Intra-articular hyaluronic acid injection versus oral non-steroidal anti-inflammatory drug for the treatment of knee osteoarthritis: a multi-center, randomized, open-label, non-inferiority trial

Evaluating the diagnostic accuracy of a screening tool for low physical activity in independently ambulating adults with knee osteoarthritis: A prospective cohort study

BACKGROUND AND PURPOSE

Patients with knee osteoarthritis (OA) can benefit from resistance training exercises, range of motion and flexibility maintenance, and low-load aerobic exercises, as per the relevant clinical guidelines. However, certain patients might be unable to progress to higher physical levels despite such physical therapy programs. This study aimed to evaluate the diagnostic accuracy of a screening tool for determining physical activity levels in individuals with OA undergoing standard physical therapy regularly, using likelihood ratios and predictive values.

METHOD

This prospective observational study included 135 patients undergoing standard physical therapy for OA from six medical facilities. The primary outcome was low physical activity or moderate to high physical activity levels based on 1-month Self-Rating Frenchay activities index scores. Backward elimination was used to perform binomial logistic regression analysis after identifying the independent variables in a univariate logistic regression analysis. Among the independent variables adopted in the logistic regression model, receiver operating characteristic analysis using Youden's index was performed for quantitative variables, which were converted to binary values at the cut-off points. Subsequently, the clinical prediction rule (CPR) was derived.

RESULTS

According to the binomial logistic regression analysis, age, knee flexion muscle strength, and visual analog scale (VAS) were risk factors for low physical activity, and the CPR was derived from these variables. The pre-test probability of the low physical activity group was 37.0% (50 out of 135 participants). For a total CPR score of three points (one point for each item: age ≤69 years, knee flexion muscle strength ≤0.36 Nm/kg, and VAS ≥33 mm), the positive likelihood ratio was 13.60 and the post-test probability increased to 88.9%.

DISCUSSION

The CPR identified patients who might not benefit from the standard physical therapy program. This screening tool could improve patient management, allowing for more tailored approaches in physical therapy programs.

Mechanism of icariin for the treatment of osteoarthritis based on network pharmacology and molecular docking method

BACKGROUND

Icarin's mechanism of action in osteoarthritis (OA) was explored using network pharmacology and the GEO database, and then further validated using molecular docking.

METHODS

GEO database using network pharmacology identified differential genes in OA based on Icariin's possible targets predicted by pharmmapper database. Combining the differentially expressed genes in OA with the OA-related targets, the overlapping targets were removed. In order to determine what Icariin's core targets are for treating OA, PPI network analysis was performed using OA-related targets and possible Icariin targets. Furthermore, molecular docking was used to verify the chemical's binding to the targets. Final steps included Gene Ontology (GO) enrichment analysis and Kyoto Encyclopedia of genes and genomes (KEGG) pathway enrichment analysis. Cytoscape was used to construct a network of compound-target-pathway-disease.

RESULTS

Protein-protein interactions between overlapping targets revealed 151 intersection targets based on a network analysis. The top ten targets with the highest enrichment scores were SRC, MAPK1, HSP90AA1, AKT1, PTPN11, ESR1, EGFR, RhoA, JAK2, and MAPK14. KEGG enrichment analysis showed that the pathways at which Icariin intervention occurs include the OA including FOXO signaling pathway, and estrogen signaling pathway. The GO analysis result showed that various biologic processes such as proteolysis, angiogenesis, innate immune response, and positive regulation of inflammatory response were involved in treatment. Molecular docking analysis confirmed that Icariin could bind well to the targets through intermolecular forces.

CONCLUSION

With its multi-targeting and multi-pathway characteristics, Icariin is a promising candidate drug for treating OA.

Potential metabolites of Arecaceae family for the natural anti-osteoarthritis medicine: A review

Osteoarthritis (OA) is a chronic inflammatory disorder of the joints caused by fluid and cartilage matrix component reduction. This disease results in symptoms of pain, deformity, and limitation of movement. In general, OA is treated with anti-inflammatory drugs and chondroprotection compounds, includes natural nutraceutical ingredients, which are expected to be effective and have minimal side effects. Arecaceae plants are widely spread worldwide, especially in tropical areas. The objective of this review is to collect information about the Arecaceae family as anti-OA agents, with the main study focusing on the primary and secondary metabolites of plants of the Arecaceae family, i.e., sugar palm (Arenga pinnata), nipa palm (Nypa fruticans), palmyra palm (Borassus flabellifer), date palm (Phoenix dactylifera), and betel nut (Areca catechu) have potential as anti-OA agents. The Arecaceae's metabolites that show anti-inflammatory and chondroprotective effects are galactomannan, fatty acids (linoleic and linolenic acids), flavonoids (quercetin, luteolin, isorhamnetin), phenolics (coumaric acid, ferulic acid), polyphenols (epicatechin), and steroids (stigmasterol, campesterol, spirostane). Based on the reports, the Arecaceae family plants become worthy of being explored and developed into natural anti-OA products, such as supplements or nutraceuticals.

Derivation of a screening tool for predicting the risk of falls in community-dwelling older adults with knee osteoarthritis

The aim of this study was to derive a screening tool for predicting the risk of falls in community-dwelling older adults with knee osteoarthritis. This prospective cohort study was conducted in four orthopedic clinics. The main outcome measure was falls or nonfalls for 5 months, and the predictors were sex, age, BMI, Kellgren-Lawrence grade, laterality, number of comorbidities, pharmacotherapy, physical therapy period, use of a cane, household, previous history of falls, visual analog scale for pain, one-leg standing test (OLST), five times sit-to-stand test (FTSST), and Frenchay activities index. Ninety outpatients (74 females and 16 males) with a mean (SD) age of 73.1 (9.3) years completed a 5-month follow-up. According to the binomial logistic regression analysis, previous history of falls [odds ratio (OR), 6.85; P = 0.019], OLST (OR, 5.97; P = 0.048), and FTSST (OR, 12.93; P = 0.034) were identified as risk factors for falls, and the clinical prediction rule was derived from these variables. The pretest probability of fallers in this study was 21.1% (19 of 90 participants). When the total screening tool score was three points (the participant scored one point for each item: previous history of falls, yes; OLST, ≤6.84 s; FTSST, ≥8.77 s), the positive likelihood ratio was 16:19, and the posttest probability increased to 81.3%. Therefore, this simple screening tool possesses potential clinical utility for identifying patients with knee osteoarthritis at high risk of falls in the future because it demonstrated sufficient diagnostic test accuracy.

Osteoarthritis of the Knee in Middle-age Athletes: Many Measures are Practiced, but Lack Sound Scientific Evidence

Osteoarthritis of the knee generally affects individuals from the fifth decade, the typical age of middle-age athletes. In the early stages, management is conservative and multidisciplinary. It is advisable to avoid sports with high risk of trauma, but it is important that patients continue to be physically active. Conservative management offers several options; however, it is unclear which ones are really useful. This narrative review briefly reports the conservative options for which there is no evidence of effectiveness, or there is only evidence of short-term effectiveness.

Different changes in the biomarker C-terminal telopeptides of type II collagen (CTX-II) following intra-articular injection of high molecular weight hyaluronic acid and oral non-steroidal anti-inflammatory drugs in patients with knee osteoarthritis: a multi-center randomized controlled study

OBJECTIVES

We previously reported, based on a multicenter randomized-control study, that the efficacy of intra-articular injections of hyaluronic acid (IA-HA) was not inferior to that of oral non-steroidal anti-inflammatory drugs (NSAIDs) in patients with knee osteoarthritis (OA). However, the molecular effects on the pathophysiology of knee OA remain unclear. C-terminal telopeptides of type II collagen (CTX-II) is reported to primarily originate from the interface between articular cartilage and subchondral bone, which is a site of potential remodeling in OA. We performed a predefined sub-analysis of the previous study to compare the changes of urinary CTX-II (uCTX-II) in response to IA-HA to those in response to NSAID for knee OA.

DESIGN

A total of 200 knee OA patients were registered from 20 hospitals and randomized to receive IA-HA (2,700 kDa HA, 5 times at 1-week intervals) or NSAID (loxoprofen sodium, 180 mg/day) for 5 weeks. The uCTX-II levels were measured before and after treatment.

RESULTS

The uCTX-II levels were significantly increased by IA-HA treatment (337.7 ± 193.8 to 370.7 ± 234.8 ng/μmol Cr) and were significantly reduced by NSAID treatment (423.2 ± 257.6 to 370.3 ± 250.9 ng/μmol Cr). The %changes of uCTX-II induced by IA-HA (11.6 ± 29.5%) and NSAID (-9.0 ± 26.7%) was significantly different (between-group difference: 20.6, 95% confidence intervals: 10.6 to 30.6).

