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Dima A, Dragosloveanu M, Romila AR, Cristea A, Marinică G, Dănilă AT, Mandici A, Cojocariu D, Vlad RA, Ciurba A, Bîrsan M. Can Hyaluronic Acid Combined with Chondroitin Sulfate in Viscosupplementation of Knee Osteoarthritis Improve Pain Symptoms and Mobility? Biomolecules 2024; 14:832. [PMID: 39062546 PMCID: PMC11274506 DOI: 10.3390/biom14070832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 07/28/2024] Open
Abstract
The objective of the present study was to assess the effect of intra-articular Hyaluronic acid (HA) and Chondroitin sulfate (CS) supplementation (Hialurom® Hondro (HH)) on pain symptoms and joint mobility. In total, 60 mg/mL sodium hyaluronate and 90 mg/mL CS were administered to 21 patients (17 females and 4 males) respecting the in-force requirements, excluding patients with some specific comorbidities. In addition to the clinical study (where the pain intensity (severity) and joint mobility were assessed), rheological characterization was conducted evaluating the following parameters: elastic modulus (G'), loss modulus (G″) oscillatory frequency (fc) at 0.5 Hz and 2.5 Hz, crossover frequency (fc), relaxation time (λ) where it was noticed that the addition of chondroitin sulfate (CS) to sodium hyaluronate (SH) significantly enhances and improves the viscoelastic properties, particularly at higher shear frequencies. A significant decrease in pain intensity felt by the subjects was found, from 7.48 (according to Wong-Baker scale)-pain close to 8 (the patient is unable to perform most activities), to more reduced values of 5.86-at 6 weeks after injection, 4.81-at 3 months after injection, and 5.24-at 6 months after injection, improvements in symptoms was fast and durable. Data related to the evolution of joint mobility show that at 6 weeks after injection, the mobility of joints increased by 17.8% and at 6 months by 35.61%. No serious adverse events were reported with undesired effects so that they would impose additional measures. Better resistance to enzymatic degradation and free radicals could be expected from the synergic combination of sodium hyaluronate and chondroitin sodium sulfate, this having a special importance for the patients, granting them the ability to perform more ample movements and reducing dependency on attendants, thus increasing quality of life.
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Affiliation(s)
- Augustin Dima
- Department of Medical Rehabilitation-Orthopedics and Traumatology, National Institute of Rehabilitation, Physical Medicine and Balneoclimatology, 2 Sf. Dumitru Street, Sector 3, 030167 Bucharest, Romania; (A.D.); (A.C.)
| | - Magda Dragosloveanu
- Department of Rehabilitation, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Street, Sector 5, 050474 Bucharest, Romania;
| | - Andreea Ramona Romila
- Department of Rehabilitation, Physical Medicine and Balneology II, National Institute of Rehabilitation, Physical Medicine and Balneoclimatology, 2 Sf. Dumitru Street, Sector 3, 030167 Bucharest, Romania;
| | - Alexandru Cristea
- Department of Medical Rehabilitation-Orthopedics and Traumatology, National Institute of Rehabilitation, Physical Medicine and Balneoclimatology, 2 Sf. Dumitru Street, Sector 3, 030167 Bucharest, Romania; (A.D.); (A.C.)
| | - Georgiana Marinică
- Medical and Pharmacovigilance Department, Rompharm Company SRL, 1A Eroilor Street, 075100 Otopeni, Romania (A.M.); (D.C.)
| | - Alexandru-Tiberiu Dănilă
- Medical and Pharmacovigilance Department, Rompharm Company SRL, 1A Eroilor Street, 075100 Otopeni, Romania (A.M.); (D.C.)
- Department Pharmaceutical Sciences II, Faculty of Pharmacy, Grigore T Popa University of Medicine and Pharmacy Iasi, 16 Universitatii Street, 700115 Iasi, Romania
| | - Alexandru Mandici
- Medical and Pharmacovigilance Department, Rompharm Company SRL, 1A Eroilor Street, 075100 Otopeni, Romania (A.M.); (D.C.)
- Department Pharmaceutical Sciences II, Faculty of Pharmacy, Grigore T Popa University of Medicine and Pharmacy Iasi, 16 Universitatii Street, 700115 Iasi, Romania
| | - Daniel Cojocariu
- Medical and Pharmacovigilance Department, Rompharm Company SRL, 1A Eroilor Street, 075100 Otopeni, Romania (A.M.); (D.C.)
- Department Pharmaceutical Sciences II, Faculty of Pharmacy, Grigore T Popa University of Medicine and Pharmacy Iasi, 16 Universitatii Street, 700115 Iasi, Romania
| | - Robert-Alexandru Vlad
- Department of Pharmaceutical Technology and Cosmetology, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology, 38 Gheorghe Marinescu Street, 540142 Targu Mures, Romania (M.B.)
| | - Adriana Ciurba
- Department of Pharmaceutical Technology and Cosmetology, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology, 38 Gheorghe Marinescu Street, 540142 Targu Mures, Romania (M.B.)
| | - Magdalena Bîrsan
- Department of Pharmaceutical Technology and Cosmetology, Faculty of Pharmacy, George Emil Palade University of Medicine, Pharmacy, Science, and Technology, 38 Gheorghe Marinescu Street, 540142 Targu Mures, Romania (M.B.)
- Department of Pharmaceutical Industry and Pharmaceutical Biotechnologies, Grigore T Popa University of Medicine and Pharmacy Iasi, 16 Universitatii Street, 700115 Iasi, Romania
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Anhesini M, Anzai A, Katayama H, Spir IAZ, Nery MM, Tiezzi OS, Otani P, Bernardo WM. Use of intra-articular hyaluronic acid in knee osteoarthritis or osteoarthritis. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2023; 69:e2023D698. [PMID: 37820190 PMCID: PMC10561918 DOI: 10.1590/1806-9282.2023d698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 07/19/2023] [Indexed: 10/13/2023]
Affiliation(s)
- Mauricio Anhesini
- Brazilian Medical Association - Guideline Group - São Paulo (SP), Brazil
| | - Adriano Anzai
- Brazilian Medical Association - Guideline Group - São Paulo (SP), Brazil
| | - Haroldo Katayama
- Brazilian Medical Association - Guideline Group - São Paulo (SP), Brazil
| | | | - Mary Martins Nery
- Brazilian Medical Association - Guideline Group - São Paulo (SP), Brazil
| | | | - Pericles Otani
- Brazilian Medical Association - Guideline Group - São Paulo (SP), Brazil
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Chavda S, Rabbani SA, Wadhwa T. Role and Effectiveness of Intra-articular Injection of Hyaluronic Acid in the Treatment of Knee Osteoarthritis: A Systematic Review. Cureus 2022; 14:e24503. [PMID: 35651409 PMCID: PMC9135165 DOI: 10.7759/cureus.24503] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2022] [Indexed: 12/30/2022] Open
Abstract
Osteoarthritis (OA) is a degenerative joint disease that causes persistent joint pain and stiffness of mainly the large peripheral weight-bearing joints. It is a leading cause of functional disability and poor quality of life. Various modalities of therapy are recommended by different research organizations at different stages of OA including non-pharmacological, pharmacological, and surgical interventions. Intra-articular injections of hyaluronic acid (HA) is widely used for over three decades in the treatment of OA. However controversies exist regarding its safety and efficacy, the number of injections and courses, type of preparation, duration of its effects, and combining it with other drugs or molecules. This study aimed to review the most recent data available in the published literature to address these. Electronic databases like Medline, Embase, ProQuest, and Google Scholar were searched for articles using keywords, intraarticular injections, hyaluronic acid, and osteoarthritis knee. The review was carried out as per PRISMA guidelines. Thirty-eight randomized control trials (RCTs) investigating the efficacy and safety of intra-articular injection of HA were included in the systematic review. Out of the 38 studies, 22 (57.9%) were double-blind, eight (21%) single-blind, three (7.9%) non-blind, four (10%) with simple randomization, and one (2.7%) was open-labeled. Total 5,025 patients were included in these studies. The mean age of the patients was 60.28 years and the osteoarthritis grade of the knee joint was 1 to 3. HA was studied as a test preparation in 19 (50%) while in another 19 (50%) it was studied as a control. In 24 (63.2%) studies, HA was used as high molecular weight preparation in eight (21%) as low molecular weight preparation while in six studies the information was not available. HA was used as a standalone preparation in 31 studies, in two studies it was injected with platelet-rich plasma (PRP) and with either low-level laser therapy (LLLT), triamcinolone (TA), betamethasone (CS), poly deoxyribonucleotide (PDRN) or dexamethasone (DX) in one study each. In the majority of the studies, HA was given as a single injection (52.6% studies) or weekly three injections (28.9% studies). In 13.2 %, it was given as weekly 5 injections and in 5.3% as weekly two injections. IA-HA injections have a limited role in the treatment of knee osteoarthritis in those patients who do not have sufficient pain relief with topical or oral medication and physical therapy. It is safe and effective except for minor side effects such as local pain and swelling lasting for a few days. Severe allergic reactions are extremely rare. They provide adequate pain relief and functional improvement for up to six months irrespective of a number of injections and type of preparations used. The combination formulations with corticosteroids or PRP or MSCs show better results than HA alone. Combining HA with newer molecules such as peptides or diclofenac for sustained and disease-modifying effects requires more studies in the future.
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Affiliation(s)
- Sumant Chavda
- Orthopedics, Ras Al Khaimah (RAK) Medical and Health Sciences University, Ras Al Khaimah, ARE
| | - Syed Arman Rabbani
- Pharmacology, Ras Al Khaimah (RAK) Medical and Health Sciences University, Ras Al Khaimah, ARE
| | - Tarun Wadhwa
- Clinical Pharmacy, Ras Al Khaimah (RAK) Medical and Health Sciences University, Ras Al Khaimah, ARE
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Hype or hope of hyaluronic acid for osteoarthritis: Integrated clinical evidence synthesis with multi-organ transcriptomics. J Orthop Translat 2022; 32:91-100. [PMID: 35116224 PMCID: PMC8777245 DOI: 10.1016/j.jot.2021.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 12/20/2022] Open
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Webner D, Huang Y, Hummer CD. Intraarticular Hyaluronic Acid Preparations for Knee Osteoarthritis: Are Some Better Than Others? Cartilage 2021; 13:1619S-1636S. [PMID: 34044600 PMCID: PMC8808930 DOI: 10.1177/19476035211017320] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE This literature review summarizes evidence on the safety and efficacy of intraarticular hyaluronic acid (IAHA) preparations approved in the United States for the treatment of osteoarthritis of the knee. DESIGN A systematic literature search was performed in PubMed, Ovid MEDLINE, and SCOPUS databases. Only studies in which clinical outcomes of individual IAHA preparations alone could be assessed when compared to placebo, no treatment, other standard knee osteoarthritis treatments, and IAHA head-to-head studies were selected. RESULTS One hundred nine articles meeting our inclusion criteria were identified, including 59 randomized and 50 observational studies. Hylan G-F 20 has been the most extensively studied preparation, with consistent results confirming efficacy in placebo-controlled studies. Efficacy is also consistently reported for Supartz, Monovisc, and Euflexxa, but not for Hyalgan, Orthovisc, and Durolane. In the head-to-head trials, high-molecular-weight (MW) Hylan G-F 20 was consistently superior to low MW sodium hyaluronate preparations (Hyalgan, Supartz) up to 20 weeks, whereas one study reported that Durolane was noninferior to Supartz. Head-to-head trials comparing high versus medium MW preparations all used Hylan G-F 20 as the high MW preparation. Of the IAHA preparations with strong evidence of efficacy in placebo-controlled studies, Euflexxa was found to be noninferior to Hylan G-F 20. There are no direct comparisons to Monovisc. One additional IAHA preparation (ie, Synovial), which has not been assessed in placebo-controlled studies, was also noninferior to Hylan G-F 20. CONCLUSION IAHA efficacy varies widely across preparations. High-quality studies are required to assess and compare the safety and efficacy of IAHA preparations.
