Saline washout for knee osteoarthritis: results of a controlled study

Evaluation of placebo fidelity and trial design methodology in placebo-controlled surgical trials of musculoskeletal conditions: a systematic review

ABSTRACT

The number of placebo surgical trials on musculoskeletal conditions is increasing, but little is known about the quality of their design and methods. This review aimed to (1) assess the level of placebo fidelity (ie, degree to which the placebo control mimicked the index procedure) in placebo trials of musculoskeletal surgery, (2) describe the trials' methodological features using the adapted Applying Surgical Placebo in Randomised Evaluations (ASPIRE) checklist, and (3) describe each trial's characteristics. We searched 4 electronic databases from inception until February 18, 2021, for randomised trials of surgery that included a placebo control for any musculoskeletal condition. Protocols and full text were used to assess placebo fidelity (categorised as minimal, low, or high fidelity). The adapted 26-item ASPIRE checklist was also completed on each trial. PROSPERO registration number: CRD42021202131. A total of 30,697 studies were identified in the search, and 22 placebo-controlled surgical trials of 2045 patients included. Thirteen trials (59%) included a high-fidelity placebo control, 7 (32%) used low fidelity, and 2 (9%) minimal fidelity. According to the ASPIRE checklist, included trials had good reporting of the "rationale and ethics" (68% overall) and "design" sections (42%), but few provided enough information on the "conduct" (13%) and "interpretation and translation" (11%) of the placebo trials. Most trials sufficiently reported their rationale and ethics, but interpretation and translation are areas for improvement, including greater stakeholder involvement. Most trials used a high-fidelity placebo procedure suggesting an emphasis on blinding and controlling for nonspecific effects.

Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop

BACKGROUND

The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges.

OBJECTIVES

To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials.

DESIGN

To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout.

SETTING

A workshop to discuss and summarise the existing knowledge and to develop the new guidelines.

RESULTS

To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect.

CONCLUSIONS

The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial.

LIMITATIONS

Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS.

FUTURE WORK

Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space.

FUNDING

Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.

Long-Term Effectiveness of Polymerized-Type I Collagen Intra-Articular Injections in Patients with Symptomatic Knee Osteoarthritis: Clinical and Radiographic Evaluation in a Cohort Study

Objective

Polymerized-type I collagen (polymerized-collagen) is a downregulator of inflammation and a tissue regenerator. The aim was to evaluate the effect of intra-articular injections (IAIs) of polymerized-collagen among patients with symptomatic knee osteoarthritis (OA) in delaying or preventing joint replacement surgery. Patients and Methods. This was a cohort study of 309 patients with knee OA. Patients with mild-to-moderate disease were treated weekly with IAIs of 2 mL of polymerized-collagen for six weeks (n = 309). Follow-up was for 6–60 months. The primary endpoints included the following determinations: (1) therapeutic effect; (2) survival from total knee replacement surgery (TKR); (3) Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and pain (visual analogue scale, VAS). Clinical improvement was defined as a decrease in pain exceeding 20 mm on the VAS and the achievement of at least 20% improvement from baseline with respect to the WOMAC score. Radiographic analysis was performed at baseline and 60 months. The joint space width in the medial, lateral, and patellofemoral compartments was calculated.

Results

Patients who received IAIs of polymerized-collagen had a statistically significant improvement in the primary criteria (p < 0.05). Kaplan–Meier survival analysis of the therapeutic effect demonstrated 98.8% survival at 60 months with TKR as the endpoint. There was no significant reduction in joint space in any compartment based on the analyzed radiographs. No serious adverse events were recorded.

Conclusion

Polymerized-collagen increased the time to TKR by at least 60 months, modifying the disease course, improving functional disability, and decreasing pain.

Surgical interventions for symptomatic mild to moderate knee osteoarthritis

BACKGROUND

Osteoarthritis affecting the knee is common and represents a continuum of disease from early cartilage thinning to full-thickness cartilage loss, bony erosion, and deformity. Many studies do not stratify their results based on the severity of the disease at baseline or recruitment.

