Why we should definitely include intra-articular hyaluronic acid as a therapeutic option in the management of knee osteoarthritis: Results of an extensive critical literature review

Safety and Efficacy of Hybrid Cooperative Complexes of Sodium Hyaluronate and Sodium Chondroitin for the Treatment of Patients with Symptomatic Knee Osteoarthritis

INTRODUCTION

Knee osteoarthritis (KOA) represents a widespread degenerative disease that causes pain and motor disability. Conservative treatments mainly focus on relieving symptoms, improving joint function, and trying to delay surgery. Safety and efficacy of hybrid cooperative complexes (2.4% sodium hyaluronate and 1.6% sodium chondroitin; HA-SC) for symptomatic KOA were investigated in a single-arm, prospective, pilot study.

METHODS

Patients with a visual analogue scale (VAS) pain score ≥ 4 and Kellgren-Lawrence Grade < 4 received a single intraarticular HA-SC injection. Patients with a VAS score change from baseline ≤ 1 received a second injection at day 30. Device-related adverse events (DR-AEs)/adverse events (AEs) were primary endpoints. Secondary endpoints included Western Ontario and McMaster Universities Osteoarthritis Index LK 3.1 (WOMAC LK 3.1), VAS, patient global assessment of disease status (PtGA), and patient proportion needing a second injection.

RESULTS

Of 83 patients with KOA (Kellgren-Lawrence Grade, 2-3), 34.9% had DR-AEs at day 7. No serious DR-AEs/AEs were reported. A significant (P < 0.0001) reduction over time in VAS pain score plus WOMAC pain, stiffness, physical function limitation, and total scores was reported. Median PtGA scores indicated a 'slight improvement' at most follow-up visits. Only 18.1% of patients required a second injection.

CONCLUSIONS

A single intraarticular HA-SC injection was safe, well-tolerated, and did not lead to major deterioration in terms of reducing knee pain, stiffness, and physical function limitation in patients with symptomatic KOA.

Are patients with knee osteoarthritis aware that platelet-rich plasma is a treatment option?

Osteoarthritis (OA) is a prevalent joint disease, particularly affecting the knees. This condition is often managed through various treatments, including intra-articular injections such as corticosteroids (CS), hyaluronic acid (HA), and platelet-rich plasma (PRP). PRP has shown promising outcomes in recent studies although it does lack strong endorsement in some clinical guidelines due to inconsistent results and lack of standardized results. This study was conducted to assess patient awareness and the frequency of PRP offered for the treatment of knee OA, compared to CS and HA. In a cross-sectional study, 46 knee OA patients were surveyed regarding their knowledge and experiences of CS, HA, and PRP injections. The questionnaires were administered between September 2022 and February 2023. Additionally, the study evaluated the severity of patients knee OA, using the Western Ontario and McMaster Universities Arthritis Index, and gathered demographic information from the participants. CS injections were offered to 93.5%, and 100% of participants had previously heard of this type of injection. HA injections were offered to 37%, and 65.9% of participants had heard of them. PRP was offered to 2%, and 6.5% had ever heard of it. This study underscores the limited awareness and utilization of PRP among knee OA patients. Patients and physicians need to be more informed of all of the treatment options available for knee OA, especially orthobiologics such as PRP. Future research in larger, diverse populations is needed.

Molecular Biology of Meniscal Healing: A Narrative Review

This review provides insights at the molecular level into the current and old methods for treating meniscal injuries. Meniscal injuries have been found to have a substantial impact on the progression of osteoarthritis. In line with the "save the meniscus" approach, meniscectomy is considered a last-resort treatment. Nevertheless, it is important to note that mechanical repair alone may not achieve the complete restoration of the meniscus. A deep understanding of the healing pathways could lead to future improvements in meniscal healing. The inclusion of cytokines and chemokines has the potential to facilitate the process of tear repair or impede the inflammatory catabolic cascade. MicroRNA (miRNA) could serve as a potential biomarker for meniscal degeneration, and RNA injections might promote collagen and growth factor production. The critical aspect of the healing process is angiogenesis within the inner zone of the meniscus. The use of collagen scaffolds and the implantation of autologous meniscus fragments have been successfully integrated into clinical settings. These findings are encouraging and underscore the need for well-designed clinical trials to explore the most effective factors that can enhance the process of meniscal repair.

Effect of intra-articular injection of a hyaluronic acid-alendronate conjugate on post-traumatic osteoarthritis induced by destabilization of the medial meniscus in rats

Osteoarthritis (OA) is a chronic degenerative joint disease characterized by pain and cartilage damage. Intra-articular (i.a) viscosupplementation with hyaluronic acid (HA) is frequently used for the management of OA. Preclinical studies have reported that bisphosphonates (BPs) may have a therapeutic potential to slow down or reverse the progression of OA. Among these, alendronate (ALN) has demonstrated chondroprotective effects in both in vitro and vivo experiments. This study evaluated the effects of a novel alendronate-hyaluronic acid (ALN-HA) conjugate on an OA in vivo model induced by medial meniscus destabilization (DMM). DMM surgery was performed on the knees of Sprague Dawley rats that received, after four weeks, one intra-articular (i.a.) injection of: (1) ALN-HA; (2) HA; (3) sodium chloride (NaCl). Sham-operated rats were used as control. Allodynia was assessed by Von Frey test. Joint degeneration was evaluated eight weeks after treatment by micro-computed tomography (micro-CT), histology, and immunohistochemistry. Collagen cross-linked C-telopeptides (CTX-I and CTX-II) serum levels were determined by ELISA. Paw withdrawal threshold increased in ALN-HA group when compared to rats treated with NaCl or HA. Micro-CT did not show differences between ALN-HA, HA and NaCl groups. ALN-HA injection produced significant improvements in articular cartilage degeneration showing an OARSI score lower than those of HA and NaCl, and reduced matrix metalloproteinase (MMP)-13, MMP-3, interleukin-6, vascular endothelial growth factor and Caspase-3 expression. CTX-I was reduced after ALN-HA treatment when compared to NaCl. Our results indicate that i.a. use of ALN after conjugation with HA limits OA development and progression in the rat DMM model, and may lead to the development of novel therapeutic strategies in OA management.

Could Hyaluronic Acid Be Considered as a Senomorphic Agent in Knee Osteoarthritis? A Systematic Review

BACKGROUND

Knee osteoarthritis (KOA) is one of the most common causes of disability in elderly patients and tends to be a major burden on social and health care spending. Despite its severe socioeconomic impact, KOA remains, to date, an incurable disease. Due to its proper characteristics, KOA represents a favorable disease model for experimenting with senotherapeutics, a group of treatments that counteract the development of age-related disorders and chronic diseases. In recent years, the use of intra-articular hyaluronic acid (IAHA) in the treatment of diseases related to the wear and tear of the articular cartilage has been gaining popularity. Given its ability in joint lubrification, shock absorption, and cell signaling, our aim is to investigate, through the existing scientific literature, its potential role as a senomorphic agent, emphasizing its crucial function in KOA patients. Indeed, senomorphics are a particular group of senotherapeutics capable of modulating the functions and morphology of senescent cells to those of young cells or delaying the progression of young cells to senescent cells in tissues.

METHODS

A search in the scientific literature (PubMed, Cochrane Library, and Google Scholar) was carried out from 2019 to 2023, thus the last 5 years.

RESULTS

One hundred thirty-eight articles were found concerning the role of hyaluronic acid injections in KOA patients. In these studies, its therapeutic efficacy, its anti-inflammatory properties, and its low risk of side effects emerged.

CONCLUSION

IAHA injections are a valuable treatment option for KOA while they can provide pain relief, improve joint function, and slow the progression of joint degeneration. The inhibitory effect of HA on MMP13 and its action as a senomorphic agent suggests that it may have additional benefits beyond its lubricating and shock-absorbing properties. In order to clarify its mechanisms of action and to optimize its clinical use, further studies are definitely needed.

The efficacy of the leg swing and quadriceps strengthening exercises versus platelet-rich plasma and hyaluronic acid combination therapy for knee osteoarthritis: A retrospective comparative study

The aim of this was to investigate the efficacy of physical exercise (leg swing and quadriceps strengthening exercises) versus platelet-rich plasma (PRP) and hyaluronic acid (HA) combination therapy. From January 2020 to August 2021, 106 patients with Kellgren-Lawrence Grade I-III knee osteoarthritis were divided into leg swing and quadriceps strengthening exercises (Group A) and intra-articular combination injections of PRP and HA (Group B) according to the treatment strategies. Patients in Group A received regular leg swing and quadriceps strengthening exercises for 3 months. Patients in Group B received 2 intra-articular combination injections of PRP (2 mL) and HA (2 mL) every 2 weeks. The primary outcome measures were the Visual Analogue Scale (VAS) and the Western Ontario and McMaster Universities (WOMAC) score. Secondary outcomes included single leg stance test and functional activity by 2-minute walk test and time up and go test. All outcomes were evaluated at baseline and again 1, 3, 6, and 12 months. The VAS and WOMAC scores were similar in both groups at 1 and 3 months after treatment (P > .05); however, Group A patients had significantly superior VAS and WOMAC scores than Group B patients at 6 and 12 months after treatment. For the single leg stance test, 2-minute walk test, and time up and go test, Group A patients were significantly superior to Group B throughout follow-up (P < .001). The leg swing and quadriceps strengthening exercises resulted in a significantly better clinical outcomes than the combined PRP and HA therapy, with a sustained lower pain score and improved quality of life, balance ability, and functional activity within 12 months.

