Intra-articular corticosteroids and the risk of knee osteoarthritis progression: results from the Osteoarthritis Initiative

Therapeutic potential of SOX family transcription factors in osteoarthritis

BACKGROUND

As the worldwide population ages, osteoarthritis has significantly increased. This musculoskeletal condition has become a pressing global health issue and thus, prevention and treatment of osteoarthritis have become the primary focus of domestic and international research. Scholarly investigations of the molecular mechanisms that are related to the occurrence and development of osteoarthritis have shed light on the pathological causes of this condition to a certain extent, providing a foundation for its prevention and treatment. However, further research is necessary to fully understand the critical role of the transcription factor SOX9 in chondrocyte differentiation and the development of osteoarthritis. As a result, there has been widespread interest in SOX transcription factors. While SOX9 has been utilized as a biomarker to indicate the occurrence and prognosis of osteoarthritis, investigations into other members of the SOX family and the development of targeted treatments around SOX9 are still required.

PURPOSE

This article considers the impact of the SOX protein on the development and inhibition of osteoarthritis and highlights the need for therapeutic approaches targeting SOX9, as supported by existing research.

RESULTS

SOX9 can contribute to the process of osteoarthritis through acetylation and ubiquitination modifications. The regulation of the WNT signalling pathway, Nrf2/ARE signalling pathway, NF-κB signalling pathway and SOX9 is implicated in the emergence of osteoarthritis. Non-coding RNA may play a role in the onset and progression of osteoarthritis by modulating various SOX family members, including SOX2, SOX4, SOX5, SOX6, SOX8, SOX9 and SOX11.

CONCLUSION

SOX9 has the capability of mitigating the onset and progression of osteoarthritis through means such as medication therapy, stem cell therapy, recombinant adeno-associated virus (rAAV) vector therapy, physical therapy and other approaches.

Intra-articular Knee Injections and Progression of Knee Osteoarthritis: Data from the Osteoarthritis Initiative

Background At least 10% of all patients with knee osteoarthritis (OA) undergo treatment with injectable corticosteroids or hyaluronic acid (HA). Although both have been shown to help with symptomatic pain relief, their long-term effects on knee OA progression remain inconclusive. Purpose To investigate the association between intra-articular knee injections, specifically corticosteroids and HA, and OA progression using a detailed whole-joint semiquantitative MRI evaluation and clinical outcomes for a period of 2 years. Materials and Methods This secondary analysis uses data from the Osteoarthritis Initiative (OAI), a multicenter, longitudinal, prospective study (February 2004 to January 2015). Participants who received a reported injection of corticosteroid or HA and propensity-score-matched controls (on age, sex, body mass index [calculated as weight in kilograms divided by height in meters squared], and clinical variables) were analyzed. Using the Whole-Organ MRI Score (WORMS) system for cartilage, bone marrow lesions, and meniscus, 3-T MRI performed at the time of injection, 2 years prior, and 2 years after were semiquantitatively graded. Postinjection progression was quantified using WORMS difference between time of injection and the 2-year follow-up. Associations with injection type were analyzed using repeated measures of analysis of covariance. Results There were 210 participants analyzed (mean age, 64 years ± 7.9 years [SD]; 126 female participants). Corticosteroids were associated with greater WORMS progression compared with controls (mean difference, 0.39; 95% CI: 0.05, 0.75; P = .02) and HA (0.42; 95% CI: 0.01, 0.84; P = .04). HA was associated with decreased WORMS progression compared with the injection-concurrent time frame (mean difference, -0.42; 95% CI: -1.34, -0.28; P = .003). Both corticosteroids (mean difference in Western Ontario and McMaster Universities Osteoarthritis Index scores, -5.20; 95% CI: -6.91, -3.48; P = .001) and HA injections (-2.15; 95% CI: -4.42, -0.13; P = .04) were associated with reduced pain after injection. Conclusion Corticosteroid injections were associated with higher OA progression than HA injections and controls, whereas HA was associated with decreased progression at MRI for up to 2 years after injection. ClinicalTrials.gov Identifier: NCT00080171 © RSNA, 2025.

Corticosteroids versus platelet-rich plasma injections for knee osteoarthritis: Where is there more evidence? A systematic review of 60 years of literature

BACKGROUND

Corticosteroid (CS) injections are often recommended by international societies for knee osteoarthritis (OA) treatment, but platelet-rich plasma (PRP) has shown higher safety and efficacy in comparative analyses. Despite this, PRP use is often not endorsed by scientific societies due to perceived insufficient body of evidence. This study aims to quantify clinical data documenting CS and PRP intra-articular injections for knee OA.

METHODS

A systematic review of the literature was conducted on CS and PRP injections for knee OA. The search, performed in March 2024, used PubMed, Cochrane, and Web of Science databases, following PRISMA and Cochrane guidelines. Data collected included publication trends, number of articles, patients evaluated, and study designs documenting CS or PRP injections.

RESULTS

Of 16,979 records, 356 studies were analyzed, covering 24,435 knee OA patients. Both treatments showed an increasing publication trend, with PRP surpassing CS in 2020. The analysis included 9,322 CS patients and 15,113 PRP patients. Among CS studies, there were 103 RCTs with 5,478 patients, 18 comparative studies with 1,095 patients, and 31 case series with 2,749 patients. Among PRP studies, there were 119 RCTs with 6,028 patients, 33 comparative studies with 2,011 patients, and 72 case series with 7,074 patients.

CONCLUSIONS

PRP injections for knee OA have been documented in more studies and in larger patient numbers compared with CS injections. The higher number of high-level trials for PRP, combined with the lower safety and efficacy documented for CS by previous meta-analyses directly comparing the two products, strongly suggests reconsidering current guidelines that favor CS, highlighting PRP's body of evidence and the potential role in the effective and safe treatment of knee OA.

Intra-articular MM-II for the treatment of knee osteoarthritis pain: Efficacy and safety results from a 26-week, phase 2b, placebo-controlled, double-blind, randomized dose-ranging trial

OBJECTIVE

Determine optimal dose, efficacy, and safety of MM-II, a suspension of large empty liposomes, for knee osteoarthritis (OA) pain.

METHOD

A double-blind phase 2b study (NCT04506463) randomized participants 3:3:3:1:3:1 to one intra-articular injection of 1, 3, or 6 mL MM-II or 1, 3, or 6 mL placebo, respectively. Inclusion criteria included age ≥40 years and radiographic and symptomatic knee OA. The primary endpoint was change from baseline in Western Ontario and McMaster Universities OA Index (WOMAC) pain (range, 0-4) 12 weeks post-injection (multiplicity-adjusted). Secondary endpoints included weekly average of daily knee pain (WADP), WOMAC pain at other visits, WOMAC function, patient global assessment (PtGA), and rescue medication use. Safety was assessed by treatment-emergent adverse events (TEAEs).

RESULTS

Overall, 396 participants received treatment. In the 3 mL MM-II vs placebo group, WOMAC pain numerically improved at week 12 (least squares mean difference [95% confidence interval], -0.24 [-0.48, 0.00]; unadjusted P = 0.047; multiplicity-adjusted P = 0.085 [primary endpoint not met]). In the same 3 mL group, WADP showed improvements at week 12 (-10.9 [-18.9, -2.8]) lasting through week 26 (-11.8 [-20.4, -3.3]; unadjusted P <0.01 at both time points). Numeric improvements were also seen in WOMAC function from week 8-26, and PtGA at weeks 16 and 26. Rescue medication use with 3 mL MM-II was consistent with reduced pain. Results were numerically superior with 3 mL MM-II vs 1 mL MM-II; 6 mL MM-II was the least efficacious dose. MM-II was well tolerated, with low TEAE incidence.

CONCLUSION

MM-II was safe, and the optimal effective dose for the treatment of knee OA pain was 3 mL.

Dexamethasone: a double-edged sword in the treatment of osteoarthritis

Glucocorticoids are widely used to manage osteoarthritis (OA) symptoms, but long-term safety concerns exist. This study investigates the therapeutic potential of dexamethasone (DEX) and triamcinolone acetonide (TA) in chondrocytes, evaluating their anti-inflammatory effects and potential detrimental actions. This study evaluated the effects of DEX and TA on the expression of pro-inflammatory genes in inflamed chondrocytes. In addition, the effects of DEX treatment on chondrocytes were analyzed using next-generation sequencing, high-resolution mass spectrometry, proliferation and metabolic rate, wound healing capacity and senescence-associated B-galactosidase assays. A single therapeutic dose of DEX (40nM) effectively reduced the expression of inflammatory genes in chondrocytes, while TA showed no such effect. DEX significantly reduced inflammation but also ECM production in inflamed chondrocytes. At 24 h, DEX treatment led to 168 differentially expressed genes (DEGs) compared to untreated inflamed cells, decreasing to 5 DEGs by 48 h, indicating a rapidly diminishing anti-inflammatory effect. Conversely, the difference between DEX-treated and healthy cells increased over time, from 666 DEGs at 24 h to 1317 DEGs at 48 h. Pathway analysis revealed potential disruptions in cell cycle, mitosis, and ECM homeostasis in DEX-treated cells compared to both healthy and inflamed controls. Interestingly, repeated DEX administration at both a therapeutic (40nM) and a high dose (1µM) induced senescence in healthy cells but not in inflamed cells. In contrast, repeated high-dose DEX reduced apoptosis marker Caspase 3/7 in inflamed but not healthy cells. Despite the transient suppression of inflammation achieved with DEX treatment, the observed decrease in ECM production and induction of senescence in healthy chondrocytes at therapeutic doses, along with apoptosis in inflamed cells at higher doses, underscore the need for caution in its intra-articular administration.

