI, -0.49 to -0.09]), but there was large uncertainty for all estimates vs placebo. The association with pain improvement remained significant only for glucosamine sulfate when data were analyzed using the mean difference on a scale from 0 to 100 and when trials at high risk of bias were excluded. Associations with improvement in joint space narrowing were found for glucosamine sulfate (SMD, -0.42 [95% CrI, -0.65 to -0.19]), chondroitin sulfate (SMD, -0.20 [95% CrI, -0.31 to -0.07]), and strontium ranelate (SMD, -0.20 [95% CrI, -0.36 to -0.05]). CONCLUSIONS AND RELEVANCE In this systematic review and network meta-analysis of studies of patients with knee osteoarthritis and at least 12 months of follow-up, there was uncertainty around the estimates of effect size for change in pain for all comparisons with placebo. Larger RCTs are needed to resolve the uncertainty around efficacy of medications for knee osteoarthritis.
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Affiliation(s)
- Dario Gregori
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Clara Minto
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | | | - Francesca Gualtieri
- Scientific Information and Library Services, Rottapharm Biotech, Monza, Italy
| | - Danila Azzolina
- Unit of Biostatistics, Epidemiology, and Public Health, Department of Cardiac, Thoracic, and Vascular Sciences, University of Padova, Padova, Italy
| | - Paola Vaghi
- Department of Biostatistics, Rottapharm Biotech, Monza, Italy
| | - Lucio C. Rovati
- Department of Clinical Research, Rottapharm Biotech, Monza, Italy
- School of Medicine and Surgery, University of Milano – Bicocca, Monza, Italy
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Altman R, Hackel J, Niazi F, Shaw P, Nicholls M. Efficacy and safety of repeated courses of hyaluronic acid injections for knee osteoarthritis: A systematic review. Semin Arthritis Rheum 2018; 48:168-175. [DOI: 10.1016/j.semarthrit.2018.01.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 01/11/2018] [Accepted: 01/16/2018] [Indexed: 12/12/2022]
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Li Q, Qi X, Zhang Z. Intra-articular oxygen-ozone versus hyaluronic acid in knee osteoarthritis: A meta-analysis of randomized controlled trials. Int J Surg 2018; 58:3-10. [PMID: 30170178 DOI: 10.1016/j.ijsu.2018.08.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 08/14/2018] [Accepted: 08/20/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Knee osteoarthritis (OA) is a common disease, imposing a great burden through pain and decreased function. Numerous methods have been tested for pain management in knee OA and the optimal method is currently still under debate. We performed a meta-analysis from randomized controlled trials (RCTs) to compare the efficacy and safety of intra-articular hyaluronic acid (HA) and oxygen-ozone in the treatment of knee OA. METHODS Electronic databases included PubMed, Embase, web of science and the Cochrane Library. High quality RCTs comparing HA with oxygen-ozone in the treatment of knee OA were selected. We assessed statistical heterogeneity for each RCT with the use of a standard Chi2 test and the I2 statistic. Quality assessment was performed by using Cochrane Collaboration's tool. All data were carried out with Stata 14.0 software. RESULTS A total of four RCTs including 289 patients were included. The present meta-analysis indicated that there was a significant difference between groups regarding the visual analog scale (VAS) and WOMAC stiffness and function. The improvements in WOMAC pain were similar. No significant difference in adverse events occurrence was observed. CONCLUSION Intra-articular injection of HA was associated with a significantly reduction in VAS score at 1st month compared to oxygen-ozone. And there was significant differences in WAMAC stiffness, and function at 6-month follow-up between groups. Based on the current evidence available, more RCTs are needed for further investigation.
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Affiliation(s)
- Qingsong Li
- Department of Orthopedics, Taizhou People's Hospital, Taizhou, 225300, China
| | - Xin Qi
- Department of Bone and Joint, First Hospital of Jilin University, Changchun, 130021, China
| | - Zhenxiang Zhang
- Department of Bone and Joint, Taizhou People's Hospital, Taizhou, 225300, China.
