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Bowden DJ, Eustace SJ, Kavanagh EC. The value of injectable viscoelastic supplements for joints. Skeletal Radiol 2023; 52:933-940. [PMID: 36104594 DOI: 10.1007/s00256-022-04178-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/30/2022] [Accepted: 08/31/2022] [Indexed: 02/02/2023]
Abstract
Intra-articular viscoelastic supplements are commonly administered by musculoskeletal radiologists for the treatment of symptomatic osteoarthritis (OA). This article provides an overview of the putative mechanism of action of the agents, a brief review of the evidence base underlying the practice, a commentary on some of the major society guidelines regarding the treatment, and a description of the adverse events that are associated with intra-articular hyaluronic acid administration.
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Affiliation(s)
- Dermot J Bowden
- Department of Radiology, Cappagh National Orthopaedic Hospital, Cappagh Rd, Finglas, Dublin 11, Republic of Ireland, D11 EV29.
| | - Stephen J Eustace
- Department of Radiology, Cappagh National Orthopaedic Hospital, Cappagh Rd, Finglas, Dublin 11, Republic of Ireland, D11 EV29
| | - Eoin C Kavanagh
- Department of Radiology, Cappagh National Orthopaedic Hospital, Cappagh Rd, Finglas, Dublin 11, Republic of Ireland, D11 EV29
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Imaging-Guided Musculoskeletal Interventions in the Lower Limb. Radiol Clin North Am 2023; 61:393-404. [PMID: 36739153 DOI: 10.1016/j.rcl.2022.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Imaging guidance is essential for musculoskeletal interventional procedures performed in the lower limb. A strong evidence supports the use of imaging guidance to improve safety, accuracy, and effectiveness of these interventions. Joints, tendons, bursae, and nerves can be effectively approached especially with ultrasound-guided injections. Here, we discuss evidence and technique of the most common image-guided musculoskeletal interventional procedures in the lower limb.
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Ultrasound-guided injection with hyaluronic acid in hip osteoarthritis: efficacy and safety in a real-life setting. Clin Rheumatol 2022; 41:2491-2498. [PMID: 35389116 DOI: 10.1007/s10067-022-06154-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 03/20/2022] [Accepted: 03/25/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND For knee OA, EULAR has included hyaluronic acid (HA) intra-articular injection in the 2003 recommendations, making the intra-articular injection a sound therapeutic option. The ultrasound-guided intra-articular injections (USGIAI) have been demonstrated to be more efficient and safe in comparison to the blind procedure. Our objectives were to evaluate the short- and medium-term efficacy and safety of USGIAI of HA in moderate hip OA and patients' additional NSAIDs/pain killer intake. PATIENTS AND METHODS Patients with hip OA (KLG II/III), that failed standard of care therapy, received 3 consecutive HA-USGIAI (case group) while other patients (KLG II/III) treated according to current guidelines were chosen as a control group. Demographic data, comorbidities and medication intake were recorded. VAS pain scale and WOMAC score were performed at baseline and at 3 months. In the case group, they were additionally scored at 6 months. At baseline and at 6 months, hip X-ray assessment was also made. Ultrasound evaluation was made at each visit. RESULTS In the case group, 15 patients were enrolled and 28 hip joints were injected. The control group consisted of 17 hip OA patients. In the case group, pain evaluated by VAS score and WOMAC score were significantly and progressively decreased (p < 0.0001) from baseline up to 3 and 6 months, respectively. Indeed, the case group showed a significantly lower NSAIDs/pain killer median intake at 3 months from baseline (p < 0.05). CONCLUSION Our data suggest that HA-USGIAI may be an effective and safe treatment for moderate hip OA with short- and medium-term benefits. Key Points • US hip evaluation before interventional maneuvers may identify capsular distension suggestive for concomitant septic involvement, microcrystal arthropathy or incipient hip osteonecrosis. • USGIAI may be fundamental to achieve an efficacious and safe injection. • HA-USGIAI may be an effective and safe treatment for moderate hip OA with short- and medium-term benefits.