Effect of intra-articular corticosteroid injections for knee osteoarthritis on the rates of subsequent knee replacement and post-operative outcomes: a national cohort study of England

BACKGROUND

Intra-articular corticosteroid injection (IACI) is an established treatment option for uncontrolled pain in osteoarthritis. There is a lack of longer-term follow-up in most studies of the effects of IACI, meaning there is scarcity of data on the impact of IACI on the subsequent need for joint replacement. Our aim was to assess the effect of IACI for knee osteoarthritis on the subsequent incidence of knee replacement surgery and on associated post-operative outcomes.

METHODS

We conducted a cohort study of knee osteoarthritis patients registered in the Clinical Practice Research Datalink (CPRD) GOLD database with an incident diagnosis between 2005 and 2019. Exposure was single or repeated IACI use, analysed separately. The primary outcome was knee replacement during 1-year and 5-year follow-ups. Secondary outcomes included post-operative patient-reported outcome measures and adverse events. Primary analyses used general practitioner practice preference for IACI as an instrumental variable given this methodology can account for strong and unmeasured confounding. Secondary analyses used propensity score matching, accounting for measured covariates only.

RESULTS

During 1-year follow-up, 1628/33,357 (4.9%) knee osteoarthritis patients underwent knee replacement, for which single IACI was associated with lower risk, which persisted to 5-year follow-up (incidence rate ratio: 0.52 [0.36, 0.77]). Conversely, in secondary propensity score analyses no association was found between IACI use and knee replacement rate at 1-year follow-up, and an estimated increased rate of knee replacement at 5-year follow-up. Use of IACI pre-joint replacement was not associated with any adverse post-operative outcomes, for example, 1-year complication rates (per 100 person-years) following knee replacement were 4.6 (3.8, 5.8), 4.0 (2.7, 6.0) and 5.0 (3.1, 8.1) among patients with no, single and repeat pre-joint replacement IACI use, respectively.

CONCLUSIONS

Findings from our main analysis suggest that short-term pain reduction following IACI for knee osteoarthritis may translate to lower rates of knee replacement over 5 years follow-up, although contradictory associations were observed in secondary analyses which likely reflected residual confounding by indication. Reassuringly, IACI use before knee replacement was not associated with post-operative adverse outcomes.

Evaluation of radiographic knee OA progression after arthroscopic meniscectomy compared with IACI for degenerative meniscus tear

The intra-articular corticosteroid injection (IACI) and arthroscopic partial meniscectomy (APM) are crucial treatment options for meniscus tears and are widely used in clinical practice. To determine whether there are differences in the progression of osteoarthritis (OA) after APM and IACI treatments for degenerative meniscal tears, and to identify the influencing factors. We finally collected the minimum joint space width (JSW), WOMAC score, and KOOS score of 189 patients after 4 years of follow-up. The mixed effects model and general estimating equation were used to analyze the differences in the progression of knee osteoarthritis and the factors affecting the progression of knee osteoarthritis in patients with degenerative meniscus tears who received different treatments. Over a 48-month follow-up period, all three groups showed a decreasing trend in knee JSW, with the IACI group having the fastest JSW decline rate at -0.020 mm/month (95% CI: -0.027 to -0.013, p < 0.01). There was no statistically significant difference in the JSW decline rate among the three groups. The WOMAC total scores for both the IACI and APM groups showed an improving trend, at -0.123/month (95% CI: -0.211 to -0.036, p < 0.01) and - 0.115/month (95% CI: -0.201 to -0.028, p < 0.01) respectively, with no statistical difference between the two groups. BMI was also a significant factor affecting postoperative JSW (regression coefficients: -0.012, 95% CI: -0.022 to 0.001, p = 0.03) and WOMAC total scores (regression coefficients: 0.189, 95% CI: 0.008 to 0.370, p = 0.04). Compared to single IACI, multiple IACI treatments resulted in faster JSW decline (B: 0.430, 95% CI: 1.012 to 2.336, p = 0.04). Patients with degenerative meniscal tears who undergo either IACI or APM treatment exhibit more pronounced progression of knee osteoarthritis compared to those in the non-treatment group. This form of deterioration is mainly driven by BMI.

The Current Status and Future Prospects of Intra-articular Injection Therapy for Hip Osteoarthritis: A Review

PURPOSE OF REVIEW

Hip osteoarthritis constitutes a prevalent condition among individuals aged 55 and above, serving as one of the primary triggers for joint discomfort and impairment, and marking a substantial origin of chronic pain particularly affecting the elderly population. Our article provides an exhaustive summary of the mechanisms of action, therapeutic efficacy, and potential adverse consequences associated with novel therapeutic modalities including glucocorticoids, hyaluronic acid, platelet-rich plasma, mesenchymal stem cells, and stromal vascular fraction. Concurrently, we conducted a comprehensive evaluation of the clinical efficacy and potential applications of various medications.

RECENT FINDINGS

In comparison to physical therapy, oral analgesics, and other nonsurgical modalities, intra-articular injection therapy is characterized by enhanced safety and greater efficacy. Moreover, when contrasted with surgical intervention, intra-articular injection demonstrates a lower degree of invasiveness and incurs fewer adverse reactions. Intra-articular treatments have shown excellent local efficacy while significantly minimizing adverse reactions in patients. These methods hold significant potential for development but require comprehensive research and thorough discussion within the academic community.

Use and safety of corticosteroid injections in joints and musculoskeletal soft tissue: guidelines from the American Society of Regional Anesthesia and Pain Medicine, the American Academy of Pain Medicine, the American Society of Interventional Pain Physicians, and the International Pain and Spine Intervention Society

BACKGROUND

Intra-articular corticosteroid (IACS) injection and peri-articular corticosteroid injection are commonly used to treat musculoskeletal conditions. Results vary by musculoskeletal region, but most studies report short-term benefit with mixed results on long-term relief. Publications showed adverse events from single corticosteroid injections. Recommended effective doses were lower than those currently used by clinicians.

METHODS

Development of the practice guideline for joint injections was approved by the Board of Directors of the American Society of Regional Anesthesia and Pain Medicine and the participating societies. A Corticosteroid Safety Work Group coordinated the development of three guidelines: peripheral nerve blocks and trigger points; joints; and neuraxial, facet, and sacroiliac joint injections. The topics included safety of the technique in relation to landmark-guided, ultrasound-guided, or radiology-aided injections; effect of the addition of the corticosteroid on the efficacy of the injectate; and adverse events related to the injection. Experts on the topics were assigned to extensively review the literature and initially develop consensus statements and recommendations. A modified version of the US Preventive Services Task Force grading of evidence and strength of recommendation was followed. A modified Delphi process was adhered to in arriving at a consensus.

RESULTS

This guideline focuses on the safety and efficacy of corticosteroid joint injections for managing joint chronic pain in adults. The joints that were addressed included the shoulder, elbow, hand, wrist, hip, knee, and small joints of the hands and feet. All the statements and recommendations were approved by all participants and the Board of Directors of the participating societies after four rounds of discussion. There is little evidence to guide the selection of one corticosteroid over another. Ultrasound guidance increases the accuracy of injections and reduces procedural pain. A dose of 20 mg triamcinolone is as effective as 40 mg for both shoulder IACS and subacromial subdeltoid bursa corticosteroid injections. The commonly used dose for hip IACS is 40 mg triamcinolone or methylprednisolone. Triamcinolone 40 mg is as effective as 80 mg for knee IACS. Overall, IACS injections result in short-term pain relief from a few weeks to a few months. The adverse events include an increase in blood glucose, adrenal suppression, detrimental effect on cartilage lining the joint, reduction of bone mineral density, and postoperative joint infection.

CONCLUSIONS

In this practice guideline, we provided specific recommendations on the role of corticosteroids in joint, bursa, and peritendon injections for musculoskeletal pain.

The Mechanisms and Safety of Corticosteroid Injections in Orthopaedic Surgery

» Corticosteroid injections (CSIs), including intra-articular, perineural, and those involving tendon sheaths or bursae, offer potential relief from osteoarthritic and inflammatory musculoskeletal pain, including gout attacks, as well as tarsal tunnel syndrome, plantar fasciitis, and interdigital neuromas.» CSI for musculoskeletal pain is commonly used as a nonoperative management option for both diagnostic and therapeutic purposes, offering pain relief, typically lasting from days to months.» CSIs are often performed prior to surgery as part of the nonoperative management of many conditions, with multiple CSIs within the year of surgery increasing postoperative infection risk in some major joints.» Despite the potential benefits of CSI, there are risks, including a potential increase in the risk of surgical site infection secondary to bacterial contamination and the immunomodulating effect of corticosteroids when given in the perioperative period.» To date, a multitude of studies across orthopaedic subspecialties has reported on perioperative infection risk associated with CSIs. However, heterogeneity in study design and patient populations has made standardized recommendations challenging. It is, therefore, difficult to elucidate, with a high level of evidence, the most appropriate perioperative timeline for CSI administration for which infection risk is nonsignificant.

Effectiveness and safety of intra-articular interventions for knee and hip osteoarthritis based on large randomized trials: A systematic review and network meta-analysis

OBJECTIVE

To quantify the effectiveness and safety of intra-articular interventions for knee and hip osteoarthritis (OA) through a systematic review and Bayesian random-effects network meta-analysis.

DESIGN

We searched CENTRAL and regulatory agency websites (inception-2023) for large, English-language, randomized controlled trials (RCTs) (≥100 patients/group) examining any intra-articular intervention.

PRIMARY OUTCOME

pain intensity.

