Longterm Effectiveness of Intraarticular Injections on Patient-reported Symptoms in Knee Osteoarthritis

Promoting Articular Cartilage Regeneration through Microenvironmental Regulation

In recent years, as the aging population continues to grow, osteoarthritis (OA) has emerged as a leading cause of disability, with its incidence rising annually. Current treatments of OA include exercise and medications in the early stages and total joint replacement in the late stages. These approaches only relieve pain and reduce inflammation; however, they have significant side effects and high costs. Therefore, there is an urgent need to identify effective treatment methods that can delay the pathological progression of this condition. The changes in the articular cartilage microenvironment, which are complex and diverse, can aggravate the pathological progression into a vicious cycle, inhibiting the repair and regeneration of articular cartilage. Understanding these intricate changes in the microenvironment is crucial for devising effective treatment modalities. By searching relevant research articles and clinical trials in PubMed according to the keywords of articular cartilage, microenvironment, OA, mechanical force, hypoxia, cytokine, and cell senescence. This study first summarizes the factors affecting articular cartilage regeneration, then proposes corresponding treatment strategies, and finally points out the future research direction. We find that regulating the opening of mechanosensitive ion channels, regulating the expression of HIF-1, delivering growth factors, and clearing senescent cells can promote the formation of articular cartilage regeneration microenvironment. This study provides a new idea for the treatment of OA in the future, which can promote the regeneration of articular cartilage through the regulation of the microenvironment so as to achieve the purpose of treating OA.

Transient receptor potential vanilloid 1: A potential therapeutic target for the treatment of osteoarthritis and rheumatoid arthritis

This study aims to determine the molecular mechanisms and analgesic effects of transient receptor potential vanilloid 1 (TRPV1) in the treatments of osteoarthritis (OA) and rheumatoid arthritis (RA). We summarize and analyse current studies regarding the biological functions and mechanisms of TRPV1 in arthritis. We search and analyse the related literature in Google Scholar, Web of Science and PubMed databases from inception to September 2023 through the multi-combination of keywords like 'TRPV1', 'ion channel', 'osteoarthritis', 'rheumatoid arthritis' and 'pain'. TRPV1 plays a crucial role in regulating downstream gene expression and maintaining cellular function and homeostasis, especially in chondrocytes, synovial fibroblasts, macrophages and osteoclasts. In addition, TRPV1 is located in sensory nerve endings and plays an important role in nerve sensitization, defunctionalization or central sensitization. TRPV1 is a non-selective cation channel protein. Extensive evidence in recent years has established the significant involvement of TRPV1 in the development of arthritis pain and inflammation, positioning it as a promising therapeutic target for arthritis. TRPV1 likely represents a feasible therapeutic target for the treatment of OA and RA.

Interventional Techniques for the Management of Knee Osteoarthritis: A Literature Review

Osteoarthritis of the knee is a prevalent condition that causes pain, discomfort, and disability that can severely impact the quality of life. This literature review aims to review the various interventional pain management techniques available to treat knee osteoarthritis. It analyzes the efficacy of various interventions such as intra-articular corticosteroids, prolotherapy, viscosupplementation, platelet-rich plasma, and genicular nerve blocks with radiofrequency ablation or cryoneurolysis. We searched databases for studies published in the past 20 years. A total of 37 articles were included. The literature supports the idea that a comprehensive treatment plan consisting of the various aforementioned techniques can provide relief for patients while delaying or avoiding joint replacement surgery.

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

Introduction

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

Methods

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

Results

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

Discussion

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

The Role of Mechanically-Activated Ion Channels Piezo1, Piezo2, and TRPV4 in Chondrocyte Mechanotransduction and Mechano-Therapeutics for Osteoarthritis

Mechanical factors play critical roles in the pathogenesis of joint disorders like osteoarthritis (OA), a prevalent progressive degenerative joint disease that causes debilitating pain. Chondrocytes in the cartilage are responsible for extracellular matrix (ECM) turnover, and mechanical stimuli heavily influence cartilage maintenance, degeneration, and regeneration via mechanotransduction of chondrocytes. Thus, understanding the disease-associated mechanotransduction mechanisms can shed light on developing effective therapeutic strategies for OA through targeting mechanotransducers to halt progressive cartilage degeneration. Mechanosensitive Ca2+-permeating channels are robustly expressed in primary articular chondrocytes and trigger force-dependent cartilage remodeling and injury responses. This review discusses the current understanding of the roles of Piezo1, Piezo2, and TRPV4 mechanosensitive ion channels in cartilage health and disease with a highlight on the potential mechanotheraputic strategies to target these channels and prevent cartilage degeneration associated with OA.