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Affiliation(s)
- David Webner
- Crozer-Keystone Health System,
Springfield, PA, USA,David Webner, Crozer-Keystone Health
System, 196 W. Sproul Road, Suite 110, Springfield, PA 19064, USA.
| | - Yili Huang
- Northwell Health, Zucker School of
Medicine at Hofstra/Northwell, Hempstead, NY, USA
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Previtali D, Merli G, Di Laura Frattura G, Candrian C, Zaffagnini S, Filardo G. The Long-Lasting Effects of "Placebo Injections" in Knee Osteoarthritis: A Meta-Analysis. Cartilage 2021; 13:185S-196S. [PMID: 32186401 PMCID: PMC8808779 DOI: 10.1177/1947603520906597] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES To quantify the placebo effect of intraarticular injections for knee osteoarthritis in terms of pain, function, and objective outcomes. Factors influencing placebo effect were investigated. DESIGN Meta-analysis of randomized controlled trials; Level of evidence, 2. PubMed, Web of Science, Cochrane Library, and grey literature databases were searched on January 8, 2020, using the string: (knee) AND (osteoarthritis OR OA) AND (injections OR intra-articular) AND (saline OR placebo). The following inclusion criteria were used: double-blind, randomized controlled trials on knee osteoarthritis, including a placebo arm on saline injections. The primary outcome was pain variation. Risk of bias was assessed using the RoB 2.0 tool, and quality of evidence was graded following the GRADE (Grading of Recommendations Assessment, Development and Evaluation) guidelines. RESULTS Out of 2,363 records, 50 articles on 4,076 patients were included. The meta-analysis showed significant improvements up to the 6-month follow-up: Visual Analogue Scale (VAS)-pain -13.4 mean difference (MD) (95% confidence interval [CI]: -21.7/-5.1; P < 0.001), Western Ontario and McMaster Osteoarthritis Index (WOMAC)-pain -3.3 MD (95% CI: -3.9/-2.7; P < 0.001). Other significant improvements were WOMAC-stiffness -1.1 MD (95% CI: -1.6/-0.6; P < 0.001), WOMAC-function -10.1 MD (95% CI: -12.2/-8.0; P < 0.001), and Evaluator Global Assessment -21.4 MD (95% CI: -29.2/-13.6; P < 0.001). The responder rate was 52% (95% CI: 40% to 63%). Improvements were greater than the "minimal clinically important difference" for all outcomes (except 6-month VAS-pain). The level of evidence was moderate for almost all outcomes. CONCLUSIONS The placebo effect of knee injections is significant, with functional improvements lasting even longer than those reported for pain perception. The high, long-lasting, and heterogeneous effects on the scales commonly used in clinical trials further highlight that the impact of placebo should not be overlooked in the research on and management of knee osteoarthritis.
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Affiliation(s)
- Davide Previtali
- Orthopaedic and Traumatology Unit,
Ospedale Regionale di Lugano, EOC, Lugano, Ticino, Switzerland
| | - Giulia Merli
- Applied and Translational Research
Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy,Giulia Merli, Applied and Translational
Research Center, IRCCS Istituto Ortopedico Rizzoli, Via di Barbiano 1/10,
Bologna 40136, Italy.
| | | | - Christian Candrian
- Orthopaedic and Traumatology Unit,
Ospedale Regionale di Lugano, EOC, Lugano, Ticino, Switzerland
| | | | - Giuseppe Filardo
- Orthopaedic and Traumatology Unit,
Ospedale Regionale di Lugano, EOC, Lugano, Ticino, Switzerland,Applied and Translational Research
Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
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Çağlar C, Kara H, Ateş O, Uğurlu M. Evaluation of Different Intraarticular Injection Therapies with Gait Analysis in a Rat Osteoarthritis Model. Cartilage 2021; 13:1134S-1143S. [PMID: 34528494 PMCID: PMC8804824 DOI: 10.1177/19476035211046042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Osteoarthritis (OA) is a degenerative disease that causes serious damage to joints, especially in elderly patients. The aim of study was to demonstrate the effectiveness of intraarticular therapies that are currently used or recently popularized in the treatment of OA. DESIGN The baseline values were determined by walking the rats on the CatWalk system. Afterwards, a monosodium iodoacetate (MIA)-induced knee OA model was created with intraarticular MIA, and the rats were walked again on the CatWalk system and post-OA values were recorded. At this stage, the rats were divided into 4 groups, and intraarticular astaxanthin, intraarticular corticosteroid, intraarticular hyaluronic acid, and intraarticular astaxanthin + hyaluronic acid were applied to the groups, respectively. The rats were walked once more and posttreatment values were obtained. Nine different dynamic gait parameters were used in the comparison. RESULTS Significant changes were measured in 6 of the 9 dynamic gait parameters after the MIA-induced knee OA model. While the best improvement was observed in run duration (P = 0.0022), stride length (P < 0.0001), and swing speed (P = 0.0355) in the astaxanthin group, the results closest to basal values in paw print length (P < 0.0001), paw print width (P = 0.0101), and paw print area (P = 0.0277) were seen in the astaxanthin + hyaluronic acid group. CONCLUSION Astaxanthin gave better outcomes than corticosteroid and hyaluronic acid in both dynamic gait parameters and histological examinations. Intraarticular astaxanthin therapy can be a good alternative to corticosteroid and hyaluronic acid currently used in intraarticular therapy to treat OA.
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Affiliation(s)
- Ceyhun Çağlar
- Orthopaedics and Traumatology
Department, Ankara City Hospital, Ankara, Turkey,Ceyhun Çağlar, Orthopaedics and
Traumatology Department, Ankara City Hospital, Ankara 06800, Turkey.
| | - Halil Kara
- Pharmacology Department, Ankara
Yıldırım Beyazıt University, Ankara, Turkey
| | - Okan Ateş
- Orthopaedics and Traumatology
Department, Diyarbakır Gazi Yaşargil Training and Research Hospital, Diyarbakır,
Turkey
| | - Mahmut Uğurlu
- Orthopaedics and Traumatology
Department, Ankara Yıldırım Beyazıt University, Ankara, Turkey
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Miller LE, Bhattacharyya S, Parrish WR, Fredericson M, Bisson B, Altman RD. Safety of Intra-Articular Hyaluronic Acid for Knee Osteoarthritis: Systematic Review and Meta-Analysis of Randomized Trials Involving More than 8,000 Patients. Cartilage 2021; 13:351S-363S. [PMID: 31735075 PMCID: PMC8808790 DOI: 10.1177/1947603519888783] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE The objective of this systematic review and meta-analysis was to report the safety of intra-articular hyaluronic acid (IAHA) in patients with symptomatic knee osteoarthritis (OA). METHODS We identified randomized controlled trials reporting the safety of IAHA versus IA saline in adults with symptomatic knee OA. Main safety outcomes were adverse events (AEs), local AEs, serious adverse events (SAEs), study withdrawals, and AE-related study withdrawals. RESULTS A total of 35 randomized controlled trials with 38 group comparisons comprising 8,078 unique patients (IAHA: 4,295, IA saline: 3,783) were included in the meta-analysis. Comparing IAHA with IA saline over a median of 6 months follow-up, there were no differences in the risk of AEs (42.4% vs. 39.7%, risk ratio [RR] = 1.01, 95% CI = 0.96-1.07, P = 0.61), SAEs (1.8% vs. 1.2%, RR = 1.44, 95% CI = 0.91-2.26, P=0.12), study withdrawals (12.3% vs. 12.7%, RR = 0.99, 95% CI = 0.87-1.12, P = 0.83), or AE-related study withdrawals (2.7% vs. 2.1%, RR = 1.37, 95% CI = 0.97-1.93, P = 0.08). Local AEs, all of which were nonserious, were more common with IAHA vs. IA saline (14.5% vs. 11.7%, RR = 1.21, 95% CI = 1.07-1.36, P = 0.003) and typically resolved within days. CONCLUSION IAHA was shown to be safe for use in patients with symptomatic knee OA. Compared with IA saline, IAHA is associated with an increased risk of nonserious, transient local reactions. There was no evidence to suggest any additional safety risks of IAHA.
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Affiliation(s)
| | | | | | - Michael Fredericson
- Department of Orthopaedic Surgery,
Division of Physical Medicine and Rehabilitation, Stanford University Medical
School, Stanford, CA, USA
| | | | - Roy D. Altman
- Division of Rheumatology and Immunology,
David Geffen School of Medicine, University of California at Los Angeles, Los
Angeles, CA, USA
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9
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The Impact of Hyaluronic Acid on Tendon Physiology and Its Clinical Application in Tendinopathies. Cells 2021; 10:cells10113081. [PMID: 34831304 PMCID: PMC8625461 DOI: 10.3390/cells10113081] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 11/01/2021] [Accepted: 11/05/2021] [Indexed: 01/17/2023] Open
Abstract
The physical-chemical, structural, hydrodynamic, and biological properties of hyaluronic acid within tendons are still poorly investigated. Medical history and clinical applications of hyaluronic acid for tendinopathies are still debated. In general, the properties of hyaluronic acid depend on several factors including molecular weight. Several preclinical and clinical experiences show a good efficacy and safety profile of hyaluronic acid, despite the absence of consensus in the literature regarding the classification according to molecular weight. In in vitro and preclinical studies, hyaluronic acid has shown physical-chemical properties, such as biocompatibility, mucoadhesivity, hygroscopicity, and viscoelasticity, useful to contribute to tendon healing. Additionally, in clinical studies, hyaluronic acid has been used with promising results in different tendinopathies. In this narrative review, findings encourage the clinical application of HA in tendinopathies such as rotator cuff, epicondylitis, Achilles, and patellar tendinopathy.
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Yamamoto T, Suzuki S, Fujii T, Mima Y, Watanabe K, Matsumoto M, Nakamura M, Fujita N. Efficacy of hyaluronic acid on intervertebral disc inflammation: An in vitro study using notochordal cell lines and human disc cells. J Orthop Res 2021; 39:2197-2208. [PMID: 33251629 DOI: 10.1002/jor.24933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 11/09/2020] [Accepted: 11/25/2020] [Indexed: 02/04/2023]
Abstract
Hyaluronic acid (HA) is widely recognized as a therapeutic target and currently used in medicine. However, HA metabolism during intervertebral disc degeneration (IVDD) has not been completely elucidated. This study aimed to evaluate the efficacy of HA on intervertebral disc (IVD) inflammation and identify the main molecules modulating HA degradation in IVDs. To assess HA function in IVD cells in vitro, we treated human disc cells and U-CH1-N cells, a notochordal nucleus pulposus cell line, with HA or hyaluronidase. Real-time reverse transcription polymerase chain reaction (RT-PCR) and Western blot analysis showed that tumor necrosis factor alpha (TNF-α)-mediated induction of the expression of TNF-α and cyclooxygenase-2 (COX2) was clearly neutralized by HA treatment, and the expression of TNF-α and COX2 was significantly induced by hyaluronidase treatment in both cell types. Additionally, Western blot analysis showed that hyaluronidase-induced phosphorylation of p38 and Erk1/2, and that TNF-α-mediated phosphorylation of p38 and Erk1/2 was clearly reduced by HA addition. In degenerating human IVD samples, immunohistochemistry for hyaluronidase showed that the expression of hyaluronidases including HYAL1, HYAL2, and cell migration-inducing protein (CEMIP) tended to increase in accordance with IVDD. In particular, HYAL1 showed statistically significant differences. In vitro study also confirmed a similar phenomenon that TNF-α treatment increased both messenger RNA and protein expression in both cell types. Our results demonstrated that HA could potentially suppress IVDD by regulating p38 and Erk1/2 pathways, and that the expression of HYAL1 was correlated with IVDD progression. These findings indicated that HYAL1 would be a potential molecular target for suppressing IVDD by controlling HA metabolism.
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Affiliation(s)
- Tatsuya Yamamoto
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Satoshi Suzuki
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Takeshi Fujii
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan.,Department of Orthopaedic Surgery, Saiseikai Yokohamashi Tobu Hospital, Kanagawa, Japan
| | - Yuichiro Mima
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan.,Department of Orthopaedic Surgery, Kawasaki Municipal Hospital, Kanagawa, Japan
| | - Kota Watanabe
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Morio Matsumoto
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Masaya Nakamura
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan
| | - Nobuyuki Fujita
- Department of Orthopaedic Surgery, School of Medicine, Keio University, Tokyo, Japan.,Department of Orthopaedic Surgery, Fujita Health University, Toyoake, Aichi, Japan
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Uzieliene I, Bironaite D, Bernotas P, Sobolev A, Bernotiene E. Mechanotransducive Biomimetic Systems for Chondrogenic Differentiation In Vitro. Int J Mol Sci 2021; 22:9690. [PMID: 34575847 PMCID: PMC8469886 DOI: 10.3390/ijms22189690] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/31/2021] [Accepted: 09/02/2021] [Indexed: 12/11/2022] Open
Abstract
Osteoarthritis (OA) is a long-term chronic joint disease characterized by the deterioration of bones and cartilage, which results in rubbing of bones which causes joint stiffness, pain, and restriction of movement. Tissue engineering strategies for repairing damaged and diseased cartilage tissue have been widely studied with various types of stem cells, chondrocytes, and extracellular matrices being on the lead of new discoveries. The application of natural or synthetic compound-based scaffolds for the improvement of chondrogenic differentiation efficiency and cartilage tissue engineering is of great interest in regenerative medicine. However, the properties of such constructs under conditions of mechanical load, which is one of the most important factors for the successful cartilage regeneration and functioning in vivo is poorly understood. In this review, we have primarily focused on natural compounds, particularly extracellular matrix macromolecule-based scaffolds and their combinations for the chondrogenic differentiation of stem cells and chondrocytes. We also discuss different mechanical forces and compression models that are used for In Vitro studies to improve chondrogenic differentiation. Summary of provided mechanical stimulation models In Vitro reviews the current state of the cartilage tissue regeneration technologies and to the potential for more efficient application of cell- and scaffold-based technologies for osteoarthritis or other cartilage disorders.
