Viscosupplementation in the management of ankle osteoarthritis: a review

Concerns beyond ankle symptoms predominate healthcare professionals' views of patients with ankle osteoarthritis: A qualitative study

OBJECTIVES

Explore healthcare professionals' perspectives on the main problems that their patients with ankle osteoarthritis experience and to propose health-related domains.

METHODS

A qualitative study using semi-structured interviews was conducted with an international multidisciplinary group of healthcare professionals identified as ankle experts. Eligibility criteria were aged ≥18 years, and a certified healthcare professional with ≥ 5-year experience post-qualification in working with ankle osteoarthritis and/or chronic ankle pain. Interviews were recorded, transcribed verbatim and thematically analysed.

RESULTS

Twenty-one healthcare professionals (20 males; mean (range) age 49 (34-72) years) from four professions (orthopaedic surgeons (n = 9), athletic trainers (n = 5), physiotherapists (n = 4) and podiatrists (n = 3)) were interviewed. Four main themes were identified: 1) people with ankle osteoarthritis have difficulty with weight-bearing activities; 2) symptoms of pain and stiffness predominate, alongside swelling, instability, weakness and poor balance; 3) chronic pain in ankle osteoarthritis has psychosocial consequences; and 4) the loss of activities of daily living and independence compromises quality of life. We proposed 15 health-related domains that emerge from the interview data.

CONCLUSION

Healthcare professionals recognise that ankle osteoarthritis patients have difficulty in physical, sporting, and occupational weight-bearing activities, and they live with persistent ankle pain, stiffness and other symptoms that have physical and psychosocial consequences. The health-related domains derived from interviews with expert healthcare professionals will contribute to the development of a core domain set for ankle osteoarthritis.

Overview of Ankle Arthropathy in Hereditary Hemochromatosis

Hereditary hemochromatosis (HH) is an autosomal recessive bleeding disorder characterized by tissue overload of iron. Clinical systemic manifestations in HH include liver disease, cardiomyopathy, skin pigmentation, diabetes mellitus, erectile dysfunction, hypothyroidism, and arthropathy. Arthropathy with joint pain is frequently reported at diagnosis and mainly involves the metacarpophalangeal and ankle joints, and more rarely, the hip and knee. Symptoms in ankle joints are in most cases non-specific, and they can range from pain and swelling of the ankle to deformities and joint destruction. Furthermore, the main radiological signs do not differ from those of primary osteoarthritis (OA). Limited data are available in the literature regarding treatment; surgery seems to be the gold standard for ankle arthropathy in HH. Pharmacological treatments used to maintain iron homeostasis can also be undertaken to prevent the arthropathy, but conclusive data are not yet available. This review aimed to assess the ankle arthropathy in the context of HH, including all its aspects: epidemiology, physiopathology, clinical and imaging presentation, and all the treatments available to the current state of knowledge.

Outcome measures in clinical studies of ankle osteoarthritis: a systematic review

OBJECTIVE

To explore and describe the outcome measures reported in primary research of ankle osteoarthritis (OA) and to propose aligned health-related domains.

METHODS

Six databases were searched, and studies were screened by two independent reviewers. Studies of participants with ankle OA who were> 18 years of age and reported outcome measure data were included. Non-English, animal, cadaveric, reviews, and studies with< 5 participants were excluded. Outcome measures were examined for content and mapped to health-related domains.

RESULTS

1386 studies were identified, of which 547 met selection criteria - reporting 250 outcome measures. Most commonly reported measures were the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Scale (n = 257 studies), plain radiographs to measure ankle alignment (n = 211), numerical rating scale for pain severity (n = 177) and goniometry to measure ankle range of motion (n = 148). Outcome measures were organised into 19 domains. The most common domains were pain severity (315 (58%) studies), ankle alignment (254 (46%)), ankle motion (181 (33%)), disability (169 (31%)) and health-related quality of life (128 (23%)). These domains fell into the Outcome Measures in Rheumatology (OMERACT) core areas of life impact and pathophysiological manifestations.

CONCLUSION

Many outcome measures are used in ankle OA research, most of which assess joint alignment, pain, and motion. Based on the outcome measures identified, we proposed 19 possible health-related domains, predominantly in the OMERACT core areas of life impact and pathophysiological manifestations of ankle OA. Clinicians and researchers can use this review in guiding selection of outcome measures.