CONCLUSIONS

While both IA-HA and NSAID improved symptoms of knee OA, uCTX-II levels were increased by IA-HA and reduced by NSAIDs treatment, suggesting these treatments may improve symptoms of knee OA through different modes of action.

Hyaluronic acid as an adjunct to microfracture in the treatment of osteochondral lesions of the talus: a systematic review of randomized controlled trials

BACKGROUND

Osteochondral lesions of the talus (OLT) are common after ankle trauma. Studies have shown that bioactive substances, such as hyaluronic acid (HA), alone, or in combination, with surgical treatment could improve cartilage regeneration and repair, but the effect of HA on patient reported outcomes is unclear.

METHODS

Literature searches were performed across four databases (PubMed, SPORTDiscus, Scopus, and The Cochrane Library) for randomized controlled trials in which at least one treatment arm involved use of HA as an adjunct to microfracture to treat patients with OLT. Primary outcomes included the American Orthopaedic Foot and Ankle Society scores (AOFAS), and the Visual Analog Scale (VAS) for pain. The level of evidence and methodological quality were evaluated using the Modified Coleman Methodology Score (MCMS).

RESULTS

Three randomized studies were eligible for review with a total of 132 patients (35, 40, 57 patients, respectively) and follow-up ranged from 10.5 to 25 months. Utilization of HA at the time of microfracture resulted in greater improvement in AOFAS scores compared to microfracture alone. The pooled effect size was moderate (Standardized Mean Difference [SMD] 0.45, 95% Confidence Interval [CI] 0.06, 0.84; P = .02) and between-study heterogeneity was low (I-squared = 0%). Utilization of HA during microfracture also led to greater improvement in VAS-pain scores compared to microfracture alone. The pooled effect size was very large (SMD -3.86, 95% CI -4.75, - 2.97; P < .001) and heterogeneity was moderate (I-squared = 69%).

CONCLUSION

Hyaluronic acid injection as an adjunct to arthroscopic MF in OLT provides clinically important improvements in function and pain at short-term follow-up compared to MF alone. Future longer-term follow-up studies are warranted to investigate the durability of MF with HA for treatment of OLT.

Burden, Treatment Patterns and Unmet Needs of Osteoarthritis in Dubai: a Retrospective Analysis of the Dubai Real-World Claims Database

Introduction

Osteoarthritis (OA) is a degenerative joint disease that impacts 3.3–3.6% of population globally with significant health and societal impact. The current study assessed the disease burden, treatment patterns, and healthcare resource utilisation (HCRU) and costs in patients with OA and subgroups of hip and/or knee OA, in Dubai, United Arab Emirates (UAE).

Methodology

This retrospective longitudinal case–control study collected OA-related data from January 1, 2014 to May 31, 2020 from the Dubai Real-World Claims Database (DRWD). Adults aged at least 18 years old with OA diagnosis and at least two claims and continuous enrolment during the study period were included in the study. The patients with OA were 1:1 matched with individuals without OA. The patients with OA were divided into four cohorts on the basis of an a priori algorithm: OA of the hip and/or knee (cohort 1) and (difficult-to-treat) subsets of patients with moderate-to-severe OA of the hip and/or knee (cohort 2), inadequate response or inability to tolerate at least three pain-related medications (cohort 3), and contraindications to nonsteroidal anti-inflammatory drugs (NSAIDs) (cohort 4).

Results

Disease burden of OA in Dubai and HCRU and treatment costs in patients with OA were evaluated from January 1, 2014 to May 31, 2021. Patients were compared with matched controls in 1:1 ratio. The overall cohort comprised 11,651 patients with a median age of 48 years and predominantly male population (61.6%). HCRU was calculated for each cohort and it was highest (United States dollar [USD] 11,354.39) in cohort 4 (patients with contraindication to NSAIDS); in cohort 3 (inability to respond to at least three pain-related medications), USD 495.30 and USD 765.14 were spent on medication and procedures, respectively. Highest cost burden was seen in cohort 4, USD 3120.49 on consumables and USD 228.18 on services.

Conclusion

Osteoarthritis imposes a substantial healthcare and economic burden in the UAE. The study findings elucidate the unmet need among patients with difficult-to-treat OA and inform development of new therapeutics to alleviate their burden.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40744-021-00391-z.

Bone marrow aspirate concentrate and scaffold for osteochondral lesions of the talus in ankle osteoarthritis: satisfactory clinical outcome at 10 years

PURPOSE

To evaluate at long-term follow-up patients undergoing a one-step procedure of debridement and BMAC seeded in situ onto a scaffold for the treatment of osteochondral lesions of the talus (OLT) in ankles affected by osteoarthritis (OA), documenting the duration of the clinical benefit and its efficacy in postponing end-stage procedures.

METHODS

This series included 56 consecutive patients. Patients were evaluated preoperatively and up to a mean of 10 years of follow-up with the AOFAS score and the AOS scale, including pain and disability subscales. Furthermore, patients were asked to rate the satisfaction and failures were documented as well.

RESULTS

The AOFAS score improved from 52.3 ± 14.3 to 73.5 ± 23.1 at 10 years (p  < 0.0005); the AOS pain and disability subscales decreased from 70.9 ± 14.1 to 37.2 ± 32.7 and from 69.0 ± 14.8 to 34.2 ± 29.3, respectively (both p < 0.0005). The overall rate of satisfaction was 61.8 ± 41.2 and 68.6% of patients would undergo again the surgical procedure. A total of 17 failures was documented, for a failure rate of 33.3%. Older patients and those with more complex cases requiring previous or combined surgeries had lower outcomes, as well as those affected by grade 3 OA, who experienced a high failure rate of 71.4%.

CONCLUSIONS

This one-step technique for the treatment of OLT in OA ankles showed to be safe and to provide a satisfactory outcome, even if patients with end stage OA presented a high revision rate at 10 years. Moreover, this procedure was effective over time, with overall good results maintained up to a long-term follow-up. However, older age, more complex cases requiring previous or combined surgeries, and advanced OA led to an overall worst outcome and a significantly higher failure rate.

FGF2: a key regulator augmenting tendon-to-bone healing and cartilage repair

Ligament/tendon and cartilage injuries are clinically common diseases that perplex most clinicians. Because of the lack of blood vessels and nerves, their self-repairing abilities are rather poor. Therefore, surgeries are necessary and also widely used to treat ligament/tendon or cartilage injuries. However, after surgery, there are still many problems that affect healing. In recent years, it has been found that exogenous FGF2 plays an important role in the repair of ligament/tendon and cartilage injuries and exerts a synergistic effect with endogenous FGF2. Therefore, FGF2 can be used as a new type of biomolecule to accelerate tendon-to-bone healing and cartilage repair after injury.

Evolution of hydrogels for cartilage tissue engineering of the knee: A systematic review and meta-analysis of clinical studies

INTRODUCTION

In recent years, studies have boosted our knowledge about the biology and disorders of articular cartilage. In this regard, the design of hydrogel-based scaffolds has advanced to improve cartilage repair. However, the efficacy of knee cartilage repair using hydrogels remains unclear. The aim of systematic review and meta-analysis was to scrutinize the efficiency of hydrogel-based therapy in correcting cartilage defects of knee (femoral condyle, patella, tibia plateau and trochlea).

METHODS

The search was conducted in PubMed to gather articles published from 2004/1/1 to 2019/10/01, addressing the effects of implant of hydrogel on knee joint cartilage regeneration. The Cochrane Collaboration's tool for estimating the risk of bias was applied to check the quality of articles. The clinical data for meta-analysis was recorded using the visual analog scale (VAS), Lysholm score, WOMAC, and IKDC. The guidelines of Cochrane Handbook for Systematic Reviews of Interventions were utilized to conduct the review and meta-analysis in the RevMan 5.3 software.

RESULTS

The search resulted in 50 clinical trials that included 2846 patients, 986 of whom received cell-based hydrogel implants while 1860 patients used hydrogel without cell. There were significant differences comparing the pain scores based on the VAS (MD: -2.97; 95% CI: -3.15 to -2.79, P<0.00001) and WOMAC (MD: -25.22; 95% CI: -31.22 to -19.22, P<0.00001) between pre- and post-treatment with hydrogels. Furthermore, there were significant improvements in the functional scores based on the IKDC total score (MD: 30.67; P<0.00001) and the Lysholm knee scale (MD: 29.26; 95% CI: 26.74 to 31.78, P<0.00001). According to the Lysholm and IKDC score and after cumulative functional analysis, there was a significant improvement in this parameter (MD: 29.25; 95% CI: 27.26 to 31.25, P<0.00001).

