Corticosteroid injection into the osteoarthritic knee: drug selection, dose, and injection frequency

Superficial Vein Thrombosis After Intra-articular Particulate Steroid Injection for Knee Osteoarthritis

ABSTRACT

Intra-articular steroid injections for knee osteoarthritis are a routine procedure in musculoskeletal clinics. While their role in osteoarthritis care is debatable, they serve as an important therapeutic option to relieve osteoarthritis-associated pain. Potential risks are self-limited (increased pain flare, local skin irritation, flushing, insomnia) or severe (septic arthritis, intravascular medication placement, and the deleterious effect on cartilage and bone). In our experience, more serious adverse events are rare. In this case, we present a complication secondary to intra-articular steroid administration that has not previously been reported in the literature: superficial vein thrombosis. This will raise awareness among clinicians, improve the informed consent process, and provide an approach for the management of subsequent injections.

Single Injection AAV2-FGF18 Gene Therapy Reduces Cartilage Loss and Subchondral Bone Damage in a Mechanically Induced Model of Osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a highly debilitating, degenerative pathology of cartilaginous joints affecting over 500 million people worldwide. The global economic burden of OA is estimated at $260-519 billion and growing, driven by aging global population and increasing rates of obesity. To date, only the multi-injection chondroanabolic treatment regimen of Fibroblast Growth Factor 18 (FGF18) has demonstrated clinically meaningful disease-modifying efficacy in placebo-controlled human trials. Our work focuses on the development of a novel single injection disease-modifying gene therapy, based on FGF18's chondroanabolic activity.

METHODS

OA was induced in Sprague-Dawley rats using destabilization of the medial meniscus (DMM) (3 weeks), followed by intra-articular treatment with 3 dose levels of AAV2-FGF18, rh- FGF18 protein, and PBS. Durability, redosability, and biodistribution were measured by quantifying nLuc reporter bioluminescence. Transcriptomic analysis was performed by RNA-seq on cultured human chondrocytes and rat knee joints. Morphological analysis was performed on knee joints stained with Safranin O/Fast Green and anti-PRG antibody.

RESULTS

Dose-dependent reductions in cartilage defect size were observed in the AAV2-FGF18- treated joints relative to the vehicle control. Total defect width was reduced by up to 76% and cartilage thickness in the thinnest zone was increased by up to 106%. Morphologically, the vehicle- treated joints exhibited pronounced degeneration, ranging from severe cartilage erosion and bone void formation, to subchondral bone remodeling and near-complete subchondral bone collapse. In contrast, AAV2-FGF18-treated joints appeared more anatomically normal, with only regional glycosaminoglycan loss and marginal cartilage erosion. While effective at reducing cartilage lesions, treatment with rhFGF18 injections resulted in significant joint swelling (19% increase in diameter), as well as a decrease in PRG4 staining uniformity and intensity. In contrast to early-timepoint in vitro RNA-seq analysis, which showed a high degree of concordance between protein- and gene therapy-treated chondrocytes, in vivo transcriptomic analysis, revealed few gene expression changes following protein treatment. On the other hand, the gene therapy treatment exhibited a high degree of durability and localization over the study period, upregulating several chondroanabolic genes while downregulating OA- and fibrocartilage-associated markers.

CONCLUSION

FGF18 gene therapy treatment of OA joints can provide benefits to both cartilage and subchondral bone, with a high degree of localization and durability.

One-Stage Tricompartmental Hypoallergenic UKA for Tricompartmental Osteoarthritis: A Case Report

Osteoarthritis (OA) is a degenerative and progressive joint disease. When all three compartments are involved, end-stage OA is treated with a total knee arthroplasty (TKA). Unicompartmental knee arthroplasty (UKA) is a primary treatment for isolated osteoarthritis. UKA has a quicker recovery time than TKA, as well as less morbidity and more tissue sparing. At the time of surgery, 17% of patients have a tricompartmental disease and most patients with a Kellegren-Lawrence grade >3 have an intact anterior cruciate ligament (ACL). Conventional TKA sacrifices the ACL. Patients with concurrent medial and lateral osteoarthritis and a functional ACL may receive a primary bi-unicondylar arthroplasty. Combined partial knee arthroplasty (CPKA) is an established practice either in bicompartmental femoro-tibial OA or in OA progression after UKA, with the addition of another UKA. A conversion of a lateral UKA to a tricompartmental joint replacement has been reported in the literature. In our case report, we describe a one-stage hypoallergenic tricompartmental UKA, with improved clinical score and no sign of early failure at the last follow-up.

Insertional biceps tendinopathy palliated successfully with intra-articular triamcinolone acetonide injection in a dog: A case report

This report describes a dog diagnosed with insertional biceps tendinopathy that was palliated with intra-articular triamcinolone acetonide injections. The patient was a 6-year-old spayed female Chihuahua dog that had left thoracic limb lameness for 3 months before presentation. On physical examination, moderate pain was elicited by performing the biceps test and isolated full elbow extension on the left thoracic limb. Gait analysis showed asymmetrical peak vertical force and vertical impulse between thoracic limbs. Computed tomography (CT) revealed enthesophyte formation on the ulnar tuberosity of the left elbow joint. Ultrasonography showed a heterogeneous fibre pattern at the biceps tendon insertion site on the left elbow joint. These findings confirmed insertional biceps tendinopathy based on physical examination, CT and ultrasonography results. The dog received an intra-articular triamcinolone acetonide injection with hyaluronic acid in the left elbow joint. Clinical signs improved after the first injection, including a range of motion, pain and gait. A second injection was given in the same manner because of recurring mild lameness 3 months later. No clinical signs were observed during the follow-up period.

