EUROVISCO Guidelines for the Design and Conduct of Clinical Trials Assessing the Disease-Modifying Effect of Knee Viscosupplementation

EUROVISCO Good Practice Recommendations for a First Viscosupplementation in Patients with Knee Osteoarthritis

RATIONALE

Viscosupplementation (VS) with hyaluronic acid is widely used in the management of knee osteoarthritis. There is no clear recommendation on the decision-making to achieve VS.

DESIGN

Based on extensive research of the literature and expert opinion, the members of the EUROVISCO (European Viscosupplementation Consensus Group) task force were asked to give their degree of agreement with 60 issues, using a Delphi method.

RESULTS

The expert panel achieved unanimous agreement in favor of the following statements: It is recommended to assess pain on a visual or 10-point numeric scale before considering VS. VS can be considered for patients with pain scores between 3 and 8. A standard x-ray must be obtained before the decision of VS. If the x-ray is normal, osteoarthritis must be confirmed by MRI or computed tomography (CT) arthrogram before considering VS. The aims of VS are relieving pain, improving function, and reducing non-steroidal anti-inflammatory drug (NSAID) consumption. The use of VS must not be considered for treating an osteoarthritis flare. VS can be envisaged as a first-line pharmacological treatment in patients having a contra-indication to NSAIDs or analgesics. VS can be considered in patients with contra-indications to arthroplasty. In the case of severe comorbidities (diabetes, hypertension, gastrointestinal disorders, renal failure), VS can avoid the use of potentially dangerous treatments. VS can be considered in patients receiving antiplatelet agents, vitamin K antagonists, and direct factor Xa or thrombin inhibitors. Five other statements obtained a high level of consensus.

CONCLUSION

These recommendations, illustrated in a decision algorithm, have been established to help practitioners in the decision-making of knee VS.

Using a Double Syringe Sterile System for MSK Aspiration/Injection Procedures Eliminates Risk of Iatrogenic Infection

Introduction

Diverse musculo-skeletal pathology can be treated conservatively by different types of injections and in most cases, results are significantly better if the existing inflammatory fluid is aspirated prior to injection of medication solutions. The present study analyses an original technique which uses infusion therapy accessories to create two types of closed sterile double syringe systems, and compares the benefits of using such a system in aspiration/injection procedures to classic aspiration injection technique that implies changing and connecting multiple syringes to the same needle, thus increasing the risk for septic complications. The aim of the present study is to minimize therapeutic risk of iatrogenic septic complications during aspiration/injection procedures.

Methods

1024 patients underwent aspiration/injection procedures in our clinic using the double syringe system between 2015 and 2020. During the early stages of the study, the second type of assembly was rendered impractical so the study continued with analyzing a single type of double syringe system using a three way infusion therapy device which is readily available, and allows the assembly of a closed sterile system with a single, two-step procedure technique. Iatrogenic local septic complications were followed by means of a six week clinical follow-up evaluation with additional investigations only if necessary.

Results

In 1024 procedures we report 0% incidence of iatrogenic septic complications, or other types of complications and recommend this technique in a vast array of rheumatic, orthopedic or traumatic conditions that require aspiration/injection procedures.

Discussion

The double syringe system is practical, easy to use, it completely eliminates the risk of iatrogenic infection due to manipulation errors, and significantly simplifies the technique for sonography guided aspiration/injection procedures for musculo-skeletal pathology.

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

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

[Conservative treatment options for arthritis of the ankle : What is possible, what is effective?]

In this article the causes of arthritis in the region of the ankle are introduced and the conservative treatment options are described and discussed more extensively. The risks of treatment with nonopioid analgesics (NOPA) are presented in detail. The topical use of nonsteroidal anti-inflammatory drugs (NSAID) should always be considered in the clinical routine. If contraindications for oral NSAIDs are present, intra-articular treatment is a meaningful option. The best evidence is currently available for viscosupplementation but the study situation for the use of platelet-rich plasma (PRP) is still not sufficiently comprehensive and there are only a few case reports on the use of mesenchymal stem cells..