Concurrent Imaging and Clinical Study of the Efficacy of Hyaluronic Acid Injection for Knee Osteoarthritis: A Synovial Membrane Investigation with Ultrasound Imaging

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.

Treatment with CR500® improves algofunctional scores in patients with knee osteoarthritis: a post-market confirmatory interventional, single arm clinical investigation

BACKGROUND

Knee osteoarthritis (OA) is a progressive and degenerative condition. Several pharmacological and non-pharmacological treatments are able to improve the OA symptoms and the structural characteristics of the affected joints. Among these, infiltrative therapy with hyaluronic acid (HA) is the most used and consolidated procedure for the pain management. The addition of skin conditioning peptides to HA promotes the cartilage remodeling processes and a better permeation of the HA-based gel containing a peptide mixture, CR500®. Furthermore, the topic route of administration is convenient over the routinely used intra-articular injective procedures. In this study, the effectiveness of CR500® was evaluated in terms of improvement of the algo-functional symptoms related to unilateral knee OA.

METHODS

38 mild and moderate OA patients were enrolled at a screening visit (V-1), treated at baseline visit (V1), and then continued the topical application of CR500® twice a week for 4 weeks, and followed-up for 3 visits (V2-V4) from week 2 to 4. Lequesne Knee Index (LKI) and Knee injury and Osteoarthritis Outcome Score (KOOS) were collected. Synovial fluid was collected and used for the quantification of neoepitope of type II collagen (C2C), C-terminal telopeptide of type II collagen (CTX-II), type II collagen propeptide (CPII), tumor necrosis factor alpha (TNFα) and HA. The expression of CD11c and CD206 was evaluated on cell pellets.

RESULTS

Three patients were excluded, thus 35 patients were included in the analysis. The treatment with CR500® was safe and well tolerated, with 7.9% patients had mild adverse events, not related to the device. The LKI total score showed a significant decrease from V1 to V4. KOOS score also showed a significant improvement of patient condition at V2, V3 and V4 in comparison with V1 for all subscales, except for KOOS sport subscale which improved only from V3. At V1 a negative correlation among KOOS pain subscale values and C2C, CPII and TNFα levels was observed, as well as a positive correlation between KOOS pain subscale and CD11c/CD206 ratio.

CONCLUSION

CR500® is safe and appear to be effective in improving pain and function in OA patients during the 4 weeks of treatment.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05661162. This trial was registered on 22/12/2022.

Infiltration therapy in the context of cartilage surgery

Guideline-based surgical cartilage therapy for focal cartilage damage offers highly effective possibilities to sustainably reduce patients' complaints and to prevent or at least delay the development of early osteoarthritis. In the knee joint, it has the potential to reduce almost a quarter of the arthroses requiring joint replacement caused by cartilage damage. Biologically effective injection therapies could further improve these results. Based on the currently available literature and preclinical studies, intra- and postoperative injectables may have a positive effect of platelet-rich plasma/fibrin (PRP/PRF) and hyaluronic acid (HA) on cartilage regeneration and, in the case of HA injections, also on the clinical outcome can be assumed. The role of a combination therapy with use of intra-articular corticosteroids is lacking in the absence of adequate study data and cannot be defined yet. With regard to adipose tissue-based cell therapy, the current scientific data do not yet justify any recommendation for its use. Further studies also regarding application intervals, timing and differences in different joints are required.

Safety and effectiveness of intra-articular injection of a highly cross-linked hyaluronic acid, LBSA0103 (Synovian): Results from a post-marketing surveillance study in South Korea

This study aimed to assess the safety and effectiveness of the highly cross-linked hyaluronic acid-LBSA0103-in patients with knee osteoarthritis (OA) as per the prescribing information (PI) in South Korea. A total of 3,140 subjects aged ≥19 years were enrolled in this post-marketing surveillance (PMS) study from 2013 to 2019. The subjects received one or two injections of LBSA0103. The median duration of follow-up was 308 days. Adverse events (AEs), adverse drug reactions (ADRs), and serious AEs (SAEs) were monitored. Effectiveness was evaluated based on an index of effectiveness in accordance with the guidelines established by the Ministry of Food and Drug Safety and using a 100-mm visual analog scale (VAS) for weight-bearing pain. Overall, 250 subjects (7.96%) experienced 292 AEs and of these, unexpected AEs occurred in 114 subjects (3.63% [95% CI: 3.00-4.35]). Injection site pain was the most frequent AE reported by 81 subjects (2.58% [95% confidence intervals (CI): 2.05-3.20]). One hundred subjects experienced 108 ADRs (3.18% [95% CI: 2.60, 3.86]) and 15 unexpected ADRs were experienced by 13 subjects (0.41% [95% CI: 0.22-0.71]). Seventeen subjects experienced 22 SAEs (0.54% [95% CI: 0.32-0.87]) during the entire PMS period, and all were considered "unlikely" related to the study drug. Most AEs were mild in terms of severity and resolved during the study period. LBSA0103 was also effective in relieving symptomatic pain in knee OA patients. The condition in more than 80% of the subjects was considered to be improved when assessed by the investigators. LBSA0103 resulted in a significant reduction in the mean VAS score at 12 weeks after the first and second injections (24.79 (± 20.55) mm and 17.63 (±12.31) mm, respectively; p<0.0001). In conclusion, LBSA0103, used for the treatment of knee OA in a real-world setting, was well tolerated, with an acceptable safety profile and consistent therapeutic effect.

Repeated intra-articular injections of umbilical cord-derived mesenchymal stem cells for knee osteoarthritis: a phase I, single-arm study

INTRODUCTION

Stem cell therapy has emerged as an effective treatment for multiple diseases, and some studies also demonstrate that it may be a promising treatment for osteoarthritis (OA). However, few studies have clarified the safety of repeated intra-articular injection of human umbilical cord-derived mesenchymal stem cells (UC-MSCs). To promote its application in treating OA, we conducted an open-label trial to investigate the safety of repeated intra-articular injections of UC-MSCs.

METHODS

Fourteen patients with OA (Kellgrene-Lawrence grade 2 or 3) who received repeated intra-articular injections of UC-MSCs were evaluated in three months of follow-up. The primary outcomes were the adverse events, and the second outcomes included visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) scores and SF-12 quality of life score.

RESULTS

A total of 5 of 14 patients (35.7%) experienced transient adverse reactions, which resolved spontaneously. All patients showed some improvement in knee function limitation and pain after receiving stem cell therapy. VAS score 6.0 to 3.5, WOMAC score 26.0 to 8.5, MOCART score 42.0 to 58.0, SF-12 score 39.0 to 46.0.

CONCLUSION

Repeated intra-articular injection of UC-MSCs demonstrates safety in treating OA and does not induce serious adverse events. This treatment may transiently improve symptoms in patients with knee OA and may be a potential therapeutic option for OA.

Three Weekly Intra-Articular Injections of Hylan G-F 20 vs Arthrocentesis in Patients with Chronic Idiopathic Knee Osteoarthritis: A Multicenter, Evaluator- and Patient-Blinded, Randomized Controlled Trial

Background

Knee osteoarthritis is a leading cause of disability worldwide. Symptoms can vary over time, leading to episodes of worsened symptoms known as flares. Intra-articular injection of hyaluronic acid has demonstrated long-term symptomatic relief in the broader knee osteoarthritis population, although its use in the flare population has not been extensively examined.

Objective

To assess the efficacy and safety of 3 once-weekly intra-articular injections of hylan G-F 20 (as single and repeat courses) in patients with chronic knee osteoarthritis, including a subpopulation that experienced flare.

Methods

Prospective randomized controlled, evaluator- and patient-blinded, multicenter trial with 2 phases: hylan G-F 20 vs arthrocentesis only (control) and 2 courses vs single-course hylan G-F 20. Primary outcomes were visual analog scale (0-100 mm) pain scores. Secondary outcomes included safety and synovial fluid analysis.