Alginate/acemannan-based beads loaded with a biocompatible ionic liquid as a bioactive delivery system

Combining biomacromolecules with green chemistry principles and clean technologies has proven to be an effective approach for drug delivery, providing a prolonged and sustained release of the encapsulated material. The current study investigates the potential of cholinium caffeate (Ch[Caffeate]), a phenolic-based biocompatible ionic liquid (Bio-IL) entrapped in alginate/acemannan beads, as a drug delivery system able to reduce local joint inflammation on osteoarthritis (OA) treatment. The synthesized Bio-IL has antioxidant and anti-inflammatory actions that, combined with biopolymers as 3D architectures, promote the entrapment and sustainable release of the bioactive molecules over time. The physicochemical and morphological characterization of the beads (ALC, ALAC0,5, ALAC1, and ALAC3, containing 0, 0.5, 1, and 3 %(w/v) of Ch[Caffeate], respectively) revealed a porous and interconnected structure, with medium pore sizes ranging from 209.16 to 221.30 μm, with a high swelling ability (up 2400 %). Ch[Caffeate] significantly improved the antioxidant activities of the constructs by 95 % and 97 % for ALAC1 and ALAC3, respectively, when compared to ALA (56 %). Besides, the structures provided the environment for ATDC5 cell proliferation, and cartilage-like ECM formation, supported by the increased GAGs in ALAC1 and ALAC3 formulations after 21 days. Further, the ability to block the secretion of pro-inflammatory cytokines (TNF-α and IL-6), from differentiated THP-1 was evidenced by ChAL-Ch[Caffeate] beads. These outcomes suggest that the established strategy based on using natural and bioactive macromolecules to develop 3D constructs has great potential to be used as therapeutic tools for patients with OA.

MRI-visible mesoporous polydopamine nanoparticles with enhanced antioxidant capacity for osteoarthritis therapy

Since the progression of osteoarthritis (OA) is closely associated with synovitis and cartilage destruction, the inhibition of inflammatory responses in synovial macrophages and reactive oxygen species (ROS) induced apoptosis in chondrocytes is crucial for OA amelioration. However, most of the current anti-inflammatory and antioxidant drugs are small molecules apt to be eliminated in vivo. Herein, mesoporous polydopamine nanoparticles (DAMM NPs) doped with arginine and manganese (Mn) ions were prepared to load dexamethasone (DEX) for OA intervention. A series of in vitro studies showed that the sustained release of DEX from DAMM NPs suppressed synovial inflammation and simultaneously inhibited toll-like receptor 3 (TLR-3) production in chondrocytes, contributing to prevention of chondrocyte apoptosis through the inflammatory factor-dependent TLR-3/NF-κB signaling pathway via modulation of macrophage-chondrocyte crosstalk. In addition, DAMM NPs exerted a predominant role in removal of ROS generated in chondrocytes. Therefore, the DEX-loaded DAMM NPs significantly attenuated OA development in mice model. Importantly, the T1-T2 magnetic contrast capabilities of DAMM NPs allowed an MRI-trackable delivery, manifesting a distinct feature widely regarded to boost the potential of nanomedicines for clinical applications. Together, our developed antioxidant-enhanced DAMM NPs with MRI-visible signals may serve as a novel multifunctional nanocarriers for prevention of OA progression.

Intra-articular corticosteroid injections are associated with a dose-dependent risk of total knee arthroplasty at 5 years

PURPOSE

Intra-articular corticosteroid injections (CSI) are used commonly for the non-operative management of patients with knee pain. Recent literature has raised concern for chondrotoxicity of CSI. The purpose of the present study is to evaluate for any dose-dependent association between CSI in non-osteoarthritic knees and subsequent total knee arthroplasty (TKA).

METHODS

The Pearl Diver database identified patients with a diagnosis of knee pain without concomitant osteoarthritis who were administered CSI over a 2-year period. Patients were compared to matched and unmatched cohorts. The primary endpoint was the incidence of TKA at 5 years. Multivariable regression analysis was used to assess CSI quantity as an independent risk factor.

RESULTS

49,443 of 986,162 (5.0%) Patients diagnosed with knee pain without concomitant knee osteoarthritis who received at least one CSI were identified. At 5 years, there was a higher incidence of TKA in the matched injection cohort relative to the non-injection matched cohort (0.26 vs 0.13%; p < 0.001) and unmatched cohort (0.26 vs. 0.10%, p < 0.001). The quantity of CSI corresponded with an increased probability of TKA at 5 years; one injection: 0.22% (OR 1.23, 95% CI [0.87-1.74], p = 0.236); two injections: 0.39% (OR 1.98 CI [1.06-3.67], p = 0.03, three or more injections: 0.49% (OR 3.22 CI [1.60-6.48], p = 0.001). The average time to TKA after one CSI was 3.03 ± 2.29 years. This time was nearly halved with three CSI (1.78 ± 0.80 years, p < 0.001).

CONCLUSIONS

Intra-articular corticosteroid injections in patients without knee osteoarthritis at the time of injection are associated with a dose-dependent risk of TKA at 5 years. CSI may not be as benign of a treatment modality as previously thought.