SECONDARY OUTCOMES

physical function and safety outcomes. Pain and function outcomes were analyzed at 2, 6, 12, 24, and 52 weeks post-randomization, and presented as standardized mean differences (SMDs) (95% credible intervals, 95% CrI). The prespecified minimal clinically important between-group difference (MID) was -0.37 SMD. Safety outcomes were presented as odds ratios (OR) (95% CrI).

FINDINGS

Among 57 RCTs (22,795 participants) examining 18 intra-articular interventions, usual care or placebo, treatment effects were larger in 35 high-risk-of-bias trials than in 22 low/unclear-risk-of-bias trials. In the main analysis (excluding high-risk-of-bias trials), triamcinolone had the highest probabilities of reaching the MID at weeks 2 and 6 (75.3% and 90%, respectively) with corresponding SMDs of -0.48 (95% CrI,-0.85 to -0.10) and -0.53 (95% CrI,-0.79 to -0.27) compared to placebo (1 trial). The complex homeopathic products Tr14/Ze14 showed therapeutic potential at week 6 compared to placebo (SMD:-0.42, 95% CrI,-0.71 to -0.11, 63.5% probability of reaching the MID, 1 trial). Hyaluronic acid had no effect on pain (SMD:-0.04, 95% CrI,-0.19 to 0.11, 11 trials) but a higher risk of dropouts due to adverse events (OR: 2.01, 95% CrI,1.08 to 3.77) and serious adverse events (OR: 1.86, 95% CrI, 1.16 to 3.03) than placebo.

CONCLUSION

Triamcinolone had the highest probabilities to have a treatment effect beyond the MID at weeks 2-6. Large RCTs with lower risk of bias indicate that the effects of 16 intra-articular interventions in knee or hip OA were smaller than the MID, and that most were consistent with placebo effects. Lack of evidence of long-term effectiveness underscores the need for further research beyond 24 weeks.

Comparison of the effectiveness of intra-infrapatellar fat pad and intra-articular glucocorticoid injection in knee osteoarthritis patients with Hoffa's synovitis: protocol for a multicentre randomised controlled trial

INTRODUCTION

The infrapatellar fat pad and synovium are the sites of immune cell infiltration and the origin of proinflammation. Studies have shown that Hoffa's synovitis may be a sign of early-stage osteoarthritis (OA). However, there have been no effective interventions specifically for Hoffa's synovitis.

METHODS AND ANALYSIS

We will conduct a multicentre, multi-blind (participant, physician, outcome assessor and data analyst blinded) randomised controlled trial to compare the effectiveness of an intra-infrapatellar fat glucocorticoid versus an intra-articular injection for Hoffa's synovitis in patients with knee OA. We will recruit 236 knee OA patients with Hoffa's synovitis at outpatient clinics in three centres. We will randomly allocate them to two groups in a 1:1 ratio. One group will receive ultrasound-guided injection of 40 mg (1 mL) triamcinolone acetonide into the infrapatellar fat pad; the other group will receive ultrasound-guided injection of 40 mg (1 mL) triamcinolone acetonide into the knee joint cavity. All patients will be followed up at 2, 4, 8, 12 and 24 weeks after the injection. Primary outcomes are (1) Hoffa's synovitis improvement rate, measured with the MRI Osteoarthritis Knee Score system (superiority outcome) at 24 weeks and (2) pain intensity, measured with the Western Ontario and McMasters University Osteoarthritis Index (WOMAC) at 2 weeks post-injection. Secondary outcomes include Hoffa's synovitis score at 2 weeks post-injection, pain intensity with the numerical rating scale, WOMAC questionnaire score improvements (function, joint stiffness and total score), improvement rates in effusion synovitis at 2 and 24 weeks, articular cartilage thickness changes at 2 and 24 weeks, Intermittent and Constant Osteoarthritis Pain score, quality of life measured with the EuroQol-5D, OARSI-OMERACT response indicators, co-interventions and side effects at 2, 4, 8, 12 and 24 weeks.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Medical Ethics Committee of the Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine (2023-178). Written informed consent will be obtained from all patients prior to data collection. The findings of this research will be shared through presentations at academic conferences and publications in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2400080474.

Current Practices and Perceived Effectiveness of Clinicians Regarding Polynucleotide Injection for Knee Osteoarthritis: A Survey-Based Evaluation

Aims: Intra-articular (IA) injection therapy, particularly IA hyaluronic acid (HA), is a common treatment for knee osteoarthritis, but it does have limitations. The injection of IA polynucleotide (PN) has emerged as an alternative, potentially offering superior clinical outcomes. This study investigates current practice patterns and the perceived effectiveness of PN among clinicians for treating knee osteoarthritis in the Republic of Korea. Methods: Based on a survey conducted among clinicians who use PN in clinical practice, we explored the current practices and assessed the perceived effectiveness of IA PN in treating knee osteoarthritis. Results: A total of 265 clinicians who used IA PN for knee osteoarthritis participated in the survey. Most clinicians (73.3%) used PN therapy for the treatment of chronic pain, with varying administration frequencies. In addition, 25.8% of clinicians used PN for the treatment of acute flare-ups. In cases of knee effusion, 55.5% of clinicians removed the effusion prior to administering PN. Clinicians rated PN as more effective than HA for both chronic pain and acute flare-ups, with higher scores for cushioning, anti-inflammatory effects, and delaying joint degeneration. The clinicians stated that patients expressed a higher satisfaction with IA PN compared with IA HA, noting improvement in joint smoothness, noise reduction, pain relief, and a reduction in heat sensation and swelling. Conclusions: The results of the present study highlight the extensive use and perceived benefits among clinicians of IA PN for knee osteoarthritis in the Republic of Korea. Further research is warranted to explore the effectiveness of PN in acute flare-ups and to validate these findings in broader populations.

Complications and opioid-prescribing patterns following genicular nerve radiofrequency ablation versus intra-articular injection: a matched cohort study

BACKGROUND AND OBJECTIVES

Genicular nerve radiofrequency ablation (GNRFA) is an emerging procedure used to relieve pain from severe knee osteoarthritis. While there have been rare reports of significant complications, their incidence has not been well established. The objective of this study was to examine complication rates at 30 and 90 days post treatment as well as characterize opioid-prescribing patterns before and after treatment.

METHODS

A large national database was queried to identify patients undergoing GNRFA from 2015 to 2022 and matched to control cohorts composed of patients receiving either intra-articular corticosteroid (CSI) or hyaluronic acid injection (HAI) of the knee. Complication rates at 30 and 90 days were analyzed. Opioid utilization was assessed in the 6 months before and after treatment.

RESULTS

Rates of infection (0.1%, CI 0.02% to 0.5% vs 0.2%, CI 0.05% to 0.6%), septic arthritis (<0.1%, CI 0.003% to 0.4% vs 0.1%, CI 0.02% to 0.5%), deep vein thrombosis (2.0%, CI 1.3% to 2.7% vs 1.6%, CI 1.0% to 2.2%), pulmonary embolism (1.2%, CI 0.6% to 1.7% vs 1.3%, CI 1.1% to 2.5%), bleeding (<0.1%, CI 0.003% to 0.4% vs 0%, CI 0% to 0.3%), seroma (<0.1%, CI 0.003% to 0.4% vs 0.2%, CI 0.05% to 0.6%), nerve injury (0%, CI 0% to 0.3% vs 0%, CI 0% to 0.3%) and thermal injury (0%, CI 0% to 0.3% vs 0%, CI 0% to 0.3%) were not different between CSI and GNRFA cohorts at 30 days. Rate of swelling was significantly greater in the GNRFA cohort (9.4%, CI 7.6% to 10.4% vs 6.4%, CI 4.8% to 7.2%, p=0.003) at 30 days. At 90 days, rates of septic arthritis (0.1%, CI 0.02% to 0.5% vs 0.3%, CI 0.08% to 0.7%), deep vein thrombosis (3.1%, CI 2.1% to 3.8% vs 3.1%, CI 2.2% to 3.9%), pulmonary embolism (1.5%, CI 0.9% to 2.1% vs 1.8%, CI 1.2% to 2.5%), and nerve injury (0%, CI 0% to 0.3% vs <0.1%, CI 0.003% to 0.4%) were not significantly different.Between HAI versus GNRFA cohorts, no significant differences were seen in rates of infection (0.3%, CI 0.08% to 0.07% vs 0.7%, CI 0.3% to 1.2%), septic arthritis (0.2%, CI 0.05% to 0.6% vs 0.4%, CI 0.2% to 0.9%), deep vein thrombosis (2.0%, CI 1.3% to 2.7% vs 1.9%, CI 1.2% to 2.7%), pulmonary embolism (1.5%, CI 0.9% to 2.2% vs 1.7%, CI 1.1% to 2.5%), bleeding (0.1%, CI 0.02% to 0.5% vs 0.2%, CI 0.05% to 0.6%), seroma (<0.1%, CI 0.03% to 0.4% vs 0%, CI 0% to 0.3%), nerve injury (0%, CI 0% to 0.3% vs 0%, CI 0% to 0.3%), swelling (14.0%, CI 11.6% to 15.1% vs 12.0%, CI 10.3% to 13.6%), and thermal injury (<0.1%, CI 0.03% to 0.4% vs <0.01%, CI 0.3% to 0.4%) at 30 days. Rates of infection (0.7%, CI 0.3% to 1.2% vs 1.4%, CI 0.9% to 2.1%), septic arthritis (0.3%, CI 0.1% to 0.8% vs 0.5%, CI 0.2% to 1.1%), deep vein thrombosis (3.6%, CI 2.6% to 4.4% vs 3.1%, CI 2.2% to 4.0%), pulmonary embolism (2.3%, CI 1.5% to 3.0% vs 2.1%, CI 1.4% to 3.0%) and nerve injury (0%, CI 0% to 0.3% vs 0.1%, CI 0.02% to 0.5%) were not significantly different at 90 days.There were no significant differences in level of pretreatment opioid utilization although overall consumption in mean daily morphine equivalents was greater in the GNRFA cohort. Opioid utilization significantly increased in the first 30 days after ablation in patients with no prior opioid use compared to controls. In patients with some and chronic prior opioid use, opioid requirements were generally decreased in all treatment groups at 6 months with no clearly superior treatment in reducing opioid consumption.

