Intra-articular administration of hylan G-F 20 in patients with symptomatic hip osteoarthritis: tolerability and effectiveness in a large cohort study in clinical practice

Bioprinting Au Natural: The Biologics of Bioinks

The development of appropriate bioinks is a complex task, dependent on the mechanical and biochemical requirements of the final construct and the type of printer used for fabrication. The two most common tissue printers are micro-extrusion and digital light projection printers. Here we briefly discuss the required characteristics of a bioink for each of these printing processes. However, physical printing is only a short window in the lifespan of a printed construct-the system must support and facilitate cellular development after it is printed. To that end, we provide a broad overview of some of the biological molecules currently used as bioinks. Each molecule has advantages for specific tissues/cells, and potential disadvantages are discussed, along with examples of their current use in the field. Notably, it is stressed that active researchers are trending towards the use of composite bioinks. Utilizing the strengths from multiple materials is highlighted as a key component of bioink development.

Intra-articular Injections of Cross-linked Hyaluronic Acid in Japanese Patients with Symptomatic Osteoarthritis of the Hip

Objectives

We investigated the efficacy and safety of Hylan G-F 20 for the treatment of hip osteoarthritis in Japanese patients.

Methods

Twenty-nine patients with hip osteoarthritis (OA) received Hylan G-F 20 injection into the hip. The visual analog scale of pain during gait (VAS-G), VAS of pain at rest, hip joint function evaluated by the Japanese Orthopaedic Association (JOA) score, health-related quality of life (HRQoL), and adverse events were evaluated before, immediately after, and at 4, 8, and 12 weeks after injection. Patients were categorized according to the severity of OA (mild and severe OA groups) and dysplasia (dysplastic and non-dysplastic groups) and these groups were compared.

Results

After the injection, VAS-G improved significantly for 12 weeks. VAS-G was lower (less pain) in the mild OA group than in the severe OA group at each time point. There were no differences in VAS-G between the dysplastic and non-dysplastic groups throughout the observation period. VAS-G improved significantly in the dysplastic group after the injection. The JOA score and HRQoL demonstrated the same tendency as VAS-G. Three patients experienced worsening of local pain immediately after the injection; however, the pain on the following day was less than that before the injection in all three hips.

Conclusions

Hylan G-F 20 injection into the hip joint was effective in reducing hip pain and can be used as a non-operative treatment option for hip OA in the Japanese population.

Viscosupplementation for hip osteoarthritis: Does systematic review of patient-reported outcome measures support use?

INTRODUCTION

Osteoarthritis of the hip is one of the leading causes of disability worldwide. There is lack of agreement among providers and governing agencies regarding the efficacy of hyaluronic acid (HA) for the management of hip osteoarthritis (OA). Therefore, the purpose of this systematic review was to determine how HA administration impacts 1) patient reported outcome measures (PROMs) and 2) rates of conversion to THA.

METHODS

The PubMed, EBSCO host, and Google Scholar electronic databases were queried for all studies published between January 1st, 2000 and January 1st, 2020 that reported on outcomes following HA administration for treatment of hip OA. The following keywords were implemented with AND and OR Boolean operators: "hip"; "osteoarthritis"; "arthritis"; "viscosupplementation"; "hyaluronic acid." Our final analysis included 39 studies and reported on a total of 5,864 patients receiving injections of HA.

RESULTS

All studies reporting on visual analog scale (VAS), patient global assessment, and total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores demonstrated improvements following HA administration. For the Lequesne Index (LI), WOMAC pain, WOMAC function, and Harris Hip Score (HHS) values, a majority of studies reported that HA would prove beneficial, with one analysis suggesting a lack of improvement. There was inconsistent evidence across studies regarding the effectiveness of HA compared to other intra-articular injections. The formulation of the administered viscosupplementation did not appear to influence outcomes. Furthermore, rates of conversion to THA were relatively low when evaluating 1- to 4-year follow-up intervals.

DISCUSSION

Non-comparative studies consistently demonstrated that HA can achieve satisfactory pain reduction and functional improvement. However, there was not enough evidence in the current literature regarding whether HA is superior to placebo or other types of intra-articular injections. Future studies should continue to compare HA to other treatment modalities in randomized controlled trials with larger sample sizes.