Unbiased transcriptome mapping and modeling identify candidate genes and compounds of osteoarthritis

Osteoarthritis (OA) is a chronic degenerative joint disease characterized by progressive cartilage loss, subchondral bone remodeling, and synovial inflammation. Given that the current therapies for advanced OA patients are limited, the understanding of mechanisms and novel therapies are urgently needed. In this study, we employed the weighted gene co-expression network (WGCNA) method and the connectivity map (CMap) database to identify the candidate target genes and potential compounds. Four groups of co-expressing genes were identified as the OA-related modules. The biological annotations of these modules indicated some critical hallmarks of OA and aging, such as mitochondrial dysfunctions and abnormal energy metabolism, and the signaling pathways, such as MAPK, TNF, and PI3K/Akt signaling pathways. Some genes, such as RELA and GADD45B, were predicted to extensively involve these critical pathways, indicating their potential functions in OA mechanisms. Moreover, we constructed the co-expressing networks of modules and identified the hub genes based on network topology. GADD45B, MAFF, and MYC were identified and validated as the hub genes. Finally, anisomycin and MG-262 were predicted to target these OA-related modules, which may be the potential drugs for OA therapy. In conclusion, this study identified the significant modules, signaling pathways, and hub genes relevant to OA and highlighted the potential clinical value of anisomycin and MG-262 as novel therapies in OA management.

Nonsteroidal Anti-inflammatory and Corticosteroid Injections for Shoulder Impingement Syndrome: A Systematic Review and Meta-analysis

CONTEXT

To determine optimal treatment strategies for shoulder impingement syndrome (SIS).

OBJECTIVE

To compare subacromial nonsteroidal anti-inflammatory injections (SNIs) and subacromial corticosteroid injections (SCIs) on pain relief and functional improvement in individuals with SIS. Second, to perform a cost analysis of the 2 injections.

DATA SOURCES

MEDLINE, SPORTDiscus, CINAHL, Embase, Web of Science, and SCOPUS databases were searched for randomized controlled trials using several keywords.

STUDY SELECTION

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized, and 10 studies comparing changes in pain or function in humans with SIS receiving SNIs or SCIs were included. Quality and risk of bias were assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 scale and the Cochrane Collaboration tool.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 1.

DATA EXTRACTION

Baseline and follow-up scores of the visual analog, Constant-Murley, and University of California Los Angeles shoulder scales were extracted to calculate effect sizes (ESs), represented as Cohen d. Metaregression and publication bias analyses were performed. Procedural and medication costs were extracted from Medicare guidelines.

RESULTS

A total of 7 high and 3 good quality studies were included, with a mean score of 21.1. Only 1 study had a high risk of bias. The meta-analyses produced pooled ESs of 0.05 (P = 0.83), 0.12 (P = 0.71), and 0.07 (P = 0.79) for each scale, respectively, with CIs crossing 0. Procedural costs were equal between groups, whereas ketorolac was the least costly medication ($0.47). There was no significant difference in side effects between the 2 injections.

CONCLUSION

SNIs are as effective as SCIs for short-term pain relief and improving function in patients with subacromial impingement syndrome. In addition, they are less expensive and cause no major difference in complications, providing a viable, cost-effective alternative for injection therapy in patients with SIS.

In Vitro Effects of Low Doses of β-Caryophyllene, Ascorbic Acid and d-Glucosamine on Human Chondrocyte Viability and Inflammation

β-caryophyllene (BCP), a plant-derived sesquiterpene, has been reported to have anti-inflammatory and antioxidant effects. The purpose of this study is to evaluate the effects of BCP in combination with ascorbic acid (AA) and d-glucosamine (GlcN) against macrophage-mediated inflammation on in vitro primary human chondrocytes. Changes in cell viability, intracellular ROS generation, gene expression of pro-inflammatory mediators, metalloproteinases (MMPs), collagen type II and aggrecan were analyzed in primary human chondrocytes exposed to the conditioned medium (CM) of activated U937 monocytes and subsequently treated with BCP alone or in combination with AA and GlcN. The CM-induced chondrocyte cytotoxicity was reduced by the presence of low doses of BCP alone or in combination with AA and GlcN. The exposure of cells to CM significantly increased IL-1β, NF-κB1 and MMP-13 expression, but when BCP was added to the inflamed cells, alone or in combination with AA and GlcN, gene transcription for all these molecules was restored to near baseline values. Moreover, chondrocytes increased the expression of collagen type II and aggrecan when stimulated with AA and GlcN alone or in combination with BCP. This study showed the synergistic anti-inflammatory and antioxidative effects of BCP, AA and GlcN at low doses on human chondrocyte cultures treated with the CM of activated U937 cells. Moreover, the combination of the three molecules was able to promote the expression of collagen type II and aggrecan. All together, these data could suggest that BCP, AA and GlcN exert a chondro-protective action.

Polymer particles for the intra-articular delivery of drugs to treat osteoarthritis

Osteoarthritis (OA) is a leading cause of chronic disability. It is a progressive disease, involving pathological changes to the entire joint, resulting in joint pain, stiffness, swelling, and loss of mobility. There is currently no disease-modifying pharmaceutical treatment for OA, and the treatments that do exist suffer from significant side effects. An increasing understanding of the molecular pathways involved in OA is leading to many potential drug targets. However, both current and new therapies can benefit from a targeted approach that delivers drugs selectively to joints at therapeutic concentrations, while limiting systemic exposure to the drugs. Delivery systems including hydrogels, liposomes, and various types of particles have been explored for intra-articular drug delivery. This review will describe progress over the past several years in the development of polymer-based particles for OA treatment, as well as their in vitro, in vivo, and clinical evaluation. Systems based on biopolymers such as polysaccharides and polypeptides, as well as synthetic polyesters, poly(ester amide)s, thermoresponsive polymers, poly(vinyl alcohol), amphiphilic polymers, and dendrimers will be described. We will discuss the role of particle size, biodegradability, and mechanical properties in the behavior of the particles in the joint, and the challenges to be addressed in future research.