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Aksoy A, Gulcu A, Tuna MM, Aslan A. Radiologically Guided Versus Blinded Intra-articular Injection in Patients With Hip Osteoarthritis: A Retrospective Comparative Study. CLINICAL MEDICINE INSIGHTS: ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2022; 15:11795441221118920. [PMID: 36032389 PMCID: PMC9411738 DOI: 10.1177/11795441221118920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 07/21/2022] [Indexed: 11/18/2022]
Abstract
Objectives: The aim of this study was to present the clinical results of patients with Kellgren-Lawrence (KL) stage 2-4 hip osteoarthritis who were administered intra-articular corticosteroid (CS) or hyaluronic acid (HA), with or without fluoroscopy. Methods: This retrospective comparative study was conducted in the clinics where the authors worked between 2010 and 2018. Patients with stage 2-4 hip osteoarthritis according to KL criteria were included in the study. Age, body mass index, American Society of Anesthesiologists stages, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (3rd, 6th, and 12th months) were recorded. Two groups were created as patients who underwent injection with or without fluoroscopy guidance. In group 1, CS (triamnisolone) was administered, and in group 2, sodium hyaluronate 88 mg/4 mL was administered. Obtained parameters were compared. Results: The WOMAC scores at 3 months of both the CS and HA groups were statistically significantly better than before the application, with the improvement in the CS group found to be significantly better than in the HA group (P = .047). At 6 months, the mean WOMAC scores of the CS and HA groups were better than prior to the application, and there was a statistically significant difference (P < .001). No significant difference was found in either the CS or HA group in the comparison of 12-month WOMAC scores with the baseline scores (P = .744 and P = .054). Conclusion: In symptomatic hip OA patients, intra-articular administration of CS and HA was seen to be effective at 3 and 6 months after administration. However, the effectiveness was determined to have disappeared within 1 year. Furthermore, in hip OA intra-articular drug applications, it was determined that the blinded technique without radiological guidance performed in the outpatient clinic is as effective and safe as the radiologically guided technique administered in the operating room.
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Affiliation(s)
- Ahmet Aksoy
- Department of Orthopedics and Traumatology, Alanya Education and Research Hospital, Alanya, Turkey
| | - Anil Gulcu
- Department of Orthopedics and Traumatology, Medical School of Alaaddin Keykubat University, Alanya, Turkey
| | - Mehmet Mert Tuna
- Department of Anesthesia and Reanimation, Alanya Education and Research Hospital, Alanya, Turkey
| | - Ahmet Aslan
- Department of Orthopedics and Traumatology, Medical School of Alaaddin Keykubat University, Alanya, Turkey
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SOUSA EDUARDOBRANCODE, HAMDAN PAULOCÉSAR, MENEGASSI ZARTURJOSÉBARCELOS, ALCHAAR ADRIENIANTUNESDOAMARAL, TIEPPO ANTONIOMARTINS, SOUZA CAIOGONÇALVESDE, PINHEIRO CARLOSBRUNOREIS, ALMEIDA JÚNIOR CYROSCALADE, ROCHA EDUARDODEMELOCARVALHO, CUNHA FABIANOGONÇALVES, PACHECO IVAN, REZENDE MARCIAUCHÔADE, SOUZA MÁRCIOPASSINIGONÇALVESDE, BRITTO DA SILVA MARCOS, CAMPOS GUSTAVOCONSTANTINODE. BRAZILIAN CONSENSUS STATEMENT ON VISCOSUPPLEMENTATION OF THE HIP (COBRAVI-Q). ACTA ORTOPÉDICA BRASILEIRA 2022; 30:e250414. [DOI: 10.1590/1413-785220223005e250414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/12/2021] [Indexed: 11/13/2022]
Abstract
ABSTRACT Objective: The Brazilian Consensus on Hip Viscosupplementation aims to generate a referential and consensual source from the theoretical knowledge and clinical experience of specialists in the field. Methods: A multidisciplinary panel was formed with 15 specialists (sports medicine, orthopedists, physiatrists and rheumatologists), based on clinical and academic experience in the use of viscosupplementation of the hip. 12 statements were prepared, discussed and voted. Each panelist gave a value between 0 and 10 on a Likert scale, specifying their level of agreement with the statement. Results: The panel reached a consensus on several aspects of viscosupplementation of the hip, with emphasis on the following statements: best indication is for mild to moderate hip arthrosis; it may be indicated in severe osteoarthritis; results may vary according to the characteristics of the viscosupplement used; Viscosupplementation should not be performed as an isolated procedure, but in conjunction with other rehabilitation and pharmacological measures; best injection technique should be based on anatomical references coupled with imaging guidance; it is a cost-effective procedure. Conclusion: Viscosupplementation is a safe and effective therapy for hip osteoarthritis, even in severe cases. Guided injection is recommended. Level of Evidence V, Expert Opinion.