Injectable therapies for knee osteoarthritis

Knee osteoarthritis is a degenerative arthritis that mainly affects older adults. Over time, osteoarthritis can result in significant and sustained discomfort, pain, and disability. Current treatment focuses on the alleviation of pain and functional impairment. While arthroplasty is the definitive management option, it subjects patients to surgical complications, and the possibility of surgical revisions. In addition, many patients are not surgical candidates. Instead, pharmacological therapy is recommended first-line for most patients. On top of pharmacological therapy, there are a range of non-operative procedural options available. However, leading professional guidelines vary in their recommendations for these agents. Therefore, we present a review of recent randomized controlled trials and meta-analyses on injectable corticosteroids, hyaluronic acid (HA), platelet-rich plasma (PRP), mesenchymal stem cell injections, and ozone therapy. The preliminary data reveal the strongest evidence in favour of corticosteroid injections, although there are promising findings regarding the long-term efficacy of HA and PRP.

Ultrasound-Guided Knee Injections Are More Accurate Than Blind Injections: A Systematic Review of Randomized Controlled Trials

Purpose

To review the current literature to determine which injection technique and needle portal placement provide the greatest accuracy for intra-articular access to the knee.

Methods

This study followed Preferred Reporting Items and Systematic Reviews and Meta-Analyses guidelines. A comprehensive literature search was conducted in March 2020 and repeated in May 2020 using electronic databases PubMed, MEDLINE, and the Cochrane Library. Data on the accuracy of intra-articular knee injection (successful injections/total number of injections) were collected. Only Level I studies were included. Study design, demographic variables, needle sizes, and method of validating accuracy were recorded. The Jadad score was used to assess methodologic quality, and a risk-of-bias assessment was performed.

Results

A total of 12 Level I human studies (1431 patients, 1315 knees) were included in this review. Seven of the studies did a direct comparison between ultrasound-guided and blind knee injections. Ultrasound-guided injections were more accurate compared with blinded knee injections in every study. The most accurate anatomical approach was an isometric quadricep contraction method with the superolateral approach.

Conclusions

This study showed that ultrasound-guided knee injections were more accurate across every anatomical needle injection site compared with blind injections. Injections made by a blind/anatomically guided method had inconsistent accuracy rates that seemed highly dependent on the portal of entry.

Level of Evidence

Level I, systematic review of Level I studies.

Common Practices in Intra-Articular Corticosteroid Injection for the Treatment of Knee Osteoarthritis: A Survey of the American Association of Hip and Knee Surgeons Membership

BACKGROUND

Knee osteoarthritis nonoperative management options remain limited. Our aim is to define the current American Association of Hip and Knee Surgeons (AAHKS) members' practices and perceptions in terms of the frequency, formulation, use of concomitant aspiration, maximum lifetime number of injections, efficacy, interval between injection and surgery and complication rates.

METHODS

A 22-question survey based on Likert scale response anchors was approved and distributed by the AAHKS Research Committee to its membership by email during the Spring 2019 meeting. Data were managed with REDCap software.

RESULTS

Membership response totaled 537 of 2365 (22.7%) members. Highlights include every respondent using intra-articular corticosteroid injections (ICIs) in their practice, and most use a three-month minimum interval, although the preferred interval is longer. Near consensus was found waiting three months before surgery. There was a great variability in the number of injections allowed, and injections before surgery were very common. Nearly all responders use a local anesthetic mixture with the cortisone injection, but there was great variation in corticosteroid type: methylprednisolone (42%), triamcinolone (41%), betamethasone (13.3%), and dexamethasone (3.7%).

CONCLUSION

The results of our survey indicate the majority of the AAHKS members who completed the survey use ICIs routinely for treatment of knee osteoarthritis. There was near consensus in ICIs, which is effective with decreasing efficacy over serial injections, and an absolute minimum interval between injections was believed by most to be three months with no clearly defined lifetime limit and strong consensus for a three-month preoperative interval. The formulation of steroid, local anesthetic, and skin preparation technique varied greatly.

