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Chang W, Chen L, Chen K. The bioengineering application of hyaluronic acid in tissue regeneration and repair. Int J Biol Macromol 2024; 270:132454. [PMID: 38763255 DOI: 10.1016/j.ijbiomac.2024.132454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 05/04/2024] [Accepted: 05/15/2024] [Indexed: 05/21/2024]
Abstract
The multifaceted role of hyaluronic acid (HA) across diverse biomedical disciplines underscores its versatility in tissue regeneration and repair. HA hydrogels employ different crosslinking including chemical (chitosan, collagen), photo- initiation (riboflavin, LAP), enzymatic (HRP/H2O2), and physical interactions (hydrogen bonds, metal coordination). In biophysics and biochemistry, HA's signaling pathways, primarily through CD44 and RHAMM receptors, modulate cell behavior (cell migration; internalization of HA), inflammation, and wound healing. Particularly, smaller HA fragments stimulate inflammatory responses through toll-like receptors, impacting macrophages and cytokine expression. HA's implications in oncology highlight its involvement in tumor progression, metastasis, and treatment. Elevated HA in tumor stroma impacts apoptosis resistance and promotes tumor growth, presenting potential therapeutic targets to halt tumor progression. In orthopedics, HA's presence in synovial fluid aids in osteoarthritis management, as its supplementation alleviates pain, enhances synovial fluid's viscoelastic properties, and promotes cartilage integrity. In ophthalmology, HA's application in dry eye syndrome addresses symptoms by moisturizing the eyes, replenishing tear film deficiencies, and facilitating wound healing. Intravitreal injections and hydrogel-based systems offer versatile approaches for drug delivery and vitreous humor replacement. For skin regeneration and wound healing, HA hydrogel dressings exhibit exceptional properties by promoting moist wound healing and facilitating tissue repair. Integration of advanced regenerative tools like stem cells and solubilized amnion membranes into HA-based systems accelerates wound closure and tissue recovery. Overall, HA's unique properties and interactions render it a promising candidate across diverse biomedical domains, showcasing immense potentials in tissue regeneration and therapeutic interventions. Nevertheless, many detailed cellular and molecular mechanisms of HA and its applications remain unexplored and warrant further investigation.
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Affiliation(s)
- WeiTing Chang
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei, Taiwan
| | - LiRu Chen
- Department of Physical Medicine and Rehabilitation, Mackay Memorial Hospital, Taipei, Taiwan; Department of Mechanical Engineering, National YangMing ChiaoTung University, Hsinchu, Taiwan
| | - KuoHu Chen
- Department of Obstetrics and Gynecology, Taipei Tzu-Chi Hospital, The Buddhist Tzu-Chi Medical Foundation, Taipei, Taiwan; School of Medicine, Tzu-Chi University, Hualien, Taiwan.
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Tarapore R, Lindsey S, Strickland P, McKinstry R. Demonstrating antibiotic stewardship while diagnosing and treating bilateral pseudoseptic arthritis: a case report. J Med Case Rep 2024; 18:242. [PMID: 38724965 PMCID: PMC11084000 DOI: 10.1186/s13256-024-04568-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2024] [Accepted: 04/29/2024] [Indexed: 05/12/2024] Open
Abstract
INTRODUCTION Although viscosupplementation is a commonly used treatment for osteoarthritis and is widely regarded as a safe treatment option, it is associated with the rare complication of pseudoseptic arthritis. Most existing case reports that cite this rare complication employed the use of early broad-spectrum antibiotics. CASE PRESENTATION In this case report, we present a 61-year-old African American female patient who presented with bilateral knee pseudoseptic arthritis in the setting of viscosupplementation. She presented 3 days after bilateral viscosupplementation injections with bilateral knee swelling, discomfort, and pain with micromotion. Her white blood cell count (WBC) was 12.83 (4.5-11 normal), her C-reactive protein (CRP) level was 159 mg/L (0-10 normal), and her erythrocyte sedimentation rate (ESR) was 79 mm/hour (0-40 normal). Her left knee aspirate yielded 38,580 WBC with a negative gram stain and negative cultures. Her right knee aspirate yielded 29,670 WBC with a negative gram stain and negative cultures. Through the utilization of careful clinical monitoring, ice therapy, and non-steroidal inflammatory medication, we were able to successfully treat this patient while maintaining proper antibiotic stewardship. CONCLUSION Pseudoseptic arthritis in the setting of viscosupplementation can be adequately treated and monitored without the use of antibiotics.
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Affiliation(s)
- Rae Tarapore
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital 201 E. University Pkwy, Baltimore, MD, 21218, USA.
| | - Sierra Lindsey
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital 201 E. University Pkwy, Baltimore, MD, 21218, USA
| | - Paige Strickland
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital 201 E. University Pkwy, Baltimore, MD, 21218, USA
| | - Robert McKinstry
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital 201 E. University Pkwy, Baltimore, MD, 21218, USA
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Lagunas-Rangel FA. Naked mole-rat hyaluronan. Biochimie 2024; 220:58-66. [PMID: 38158036 DOI: 10.1016/j.biochi.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/03/2024]
Abstract
Naked mole rats (NMRs) are renowned for their exceptional longevity and remarkable maintenance of health throughout their lifetime. Their subterranean lifestyle has led to adaptations that have resulted in elevated levels of a very high molecular weight hyaluronan in their tissues. Hyaluronan, a glycosaminoglycan, is a key component of the extracellular matrix, which plays a critical role in maintaining tissue structure and regulating cell signaling pathways. This phenomenon in NMRs is attributed to a higher processing and production capacity by some of their hyaluronan synthases, along with lower degradation by certain hyaluronidases. Furthermore, this adaptation indirectly confers several advantages to NMRs, such as the preservation of skin elasticity and youthful appearance, accelerated wound healing, protection against oxidative stress, and resistance to conditions such as cancer and arthritis, largely attributable to CD44 signaling and other intricate mechanisms. Thus, the main objective of this study was to conduct a comprehensive study of the distinctive features of NMR hyaluronan, particularly emphasizing the currently known molecular mechanisms that contribute to its beneficial properties. Furthermore, this research delves into the potential applications of NMR hyaluronan in both cosmetic and therapeutic fields, as well as the challenges involved.
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Affiliation(s)
- Francisco Alejandro Lagunas-Rangel
- Department of Genetics and Molecular Biology, Centro de Investigación y de Estudios Avanzados Del Instituto Politécnico Nacional, Mexico City, Mexico.
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Langworthy M, Lascarides P, Ngai W, Steele K, Huang Y. Three once-weekly intra-articular injections of Hylan G-F 20 significantly improve pain relief compared with placebo in patients with chronic idiopathic knee osteoarthritis: a single-centre, evaluator-blinded and patient-blinded, randomized controlled trial. Drugs Context 2024; 13:2023-11-3. [PMID: 38601838 PMCID: PMC11006243 DOI: 10.7573/dic.2023-11-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/06/2024] [Indexed: 04/12/2024] Open
Abstract
Background Clinical trials on the use of viscosupplementation with hyaluronic acid (HA) in patients with knee osteoarthritis (KOA) are inconsistent, making it challenging to determine its value in clinical practice. One issue is the availability of various HA products on the market; differences in their chemical features can impact patient outcomes. Herein, we assess the efficacy and safety of three once-weekly intra-articular (IA) injections of Hylan G-F 20, a high-molecular-weight and highly crosslinked HA product, in patients with KOA. We hypothesized that Hylan G-F 20 would provide significant pain relief with no increased safety risk compared with IA saline (placebo). Methods This was a 26-week, patient-blinded and evaluator-blinded, single-centre, randomized placebo- controlled trial. Men or women ≥18 years of age with Larsen grade II or III KOA were included. Patients received IA injections of either Hylan G-F 20 or placebo once a week for 3 weeks. The primary endpoints were the week 12 and 26 visits. Primary efficacy outcomes included visual analogue scale (VAS) pain scores, patient activity level and an overall assessment of clinical condition. Secondary outcomes included adverse events (AEs) that emerged during treatment. The primary analysis included the intention-to-treat population. An alpha level of 0.05 was used in the statistical analysis. Results Thirty patients were included in the intention-to-treat population (15 per group). All efficacy outcomes were statistically significant in favour of Hylan G-F 20, except night pain and inactivity stiffness, for both patient- assessed (all p=0.0001 at week 12) and evaluator-assessed (all p=0.0001 at week 12 and p=0.0004-0.0180 at week 26) measurements. There was also a greater proportion of symptom-free patients and those with a >50% improvement in their VAS scores, except night pain, in the Hylan G-F 20 group (p=0.001-0.003 in patient-assessed scores and p<0.0001 to 0.002 in evaluator-assessed scores at week 12). Two patients, one in each group, experienced an AE; no sequelae occurred, and no special treatment was required for either AE. No patients withdrew from the study prematurely due to an AE. Conclusion In patients with chronic idiopathic KOA, Hylan G-F 20 provides significant improvements in pain relief compared with placebo with no added safety concerns.
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Affiliation(s)
| | - Peter Lascarides
- Northwell Health, Northern Westchester Hospital, Mt Kisco, NY, USA
| | | | | | - Yili Huang
- Zucker School of Medicine at Hofstra/Northwell, Northwell Phelps Hospital, Sleepy Hollow, NY, USA
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Aratikatla A, Maffulli N, Gupta M, Potti IA, Potty AG, Gupta A. Wharton's jelly and osteoarthritis of the knee. Br Med Bull 2024; 149:13-31. [PMID: 38061765 PMCID: PMC10993459 DOI: 10.1093/bmb/ldad030] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 11/14/2023] [Accepted: 11/15/2023] [Indexed: 03/16/2024]
Abstract
INTRODUCTION The existing treatment modalities for knee osteoarthritis (OA) do not actually address the pathology. Biological therapies, including those using material derived from perinatal tissues, represent a ground-breaking approach to alleviating the symptoms of OA of the knee. SOURCE OF DATA Current scientific literature published in PubMed (MEDLINE), Embase and Scopus databases. Trials registered in various clinical trial databases. AREAS OF AGREEMENT Perinatal tissues including Wharton's jelly (WJ) and associated mesenchymal stem cells (MSCs) can be used for the management of knee OA. AREAS OF CONTROVERSY The efficacy of WJ and associated MSCs in the management of knee OA is still controversial. GROWING POINTS The use of WJ and associated MSCs in the management of knee OA is safe and appears to be effective. AREAS TIMELY FOR DEVELOPING RESEARCH The present published evidence suggests that WJ tissue and associated MSCs offer an encouraging alternative for the management of knee OA. The published in vitro, preclinical and clinical investigations demonstrate the therapeutic potential of WJ and promote further research in this field to provide symptomatic relief to patients suffering from OA, aiming also to regenerate the osteoarthritic hyaline cartilage, with disease-modifying effects. Future adequately powered randomized controlled trials should be undertaken to establish whether WJ is helpful in the management of OA of the knee.
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Affiliation(s)
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Fisciano 84084, Italy
- Department of Trauma and Orthopaedics, Ospedale Sant’ Andrea, Sapienza University of Rome, Rome, Italy
- Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, London E1 4DG, UK
- School of Pharmacy and Bioengineering, Keele University School of Medicine, Stoke on Trent ST5 5BG, UK
| | - Manu Gupta
- Polar Aesthetics Dental & Cosmetic Centre, Noida, Uttar Pradesh 201301, India
| | - Ishana A Potti
- South Texas Orthopaedic Research Institute (STORI Inc.), Laredo, TX 78045, USA
| | - Anish G Potty
- South Texas Orthopaedic Research Institute (STORI Inc.), Laredo, TX 78045, USA
| | - Ashim Gupta
- South Texas Orthopaedic Research Institute (STORI Inc.), Laredo, TX 78045, USA
- Future Biologics, Lawrenceville, GA 30043, USA
- BioIntegrate, Lawrenceville, GA 30043, USA
- Regenerative Orthopaedics, Noida 201301, India
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Onu I, Gherghel R, Nacu I, Cojocaru FD, Verestiuc L, Matei DV, Cascaval D, Serban IL, Iordan DA, Tucaliuc A, Galaction AI. Can Combining Hyaluronic Acid and Physiotherapy in Knee Osteoarthritis Improve the Physicochemical Properties of Synovial Fluid? Biomedicines 2024; 12:449. [PMID: 38398051 PMCID: PMC10886650 DOI: 10.3390/biomedicines12020449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 02/09/2024] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
Known as the degenerative disease of the knee with the highest prevalence, knee osteoarthritis (KOA) is characterized by a gradual destructive mechanism that, in severe cases, can provoke the need for total knee substitution. As the disease progresses, various enzymatic, immunological, and inflammatory processes abnormally degrade hyaluronic acid (HA), SF's main component, and affect the concentrations of specific proteins, with the final results seriously endangering synovial fluid (SF)'s rheological and tribological features and characteristics. No effective treatments have been found to stop the progression of KOA, but the injection of HA-based viscoelastic gels has been considered (alone or combined with physiotherapy (PT)) as an alternative to symptomatic therapies. In order to evaluate the effect of viscosupplementation and PT on the characteristics of SF, SF aspirated from groups treated for KOA (HA Kombihylan® and groups that received Kombihylan® and complex PT) was analyzed and compared from analytical, spectrophotometrical, and rheological perspectives. In the patients treated with PT, the SF extracted 6 weeks after viscosupplementation had a superior elastic modulus (G') and viscous moduli (G″), as well as a homogeneous distribution of proteins and polysaccharides. The viscosupplementation fluid improved the bioadhesive properties of the SF, and the use of the viscosupplementation fluid in conjunction with PT was found to be favorable for the distribution of macromolecules and phospholipids, contributing to the lubrication process and the treatment of OA-affected joints.