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Rodriguez-García SC, Castellanos-Moreira R, Uson J, Naredo E, O'Neill TW, Doherty M, Boesen M, Pandit H, Möller Parera I, Vardanyan V, Terslev L, Kampen WU, D'Agostino MA, Berenbaum F, Nikiphorou E, Pitsillidou I, de la Torre-Aboki J, Carmona L. Efficacy and safety of intra-articular therapies in rheumatic and musculoskeletal diseases: an overview of systematic reviews. RMD Open 2021; 7:rmdopen-2021-001658. [PMID: 34103406 PMCID: PMC8186751 DOI: 10.1136/rmdopen-2021-001658] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022] Open
Abstract
Objective To summarise the evidence on intra-articular therapies (IAT) to inform the 2020 EULAR recommendations. Methods An overview of systematic reviews (SR) including randomised-controlled trials (RCTs) of IAT in adults with arthropathies was performed up to July 2020. Pain, function, and frequency of adverse events were the main efficacy and safety outcomes, respectively. Quality was assessed with the A MeaSurement Tool to Assess Systematic Reviews (AMSTAR)-2 tool. Results Of 184 references identified, 16 met the inclusion criteria, and a search of their reference lists identified 16 additional SRs. After quality assessment, 29 were finally included. Of these, 18 focused on knee osteoarthritis (KOA), 6 on hip osteoarthritis (HOA), 3 on shoulder capsulitis (SC), and 3 on rheumatoid arthritis. Overall, hyaluronic acid showed a small effect on pain and function in KOA but not in HOA or shoulder capsulitis. Intra-articular glucocorticoids showed a small effect in pain and function in KOA and function in HOA and SC. Platelet-rich plasma showed benefit in pain and function in KOA but not in HOA. Mesenchymal stem cells behaved similarly. Most SR results were of moderate quality and RCTs included often presented a high risk of bias, mainly due to inadequate blinding and heterogeneous results. All interventions were well tolerated with no clear safety differences. Conclusions This overview underlines that most IAT currently used in KOA, HOA, and SC exert small effects and are well tolerated. However, no firm conclusions can be drawn for inflammatory arthritis due to the limited data found.
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Affiliation(s)
| | | | - Jacqueline Uson
- Rheumatology, Hospital Universitario de Mostoles, Madrid, Spain.,Medicine, Universidad Rey Juan Carlos, Madrid, Spain
| | - Esperanza Naredo
- Rheumatology, Hospital Universitario Fundacion Jimenez Diaz, Madrid, Spain.,Rheumatology - Joint and Bone Research Unit, Hospital Universitario Fundación Jiménez Díaz, IIS Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Madrid, Spain
| | - Terence W O'Neill
- Rheumatology, Centre for Epidemiology Versus Arthritis, University of Manchester & NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Mikael Boesen
- Radiology, Copenhagen University Hospital Bispebjerg- Frederiksberg, Copenhagen, Denmark
| | | | - Ingrid Möller Parera
- Facultad de Medicina y Ciencias de La Salud, Universidad de Barcelona, Barcelona, Spain.,Rheumatology, Instituto POAL de Reumatología, Barcelona, Spain
| | - Valentina Vardanyan
- Rheumatology, Yerevan State Medical University after Mkhitar Heratsi, Yerevan, Armenia
| | - Lene Terslev
- Center for Rheumatology and Spine Diseases, Rigshospitalet, Copenhagen, Denmark
| | | | - Maria Antonieta D'Agostino
- Rheumatology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.,Faculty of Medicine and Surgery, Catholic University of the Sacred Heart, Rome, Italy
| | - Francis Berenbaum
- Rheumatology, AP-HP Saint-Antoine hospital, Paris, France.,Sorbonne University - INSERM CRSA, Paris, France
| | - Elena Nikiphorou
- Centre for Rheumatic Diseases, King's College London, London, UK.,Rheumatology Department, King's College Hospital, London, UK
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Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part IV, hip. Eur Radiol 2021; 32:551-560. [PMID: 34146140 PMCID: PMC8660721 DOI: 10.1007/s00330-021-07997-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/22/2021] [Accepted: 04/12/2021] [Indexed: 12/01/2022]
Abstract
Objectives Image-guided musculoskeletal interventional procedures around the hip are widely used in daily clinical practice. The need for clarity concerning the actual added value of imaging guidance and types of medications to be offered led the Ultrasound and the Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) to promote, with the support of its Research Committee, a collaborative project to review the published literature on image-guided musculoskeletal interventional procedures in the lower limb in order to derive a list of clinical indications. Methods In this article, we report the results of a Delphi-based consensus of 53 experts who reviewed the published literature for evidence on image-guided interventional procedures offered in the joint and soft tissues around the hip in order of their clinical indications. Results Ten statements concerning image-guided treatment procedures around the hip have been collected by the panel of ESSR experts. Conclusions This work highlighted that there is still low evidence in the existing literature on some of these interventional procedures. Further large prospective randomized trials are essential to better confirm the benefits and objectively clarify the role of imaging to guide musculoskeletal interventional procedures around the hip. Key Points • Expert consensus produced a list of 10 evidence-based statements on clinical indications of image-guided interventional procedures around the hip. • The highest level of evidence was only reached for one statement. • Strong consensus was obtained for all statements. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-07997-5.