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Leighton R, Fitzpatrick J, Smith H, Crandall D, Flannery CR, Conrozier T. Systematic clinical evidence review of NASHA (Durolane hyaluronic acid) for the treatment of knee osteoarthritis. Open Access Rheumatol 2018; 10:43-54. [PMID: 29849470 PMCID: PMC5967379 DOI: 10.2147/oarrr.s162127] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Pain and limitations in joint mobility associated with knee osteoarthritis (OA) are clinically challenging to manage, and advanced progression of disease can often lead to total knee arthroplasty. Intra-articular injection of hyaluronic acid (HA), also referred to as viscosupplementation, is a non-surgical treatment approach for OA, the effectiveness of which may depend on the HA composition, and the length of time over which it resides in the joint. One of the available options for such therapies includes NASHA (Durolane HA), a non-animal, biofermentation-derived product, which is manufactured using a process that stabilizes the HA molecules to slow down their rate of degradation and produce a unique formulation with a terminal half-life of ~1 month. The objectives of the current review were to assess, in patients with OA of the knee, the efficacy and safety of intra-articular treatment with NASHA relative to control (saline) injections, other HA products, and other injectables (corticosteroids, platelet-rich plasma, mesenchymal stem cells). Methods This systematic evidence review examines patient outcomes following NASHA treatment as described in published data from studies conducted in subjects with knee OA. A Preferred Reporting Items for Systematic Reviews and Meta-analyses-compliant literature search strategy yielded 11 eligible clinical studies with a variety of comparator arms. Outcomes assessed at various time points following intra-articular treatment included measures of pain, function, quality of life, and incidence of treatment-related adverse events (AEs). Results The available evidence reported for the clinical studies assessed demonstrates sustained and effective relief of knee OA symptoms following a single injection of NASHA. In addition, an excellent biocompatibility profile is observed for NASHA as an intra-articular therapy for OA, as reflected by the low rate of AEs associated with treatment. Conclusion Treatment with NASHA is an effective and safe single-injection procedure, which can be beneficial in the clinical management of knee OA.
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Affiliation(s)
- Ross Leighton
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - Jane Fitzpatrick
- Sports Medicine Professionals Pty Ltd, Richmond, VIC, Australia.,University of Western Australia, Perth, WA, Australia
| | | | | | | | - Thierry Conrozier
- Department of Rheumatology, Hospital Nord Franche-Comte, Belfort, France
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Mixed Treatment Comparisons for Nonsurgical Treatment of Knee Osteoarthritis: A Network Meta-analysis. J Am Acad Orthop Surg 2018; 26:325-336. [PMID: 29688920 DOI: 10.5435/jaaos-d-17-00318] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION Knee osteoarthritis (KOA) is a significant health problem with lifetime risk of development estimated to be 45%. Effective nonsurgical treatments are needed for the management of symptoms. METHODS We designed a network meta-analysis to determine clinically relevant effectiveness of nonsteroidal anti-inflammatory drugs, acetaminophen, intra-articular (IA) corticosteroids, IA platelet-rich plasma, and IA hyaluronic acid compared with each other as well as with oral and IA placebos. We used PubMed, EMBASE, and Cochrane Central Register of Controlled Trials to perform a systematic search of KOA treatments with no date limits and last search on October 7, 2015. Article inclusion criteria considered the following: target population, randomized controlled study design, English language, human subjects, treatments and outcomes of interest, ≥30 patients per group, and consistent follow-up. Using the best available evidence, two abstractors independently extracted pain and function data at or near the most common follow-up time. RESULTS For pain, all active treatments showed significance over oral placebo, with IA corticosteroids having the largest magnitude of effect and significant difference only over IA placebo. For function, no IA treatments showed significance compared with either placebo, and naproxen was the only treatment showing clinical significance compared with oral placebo. Cumulative probabilities showed naproxen to be the most effective individual treatment, and when combined with IA corticosteroids, it is the most probable to improve pain and function. DISCUSSION Naproxen ranked most effective among conservative treatments of KOA and should be considered when treating pain and function because of its relative safety and low cost. The best available evidence was analyzed, but there were instances of inconsistency in the design and duration among articles, potentially affecting uniform data inclusion.