Results

Ninety-four patients (104 knees) were enrolled in Phase I, with 31 knees representing flare patients. Seventy-six patients (82 knees) were enrolled in Phase II. Long-term follow-up was 26 to 34 weeks. In flare patients, hylan G-F 20 showed significantly more improvement than the controls for all primary outcomes except pain at night (P = 0.063). Both 1 and 2 courses of hylan G-F 20 showed significant improvements from baseline for primary outcomes with no differences in efficacy between groups in the intention-to-treat population at the end of Phase II. Two courses of hylan G-F 20 showed better improvement in pain with motion (P = 0.0471) at long-term follow-up. No general side effects were reported, and local reactions (pain/swelling of the injected joint) resolved within 1 to 2 weeks. Hylan G-F 20 was also associated with reduced effusion volume and protein concentration.

Conclusions

Hylan G-F 20 significantly improves pain scores vs arthrocentesis in flare patients with no safety concerns. A repeat course of hylan G-F 20 was found to be well tolerated and efficacious.

Effects of platelet-rich plasma on subchondral bone marrow edema and biomarkers in synovial fluid of knee osteoarthritis

BACKGROUND

The aim of the study was to investigate the effect of platelet-rich plasma (PRP) on subchondral bone marrow edema (BME) and the level of biomarkers in synovial fluid of the knee osteoarthritis.

METHODS

Eighty-one patients with symptomatic knee osteoarthritis were randomly divided into two groups according to the number of inpatients. Forty-five cases were treated with intra-articular injection of PRP (PRP group), 36 cases were treated with sodium hyaluronate (SH group), and the clinical effects were evaluated using the Visual Analogue Scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. The changes of subchondral BME were assessed by magnetic resonance imaging (MRI) before and after treatment. The levels of TNFα, IL-6, MCP-1, MMP-1, MMP-3, and MMP-9 in synovial fluid were also detected.

RESULTS

All the patients completed the corresponding treatment and were followed up for 12 months without serious complications. After the treatment, the VAS and WOMAC scores of the two groups were significantly decreased, and the difference was statistically significant at different time points (P < 0.05). The VAS and WOMAC scores of the PRP group were better than those of the SH group (P < 0.05). MRI showed that the subchondral bone edema of the two groups were reduced in varying degrees, and the reduction was more noticeable in the PRP group (P < 0.05). The levels of TNFα, IL-6, MCP-1, MMP-1, MMP-3, and MMP-9 in two groups were decreased, and the difference was statistically significant at different time points (P < 0.05). However, the levels of TNFα, IL-6, MCP-1, MMP-1, MMP-3, and MMP-9 in the PRP group were significantly lower than those in the SH group (P < 0.05).

CONCLUSIONS

Intra-articular injection of PRP can significantly reduce the subchondral BME and the level of biomarkers in synovial fluid of the symptomatic knee osteoarthritis.

The Association between Radiographic Features and the Duration of Effectiveness of a Single Injection of Extended-Release Hyaluronic Acid (HANOX-M-XL) in Patients with Knee Osteoarthritis: Preliminary Results of a Prospective Trial

BACKGROUND

Advanced radiological stage of knee osteoarthritis (OA) is predictive of poor response to viscosupplementation (VS). To date, the impact of x-ray features on the duration of effectiveness (DE) of VS has not been investigated.

OBJECTIVES

To investigate the radiological features associated with DE of VS in patients with knee OA.

METHODS

Cross-sectional study in patients with knee OA treated with 1 injection of cross-linked hyaluronic acid (HA). The primary outcome was DE, self-assessed by the patients in weeks of effectiveness. Radiological features (joint space narrowing-JSN topography and Kellgren-Lawrence [K-L] grade) associated with DE were studied.

RESULTS

Fifty-one patients-33 females (76 knees)-were analyzed. The average DE was 52.0 (24.7) weeks (range, 13-155 weeks). In the bivariate analysis, DE was 14 weeks longer in those with K-L grades 1 and 2 (62.6 ± 36.4 weeks) than in those with K-L 3 and 4 (48.9 ± 18.6) (P = 0.03). DE was not significantly different according to the involved compartment(s). It was significantly longer in men than in women (60 ± 31.4 vs. 47 ± 16 weeks; P = 0.035). In multivariate analysis, K-L grade (1-2 vs. 3-4) (P = 0.007), male gender (0.02), and older age (0.04) were independently associated with a longer DE.

CONCLUSION

DE of a single injection of extended-release HA is longer in K-L 1-2 than in K-L 3-4 OA knees, regardless of the JSN topography. However, even the patients with more advanced OA benefited from HANOX-M-XL injection for an average duration barely less than 1 year.

Safety of Epidural Hyaluronic Acid Injections in Managing the Symptoms of Lumbar Foraminal Stenosis: A Prospective Preliminary Study

Lumbar foraminal stenosis (LFS) of degenerative origin is a common reason for distorted neurodynamics of nerve roots, causing radicular pain that is difficult to resolve with conservative treatments. A hyaluronic acid (HA), providing a sliding layer in the mechanical interface of a nerve root in a narrowed lateral recess, could potentially improve its neurodynamics and the trophic, leading to radicular pain reduction and improvement of function. This study aimed to assess the usefulness of ultrasound-guided HA epidural injections combined with neuromobilization in the conservative treatment of LFS. A group of 10 consecutively admitted patients with MRI-confirmed LFS and reduced straight leg raise (SLR) test results were qualified for a single HA epidural injection along with self-performed neuromobilization. Three measurement tools were used for primary outcomes: the numeric rating scale (NRS) for pain intensity, the Oswestry disability index (ODI) and the Roland-Morris questionnaire (RMQ) for disability level, and the angle of pain-free elevation in the SLR test as a functional assessment. The treatment was accomplished in all patients (100%). Overall, 60% of the patients completed all follow-up visits. There were no statistically significant differences regarding the results of the NRS, ODI, or RMQ; however, a statistically significant increase in the results of the SLR test was noted (p = 0.015). Three patients reported a flare-up of the symptoms shortly after injection but without neurological deficits. In conclusion, an epidural HA injection combined with a self-administered exercise program is a promising method and might be a beneficial way to enhance the neurodynamics of nerve roots in LFS and offer an option for steroid treatment. However, this method of epidural HA administration in LFS should be verified in further studies to confirm its efficiency and safety.

Recombinant protein drugs-based intra articular drug delivery systems for osteoarthritis therapy

Osteoarthritis (OA) is the most prevalent chronic degenerative joint disease. It weakens the motor function of patients and imposes a significant economic burden on society. The current medications commonly used in clinical practice do not meet the need for the treatment of OA. Recombinant protein drugs (RPDs) can treat OA by inhibiting inflammatory pathways, regulating catabolism/anabolism, and promoting cartilage repair, thereby showing promise as disease-modifying OA drugs (DMOADs). However, the rapid clearance and short half-life of them in the articular cavity limit their clinical translation. Therefore, the reliable drug delivery systems for extending drug treatment are necessary for the further development. This review introduces RPDs with therapeutic potential for OA, and summarizes their research progress on related drug delivery systems, and make proper discussion on the certain keys for optimal development of this area.

Efficacy and safety of GLucocorticoid injections into InfrapaTellar faT pad in patients with knee ostEoarthRitiS: protocol for the GLITTERS randomized controlled trial

BACKGROUND

Knee osteoarthritis (OA) is a prevalent disabling disorder that involves changes in articular cartilage damage, subchondral bone remodeling, synovitis, and abnormal infrapatellar fat pad (IPFP). Due to the complicated etiology and numerous phenotypes of knee OA, limited improvement is achieved for treatments among knee OA patients with different phenotypes. Inflammatory OA phenotype is a typical knee OA phenotype, and individualized treatment targeting inflammation is a promising way to obtain an optimal therapeutic effect for people with inflammatory knee OA phenotype. Glucocorticoid is a traditional anti-inflammatory drug for knee OA, and intra-articular glucocorticoid injections are recommended clinically. However, emerging evidence has shown that repeated intra-articular glucocorticoid injections in the long term would induce cartilage loss. IPFP and its adjacent synovium are considered as the main source of inflammation in knee OA. This GLITTERS trial aims to investigate if a glucocorticoid injection into the IPFP is effective and safe over 12 weeks among knee OA patients with an inflammatory phenotype.

METHODS

GLITTERS is a multicenter, double-blinded, randomized, and placebo-controlled clinical trial among knee OA patients with both Hoffa-synovitis and effusion-synovitis. Sixty participants will be allocated randomly and equally to either the glucocorticoid group or the control group. Each group will receive an injection of glucocorticoid or saline into the IPFP with an intra-articular hyaluronic acid injection as a background treatment at baseline and be followed at 4, 8, and 12 weeks. The primary outcomes will be changes in knee pain on a visual analog scale and effusion-synovitis volume measured on magnetic resonance imaging (MRI). The secondary outcomes will be changes in the total score of Western Ontario and McMaster Universities Osteoarthritis Index score, MRI-detected Hoffa-synovitis score, quality of life, pain medication use, IPFP volume, and the incidence of adverse reactions. Data analyses based on the intention-to-treat principle will include mixed-effects regressions, Wilcoxon rank-sum tests, and chi-square tests (or Fisher's exact test).