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Affiliation(s)
- Ilona Uzieliene
- State Research Institute Centre for Innovative Medicine, Department of Regenerative Medicine, LT-08406 Vilnius, Lithuania; (I.U.); (D.B.); (P.B.)
| | - Daiva Bironaite
- State Research Institute Centre for Innovative Medicine, Department of Regenerative Medicine, LT-08406 Vilnius, Lithuania; (I.U.); (D.B.); (P.B.)
| | - Paulius Bernotas
- State Research Institute Centre for Innovative Medicine, Department of Regenerative Medicine, LT-08406 Vilnius, Lithuania; (I.U.); (D.B.); (P.B.)
| | - Arkadij Sobolev
- Latvian Institute of Organic Synthesis, 21 Aizkraukles Str., LV-1006 Riga, Latvia;
| | - Eiva Bernotiene
- State Research Institute Centre for Innovative Medicine, Department of Regenerative Medicine, LT-08406 Vilnius, Lithuania; (I.U.); (D.B.); (P.B.)
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Zhao D, Pan JK, Yang WY, Han YH, Zeng LF, Liang GH, Liu J. Intra-Articular Injections of Platelet-Rich Plasma, Adipose Mesenchymal Stem Cells, and Bone Marrow Mesenchymal Stem Cells Associated With Better Outcomes Than Hyaluronic Acid and Saline in Knee Osteoarthritis: A Systematic Review and Network Meta-analysis. Arthroscopy 2021; 37:2298-2314.e10. [PMID: 33713757 DOI: 10.1016/j.arthro.2021.02.045] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 02/26/2021] [Accepted: 02/26/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a network meta-analysis to evaluate clinical efficacy and treatment-related adverse events (AEs) of intra-articular hyaluronic acid (HA), leukocyte-poor platelet-rich plasma (LP-PRP), leukocyte-rich platelet-rich plasma (LR-PRP), bone marrow mesenchymal stem cells (BM-MSCs), adipose mesenchymal stem cells (AD-MSCs), and saline (placebo) during 6 and 12 months of follow-up. METHODS Six databases were searched for randomized controlled trials. Outcome assessment included the visual analog scale (VAS) score, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain subscore, WOMAC score, International Knee Documentation Committee (IKDC) subjective score, and treatment-related AEs. Main inclusion criteria were at least one of the aforementioned outcome measurements, a minimum follow-up period of 5 months, and >80% patient follow-up. Treatments combined with the use of other operations or drugs were excluded. RESULTS Forty-three studies meeting the eligibility criteria were included. At 6 months, VAS scores and WOMAC pain subscores showed that AD-MSCs were the best treatment option (surface under the cumulative ranking curve [SUCRA] = 96.7%, SUCRA = 85.3%, respectively). According to WOMAC scores and subjective IKDC scores, LP-PRP was the most effective treatment (SUCRA = 86.0%, SUCRA = 80.5%, respectively). At 12 months, only AD-MSCs were associated with improved VAS scores compared with the placebo (weighted mean difference [WMD] = -20.93, 95% credibility interval [CrI], -41.71 to -0.78). Both LP-PRP and AD-MSCs were more beneficial than the placebo for improving WOMAC pain subscores (WMD = -30.08; 95% CrI, -53.59 to -6.25; WMD = -34.85; 95% CrI, -68.03 to -4.86, respectively). For WOMAC scores, LP-PRP and LR-PRP were significantly associated with improved WOMAC scores compared with the placebo after sensitivity analysis was performed (WMD = -35.26; 95% CrI, -64.99 to -6.01; WMD = -38.69; 95% CrI, -76.21 to -2.76). LP-PRP exhibited relatively better efficacy in improving subjective IKDC scores than the placebo (WMD = 13.67; 95% CrI, 4.05-23.39). Regarding safety, all treatments except for LP-PRP (relative risk = 1.83; 95% CrI, 0.89-4.64) increased treatment-related AEs compared with the placebo. CONCLUSIONS Based on the results of current research findings, during 6 months of follow-up, AD-MSCs relieved pain the best; LP-PRP was most effective for functional improvement. During the 12-month follow-up, both AD-MSCs and LP-PRP showed potential clinical pain relief effects; functional improvement was achieved with LP-PRP. Unfortunately, AD-MSC/LP-PRP functional comparisons were only based on WOMAC scores due to missing IKDC scores. BM-MSCs seem to have potentially beneficial effects, but the wide credibility interval makes it impossible to draw a well-supported conclusion. HA viscosupplementation clinical efficacy was lower than that of biological agents during follow-up, which may be related to the properties of the drugs. Considering the evaluation of treatment-related AEs, LP-PRP is the most advisable choice; although the AEs of these treatments are not serious, they may affect treatment compliance and satisfaction. LEVEL OF EVIDENCE Level II, meta-analysis of Level I and II studies.
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Affiliation(s)
- Di Zhao
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Jian-Ke Pan
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Wei-Yi Yang
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Yan-Hong Han
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ling-Feng Zeng
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China; Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Gui-Hong Liang
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China; Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China
| | - Jun Liu
- Department of Orthopedics, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou, China; Bone and Joint Research Team of Degeneration and Injury, Guangdong Provincial Academy of Chinese Medical Sciences, Guangzhou, China.
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Arthrocentesis and Sodium Hyaluronate Infiltration in Temporomandibular Disorders Treatment. Clinical and MRI Evaluation. J Funct Morphol Kinesiol 2020; 5:jfmk5010018. [PMID: 33467234 PMCID: PMC7739436 DOI: 10.3390/jfmk5010018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 11/25/2022] Open
Abstract
Arthrocentesis in temporomandibular joint disorders can be associated with the intra-articular infiltration of various drugs with the objective of increase treatment efficacy. The aim of this study was to evaluate the clinical indexes variation in patients affected by temporomandibular joint disorders treated with arthrocentesis and sodium hyaluronate (SH) injections. A total of 28 patients suffering from temporomandibular joint disorders underwent one cycle of five arthrocentesis and infiltrations of sodium hyaluronate. Spontaneous mouth opening improved from 36.3 ± 7.5 mm to 45.1 ± 1.9 mm at six months follow-up. A significant reduction in the pain at rest and during mastication mean values emerged at follow-up (p < 0.0001). The mean masticatory efficiency, evaluated through a visual analogic scale, showed improvement at the follow-up period, highlighted by the increase of mean value from a baseline of 3.1 ± 1.2 to a mean value of 8.5 ± 1.2 (p < 0.0001). The mean severity of the joint damage at baseline time was 2.4 ± 0.9 and decreased to 0.4 ± 0.3 at the end of the follow-up period. The decrease in values is confirmed by statistical test (p < 0.05). Our data show how arthrocentesis integrated with sodium hyaluronate infiltrations performed under local anesthesia is a valid method of treating temporomandibular joint disorders.
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Richardson C, Plaas A, Block JA. Intra-articular Hyaluronan Therapy for Symptomatic Knee Osteoarthritis. Rheum Dis Clin North Am 2019; 45:439-451. [DOI: 10.1016/j.rdc.2019.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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15
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Safety of Intra-articular Hyaluronic Acid Injections in Osteoarthritis: Outcomes of a Systematic Review and Meta-Analysis. Drugs Aging 2019; 36:101-127. [PMID: 31073925 PMCID: PMC6509101 DOI: 10.1007/s40266-019-00657-w] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Some controversy exists regarding the safety of intra-articular hyaluronic acid (IAHA) in the management of osteoarthritis (OA). OBJECTIVE The objective of this study was to re-assess the safety profile of IAHA in patients with OA, through a comprehensive meta-analysis of randomized, placebo-controlled trials. METHODS A comprehensive literature search was undertaken in the databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus. Randomized, double-blind, placebo-controlled, parallel-group trials that assessed adverse events (AEs) with IAHA in patients with OA were eligible for inclusion. Authors and/or study sponsors were contacted to obtain the full report of AEs. The primary outcomes were overall severe and serious AEs, as well as the following MedDRA System Organ Class (SOC)-related AEs: gastrointestinal, cardiac, vascular, respiratory, nervous system, skin and subcutaneous tissue disorders, musculoskeletal, renal and urinary disorders, infections and infestations, and hypersensitivity reaction. RESULTS Database searches initially identified 1481 records. After exclusions according to the selection criteria, 22 studies were included in the qualitative synthesis, and nine studies having adequate data were ultimately included in the meta-analysis. From the studies excluded according to the pre-specified selection criteria, 21 with other pharmacological OA treatments permitted during the trials were a posteriori included in a parallel qualitative synthesis, from which eight studies with adequate data were finally included in a parallel meta-analysis. Since this meta-analysis was designed to assess safety, the exclusion criterion on concomitant anti-OA medication was crucial. However, due to the high number of studies that allowed mainly concomitant oral non-steroidal anti-inflammatory drugs (NSAIDs), we decided to include them in a post hoc parallel analysis in order to compare the results from the two analyses. No statistically significant difference in odds was found between IAHA and placebo for all types of SOC-related disorders, except for infections and infestations, for which significantly lower odds were found with IAHA compared with placebo, both overall (odds ratio [OR] = 0.61, 95% confidence interval [CI] 0.40-0.93; I2 = 0%) and in studies without concomitant anti-OA medication (OR = 0.49, 95% CI 0.27-0.89). There were significant increased odds of reporting serious AEs with IAHA compared with placebo, both overall (OR = 1.78, 95% CI 1.21-2.63; I2 = 0%) and in studies with concomitant anti-OA medication (OR = 1.78, 95% CI 1.10-2.89), but not in studies without concomitant anti-OA medication (OR = 1.78, 95% CI 0.92-3.47). CONCLUSIONS Using the available data on studies without any concomitant anti-OA medication permitted during clinical trials, IAHA seems not to be associated with any safety issue in the management of OA. However, this evidence was associated with only a "low" to "moderate" certainty. A possible association with increased risk of serious AEs, particularly when used with concomitant OA medications, requires further investigation.
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Pei Y, Cui F, Du X, Shang G, Xiao W, Yang X, Cui Q. Antioxidative nanofullerol inhibits macrophage activation and development of osteoarthritis in rats. Int J Nanomedicine 2019; 14:4145-4155. [PMID: 31239673 PMCID: PMC6559768 DOI: 10.2147/ijn.s202466] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/16/2019] [Indexed: 12/28/2022] Open
Abstract
Background: There is emerging evidence which suggests that cellular ROS including nitric oxide (NO) are important mediators for inflammation and osteoarthritis (OA). Water-soluble polyhydroxylated fullerene C60 (fullerol) nanoparticle has been demonstrated to have an outstanding ability to scavenge ROS. Purpose: The objective of this study is to assess the effects of fullerol on inflammation and OA by in vitro and in vivo studies. Methods: For in vitro experiments, primary mouse peritoneal macrophages and a macrophage cell line RAW264.7 were stimulated to inflammatory phenotypes by lipopolysaccharide (LPS) in the presence of fullerol. For the animal study, OA model was created by intra-articular injection of monoiodoacetate into the knee joints of rats and fullerol was intravenously injected immediately after OA induction. Results: NO production and pro-inflammatory gene expression induced by LPS was significantly diminished by fullerol in both macrophage cell types. Meanwhile, fullerol could remarkably reduce phosphorylation of p38 mitogen-activated protein kinase, and protein level of transcription factors nuclear factor-kappaB and forkhead box transcription factor 1 within the nucleus. The animal study delineated that systematic administration of fullerol prevented OA, inhibiting inflammation of synovial membranes and the damage toward the cartilage chondrocytes in the OA joints. Conclusion: Antioxidative fullerol may have a potential therapeutic application for OA.