Intra-articular Injections With Either Triamcinolone Hexacetonide, Stanozolol, Hylan G-F 20, or a Platelet Concentrate Improve Clinical Signs in Police Working Dogs With Bilateral Hip Osteoarthritis

Objectives: To compare the effect of intra-articular treatment with triamcinolone hexacetonide (TH), stanozolol, hyaluronan, and a platelet concentrate in police working dogs with bilateral hip osteoarthritis (OA). Study Design: Prospective, longitudinal, double-blinded, negative controlled study. Sample Population: Fifty police working dogs with naturally occurring hip OA. Methods: Animals were randomly assigned to a control group (CG, n = 10), TH group (THG, n = 10), platelet concentrate group (PCG, n = 10), stanozolol group (SG, n = 10), and Hylan G-F 20 group (HG). On days 0 (T0), 8, 15, 30, 90, and 180 days post-treatment, weight-bearing distribution was evaluated. In those days, and on days 60, 120, and 150, four clinical metrology instruments were completed. Kaplan-Meier estimators were conducted and compared with the log-rank test. Cox proportional hazard regression analysis was performed to determine treatment survival. Significance was set at p < 0.05. Results: Patients had a mean age of 6.5 ± 2.4 years and body weight of 26.7 ± 5.2 kg. At T0, hips were classified as mild (n = 35), moderate (n = 10), and severe (n = 5), according to the Orthopedic Foundation for Animals grading scheme. No differences were found between groups at that moment considering age, body weight, OFA hip score, and all assessments performed. All treatments improved clinical signs in various OA dimensions in some groups, with a broad effect interval. PCG showed a lower range of variation while maintaining a positive result for more extended periods (p < 0.01 for symmetry index and 0.01 < p < 0.04 in the majority of scores). Breed, age, sex, and OFA grade did not significantly influence response to treatment. Conclusions and Clinical Relevance: This is the first prospective, negative controlled, double-blinded study to compare the effect of a single administration of these IA treatments in dogs with hip OA. HG and PCG recorded more significant improvements throughout the 180-day follow-up. In particular, PCG also registered a lower variation in results, seemingly the best therapeutic option. Nevertheless, improvements were still observed in THG and SG, and these treatment options can be considered, mainly when the first two treatments are not available.

GSK3787-Loaded Poly(Ester Amide) Particles for Intra-Articular Drug Delivery

Osteoarthritis (OA) is a debilitating joint disorder affecting more than 240 million people. There is no disease modifying therapeutic, and drugs that are used to alleviate OA symptoms result in side effects. Recent research indicates that inhibition of peroxisome proliferator-activated receptor δ (PPARδ) in cartilage may attenuate the development or progression of OA. PPARδ antagonists such as GSK3787 exist, but would benefit from delivery to joints to avoid side effects. Described here is the loading of GSK3787 into poly(ester amide) (PEA) particles. The particles contained 8 wt.% drug and had mean diameters of about 600 nm. Differential scanning calorimetry indicated the drug was in crystalline domains in the particles. Atomic force microscopy was used to measure the Young's moduli of individual particles as 2.8 MPa. In vitro drug release studies showed 11% GSK3787 was released over 30 days. Studies in immature murine articular cartilage (IMAC) cells indicated low toxicity from the drug, empty particles, and drug-loaded particles and that the particles were not taken up by the cells. Ex vivo studies on murine joints showed that the particles could be injected into the joint space and resided there for at least 7 days. Overall, these results indicate that GSK3787-loaded PEA particles warrant further investigation as a delivery system for potential OA therapy.

Multidisciplinary integrated approach for older adults with symptomatic osteoarthritis: SIMFER and SI-GUIDA Joint Position Statement

Multidisciplinary approach to osteoarthritis (OA) in older patients, whose functional decline is multifactorial and who present with multiple symptoms, has been long advocated, but it is still seldom implemented in daily practice. Therefore, further indications for the management of OA are eagerly awaited and should consider the specific clinical features of this population, including the presence of frailty and comorbidities. This clinical approach should be based both on well-grounded evidence and practical experience of experts in OA management. This manuscript comments the multidisciplinary integrated approach for OA management in the older population, according to the opinion of a multidisciplinary Panel of Experts. This project was developed by a Steering Committee, which consisted of three experts that were identified by the Italian Society of Physical and Rehabilitation Medicine (Società Italiana di Medicina Fisica e Riabilitativa, SIMFER) and the Italian Society for Unified and Interdisciplinary Management of Musculoskeletal Pain and Algodystrophy (Società Italiana per la Gestione Unificata e Interdisciplinare del Dolore muscolo-scheletrico e dell'Algodistrofia, SI-GUIDA). The Steering Committee identified key evidence on the management of OA in the older through systematic research in MEDLINE and EMBASE, selected the most relevant paper among those identified, and defined some questions concerning current unmet needs in the management of symptomatic OA in the older accordingly. The Panel discussed the identified evidence and questions during two meetings. The discussion was used to generate seven statements with relevance to clinical practice. In conclusion, older adults with symptomatic OA present multiple concomitant issues, including other diseases, marked pain, poly-pharmacy, and often poor psychological and/or socioeconomical status. According to the above-described evidence, it is crucial that the approach to those patients is multidisciplinary and based on the use of dedicated tools. A combination of exercise, mechanical support and properly selected analgesic treatment will greatly help the management of the OA patient, improving at the same time his/her quality of life.