CONCLUSIONS

This meta-analysis indicated clinically and statistically significant improvements in the pain score (VAS and WOMAC) and the functional score (IKDC and Lysholm) after the administration of hydrogel compared to pretreatment status. So, the current evidence shows the efficiency of hydrogel-based therapy in correcting and repairing knee cartilage defects.

Lack of standardization among clinical trials of injection therapies for knee osteoarthritis: a systematic review

Purpose: Osteoarthritis (OA) of the knee is a debilitating, expensive, and prevalent disease, and interest in the non-surgical management of knee OA has grown recently. Our objective was to systematically assess the level of heterogeneity among all clinical trials and published studies regarding injections for knee osteoarthritis, in terms of treatment of interest, outcomes evaluated, and time points of outcome assessment. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to review all published studies and publically available clinical trials from 1 January 2013 to 3 May 2019evaluating intra-articular injections to treat knee OA. Their treatment group and specifics of methodology were scrutinized and compared. Results: 84 published studies and 114 clinical trials were included. Within the 84 published studies, the most common injection treatment studied was hyaluronic acid [N = 22; 26.2%]. In total, 29 different injection treatment groups were utilized. The most common time point for patient evaluation post-injection was 6 months (N = 33 studies; 50.0%), and ranged from 1 week (N = 9 studies; 13.6%) to 7 years (N = 1 study; 1.5%). The most common patient-reported outcome (PRO) measure assessed in the included studies was Western Ontario and McMaster's University Osteoarthritis Index (WOMAC) [N = 44 studies; 66.7%]. For the 114 clinical trials identified, the most common injection treatment studied is platelet-rich plasma in isolation (N = 19; 16.7%). Forty-two different injection treatment types/groups are utilized. The most common PRO measure assessed was WOMAC (N = 77 trials; 67.5%). Overall there were 34 different patient-reported outcome measures used. Conclusions: Research efforts to find the most effective injection therapy for knee OA continue with a tremendous number of injection therapies still being evaluated. Substantial heterogeneity exists in these completed and ongoing trials in terms of patient demographics, OA grades, outcome scores and relatively short-term timing of assessments, with no clear standardization of testing protocol despite proposing to answer the same clinical question. We recommend that studies of this genre going forward be standardized in terms of outcome measures and longer-term follow-up time points, and should incorporate functional assessment evaluations and imaging studies.

Therapeutic effects of triptolide from Tripterygium wilfordii Hook. f. on interleukin-1-beta-induced osteoarthritis in rats

Osteoarthritis (OA) is a common yet destructive disease affecting the articular cartilage, and is a major cause of immense suffering and disability for millions of people. Previous studies have shown that triptolide (TPL), an active compound derived from Tripterygium wilfordii, has potent immunosuppressive and anti-inflammatory activities useful for treating chronic diseases. However, whether TPL has immunosuppressive activity against OA is not known. In this study, we assessed the therapeutic effects of TPL on interleukin-1-beta (IL-1β)-induced OA in rats. Histological and protein analyses revealed that TPL not only could inhibit interleukin-6 (IL-6) and cyclooxygenase-2 (COX2) protein expression in cells and disrupt inflammation, but it also reduced the expression of matrix metalloproteinase (MMP)-3 and 13. Our results also supported the ability of TPL to suppress the osteoprotegerin/receptor activator of nuclear factor kappa-beta (NF-κB)/receptor activator of NF-κB ligand (OPG/RANK/RANKL) and NF-κB signaling pathways induced by IL-1β. Together these data suggest that TPL may be a potentially valuable treatment for OA, regulating associated inflammation and pain.

Comparison of patient-reported outcomes of treatment with low- and intermediate molecular weight hyaluronic acid in Japanese patients with symptomatic knee osteoarthritis: A prospective, randomized, single-blind trial

Objectives

The objective of this study was to compare the clinical outcomes of treatment with low- or intermediate-molecular-weight hyaluronic acid (HA) in patients with knee osteoarthritis (OA).

Methods

In total, 59 patients with OA who fulfilled the criteria of the American College of Rheumatology for OA were enrolled. Patients were randomly assigned in a 1:1 ratio to the low- or intermediate-molecular-weight HA group. An intraarticular injection of HA into the knee joint was performed five times per week. The visual analog scale for pain (pain VAS) and Japanese Knee Osteoarthritis Measure (JKOM) score were analyzed at baseline and week 6 to assess the outcomes.

Results

Pain VAS and JKOM score were significantly improved in both groups. At follow-up, there were no significant between-group differences in pain VAS or total JKOM score. Moreover, reduction in pain VAS and JKOM score was not significantly different between the two groups.

Conclusions

Both low- and intermediate-molecular-weight HA have significant efficacy in the first-line treatment of patients with knee OA as indicated by patient-reported outcomes. However, there does not appear to be any difference between the efficacy of low- and intermediate-molecular-weight HA as indicated by the JKOM score. We believe that the results of this study provide important insights into the clinical management of Japanese patients with knee OA.

Hyaluronic Acid Injections or Oral Nonsteroidal Anti-inflammatory Drugs for Knee Osteoarthritis: Systematic Review and Meta-analysis of Randomized Trials

BACKGROUND

Intra-articular hyaluronic acid (HA) injections and oral nonsteroidal anti-inflammatory drugs (NSAIDs) are common treatments for symptomatic knee osteoarthritis (OA). However, the comparative effects of these treatments are unclear.

PURPOSE

To compare the efficacy and safety of intra-articular HA injections compared with oral NSAIDs for the treatment of knee OA.

STUDY DESIGN

Systematic review; Level of evidence, 1.

METHODS

We systematically searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for randomized trials of knee OA treatment with HA injections compared with oral NSAIDs. The main outcomes were knee pain, knee function, adverse events (AEs), serious AEs, study withdrawals, and study withdrawals because of AEs. Pooled effect sizes were reported at the final follow-up with standardized mean difference (SMD) for efficacy outcomes and risk ratio (RR) for safety outcomes.

RESULTS

In 6 randomized trials of 831 patients (414 HA, 417 NSAIDs), with follow-up ranging from 5 to 26 weeks, HA injections were associated with small, statistically significant improvements in knee pain (SMD, 0.15; P = .04) and knee function (SMD, 0.23; P = .01) compared with oral NSAIDs. The risk of AEs was lower with HA compared with NSAIDs (19.8% vs 29.0%; RR, 0.74; P = .01). The risk of a serious AE (RR, 1.37; P = .71), study withdrawal (RR, 1.05; P = .68), or study withdrawal because of an AE (RR, 0.65; P = .22) was comparable between groups. Gastrointestinal concerns were the most frequent AE reported, occurring more often with NSAIDs (23.4% vs 14.1%; P = .001). AEs reported more frequently with HA injections were injection site pain (11.7% vs 4.7%; P < .001), headache (8.4% vs 4.4%; P = .03), and arthralgia (8.1% vs 2.9%; P = .001). Significant heterogeneity or publication bias was not observed for any outcome.

CONCLUSION

Comparing short-term outcomes of HA injections with oral NSAIDs for treatment of knee OA, HA injections provided statistically significant but not clinically important improvements in knee pain and function, along with a lower overall risk of AEs.

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

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

Articular cartilage regeneration: The role of endogenous mesenchymal stem/progenitor cell recruitment and migration

BACKGROUND

Trauma- or osteoarthritis-related cartilage damage resulted in functional decline of joints and heavy burden of public health. Recently, the reparative role of mesenchymal stem/progenitor cells (MSCs) in articular cartilage (AC) reconstruction is drawing more and more attention.

OBJECTIVE

To provide a review on (1) the locations and categories of joint-resident MSCs, (2) the regulation of chondrogenic capacities of MSCs, (3) the migratory approaches of MSCs to diseased AC and regulatory mechanisms.

METHODS

PubMed and Web of Science were searched for English-language articles related to MSC recruitment and migration for AC repair until June 2019. The presence of various MSCs in or around joints, the potential approaches to diseased AC` and the regenerative capacities of MSCs were reviewed.

