Intra-Articular, Single-Shot Hylan G-F 20 Hyaluronic Acid Injection Compared with Corticosteroid in Knee Osteoarthritis: A Double-Blind, Randomized Controlled Trial

Genicular Artery Embolization, Radiofrequency Ablation, and Corticosteroid Therapy for Knee Osteoarthritis: A Cost-Effectiveness Analysis Using Randomized Clinical Trial Data

Background: Many patients with symptomatic knee osteoarthritis (KOA) are refractory to traditional nonsurgical treatments such as intraarticular corticosteroid (CS) injection but are not yet eligible for or decline surgery. Genicular artery embolization (GAE) and radiofrequency ablation (RFA) are emerging adjunctive or alternative minimally invasive treatments. Objective: To perform a cost-effectiveness analysis (CEA) comparing CS, GAE, and RFA, for treatment of symptomatic KOA using a Markov model based on a de novo network meta-analysis (NMA) of randomized control trials. Methods: CEA was conducted to compare GAE and RFA to CS using a Markov cohort state-transition model from a U.S. Medicare payer's perspective over a 4-year time horizon. The model incorporated each treatment's success and attrition rates, costs, and utility benefit. Utility benefit values were derived at short-term (0.5-3 months) and long-term (6-12 months) posttreatment follow-up from NMA of published RCTs using an outcome of improved knee pain and/or function. Analyses were conducted at a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY). Sensitivity analyses were performed, including when simulating various cost setting scenarios (i.e., office vs hospital outpatient treatment). Results: RFA demonstrated larger treatment effect than GAE, more pronounced at short-term [standardized mean difference (SMD), -1.6688, 95% CI [-2.7806; -0.5571], p=.003] than long-term (SMD -0.3822, 95% CI [-1.9743; 1.2100], p=.64) follow-up. Across cost setting scenarios, incremental cost-effectiveness ratios relative to CS were $561-1563/QALY for GAE versus $76-429/QALY for RFA (not counting scenarios in which RFA was dominated by CS). GAE demonstrated higher cost-effectiveness probability compared to RFA (41.6-54.8% vs. 18.4-29.2%, respectively). GAE was more cost-effective than RFA when the GAE clinical success rate and post-GAE utility value exceeded 32.1-51.0% and 0.562-0.617, respectively, and when the GAE quarterly attrition rate was less than 8.8-17.4%. RFA was more cost-effective when baseline pre-treatment utility values exceeded 0.695-0.713. Neither GAE costs nor RFA costs were sensitive parameters. Conclusion: Across scenarios, GAE was consistently the most likely cost-effective treatment option compared to RFA and CS, although clinical success rates, attrition rates, and utility values impact its cost-effectiveness. Clinical Impact: GAE is likely to be more cost-effective than RFA or CS for treatment of symptomatic KOA.

Intra-articular corticosteroids for the treatment of osteoarthritis: A systematic review and meta-analysis on the comparison of different molecules and doses

Purpose

The purpose of this study was to quantify and compare the clinical relevance of the different intra-articular corticosteroids (CS) effects in vivo for osteoarthritis (OA) treatment.

Methods

The search was conducted on PubMed, Cochrane, and Web of Science in October 2023. The PRISMA guidelines were used. Inclusion criteria: animal or human randomized controlled trials (RCTs), English language and no time limitation, on the comparison of different intra-articular CS for OA treatment. The articles' quality was assessed using the Cochrane RoB2 and GRADE guidelines for human RCTs, and SYRCLE's tool for animal RCTs.

Results

Eighteen RCTs were selected (16 human and 2 animal studies), including 1577 patients (1837 joints) and 31 animals (51 joints). The CS used were triamcinolone (14 human and 2 animal studies), methylprednisolone (7 human and 1 animal study), betamethasone (3 human studies) and dexamethasone (1 human study). All studies addressed knee OA except for three human and one animal study. A meta-analysis was performed on the comparison of methylprednisolone and triamcinolone in humans with knee OA analysing VAS pain at very short- (≤2 weeks), short- (>2 and ≤4 weeks), mid- (>4 and ≤8 weeks), long- (>8 and ≤ 12 weeks), and very long-term (>12 and ≤24 weeks). Triamcinolone showed better post-injection values compared to methylprednisolone at very short-term (p = 0.028). No difference in terms of VAS improvement was observed at any follow-up.

Conclusions

The available preclinical and clinical literature provides limited evidence on the comparison of different CS, hindering the possibility of determining the best CS approach in terms of molecule and dose for the intra-articular injection of OA joints.

Level of Evidence

Level I.

Platelet-Rich Plasma, Bone Marrow Aspirate Concentrate, and Hyaluronic Acid Injections Outperform Corticosteroids in Pain and Function Scores at a Minimum of 6 Months as Intra-Articular Injections for Knee Osteoarthritis: A Systematic Review and Network Meta-analysis

PURPOSE

To compare the efficacy of common intra-articular injections used in the treatment of knee osteoarthritis, including corticosteroid (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and bone marrow aspirate concentrate (BMAC), with a minimum follow-up of 6-months.

METHODS

A literature search was conducted using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in August 2022 in the following databases: PubMed/MEDLINE, Scopus, Cochrane Database of Controlled Trials, and the Cochrane Database of Systematic Reviews. Level I to II randomized clinical trials with a minimum follow-up of 6 months that investigated the treatments of interest were included. Patient-reported outcome scores for pain and function at baseline and at latest follow-up were extracted, and the change in scores was converted to uniform 0 to 100 scales. Arm-based Bayesian network meta-analysis using a random-effects model was created to compare the treatment arms in pain and function.

RESULTS

Forty-eight studies comprising a total of 9,338 knees were included. The most studied intra-articular injection was HA (40.9%), followed by placebo (26.2%), PRP (21.5%), CS (8.8%), and then BMAC (2.5%). HA and PRP both led to a significant improvement in pain compared with placebo. HA, PRP, and BMAC all led to a significant improvement in function scores when compared with placebo. Surface under the cumulative ranking curves (SUCRAs) of the interventions revealed that PRP, BMAC, and HA were the treatments with the highest likelihood of improvement in both pain and function, with overall SUCRA scores of 91.54, 76.46, and 53.12, respectively. The overall SUCRA scores for CS and placebo were 15.18 and 13.70, respectively.

CONCLUSIONS

At a minimum 6-month follow-up, PRP demonstrated significantly improved pain and function for patients with knee osteoarthritis compared with placebo. Additionally, PRP exhibited the highest SUCRA values for these outcomes when compared with BMAC, HA, and CS.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I to II studies.

Minimal clinically important change of knee flexion in people with knee osteoarthritis after non-surgical interventions using a meta-analytical approach

BACKGROUND

Minimal clinically important change (MCIC) represents the minimum patient-perceived improvement in an outcome after treatment, in an individual or within a group over time. This study aimed to determine MCIC of knee flexion in people with knee OA after non-surgical interventions using a meta-analytical approach.

METHODS

Four databases (MEDLINE, Cochrane, Web of Science and CINAHL) were searched for studies of randomised clinical trials of non-surgical interventions with intervention duration of ≤ 3 months that reported change in (Δ) (mean change between baseline and immediately after the intervention) knee flexion with Δ pain or Δ function measured using tools that have established MCIC values. The risk of bias in the included studies was assessed using version 2 of the Cochrane risk-of-bias tool for randomised trials (RoB 2). Bayesian meta-analytic models were used to determine relationships between Δ flexion with Δ pain and Δ function after non-surgical interventions and MCIC of knee flexion.

RESULTS

Seventy-two studies (k = 72, n = 5174) were eligible. Meta-analyses included 140 intervention arms (k = 61, n = 4516) that reported Δ flexion with Δ pain using the visual analog scale (pain-VAS) and Δ function using the Western Ontario and McMaster Universities Osteoarthritis Index function subscale (function-WOMAC). Linear relationships between Δ pain at rest-VAS (0-100 mm) with Δ flexion were - 0.29 (- 0.44; - 0.15) (β: posterior median (CrI: credible interval)). Relationships between Δ pain during activity VAS and Δ flexion were - 0.29 (- 0.41, - 0.18), and Δ pain-general VAS and Δ flexion were - 0.33 (- 0.42, - 0.23). The relationship between Δ function-WOMAC (out of 100) and Δ flexion was - 0.15 (- 0.25, - 0.07). Increased Δ flexion was associated with decreased Δ pain-VAS and increased Δ function-WOMAC. The point estimates for MCIC of knee flexion ranged from 3.8 to 6.4°.

CONCLUSIONS

The estimated knee flexion MCIC values from this study are the first to be reported using a novel meta-analytical method. The novel meta-analytical method may be useful to estimate MCIC for other measures where anchor questions are problematic.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022323927.

The Effect of Aspiration and Corticosteroid Injection After ACL Injury on Postoperative Infection Rate

BACKGROUND

Injecting bioactive substances into the knee is common in orthopaedic practice, and recently it has been shown to mitigate risk factors for posttraumatic osteoarthritis. Therefore, understanding the influence of these injections on postoperative infection rate is imperative.

HYPOTHESIS

Postinjury aspiration and corticosteroid injection (CSI) of the knee before anterior cruciate ligament (ACL) reconstruction (ACLR) would not increase the risk of postoperative infection.

STUDY DESIGN

Cohort Study; Level of evidence, 3.