Intra-articular Corticosteroid Injections for Symptomatic Knee Osteoarthritis: What the Orthopaedic Provider Needs to Know

Intra-articular corticosteroid injections have been used for decades in the management of symptomatic osteoarthritis of the knee and remain a common practice. The pain relief from a steroid injection is thought to work by reducing inflammation within the arthritic knee. Substantial variability remains among providers with regard to the technique used to perform the procedure, including the site of the injection, the medications injected, and the level of sterility. The success of steroid injections in relieving arthritic knee pain most often occurs in the short term. However, the efficacy of intra-articular corticosteroid injections varies within the published literature. The latest American Academy of Orthopaedic Surgeons clinical practice guideline does not support conclusive recommendations about the use of intra-articular corticosteroid injections for symptomatic knee osteoarthritis. Providers should be aware of the adverse effects and potential complications of these injections when using them in clinical practice.

Triamcinolone acetonide extended-release in patients with osteoarthritis and type 2 diabetes: a randomized, phase 2 study

Objective

Approximately 30% of patients with type 2 diabetes mellitus have knee osteoarthritis. IA corticosteroids used to manage osteoarthritis pain can elevate blood glucose in these patients. We compared blood glucose levels following intra-articular injection of triamcinolone acetonide extended-release (TA-ER), an extended-release, microsphere-based triamcinolone acetonide formulation, vs standard triamcinolone acetonide crystalline suspension (TAcs) in patients with knee osteoarthritis and comorbid type 2 diabetes.

Methods

In this double-blind, randomized, parallel-group, phase 2 study (NCT02762370), 33 patients with knee osteoarthritis (American College of Rheumatology criteria) and type 2 diabetes mellitus (HbA1c 6.5-9.0% [48-75 mmol/mol]; 1-2 oral hypoglycaemic agents) were treated with intra-articular TA-ER (32 mg n = 18) or TAcs 40 mg (n = 15). Continuous glucose monitoring-measured glucose (CGMG) was assessed from 1 week pre-injection through 2 weeks postinjection. Endpoints included change in average daily CGMG from baseline (days -3 to -1) to days 1-3 postinjection (CGMGdays1-3) (primary) and percent time average hourly CGMG levels remained in prespecified glycaemic ranges.

Results

The change CGMGdays1-3 was significantly lower following TA-ER vs TAcs (14.7 vs 33.9 mg/dl, least-squares-mean-difference [95% CI]: -19.2 [-38.0, -0.4]; P = 0.0452). The percentage of time over days 1-3 that CGMG was in the target glycaemic range (70-180 mg/dl) was numerically greater for TA-ER (63.3%) vs TAcs (49.7%), and that CGMG was >180 mg/dl was lower for TA-ER (34.5%) vs TAcs (49.9%). Non-glycaemic adverse events were mild and comparable between groups.

Conclusion

TA-ER may enable intra-articular corticosteroid treatment with minimal blood glucose disruption in patients with knee osteoarthritis and type 2 diabetes mellitus.

Trial registration

ClinicalTrials.gov, https://clinicaltrials.gov, NCT02762370.

Interventional radiology techniques for pain reduction and mobility improvement in patients with knee osteoarthritis

Osteoarthritis of the knee is the most common cause of chronic knee pain being more prevalent in middle-aged and elderly patients. Symptomatic patients complain of pain and mobility impairment. Therapeutic armamentarium includes physical therapy, oral pharmacologic therapy, intra-articular injections, nerve ablation or modulation, trans-catheter arterial embolization, minimally invasive arthroscopic treatment and partial or total knee arthroplasty. Interventional radiology therapies for knee osteoarthritis include intra-articular injections, neurotomy and neuromodulation techniques as well as transcatheter intra-arterial therapies. These therapies aim to control pain and inflammation, improve mobility and function whilst the novel cell-based therapies have the potential for bone and cartilage regenerative repair facilitating the delay to surgery. The purpose of this review is to illustrate the technical aspects, the indications and the methodology of local therapies for knee osteoarthritis performed by interventional radiologists and provide current evidence.

Evidence-based guidelines for intra-articular injection in knee osteoarthritis: Formulating and evaluating research questions

OBJECTIVE

To formulate and evaluate clinical questions about intra-articular injection for knee osteoarthritis in developing clinical practice guidelines and to introduce a new methodology for framing relevant questions.

METHODS

We framed the clinical questions and evaluated the importance of these questions according to the following four steps: (a) first round questionnaire survey intended to get the clinical questions from doctors; (b) evaluating importance of questions via second round questionnaire survey intended to summarize and rank the clinical questions; (c) consensus conference was conducted by clinical and methodological experts; and (d) confirm the important clinical questions according to PICO (Patients, Intervention, Comparison and Outcomes) principles.

