EULAR recommendations for intra-articular therapies

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

OBJECTIVE

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

DESIGN

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

PRIMARY OUTCOME

pain intensity.

SECONDARY OUTCOMES

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

FINDINGS

Among 57 RCTs (22,795 participants) examining 18 intra-articular interventions, usual care or placebo, treatment effects were larger in high-risk-of-bias trials (n = 35) than low/unclear-risk-of-bias trials (n = 22). In the main analysis (excluding high-risk-of-bias trials), triamcinolone had the highest probabilities of reaching the MID at weeks 2-6 (75.3% and 90%, respectively) with corresponding SMDs of -0.48 (95%CrI,-0.85 to -0.10) and -0.53 (95%CrI,-0.79 to -0.27) compared to placebo. Tr14/Ze14 homeopathic product showed therapeutic potential at week 6 compared to placebo (SMD:-0.42, 95%CrI,-0.71 to -0.11, 63.5% probability of reaching the MID). Hyaluronic acid had higher risk of dropouts due to adverse events (OR:2.01, 95%CrI,1.08 to 3.77) and serious adverse events (OR:1.86, 95%CrI,1.16 to 3.03) than placebo.

CONCLUSION

Triamcinolone had the highest probabilities to have a treatment effect beyond the MID at weeks 2-6. Large RCTs with lower risk of bias do not support the notion that 16 other intra-articular interventions assessed improve pain or function beyond placebo effects in knee or hip OA. Lack of evidence of long-term effectiveness underscores the need for further research beyond 24-52 weeks.

Interventional Radiology for Rheumatic Diseases

Imaging plays a key role in the management of rheumatological pathologies, also as guidance for diagnostic and therapeutic interventional procedures, as it can provide better accuracy and safety compared to palpation-guided interventions. Inflammatory and degenerative conditions nonresponsive to systemic treatment may benefit from intra-articular and periarticular administration of drugs, with therapeutic and symptomatic actions or providing a bridge for surgery. Desired effects include reduction of inflammation and pain and improvement of physical function of patients. Training and knowledge of indications, appropriate procedures, contraindications, and side effects are necessary to obtain maximum accuracy and safety in performing interventional procedures.

To stop or not to stop novel oral anticoagulants prior to performing joint interventional maneuvers? Evidence from a prospective study that the therapy can be maintained

Anticoagulation is common in patients undergoing routine musculoskeletal interventional maneuvers. Previous retrospective studies have established the safety of continuing anticoagulation with novel oral anticoagulants (NOACs) when performing this kind of interventions. Indeed, ultrasound (US)-guided interventional maneuvers have shown a superior safety profile compared to blind anatomical maneuvers. To evaluate prospectively the periprocedural bleeding events in NOAC-anticoagulated patients undergoing interventional articular or periarticular procedures. Consecutive patients diagnosed with inflammatory or degenerative rheumatologic pathology requiring interventional maneuvers were prospectively recruited. Group 1 was treated with NOACs, group 2 was treated with vitamin K antagonists, and group 3 was not anticoagulated. Prior to the international maneuver, NOAC therapy was continuously administered, in regimens dictated by the underlying anticoagulation indication. Demographics, comorbidities, laboratory parameters, locally administered medication (corticosteroids or viscosupplementation), interventional maneuver location, needle size, and local bleeding events were recorded. Post-procedural control was performed at 30 min, 48 h, and 7 days. No articular/periarticular bleeding event occurred in patients treated with NOACs, regardless of their type and dosage, locally administered medication, needle size, location, and number of interventions per individual. Several patients in all groups developed small superficial ecchymoses at the injection site. Our results suggest that NOACs are safe to be used in a continuous regimen prior to US-guided injections, even as dual antithrombotic therapy (in combination with aspirin). The use of lower gauge needles, chosen for viscosupplementation therapy, was not burdened with adverse effects on the procedural outcome. Key Points • Currently, no prospective studies have been performed to establish the safety of continuous NOAC anticoagulation when performing routine intra- or periarticular interventional maneuvers. • The study offers an extensive view on a wide spectrum of intra- and periarticular interventional maneuvers including anatomic targets and needle sizes that were not previously assessed. • The study offers a perspective into performing repetitive maneuvers in the same patient, both over a short time and at longer intervals. • The zero periprocedural bleeding risk observed in our study may reassure practitioners and suggest that US-guided interventional therapeutic interventions are safe in patients treated with a continuous regimen of different NOACs.

Gout arthritis of the ankle successfully treated with arthroscopic debridement: A case report

INTRODUCTION

Gout is an inflammatory arthritis that causes acute pain due to the accumulation of uric acid crystals. Hyperuricemia primarily causes it, resulting in the deposition of monosodium urate crystals in and around joints. Gout can affect joints such as the metatarsophalangeal joint and the foot's talus bone. Treatment involves addressing hyperuricemia and managing symptoms with medications like febuxostat. Surgical treatment is crucial, especially in cases of chronic tophaceous gout or severe joint damage, including arthroscopic debridement, ankle arthrodesis, or total ankle arthroplasty.

CASE PRESENTATION

A 32-year-old male with a history of hyperuricemia experienced pain in his left ankle for a year. The ankle was swollen and prone to pain when he walked. Magnetic resonance imaging (MRI) tests revealed the thickening and irregular shape of the anterior talofibular ligament (ATFL), suggesting a rupture. The arthroscopic operation revealed a crystal deposit, leading to the diagnosis of gout arthritis and subsequent debridement for the patient. Following the surgery, the patient experienced minimal pain, an improved range of motion, and a significant improvement in swelling within a week. The patient was able to walk with minimal assistance and without aid.

