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Chacur C, Mocritcaia A, Sanmartí R. Pseudoseptic arthritis as a complication of intra-articular infiltration of hyaluronic acid in a patient with rheumatoid arthritis. REUMATOLOGIA CLINICA 2024; 20:166-168. [PMID: 38443228 DOI: 10.1016/j.reumae.2024.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/07/2023] [Indexed: 03/07/2024]
Abstract
Pseudoseptic arthritis is a rare complication of hyaluronic acid (HA) injections that often is difficult to differentiate from septic arthritis. Patients present acute pain, swelling and joint effusion normally around 24h after the second or third HA infiltration. We describe a female patient with seropositive rheumatoid arthritis and flare-ups of knee arthritis with pseudoseptic features in the past, who develops pseudoseptic arthritis of the knee following her first injection of hyaluronic acid.
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Affiliation(s)
- Chafik Chacur
- Servicio de Reumatología, Hospital Clínic, Barcelona, Spain.
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Sedrak P, Hache P, Horner NS, Ayeni OR, Adili A, Khan M. Differential characteristics and management of pseudoseptic arthritis following hyaluronic acid injection is a rare complication: a systematic review. J ISAKOS 2020; 6:94-101. [PMID: 33832983 DOI: 10.1136/jisakos-2020-000438] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 08/05/2020] [Accepted: 09/19/2020] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Acute pseudoseptic arthritis is a rare complication of hyaluronic acid (HA) injections that is not well documented in the literature. Practitioners initially suspect the symptoms of this complication to represent septic arthritis, cautiously prescribing antibiotics. This review identifies that time to presentation of symptoms postinjection, negative cell cultures and lack of crystallisation could be used as differentials to suspect pseudoseptic arthritis and to prescribe anti-inflammatory drugs while closely monitoring change of symptoms. OBJECTIVE The purpose of this study was to describe the presentation, diagnosis and treatment of pseudoseptic arthritis. EVIDENCE REVIEW A systematic review of the literature was conducted for studies reporting the use of HA injections for osteoarthritis resulting in pseudoseptic arthritis using the electronic databases MEDLINE, Embase and PubMed. Pertinent data were abstracted from the search yield. A unique case of a pseudoseptic reaction is also presented. FINDINGS A total of 11 studies (28 cases), all of level IV and V evidence were included in this review. Reported cases of pseudoseptic arthritis in the literature present with severe joint pain (100%), effusion (100%), inability to weight-bear, functional impairment, and occasionally fever (22.2%). C reactive protein and erythrocyte sedimentation rate are generally elevated (71.4% and 85.7%, respectively), and leucocytosis above 10 000 was less common (50%). All reported cases in the literature identified aseptic growth on arthrocentesis, despite four cases (15.4%) reporting synovial leucocyte counts above 50 000. The presented case is the highest reported leucocyte count at 1 74 960 cells/mm3. CONCLUSIONS AND RELEVANCE Acute pseudoseptic arthritis is rare, but a number of cases have been reported in the literature. A high degree of suspicion for pseudoseptic arthritis may be maintained in patients who present under 72 hours following HA injection. Initial antibiotic treatment, along with anti-inflammatory medications until cultures are confirmed to be negative at 5 days, is a cautious approach. However, the strength of this conclusion is limited by the few reported cases. Ultimately, this review is intended to inform practitioners of the symptoms, diagnosis and treatment of this complication, such that it could be safely differentiated from septic arthritis. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Phelopater Sedrak
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Philip Hache
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Nolan S Horner
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Anthony Adili
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada
| | - Moin Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Centre, Hamilton, Ontario, Canada
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Ikuta F, Takahashi K, Kiuchi S, Watanabe A, Okuaki T, Oshima Y, Watanabe H, Hashimoto S. Effects of repeated intra-articular hyaluronic acid on cartilage degeneration evaluated by T1ρ mapping in knee osteoarthritis. Mod Rheumatol 2020; 31:912-918. [PMID: 32990487 DOI: 10.1080/14397595.2020.1830483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Intra-articular injection of hyaluronic acid (IAHA) has been used for the treatment of knee osteoarthritis (OA), but its effectiveness remains controversial. This study analyzed knee OA over time by magnetic resonance imaging (MRI) T1ρ mapping to objectively evaluate whether long-term repeated administration of IAHA influences cartilage degeneration. METHODS Sixty knees of 60 patients [58.3 ± 12.5 years (mean ± standard deviation)] who had multiple T1ρ mapping images were retrospectively analyzed. We calculated the T1ρ values of the medial femorotibial cartilage and classified changes in degenerative areas over time into 3 groups: Improvement, No Change, and Deterioration. RESULTS Average time between 2 MRI scans was 7.6 ± 1.2 months. The number of IAHA administrations was 15.5 ± 21.3, 8.39 ± 7.19, and 5.80 ± 7.49 in the Improvement, No Change, and Deterioration groups, respectively. Body mass index and number of IAHA administrations were significant factors causing change in the area of degeneration (p < .05) independent of age, sex, Kellgren-Lawrence grade, and posterior horn meniscus tears. CONCLUSION Cartilage degeneration may be improved with a higher number of administrations of IAHA, based on T1ρ mapping results. This highlights the possibility of increased treatment effectiveness of IAHA for knee OA with repeated administrations.