Efficacy of a Single Intra-Articular HYMOVIS ONE Injection for Managing Symptomatic Hip Osteoarthritis: A 12-Month Follow-Up Retrospective Analysis of the ANTIAGE Register Data

Purpose

The use of ultrasound (US) guidance has allowed hip osteoarthritis to be treated with intra-articular (IA) injections. HYMOVIS ONE (HYADD4-G) is a new hyaluronic acid (HA) derivative product with unusual characteristics, and it has been used with good results in knee osteoarthritis (OA). This study assessed the efficacy and safety of a single HYMOVIS ONE injection in patients affected by symptomatic hip OA.

Patients and Methods

This post-marketing cohort study assessed data from the ANTIAGE Register. Inclusion criteria were age ≥40 years, symptomatic hip OA (Kellgren-Lawrence grade I-III) of ≥1-year duration, and ≥12 months follow-up. All patients received a single HYMOVIS ONE (32 mg/4 mL) injection at baseline. Values for 10-cm visual analogue scale (VAS) pain scores, the Lequesne index, and nonsteroidal anti-inflammatory drug (NSAID) consumption were evaluated at 6 and 12 months. Adverse events were also recorded.

Results

The included patients (n = 198) consisted of 42.5% women, with a mean (± SD) age at baseline of 62 (± 14.2) years and a mean (± SD) body mass index of 26.3 (± 2.5). The mean (SD) Lequesne index and VAS pain scores at baseline were 11.5 (± 4.6) and 6.4 cm (± 2.2), respectively. All groups exhibited statistically significant reductions at all time points compared to baseline. At 12 months, the VAS pain score was reduced by 17.2%, the Lequesne index by 33.7%, and NSAID consumption by 41.7%.

Conclusion

Our study supports the clinical efficacy and safety of a single HYMOVIS ONE injection for managing symptoms in patients with hip OA, confirming previous data on the use of HYMOVIS as a background therapy in the management of knee osteoarthritis.

Intra-Articular Viscosupplementation for Patients with Hip Osteoarthritis: A Meta-Analysis and Systematic Review

BACKGROUND The aim of this study was to review the efficacy and safety of intra-articular (IA) viscosupplementation (VS) for hip osteoarthritis (OA). MATERIAL AND METHODS We searched Medline, Clinical Trial Register Center, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) comparing VS with placebo injection for hip OA. We included suitable studies, assessed the quality of studies, and extracted data on pain reduction, function improvement at different time points, and safety profiles. The comparisons of pain and function outcome were performed by meta-analysis. RESULTS Five high-quality randomized controlled studies trials (RCTs) with 591 patients with hip OA were identified. Although several trials demonstrated a significant decline in pain in VS groups during follow-up compared to baseline, without severe adverse events, the pooled analysis did not show VS was superior to placebo at any time windows [7-14 days: standardized mean difference (SMD): -0.18; 95% CI, -0.47 to 0.10, p=0.21; 28-30 days: 0.02 (-0.15, 0.19), p=0.82; or at final visit: -0.14 (-0.46, 0.18), p=0.38]. Similar results were also observed in the combined data of functional results. CONCLUSIONS IA VS does not reduce pain or improve function significantly better than placebo in a short-term follow-up. The benefits and safety of VS should be further assessed by sufficiently-sized, methodologically sound studies with validated assessment of more clinically relevant end-points.

Intra-articular therapy in hip osteoarthritis

Several therapeutic options have been used in the past for treatment of patients with hip osteoarthritis (HO). In recent years we have witnessed to the introduction of the intra-articular injection (IA) of hyaluronic acid (HA) in clinical practice. This technique was initially used to treat knee arthritis, for which was actually introduced, but hip anatomy itself (deeper joint structure) and technical features (different methods) pose more challenges. However, results look promising in terms of symptoms improvement and delaying prosthetic surgery. Indeed, it does appear mandatory to increase pool of available data with further studies in order to refine techniques, make them more effective, and target patients who could potentially benefit more than others from treatment.