Retreatment with Hyaluronic Acid Viscosupplementation in Knee Osteoarthritis: Agreement between EUROVISCO Guidelines and Current Medical Practice

OBJECTIVES

This work studied if and how current clinical practice agrees with European Viscosupplementation Consensus Group (EUROVISCO) recommendations and how this agreement might be different according to physician's specialization. In addition, this work aimed to identify key decision factors that practitioners consider in their decision to retreat or not a patient with hyaluronic acid viscosupplementation.

METHODS

Practitioners have been invited by e-mail to participate in an online exercise on viscosupplementation retreatment. They received a fictional patient case at random among a set of predefined fictional cases. The platform asked the practitioner if he/she would retreat the patient with viscosupplementation or not. To take a decision, the practitioner could select questions among a list of predefined questions. Among them, some were related to criteria used in the EUROVISCO decision tree and others served as confounding factors.

RESULTS

A total of 506 practitioners participated to the exercise, of which 399 gave their decision about the case assigned to them by the platform. The observed agreement between practitioner decisions and EUROVISCO recommendations was 58.89 ± 4.95% (95% confidence interval [CI]). Overall, the decision to retreat was taken in 47.87% of the cases, while the EUROVISCO guidelines follow-up would have led to 55.89% retreatment for the same cases (P = 0.03).

CONCLUSIONS

In current practice, physicians tended to reinject their patients less than recommended, although EUROVISCO guidelines for viscosupplementation retreatment consider decision criteria that clearly correspond to those of practitioners in real life. These include the patients' willingness to be treated or the patients' perception of the effectiveness of the treatment.

Viscosupplementation for the treatment of osteoarthritis. The contribution of EUROVISCO group

Viscosupplementation (VS) is a symptomatic treatment for knee and other joint osteoarthritis (OA). Despite a long history of use, conflicting opinions remain on the best clinical indications and the most appropriate patients to be treated with intra-articular hyaluronic acid (IA-HA), the optimal dosing regimen and the modalities of retreatment. A multidisciplinary committee of European experts on OA (EUROVISCO) was constituted to formulate recommendations, aimed at helping physicians in the decision-making and the optimal achievement of VS. Before each session members were tasked to collate an exhaustive literature review. Level of evidence and strength of recommendation were based on the level of agreement for each item according to the Delphi method. In 2015, a consensus position was proposed for 24 statements. Among those that obtained a consensual agreement, the working group stressed that VS is effective in mild/moderate knee OA but is not an alternative to surgery in advanced OA, and that dosing regimen must be supported by controlled trials. In 2018, two decision algorithms for the retreatment with IA-HA in knee OA were published. Among the key recommendations, the experts recommended to re-treat every year patients with high risk of OA progression, even if not symptomatic. In 2020, EUROVISCO published two sets of recommendations for the design of clinical trials on the disease-modifying effect of VS and for optimizing the results of VS. The working group underlined that an accurate analysis of radiological features and symptoms and a careful clinical examination may improve the chances of success of VS, as well as good technique of injection and the use of imaging guidance. Based on the exhaustive analysis of the literature and their own clinical experience, the EUROVISCO experts offer a wide range of recommendations intended to help practitioners, particularly in certain cases where the specific characteristics of the patients make the therapeutic decision difficult.

Does vitamin D improve symptomatic and structural outcomes in knee osteoarthritis? A systematic review and meta-analysis

OBJECTIVE

To provide evidence on the effects of vitamin D supplementation on knee osteoarthritis (KOA) and new targets for clinical prevention and treatment of KOA.

METHOD

The PubMed, Embase, Web of science, Wanfang, CNKI and SinoMed databases were retrieved to investigate the effects of vitamin D supplementation on patients with KOA. The search time was from databases establishment to 15 November 2020. RevMan5.3 software was used for meta-analysis. The results were expressed as standardized mean difference (SMD) with 95% confidence interval (CI) or weighted mean difference (WMD) with 95% confidence interval (CI).