RESULTS

After the first round questionnaire survey, the number of clinical questions was 26. Thirteen of these 26 questions were regarded as important questions by the second questionnaire survey. Ultimately, the 13 important clinical questions were determined in a consensus conference. All included questions were deconstructed by clinical experts and methodologists based on the PICO principles.

CONCLUSION

The present study describes an approach about the selection of clinical questions and importance evaluation. Relevant important clinical questions about intra-articular injection for knee osteoarthritis are determined according to the methodology. It could help other guideline developers to utilize this method to frame clinical questions.

Nonsurgical Management of Osteoarthritis Knee Pain in the Older Adult: An Update

Symptomatic knee osteoarthritis is a common complaint of many elderly patients in primary care offices. For those unable or unwilling to undergo knee replacement, the primary practitioners' understanding of the strengths and weaknesses of the available treatment modalities for pain relief is critical to successful in-office counseling and expectation management. Treatment requires a multimodal approach of nonpharmacologic and pharmacologic therapies to achieve a maximal clinical benefit. The focus of this review is on the nonsurgical options for treatment of knee osteoarthritis in patients aged 65 and older.

Intra-articular injection of mesenchymal stem cells in treating knee osteoarthritis: a systematic review of animal studies

PURPOSE

Mesenchymal stem cells (MSCs) injection has emerged as a novel treatment for knee osteoarthritis (KOA) but with inconsistent results in the experimental studies. Thus, the purpose of the present study is to evaluate the preclinical animal studies of MSCs injection for KOA and to determine the evidence for a role for MSCs in further clinical trials.

METHODS

A systematic search of KOA animal studies published through Aug 2017 was conducted using the PubMed, Embase and Web of science. Criteria for eligibility were animal studies assessing the therapeutic effects of MSCs intra-articular injection to animals with KOA. The methodological quality of included studies was assessed by the SYRCLE tool for assessing risk of bias in animal intervention studies. Descriptive synthesis was performed. Evidence quality was evaluated based on the Confidence in the Evidence from Reviews of Qualitative research (CERQual) tool.

RESULTS

Twenty-three KOA animal studies were eligible for inclusion. According to the SYRCLE's tool, all included studies had high risk of bias. Between-study heterogeneity was substantial. The included studies varied in terms of species, modeling methods, MSCs origin, treatment timing, injections frequency, transplantation type and dose of MSCs. The following outcomes, gross morphology, histological analysis, immunohistochemical analysis, radiological evaluation or behavior analysis, were reported in the primary studies. For all outcomes, the evidence quality was low or very low.

CONCLUSIONS

We do not have absolute confidence to recommend use MSCs injection for KOA clinical trials. Based on the internal and external validity of current animal studies, high quality experimental studies and efforts for effective translation from preclinical studies to clinical trials are still required.

Osteoarthritis of the knee

Osteoarthritis of the knee is a degenerative condition that is commonly seen in the elderly population and sometimes occurs earlier in the athletic population. Pain and stiffness are common features, which can be debilitating. Clinical assessment of the knee joint requires consideration of its associated muscles, ligaments, tendons, bursae and menisci. The aim of this article is to provide an overview of knee pain assessment, to discuss the diagnosis of knee osteoarthritis, and to review some evidence-based management options.

A protocol for developing a clinical practice guideline for intra-articular injection for treating knee osteoarthritis

Introduction

Osteoarthritis (OA) is the most prevalent disorder of articulating joints in humans. As one of the steps of advanced pharmacological management, intra-articular treatment is applied in knee OA. However, there is no clinical practice guideline (CPG) involving intra-articular injection for knee OA. Here, we will develop a CPG according to a recognized methodology.

Methods and analysis

We will develop the new CPG according to the Institute of Medicine, the Appraisal of Guidelines for Research & Evaluation Ⅱ (AGREE Ⅱ), and WHO guideline handbook and make recommendations based on systematic reviews. We will establish a Guideline Working Group (including a Guideline Steering Subgroup, a Guideline Development Subgroup, and a Guideline Secretary Subgroup); formulate clinical questions in the form of Population, Intervention, Comparison, Outcomes (PICO); and complete a literature search. The consensus will be developed through evidence syntheses and the Delphi method. We will also consider patients' values or preferences, peer review results, and declaration of interests in developing CPG. The present CPG was registered on the International Practice Guidelines Registry Platform (http://www.guidelines-registry.org/), and the registration number is IPGRP-2016CN004.

Ethics and dissemination

The protocol will provide us a roadmap to systematically develop evidence-based CPG for intra-articular injection for knee OA. The work will be disseminated electronically and in print. The guideline would be the first CPG that is developed primarily by orthopedic specialists in China and strictly based on systematic methodology.

Nonsurgical Management of Osteoarthritis Knee Pain in the Older Adult

Symptomatic knee osteoarthritis is a common complaint of many elderly patients in primary care offices. For those unable or unwilling to undergo knee replacement, the primary practitioners' understanding of the strengths and weaknesses of the available treatment modalities for pain relief is critical to successful in-office counseling and expectation management. Treatment requires a multimodal approach of nonpharmacologic and pharmacologic therapies to achieve a maximal clinical benefit. The focus of this review is on the nonsurgical options for treatment of knee osteoarthritis in patients aged 65 and older.

Intra-articular treatment of knee osteoarthritis: from anti-inflammatories to products of regenerative medicine

OBJECTIVES

Knee osteoarthritis (OA) is a debilitating condition that may ultimately require total knee arthroplasty (TKA). Non-operative treatments are bracing, oral analgesics, physical therapy, and intra-articular knee injection (IAKI). The objective of this paper is to provide a systematic literature review regarding intra-articular treatment of knee OA and insight into promising new products of regenerative medicine that may eventually have a substantial effect on treatment.