METHODS

All patients between the ages of 10 and 65 years who underwent primary bone-patellar tendon-bone ACLR by 1 fellowship-trained sports medicine orthopaedic surgeon between January 1, 2011, and September 8, 2020, at 1 of 2 major academic centers were evaluated for inclusion. A total of 693 patients were included, with 273 patients receiving postinjury and preoperative aspiration and CSI. A postoperative infection was defined as a patient returning to the operating room for an intra-articular washout. The intervals-measured in days-between the CSI and ACLR and between ACLR and the final follow-up were recorded. To further evaluate the infection risk in each cohort (total cohort; aspiration and injection cohort; no aspiration and injection cohort), the upper 95% confidence bound for the infection risk was calculated for each cohort.

RESULTS

There were no postoperative infections in the 693 patients included in this study. The upper 95% confidence bounds were 0.4%, 1.1%, and 0.7% for the total cohort, the cohort that underwent aspiration and injection, and the cohort that did not, respectively. The median number of days between the surgical date and that of the aspiration and injection was 34 days, and the mean follow-up for the entire cohort was 337.4 days (95% CI, 307.6-367.3).

CONCLUSION

Postinjury and preoperative aspiration and CSI is a safe intervention that can be used before ACLR. Future studies with larger sample sizes, longer patient follow-ups, and multiple surgeons would be helpful to both better understand infection risk and better identify the influence of CSI on preventing posttraumatic osteoarthritis.

Histological features of knee osteoarthritis treated with triamcinolone acetonide and hyaluronic acid

Osteoarthritis (OA) is one of the most common degenerative joint diseases leading to disability in the end stage. Although intra-articular triamcinolone acetonide (TA) is one of the OA treatments that have been widely used, the side effects of such corticosteroids are still controversial. Intra-articular hyaluronic acid (HA) injection is another therapeutic option for patients with OA who do not want to use corticosteroids because of their side effects. However, the difference between the histological features associated with TA and HA in the treatment of OA remains unclear. Thus, the present study aimed to compare the histological effects of TA and HA on the cartilage of patients with knee OA. In the current study, 31 patients diagnosed with grade 3-4 knee OA on the Kellgren-Lawrence radiographic grading scale were separated into three groups: TA (n=12); HA (n=7) and untreated group (n=12). Histological examination of the whole articular cartilages of the patients was performed with hematoxylin and eosin and Alcian staining, as well as using a TUNEL assay. Clinical data such as cartilage thickness, structural and component deterioration, proteoglycan levels, apoptosis and empty lacunae were compared between the three groups. The results showed a high level of deterioration in both TA and HA groups but not in the untreated group, although the thickness of cartilage in the HA group was lower compared with that in the TA and untreated groups. The proteoglycan levels in the TA group were lower compared with those in the HA group. Moreover, the number of empty lacunae in the HA group was higher compared with that in the TA group, while no difference in apoptosis was found between TA and HA groups. A significant difference was not found in the histological staining between TA and HA groups. On the other hand, a significant difference was found in cartilage deterioration between the medial and lateral sides in these groups. TA and HA groups showed comparable histological results. TA injection is cheaper and easier but has more adverse effects for patients with knee OA than HA injection. Therefore, orthopaedists should select TA or HA based on the economic and specific needs of patients.

The OA Trial Bank: Update of individual patient data meta-analysis of intra-articular glucocorticoids in persons with knee and hip osteoarthritis

Objective

To evaluate the efficacy of intra--articular (IA) glucocorticoid for knee or hip osteoarthritis (OA) in specific subgroups of patients according to the baseline severity of pain and inflammatory signs using individual patient data (IPD) from existing trials. Furthermore, this study aims to assess if a baseline pain cut-off was associated with clinically important effectiveness of IA glucocorticoid. This is an update of an IA glucocorticoid IPD meta-analysis by the OA Trial Bank.

Method

Randomized trials evaluating one or more IA glucocorticoid preparations in hip and knee OA, published to May 2018 were selected. IPD of patient and disease characteristics and outcome measures were acquired. The primary outcome was pain severity at short-term follow-up (up to 4 weeks). Potential interaction effect of severe pain (≥70 points, 0-100 scale) and signs of inflammation at baseline were studied using a two-stage approach with general liner model followed by random effects model. Analysis of trend was conducted, assessing if a baseline pain cut-off was associated with the threshold for clinically important treatment effect of IA glucocorticoid compared to placebo.

Results

Four out of 16 eligible randomized clinical trials (n ​= ​641) were combined with the existing OA Trial Bank studies (n ​= ​620), yielding 1261 participants from eleven studies. Participants with severe baseline pain compared to those with less severe pain had greater pain reduction at mid-term (around 12 weeks) (mean reduction: -6.90 (95%CI -10.91; -2.90)), but not at short- and long-term. No interaction effects were found between inflammatory signs and IA glucocorticoid injections compared to placebo at all follow-up time-points. Analysis of trend demonstrated treatment response to IA glucocorticoid from baseline pain levels >50 (0-100 scale) and above.

Conclusion

This updated IPD meta-analysis demonstrated that participants with severe pain compared to those with less severe pain at baseline experienced significantly more pain relief with IA glucocorticoid compared with placebo at mid-term.

A randomized controlled study of the long-term efficacy of cooled and monopolar radiofrequency ablation for the treatment of chronic pain related to knee osteoarthritis

Background

Chronic knee pain due to osteoarthritis (OA) is expected to become more prevalent. Although conventional therapies may provide relief they are not long-lasting. Persistent pain may lead to total knee replacement, which is not free of adverse outcomes. Monopolar and cooled radiofrequency ablation (RFA) of genicular nerves is an effective option. However, either method may provide distinctive results depending on expected lesion size, a key aspect considering the anatomical variability of knee innervations. This prospective, double-blind, randomized controlled trial evaluated the efficacy and durability of knee RFA using a cooled probe or a monopolar probe of comparable diameter.

Methods

This investigator-initiated, post-market, double-blinded, prospective, randomized controlled trial was approved by the Western IRB. 79 subjects with chronic knee pain due to knee OA were enrolled in multiple locations of a single center. 75 subjects were randomized (1:1) into RFA treatment with either a 4 ​mm/17G cooled active tip (CRFA) or a 10 ​mm/16G monopolar active tip (MRFA) using conventional procedures. Primary endpoint was change in knee pain level (100 ​mm VAS score) from baseline at 24-week post-treatment. Other endpoints include change in functionality, global perceived effect, and frequency of adverse events. Evaluation spanned to 52-week post-treatment. Significance of results (p ​< ​0.05) was calculated using standard statistical analyses.

Results

Both CRFA and MRFA provided significant reduction (41 ​mm and 39 ​mm, respectively) of chronic knee pain at 24-week. At the 52-week visit, reduction in pain level was sustained for CRFA (42 ​mm) but seems to decrease for MRFA (31 ​mm). Improvements in functionality were also significant and sustained with both treatments, although tend to decrease with MRFA at 52-week. Most patients also perceived a very good/good effect of treatments along the duration of the study.

Conclusion

RFA of knee genicular nerves for the treatment of OA chronic pain is effective for 52 weeks post-ablation when using a CRFA (4 ​mm/17G active tip) or MRFA (10 ​mm/16G active tip). The benefits of CRFA seems to be better sustained beyond 24 weeks than the ones of MRFA, although no significant differences were observed at 52 weeks.

A Randomized Trial of Intra-articular Injection Therapy for Knee Osteoarthritis

BACKGROUND

Intra-articular injections are widely used for conservative treatment of knee osteoarthritis (OA). However, rigorous data are lacking regarding the comparative therapeutic effectiveness of these injections.

PURPOSE

The aim of this study was to compare clinical outcomes after intra-articular injections of glucocorticoid, hyaluronic acid, platelet-rich plasma (PRP), or placebo in patients with mild or moderate OA of the knee.

MATERIALS AND METHODS

In a double-blinded, placebo-controlled, single-center trial, we randomly assigned knees with early- to middle-stage knee OA (Kellgren-Lawrence grade 1-3) to an intra-articular injection with one of these substances: glucocorticoid, hyaluronic acid, PRP, or placebo. Primary outcome was pain reduction within 6 months after the injection, assessed with the numeric rating scale (NRS; range, 0-100). Secondary outcome parameters included WOMAC scores, Tegner Activity Scale, knee mobility, and adverse events. Finally, a linear mixed-effects model was calculated and corrected for possible patient and covariate effects.

RESULTS

One hundred twenty knees (30 knees per treatment group) in 95 patients (41 female) were included in the final analysis. The median age of patients was 60 years (interquartile range, 54.0-68.0). There was no evidence that the drug effects of primary and secondary outcome parameters differed over time. The median pain at baseline was 32.5 (interquartile range, 15.00-50.00) on NRS. The changes in pain level during the first 6 months compared with baseline were small (within ±5 points on NRS), whereas the intrapatient variability was large between -20 and +20 points. Secondary outcome parameters did not differ significantly among the groups. Kellgren-Lawrence grade did not have a statistically significant effect on pain reduction ( P = 0.61).

CONCLUSIONS

There is no evidence that knee injections with glucocorticoid, PRP, or hyaluronic acid have superior short- or long-term effects in patients with low pain level at baseline and early- to middle-stage knee OA when compared with placebo.