RESULTS

Various intra- and peri-articular MSCs, with inherent migratory potentials, are present in multiple stem cell niches in or around joints. The recruitment and migration of joint-resident MSCs play crucial roles in endogenous AC repair. Multiple recruiting signals, such as chemokines, growth factors, etc., emerge during the development of AC diseases and participate in the regulation of MSC mobilization. Motivated MSCs could migrate into cartilage lesions and then exert multiple reparative potentials, including extracellular matrix (ECM) reconstruction and microenvironment modulation.

CONCLUSION

In general, AC repair based on endogenous MSC recruitment and migration is a feasible strategy, and a promising research field. Furthermore, endogenous AC repair mediated by native MSCs would provide new opportunities to efficient preventative or therapeutic options for AC diseases.

Is Intra-Articular Injection of Synvisc Associated with a Delay to Knee Arthroplasty in Patients with Knee Osteoarthritis?

OBJECTIVE

There is debate about the effectiveness of intra-articular (IA) hyaluronic acid (HA) injections. We asked the following questions: (1) What is the epidemiology of IA HA use in knee arthroplasty (KA) patients? (2) Is Synvisc associated with a delay to KA? (3) Is there a difference in the delay to KA with the number of HA courses?

DESIGN

The Optum Clinformatics data set (2006-June 2016) was used to identify patients with knee osteoarthritis (OA). Patients who did not receive IA HA were identified, along with those who received Synvisc or non-Synvisc HA. The median duration from knee OA to KA was compared using quantile regression modeling with propensity score weighting. The trend in time to KA with each HA course was evaluated.

RESULTS

Of 4,027,848 knee OA patients, 141,305 patients underwent KA. Overall median time from knee OA diagnosis to KA was 1.2 years (average: 1.9 ± 1.9 years; interquartile range of 0.4-2.8 years). HA patients had significantly longer adjusted median time to KA by at least 7 months (P < 0.001). After adjusting for the time to HA and number of injections, Synvisc patients had 1.7 months longer time to KA than non-Synvisc HA patients (P < 0.001). There was a trend toward longer time to KA with more HA courses.

CONCLUSIONS

Most KA patients did not use HA (73.7%) and when received, it was associated with a longer median time to KA by at least 7 months, though the cause and effect could not be examined. The delay to KA increased with more HA courses.

Bioactive factors for cartilage repair and regeneration: Improving delivery, retention, and activity

Articular cartilage is a remarkable tissue whose sophisticated composition and architecture allow it to withstand complex stresses within the joint. Once injured, cartilage lacks the capacity to self-repair, and injuries often progress to joint wide osteoarthritis (OA) resulting in debilitating pain and loss of mobility. Current palliative and surgical management provides short-term symptom relief, but almost always progresses to further deterioration in the long term. A number of bioactive factors, including drugs, corticosteroids, and growth factors, have been utilized in the clinic, in clinical trials, or in emerging research studies to alleviate the inflamed joint environment or to promote new cartilage tissue formation. However, these therapies remain limited in their duration and effectiveness. For this reason, current efforts are focused on improving the localization, retention, and activity of these bioactive factors. The purpose of this review is to highlight recent advances in drug delivery for the treatment of damaged or degenerated cartilage. First, we summarize material and modification techniques to improve the delivery of these factors to damaged tissue and enhance their retention and action within the joint environment. Second, we discuss recent studies using novel methods to promote new cartilage formation via biofactor delivery, that have potential for improving future long-term clinical outcomes. Lastly, we review the emerging field of orthobiologics, using delivered and endogenous cells as drug-delivering "factories" to preserve and restore joint health. Enhancing drug delivery systems can improve both restorative and regenerative treatments for damaged cartilage. STATEMENT OF SIGNIFICANCE: Articular cartilage is a remarkable and sophisticated tissue that tolerates complex stresses within the joint. When injured, cartilage cannot self-repair, and these injuries often progress to joint-wide osteoarthritis, causing patients debilitating pain and loss of mobility. Current palliative and surgical treatments only provide short-term symptomatic relief and are limited with regards to efficiency and efficacy. Bioactive factors, such as drugs and growth factors, can improve outcomes to either stabilize the degenerated environment or regenerate replacement tissue. This review highlights recent advances and novel techniques to enhance the delivery, localization, retention, and activity of these factors, providing an overview of the cartilage drug delivery field that can guide future research in restorative and regenerative treatments for damaged cartilage.

Towards reaching consensus on hyaluronic acid efficacy in knee osteoarthritis

Intra-articular injection of hyaluronic acid (HA) is a controversial treatment for knee osteoarthritis (OA). While clinical efficacy of HA relative to saline injections has been demonstrated in many studies, these results are of limited value in real-world clinical practice since saline injection is not a knee OA treatment. Instead, rigorous postmarket comparative studies of HA versus approved knee OA treatments are encouraged. The conduct of such studies is particularly important given the paucity and heterogeneous nature of current evidence regarding nonsurgical knee OA treatment. KEY POINTS: • Societal guidelines recommend nonsteroidal anti-inflammatory drugs and corticosteroid injections, but not hyaluronic acid injections, for knee osteoarthritis (OA) despite inconsistent supportive data. • This article encourages rigorous comparative post-approval studies to clarify the role of nonsurgical treatments used in clinical practice for knee OA.

The effectiveness of high molecular weight hyaluronic acid for knee osteoarthritis in patients in the working age: a randomised controlled trial

Background

High molecular weight (HMW) hyaluronic acid (HA) is a treatment option for knee osteoarthritis (OA). The efficacy of HMW-HA in knee OA is investigated extensively, but the effectiveness in patients in the working age is unknown. Nevertheless, the number knee OA patients in the working age is increasing. Surgical treatment options are less eligible in these patients and productivity losses are high. In this study the effectiveness of intra-articular HMW-HA added to regular non-surgical usual care in everyday clinical practice (UC) compared to UC over 52 weeks in symptomatic knee OA patients in the working age was investigated.

Methods

In this open labelled randomized controlled trial, subjects aged between 18 and 65 years with symptomatic knee OA (Kellgren and Lawrence I-III) were enrolled and randomized to UC + 3 weekly injections with HMW-HA (intervention) or UC only (control). The primary outcome was the between group difference in responders to therapy according to OMERACT-OARSI criteria after 52 weeks. These criteria include the domains pain, knee related function and patient’s global assessment (PGA). Function was evaluated with the KOOS questionnaire. Pain was assessed with the Numeric Rating Scale. Secondary outcome comprised the between group difference on the individual responder domains, as analysed with a random effects model. Odds Ratios (OR) were calculated by logistic regression analysis. Sensitivity analyses were performed.

Results

In total, 156 subjects were included (intervention group 77, control group 79). Subjects in the intervention group (HMW-HA + UC) were more often responder compared to the controls (UC). Depending on whether pain during rest or pain during activity was included in the responder domains, 57.1% versus 34.2% (p = 0.006) and 54.5% versus 34.2% (p = 0.015) was responder to therapy respectively. The results of the secondary outcome analyses show that scores on individual responder domains over all follow-up moments were statistically significant in favour of the intervention group in the domains pain during rest (δ 0.8, 95%CI 0.2; 1.4, p = 0.010), knee related function (δ − 6.8, 95%CI -11.9; − 1.7, p = 0.010) and PGA (δ − 0.7, 95%CI -0.9; − 0.4, p < 0.0001).

Conclusions

Intra-articular HMW-HA added to usual care is effective for knee OA in patients in the working age.

Trial registration

www.trialregister.nl, NTR1651, registered 2009-3-3.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2546-8) contains supplementary material, which is available to authorized users.

Cost-of-illness of knee osteoarthritis: potential cost savings by not undergoing arthroplasty within the first 2 years

Purpose

Although knee arthroplasty (KA) is the largest source of hospitalization costs for knee osteoarthritis (OA), some studies have suggested reducing the use of “low-value” interventions, such as intra-articular hyaluronic acid (HA), to lower health care costs. However, those studies fail to consider that HA has demonstrated benefits in extending time to more costly KA or avoiding KA altogether. We evaluated 1) the overall knee OA costs (direct) within a 2-year period; 2) the relative contribution of HA and KA costs; 3) the direct cost savings from HA patients not undergoing KA.

Patients and methods

Knee OA patients were identified from the Optum Clinformatics data set, which includes physician, facility, and pharmacy claims data from privately insured patients of all ages. Patients were stratified in the no HA, non-hylan G-F 20, and hylan G-F 20 cohorts. The cumulative costs (payer perspective) were evaluated for all knee OA-related claims (adjusted to Consumer Price Index Jan 2017$) for patients who had at least 2 years follow-up. Costs were stratified into various clinical categories.