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Affiliation(s)
- Ilie Onu
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa”, 700454 Iasi, Romania; (I.O.); (I.N.); (F.-D.C.); (L.V.); (D.-V.M.); (A.-I.G.)
- Department of Physiotherapy, Micromedica Clinic, 610119 Piatra Neamt, Romania
| | - Robert Gherghel
- Department of Physiotherapy, Micromedica Clinic, 610119 Piatra Neamt, Romania
- Department of Morpho-Functional Sciences II, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
| | - Isabella Nacu
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa”, 700454 Iasi, Romania; (I.O.); (I.N.); (F.-D.C.); (L.V.); (D.-V.M.); (A.-I.G.)
- Petru Poni Institute of Macromolecular Chemistry, 41-A Grigore Ghica Voda Alley, 700487 Iasi, Romania
| | - Florina-Daniela Cojocaru
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa”, 700454 Iasi, Romania; (I.O.); (I.N.); (F.-D.C.); (L.V.); (D.-V.M.); (A.-I.G.)
| | - Liliana Verestiuc
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa”, 700454 Iasi, Romania; (I.O.); (I.N.); (F.-D.C.); (L.V.); (D.-V.M.); (A.-I.G.)
| | - Daniela-Viorelia Matei
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa”, 700454 Iasi, Romania; (I.O.); (I.N.); (F.-D.C.); (L.V.); (D.-V.M.); (A.-I.G.)
| | - Dan Cascaval
- Department of Organic, Biochemical and Food Engineering, Faculty of Chemical Engineering and Environmental Protection “Cristofor Simionescu”, Technical University “Gheorghe Asachi”, 700050 Iasi, Romania; (D.C.); (A.T.)
| | - Ionela Lacramioara Serban
- Department of Morpho-Functional Sciences II, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
| | - Daniel Andrei Iordan
- Department of Individual Sports and Kinetotherapy, Faculty of Physical Education and Sport, “Dunarea de Jos” University of Galati, 800008 Galati, Romania
- Center of Physical Therapy and Rehabilitation, “Dunărea de Jos” University of Galati, 800008 Galati, Romania
| | - Alexandra Tucaliuc
- Department of Organic, Biochemical and Food Engineering, Faculty of Chemical Engineering and Environmental Protection “Cristofor Simionescu”, Technical University “Gheorghe Asachi”, 700050 Iasi, Romania; (D.C.); (A.T.)
| | - Anca-Irina Galaction
- Department of Biomedical Sciences, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa”, 700454 Iasi, Romania; (I.O.); (I.N.); (F.-D.C.); (L.V.); (D.-V.M.); (A.-I.G.)
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Valachová K, Hassan ME, Šoltés L. Hyaluronan: Sources, Structure, Features and Applications. Molecules 2024; 29:739. [PMID: 38338483 PMCID: PMC10856924 DOI: 10.3390/molecules29030739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/28/2024] [Accepted: 02/01/2024] [Indexed: 02/12/2024] Open
Abstract
Hyaluronan (HA) is a non-sulfated glycosaminoglycan that is present in a variety of body tissues and organs. Hyaluronan has a wide range of biological activities that are frequently influenced by molar mass; however, they also depend greatly on the source, purity, and kind of impurities in hyaluronan. High-molar-mass HA has anti-inflammatory, immunosuppressive, and antiangiogenic properties, while low-molar-mass HA has opposite properties. A number of chemical modifications have been performed to enhance the stability of HA and its applications in medical practice. Hyaluronan is widely applied in medicine, such as viscosupplementation, ophthalmology, otolaryngology, wound healing, cosmetics, and drug delivery. In this review, we summarized several medical applications of polymers based on the hyaluronan backbone.
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Affiliation(s)
- Katarína Valachová
- Centre of Experimental Medicine, Institute of Experimental Pharmacology and Toxicology, Slovak Academy of Sciences, Dúbravská cesta 9, 84104 Bratislava, Slovakia
| | - Mohamed E. Hassan
- Centre of Experimental Medicine, Institute of Experimental Pharmacology and Toxicology, Slovak Academy of Sciences, Dúbravská cesta 9, 84104 Bratislava, Slovakia
- Centre of Excellence, Encapsulation & Nanobiotechnology Group, Chemistry of Natural and Microbial Products Department, National Research Centre, El Behouth Street, Cairo 12622, Egypt
| | - Ladislav Šoltés
- Centre of Experimental Medicine, Institute of Experimental Pharmacology and Toxicology, Slovak Academy of Sciences, Dúbravská cesta 9, 84104 Bratislava, Slovakia
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Dıracoglu D, Sezikli S, Dernek B, Yildirim MA, Sen EI. Different doses of hyaluronic acid injections in patients with knee osteoarthritis: A multicenter, randomized, prospective, single-blind, clinical study. J Back Musculoskelet Rehabil 2024; 37:629-639. [PMID: 38160332 DOI: 10.3233/bmr-230097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Many formulations and dosing regimens are available for hyaluronic acid (HA). OBJECTIVE To compare different doses of linear, high-molecular weight (HMW) HA injections among patients with knee osteoarthritis (OA). METHODS Hundred patients were included in this randomized, single-blinded trial and randomly divided into three HA injection groups. The first group received five weekly 20 mg HA injections, the second group received three weekly 32 mg HA injections, and the third group received a single 48 mg HA injection. Patients were evaluated at baseline, 1, 3, and 6 months after the last injection for pain, stiffness, and function using the visual analog scale (VAS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Quality of life, patient's global assessment, and Timed Up and Go (TUG) test scores were also evaluated. RESULTS There was significant improvement in the WOMAC, VAS-pain, quality of life, patient's global assessment, and TUG test mean scores at all follow-up time points (p< 0.001). However, the groups showed no significant differences in WOMAC, VAS-activity pain, and patient global scores at any follow-up point. CONCLUSION Intra-articular injections of different doses of linear HMW HA can improve pain, stiffness, function, and quality of life in patients suffering from knee OA over a six-month period.
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Affiliation(s)
- Demirhan Dıracoglu
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Selim Sezikli
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Bahar Dernek
- Istanbul Physical Medicine and Rehabilitation Education Research Hospital, Department of Physical Medicine and Rehabilitation, University of Health Sciences, Istanbul, Turkey
| | - Mustafa Aziz Yildirim
- Department of Physical Medicine and Rehabilitation, Başakşehir Çam and Sakura City Hospital, Istanbul, Turkey
| | - Ekin Ilke Sen
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Istanbul University, Istanbul, Turkey
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Yılmaz S, Kurt M, Kekeç AF, Yıldırım A. Effectiveness of gonarthrosis treatment via intra-articular injections of linear vs. cross-linked hyaluronic acids. Jt Dis Relat Surg 2024; 35:138-145. [PMID: 38108175 PMCID: PMC10746903 DOI: 10.52312/jdrs.2023.1403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/22/2023] [Indexed: 12/19/2023] Open
Abstract
OBJECTIVES The study aimed to compare the outcomes of single-dose cross-linked hyaluronic acid and the linear regimen of three doses of HA knee injections among patients with gonarthrosis. PATIENTS AND METHODS This single-center, retrospective study was conducted with 60 patients (47 females, 13 males; mean age: 57.9±4.29 years; range, 50 to 65 years) with Kellgren-Lawrence Grade 2 or 3 gonarthrosis between February 2020 and February 2022. Patients were either subjected to intra-articular cross-linked hyaluronic acid (n=30) or linear hyaluronic acid (n=30) injection treatments. Comprehensive assessments of the patients were conducted prior to the injections, as well as at three and six months after injection. The two injection groups were compared regarding the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Score. RESULTS Both injections showed a statistically significant improvement from baseline in both WOMAC and Oxford Knee Score at three and six months (p<0.001). There was no notable distinction in the alteration of WOMAC knee scores between the two injection types. However, a notable discrepancy was observed in the elevation of Oxford Knee Score among patients who received cross-linked knee injections compared to those who underwent linear hyaluronic acid knee injections, signifying a significant increase in the former group (p<0.001). CONCLUSION The advantage of a single-dose administration of cross-linked HA knee injections, as opposed to the three-dose regimen required for linear hyaluronic acid, translates into reduced time and cost for the injection process. Moreover, this approach minimizes injection-associated discomfort for patients due to the singular dose administration.
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Affiliation(s)
| | | | - Ahmet Fevzi Kekeç
- Necmettin Erbakan Üniversitesi, Meram Tıp Fakültesi, Ortopedi ve Travmatoloji Anabilim Dalı, 42090 Meram, Konya, Türkiye.
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Velot É, Balmayor ER, Bertoni L, Chubinskaya S, Cicuttini F, de Girolamo L, Demoor M, Grigolo B, Jones E, Kon E, Lisignoli G, Murphy M, Noël D, Vinatier C, van Osch GJVM, Cucchiarini M. Women's contribution to stem cell research for osteoarthritis: an opinion paper. Front Cell Dev Biol 2023; 11:1209047. [PMID: 38174070 PMCID: PMC10762903 DOI: 10.3389/fcell.2023.1209047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 09/18/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
- Émilie Velot
- Laboratory of Molecular Engineering and Articular Physiopathology (IMoPA), French National Centre for Scientific Research, University of Lorraine, Nancy, France
| | - Elizabeth R. Balmayor
- Experimental Orthopaedics and Trauma Surgery, Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH Aachen University Hospital, Aachen, Germany
- Rehabilitation Medicine Research Center, Mayo Clinic, Rochester, MN, United States
| | - Lélia Bertoni
- CIRALE, USC 957, BPLC, École Nationale Vétérinaire d'Alfort, Maisons-Alfort, France
| | | | - Flavia Cicuttini
- Musculoskeletal Unit, Monash University and Rheumatology, Alfred Hospital, Melbourne, VIC, Australia
| | - Laura de Girolamo
- IRCCS Ospedale Galeazzi - Sant'Ambrogio, Orthopaedic Biotechnology Laboratory, Milan, Italy
| | - Magali Demoor
- Normandie University, UNICAEN, BIOTARGEN, Caen, France
| | - Brunella Grigolo
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio RAMSES, Bologna, Italy
| | - Elena Jones
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, Leeds, United Kingdom
| | - Elizaveta Kon
- IRCCS Humanitas Research Hospital, Milan, Italy
- Department ofBiomedical Sciences, Humanitas University, Milan, Italy
| | - Gina Lisignoli
- IRCCS Istituto Ortopedico Rizzoli, Laboratorio di Immunoreumatologia e Rigenerazione Tissutale, Bologna, Italy
| | - Mary Murphy
- Regenerative Medicine Institute (REMEDI), School of Medicine, University of Galway, Galway, Ireland
| | - Danièle Noël
- IRMB, University of Montpellier, Inserm, CHU Montpellier, Montpellier, France
| | - Claire Vinatier
- Nantes Université, Oniris, INSERM, Regenerative Medicine and Skeleton, Nantes, France
| | - Gerjo J. V. M. van Osch
- Department of Orthopaedics and Sports Medicine and Department of Otorhinolaryngology, Department of Biomechanical Engineering, University Medical Center Rotterdam, Faculty of Mechanical, Maritime and Materials Engineering, Delft University of Technology, Delft, Netherlands
| | - Magali Cucchiarini
- Center of Experimental Orthopedics, Saarland University and Saarland University Medical Center, Homburg/Saar, Germany
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Sydor MJ, Serban MA. The Application of Fluorescence Anisotropy for Viscosity Measurements of Small Volume Biological Analytes. JOURNAL OF EXPERIMENTAL AND THEORETICAL ANALYSES 2023; 1:86-96. [PMID: 38633433 PMCID: PMC11022525 DOI: 10.3390/jeta1020007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Time-resolved fluorescence anisotropy has been extensively used to detect changes in bimolecular rotation associated with viscosity levels within cells and other solutions. Physiological alterations of the viscosity of biological fluids have been associated with numerous pathological causes. This current work serves as proof of concept for a method to measure viscosity changes in small analyte volumes representative of biological fluids. The fluorophores used in this study were fluorescein disodium salt and Enhanced Green Fluorescent Protein (EGFP). To assess the ability of the method to accurately detect viscosity values in small volume samples, we conducted measurements with 12 μL and 100 μL samples. No statistically significant changes in determined viscosities were recorded as a function of sample volume for either fluorescent probe. The anisotropy of both fluorescence probes was measured in low viscosity standards ranging from 1.02 to 1.31 cP, representative of physiological fluid values, and showed increasing rotational correlation times in response to increasing viscosity. We also showed that smaller fluid volumes can be diluted to accommodate available cuvette volume requirements without a loss in the accuracy of detecting discrete viscosity variations. Moreover, the ability of this technique to detect subtle viscosity changes in complex fluids similar to physiological ones was assessed by using fetal bovine serum (FBS) containing samples. The presence of FBS in the analytes did not alter the viscosity specific rotational correlation time of EGFP, indicating that this probe does not interact with the tested analyte components and is able to accurately reflect sample viscosity. We also showed that freeze-thaw cycles, reflective of the temperature-dependent processes that biological samples of interest could undergo from the time of collection to analyses, did not impact the viscosity measurements' accuracy. Overall, our data highlight the feasibility of using time-resolved fluorescence anisotropy for precise viscosity measurements in biological samples. This finding is relevant as it could potentially expand the use of this technique for in vitro diagnostic systems.