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Affiliation(s)
- Futoshi Ikuta
- Department of Orthopaedic Surgery, Nippon Medical School, Tokyo, Japan.,Inanami Spine and Joint Hospital, Tokyo, Japan
| | - Kenji Takahashi
- Department of Orthopaedics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Atsuya Watanabe
- Department of General Medical Services, Graduate School of Medicine, Chiba University, Chiba, Japan
| | | | - Yasushi Oshima
- Department of Orthopaedic Surgery, Nippon Medical School, Tokyo, Japan
| | - Hiroshi Watanabe
- Department of Orthopaedic Surgery, Nippon Medical School, Tokyo, Japan
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Niemelä TM, Tulamo RM, Carmona JU, López C. Evaluation of the effect of experimentally induced cartilage defect and intra-articular hyaluronan on synovial fluid biomarkers in intercarpal joints of horses. Acta Vet Scand 2019; 61:24. [PMID: 31146775 PMCID: PMC6543688 DOI: 10.1186/s13028-019-0460-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Accepted: 05/27/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Inflammatory and degenerative activity inside the joint can be studied in vivo by analysis of synovial fluid biomarkers. In addition to pro-inflammatory mediators, several anabolic and anti-inflammatory substances are produced during the disease process. They counteract the catabolic effects of the pro-inflammatory cytokines and thus diminish the cartilage damage. The response of synovial fluid biomarkers after intra-articular hyaluronan injection, alone or in combination with other substances, has been examined only in a few equine studies. The effects of hyaluronan on some pro-inflammatory mediators, such as prostaglandin E2, have been documented but especially the effects on synovial fluid anti-inflammatory mediators are less studied. In animal models hyaluronan has been demonstrated to reduce pain via protecting nociceptive nerve endings and by blocking pain receptor channels. However, the results obtained for pain-relief of human osteoarthritis are contradictory. The aim of the study was to measure the synovial fluid IL-1ra, PDGF-BB, TGF-β1 and TNF-α concentrations before and after surgically induced cartilage defect, and following intra-articular hyaluronan injection in horses. Eight Standardbred horses underwent bilateral arthroscopic surgeries of their intercarpal joints under general anaesthesia, and cartilage defect was created on the dorsal edge of the third carpal bone of one randomly selected intercarpal joint of each horse. Five days post-surgery, one randomly selected intercarpal joint was injected intra-articular with 3 mL HA (20 mg/mL). RESULTS Operation type had no significant effect on the synovial fluid IL-1ra, PDGF-BB, TGF-β1 and TNF-α concentrations but compared with baseline, synovial fluid IL-1ra and TNF-α concentrations increased. Intra-articular hyaluronan had no significant effect on the biomarker concentrations but a trend of mild improvement in the clinical signs of intra-articular inflammation was seen. CONCLUSIONS Creation of the cartilage defect and sham-operation lead to an increase of synovial fluid IL-1ra and TNF-α concentrations but changes in concentrations of anabolic growth factors TGF-β1 and PDGF-BB could not be documented 5 days after the arthroscopy. Intra-articular hyaluronan was well tolerated. Further research is needed to document possible treatment effects of intra-articular hyaluronan on the synovial fluid biomarkers of inflammation and cartilage metabolism.