Is the Combination of Platelet-Rich Plasma and Hyaluronic Acid the Best Injective Treatment for Grade II-III Knee Osteoarthritis? A Prospective Study

Background

Knee osteoarthritis is a common disease with increasing incidence and prevalence in western countries. It can cause severe pain and functional limitations, thereby representing a threat for patients' quality of life and a burden for national health systems. Intra-articular injections with hyaluronic acid (HA) and platelet-rich plasma (PRP) have been used for decades in order to reduce the symptoms caused by osteoarthritis. In recent years, a combination of HA and PRP has been introduced in clinical practice with the aim to minimize the clinical presentation of osteoarthritis and potentially delay articular degeneration.

Materials and Methods

Sixty cases with grade II-III knee osteoarthritis according to the Kellgren-Lawrence classification were included in a prospective study, focused on the evaluation of clinical and functional outcomes after intra-articular knee injections. Cases were randomly divided into three groups. Twenty cases (Group A) were injected with HA, 20 (Group B) had PRP, and the remaining 20 (Group C) received a combination of HA and PRP. Basal WOMAC score and VAS score were recorded before the treatment and repeated within 3 and 6 months after the treatment.

Results

At 6-month follow-up, Group C (PRP + HA) was the one with the lowest WOMAC and VAS mean values. It was also the only group that reported a reduction in the two values both in the first three months and in the following three months. No major complication was recorded.

Conclusion

The combination of platelet-rich plasma and hyaluronic acid can be effective in the treatment of grade II-III knee osteoarthritis in a short-to-mid-term scenario. It represents an innovative and valuable alternative to the administration of its two components alone.

Is intraarticular enjections effective on pain management in patients with late stage primer gonarthrosis during COVID-19 pandemic? A single centre experience

Background: Primary gonarthrosis is a progressive disease that increases with age and leads to limitations in activities of daily living. Until surgery is performed, nonsteroidal anti-inflammatory drugs, intraarticular injections, and physical therapy methods are used. Purpose: This study aims to compare the clinical outcomes of intra- articular corticosteroid (CCS) and hyaluro nic acid (HA) injections for pain relief in primary gonartrhosis in COVID -19 pandemic period. Study Design: Retrospective Cohort Study. Methods: In this study, 88 patients who underwent intra-articular CCS and HA injection between August 2020 and March 2021 due to Kellgren-Lawrence stage 2 and higher gonarthrosis were investigated. Patients were divided into two groups. Group I represents the patients who received HA injections, and group II represents the patients who received CCS injection. Western Ontario and McMaster Universities Arthritis Index (WOMAC) and Knee Society Score (KSS) scores were used for the preoperative and postoperative functional evaluations of the patients. Results: Group I included 40 patients and group II included 48 patients. The mean age was 59.4 ± 7.3 years, and the average follow-up period was 12 ± 2,6 months. The pre-intervention WOMAC scores were 13,5 in Group I and 13.6 in Group II, KSS scores were 26,5 in Group I and 25,2 in Group II. While there was a significant change in the control at month 1 in both groups, no difference was found between the groups. At the 6th month control, the improvement in group 1 continued at a significant level compared to the pre-injection period, while group 2 returned to the pre-injection level. (p

A comprehensive review of intraarticular knee injection therapy, geniculate injections, and peripheral nerve stimulation for knee pain in clinical practice

The knee is the most common joint in adults associated with morbidity. Many pathologies are associated with knee damage, such as gout or rheumathoid arthritis, but the primary condition is osteoarthritis (OA). Not only can osteoarthritis cause significant pain, but it also can result in signficant disability as well. Treatment for this condition varies, starting off with oral analgesics and physical therapy to surgical total knee replacmenet. In the gamut of this various treatments, a conservative approach has included intra articular steroid injections. With time, researchers and clinicians determined that other components injected to the knee may additionally provide relief of this condition. In this investigation, we describe different types of knee injections such as platelet-rich plasma (PRP), hyaluronic acid, stem cells, and prolotherapy. Additionally, we describe the role of geniculate knee injections, radiofrequency, and periopheral nerve stimulation. These treatments should be considered for patients with knee pain refractory to conservative therapies.

Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis: A Systematic Review and Network Meta-analysis

BACKGROUND

In younger patients and those without severe degenerative changes, the efficacy of intra-articular (IA) injections as a nonoperative modality for treating symptomatic knee osteoarthritis (OA)-related pain while maintaining function has become a subject of increasing interest.

PURPOSE

To assess and compare the efficacy of different IA injections used for the treatment of knee OA, including hyaluronic acid (HA), corticosteroids (CS), platelet-rich plasma (PRP), and plasma rich in growth factors (PRGF), with a minimum 6-month patient follow-up.

STUDY DESIGN

Meta-analysis of randomized controlled trials; Level of evidence, 1.

METHODS

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Mean or mean change from baseline and standard deviation for outcome scores regarding pain and function were recorded at the 6-month follow-up and converted to either a 0 to 100 visual analog scale score for pain or a 0 to 100 Western Ontario and McMaster Universities Osteoarthritis Index score for function. A frequentist network meta-analysis model was developed to compare the effects of HA, CS, PRP, PRGF, and placebo on patient-reported outcomes.

RESULTS

All IA treatments except CS were found to result in a statistically significant improvement in outcomes when compared with placebo. PRP demonstrated a clinically meaningful difference in function-related improvement when compared with CS and placebo due to large effect sizes. Studies evaluating outcomes of PRGF reported significant improvement when compared with placebo due to large effect sizes, whereas a potential clinically significant difference was detected in the same comparison parameters in pain evaluation. With regard to improvements in pain, function, and both combined, PRP was found to possess the highest probability of efficacy, followed by PRGF, HA, CS, and placebo.

CONCLUSION

PRP yielded improved outcomes when compared with PRGF, HA, CS, and placebo for the treatment of symptomatic knee OA at a minimum 6-month follow-up. Further investigations evaluating different IA and other nonoperative treatment options for patients with knee OA are warranted to better understand the true clinical efficacy and long-term outcomes of nonsurgical OA management.

Management of osteoarthritis: From drug molecules to nano/micromedicines

With the change in lifestyle and aging of the population, osteoarthritis (OA) is emerging as a major medical burden globally. OA is a chronic inflammatory and degenerative disease initially manifesting with joint pain and eventually leading to permanent disability. To date, there are no drugs available for the definitive treatment of osteoarthritis and most therapies have been palliative in nature by alleviating symptoms rather than curing the disease. This coupled with the vague understanding of the early symptoms and methods of diagnosis so that the disease continues as a global problem and calls for concerted research efforts. A cascade of events regulates the onset and progression of osteoarthritis starting with the production of proinflammatory cytokines, including interleukin (IL)‐1β, IL‐6, tumor necrosis factor (TNF)‐α; catabolic enzymes, such as matrix metalloproteinases (MMPs)‐1, ‐3, and ‐13, culminating into cartilage breakdown, loss of lubrication, pain, and inability to load the joint. Although intra‐articular injections of small and macromolecules are often prescribed to alleviate symptoms, low residence times within the synovial cavity severely impair their efficacy. This review will briefly describe the factors dictating the onset and progression of the disease, present the current clinically approved methods for its treatment and diagnosis, and finally elaborate on the main challenges and opportunities for the application of nano/micromedicines in the treatment of osteoarthritis. Thus, future treatment regimens will benefit from simultaneous consideration of the mechanobiological, the inflammatory, and tissue degradation aspects of the disease.

This article is categorized under:

Nanotechnology Approaches to Biology > Nanoscale Systems in Biology

Implantable Materials and Surgical Technologies > Nanotechnology in Tissue Repair and Replacement

A clinical model for predicting knee replacement in early-stage knee osteoarthritis: data from osteoarthritis initiative

BACKGROUND

Knee osteoarthritis (OA) progresses in a heterogeneous way, as a majority of the patients gradually worsen over decades while some undergo rapid progression and require knee replacement. The aim of this study was to develop a predictive model that enables quantified risk prediction of future knee replacement in patients with early-stage knee OA.

METHODS

Patients with early-stage knee OA, intact MRI measurements, and a follow-up time larger than 108 months were retrieved from the Osteoarthritis Initiative database. Twenty-five candidate predictors including demographic data, clinical outcomes, and radiographic parameters were selected. The presence or absence of knee replacement during the first 108 months of the follow-up was regarded as the primary outcome. Patients were randomly divided into derivation and validation groups in the ratio of three to one. Nomograms were developed based on multivariable logistic regressions of derivation group via R language. Those models were further tested in the validation group for external validation.

RESULTS

A total of 839 knees were enrolled, with 98 knees received knee replacement during the first 108 months. Glucocorticoid injection history, knee OA in the contralateral side, extensor muscle strength, area of cartilage deficiency, bone marrow lesion, and meniscus extrusion were selected to develop the nomogram after multivariable logistic regression analysis. The bias-corrected C-index and AUC of our nomogram in the validation group were 0.804 and 0.822, respectively.

CONCLUSION

Our predicting model provided simplified identification of patients with high risk of rapid progression in knee OA, which showed adequate predictive discrimination and calibration.

KEY POINTS

• Knee OA progresses in a heterogeneous way and rises to a challenge when making treatment strategies. • Our predicting model provided simplified identification of patients with high risk of rapid progression in knee OA.

Conservative treatment of knee osteoarthritis: A review of the literature

Knee osteoarthritis (KOA) is a common chronic debilitating disease with an estimated prevalence of 23.9% in the general adult population. The condition is characterised by joint pain, functional impairment and significant reduction in quality of life. Management for KOA can generally be divided into conservative (non-operative) and surgical (operative) measures. Conservative management broadly compromises pharmacological and non-pharmacological options and is conventionally the first line treatment to avoid or delay the need for surgical management. The aim of this study is to provide an overview of the current recommendations, efficacy and safety profile of different conservative treatments through a review of the literature.