OBJECTIVES

To assess the benefits and harms of surgical intervention for the management of symptomatic mild to moderate knee osteoarthritis defined as knee pain and radiographic evidence of non-end stage osteoarthritis (Kellgren-Lawrence grade 1, 2, 3 or equivalent on MRI/arthroscopy). Outcomes of interest included pain, function, radiographic progression, quality of life, short-term serious adverse events, re-operation rates and withdrawals due to adverse events.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and Embase up to May 2018. We also conducted searches of ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for ongoing trials. Authors of trials were contacted if some but not all their participants appeared to fit our inclusion criteria.

SELECTION CRITERIA

We included randomised controlled trials that compared surgery to non-surgical interventions (including sham and placebo control groups, exercise or physiotherapy, and analgesic or other medication), injectable therapies, and trials that compared one type of surgical intervention to another surgical intervention in people with symptomatic mild to moderate knee osteoarthritis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials and extracted data using standardised forms. We analysed the quality of evidence using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach.

MAIN RESULTS

A total of five studies involving 566 participants were identified as eligible for this review. Single studies compared arthroscopic partial meniscectomy to physical therapy (320 participants), arthroscopic surgery (debridement ± synovectomy ± chondroplasty) to closed needle joint lavage with saline (32 participants) and high tibial osteotomy surgery to knee joint distraction surgery (62 participants). Two studies (152 participants) compared arthroscopic surgery (washout ± debridement; debridement) to a hyaluronic acid injection. Only one study was at low risk of selection bias, and due to the difficulty of blinding participants to their treatment, all studies were at risk of performance and detection bias.Reporting of results in this summary has been restricted to the primary comparison: surgical intervention versus non-surgical intervention.A single study, included 320 participants with symptoms consistent with meniscal tear. All subjects had the meniscal tear confirmed on knee MRI and radiographic evidence of mild to moderate osteoarthritis (osteophytes, cartilage defect or joint space narrowing). Patients with severe osteoarthritis (KL grade 4) were excluded. The study compared arthroscopic partial meniscectomy and physical therapy to physical therapy alone (a six-week individualised progressive home exercise program). This study was at low risk of selection bias and outcome reporting biases, but was susceptible to performance and detection biases. A high rate of cross-over (30.2%) occurred from the physical therapy group to the arthroscopic group.Low-quality evidence suggests there may be little difference in pain and function at 12 months follow-up in people who have arthroscopic partial meniscectomy and those who have physical therapy. Evidence was downgraded to low quality due to risk of bias and imprecision.Mean pain was 19.3 points on a 0 to 100 point KOOS pain scale with physical therapy at 12 months follow-up and was 0.2 points better with surgery (95% confidence interval (CI) 4.05 better to 3.65 points worse with surgery, an absolute improvement of 0.2% (95% CI 4% better to 4% worse) and relative improvement 0.4% (95% CI 9% better to 8% worse) (low quality evidence). Mean function was 14.5 on a 0 to 100 point KOOS function scale with physical therapy at 12 months follow-up and 0.8 points better with surgery (95% CI 4.3 better to 2.7 worse); 0.8% absolute improvement (95% CI 4% better to 3% worse) and 2.1% relative improvement (95% CI 11% better to 7% worse) (low quality evidence).Radiographic structural osteoarthritis progression and quality of life outcomes were not reported.Due to very low quality evidence, we are uncertain if surgery is associated with an increased risk of serious adverse events, incidence of total knee replacement or withdrawal rates. Evidence was downgraded twice due to very low event rates, and once for risk of bias.At 12 months, the surgery group had a total of three serious adverse events including fatal pulmonary embolism, myocardial infarction and hypoxaemia. The physical therapy alone group had two serious adverse events including sudden death and stroke (Peto OR 1.58, 95% CI 0.27 to 9.21); 1% more events with surgery (95% CI 2% less to 3% more) and 58% relative change (95% CI 73% less to 821% more). One participant in each group withdrew due to adverse events.Two of 164 participants (1.2%) in the physical therapy group and three of 156 in the surgery group underwent conversion to total knee replacement within 12 months (Peto OR 1.76, 95% CI 0.43 to 7.13); 1% more events with surgery (95% CI 2% less to 5% more); 76% relative change (95% CI 57% less to 613% more).