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Louis ML, Magalon J, Jouve E, Bornet CE, Mattei JC, Chagnaud C, Rochwerger A, Veran J, Sabatier F. Growth Factors Levels Determine Efficacy of Platelets Rich Plasma Injection in Knee Osteoarthritis: A Randomized Double Blind Noninferiority Trial Compared With Viscosupplementation. Arthroscopy 2018; 34:1530-1540.e2. [PMID: 29366744 DOI: 10.1016/j.arthro.2017.11.035] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the noninferiority of a single platelet-rich plasma (PRP) injection compared with hyaluronic acid (HA), to alleviate pain and enhance functional capacity in knee osteoarthritis, and identify biological characteristics of PRP that may affect their efficacy. METHODS Fifty-four patients with symptomatic knee osteoarthritis received a single injection of either PRP (26 patients) or HA (28 patients). They were assessed at baseline and at 1, 3, and 6 months. The primary endpoint was the change in Western Ontario and McMaster Universities Arthritis Index (WOMAC) score at 3 months, and secondary endpoints were responders' rate (improvement of at least 5 points or 40% of WOMAC total score at 3 months) of pain evaluation and patient's subjective satisfaction. Cell counts and the contents of vascular endothelial growth factor (VEGF), platelet-derived growth factor-AB (PDGF-AB), transforming growth factor beta 1 (TGF-β1) content of injected PRP were assessed to analyze their relationship with clinical outcome. RESULTS Both treatments proved their improvement in knee functional status and symptom relief, with a significant decrease observed at 1 month on all scores except for pain VAS in PRP group and WOMAC function score in the HA group. No difference between groups regarding WOMAC and VAS scores was observed. A higher percentage of responders was observed in the PRP group (72.7%) than in the HA group (45.8%) without significance (P = .064). The quantity of injected PDGF-AB and TGF-β1 correlated with the change in WOMAC scores at 3 months and was lower in responders than in nonresponders (P = .009 and P = .003, respectively). CONCLUSIONS Current results indicated that a single injection of very pure PRP offers a significant clinical improvement in the management of knee osteoarthritis, equivalent to a single HA injection in this patient population. Moreover, a significant correlation between the doses of TGF-β1 and PDGF-AB and the worsening of WOMAC score 3 months after the procedure was found. LEVEL OF EVIDENCE Level II, randomized double blind controlled trial.
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Affiliation(s)
- Marie Laure Louis
- Orthopedic Department, Hôpital Nord, AP-HM, Marseille, France; ICOS, Sport and Orthopedics Surgery Institute, Marseille, France
| | - Jeremy Magalon
- Cell Therapy Laboratory, Hôpital de la Conception, AP-HM, INSERM CIC BT 1409, Marseille, France; Hematology and Vascular Biology Department, Hôpital de la Conception, AP-HM, Marseille, France; Vascular Research Center of Marseille, Aix-Marseille University, INSERM UMR 1076, Marseille, France.
| | - Elizabeth Jouve
- Unité de Pharmacométrie CIC-CPCET, Service de Pharmacologie Clinique et Pharmacovigilance, Hôpital de la Timone, AP-HM, Marseille, France
| | | | | | | | | | - Julie Veran
- Unité de Pharmacométrie CIC-CPCET, Service de Pharmacologie Clinique et Pharmacovigilance, Hôpital de la Timone, AP-HM, Marseille, France
| | - Florence Sabatier
- Unité de Pharmacométrie CIC-CPCET, Service de Pharmacologie Clinique et Pharmacovigilance, Hôpital de la Timone, AP-HM, Marseille, France; Hematology and Vascular Biology Department, Hôpital de la Conception, AP-HM, Marseille, France; Vascular Research Center of Marseille, Aix-Marseille University, INSERM UMR 1076, Marseille, France
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Ran J, Yang X, Ren Z, Wang J, Dong H. Comparison of intra-articular hyaluronic acid and methylprednisolone for pain management in knee osteoarthritis: A meta-analysis of randomized controlled trials. Int J Surg 2018; 53:103-110. [DOI: 10.1016/j.ijsu.2018.02.065] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2018] [Revised: 02/22/2018] [Accepted: 02/28/2018] [Indexed: 01/07/2023]
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