DISCUSSION

Gout arthritis and ATFL injuries share common clinical features, including joint swelling, limited motion, and joint deformity. The presence of monosodium urate (MSU) crystals and inflammation in both conditions complicates diagnosis. Performing arthroscopic debridement surgery in gout arthritis presents challenges due to tophi and inflammation, as well as the risk of articular cartilage damage. Expertise is crucial for successful arthroscopic debridement, with patient selection, preoperative planning, and thorough removal of MSU crystals being key factors.

CONCLUSION

Thorough evaluation, patient selection, preoperative planning, joint identification, removal of MSU crystals, and comprehensive postoperative care are crucial for successful arthroscopic debridement for gout arthritis of the ankle.

Role of Preoperative Intra-Articular Corticosteroid Injections on Periprosthetic Joint Infection in Total Hip Arthroplasty and Its Association With Preoperative Timing: A Single-Center Series of 5,909 Hips

BACKGROUND

Preoperative intra-articular corticosteroid injections to the hip joint increase the risk of periprosthetic joint infection (PJI) during primary total hip arthroplasty (THA). This study aimed to determine the relationship between preoperative timing of intra-articular corticosteroid injections and PJI risk following THA using data from a single-center hospital.

METHODS

This single-center, retrospective cohort study included patients who underwent a THA between 2014 and 2020. Medical records were checked for intra-articular corticosteroid injections and PJI within 1 year of surgery. Patients were categorized into groups based on whether they received "no injection" or "injection 0 to 3 months," "3 to 6 months," and "> 6 months prior to THA." Hazard ratios (HRs) for these groups were calculated using multivariate Cox regression analysis, correcting for potential confounders, and presented with 95% confidence intervals [95% CIs].

RESULTS

In total, 4,507 patients (5,909 THAs) were identified. A total of 1,581 patients (27%) received an injection prior to THA. Without considering the timing factor, no increased risk for PJI following an intra-articular injection was noted (P = .19). Comparing the specified groups using multivariate analysis, corticosteroid injection within 3 months of THA showed an increased risk of PJI (HR 2.63, 95% CI 1.18 to 5.87, P = .018), but this effect was not observed for the "injection 3 to 6 months" group (HR 1.51, 95% CI 0.74 to 3.08, P = .264).

CONCLUSIONS

Corticosteroid injections administered up to 3 months prior to THA increased the risk of PJI within 1 year after THA, with an HR of 2.63; however, injections between 3 and 6 months before surgery did not have a significantly higher infection rate.

Knowledge, attitudes, and practices of gouty arthritis in the general population aged > 30

BACKGROUND

A knowledge of gouty arthritis could help in the primary prevention of the disease development and lead to an early diagnosis if it occurs. This study investigated the knowledge, attitudes, and practices (KAP) toward gouty arthritis in the general population > 30 years old.

METHODS

This web-based cross-sectional study was conducted among the general population > 30 years old between January and March 2023 in Chengdu, Sichuan. The questionnaire was designed by the investigators based on the available guidelines (Cronbach's α = 0.846). A score above 70% indicated good knowledge, a positive attitude, and proactive practice. Multivariable and structural equation modeling (SEM) analyses were performed to analyze the factors influencing KAP.

RESULTS

A total of 537 questionnaires were included. The knowledge, attitudes, and practices scores were 13.12 ± 6.41, 25.28 ± 3.97, and 45.25 ± 5.77, respectively. Female (OR = 0.47, 95%CI: 0.31-0.71, P < 0.001), suburban living (OR = 0.18, 95%CI: 0.04-0.78, P = 0.022), heads of institution/organization and professional and technical staff (OR = 2.04, 95%CI: 1.23-3.39, P = 0.006), and an income of < 2,000 yuan (OR = 0.35, 95%CI: 0.14-0.85, P = 0.021) were independently associated with knowledge. Female (OR = 2.17, 95%CI: 1.43-3.30, P < 0.001), age (OR = 1.03, 95%CI: 1.01-1.05, P = 0.001), college and above education (OR = 2.26, 95%CI: 1.16-4.41, P = 0.017), an income of 5,000-10,000 yuan (OR = 2.05, 95%CI: 1.27-3.31, P = 0.003), and an income of > 10,000 yuan (OR = 2.07, 95%CI: 1.12-3.81, P = 0.020) were independently associated with attitudes. Attitude (OR = 1.31, 95%CI: 1.23-1.40, P < 0.001), female (OR = 1.62, 95%CI: 1.01-2.58, P = 0.044), and age (OR = 1.02, 95%CI: 1.00-1.04, P = 0.016) were independently associated with practices. The structural equation modeling analysis showed that knowledge directly influenced attitude (β=-0.10, P < 0.001) and indirectly influenced practice (β=-0.07, P < 0.001), and attitude directly influenced practice (β = 0.68, P < 0.001).

CONCLUSION

The general population over 30 years old had inadequate knowledge, unfavorable attitudes, and less proactive practices toward gouty arthritis. Targeted interventions should focus on enhancing knowledge about gout and promoting positive attitudes toward its management.