AUTHORS' CONCLUSIONS

The review found no placebo-or sham-controlled trials of surgery in participants with symptomatic mild to moderate knee osteoarthritis. There was low quality evidence that there may be no evidence of a difference between arthroscopic partial meniscectomy surgery and a home exercise program for the treatment of this condition. Similarly, low-quality evidence from a few small trials indicates there may not be any benefit of arthroscopic surgery over other non-surgical treatments including saline irrigation and hyaluronic acid injection, or one type of surgery over another. We are uncertain of the risk of adverse events or of progressing to total knee replacement due to very small event rates. Thus, there is uncertainty around the current evidence to support or oppose the use of surgery in mild to moderate knee osteoarthritis. As no benefit has been demonstrated from the low quality trials included in this review, it is possible that future higher quality trials for these surgical interventions may not contradict these results.

Use of Saline as a Placebo in Intra-articular Injections in Osteoarthritis: Potential Contributions to Nociceptive Pain Relief

Background:

Osteoarthritis of the knee (OAK) is a severe debilitating condition characterized by joint pain, stiffness, and resultant limited mobility. In recent years, intra-articular (IA) injections have been used to relieve symptoms and have succeeded to varying degrees either with sodium hyaluronate preparations or with a biologic.

Objective:

The objective of this review is to evaluate multiple studies that demonstrate some relief from the symptoms of OAK in the saline arm of various clinical trials.

Method:

A thorough literature search (PubMed) was performed assessing the pain efficacy of various compounds compared to saline injections in clinical trials. A total of 73 studies were identified in the literature search including a total of 5,816 patients. These clinical trials all involved the IA injection of a viscosupplement (hyaluronate, platelet rich plasma (PRP), etc.) or a biologic (the low molecular weight fraction (< 5kDa) of human serum albumin (LMWF-5A)). For all of these studies, the control arm was injection of sterile physiological saline that approximates the salt concentration and total solute concentration of blood and most tissues.

Results:

Based on our review of the current literature, the tested compounds performed with mixed results when compared to saline injections. Moreover, OAK is a variable disease, with severity measured on the Kellgren and Lawrence (KL) scale where various hyaluronate preparations have a therapeutic effect mostly on KL 2-3 patients while a biologic works best on KL 3-4 patients.

Conclusion:

Since the effect of saline injection is always greater than no treatment, the evaluations of these treatments can be confounded in clinical trials. Therefore, the question of whether there are known therapeutic effects of saline injections might explain these results.

An epidemiologic analysis of clinical practice guidelines for non-arthroplasty treatment of osteoarthritis of the knee

PURPOSE

To analyze the current practice patterns of non-arthroplasty treatment of knee osteoarthritis (OA) and to assess the impact of the American Academy of Orthopaedic Surgeons clinical practice guidelines on the management of OA of the knee, particularly as they relate to the use of arthroscopic treatment.

METHODS

The United Healthcare Database (2004-2009, 11 million patients, 216 million records) was used for the study and was searched using Boolean language for International Classification of Diseases, Ninth Edition, Clinical Modification and Current Procedural Terminology, fourth revision codes. A reference group was defined as patients treated with knee arthroplasty in 2009 and diagnosed with knee OA in the same record. Clinical practice patterns in the 5 years preceding arthroplasty were analyzed in this group.

RESULTS

The reference group consisted of 12,806 patients undergoing total knee arthroplasty in 2009 with a documented diagnosis of OA at the time of surgery, with prior nonoperative treatment strategies analyzed during the preceding 5 years (2004-2009); 10.0% of patients were prescribed physical therapy specific to OA, 2.6% received an unloader brace, 0.52% underwent acupuncture, 43.5% were administered intra-articular corticosteroids, and 15.4% received viscosupplementation injections. During the 5 years before arthroplasty, 2,505 patients (19.6%) underwent arthroscopy and debridement/lavage, 35% of whom did not have a diagnosis code for mechanical pathology. Within 1 year of knee arthroplasty, 2,028 of the 2,505 knee arthroscopies (80.9%) were performed.

CONCLUSIONS

The findings show that significant gaps do exist between the evidence-based American Academy of Orthopaedic Surgeons recommendations and actual practice patterns in the United States between 2004 and 2009.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

A review of the treatment methods for cartilage defects

The purpose of this article is to provide a broad review of the literature related to the treatment of cartilage defects and degenerated cartilage in animals with some inferences to the treatment in humans. Methods range from the insertion of osteochondral tissue or cells to the application of radio frequency or insertion of scaffolds and growth factors alone or in combination. Debridement, microfracture, radio frequency, and chondrocyte implantation are all methods normally utilized when treating smaller articular cartilage defects. Scaffolds and mosaicplasty are examples of methods to treat larger defects. This review will cover all major treatment methods currently used to treat articular cartilage defects.