CONCLUSION

Our study demonstrated that GNRFA possesses a safety profile similar to that of intra-articular injections although significant adverse events such as venous thromboembolism and septic arthritis may occur rarely. Although opioid utilization generally increased in the 30 days after ablation compared with intra-articular injection, similar reduction in opioid consumption at 6 months was seen in patients with prior opioid use in the ablation and control cohorts.

Avascular necrosis or rapid destruction of the hip following hip intra-articular corticosteroid injections: a systematic review

PURPOSE

This study aimed to systematically review the literature to identify the incidence of avascular necrosis (AVN) following hip intra-articular corticosteroid injections (IACSIs) as well as to elucidate risk factors that may predispose patients to AVN following IACSI.

METHODS

The MEDLINE, Embase, PubMed, and Web of Science databases were systematically searched through inception to July 21, 2024, in accordance with the PRISMA statement with data extracted for descriptive analysis. The inclusion criteria were hip IACSI and AVN of the femoral head. AVN identified solely prior to IACSI, animal studies, in vitro studies, and studies on paediatric populations were excluded.

RESULTS

A total of 3,652 studies were identified and screened resulting in a total of 14 studies that met the inclusion criteria. Seven were case reports, four were retrospective case-series, and three were retrospective cohort studies. The incidence of femoral head AVN following IACSI ranged from 0.6 to 20.4%. Kelly et al. reported that patient-related factors associated with increased rate of AVN included elevated BMI (p = 0.025), history of cancer therapy (p = 0.012), low serum Vitamin D (p = 0.030), and multiple injections (p = 0.004).

CONCLUSION

In the present literature, the incidence of AVN after hip IACSI ranges from 0.6 to 20.4% with mean follow-up times ranging from 5.4 to 25.3 months. Further randomized controlled trials are necessary to elucidate if there is a causative relationship between hip IACSI and AVN.

Intra-articular knee injections in patients with primary osteoarthritis in a tertiary clinical setting: a best practice implementation project

AIMS

This project aimed to improve physicians' adherence to evidence-based practices regarding the selection and administration of intra-articular knee injections for patients with osteoarthritis. The project also aimed to empower patients by increasing their awareness of these evidence-based practices.

INTRODUCTION

In the management of knee osteoarthritis, intra-articular injections are commonly used when initial treatments prove inadequate. However, issues such as patients' demand for rapid relief and variability in physicians' familiarity with optimal practices often lead to suboptimal treatment decisions and potential adverse outcomes.

METHODS

This project followed the JBI Evidence Implementation Framework, which is grounded in an audit, feedback, and re-audit process. Initially, physicians were surveyed on the topic under consideration, and hospital records were reviewed. Subsequently, targeted interventions were implemented, including briefings and the distribution of informative flyers.

RESULTS

The baseline audit indicated low adherence with all audit criteria. Various parameters, such as adherence to best clinical practices, informed decision-making by patients, and the recommendation of alternative treatment modalities, were significantly lacking. Following the interventions, substantial improvements were observed, including higher rates of adherence to best clinical practices by physicians for multiple criteria, such as stepwise referral to conservative therapy options and the content of intra-articular injections.

CONCLUSIONS

Adherence to best clinical practices can be improved through educational briefings for physicians on the most current evidence-based treatment practices for injectable substances in knee osteoarthritis. The active engagement of patients, facilitated by informative flyers and physician assistance, contributed to better involvement in their treatment choices. However, the participation of health care institutions and providers as well as lifelong education practices may be necessary for more comprehensive and sustainable changes.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A277.

Intraarticular gold for knee osteoarthritis: An ancillary analysis of biomarkers and outcome of a pilot study

Objective

In a previous pilot study, we have shown that intraarticular gold micro-particles can reduce knee osteoarthritis (KOA) pain at two years follow-up. Proteomic changes in serum and synovial fluid within eight weeks were associated with multiple inflammatory and immunological processes. The relation between the different biomarkers and the outcome measures is not known. We hypothesized that improvement in pain and function were associated with specific groups of biomarkers. We present the integrative analyses between proteomic biomarkers and outcomes.

Design

A cohort of 30 patients, with moderate KOA, were included. Using the patients' synovial fluid as the carrier, 20 ​mg gold microparticles were injected intraarticularly. Clinical outcome measures at inclusion, 8 weeks, and 2 years, were the PainDetect questionnaire, WOMAC pain, stiffness, and function. In addition, Quantitative Sensory Testing, Pain Pressure Threshold, Temporal Summation, Conditioned Pain Modulation, and pain diary were assessed at inclusion and after 8 weeks. Proteomic analysis was performed on SF and blood samples before and after 8 weeks of treatment.

Results

Linear combinations of serum or synovial biomarkers changed significantly alongside the effect measures and PainDetect scores following gold micro-particle treatment. Of particular interest was identifying multiple members of a molecular complex that is suggestive of neural tissue regeneration and modulation following gold micro-particle treatment.

Conclusions

Gold microparticles are a possible future option for the treatment of knee osteoarthritis. The treatment triggers putative regenerative and inflammation-modulating molecular mechanisms.

Recent Strategies and Advances in Hydrogel-Based Delivery Platforms for Bone Regeneration

Bioactive molecules have shown great promise for effectively regulating various bone formation processes, rendering them attractive therapeutics for bone regeneration. However, the widespread application of bioactive molecules is limited by their low accumulation and short half-lives in vivo. Hydrogels have emerged as ideal carriers to address these challenges, offering the potential to prolong retention times at lesion sites, extend half-lives in vivo and mitigate side effects, avoid burst release, and promote adsorption under physiological conditions. This review systematically summarizes the recent advances in the development of bioactive molecule-loaded hydrogels for bone regeneration, encompassing applications in cranial defect repair, femoral defect repair, periodontal bone regeneration, and bone regeneration with underlying diseases. Additionally, this review discusses the current strategies aimed at improving the release profiles of bioactive molecules through stimuli-responsive delivery, carrier-assisted delivery, and sequential delivery. Finally, this review elucidates the existing challenges and future directions of hydrogel encapsulated bioactive molecules in the field of bone regeneration.

The role of ferroptosis in osteoarthritis: Progress and prospects

Osteoarthritis (OA) is the most prevalent degenerative joint disease, marked by cartilage degeneration, synovitis, and subchondral bone changes. The absence of effective drugs and treatments to decelerate OA's progression highlights a significant gap in clinical practice. Ferroptosis, an iron-dependent cell death driven by lipid peroxidation, has emerged as a research focus in osteoarthritic chondrocytes. This form of cell death is characterized by imbalances in iron and increased lipid peroxidation within osteoarthritic chondrocytes. Key antioxidant mechanisms, such as Glutathione Peroxidase 4 (GPX4) and the Nuclear Factor Erythroid 2-Related Factor 2 (NRF2) pathway, are vital in countering ferroptosis in osteoarthritic chondrocytes. This review collates recent findings on ferroptosis in osteoarthritic chondrocytes, emphasizing iron regulation, lipid peroxidation, and antioxidative responses. It also explores emerging therapeutics aimed at mitigating OA by targeting ferroptosis in chondrocytes.

Corticosteroid injections for the treatment of osteoarthritis present a wide spectrum of effects ranging from detrimental to disease-modifying: A systematic review of preclinical evidence by the ESSKA Orthobiologic Initiative

PURPOSE

Aim of this systematic review of preclinical evidence was to determine the effects of intra-articular corticosteroid (CS) injections in joints affected by osteoarthritis (OA).

METHODS

A systematic review was performed on animal studies evaluating intra-articular CS injections for OA joints. The search was performed on PubMed, Cochrane, and Web of Science databases. A synthesis of the results was performed investigating CS effects by evaluating studies comparing CS with control groups. Morphological, histological, immunohistochemistry evaluations, clinical outcomes, biomarkers and imaging results were evaluated. The risk of bias was assessed according to the Systematic Review Centre for Laboratory Animal Experimentation's tool.

RESULTS

Thirty-two articles analysing CS effects in OA animal models were included (1079 joints), 18 studies on small and 14 on large animals. CS injections showed overall positive effects in at least one of the outcomes in 68% of the studies, while 16% reported a deleterious effect. CS improved cartilage and synovial outcomes in 68% and 60% of the studies, but detrimental effects were documented in 11% and 20% of the studies, respectively. Clinical parameters evaluated in terms of pain, lameness or joint swelling improved in 63% of the studies but deteriorated in 13%. Evidence is limited on imaging and biomarkers results, as well as on the best CS type, dose, formulation and injection protocol. The risk of bias assessment revealed a 28% low and an 18% high risk of bias.

CONCLUSION

Intra-articular CS injections induced a wide range of results on OA joints in experimental animal models, from disease-modifying and positive effects on pain and joint function at short-term evaluation to the lack of benefit or even negative effects. This underlines the need to identify more specific indications and treatment modalities to avoid possible detrimental effects while maximising the anti-inflammatory properties and the benefits of intra-articular CS in OA joints.

LEVEL OF EVIDENCE

Level II.