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Affiliation(s)
- Matthew J. Sydor
- BioSpectroscopy Core, Center for Biomolecular Structure and Dynamics, University of Montana, Missoula, MT 59812, USA
| | - Monica A. Serban
- Department of Biomedical and Pharmaceutical Sciences, University of Montana, Missoula, MT 59812, USA
- Montana Biotechnology Center (BIOTECH), University of Montana, Missoula, MT 59812, USA
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12
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de Roy L, Eichhorn K, Faschingbauer M, Schlickenrieder K, Ignatius A, Seitz AM. Impact of hyaluronic acid injection on the knee joint friction. Knee Surg Sports Traumatol Arthrosc 2023; 31:5554-5564. [PMID: 37843587 PMCID: PMC10719131 DOI: 10.1007/s00167-023-07602-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/21/2023] [Indexed: 10/17/2023]
Abstract
PURPOSE The purpose of this in vitro study was to investigate whether or not hyaluronic acid supplementation improves knee joint friction during osteoarthritis progression under gait-like loading conditions. METHODS Twelve human cadaveric knee joints were equally divided into mild and moderate osteoarthritic groups. After initial conservative preparation, a passive pendulum setup was used to test the whole joints under gait-like conditions before and after hyaluronic acid supplementation. The friction-related damping properties given by the coefficient of friction µ and the damping coefficient c (in kg m2/s) were calculated from the decaying flexion-extension motion of the knee. Subsequently, tibial and femoral cartilage and meniscus samples were extracted from the joints and tested in an established dynamic pin-on-plate tribometer using synthetic synovial fluid followed by synthetic synovial fluid supplemented with hyaluronic acid as lubricant. Friction was quantified by calculating the coefficient of friction. RESULTS In the pendulum tests, the moderate OA group indicated significantly lower c0 values (p < 0.05) under stance phase conditions and significantly lower µ0 (p = 0.01) values under swing phase conditions. No degeneration-related statistical differences were found for µend or cend. Friction was not significantly different (p > 0.05) with regard to mild and moderate osteoarthritis in the pin-on-plate tests. Additionally, hyaluronic acid did not affect friction in both, the pendulum (p > 0.05) and pin-on-plate friction tests (p > 0.05). CONCLUSION The results of this in vitro study suggested that the friction of cadaveric knee joint tissues does not increase with progressing degeneration. Moreover, hyaluronic acid viscosupplementation does not lead to an initial decrease in knee joint friction.
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Affiliation(s)
- Luisa de Roy
- Institute of Orthopedic Research and Biomechanics, Center for Trauma Research, Ulm University Medical Center, Helmholtzstraße 14, 89081, Ulm, Germany
| | - Kerstin Eichhorn
- Institute of Orthopedic Research and Biomechanics, Center for Trauma Research, Ulm University Medical Center, Helmholtzstraße 14, 89081, Ulm, Germany
| | - Martin Faschingbauer
- Department of Orthopedic Surgery, RKU, Ulm University Medical Center, Ulm, Germany
| | - Klaus Schlickenrieder
- Faculty of Production Engineering and Management, Ulm University of Applied Sciences, Ulm, Germany
| | - Anita Ignatius
- Institute of Orthopedic Research and Biomechanics, Center for Trauma Research, Ulm University Medical Center, Helmholtzstraße 14, 89081, Ulm, Germany
| | - Andreas Martin Seitz
- Institute of Orthopedic Research and Biomechanics, Center for Trauma Research, Ulm University Medical Center, Helmholtzstraße 14, 89081, Ulm, Germany.
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13
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Qiao X, Yan L, Feng Y, Li X, Zhang K, Lv Z, Xu C, Zhao S, Liu F, Yang X, Tian Z. Efficacy and safety of corticosteroids, hyaluronic acid, and PRP and combination therapy for knee osteoarthritis: a systematic review and network meta-analysis. BMC Musculoskelet Disord 2023; 24:926. [PMID: 38037038 PMCID: PMC10687893 DOI: 10.1186/s12891-023-06925-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/26/2023] [Indexed: 12/02/2023] Open
Abstract
OBJECTIVE There are many injectable treatments for knee osteoarthritis with different characteristics and effects, the aim is to understand which one can lead to better and safer results. METHODS The PRISMA principles were followed when doing the literature search. Web of Science databases, Embase, the Cochrane Library, PubMed, and the Wanfang database were searched to identified randomized controlled trials that assessed the efficacy of corticosteroids (CSC), platelet-rich plasma (PRP), hyaluronic acid (HA), and combination therapy in treating KOA. Risk of bias was assessed using the relevant Cochrane tools (version 1.0). The outcome measure included the visual analog scale (VAS) score, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, and treatment-related adverse events. The network meta-analysis was performed using STATA17 software and a Bayesian stratified random effects model. RESULTS Network meta-analysis using the Bayesian random-effects model revealed 35 studies with 3104 participants. PRP showed the best WOMAC score at a 3-month follow-up, followed by PRP + HA, HA, placebo, and CSC; PRP + HA scored the highest VAS, followed by PRP, CSC, HA, and placebo. PRP, CSC, HA, and placebo had the highest WOMAC scores six months following treatment; PRP + HA showed the best VAS scores. PRP showed the best WOMAC score at 12 months, followed by PRP + HA, HA, placebo, and CSC; The best VAS score was obtained with PRP, followed by PRP + HA, HA, and CSC. No therapy demonstrated a rise in adverse events linked to the treatment in terms of safety. CONCLUSIONS The current study found that PRP and PRP + HA were the most successful in improving function and alleviating pain after 3, 6, and 12 months of follow-up. CSC, HA, PRP, and combination therapy did not result in an increase in the incidence of treatment-related side events as compared to placebo.
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Affiliation(s)
- Xiaochen Qiao
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, JinZhong Hospital Affiliated to Shanxi Medical University, 689 Huitong South Road, Jinzhong, Shanxi, 030600, PR China
| | - Lei Yan
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
| | - Yi Feng
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
| | - Xiaoyan Li
- Xihua Yang Shanxi Province Cancer Hospital, Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, Shanxi, 030013, PR China
| | - Kun Zhang
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
| | - Zhi Lv
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
| | - Chaojian Xu
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China
| | - Sen Zhao
- Taiyuan Hand Surgery Hospital, Taiyuan, Shanxi, 030001, PR China
| | - Fengrui Liu
- Orthopedics Department, First Hospital of Shanxi Medical University, Taiyuan, Shanxi, 030001, PR China
| | - Xihua Yang
- Xihua Yang Shanxi Province Cancer Hospital, Shanxi Hospital Affiliated to Cancer Hospital, Chinese Academy of Medical Sciences, Cancer Hospital Affiliated to Shanxi Medical University, Taiyuan, Shanxi, 030013, PR China.
| | - Zhi Tian
- Second Clinical Medical College, Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China.
- Department of Orthopedics, Shanxi Key Laboratory of Bone and Soft Tissue Injury Repair, The Second Hospital of Shanxi Medical University, 382 Wuyi Road, Taiyuan, Shanxi, 030001, PR China.
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Zhou X, Li Z, Xing B. Efficacy and safety of TRPV1-related preparations in the treatment of inflammatory arthralgia. Medicine (Baltimore) 2023; 102:e36268. [PMID: 38013379 PMCID: PMC10681444 DOI: 10.1097/md.0000000000036268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 11/01/2023] [Indexed: 11/29/2023] Open
Abstract
BACKGROUND Currently, medications for the treatment of inflammatory arthralgia are limited. The role and safety of transient receptor potential vanilloid subtype 1 (TRPV1)-related preparations in reducing inflammatory arthralgia have not yet been fully established. Thus, we aimed to review the efficacy and safety of TRPV1-related preparations for the treatment of inflammatory arthralgia. METHODS We searched PubMed, Web of Science, Cochrane, and Embase databases for relevant studies, and the primary outcome was pain score (VAS, PI, NRS, and WOMAC). RESULTS Six randomized controlled trials involving 481 patients were analyzed. Patients with inflammatory arthralgia who received TRPV1-related preparations had lower pain scores after treatment than those who received placebo or nonsteroidal anti-inflammatory agents (standardized mean difference = -0.525; 95% confidence interval [CI], -0.789 to -0.261; P < .001). There was no significant difference in the incidence of total adverse reactions between the TRPV1-related preparations and control groups (relative risk = 1.225; 95% CI, 0.685 to 2.191; P = .494). CONCLUSION TRPV1-related preparations are clinically safe and effective in the treatment of inflammatory arthralgia and are superior to placebo or nonsteroidal drugs. This may be the preferred treatment for patients with inflammatory arthralgia.
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Affiliation(s)
- Xin Zhou
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Ziping Li
- Guangzhou University of Chinese Medicine, Guangzhou, Guangdong, China
| | - Bingfeng Xing
- The First Affiliated Hospital/School of Clinical Medicine of Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
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15
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Lippi L, Ferrillo M, Turco A, Folli A, Moalli S, Refati F, Perrero L, Ammendolia A, de Sire A, Invernizzi M. Multidisciplinary Rehabilitation after Hyaluronic Acid Injections for Elderly with Knee, Hip, Shoulder, and Temporomandibular Joint Osteoarthritis. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:2047. [PMID: 38004096 PMCID: PMC10672933 DOI: 10.3390/medicina59112047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 11/12/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023]
Abstract
Osteoarthritis (OA) is a prevalent degenerative joint condition characterized by cartilage deterioration, joint inflammation, and functional limitations, particularly impacting the elderly population. Rehabilitation and hyaluronic acid (HA) injections are common therapeutic approaches routinely used in clinical practice, but their synergistic potential is far from being fully characterized. Thus, the aim of this narrative review was to elucidate the multilevel benefits and synergies of integrating these two approaches in multidisciplinary OA rehabilitation. This narrative review follows the scale for the assessment of narrative review articles (SANRA) criteria and involves a comprehensive literature search from July to August 2023. Two independent reviewers screened studies, including those involving human subjects with OA, rehabilitation strategies, and outcomes following HA injection, published in English. Results: HA injections might improve joint biomechanics, reducing friction, absorbing shocks, and potentially regulating inflammation. Rehabilitation plays a pivotal role in strengthening muscles, increasing the range of motion, and enhancing overall function. Optimizing rehabilitation following HA injection might provide additional benefits in joint health. OA management requires a multidisciplinary approach integrating HA injections, rehabilitation, and personalized care. Challenges in patient adherence and healthcare resources currently exist, but emerging technologies offer opportunities to enhance patient engagement and monitoring optimizing sustainability and outcomes of patients with knee, hip, shoulder, and temporomandibular joint OA.
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Affiliation(s)
- Lorenzo Lippi
- Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (L.L.); (A.T.); (A.F.); (S.M.); (F.R.); (M.I.)