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Affiliation(s)
- Yilun Pei
- Orthopaedic Research Lab, University of Virginia, Charlottesville, VA, USA
| | - Fuai Cui
- Orthopaedic Research Lab, University of Virginia, Charlottesville, VA, USA.,Department of Biochemistry and Molecular Biology, School of Basic Medical Sciences, Shandong University, Jinan, Shandong, China
| | - Xuejun Du
- Orthopaedic Research Lab, University of Virginia, Charlottesville, VA, USA
| | - Guowei Shang
- Orthopaedic Research Lab, University of Virginia, Charlottesville, VA, USA
| | - Wanan Xiao
- Orthopaedic Research Lab, University of Virginia, Charlottesville, VA, USA
| | - Xinlin Yang
- Orthopaedic Research Lab, University of Virginia, Charlottesville, VA, USA
| | - Quanjun Cui
- Orthopaedic Research Lab, University of Virginia, Charlottesville, VA, USA
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Tallarita M, De Iorio M, Baio G. A comparative review of network meta-analysis models in longitudinal randomized controlled trial. Stat Med 2019; 38:3053-3072. [PMID: 31050822 DOI: 10.1002/sim.8169] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 02/14/2019] [Accepted: 03/27/2019] [Indexed: 11/11/2022]
Abstract
Network meta-analysis (NMA) technique extends the standard meta-analysis methods, allowing pairwise comparison of all treatments in a network in the absence of head-to-head comparisons. Traditional NMA models consider a single endpoint for each trial. However, in many cases, trials in the network have different durations and/or report data at multiple time points. Moreover, these time points are often not the same for all trials. In this work, we review the most relevant methods that incorporate multiple time points and allow indirect comparisons of treatment effects across different longitudinal studies. In particular, we focus on the mixed treatment comparison developed by Dakin et al,[10] on the Bayesian evidence synthesis techniques-integrated two-component prediction developed by Ding et al,[11] and on the more recent method based on fractional polynomials by Jansen et al.[12] We highlight the main features of each model and illustrate them in simulations and in a real data application. Our study shows that methods based on fractional polynomials offer a flexible modeling strategy in most applications.
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Affiliation(s)
- Marta Tallarita
- Department of Statistical Science, University College London, London, UK
| | - Maria De Iorio
- Department of Statistical Science, University College London, London, UK.,Yale-NUS College, Singapore
| | - Gianluca Baio
- Department of Statistical Science, University College London, London, UK
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Nicholls M, Shaw P, Niazi F, Bhandari M, Bedi A. The Impact of Excluding Patients with End-Stage Knee Disease in Intra-Articular Hyaluronic Acid Trials: A Systematic Review and Meta-Analysis. Adv Ther 2019; 36:147-161. [PMID: 30506407 PMCID: PMC6318255 DOI: 10.1007/s12325-018-0847-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Indexed: 12/31/2022]
Abstract
Introduction The Kellgren–Lawrence (K–L) grade is the most commonly used measure of radiographic disease severity in knee osteoarthritis (OA). Studies suggest that intra-articular hyaluronic acid (IA-HA) should only be considered in cases of early stage knee OA. The purpose of this review was to determine if trials administering IA-HA in early-moderate knee OA patients demonstrated greater pain relief than studies that also included patients with end-stage disease. Methods We conducted a systematic search of the literature to identify randomized controlled trials (RCT) comparing IA-HA with saline injections and that diagnosed disease severity using the K–L grade criteria. The primary outcome was mean change in pain from baseline at 4–13 weeks and 22–27 weeks. Safety was evaluated on the total number of participants experiencing a treatment-related adverse event (AE). Results Twenty RCTs were included. In the early-moderate OA subgroup, the mean change in pain scores was statistically significant favoring IA-HA from baseline to 4–13 weeks [SMD = − 0.30, 95% CI − 0.44 to − 0.15, p < 0.0001] and within 22–27 weeks [SMD = − 0.27, 95% CI − 0.39 to − 0.16, p < 0.00001]. No significant differences were observed in the late OA subgroup. IA-HA was associated with a significantly greater risk of treatment-related AEs relative to saline in the late OA subgroup [RR = 1.76, 95% CI 1.16–2.67, p = 0.008]. Conclusion IA-HA provides significant pain relief compared to saline for patients with early-moderate knee OA, compared to cohorts including patients with end-stage OA (KL grade 4), with no increase in the risk of treatment-related AEs, up to 6 months. Patients with end-stage disease had lower levels of pain relief and may be diluting study results if included in the treatment cohort. Funding Ferring Pharmaceuticals. Electronic supplementary material The online version of this article (10.1007/s12325-018-0847-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mathew Nicholls
- Virginia Mason Orthopaedics and Sports Medicine, Seattle, WA, USA.
| | - Peter Shaw
- Ferring Pharmaceuticals Inc., Parsippany, NJ, USA
| | - Faizan Niazi
- Ferring Pharmaceuticals Inc., Parsippany, NJ, USA
| | - Mohit Bhandari
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
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Sarda P, Butt D, Elnikety S, Fitzgerald C, Corbett S. Does Hyaluronan improve pain or function following Arthroscopic Subacromial decompression (ASD) surgery of Shoulder? Results of a level 1 RCT. Indian J Orthop 2019; 53:595-601. [PMID: 31488925 PMCID: PMC6699218 DOI: 10.4103/ortho.ijortho_50_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Sodium hyaluronate (hyaluronan) can be used as a synovial fluid substitute following arthroscopic surgery. In this study, we examined its effect on pain and function following arthroscopic subacromial arthroscopic decompression (ASAD). METHODOLOGY A prospective, randomized, and single-blinded design was used (13/LO0427) to compare the effect of a single postprocedure subacromial instillation of 10 ml hyaluronan, against 10 ml saline control. All patients had interscalene block along with general anesthesia and followed standard postoperative rehabilitation protocol. A power calculation for a 6-point difference in Oxford Shoulder Score (OSS) indicated a minimum sample size of 44. Participants were assessed preoperatively, and at 12 weeks using the following outcome measures -Oxford Shoulder Score (OSS), visual analog score (VAS), European quality of life score (EUROQOL), and Disability of the arm, shoulder, and hand (DASH) scores. RESULTS 46 patients were included for analysis. Both groups showed a mean improvement in OSS of 9 points (P = 0.0001), DASH (10 points, P < 0.05), and EUROQOL (0.13, P < 0.05). No significant difference was observed between groups in any of the recorded outcomes. Apart from one case of frozen shoulder in each group, no other complications were noted. CONCLUSION While both groups showed improved pain and function scores after ASAD, no significant difference was seen between groups receiving placebo or hyaluronan. The intervention is safe but, in this study, has not been shown to improve postoperative pain or function over ASAD alone. Level of evidence: I.
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Affiliation(s)
- Praveen Sarda
- Department of Orthopaedics, Manchester University Hospital NHS Trust, Manchester, UK,Address for correspondence: Dr. Praveen Sarda, Manchester Royal Infirmary, Oxford Road, Manchester, M13 9WL, UK. E-mail:
| | - David Butt
- Department of Orthopaedics, Guy's and St Thomas Hospital NHS Trust, London, UK
| | - Sherif Elnikety
- Department of Orthopaedics, Guy's and St Thomas Hospital NHS Trust, London, UK
| | - Claire Fitzgerald
- Department of Orthopaedics, Guy's and St Thomas Hospital NHS Trust, London, UK
| | - Steven Corbett
- Department of Orthopaedics, Guy's and St Thomas Hospital NHS Trust, London, UK
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Özkılıç R, Kuru T, İpek S, Keskin E, Kaya YE. Diz Osteoartritinde İntraartiküler Hyalüronik Asit ve Tenoksikamın Ağrı ve Diz Eklem Fonksiyonları Üzerine Etkilerinin Karşılaştırılması. ACTA MEDICA ALANYA 2018. [DOI: 10.30565/medalanya.419286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Recent advances in hyaluronic acid based therapy for osteoarthritis. Clin Transl Med 2018; 7:6. [PMID: 29450666 PMCID: PMC5814393 DOI: 10.1186/s40169-017-0180-3] [Citation(s) in RCA: 159] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 12/22/2017] [Indexed: 12/15/2022] Open
Abstract
Osteoarthritis is a debilitating disease that has increased in prevalence across the world due to the aging population. Currently, physicians use a plethora of treatment strategies to try and slow down the progression of the disease, but none have been shown to ubiquitously treat and cure the disease. One of the strategies uses the high molecular weight molecule hyaluronic acid as either an injectable or oral supplement for treatment. Hyaluronic acid (HA) is a relatively new treatment that has shown varied results through several clinical trials. It can be used as a scaffold for engineering new treatments and several new preparations have just been added to the market. A comprehensive search was conducted through several search databases according our inclusion and exclusion criteria. This review included 44 prospective clinical trial investigating the feasibility and efficacy of HA injection for knee, hip, and ankle osteoarthritis. This review will take a closer look at hyaluronic acid and its properties, as well clinical effectiveness and future options.
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Concoff A, Sancheti P, Niazi F, Shaw P, Rosen J. The efficacy of multiple versus single hyaluronic acid injections: a systematic review and meta-analysis. BMC Musculoskelet Disord 2017; 18:542. [PMID: 29268731 PMCID: PMC5740709 DOI: 10.1186/s12891-017-1897-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 12/08/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Intra-articular hyaluronic acid (IA-HA) is a common therapy used to treat knee pain and suppress knee inflammation in knee osteoarthritis (OA), typically prescribed in regimens ranging from a single injection to 5 weekly injections given once weekly. We conducted a systematic review to determine the efficacy of IA-HA, with subgroup analyses to explore the differences in knee pain and adverse events (AEs) across different dosing regimens. METHODS We conducted a systematic search of the literature to identify studies evaluating IA-HA for the management of knee OA compared to IA-saline. Primary outcome measure was the mean knee pain score at 13 Weeks (3 months) or 26 weeks (6 months). Secondary outcome was the number of treatment-related AEs and treatment-related serious adverse events (SAEs). We evaluated differences in levels of pain and AEs/SAEs between dosing regimens compared to IA-Saline. RESULTS Thirty articles were included. Overall, IA-HA injections were associated with less knee pain compared to IA-Saline injections for all dosing regimens. 2-4 injections of IA-HA vs. IA-Saline produced the largest effect size at both 3-months and 6-months (Standard mean difference [SMD] = -0.76; -0.98 to -0.53, 95% CI, P < 0.00001, and SMD = -0.36; -0.63 to -0.09 95% CI, P = 0.008, respectively). Additionally, single injection studies yielded a non-significant treatment effect at 3 and 6 months, while ≥5 5 injections demonstrated a significant improvement in pain only at 6 months. Five or more injections of IA-HA were associated with a higher risk of treatment-related AEs compared to IA-Saline (Risk ratio [RR] = 1.67; 1.09 to 2.56 95% CI, p = 0.02), which was a result not seen within the 1 and 2-4 injection subgroups. CONCLUSION Overall, 2-4 and ≥5 injection regimens provided pain relief over IA-Saline, while single injection did not. Intra-articular injections of HA used in a 2-4 injection treatment regimen provided the greatest benefit when compared to IA-Saline with respect to pain improvement in patients with knee OA, and was generally deemed safe with few to no treatment-related AEs reported across studies. Future research is needed to directly compare these treatment regimens.
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Affiliation(s)
- Andrew Concoff
- Departments of Orthopedics and Rheumatology, St. Jude Medical Center, Fullerton, California, USA.
| | - Parag Sancheti
- Sancheti Institute for Orthopaedics and Rehabilitation, Maharashtra, India
| | - Faizan Niazi
- Ferring Pharmaceuticals Inc., Parsippany, NJ, USA
| | - Peter Shaw
- Ferring Pharmaceuticals Inc., Parsippany, NJ, USA
| | - Jeffrey Rosen
- Department of Orthopaedics & Rehabilitation, New York Presbyterian Queens; Department of Clinical Orthopaedic Surgery, Weill Medical College of Cornell University, New York, NY, USA
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Effectiveness of 3 Weekly Injections Compared With 5 Weekly Injections of Intra-Articular Sodium Hyaluronate on Pain Relief of Knee Osteoarthritis or 3 Weekly Injections of Other Hyaluronan Products: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil 2017; 98:1042-1050. [DOI: 10.1016/j.apmr.2017.01.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 01/18/2017] [Accepted: 01/18/2017] [Indexed: 11/21/2022]
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O'Hanlon CE, Newberry SJ, Booth M, Grant S, Motala A, Maglione MA, FitzGerald JD, Shekelle PG. Hyaluronic acid injection therapy for osteoarthritis of the knee: concordant efficacy and conflicting serious adverse events in two systematic reviews. Syst Rev 2016; 5:186. [PMID: 27814744 PMCID: PMC5097414 DOI: 10.1186/s13643-016-0363-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 10/21/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The prevalence of knee osteoarthritis (OA)/degenerative joint disease (DJD) is increasing in the USA. Systematic reviews of treatment efficacy and adverse events (AEs) of hyaluronic acid (HA) injections report conflicting evidence about the balance of benefits and harms. We review evidence on efficacy and AEs of intraarticular viscosupplementation with HA in older individuals with knee osteoarthritis and account for differences in these conclusions from another systematic review. METHODS We searched PubMed and eight other databases and gray literature sources from 1990 to December 12, 2014. Double-blind placebo-controlled randomized controlled trials (RCTs) reporting functional outcomes or quality-of-life; RCTs and observational studies on delay/avoidance of arthroplasty; RCTs, case reports, and large cohort studies and case series assessing safety; and systematic reviews reporting on knee pain were considered for inclusion. A standardized, pre-defined protocol was applied by two independent reviewers to screen titles and abstracts, review full text, and extract details on study design, interventions, outcomes, and quality. We compared our results with those of a prior systematic review and found them to be discrepant; our analysis of why this discrepancy occurred is the focus of this manuscript. RESULTS Eighteen RCTs reported functional outcomes: pooled analysis of ten placebo-controlled, blinded trials showed a standardized mean difference of -0.23 (95 % confidence interval (CI) -0.45 to -0.01) favoring HA at 6 months. Studies reported few serious adverse events (SAEs) and no significant differences in non-serious adverse events (NSAEs) (relative risk (RR) [95 % CI] 1.03 [0.93-1.15] or SAEs (RR [95 % CI] 1.39 [0.78-2.47]). A recent prior systematic review reported similar functional outcomes, but significant SAE risk. Differences in SAE inclusion and synthesis accounted for the disparate conclusions. CONCLUSIONS Trials show a small but significant effect of HA on function on which recent systematic reviews agree, but lack of AE synthesis standardization leads to opposite conclusions about the balance of benefits and harms. A limitation of the re-analysis of the prior systematic review is that it required imputation of missing data.