Injectable Capsaicin for the Management of Pain Due to Osteoarthritis

Capsaicin is a potent agonist of the TRPV1 channel, a transduction channel that is highly expressed in nociceptive fibers (pain fibers) throughout the peripheral nervous system. Given the importance of TRPV1 as one of several transduction channels in nociceptive fibers, much research has been focused on the potential therapeutic benefits of using TRPV1 antagonists for the management of pain. However, an antagonist has two limitations. First, an antagonist in principle generally only affects one receptor. Secondly, most antagonists must have an ongoing presence on the receptor to have an effect. Capsaicin overcomes both liabilities by disrupting peripheral terminals of nociceptive fibers that express TRPV1, and thereby affects all of the potential means of activating that pain fiber (not just TRPV1 function). This disruptive effect is dependent on the dose and can occur within minutes. Thus, unlike a typical receptor antagonist, continued bioavailability at the level of the receptor is not necessary. By disrupting the entire terminal of the TRPV1-expressing nociceptive fiber, capsaicin blocks all the activation mechanisms within that fiber, and not just TRPV1 function. Topical capsaicin, an FDA approved treatment for neuropathic pain, addresses pain from abnormal nociceptor activity in the superficial layers of the skin. Effects after a single administration are evident over a period of weeks to months, but in time are fully reversible. This review focuses on the rationale for using capsaicin by injection for painful conditions such as osteoarthritis (OA) and provides an update on studies completed to date.

Septic arthritis following joint injections: a 17 years retrospective study in an Academic General Hospital

BACKGROUND

Septic arthritis following intra-articular infiltrations is an uncommon devastating complication correlated  to high costs for the health service and often to poor outcomes. The purpose of this study is to assess a 17-years experience in a single academic multispecialist hospital managing this uncommon complication in Orthopaedic practice.

METHODS

Patients with diagnosis of septic arthritis following joint injections treated in our hospital from January 2002 to December 2019 were included in the study. Clinical and demographic data, pathogens, injected agent, conservative/surgical treatments were reviewed. Patient were classified according to the ore operative Charlson Comorbidity Index (CCI) and the Cierny-Mader Classification(CMC). Furthermore follow-up outcome and time occurred to infection eradication were registered.

RESULTS

We included in the study 11 patients with a median age of 74 years old (IQR= 61.5 - 79). The median CCI was 3  (IQR= 2 - 5) and the majority of patients belong to CMC = B class. Septic arthritis occurred mainly following corticosteroids injections and more frequently involving knees. The pathogen more often isolated was Staphylococcus aureus. Five (45%) patients referred an history of multiple intrarticular injections. 7 patients (64%) had a complete resolution following an arthroscopic debridement, 4 (36%) patients underwent to a 2-stage replacement and one of them hesitated in an arthrodesis because of a recurrent periprothesic joint infection and extensor apparatus insufficiency.

CONCLUSION

The authors observed a potential increased risk of septic arthritis following joint injection in patients with history of multiple injections and poor health/immunological conditions. They recommend an early arthroscopic debridement as the treatment of choice especially in septic knees  performed in a multispecialist dedicated center.

Efficacy and predictive factors of response to intra-articular corticosteroids in knee osteoarthritis

In knee osteoarthritis (KOA), synovial inflammation is linked with pain, swelling and structural abnormalities. Intra-articular corticosteroids (IACS) have been considered for pain relief in subjects who are non-responders to standard therapy. However, the results vary across different studies. This review aims to determine efficacy of IACS in KOA by review of the existing data.

In several randomized controlled trials (RCTs), meta-analyses and uncontrolled studies a single IACS resulted in pain relief from 1 to a few weeks. In a few studies repeated IACS every three months provided a longer duration of pain relief and functional improvement in a proportion of patients. Baseline synovitis was predictor of treatment response in some but not all studies.

Based upon the existing data, IACS provides a short-term pain relief in a proportion of patients. Given, anti-inflammatory properties of IACS, it is likely to be more effective in subgroups of KOA who display inflammatory phenotype.