Interactions between Hyaluronan and Its Receptors (CD44, RHAMM) Regulate the Activities of Inflammation and Cancer

The glycosaminoglycan hyaluronan (HA), a major component of extracellular matrices, and cell surface receptors of HA have been proposed to have pivotal roles in cell proliferation, migration, and invasion, which are necessary for inflammation and cancer progression. CD44 and receptor for HA-mediated motility (RHAMM) are the two main HA-receptors whose biological functions in human and murine inflammations and tumor cells have been investigated comprehensively. HA was initially considered to be only an inert component of connective tissues, but is now known as a “dynamic” molecule with a constant turnover in many tissues through rapid metabolism that involves HA molecules of various sizes: high molecular weight HA (HMW HA), low molecular weight HA, and oligosaccharides. The intracellular signaling pathways initiated by HA interactions with CD44 and RHAMM that lead to inflammatory and tumorigenic responses are complex. Interestingly, these molecules have dual functions in inflammations and tumorigenesis. For example, the presence of CD44 is involved in initiation of arthritis, while the absence of CD44 by genetic deletion in an arthritis mouse model increases rather than decreases disease severity. Similar dual functions of CD44 exist in initiation and progression of cancer. RHAMM overexpression is most commonly linked to cancer progression, whereas loss of RHAMM is associated with malignant peripheral nerve sheath tumor growth. HA may similarly perform dual functions. An abundance of HMW HA can promote malignant cell proliferation and development of cancer, whereas antagonists to HA-CD44 signaling inhibit tumor cell growth in vitro and in vivo by interfering with HMW HA-CD44 interaction. This review describes the roles of HA interactions with CD44 and RHAMM in inflammatory responses and tumor development/progression, and how therapeutic strategies that block these key inflammatory/tumorigenic processes may be developed in rodent and human diseases.

Symposium: evidence for the use of intra-articular cortisone or hyaluronic acid injection in the hip

The primary purpose of this review article is to discuss the role of diagnostic, corticosteroid, hyaluronic acid (HA) and platelet rich plasma (PRP) in the treatment of osteoarthritis (OA) and femoroacetabular impingement (FIA). These treatments play an important biological role in the non-operative management of these conditions. Two independent reviewers performed an search of PubMed for articles that contained at least one of the following search terms pertaining to intra-articular hip injection-local anaesthetic, diagnostic, ultrasound, fluoroscopic, image guided, corticosteroid, HA, PRP, OA, labral tears and FAI. Seventy-two full text articles were suitable for inclusion. There were 18 articles addressing the efficacy of diagnostic intra-articular hip injections. With respect to efficacy in OA there were 25 articles pertaining to efficacy of corticosteroid, 22 of HA and 4 of PRP. There were three articles addressing the efficacy of biologics in FAI. Diagnostic intra-articular hip injections are sensitive and specific for differentiating between intra-articular, extra-articular and spinal causes of hip symptoms. Ultrasound and fluoroscopy improves the precision of intra-articular positioning of diagnostic injections. Corticosteroids are more effective than HA and PRP in alleviating pain from hip OA. A higher dose of corticosteroids produces a longer benefit but volume of injection has no significant effect. Intra-articular corticosteroids do not increase infection rates of subsequent arthroplasty. There is currently limited evidence to warrant the routine use of therapeutic injections in the management of labral tears and FIA.

Is intra-articular hyaluronic acid effective in treating osteoarthritis of the hip joint?

Hyaluronic acid (HA) injections are used to treat osteoarthritis of the hip but their efficacy has not been clearly established. The purpose of this meta-analysis was to determine the effect of HA injections on hip pain. There were twenty-three studies that met our criteria and the mean decrease in visual analog scores (VAS) was -1.97 (95% CL, 2.83 to -1.12, P<0.0001). However, the clinical relevance of this change is difficult to determine since the decrease in VAS was only -0.27 in the six randomized trials in the study and the duration of follow-up in most studies was less than six months. Multicenter randomized trials are needed to determine the true efficacy of HA injections in decreasing pain associated with hip osteoarthritis.

Bilateral Hip Joint Hylan G-F 20 Granulomatous Synovitis due to Viscosupplementation Injections

We present the diagnosis of bilateral granulomatous inflammation of the hip joints associated with Hylan G-F 20 viscosupplementation injections. Clinicians recommending therapeutic Hylan injections for the management of hip arthritis should maintain clinical awareness regarding this potential complication.