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
| | - Martina Ferrillo
- Department of Health Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy
| | - Alessio Turco
- Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (L.L.); (A.T.); (A.F.); (S.M.); (F.R.); (M.I.)
| | - Arianna Folli
- Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (L.L.); (A.T.); (A.F.); (S.M.); (F.R.); (M.I.)
| | - Stefano Moalli
- Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (L.L.); (A.T.); (A.F.); (S.M.); (F.R.); (M.I.)
| | - Fjorelo Refati
- Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (L.L.); (A.T.); (A.F.); (S.M.); (F.R.); (M.I.)
| | - Luca Perrero
- Neurorehabilitation Unit, Azienda Ospedaliera SS Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy;
| | - Antonio Ammendolia
- Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (A.A.); (A.d.S.)
- Research Center on Musculoskeletal Health, MusculoSkeletalHealth@UMG, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy
| | - Alessandro de Sire
- Department of Medical and Surgical Sciences, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (A.A.); (A.d.S.)
- Research Center on Musculoskeletal Health, MusculoSkeletalHealth@UMG, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy
| | - Marco Invernizzi
- Department of Health Sciences, University of Eastern Piedmont “A. Avogadro”, 28100 Novara, Italy; (L.L.); (A.T.); (A.F.); (S.M.); (F.R.); (M.I.)
- Translational Medicine, Dipartimento Attività Integrate Ricerca e Innovazione (DAIRI), Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, 15121 Alessandria, Italy
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16
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Goncu Y, Ay N. Boron Nitride's Morphological Role in the Design of Injectable Hyaluronic Acid Based Hybrid Artificial Synovial Fluid. ACS Biomater Sci Eng 2023; 9:6345-6356. [PMID: 37847245 DOI: 10.1021/acsbiomaterials.3c01121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
The treatment process of osteoarthritis (OA) is challenging as it affects not only cartilage but also subchondral bone, ligament attachment capsules, synovium, and surrounding muscle tissue. Therefore, the search for preventive treatment or methods to slow the onset of the condition. Hexagonal boron nitride (hBN) has a graphite-like lamellar structure and is thought to facilitate cartilage movement for biomedical applications, just like in bearing systems. Hyaluronic acid (HA) is one of the natural polymers that can be used to transport boron nitride and maintain its presence in joints for a long time. In this study, hybrid hydrogels were formulated by using boron nitride nanoparticles and nanosheets. The rheological properties of the hydrogels were evaluated according to the structural differences of hBN. Characterizations have shown that hybrid hydrogels can be produced in injectable form, and the rheological properties are strongly related to the structural properties of the added particle. It has been determined that hBN added to the hydrogel structure reduces the dynamic viscosity of the zero-shear point and the deformation rate of the hydrogel and also changes the viscoelastic properties of the hydrogel depending on boron nitride's structural differences. The suggested mechanism is the hybrid hydrogel that exhibits lower viscosity as the layers detach from each other or disperses the agglomerates under applied shear stress. hBN, which has been proposed as a new strategy for joint injections, is thought to be a promising candidate for the treatment of OA due to its lamellar structures.
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Affiliation(s)
- Yapıncak Goncu
- Department of Biomedical Engineering, Eskisehir Osmangazi University, Engineering Architecture Faculty, Meselik Campus, Eskisehir 26480, Turkiye
| | - Nuran Ay
- Department of Material Science and Engineering, Eskisehir Technical University, Engineering Faculty, Ikieylul Campus, Eskisehir 26555, Turkiye
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17
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Atwal A, Dale TP, Snow M, Forsyth NR, Davoodi P. Injectable hydrogels: An emerging therapeutic strategy for cartilage regeneration. Adv Colloid Interface Sci 2023; 321:103030. [PMID: 37907031 DOI: 10.1016/j.cis.2023.103030] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 11/02/2023]
Abstract
The impairment of articular cartilage due to traumatic incidents or osteoarthritis has posed significant challenges for healthcare practitioners, researchers, and individuals suffering from these conditions. Due to the absence of an approved treatment strategy for the complete restoration of cartilage defects to their native state, the tissue condition often deteriorates over time, leading to osteoarthritic (OA). However, recent advancements in the field of regenerative medicine have unveiled promising prospects through the utilization of injectable hydrogels. This versatile class of biomaterials, characterized by their ability to emulate the characteristics of native articular cartilage, offers the distinct advantage of minimally invasive administration directly to the site of damage. These hydrogels can also serve as ideal delivery vehicles for a diverse range of bioactive agents, including growth factors, anti-inflammatory drugs, steroids, and cells. The controlled release of such biologically active molecules from hydrogel scaffolds can accelerate cartilage healing, stimulate chondrogenesis, and modulate the inflammatory microenvironment to halt osteoarthritic progression. The present review aims to describe the methods used to design injectable hydrogels, expound upon their applications as delivery vehicles of biologically active molecules, and provide an update on recent advances in leveraging these delivery systems to foster articular cartilage regeneration.
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Affiliation(s)
- Arjan Atwal
- School of Pharmacy and Bioengineering, Hornbeam building, Keele University, Staffordshire ST5 5BG, United Kingdom; Guy Hilton Research Centre, School of Pharmacy and Bioengineering, Keele University, Staffordshire ST4 7QB, United Kingdom
| | - Tina P Dale
- School of Pharmacy and Bioengineering, Hornbeam building, Keele University, Staffordshire ST5 5BG, United Kingdom; Guy Hilton Research Centre, School of Pharmacy and Bioengineering, Keele University, Staffordshire ST4 7QB, United Kingdom
| | - Martyn Snow
- Department of Arthroscopy, Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham B31 2AP, United Kingdom; The Robert Jones and Agnes Hunt Hospital, Oswestry, Shropshire SY10 7AG, United Kingdom
| | - Nicholas R Forsyth
- School of Pharmacy and Bioengineering, Hornbeam building, Keele University, Staffordshire ST5 5BG, United Kingdom; Guy Hilton Research Centre, School of Pharmacy and Bioengineering, Keele University, Staffordshire ST4 7QB, United Kingdom; Vice Principals' Office, University of Aberdeen, Kings College, Aberdeen AB24 3FX, United Kingdom
| | - Pooya Davoodi
- School of Pharmacy and Bioengineering, Hornbeam building, Keele University, Staffordshire ST5 5BG, United Kingdom; Guy Hilton Research Centre, School of Pharmacy and Bioengineering, Keele University, Staffordshire ST4 7QB, United Kingdom.
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18
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Porcello A, Hadjab F, Ajouaou M, Philippe V, Martin R, Abdel-Sayed P, Hirt-Burri N, Scaletta C, Raffoul W, Applegate LA, Allémann E, Jordan O, Laurent A. Ex Vivo Functional Benchmarking of Hyaluronan-Based Osteoarthritis Viscosupplement Products: Comprehensive Assessment of Rheological, Lubricative, Adhesive, and Stability Attributes. Gels 2023; 9:808. [PMID: 37888381 PMCID: PMC10606320 DOI: 10.3390/gels9100808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 09/30/2023] [Accepted: 10/07/2023] [Indexed: 10/28/2023] Open
Abstract
While many injectable viscosupplementation products are available for osteoarthritis (OA) management, multiple hydrogel functional attributes may be further optimized for efficacy enhancement. The objective of this study was to functionally benchmark four commercially available hyaluronan-based viscosupplements (Ostenil, Ostenil Plus, Synvisc, and Innoryos), focusing on critical (rheological, lubricative, adhesive, and stability) attributes. Therefore, in vitro and ex vivo quantitative characterization panels (oscillatory rheology, rotational tribology, and texture analysis with bovine cartilage) were used for hydrogel product functional benchmarking, using equine synovial fluid as a biological control. Specifically, the retained experimental methodology enabled the authors to robustly assess and discuss various functional enhancement options for hyaluronan-based hydrogels (chemical cross-linking and addition of antioxidant stabilizing agents). The results showed that the Innoryos product, a niacinamide-augmented linear hyaluronan-based hydrogel, presented the best overall functional behavior in the retained experimental settings (high adhesivity and lubricity and substantial resistance to oxidative degradation). The Ostenil product was conversely shown to present less desirable functional properties for viscosupplementation compared to the other investigated products. Generally, this study confirmed the high importance of formulation development and control methodology optimization, aiming for the enhancement of novel OA-targeting product critical functional attributes and the probability of their clinical success. Overall, this work confirmed the tangible need for a comprehensive approach to hyaluronan-based viscosupplementation product functional benchmarking (product development and product selection by orthopedists) to maximize the chances of effective clinical OA management.
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Affiliation(s)
- Alexandre Porcello
- School of Pharmaceutical Sciences, University of Geneva, CH-1206 Geneva, Switzerland; (M.A.); (E.A.); (O.J.)
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CH-1206 Geneva, Switzerland
| | - Farid Hadjab
- Development Department, Albomed GmbH, D-90592 Schwarzenbruck, Germany;
| | - Maryam Ajouaou
- School of Pharmaceutical Sciences, University of Geneva, CH-1206 Geneva, Switzerland; (M.A.); (E.A.); (O.J.)
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CH-1206 Geneva, Switzerland
| | - Virginie Philippe
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland; (V.P.); (P.A.-S.); (N.H.-B.); (C.S.); (W.R.); (L.A.A.)
- Orthopedics and Traumatology Service, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland;
| | - Robin Martin
- Orthopedics and Traumatology Service, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland;
| | - Philippe Abdel-Sayed
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland; (V.P.); (P.A.-S.); (N.H.-B.); (C.S.); (W.R.); (L.A.A.)
- STI School of Engineering, Federal Polytechnic School of Lausanne, CH-1015 Lausanne, Switzerland
| | - Nathalie Hirt-Burri
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland; (V.P.); (P.A.-S.); (N.H.-B.); (C.S.); (W.R.); (L.A.A.)
| | - Corinne Scaletta
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland; (V.P.); (P.A.-S.); (N.H.-B.); (C.S.); (W.R.); (L.A.A.)
| | - Wassim Raffoul
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland; (V.P.); (P.A.-S.); (N.H.-B.); (C.S.); (W.R.); (L.A.A.)
| | - Lee Ann Applegate
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland; (V.P.); (P.A.-S.); (N.H.-B.); (C.S.); (W.R.); (L.A.A.)
- Center for Applied Biotechnology and Molecular Medicine, University of Zurich, CH-8057 Zurich, Switzerland
- Oxford OSCAR Suzhou Center, Oxford University, Suzhou 215123, China
| | - Eric Allémann
- School of Pharmaceutical Sciences, University of Geneva, CH-1206 Geneva, Switzerland; (M.A.); (E.A.); (O.J.)
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CH-1206 Geneva, Switzerland
| | - Olivier Jordan
- School of Pharmaceutical Sciences, University of Geneva, CH-1206 Geneva, Switzerland; (M.A.); (E.A.); (O.J.)
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CH-1206 Geneva, Switzerland
| | - Alexis Laurent
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland; (V.P.); (P.A.-S.); (N.H.-B.); (C.S.); (W.R.); (L.A.A.)
- Manufacturing Department, LAM Biotechnologies SA, CH-1066 Epalinges, Switzerland
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Vassallo V, Di Meo C, Toro G, Alfano A, Iolascon G, Schiraldi C. Hyaluronic Acid-Based Injective Medical Devices: In Vitro Characterization of Novel Formulations Containing Biofermentative Unsulfated Chondroitin or Extractive Sulfated One with Cyclodextrins. Pharmaceuticals (Basel) 2023; 16:1429. [PMID: 37895900 PMCID: PMC10610477 DOI: 10.3390/ph16101429] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/29/2023] [Accepted: 10/03/2023] [Indexed: 10/29/2023] Open
Abstract
Currently, chondroitin sulfate (CS) and hyaluronic acid (HA) pharma-grade forms are used for osteoarthritis (OA) management, CS as an oral formulations component, and HA as intra-articular injective medical devices. Recently, unsulfated chondroitin, obtained through biofermentative (BC) manufacturing, has been proposed for thermally stabilized injective preparation with HA. This study aimed to highlight the specific properties of two commercial injective medical devices, one based on HA/BC complexes and the other containing HA, extractive CS, and cyclodextrins, in order to provide valuable information for joint disease treatments. Their biophysical and biomechanical features were assayed; in addition, biological tests were performed on human pathological chondrocytes. Rheological measurements displayed similar behavior, with a slightly higher G' for HA/BC, which also proved superior stability to the hyaluronidase attack. Both samples reduced the expression of specific OA-related biomarkers such as NF-kB, interleukin 6 (IL-6), and metalloprotease-13 (MMP-13). Moreover, HA/BC better ensured chondrocyte phenotype maintenance by up-regulating collagen type 2A1 (COLII) and aggrecan (AGN). Notwithstanding, the similarity of biomolecule components, the manufacturing process, raw materials characteristics, and specific concentration resulted in affecting the biomechanical and, more interestingly, the biochemical properties, suggesting potential better performances of HA/BC in joint disease treatment.