Joint lavage for osteoarthritis of the knee

BACKGROUND

Osteoarthritis is the most common form of joint disorder and a leading cause of pain and physical disability. Observational studies suggested a benefit for joint lavage, but recent, sham-controlled trials yielded conflicting results, suggesting joint lavage not to be effective.

OBJECTIVES

To compare joint lavage with sham intervention, placebo or non-intervention control in terms of effects on pain, function and safety outcomes in patients with knee osteoarthritis.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, and CINAHL up to 3 August 2009, checked conference proceedings, reference lists, and contacted authors.

SELECTION CRITERIA

We included studies if they were randomised or quasi-randomised trials that compared arthroscopic and non-arthroscopic joint lavage with a control intervention in patients with osteoarthritis of the knee. We did not apply any language restrictions.

DATA COLLECTION AND ANALYSIS

Two independent review authors extracted data using standardised forms. We contacted investigators to obtain missing outcome information. We calculated standardised mean differences (SMDs) for pain and function, and risk ratios for safety outcomes. We combined trials using inverse-variance random-effects meta-analysis.

MAIN RESULTS

We included seven trials with 567 patients. Three trials examined arthroscopic joint lavage, two non-arthroscopic joint lavage and two tidal irrigation. The methodological quality and the quality of reporting was poor and we identified a moderate to large degree of heterogeneity among the trials (I(2) = 65%). We found little evidence for a benefit of joint lavage in terms of pain relief at three months (SMD -0.11, 95% CI -0.42 to 0.21), corresponding to a difference in pain scores between joint lavage and control of 0.3 cm on a 10-cm visual analogue scale (VAS). Results for improvement in function at three months were similar (SMD -0.10, 95% CI -0.30 to 0.11), corresponding to a difference in function scores between joint lavage and control of 0.2 cm on a WOMAC disability sub-scale from 0 to 10. For pain, estimates of effect sizes varied to some degree depending on the type of lavage, but this variation was likely to be explained by differences in the credibility of control interventions: trials using sham interventions to closely mimic the process of joint lavage showed a null-effect. Reporting on adverse events and drop out rates was unsatisfactory, and we were unable to draw conclusions for these secondary outcomes.

AUTHORS' CONCLUSIONS

Joint lavage does not result in a relevant benefit for patients with knee osteoarthritis in terms of pain relief or improvement of function.

Efficacy of joint lavage in knee osteoarthritis: meta-analysis of randomized controlled studies

OBJECTIVE

Regarding the efficacy of joint lavage in the treatment of knee OA, we evaluated reports of randomized controlled trials (RCTs) to assess the efficacy of joint lavage alone or joint lavage combined with IA steroid injection to alleviate pain and improve function in knee OA.

METHODS

We searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials for all reports published since 1966 of RCTs, evaluating either the efficacy of joint lavage alone or of joint lavage combined with steroid injection for knee OA on pain intensity and physical function. The time point for evaluation was a priori fixed at 3 months. Effect size (ES) was calculated to compare results across studies.

RESULTS

From the 49 articles identified, reports of six RCTs were analysed for a total of 855 OA patients (511 in the treatment group and 344 in the control group). The pooled ES of the joint lavage vs placebo was not significant for pain intensity [ES = 0.17 (-0.37, 0.71)] or physical function [ES = -0.15 (-0.34, 0.04)], nor was the pooled ES of joint lavage combined with steroid injection vs joint lavage alone significant for pain intensity [ES = -0.82 (-2.47, 0.82)] or physical function [ES = 0.09 (-0.28, 0.45)].

CONCLUSIONS

This meta-analysis of RCTs investigating joint lavage for knee OA suggests that at 3 months, (i) joint lavage alone does not provide significant improvement in pain or function and (ii) the combination of joint lavage and IA steroid injection is no more efficacious than lavage alone.

[Assessing the efficacy of non-arthroscopic joint lavage in patients with osteoarthritis of the knee]

OBJECTIVE

To evaluate the efficacy of joint lavage in patients with osteoarthritis of the knee.