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Affiliation(s)
- Tytti Maaria Niemelä
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 57, 00014 Helsinki, Finland
| | - Riitta-Mari Tulamo
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 57, 00014 Helsinki, Finland
| | - Jorge Uriel Carmona
- Grupo de Investigación Terapia Regenerativa, Departamento de Salud Animal, Universidad de Caldas, Calle 65 No26-10, Manizales, Caldas, Colombia
| | - Catalina López
- Grupo de Investigación Terapia Regenerativa, Departamento de Salud Animal, Universidad de Caldas, Calle 65 No26-10, Manizales, Caldas, Colombia
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Niemelä TM, Tulamo RM, Aaltonen K, Sankari SM, Hielm-Björkman AK. Changes in biomarkers in equine synovial fluid two weeks after intra-articular hyaluronan treatment: a randomised double-blind clinical trial. BMC Vet Res 2018; 14:186. [PMID: 29907111 PMCID: PMC6003042 DOI: 10.1186/s12917-018-1512-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 06/01/2018] [Indexed: 05/29/2023] Open
Abstract
BACKGROUND Inflammatory and degenerative activity inside the joint can be studied in vivo via analysis of synovial fluid (SF) biomarkers, which are molecular markers of inflammatory processes and tissue turnover. The aim of this study was to investigate the response of selected biomarkers in the SF after an intra-articular (IA) high-molecular-weight non-animal stabilized hyaluronic acid (NASHA) treatment. Our hypothesis was that prostaglandin E2 (PGE2), substance P, aggrecan chondroitin sulfate 846 epitope (CS846), and carboxypeptide of type II collagen (CPII) concentrations in SF would decrease more in the NASHA than in the placebo group. Twenty-eight clinically lame horses with positive responses to diagnostic IA anaesthesia of the metacarpophalangeal or metatarsophalangeal joints were randomized into treatment (n = 15) and control (n = 13) groups. After collection of baseline SF samples followed by IA diagnostic anaesthesia, horses in the treatment group received 3 ml of a NASHA product IA. Those in the placebo group received an equivalent volume of sterile 0.9% saline solution. The horses were re-evaluated and a second SF sample was obtained after a 2-week period. RESULTS CS846 concentration decreased in the NASHA group only (P = 0.010). Both PGE2 and CPII concentrations decreased within the groups (PGE2, P = 0.010 for the NASHA group; P = 0.027 for the placebo group; CPII, P < 0.001 for NASHA group; P = 0.009 for placebo group). No significant treatment effect for any biomarker was found between groups. NASHA induced an increase in white blood cell count; this was significant compared with baseline (P = 0.021) and the placebo group (P = 0.045). CONCLUSIONS Although the SF concentration of the cartilage-derived biomarker CS846 decreased in the NASHA group, no statistically significant treatment effect of any of the biomarkers were observed between treatment groups. The significant increase in SF white blood cell count after IA NASHA may indicate a mild inflammatory response. However, as no clinical adverse effects were observed, we conclude that IA NASHA was well tolerated.
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Affiliation(s)
- Tytti M Niemelä
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 57, 00014, Helsinki, Finland.
| | - Riitta-Mari Tulamo
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 57, 00014, Helsinki, Finland
| | - Kaisa Aaltonen
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 57, 00014, Helsinki, Finland
| | - Satu M Sankari
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 57, 00014, Helsinki, Finland
| | - Anna K Hielm-Björkman
- Department of Equine and Small Animal Medicine, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 57, 00014, Helsinki, Finland
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Muramatsu K, Tajima Y, Kaneko R, Yanagita Y, Hirai H, Hiura N. Characterization of poly(L-glutamic acid)-grafted hyaluronan as a novel candidate medicine and biomedical device for intra-articular injection. J Biomed Mater Res A 2017; 105:3006-3016. [DOI: 10.1002/jbm.a.36155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2016] [Revised: 05/30/2017] [Accepted: 06/15/2017] [Indexed: 12/31/2022]
Affiliation(s)
- Kazuaki Muramatsu
- Division of Life Science and Engineering; School of Science and Engineering, Tokyo Denki University, Ishizaka, Hatoyama-cho, Hiki-gun; Saitama 350-0394 Japan