Intra-articular corticosteroid injections for osteoarthritis: A qualitative study of patients' and clinicians' experiences

BACKGROUND

Osteoarthritis is a leading cause of joint pain and disability. Intra-articular corticosteroid injections (IACs) are often used in primary care once other recommended treatments have failed. Evidence shows that IACs provide short-term relief of osteoarthritis symptoms, yet little is known about patients' and primary care clinicians' experiences and beliefs about their use. We explored patients' and primary care clinicians' views about IACs, including the benefits, disadvantages, perceived risks of treatment, when they are used, and factors that affect decision-making.

METHODS

We conducted individual interviews with patients and primary care clinicians and used inductive thematic analysis to investigate their views and experiences of intra-articular corticosteroid injections for osteoarthritis (IACs).

FINDINGS

We interviewed 38 patients and 19 primary care clinicians. We identified 6 patient themes: variation in access; awareness of IACs; views of risk and trust; effectiveness of IACs; variation in onset and effect duration; and an alternative to undesirable treatments. In the interviews with clinicians, we identified an overarching theme of caution and competence, which included eight subthemes: confidence and (dis)comfort with practical procedures; risk of adverse outcomes; training; uncertainty about evidence and guidelines; technical uncertainties; IACs use on the osteoarthritis pathway; perceived benefits and impacts of IACs; and the possibility of placebo.

CONCLUSION

Patients and clinicians valued IACs' potential to relieve symptoms and improve quality of life. Variability in patients' access to treatment appears related to clinicians' confidence in delivering injections and their concerns about the evidence base. Variation in dose frequency and timing reflect clinicians' uncertainty about current guidance. Despite variation in effectiveness patients preferred IACs to other forms of pain medication and to delay or avoid surgery. IACs were mostly used as an adjunct treatment before surgery was offered. These findings can inform further research into the effectiveness of IACs and improvements in information and guidance.

Pain Management in Knee Osteoarthritis: Insights from an Exploratory Online Survey of Italian Patients and Physicians

BACKGROUND

In Italy, knee osteoarthritis (KOA) accounts for over 5 million prevalent cases and requires long-term multidisciplinary management. The most frequent KOA symptom is pain. The aim of the survey is to provide a national overview of the current management of moderate-to-severe pain associated with KOA from both clinicians' and patients' perspectives.

METHODS

An exploratory qualitative survey was conducted in Italy between July and October 2023. The survey participants were members of four national scientific societies and two patient associations who were invited to participate via email and given an online questionnaire. Questions included a mix of single and multiple responses and scalar items.

RESULTS

In total, 1473 clinicians and 150 patients with KOA completed the questionnaire. Patients rated knee pain as both the most burdensome symptom and the most frequent reason for treatment dissatisfaction and seeking consultation. One in two patients declared that they were unsatisfied/little satisfied with the current prescribed analgesic treatments. The clinicians surveyed preferentially prescribed intra-articular hyaluronic acid, oral non-steroidal anti-inflammatory drugs/paracetamol, non-pharmacological intervention, and intra-articular corticosteroids. The clinicians' selection of analgesic therapy often failed to adequately meet patients' expectations for pain relief.

CONCLUSIONS

Our findings highlight the current unmet needs of patients with KOA in Italy and call for new approaches to effectively optimize the management of KOA-associated pain.

Knee osteoarthritis: disease burden, available treatments, and emerging options

Osteoarthritis (OA) is a prevalent condition that affects nearly 528 million people worldwide, including 23% of the global population aged ⩾40, and is characterized by progressive damage to articular cartilage, which often leads to substantial pain, stiffness, and reduced mobility for affected patients. Pain related to OA is a barrier to maintaining physical activity and a leading cause of disability, accounting for 2.4% of all years lived with disability globally, reducing the ability to work in 66% of US patients with OA and increasing absenteeism in 21% of US patients with OA. The joint most commonly involved in OA is the knee, which is affected in about 60%-85% of all OA cases. The aging population and longer life expectancy, coupled with earlier and younger diagnoses, translate into a growing cohort of symptomatic patients in need of alternatives to surgery. Despite the large number of patients with knee OA (OAK) worldwide, the high degree of variability in patient presentation can lead to challenges in diagnosis and treatment. Multiple society guidelines recommend therapies for OAK, but departures from guidelines by healthcare professionals in clinical settings reflect a discordance between evidence-based treatment algorithms and routine clinical practice. Furthermore, disease-modifying pharmacotherapies are limited, and treatment for OAK often focuses solely on symptom relief, rather than underlying causes. In this narrative review, we summarize the patient journey, analyze current disease burden and nonsurgical therapy recommendations for OAK, and highlight emerging and promising therapies-such as cryoneurolysis, long-acting corticosteroids, and gene therapies-for this debilitating condition.

A Study on the Effectiveness of Musculoskeletal Corticosteroid Injections for Reducing Patient Symptom Scores in Primary Care Practice

OBJECTIVES

To present data on the effectiveness of corticosteroid injections (CSI) in reducing symptom scores for musculoskeletal conditions in patients treated in an NHS primary care CSI service. The data will also examine whether adding local anaesthetic to the corticosteroid preparation affects the overall patient outcomes in symptom scores.

METHODS

A Patient-reported outcomes (PRO) questionnaire was used to collect data. Patients were asked to complete the questionnaire post-CSI. Patients were asked to rate their symptoms on a score of 0-6 before and after their injection. Data were calculated using standard deviation and paired t-test to assess the effectiveness of CSI in reducing symptom scores.

RESULTS

Overall, 172 patients (79.6%) reported an improvement in symptomatology post CSI. Improvements were seen across all injection sites. Of those taking medication for their symptoms, 73 patients (55.7%) reported that they were able to reduce their medication. Data did not suggest that adding local anaesthetic to the injectate resulted in better patient outcomes. Post-injection symptom scores were statistically similar across all clinicians.

CONCLUSION

83.7% of patients experienced a reduction in symptom scores post injection. Adding lidocaine to the injectate preparation did not result in any statistically significant improvement in patient outcome. Over half of the participants were able to reduce their medication post injection, which demonstrates this is a highly effective primary care service for treatment/management of some MSK conditions.

Safety and efficacy of an allogeneic adipose-derived mesenchymal stem cell preparation in the treatment of knee osteoarthritis: A Phase I/IIa randomised controlled trial

Objectives

To assess the safety and efficacy of an allogeneic adipose-derived mesenchymal stem cell preparation (MAG200) in the treatment of knee osteoarthritis over 12 months.

Design

A single-centre, double-blind, ascending dose, randomised controlled trial. 40 participants with moderate knee osteoarthritis were randomised to receive a single intra-articular injection of MAG200 (dose cohorts:10, 20, 50, 100 ​× ​106 ​cells) or placebo. Primary objectives were safety and efficacy according to a compound responder analysis of minimal clinically important difference in pain (numerical pain rating scale [NPRS]) and function (Knee Injury and Osteoarthritis Outcome Score - Function in Daily Living subscale [KOOSADL]) at month 12. Secondary efficacy outcomes included changes from baseline in patient reported outcome measures and evaluation of disease-modification using quantitative MRI.

Results

Treatment was well tolerated with no treatment-related serious adverse events. MAG200 cohorts reported a greater proportion of responders than placebo and demonstrated clinical and statistically significant improvement in pain and clinically relevant improvement in all KOOS subscales. MAG200 demonstrated a reproducible treatment effect over placebo, which was clinically relevant for pain in the 10 ​× ​106 dose cohort (mean difference NPRS:-2.25[95%CI:-4.47,-0.03, p ​= ​0.0468]) and for function in the 20 ​× ​106 and 100 ​× ​106 dose cohorts (mean difference KOOSADL:10.12[95%CI:-1.51,21.76, p ​= ​0.0863] and 10.81[95%CI:-1.42,23.04, p ​= ​0.0810] respectively). A trend in disease-modification was observed with improvement in total knee cartilage volume in MAG200 10, 20, and 100 ​× ​106 dose cohorts, with progression of osteoarthritis in placebo, though this was not statistically significant. No clear dose response was observed.

Conclusion

This early-phase study provides supportive safety and efficacy evidence to progress MAG200 to later-stage trial development.

Trial registration

ACTRN12617001095358/ACTRN12621000622808.

The mediation effects of malalignment on the relation of sex to the risk of incidence tibiofemoral osteoarthritis

OBJECTIVE

To investigate to what extent the higher risk of tibiofemoral radiographic osteoarthritis (TFROA) in females vs. males can be explained by knee malalignment.

DESIGN

Using data from Multicenter Osteoarthritis Study (MOST) and Osteoarthritis Initiative (OAI), we examined the relation of sex to the incident medial and lateral TFROA and performed mediation analyses to assess to what extent varus and valgus malalignments account for sex differences in the incident medial or lateral TFROA.

RESULTS

Of the 3462 knees without medial and lateral TFROA in MOST, the 7-year risks of medial and lateral TFROA were 16.9% and 10.0% in females, and 15.8% and 4.2% in males, respectively. Females had 2.31-fold (95% confidence interval [95% CI]: 1.73 to 3.08) higher incident lateral TFROA than males, and the relative risk (RR) of the indirect effect of sex on lateral TFROA through valgus malalignment was 1.15 (95% CI: 1.09 to 1.20), accounting for 23% of its total effect on lateral TFROA. In OAI (n = 3095 knees), females had 1.54-fold (95% CI: 1.15 to 2.04) higher incident lateral TFROA than males, and RR of the indirect effect of sex on lateral TFROA through valgus malalignment was 1.10 (95% CI: 1.04 to 1.21), accounting for 26% of its total effect on lateral TFROA. No apparent sex difference in the incident medial TFROA was found in MOST (RR = 1.05, 95% CI: 0.89 to 1.25) or OAI (RR = 1.02, 95% CI: 0.84 to 1.19).