Lubricants for osteoarthritis treatment: From natural to bioinspired and alternative strategies

Osteoarthritis is the most common degenerative and highly prevalent joint disease, characterized by progressive loss and destruction of articular cartilage. The damaged cartilage surface has an increased friction, which causes patients to suffer from serious pain. Restoring the lubrication ability of the joint is central to the treatment of osteoarthritis, a key topic in medical research. A variety of lubricants have been designed to reduce friction in joints and promote cartilage tissue repair to alleviate the symptoms of osteoarthritis. Herein, we review the recent progress of lubricants from the three perspectives of natural, bioinspired, and alternative strategies for osteoarthritis treatment, as well as the structural characterization and lubrication properties of such lubricants. Specifically, natural lubricants include glycosaminoglycans, lubricin and lipids in joints, bioinspired lubricants include scaffolds mimicking hyaluronic acid or lubricin, and alternative lubricants include modified lubricants based on hyaluronic acid, lipids, nanoparticles, and peptides. We also discuss the current challenges and long-term perspectives for further research in this area.

Effects and Safety of Intra-Articular Sodium Hyaluronate Injection for the Treatment of Ankle Osteoarthritis: A Prospective Clinical Trial

Various nonoperative treatments have been implemented to reduce pain and improve the quality of life in patients with ankle osteoarthritis. Among these treatments, intra-articular hyaluronate injection has proven efficacy and safety in patients with knee osteoarthritis. The purpose of this study was to evaluate the efficacy and complications of hyaluronate injection using various clinical scoring systems. This study included 37 patients with unilateral ankle osteoarthritis (grade 2 or 3 according to the Takakura classification) who did not respond to previous pharmacological treatment. 3 weekly hyaluronate injections (2 mL Hyruan Plus®) were administered. The efficacy of intra-articular hyaluronate injection was evaluated on the basis of patient-reported foot and ankle clinical assessment at a mean follow-up of 13.8 ± 8.3 (range 6-33) months. Ankle Osteoarthritis Scale scores for pain and disability, American Orthopedic Foot and Ankle Society ankle-hindfoot scores, and visual analog scale for pain significantly improved at the final follow-up compared to that before intra-articular hyaluronate injection (p ≤ .05). When patients were dichotomized according to age, sex, body mass index, symptom duration, and Takakura classification, all these factors were not related to clinical outcomes. This study suggests that 3 weekly intra-articular hyaluronate injections can be performed safely to reduce pain and improve function without serious complications in patients with early or intermediate-grade ankle osteoarthritis when patients inadequately respond to medication. Larger controlled studies are needed to clarify the effects of hyaluronate injection and identify patients who can benefit most from hyaluronate injection.

[Conservative treatment options for arthritis of the ankle : What is possible, what is effective?]

In this article the causes of arthritis in the region of the ankle are introduced and the conservative treatment options are described and discussed more extensively. The risks of treatment with nonopioid analgesics (NOPA) are presented in detail. The topical use of nonsteroidal anti-inflammatory drugs (NSAID) should always be considered in the clinical routine. If contraindications for oral NSAIDs are present, intra-articular treatment is a meaningful option. The best evidence is currently available for viscosupplementation but the study situation for the use of platelet-rich plasma (PRP) is still not sufficiently comprehensive and there are only a few case reports on the use of mesenchymal stem cells..

[The role of arthroscopy in diagnostics and treatment of arthritis of the ankle joint]

The arthroscopic treatment of arthritis of the ankle joint is very limited and is only indicated for early stages of arthritis with impingement, strictly localized forms and more for young patients. The most important aim of arthroscopy is to improve the range of motion (ROM) of the ankle by removal of bony projections (dorsal and ventral) and an extensive synovectomy with debridement. In cases of narrowing of the joint space to less than 2 mm and/or malalignment, the indications for arthroscopy should be considered very cautiously. This is independent of the localization of the narrowing, especially if the complete joint is affected. If necessary, arthroscopy can then be carried out as an additional intervention in cases of conversion osteotomy in order to improve the ROM.

Association of Sports Participation With Osteoarthritis: A Systematic Review and Meta-Analysis

Background:

The association between participating in sport and osteoarthritis is not fully understood.

Purpose:

To investigate the association between osteoarthritis and participating in sports not listed in previous reviews: American football, archery, baseball, bobsleigh, curling, handball, ice hockey, shooting, skeleton, speed skating, and wrestling.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

We searched 4 electronic databases and hand searched recent/in-press editions of relevant journals. The criteria for study selection were case-control studies, cohort studies, nested case-control studies, and randomized trials with a control group that included adults to examine the effect of exposure to any of the included sports on the development of osteoarthritis.