Acide hyaluronique intra-articulaire dans la gonarthrose: résultats cliniques d'une famille de produits (ARTHRUM), avec méta-analyses comparatives

Introduction

La viscosupplémentation est largement pratiquée, pour réduire la douleur dans l'arthrose (OA), par des injections intra articulaires (IA) d'acide hyaluronique (AH). En Europe, ces produits sont des dispositifs médicaux de classe III, pour lesquels la réglementation Medical Device Regulation (MDR) impose une évaluation clinique, basée sur des études spécifiques et/ou une revue bibliographique des dispositifs équivalents. L'objet de cet article est de présenter une revue comparative entre une famille de dispositifs (ARTHRUM, de LCA Pharmaceuticals, Chartres, France) et un groupe important de dispositifs AH IA présumés équivalents dont les résultats et ceux de leurs contrôles, ont fait l'objet de publications dans des journaux scientifiques.

Méthodes

Pour rejoindre les critères utilisés dans la plupart des études ARTHRUM, les sous-scores de l'indice Western Ontario and McMaster Universities ont été sélectionnés pour la douleur (WOMAC A), la raideur (WOMAC B) et la fonction (WOMAC C). Le critère principal était la variation du score WOMAC A depuis T0 (date d'inclusion) jusqu'à T6 (6 mois). Les autres critères WOMAC ont été évalués à T1, T3, T6 et complétés par les taux de répondeurs au traitement selon OMERACT-OARSI. Cinquante articles ont été sélectionnés, incluant des résultats portant sur plus de 12.000 patients. Ceux-ci ont été répartis en trois groupes: ARTHRUM, EQUIVALENTS et CONTROLES. Pour obtenir des comparaisons quantitatives, des méta-analyses furent réalisées pour chaque critère individuel. Les intervalles de confiance (CI) à 95% de chaque variation par rapport à l'inclusion, ont permis d'évaluer la pertinence clinique en se référant à un minimum validé dans la littérature de l'OA. L'investigation a été complétée par des comparaisons entre groupes et par l'évaluation de la tolérance.

Résultats

Pour les scores WOMAC A, B et C, l'intégralité de CI 95% était toujours supérieure à l'amélioration minimale cliniquement perceptible (MPCI), pour les groupes ARTHRUM et EQUIVALENTS, ce qui n'a pas été observé pour la totalité des critères, avec le groupe CONTROLES. Dans les comparaisons, les groupes ARTHRUM et EQUIVALENTS ont été significativement meilleurs que le groupe CONTROLES pour chaque critère. La taille de l'effet (ES) sur la douleur, pour les groupes ARTHRUM et EQUIVALENTS, a varié de 0,28 à 0,56 et de 0,23 to 0,27, respectivement. Globalement, ARTHRUM a toujours été évalué non-inférieur aux EQUIVALENTS, et parfois statistiquement et cliniquement supérieur.

Conclusions

La comparaison des études cliniques ARTHRUM, avec les études tirées de la recherche bibliographique, permet de conclure que l'efficacité clinique des dispositifs médicaux ARTHRUM, pour réduire la douleur et améliorer la fonction dans la gonarthrose, sur une période de six mois, est au moins aussi élevée que celle des dispositifs équivalents. Avec un bon profil de tolérance (taux plus faible d'effets indésirables, et aucun sévère), le rapport risque-bénéfice est en faveur de la viscosupplémentation avec ARTHRUM.

Intraarticular Hyaluronic Acid Preparations for Knee Osteoarthritis: Are Some Better Than Others?

OBJECTIVE

This literature review summarizes evidence on the safety and efficacy of intraarticular hyaluronic acid (IAHA) preparations approved in the United States for the treatment of osteoarthritis of the knee.

DESIGN

A systematic literature search was performed in PubMed, Ovid MEDLINE, and SCOPUS databases. Only studies in which clinical outcomes of individual IAHA preparations alone could be assessed when compared to placebo, no treatment, other standard knee osteoarthritis treatments, and IAHA head-to-head studies were selected.

RESULTS

One hundred nine articles meeting our inclusion criteria were identified, including 59 randomized and 50 observational studies. Hylan G-F 20 has been the most extensively studied preparation, with consistent results confirming efficacy in placebo-controlled studies. Efficacy is also consistently reported for Supartz, Monovisc, and Euflexxa, but not for Hyalgan, Orthovisc, and Durolane. In the head-to-head trials, high-molecular-weight (MW) Hylan G-F 20 was consistently superior to low MW sodium hyaluronate preparations (Hyalgan, Supartz) up to 20 weeks, whereas one study reported that Durolane was noninferior to Supartz. Head-to-head trials comparing high versus medium MW preparations all used Hylan G-F 20 as the high MW preparation. Of the IAHA preparations with strong evidence of efficacy in placebo-controlled studies, Euflexxa was found to be noninferior to Hylan G-F 20. There are no direct comparisons to Monovisc. One additional IAHA preparation (ie, Synovial), which has not been assessed in placebo-controlled studies, was also noninferior to Hylan G-F 20.

CONCLUSION

IAHA efficacy varies widely across preparations. High-quality studies are required to assess and compare the safety and efficacy of IAHA preparations.

Intra-articular hyaluronic acid in knee osteoarthritis: clinical data for a product family (ARTHRUM), with comparative meta-analyses

Introduction

Viscosupplementation is widely practiced, to reduce pain in osteoarthritis (OA), using intra articular (IA) injections of hyaluronic acid (HA). In Europe, these products are class III medical devices, for which the Medical Device Regulation (MDR) requires clinical assessment, based on specific studies and/or a bibliographical review of equivalent devices. The purpose of this article is to present a comparative review between a family of devices (ARTHRUM, from LCA Pharmaceuticals, Chartres, France) and an extensive group of presumed equivalent IA HA devices or their controls, whose results have been published in Scientific journals.

Methods

To meet the criteria used in most ARTHRUM studies, the Western Ontario and McMaster Universities’ index sub-scores were selected for pain (WOMAC A), stiffness (WOMAC B) and function (WOMAC C). The main criterion was the variation of the WOMAC A score from T0 (date of inclusion) to T6 (6 months). The other WOMAC criteria were assessed at T1, T3, T6 and complemented by OMERACT-OARSI rates of responders to the treatment. Fifty articles were selected, containing treatment details on more than 12,000 patients. These were divided into three groups: ARTHRUM, EQUIVALENTS and CONTROLS. To get quantitative comparisons, meta-analyses were performed for each criterion individually. The 95% confidence interval of each difference from baseline, was used to assess the clinical relevance, with reference to a minimum validated in OA literature. Comparisons between groups and tolerance assessment completed the investigation.

Results

For the WOMAC A, B and C scores, the full 95% CI was always above the minimal perceptible clinical improvement (MPCI), in the ARTHRUM and EQUIVALENTS groups, but not for all criteria in the CONTROLS group. In the comparisons, both ARTHRUM and EQUIVALENTS groups were significantly better than the CONTROLS group for each criterion. The effect size (ES) on pain, for the ARTHRUM and EQUIVALENTS groups, varied from 0.28 to 0.56 and from 0.23 to 0.27, respectively. Overall, ARTHRUM was estimated always non-inferior to EQUIVALENTS, and sometimes statistically and clinically superior.

Conclusions

The comparison of ARTHRUM clinical studies, with studies selected through bibliographic research, leads to the conclusion that the clinical efficacy of the ARTHRUM medical devices, to reduce pain and improve the function in knee OA, during a six-month period, is at least as great as those of equivalent products. With good tolerance results (lowest rate of adverse events, and none of them serious), the risk benefit ratio favours using viscosupplementation with ARTHRUM.

Comparison between intra-articular infiltrations of placebo, steroids, hyaluronic and PRP for knee osteoarthritis: a Bayesian network meta-analysis

INTRODUCTION

Regarding the efficacy of intra-articular injections of platelet-rich plasma, hyaluronic acid and corticosteroids, current evidence is controversial. The superiority of one technique over another is questioned and debates are ongoing. The purpose of the present study was to compare and investigate the efficacy of these intra-articular infiltrations in patients with knee osteoarthritis (OA). A Bayesian network meta-analysis of randomized clinical trials (RCTs) was conducted comparing patient outcomes at 3, 6 and 12-months of follow-up.

MATERIALS AND METHODS

This Bayesian network meta-analysis was conducted according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health care interventions. All the RCTs comparing the outcomes of two or more intra-articular infiltrations of interest for knee OA were considered for inclusion. The outcomes of interest were the WOMAC and VAS scores. The network meta-analyses were performed using the STATA routine for Bayesian hierarchical random-effects models.

RESULTS

Data from 30 RCTs (3463 patients) were collected. At 3-months follow-up, PRP showed the best WOMAC scores, followed by the Placebo, CCS and HA. At 6-months follow-up, PRP showed the best WOMAC scores, followed by HA, CCS and Placebo. At 12-months follow-up, PRP showed the best WOMAC scores, followed by the Placebo, HA and CCS. At 3-months follow-up, the PRP showed the best VAS scores, followed by CCS, HA and Placebo. At 6-months follow-up, PRP showed the best VAS scores, followed by CCS, Placebo and HA. At 12-months follow-up, the PRP showed the best VAS scores, followed by CCS, Placebo and HA.