DESIGN

We conducted an open prospective study involving 111 patients of whom 77% were females. The patients' age range was 43-81 years and the average age 64±8.7 years. All patients had gonarthrosis as diagnosed according to the (ACR) American College of Rheumatology criteria (Kellgren radiographic grades II and III). Patients were randomly distributed between two treatment groups: a) Joint lavage without non-steroidal anti-inflammatory drugs (NAJL, n=57), and b) non-steroidal anti-inflammatory drugs alone (NSAIDs, n=54). Evaluations were done at baseline and one, three, and six months after enrollment. Clinical and demographic variables, and WOMAC index scores, were recorded and patient improvement was determined by following the OARSI guidelines. Statistical analyses included chi-square, analysis of covariance (baseline WOMAC) with one between-subject factor (treatment). Post-hoc comparisons were made with Sidak's adjustment.

RESULTS

The respective improvement rates as measured by the OARSI index for the patients in the JL and NSAIDs groups were 50.9 and 31.5% at 1 month; 55.4 and 38.9% at three months; and 63.2 and 64.8% at six months. The patients in both groups were seen to improve from the first month (P=.038). At the end of the six-month follow-up period, the WOMAC score had decreased significantly in both groups (P=.000), with no significant differences between them.

CONCLUSIONS

Six months after treatment, joint lavage proved as effective as NSAIDs in patients with gonarthrosis, so it constitutes an effective therapeutic choice in those cases where NSAIDs are contraindicated.

Treatment of osteoarthritis of the knee (nonarthroplasty)

The clinical practice guideline was explicitly developed to include only treatments less invasive than knee replacement (ie, arthroplasty). Patients with symptomatic osteoarthritis of the knee are to be encouraged to participate in self-management educational programs and to engage in self-care, as well as to lose weight and engage in exercise and quadriceps strengthening. The guideline recommends taping for short-term relief of pain as well as analgesics and intra-articular corticosteroids, but not glucosamine and/or chondroitin. Patients need not undergo needle lavage or arthroscopy with débridement or lavage. Patients may consider partial meniscectomy or loose body removal or realignment osteotomy, as conditions warrant. Use of a free-floating interpositional device should not be considered for symptomatic unicompartmental osteoarthritis of the knee. Lateral heel wedges should not be prescribed for patients with symptomatic medial compartmental osteoarthritis of the knee. The work group was unable either to recommend or not recommend the use of braces with either valgus- or varus-directing forces for patients with medial unicompartmental osteoarthritis; the use of acupuncture or of hyaluronic acid; or osteotomy of the tibial tubercle for isolated symptomatic patellofemoral osteoarthritis.

Assessment of the efficacy of joint lavage in rabbits with osteoarthritis of the knee

We investigated the efficacy of joint lavage to alter the progression of the disease process in a rabbit model of knee OA in varying stages of the disease. Thirty-three white rabbits were operated to induce OA, and then the rabbits were divided into three groups (10 in each) randomly. In group 1, on week 1 after the operation, joint lavage was performed on both knees in five rabbits as treatment group, and the other five rabbits were used as control group received no intervention. By the end of week 2 after operation, the rabbits were sacrificed. In group 2, five received joint lavage on week 2, and all were sacrificed on week 3. In group3, five received joint lavage on week 3, and all were sacrificed on week 4. In each group, histological evaluation showed that both the breakdown of articular cartilage and the inflammation of synovium were less in the knees treated with joint lavage than that in the control knees. The enzyme-linked immunosorbent assay revealed that the expression of IL-1beta and TNF-alpha in synovial fluid decreased significantly in the treatment group. Our findings suggested that joint lavage was beneficial for OA at different phases of OA in rabbit models. Joint lavage may be a beneficial method for the treatment of OA clinically.

The Use of Arthroscopy in the Athlete with Knee Osteoarthritis

Arthroscopy is an important technique in the diagnosis, classification, and treatment of the athlete with osteoarthritis (OA). Reliability of the current classification systems improves with training and experience. Arthroscopy remains superior to imaging in the diagnosis of OA. Arthroscopic lavage and debridement provide benefit in a significant percentage of patients. The reasons for improvement are not fully defined. Arthroscopic treatment of OA is not curative, and results deteriorate with time. Variability in the use of medical management, arthroscopy, osteotomy, and arthroplasty remains among different practitioners. Indications for arthroscopy require further clarification based upon empiric evidence.