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Affiliation(s)
- Claire E O'Hanlon
- RAND Corporation, 1776 Main St., Santa Monica, CA, 90407, USA. .,Pardee RAND Graduate School, 1776 Main St., Santa Monica, CA, 90407, USA.
| | | | - Marika Booth
- RAND Corporation, 1776 Main St., Santa Monica, CA, 90407, USA
| | - Sean Grant
- RAND Corporation, 1776 Main St., Santa Monica, CA, 90407, USA
| | - Aneesa Motala
- RAND Corporation, 1776 Main St., Santa Monica, CA, 90407, USA
| | | | - John D FitzGerald
- RAND Corporation, 1776 Main St., Santa Monica, CA, 90407, USA.,Division of Rheumatology, Department of Internal Medicine, UCLA, 1000 Veteran Avenue, Los Angeles, CA, 90095, USA
| | - Paul G Shekelle
- RAND Corporation, 1776 Main St., Santa Monica, CA, 90407, USA.,Veterans Affairs Greater Los Angeles Healthcare System, 11301 Wilshire Boulevard, Los Angeles, CA, 90073, USA
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Islam S, Shajib MS, Ahmed T. Antinociceptive effect of methanol extract of Celosia cristata Linn. in mice. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2016; 16:400. [PMID: 27770773 PMCID: PMC5075210 DOI: 10.1186/s12906-016-1393-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Accepted: 10/11/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Celosia cristata Linn. (Amaranthaceae) is used in traditional medicine for the treatment of headache, sores, ulcers, eye inflammations, skin eruption, painful menstruation and carpal tunnel syndrome. This study was performed to evaluate the antinociceptive activity of methanol extract of the whole plant of C. cristata (MECC). METHODS The evaluation of the antinociceptive effect of MECC was performed using thermal (hot plate, tail immersion test) and chemical (acetic acid, formalin, and glutamate-induced nociception test) pain models in mice at four different doses (50, 100, 200, 400 mg/kg; p.o.). Involvement of opioid receptors mediated central antinociceptive mechanism of MECC was evaluated using naloxone. Furthermore, the association of ATP-sensitive K+ channel and cGMP pathway were evaluated using glibenclamide and methylene blue respectively. RESULTS Oral treatment of MECC produced significant, strong and dose-dependent central and peripheral antinociceptive effect in experimental pain models. MECC significantly increased the latency time of thermal threshold in both hot plate and tail immersion test. The inhibition of writhing syndrome by the extract in the acetic acid-induced writhing test was remarkable. MECC significantly reduced the formalin-induced neurogenic and inflammatory pain. In addition, the inhibition of glutamate-induced paw licking and edema by MECC was significant. The antinociceptive effect was significantly reversed by naloxone and glibenclamide, suggesting the association of opioid and ATP-sensitive K+ channel system respectively. In addition, MECC also demonstrated the involvement of cGMP pathway in the antinociceptive action. CONCLUSION The study suggests that C. cristata possess significant antinociceptive effect which is associated with both central and peripheral mechanisms and provides a rationale for its extensive use at different painful conditions in traditional medicine.
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Affiliation(s)
- Shanta Islam
- Department of Pharmacy, Stamford University Bangladesh, 51 Siddeswari Road, 1217 Dhaka, Bangladesh
| | - Md Shafiullah Shajib
- Department of Pharmacy, Stamford University Bangladesh, 51 Siddeswari Road, 1217 Dhaka, Bangladesh
| | - Tajnin Ahmed
- Department of Pharmacy, Stamford University Bangladesh, 51 Siddeswari Road, 1217 Dhaka, Bangladesh
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Clinical benefit of intra-articular saline as a comparator in clinical trials of knee osteoarthritis treatments: A systematic review and meta-analysis of randomized trials. Semin Arthritis Rheum 2016; 46:151-159. [DOI: 10.1016/j.semarthrit.2016.04.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 03/31/2016] [Accepted: 04/15/2016] [Indexed: 02/08/2023]
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Altman RD, Bedi A, Karlsson J, Sancheti P, Schemitsch E. Product Differences in Intra-articular Hyaluronic Acids for Osteoarthritis of the Knee. Am J Sports Med 2016; 44:2158-65. [PMID: 26578719 DOI: 10.1177/0363546515609599] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Knee osteoarthritis (OA) is a common and often disabling joint disorder among adults that may result in impaired activity and daily function. A variety of treatment options are currently available and prescribed for knee OA depending on the severity of the disorder and physician preference. Intra-articular hyaluronic acid (IA-HA) injection is a treatment for knee OA that reportedly provides numerous biochemical and biological benefits, including shock absorption, chondroprotection, and anti-inflammatory effects within the knee. Clarity is needed as to whether the available IA-HA products should be considered for therapy as a group or whether there are significant differences in the products that need to be considered in treatment of OA of the knee. PURPOSE To determine whether there are differences in efficacy and safety with respect to intrinsic properties of available IA-HA injections for knee OA. STUDY DESIGN Meta-analysis. METHODS A comprehensive literature search of the Medline, EMBASE, and PubMed databases was conducted for all existing randomized trials of IA-HA. The primary outcome measure analyzed was the mean pain score at the reported follow-up nearest to 26 weeks after injection. Pooled efficacy and safety results were recorded for subgroupings of HA product characteristics. RESULTS A total of 68 studies were included for analysis. Products with an average molecular weight ≥3000 kDa provided favorable efficacy results when compared with products of an average molecular weight <3000 kDa. Products with a molecular weight ≥3000 kDa demonstrated significantly fewer discontinuations due to treatment-related adverse events than did ≤1500 kDa counterparts, while trial discontinuation rates were similar between biological fermentation-derived HA products and avian-derived HA. The results did not demonstrate a significant difference in the occurrence of effusion across molecular weight subgroups. Additionally, biological fermentation-derived HA had a significantly smaller incidence of effusion than did avian-derived HA. Biological fermentation-derived HA demonstrated fewer acute flare-ups at the injection site than did avian-derived HA products, while high-molecular-weight products demonstrated the highest rate of injection site flare-up. CONCLUSION Despite similarities, IA-HA products should not be treated as a group, as there are differences in IA-HA products that influence both efficacy and safety. In the available literature, IA-HA products with a molecular weight ≥3000 kDa and those derived from biological fermentation relate to superior efficacy and safety-factors that may influence selection an IA-HA product for OA of the knee.
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Affiliation(s)
- Roy D Altman
- Division of Rheumatology and Immunology, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Asheesh Bedi
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jon Karlsson
- Department of Orthopedics, Sahlgrenska Academy, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Parag Sancheti
- Sancheti Institute for Orthopaedics and Rehabilitation, Pune, Maharashtra, India
| | - Emil Schemitsch
- Department of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada
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Habib G, Khatib M, Sakas F, Artul S, Jabaly-Habib H. Pre-injection of hyaluronic acid does not affect the systemic effects of intra-articular depot betamethasone injection at the knee joint. Clin Rheumatol 2016; 36:217-221. [PMID: 27423207 DOI: 10.1007/s10067-016-3352-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/02/2016] [Accepted: 07/07/2016] [Indexed: 11/25/2022]
Abstract
Intra-articular injection (IAI) of both hyaluronic acid (HA) and depot-steroid preparations had the advantage of quick and prolonged favorable effects on pain relief among patients with symptomatic osteoarthritis of the knee (OAK). The effect of IAI of HA on the systemic effects of the intra-articular steroids had not been investigated. Non-selected patients attending the rheumatology clinic with symptomatic OAK who failed NSAIDS and physical therapy were offered an IAI of HA at the knee joint followed 20 min later by an IAI of 1 ml of Celestone Chronodose at the same joint (group 1). Morning serum levels of cortisol were obtained just prior to the IAI and 1, 2 and 8 days later. Demographic, clinical, and laboratory parameters were obtained also from all the patients. Age- and sex-matched group of patients from the same clinic were recruited as a control group (group 2). Mean baseline serum cortisol levels in group 1 was 381 ± 154 mmol/l vs. 376 ± 119 in group 2 (p = 0.954). Morning serum cortisol levels at day 1 and day 2 were 24 ± 6 and 22 ± 6 mmol/l, respectively, in group 1 patients vs. 27 ± 5.8 (p = 0.214) and 25 ± 5.6 mmol/l (p = 0.200), respectively, in group 2. These levels were significantly lower than baseline levels in each group. Morning serum cortisol levels at day 8 in group 1 and group 2 were 349 ± 128 and 314 ± 99 mmol/l, respectively (p = 0.419). Pre-injection of HA at the knee joint did not affect the systemic effect on the hypothalamic-pituitary-adrenal axis of IAI of Celestone Chronodose.
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Affiliation(s)
- George Habib
- Rheumatology Unit, Laniado Medical Center, Netanya, 42150, Israel. .,Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel. .,Rheumatology Clinic, Nazareth Hospital, Nazareth, Israel.
| | - Muhamad Khatib
- Department of Medicine, Poriya Medical Center, Poriya, Israel
| | - Fahed Sakas
- Department of Medicine, Rambam Medical Center, Haifa, Israel
| | - Suheil Artul
- Gallile Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel.,Department of Radiology, Nazareth Hospital, Nazareth, Israel
| | - Haneen Jabaly-Habib
- Gallile Faculty of Medicine, Bar-Ilan University, Ramat Gan, Israel.,Ophthalmology Division, Poriya Medical Center, Poriya, Israel
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Migliore A, Bizzi E, De Lucia O, Delle Sedie A, Tropea S, Bentivegna M, Mahmoud A, Foti C. Differences Regarding Branded HA in Italy, Part 2: Data from Clinical Studies on Knee, Hip, Shoulder, Ankle, Temporomandibular Joint, Vertebral Facets, and Carpometacarpal Joint. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2016; 9:117-31. [PMID: 27279754 PMCID: PMC4898442 DOI: 10.4137/cmamd.s39143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 04/06/2016] [Accepted: 04/13/2016] [Indexed: 01/29/2023]
Abstract
OBJECTIVES The aim of the current study is to collect scientific data on all branded hyaluronic acid (HA) products in Italy that are in use for intra-articular (IA) injection in osteoarthritis (OA) compared with that reported in the leaflet. METHODS An extensive literature research was performed for all articles reporting data on the IA use of HA in OA. Selected studies were taken into consideration only if they are related to products based on HAs that are currently marketed in Italy with the specific joint indication for IA use in patients affected by OA. RESULTS Sixty-two HA products are marketed in Italy: 30 products are indicated for the knee but only 8 were proved with some efficacy; 9 products were effective for the hip but only 6 had hip indication; 7 products proved to be effective for the shoulder but only 3 had the indication; 5 products proved effective for the ankle but only one had the indication; 6 products were effective for the temporomandibular joint but only 2 had the indication; only 2 proved effective for vertebral facet joints but only 1 had the indication; and 5 products proved effective for the carpometacarpal joint but only 2 had the indication. CONCLUSIONS There are only a few products with some evidences, while the majority of products remain without proof. Clinicians and regulators should request postmarketing studies from pharmaceuticals to corroborate with that reported in the leaflet and to gather more data, allowing the clinicians to choose the adequate product for the patient.