DISCUSSION

GLITTERS may provide high-quality evidence for the efficacy and safety of ultrasound-guided glucocorticoid injections into IPFP among people with inflammatory knee OA in a short term. The results of this trial are expected to provide a reliable reference for a longer-term risk-benefit profile of this treatment in the future.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05291650. Registered on 23 March 2022.

Effects of Hyaluronic Acid With Intra-articular Corticosteroid Injections in the Management of Subtalar Post-traumatic Osteoarthritis - Randomized Comparative Trial

We investigated the potential of exogenous hyaluronic acid (HA) associated with corticosteroid injections to improve pain and function for the treatment of post-traumatic subtalar osteoarthritis, in comparison with isolated intra-articular corticosteroid. Twenty-five symptomatic participants (50 ± 8 years) with a minimum follow-up of 1 year after surgery for calcaneus fractures were enrolled. Participants were randomly assigned into a therapeutic group that underwent isolated corticosteroid intra-articular subtalar injection (Corticosteroid Group, n = 12) or a combination of HA plus corticosteroid (HA+C Group, n = 13). All participants underwent three repeated injections with intervals of 1 week. We assessed the visual analog scale of pain (VAS) and the AOFAS scores at 4 moments: before treatment (pre), 4-, 12-, and 24-weeks following the last injection. HA+C Group showed lower VAS at the 12th (p = .003) and 24th weeks (p = .003) and greater AOFAS at the 4th (p = 0.040), 12th (p = .014), and 24th weeks (p = .021), in comparison to Corticosteroid Group. We observed a reduction in VAS in the Corticosteroid Group only at the 4th week (p = .007), compared with pretreatment values. In the HA+C Group, VAS presented lower levels at the 4- (p < .001), 12- (p < .001), and 24 weeks (p < .001). In the Corticosteroid Group, participants presented higher AOFAS score only at the 4th week (p < .001), while in the HA+C Group, the AOFAS scores were greater at the 4th, 12th, and 24th weeks compared to baseline (p < .001). The combination of exogenous HA and corticosteroid showed greater and longer analgesic effects and function improvement in comparison with isolated intra-articular corticosteroids.

Efficacy and safety of platelet-rich plasma combined with hyaluronic acid versus platelet-rich plasma alone for knee osteoarthritis: a systematic review and meta-analysis

Purpose

To systematically evaluate the curative efficacy and safety of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) in the treatment of knee osteoarthritis (KOA), comparing with platelet-rich plasma alone.

Methods

Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI) and Embase were searched for randomized controlled trials (RCTs) and cohort studies regarding the efficacy and safety of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) in the treatment of knee osteoarthritis (KOA) comparing with platelet-rich plasma alone before January 15, 2022. The methodological quality of the ultimately included studies was assessed comprehensively, and meta-analysis was implemented using RevMan 5.3 software.

Results

Thirteen articles (9 RCTs, 4 cohort studies), including 1118 patients, were covered. There was no significant difference between the PRP + HA therapy and PRP-alone therapy in VAS scores at 3 months, 6 months and 12 months, WOMAC total scores at 3 months and KOOS at 1 month and 6 months. Compared with PRP-alone therapy, PRP + HA therapy was associated with significantly better improvement in VAS scores at 1 month, WOMAC total scores at 6 months, KOOS at 3 months, IKDC scores at 6 months and Lequesne index scores at 3 and 6 months. However, the smallest treatment effect of VAS scores, WOMAC total scores, KOOS and IKDC scores did not exceed the minimum clinically important difference (MCID). However, PRP + HA therapy got a greater reduction in the rate of adverse events, compared with PRP-alone therapy.

Conclusion

The results of this meta-analysis indicated that PRP + HA therapy was not found to be superior to PRP-alone therapy in pain relief and function improvement for patients with KOA. However, combined PRP with HA injections was generally safer than PRP injections alone, by assessing the incidence of adverse events.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13018-022-03398-6.

Hyaluronic acid in the treatment of osteoarthritis of various localization: A review

The article discusses the treatment of osteoarthritis (OA), the prevalence of which is high, and according to some forecasts it will increase by 50% in the next 20 years. The authors emphasize the high comorbidity among patients suffering from OA and high cardiovascular and gastrointestinal risks with frequent use of NSAIDs, the volume of consumption of which is constantly increasing. Discussing recommendations for the treatment of patients with OA, the article focuses on the use of hyaluronic acid (HA) preparations in the treatment of OA. The mechanisms of anti-inflammatory and chondroprotective actions of HA in the joint, its effect on cartilage and synovial membrane are discussed. Attention is drawn to the fact that, despite more than 30 years of experience in the effective use of HA preparations in the treatment of OA, this procedure is still a subject of controversy among international professional communities. The article presents data from meta-analyses and systematic reviews confirming the effectiveness of the use of intra-articular management of HA preparations in OA of various localization (knee joints, hip joints, hand joints). In conclusion, the recommendations of the technical expert group established at the International Symposium on Intra-Articular Treatment are given to determine the criteria for the successful administration of HA in OA of various localizations, as well as predictors of success and non-success of therapy with HA drugs. The experts identified indications, contraindications for intra-articular administration of HA preparations, as well as conditions associated with an increased risk of therapy failure. In conclusion, the authors draw conclusions about the importance of using HA preparations for intra-articular administration for the treatment of OA, starting from the early stages, following the recommendations of experts.

Molecular Dynamics Investigation of Hyaluronan in Biolubrication

Aqueous solution of strongly hydrophilic biopolymers is known to exhibit excellent lubrication properties in biological systems, such as the synovial fluid in human joints. Several mechanisms have been proposed on the biolubrication of joints, such as the boundary lubrication and the fluid exudation lubrication. In these models, mechanical properties of synovial fluid containing biopolymers are essential. To examine the role of such biopolymers in lubrication, a series of molecular dynamics simulations with an all-atom classical force field model were conducted for aqueous solutions of hyaluronan (hyaluronic acid, HA) under constant shear. After equilibrating the system, the Lees-Edwards boundary condition was imposed, with which a steady state of uniform shear flow was realized. Comparison of HA systems with hydrocarbon (pentadecane, PD) solutions of similar mass concentration indicates that the viscosity of HA solutions is slightly larger in general than that of PDs, due to the strong hydration of HA molecules. Effects of added electrolyte (NaCl) were also discussed in terms of hydration. These findings suggest the role of HA in biolubirication as a load-supporting component, with its flexible character and strong hydration structure.

Treatment of Knee Osteochondral Fractures

Osteochondral lesions (OCLs) that are frequently encountered in skeletally immature and adult patients are more common than once thought, and their incidence rate is rising. These lesions can appear in many synovial joints of the body, such as the shoulder, elbow, hip, and ankle, occurring most often in the knee. The term osteochondral lesion includes a vast spectrum of pathologies such as osteochondritis dissecans, osteochondral defects, osteochondral fractures, and osteonecrosis of the subchondral bone. When considering this, the term osteochondral fracture is preserved only for an osteochondral defect that combines disruption of the articular cartilage and subchondral bone. These fractures commonly occur after sports practice and are associated with acute lateral patellar dislocations. Many of these lesions are initially diagnosed by plain radiographs; however, a computed tomography (CT) scan or magnetic resonance imaging (MRI) can add significant value to the diagnosis and treatment. Treatment methods may vary depending on the location and size of the fracture, fragment instability, and skeletal maturity. The paper reports a 14-year-old boy case with an osteochondral fracture due to sports trauma. The medical approach involved an arthrotomy of the knee, drainage of the hematoma, two Kirschner wires (K-wires) for temporary fixation to restructure anatomic alignment, and a titanium Herbert screw fixing the fracture permanently. The patient had a favorable postoperative outcome with no residual pain, adequate knee stability, and a normal range of motion. The mobility of the knee was fully recovered.