Results

The study cohort included 2,030,497 knee OA patients, of which 65,144 patients (3.2%) underwent KA. The cost of treating knee OA within the 2-year follow-up period was estimated to be $4.99 billion (B). The majority of the costs (69%) were attributed to KA patients (3.2% of patients). In all, 15.9% of the HA patients underwent KA within 2 years, but HA only contributed 1.7% to the total costs for these patients. The remaining 84.1% of HA patients did not undergo KA, which saved an estimated total of $1.54B (average $20,740 per patient) or 83.9%, after accounting for their non-KA therapies.

Conclusion

Our study estimated substantial cost savings through a large percentage of HA patients not undergoing KA. Although a fraction of patients moved on from their conservative therapy to undergo KA within the 2-year period, HA attributed to <2% of their total treatment costs.

Antinociceptive effects of hyaluronic acid on monoiodoacetate-induced ankle osteoarthritis in rats

Purpose

Ankle osteoarthritis (OA) causes significant pain and debilitation; yet, its underlying mechanisms remain unclear. Clinically, hyaluronic acid (HA) is widely used to treat OA. The present study aimed to investigate the roles of HA in pain-related behavior, joint function, swelling, and pathological changes in cartilage in a rat model of monoiodoacetate (MIA)-induced ankle OA.

Materials and methods

Male Sprague Dawley rats were assigned to three experimental groups as follows: 1) MIA rats injected with 1 mg MIA in the right tibiotarsal joint for two consecutive days; 2) sham rats injected with saline instead of MIA; and 3) MIA-HA rats injected with HA in the tibiotarsal joint at 7, 14, and 21 days after MIA injection. Joint swelling, range of motion (ROM), and pain-related behavior were evaluated 1 day before and on the 7th, 14th, 21st, and 28th day after MIA or saline injection. Pathological changes in the ankle joint were assessed 28 days after MIA or saline injection.

Results

No significant difference in the degree of ankle swelling or ROM reduction was observed between MIA rats and MIA-HA rats. However, compared with those in MIA rats, mechanical and thermal hypersensitivity was significantly reduced and stride length significantly improved in MIA-HA rats. Histologic analysis revealed that cartilage degeneration was significantly suppressed in MIA-HA rats compared with that in MIA rats, reflecting the chondroprotective effects of HA.

Conclusion

HA improved pain-related behavior and stride length and suppressed MIA-induced cartilage degeneration. HA may thus inhibit OA progression and suppress peripheral and/or central sensitization.

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

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

Viscosupplementation for Osteoarthritis of the Knee: A Key Opinion Leader Panel Discussion

With a sharp rise in the prevalence of osteoarthritis of the knee (OAK) in a younger population, new management strategies are needed to preserve mobility, improve patients' quality of life, and reduce the effects of potential disease-related comorbidities. Viscosupplementation with the use of hyaluronic acid (HA) injection is a treatment option for OAK that can provide lubrication and elastic shock absorption, leading to potential pain relief, improved function, and reduced stiffness. A key opinion leader (KOL) panel discussion was held December 3, 2016, with the objective of sharing opinions, ideas, information, and trends regarding OAK and the potential treatment and management offered by viscosupplementation. The panel concluded that viscosupplementation with HA injections presents a viable, cost-effective, and safe alternative for the treatment of OAK.

DISCLOSURES

This panel discussion and report was facilitated by Magellan Rx Manage-ment and funded by Sanofi. Bert and Ruane report fees from Sanofi outside of this project. Sgaglione reports royalty payments from Zimmer Biomet and Wolters Kluwer. Dasa has received fees from Bioventus and Myoscience. All the authors received an honorarium for work on this project. Lopes is employed by Magellan Rx Management.

Photo-crosslinked HAMA hydrogel with cordycepin encapsulated chitosan microspheres for osteoarthritis treatment

Autophagy is a protective mechanism in normal cartilage. The present study aimed to investigate the synergistic therapeutic effect of promotion of chondrocyte autophagy via exposure to cordycepin encapsulated by chitosan microspheres (CM-cordycepin) and photo-crosslinked hyaluronic acid methacrylate (HAMA) hydrogel, with the goal of evaluating CM-cordycepin as a treatment for patients with osteoarthritis. First, we developed and evaluated the characteristics of HAMA hydrogels and chitosan microspheres. Next, we measured the effect of cordycepin on cartilage matrix degradation induced by IL1-β in chondrocytes and an ex vivo model. Cordycepin protects cartilage from degradation partly by activation of autophagy. Moreover, we surgically induced osteoarthritis in mice, which were injected intra-articularly with CM-cordycepin and HAMA. The combination of CM-cordycepin and HAMA hydrogel retarded the progression of surgically induced OA. Cordycepin ameliorated cartilage matrix degradation at least partially by inducing autophagy in vivo. Our results demonstrate that the combination of cordycepin encapsulated by CMs and photo-crosslinked HAMA hydrogel could be a promising strategy for treating patients with osteoarthritis.

Sulfated hyaluronan attenuates inflammatory signaling pathways in macrophages involving induction of antioxidants

It is well recognized that high molecular weight hyaluronan (H-HA) exerts potent anti-inflammatory effects while its fragmentation into low molecular weight HA (L-HA) is discussed to promote inflammation. Chemical modification of HA with sulfate groups has been shown to foster its anti-inflammatory activity which seems to be maintained in sulfated low molecular weight HA derivatives (sL-HA). However, the molecular mechanisms by which sL-HA produces its anti-inflammatory activity are not understood. In this study, we used global quantitative proteomics combined with targeted analysis of key proteins to characterize the effect of sL-HA on fully differentiated human inflammatory macrophages (iMФ). Culture of iMФ with sL-HA did not affect cell viability but resulted in a reduced pro-inflammatory cytokine response of iMФ after activation indicating a profound counter-regulation of their initial inflammatory phenotype. Rapid internalization of sL-HA involving CD44 and scavenger receptors was observed. Furthermore, an upregulation of the antioxidants SOD2 and SOD3 was found while no oxidative stress was induced. Consequently, activity of transcription factors for inflammatory gene expression was downregulated in iMФ with sL-HA after activation whereas anti-inflammatory proteins were induced. This study proves anti-inflammatory properties of sL-HA and provides information on its regulatory mode of action on iMФ.

In vitro effects of hyaluronic acid on human periodontal ligament cells

Background

Hyaluronic acid (HA) has been reported to have a positive effect on periodontal wound healing following nonsurgical and surgical therapy. However, to date, a few basic in vitro studies have been reported to investigating the potential of HA on human periodontal ligament (PDL) cell regeneration. Therefore, the aim of this study was to investigate the effect of HA on PDL cell compatibility, proliferation, and differentiation in vitro.

Methods

Either non-cross-linked (HA_ncl) or cross-linked (HA_cl) HA was investigated. Human PDL cells were seeded in 7 conditions as follows (1) Control tissue culture plastic (TCP) (2) dilution of HA_ncl (1:100), (3) dilution of HA_ncl (1:10), 4) HA_ncl directly coated onto TCP, (5) dilution of HA_cl (1:100), 6) dilution of HA_cl (1:10) and (7) HA_cl directly coated onto TCP. Samples were then investigated for cell viability using a live/dead assay, an inflammatory reaction using real-time PCR and ELISA for MMP2, IL-1 and cell proliferation via an MTS assay. Furthermore, the osteogenic potential of PDL cells was assessed by alkaline phosphatase(ALP) activity, collagen1(COL1) and osteocalcin(OCN) immunostaining, alizarin red staining, and real-time PCR for genes encoding Runx2, COL1, ALP, and OCN.

Results

Both HA_ncl and HA_cl showed high PDL cell viability (greater than 90%) irrespective of the culturing conditions. Furthermore, no significant difference in both mRNA and protein levels of proinflammatory cytokines, including MMP2 and IL-1 expression was observed. Both diluted HA_ncl and HA_cl significantly increased cell numbers compared to the controlled TCP samples at 3 and 5 days. HA_ncl and HA_cl in standard cell growth media significantly decreased ALP staining, COL1 immunostaining and down-regulated early osteogenic differentiation, including Runx2, COL1, and OCN mRNA levels when compared to control samples. When osteogenic differentiation medium (ODM) was added, interestingly, the expression of early osteogenic markers increased by demonstrating higher levels of COL1 and ALP expression; especially in HA 1:10 diluted condition. Late stage osteogenic markers remained inhibited.