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Affiliation(s)
- A Migliore
- Rheumatology, S. Pietro Fatebenefratelli Hospital, Rome, Italy
| | - E Bizzi
- Rheumatology, S. Pietro Fatebenefratelli Hospital, Rome, Italy
| | - O De Lucia
- Division and Chair of Rheumatology, Gaetano Pini Institute, Milan, Italy
| | | | - S Tropea
- Rete Reumatologica, ASP 7 RG, Ragusa, Italy
| | - M Bentivegna
- Rete Reumatologica Coordinator, ASP 7 RG, Ragusa, Italy
| | - A Mahmoud
- Physical Medicine, Rheumatology and Rehabilitation Department, Ain Shams University, Cairo, Egypt.; Physical and Rehabilitation Medicine, Tor Vergata University, Rome, Italy
| | - C Foti
- Physical and Rehabilitation Medicine, Clinical Sciences and Translational Medicine Department, Tor Vergata University, Rome, Italy
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Tammachote N, Kanitnate S, Yakumpor T, Panichkul P. Intra-Articular, Single-Shot Hylan G-F 20 Hyaluronic Acid Injection Compared with Corticosteroid in Knee Osteoarthritis: A Double-Blind, Randomized Controlled Trial. J Bone Joint Surg Am 2016; 98:885-92. [PMID: 27252432 DOI: 10.2106/jbjs.15.00544] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of knee osteoarthritis with hyaluronic acid or corticosteroid injection has been widely used. The purpose of this study was to compare the efficacy of hyaluronic acid (hylan G-F 20) with triamcinolone acetonide as a single intra-articular injection for knee osteoarthritis. METHODS This study was a prospective, randomized, double-blind clinical trial. Participants with symptomatic knee osteoarthritis were recruited. They were randomized to receive a single-shot, intra-articular injection of either 6 mL of hylan G-F 20 or 6 mL of a solution comprising 1 mL of 40-mg triamcinolone acetonide and 5 mL of 1% lidocaine with epinephrine. The primary outcomes were knee pain severity, knee function, and range of motion at 6 months. Ninety-nine patients were assessed before injection and underwent a 6-month follow-up. Patients and evaluators were blinded. Multilevel regression models were used to estimate differences between the groups. RESULTS At the 6-month follow-up, compared with patients who took hylan G-F 20, patients who took triamcinolone acetonide had similar improvement in knee pain, knee function, and range of motion. The difference in mean outcome scores between groups was, with regard to knee pain, a visual analog scale (VAS) score of 3 points (95% confidence interval [95% CI], -6 to 11 points); with regard to knee function, a modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score of 0 points (95% CI, -8 to 6 points); and, with regard to range of motion, flexion of -1° (95% CI, -5° to 2°) and extension of 0° (95% CI, -0.5° to 0.5°). However, patients who took triamcinolone acetonide had better pain improvement from 24 hours until 1 week after injection; the mean difference between groups with regard to the VAS score was 12 points (95% CI, 5 to 20 points; p = 0.002) at 24 hours and 9 points (95% CI, 1 to 15 points; p = 0.018) at 1 week. At 2 weeks after injection, patients who took triamcinolone acetonide also had better knee functional improvement; the mean difference between groups for the modified WOMAC score was 6 points (95% CI, 0.7 to 12 points; p = 0.03). Both groups had improvement in pain, knee function, and range of motion during the 6-month follow-up (p < 0.0001). CONCLUSIONS Triamcinolone acetonide provided similar improvement in knee pain, function, and range of motion compared with hylan G-F 20 at the 6-month follow-up, with better pain control in the first week and better knee functional improvement in the second week. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Nattapol Tammachote
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Khlong Nueng, Khlong Luang, Pathumthani, Thailand Orthopaedic Outpatient Unit, Thammasat University Hospital, Khlong Nueng, Khlong Luang, Pathumthani, Thailand
| | - Supakit Kanitnate
- Department of Orthopaedics, Faculty of Medicine, Thammasat University, Khlong Nueng, Khlong Luang, Pathumthani, Thailand Orthopaedic Outpatient Unit, Thammasat University Hospital, Khlong Nueng, Khlong Luang, Pathumthani, Thailand
| | - Thanasak Yakumpor
- Orthopaedic Outpatient Unit, Thammasat University Hospital, Khlong Nueng, Khlong Luang, Pathumthani, Thailand Department of Orthopaedics, Faculty of Medicine, Burapha University, Saen Sook Sub-district, Mueang District, Chonburi, Thailand
| | - Phonthakorn Panichkul
- Orthopaedic Outpatient Unit, Thammasat University Hospital, Khlong Nueng, Khlong Luang, Pathumthani, Thailand Hip and Knee Center, Bangkok Hospital Medical Center, Bangkok, Thailand
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Hyaluronic Acid Suppresses the Expression of Metalloproteinases in Osteoarthritic Cartilage Stimulated Simultaneously by Interleukin 1β and Mechanical Load. PLoS One 2016; 11:e0150020. [PMID: 26934732 PMCID: PMC4774918 DOI: 10.1371/journal.pone.0150020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Accepted: 02/08/2016] [Indexed: 12/05/2022] Open
Abstract
Purpose In patients with osteoarthritis (OA), intraarticular injection of hyaluronic acid (HA) frequently results in reduced pain and improved function for prolonged periods of time, i.e. more than 6 months. However, the mechanisms underlying these effects are not fully understood. Our underlying hypothesis is that HA modifies the enzymatic breakdown of joint tissues. Methods To test this hypothesis, we examined osteochondral cylinders from 12 OA patients. In a bioreactor, these samples were stimulated by interleukin 1β (Il1ß) (2 ng/ml) plus mechanical load (2.0 Mpa at 0.5 Hz horizontal and 0.1 Hz vertical rotation), thus the experimental setup recapitulated both catabolic and anabolic clues of the OA joint. Results Upon addition of HA at either 1 or 3 mg/ml, we observed a significant suppression of expression of metalloproteinase (MMP)-13. A more detailed analysis based on the Kellgren and Lawrence (K&L) OA grade, showed a much greater degree of suppression of MMP-13 expression in grade IV as compared to grade II OA. In contrast to the observed MMP-13 suppression, treatment with HA resulted in a suppression of MMP-1 expression only at 1 mg/ml HA, while MMP-2 expression was not significantly affected by either HA concentration. Conclusion Together, these data suggest that under concurrent catabolic and anabolic stimulation, HA exhibits a pronounced suppressive effect on MMP-13. In the long-run these findings may benefit the development of treatment strategies aimed at blocking tissue degradation in OA patients.
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Porcellini G, Merolla G, Giordan N, Paladini P, Burini A, Cesari E, Castagna A. Intra-articular glenohumeral injections of HYADD®4-G for the treatment of painful shoulder osteoarthritis: a prospective multicenter, open-label trial. JOINTS 2016; 3:116-21. [PMID: 26889467 DOI: 10.11138/jts/2015.3.3.116] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE numerous experimental and clinical studies in osteoarthritis (OA) have demonstrated that intra-articular (IA) administration of hyaluronic acid can improve the altered rheological properties of the synovial fluid and exert protective and reparative effects on the joint structure. The objective of this study was to evaluate the safety and performance of HYADD®4-G (Hymovis®) in patients with glenohumeral joint OA. METHODS forty-one patients with shoulder pain and limited shoulder function resulting from concentric glenohumeral joint OA were enrolled in a multicenter clinical trial. Patients received two HYADD®4-G injections administered one week apart. The main outcome measure was improvement in shoulder pain on movement at six months as assessed through a 100-mm visual analog scale (VAS), range of motion (ROM) values, and Constant-Murley Shoulder Outcome Score (CS). RESULTS two IA injections of HYADD®4-G (Hymovis®) significantly decreased pain and improved shoulder function for up to six months from the first injection. The VAS score decreased (from 66.1 mm to 37.7 mm at six months) and improvements were recorded in the total CS and in the ROM values ( rotation decreased from a mean value of 54.2° at baseline to 63.2° at six months and internal rotation from a mean value of 44.0° at baseline to 45.7° at 26 weeks). No serious adverse events occurred. CONCLUSIONS the study results demonstrated that two IA injections of HYADD®4-G (Hymovis®) may be a safe and effective treatment option for shoulder pain associated with glenohumeral OA and that the effects of the injections are still present for up to six months after the treatment. LEVEL OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Giuseppe Porcellini
- Unit of Shoulder and Elbow Surgery, D. Cervesi Hospital, Cattolica (RN), AUSL della Romagna Ambito Rimini, Italy
| | - Giovanni Merolla
- Unit of Shoulder and Elbow Surgery, D. Cervesi Hospital, Cattolica (RN), AUSL della Romagna Ambito Rimini, Italy; "Marco Simoncelli" Biomechanics Laboratory D. Cervesi Hospital, Cattolica (RN), AUSL della Romagna Ambito Rimini, Italy
| | - Nicola Giordan
- Research and Development Department - Fidia Farmaceutici SpA, Abano Terme (PD), Italy
| | - Paolo Paladini
- Unit of Shoulder and Elbow Surgery, D. Cervesi Hospital, Cattolica (RN), AUSL della Romagna Ambito Rimini, Italy
| | - Andrea Burini
- Research and Development Department - Fidia Farmaceutici SpA, Abano Terme (PD), Italy
| | - Eugenio Cesari
- Unit of Orthopaedics, Istituto Clinico Humanitas, Rozzano (MI), Italy
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Jevsevar D, Donnelly P, Brown GA, Cummins DS. Viscosupplementation for Osteoarthritis of the Knee: A Systematic Review of the Evidence. J Bone Joint Surg Am 2015; 97:2047-60. [PMID: 26677239 DOI: 10.2106/jbjs.n.00743] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The purpose of this analysis was to determine the clinical significance of injectable hyaluronic acid (HA) in the treatment of knee osteoarthritis, and to assess which trial-level factors influence the overall treatment effect of HA on pain (as measured by a VAS [visual analog scale] or the WOMAC [Western Ontario and McMaster Universities Osteoarthritis Index]) and the WOMAC function and WOMAC stiffness subscales. METHODS A comprehensive literature search of PubMed, EMBASE, the Physiotherapy Evidence Database, and the Cochrane Central Register of Controlled Trials was done to locate randomized controlled trials that compared HA with control treatment and had a minimum of thirty patients per subgroup. To be considered for inclusion, each article had to include VAS or WOMAC pain, WOMAC function, and/or WOMAC stiffness as outcomes because the minimal important difference (MID) has been established for these instruments. A "best-evidence" systematic review and meta-analysis of nineteen trials was performed; because of high heterogeneity among the trials, meta-regression analyses were conducted to determine the influence of trial characteristics on overall HA treatment effects for pain, function, and stiffness. RESULTS The most consistent finding was that double-blinded, sham-controlled trials had much smaller treatment effects than trials that were not sufficiently blinded (p < 0.05). For double-blinded trials, the overall treatment effect was less than half of the MID for pain, function, and stiffness. Other significant associations were found for cross-linked HAs and follow-up duration. However, the effect sizes among double-blinded trials of cross-linked HAs were still less than half of the MIDs for pain and stiffness. The statistically significant effect of follow-up duration disappeared when the open-label trials were removed from the analysis. CONCLUSIONS Meta-analysis of only the double-blinded, sham-controlled trials with at least sixty patients did not show clinically important differences of HA treatment over placebo. When all literature was added to the analysis, the overall effect was greater but was biased toward stronger treatment effects because of the influence of nonblinded or improperly blinded trials.