Duration of symptom relief after intra-articular injection of hyaluronic acid combined with sorbitol (anti-ox-vs) in symptomatic hip osteoarthritis

The intra-articular administration of hyaluronic acid (HA) in hip osteoarthritis (OA) has been recently increased following the use of ultrasound guidance to perform an accurate delivery of the injected product. Viscosupplementation in hip OA seems to show similar results to those obtained by viscosupplementation in knee OA. However, an unmet need is the duration of symptomatic relief, therefore several new products are proposed to prolong and increase symptomatic effects. Among these, an innovative viscosupplement has been produced from high a concentration of HA combined with a high concentration of sorbitol as a free radical scavenger. The aim of this study is to evaluate the mid-term pain-relief effect of an ultrasound-guided injection of SynolisV-A (ANTI-OX-VS) in patients suffering from symptomatic hip osteoarthritis. Lequesne index, Health Assessment Questionnaire (HAQ), pain reduction, Global Patient Assessment (GPA), Global Medical Assessment (GMA) and reduction in monthly analgesic consumption were assessed during the 12-month follow-up after the injection. A total of 20 patients were enrolled in the study and received one IA US-guided injection of two syringes of ANTI-OX-VS into the target hip. Eleven drop-out patients were registered, of whom 2 were for loss of efficacy at 6 months, 1 for loss of efficacy at 9 months and 8 patients for severe comorbilities. Mean scores of all clinical parameters evaluated at each control visit were significantly different when compared with baseline mean value. No systemic adverse events were observed. Even though the sample size of this study is limited, the results suggest a durable good efficacy of a 4-ml single injection of ANTI-OX-VS in hip OA, at least for the patients who completed the study. A larger number of patients and an RCT are needed to confirm these data, investigating also the predictive factors of clinical response to ANTI-OX-VS.

Sorbitol-modified hyaluronic acid reduces oxidative stress, apoptosis and mediators of inflammation and catabolism in human osteoarthritic chondrocytes

OBJECTIVE AND DESIGN

Our study was designed to elucidate the precise molecular mechanisms by which sorbitol-modified hyaluronic acid (HA/sorbitol) exerts beneficial effects in osteoarthritis (OA).

METHODS

Human OA chondrocytes were treated with increasing doses of HA/sorbitol ± anti-CD44 antibody or with sorbitol alone and thereafter with or without interleukin-1beta (IL-1β) or hydrogen peroxide (H2O2). Signal transduction pathways and parameters related to oxidative stress, apoptosis, inflammation, and catabolism were investigated.

RESULTS

HA/sorbitol prevented IL-1β-induced oxidative stress, as measured by reactive oxygen species, p47-NADPH oxidase phosphorylation, 4-hydroxynonenal (HNE) production and HNE-metabolizing glutathione-S-transferase A4-4 expression. Moreover, HA/sorbitol stifled IL-1β-induced metalloproteinase-13, nitric oxide (NO) and prostaglandin E2 release as well as inducible NO synthase expression. Study of the apoptosis process revealed that this gel significantly attenuated cell death, caspase-3 activation and DNA fragmentation elicited by exposure to a cytotoxic H2O2 dose. Examination of signaling pathway components disclosed that HA/sorbitol prevented IL-1β-induced p38 mitogen-activated protein kinase and nuclear factor-kappa B activation, but not that of extracellular signal-regulated kinases 1 and 2. Interestingly, the antioxidant as well as the anti-inflammatory and anti-catabolic effects of HA/sorbitol were attributed to sorbitol and HA, respectively.

CONCLUSIONS

Altogether, our findings support a beneficial effect of HA/sorbitol in OA through the restoration of redox status and reduction of apoptosis, inflammation and catabolism involved in cartilage damage.

Viscosupplementation for osteoarthritis: a primer for primary care physicians

INTRODUCTION

Osteoarthritis (OA) constitutes a growing public health burden and the most common cause of disability in the United States. Non-pharmacologic modalities and conservative pharmacologic therapies are recommended for the initial treatment of OA, including acetaminophen, and topical and oral non-steroidal anti-inflammatory drugs. However, safety concerns continue to mount regarding the use of these treatments and none have been shown to impact disease progression. Viscosupplementation with injections of hyaluronans (HAs) are indicated when non-pharmacologic and simple analgesics have failed to relieve symptoms (e.g., pain, stiffness) associated with knee OA. This review evaluates literature focusing on the efficacy and/or safety of HA injections in treating OA of the knee and in other joints, including the hip, shoulder, and ankle.

METHODS

Relevant literature on intra-articular (IA) HA injections as a treatment for OA pain in the knee and other joints was identified through PubMed database searches from inception until January 2013. Search terms included "hyaluronic acid" or "hylan", and "osteoarthritis".