Conclusions

Both non-cross-linked and cross-linked HA maintained high PDL cell viability, increased proliferation, and early osteogenic differentiation. However, HA was consistently associated with a significant decrease in late osteogenic differentiation of primary human PDL cells. Future in vitro and animal research is necessary to further characterize the effect of HA on periodontal regeneration.

TNF-α concentrations in pre-operative synovial fluid for predicting early post-operative function and pain after fast-track total knee arthroplasty

BACKGROUND

Tumor necrosis factor-alpha (TNF-α) helps regulate neuroinflammation and anxiety and could conceivable predict early post-operative pain and function after fast-track total knee arthroplasty (TKA).

METHODS

In patients with severe osteoarthritic knees undergoing TKA, we assessed: the correlations between pre-operative concentrations of TNF-α in synovial fluid; pre- and six-week post-operative knee function and pain; pre- and post-operative anxiety; pre- and post-operative synovial fluid concentrations of cartilage oligomeric matrix protein (COMP); age and body mass index (BMI).

RESULTS

Of 100 enrolled patients, 78 had evaluable TNF-α data, and 58 had evaluable COMP data. Pre-operative TNF-α concentrations were inversely correlated with post-operative pain scores during walking (r_S=-0.26, P=0.03) and with change of pain at rest during six weeks after TKA (r_s=-0.28, P=0.03) and were directly correlated with a higher post-operative Knee Society score (KSS) (r_S=0.43, P<0.001) and with greater increases in this score during six weeks after TKA (r_S=0.33, P=0.001). Mean TNF-α concentrations were higher in the 39 patients reporting any pre-operative pain at rest than in 36 patients reporting no pre-operative pain (P=0.015) and were the only independent predictor of pre-operative pain at rest (OR=13, P=0.02). Independent predictors of better post-operative knee function were higher log-transformed TNF-α concentrations (β=0.38, P=0.002) and male sex (β=0.28, P=0.02).

CONCLUSIONS

High levels of pre-operative TNF-α concentrations could be used as an independent predictor of better knee function at six weeks of follow-up. In patients with lower pre-operative TNF-α concentrations, post-operative pain management may improve the early outcome of the operated joint.

Nonsurgical Management of Osteoarthritis Knee Pain in the Older Adult

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

Chondroprotective effect of high-molecular-weight hyaluronic acid on osteoarthritic chondrocytes in a co-cultivation inflammation model with M1 macrophages

BACKGROUND

Osteoarthritis (OA) is described by an imbalance between anabolic and catabolic processes in the affected joint. This dysregulation of metabolism affects not only chondrocytes within cartilage tissue but also the cells of the synovial membrane across the border of the joint. An important factor in OA is the low viscosity of the synovial fluid. High-molecular-weight hyaluronic acid (HA) can be used to increase the viscosity and also reduce inflammatory processes. The purpose was to establish an in vitro inflammation model and to evaluate the effects of high-molecular-weight HA in a co-cultivation inflammation model of osteoarthritic chondrocytes and M1 macrophages.

METHODS

For the establishment of the inflammation model THP-1 cells were, at first, differentiated to M0 macrophages and then activated to the M1 subtype after 5 days of resting period. Surface markers, cytokine release, and gene expression, were analyzed to examine the successful differentiation. In the inflammation model, the defined M1 macrophages were co-cultivated with osteoarthritic chondrocytes for 2 days, with and without the addition of 10 % HA and further analyzed for chondrogenic gene expression markers and the release of cytokines in the supernatant.

RESULTS

The differentiation and activation process was successful as M1 macrophages expressed higher levels of pro-inflammatory cytokines and specific genes. Similarly, the surface marker CD14 was significantly decreased compared to M0 macrophages. For the co-culture system, the analysis of gene expression showed that HA increased the expression of cartilage-specific genes while catabolic-encoding genes exhibited lower expression levels than the control group. This positive effect of HA was also demonstrated by the measurement of pro-inflammatory cytokines, as their level decreased.

CONCLUSION

Our study implies that high-molecular-weight HA has a chondroprotective effect in the present co-cultivation inflammation model, as it decreases pro-inflammatory cytokines and increases anabolic factors.

Product Differences in Intra-articular Hyaluronic Acids for Osteoarthritis of the Knee

BACKGROUND

Knee osteoarthritis (OA) is a common and often disabling joint disorder among adults that may result in impaired activity and daily function. A variety of treatment options are currently available and prescribed for knee OA depending on the severity of the disorder and physician preference. Intra-articular hyaluronic acid (IA-HA) injection is a treatment for knee OA that reportedly provides numerous biochemical and biological benefits, including shock absorption, chondroprotection, and anti-inflammatory effects within the knee. Clarity is needed as to whether the available IA-HA products should be considered for therapy as a group or whether there are significant differences in the products that need to be considered in treatment of OA of the knee.

PURPOSE

To determine whether there are differences in efficacy and safety with respect to intrinsic properties of available IA-HA injections for knee OA.

STUDY DESIGN

Meta-analysis.

METHODS

A comprehensive literature search of the Medline, EMBASE, and PubMed databases was conducted for all existing randomized trials of IA-HA. The primary outcome measure analyzed was the mean pain score at the reported follow-up nearest to 26 weeks after injection. Pooled efficacy and safety results were recorded for subgroupings of HA product characteristics.

RESULTS

A total of 68 studies were included for analysis. Products with an average molecular weight ≥3000 kDa provided favorable efficacy results when compared with products of an average molecular weight <3000 kDa. Products with a molecular weight ≥3000 kDa demonstrated significantly fewer discontinuations due to treatment-related adverse events than did ≤1500 kDa counterparts, while trial discontinuation rates were similar between biological fermentation-derived HA products and avian-derived HA. The results did not demonstrate a significant difference in the occurrence of effusion across molecular weight subgroups. Additionally, biological fermentation-derived HA had a significantly smaller incidence of effusion than did avian-derived HA. Biological fermentation-derived HA demonstrated fewer acute flare-ups at the injection site than did avian-derived HA products, while high-molecular-weight products demonstrated the highest rate of injection site flare-up.

CONCLUSION

Despite similarities, IA-HA products should not be treated as a group, as there are differences in IA-HA products that influence both efficacy and safety. In the available literature, IA-HA products with a molecular weight ≥3000 kDa and those derived from biological fermentation relate to superior efficacy and safety-factors that may influence selection an IA-HA product for OA of the knee.

Hyaluronic Acid Injections in Medicare Knee Osteoarthritis Patients Are Associated With Longer Time to Knee Arthroplasty

BACKGROUND

Few nonoperative treatment options for knee osteoarthritis (OA) are available, but there is ongoing debate about the effectiveness of intra-articular (IA) hyaluronic acid (HA) injections. We investigated whether the formulation of IA HA, or its combined use with IA corticosteroid (CS), may be contributing to some of the reported variation in clinical outcomes.

METHODS

The 5% Part B Medicare data (2005-2012) were used to identify knee OA patients who underwent knee arthroplasty (KA). The time from diagnosis of OA to KA was compared between patients with (HA) and without (no HA) IA HA use, using quantile regression with propensity score adjustment. These were further stratified by type of IA HA. Patient factors associated with time to KA were also assessed using Cox regression.

RESULTS

The "HA" cohort was associated with a longer time to KA of 8.7 months (95% confidence interval: 8.3-9.1 months; P < .001) compared with the "no HA" cohort, with extended time to KA in the bioengineered Euflexxa IA HA cohort. Patient factors associated with longer time to KA included women, younger patients, minority patients, patients with fewer comorbidities, and IA CS injection use. Patients with both IA HA and IA CS had an additional 6.3 months (95% confidence interval: 5.5-7.0 months; P < .001) to KA over those with only IA HA.

CONCLUSION

In a large cohort of elderly patients undergoing KA, there was a significant longer time from diagnosis of OA to KA in those receiving IA HA. It is unclear if the extended time may lead to less KA utilization.

Hyaluronic acid induces the release of growth factors from platelet-rich plasma

Background/Objective

Platelet-rich plasma (PRP) and hyaluronic acid (HA) injection are both therapeutic options for osteoarthritis and chronic tendinopathy. Although several comparative studies on the two have been published, the effects of mixing PRP and HA are not fully understood. The purpose of this study is to investigate the influence of HA on platelets in PRP by measuring releasing growth factors.