RESULTS

A total of 1599 patients with osteoarthritis of the knee were included in the study, which involved six articles. The results of the meta-analysis showed that vitamin D supplementation is statistically significant for WOMAC score (SMD = - 0.67, 95% CI - 1.23 to - 0.12) in patients with KOA, including WOMAC pain score (SMD = - 0.32, 95% CI - 0.63 to - 0.02), function score (SMD = - 0.34, 95% CI - 0.60 to - 0.08) and stiffness score (SMD = - 0.13, 95% CI - 0.26 to - 0.01). In subgroup analysis, vitamin D supplementation less than 2000 IU was statistically significant for the reduction of stiffness score (SMD = - 0.22, 95% CI - 0.40 to - 0.04). Vitamin D supplements can reduce synovial fluid volume progression in patients with KOA (SMD = - 0.20, 95% CI - 0.39 to - 0.02). There was no statistical significance in improving tibia cartilage volume (SMD = 0.12, 95% CI - 0.05 to 0.29), joint space width (SMD = - 0.10, 95% CI - 0.26 to 0.05) and bone marrow lesions (SMD = 0.03, 95% CI - 0.26 to 0.31).

CONCLUSION

Vitamin D supplements can improve WOMAC pain and function in patients with KOA. But there is a lack of strong evidence that vitamin D supplementation can prevent structural progression in patients with KOA.

Osteoarthritis year in review 2020: epidemiology & therapy

This personal choice of research themes and highlights from within the past year (1 May 2019 to 14 April 2020) spans descriptive, analytical-observational, and intervention studies. Descriptive estimates of the burden of osteoarthritis continue to underscore its position as a leading cause of disability worldwide, but whose burden is often felt greatest among disadvantaged and marginalised communities. Many of the major drivers of that burden are known but epidemiological studies continue the important work of elaborating on their timing, dose, specificity, and reversibility and placing them within an appropriate multi-level framework. A similar process of elaboration is seen also in studies (re-)estimating the relative benefits and risks of existing interventions, in some cases helping to identify low-value care, unwarranted variation, and initiating processes of deprescribing and decommissioning. Such research need not engender therapeutic nihilism. Our review closes by highlighting some emerging evidence on the efficacy and safety of novel therapeutic interventions and with a selective roll-call of methodological and meta-research in OA illustrating the continued commitment to improving research quality.

The tribology of cartilage: Mechanisms, experimental techniques, and relevance to translational tissue engineering

Diarthrodial joints, found at the ends of long bones, function to dissipate load and allow for effortless articulation. Essential to these functions are cartilages, soft hydrated tissues such as hyaline articular cartilage and the knee meniscus, as well as lubricating synovial fluid. Maintaining adequate lubrication protects cartilages from wear, but a decrease in this function leads to tissue degeneration and pathologies such as osteoarthritis. To study cartilage physiology, articular cartilage researchers have employed tribology, the study of lubrication and wear between two opposing surfaces, to characterize both native and engineered tissues. The biochemical components of synovial fluid allow it to function as an effective lubricant that exhibits shear-thinning behavior. Although tribological properties are recognized to be essential to native tissue function and a critical characteristic for translational tissue engineering, tribology is vastly understudied when compared to other mechanical properties such as compressive moduli. Further, tribometer configurations and testing modalities vary greatly across laboratories. This review aims to define commonly examined tribological characteristics and discuss the structure-function relationships of biochemical constituents known to contribute to tribological properties in native tissue, address the variations in experimental set-ups by suggesting a move toward standard testing practices, and describe how tissue-engineered cartilages may be augmented to improve their tribological properties.

Comparison of intra-articular injection of parecoxib vs oral administration of celecoxib for the clinical efficacy in the treatment of early knee osteoarthritis

BACKGROUND

Non-steroid anti-inflammatory drugs (NSAIDs) have played a crucial role in the treatment of osteoarthritis, especially in the early stages. However, the cardiovascular risk and adverse gastrointestinal reactions of oral NSAIDs in elderly people cannot be underestimated. Intra-articular injection of NSAIDs may be a new attempt for early knee osteoarthritis treatment. Parecoxib may be a suitable drug for intra-articular injection.

AIM

To observe the clinical efficacy of the intra-articular injection of parecoxib for early knee osteoarthritis.

METHODS

Early knee osteoarthritis patients (n = 110) were retrospectively analyzed. These patients were divided into three groups: Basic treatment + oral glucosamine (group A, n = 37), oral celecoxib + basic treatment + oral glucosamine (group B, n = 37), and intra-articular injection of parecoxib + basic treatment + oral glucosamine (group C, n = 36). Intra-articular injection of parecoxib was performed once every 2 wk at a dose of 40 mg each time, for three times total. The three groups were compared in terms of visual analogue scale (VAS) scores, Hospital for Special Surgery (HSS) scores and patient satisfaction before and after treatment. The levels of inflammatory cytokines in the synovial fluid were detected in the three groups before and after treatment.