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Affiliation(s)
- David Jevsevar
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH 03756. E-mail address:
| | - Patrick Donnelly
- Research and Scientific Affairs Department, American Academy of Orthopaedic Surgeons, 9400 West Higgins Road, Rosemont, IL 60018. E-mail address for P. Donnelly: . E-mail address for D.S. Cummins:
| | - Gregory A Brown
- Franciscan Orthopedic Associates at St. Joseph, 1608 South J Street, 4th Floor, Tacoma, WA 98405. E-mail address:
| | - Deborah S Cummins
- Research and Scientific Affairs Department, American Academy of Orthopaedic Surgeons, 9400 West Higgins Road, Rosemont, IL 60018. E-mail address for P. Donnelly: . E-mail address for D.S. Cummins:
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Kasetvatin C, Rujivipat S, Tiyaboonchai W. Combination of elastic liposomes and low frequency ultrasound for skin permeation enhancement of hyaluronic acid. Colloids Surf B Biointerfaces 2015; 135:458-464. [DOI: 10.1016/j.colsurfb.2015.07.078] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 07/05/2015] [Accepted: 07/28/2015] [Indexed: 11/25/2022]
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Bannuru RR, McAlindon TE, Sullivan MC, Wong JB, Kent DM, Schmid CH. Effectiveness and Implications of Alternative Placebo Treatments: A Systematic Review and Network Meta-analysis of Osteoarthritis Trials. Ann Intern Med 2015. [PMID: 26215539 DOI: 10.7326/m15-0623] [Citation(s) in RCA: 127] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Placebo controls are essential in evaluating the effectiveness of medical treatments. Although it is unclear whether different placebo interventions for osteoarthritis vary in efficacy, systematic differences would substantially affect interpretation of the results of placebo-controlled trials. OBJECTIVE To evaluate the effects of alternative placebo types on pain outcomes in knee osteoarthritis. DATA SOURCES MEDLINE, EMBASE, Web of Science, Google Scholar, and Cochrane Database from inception through 1 June 2015 and unpublished data. STUDY SELECTION 149 randomized trials of adults with knee osteoarthritis that reported pain outcomes and compared widely used pharmaceuticals against oral, intra-articular, topical, and oral plus topical placebos. DATA EXTRACTION Study data were independently double-extracted; study quality was assessed by using the Cochrane risk of bias tool. DATA SYNTHESIS Placebo effects that were evaluated by using a network meta-analysis with 4 separate placebo nodes (differential model) showed that intra-articular placebo (effect size, 0.29 [95% credible interval, 0.09 to 0.49]) and topical placebo (effect size, 0.20 [credible interval, 0.02 to 0.38]) had significantly greater effect sizes than did oral placebo. This differential model showed marked differences in the relative efficacies and hierarchy of the active treatments compared with a network model that considered all placebos equivalent. In the model accounting for differential effects, intra-articular and topical therapies were superior to oral treatments in reducing pain. When these differential effects were ignored, oral nonsteroidal anti-inflammatory drugs were superior. LIMITATIONS Few studies compared different placebos directly. The study could not decisively conclude whether disease severity and co-interventions systematically differed between trials evaluating different placebos. CONCLUSION All placebos are not equal, and some can trigger clinically relevant responses. Differential placebo effects can substantially alter estimates of the relative efficacies of active treatments, an important consideration for the design of clinical trials and interpretation of their results. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Raveendhara R. Bannuru
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
| | - Timothy E. McAlindon
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
| | - Matthew C. Sullivan
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
| | - John B. Wong
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
| | - David M. Kent
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
| | - Christopher H. Schmid
- From Tufts Medical Center, Sackler School of Graduate Biomedical Sciences of Tufts University, Boston, Massachusetts, and Brown University School of Public Health, Providence, Rhode Island
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Ip D, Fu NY. Can combined use of low-level lasers and hyaluronic acid injections prolong the longevity of degenerative knee joints? Clin Interv Aging 2015; 10:1255-8. [PMID: 26346122 PMCID: PMC4531024 DOI: 10.2147/cia.s86907] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background This study evaluated whether half-yearly hyaluronic acid injection together with low-level laser therapy in addition to standard conventional physical therapy can successfully postpone the need for joint replacement surgery in elderly patients with bilateral symptomatic tricompartmental knee arthritis. Methods In this prospective, double-blind, placebo-controlled study, 70 consecutive unselected elderly patients with bilateral tricompartmental knee arthritis were assigned at random to either one of two conservative treatment protocols to either one of the painful knees. Protocol A consisted of conventional physical therapy plus a sham light source plus saline injection, and protocol B consisted of protocol A with addition of half-yearly hyaluronic acid injection as well as low-level laser treatment instead of using saline and a sham light source. Treatment failure was defined as breakthrough pain necessitating joint replacement. Results Among the 140 painful knees treated with either protocol A or protocol B, only one of the 70 painful knees treated by protocol B required joint replacement, whereas 15 of the 70 painful knees treated by protocol A needed joint replacement surgery (P<0.05). Conclusion We conclude that half-yearly hyaluronic acid injections together with low-level laser therapy should be incorporated into the standard conservative treatment protocol for symptomatic knee arthritis, because it may prolong the longevity of the knee joint without the need for joint replacement.
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Affiliation(s)
- David Ip
- Asia Medical Pain Centre, Grand Plaza, Mong Kok, Hong Kong
| | - Nga Yue Fu
- Asia Medical Pain Centre, Grand Plaza, Mong Kok, Hong Kong
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Strand V, McIntyre LF, Beach WR, Miller LE, Block JE. Safety and efficacy of US-approved viscosupplements for knee osteoarthritis: a systematic review and meta-analysis of randomized, saline-controlled trials. J Pain Res 2015; 8:217-28. [PMID: 26005358 PMCID: PMC4428363 DOI: 10.2147/jpr.s83076] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Intra-articular injection of hyaluronic acid is a common, yet controversial, therapeutic option for patients with knee osteoarthritis (OA). The purpose of this research was to determine the safety and efficacy of US-approved viscosupplements for symptomatic knee OA. METHODS We searched MedLine and EMBase for randomized, sham-controlled trials evaluating safety and/or clinical efficacy of US-approved viscosupplements in patients with symptomatic knee OA. Knee pain severity and knee joint function were assessed at 4 to 13 weeks and 14 to 26 weeks. Safety outcomes included serious adverse events, treatment-related serious adverse events, patient withdrawal, and adverse event-related patient withdrawal occurring at any time during follow-up. RESULTS A total of 29 studies representing 4,866 unique patients (active: 2,673, control: 2,193) were included. All sham-controlled trials used saline injections as a control. Viscosupplementation resulted in very large treatment effects between 4 and 26 weeks for knee pain and function compared to preinjection values, with standardized mean difference values ranging from 1.07 to 1.37 (all P<0.001). Compared to controls, standardized mean difference with viscosupplementation ranged from 0.38 to 0.43 for knee pain and 0.32 to 0.34 for knee function (all P<0.001). There were no statistically significant differences between viscosupplementation and controls for any safety outcome, with absolute risk differences of 0.7% (95% confidence interval [CI]: -0.2 to 1.5%) for serious adverse events, 0% (95% CI: -0.4 to 0.4%) for treatment-related serious adverse events, 0% (95% CI: -1.6 to 1.6%) for patient withdrawal, and 0.2% (95% CI: -0.4 to 0.8%) for adverse event-related patient withdrawal. CONCLUSION Intra-articular injection of US-approved viscosupplements is safe and efficacious through 26 weeks in patients with symptomatic knee OA.
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Affiliation(s)
- Vibeke Strand
- Stanford University School of Medicine, Palo Alto, CA, USA
| | | | | | - Larry E Miller
- Miller Scientific Consulting, Inc., Asheville, NC, USA ; The Jon Block Group, San Francisco, CA, USA
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van der Weegen W, Wullems JA, Bos E, Noten H, van Drumpt RAM. No difference between intra-articular injection of hyaluronic acid and placebo for mild to moderate knee osteoarthritis: a randomized, controlled, double-blind trial. J Arthroplasty 2015; 30:754-7. [PMID: 25548079 DOI: 10.1016/j.arth.2014.12.012] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 11/11/2014] [Accepted: 12/09/2014] [Indexed: 02/01/2023] Open
Abstract
The main goal of our study was to examine the effectiveness and safety of Fermathron plus, a specific brand of hyaluronic acid (HA), in patients with mild to moderate knee osteoarthritis. In a randomized, controlled, double-blind trial, 196 patients with symptomatic knee osteoarthritis (mean age ± SD, 59.4 ± 9.9 years, Kellgren-Lawrence grade 1-3) were given either 3 weekly intra-articular injections of HA or saline (placebo). Although pain and functional scores (WOMAC scale) improved significantly from baseline up to 6 months, HA was not superior to placebo at any follow-up (VAS pain 50 m walking from 56.4 to 38.1, P < .001, and 58.2 to 39.6, P < .001, respectively). No subgroup analysis resulted in superior outcomes. No serious adverse events were noticed.
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Affiliation(s)
| | - Jorgen A Wullems
- Department of Orthopedic Surgery, St. Anna hospital, Geldrop, The Netherlands
| | - Ellis Bos
- Department of Orthopedic Surgery, St. Anna hospital, Geldrop, The Netherlands
| | - Hub Noten
- Department of Orthopedic Surgery, Elkerliek hospital, Helmond, The Netherlands
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Jansen JP, Vieira MC, Cope S. Network meta-analysis of longitudinal data using fractional polynomials. Stat Med 2015; 34:2294-311. [PMID: 25877808 DOI: 10.1002/sim.6492] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Revised: 02/15/2015] [Accepted: 03/09/2015] [Indexed: 12/14/2022]
Abstract
Network meta-analysis of randomized controlled trials (RCTs) are often based on one treatment effect measure per study. However, many studies report data at multiple time points. Furthermore, not all studies measure the outcomes at the same time points. As an alternative to a network meta-analysis based on a synthesis of the results at one time point, a network meta-analysis method is presented that allows for the simultaneous analysis of outcomes at multiple time points. The development of outcomes over time of interventions compared in an RCT is modeled with fractional polynomials, and the differences between the parameters of these polynomials within a trial are synthesized across studies with a Bayesian network meta-analysis. The proposed models are illustrated with an analysis of RCTs evaluating interventions for osteoarthritis of the knee. Fixed and random effects second order fractional polynomials were applied to the case study. Network meta-analysis with models that represent the treatment effects in terms of several parameters using fractional polynomials can be considered a useful addition to models for network meta-analysis of repeated measures previously proposed. When RCTs report treatment effects at multiple follow-up times, these models can be used to synthesize the results even if reporting times differ across the studies.
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Affiliation(s)
- J P Jansen
- Redwood Outcomes, San Francisco, CA, U.S.A.,Tufts University School of Medicine, Boston, MA, U.S.A
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Tang ACW, Tang SFT, Hong WH, Chen HC. Kinetics features changes before and after intra-articular hyaluronic acid injections in patients with knee osteoarthritis. Clin Neurol Neurosurg 2015; 129 Suppl 1:S21-6. [DOI: 10.1016/s0303-8467(15)30007-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Trueba Davalillo CÁ, Trueba Vasavilbaso C, Navarrete Álvarez JM, Coronel Granado P, García Jiménez OA, Gimeno Del Sol M, Gil Orbezo F. Clinical efficacy of intra-articular injections in knee osteoarthritis: a prospective randomized study comparing hyaluronic acid and betamethasone. Open Access Rheumatol 2015; 7:9-18. [PMID: 27790040 PMCID: PMC5045121 DOI: 10.2147/oarrr.s74553] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Osteoarthritis (OA) is the most common joint disease and leading cause of disability. Intra-articular (IA) administration of hyaluronic acid (HA) or corticosteroids (CS) have been previously studied, though using insufficient number of patients or short follow-up periods. Objective We evaluate HA and CS in patients with knee OA in terms of clinical efficacy over 12 months. Methods We used a prospective, randomized study with parallel groups. Randomized patients received IA injections of HA or betamethasone (BM). The primary outcomes were improvement in pain using Visual Analog Scale and function in the Western Ontario and McMaster University Osteoarthritis Index (Likert scale). Follow-up visits were scheduled at 3 months, 6 months, 9 months, and 12 months. Results A total of 200 patients were included. Pain was significantly reduced in both groups at the first follow-ups. At 12 months, the mean pain reduction in the HA group was 33.6% (95% CI: 31.1–36.1) compared to 8.2% (95% CI: 5.2–11.1) in BM (P<0.0001). Function improvement was higher in HA through every visit, and mean improvement at 12 months was 47.5% (95% CI: 45.6–49.3) in HA patients vs 13.2% (95% CI: 11.4–14.9) in the BM group (P<0.0001). All patients from both groups achieved the Minimal Clinically Important Improvement (MCII) for both pain and function up to 6 months. At 9 months and 12 months, the MCII figures were higher in HA group with ≥80% compared to ≤10% in BM group (P<0.0001). Adverse reactions were rare and related to the administration procedure. Conclusion Both treatments effectively controlled OA symptoms. BM showed higher short-term effectiveness, while HA showed better long-term effectiveness, maintaining clinical efficacy in a large number of patients 1 year after administration.