| | - Yuya Tajima
- Division of Life Science and Engineering; School of Science and Engineering, Tokyo Denki University, Ishizaka, Hatoyama-cho, Hiki-gun; Saitama 350-0394 Japan
| | - Rin Kaneko
- Division of Life Science and Engineering; School of Science and Engineering, Tokyo Denki University, Ishizaka, Hatoyama-cho, Hiki-gun; Saitama 350-0394 Japan
| | - Yuta Yanagita
- Division of Life Science and Engineering; School of Science and Engineering, Tokyo Denki University, Ishizaka, Hatoyama-cho, Hiki-gun; Saitama 350-0394 Japan
| | - Hiroyuki Hirai
- Division of Life Science and Engineering; School of Science and Engineering, Tokyo Denki University, Ishizaka, Hatoyama-cho, Hiki-gun; Saitama 350-0394 Japan
| | - Nana Hiura
- Division of Life Science and Engineering; School of Science and Engineering, Tokyo Denki University, Ishizaka, Hatoyama-cho, Hiki-gun; Saitama 350-0394 Japan
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Chevalier X, Migliore A. Safety and Tolerability of Intra-Articular Hyaluronic Acid Injection (Sinovial®) in Experimental and Clinical Practice. EUR J INFLAMM 2013. [DOI: 10.1177/1721727x1301100301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Osteoarthritis (OA) requires long-term treatment, therefore, tolerability is a key factor in treatment choice. Hyaluronic acid (HA), a glycosaminoglycan with viscoelastic properties, a major component of synovial fluid and the extracellular matrix of the joint cartilage, plays key roles in synovial fluid viscosity and maintaining normal cartilage. Viscosupplementation is an intra-articular (IA) injection of exogenous HA in an effort to delay joint mobility loss. Commercially available viscosupplementation includes HA of different average molecular weight (MW), concentration and origins, with varying tolerability. This review describes the tolerability and safety profile of Sinovial® in knee and hip OA. A literature search of PubMed using the search queries [Sinovial® OR hyaluronic acid OR hyaluronan] and [intra-articular OR osteoarthritis] was performed using terms as medical subject headings and free text searches. Studies were selected manually for inclusion in this review. Sinovial® is a low-medium MW HA of non-avian origin, produced by biofermentation to ensure the product is pure and free of allergenic animal proteins. We analyzed data regarding the tolerability of Sinovial® in OA patients. This formulation has a favorable tolerability profile; no systemic reactions have been reported and most adverse events (AEs) are mild, transient and easily managed local injection site reactions. Reactions — pain and burning at the injection site - are typical of IA injections. AEs with Sinovial® used in the hip are similar to knee OA.
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Affiliation(s)
- X. Chevalier
- Department of Rheumatology, Hôpital Henri Mondor University Paris XII, UPEC, Créteil, France
| | - A. Migliore
- Department of Rheumatology, Ospedale S. Pietro FBF, Rome, Italy
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Chalmers PN, Ellman MB, Chahal J, Verma NN. Injection Therapy in the Management of Musculoskeletal Injuries of the Knee. OPER TECHN SPORT MED 2012. [DOI: 10.1053/j.otsm.2012.03.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Peterson C, Hodler J. Adverse events from diagnostic and therapeutic joint injections: a literature review. Skeletal Radiol 2011; 40:5-12. [PMID: 19949787 DOI: 10.1007/s00256-009-0839-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2009] [Revised: 11/02/2009] [Accepted: 11/05/2009] [Indexed: 02/02/2023]
Abstract
This review article classifies the various adverse reactions arising from intra-articular injections by severity, diagnostic category, and whether they are due to corticosteroid, local anesthetic or viscosupplementation injections. Life-threatening and serious adverse events from intra-articular injections are rare and range from local complications to systemic afflictions. Measures to reduce the likelihood of an adverse event occurring are outlined and patients with significant features in their clinical histories, predisposing them to adverse events, are highlighted.
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Affiliation(s)
- Cynthia Peterson
- Radiology, Orthopaedic University Hospital of Balgrist, Forchstrasse 340, 8008, Zürich, Switzerland.