Methods

PRP was produced from nine healthy adult volunteers (mean age, 32.8 ± 2.9 years; range, 29–37) with a commercial separation system. HA of weight-average molecular weight of 50–120 kDa was used. PRP group (PRP 1 mL + phosphate buffered saline 0.2 mL) and PRP + HA group (PRP 1 mL + HA 0.2 mL) were incubated at 37°C for 2 hours. The amounts of transforming growth factor β1 (TGF-β1) and platelet-derived growth factor (PDGF-AA) released from the PRP and PRP + HA samples were measured on Day 0, Day 3, and Day 5. In addition, the same growth factors on Day 5 were measured for PRP + high HA group (PRP 1 mL + HA 0.6 mL) with five donors. After collecting all of the samples on Day 5, the remaining gels were observed with Giemsa stain. Statistical analyses were performed using paired t tests to compare the PRP and HA groups at each time point, and a one-way analysis of variance (one-way ANOVA) with Tukey post hoc tests was used to compare the PRP, PRP + HA, and PRP + high HA groups.

Results

The TGF-β1 concentrations in the PRP and PRP + HA were 24.3 ± 7.2 μg/mL and 22.4 ± 1.8 μg/mL (p = 0.689) on Day 0, 17.2 ± 13.9 μg/mL and 25.4 ± 7.1 μg/mL (p = 0.331) on Day 3, and 12.7 ± 10.5 μg/mL and 33.7 ± 8.3 μg/mL (p = 0.034) on Day 5. The TGF-β1 concentrations on Day 5 were 24.1 ± 5.2 μg/mL (PRP group), 28.3 ± 2.4 μg/mL (PRP + HA), and 31.9 ± 4.8 μg/mL (PRP + high HA; one-way ANOVA: p = 0.003; post hoc PRP vs. PRP + HA: p = 0.016). The PDGF-AA concentrations in the PRP and PRP + HA groups were 2.30 ± 1.21 μg/mL and 2.32 ± 0.79 μg/mL (p = 0.931) on Day 0, 2.03 ± 0.53 μg/mL and 2.13 ± 0.73 μg/mL (p = 0.500) on Day 3, and 1.51 ± 0.40 μg/mL and 2.00 ± 0.52 μg/mL (p = 0.003) on Day 5. The PDGF-AA concentrations were 1.48 ± 0.46 μg/mL (PRP group), 1.94 ± 0.57 μg/mL (PRP + HA), and 2.69 ± 0.70 μg/mL (PRP + high HA; one-way ANOVA: p = 0.0002; PRP vs. PRP + high HA: p = 0.002; PRP + HA vs. PRP + high HA: p = 0.011) on Day 5. The PRP showed larger coagulated masses than the PRP + HA. The high concentration HA group had the smallest coagulated mass of all of the group.

Conclusion

The levels of growth factors released by PRP on Day 5 were increased by the addition of HA. A mixture of PRP and HA may be a more effective therapy than PRP or HA alone for osteoarthritis and tendinopathy.

Abnormal Subcortical Brain Morphology in Patients with Knee Osteoarthritis: A Cross-sectional Study

Despite the involvement of subcortical brain structures in the pathogenesis of chronic pain and persistent pain as the defining symptom of knee osteoarthritis (KOA), little attention has been paid to the morphometric measurements of these subcortical nuclei in patients with KOA. The purpose of this study is to explore the potential morphological abnormalities of subcortical brain structures in patients with KOA as compared to the healthy control subjects by using high-resolution MRI. Structural MR data were acquired from 26 patients with KOA and 31 demographically similar healthy individuals. The MR data were analyzed by using FMRIB’s integrated registration and segmentation tool. Both volumetric analysis and surface-based shape analysis were performed to characterize the subcortical morphology. The normalized volumes of bilateral caudate nucleus were significantly smaller in the KOA group than in the control group (P = 0.004). There was also a trend toward smaller volume of the hippocampus in KOA as compared to the control group (P = 0.027). Detailed surface analyses further localized these differences with a greater involvement of the left hemisphere (P < 0.05, corrected) for the caudate nucleus. Hemispheric asymmetry (right larger than left) of the caudate nucleus was found in both KOA and control groups. Besides, no significant correlation was found between the structural data and pain intensities. Our results indicated that patients with KOA had statistically significant smaller normalized volumes of bilateral caudate nucleus and a trend toward smaller volume of the hippocampus as compared to the control subjects. Further investigations are necessary to characterize the role of caudate nucleus in the course of chronicity of pain associated with KOA.

Boiogito, a Kampo medicine, improves hydrarthrosis in a rat model of knee osteoarthritis

BACKGROUND

Hydrarthrosis, which is associated with knee pain and limited range of motion, decreases the quality of life (QOL) of patients with osteoarthritis (OA). The Kampo medicine boiogito is prescribed for the treatment of knee OA with hydrarthrosis; however, its precise mechanisms of action remain unknown. The purposes of this study were to assess the pharmacological effects of boiogito and its mechanisms of action on joint effusion in rats with surgically induced OA.

METHODS

A rat OA model was produced by transecting the anterior (cranial) cruciate ligament, medial collateral ligament, and medial meniscus in the right knee joints of 7-week-old female Wistar rats. The rats were given chow containing boiogito (1 or 2%) or indomethacin (0.002 %) for 4 weeks after surgical transection. Levels of interleukin-1β (IL-1β) and hyaluronic acid (HA) were measured by enzyme-linked immunosorbent assay. Knee joint pain was assessed using an incapacitance tester. Osmotic water permeability in cultured rabbit synovial cells was assessed using stopped-flow analysis.

RESULTS

Increased synovial fluid volume and knee joint pain were observed in rats with surgically induced OA. In rats with OA, levels of IL-1β and HA in the articular cavity were higher but concentration of HA in synovial fluid was lower than in sham-operated rats, suggesting excessive synovial fluid secretion. Administration of boiogito improved hydrarthrosis, IL-1β, and HA concentrations and alleviated knee joint pain in rats with OA. Indomethacin reduced IL-1β and knee joint pain but failed to improve hydrarthrosis or HA concentration in rats with OA. Osmotic water permeability in synovial cells, which is related to the function of the water channel aquaporin, was decreased by treatment with boiogito.

CONCLUSION

Boiogito ameliorates the increased knee joint effusion in rats with OA by suppressing pro-inflammatory cytokine IL-1β production in the articular cavity and regulating function of water transport in the synovium. The improvement of hydrarthrosis by boiogito results in the increased HA concentration in synovial fluid, thus reducing joint pain. Boiogito may be a clinically useful treatment of QOL in patients with OA with hydrarthrosis.

Effectiveness and Implications of Alternative Placebo Treatments: A Systematic Review and Network Meta-analysis of Osteoarthritis Trials

BACKGROUND

Placebo controls are essential in evaluating the effectiveness of medical treatments. Although it is unclear whether different placebo interventions for osteoarthritis vary in efficacy, systematic differences would substantially affect interpretation of the results of placebo-controlled trials.

OBJECTIVE

To evaluate the effects of alternative placebo types on pain outcomes in knee osteoarthritis.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, Google Scholar, and Cochrane Database from inception through 1 June 2015 and unpublished data.

STUDY SELECTION

149 randomized trials of adults with knee osteoarthritis that reported pain outcomes and compared widely used pharmaceuticals against oral, intra-articular, topical, and oral plus topical placebos.

DATA EXTRACTION

Study data were independently double-extracted; study quality was assessed by using the Cochrane risk of bias tool.

DATA SYNTHESIS

Placebo effects that were evaluated by using a network meta-analysis with 4 separate placebo nodes (differential model) showed that intra-articular placebo (effect size, 0.29 [95% credible interval, 0.09 to 0.49]) and topical placebo (effect size, 0.20 [credible interval, 0.02 to 0.38]) had significantly greater effect sizes than did oral placebo. This differential model showed marked differences in the relative efficacies and hierarchy of the active treatments compared with a network model that considered all placebos equivalent. In the model accounting for differential effects, intra-articular and topical therapies were superior to oral treatments in reducing pain. When these differential effects were ignored, oral nonsteroidal anti-inflammatory drugs were superior.

LIMITATIONS

Few studies compared different placebos directly. The study could not decisively conclude whether disease severity and co-interventions systematically differed between trials evaluating different placebos.