METHODS

A literature search was executed using Medline, Cochrane, and Embase with keywords "knee osteoarthritis" and "injection." Specifically, 45 articles that discussed intra-articular knee injection using corticosteroids, hyaluronic acid, analgesics, local anesthetics, and newer products of regenerative medicine, such as platelet-rich plasma (PRP) and mesenchymal stem cells (MSC), were analyzed. Of these, eleven were level 1, three were level 2, twelve were level 3, two were level 4, and seventeen were level 5 evidence. Papers included animal models.

RESULTS

Local anesthetics have potential side effects and may only be effective for a few hours. Morphine and ketorolac may provide significant pain relief for 24 hours. Corticosteroids may give patients weeks to months of effective analgesia, but complications may occur, such as systemic hyperglycemia, septic arthritis, and joint degradation . Hyaluronic acid is a natural component of synovial fluid, but efficacy with respect to analgesia is controversial. Platelet-rich plasma formulations, autologous conditioned serum, autologous protein solution, and mesenchymal stem cell injections contain anti-inflammatory molecules and have been proposed to attenuate joint destruction or potentially remodel the joint.

CONCLUSIONS

Currently, knee OA treatment does not address the progressively inflammatory environment of the joint. More investigation is needed regarding products of regenerative medicine, but they may ultimately have profound implications in the way knee OA is managed.

Intra-articular corticosteroid for knee osteoarthritis

BACKGROUND

Knee osteoarthritis is a leading cause of chronic pain, disability, and decreased quality of life. Despite the long-standing use of intra-articular corticosteroids, there is an ongoing debate about their benefits and safety. This is an update of a Cochrane review first published in 2005.

OBJECTIVES

To determine the benefits and harms of intra-articular corticosteroids compared with sham or no intervention in people with knee osteoarthritis in terms of pain, physical function, quality of life, and safety.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE (from inception to 3 February 2015), checked trial registers, conference proceedings, reference lists, and contacted authors.

SELECTION CRITERIA

We included randomised or quasi-randomised controlled trials that compared intra-articular corticosteroids with sham injection or no treatment in people with knee osteoarthritis. We applied no language restrictions.

DATA COLLECTION AND ANALYSIS

We calculated standardised mean differences (SMDs) and 95% confidence intervals (CI) for pain, function, quality of life, joint space narrowing, and risk ratios (RRs) for safety outcomes. We combined trials using an inverse-variance random-effects meta-analysis.

MAIN RESULTS

We identified 27 trials (13 new studies) with 1767 participants in this update. We graded the quality of the evidence as 'low' for all outcomes because treatment effect estimates were inconsistent with great variation across trials, pooled estimates were imprecise and did not rule out relevant or irrelevant clinical effects, and because most trials had a high or unclear risk of bias. Intra-articular corticosteroids appeared to be more beneficial in pain reduction than control interventions (SMD -0.40, 95% CI -0.58 to -0.22), which corresponds to a difference in pain scores of 1.0 cm on a 10-cm visual analogue scale between corticosteroids and sham injection and translates into a number needed to treat for an additional beneficial outcome (NNTB) of 8 (95% CI 6 to 13). An I(2) statistic of 68% indicated considerable between-trial heterogeneity. A visual inspection of the funnel plot suggested some asymmetry (asymmetry coefficient -1.21, 95%CI -3.58 to 1.17). When stratifying results according to length of follow-up, benefits were moderate at 1 to 2 weeks after end of treatment (SMD -0.48, 95% CI -0.70 to -0.27), small to moderate at 4 to 6 weeks (SMD -0.41, 95% CI -0.61 to -0.21), small at 13 weeks (SMD -0.22, 95% CI -0.44 to 0.00), and no evidence of an effect at 26 weeks (SMD -0.07, 95% CI -0.25 to 0.11). An I(2) statistic of ≥ 63% indicated a moderate to large degree of between-trial heterogeneity up to 13 weeks after end of treatment (P for heterogeneity≤0.001), and an I(2) of 0% indicated low heterogeneity at 26 weeks (P=0.43). There was evidence of lower treatment effects in trials that randomised on average at least 50 participants per group (P=0.05) or at least 100 participants per group (P=0.013), in trials that used concomittant viscosupplementation (P=0.08), and in trials that used concomitant joint lavage (P≤0.001).Corticosteroids appeared to be more effective in function improvement than control interventions (SMD -0.33, 95% CI -0.56 to -0.09), which corresponds to a difference in functions scores of -0.7 units on standardised Western Ontario and McMaster Universities Arthritis Index (WOMAC) disability scale ranging from 0 to 10 and translates into a NNTB of 10 (95% CI 7 to 33). An I(2) statistic of 69% indicated a moderate to large degree of between-trial heterogeneity. A visual inspection of the funnel plot suggested asymmetry (asymmetry coefficient -4.07, 95% CI -8.08 to -0.05). When stratifying results according to length of follow-up, benefits were small to moderate at 1 to 2 weeks after end of treatment (SMD -0.43, 95% CI -0.72 to -0.14), small to moderate at 4 to 6 weeks (SMD -0.36, 95% CI -0.63 to -0.09), and no evidence of an effect at 13 weeks (SMD -0.13, 95% CI -0.37 to 0.10) or at 26 weeks (SMD 0.06, 95% CI -0.16 to 0.28). An I(2) statistic of ≥ 62% indicated a moderate to large degree of between-trial heterogeneity up to 13 weeks after end of treatment (P for heterogeneity≤0.004), and an I(2) of 0% indicated low heterogeneity at 26 weeks (P=0.52). We found evidence of lower treatment effects in trials that randomised on average at least 50 participants per group (P=0.023), in unpublished trials (P=0.023), in trials that used non-intervention controls (P=0.031), and in trials that used concomitant viscosupplementation (P=0.06).Participants on corticosteroids were 11% less likely to experience adverse events, but confidence intervals included the null effect (RR 0.89, 95% CI 0.64 to 1.23, I(2)=0%). Participants on corticosteroids were 67% less likely to withdraw because of adverse events, but confidence intervals were wide and included the null effect (RR 0.33, 95% CI 0.05 to 2.07, I(2)=0%). Participants on corticosteroids were 27% less likely to experience any serious adverse event, but confidence intervals were wide and included the null effect (RR 0.63, 95% CI 0.15 to 2.67, I(2)=0%).We found no evidence of an effect of corticosteroids on quality of life compared to control (SMD -0.01, 95% CI -0.30 to 0.28, I(2)=0%). There was also no evidence of an effect of corticosteroids on joint space narrowing compared to control interventions (SMD -0.02, 95% CI -0.49 to 0.46).