Nano-Micron Combined Hydrogel Microspheres: Novel Answer for Minimal Invasive Biomedical Applications

Hydrogels, key in biomedical research for their hydrophilicity and versatility, have evolved with hydrogel microspheres (HMs) of micron-scale dimensions, enhancing their role in minimally invasive therapeutic delivery, tissue repair, and regeneration. The recent emergence of nanomaterials has ushered in a revolutionary transformation in the biomedical field, which demonstrates tremendous potential in targeted therapies, biological imaging, and disease diagnostics. Consequently, the integration of advanced nanotechnology promises to trigger a new revolution in the realm of hydrogels. HMs loaded with nanomaterials combine the advantages of both hydrogels and nanomaterials, which enables multifaceted functionalities such as efficient drug delivery, sustained release, targeted therapy, biological lubrication, biochemical detection, medical imaging, biosensing monitoring, and micro-robotics. Here, this review comprehensively expounds upon commonly used nanomaterials and their classifications. Then, it provides comprehensive insights into the raw materials and preparation methods of HMs. Besides, the common strategies employed to achieve nano-micron combinations are summarized, and the latest applications of these advanced nano-micron combined HMs in the biomedical field are elucidated. Finally, valuable insights into the future design and development of nano-micron combined HMs are provided.

The challenge of pharmacotherapy for musculoskeletal pain: an overview of unmet needs

Musculoskeletal disorders are characterized by several impairments, including pain, affecting muscles, bones, joints and adjacent connective tissue, resulting in temporary or permanent functional limitations and disability. Musculoskeletal pain is particularly prevalent worldwide and greatly impacts the quality of life, social participation and economic burden. To date, several issues persist about the classification of musculoskeletal pain and its management strategies and resources. The treatment of musculoskeletal pain conditions is complex and often requires a multimodal approach, including pharmacological and non-pharmacological therapy that might be ineffective in many cases, resulting in poor patient satisfaction and controversial expectations about the potential benefits of available interventions. This manuscript provides an overview of unmet needs in managing musculoskeletal pain, particularly focusing on pharmacotherapeutic pitfalls in this context.

Enhancing Musculoskeletal Injection Safety: Evaluating Checklists Generated by Artificial Intelligence and Revising the Preformed Checklist

Background Musculoskeletal disorders are a significant global health issue, necessitating advanced management strategies such as intra-articular and extra-articular injections to alleviate pain, inflammation, and mobility challenges. As the adoption of these interventions by physicians grows, the importance of robust safety protocols becomes paramount. This study evaluates the effectiveness of conversational artificial intelligence (AI), particularly versions 3.5 and 4 of Chat Generative Pre-trained Transformer (ChatGPT), in creating patient safety checklists for managing musculoskeletal injections to enhance the preparation of safety documentation. Methodology A quantitative analysis was conducted to evaluate AI-generated safety checklists against a preformed checklist adapted from reputable medical sources. Adherence of the generated checklists to the preformed checklist was calculated and classified. The Wilcoxon signed-rank test was used to assess the performance differences between ChatGPT versions 3.5 and 4. Results ChatGPT-4 showed superior adherence to the preformed checklist compared to ChatGPT-3.5, with both versions classified as very good in safety protocol creation. Although no significant differences were present in the sign-in and sign-out parts of the checklists of both versions, ChatGPT-4 had significantly higher scores in the procedure planning part (p = 0.007), and its overall performance was also higher (p < 0.001). Subsequently, the preformed checklist was revised to incorporate new contributions from ChatGPT. Conclusions ChatGPT, especially version 4, proved effective in generating patient safety checklists for musculoskeletal injections, highlighting the potential of AI to streamline clinical practices. Further enhancements are necessary to fully meet the medical standards.

Pain Management Strategies in Osteoarthritis

Pain is the major symptom of osteoarthritis (OA) and is an important factor in strategies to manage this disease. However, the current standard of care does not provide satisfactory pain relief for many patients. The pathophysiology of OA is complex, and its presentation as a clinical syndrome is associated with the pathologies of multiple joint tissues. Treatment options are generally classified as pharmacologic, nonpharmacologic, surgical, and complementary and/or alternative, typically used in combination to achieve optimal results. The goals of treatment are the alleviation of symptoms and improvement in functional status. Several studies are exploring various directions for OA pain management, including tissue regeneration techniques, personalized medicine, and targeted drug therapies. The aim of the present narrative review is to extensively describe all the treatments available in the current practice, further describing the most important innovative therapies. Advancements in understanding the molecular and genetic aspects of osteoarthritis may lead to more effective and tailored treatment approaches in the future.

Physiatry for Treating Hip, Knee, and Back Pain

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

[Pain reduction by radiosynoviorthesis in rheumatism-induced synovitis of the elbow : Results of a retrospective multicenter data analysis]

BACKGROUND

Radiosynoviorthesis (RSO) is a nuclear medical local treatment modality for inflammatory joint diseases. It is indicated in patients with rheumatoid arthritis (RA) in joints with persistent synovitis despite adequate pharmacotherapy. Arthritis of the elbow joint occurs in up to 2/3 of patients with RA. Intra-articular radiotherapy using the beta emitter [186Re] rhenium sulfide leads to sclerosis of the inflamed synovial membrane with subsequent pain alleviation. The clinical efficacy in cubital arthritis, however, has so far only been described in small monocentric studies.

OBJECTIVE

The degree of pain alleviation by RSO was analyzed in patients with rheumatoid cubital arthritis, treated in several nuclear medical practices specialized in RSO.

MATERIAL AND METHODS

The subjective pain intensity before and after RSO was documented in a total of 107 patients with rheumatic cubital arthritis using a 10-step numeric rating scale (NRS). A difference of ≥ -2 is rated as a significant improvement. Follow-up examinations were done after a mean interval of 14 months after RSO (at least 3 months, maximum 50 months).