CONCLUSION

Females had a higher risk of developing lateral TFROA than males; however, valgus malalignment only modestly explained such a difference.

What is New in Osteoarthritis Imaging?

Osteoarthritis (OA) is the leading joint disorder globally, affecting a significant proportion of the population. Recent studies have changed our understanding of OA, viewing it as a complex pathology of the whole joint with a multifaceted etiology, encompassing genetic, biological, and biomechanical elements. This review highlights the role of imaging in diagnosing and monitoring OA. Today's role of radiography is discussed, while also elaborating on the advances in computed tomography and magnetic resonance imaging, discussing semiquantitative methods, quantitative morphologic and compositional techniques, and giving an outlook on the potential role of artificial intelligence in OA research.

Intra-articular corticosteroids for the treatment of osteoarthritis: A systematic review and meta-analysis on the comparison of different molecules and doses

Purpose

The purpose of this study was to quantify and compare the clinical relevance of the different intra-articular corticosteroids (CS) effects in vivo for osteoarthritis (OA) treatment.

Methods

The search was conducted on PubMed, Cochrane, and Web of Science in October 2023. The PRISMA guidelines were used. Inclusion criteria: animal or human randomized controlled trials (RCTs), English language and no time limitation, on the comparison of different intra-articular CS for OA treatment. The articles' quality was assessed using the Cochrane RoB2 and GRADE guidelines for human RCTs, and SYRCLE's tool for animal RCTs.

Results

Eighteen RCTs were selected (16 human and 2 animal studies), including 1577 patients (1837 joints) and 31 animals (51 joints). The CS used were triamcinolone (14 human and 2 animal studies), methylprednisolone (7 human and 1 animal study), betamethasone (3 human studies) and dexamethasone (1 human study). All studies addressed knee OA except for three human and one animal study. A meta-analysis was performed on the comparison of methylprednisolone and triamcinolone in humans with knee OA analysing VAS pain at very short- (≤2 weeks), short- (>2 and ≤4 weeks), mid- (>4 and ≤8 weeks), long- (>8 and ≤ 12 weeks), and very long-term (>12 and ≤24 weeks). Triamcinolone showed better post-injection values compared to methylprednisolone at very short-term (p = 0.028). No difference in terms of VAS improvement was observed at any follow-up.

Conclusions

The available preclinical and clinical literature provides limited evidence on the comparison of different CS, hindering the possibility of determining the best CS approach in terms of molecule and dose for the intra-articular injection of OA joints.

Level of Evidence

Level I.

Pharmacologic interventions for primary glenohumeral osteoarthritis

ABSTRACT

Primary glenohumeral osteoarthritis is a multifactorial condition with a complex cause that affects patients across different age groups, impairing physiologic and psychologic well-being, and substantially reducing patient quality of life and overall productivity. To effectively manage this condition, healthcare providers need to be well informed about treatment guidelines, as well as the available therapeutic options and the evidence supporting their use. Nonsurgical interventions should be regarded as the primary treatment option, particularly for patients in the initial phases of this condition. No conclusive guidelines exist for treating young and active patients, and the literature lacks high-quality data to evaluate the efficacy, safety, and long-term consequences of several interventions, regardless of patient characteristics and expectations.

Viscosupplementation Is Effective for the Treatment of Osteoarthritis in the Hip: A Systematic Review

PURPOSE

To assess the efficacy of intra-articular viscosupplementation as a therapeutic intervention for hip osteoarthritis (OA), as well as to assess the duration of efficacy, effect of dose, composition and number of injections of the viscosupplement, and the incidence of adverse effects.

METHODS

We performed a systematic review using the literature search from the following databases: Embase, Medline, PubMed, Web of Science, and Scopus. Quality assessment of the included studies was performed using the Modified Newcastle-Ottawa Quality Assessment Scale. Random-effects meta-analysis and mixed-effects subgroup analysis were carried out, but due to the high heterogeneity, low level of evidence, and high risk of bias of the included studies after analyzing the data, weighted means and pooled estimates have not been provided. Instead, we have provided a subjective synthesis of the results.

RESULTS

Forty studies were included in the analysis from an initial search of 3,265 studies, with data from a total of 3,350 patients. The level of available evidence was low with an overall high risk of bias. Nearly all studies showed a reduction in mean pain at 1 month, 3 months, and 6 months of follow-up, as well as at the end point, and an improvement in mean patient-reported function was also seen at these time points. However, heterogeneity was extremely high at all time points and remained despite attempts at removing outliers. Subgroup analyses looking at the effects of dose, volume, composition of viscosupplement, and number of injections were carried out, but substantial heterogeneity still remained. There were no lasting adverse effects.

CONCLUSIONS

Weak evidence suggests that viscosupplementation improves patient-reported pain and function at end point compared to baseline, regardless of dose, volume, composition, and number of injections. However, due to the high heterogeneity, low level of evidence, and high risk of bias in the current available literature, the strength of our conclusions is limited.

LEVEL OF EVIDENCE

Level IV, systematic review of level I to IV studies.

Single dose thermoresponsive dexamethasone prodrug completely mitigates joint pain for 15 weeks in a murine model of osteoarthritis

In this study, we aimed to assess the analgesic efficacy of a thermoresponsive polymeric dexamethasone (Dex) prodrug (ProGel-Dex) in a mouse model of osteoarthritis (OA). At 12 weeks post model establishment, the OA mice received a single intra-articular (IA) injection of ProGel-Dex, dose-equivalent Dex, or Saline. Comparing to Saline and Dex controls, ProGel-Dex provided complete and sustained pain relief for >15 weeks according to incapacitance tests. In vivo optical imaging confirmed the continuous presence of ProGel-Dex in joints for 15 weeks post-injection. According to micro-CT analysis, ProGel-Dex treated mice had significantly lower subchondral bone thickness and medial meniscus bone volume than Dex and Saline controls. Except for a transient delay of body weight increase and slightly lower endpoint liver and spleen weights, no other adverse effect was observed after ProGel-Dex treatment. These findings support ProGel-Dex's potential as a potent and safe analgesic candidate for management of OA pain.

Contralateral knee osteoarthritis is a risk factor for ipsilateral knee osteoarthritis progressing: a case control study

BACKGROUND

Knee osteoarthritis (KOA) is a highly disabling disease, and studying its progression is crucial. However, it is still unclear whether the progression of ipsilateral knee osteoarthritis is influenced by contralateral knee osteoarthritis.

METHODS

Data were collected from the OAI database and divided into two study cohorts (right/left KOA cohort). Each cohort had a target knee (right/left knee) and was further divided into two groups (exposure/control group). The demographic data of both cohorts were balanced at baseline by propensity score matching (PSM), and the data included rating scale and radiographic and clinical data. After checking for balance in the matched variables, we then compared the differences between the two groups in each cohort. Our primary focus was on the minimum joint space width (mJSW) of the target knee, which was measured four years after baseline. The secondary outcome was the arthroplasty rate of the target knee within nine years.

RESULTS

In this study, a total of 678 participants were enrolled and matched. After 1:1 PSM of the baseline demographic data, 98 participants in the right KOA cohort (RKOAC) were successfully matched, and 117 participants in the left KOA cohort (LKOAC) were successfully matched. Furthermore, the standardized mean difference (SMD) of the matched variables in both cohorts was less than 0.25. After analyzing the outcome metrics, we found that the target knee had a significantly lower mJSW in the fourth year after baseline and a significantly greater arthroplasty rate within nine years in the exposed group than in the control group. RKOAC: mJSW (exposure: 2.6(1.1 ~ 3.6) vs. control: 3.3(2.0 ~ 4.2), P < 0.05), arthroplasty rate (exposure: 14(14.3%) vs. control: 4(4.1%), P < 0.05); LKOAC: mJSW (exposure: 3.1(2 ~ 3.9) vs. control: 3.4(2.6 ~ 4.2), P < 0.05), arthroplasty rate (exposure: 16(13.7%) vs. control: 7(6%), P < 0.05).

CONCLUSIONS

Patients with knee osteoarthritis experienced greater progression of osteoarthritis when the contralateral knee was also affected.

Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications

Corticosteroid injections can be associated with a range of potential side effects, which may be classified as local or systemic and further stratified as immediate or delayed in onset. Radiologists performing image-guided musculoskeletal injections should recognize the potential side effects of corticosteroid medication when counseling patients before injection and consider such side effects in planning individual injections. This Review summarizes the available evidence regarding the local and systemic side effects of corticosteroid injections performed for musculoskeletal indications. Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury. Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis. Additional targeted counseling is warranted regarding side effects that are specific to certain patient populations (i.e., premenopausal women, patients with diabetes, athletes, and pediatric patients). Corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint. Guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. Further research is needed regarding the long-term complications of continuous corticosteroid use, particularly with regard to osseous effects.

Nonsteroidal Anti-Inflammatory Drug Injections versus Steroid Injections in the Management of Upper and Lower Extremity Orthopedic Conditions: A Systematic Review with Meta-Analysis

BACKGROUND

Although corticosteroid injections are an effective treatment for musculoskeletal pathologies, they may not be suitable for all patients. The purpose of this systematic review was to compare clinical outcomes between patients who received NSAID and corticosteroid injections for various orthopedic conditions.

METHODS

Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched, and meta-analyses were performed using a random-effects model for outcomes presented in three or more studies. Other studies were qualitatively analyzed.