Joint lavage for treating recurrent knee involvement in patients with juvenile idiopathic arthritis

OBJECTIVE

To retrospectively evaluate the benefits of knee joint lavage with intraarticular glucocorticoid injection in patients who have juvenile idiopathic arthritis with knee involvement unresponsive to repeated intraarticular glucocorticoid injections.

PATIENTS

Seventeen knees in 10 children (eight girls and two boys) were treated from 1997 to 2000. Mean age was 14 years 9 months and mean disease duration was 7.2 years. The diagnoses were juvenile oligoarthritis (n = 6, including two with extended disease), systemic arthritis (n = 2), juvenile spondyloarthropathy (n = 1), and juvenile dermatomyositis (n = 1). Repeated intraarticular triamcinolone hexacetonide injections had been performed in all the patients, the mean number of injections being 2.2 per patient within the last 30 months. Plain radiographs were normal in six of the eight patients. Mean erythrocyte sedimentation rate was 21.7 mm/h and mean C-reactive protein level was 20.6 mg/l. Joint fluid was obtained from 10 knees and had a mean cell count of 12?660 mm(-3). Second-line therapy was with methotrexate alone or combined with cyclosporine or azathioprine. Oral glucocorticoids and/or nonsteroidal antiinflammatory drugs were used for symptom relief. TREATMENT PROCEDURE: Lavage was performed under strict aseptic conditions with simple analgesia, on a day-hospital basis. After aspiration of the joint, lavage was performed with saline, and a delayed-action glucocorticoid was injected. The knee joint was immobilized in the extended position for 48 h. Efficacy criteria were presence of effusion, presence of pain, and presence of a systemic treatment-sparing effect.

RESULTS

Freedom from effusion and pain was noted in all 17 knees after 1 month, in eight (47%) knees after 6 months, and in seven (41%) knees after 12 months. The patients with the longest lasting improvements had systemic polyarthritis. After joint lavage, second-line treatment was reduced in two patients and oral glucocorticoid therapy was stopped in two others. None of the variables studied (age, sex, disease duration, inflammatory syndrome, or joint fluid cytology) predicted a good response. No adverse effects were recorded.

CONCLUSION

These preliminary results show that joint lavage with glucocorticoid injection is safe in children. The improvements were modest, but the patients had a history of arthritis refractory to multiple triamcinolone hexacetonide injections. Thus, joint lavage may have a place in the treatment pyramid just before synovectomy.

Traumatic haemarthrosis of the knee

BACKGROUND

Haemarthrosis of the knee after trauma is a common problem often seen in accident and emergency departments.

OBJECTIVE

: To evaluate the injuries sustained after haemarthrosis of the knee in a relatively young population, and to assess the need for performing cultures on aspirated blood.

PATIENTS AND METHODS

The notes of 510 patients who were seen at the accident and emergency department of the Alexandra Hospital, Redditch, between 1990 and 1999 were retrospectively studied. The age, sex, mechanism of injury, final diagnosis and management were recorded. The exact diagnosis was confirmed by a magnetic resonance imaging scan or arthroscopy findings. All the patients had their knee aspirate cultured, and the reports on the culture of aspirated blood were obtained from the department of pathology.

RESULTS

A fall was the major cause of haemarthrosis in 52%, followed by sports injury in 38%. The medical records of all 510 patients were reviewed. All patients' follow-up records were seen, most patients were followed up in the orthopaedic outpatient clinic and some in the accident and emergency follow-up clinic, all attended at least three or more clinics before discharge.

CONCLUSION

Culture of the aspirate of all patients was felt to be a waste of time and money. Nearly 40% of cases were thought to be idiopathic and settled conservatively without intervention.