DISCUSSION

Current evidence indicates that HA injections are beneficial and safe for patients with OA of the knee. IA injections of HAs treat the symptoms of knee OA and may also have disease-modifying properties, potentially delaying progression of OA. Although traditionally reserved for second-line treatment, evidence suggests that HAs may have value as a first-line therapy in the treatment of knee OA as they have been shown to be more effective in earlier stages and grades of disease, more recently diagnosed OA, and in less severe radiographic OA.

CONCLUSION

For primary care physicians who treat and care for patients with OA of the knee, IA injection with HAs constitutes a safe and effective treatment that can be routinely administered in the office setting.

Intra-articular hyaluronic Acid as treatment in elderly and middle-aged patients with knee osteoarthritis

Introduction:

Osteoarthritis is the most common age-related degenerative joint disease. It affects all the joints containing hyaline cartilage. Knee osteoarthritis is the most cumbersome in terms of prevalence and disability. The aim of this study to evaluate the efficacy of intra-articular hyaluronic acid in patients with knee osteoarthritis with regard to joint pain and function, as well as patient satisfaction, assessed at one month and at one year, and by age group.

Methods:

In this prospective randomised study, 172 patients who were diagnosed knee OA and who received three consecutive intra-articular injections of HA weekly were included. Patients 65 years of age or older were accepted as the “elderly group”, and those under 65 were accepted as the “middle-aged group”. Clinical evaluations of efficacy and safety were conducted at the beginning of the study, one month after the third injection, and one year after the third injection.

Results:

In the two groups, the intragroup analysis revealed significant improvements following injection when compared with preinjection values. According to the last followup controls (after 12 months) in the middle-aged group, VAS activity pain, VAS rest pain, WOMAC physical function, and WOMAC pain values were found to be statistically lower when compared with pre-injection values. In the elderly group, no statistically significant differences were found between pre-injection and after 12 months.

Conclusion:

We can conclude that intra-articular joint HA injections are effective in both young and old patients with OA with regard to pain and functional status over a short-term period. Further, HA injections in patients younger than 65 years can be planned for a one-year period.

Targeting care: tailoring nonsurgical management according to clinical presentation

International evidence-based guidelines recommend a multitude of nonsurgical treatment options for the management of osteoarthritis. This article summarizes the evidence available for patient characteristics that have been analyzed as potential predictors of response to nonsurgical interventions for patients with hip and knee osteoarthritis. The specific variables targeted for this review include body mass index, psychological factors, muscle strength, tibiofemoral alignment, radiographic changes, and signs of inflammation. Several studies provide moderate to good evidence of potential predictors of response to nonsurgical treatments, and areas for future research are illuminated.

Kinematic and kinetic modifications in walking pattern of hip osteoarthritis patients induced by intra-articular injections of hyaluronic acid

BACKGROUND

A growing body of evidence points to the efficacy of intra-articular injections of hyaluronic acid, in dealing with pain and function in hip osteoarthritis. To date, however, no data exist as to this treatment's effect on walking pattern.

METHODS

We performed a prospective, open study in order to verify, in a group of 20 hip osteoarthritis patients (12 men, 8 women, mean age 60.5, range 47-73), the clinical effects of 3 intra-articular injections of 2 ml of hyaluronic acid in the hip (1/week) in terms of pain and function at 1 (T1), 3 (T2) and 6-month (T3) follow-ups, as well as changes in the kinematics and kinetics of gait at 6-month follow-up.

FINDINGS

Pain as measured with visual analog scale significantly dropped after this procedure (P<0.0001). A significant improvement was noted regarding stiffness (P=0.005) and disability (P=0.04), as measured by the Western Ontario and McMaster Universities osteoarthritis index. As regards gait analysis, patients at T3 walked with higher cadence (P=0.004) and stride length (P=0.02) compared to T0. Moreover, a significant increase for the pelvic tilt at heel contact (P=0.0004) and for hip flexion-extension moment at loading response sub-phases of gait cycle (P=0.02) was noted at T3.

INTERPRETATION

In line with current literature, our patients display clinical improvement 6 months after intra-articular injections of hyaluronic acid, accompanied by changes in walking pattern, as measured by instrumental gait analysis. The kinematic and kinetic changes observed may be the consequence of the therapeutic effect of intra-articular injections of hyaluronic acid.