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Intra-Articular Hyaluronic Acid Injections Less Than 6 Months Before Total Hip Arthroplasty: Is It Safe? A Retrospective Cohort Study in 565 Patients. J Arthroplasty 2021; 36:1003-1008. [PMID: 33097337 DOI: 10.1016/j.arth.2020.09.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Intra-articular hyaluronic acid (IAHA) can be injected into an osteoarthritic hip joint to reduce pain and to improve functionality. Several studies report IAHA to be safe, with minor adverse effects that normally disappear spontaneously within a week. However, intra-articular corticosteroids prior to total hip arthroplasty (THA) have been associated with increased infection rates. This association has never been investigated for IAHA and THA. We aimed to assess the influence of IAHA on the outcome of THA, with an emphasis on periprosthetic joint infection (PJI). METHODS At a mean follow-up of 52 months (±18), we compared complication rates, including superficial and deep PJIs, of THA in patients who received an IAHA injection ≤6 months prior to surgery (injection group) with that of patients undergoing THA without any previous injection in the ipsilateral hip (control group). One hundred thirteen patients (118 hips) could be retrospectively included in the injection group, and 452 patients (495 hips) in the control group. RESULTS No differences in baseline characteristics nor risk factors for PJI between the 2 groups were found. The clinical outcomes in terms of VAS pain scores (1.4 vs 1.7 points, P = .11), modified Harris Hip Scores (77 vs 75 points, P = .09), and Hip disability and Osteoarthritis Outcome Scores (79 vs 76 points, P = .24) did not differ between the injection group and the control group. Also, complications in terms of persistent wound leakage (0% vs 1.2%, P = .60), thromboembolic events (0% vs 0.6%, P = 1.00), periprosthetic fractures (1.7% vs 1.2%, P = .65), and dislocations (0% vs 0.4%, P = 1.00) did not differ. However, in the injection group there was a higher rate of PJIs (4% vs 0%, P < .001) and postoperative wound infections (9% vs 3%, P = .01), compared to the control group. CONCLUSION Our findings suggest that IAHA performed 6 months or less prior to THA may pose a risk for increased rates of PJI. We recommend refraining from performing THA within 6 months after IAHA administration.
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Schiavi P, Calderazzi F, Pedrini MF, Tacci F, Vaienti E, Pogliacomi F. Efficacy and safety of viscosupplementation with hyaluronic acid for hip osteoarthritis: results from a cross-sectional study with a minimum follow-up of 4 years. ACTA BIO-MEDICA : ATENEI PARMENSIS 2020; 91:e2020032. [PMID: 33559627 PMCID: PMC7944698 DOI: 10.23750/abm.v91i14-s.11110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Accepted: 12/14/2020] [Indexed: 11/23/2022]
Abstract
Background and aim of the work: Osteoarthritis is the most common cause of disability in elderly. Hip osteoarthritis is the second most frequent form affecting a large joint and the social and economic impact on society of its related disability is expected to increase. The purpose of this study was to verify the efficacy and safety of ultrasound-guided viscosupplementation with high weight hyaluronic acid in hip osteoarthritis. Methods: 183 patients with painful hip OA (Kellgren-Lawrence 1-2-3) were treated from January 2014 to December 2016 with viscosupplementation. Patients were evaluated before injection (T0) and after 1,2,3,4 (T1-T2-T3-T4) years through the VAS scale and Harris Hip Score (HHS). Patients who underwent to subsequent injections were followed and assessed. Subjects who underwent prosthesis were analyzed for a minimum of 6 months in order to detect any early postoperative complication. Results: The mean improvement of HHS and VAS between T0 and T1 was statistically significant. Patients who underwent subsequent injections showed a higher improvement even if statistical significance was not observed. Results showed that patients with grade 2 of osteoarthritis had the higher change in the scores. No adverse effects were registered. No early complications were reported in those patients who needed prosthesis. Discussion and Conclusions: Results observed confirm that ultrasound-guided viscosupplementation with high weight hyaluronic acid could be a possibility in the treatment of hip osteoarthritis, especially in patients with Kellgren-Lawrence grade 2 of disease. Subsequent injections are not characterized by similar positive effects. Outcomes of prosthetic surgery are not influenced by viscosupplementation.
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Affiliation(s)
- Paolo Schiavi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Filippo Calderazzi
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | | | - Fabrizio Tacci
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Enrico Vaienti
- Orthopaedic Clinic, Department of Medicine and Surgery, University Hospital of Parma, Italy.
| | - Francesco Pogliacomi
- PARMA UNIVERSITY DEPARTMENT OF SURGICAL SCIENCES ORTHOPAEDIC AND TRAUMATOLOGY SECTION.
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