Co-treatment with Oral Duloxetine and Intraarticular Injection of Corticosteroid plus Hyaluronic Acid Reduces Pain in the Treatment of Knee Osteoarthritis

BACKGROUND

Knee osteoarthritis (OA) is a common form of arthritis in elders which can lead to reduced daily activity and quality of life. It is important to administer a proper treatment with high efficacy and low side effects. In this study, we evaluated the efficacy of co-treatment with oral duloxetine and intraarticular (IA) injection of hyaluronic acid (HA) and corticosteroid (CS) in patients with knee OA.

OBJECTIVES

This study aimed to test the hypothesis that an IA injection of CS+HA combined with duloxetine could achieve pain management superior to that of an IA injection of CS+HA alone in patients experiencing knee OA related pain.

STUDY DESIGN

This study adopted a prospective, randomized, open-label blind endpoint study design.

SETTING

The investigation was performed at Beijing Tiantan Hospital Affiliated with the Capital Medical University from October 2019 to December 2021. The study plan was approved by the Ethics Committee of Beijing Tiantan Hospital (KY 2019-086-02).

METHODS

A total of 150 patients were randomly allocated to receive either duloxetine combined with an IA injection (n = 75) or a single IA injection alone (n = 75). All patients were followed for 24 weeks. The primary outcome was the change in the weekly 24 hours average mean pain scores, and the secondary outcomes included the proportion of patients with >= 30% or >= 50% pain reduction, Brief Pain Inventory (BPI) items, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, Patient Global Impression Improvement (PGI-I) ratings, hospital anxiety and depression scale (HADS) scores and adverse events (AEs)..

RESULTS

Patients in the experimental group had significantly greater improvement in the change of weekly mean of the 24 hours average pain scores, BPI pain severity ratings (P < 0.001) and WOMAC scores (P < 0.001) at the study endpoint. A significantly greater percentage of patients in the experimental group rated PGI-I of <= 2 (P = 0.021) and >= 50% pain reduction (P = 0.029) at 24 weeks. There was no difference in the proportion of patients with <= 30% pain reduction, the HADS scores or frequency of AEs between the 2 groups.

LIMITATIONS

The effectiveness and safety were examined only up to 24 weeks after treatment, and we did not perform a long-term follow-up as most previous studies have. Optimum dosage of duloxetine, as well as different molecular-weight HA, should be investigated in future studies.

CONCLUSION

Patients receiving co-treatment with oral duloxetine and IA (HA+CS) injections experienced considerable improvement in pain and knee function compared to those who received an IA injection alone.

Fluoroscopic Confirmation of Needle Location in Ultrasound-guided Genicular Nerve Radiofrequency Thermocoagulation

BACKGROUND

Radiofrequency thermocoagulation of genicular nerves is an effective treatment for chronic pain due to knee osteoarthritis. The procedure can be performed under fluoroscopic or ultrasonographic guidance.

OBJECTIVES

The aim of this study was to fluoroscopically check the final location  of the needle in ultrasound-guided genicular nerve radiofrequency thermocoagulation and evaluate the treatment's success in patients with knee pain.

STUDY DESIGN

A 2-center, prospective study.

SETTING

A private clinic and a tertiary care health center.

METHODS

Thirty-two patients who had unilateral knee pain, and grade 3-4 knee osteoarthritis according to the Kellgren-Lawrence classification were included. Following diagnostic genicular nerve blocks in patients whose knee pain was relieved by >= 50%, radiofrequency thermocoagulation was applied to these nerves. The final position of the needle was checked via fluoroscopy in anteroposterior and lateral planes.

RESULTS

The needle was located in the one-third anterior portion of the bone shaft in 69 of 96 patients (71.9%), between one-third and two-thirds in 21 (21.9%), and in the one-third posterior portion in 6 (6.3%). The mean Numeric Rating Scale score for pain was 7.69 ± 0.99 before treatment, 4.03 ± 1.26 at one week, 2.53 ± 1.24 at one month, and 2.19 ± 1.71 at 3 months, indicating a statistically significant decrease (P < 0.001).

LIMITATIONS

The lack of a study group in which genicular nerve radiofrequency thermocoagulation was performed under fluoroscopy guidance could be cited among the limitations of this clinical study.