Effects of short-duration treatment of cartilage with punicalagin and genipin and the implications for treatment of osteoarthritis

Punicalagin (PA) not only binds type II collagen, but also blocks its MMP-13-mediated degradation, and genipin (GNP) is a collagen cross-linking agent. We hypothesized that these drugs could mitigate the loss of cartilage if administered in the early phase of osteoarthritis, and experiments were designed to provide proof-of-concept. Porcine cartilage was exposed to both drugs in a manner designed to simulate intra-articular (IA) injection. Based on penetration of PA into cartilage, the rate of drug diffusion was conservatively estimated at 2 μm per minute. GNP caused a measurable degree of cross-linking, increased compressive resistance and coefficient of friction, and substantially inhibited degradation by collagenase, but not by hyaluronidase. Pre-incubation of GNP with collagenase had no effect on enzymatic activity. PA did not cross-link collagen nor affect the mechanical properties of cartilage. It did, however, increase resistance to degradation by collagenase and hyaluronidase. Furthermore, it reacted with collagenase in solution and inhibited its subsequent enzymatic activity. Effects of PA and GNP were not additive. The chondroprotective effect of semi-weekly IA injections was investigated in the monoiodoacetate-induced model of OA in rats. Quantitative histology suggested that injection of PA decreased the amount of cartilage lost compared to saline-injected controls, and the addition of GNP made no difference. This study supports the notion that IA delivery of PA could mitigate OA-induced cartilage erosion.

Intra-articular corticosteroid injections increase the risk of requiring knee arthroplasty

Aims

Recent studies have suggested that corticosteroid injections into the knee may harm the joint resulting in cartilage loss and possibly accelerating the progression of osteoarthritis (OA). The aim of this study was to assess whether patients with, or at risk of developing, symptomatic osteoarthritis of the knee who receive intra-articular corticosteroid injections have an increased risk of requiring arthroplasty.

Methods

We used data from the Osteoarthritis Initiative (OAI), a multicentre observational cohort study that followed 4,796 patients with, or at risk of developing, osteoarthritis of the knee on an annual basis with follow-up available up to nine years. Increased risk for symptomatic OA was defined as frequent knee symptoms (pain, aching, or stiffness) without radiological evidence of OA and two or more risk factors, while OA was defined by the presence of both femoral osteophytes and frequent symptoms in one or both knees. Missing data were imputed with multiple imputations using chained equations. Time-dependent propensity score matching was performed to match patients at the time of receving their first injection with controls. The effect of corticosteroid injections on the rate of subsequent (total and partial) knee arthroplasty was estimated using Cox proportional-hazards survival analyses.

Results

After removing patients lost to follow-up, 3,822 patients remained in the study. A total of 249 (31.3%) of the 796 patients who received corticosteroid injections, and 152 (5.0%) of the 3,026 who did not, had knee arthroplasty. In the matched cohort, Cox proportional-hazards regression resulted in a hazard ratio of 1.57 (95% confidence interval (CI) 1.37 to 1.81; p < 0.001) and each injection increased the absolute risk of arthroplasty by 9.4% at nine years’ follow-up compared with those who did not receive injections.

Conclusion

Corticosteroid injections seem to be associated with an increased risk of knee arthroplasty in patients with, or at risk of developing, symptomatic OA of the knee. These findings suggest that a conservative approach regarding the treatment of these patients with corticosteroid injections should be recommended. Cite this article: Bone Joint J 2020;102-B(5):586–592.

Effectiveness of intramuscular gluteal glucocorticoid injection versus intra-articular glucocorticoid injection in knee osteoarthritis: design of a multicenter randomized, 24 weeks comparative parallel-group trial

Background

The knee is symptomatically the most frequent affected joint in osteoarthritis and, in the Netherlands and other Western countries, is mainly managed by general practitioners (GPs). An intra-articular glucocorticoid injection is recommended in (inter) national guidelines for patients with knee osteoarthritis as an option for a flare of knee pain and/or for those who are not responding well to pain medication. An innovative approach that could replace the intra-articular injection is an intramuscular gluteal glucocorticoid injection. An intramuscular injection is easier to perform than an intra-articular injection with lesser risk of severe local adverse reactions. We hypothesize that intramuscular gluteal glucocorticoid injection is non-inferior in reducing knee pain compared to intra-articular glucocorticoid injection, with potentially a longer lasting effect than intra-articular injection.