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Affiliation(s)
- Valentina Vassallo
- Department of Experimental Medicine, Section of Biotechnology, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (V.V.); (C.D.M.); (A.A.)
| | - Celeste Di Meo
- Department of Experimental Medicine, Section of Biotechnology, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (V.V.); (C.D.M.); (A.A.)
| | - Giuseppe Toro
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (G.T.); (G.I.)
| | - Alberto Alfano
- Department of Experimental Medicine, Section of Biotechnology, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (V.V.); (C.D.M.); (A.A.)
| | - Giovanni Iolascon
- Department of Medical and Surgical Specialties and Dentistry, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (G.T.); (G.I.)
| | - Chiara Schiraldi
- Department of Experimental Medicine, Section of Biotechnology, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; (V.V.); (C.D.M.); (A.A.)
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20
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Malik KN, Camp N, Chan J, Ballard M. Interventional Techniques for the Management of Knee Osteoarthritis: A Literature Review. Cureus 2023; 15:e47133. [PMID: 38022320 PMCID: PMC10650933 DOI: 10.7759/cureus.47133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2023] [Indexed: 12/01/2023] Open
Abstract
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.
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Affiliation(s)
- Kashif N Malik
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Nathan Camp
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
| | - Justin Chan
- Pain Management, Western University of Health Sciences, Pomona, USA
| | - Matthew Ballard
- Physical Medicine and Rehabilitation, Casa Colina Hospital, Pomona, USA
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21
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Moka E, Allam AES, Rekatsina M, Abed L, Paladini A, AlKharabsheh A, Vadalouca A, Varrassi G. Current Approaches to Four Challenging Pain Syndromes. Cureus 2023; 15:e45573. [PMID: 37868397 PMCID: PMC10586888 DOI: 10.7759/cureus.45573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
During a conference of pain specialists, some of the experts addressed the potential management of four prevalent but difficult painful conditions, namely, chronic postsurgical pain (CPSP), knee osteoarthritis, chest trauma, and facet joint arthropathy. In all cases, the conditions posed challenges in accurate diagnoses as well as safe, effective treatments, especially using locoregional blocks. It is not clear why some surgical patients develop CPSP and others do not, although some risk factors have been identified. More importantly, the transitional phase of pain from acute to chronic deserves greater scrutiny. It appears as if more aggressive and more effective perioperative and postoperative analgesia could help mitigate or possibly prevent CPSP. Knee osteoarthritis is prevalent but is often managed pharmacologically and then with joint replacement; many patients simply live with the condition which can be viewed as a disease of the entire joint. New approaches with intra-articular injections of hyaluronic acid, platelet-rich plasma, and botulinum toxin may provide safe, effective, and durable pain control. Chest trauma can be extremely painful and a source of morbidity, but its management tends to rely on watchful waiting and drug therapy. New approaches to regional nerve blocks can be beneficial and may reduce troublesome symptoms such as the inability to cough or clear the lungs. Facet joint arthropathy is very prevalent among older people but is not completely clarified. It may be the source of intense pain with limited management strategies. The role of nerve blocks in facet joint arthropathy is an important new addition to the armamentarium of pain management, particularly for geriatric patients.
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Affiliation(s)
- Eleni Moka
- Department of Anesthesiology, Creta InterClinic Hospital, Herakleion, GRC
| | - Abdallah El-Sayed Allam
- Morphological Madrid Research Center (MoMaRC), UltraDissection Spain EchoTraining School, Madrid, ESP
- Physical Medicine, Rheumatology and Rehabilitation, Tanta University Hospitals & Faculty of Medicine, Tanta University, Tanta, EGY
| | | | - Lynda Abed
- Anesthesia and Intensive Care, Djilali Bounaama Douera Hospital University, Algiers, DZA
| | - Antonella Paladini
- Department of Life, Health and Environmental Sciences (MESVA, University of L'Aquila, L'Aquila, ITA
| | - Abdullah AlKharabsheh
- King Abdullah University Hospital, Jordan University of Science and Technology, Amman, JOR
| | - Athina Vadalouca
- Pain and Palliative Care Center, Athens Medical Hospital, Athens, GRC
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22
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Budai L, Budai M, Fülöpné Pápay ZE, Szalkai P, Niczinger NA, Kijima S, Sugibayashi K, Antal I, Kállai-Szabó N. Viscoelasticity of Liposomal Dispersions. NANOMATERIALS (BASEL, SWITZERLAND) 2023; 13:2340. [PMID: 37630925 PMCID: PMC10459094 DOI: 10.3390/nano13162340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 08/08/2023] [Accepted: 08/12/2023] [Indexed: 08/27/2023]
Abstract
Janus-faced viscoelastic gelling agents-possessing both elastic and viscous characteristics-provide materials with unique features including strengthening ability under stress and a liquid-like character with lower viscosities under relaxed conditions. The mentioned multifunctional character is manifested in several body fluids such as human tears, synovial liquids, skin tissues and mucins, endowing the fluids with a special physical resistance property that can be analyzed by dynamic oscillatory rheology. Therefore, during the development of pharmaceutical or cosmetical formulations-with the intention of mimicking the physiological conditions-rheological studies on viscoelasticity are strongly recommended and the selection of viscoelastic preparations is highlighted. In our study, we aimed to determine the viscoelasticity of various liposomal dispersions. We intended to evaluate the impact of lipid concentration, the presence of cholesterol or 1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC) and the gelling agents polyvinyl alcohol (PVA) and hydroxyethylcellulose (HEC) on the viscoelasticity of vesicular systems. Furthermore, the effect of two model drugs (phenyl salicylate and caffeine) on the viscoelastic behavior of liposomal systems was studied. Based on our measurements, the oscillation rheological properties of the liposomal formulations were influenced both by the composition and the lamellarity/size of the lipid vesicles.
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Affiliation(s)
- Lívia Budai
- Department of Pharmaceutics, Semmelweis University, Hőgyes Str. 7, 1092 Budapest, Hungary; (L.B.); (M.B.); (Z.E.F.P.); (P.S.); (N.A.N.)
| | - Marianna Budai
- Department of Pharmaceutics, Semmelweis University, Hőgyes Str. 7, 1092 Budapest, Hungary; (L.B.); (M.B.); (Z.E.F.P.); (P.S.); (N.A.N.)
| | - Zsófia Edit Fülöpné Pápay
- Department of Pharmaceutics, Semmelweis University, Hőgyes Str. 7, 1092 Budapest, Hungary; (L.B.); (M.B.); (Z.E.F.P.); (P.S.); (N.A.N.)
| | - Petra Szalkai
- Department of Pharmaceutics, Semmelweis University, Hőgyes Str. 7, 1092 Budapest, Hungary; (L.B.); (M.B.); (Z.E.F.P.); (P.S.); (N.A.N.)
| | - Noémi Anna Niczinger
- Department of Pharmaceutics, Semmelweis University, Hőgyes Str. 7, 1092 Budapest, Hungary; (L.B.); (M.B.); (Z.E.F.P.); (P.S.); (N.A.N.)
| | - Shosho Kijima
- Faculty of Pharmacy and Pharmaceutical Sciences, Josai University, 1-1 Keyakidai, Sakado 350-0295, Saitama, Japan; (S.K.); (K.S.)
| | - Kenji Sugibayashi
- Faculty of Pharmacy and Pharmaceutical Sciences, Josai University, 1-1 Keyakidai, Sakado 350-0295, Saitama, Japan; (S.K.); (K.S.)
| | - István Antal
- Department of Pharmaceutics, Semmelweis University, Hőgyes Str. 7, 1092 Budapest, Hungary; (L.B.); (M.B.); (Z.E.F.P.); (P.S.); (N.A.N.)
| | - Nikolett Kállai-Szabó
- Department of Pharmaceutics, Semmelweis University, Hőgyes Str. 7, 1092 Budapest, Hungary; (L.B.); (M.B.); (Z.E.F.P.); (P.S.); (N.A.N.)
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23
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Babu A, Channaveera C, Gupta A, Mittal MK, Johnson DS. Clinical and radiological efficacy of single-dose intra-articular high-molecular-weight hyaluronic acid in knee osteoarthritis. J Family Med Prim Care 2023; 12:1692-1696. [PMID: 37767433 PMCID: PMC10521855 DOI: 10.4103/jfmpc.jfmpc_486_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 06/19/2023] [Accepted: 06/21/2023] [Indexed: 09/29/2023] Open
Abstract
Context While visco-supplementation is being used for the treatment of knee osteoarthritis (OA), the published reports vary widely in benefits afforded by this treatment. It was therefore proposed to assess the objective parameters along with subjective outcomes. Aims Our study assessed the radiological and clinical efficacy of single-dose high-molecular-weight intra-articular hyaluronic acid (HMW-IAHA) injection in knee OA. Settings and Design This interventional cohort study was conducted in a calculated sample size of 44 patients with knee OA. Materials and Methods Visual analog scale (VAS) and knee OA and outcome score (KOOS) were used for clinical assessment, and whole organ magnetic resonance imaging score (WORMS) for radiological assessment. The subjects were given a single dose of HMW-IAHA injection, 90 mg/3 ml, and were assessed on day 0 and day 90. Statistical Analysis Statistical Package for Social Sciences (SPSS) software was used. Results At the day 90 follow-up, there was an improvement in mean ± standard deviation values of VAS score (day 0: 8.53 ± 0.81, day 90: 5.97 ± 0.87), KOOS score (day 0: 27.33 ± 15.18, day 90: 57.26 ± 14.26), and the cartilage signal and morphology in the medial femorotibial joint (day 0: 11.02 ± 6.26 and day 90: 10.91 ± 6.22) and patellofemoral joint (day 0: 10.35 ± 4.36 and day 90: 10.28 ± 4.39) compartments. There was a decrease in synovitis score from 2.3 ± 1.61 to 1.3 ± 1.3 in the medial femorotibial joint compartment and total WORMS score (day 0: 66.57 ± 36.06, day 90: 65.14 ± 35.62). Conclusions A single dose of intra-articular injection with high-molecular-weight hyaluronic acid produces improvement in the clinical symptoms and quality of life as well as is effective in maintaining the articular cartilage integrity and reducing synovial inflammation.
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Affiliation(s)
- Anjana Babu
- Department of Physical Medicine and Rehabilitation, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India
| | - Chethan Channaveera
- Department of Physical Medicine and Rehabilitation, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, Delhi, India
| | - Ajay Gupta
- Department of Physical Medicine and Rehabilitation, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India
| | - Mahesh K. Mittal
- Department of Radiodiagnosis, Subharti Medical College, Meerut, Uttar Pradesh, India
| | - Deepthi S. Johnson
- Department of Physical Medicine and Rehabilitation, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, Delhi, India
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24
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Iaconisi GN, Lunetti P, Gallo N, Cappello AR, Fiermonte G, Dolce V, Capobianco L. Hyaluronic Acid: A Powerful Biomolecule with Wide-Ranging Applications-A Comprehensive Review. Int J Mol Sci 2023; 24:10296. [PMID: 37373443 DOI: 10.3390/ijms241210296] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/08/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
Hyaluronic acid (HA) is a glycosaminoglycan widely distributed in the human body, especially in body fluids and the extracellular matrix of tissues. It plays a crucial role not only in maintaining tissue hydration but also in cellular processes such as proliferation, differentiation, and the inflammatory response. HA has demonstrated its efficacy as a powerful bioactive molecule not only for skin antiaging but also in atherosclerosis, cancer, and other pathological conditions. Due to its biocompatibility, biodegradability, non-toxicity, and non-immunogenicity, several HA-based biomedical products have been developed. There is an increasing focus on optimizing HA production processes to achieve high-quality, efficient, and cost-effective products. This review discusses HA's structure, properties, and production through microbial fermentation. Furthermore, it highlights the bioactive applications of HA in emerging sectors of biomedicine.