CONCLUSION

All placebos are not equal, and some can trigger clinically relevant responses. Differential placebo effects can substantially alter estimates of the relative efficacies of active treatments, an important consideration for the design of clinical trials and interpretation of their results.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Modulation of Hyaluronan Synthesis by the Interaction between Mesenchymal Stem Cells and Osteoarthritic Chondrocytes

Bone marrow mesenchymal stem cells (BM-MSCs) are considered a good source for cellular therapy in cartilage repair. But, their potential to repair the extracellular matrix, in an osteoarthritic environment, is still controversial. In osteoarthritis (OA), anti-inflammatory action and extracellular matrix production are important steps for cartilage healing. This study examined the interaction of BM-MSC and OA-chondrocyte on the production of hyaluronan and inflammatory cytokines in a Transwell system. We compared cocultured BM-MSCs and OA-chondrocytes with the individually cultured controls (monocultures). There was a decrease in BM-MSCs cell count in coculture with OA-chondrocytes when compared to BM-MSCs alone. In monoculture, BM-MSCs produced higher amounts of hyaluronan than OA-chondrocytes and coculture of BM-MSCs with OA-chondrocytes increased hyaluronan production per cell. Hyaluronan synthase-1 mRNA expression was upregulated in BM-MSCs after coculture with OA-chondrocytes, whereas hyaluronidase-1 was downregulated. After coculture, lower IL-6 levels were detected in BM-MSCs compared with OA-chondrocytes. These results indicate that, in response to coculture with OA-chondrocytes, BM-MSCs change their behavior by increasing production of hyaluronan and decreasing inflammatory cytokines. Our results indicate that BM-MSCs per se could be a potential tool for OA regenerative therapy, exerting short-term effects on the local microenvironment even when cell:cell contact is not occurring.

Current concepts on the use of corticosteroid injections for knee osteoarthritis

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

scAAVIL-1ra dosing trial in a large animal model and validation of long-term expression with repeat administration for osteoarthritis therapy

A gene therapeutic approach to treat osteoarthritis (OA) appears to be on the horizon for millions of people who suffer from this disease. Previously we described optimization of a scAAVIL-1ra gene therapeutic vector and initially tested this in an equine model verifying long-term intrasynovial IL-1ra protein at therapeutic levels. Using this vector, we carried out a dosing trial in six horses to verify protein levels and establish a dose that would express relevant levels of therapeutic protein for extended periods of time (8 months). A novel arthroscopic procedure used to detect green fluorescence protein (GFP) fluorescence intrasynovially confirmed successful transduction of the scAAVGFP vector in both the synovial and cartilage tissues. No evidence of intra-articular toxicity was detected. Immune responses to vector revealed development of neutralizing antibodies (Nabs) within 2 weeks of administration, which persisted for the duration of the study but did not lower protein expression intra-articularly. Re-dosing with a different serotype to attain therapeutic levels of protein confirmed establishment of successful transduction. This is the first study in an equine model to establish a dosing/redosing protocol, as well as examine the Nab response to capsid and supports further clinical investigation to determine the clinical efficacy of scAAVIL-1ra to treat OA.

Eucommia ulmoides Oliv. bark aqueous extract inhibits osteoarthritis in a rat model of osteoarthritis

ETHNOPHARMACOLOGICAL RELEVANCE

Eucommia ulmoides Oliv. bark (EU) is a common traditional Chinese herbal medicine for treatment of osteoarthritis (OA), but its therapeutic effect on OA and the underlying mechanisms have not been fully clarified. Our previous study showed that Eucommia ulmoides Oliv. bark aqueous extract (EUE) had a protective effect on cartilage, and this study was aimed to investigate the anti-osteoarthritis effect and mechanisms of EUE in a rat model of osteoarthritis.

MATERIALS AND METHODS

Thirty-two 5-week-old specific pathogen-free Sprague-Dawley rats which were randomized into four even groups (n=8). Group A received sham operation while the OA model was established using the modified Hulth technique in groups B, C and D. For eight weeks after operation, in addition to routine feeding, group A received gavage with deionized water, group B with deionized water, group C with 1.35 g/kg/day EUE, and group D with 2.7 g/kg/day EUE. Eight weeks postoperatively, all of the animals were euthanized for radiological, gross and histopathological observations to evaluate the effect of EUE on OA and to determine its potential mechanisms.

RESULTS

Radiological and histopathological observations showed that the articular degenerative changes were significantly more alleviated in groups C and D than in group B, while there were no obviously degenerative manifestations in group A. Mankin׳s scores in groups C and D were significantly lower than in group B (P<0.01). The severity of OA was significantly less in group D than in group C (P<0.01). The IL-1β and IL-6 contents in serum and MMP-3 secretion in articular cartilage were significantly lower in groups C and D than those in group B (P<0.01), and significantly lower in group D than those in group C (P<0.01). Compared with group B, phosphorylated Akt was significantly down-regulated in groups C and D.

CONCLUSIONS

EUE may inhibit the progression of osteoarthritis by inhibiting the PI3K/Akt pathway to delay cartilage degeneration, reduce inflammatory cytokines and prevent MMP-3 secretion. Therefore, EU is a potential therapeutic agent for OA, but its efficacy is limited.

Ultrasound-guided percutaneous injection to treat de Quervain's disease using three different techniques: a randomized controlled trial

PURPOSE

To compare the six-month outcome of three different ultrasound-guided treatments for de Quervain's disease (DQD).

METHODS

We prospectively treated 75 consecutive patients (51 females, 24 males, mean age ± standard deviation = 45.3 ± 9.8 years) with DQD. Patients' features (hand dominance, intraretinaculum septum, accessory tendons) were recorded. Visual analogue scale (VAS), reduced disability (quickDASH) score, and retinaculum thickness were evaluated at baseline and after one (excluding retinaculum thickness), three, and six months. Patients were randomized into three groups of 25 patients each treated under ultrasound guidance: Group A (1 ml methylprednisolone acetate; mean baseline thickness = 1.6 mm; mean baseline VAS = 6; mean baseline quickDASH = 55); Group B (1 ml methylprednisolone acetate +15-day delayed 2 ml saline 0.9 %; 1.4; 6; 56); Group C (1 ml methylprednisolone acetate +15-day delayed 2 ml low molecular weight hyaluronic acid; 1.7; 6; 55).

RESULTS

After one month results were: Group A mean VAS = 2; mean quickDASH = 23; Group B 2; 22; Group C 2; 21. After three months results were: Group A retinaculum thickness = 0.7 mm; 3; 27); Group B 0.8 mm; 1; 25; Group C 0.5 mm; 1; 23. After six months results were: Group A 1.5 mm; 3; 51; Group B 1 mm; 2; 51; Group C 0.7 mm; 1; 26 (P < 0.001 for all vs. baseline). Patients' age, sex, hand dominance, presence of subcompartment dividing septum, and supernumerary tendons had no influence on outcome (P  ≥  0.177).

CONCLUSION

Addition of hyaluronic acid to ultrasound-guided injections of steroids to treat DQD seems to improve the outcome and to reduce the recurrence rate.

KEY POINTS

• Ultrasound guidance allows for safe injection procedures to treat de Quervains' disease • Steroid injections allow prompt recovery in de Quervain's disease with short-term recurrence • Addition of hyaluronic acid allows recurrence rate reduction compared to simple steroid injections.

The degeneration and destruction of femoral articular cartilage shows a greater degree of deterioration than that of the tibial and patellar articular cartilage in early stage knee osteoarthritis: a cross-sectional study

OBJECTIVE

The aim of the present study was to examine whether the degenerative and morphological changes of articular cartilage in early stage knee osteoarthritis (OA) occurred equally for both femoral- and tibial- or patellar- articular cartilage using magnetic resonance imaging (MRI)-based analyses.

DESIGN

This cross-sectional study was approved by the ethics committee of our university. Fifty patients with early stage painful knee OA were enrolled. The patients underwent 3.0 T MRI on the affected knee joint. Healthy volunteers who did not show MRI-based OA changes were also recruited as controls (n = 19). The degenerative changes of the articular cartilage were quantified by a T2 mapping analysis, and any structural changes were conducted using Whole Organ Magnetic Resonance Imaging Score (WORMS) technique.

RESULTS

All patients showed MRI-detected OA morphological changes. The T2 values of femoral condyle (FC) (P < 0.0001) and groove (P = 0.0001) in patients with early stage knee OA were significantly increased in comparison to those in the control, while no significant differences in the T2 values of patellar and tibial plateau (TP) were observed between the patients and the control. The WORMS cartilage and osteophyte scores of the femoral articular cartilage were significantly higher than those in the patellar- (P = 0.001 and P = 0.007, respectively) and tibial- (P = 0.0001 and P < 0.0001, respectively) articular cartilage in the patients with early stage knee OA.

CONCLUSIONS

The degradation and destruction of the femoral articular cartilage demonstrated a greater degree of deterioration than those of the tibial- and patellar- articular cartilage in patients with early stage knee OA.