CONCLUSION

Intra-articular injections of PRP demonstrated the best overall outcome compared to steroids, hyaluronic acid and placebo for patients with knee osteoarthrosis at 3, 6 and 12-months follow-up. Among CCS, hyaluronic acid and placebo, no discrepancies were detected.

LEVEL OF EVIDENCE

I, Bayesian network meta-analysis of RCTs.

A Comprehensive Review of Viscosupplementation in Osteoarthritis of the Knee

PURPOSE OF REVIEW

The purpose of this systematic review is to discuss emerging evidence in the field of viscosupplementation for chronic knee pain secondary to Osteoarthritis (OA). This review focuses on types of viscosupplementation that are clinically available currently, evidence to support their use, contraindications, and adverse events.

RECENT FINDINGS

OA, also known as degenerative joint disease, is the most common form of arthritis in the United States, affecting 54.4 million, or 22.7% of the adult population. The knee is the most common joint affected in OA, with up to 41% involvement, 30% in the hands, and 19% in the hips. The pathophysiology of OA is complex, with contributing factors including mechanical stress to the joint, as well as many person-specific factors such as genetic susceptibility, ethnicity, nutrition, and sex. Treatment modalities include weight control, exercise, non-steroidal and steroidal anti-inflammatory drugs, opioids, intra-articular platelet-rich plasma, placebo, corticosteroid injection, intra-articular viscosupplementation, and surgery. Viscosupplementation consists of injection of hyaluronic acid (HA) into affected joints, intending to restore the physiologic viscoelasticity in the synovial fluid (SF) in the absence of inflammation. HA has also been shown to downregulate pro-inflammatory factors, such as PGE2 and NFkB, and proteases and proteinases known to break down the joint matrix.The contraindications for HA injection are similar to any other injection therapy, and adverse events are usually mild, local, and transient. Viscosupplementation (VS) is effective over placebo and more effective than NSAIDs and corticosteroids in pain reduction and improved functionality; however, guidelines recommend neither for nor against its use, demonstrating variability in the existing evidence base.Current VS options divide primarily into native vs. cross-linked and low-molecular-weight vs. high-molecular-weight. Current treatment options include Hylan g-f-20, Sodium Hyaluronate preparations (Suparts Fx, Euflexxa, Gelsyn-3, Durolane, Hyalgen), single-use agents (Gel-One, Synvisc-One, Monovisc), and Hyaluronan (Orthovisc, Monovisc, Hymovic). They share a common safety profile, and all have evidence supporting their efficacy. Their specific details are reviewed here.

SUMMARY

OA is the most common form of arthritis. It is a chronic, debilitating illness with a high impact on the functionality and quality of life of a significant part of the population in the western world. Treatments include medical management, physical therapy, activity modification, injection, and surgery. VS effectively reduces pain, increases functionality, and delays surgery in the knee to treat osteoarthritis. While previous studies have demonstrated variable results, more evidence is becoming available generally supportive of the benefit of VS in the treatment of knee OA.

Current advances in the biosynthesis of hyaluronic acid with variable molecular weights

Hyaluronic acid (HA) is a naturally formed acidic mucopolysaccharide, with excellent moisturising properties and used widely in the medicine, cosmetics, and food industries. The industrial production of specific molecular weight HA has become imperative. Different biological activities and physiological functions of HA mainly depend on the degree of polymerisation. This article reviews the research status and development prospects of the green biosynthesis and molecular weight regulation of HA. There is an application-based prerequisite of specific molecular weight of HA that could be regulated either during the fermentation process or via a controlled HA degradation process. This work provides an important theoretical basis for the downstream efficient production of diversified HA, which will further accelerate the research applications of HA and provide a good scientific basis and method reference for the study of the molecular weight regulation of similar biopolymers.

Clinical effectiveness and safety of intra-articular injection of HYALGO in the management of knee osteoarthritis symptoms: A multicenter prospective study

BACKGROUND

The reduced concentration of hyaluronic acid in the synovial fluid, leading to impairment of joint function and painful symptomatology during knee osteoarthritis (OA), can be restored by using injectable formulations of hyaluronic acid (HA) and chondroitin sulfate (CS), variable for relative composition, HA/CS molecular modifications, and injection protocols. The present study aims to assess the safety and performance of the intra-articular (IA) viscosupplementing agent HYALGO, a formulation combining 40 mg/mL HA (>1700 kDa) and 40 mg/mL CS, in the treatment of patients suffering from knee OA.

METHODS

74 patients affected by knee lesions classified as grade II and III according to Kellgren and Lawrence classification were prospectively recruited and treated with three HYALGO injections (2 mL) given one week apart. Visual analogue scale (VAS) pain changes were monitored at each injection and over-time at 6, 14, and 26 weeks of follow-up. Secondary endpoints were: Western Ontario McMaster University Osteoarthritis index (WOMAC), Patient's Global Assessment (PGA) score, Clinical Observer Global Assessment (COGA) score, Outcome Measures in Rheumatology Committee (OMERACT) and Osteoarthritis Research Society International (OARSI) responders rates. Patients were also assessed for changes in their ultrasound joint scores according to the criteria of the OMERACT US Task Force Group.

RESULTS

Pain reduction was statistically significant starting from the first IA injection. Mean pain reduction from baseline to week 26 was -90.6%. At 26 weeks, WOMAC Pain was reduced by -62.7%, WOMAC Stiffness by -47.2%, WOMAC Physical Function by -54.1%; Total WOMAC by -53.8%. The VAS PGA change from baseline was -48.0 [mm] and VAS COGA -41.0 [mm]. Responders at week 26 were 78.4%. Ultrasound parameters (joint effusion, synovial thickness, and popliteal cysts) improved or remained stable from baseline to week 6.

CONCLUSIONS

Three injections of HYALGO were safe and effective to manage symptomatic knee OA, with a beneficial effect that increased progressively over time, peaking 6 months after injection.

Clinical therapy of platelet-rich plasma vs hyaluronic acid injections in patients with knee osteoarthritis: A systematic review and meta-analysis of randomized double-blind controlled trials

OBJECTIVE:

Knee osteoarthritis (KOA) is the most common degenerative disease of the joints caused by articular cartilage injury, degeneration of joint edges and hyperplasia of subchondral bone. The purpose of this study is to investigate the efficacy and safety of clinical therapy of platelet-rich plasma vs hyaluronic acid injections in patients with KOA.

METHODS:

We systematically investigated Pubmed, Embase, and the Cochrane Library for all related articles published through May 2020. Any study was included that compared the effect of platelet-rich plasma (PRP) and hyaluronic acid (HA) in patients with KOA. The search terms included “platelet-rich plasma,” “PRP,” “hyaluronic acid,” “HA,” “knee,” “osteoarthritis,” “arthritis,” “KOA”. Review Manager 5.3 was used to analyze and calculate data regarding these outcome indicators.

RESULTS:

In this study, 1. Six randomized double-blind controlled trials were included, including 338 patients in the PRP group and 323 patients in the HA group. 2. Meta-analysis results showed that the Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC) Total Score was differed significantly between the PRP and HA groups at the 1, 6, 12 months follow-up (MD = 3.39, 95% CI: 2.85–3.92, P < .05). In a comparison of Physical function scores at the 12 months follow-up, PRP improved knee function scores more than HA (MD = 3.28; 95% CI: 2.13–4.43; P < .05). However, International Knee Documentation Committee (IKDC), Tegner Activity scores, EuroQol visual analogue scale (EQ-VAS), and Adverse Events (AEs) were all not significantly different (P > .05). 3. Results showed that compared with HA, PRP had significant advantages in relevant improving knee function and quality of life.

CONCLUSION:

In improving knee function and quality of life, PRP showed superiority over HA in long-term follow-up from well-designed double-blind trials, but a large number of high-quality multi-center studies are still needed to provide more sufficient evidence.

Do preoperative intra-articular corticosteroid and hyaluronic acid injections affect time to total joint arthroplasty?

INTRODUCTION

Intra-articular corticosteroid (CSI) or hyaluronic acid (HAI) injections alleviate symptoms of osteoarthritis in patients who may be candidates for total hip or total knee arthroplasty (THA/TKA). However, their effect on time to total joint arthroplasty (TJA) and complications remains uncertain. We sought to evaluate (1) delay in time to surgery for patients receiving injections prior to THA/TKA (2) incidence of patients that receive injections, (3) type and number of injections, and (4) compare complication rates between patients with and without injections.

METHODS

We retrospectively reviewed 3340 consecutive TJA (1770 THA and 1570 TKA). Patients were divided into two cohorts depending if they received preoperative intra-articular injection or not. We identified dates of first clinic presentation and index surgery, injection type, total administered, and 90-day complications, including periprosthetic joint infection.

RESULTS

150/1770 THA and 192/1570 TKA patients received injections (8.5%vs.12.2%,p = 0.0004). Time from first presentation to clinic to TJA was significantly greater in patients receiving injections [12.4 ± 11 months vs.7.3 ± 10.7,p < 0.001 for THA; 20.0 ± 17.4 months vs.11.6 ± 15.4,p < 0.001 for TKA]. This delay in time was greater in TKA versus THA (8.4 months vs.5.1,p < 0.001). TKA patients had a higher incidence of receiving HAI versus THA patients (9%vs.0.6%,p < 0.0001). There were no differences in overall complication profiles (p = 0.19 for THA, p = 0.3 for TKA).