Hyaluronic acid for the treatment of osteoarthritis in all joints except the knee: what is the current evidence?

BACKGROUND

The use of intra-articular hyaluronic acid (HA) is a well known treatment in patients with knee osteoarthritis (OA). In other joints, less evidence is available about the efficacy of treatment with intra-articular HA. HA is also used intra-articularly in the metatarsophalangeal-1 joint, the ankle, the hip, the sacroiliac joint, the facet joints, the carpometacarpal-1 joint, the shoulder and the temporo-mandibular joint. In this systematic review we include all prospective studies about the effects of intra-articular HA in the above-mentioned joints. Its use in the knee joint, however, will be discussed in a separate article in this journal.

METHODS

A systematic review was conducted using databases including MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, and EMBASE.

RESULTS

After performing a solid systematic review using a rigid methodology and trying to pool the outcomes of different studies, we noticed that, compared with baseline, there is statistical evidence for a positive effect of intra-articular HA. However, there is limited evidence HA is superior to placebo and no evidence that intra-articular HA is better than corticosteroids or other conservative therapies.

CONCLUSION

Our recommendation for future research is that one should focus on adequately powered randomized trials comparing HA treatment with other types of intra-articular or conservative treatment. We think it is useless to further perform and publish (large) non-comparative prospective studies about the use of HA in the treatment of problems caused by OA. It is well perceived that HA exerts positive effects in the treatment of OA, but up to now there is no (strong) evidence available that HA is superior to other treatments of OA such as corticosteroids, physiotherapy or other conservative measures.

The impact of treatment with hylan G-F 20 on progression to total hip arthroplasty in patients with symptomatic hip OA: a retrospective study

INTRODUCTION

There is scarce data available on intra-articular hyaluronan's ability to modify the progression of osteoarthritis (OA).

OBJECTIVE

The purpose of this retrospective pilot study was to assess the impact of treatment with hylan G-F 20 on progression to total hip replacement (THR) in patients with symptomatic hip OA.

RESEARCH DESIGN AND METHODS

The records of patients presenting with symptomatic hip OA and treated with hylan G-F 20 were analysed. Endpoints were the number of THRs performed and the survival time (in months) between commencement of treatment and THR, if performed. Endpoints were evaluated for the entire study population and for those sub-groups of patients which were, or were not, defined as candidates for THR prior to intra-articular treatment. Predictive factors of progression to THR were also assessed.

RESULTS

A total of 850 patients' records were evaluated and 224 patients' data were included in the study and evaluated. Eighty-four patients (37.5%) progressed to THR, 206 patients (92.0%) achieved 12 months survival, 170 patients (75.9%) achieved 24 months survival, and 69 patients (30.8%) achieved 5 years survival. Mean survival time was 36 months. Classification as a THR candidate, Lequesne score, ultrasound pattern and the presence of diabetes were predictive factors for progression to THR.

CONCLUSIONS

These results suggest that hylan G-F 20 could be included in the management of symptomatic hip OA before recommendation for THR, particularly in patients presenting with milder symptoms, or in patients where, due to comorbidities or personal choice, THR is not a feasible option. Limitations of this study include the retrospective study design and the lack of a control group to determine any placebo effect of hylan G-F 20. Further prospective studies are therefore needed to corroborate these results.

Efficacy and Safety Profile of Intra-Articular Administration of Jointex® in Patients Suffering from Symptomatic Hip Osteoarthritis: An Open, Prospective Study with a 12-Month Follow-up