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Weil AJ. High molecular weight hyaluronan for treatment of chronic shoulder pain associated with glenohumeral arthritis. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2011; 4:99-105. [PMID: 22915936 PMCID: PMC3417880 DOI: 10.2147/mder.s22423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Background There is insufficient evidence to determine whether intra-articular injections may be effective for treatment of glenohumeral osteoarthritis. Euflexxa® (high molecular weight hyaluronate), a bioengineered high molecular weight hyaluronan, has been shown to be a safe and effective treatment for patients with knee osteoarthritis. There is also support for the use of hyaluronate injection for the treatment of chronic shoulder pain associated with osteoarthritis or rotator cuff damage. This small-scale exploratory study was conducted to evaluate the safety and efficacy of high molecular weight hyaluronate for the treatment of chronic shoulder pain associated with osteoarthritis. Methods Subjects with glenohumeral osteoarthritis and chronic pain (n = 27) received one injection per week for 3 weeks of high molecular weight hyaluronate and were assessed for changes in pain (100 mm visual analog scale [VAS]), range of motion, and the subject’s and physician’s global assessment over 26 weeks. Subjects were also assessed for pain, stiffness, and physical functioning using the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Finally, responses were evaluated using modified Outcome Measures in Rheumatoid Arthritis Clinical Trials (OMERACT)-Osteoarthritis Research Society International (OARSI) Proposition D criteria. Safety was assessed by recording adverse events. Results High molecular weight hyaluronate significantly improved pain (VAS, WOMAC), range of motion, stiffness, and physical functioning scores; 77.8% of subjects were rated as having an OMERACT-OARSI Proposition D high response. There were no serious adverse events, and none were considered to be related to treatment. Conclusion Treatment with high molecular weight hyaluronate improves pain, stiffness, and range of motion, and may have an acceptable safety and tolerability profile. A randomized, double-blind, placebo-controlled clinical trial may be warranted to investigate further the efficacy and safety of intra-articular high molecular weight hyaluronate for treatment of chronic shoulder pain in patients with glenohumeral osteoarthritis.
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Albano MB, Vidigal L, de Oliveira MZ, Namba MM, da Silva JLV, de Assis Pereira Filho F, Barbosa MA, da Silva EMB. MACROSCOPIC ANALYSES OF THE EFFECTS OF HYALURONATES AND CORTICOSTEROIDS ON INDUCED OSTEOARTHRITIS IN RABBITS' KNEES. Rev Bras Ortop 2010; 45:273-8. [PMID: 27022552 PMCID: PMC4799149 DOI: 10.1016/s2255-4971(15)30368-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To evaluate the effects of intra-articular injections of corticosteroids, native hyaluronic acid and branched-chain hyaluronic acid in experimentally-induced osteoarthrosis. METHODS 44 rabbits underwent anterior cruciate ligament resection and were then divided into four groups of eleven. Group 1: one intra-articular injection of saline solution per week, for three weeks; Group 2: three injections (one per week) of native hyaluronic acid; Group 3: three injections (one per week) of branched-chain hyaluronic acid; Group 4: two injections of betamethasone with an interval of three weeks. The cartilage of the tibial plateaus was evaluated macroscopically twelve weeks after surgery. Changes to the joint surface were graded as follows: Grade 0: smooth joint surface without relief changes; Grade 1: rough surface without any depressions; Grade 2: similar to grade 1, but with depressions on the joint surface; and Grade 3: subchondral bone exposure. The statistical analysis consisted of the use of Student's t test, chi-square test and analysis of variance (ANOVA). The significance level used was 5%. RESULTS A statistical difference was found between the control group and the three study groups 2, 3, 4 in relation to the development and severity of arthrosis. However, there was no difference between the groups regarding the drugs studied. CONCLUSION A similar degree of attenuation of the osteoarthrosis process in the rabbits' knees was found with the use of intra-articular injections of low-molecular-weight and high-molecular-weight glycosaminoglycans, and the corticosteroid betamethasone, compared with placebo.
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Affiliation(s)
- Mauro Batista Albano
- Mestre em Clínica Cirúrgica pela UFPR; Professor do Curso de Especialização em Traumatologia Esportiva e Artroscopia da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR
| | - Leandro Vidigal
- Médico Ortopedista; Aluno de Pós-graduaão Universidade Federal do Paraná (SOT-UFPR)
| | | | - Mario Massatomo Namba
- Mestre em Clínica Cirúrgica pela UFPR; Professor e Coordenador do Curso de Especializa9ão em Traumatologia Esportiva da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR; Membro Titular da SBOT
| | - João Luiz Vieira da Silva
- Mestre e Doutor em Clínica Cirúrgica pela UFPR; Professor do Curso de Especializa9ão em Traumatologia Esportiva e Artroscopia da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR; Membro Titular da SBOT
| | - Francisco de Assis Pereira Filho
- Professor do Curso de Especializa9ão em Traumatologia Esportiva e Artroscopia da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR; Membro Titular da SBOT
| | - Marcio Alves Barbosa
- Professor do Curso de Especializa9ão em Traumatologia Esportiva e Artroscopia da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR; Membro Titular da SBOT
| | - Elias Marcelo Batista da Silva
- Professor do Curso de Especializa9ão em Traumatologia Esportiva e Artroscopia da UFPR; Membro do Serviço de Ortopedia e Traumatologia da UFPR; Membro Titular da SBOT
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Conduah AH, Baker CL, Baker CL. Managing joint pain in osteoarthritis: safety and efficacy of hylan G-F 20. J Pain Res 2009; 2:87-98. [PMID: 21197297 PMCID: PMC3004631 DOI: 10.2147/jpr.s4732] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
The use of intra-articular viscosupplementation in the nonoperative management of patients with osteoarthritis has become quite popular. Recent clinical data have demonstrated that the anti-inflammatory and chondroprotective actions of hyaluronic acid viscosupplementation reduce pain while improving patient function. We review the basic science and development of viscosupplementation and discuss the mounting evidence in support of the efficacy and safety profile of hylan G-F 20. Recent evidence suggesting a disease-modifying effect of hylan G-F 20 is also assessed. Furthermore, although the primary focus of this article is on treatment of osteoarthritis of the knee, we also discuss the use of viscosupplementation in other joints, such as the hip, ankle, and shoulder.