CONCLUSIONS

The final position of the needle tip in radiofrequency thermocoagulation of genicular nerves can exist at the one-third anterior of the bone shaft, without a need for further advancing the needle to the posterior portion. Although performed more distally compared to fluoroscopy guidance, ultrasound-guided genicular nerve radiofrequency thermocoagulation still provides effective analgesia.

A Double-Blind, Placebo-Controlled Study of Ultrasound-Guided Pulsed Radiofrequency Treatment of the Saphenous Nerve for Refractory Osteoarthritis-Associated Knee Pain

BACKGROUND

While the efficacy of pulsed radiofrequency (PRF) for shoulder pain has been demonstrated, its efficacy on the saphenous nerves for knee osteoarthritis (OA)-associated pain has only been reported in observational studies.

OBJECTIVES

The aim of this study was to compare saphenous nerve PRF to placebo for knee OA-associated pain.

STUDY DESIGN

Patients, practitioners, and outcome assessor-blinded randomized placebo-controlled trial.

SETTING

Pain management clinics at 2 hospitals in Japan.

METHODS

Patients were randomly allocated to the PRF (n = 37) or placebo group (n = 33). Patients aged 40-85 years with refractory anteromedial knee pain. PRF in the saphenous nerve under ultrasound guidance. The placebo group underwent the same procedure, but with motor stimulation. The primary endpoint was the average pain intensity measured using the visual analog scale (VAS) at the 12-week post-treatment visit; secondary outcomes included the average VAS at 1 and 4 weeks, and pain intensities at rest, in flexion, at standing, and at walking. Other secondary outcomes were knee pain, symptoms, activities of daily living, knee-related quality of life, mobility, range of motion, and adverse events.

RESULTS

In the PRF group, the mean VAS score was 52.41 ± 26.17 at 12 weeks, while in the sham group, the mean VAS score was 63.06 ± 27.12 (P < 0.05). There were no significant differences between the groups in any of the secondary outcomes.

LIMITATIONS

Patients with comorbidities were excluded from this study. The follow-up time was limited to 12 weeks.

CONCLUSIONS

Ultrasound-guided saphenous nerve PRF proved to be effective for at least 12 weeks in patients with knee OA and showed no adverse events.

Prevalence and Characteristics of Onychomycosis in Patients with Knee Osteoarthritis: A Single-centre Prospective Cross-sectional Study

Knee disorders that compromise patients’ lower leg movements and self-care may put these patients at greater risk of onychomycosis. However, little is known about the prevalence of onychomycosis in patients with knee diseases. This study evaluated the prevalence and characteristics of onychomycosis in patients with knee osteoarthritis. A total of 520 consecutive patients with symptomatic knee osteoarthritis who visited the Department of Orthopedics for a potential knee surgery were evaluated for onychomycosis by PCR-based reverse blot hybridization assay. Of the 520 patients, 308 (59.2%) were diagnosed with onychomycosis. Age (p = 0.004), male sex (p = 0.015), and being barefooted (p = 0.031) were statistically significant risk factors for onychomycosis. Knee disease severity, based on Kellgren-Lawrence grade, was associated with severity of onychomycosis. The impairment of physical function and self-care caused by knee disorders may increase the prevalence of onychomycosis in these patients.

The Treatment of Bone Marrow Lesions Associated with Advanced Knee Osteoarthritis: Comparing Intraosseous and Intraarticular Injections with Bone Marrow Concentrate and Platelet Products

BACKGROUND

Bone marrow lesions are a radiographic indication of bony pathology closely associated with advanced osteoarthritis of the adjacent joint. Injection of autologous orthobiologic products, including bone marrow concentrate and platelet-rich plasma, have demonstrated safety and efficacy in treating both advanced osteoarthritis (via intraarticular injection) and associated bone marrow lesions (via intraosseous injection). The relative efficacy of intraarticular versus intraosseous injection of orthobiologics has not been evaluated at the present time.

OBJECTIVES

The objective was to evaluate differences in orthobiologic bone marrow lesions treatment, either as a collateral result of intraarticular injection with bone marrow concentrate and platelet products alone, or intraosseous plus intraarticular injection as measured by patient reported outcomes.

STUDY DESIGN

This study employed a prospective case-matched cohort design.

SETTING

This study took place at a single outpatient interventional orthopedic pain clinic.