RESULTS

The mean NRS value was 7.3 ± 2.1 before RSO and 2.8 ± 2.2 after RSO. A significant pain alleviation was seen in 78.5% of all patients treated. The subgroup analysis also showed a significant improvement in the pain symptoms in all groups depending on the time interval between the RSO and the control examination. A significant pain progression was not observed. The degree of pain relief was independent of the time of follow-up.

CONCLUSION

Using RSO for local treatment of rheumatoid cubital arthritis leads to a significant and long-lasting pain relief in more than ¾ of the treated patients.

Ultrasonography in rheumatology: time to learn from patient views

OBJECTIVE

The objective of this observational, descriptive, cross-sectional, multicentre study was to assess the perceived quality and grade of satisfaction expressed by patients with chronic arthropathies regarding the use of musculoskeletal (MSK) ultrasonography by rheumatologists as an integrated clinical care tool.

METHODS

All Spanish rheumatology departments with MSK ultrasonography incorporated in their healthcare services were invited to participate in the study. A Spanish-language survey was offered to fill out anonymously to all consecutive patients with chronic arthropathies under follow-up in the rheumatology outpatient clinics who attended their centre for a period of 3 months. The survey consisted of three sections. The first section contained patients' demographics, disease data, frequency of performing rheumatological ultrasound and information about who performed their ultrasound assessments. The second section consisted of 14 questions about patient's experience and opinion on different aspects of the management, performance and perceived usefulness of performing ultrasound, to be answered on a Likert scale 1-5. The third section of the survey was addressed to the rheumatologist ultrasonographers.

RESULTS

Nine hundred and four patients from 16 university hospital rheumatology departments completed the survey. All questions reached an overall favourable response ≥ 80%. Patients who reported usual ultrasound examinations in their rheumatology care and those in which it was their attending rheumatologist who performed the ultrasound assessments responded more favourably.

CONCLUSION

Our encouraging patient-centred results may be useful in facilitating the implementation of rheumatological ultrasound in rheumatology care worldwide. Key Points • This is the largest multicentre survey carried out in patients with chronic joint diseases designed to assess their experience and perceived benefits with the use of ultrasonography performed by rheumatologists in daily practice. • Musculoskeletal ultrasound incorporated into rheumatology care was very well accepted and valued by most patients. • The patients perceived that ultrasonography helps not only their rheumatologist but also themselves to better understand their condition. • The patients believed that ultrasonography helps them accept and comply with the proposed treatment.

Multidisciplinary Rehabilitation after Hyaluronic Acid Injections for Elderly with Knee, Hip, Shoulder, and Temporomandibular Joint Osteoarthritis

Osteoarthritis (OA) is a prevalent degenerative joint condition characterized by cartilage deterioration, joint inflammation, and functional limitations, particularly impacting the elderly population. Rehabilitation and hyaluronic acid (HA) injections are common therapeutic approaches routinely used in clinical practice, but their synergistic potential is far from being fully characterized. Thus, the aim of this narrative review was to elucidate the multilevel benefits and synergies of integrating these two approaches in multidisciplinary OA rehabilitation. This narrative review follows the scale for the assessment of narrative review articles (SANRA) criteria and involves a comprehensive literature search from July to August 2023. Two independent reviewers screened studies, including those involving human subjects with OA, rehabilitation strategies, and outcomes following HA injection, published in English. Results: HA injections might improve joint biomechanics, reducing friction, absorbing shocks, and potentially regulating inflammation. Rehabilitation plays a pivotal role in strengthening muscles, increasing the range of motion, and enhancing overall function. Optimizing rehabilitation following HA injection might provide additional benefits in joint health. OA management requires a multidisciplinary approach integrating HA injections, rehabilitation, and personalized care. Challenges in patient adherence and healthcare resources currently exist, but emerging technologies offer opportunities to enhance patient engagement and monitoring optimizing sustainability and outcomes of patients with knee, hip, shoulder, and temporomandibular joint OA.

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

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

Hyaluronic Acid in Rheumatology

Hyaluronic acid (HA), also known as hyaluronan, is an anionic glycosaminoglycan widely distributed throughout various tissues of the human body. It stands out from other glycosaminoglycans as it lacks sulfation and can attain considerable size: the average human synovial HA molecule weighs about 7 million Dalton (Da), equivalent to roughly 20,000 disaccharide monomers; although some sources report a lower range of 3-4 million Da. In recent years, HA has garnered significant attention in the field of rheumatology due to its involvement in joint lubrication, cartilage maintenance, and modulation of inflammatory and/or immune responses. This review aims to provide a comprehensive overview of HA's involvement in rheumatology, covering its physiology, pharmacology, therapeutic applications, and potential future directions for enhancing patient outcomes. Nevertheless, the use of HA therapy in rheumatology remains controversial with conflicting evidence regarding its efficacy and safety. In conclusion, HA represents a promising therapeutic option to improve joint function and alleviate inflammation and pain.

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

Background

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

Objective

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

Methods

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

Results

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

Conclusions

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

Ultrasound-Guided Transcutaneous Injection in the Lacrimal Gland: A Description of Sonoanatomy and Technique

Purpose: To develop a method of injecting a volume up to 50% of the lacrimal gland (LG) volume while minimizing patient discomfort and maximizing accurate drug delivery. Herein we describe a series of ultrasound (US)-guided transcutaneous injections in the LG and discuss the safety and feasibility of this technique. Methods: Ultrasonography was performed in 40 patients with aqueous deficient dry eye disease using a GE Logic E10 (Milwaukee, Wisconsin, USA) US machine with a 6-24 MHz transducer. US was performed by 2 medical experts in ultrasonography. We recorded the injection and observed an enlargement of the LG ensuring delivery within the LG before the needle was removed. Assessment of injection-related adverse event was performed immediately after the injection. Results: The position of the injection needle within the LG was documented in all 40 patients. Injection of the stem cells and vehicle (N = 20) or solely vehicle (N = 20) led to an enlargement of the glandular structures in all cases. No serious adverse reactions related to the injections were observed. Conclusion: US-guided injection into the LG enables injection on a closed eye causing minimum patient discomfort and maximum certainty of accurate drug delivery. US can provide real-time images and may be used to safely guide the needle ensuring correct placement and injection within the gland capsule. This reduces the risk of injury to the eye and adjacent structures and makes a precise transcutaneous injection possible. Clinical Trial Registration number: NCT04615455.