Hip osteoarthritis represents a statistically relevant problem in clinical practice; previous reports showed different efficacy and safety profiles for intra-articular use of hyaluronic acid in hip osteoarthritis-affected patients, and in this sense, to add evidence to this topic, data regarding safety and efficacy of ultrasound-guided viscosupplementation are reported in order to establish whether such a therapeutic tool may represent a valid option. This study investigates the safety and efficacy profiles of ultrasound-guided intra-articular injections of Jointex® in hip osteoarthritis affected patients. This is a prospective multicentric study carried out in public hospitals. Adult outpatients suffering from symptomatic hip OA (Kellgren and Lawrence Grade 2, 3 or 4) were injected with one syringe of 4 ml (2 vials) of Jointex® under ultrasound guidance, repeated after six months; when clinically necessary an adjunctive injection was performed. Patients' characteristics, such as gender, age, weight, height and BMI, smoking habit, unilateral or bilateral hip OA, radiological grade for hip OA following Kellgren-Lawrence grading and duration of disease, were evaluated. Patients were assessed at baseline and at every control visit and injection time for Lequesne index as primary endpoint, pain (evaluated by VAS) and NSAID consumption (number of days patients assumed NSAID in the last month) both as secondary endpoint. A total of 180 patients entered the study, all of whom received at least one IA US-guided injection of Jointex® into the hip joint. A total of 36 drop outs were registered, and both distribution and causes of drop out were recorded. A total of 389 injections were carried out, as 18 patients were affected by bilateral hip OA and 7 patients affected by monolateral hip OA required one more injection for symptomatic relief in respect to other patients. Scores obtained for primary as well as secondary study endpoints reached statistical significance when compared with scores obtained at baseline visit. Lequesne index mean scores obtained at each control visit, when compared with baseline mean value, were significantly different (p<0.001 for all control visits vs baseline). Similarly, results obtained for secondary endpoints, such as Pain VAS and NSAID consumption, when compared with results obtained at the baseline visit, showed a statistical significance (p<0.001 for all control visits vs baseline). We also evaluated how many patients reached an improvement in Lequesne algo-functional index of at least 70% at 6- and 12-month control visits: a percentage of 21.23% of patients attending the 6-month control visit showed such improvement, while at the 12-month control the percentage was 20%. No local or systemic infectious adverse events were reported during the whole follow-up time. Twenty-seven patients out of 180 reported a transient discomfort in the treated hip for 1–3 days after injection that regressed spontaneously or with paracetamol 1 g two or three times a day. No systemic adverse events were observed. Intra-articular administration of Jointex® in hip OA-affected patients seems to be an efficacious and safe therapeutic option.

Viscosupplementation in the management of ankle osteoarthritis: a review

INTRODUCTION

Osteoarthritis (OA) is a disease of synovial joints and is the most common cause of chronic pain. Viscosupplementation (VS) with hyaluronic acid (HA) is largely used for knee osteoarthritis therapy but the evidence for its usefulness in ankle osteoarthritis is limited. The objective of this review is to assess the efficacy of viscosupplementation treatment of ankle osteoarthritis in the current literature.

METHODS

The following databases were searched: Medline (period 2006-2008), Database of Abstract on Reviews and Effectiveness and Cochrane Database of Systematic Reviews. Reference lists of relevant articles were controlled for additional references. The search terms Review, Viscosupplementation (VS), Osteoarthritis (OA), Hyaluronic acid (HA), Hyaluronan, Sodium hyaluronate, Ankle OA, Ankle joint were used to identify all studies relating to the use of VS therapy for the ankle OA. Methodological quality of included studies was assessed by assigning level of evidence as previously defined by the Centre for Evidence Based Medicine (CEBM).

RESULT

Seven articles concerning the efficacy of a total of 275 patients undergoing VS treatment for ankle OA were included. One European study, one Taiwanese study, one Italian study, one Turkish study and three American studies with level of evidence ranging from I to IV evaluated the following products: Hyalgan, Synvisc, Supartz, Adant.

CONCLUSION

Viscosupplementation is used widely in knee OA and is included in the professional guidelines for treatment of the disease in this joint. The potential for treating osteoarthritis of the ankle joint by viscosupplementation has been suggested in the literature, however, no dosing studies have been published to date, and dosing in the ankle joint remains an area for discussion. Viscosupplementation could potentially provide an useful alternative in treating such patients with painful ankle OA.

Hylan g-f 20: review of its safety and efficacy in the management of joint pain in osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a chronic degenerative joint disease that is a clinically and economically important disease. The increased prevalence of OA with aging, coupled to the demographics of aging populations, make OA a high priority health care problem. Viscosupplementation (VS) is a well-established treatment option in knee OA that is included in the professional guidelines for treatment of this joint disease, and could potentially provide a useful alternative in treating such patients with painful OA. Theoretically VS is an approach that should apply to all synovial joints.

OBJECTIVES

The aim of this review is to assess the efficacy and safety of viscosupplementation with Hylan GF-20 (Synvisc(®)) in the management of joint pain in osteoarthritis.