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Affiliation(s)
- Giorgia Natalia Iaconisi
- Department of Biological and Environmental Sciences and Technologies, University of Salento, 73100 Lecce, Italy
| | - Paola Lunetti
- Department of Biological and Environmental Sciences and Technologies, University of Salento, 73100 Lecce, Italy
| | - Nunzia Gallo
- Department of Engineering for Innovation, University of Salento, 73100 Lecce, Italy
| | - Anna Rita Cappello
- Department of Pharmacy, Health, and Nutritional Sciences, University of Calabria, 87036 Arcavacata di Rende, Italy
| | - Giuseppe Fiermonte
- Department of Biosciences, Biotechnologies and Biopharmaceutics, University of Bari, 70125 Bari, Italy
| | - Vincenza Dolce
- Department of Pharmacy, Health, and Nutritional Sciences, University of Calabria, 87036 Arcavacata di Rende, Italy
| | - Loredana Capobianco
- Department of Biological and Environmental Sciences and Technologies, University of Salento, 73100 Lecce, Italy
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25
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Volova LT, Kotelnikov GP, Shishkovsky I, Volov DB, Ossina N, Ryabov NA, Komyagin AV, Kim YH, Alekseev DG. 3D Bioprinting of Hyaline Articular Cartilage: Biopolymers, Hydrogels, and Bioinks. Polymers (Basel) 2023; 15:2695. [PMID: 37376340 DOI: 10.3390/polym15122695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 05/29/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Abstract
The musculoskeletal system, consisting of bones and cartilage of various types, muscles, ligaments, and tendons, is the basis of the human body. However, many pathological conditions caused by aging, lifestyle, disease, or trauma can damage its elements and lead to severe disfunction and significant worsening in the quality of life. Due to its structure and function, articular (hyaline) cartilage is the most susceptible to damage. Articular cartilage is a non-vascular tissue with constrained self-regeneration capabilities. Additionally, treatment methods, which have proven efficacy in stopping its degradation and promoting regeneration, still do not exist. Conservative treatment and physical therapy only relieve the symptoms associated with cartilage destruction, and traditional surgical interventions to repair defects or endoprosthetics are not without serious drawbacks. Thus, articular cartilage damage remains an urgent and actual problem requiring the development of new treatment approaches. The emergence of biofabrication technologies, including three-dimensional (3D) bioprinting, at the end of the 20th century, allowed reconstructive interventions to get a second wind. Three-dimensional bioprinting creates volume constraints that mimic the structure and function of natural tissue due to the combinations of biomaterials, living cells, and signal molecules to create. In our case-hyaline cartilage. Several approaches to articular cartilage biofabrication have been developed to date, including the promising technology of 3D bioprinting. This review represents the main achievements of such research direction and describes the technological processes and the necessary biomaterials, cell cultures, and signal molecules. Special attention is given to the basic materials for 3D bioprinting-hydrogels and bioinks, as well as the biopolymers underlying the indicated products.
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Affiliation(s)
- Larisa T Volova
- Research and Development Institute of Biotechnologies, Samara State Medical University, Chapayevskaya St. 89, 443099 Samara, Russia
| | - Gennadiy P Kotelnikov
- Research and Development Institute of Biotechnologies, Samara State Medical University, Chapayevskaya St. 89, 443099 Samara, Russia
| | - Igor Shishkovsky
- Skolkovo Institute of Science and Technology, Moscow 121205, Russia
| | - Dmitriy B Volov
- Research and Development Institute of Biotechnologies, Samara State Medical University, Chapayevskaya St. 89, 443099 Samara, Russia
| | - Natalya Ossina
- Research and Development Institute of Biotechnologies, Samara State Medical University, Chapayevskaya St. 89, 443099 Samara, Russia
| | - Nikolay A Ryabov
- Research and Development Institute of Biotechnologies, Samara State Medical University, Chapayevskaya St. 89, 443099 Samara, Russia
| | - Aleksey V Komyagin
- Research and Development Institute of Biotechnologies, Samara State Medical University, Chapayevskaya St. 89, 443099 Samara, Russia
| | - Yeon Ho Kim
- RokitHealth Care Ltd., 9, Digital-ro 10-gil, Geumcheon-gu, Seoul 08514, Republic of Korea
| | - Denis G Alekseev
- Research and Development Institute of Biotechnologies, Samara State Medical University, Chapayevskaya St. 89, 443099 Samara, Russia
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26
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Porcello A, Gonzalez-Fernandez P, Jeannerat A, Peneveyre C, Abdel-Sayed P, Scaletta C, Raffoul W, Hirt-Burri N, Applegate LA, Allémann E, Laurent A, Jordan O. Thermo-Responsive Hyaluronan-Based Hydrogels Combined with Allogeneic Cytotherapeutics for the Treatment of Osteoarthritis. Pharmaceutics 2023; 15:pharmaceutics15051528. [PMID: 37242774 DOI: 10.3390/pharmaceutics15051528] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 05/28/2023] Open
Abstract
Thermo-responsive hyaluronan-based hydrogels and FE002 human primary chondroprogenitor cell sources have both been previously proposed as modern therapeutic options for the management of osteoarthritis (OA). For the translational development of a potential orthopedic combination product based on both technologies, respective technical aspects required further optimization phases (e.g., hydrogel synthesis upscaling and sterilization, FE002 cytotherapeutic material stabilization). The first aim of the present study was to perform multi-step in vitro characterization of several combination product formulas throughout the established and the optimized manufacturing workflows, with a strong focus set on critical functional parameters. The second aim of the present study was to assess the applicability and the efficacy of the considered combination product prototypes in a rodent model of knee OA. Specific characterization results (i.e., spectral analysis, rheology, tribology, injectability, degradation assays, in vitro biocompatibility) of hyaluronan-based hydrogels modified with sulfo-dibenzocyclooctyne-PEG4-amine linkers and poly(N-isopropylacrylamide) (HA-L-PNIPAM) containing lyophilized FE002 human chondroprogenitors confirmed the suitability of the considered combination product components. Specifically, significantly enhanced resistance toward oxidative and enzymatic degradation was shown in vitro for the studied injectable combination product prototypes. Furthermore, extensive multi-parametric (i.e., tomography, histology, scoring) in vivo investigation of the effects of FE002 cell-laden HA-L-PNIPAM hydrogels in a rodent model revealed no general or local iatrogenic adverse effects, whereas it did reveal some beneficial trends against the development of knee OA. Overall, the present study addressed key aspects of the preclinical development process for novel biologically-based orthopedic combination products and shall serve as a robust methodological basis for further translational investigation and clinical work.
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Affiliation(s)
- Alexandre Porcello
- School of Pharmaceutical Sciences, University of Geneva, CH-1206 Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CH-1206 Geneva, Switzerland
| | - Paula Gonzalez-Fernandez
- School of Pharmaceutical Sciences, University of Geneva, CH-1206 Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CH-1206 Geneva, Switzerland
| | - Annick Jeannerat
- Preclinical Research Department, LAM Biotechnologies SA, CH-1066 Epalinges, Switzerland
| | - Cédric Peneveyre
- Preclinical Research Department, LAM Biotechnologies SA, CH-1066 Epalinges, Switzerland
| | - Philippe Abdel-Sayed
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland
- STI School of Engineering, Ecole Polytechnique Fédérale de Lausanne, CH-1015 Lausanne, Switzerland
| | - Corinne Scaletta
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland
| | - Wassim Raffoul
- Lausanne Burn Center, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland
- Plastic, Reconstructive, and Hand Surgery Service, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland
| | - Nathalie Hirt-Burri
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland
| | - Lee Ann Applegate
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland
- Lausanne Burn Center, Lausanne University Hospital, University of Lausanne, CH-1011 Lausanne, Switzerland
- Center for Applied Biotechnology and Molecular Medicine, University of Zurich, CH-8057 Zurich, Switzerland
- Oxford OSCAR Suzhou Center, Oxford University, Suzhou 215123, China
| | - Eric Allémann
- School of Pharmaceutical Sciences, University of Geneva, CH-1206 Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CH-1206 Geneva, Switzerland
| | - Alexis Laurent
- Preclinical Research Department, LAM Biotechnologies SA, CH-1066 Epalinges, Switzerland
- Regenerative Therapy Unit, Lausanne University Hospital, University of Lausanne, CH-1066 Epalinges, Switzerland
| | - Olivier Jordan
- School of Pharmaceutical Sciences, University of Geneva, CH-1206 Geneva, Switzerland
- Institute of Pharmaceutical Sciences of Western Switzerland, University of Geneva, CH-1206 Geneva, Switzerland
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27
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Sconza C, Di Matteo B, Queirazza P, Dina A, Amenta R, Respizzi S, Massazza G, Ammendolia A, Kon E, de Sire A. Ozone Therapy versus Hyaluronic Acid Injections for Pain Relief in Patients with Knee Osteoarthritis: Preliminary Findings on Molecular and Clinical Outcomes from a Randomized Controlled Trial. Int J Mol Sci 2023; 24:ijms24108788. [PMID: 37240135 DOI: 10.3390/ijms24108788] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Revised: 05/11/2023] [Accepted: 05/12/2023] [Indexed: 05/28/2023] Open
Abstract
Ozone therapy (OT) is used for the treatment of multiple musculoskeletal disorders. In recent years, there has been a growing interest in its use for the treatment of osteoarthritis (OA). The aim of this double-blind randomized controlled trial was to evaluate the efficacy of OT compared with hyaluronic acid (HA) injections for pain relief in patients with knee OA. Patients with knee OA for at least three months were included and randomly assigned to receive three intra-articular injections of ozone or HA (once a week). Patients were assessed at baseline and at 1, 3, and 6 months after the injections for pain, stiffness, and function using the WOMAC LK 3.1, the NRS, and the KOOS questionnaire. Out of 55 patients assessed for eligibility, 52 participants were admitted to the study and randomly assigned into the 2 groups of treatment. During the study, eight patients dropped out. Thus, a total of 44 patients, reached the endpoint of the study at 6 months. Both Group A and B consisted of 22 patients. At 1-month follow-up after injections, both treatment groups improved statistically significantly from baseline in all outcomes measured. At 3 months, improvements remained similarly consistent for Group A and Group B. At 6-month follow-up, the outcomes were comparable between the 2 groups, showing only a worsening trend in pain. No significant differences were found between the two groups in pain scores. Both therapies have proven to be safe, with the few recorded adverse events being mild and self-limiting. OT has demonstrated similar results to HA injections, proving to be a safe approach with significant effects on pain control in patients affected by knee OA. Due to its anti-inflammatory and analgesic effects, ozone might be considered as a potential treatment for OA.
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Affiliation(s)
- Cristiano Sconza
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Berardo Di Matteo
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Paolo Queirazza
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Arianna Dina
- Physical Medicine and Rehabilitation, University of Milan, 20122 Milan, Italy
| | - Roberta Amenta
- Department of Rehabilitation, Casa di Cura Villa Aurelia, 96100 Syracuse, Italy
| | - Stefano Respizzi
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Giuseppe Massazza
- Division of Physical Medicine and Rehabilitation, Department of Surgical Sciences, University of Turin, 10124 Turin, Italy
| | - Antonio Ammendolia
- Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", 88100 Catanzaro, Italy
| | - Elizaveta Kon
- Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- IRCCS Humanitas Research Hospital, 20089 Milan, Italy
| | - Alessandro de Sire
- Department of Medical and Surgical Sciences, University of Catanzaro "Magna Graecia", 88100 Catanzaro, Italy
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Blicharski T, Łukasik P, Plebanski R, Żęgota Z, Szuścik M, Moster E, Pavelka K, Jeon S, Park SL. Efficacy and Safety of Intra-Articular Cross-Linked Sodium Hyaluronate for the Treatment of Knee Osteoarthritis: A Prospective, Active-Controlled, Randomized, Parallel-Group, Double-Blind, Multicenter Study. J Clin Med 2023; 12:jcm12082982. [PMID: 37109318 PMCID: PMC10145240 DOI: 10.3390/jcm12082982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
The safety and efficacy of Hyruan ONE (test product), an intra-articular cross-linked sodium hyaluronate injection, to treat mild-to-moderate knee osteoarthritis was compared with that of Durolane (comparator) in a prospective, active-controlled, parallel-group, double-blind (masked-observed), multicenter non-inferiority study. European patients (n = 284) were randomized 1:1 (test product:comparator) and received one injection of cross-linked hyaluronic acid (60 mg/3 mL). In total, 280 patients completed the study. The primary endpoint of mean change in Western Ontario and McMaster University (WOMAC)-Likert Pain sub-scores from baseline at week 13 revealed changes of -5.59 and -5.54 for the test and comparator groups, respectively, demonstrating non-inferiority of the test product (difference, -0.05 [95% confidence interval, -0.838 to 0.729]). Secondary endpoint results, which included changes in WOMAC-Likert Pain sub-score from baseline to 26 weeks post-injection and changes in WOMAC-Likert Total score and Physical Function and Stiffness sub-scores, changes in patients' and investigators' global assessments, use of rescue medication, and responder rates at 13 and 26 weeks post-injection were similar between the groups. Incidence of adverse events was also similar. In both groups, most treatment-emergent adverse events were mild/moderate. Hyruan ONE was non-inferior to the comparator at 13 weeks post-injection in European patients with mild-to-moderate knee osteoarthritis.