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Abstract
Viscosupplementation refers to the concept of synovial fluid replacement with intra-articular injections of hyaluronic acid (HA) for the relief of pain associated with osteoarthritis (OA). Intra-articular viscosupplementation was approved by the Food and Drug Administration (FDA) in 1997. It is currently indicated only for the treatment of pain associated with knee OA. However, OA can occur in several of the weight-bearing joints of the foot and ankle. Ankle OA produces chronic disability that directly impacts the quality of life. There is only limited published literature relating to the use of HA in the ankle. This paper will review the authors’ experience, indications, clinical outcomes, and complications of viscosupplementation therapy in patients with ankle OA.
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Efficacy of Hylan G-F 20 and Sodium Hyaluronate in the treatment of osteoarthritis of the knee -- a prospective randomized clinical trial. Knee 2008; 15:318-24. [PMID: 18430574 DOI: 10.1016/j.knee.2008.02.012] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2008] [Revised: 02/24/2008] [Accepted: 02/25/2008] [Indexed: 02/02/2023]
Abstract
In this independent prospective randomized trial, we compared the clinical effectiveness, functional outcome and patient satisfaction following intra articular injection with two viscosupplementation agents - Hylan G-F-20 (n=199) and Sodium Hyaluronate (n=193) in patients with osteoarthritis (OA) of the knee. All patients were prospectively reviewed by blinded independent assessors at pre injection, 6 weeks, 3, 6, 12 months. Knee pain and patient satisfaction were measured on a visual analogue scale. Functional outcome was assessed using WOMAC, Oxford knee score and EuroQol EQ-5D scores. Knee pain on VAS improved from 6.7 to 3.2 by 6 weeks (p=0.02) and was sustained until 12 months (3.7, p=0.04) with Hylan G-F 20. In the Sodium Hyaluronate group, pain improved from 6.6 to 5.7 at 6 weeks (p>0.05) and to 4.1 at 3 months (p=0.04) but was sustained only until 6 months (5.9, p>0.05). Improvement in the WOMAC pain subscale was significantly superior in the Hylan G-F 20 group at 3 months (p=0.02), 6 months (p=0.01) and 12 months (p=0.007). There was no significant difference in the EQ-5D scores at 6 weeks and 3 months between the two groups. The numbers of treatment related adverse events were higher (39 vs. 30) in the Hylan G-F 20 group. One patient in the Hylan G-F 20 group who had a serious adverse event was also included in the final analysis. Although both treatments offered significant pain reduction, it was achieved earlier and sustained for a longer period with Hylan G-F 20. From this study, it appeared that the clinical effectiveness and general patient satisfaction are better amongst patients who received Hylan G-F 20.