Intra-articular therapy in osteoarthritis

The medical literature was reviewed from 1968-2002 using Medline and the key words "intra-articular" and "osteoarthritis" to determine the various intra-articular therapies used in the treatment of osteoarthritis. Corticosteroids and hyaluronic acid are the most frequently used intra-articular therapies in osteoarthritis. Other intra-articular substances such as orgotein, radiation synovectomy, dextrose prolotherapy, silicone, saline lavage, saline injection without lavage, analgesic agents, non-steroidal anti-inflammatory drugs, glucosamine, somatostatin, sodium pentosan polysulfate, chloroquine, mucopolysaccharide polysulfuric acid ester, lactic acid solution, and thiotepa cytostatica have been investigated as potentially therapeutic in the treatment of arthritic joints. Despite the lack of strong, convincing, and reproducible evidence that any of the intra-articular therapies significantly alters the progression of osteoarthritis, corticosteroids and hyaluronic acid are widely used in patients who have failed other therapeutic modalities for lack of efficacy or toxicity. As a practical approach for a knee with effusion, steroid injections should be considered while the presence of symptomatic "dry" knees may favour the hyaluronic acid approach. The virtual absence of serious side effects, coupled with the perceived benefits, make these approaches attractive.

Joint irrigation as treatment for osteoarthritis

Irrigation is necessary to achieve distension and visualization of the joint during arthroscopy. Clinical improvement observed after diagnostic arthroscopy has been attributed to irrigation, and this is supported by sound pathophysiologic rationales. Studies have been performed using various irrigation techniques with and without concomitant arthroscopy. Unblinded studies have generally yielded favorable results, although recent blinded studies have demonstrated a substantial and durable placebo effect, but little support for the benefit of the irrigation procedure.

Arthroscopic management of osteoarthritis of the knee

Recent advances in instrumentation and a growing understanding of the pathophysiology of osteoarthritis have led to increased use of arthroscopy for the management of degenerative arthritis of the knee. Techniques include lavage and débridement, abrasion arthroplasty, subchondral penetration procedures (drilling and microfracture), and laser/thermal chondroplasty. In most patients, short-term symptomatic relief can be expected with arthroscopic lavage and débridement. Greater symptomatic relief and more persistent pain relief can be achieved in patients who have acute onset of pain, mechanical disturbances from cartilage or meniscal fragments, normal lower extremity alignment, and minimal radiographic evidence of degenerative disease. Arthroscopic chondroplasty techniques provide unpredictable results. Concerns include the durability of the fibrocartilage repair tissue in subchondral penetration procedures and thermal damage to subchondral bone and adjacent normal articular cartilage in laser/thermal chondroplasty. Although recent prospective, randomized, double-blinded studies have demonstrated that outcomes after arthroscopic lavage or débridement were no better than placebo procedure for knee osteoarthritis, controversy still exists. With proper selection, patients with early degenerative arthritis and mechanical symptoms of locking or catching can benefit from arthroscopic surgery.

Tidal irrigation as treatment for knee osteoarthritis: a sham-controlled, randomized, double-blinded evaluation

OBJECTIVE

To evaluate the effectiveness of tidal irrigation (TI) in comparison with a well-matched sham irrigation (SI) procedure as a treatment for knee osteoarthritis (OA).

METHODS

One hundred eighty subjects with knee OA were randomized to receive TI or SI, with clinical followup over the ensuing 12 months. The primary outcomes of interest were change in pain and function, as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Subjects and the nurse assessor were blinded, and success of blinding was assessed.

RESULTS

Although the study groups were otherwise comparable, the baseline WOMAC pain and physical functioning scores were higher (worse) in the SI group. After adjustment for baseline, there were no differences between the effects of

Effects of joint lavage and steroid injection in patients with osteoarthritis of the knee: results of a multicenter, randomized, controlled trial

OBJECTIVE

To evaluate the efficacy of joint lavage and intraarticular steroid injection, alone and in combination, in the treatment of patients with symptomatic knee osteoarthritis (OA).

METHODS

Ninety-eight patients with painful tibiofemoral OA were enrolled in a prospective, randomized, controlled, 2 x 2 factorial-design trial of 6 months' duration. The 4 treatment groups consisted of 1) intraarticular placebo (1.5 ml of 0.9% normal saline), 2) intraarticular corticosteroids (3.75 mg of cortivazol in 1.5 ml), 3) joint lavage and intraarticular placebo, and 4) joint lavage and intraarticular corticosteroid. Outcome measures evaluated at baseline, week 1, week 4, week 12, and week 24 included severity of pain (100-mm visual analog scale [VAS]), global status (100-mm VAS), and Lequesne's functional index.