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Grants
- T.B., T.H., A.G., J.B., P.Ł., R.P., Z.Ż., M.S., E.M., K.P., and T.T. received a study grant from LG Chem, Ltd. S.J. and S.L.P. are full-time employees of LG Chem, Ltd LG Chem
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Affiliation(s)
- Tomasz Blicharski
- Clinic of Rehabilitation and Orthopedics, Medical University of Lublin, 20-090 Lublin, Poland
| | - Piotr Łukasik
- Trauma and Orthopedic Ward, NZOZ Medi-Spatz, 44-100 Gliwice, Poland
| | | | - Zbigniew Żęgota
- Specjalistyczny Osrodek Leczniczo Badawczy (Specialist Treatment and Research Center), 14-100 Ostroda, Poland
| | - Marek Szuścik
- Orthopedic Department, Rydygier's Hospital, 31-826 Krakow, Poland
| | - Erik Moster
- Rheumatic Center of Dr. Mostera, 61500 Brno, Czech Republic
| | - Karel Pavelka
- Institute of Rheumatology, 12850 Prague, Czech Republic
| | - Seonhui Jeon
- Life Sciences, LG Chem, Ltd., Seoul 07336, Republic of Korea
| | - So La Park
- Life Sciences, LG Chem, Ltd., Seoul 07336, Republic of Korea
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Richard MJ, Driban JB, McAlindon TE. Pharmaceutical treatment of osteoarthritis. Osteoarthritis Cartilage 2023; 31:458-466. [PMID: 36414224 DOI: 10.1016/j.joca.2022.11.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 10/28/2022] [Accepted: 11/13/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To review the current state of pharmaceutical treatment recommendations for the management of osteoarthritis. METHOD A narrative review was drafted to describe treatment guidelines, mechanism of action, pharmacokinetics, and toxicity for nine classes of pharmaceuticals: 1) oral nonsteroidal anti-inflammatory drugs (NSAIDs), 2) topical NSAIDs, 3) COX-2 inhibitors, 4) duloxetine, 5) intra-articular corticosteroids, 6) intra-articular hyaluronic acid, 7) acetaminophen (paracetamol), 8) tramadol, and 9) capsaicin. RESULTS In general, oral and topical NSAIDs, including COX-2 inhibitors, are strongly recommended first-line treatments for osteoarthritis due to their ability to improve pain and function but are associated with increased risks in patients with certain comorbidities (e.g., heightened cardiovascular risks). Intra-articular corticosteroid injections are generally recommended for osteoarthritis management and have relatively minor adverse effects. Other treatments, such as capsaicin, tramadol, and acetaminophen, are more controversial, and many updated guidelines offer differing recommendations. CONCLUSION The pharmaceutical management of osteoarthritis is a constantly evolving field. Promising treatments are emerging, and medicines that were once considered conventional (e.g., acetaminophen) are gradually becoming less acceptable based on concerns with efficacy and safety. Clinicians need to consider the latest evidence and recommendations to make an informed decision with their patients about how to optimize treatment plans for patients with knee, hip, polyarticular, or hand osteoarthritis.
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Affiliation(s)
- M J Richard
- Division of Rheumatology, Immunology, and Allergy, Tufts Medical Center, Boston, MA, USA.
| | - J B Driban
- Division of Rheumatology, Immunology, and Allergy, Tufts Medical Center, Boston, MA, USA.
| | - T E McAlindon
- Division of Rheumatology, Immunology, and Allergy, Tufts Medical Center, Boston, MA, USA.
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Mol S, Taanman-Kueter EWM, van der Steen BA, Groot Kormelink T, van de Sande MGH, Tas SW, Wauben MHM, de Jong EC. Hyaluronic Acid in Synovial Fluid Prevents Neutrophil Activation in Spondyloarthritis. Int J Mol Sci 2023; 24:ijms24043066. [PMID: 36834478 PMCID: PMC9964069 DOI: 10.3390/ijms24043066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/31/2023] [Accepted: 02/01/2023] [Indexed: 02/09/2023] Open
Abstract
Spondyloarthritis (SpA) patients suffer from joint inflammation resulting in tissue damage, characterized by the presence of numerous neutrophils in the synovium and synovial fluid (SF). As it is yet unclear to what extent neutrophils contribute to the pathogenesis of SpA, we set out to study SF neutrophils in more detail. We analyzed the functionality of SF neutrophils of 20 SpA patients and 7 disease controls, determining ROS production and degranulation in response to various stimuli. In addition, the effect of SF on neutrophil function was determined. Surprisingly, our data show that SF neutrophils in SpA patients have an inactive phenotype, despite the presence of many neutrophil-activating stimuli such as GM-CSF and TNF in SF. This was not due to exhaustion as SF neutrophils readily responded to stimulation. Therefore, this finding suggests that one or more inhibitors of neutrophil activation may be present in SF. Indeed, when blood neutrophils from healthy donors were activated in the presence of increasing concentrations of SF from SpA patients, degranulation and ROS production were dose-dependently inhibited. This effect was independent of diagnosis, gender, age, and medication in the patients from which the SF was isolated. Treatment of SF with the enzyme hyaluronidase strongly reduced the inhibitory effect of SF on neutrophil activation, indicating that hyaluronic acid that is present in SF may be an important factor in preventing SF neutrophil activation. This finding provides novel insights into the role of soluble factors in SF regulating neutrophil function and may lead to the development of novel therapeutics targeting neutrophil activation via hyaluronic acid or associated pathways.
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Affiliation(s)
- Sanne Mol
- Department of Experimental Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Department of Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CL Utrecht, The Netherlands
| | - Esther W. M. Taanman-Kueter
- Department of Experimental Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Baltus A. van der Steen
- Department of Experimental Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Tom Groot Kormelink
- Department of Experimental Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands
| | - Marleen G. H. van de Sande
- Department of Experimental Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Sander W. Tas
- Department of Experimental Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Department of Rheumatology and Clinical Immunology, Amsterdam Rheumatology and Immunology Center, Amsterdam University Medical Centers, University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Marca H. M. Wauben
- Department of Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CL Utrecht, The Netherlands
| | - Esther C. de Jong
- Department of Experimental Immunology, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, Location AMC, 1105 AZ Amsterdam, The Netherlands
- Correspondence: ; Tel.: +31-20-5664963
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31
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Alexandres Rios de Los Rios D, Guaschi Herretes A, Hernández Herrero D. [Analysis of reinjection periodicity in knee osteoarthritis with different types of hyaluronic acids]. Rehabilitacion (Madr) 2023; 57:100734. [PMID: 35527076 DOI: 10.1016/j.rh.2022.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 12/29/2021] [Accepted: 02/13/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To evaluate the periodicity of hyaluronic acid (HA) reinjection in patients with knee osteoarthritis. Secondary aim: To relate the degree of arthrosis with the time between infiltrations and the possible study by subgroups between the different commercial preparations. DESIGN Retrospective observational study. MATERIALS AND METHOD Review of medical records and X-rays of patients with knee osteoarthritis that had been treated with intra-articular HA at the Rehabilitation Service in the period between January 2017 and June 2019. VARIABLES Socio-demographic, Laterality, Intervention Date, Degree of Arthrosis according to Kellgren and Lawrence, HA used, Time between filtrations. Statistical analysis carried out by Kaplan-Meier curves, taking into account the reinfiltration as final event, and Kruskal-Wallis test for non-parametric quantitative data. RESULTS We analysed 110 infiltration acts in 67 patients: average age at the time of infiltration 72.12 years, 85.1% women, 59.1% right knee. 4 types of HA: 33 cases at 1%. MW: 0.9MDa (HA1), 12 at 1.5%. MW: 1.5-2MDa (HA2), 42 at 2%. MW: 1.2MDa (HA3) and 6 Hylan G-F20. MW: 6MDa (HA4). We reinfiltrated in 31 occasions (28.2%). Average of months (IC 95%) between infiltrations: HA1 6.9 (5.7-8.16), HA2 12.5 (0-35), HA3 9.3 (5.5-13.1), HA4 5 (3-6.9). In 2 cases where it was not possible to establish the type of infiltrated formulations, the mean value between reinfiltrations was 8.5 (5.6-11.4) There were no statistically significant results by relating the HA type or the degree of arthrosis with the reinfiltration time. CONCLUSIONS In our study, we observe that the HA3 presented a longer time between infiltrations in comparison with other types, with no possibility to detect significant differences.
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Affiliation(s)
| | - A Guaschi Herretes
- Departamento de Medicina Física y Rehabilitación, Hospital Universitario La Paz, Madrid, España
| | - D Hernández Herrero
- Departamento de Medicina Física y Rehabilitación, Hospital Universitario La Paz, Madrid, España
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Hart DA. Osteoarthritis as an Umbrella Term for Different Subsets of Humans Undergoing Joint Degeneration: The Need to Address the Differences to Develop Effective Conservative Treatments and Prevention Strategies. Int J Mol Sci 2022; 23:ijms232315365. [PMID: 36499704 PMCID: PMC9736942 DOI: 10.3390/ijms232315365] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 11/30/2022] [Accepted: 12/04/2022] [Indexed: 12/12/2022] Open
Abstract
Osteoarthritis (OA) of joints such as the knee and hip are very prevalent, and the number of individuals affected is expected to continue to rise. Currently, conservative treatments after OA diagnosis consist of a series of increasingly invasive interventions as the degeneration and pain increase, leading very often to joint replacement surgery. Most interventions are focused on alleviating pain, and there are no interventions currently available that stop and reverse OA-associated joint damage. For many decades OA was considered a disease of cartilage, but it is now considered a disease of the whole multi-tissue joint. As pain is the usual presenting symptom, for most patients, it is not known when the disease process was initiated and what the basis was for the initiation. The exception is post-traumatic OA which results from an overt injury to the joint that elevates the risk for OA development. This scenario leads to very long wait lists for joint replacement surgery in many jurisdictions. One aspect of why progress has been so slow in addressing the needs of patients is that OA has been used as an umbrella term that does not recognize that joint degeneration may arise from a variety of mechanistic causes that likely need separate analysis to identify interventions unique to each subtype (post-traumatic, metabolic, post-menopausal, growth and maturation associated). A second aspect of the slow pace of progress is that the bulk of research in the area is focused on post-traumatic OA (PTOA) in preclinical models that likely are not clearly relevant to human OA. That is, only ~12% of human OA is due to PTOA, but the bulk of studies investigate PTOA in rodents. Thus, much of the research community is failing the patient population affected by OA. A third aspect is that conservative treatment platforms are not specific to each OA subset, nor are they integrated into a coherent fashion for most patients. This review will discuss the literature relevant to the issues mentioned above and propose some of the directions that will be required going forward to enhance the impact of the research enterprise to affect patient outcomes.
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Affiliation(s)
- David A Hart
- Department of Surgery, Faculty of Kinesiology, McCaig Institute for Bone & Joint Health, University of Calgary, Calgary, AB T2N 4N1, Canada
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33
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Zhang Q, Liu T, Gu Y, Gao Y, Ni J. Efficacy and safety of platelet-rich plasma combined with hyaluronic acid versus platelet-rich plasma alone for knee osteoarthritis: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:499. [PMCID: PMC9675184 DOI: 10.1186/s13018-022-03398-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 11/10/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose To systematically evaluate the curative efficacy and safety of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) in the treatment of knee osteoarthritis (KOA), comparing with platelet-rich plasma alone. Methods Cochrane Library, PubMed, China National Knowledge Infrastructure (CNKI) and Embase were searched for randomized controlled trials (RCTs) and cohort studies regarding the efficacy and safety of platelet-rich plasma (PRP) combined with hyaluronic acid (HA) in the treatment of knee osteoarthritis (KOA) comparing with platelet-rich plasma alone before January 15, 2022. The methodological quality of the ultimately included studies was assessed comprehensively, and meta-analysis was implemented using RevMan 5.3 software. Results Thirteen articles (9 RCTs, 4 cohort studies), including 1118 patients, were covered. There was no significant difference between the PRP + HA therapy and PRP-alone therapy in VAS scores at 3 months, 6 months and 12 months, WOMAC total scores at 3 months and KOOS at 1 month and 6 months. Compared with PRP-alone therapy, PRP + HA therapy was associated with significantly better improvement in VAS scores at 1 month, WOMAC total scores at 6 months, KOOS at 3 months, IKDC scores at 6 months and Lequesne index scores at 3 and 6 months. However, the smallest treatment effect of VAS scores, WOMAC total scores, KOOS and IKDC scores did not exceed the minimum clinically important difference (MCID). However, PRP + HA therapy got a greater reduction in the rate of adverse events, compared with PRP-alone therapy. Conclusion The results of this meta-analysis indicated that PRP + HA therapy was not found to be superior to PRP-alone therapy in pain relief and function improvement for patients with KOA. However, combined PRP with HA injections was generally safer than PRP injections alone, by assessing the incidence of adverse events.