RESULTS

A total of 28 articles with 2113 patients were included. A meta-analysis of five studies in patients with shoulder impingement syndrome demonstrated that there was no significant difference in the pain visual analogue scale (VAS) between subacromial NSAID injections and corticosteroid injections at 1 month [weighted mean difference (WMD) -0.244; 95% CI, -1.232 to 0.745; I2, 94.5%]. For patients with knee osteoarthritis, a meta-analysis of three studies demonstrated that there was no significant difference between intraarticular NSAID injections and corticosteroid injections in pain VAS at 1 month (WMD 0.754; 95% CI, -0.413 to 1.921; I2, 90.2%) and 3 months (WMD-0.089; 95% CI, -0.345 to 0.166; I2, 0%). A review of the studies assessing pain outcomes for hip osteoarthritis, adhesive capsulitis, and plantar fasciitis showed no significant differences between the NSAID and corticosteroid groups.

CONCLUSION

NSAID injections may be safe and effective alternatives to steroid injections, especially in shoulder impingement syndrome and knee osteoarthritis.

Intra-articular corticosteroid injections provide a clinically relevant benefit compared to placebo only at short-term follow-up in patients with knee osteoarthritis: A systematic review and meta-analysis

PURPOSE

To quantify the clinical relevance of intra-articular corticosteroid effects compared to placebo for the injective treatment of knee osteoarthritis (OA).

METHODS

The PubMed, Cochrane Library and Web of Science databases were searched on May 3, 2023. This study was conducted in accordance with the PRISMA guidelines. The inclusion criteria were randomized controlled trials (RCTs), published in English, with no time limitation regarding publication date, comparing intra-articular corticosteroids and placebo injections for knee OA. The effects were quantified at short- (≤6 weeks), mid- (>6 weeks and ≤3 months), and long-term (≥6 months) follow-ups. The minimal clinically important difference (MCID) for the outcomes (visual analogue scale for pain - VAS: 1.4, Western Ontario and McMaster University Osteoarthritis Index - WOMAC: 9) was used to interpret the clinical improvement provided by intra-articular corticosteroid injections compared to placebo. The quality of each article was assessed using the Cochrane RoB 2 tool and the GRADE guidelines.

RESULTS

Among the 1030 articles retrieved, 11 RCTs (842 patients) were included. A comparison of the two groups revealed statistically significant differences in the improvement of VAS and WOMAC scores in terms of the mean difference (MD); this difference was in favour of corticosteroids at short-term (p < 0.001, MD = -1.6 and p < 0.001, MD = -9.9, respectively) and mid-term follow-ups (p = 0.001, mean MD = -1.3 and p = 0.005, MD = -4.9, respectively). No difference was observed at the long-term follow-up. The MDs between the improvements in the two groups reached the MCID values for the VAS and WOMAC only at the short-term follow-up. The RoB 2 tool and the GRADE evaluations showed the presence of risk of bias and limited quality of evidence.

CONCLUSION

This systematic review and meta-analysis demonstrated that intra-articular corticosteroid injections offer clinically perceivable pain relief and functional improvement higher than the placebo effect only at short-term follow-up in patients affected by knee OA, with benefits losing clinical relevance already after 6 weeks. These results, together with the low number and the limited quality of the RCTs comparing this treatment with placebo, question the indication for the use of corticosteroid injections in clinical practice for the treatment of knee OA.

LEVEL OF EVIDENCE

Level I.

Supramolecular self-assembly of EGCG-selenomethionine nanodrug for treating osteoarthritis

Osteoarthritis (OA) has emerged as a significant health concern among the elderly population, with increasing attention paid to ferroptosis-induced OA in recent years. However, the prolonged use of nonsteroidal anti-inflammatory drugs or corticosteroids can lead to a series of side effects and limited therapeutic efficacy. This study aimed to employ the Mannich condensation reaction between epigallocatechin-3-gallate (EGCG) and selenomethionine (SeMet) to efficiently synthesize polyphenol-based nanodrugs in aqueous media for treating OA. Molecular biology experiments demonstrated that EGCG-based nanodrugs (ES NDs) could effectively reduce glutathione peroxidase 4 (GPX4) inactivation, abnormal Fe2+ accumulation, and lipid peroxidation induced by oxidative stress, which ameliorated the metabolic disorder of chondrocytes and other multiple pathological processes triggered by ferroptosis. Moreover, imaging and histopathological analysis of the destabilization of the medial meniscus model in mice confirmed that ES NDs exhibiting significant therapeutic effects in relieving OA. The intra-articular delivery of ES NDs represents a promising approach for treating OA and other joint inflammatory diseases.

Physiatry for Treating Hip, Knee, and Back Pain

Physical Medicine and Rehabilitation (PM&R) is a rapidly expanding field. Physicians who practice PM&R are known as physiatrists and provide care primarily for patients who have disabilities or physical impairments affecting the musculoskeletal system, brain, and spinal cord. Physiatrists may work in an inpatient or outpatient setting, with outpatient physiatrists being an invaluable resource in treating patients experiencing pain. It is worthwhile to refer patients experiencing hip, knee, or back pain to a PM&R specialist because of their skill in making specific and accurate diagnoses, as well as providing a wide range of modalities to treat pain and augment function such as management of pain medications, osteopathic manipulative therapy, trigger point injections, intra-articular steroid injections, orthobiologic therapy, and interventional spinal procedures. Emphasis is on the use of the least invasive modality before employing more invasive treatments. The need for physiatrists to help individuals maximize function and enhance quality of life is increasing with the aging population, expanding workforce of older adults, and a growing population of people with a disability, especially since the COVID-19 pandemic.

Adeno-Associated Virus-Delivered Fibroblast Growth Factor 18 Gene Therapy Promotes Cartilage Anabolism

OBJECTIVE

To determine the characterization of chondrogenic properties of adeno-associated virus type 2 (AAV2)-delivered hFGF18, via analysis of effects on primary human chondrocyte proliferation, gene expression, and in vivo cartilage thickness changes in the tibia and meniscus.

DESIGN

Chondrogenic properties of AAV2-FGF18 were compared with recombinant human FGF18 (rhFGF18) in vitro relative to phosphate-buffered saline (PBS) and AAV2-GFP negative controls. Transcriptome analysis was performed using RNA-seq on primary human chondrocytes treated with rhFGF18 and AAV2-FGF18, relative to PBS. Durability of gene expression was assessed using AAV2-nLuc and in vivo imaging. Chondrogenesis was evaluated by measuring weight-normalized thickness in the tibial plateau and the white zone of the anterior horn of the medial meniscus in Sprague-Dawley rats.

RESULTS

AAV2-FGF18 elicits chondrogenesis by promoting proliferation and upregulation of hyaline cartilage-associated genes, including COL2A1 and HAS2, while downregulating fibrocartilage-associated COL1A1. This activity translates to statistically significant, dose-dependent increases in cartilage thickness in vivo within the area of the tibial plateau, following a single intra-articular injection of the AAV2-FGF18 or a regimen of 6 twice-weekly injections of rhFGF18 protein relative to AAV2-GFP. In addition, we observed AAV2-FGF18-induced and rhFGF18-induced increases in cartilage thickness of the anterior horn of the medial meniscus. Finally, the single-injection AAV2-delivered hFGF18 offers a potential safety advantage over the multi-injection protein treatment as evidenced by reduced joint swelling over the study period.

CONCLUSION

AAV2-delivered hFGF18 represents a promising strategy for the restoration of hyaline cartilage by promoting extracellular matrix production, chondrocyte proliferation, and increasing articular and meniscal cartilage thickness in vivo after a single intra-articular injection.

FactFinders for patient safety: Preventing local anesthetic-related complications: Local anesthetic chondrotoxicity and stellate ganglion blocks

This series of FactFinders presents a brief summary of the evidence and outlines recommendations to improve our understanding and management of several potential local anesthetic-related complications. Evidence in support of the following facts is presented. (1) Chondrotoxicity: Which Local Anesthetics are Safest for Intraarticular Injection? -- There are drug-, concentration-, and time-dependent chondrotoxic effects that vary between local anesthetics. Current evidence related to commonly used local anesthetics indicates that with exposure to equivalent volumes, bupivacaine, at concentrations of 0.5 % or higher, is the most chondrotoxic agent, while ropivacaine, at concentrations equal to or less than 0.5 %, is the least chondrotoxic in vitro. There is minimal published evidence that confirms these findings in vivo. (2) Minimizing Risks with Stellate Ganglion Blocks -- Evidence suggests that fluoroscopic or ultrasound guidance reduces the risk and increases the accuracy of SGB. Utilizing ultrasound guidance has the added benefit of soft tissue visualization, especially vascular structures, which has the potential to prevent adverse outcomes when compared to the fluoroscopic technique.

Non-operative Treatment Options for Osteoarthritis in the Hip

With the increased disability associated with osteoarthritis (OA) progression, and the significant socioeconomic burden of joint replacement surgeries, there is a need for more reliable conservative treatments for patients presenting with hip OA. Most studies of OA treatments involve the knee. We conducted a literature search and reviewed non-operative hip OA treatment recommendations by the Osteoarthritis Research Society International, the American College of Rheumatology, American Academy of Orthopedic Surgeons, and European Alliance of Associations for Rheumatology, as well as Cochrane Reviews. Non-steroidal anti-inflammatory drugs and corticosteroid injections are the most supported and recommended options for hip OA; other medications with potential benefits for short-term pain relief include acetaminophen and tramadol. Most societies recommend against the use of glucosamine, typical opioids, and viscosupplementation injections. Platelet-rich plasma has potential benefits, but evidence of its effectiveness is incomplete. Further research is needed to better inform and guide clinicians who create treatment plans for patients with symptomatic hip OA.