Musculoskeletal corticosteroid injections: Recommendations of the French Society for Rheumatology (SFR)

Musculoskeletal corticosteroid injections are widely performed, although the exact practice varies greatly due to advances in knowledge and techniques. This justifies updating and drawing up good practice recommendations. Using a consensus model formalized by the French National Authority for Health (HAS) and based on a literature review that resulted in a "white book", 13 recommendations were developed by a group of experts. These recommendations were then sent online to 48 specialists for evaluation, 27 of whom were rheumatologists and 15 of whom were general practitioners. These recommendations were also presented at the 34th annual meeting of the French Society for Rheumatology (SFR) (Paris, December 2021) at a symposium attended by a hundred or so rheumatologists, who voted on these recommendations in person. The results are presented as an overall score out of 10, a median out of 10 and as tertiles. The agreement was excellent for 10 of these 13 recommendations, with mean values of 8.5 to 9.1 out of 10, median values of 9 or 10 out of 10 and agreement of 91.7% to 97.9%, which corresponds to a consensus. The 3 other recommendations were broadly supported but were the subject of more debate. One relates to patient information (mean 7.3/10, median 8/10, upper tertile 72.9%) with discussion about the waiting period. Another related to the summary report (mean 8.4/10, median 9, upper tertile 91.7%) with discussions about its content and the need to specify the lot number of the injected product. The last one related to periprosthetic injections and the need to consult and get approval from a specialist (mean 8.0/10, median 8, upper tertile 83.3%) with mostly the general practitioners having reservations. In all, there is a very strong consensus among the musculoskeletal corticosteroid injection experts and specialists consulted, which justifies them being taken into consideration to improve our daily practice.

Current evidence and practical knowledge for ultrasound-guided procedures in rheumatology: Joint aspiration, injection, and other applications

Ultrasound (US)-guided procedures have increasingly gained their role in the daily practice of rheumatology, owing to the growing evidence supporting their utility. The utilization of US guidance in procedures may enhance their accuracy, efficacy, and safety. This article presents a comprehensive review of the current evidence and practical knowledge pertaining to US-guided procedures in rheumatology, encompassing joint aspirations, injections, and other applications such as tendon sheath injections. We provide a detailed description of the US-guided procedure process and compare the in-plane and out-of-plane view methods, along with practical techniques based on existing evidence or our own expertise. For each joint, we summarize how to perform procedures with figures to facilitate a better understanding. Additionally, we introduce other applications of US-guided procedures for tendons, enthesis, bursae, and nerves as well as emerging therapies such as US-guided fascia hydrorelease. By utilizing these US techniques, rheumatologists can achieve the ability to manage a wider range of musculoskeletal conditions.

Prognostic Factors Related to Clinical Response in 210 Knees Treated by Platelet-Rich Plasma for Osteoarthritis

Many studies have shown the effectiveness of platelet-rich plasma (PRP) in the treatment of knee osteoarthritis. We aimed to determine the factors associated with good or poor response to PRP injections in knee osteoarthritis. This was a prospective observational study. Patients with knee osteoarthritis were recruited from a university hospital. PRP was injected twice at a one-month interval. Pain was assessed on a visual analog scale (VAS) and function was assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Radiographic stage was collected and defined according to the Kellgren-Lawrence classification. Patients were classified as responders if they met the OMERACT-OARSI criteria at 7 months. We included 210 knees. At 7 months, 43.8% were classified as responders. Total WOMAC and VAS were significantly improved between M0 and M7. Physical therapy and a heel-buttock distance >35 cm were the two criteria associated with poor response at M7 by multivariate analysis. Pain VAS at M7 appeared to be lower in patients with osteoarthritis for less than 24 months. No adverse effects were reported. PRP treatment in knee osteoarthritis appears to be well-tolerated and effective, even in patients who reacted poorly to hyaluronic acid. Response was not associated with radiographic stage.

Bleeding complications in patients on warfarin undergoing joint injection/aspiration: systematic review and meta-analysis

Steroid injections in joints are commonly administered for the management of inflammatory or degenerative conditions. There is substantial controversy as to whether to continue warfarin when undertaking joint injection or aspiration. To assess the rate of bleeding complications in patients on warfarin undergoing joint injection/aspiration. Systematic review and meta-analysis. A literature search of 3 online databases was conducted by 2 reviewers using the Cochrane methodology for systematic reviews. Eligibility criteria were any study that reported bleeding complication rates in adult patients on warfarin undergoing a joint injection/aspiration whilst taking warfarin anticoagulation. Studies reporting on less than 5 patients were excluded. Meta-analysis was conducted using a random effects model. The search of databases resulted in a total of 1547 articles. After screening, 8 articles were deemed suitable for inclusion in the analysis, involving 871 injection/aspiration procedures. There were only 5 reported cases of bleeding. On meta-analysis the estimated bleeding complication rate was 1.5% (95% CI 0.5-4.5%). This meta-analysis shows that it is safe to perform joint injection and aspiration in patients on warfarin without routine prior testing of INR. Level of evidence: Level 4.