CONCLUSION

Injections are associated with an increased time to TJA by a statistically significant amount, however its clinical significance is debatable. Injections are safe if administered at least three months preoperatively. If patients present with appropriate surgical indications and are ready, we do not recommend intra-articular injections to delay surgery.

The intra-articular administration of triamcinolone hexacetonide in the treatment of osteoarthritis. Its effects in a naturally occurring canine osteoarthritis model

OBJECTIVE

To evaluate the effect of an intra-articular (IA) administration of triamcinolone hexacetonide, compared with saline.

PATIENTS AND METHODS

Forty (N = 40) hip joints were randomly assigned to a treatment group (THG, n = 20, receiving IA triamcinolone hexacetonide) and a control group (CG, n = 20, receiving IA saline). On treatment day (T0), and at 8, 15, 30, 90 and 180 days post-treatment, weight distribution, joint range of motion, thigh girth, digital thermography, radiographic signs, synovial fluid interleukin-1 and C-reactive protein levels were evaluated. Data from four Clinical Metrology Instruments was also gathered. Results were compared Repeated Measures ANOVA, with a Huynh-Feldt correction, Paired Samples T-Test or Wilcoxon Signed Ranks Test. A Kaplan-Meier test was performed to compare both groups, with p<0.05.

RESULTS

Joints were graded as mild (65%), moderate (20%) and severe (15%). Patients of both sexes, with a mean age of 6.5±2.4 years and bodyweight of 26.7±5.2kg, were included. No differences were found between groups at T0. Comparing THG to CG, weight distribution showed significant improvements in THG from 8 (p = 0.05) up to 90 days (p = 0.01). THG showed lower values during thermographic evaluation in the Lt view (p<0.01). Pain and function scores also improved from 30 to 180 days. Increasing body weight, age, and presence of caudolateral curvilinear osteophyte corresponded to worse response to treatment. Results of the Kaplan Meier test showed significant differences between groups, with THG performing better considering several evaluations and scores.

CONCLUSION

THG recorded significant improvements in weight-bearing and in with the considered CMIs, particularly pain scores. Lower thermographic values were registered in THG up to the last evaluation day. Age, sex, and radiographic findings did significantly influenced response to treatment.

Critical appraisal of intra-articular glucocorticoid injections for symptomatic osteoarthritis of the knee

OBJECTIVE

Intra-articular (IA) injections of glucocorticoids (GCs) have been shown to decrease pain, increase mobility, and improve quality of life in patients with osteoarthritis (OA) of the knee. Concerns about cartilage loss with IA GCs have prompted reconsideration of their use in knee OA. This review has three objectives: 1) critically review the clinical, molecular, and structural effects of IA GCs in knee OA; 2) provide a design for a clinical trial aimed at improving our understanding of the long-term consequences of IA GCs; and 3) provide practical guidance on the use of IA GCs in patients with knee OA based on current information.

DESIGN

A narrative review of current literature on the use of IA GCs for OA of the knee.

RESULTS

Important questions remain to be fully answered with respect to IA GCs, including long-term effects on all aspects of the structural and molecular environment of the knee, and identification of factors that can reliably predict a positive or negative response to IA GCs.

CONCLUSIONS

While awaiting results from an appropriately designed study, several provisional statements regarding IA GCs can be put forward: 1) IA GCs appear to be a relatively safe option that is effective in specific patients with symptomatic knee OA; 2) there is no definitive evidence that IA GCs accelerate joint deterioration to an important extent or hastens the requirement for knee replacement; and 3) there are few contraindications to IA GCs and injection-associated complications are rare when IA GCs are delivered with proper technique.

Intra-Articular Injections of Hyaluronic Acid or Steroids Associated With Better Outcomes Than Platelet-Rich Plasma, Adipose Mesenchymal Stromal Cells, or Placebo in Knee Osteoarthritis: A Network Meta-analysis

PURPOSE

To evaluate the clinical effects of hyaluronic acid (HA), steroids, platelet-rich plasma (PRP), or adipose mesenchymal stromal cell (MSC) injections in the treatment of knee osteoarthritis (OA).

METHODS

Randomized controlled trials with OA of the knee that compared HA, steroids, PRP, adipose MSC, or their combination with placebo or in head-to-head combination were identified from the MEDLINE, EMBASE, Cochrane Library, Web of Science, and SCOPUS databases up to June 30, 2019. We performed a network meta-analysis of the relevant literature to determine whether there was benefit from HA, steroids, PRP, or adipose MSC treatment as compared with placebo.

RESULTS

A total of 43 trials covering 5554 patients were included. Steroids were ranked most likely to be effective for the management of pain or function, with adipose MSC and multiple PRP appearing least likely to be effective. Although no significant difference was observed among the 6 interventions, except for single PRP with respect to adverse effects, steroids and HA exhibited a lower rate of AEs compared with the placebo. In view of severe adverse effects, only single PRP was superior to placebo. Direct pairwise meta-analysis for pain relief showed that HA was superior to placebo or single PRP, but steroids had a significantly worse effect than single PRP. In addition, direct pairwise meta-analysis for adverse effects favored steroids in comparison to HA.

CONCLUSIONS

The ranking statistics like surface under the cumulative ranking curve values of our network meta-analysis support the use of steroids and HA for appropriate patients with knee OA. For pain relief and AEs, steroids are most likely the best treatment, followed by HA. Single PRP, multiple PRP, and adipose MSC interventions do not result in a relevant reduction of joint pain nor improvement of joint function compared with placebo. However, treatment effect differences were small and potentially not clinically meaningful, indicating that other factors, such as cost and patient preferences, may be more important in patients with knee OA.

LEVEL OF EVIDENCE

meta-analysis of non-homogenous randomized controlled trials, Level II.

Efficacy and Safety of Hylan G-F 20 Versus Intra-Articular Corticosteroids in People with Knee Osteoarthritis: A Systematic Review and Network Meta-Analysis

Background:

Direct injection of corticosteroids into the joint is a standard treatment for knee osteoarthritis (OA). However, the treatment is somewhat controversial with regard to the benefit of both single and repeated injections; evidence that they are beneficial comes from small studies that show only modest improvements. The aim of this study was to estimate the short- and long-term clinical efficacy and safety of hylan G-F 20 versus intra-articular corticosteroids (IACS) for the treatment of pain in knee OA using Bayesian network meta-analysis.

Methods:

Based on a pre-specified protocol, MEDLINE, Embase, and CENTRAL were searched from inception to June 2018 to identify randomized controlled trials. The Cochrane Collaboration’s tool for assessing risk of bias in randomized trials was used to assess the included studies. Hylan G-F 20 and IACS were compared using Bayesian network meta-analysis. Efficacy was evaluated at 1, 3, and 6 months, and at the final follow-up for safety outcomes. A pain hierarchy was used to select 1 pain outcome per study.

Results:

Forty-two trials were included for analysis. The network meta-analysis of pain showed that hylan G-F 20 may be equivalent to IACS in the short-term, but by 6 months the benefit relative to IACS was statistically significant, standardized mean difference (95% credible interval): –0.13 (–0.26, –0.01). There were no statistical differences in adverse events.

Conclusions:

Hylan G-F 20 may perform better in relieving pain at 6 months post-injection compared to IACS. Both agents were relatively well tolerated, with no clear differences in safety.

High molecular weight Intraarticular hyaluronic acid for the treatment of knee osteoarthritis: a network meta-analysis

Background

The 2013 American Academy of Orthopaedic Surgeons (AAOS) guidelines made strong recommendations against intraarticular hyaluronic acid (IAHA) for patients with knee osteoarthritis (OA), as evidence supporting improvements in pain did not meet the minimal clinically important improvement (MCII) threshold. However, there may be important distinctions based on IAHA molecular weight (MW). Hence our objective was to evaluate the efficacy of IAHAs in knee OA based on molecular weight.

Methods

Randomized controlled trials were searched within MEDLINE, Embase, and CENTRAL and selected based on AAOS criteria. A pain measure hierarchy and longest follow-up were used to select one effect size from each trial. Mean differences between interventions were converted to standardized mean differences (SMDs) and incorporated into a random-effects Bayesian network meta-analysis. High MW (HMW) was defined as ≥6000 kDa, and low MW (LMW) as < 750 kDa.

Results

HMW IAHA was associated with a statistically significant and possibly clinically significant improvement in pain (SMD − 0.57 (95% credible interval [Crl]: − 1.04, − 0.11), exceeding the − 0.50 MCII threshold. LMW IAHA had a lesser, non-significant improvement (− 0.23, 95% Crl: − 0.67, 0.20). Back-transforming SMDs to the WOMAC pain scale indicated a 14.65 (95% CI: 13.93, 15.62) point improvement over IA placebo, substantially better than the 8.3 AAOS MCII threshold.

Conclusions

Unlike LMW IAHA, HMW IAHA exceeded the MCII threshold for pain relief, suggesting that improvements can be subjectively perceived by the treated patient. Amalgamation of LMW and HMW may have blurred the benefits of IAHA in the past, leading to negative recommendations. Differentiation according to MW offers refined insight for treatment with IAHA.

Supplementary information

Supplementary information accompanies this paper at 10.1186/s12891-020-03729-w.

Recommendations of the French Society of Rheumatology on pharmacological treatment of knee osteoarthritis

OBJECTIVES

To establish recommendations for pharmacological treatment of knee osteoarthritis specific to France.