Enhancement of the functionality of women with knee osteoarthritis by a gel formulation with Caryocar coriaceum Wittm ("Pequi") nanoencapsulated pulp fixed oil

Osteoarthritis (OA) is a degenerative joint disease that occurs when there is a change in the mechanical and biological properties of the articular cartilage and the subchondral bone; The condition is more prevalent in women than in men. Pequi oil (PO), which is extracted from the fruits of the pequi tree (Caryocar coriaceum Wittm), is widely used in traditional medicine in the Brazilian northeast for the management of inflammation and joint pain. The aim of this study was to develop a pharmaceutical formulation containing Carbopol® hydrogel nanoencapsulated with pequi pulp fixed oil (PeONC) and evaluate its therapeutic effect on functionality and pain in women with knee osteoarthritis. The study was divided into two stages: Stage 1 - preparation and physico-chemical characterization of the pharmaceutical formulation containing PeONC, cell viability assays and skin irritability testing. Step 2 - A double-blind randomized clinical trial evaluating knee symptoms, quality of life, pressure pain, function, muscle strength and range of motion. The nanoformulation was in a gel form, with a particle size of 209.5 ± 1.06 nm, a pH of 6.23 ± 0.45, a zeta potential of - 23.1 ± 0.4 mV, a polydispersity index of 0.137 ± 0.52, and containing nanocapsules with a spherical shape a polymeric wall and an oily nucleus. The gel showed no cytotoxicity and was not irritating to human skin. The treatment with PeONC increased the strength of the knee flexor and extensor muscles and the total motion range of the knee. In addition, the treatment reduced knee instability, pain, swelling, and locking; There was also an improvement in some items of the SF-36 quality of life questionnaire such as in respect of functional capacity and social aspects. In conclusion, PeONC was found to be a stable, safe formulation with no toxicity in respect of topical use in humans. Additionally, the treatment produced an increase in muscle strength and functionality that was associated with reduced knee symptoms and improved quality of life. Our findings showed that in a group of women treated with PeONC mitigated the symptoms of knee osteoarthritis.

Medial compartment cartilage repair and lower extremity biomechanical changes after single-plane high tibial osteotomy of distal tibial tuberosity

OBJECTIVE

To observe the cartilage repair of the medial compartment and the biomechanical changes of the lower extremities after single-plane high tibial osteotomy of distal tibial tuberosity (DTT-HTO).

METHODS

A total of 30 patients, including 11 males and 19 females, who underwent DTT-HTO with arthroscopic operation in our hospital from January 2020 to January 2021 and underwent arthroscopic exploration again during the second operation for internal fixation were enrolled. There were 32 knees, including 13 left knees and 19 right knees. Age ranged from 50 to 78, with an average of 63.20 ± 6.61 years old. All patients completed two surgeries and were followed up, and no adverse events occurred during the period. International Cartilage Repair Society (ICRS) was used to assess the cartilage condition of the medial compartment of the knee during the two surgeries. In this paper, the weight-bearing line ratio (WBLR), the medial proximal tibia angle (MPTA), the femoral tibial angle (FTA) and the posterior tibial slope (PTS) were used to evaluate the changes of the mechanical state of the lower limbs. The visual analogue scale (VAS) score and the Western Ontario and McMaster University Osteoarthritis (WOMAC) Index score were used to evaluate the improvement in knee pain and function.

RESULTS

All patients completed two operations without adverse events and serious complications. The medial compartment cartilage of all patients had different degrees of repair during the second operation, and the difference was statistically significant compared with the first operation (P < 0.05). During the second operation, the WBLR was corrected from (17.69 ± 2.16)% to (60.90 ± 1.97)%, the MPTA was corrected from (80.72 ± 1.61)° to (89.91 ± 2.58)°, the FTA was corrected from (182.31 ± 3.03)° to (171.81 ± 2.24)°, the difference was statistically significant (P < 0.05). There was no statistical difference in PTS between the two surgeries (P > 0.05). At the second operation, the VAS score decreased from 7.50 ± 1.34 to 0.34 ± 0.85, the WOMAC score decreased from 119.50 ± 10.43 to 46.25 ± 4.13, and the difference was statistically significant (P < 0.05).

CONCLUSION

DTT-HTO can significantly correct the weight-bearing line, restore the biomechanical parameters of the lower limb to the normal range, significantly relieve pain and improve knee function, and the medial compartment cartilage repair and regeneration phenomenon will occur after the correction of the weight-bearing line.

Ultrasound-guided intra-articular injection of expanded umbilical cord mesenchymal stem cells in knee osteoarthritis: a safety/efficacy study with MRI data

Aim: This study has the primary objective of studying the effect of Wharton jelly mesenchymal stem cells (WJMSCs) in the treatment of knee osteoarthritis. As a secondary end point, we report on the efficacy of such therapy. Patients and methods: 16 patients with advanced Kellgren stage were treated using two doses of expanded WJMSCs given 1 month apart. Patients were followed for 48 months using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and 12 months using magnetic resonance imaging (MRI). Results: Treatment was well tolerated. One patient developed moderate effusion and one superficial phlebitis. We observed functional and pain improvement at 12 and 48 months (p < 0.0001), with statistically significant improvement on MRI scans at 12 months in cartilage loss, osteophytes, bone marrow lesions, effusion and synovitis (p < 0.01), and highly significant improvement in subchondral sclerosis (p < 0.0001). Conclusion: WJMSCs are safe and potentially effective in producing significant improvement in KOOS and MRI scores when administered intra-articularly in knee osteoarthritis cases under ultrasound guidance.

A Review of the Clinical Effectiveness and Safety of Hybrid Cooperative Complexes in Intra-articular Viscosupplementation

Viscosupplementation by intra-articular (i.a.) injection of the non-sulfated glycosaminoglycan (GAG) hyaluronic acid (HA) is a conservative therapy widely accepted in clinical practice for the management of osteoarthritis (OA) and joint diseases. The aim of viscosupplementation is to restore the rheological properties of the synovial fluid to relieve joint inflammation and pain and improve joint function through a chondroprotective effect. However, there is a range of hyaluronic acid products for OA that differ in preparation, molecular weight, rheological characteristics and concentration, and different i.a. formulations are more suited to particular patient populations and clinical situations, in part because of anatomical differences between joints. This paper focuses on innovative hybrid cooperative complexes of high and low molecular weight hyaluronic acid (HA-HL) and hyaluronic acid plus sodium chondroitin (HA-SC) that have been developed. Both products are formulated with pharmaceutical-grade, highly purified hyaluronic acid obtained with a multi-step biofermentation process, with properties that make them suitable across a range of degenerative joint diseases. They represent progress in building on the symptomatic and functional benefits of viscosupplementation in joint disease, with the additional beneficial effect of treating the patient with a high concentration of GAGs by a low number of injections. Here, we review the clinical evidence for the efficacy of a hybrid cooperative compound of HA-HL in various degenerative joint diseases, which suggests a synergistic effect of the different molecular weight hyaluronans that together more closely mimic the physiological composition of synovial fluid. Similarly, the evidence shows that HA-SC is safe, effective, and well tolerated in hip OA, with rapid and clinically significant improvements in pain symptoms and functionality. Such innovations in viscosupplementation expand the usefulness of the modality in the management of OA and other joint diseases, complemented by a lack of systemic or local side effects that allow the concurrent use of other drugs if needed.

Injectable Natural Polymer Hydrogels for Treatment of Knee Osteoarthritis

Osteoarthritis (OA) is a serious chronic and degenerative disease that increasingly occurs in the aged population. Its current clinical treatments are limited to symptom relief and cannot regenerate cartilage. Although a better understanding of OA pathophysiology has been facilitating the development of novel therapeutic regimen, delivery of therapeutics to target sites with minimal invasiveness, high retention, and minimal side effects remains a challenge. Biocompatible hydrogels have been recognized to be highly promising for controlled delivery and release of therapeutics and biologics for tissue repair. In this review, the current approaches and the challenges in OA treatment, and unique properties of injectable natural polymer hydrogels as delivery system to overcome the challenges are presented. The common methods for fabrication of injectable polysaccharide-based hydrogels and the effects of their composition and properties on the OA treatment are detailed. The strategies of the use of hydrogels for loading and release cargos are also covered. Finally, recent efforts on the development of injectable polysaccharide-based hydrogels for OA treatment are highlighted, and their current limitations are discussed.

Intra-articular drug delivery systems for osteoarthritis therapy: shifting from sustained release to enhancing penetration into cartilage

Osteoarthritis (OA) is a progressive chronic inflammation that leads to cartilage degeneration. OA Patients are commonly given pharmacological treatment, but the available treatments are not sufficiently effective. The development of sustained-release drug delivery systems (DDSs) for OA may be an attractive strategy to prevent rapid drug clearance and improve the half-life of a drug at the joint cavity. Such delivery systems will improve the therapeutic effects of anti-inflammatory effects in the joint cavity. Whereas, for disease-modifying OA drugs (DMOADs) which target chondrocytes or act on mesenchymal stem cells (MSCs), the cartilage-permeable DDSs are required to maximize their efficacy. This review provides an overview of joint structure in healthy and pathological conditions, introduces the advances of the sustained-release DDSs and the permeable DDSs, and discusses the rational design of the permeable DDSs for OA treatment. We hope that the ideas generated in this review will promote the development of effective OA drugs in the future.