Construction and evaluation of a clinically relevant model of septic arthritis

Despite the creation of several experimental animal models for the study of septic arthritis, a protocol detailing the development of a reliable and easily reproducible animal model has not yet been reported. The experimental protocol described herein for the development of a clinically relevant mouse model of septic arthritis includes two main study stages: the first stage consisting of the preparation of the mice and of the methicillin-resistant Staphylococcus aureus (MRSA) cultures, followed by direct inoculation of MRSA into the knee joints of C57BL/6J mice (25-40 min); and a second study stage consisting of multiple sample collection and data analysis (1-3 days). This protocol may be carried out by researchers skilled in mouse care and trained to work with biosafety-level-2 agents such as MRSA. The model of septic arthritis described here has demonstrated clinical relevance in developing intra-articular inflammation and cartilage destruction akin to that of human patients. Moreover, we describe methods for serum, synovial fluid and knee joint tissue analysis that were used to confirm the development of septic arthritis in this model, and to test potential treatments. This protocol confers the advantages of enabling granular evaluation of the pathophysiology of MRSA infection and of the efficacy of therapeutic medications; it may also be employed to study a range of native joint diseases beyond inflammatory pathologies alone.

Efficacy, Safety, and Accuracy of Intra-articular Therapies for Hand Osteoarthritis: Current Evidence

The lifetime risk of symptomatic hand osteoarthritis (OA) is 39.8%, with one in two women and one in four men developing the disease by age 85 years and no disease-modifying drug (DMOAD) available so far. Intra-articular (IA) therapy is one of the options commonly used for symptomatic alleviation of OA disease as it can circumvent systemic exposure and potential side effects of oral medications. The current narrative review focuses on the efficacy and safety profiles of the currently available IA agents in hand OA (thumb-base OA or interphalangeal OA) such as corticosteroids and hyaluronic acid (HA), as well as the efficacy and safety of IA investigational injectates in phase 2/3 clinical trials such as prolotherapy, platelet-rich plasma, stem cells, infliximab, interferon-? and botulinum toxin, based on the published randomized controlled trials on PubMed database. The limited published literature revealed the short-term symptomatic benefits of corticosteroids in interphalangeal OA while long-term data are lacking. Most of the short-term studies showed no significant difference between corticosteroids and hyaluronic acid in thumb-base OA, usually with a faster onset of pain relief in the corticosteroid group and a slower but greater (statistically insignificant) pain improvement in the HA group. The majority of studies in investigational agents were limited by small sample size, short-term follow-up, and presence of serious side effects. In addition, we reported higher accuracy rates of drug administrations under imaging guidance than landmark guidance (blind method), and then briefly describe challenges for the long-term efficacy and prospects of IA therapeutics.

Chemically modified small interfering RNA targeting Hedgehog signaling pathway for rheumatoid arthritis therapy

Rheumatoid arthritis (RA) is an inflammatory disease that leads to disability; however, existing therapies are still unsatisfactory. Activated fibroblast-like synoviocytes (FLSs) play an essential role in synovitis formation and joint destruction in RA. The Hedgehog signaling pathway is aberrantly activated and contributes to the aggressive phenotype of RA-FLSs. However, it remains uncertain whether inhibiting Smoothened (SMO), a critical component of the Hedgehog signaling pathway, is an effective treatment for RA. Here, we design a series of small interfering RNAs (siRNAs) that specifically target the SMO gene. With precise chemical modifications, siRNAs' efficacy and stability are significantly improved, and the off-target effects are minimized. The optimized chemically modified siRNA (si-S1A3-Chol) decreases RA-FLS proliferation and invasiveness without the transfection reagent. Furthermore, si-S1A3-Chol injected intra-articularly effectively alleviates joint destruction and improves motor function in collagen-induced arthritis mouse models. Consequently, our results demonstrate that chemically modified siRNA targeting the Hedgehog signaling pathway may be a potential therapy for RA.

Optimizing the anti-inflammatory strategies in (osteo)arthritis: local or systemic?

Arthritis is affecting millions of people globally, involvement and distribution depending on the type of arthritis. The most common arthritic conditions are osteoarthritis (OA) and rheumatoid arthritis (RA). Despite the pathogeneses being fundamentally different, both joint diseases share the same need for local treatment of synovitis. No current treatment can stop the progression of OA. Local articulate treatment including glucocorticoid (GC) injections, radiosynoviorthesis (RSO) and surgical synovectomy are the only options to relieve pain and temporally improve movability before surgical intervention. For RA, despite effective systemic treatments, similarly need for local articulate treatment is still present, especially early in the disease, but also in case of recurrent episodes of disease flare. Current evidence supports local GC injection as first line treatment for persistent synovitis in a single or a few joints. RSO provides an evident and effective alternative for GC refractory synovitis, especially in early RA. Surgical synovectomy is an invasive alternative, but with less documented efficacy. Whether one unsuccessful intraarticular GC injection is enough to change of mode of action for local treatment is still unclear and needs to be further investigated. In conclusion persistent single joint synovitis in OA and RA is well treated with local treatment. Intra-articular GC injection is considered as first line of treatment, but RSO provides an additional treatment alternative with less side effects and better evidence of efficacy than surgical synovectomy.