RESULTS

All patients were followed up for an average of 15.5 ± 2.7 mo. The clinical efficacy was estimated by VAS and HSS scores at 12 mo after treatment. Inflammatory cytokine levels in the synovial fluid were evaluated at 3 mo after treatment. VAS and HSS scores were significantly improved in each group compared with before (P < 0.001). There were significant differences among the three groups in VAS and HSS scores (P < 0.001). The clinical efficacy of group C was superior to that of groups A and B (P < 0.001), while group B outperformed group A in this respect (P < 0.001). The patient satisfaction was the highest in group C (P < 0.001). After treatment, the levels of tumor necrosis factor α (TNF-α) and interleukin (IL)-6 in the synovial fluid decreased in each group compared with before (P < 0.001), while the levels of IL-10 increased (P < 0.001). The three groups differed significantly in the levels of TNF-a, IL-6 and IL-10 in the synovial fluid after treatment (P < 0.001).

CONCLUSION

For patients with early knee osteoarthritis, intra-articular injection of parecoxib could effectively improve clinical symptoms. This method may be a reliable alternative for early knee osteoarthritis.

Hyaluronan derivative HYMOVIS® increases cartilage volume and type ii collagen turnover in osteoarhritic knee: data from MOKHA study

BACKGROUND

The objective of this pilot study was to identify biological, clinical or structural biomarkers of an intra-articular hyaluronic acid injection efficacy (HYMOVIS®) for the design of a larger placebo-controlled clinical trial studying the disease-modifying activity of this treatment.

METHODS

Forty six patients with symptomatic knee Osteoarthritis (OA) were enrolled in this open-label, prospective, multicenter, pilot study. Patients received two treatment cycles of intra-articular injections (3 mL) of HYMOVIS® (8 mg/mL of hyaluronic acid hexadecylamide) at 6 months interval. Each treatment cycle involved two intra-articular injections 1 week apart. All patients had Magnetic Resonance Imaging (MRI) of the target knee at baseline and 1 year, and blood samples to assess joint biomarkers. The primary outcome was the change in type II collagen-specific biomarkers (Coll2-1, Coll2-1NO2 and CTX-II) after HYMOVIS® treatment versus baseline. Secondary endpoints included levels changes in aggrecan chondroitin sulfate 846 epitope (CS-846), Cartilage Oligomeric Matrix Protein (COMP), procollagen type II N-terminal propeptide (PIIANP), Matrix Metalloprotease (MMP)-3, Myeloperoxidase (MPO) and Interleukin (IL)-6 serum biomarkers, the ratio Coll2-1/PIIANP, CTX-II/PIIANP, variation of MRI cartilage volume, and Knee injury and Osteoarthritis Outcome Score (KOOS) index.

RESULTS

Coll2-1 serum levels significantly increased overtime while Coll2-1NO2 levels were only increased at D360. Serum PIIANP levels also progressively and significantly enhanced with time. In contrast, other serum biomarker levels including CTX-II, CS-846, COMP, MMP-3, MPO or IL-6 did not change significantly overtime. Interestingly, the ratios Coll2-1/PIIANP and CTX-II/PIIANP decreased, indicating a decrease of cartilage catabolism. Compared to baseline value, MRI cartilage volume and thickness increased in lateral femoral and lateral trochlea compartments and not in medial compartment. These results, in addition to an improvement of T2 mapping score suggest a positive structural effect of the product. Interestingly, WORMS effusion score, an indicator of synovitis, significantly decreased. Finally, global KOOS score and subscales significantly increased overtime while pain at rest, walking pain and patients or investigators global assessment of disease activity decreased. The safety profile was favorable with a low incidence of injection-site pain.

CONCLUSION

HYMOVIS®, a well-tolerated intra-articular treatment, significantly enhanced type II collagen turnover as suggested by the increase in Coll2-1 and PIIANP levels and cartilage volume observed by MRI in lateral knee compartment. Importantly, this study provides critical information for the design of a larger phase III clinical trial investigating Disease Modifying effect of HYMOVIS®.

TRIAL REGISTRATION

http://www.isrctn.com/ISRCTN12227846 11/02/2015.