The Effects of Ultrasound-Guided Intra-Articular Injections with Hyaluronic Acid and Corticosteroids in Patients with Hip Osteoarthritis: A Long-Term Real-World Analysis

Intra-articular (IA) ultrasound-guided hip injections are currently considered a cornerstone of the conservative management of symptomatic hip osteoarthritis (HOA), although their effect on clinical outcomes has not been fully elucidated.The purpose of this study is to investigate the effectiveness of ultrasound-guided IA hip injections of hyaluronic acid (HA) with or without corticosteroids (CS) on pain relief and functional improvement in patients with HOA. In total, 167 patients with HOA were assessed at baseline (T0) and 12 months after injection (T1) using the VAS and GLFS scores. The sample consisted mainly of female subjects (58.1%), presenting an average age of 70.6 ± 12.2 years and grade 3 HOA (63.9%) according to the Kellgren-Lawrence classification. Most of the patients (76.2%) underwent unilateral hip injection with a combination of medium-high molecular weight HA (1500-2000 kDa) and CS. At T1, lower use of anti-inflammatory drugs, an increase in the consumption of chondroprotectors, and an overall reduction of instrumental physical therapies and therapeutic exercise were recorded. In addition, a statistically significant intragroup and between-group decrease observed at T1 for both the VAS and GLFS. Study results suggested that intra-articular hip injections with HA alone and with CS could represent a useful therapeutic tool for pain reduction and functional improvement for patients with hip osteoarthritis.

Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines

OBJECTIVES

Guideline adherence for hip and knee osteoarthritis management is often poor, possibly related to the quality and/or inconsistent recommendations. This systematic review of hip and knee osteoarthritis guidelines aimed to appraise the quality and consistency in recommendations across higher-quality guidelines.

METHODS

Eight databases, guideline repositories, and professional associations websites were searched on 27/10/2022. Guideline quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II tool) (six domains). Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consistency in recommendations across higher-quality guidelines was reported descriptively. This review was registered prospectively (CRD42021216154).

RESULTS

Seven higher-quality and 18 lesser-quality guidelines were included. AGREE II domain scores for higher-quality guidelines were > 60% except for applicability (average 46%). Higher-quality guidelines consistently recommended in favour of education, exercise, and weight management and non-steroidal anti-inflammatory drugs (hip and knee), and intra-articular corticosteroid injections (knee). Higher quality guidelines consistently recommended against hyaluronic acid (hip) and stem cell (hip and knee) injections. Other pharmacological recommendations in higher-quality guidelines (e.g., paracetamol, intra-articular corticosteroid (hip), hyaluronic acid (knee)) and adjunctive treatments (e.g., acupuncture) were less consistent. Arthroscopy was consistently recommended against in higher-quality guidelines. No higher-quality guidelines considered arthroplasty.

CONCLUSION

Higher-quality guidelines for hip and knee osteoarthritis consistently recommend clinicians implement exercise, education, and weight management, alongside consideration of Non-Steroidal Anti-Inflammatory Drugs and intra-articular corticosteroid injections (knee). Lack of consensus on some pharmacological options and adjunctive treatments creates challenges for guideline adherence. Future guidelines must prioritise providing implementation guidance, considering consistently low applicability scores.

Intra-articular autologous conditioned serum and triamcinolone injections in patients with knee osteoarthritis: a controlled, randomized, double-blind study

OBJECTIVE

This study was performed to assess the impact of autologous conditioned serum (ACS) when added to preceding intra-articular glucocorticoid therapy on pain, function, and quality of life outcomes over 24 weeks.

METHODS

In this single-center, randomized controlled trial involving 40 patients with advanced knee osteoarthritis (Kellgren-Lawrence grades III and IV), ACS or saline placebo was injected after 40 mg triamcinolone acetonide (TA) intra-articular injection. Numerical rating scale (NRS) pain scores and Knee Injury and Osteoarthritis Outcome Score (KOOS) assessments were conducted at baseline and at weeks 3, 6, 12, and 24. The primary endpoint was the change in KOOS Pain at 24 weeks. Patient safety events were also monitored.

RESULTS

At week 24, TA + ACS significantly improved KOOS Pain, Symptoms, Activities of Daily Living, Quality of Life, and KOOS Sport scores. TA + ACS also outperformed TA + placebo in NRS pain scores (average and maximum intensity) at week 24 and NRS pain score (at rest) at weeks 12 and 24. The TA injection followed by ACS or placebo was well-tolerated.

CONCLUSION

ACS adds long-term pain relief and functional improvement to the short-term pain relief provided by glucocorticoids.

Methods of Conservative Intra-Articular Treatment for Osteoarthritis of the Hip and Knee

BACKGROUND

Osteoarthritis is a degenerative joint disease that is becoming increasingly common as the population ages. Conservative treatment for hip or knee osteoarthritis has been limited to pain control. Intra-articular injections for targeted local treatment have been widely used in clinical practice for many years.

METHODS

This review is based on publications retrieved by a selective literature search, including recent meta-analyses, systematic reviews, randomized controlled trials (RCTs), and current guidelines.

RESULTS

In Germany, the 12-month prevalence of osteoarthritis in adults is 17.9%. Conservative treatments are intended to alleviate symptoms and do not affect the progression of the disease. Glucocorticoids can be used to relieve otherwise intractable pain in the short term, but their prolonged use increases the risk of cartilage loss and progression of osteoarthritis. According to multiple guidelines, there is only weak evidence for the use of hyaluronic acid. Evidence does exist that high-molecular-weight hyaluronic acid may lead to better outcomes than the low-molecular-weight form. RCTs have revealed no more than short-term clinical efficacy for a variety of specific therapeutic approaches, including the use of cytokine inhibitors. Other treatments, e.g., with platelet-enriched plasma, aspirates from bone marrow or adipose tissue, or expanded mesenchymal stromal cells (MSC), have not been found to have clinically relevant long-term effects.

CONCLUSION

In view of the scant available evidence, further standardized RCTs will be needed to give a more comprehensive picture of the efficacy of intra-articular treatments for hip and knee osteoarthritis.

What Is the Efficacy of Intra-articular Injections in the Treatment of Ankle Osteoarthritis? A Systematic Review

BACKGROUND

Ankle osteoarthritis (OA) is painful and can impact a patient's physical and mental quality of life. Although intra-articular injections are commonly used to alleviate symptoms, there is conflicting evidence concerning their efficacy. Therefore, an updated systematic review would be informative.

QUESTION/PURPOSE

In this systematic review, we asked: Are there clinically important benefits or harms associated with the use of intra-articular injections in the treatment of ankle OA?

METHODS

We used PubMed, Embase, and the Cochrane Library to search for randomized controlled trials on intra-articular injections for the treatment of ankle OA in June 2021, and updated the search in January 2022; eligible dates were from the date of inception of each database through January 2022. Reference lists of eligible studies and previous reviews were manually screened. Two reviewers independently assessed studies for eligibility. We included seven studies. Three compared hyaluronic acid (HA) with saline, one compared HA with exercise, one compared four different regimens of HA [ 34 ], one compared platelet-rich plasma (PRP) with saline, and one compared botulinum toxin Type A (BoNT-A) with HA. A total of 340 patients were included: 141 in the HA arms, 48 in the PRP arm, 38 in the BoNT-A arm, and 113 in the saline arms. Across all studies, the mean age was 52 ± 21 years, and 35% were women (119 of 340 patients). Methodologic quality was assessed using the Cochrane Risk of Bias 2.0 tool. Of the included studies, the risk of bias was low in two studies, presented some concerns in one study, and was high in four studies. According to the Grading of Recommendations Assessment, Development, and Evaluation methodology, the level of evidence was very low for HA, moderate for PRP, and very low for BoNT-A. The level of heterogeneity was high, and we opted to perform a systematic review rather than a meta-analysis. A clinically relevant difference was based on whether the between-group difference surpassed the cutoff point determined as the minimum clinically important difference.

RESULTS

No clinically relevant differences were found among HA, PRP, and BoNT-A and their control groups at 3, 6, or 12 months. No studies reported any serious adverse events in any treatment group.

CONCLUSION

Given the lack of observed efficacy in this systematic review, these treatments should not be used in practice until or unless future high-quality studies find evidence of efficacy.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Debate: Intra-articular steroid injections for osteoarthritis - harmful or helpful?☆,☆☆

Intra-articular corticosteroids injections are a widely used treatment for pain from symptomatic osteoarthritis. Systematic reviews show that the treatment effect is modest compared with intra-articular saline (often considered as placebo) and lasts for 2-4 weeks on average. Potentially as a consequence of limited therapeutic duration, repeated injections are often given up to 4 injections annually. In this context of repeat injections, recent evidence has emerged that intra-articular corticosteroids might be associated with more MRI-assessed quantitative cartilage thickness loss than saline injections. Guidelines vary in the recommendation for use of intra-articular corticosteroids. Given the frequency with which intra-articular corticosteroids injections are used, the size and scale of the population with osteoarthritis, it is critical to fully understand the benefits and drawbacks of intra-articular corticosteroids injections. That is the focus of this debate article.

Current evidence on mesenchymal stem cells for hip osteoarthritis: a narrative review

There are limited data on the use of mesenchymal stem cell injections for hip osteoarthritis. The goal of this study was to evaluate the literature by analyzing outcomes and comparing methodologies. Online search of PubMed, SportsDiscus and Case Reports Keywords was completed using the keywords 'stem cells' and 'hip' and 'osteoarthritis'. Six studies met the inclusion and exclusion criteria. Five out the six studies had statistically significant improvement in patient reported outcomes after mesenchymal stem cell injections. Only two studies provided information on radiological changes and findings were positive. None of the studies reported major complications. Small series of non-randomized controlled trials completed to date in the use of mesenchymal stem cells for the treatment of hip osteoarthritis reported the procedures to be safe and provide a positive clinical response. Randomized controlled trials must be performed to further confirm mesenchymal stem cells as a treatment option for hip osteoarthritis.

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

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