Thermosensitive In Situ Gels for Joint Disorders: Pharmaceutical Considerations in Intra-Articular Delivery

The intra-articular administration of conventional drug solutions or dispersions in joint diseases such as osteoarthritis has a relatively short retention time and, therefore, limited therapeutic effect. Thermosensitive polymer solutions that exhibit a sol-gel phase transition near body temperature after injection can prolong drug retention by providing a depot from which the drug release is sustained while relieving inflammation and preventing degradation of the joint complex. Thermosensitive hydrogels have in recent times garnered considerable attention in the intra-articular therapeutics of joint diseases such as osteoarthritis. Among the stimuli-responsive gelling systems, most research has focused on thermosensitive hydrogels. These gels are preferred over other stimuli-sensitive hydrogels since they have well-controlled in situ gelling properties and are also easier to load with drugs. Temperature-sensitive polymers, such as block copolymers or poloxamers, are frequently used to modify their gelation properties, usually in combination with other polymers. They are compatible with most drugs but may pose formulation challenges in terms of their low-response time, highly fragile nature, and low biocompatibility. The stability and biodegradability of implant hydrogels can control the drug release rate and treatment efficacy. This review stresses the application of thermosensitive gels in joint disorders and summarizes recent developments for intra-articular application, including the incorporation of nanoparticles. The hydrogel composition, drug release mechanisms, and the challenges involved in their formulation and storage are also discussed.

Assessment of joint pharmacokinetics and consequences for the intraarticular delivery of biologics

Intraarticular (IA) injections provide the opportunity to deliver biologics directly to their site of action for a local and efficient treatment of osteoarthritis. However, the synovial joint is a challenging site of administration since the drug is rapidly eliminated across the synovial membrane and has limited distribution into cartilage, resulting in unsatisfactory therapeutic efficacy. In order to rationally develop appropriate drug delivery systems, it is essential to thoroughly understand the unique biopharmaceutical environments and kinetics in the joint to adequately simulate them in relevant experimental models. This review presents a detailed view on articular kinetics and drug-tissue interplay of IA administered drugs and summarizes how these can be translated into reasonable formulation strategies by identification of key factors through which the joint residence time can be prolonged and specific structures can be targeted. In this way, pros and cons of the delivery approaches for biologics will be evaluated and the extent to which biorelevant models are applicable to gain mechanistic insights and ameliorate formulation design is discussed.

EULAR points to consider for the use of imaging to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs)

OBJECTIVES

To develop evidence-based Points to Consider (PtC) for the use of imaging modalities to guide interventional procedures in patients with rheumatic and musculoskeletal diseases (RMDs).

METHODS

European Alliance of Associations for Rheumatology (EULAR) standardised operating procedures were followed. A systematic literature review was conducted to retrieve data on the role of imaging modalities including ultrasound (US), fluoroscopy, MRI, CT and fusion imaging to guide interventional procedures. Based on evidence and expert opinion, the task force (25 participants consisting of physicians, healthcare professionals and patients from 11 countries) developed PtC, with consensus obtained through voting. The final level of agreement was provided anonymously.

RESULTS

A total of three overarching principles and six specific PtC were formulated. The task force recommends preference of imaging over palpation to guide targeted interventional procedures at peripheral joints, periarticular musculoskeletal structures, nerves and the spine. While US is the favoured imaging technique for peripheral joints and nerves, the choice of the imaging method for the spine and sacroiliac joints has to be individualised according to the target, procedure, expertise, availability and radiation exposure. All imaging guided interventions should be performed by a trained specialist using appropriate operational procedures, settings and assistance by technical personnel.

CONCLUSION

These are the first EULAR PtC to provide guidance on the role of imaging to guide interventional procedures in patients with RMDs.

Triamcinolone acetonide-loaded nanoparticles encapsulated by CD90+ MCSs-derived microvesicles drive anti-inflammatory properties and promote cartilage regeneration after osteoarthritis

Background

Osteoarthritis (OA) is a highly prevalent human degenerative joint disorder that has long plagued patients. Glucocorticoid injection into the intra-articular (IA) cavity provides potential short-term analgesia and anti-inflammatory effects, but long-term IA injections cause loss of cartilage. Synovial mesenchymal stem cells (MSCs) reportedly promote cartilage proliferation and increase cartilage content.

Methods

CD90⁺ MCS-derived micro-vesicle (CD90@MV)-coated nanoparticle (CD90@NP) was developed. CD90⁺ MCSs were extracted from human synovial tissue. Cytochalasin B (CB) relaxed the interaction between the cytoskeleton and the cell membranes of the CD90⁺ MCSs, stimulating CD90@MV secretion. Poly (lactic-co-glycolic acid) (PLGA) nanoparticle was coated with CD90@MV, and a model glucocorticoid, triamcinolone acetonide (TA), was encapsulated in the CD90@NP (T-CD90@NP). The chondroprotective effect of T-CD90@NP was validated in rabbit and rat OA models.

Results

The CD90@MV membrane proteins were similar to that of CD90⁺ MCSs, indicating that CD90@MV bio-activity was similar to the cartilage proliferation-inducing CD90⁺ MCSs. CD90@NP binding to injured primary cartilage cells was significantly stronger than to erythrocyte membrane-coated nanoparticles (RNP). In the rabbit OA model, the long-term IA treatment with T-CD90@NP showed significantly enhanced repair of damaged cartilage compared to TA and CD90⁺ MCS treatments. In the rat OA model, the short-term IA treatment with T-CD90@NP showed effective anti-inflammatory ability similar to that of TA treatment. Moreover, the long-term IA treatment with T-CD90@NP induced cartilage to restart the cell cycle and reduced cartilage apoptosis. T-CD90@NP promoted the regeneration of chondrocytes, reduced apoptosis via the FOXO pathway, and influenced type 2 macrophage polarization to regulate inflammation through IL-10.