METHODS

Using data from a prospective orthobiologic treatment registry of knee patients, a population of knee osteoarthritis with bone marrow lesions patients who had undergone only intraarticular knee injections of bone marrow concentrate and platelets (for symptomatic advanced osteoarthritis) were age, gender, and disease severity case-matched to a series of advanced osteoarthritis and bone marrow lesions patients who underwent intraosseous plus intraarticular injections. Self-reported patient outcomes for Numeric Pain Scale, International Knee Documentation Committee, lower extremity functional scale, and a modified single assessment numeric evaluation were compared between the 2 treatment groups.

RESULTS

Eighty patients were included, 40 in each group. Although pain and functional outcome scores were significantly improved in both treatment groups, there was no statistically significant differences in patient reported outcomes based on the type of treatment.

LIMITATIONS

There are several limitations to this study, including multiple providers performing the injections, varying onset of symptoms to treatment, and additional injections after their initial treatment, that were not controlled. In addition, increasing the sample size may be beneficial as well, particularly with the large bone marrow lesions group, which did suggest possible improvement with intraosseous plus intraarticular over the intraarticular, although was not statistically significant in our sample. Limited data availability for this cohort as well as some missing data are other limitations to consider.

CONCLUSION

Treating knee bone marrow lesions with intraosseous bone marrow concentrate and platelet products did not affect patient reported outcomes.

Weight loss exclusively through diet for knee osteoarthritis

INTRODUCTION

Knee osteoarthritis is a highly prevalent chronic disease, associated with various risk factors and with multiple treatment options. Overweight is among the main risk factors and also constitutes an aggravating factor of the symptoms. It has been suggested that weight loss would be able to improve symptoms and to stop the progression. It can be achieved by several methods: exercise, diet, drugs, surgery, or a combination of them. Apparently, diet is a reasonable option given its availability, low technical complexity and greater acceptability, especially in the population susceptible to developing knee osteoarthritis, but it is not clear whether the benefit of diet as the only intervention leads to symptomatic improvement.

METHODS

We searched in Epistemonikos, the largest database of systematic reviews in health, which is maintained by screening multiple information sources, including MEDLINE, EMBASE, Cochrane, among others. We extracted data from the systematic reviews, reanalyzed data of primary studies, conducted a meta-analysis and generated a summary of findings table using the GRADE approach.

RESULTS AND CONCLUSIONS

We identified seven systematic reviews including six primary studies overall, all corresponding to randomized trials. We concluded diet may improve functionality and quality of life, with probably minimal or no adverse effects. However, we are uncertain whether diet reduces pain as the certainty of the evidence has been assessed as very low.

Dynamics of biochemical markers of connective tissue metabolism in patients with knee osteoarthritis during conservative treatment with laser therapy

OBJECTIVE

Introduction: The biochemical markers of the connective tissue metabolism in blood serum may characterize the disturbances in inflammatory, destructive processes, and also serve the criteria for diagnostic evaluation of the state of cartilage and bone tissue of the joints in knee osteoarthritis to control the effectiveness of conservative treatment. The aim: determination of biochemical markers of connective tissue metabolism in the blood of patients with the 1st and 2nd stages of knee osteoarthritis in order to prove the effectiveness of the complex conservative treatment of patients with the use of low-intensity infrared laser radiation.

PATIENTS AND METHODS

Materials and methods: During the study we examined 80 patients with the 1st and 2nd stages of knee osteoarthritis according to the Kellgren and Lawrence classification. Some patients were prescribed diclofenac sodium and glucosamine hydrochloride, others were prescribed an additional course of laser therapy.

RESULTS

Results: At the end of the treatment the group of patients with knee osteoarthritis who were treated with the use of laser therapy, diclofenac sodium and glucosamine hydrochloride, showed a decrease in the content of the following blood serum components: glycoproteins (by 28.9 %), sialic acids (by 28.8 %), chondroitinsulfates (by 91.3 %) due to chondroitin-6-sulfate, activity of alkaline phosphatase (by 36.1 %) compared with the indicators before treatment.

CONCLUSION

Conclusions: a more significant decrease in the inflammation and destruction of the cartilage tissue of the affected joints was observed during knee osteoarthritis treatment with the use of laser therapy than without it.