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Conrozier T, Chevalier X. Long-term experience with hylan GF-20 in the treatment of knee osteoarthritis. Expert Opin Pharmacother 2008; 9:1797-804. [DOI: 10.1517/14656566.9.10.1797] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Alijotas-Reig J, Garcia-Gimenez V. Delayed immune-mediated adverse effects related to hyaluronic acid and acrylic hydrogel dermal fillers: clinical findings, long-term follow-up and review of the literature. J Eur Acad Dermatol Venereol 2008; 22:150-61. [PMID: 18211407 DOI: 10.1111/j.1468-3083.2007.02354.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Implantation of dermal filler for cosmetic purposes is becoming increasingly common worldwide. It is thought that hyaluronic acid (HA) alone or combined with acrylic hydrogels (HA-AH) does not have severe nor persistent side-effects. However, recent evidence may show that major, local and/or systemic, immediate or delayed adverse effects may appear in relation with its use. OBJECTIVE To evaluate the clinical complaints, laboratory data, treatment and follow-up of patients with delayed adverse effects related to HA and HA-AH implant fillers. DESIGN Prospective, case-series study of patients filled with HA and HA-AH compounds. SETTING The study has been done in a tertiary, teaching university hospital. PATIENTS We report on a series of 25 patients, 15 of them in prospective manner, with severe, delayed side-effects related to HA-AH. Inclusion criteria have been drawn up. Patients with immediate side-effects were excluded. Patients were submitted to a clinical follow-up, battery of blood tests and thorax X-ray films. Besides, a review of the literature was made. We undertook a computed-assisted (MEDLINE), National Library of Medicine, Bethesda, MD, USA, search of the literature from 1996 up to December 2005. MAIN OUTCOME Clinical evaluation of granulomas, skin manifestations and other local and systemic immune-mediated disorders possibly related to HA and HA-AH fillers or their cumulative interaction with previously administered fillers. RESULTS Of 25 cases, 16 were filled with HA alone and 9 with a HA-AH compounds. Of 15 cases analysed and with long-term follow-up, 10 were filled with HA alone, and the remaining five were filled with a HA-AH. Time latency average up to beginning of symptoms was 13.7 months. Three of these 15 cases had been filled before with silicone and another one with Artecoll. Tender nodules were seen in 14 patients. Systemic manifestations appeared in three cases. Laboratory abnormalities were noted in all studied cases. After 16-month average follow-up, seven patients seem to be cured, and six have recurrent bouts. Two cases were lost during follow-up. CONCLUSION Although in some cases, these clinical complications might have been associated with previous fillers or with other unknown foreign bodies, we feel that, although infrequently, delayed and recurrent chronic inflammatory and granulomatous reactions may complicate HA and HA-AH implant fillers.
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Affiliation(s)
- J Alijotas-Reig
- Ageing Research and Autoimmune Diseases Unit, Department of Internal Medicine I, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
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Tahiri L, Benbouazza K, Amine B, Hajjaj-Hassouni N. Acute pseudoseptic arthritis after viscosupplementation of the knee: a case report. Clin Rheumatol 2007; 26:1977-9. [PMID: 17436053 DOI: 10.1007/s10067-007-0598-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2007] [Revised: 02/21/2007] [Accepted: 02/28/2007] [Indexed: 12/01/2022]
Abstract
Intra-articular injections of hyaluronan are generally well tolerated; the most common adverse event associated with their use is an inflammatory reaction or a flare at the injection site. Naturally derived sodium hyaluronates have not been associated with pseudosepsis; we describe a case of severe arthritis mimicking acute septic arthritis after naturally hyaluronan. A 70-year-old woman had a medial femorotibial and patellofemoral compartment knee osteoarthritis. Hyaluronic acid injection was indicated because of the persistence of a pain while walking and restricted ability to walk 100 m, as well as the installation of a flessum. She was admitted for an evaluation of a joint effusion occurring within 48 h after the first hyaluronic acid intra-articular injection (first course), with no fever or chills. Joint fluid was found to be cloudy and contained 24,000 cells per mm(3). A knee aspiration was performed to evaluate the possibility of a joint infection. The examination of synovial fluid under phase contrast and polarizing microscopes showed no crystals, and culture on standard media was negative. Acute septic arthritis was considered to be the most likely diagnosis, and probabilistic antibiotic therapy was started. The result of the bacteriological examinations also returned negative. The absence of general signs, particularly fever and chills, with fast effusion regression in less than 4 days did not plead in favor of a septic origin. In front of this beam of arguments, antibiotic therapy was stopped after 4 days. The nonsteroidal anti-inflammatory drug (Nimésulide) was given. The clinical and laboratory test abnormalities were normalized within 2 weeks. Our case has the particularity to occur after using Curavisc, which is known as producing no allergenic reactions. Moreover, the described reaction occurred with the very first infiltration within the very first course.