METHODS

On behalf of the French Society of Rheumatology (SFR), a bibliography group analyzed the literature on the efficacy and safety of each pharmacological treatment for knee osteoarthritis. This group joined a multidisciplinary working group to draw up recommendations. Strength of recommendation and quality of evidence level were assigned to each recommendation. A review committee gave its level of agreement.

RESULTS

Five general principles were established: 1) need to combine pharmacological and non-pharmacological treatments, 2) personalization of treatment, 3) symptomatic and/or functional aim of pharmacological treatments, 4) need to regularly re-assess the treatments and 5) discussion about arthroplasty if medical treatment fails. Six recommendations involved oral treatments: 1) paracetamol should not necessarily be prescribed systematically and/or continuously, 2) NSAIDs, possibly as first-line, 3) weak opioids, 4) strong opioids, 5) symptomatic slow-acting drugs of osteoarthritis, and 6) duloxetine (off-label use). Two recommendations involved topical agents (NSAIDs and capsaicin<1%). Three recommendations involved intra-articular treatments: corticosteroid or hyaluronic acid injections that can be proposed to patients. The experts did not draw a conclusion about the benefits of platelet-rich plasma injections.

CONCLUSION

These are the first recommendations of the SFR on the pharmacological treatment of knee osteoarthritis.

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.

Minimally Invasive Therapies for Osteoarthritic Hip Pain: a Comprehensive Review

PURPOSE OF REVIEW

Osteoarthritis (OA) is a highly prevalent cause of chronic hip pain, affecting 27% of adults aged over 45 years and 42% of adults aged over 75 years. Though OA has traditionally been described as a disorder of "wear-and-tear," recent studies have expanded on this understanding to include a possible inflammatory etiology as well, damage to articular cartilage produces debris in the joint that is phagocytosed by synovial cells which leads to inflammation.

RECENT FINDINGS

Patients with OA of the hip frequently have decreased quality of life due to pain and limited mobility though additional comorbidities of diabetes, cardiovascular disease, poor sleep quality, and obesity have been correlated. Initial treatment with conservative medical management can provide effective symptomatic relief. Physical therapy and exercise are important components of a multimodal approach to osteoarthritic hip pain. Patients with persistent pain may benefit from minimally invasive therapeutic approaches prior to consideration of undergoing total hip arthroplasty. The objective of this review is to provide an update of current minimally invasive therapies for the treatment of pain stemming from hip osteoarthritis; these include intra-articular injection of medication, regenerative therapies, and radiofrequency ablation.

Clinical Efficacy of Intra-articular Mesenchymal Stromal Cells for the Treatment of Knee Osteoarthritis: A Double-Blinded Prospective Randomized Controlled Clinical Trial

BACKGROUND

Currently, there are limited nonoperative treatment options available for knee osteoarthritis (OA). Cell-based therapies have emerged as promising treatments for knee OA. Autologous stromal vascular fraction (SVF) has been identified as an efficient medium for intra-articular administration of progenitor cells and mesenchymal stem cells derived from adipose tissue.

HYPOTHESIS

Patients receiving intra-articular SVF would show significantly greater improvement than patients receiving placebo injections, and this improvement would be dose dependent.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This was a multisite prospective double-blinded randomized placebo-controlled clinical trial. Adult patients with symptomatic knee OA were eligible. Thirty-nine patients were randomized to high-dose SVF, low-dose SVF, or placebo (1:1:1). SVF was obtained via liposuction, processed to create the cellular implant, and injected during the same clinical visit. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores and magnetic resonance images were obtained preoperatively and at 6 and 12 months after injection. The Wilcoxon rank sum nonparametric test was utilized to assess statistical significance, and the Hodges-Lehmann location shift was used to assess superiority.

RESULTS

The median percentage change in WOMAC score at 6 months after injection for the high-dose, low-dose, and placebo groups was 83.9%, 51.5%, and 25.0%, respectively. The high- and low-dose groups had statistically significant changes in WOMAC scores when compared with the placebo group (high dose, P = .04; low dose, P = .02). The improvements were dose dependent. The median percentage change in WOMAC score from baseline to 1 year after injection for the high-dose, low-dose, and placebo groups was 89.5%, 68.2%, and 0%, respectively. The high- and low-dose groups displayed a greater percentage change at 12 months when compared with the placebo group (high dose, P = .006; low dose, P = .009). Magnetic resonance image review revealed no changes in cartilage thickness after treatment. No serious adverse events were reported.

CONCLUSION

Intra-articular SVF injections can significantly decrease knee OA symptoms and pain for at least 12 months. The efficacy and safety demonstrated in this placebo-controlled trial support its implementation as a treatment option for symptomatic knee OA.

REGISTRATION

NCT02726945 (ClinicalTrials.gov identifier).

Treatment of degenerative meniscal tear with intrameniscal injection of platelets rich plasma

PURPOSE

The purpose of this retrospective study was to describe our preliminary results of intra-meniscal administration of platelet rich plasma (PRP) in patients with degenerative meniscal tears of the knee.

MATERIAL AND METHOD

Ten patients with degenerative meniscal tears according to the Stoller classification and without knee osteoarthritis were included. There were 7 men and 3 women with a mean age of 40.4±13.6 [SD] years (range: 18-59 years). Patients were prospectively assessed at baseline and 3- and 6-months after intra meniscal PRP administration. Evaluation included the knee injury and osteoarthritis outcome score (KOOS), pain visual analog scale, and return to competition and training. MRI follow-up was performed 6 months after PRP administration. Adverse events were recorded.

RESULTS

Volume of injected PRP was standardized to 4.0mL. Adverse events during PRP administration was moderate pain in 8 patients (8/10; 80%). Mean KOOS total score significantly improved from 56.6±15.7 (SD) to 72.7±18.5 (SD) (P=0.0007). All six patients practicing sports regularly were able to recover competition or training. In seven patients who underwent MRI follow-up at 6 months, MRI showed stability of the meniscal tears and similar Stoller grades.

CONCLUSION

Intra-meniscal administration of PRP under ultrasound guidance directly into meniscal degenerative lesions is feasible and safe. Further randomized controlled studies are needed to definitely confirm the effectiveness of this procedure.

Injections intra articulaires (IA) d'acide hyaluronique (AH) dans le traitement symptomatique de la gonarthrose : une méta-analyse des injections uniques (mono-injections)

Introduction

La viscosupplémentation du liquide synovial par injections intra articulaires (IA) d'acide hyaluronique (AH), est un traitement symptomatique bien connu dans la gonarthrose. La question se pose de savoir si les traitements par injection unique (mono-injection) peuvent présenter autant d'efficacité que les multi-injections (3 à 5).

Méthodes

Une méta-analyse des résultats publiés pour les essais de mono-injections IA de AH a été réalisée. Le critère d'efficacité retenu a été le sous-score douleur de l'indice Western Ontario and MacMaster universities (WOMAC A). Toutes les conceptions d'études ont été admises, depuis les essais randomisés contrôlés jusqu'aux études observationnelles ouvertes à simple bras. Une recherche extensive a été effectuée à partir de PubMed, Google, Google Scholar, et des listes de références trouvées dans les méta-analyses récentes, pour obtenir tous les articles publiés avant fin avril 2018. Les profils des populations furent analysés en termes d'âge, de sexe, d'indice de masse corporelle (IMC) et de stade radiologique selon Kellgren-Lawrence (KL). Les résultats d'injection IA unique de placebo, ont été pris en compte pour créer une base permettant des comparaisons post-hoc. Chaque bras AH IA étudié a été comparé à un bras placebo IA (seul ou mixé), de manière à présenter un profil KL similaire, contrôlé à l'aide du test Chi². Les tailles de l'effet (ES) avec intervalles de confiance (IC 95%) et p-valeurs furent calculées et synthétisées pour chacune des visites de contrôle à 1, 2, 3 et 6 mois. En parallèle, une approche globale a été utilisée afin de représenter les variations par rapport à la baseline, pour chacun des sous-groupes étudiés.

Résultats

En partant de 1 547 citations, 28 études ont été incluses dans la méta-analyse, décrivant 4 129 patients traités par mono-injection: 3 360 ont reçu de l'AH IA et 769 patients ont reçu du placebo IA. Le patient moyen (SD) traité par AH IA était âgé de 61,2 (9,6) ans dont 63% de femmes, avec un IMC de 28,0 (4,1) kg/m², et un stade radiologique à 47% KL III pour 3% KL IV. Un bon appariement du profil KL a été obtenu pour 26 des 31 bras AH IA. Sur l'ensemble de la population AH IA, ES = 0,30 (0,25; 0,35) à 3 mois et ES = 0,39 (0,33; 0,44) à 6 mois. Dans une analyse restreinte, après élimination des cas aberrants, des KL mal appariés et des bras actifs < 30 patients, les résultats sont restés inchangés, ES = 0,29 (0,23; 0,34) et ES = 0,40 (0,34; 0,45) à 3 et 6 mois respectivement, tandis que l'hétérogénéité était améliorée.

Discussion

Il existe certainement des limites à la méthode de comparaison post-hoc versus placebo, appliquée à des essais individuels. Mais pour chaque synthèse par sous-groupe ou groupe, les résultats ont été confirmés en utilisant plusieurs approches statistiques et différentes méthodes de pondération. Cette méta-analyse suggère que les résultats des mono-injections sont similaires à ceux des multi-injections d'acide hyaluronique intra articulaire en termes de soulagement de la douleur, dans le traitement de la gonarthrose.