Supplementary Information The online version contains supplementary material available at 10.1186/s13018-022-03398-6.
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Affiliation(s)
- Qing Zhang
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, 410000 Hunan People’s Republic of China
| | - Tuodong Liu
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, 410000 Hunan People’s Republic of China
| | - Yuan Gu
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, 410000 Hunan People’s Republic of China
| | - Yongquan Gao
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, 410000 Hunan People’s Republic of China
| | - Jiangdong Ni
- grid.216417.70000 0001 0379 7164Department of Orthopaedics, The Second Xiangya Hospital, Central South University, No. 139 Renmin Street, Changsha, 410000 Hunan People’s Republic of China
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Filatova YS, Soloviev IN. Hyaluronic acid in the treatment of osteoarthritis of various localization: A review. TERAPEVT ARKH 2022; 94:1014-1019. [DOI: 10.26442/00403660.2022.08.201790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 10/12/2022] [Indexed: 02/25/2023]
Abstract
The article discusses the treatment of osteoarthritis (OA), the prevalence of which is high, and according to some forecasts it will increase by 50% in the next 20 years. The authors emphasize the high comorbidity among patients suffering from OA and high cardiovascular and gastrointestinal risks with frequent use of NSAIDs, the volume of consumption of which is constantly increasing. Discussing recommendations for the treatment of patients with OA, the article focuses on the use of hyaluronic acid (HA) preparations in the treatment of OA. The mechanisms of anti-inflammatory and chondroprotective actions of HA in the joint, its effect on cartilage and synovial membrane are discussed. Attention is drawn to the fact that, despite more than 30 years of experience in the effective use of HA preparations in the treatment of OA, this procedure is still a subject of controversy among international professional communities. The article presents data from meta-analyses and systematic reviews confirming the effectiveness of the use of intra-articular management of HA preparations in OA of various localization (knee joints, hip joints, hand joints). In conclusion, the recommendations of the technical expert group established at the International Symposium on Intra-Articular Treatment are given to determine the criteria for the successful administration of HA in OA of various localizations, as well as predictors of success and non-success of therapy with HA drugs. The experts identified indications, contraindications for intra-articular administration of HA preparations, as well as conditions associated with an increased risk of therapy failure. In conclusion, the authors draw conclusions about the importance of using HA preparations for intra-articular administration for the treatment of OA, starting from the early stages, following the recommendations of experts.
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Saornil JV, Sánchez Milá Z, Campón Chekroun AM, Baraja Vegas L, Vicente Mampel J, Frutos Llanes R, Barragán Casas JM, Rodríguez-Sanz D. Comparative Study of the Efficacy of Hyaluronic Acid, Dry Needling and Combined Treatment in Patellar Osteoarthritis-Single-Blind Randomized Clinical Trial. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10912. [PMID: 36078628 PMCID: PMC9517789 DOI: 10.3390/ijerph191710912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/21/2022] [Accepted: 08/30/2022] [Indexed: 06/15/2023]
Abstract
Background: Osteoarthritis of the knee is one of the most common ailments worldwide, and pain management of this condition is critical. Methods: A multicentre randomized controlled trial RCT with three months of follow-up, conducted in parallel groups: hyaluronic acid (HA), dry needling (DN) and ultrasound (US) and isometrics of quadriceps. 60 participants took part in the RCT who were diagnosed with osteoarthritis (Grade 3) of the knee by MRI and active adults (age: 23.41 ± 1.68 years; height: 1.79 ± 0.08 m; body mass: 78.33 ± 9.03 kg; body mass index (BMI): 24.14 ± 1.45 kg/m2). After the assigned intervention, VAS, WOMAC, IPAQ and the Star Excursion Balance test were measured at baseline. At 24 h, 15 days, 30 days, 90 days and 180 days follow-up, all variables were measured again. Results: Comparing statistically significant differences between groups, VAS scores were significant at post-test measurement (HA vs. US + isometric and DN vs. US + isometric) at 24 h (HA vs. DN), at 15 days (HA vs. US + isometric and DN vs. US + isometric) and at 1 month (US + isometric vs. HA and US + isometric vs. DN). Conclusions: There is an improvement in pain intensity in knee osteoarthritis in the short term in patients undergoing DN and conventional US + isometric treatment, but in the long term the HA group shows an improvement in pain intensity. There is also a significant difference in the improvement of knee function at different phases of the study in the various intervention groups. The combination of DN and HA in clinical practice is the best option for the treatment of osteoarthritis.
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Affiliation(s)
- Jorge Velázquez Saornil
- Departamento de Fisioterapia, Facultad de Ciencias de la Salud, Universidad Católica de Ávila, C/Canteros s/n, 05005 Ávila, Spain
| | - Zacarías Sánchez Milá
- Departamento de Fisioterapia, Facultad de Ciencias de la Salud, Universidad Católica de Ávila, C/Canteros s/n, 05005 Ávila, Spain
| | | | - Luis Baraja Vegas
- Departamento de Fisioterapia, Facultad de Medicina y Ciencias de la Salud, Universidad Católica de Valencia, C/Quevedo, 2, 46001 Valencia, Spain
| | - Juan Vicente Mampel
- Departamento de Fisioterapia, Facultad de Medicina y Ciencias de la Salud, Universidad Católica de Valencia, C/Quevedo, 2, 46001 Valencia, Spain
| | - Raúl Frutos Llanes
- Departamento de Fisioterapia, Facultad de Ciencias de la Salud, Universidad Católica de Ávila, C/Canteros s/n, 05005 Ávila, Spain
| | - José Manuel Barragán Casas
- Departamento de Fisioterapia, Facultad de Ciencias de la Salud, Universidad Católica de Ávila, C/Canteros s/n, 05005 Ávila, Spain
| | - David Rodríguez-Sanz
- Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, Avenida Séneca, 2, 28040 Madrid, Spain
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Delbaldo C, Tschon M, Martini L, Fini M, Codispoti G. Benefits of Applying Nanotechnologies to Hydrogels in Efficacy Tests in Osteoarthritis Models-A Systematic Review of Preclinical Studies. Int J Mol Sci 2022; 23:ijms23158236. [PMID: 35897805 PMCID: PMC9368605 DOI: 10.3390/ijms23158236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 07/21/2022] [Accepted: 07/24/2022] [Indexed: 12/09/2022] Open
Abstract
Osteoarthritis (OA) is a severe musculoskeletal disease with an increasing incidence in the worldwide population. Recent research has focused on the development of innovative strategies to prevent articular cartilage damage and slow down OA progression, and nanotechnologies applied to hydrogels have gained particular interest. The aim of this systematic review is to investigate the state of the art on preclinical in vitro and in vivo efficacy studies applying nanotechnologies to hydrogels in OA models to elucidate the benefits of their applications. Three databases were consulted for eligible papers. The inclusion criteria were in vitro and in vivo preclinical studies, using OA cells or OA animal models, and testing hydrogels and nanoparticles (NPs) over the last ten years. Data extraction and quality assessment were performed. Eleven papers were included. In vitro studies evidenced that NP-gels do not impact on cell viability and do not cause inflammation in OA cell phenotypes. In vivo research on rodents showed that these treatments could increase drug retention in joints, reducing inflammation and preventing articular cartilage damage. Nanotechnologies in preclinical efficacy tests are still new and require extensive studies and technical hits to determine the efficacy, safety, fate, and localization of NPs for translation into an effective therapy for OA patients.
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Safety of intra-articular platelet rich plasma injections for large joint osteoarthritis: a review article. CURRENT ORTHOPAEDIC PRACTICE 2022. [DOI: 10.1097/bco.0000000000001142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Acharya K, Si V, Madi S. Improvement in condition specific and generic quality of life outcomes in patients with knee osteoarthritis following single intraarticular viscosupplementation injection. J Clin Orthop Trauma 2022; 27:101828. [PMID: 35310785 PMCID: PMC8924687 DOI: 10.1016/j.jcot.2022.101828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 01/12/2022] [Accepted: 03/02/2022] [Indexed: 10/18/2022] Open
Abstract
Background Non-operative management of Osteoarthritis (OA) can be challenging. The intra-articular injection with hyaluronic acid (IAHA), corticosteroids and Platelet rich plasma are some of the popular modalities which are increasingly being employed as a stop-gap strategy before considering any surgical intervention for OA management. Among these, the intra-articular HA (IAHA) has been widely studied with variable and conflicting results. Method This was a prospective observational study conducted in adults with knee OA. Suitable patients were given IAHA (Synvisc-One®) on an out-patient basis. They were assessed in terms of VAS score, WOMAC score and SF36 scores at successive follow-up visits at 8, 24 and 52 weeks. Results 50 patients were recruited in this study and followed for 52 weeks post injection of HA. Mean and SD values of VAS, WOMAC and SF36 scores were on a decreasing trend in each follow up visit. Percentage change between the visits was also statistically significant. The improvement in pain scores at successive visits was significant in KL grade 1 OA than grade 2 or 3 indicating strong association between them. Conclusion Short-term (up to one year) beneficial effects of intra-articular viscosupplementation with HA in early primary knee OA can be seen with a decreasing trend in the intensity of pain and an increasing trend in improving the physical functioning and health-related quality of life.
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Affiliation(s)
| | | | - Sandesh Madi
- Corresponding author. Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, 576104, Karnataka, India.
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39
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Jang G, Lee SA, Hong JH, Park BR, Kim DK, Kim CS. Chondroprotective Effects of 4,5-Dicaffeoylquinic Acid in Osteoarthritis through NF-κB Signaling Inhibition. Antioxidants (Basel) 2022; 11:antiox11030487. [PMID: 35326137 PMCID: PMC8944529 DOI: 10.3390/antiox11030487] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 02/26/2022] [Accepted: 02/26/2022] [Indexed: 01/27/2023] Open
Abstract
Osteoarthritis (OA) is characterized by cartilage degradation, inflammation, and pain. The dicaffeoylquinic acid (diCQA) isomer, 4,5-diCQA, exhibits antioxidant activity and various other health-promoting benefits, but its chondroprotective effects have yet to be elucidated. In this study, we aimed to investigate the chondroprotective effects of 4,5-diCQA on OA both in vitro and in vivo. Primary rat chondrocytes were pre-treated with 4,5-diCQA for 1 h before stimulation with interleukin (IL)-1β (5 ng/mL). The accumulation of nitrite, PGE2, and aggrecan was observed using the Griess reagent and ELISA. The protein levels of iNOS, COX-2, MMP-3, MMP-13, ADMATS-4, MAPKs, and the NF-κB p65 subunit were measured by Western blotting. In vivo, the effects of 4,5-diCQA were evaluated for 2 weeks in a destabilization of the medial meniscus (DMM)-surgery-induced OA rat model. 4,5-diCQA significantly inhibited IL-1β-induced expression of nitrite, iNOS, PGE2, COX-2, MMP-3, MMP-13, and ADAMTS-4. 4,5-diCQA also decreased the IL-1β-induced degradation of aggrecan. It also suppressed the IL-1β-induced phosphorylation of MAPKs and translocation of the NF-κB p65 subunit to the nucleus. These findings indicate that 4,5-diCQA inhibits DMM-surgery-induced cartilage destruction and proteoglycan loss in vivo. 4,5-diCQA may be a potential therapeutic agent for the alleviation of OA progression. In this study, diclofenac was set to be administered once every two days, but it showed an effect on OA. These results may be used as basic data to suggest a new dosing method for diclofenac.
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Affiliation(s)
- Goeun Jang
- Department of Oral Biochemistry, College of Dentistry, Chosun University, Gwangju 61452, Korea; (G.J.); (S.A.L.)
| | - Seul Ah Lee
- Department of Oral Biochemistry, College of Dentistry, Chosun University, Gwangju 61452, Korea; (G.J.); (S.A.L.)
| | - Joon Ho Hong
- Nano Bio Research Center, Jeonnam Bioindustry Foundation, Wando 59108, Korea;
| | - Bo-Ram Park
- Department of Dental Hygiene, College of Health and Welfare, Kyungwoon University, Gumi 39160, Korea;
| | - Do Kyung Kim
- Oral Biology Research Institute, College of Dentistry, Chosun University, Gwangju 61452, Korea;
| | - Chun Sung Kim
- Department of Oral Biochemistry, College of Dentistry, Chosun University, Gwangju 61452, Korea; (G.J.); (S.A.L.)
- Correspondence: ; Tel.: +82-62-230-7088; Fax: +82-62-232-6896
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