Methods/design

The study will be a pragmatic randomized controlled non-inferiority trial with two parallel groups. A total of 140 patients aged 45 years and older with knee osteoarthritis who contacted their general practitioner and have persistent knee pain (score ≥ 3 on 0–10 numerical rating scale; 0 = no knee pain) will be included.

Patients will be randomly allocated (1:1) to an injection of 40 mg triamcinolone acetonide intra-articular in the knee joint or intramuscular in the ipsilateral ventrogluteal area.

The effect of treatment will be evaluated by questionnaires at 2, 4, 8, 12, and 24 weeks after injection. The primary outcome is patients’ reported severity of knee pain measured with the pain subscale of the Knee injury and Osteoarthritis Outcome Score 4 weeks after injection. Statistical analysis will be based on both the per-protocol and the intention-to-treat principle.

Discussion

This study will evaluate non-inferiority of intramuscular glucocorticoid injection compared to intra-articular glucocorticoid injection for knee osteoarthritis symptoms.

Trial registration

This trial is registered in the Dutch Trial Registry (number NTR6968) at 2018-01-22 (https://www.trialregister.nl/trial/6784). Issue date: 1 October 2019.

Trial sponsor

Erasmus MC University Medical Center Rotterdam.

PO-box 2040.

3000 CA Rotterdam.

The Netherlands.

Intra-articular corticosteroids and the risk of knee osteoarthritis progression: results from the Osteoarthritis Initiative

OBJECTIVE

A recent randomized clinical trial reported that repeated intra-articular corticosteroids (IACs) were associated with a greater cartilage loss. This study aimed to examine the relation of IACs to knee radiographic osteoarthritis (ROA) progression in a real-world setting.

DESIGN

A cohort that initiated IACs and a comparison cohort without IACs from participants with mild to moderate knee ROA in the Osteoarthritis Initiative (OAI) were assembled (from 0-month to 48-month). Two measures of knee ROA progression were assessed during the follow-up period: (1) an increase in Kellgren and Lawrence (KL) grade by ≥1 grade or having a knee replacement (i.e., KL grade worsening); and (2) a decrease in joint space width (JSW) by ≥0.7 mm or having a knee replacement (i.e., JSW worsening). The associations of IACs initiation using a propensity-score matched cohort study and continuous IACs using marginal structural models with the risk of knee ROA progression were examined.

RESULTS

Among 684 propensity-score matched participants at baseline (148 IACs initiators, 536 comparators), 65 knees (21.7/100 person-years) in the IACs initiation cohort and 90 knees (7.1/100 person-years) in the comparison cohort experienced KL worsening. The hazard ratios (HRs) of KL worsening from IACs initiation and continuous IACs were 3.02 (95% confidence interval [CI], 2.19-4.16) and 4.67 (95% CI, 2.92-7.47), respectively. The corresponding HRs of JSW worsening were 2.93 (95% CI, 2.13-4.02) and 3.26 (95% CI, 1.78-5.96), respectively. All HRs for continuous use of IACs were further away from the null.

CONCLUSIONS

IACs, especially continuous IACs, may be associated with an increased risk of knee ROA progression.

Interventional radiology techniques for pain reduction and mobility improvement in patients with knee osteoarthritis

Osteoarthritis of the knee is the most common cause of chronic knee pain being more prevalent in middle-aged and elderly patients. Symptomatic patients complain of pain and mobility impairment. Therapeutic armamentarium includes physical therapy, oral pharmacologic therapy, intra-articular injections, nerve ablation or modulation, trans-catheter arterial embolization, minimally invasive arthroscopic treatment and partial or total knee arthroplasty. Interventional radiology therapies for knee osteoarthritis include intra-articular injections, neurotomy and neuromodulation techniques as well as transcatheter intra-arterial therapies. These therapies aim to control pain and inflammation, improve mobility and function whilst the novel cell-based therapies have the potential for bone and cartilage regenerative repair facilitating the delay to surgery. The purpose of this review is to illustrate the technical aspects, the indications and the methodology of local therapies for knee osteoarthritis performed by interventional radiologists and provide current evidence.