Systematic Literature Review and Expert Opinion for the Use of Viscosupplementation with Hyaluronic Acid in Different Localizations of Osteoarthritis

Osteoarthritis (OA) is a significant cause of disability. Considering the increasing diffusion of the viscosupplementation (VS) with hyaluronic acid (HA), the International Symposium Intra Articular Treatment (ISIAT) appointed a Technical Expert Panel (TEP) to identify the criteria for successful VS with a specific HA in OA; this through a systematic literature review (SLR), performed following the PRISMA guidelines interrogating Medline, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Grey Matters and American College of Rheumatology (ACR/EULAR) databases and the opinion of international experts. The research included only studies on adults and humans without limitations of language or time of publication. Researchers extracted both quantitative and qualitative data from each study. Mixed Methods Appraisal Tool (MMAT) was used to perform quality analysis for the level of evidence. The SLR retrieved 385 papers, 25 of which were suitable for the analysis. The TEP focused on the different formulations of the product Sinovial^® [HA 0.8%, HA 1.6%, HA 2%, 800–1200 kDa, HA 3.2% (1400–2100 kDa/65–110 kDa)]. The choice was due to the vast amount of evidence available. The TEP weighed the evidence in two rounds of a Delphi survey; the results, and any disagreement, were discussed in a final session. Three domains were considered: 1) the patients’ characteristics associated with the best results; 2) the contraindications and the conditions linked to increased risk of failure; 3) the clinical conditions in which VS is considered appropriate. The TEP concluded that VS with HA is safe and effective in the treatment of knee and hip OA of grades I to III and that it is possible to undertake VS in other situations (eg grade IV Kellgren-Lawrence – KL); a comprehensive examination of the patient should be performed before the procedure.

Acide hyaluronique intra-articulaire dans la gonarthrose: résultats cliniques d'une famille de produits (ARTHRUM), avec méta-analyses comparatives

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.

Does the Presence of Neuropathic Pain Influence the Response to Hyaluronic Acid in Patients with Knee Osteoarthritis?

OBJECTIVES

Up to 50% of patients with symptomatic knee osteoarthritis (OA) present with neuropathic pain (NP) features. We assessed the impact of NP according to DN4 (Douleurs Neuropathiques 4 questions) score on the response to intra-articular (IA) hyaluronic acid (HA) injections and the effects of HA injections on NP.

MATERIALS AND METHODS

We conducted a post hoc analysis from a multicenter, randomized, double-blind, noninferiority trial comparing the efficacy of 2 HA in symptomatic knee OA at 24 weeks. At baseline, demographic, anthropometric, radiologic data, and symptoms were recorded. The symptomatic effect of HA was assessed by VAS pain, patient global assessment (PGA), WOMAC, DN4, and OMERACT-OARSI response.

RESULTS

A total of 187 patients were included. NP according to DN4 score was present in 20 patients (10.7%) at baseline. Most common positive DN4 items were tingling (36.9%) and burning (36.4%). NP was associated with WOMAC pain score (P = 0.02). The presence of NP at baseline did not affect the symptomatic improvement after HA injections according to the VAS pain (P = 0.71), PGA (P = 050), WOMAC pain (P = 0.89), WOMAC function (P = 0.52), and rate of OMERACT-OARSI responders (P = 0.21). The prevalence of patients with NP decreased by 50% (n = 10) at 24 weeks after HA injections. Most improved DN4 items were itching (90%), hypoesthesia to pinprick (88%), and burning (50%).

CONCLUSION

In our study, NP was associated with pain severity, but did not influence the response to IA HA. On the other hand, HA injections reduced some NP features, especially itching, sting hypoesthesia, and burning.

Intra-articular Hymovis injection for managing hip OA in active sportsmen. A 24-month observational retrospective clinical investigation

BACKGROUND

Hip Osteoarthitis (OA) risk is sport-specific and depends on frequency, intensity, and type of mechanic stress the hip is subjected to. This retrospective observational study aims to investigate the safety and performance of Hymovis (HYADD-4) injection, a hexadecyl (C-16) HA-derivative, when used to manage symptomatic hip OA in active middle-aged sportsmen over a 24-month observation period.

METHODS

The retrospective analysis included clinical records of active sportsmen, aged between 40 and 65 years, and suffering from symptomatic Kellgren-Lawrence grade II to III hip OA, treated with two (24 mg/3 ml) Hymovis injections, two weeks apart, every 3-4 months, for two years. When available, data on MRI examination were included in the analysis as well as Heidelberg Sports Activity Score (HAS) and Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaires.

RESULTS

Thirty patients (56.4 ± 7.3 years) were included in the study, sixteen cyclists and 14 tennis players. For all patients, HAS and most HAGOS scores improved significantly (p < 0.05) at the first control visit (4 months) and further improved over time. For all other scores an important clinical benefit was experienced by more than 50% of participants. No adverse events were recorded.

CONCLUSION

Treatment of hip OA in active sportsmen with Hymovis seems a safe and effective approach for the management of OA symptoms, by potentially protecting cartilage and subchondral bone from further damage.

Intra-articular hyaluronic acid in knee osteoarthritis: clinical data for a product family (ARTHRUM), with comparative meta-analyses

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.

Assessment of the Response Profile to Hyaluronic Acid Plus Sorbitol Injection in Patients with Knee Osteoarthritis: Post-Hoc Analysis of a 6-Month Randomized Controlled Trial

In a previous randomized trial, the non-inferiority of two hyaluronic acid injections (Synolis VA versus Synvisc-One) was assessed in patients with knee OA, with a response rate of 79% for Synolis VA. To assess whether a responder profile could be established for this treatment modality, we used the Synolis VA arm of a published 6-month prospective, multicenter, comparative, randomized, double-blinded trial. At baseline and during the study, pain and function were assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Ninety-six subjects from the intention-to-treat trial were included in the analysis. The 6-month change of WOMAC Pain with Synolis VA was not associated with any baseline clinical data. However, the change in WOMAC Function was significantly associated with its baseline level, even after adjustment for potential confounding variables (p = 0.028), i.e., a poorer physical function at baseline was associated with a better response. In conclusion, in addition to the high absolute response rate to Synolis VA, the probability of success is even increased if administered in patients with more limited physical function at baseline. Further research with other potential confounding clinical variables is warranted in order to better applicate the concept of personalized medicine.

Superficial Needling Acupuncture vs Sham Acupuncture for Knee Osteoarthritis: A Randomized Controlled Trial

BACKGROUND

Acupuncture has been an alternative approach for pain management, but trial evidence is conflicting.

METHODS

Eighty-six patients with knee osteoarthritis were randomly assigned in a 1:1 ratio from June 14, 2017, to January 20, 2019, to receive either superficial needling acupuncture treatment or sham acupuncture for 10 sessions over a 4-week treatment period, followed by a 6-week follow-up period. The primary outcome was the change of pain intensity at week 4 measured using a 100-mm visual analogue scale. Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index and 36-Item Short Form Health Survey.

RESULTS

At the end of the 4-week treatment period, mean changes in the visual analogue scale were -30.8 (95% confidence interval [CI], -38.2 to -23.0; p <.001) in the acupuncture group and -26.7 (95% CI, -34.4 to -18.8; P <.001) in the sham group. The difference between the acupuncture group and the sham group was -4.1 (95% CI, -14.4 to 6.2; P = 0.431). At week 10, the difference between the groups was -2.2 (95% CI, -13.1 to 8.8; P =0.699). There was no statistically significant difference in Western Ontario and McMaster Universities Osteoarthritis Index subscores (pain, stiffness, and physical function) and 36-Item Short Form Health Survey-related outcomes across groups from weeks 2 to 10. The incidence of treatment-related adverse events was 4.4% in the acupuncture group and 0.8% in the sham acupuncture group. All adverse events were classified as mild.

CONCLUSION

Acupuncture for 4 weeks is not superior to non-penetrating sham acupuncture. The current study cannot confirm that superficial acupuncture has efficacy for the treatment of knee osteoarthritis.

Intra-Articular Hybrid Hyaluronic Acid Injection Treatment in Overweight Patients with Knee Osteoarthritis: A Single-Center, Open-Label, Prospective Study

Background: A BMI > 25 is the most decisive, albeit modifiable, risk factor for knee osteoarthritis (KOA). This study aimed at assessing the efficacy of intra-articular injections of hybrid hyaluronic acid (HA) complexes (Sinovial® H-L) for the treatment of KOA in overweight patients in terms of disease severity, cardiocirculatory capacity, and quality of life. Materials: In this single-site, open-label, prospective trial, 37 patients with symptomatic knee OA were assessed at baseline and 3 months after ultrasound-guided intra-articular injection of hybrid HA complexes (Sinovial® H-L). Results: Primary variables displaying a statistically significant improvement after treatment were pain (VAS), disease severity (WOMAC), and cardiopulmonary capacity (6 min walk test). Among secondary variables, quality of life (SF-12) improved significantly, as did analgesic intake for pain control. No statistically significant difference was observed in body fat and muscle mass percentage measured by bioelectrical impedance analysis. Conclusions: Intra-articular hybrid HA injections are significantly effective in improving OA-related disease severity, cardiopulmonary function, and analgesic intake. This supports the role of hybrid HA viscosupplementation as a nonpharmacological treatment to relieve pain, reduce disability, improve quality of life, and limit the risk of polypharmacy in overweight patients with knee OA.