METHODS

THE FOLLOWING DATABASES WERE SEARCHED: Medline, Database of Abstract on Reviews and Effectiveness, Cochrane Database of Systematic Reviews. Furthermore, the lists of references of retrieved publications were manually checked for additional references. The search terms Review, Viscosupplementation, Osteoarthritis, Hyaluronic acid, Hyaluronan, Sodium Hyaluronate, Hylan GF-20, Synvisc, intra-articular injection were used to identify all studies relating to the use of Synvisc(®) viscosupplementation therapy in OA.

RESULTS

Hylan GF-20 is a safe and effective treatment for decreasing pain and improving function in patients suffering from knee and hip OA but new evidences are emerging for its use in other joints.

Hylan G-F 20 improves hip osteoarthritis: a prospective, randomized study

We compared the efficacy and safety of intra-articular hylan G-F 20 with methylprednisolone acetate (MPA) for treating symptomatic Kellgren-Lawrence grade (KLG) 2 or 3 hip osteoarthritis in a prospective, randomized, multicenter, double-blind trial (N = 313). Two injections of hylan G-F 20 were administered 2 weeks apart (n = 150), or 1 injection of 40 mg MPA and 1 sham injection 2 weeks later (n = 155). The Western Ontario and McMaster Universities Arthritis Index (WOMAC) (total and subscale), clinician observations, and patient global assessments were collected at baseline and at weeks 4, 8, 12, 16, 20, and 26 (intent-to-treat population was analyzed; n = 305). Responder rates were assessed by WOMAC domain A, and criteria were established by the Outcome Measures in Rheumatology Clinical Trials-Osteoarthritis Research Society International (OMERACT-OARSI). At week 26, WOMAC A improved by 16.6 mm for hylan G-F 20 versus 13.6 mm for MPA. Response rates were higher with hylan G-F 20 versus MPA in patients with more advanced disease (KLG 3) and were similar between hylan G-F 20 and MPA in patients with less advanced disease (KLG 2). Adverse events were similar between groups and between patients with KLG 2 or 3. Hylan G-F 20 provided clinically meaningful improvements in pain and function, comparable with those of MPA, with good safety and tolerability. Thus, we conclude it is an appropriate option for treating hip osteoarthritis.

Managing joint pain in osteoarthritis: safety and efficacy of hylan G-F 20

The use of intra-articular viscosupplementation in the nonoperative management of patients with osteoarthritis has become quite popular. Recent clinical data have demonstrated that the anti-inflammatory and chondroprotective actions of hyaluronic acid viscosupplementation reduce pain while improving patient function. We review the basic science and development of viscosupplementation and discuss the mounting evidence in support of the efficacy and safety profile of hylan G-F 20. Recent evidence suggesting a disease-modifying effect of hylan G-F 20 is also assessed. Furthermore, although the primary focus of this article is on treatment of osteoarthritis of the knee, we also discuss the use of viscosupplementation in other joints, such as the hip, ankle, and shoulder.

Knee vs hip single-joint intra-articular hyaluronic acid injection in patients with both hip and knee osteoarthritis: a pilot study

This paper aims to compare the results of single-joint knee vs hip hyaluronic acid (HA) injections in patients with osteoarthritis (OA) involving both the knee and hip joints. Thirty-eight patients who were diagnosed to have both hip and knee OA were enrolled. Patients were divided into two groups to receive HA injection three times at 1-week intervals either to the hip or knee joints. Pain level during activities and rest was measured by using visual analog scale (VAS). Western Ontario and McMaster University Osteoarthritis Index (WOMAC 5-point Likert 3.0) was also used prior to the injections and 1 month after the 3rd injection. In the knee injection group, the intragroup analysis revealed significant improvements in VAS activity pain, VAS rest pain, and WOMAC pain values following injection when compared with preinjection values, while no significant difference was detected in WOMAC stiffness, WOMAC physical function, and WOMAC total values. In the hip injection group, VAS activity pain, VAS rest pain, WOMAC pain, WOMAC stiffness, WOMAC physical function, and WOMAC total values showed significant improvement after the injection when compared with preinjection values. Although statistically not significant (p > 0.05), the comparison of the differences (preinjection-postinjection) between the groups demonstrated higher values in the hip injection group. We imply that intra-articular single-joint HA injections either to the knee or hip joints in OA patients with involvement of both of these joints are effective with regard to pain and functional status.