RESULTS

No interaction between steroid injection and joint lavage was demonstrated. Patients who had undergone joint lavage had significantly improved pain VAS scores at week 24 (P = 0.020). In contrast, corticosteroid injection had no long-term effect (P = 0.313); corticosteroid injection was associated with a decrease in pain only at week 1 (P = 0.003) and week 4 (P = 0.020). After week 4, Lequesne's functional index was not significantly improved regardless of the assigned treatment.

CONCLUSION

Compared with placebo, both treatments significantly relieved pain but did not improve functional impairment. The effects of the 2 treatments were additive. Cortivazol provided short-term relief of pain (up to week 4). The effects of joint lavage persisted up to week 24.

Nonpharmacological approaches to pain in osteoarthritis. Available options

Many treatments or techniques have been developed to combat pain in osteoarthritis. These can reduce drug consumption and toxicity, or even delay the need for joint replacement surgery. Pain management in osteoarthritis should start with education, psychological support and environmental measures, reassuring patients that such pain is a reversible state, not associated with aging and irreversible loss of ability. Physiotherapy and exercises are very important for maintaining muscle strength, joint stability and mobility, but should be closely monitored for optimal efficacy. Splints and weight reduction in the obese are useful, depending on the joints involved. Preventive surgery such as cruciate ligament repair or osteotomy should be considered for cases with moderate osteoarthritis. Intraarticular lavage is effective in the short term, and the effectiveness is increased with the use of an arthroscope when meniscus tears or cartilage fragments are associated with osteoarthritis. Nonconventional therapies such as homeopathy, acupuncture and transcutaneous electrical nerve stimulation can be tried at all stages; even if not really efficient, most of these techniques are usually innocuous. Doctors should be aware of these neglected techniques for a better, well tolerated and cost-effective management of pain associated with osteoarthritis.

Intraarticular injections of hyaluronan in patients with cartilage abnormalities and knee pain. A one-year double-blind, placebo-controlled study

OBJECTIVE

To compare the effect of intraarticular injections of hyaluronan and placebo (vehicle, saline) in patients with knee pain on exertion and with joint cartilage abnormalities.

METHODS

Fifty-two patients with arthroscopically verified deep cartilage fissures and villus-like flakes in the symptomatic knee were randomly assigned to receive intraarticular injections of 2.5 ml of either hyaluronan or vehicle, weekly for 5 weeks. The effect was evaluated by both primary and secondary parameters of efficacy at 2, 4, 13, 26, and 52 weeks.

RESULTS

At the followup visits, both groups had improvement from baseline; however, there was no difference between the groups in any of the relevant variables at any time point.

CONCLUSION

The effects of intraarticular hyaluronan do not differ significantly from those of placebo in patients with knee pain and cartilage disease.

Chondroscopy: a new method for scoring chondropathy

The purpose of this study was to evaluate the performance (simplicity, reproducibility, relevance) of chondroscopy as a method for evaluating cartilage damage. Chondroscopy consisted in endoscopic evaluation of the knee using a 2.7-mm Storz arthroscope under local anesthesia and recorded on videotape. Scoring of chondropathy was based on physician's overall assessment using a 100-mm-length visual analogue scale (VAS) and size and grade of cartilage lesions. Reproducibility was evaluated by variability (coefficient of variation [CV]) in the reading of chondroscopic evaluations of five patients five times by one physician and one time each by four different physicians. The correlations between scoring of chondropathy (VAS) and radiological articular joint space narrowing, demographic data (sex, age, weight), and disease characteristics (localization, etiology, activity) were studied in 84 outpatients fulfilling the American College of Rheumatology criteria for the diagnosis of osteoarthritis of the knee. The grade and size of the lesions were both correlated with the physician's overall assessment (r = 0.713 and r = 0.816, respectively). These two variables accounted for 72% of the variance of the VAS (multiple regression analysis). Intraobserver reproducibility was better than interobserver reproducibility (CV, 9% and 37%, respectively). There was a strong correlation between the scoring of chondropathy (VAS) and radiological joint space narrowing (r = .646, P < .0001). Moreover, in 17 of 33 patients without radiological joint space narrowing, VAS was > 20 mm. At variance, the body mass index was the single clinical variable found to correlate with the scoring of chondropathy (r = .282, P < .001).(ABSTRACT TRUNCATED AT 250 WORDS)