Knee Osteoarthritis Pain Management with an Innovative High and Low Molecular Weight Hyaluronic Acid Formulation (HA-HL): A Randomized Clinical Trial

INTRODUCTION

The objective of this study was to compare a single intra-articular injection of an innovative high and low molecular weight hyaluronic acid formulation (HA-HL) versus placebo in treating moderate-to-severe symptomatic knee osteoarthritis.

METHODS

Subjects with primary osteoarthritis knee pain (Kellgren and Lawrence grade 2-3) were randomly assigned to intra-articular HA-HL or placebo in a prospective, double-blind, 24-week study. The primary outcome variable was change from screening to week 24 of a Visual Analogue Scale (VAS) pain score. Secondary outcomes included Lequesne's algofunctional index, EuroQol 5-Dimension Questionnaire, 5-level version (EQ-5D-5L), Outcome Measures in Arthritis Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI) response and rescue medication usage.

RESULTS

In a total of 692 randomized patients, a rapid decrease was observed in mean VAS pain score from baseline to week 1 (26 ± 24 mm in the HA-HL group vs. 23 ± 23 mm in the placebo group); pain intensity continued to decrease during 24 weeks of follow-up, reaching a mean change from baseline of 35 ± 28 mm vs. 32 ± 27 mm at week 24. Mixed model analysis demonstrated statistically significant differences between groups in favor of the HA-HL group at weeks 1, 6, 12, and 24. HA-HL was also more effective than placebo in improving Lequesne's algofunctional index, OMERACT-OARSI response, and health-related quality of life. The use of rescue medication (paracetamol 500 mg tablets; ≤ 6 per day) was lower in the HA-HL group. Both treatments were similarly well tolerated.

CONCLUSIONS

A single intra-articular injection of an innovative high and low molecular weight hyaluronic acid formulation (HA-HL) is effective in providing fast, sustained, and clinically relevant reductions in pain, functional limitation, and health-related quality of life that were apparent at 1 week after the intra-articular injection and maintained throughout the 24-week follow-up in subjects with painful knee osteoarthritis, with a good safety profile.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03200288.

Long-Term Outcomes of Single versus Multiple Courses of Viscosupplementation for Osteoarthritic Knee Pain: Real-World, Multi-Practice Experience Over a Six-Year Period

INTRODUCTION

Viscosupplementation (VS) is a safe and effective local treatment for osteoarthritis (OA) of the knee. While much research has been completed evaluating its efficacy, comparatively little research has been completed examining the effects of multiple, repeat courses of treatment versus a single course of treatment.

METHODS

We retrospectively reviewed real-world data from a large cohort of patients receiving treatment for OA of the knee at 16 rehabilitation clinics. Patients were grouped based on whether they received a single course of treatment or multiple courses. Outcomes for this study included pain (measured via the visual analog scale, VAS) and functional ability (measured via the Western Ontario and McMaster Universities Arthritis Index (WOMAC)). Pain and function scores were collected at baseline (prior to treatment administration) and one week following each course of treatment.

RESULTS

Patients receiving multiple courses of treatment saw greater improvements than those receiving a single course. For VAS, maximal improvement occurred after the fourth course (66% improvement: 1.7±1.2 vs 5.0±2.4 at baseline, p<0.0001). WOMAC scores saw maximal improvement up to the fourth course for all domains (pain: 74%: 2.5±3.3 vs 9.5±5.3, p<0.0001; stiffness: 61%: 1.3±1.0 vs 3.3±2.0, p<0.0001; function: 66%: 9.5±7.2 vs 28.3±14.1, p<0.0001). When scores from multiple courses were averaged, improvements were maintained through the fourth course for VAS (3.4±2.8) and all WOMAC domains (pain: 6.1±5.0; stiffness: 3.0±2.2; function: 23.4±17.3).

DISCUSSION

Our results indicate that multiple courses of treatment are associated with greater improvements than a single course of VS, and that these improvements continue through four courses of treatment.

Are there different gait profiles in patients with advanced knee osteoarthritis? A machine learning approach

BACKGROUND

Determine whether knee kinematics features analyzed using machine-learning algorithms can identify different gait profiles in knee OA patients.

METHODS

3D gait kinematic data were recorded from 42 patients (Kellgren-Lawrence stages III and IV) walking barefoot at individual maximal gait speed (0.98 ± 0.34 m/s). Principal component analysis, self-organizing maps, and k-means were applied to the data to identify the most relevant and discriminative knee kinematic features and to identify gait profiles.

FINDINGS

Four different gait profiles were identified and clinically characterized as type 1: gait with the knee in excessive varus and flexion (n = 6, 14%, increased knee adduction and increased maximum and minimum knee flexion, p < 0.01); type 2: gait with knee external rotation, either in varus or valgus (n = 11, 26%, excessive maximum and minimum external rotation, p < 0.001); type 3: gait with a stiff knee (n = 17, 40%, decreased knee flexion range of motion, p < 0.001); and type 4: gait with knee varus 'thrust' and decreased rotation (n = 8, 19%, increased and reduced range of motion in the coronal and transverse plane, respectively, p < 0.05).

INTERPRETATION

In a group of patients with homogeneous Kellgren-Lawrence classification of knee OA, gait kinematics data permitted to identify four different gait profiles. These gait profiles can be a valuable tool for helping surgical decisions and treatment. To allow generalization, further studies should be carried with a larger and heterogeneous population.

One-Year, Efficacy and Safety Open Label Study, with a Single Injection of a New Hyaluronan for Knee OA: The SOYA Trial

Purpose

To assess the efficacy and safety of a single injection of a new formulation of hyaluronic acid (MPS-HA2%) in patients with symptomatic knee osteoarthritis after 12 months’ follow-up.

Patients and Methods

Prospective, single-arm, multicentre, open-label, 12-month follow-up study. Patients with Kellgren–Lawrence (KL) 2–3 and visual analogue scale (VAS) pain scores of ≥40–< 80 mm received a single injection of MPS-HA2%. The primary outcome was the reduction in VAS pain scores from baseline, and the secondary outcomes were the Western Ontario and McMaster (WOMAC) Universities Osteoarthritis Index, the minimum clinically important improvement (MCII), and patient and investigator global assessments (PGA, IGA) measured on 5-point Likert scale. Adverse events were recorded throughout the study for safety purposes.

Results

A total of 101 patients (mean age: 68 years; 74% female; and 78% overweight) were included. The mean reduction in pain at 12 months was 37.7%; the total WOMAC score improved by 36.5% and the pain, stiffness and physical function subscores returned improvements of 32.1%, 34.1% and 32.7%, respectively (p=0.0001 with respect to baseline). At 12 months, a statistically significant 62.2% of patients obtained an improvement equal to or greater than the MCII. The mean PGA score at baseline was 2.44 and 1.46 at 12 months (p<0.05), and the mean IGA scores at equivalent timepoints were 2.29 and 1.48 (p<0.05). Fourteen patients received a second injection at the 6-month follow-up visit. Eight patients reported a total of 12 treatment-related adverse events that were local, non-serious and of mild-to-moderate intensity.

Conclusion

With just a single intra-articular injection, this not controlled trial suggests that MPS-HA2% is effective 12 months after the procedure in most cases. Patient tolerability and safety were both optimal (NCT03852914).

An Investigator-Initiated, Prospective, Single-Center, Open-Label Clinical Study to Evaluate Safety and Performance of Intra-Articular Hyaluronic Acid (IA-HA) (Biovisc Ortho) in Patients with Osteoarthritis (OA) of the Knee

Objective

IA-HA is injected into the osteoarthritis knee as a viscosupplementation for therapeutic purposes. This clinical trial was carried out for evaluating the efficacy and safety of Biovisc Ortho IA-HA (20 mg/2 mL) in a 2 mL prefilled syringe.

Design

The study was conducted as an open-label, single-center, single-arm clinical trial in India. Patients of knee OA with moderate to severe symptoms for a minimum duration of 3 months were included in the study. Five visits were conducted at weekly intervals and the investigational product was administered at each visit. Two follow-up visits were conducted at 3 and 6 months after the completion of the last injection cycle. The primary outcome variable was change in KOOS pain score from baseline. The secondary outcome variables were analyzed for other KOOS scales and safety of the device.

Results

Change in KOOS pain score at 6 months from baseline was 29.71±15.74 and the change in mean KOOS score for pain was statistically significant (p<0.0001) for all post-baseline visits. Statistically significant improvement was observed for mean values of efficacy assessments (KOOS) during the study period (6 months) for all the domains evaluated, including pain, joint function and quality of life.

Conclusion

Despite being an open, noncomparative study, the safety and efficacy results of IA-HA establish the therapeutic effect of the treatment throughout the study period of 6 months and are safe.