Treatment modalities for hip and knee osteoarthritis: A systematic review of safety

Current guidelines on the management of hip and knee osteoarthritis (OA) do not compare safety of treatment modalities. We therefore systematically reviewed 20 studies investigating mortality and serious complications of both medical and surgical treatments for hip and knee OA using PubMed, Scopus, Web of Knowledge and Google Scholar. Mortality was the highest for naproxen (hazard ratio (HR) = 3 (1.9, 4.6)) and lowest for total hip replacement (relative risk (RR) = 0.7 (0.7, 0.7)). Highest gastrointestinal complications were reported for diclofenac (odds ratio (OR) = 4.77 (3.94, 5.76)) and lowest for total knee replacement (HR = 0.6 (0.49, 0.75)). Ibuprofen had the highest renal complications (OR = 2.32 (1.45, 3.71)), whereas celecoxib had the highest cardiovascular risk (OR = 2.26 (1, 5.1)) and lowest was for tramadol (RR = 1.1 (0.87, 1.4)). Results show that medical management of hip and knee OA, particularly with non-steroidal anti-inflammatory drugs, may carry higher mortality compared to surgery. Careful consideration should be given to medical management taking into account known co-morbidities.

Intra-Articular Hyaluronic Acid in the Symptomatic Treatment of Knee Osteoarthritis: A Meta-Analysis of Single-Injection Products

Background

Viscosupplementation of the synovial fluid with intra-articular hyaluronic acid (IA HA) is a well-known symptomatic treatment of knee osteoarthritis. The question arises whether a monoinjection (ie, single injection) could be as efficient as multi-injection (ie, 3-5 injections) regimens.

Methods

A meta-analysis of published studies relating to IA HA monoinjection trials was performed. The efficacy criterion was the Western Ontario and MacMaster Universities pain subscore. Any study design was accepted, from randomized control trials to single-arm observational open-label studies. An extensive search was performed using PubMed, Google, Google Scholar, and references found in recent meta-analyses, for all articles published before end of April 2018. Population profiles were analyzed in terms of age, sex, body mass index (BMI), and Kellgren-Lawrence (KL) radiology grades. Results of intra-articular single injection of placebo were collected to create a database allowing post hoc comparisons. Each IA HA study arm was compared to an IA placebo arm (either pooled or not), to present a similar KL profile controlled with the χ² test. The effect size (ES) (95% CI) and P values were calculated and synthesized for each follow-up visit at 1, 2, 3, and 6 months. In parallel, a global approach was used to represent the variations from baseline for each group or subgroup studied.

Results

From 1547 citations, 28 studies were included in the meta-analysis, representing 4129 patients treated with monoinjection: 3360 received IA HA and 769 patients received IA placebo. The mean (SD) IA HA patient was 61.2 (9.6) years, 63% women, BMI 28.0 (4.1), 47% KL III, and 3% KL IV. A good placebo KL profile matching was obtained for 26 of the 31 IA HA arms. For the whole IA HA population, ES = 0.30 (95% CI, 0.25-0.35) at 3 months and ES = 0.39 (95% CI, 0.33-0.44) at 6 months. In a restricted analysis, after removal of outliers, poorly KL matched and active arms <30 patients, results remained unchanged, ES = 0.29 (95% CI, 0.23-0.34) and ES = 0.40 (95% CI, 0.34-0.45) at 3 and 6 months respectively, whilst heterogeneity was improved.

Conclusions

There are certainly limits to the post hoc placebo comparison method, for individual studies. But for each synthesis per subgroup or group, the results were properly confirmed using multiple statistical approaches and weighing methods. This meta-analysis suggests that monoinjections produce results similar to multi-injections of IA HA in terms of pain relief in the treatment of knee osteoarthritis. (Curr Ther Res Clin Exp. 2019; 80:XXX-XXX).

Physical and Chemical Compatibility of Extended-Release Triamcinolone Acetonide (TA-ER) with Common Local Anesthetics

Introduction

Intra-articular (IA) corticosteroids are used extensively for the treatment of patients with knee osteoarthritis pain. In clinical practice, local anesthetics are frequently combined with corticosteroids prior to IA injection to provide rapid-onset analgesia. From this common practice there is no evidence to suggest that the addition of local anesthetics to corticosteroid preparations, including triamcinolone acetonide (TA), alters the physical properties or efficacy of the corticosteroid. Triamcinolone acetonide extended-release (TA-ER, formerly FX006) is a novel, microsphere-based TA formulation that demonstrated analgesic efficacy in phase 2 and 3 randomized controlled trials.

Methods

The current study assessed the compatibility of TA-ER and lidocaine, ropivacaine, and/or bupivacaine in vitro. The TA-ER and local anesthetic mixtures were assayed for changes in syringeability, pH, particle size, percentage free drug, purity, and appearance compared with TA-ER alone.

Results

By these measures, the combination of local anesthetics with TA-ER did not negatively impact the chemical or physical properties of TA-ER when compared to TA-ER controls.

Conclusion

These results demonstrate that lidocaine, bupivacaine, and ropivacaine are physically and chemically compatible with TA-ER, suggesting that local anesthetic solutions can be added to TA-ER preparations in clinical practice without adversely affecting TA-ER in vitro product characteristics.

Funding

Flexion Therapeutics, Inc.

Origin and Efficacy of Hyaluronan Injections in Knee Osteoarthritis: Randomized, Double-Blind Trial

BACKGROUND Several hyaluronan preparations are available that have different dosage forms, origins, and concentrations. The objective of the study was to compare the efficacy of intra-articular chemically cross-linked hyaluronan (CCH) and avian-derived hyaluronan (ADH) injections in knee osteoarthritis (KOA) patients. MATERIAL AND METHODS In total, 258 patients were randomized into 2 groups of 129 each: patients who received CCH injection (CCH group) and patients who received ADH injection (ADH group). Radiographic Kellgren-Lawrence score, visual analog scale (VAS) pain score, Lequesne index score, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, single-limb stance (SLS) test, and timed "Up-and-Go" (TUG) test were performed. The Mann-Whitney U test or independent t-test following Bonferroni adjustment was performed for statistical analysis at 95% of confidence level. RESULTS The CCH group had improved VAS pain score (P<0.0001, q=54.803), total WOMAC score (P<0.0001, q=4.753), Lequesne index score (P<0.0001, q=3.208), and SLS time (P<0.0001, q=8.76) at the end of 6 months as compared to those in the ADH group. After 6 months of follow-up, the ADH group had improved TUG time (P=0.0148, q=3.385) as compared to baseline. Both groups of patients had the similar improvement in Kellgren-Lawrence score and mild to moderate adverse effects after 6 months. CONCLUSIONS CCH injection was superior to ADH injection.

Intra-Articular Injection of Alginate-Microencapsulated Adipose Tissue-Derived Mesenchymal Stem Cells for the Treatment of Osteoarthritis in Rabbits

We investigated the effects of intra-articular injections of alginate-microencapsulated adipose tissue-derived mesenchymal stem cells (ASCs) during osteoarthritis (OA) development in a rabbit model of anterior cruciate ligament transection (ACLT). We induced OA in mature New Zealand white rabbits by bilateral ACLT. Stifle joints were categorised into four groups according to intra-articular injection materials. Alginate microbeads and microencapsulated ASCs were prepared using the vibrational nozzle technology. Two weeks after ACLT, the rabbits received three consecutive weekly intra-articular injections of 0.9% NaCl, alginate microbeads, ASCs, or microencapsulated ASCs, into each joint. Nine weeks after ACLT, we euthanised the rabbits and collected bilateral femoral condyles for macroscopic, histological, and immunohistochemical analyses. Macroscopic evaluation using the modified OA Research Society International (OARSI) score and total cartilage damage score showed that cartilage degradation on the femoral condyle was relatively low in the microencapsulated-ASC group. Histological analysis of the lateral femoral condyles indicated that microencapsulated ASCs had significant chondroprotective effects. Immunohistochemically, the expression of MMP-13 after the articular cartilage damage was relatively low in the microencapsulated-ASC-treated stifle joints. During the development of experimental OA, as compared to ASCs alone, intra-articular injection of microencapsulated ASCs significantly decreased the progression and extent of OA.

Injections for Knee Osteoarthritis: Corticosteroids, Viscosupplementation, Platelet-Rich Plasma, and Autologous Stem Cells

This article reviews the benefits of corticosteroid, viscosupplementation, platelet-rich plasma, and autologous mesenchymal stem cell injections for the treatment of patients with knee osteoarthritis. Integrating injections into both clinical and surgical practices is complicated given existing health insurance reimbursement policies. This review describes the outcomes associated with these interventions and appropriate methods of navigating the existing reimbursement pathways to help providers implement these treatments into their practices.

Osteoarthritis year in review 2017: clinical

This review is based on a systematic review of the literature relevant to clinical topics in osteoarthritis (OA) performed for the time period February 22, 2016 to April 1, 2017. A PubMed search using the terms "osteoarthritis" and "treatment or epidemiology" returned over 800 papers, of which 57 are reviewed here, with inclusion primarily based on relevance to clinical OA. Epidemiologic studies in this time frame focused on the incidence and prevalence of OA, comorbidities and mortality in relation to OA (particularly obesity and cardiovascular disease), and multiple joint involvement. Papers on therapeutic approaches to OA considered: non-pharmacologic options, a number of topical, oral, and intra-articular therapies, as well as the cost-effectiveness of some OA treatments. There an enormous need to identify novel strategies to reduce the impact of this highly prevalent and debilitating condition.