Conclusion

This study confirmed that T-CD90@NP promoted chondrocyte proliferation and anti-inflammation, improving the effects of a clinical glucocorticoid treatment plan.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s12951-022-01367-z.

Long-term injection of glucocorticoids in the knee joint cavity promotes loss of cartilage content.

CD90-positive stem cell vesicles encapsulated with Triamcinolone acetonide-loaded nanoparticles have good materials.

T-CD90@NPs drive anti-inflammatory properties and promote cartilage regeneration after osteoarthritis.

T-CD90@NPs regulate the polarization of type 2 macrophages to resist inflammation.

T-CD90@NPs promote chondrocyte regeneration through the FOXO signaling pathway.

Do Glucocorticoid Injections Increase the Risk of Knee Osteoarthritis Progression Over 5 Years?

OBJECTIVE

Recent findings have demonstrated that intraarticular (IA) glucocorticoid injections can be deleterious for knees with osteoarthritis (OA). This study was undertaken to assess, in a real-life setting, the risk of knee OA progression in patients who received IA glucocorticoid injections over a 5-year follow-up period.

METHODS

We used marginal structural modeling with inverse probability of treatment weighting to determine the causal association between IA glucocorticoid injections and the 5-year risk of disease progression in patients with symptomatic knee OA from the Knee and Hip Osteoarthritis Long-term Assessment cohort. OA progression was defined as an incident total knee replacement (TKR) and/or radiographic worsening (Kellgren/Lawrence [K/L] grade or joint space narrowing [JSN]). We also examined these outcomes in knees that received IA hyaluronan (IAHA) injections.

RESULTS

Among the 564 patients with knee OA included in the study sample, 51 (9.0%) and 99 (17.5%) received IA glucocorticoid or IAHA injections, respectively, and 414 (63.1%) did not receive any injection during follow-up. Compared to untreated knees, those treated with IA glucocorticoid injections had a similar risk of incident TKR (hazard ratio [HR] 0.92 [95% confidence interval (95% CI) 0.20, 4.14]; P = 0.91) or K/L grade worsening (HR 1.33 [95% CI 0.64, 2.79]; P = 0.44). IAHA injections had no effect on the risk of TKR (HR 0.81 [95% CI 0.14, 4.63]; P = 0.81) or K/L grade worsening (HR 1.36 [95% CI 0.85, 2.17]; P = 0.20). Similar results were obtained for JSN, and when TKR and radiographic outcomes were combined.

CONCLUSION

In this study, IA glucocorticoid injections for symptomatic knee OA did not significantly increase the 5-year risk of incident TKR or radiographic worsening. These findings should be interpreted cautiously and replicated in other cohorts.

Improvement in condition specific and generic quality of life outcomes in patients with knee osteoarthritis following single intraarticular viscosupplementation injection

Background

Non-operative management of Osteoarthritis (OA) can be challenging. The intra-articular injection with hyaluronic acid (IAHA), corticosteroids and Platelet rich plasma are some of the popular modalities which are increasingly being employed as a stop-gap strategy before considering any surgical intervention for OA management. Among these, the intra-articular HA (IAHA) has been widely studied with variable and conflicting results.

Method

This was a prospective observational study conducted in adults with knee OA. Suitable patients were given IAHA (Synvisc-One®) on an out-patient basis. They were assessed in terms of VAS score, WOMAC score and SF36 scores at successive follow-up visits at 8, 24 and 52 weeks.

Results

50 patients were recruited in this study and followed for 52 weeks post injection of HA. Mean and SD values of VAS, WOMAC and SF36 scores were on a decreasing trend in each follow up visit. Percentage change between the visits was also statistically significant. The improvement in pain scores at successive visits was significant in KL grade 1 OA than grade 2 or 3 indicating strong association between them.

Conclusion

Short-term (up to one year) beneficial effects of intra-articular viscosupplementation with HA in early primary knee OA can be seen with a decreasing trend in the intensity of pain and an increasing trend in improving the physical functioning and health-related quality of life.

Intra-articular therapies: patient preferences and professional practices in European countries

To assess patient perspective and professional practice of intraarticular therapies (IATs) across Europe, an expert international multidisciplinary panel designed two open web-based surveys: one targeting people who had experienced at least two IATs (44 items); and one targeting health care providers (HCPs) (160 items). Surveys were disseminated via patient and professional associations and social media. A descriptive analysis was performed. The surveys were answered by 200 patients and 186 HCPs from 26 countries, showing that IAT is routinely performed by rheumatologists (97%) and orthopaedic surgeons (89%), with specific training being compulsory in a few countries. The most frequent indications for IAT are arthritis (76%), osteoarthritis (74%), crystal arthritis (71%) and bursitis (70%); the most frequently injected joints are knee (78%) and shoulder (70%); and the most used compounds are glucocorticoids. The majority of HCPs report informing patients about side-effects (73%), benefits (72%), and the nature of the procedure (72%), which coincides with 27% of patients reporting that they had not been informed about benefits or potential complications of IATs; 73% of patients had not been asked whether they wanted an anaesthetic. Few HCPs (10%) obtain written consent (56% get oral consent, being mandatory for 32%), a procedure deemed necessary by 41% of the patients. 50% of patients reported a clear benefit of IAT and 20% experienced complications including pain, impaired mobility, rashes, or swelling. In summary, the practice of IAT is variable across Europe, and although patients perceive it as relatively safe and usually effective procedure, some gaps were identified.