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Affiliation(s)
- L Tahiri
- Rheumatology B Department, El Ayachi Hospital, Sale, Morocco
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Dykgraaf S, Dechant JE, Johns JL, Christopher MM, Bolt DM, Snyder JR. Effect of Intrathecal Amikacin Administration and Repeated Centesis on Digital Flexor Tendon Sheath Synovial Fluid in Horses. Vet Surg 2007; 36:57-63. [PMID: 17214821 DOI: 10.1111/j.1532-950x.2007.00235.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To determine the effect of intrathecal amikacin administration and repeated tenovaginocentesis on the total nucleated cell count (TNCC), total protein (TP) concentration and cytologic characteristics of synovial fluid of the equine digital flexor tendon sheath (DFTS). STUDY DESIGN Randomized, cross-over experimental design. ANIMALS Adult horses (n=8). METHODS Synovial fluid was aseptically collected from the DFTS and either 1 mL amikacin sulfate (250 mg/mL) or lactated Ringer's solution (LRS) was injected into the DFTS. Serial synovial fluid samples were obtained at 0, 12, 24, 48, and 72 hours. The opposite treatment was administered to the contralateral DFTS after a washout period of 2 weeks. RESULTS Treatment increased TP concentration, TNCC, percentage of neutrophils, and neutrophil counts from baseline levels. There was no difference between treatment of the DFTS with amikacin or LRS. Values peaked at 12-24 hours after the initial centesis and then declined toward baseline levels. CONCLUSIONS Injection and repeat centesis of the normal DFTS with 250 mg amikacin or an equivalent volume of LRS resulted in mild increases in synovial fluid analytes from baseline. Synovial inflammation in this study was not accompanied by lameness at the walk and measured analytes returned toward baseline levels within 12-24 hours of first injection. CLINICAL RELEVANCE The effect of tenovaginocentesis and intrathecal administration of amikacin or LRS on DFTS synovial fluid values are modest in most horses; however, some horses can develop marked increases in synovial fluid values that may be interpreted as sepsis.
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Affiliation(s)
- Susanne Dykgraaf
- Veterinary Medical Teaching Hospital and the Department of Surgical and Radiological Sciences, School of Veterinary Medicine, University of California, Davis, CA 95616, USA.
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Abstract
Intra-articular viscosupplementation with hyaluronic acid has become an increasingly accepted therapeutic alternative in the symptomatic management of osteoarthritis. Basic science research has documented numerous potential actions of exogenous hyaluronic acid upon the diseased joint. A substantial aggregate of clinical data suggests that viscosupplementation is clinically safe and suggests some therapeutic efficacy with regard to pain relief. However, a robust placebo effect and industry bias have obscured these outcomes considerably. Although recent attention has focused on the disease-modifying potential of this treatment option, definitive evidence is lacking. This paper will review the development, experience, indications, and clinical outcomes of viscosupplementation therapy in patients with osteoarthritis.
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Affiliation(s)
- Stephen F Brockmeier
- Department of Orthopaedic Surgery, Georgetown University Hospital, 3800 Reservoir Road NW, Washington, DC 20007, USA
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Jackson DW, Simon TM. Intra-articular distribution and residence time of Hylan A and B: a study in the goat knee. Osteoarthritis Cartilage 2006; 14:1248-57. [PMID: 16822684 DOI: 10.1016/j.joca.2006.05.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2006] [Accepted: 05/27/2006] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study evaluates the viscosupplementation material Hylan A and B in relation to its: (1) joint distribution, residence time and mechanism of removal and/or degradation, and (2) associated synovial fluid leukocyte response, in a goat model. METHOD One green fluorophore was covalently bound to the Hylan A low molecular weight (MW) molecule (viscous fluid fraction) and a second red fluorophore was covalently bound to Hylan B high MW molecule (globule gel-like fraction). Goats were anesthetized and the right knee received 0.5 ml of test material or unbound fluorophore dyes. Gross and histological serial evaluations were performed over an 8-week period. RESULTS By 24 h, the non-covalently linked control labels were not present in the tissues. For the covalently linked labels, the green fluorophore Hylan A diminished rapidly in intensity grossly but persisted to 28 days within the superficial synovial and articular cartilage layers in histologic sections. The red fluorophore linked Hylan B was seen only as globules in the synovial fluid. Mononuclear cells remained attached to these globules for 28 days and showed phagocytosis of the globules as well as the green fluorophore Hylan A. The globules were absent at 56 days after injection. The synovial fluid leukocyte count peaked at 24h (mean 9767 cells/mm(3) +/- 8574 S.D.) and declined by 7 days. CONCLUSIONS The smaller MW Hylan was removed more rapidly than the higher MW Hylan. The globules were degraded by a different mechanism involving monocytes/macrophages on the surface of the higher MW globules.
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Affiliation(s)
- D W Jackson
- Orthopaedic Research Institute, Southern California Center for Sports Medicine, Long Beach, CA, USA
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