AUTHORS' CONCLUSIONS

Whether there are clinically important benefits of intra-articular corticosteroids after one to six weeks remains unclear in view of the overall quality of the evidence, considerable heterogeneity between trials, and evidence of small-study effects. A single trial included in this review described adequate measures to minimise biases and did not find any benefit of intra-articular corticosteroids.In this update of the systematic review and meta-analysis, we found most of the identified trials that compared intra-articular corticosteroids with sham or non-intervention control small and hampered by low methodological quality. An analysis of multiple time points suggested that effects decrease over time, and our analysis provided no evidence that an effect remains six months after a corticosteroid injection.

Current concepts on the use of corticosteroid injections for knee osteoarthritis

Intraarticular corticosteroid injections are commonly used by the primary care providers and orthopedic surgeons to treat knee pain associated with osteoarthritis (OA). There is a spectrum of options for treating knee OA, ranging from ice therapy to partial or total knee replacement surgery. In mid-range treatment spectrum are different kinds of injections, with the most widely used being corticosteroid and hyaluronic acid. In addition, there are different types of corticosteroids used and also commonly mixed with different local anesthetics. The purpose of this paper is address current concepts on the use of corticosteroid steroid therapy for the treatment of knee OA.

The Effect of Intra-articular Corticosteroids on Articular Cartilage: A Systematic Review

Background:

Intra-articular (IA) corticosteroid therapy has been used for the treatment of inflammation and pain in the knee since the 1950s.

Purpose:

To review the current literature on the effects of IA corticosteroids on articular cartilage.

Study Design:

Systematic review.

Methods:

A MEDLINE and SCOPUS database search was performed, and studies were selected for basic science and clinical trial research on corticosteroids with direct outcome measures of cartilage health. Preliminary searches yielded 1929 articles, and final analysis includes 40 studies.

Results:

Methylprednisolone, dexamethasone, hydrocortisone, betamethasone, prednisolone, and triamcinolone were reported to display dose-dependent deleterious effects on cartilage morphology, histology, and viability in both in vitro and in vivo models. The beneficial animal in vivo effects of methylprednisolone, hydrocortisone, and triamcinolone occurred at low doses (usually <2-3 mg/dose or 8-12 mg/cumulative total dose in vivo), at which increased cell growth and recovery from damage was observed; the single human clinical trial indicated a beneficial effect of triamcinolone. However, at higher doses (>3 mg/dose or 18-24 mg/cumulative total dose in vivo), corticosteroids were associated with significant gross cartilage damage and chondrocyte toxicity. Dose and time dependency of corticosteroid chondrotoxicity was supported in the in vitro results, however, without clear dose thresholds.

Conclusion:

Corticosteroids have a time- and dose-dependent effect on articular cartilage, with beneficial effects occurring at low doses and durations and detrimental effects at high doses and durations. Clinically, beneficial effects are supported for IA administration, but the lowest efficacious dose should be used.

Clinical efficacy of intra-articular injections in knee osteoarthritis: a prospective randomized study comparing hyaluronic acid and betamethasone

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.

Aspiration and injection of the knee joint: approach portal

Aspiration and injection of the knee joint is a commonly performed medical procedure. Injection of corticosteroid for the treatment of osteoarthritis is the most common reason for knee joint injection, and is performed as an office procedure. Debate exists among practitioners as to the 'best' approach portal for knee injection. This paper examines the various approach portals for injection and/or aspiration of the knee joint, as well as the accuracy of each approach. Searches were made of electronic databases, and appropriate papers were identified and hand-searched. Although there is some evidence that particular approach portals may be more efficacious in the presence of specific knee joint pathologies, generally, in experienced hands, it is of no clinical consequence as to which approach portal is utilised for aspiration or injection of the knee joint. No approach portal is 100% accurate, and the accuracy of injection of the knee joint may be enhanced by the use of techniques such as ultrasound. Practitioners are reminded that they should continuously refine and practice their preferred technique. Knee joint aspiration and injection is a common, simple, and generally safe office procedure.