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Affiliation(s)
| | | | | | | | | | | | - Félix Gil Orbezo
- Orthopedic service, Hospital Español de México, México DF, Mexico
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Pal S, Thuppal S, Reddy KJ, Avasthi S, Aggarwal A, Bansal H, Mohanasundaram S, Bailleul F. Long-Term (1-Year) Safety and Efficacy of a Single 6-mL Injection of Hylan G-F 20 in Indian Patients with Symptomatic Knee Osteoarthritis. Open Rheumatol J 2014; 8:54-68. [PMID: 25328555 PMCID: PMC4196249 DOI: 10.2174/1874312901408010054] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Revised: 07/19/2014] [Accepted: 08/23/2014] [Indexed: 01/13/2023] Open
Abstract
INTRODUCTION The prevalence of symptomatic knee osteoarthritis (OA) among Asians ≥65 years is estimated to double by 2040. This study was designed to evaluate the safety and efficacy of a single, 6-mL intra-articular injection of hylan G-F 20 in Indian patients with knee OA at 26 weeks through to 52 weeks. METHODS This study was an open-label, multicentre, phase 4 clinical trial. Enrolled patients (N=394) were ≥30 years old with Kellgren-Lawrence grade 1-3 OA; all patients received hylan G-F 20. WOMAC, SF-12, PTGA, and COGA scores, and OA medication use were evaluated at weeks 1, 4, 12, 26, 39, and 52 (initial treatment phase). At 26, 39, or 52 weeks, eligible patients could participate in a repeat treatment phase. McNemar-Bowkers, paired t-tests and ANOVA analyses were performed (alpha=0.05). RESULTS At 26 weeks, statistically significant changes from baseline were observed in all efficacy parameters, including the primary efficacy endpoint of WOMAC A1 (p<0.0001). Improvements continued for 52 weeks. No significant changes occurred in concomitant medication use. Eleven patients (2.8%) were re-injected at week 26 or 52. After repeat injection, statistically significant decreases were observed in WOMAC A1, WOMAC C and PTGA scores (p≤0.028). Twenty-three (5.8%) patients reported 26 local target knee AEs. CONCLUSION Among Indian patients within this study, a 6-mL hylan G-F 20 injection was well tolerated and effective in treating symptomatic knee OA with significant long-term (1 year) improvement of outcomes. When needed, repeat treatment was safe and efficacious for 4 weeks. TRIAL REGISTRATION Clinical Trial Registry of India (CTRI/2010/091/000052) www.ctri.nic.in/Clinicaltrials/login.php.
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Affiliation(s)
| | | | - K J Reddy
- Apollo Hospitals, Andhra Pradesh, India
| | - Sachin Avasthi
- Department of Orthopaedics, GSVM Medical College and Associated Hospital, Uttar Pradesh, India
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Abstract
CONTEXT Viscosupplementation (VS) and physical therapy are both used to treat pain associated with knee osteoarthritis (OA). EVIDENCE ACQUISITION PubMed and EMBASE searches were performed to July 2013. Search terms included hyaluronic acid OR hylan, physical therapy OR exercise, AND osteoarthritis. STUDY DESIGN Clinical review. LEVEL OF EVIDENCE Level 4. RESULTS The efficacy and safety of VS in painful knee OA is well documented, as are the appropriate candidates for this intervention. Studies suggest that adding VS to physical therapy and therapeutic exercise may lead to improved pain reduction and increased functionality compared with physical therapy alone. CONCLUSION Appropriately selected patients undergoing physical therapy for knee OA may benefit from VS.
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Affiliation(s)
- Holly J Silvers
- Santa Monica Orthopaedic and Sports Medicine Research Foundation, Santa Monica, California ; Department of Biomechanics and Movement Science, University of Delaware, Newark, Delaware
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Abstract
PURPOSE To provide an overview of the diagnosis and pathophysiology of osteoarthritis (OA), and to describe appropriate treatments for knee OA, with a focus on the efficacy and safety of viscosupplementation. Because nurse practitioners (NPs) can inject viscosupplements, a section on injection technique is included. DATA SOURCES Manuscripts were identified using PubMed and EMBASE with a review of the reference lists from retrieved articles. CONCLUSIONS Viscosupplements are safe and effective at improving function and alleviating knee pain from OA for up to 26 weeks. IMPLICATIONS FOR PRACTICE As the number of patients with OA is increasing, NPs need to be prepared to prescribe various treatment options to alleviate osteoarthritic knee pain, including viscosupplementation.
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Trigkilidas D, Anand A. The effectiveness of hyaluronic acid intra-articular injections in managing osteoarthritic knee pain. Ann R Coll Surg Engl 2013. [PMID: 24165334 DOI: 10.1308/003588413x13629960049432] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Knee osteoarthritis (OA) is a common and progressive joint disease. Treatment options for knee OA vary from simple analgesia in mild cases to knee replacement for advanced disease. Knee pain due to moderate OA can be targeted with intra-articular injections. Steroid injections have been used widely in managing acute flare-ups of the disease. In recent years, viscosupplementation has been used as a therapeutic modality for the management of knee OA. The principle of viscosupplementation is based on the physiological properties of the hyaluronic acid (HA) in the synovial joint. Despite a sound principle and promising in vitro studies, clinical studies have been less conclusive on the effectiveness of HA in managing osteoarthritic knee pain. The aim of this systematic review was to assess the effectiveness of HA intra-articular injections in the management of osteoarthritic knee pain. METHODS A systematic review of the literature was performed using MEDLINE®, Embase™ and CINAHL® (Cumulative Index to Nursing and Allied Health Literature). The databases were searched for randomised controlled trials available on the effectiveness of HA intra-articular injections in managing osteoarthritic knee pain. RESULTS The search yielded 188 studies. Of these, 14 met the eligibility criteria and were reviewed in chronological order. CONCLUSIONS HA intra-articular injections have a modest effect on early to moderate knee OA. The effect peaks at around 6-8 weeks following administration, with a doubtful effect at 6 months.
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Affiliation(s)
- D Trigkilidas
- University of Warwick, 103 Linden Gardens, Enfield EN1 4DY, UK.
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Trigkilidas D, Anand A. The effectiveness of hyaluronic acid intra-articular injections in managing osteoarthritic knee pain. Ann R Coll Surg Engl 2013; 95:545-51. [DOI: 10.1308/rcsann.2013.95.8.545] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Introduction Knee osteoarthritis (OA) is a common and progressive joint disease. Treatment options for knee OA vary from simple analgesia in mild cases to knee replacement for advanced disease. Knee pain due to moderate OA can be targeted with intra-articular injections. Steroid injections have been used widely in managing acute flare-ups of the disease. In recent years, viscosupplementation has been used as a therapeutic modality for the management of knee OA. The principle of viscosupplementation is based on the physiological properties of the hyaluronic acid (HA) in the synovial joint. Despite a sound principle and promising in vitro studies, clinical studies have been less conclusive on the effectiveness of HA in managing osteoarthritic knee pain. The aim of this systematic review was to assess the effectiveness of HA intra-articular injections in the management of osteoarthritic knee pain. Methods A systematic review of the literature was performed using MEDLINE®, Embase™ and CINAHL® (Cumulative Index to Nursing and Allied Health Literature). The databases were searched for randomised controlled trials available on the effectiveness of HA intra-articular injections in managing osteoarthritic knee pain. Results The search yielded 188 studies. Of these, 14 met the eligibility criteria and were reviewed in chronological order. Conclusions HA intra-articular injections have a modest effect on early to moderate knee OA. The effect peaks at around 6–8 weeks following administration, with a doubtful effect at 6 months.
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Abstract
This article provides physicians specializing in nonsurgical sports medicine with an overview of viscosupplementation as a treatment for osteoarthritis (OA) pain. Osteoarthritis is a painful, disabling condition that is becoming more prevalent in patients and is generally treated using conservative nonpharmacologic measures. If conservative measures are unsuccessful at alleviating pain, current recommendations include prescribing acetaminophen and nonsteroidal anti-inflammatory drugs to patients. However, long-term use of these agents increases the risk for liver, cardiovascular, gastrointestinal, and/or renal complications in patients. Viscosupplementation is the term used for intra-articular injection of hyaluronic acid/hylans. Intra-articular injections of these agents have good safety profiles and have shown efficacy for treating knee OA pain. Viscosupplementation injections relieve pain for ≤ 26 weeks, which is longer than the short-term pain relief derived from nonsteroidal anti-inflammatory drugs and corticosteroid injections. Additionally, viscosupplementation administered to patients in earlier stages of OA may be more beneficial than when given later in the treatment of OA. As part of a multimodal algorithm, viscosupplementation combined with conventional therapy or other pharmacologic agents has been shown to be more effective at managing OA than conventional care alone. This article reviews the evidence for using viscosupplementation as part of a comprehensive program for managing OA in patients.
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Divine JG, Shaffer MD. Use of viscosupplementation for knee osteoarthritis: an update. Curr Sports Med Rep 2013; 10:279-84. [PMID: 23531974 DOI: 10.1249/jsr.0b013e31822ed1b4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Because of the rising numbers of patients affected by osteoarthritis (OA), management decisions on how to minimize pain and improve function in OA patients are important. Intra-articular hyaluronic acid (IAHA) knee injections have become a common treatment in the management of knee OA. In an editorial appearing in the 2007 National Knowledge Week on Osteoarthritis: National Health Service Evidence, four questions were asked about the clinical use of IAHA treatment for OA: 1) Who is the ideal candidate for HA viscosupplementation? 2) Do the mechanical and biological effects differ in importance in different stages of the disease? 3) What is the ideal dose in early- and late-stage OA? 4) Can the biological effect be delivered by means other than injection? These key issues are addressed. On the basis of results from several systemic reviews and meta-analyses, we conclude that IAHA knee injections in patients with knee OA result in modest improvements when measured by validated outcomes.
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Affiliation(s)
- Jon G Divine
- Division of Sports Medicine Biodynamics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.
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Lucas Y Hernandez J, Darcel V, Chauveaux D, Laffenêtre O. Viscosupplementation of the ankle: a prospective study with an average follow-up of 45.5 months. Orthop Traumatol Surg Res 2013; 99:593-9. [PMID: 23845277 DOI: 10.1016/j.otsr.2013.02.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 02/04/2013] [Accepted: 02/06/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Providing pain relief for ankle osteoarthritis and delaying the need for a radical surgery procedure is difficult to achieve with analgesics that have limited efficacy or are not devoid of substantial side effects. HYPOTHESIS The goals of this study were to evaluate the efficacy of viscosupplementation, explore which factors better predict Patient's response and propose an injection protocol. MATERIALS AND METHODS Eighteen patients (26 ankles) with ankle osteoarthritis were included, with seven of them having received multiple series of injections. The average age was 60 years. Series of three injections, performed in the operating room under fluoroscopy-guidance, were evaluated after 4 and 12 months and then annually with the AOFAS score; patient satisfaction was also assessed. RESULTS The average AOFAS score increased significantly from 61.8 ± 15 before the injections to 74.4 ± 14.5 and 73.7 ± 16.6 after 4 and 12 months, respectively. The average follow-up was 45.5 months and 73% of patients were satisfied or very satisfied. There were no adverse effects or intolerance. In patients receiving more than one series of injections, the average delay between series was 27.8 (range 15-43) months. Five patients had a radical surgery procedure after an average of 27 months of effective viscosupplementation. DISCUSSION This prospective study showed that viscosupplementation had a significant positive effect (P<0.05) in patients with ankle osteoarthritis when a three-injection protocol was used every two years on average. Neither etiology nor severity of the osteoarthritis was predictive of the response. In our opinion, fluoroscopy-guidance is essential for these injections. LEVEL OF EVIDENCE Level IV cohort study.
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Miller LE, Block JE. US-Approved Intra-Articular Hyaluronic Acid Injections are Safe and Effective in Patients with Knee Osteoarthritis: Systematic Review and Meta-Analysis of Randomized, Saline-Controlled Trials. CLINICAL MEDICINE INSIGHTS. ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2013; 6:57-63. [PMID: 24027421 PMCID: PMC3767581 DOI: 10.4137/cmamd.s12743] [Citation(s) in RCA: 115] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We conducted a systematic review and meta-analysis of randomized saline-controlled trials to determine the safety and efficacy of US-approved intra-articular hyaluronic acid (IAHA) injections for symptomatic knee osteoarthritis. A total of 29 studies representing 4,866 unique subjects (IAHA: 2,673, saline: 2,193) were included. IAHA injection resulted in very large treatment effects between 4 and 26 weeks for knee pain and function compared to pre-injection values, with standardized mean difference (SMD) values ranging from 1.07-1.37 (all P < 0.001). Compared to saline controls, SMDs with IAHA ranged from 0.38-0.43 for knee pain and 0.32-0.34 for knee function (all P < 0.001). There were no statistically significant differences between IAHA and saline controls for any safety outcome, including serious adverse events (SAEs) (P = 0.12), treatment-related SAEs (P = 1.0), study withdrawal (P = 1.0), and AE-related study withdrawal (P = 0.46). We conclude that intra-articular injection of US-approved HA products is safe and efficacious in patients with symptomatic knee osteoarthritis.
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Affiliation(s)
- Larry E. Miller
- Miller Scientific Consulting, Inc., Arden, NC, USA
- The Jon Block Group, San Francisco, CA, USA
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