Non-Inferiority of a Single Injection of Sodium Hyaluronate Plus Sorbitol to Hylan G-F20: A 6-Month Randomized Controlled Trial

Introduction

Several viscosupplement treatments are available for patients suffering from painful osteoarthritis (OA) of the knee, but few comparative clinical trials have been conducted. The primary objective of the trial was to demonstrate the non-inferiority of Synolis VA (80 mg hyaluronic acid and 160 mg sorbitol) (Group HA1) to Synvisc-One (48 mg hylan GF-20) (Group HA2) at Day 168 in terms of pain relief efficacy in patients with knee OA (Kellgren and Lawrence radiological stage II or III) in whom oral treatment with analgesics, NSAIDs or weak opioids provided insufficient clinical responses or were poorly tolerated.

Methods

This was a prospective, multicentre, comparative, randomized, double-blinded trial comparing the two previously indicated viscosupplements, HA1 and HA2. The average VAS pain score (1–100) was 62.5 at baseline (Day 0). The patients were randomized into two parallel groups at Day 0 and followed until Day 168. They received one injection of either HA1 or HA2. The primary end point was the evolution of the Western Ontario and McMaster University (WOMAC) pain index at D168 in the groups. One of the secondary end points was the daily assessment of this index by the patient for 7 days following the injection and thereafter at Day 14. The other secondary end points were the WOMAC pain, stiffness, function and total scores assessed at Day 28, Day 84 and Day 168. At Day 168, efficacy and satisfaction were assessed by the evaluator and by the patient using a Likert scale (7 points). Moreover, the number of strict responders in each group was evaluated according to the The Osteoarthritis Research Society International (OARSI) Standing Committee for Clinical Trials Response Criteria Initiative and the Outcome Measures in Rheumatology (OMERACT) criteria (OMERACT-OARSI). The per protocol (PP) population was used for the primary analysis.

Results

A total of 202 patients were randomized. The patients were predominantly female (66%). The median age of the whole population was 65 years, and the median body mass index was 27.4 kg/m². No statistically significant differences between the two treatment groups were observed for any of the demographic criteria. At Day 168, 197 had had no protocol violations (94 in the HA1 group and 103 in the HA2 group). The WOMAC pain score decreased in the two groups: − 29.2 ± 24.1 (SD) in the HA1 group and − 31.6 ± 25.5 (SD) in the HA2 group, confirming the non-inferiority of Synolis VA (P = 0.57 for the difference between groups). Regarding the secondary end points, no significant difference was observed at Day 14, Day 28, Day 84 or Day 168 for all the outcomes except stiffness at Day 28 (P = in favour of treatment received in HA2). The rate of responders was comparable between the two groups: 79% for HA1 and 77% for HA2. Both products were well tolerated. Serious adverse events were reported by four patients in the HA1 group and 3 in the HA2 group.

Conclusion

In this trial, we confirmed the non-inferiority of Synolis VA compared to Synvisc-One at Day 168 according to the WOMAC pain score. Safety was satisfying and comparable in the two groups.

Trial Registration

2017-A00034-49.

The comparison effects of intra-articular injection of Platelet Rich Plasma (PRP), Plasma Rich in Growth Factor (PRGF), Hyaluronic Acid (HA), and ozone in knee osteoarthritis; a one year randomized clinical trial

BACKGROUND

Our study compare the short and long-term efficacy of the intra articular injections (IAIs) of hyaluronic acid (HA), platelet-rich plasma (PRP), plasma rich in growth factors (PRGF), and ozone in patients with knee osteoarthritis (OA).

METHODS

In this randomized clinical trial, 238 patients with mild to moderate knee OA were randomized into 4 groups of IAIs: HA (3 doses weekly), PRP (2 doses with 3 weeks interval), PRGF (2 doses with 3 weeks interval), and Ozone (3 doses weekly). Our outcome measures were the mean changes from baseline (immediately from the first injections) until 2,6, and 12 months post intervention in scores of visual analog scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lequesne index.

RESULTS

A total of 200 patients enrolled in the final analysis. The mean age of patients was 56.9 ± 6.3 years, and 69.5% were women. In 2 months follow up, significant improvement of pain, stiffness, and function were seen in all groups compared to the baseline, but the ozone group had the best results (P < 0.05). In 6 month follow up HA, PRP, and PRGF groups demonstrated better therapeutic effects in all scores in comparison with ozone (P < 0.05). At the end of the 12th month, only PRGF and PRP groups had better results versus HA and ozone groups in all scores (P < 0.05). Despite the fact that ozone showed better early results, its effects begin to wear off earlier than other products and ultimately disappear in 12 months.

CONCLUSIONS

Ozone injection had rapid effects and better short-term results after 2 months, but its therapeutic effects did not persist after 6 months and at the 6-month follow up, PRP,PRGF and HA were superior to ozone. Only patients in PRP and PRGF groups improved symptoms persisted for 12 months. Therefore, these products could be the preferable choices for long-term management.

TRIAL REGISTRATION

Registered in the Iranian Center of Clinical Trials ( www.irct.ir ) in 11/11/2017 with the following code: IRCT2017082013442N17.

Efficacy and safety of viscosupplementation with hyaluronic acid for hip osteoarthritis: results from a cross-sectional study with a minimum follow-up of 4 years

Background and aim of the work:

Osteoarthritis is the most common cause of disability in elderly. Hip osteoarthritis is the second most frequent form affecting a large joint and the social and economic impact on society of its related disability is expected to increase. The purpose of this study was to verify the efficacy and safety of ultrasound-guided viscosupplementation with high weight hyaluronic acid in hip osteoarthritis.

Methods:

183 patients with painful hip OA (Kellgren-Lawrence 1-2-3) were treated from January 2014 to December 2016 with viscosupplementation. Patients were evaluated before injection (T0) and after 1,2,3,4 (T1-T2-T3-T4) years through the VAS scale and Harris Hip Score (HHS). Patients who underwent to subsequent injections were followed and assessed. Subjects who underwent prosthesis were analyzed for a minimum of 6 months in order to detect any early postoperative complication.

Results:

The mean improvement of HHS and VAS between T0 and T1 was statistically significant. Patients who underwent subsequent injections showed a higher improvement even if statistical significance was not observed. Results showed that patients with grade 2 of osteoarthritis had the higher change in the scores. No adverse effects were registered. No early complications were reported in those patients who needed prosthesis.

Discussion and Conclusions:

Results observed confirm that ultrasound-guided viscosupplementation with high weight hyaluronic acid could be a possibility in the treatment of hip osteoarthritis, especially in patients with Kellgren-Lawrence grade 2 of disease. Subsequent injections are not characterized by similar positive effects. Outcomes of prosthetic surgery are not influenced by viscosupplementation.

Single-Dose Intra-Articular Administration of a Hybrid Cooperative Complex of Sodium Hyaluronate and Sodium Chondroitin in the Treatment of Symptomatic Hip Osteoarthritis: A Single-Arm, Open-Label, Pilot Study

Introduction

Intra-articular (i.a.) hyaluronic acid is an accepted conservative therapy for knee osteoarthritis (OA). This study evaluated the safety and efficacy of a single i.a. injection of an innovative formulation of sodium hyaluronate 2.4% plus sodium chondroitin non-sulphated 1.6% of biotechnological origin (HA-SC) for the treatment of patients with radiographically confirmed symptomatic hip OA and moderate-to-severe pain.

Methods

In this prospective, multicenter, open-label, pilot study, HA-SC was administered using a standard ultrasound-guided procedure. Adverse events, global/local evaluation of tolerability, and use of rescue analgesics were recorded. Efficacy endpoints included visual analogue scale (VAS) measurement of hip pain, changes in Lequesne’s algofunctional Index, and assessment of global status.

Results

Treatment was well tolerated; adverse device events of moderate-to-severe intensity, most commonly, injection site pain/localized arthralgia occurred in 20.8% of subjects. Global evaluation of tolerability was rated as excellent or good (75.0%), fair (16.7%), and poor (8.3%) by subjects and 77.1, 14.6, and 8.3%, respectively, by investigators. There was a rapid and significant decrease in hip pain after a single injection; VAS pain score decreased from a mean of 67.5 mm at baseline to 29.3 mm by day 7, with the effects sustained during 6 months of follow-up (P < 0.0001). There were significant improvements in Lequesne’s Index for hip OA total scores at all time points during follow-up (P < 0.0001). The majority of subjects reported ‘Very much improved’ or ‘Slightly improved’ global improvement at any time point. Use of rescue paracetamol was generally low.

Conclusions

A single i.a. injection of an innovative HA-SC formulation was well tolerated, safe, and effective in the treatment of symptomatic hip OA.

Efficacy and Safety of Hylan G-F 20 Versus Intra-Articular Corticosteroids in People with Knee Osteoarthritis: A Systematic Review and Network Meta-Analysis

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.