Results:

The search returned 6197 articles after deduplication. Nine studies were included in the final review, covering hip, knee, and ankle osteoarthritis. There were no studies covering archery, baseball, skeleton, speed skating, or curling. The 6 sports included in the review were analyzed as a collective; the results of the meta-analysis indicated that participation in the sports analyzed was associated with an increased risk of developing osteoarthritis of the hip (relative risk [RR] = 1.67 [95% confidence interval (CI), 1.15-2.41]; P = .04), knee (RR = 1.60 [95% CI, 1.23-2.08]; P < .001), and ankle (RR = 7.08 [95% CI, 1.24-40.51]; P = .03) as compared with controls. Meta-analysis suggested a significantly increased likelihood of developing hip osteoarthritis through participating in wrestling (RR = 1.78 [95% CI, 1.20-2.64]; P = .004) and ice hockey (RR = 1.70 [95% CI, 1.27-2.29]; P < .001), while there was no significant difference through participating in handball (RR = 2.50 [95% CI, 0.85-7.36]; P = .10). Likelihood of developing knee osteoarthritis was significantly increased in wrestling (RR = 2.22 [95% CI, 1.59-3.11]) and ice hockey (RR = 1.52 [95% CI, 1.18-1.96]; both P < .002). According to the meta-analysis, shooting did not have a significant effect on the RR of knee osteoarthritis as compared with other sports (RR = 0.43 [95% CI, 0.06-2.99]; P = .39).

Conclusion:

The likelihood of developing hip and knee osteoarthritis was increased for ice hockey and wrestling athletes, and the risk of developing hip osteoarthritis was increased for handball athletes. The study also found that participation in the sports examined, as a collective, resulted in an increased risk of developing hip, knee, and ankle osteoarthritis.

The importance of objectively measuring functional tests in complement to self-report assessments in patients with knee osteoarthritis

BACKGROUND

Osteoarthritis (OA) is a chronic degenerative disease which can result in chronic pain, loss of joint function and consequently decline in quality of life.

RESEARCH QUESTION

A variety of instruments that measure the different dimensions of health status in patients with OA are available. However, despite the fact that WOMAC and other questionnaires and scales may provide additional understanding regarding the patient's condition, some studies have reported discrepancies between patients' perceptions and their actual ability to perform the task. The aim of the present study was investigate the physical capabilities with the function domain of WOMAC.

METHODS

This study has a cross-sectional design including patients diagnosed with moderate to severe knee OA (i.e., grades II, III and IV) according to the Kellgren-Lawrence. These patients were submitted to the battery of functional tests recommended by the OARSI group (30-second chair stand test, 40 m fast paced walking test, Stair climb test, timed "Up and Go", and Six-minute walking test) and filled the WOMAC. Pearson's correlation and multiple linear regression was applied.

RESULTS

A total of 153 patients were included. A significant and weak correlation was observed between WOMAC and the 40-meter walking test, TUG, stair-climbing test, and the 6MWT. In addition, 30-second chair stand test demonstrated a significant and moderate correlation (r=-0.503). The multiple regression analysis results indicated that only 30-second chair stand test was a significant (p = 0.001) predictor of WOMAC. This result remains significant even after adjusting for age, BMI, total muscle mass, and number of knees affected SIGNIFICANCE: The 30-second chair stand test is associated with the WOMAC function domain. There is no correlation of this domain with any other functional tests, emphasizing the importance of including other tests for a global evaluation.

Use of viscosupplementation for the recovery of active football players complaining of knee pain

Objective

The aim of this study is to investigate the effect of intra-articular hyaluronic acid administration in active football players complaining of knee pain after sports activity. Efficacy and safety profiles of intra-articular hyaluronic acid and time needed for football players to recover and restart sports activity were examined.

Methods

Clinical data of active football players reporting knee pain after sports activity were included in this retrospective study. All patients who received an intra-articular injection at time 0 and after 2 weeks were included in the study. Patients underwent laboratory examination, knee X-ray, ultrasound, and clinical examination before receiving the intra-articular injection. Effusions or cysts were drained before injections. Lequesne index score, pain visual analog scale (VAS) score, and patient’s global assessment score were recorded at time 0 (day of the first injection), 1 and 2 days after the first injection, at 2 weeks (day of the second injection), and at follow-up visits. Only data from patients completing the follow-up were analyzed.

Results

Data from 17 patients were analyzed: 16 males and one female, of which three were professional players (two males and one female) and 14 were nonprofessional players. The mean age of patients was 39.8±11.8 years. Two patients (one male and one female) showed joint effusion. Two patients reported relevant joint pain after injection that regressed without any medication. At the first week, all parameters examined indicated improvement that was maintained until the end of follow-up. One day after the first and second injection, patients reported a slight increase in pain VAS score, which was not statistically significant, and the pain resolved after 1 day. All patients successfully restarted playing after the first injection within 3.1±2.0 days and kept playing after the second injection following our indication (1 day of break).

Conclusion

The use of a medium-molecular weight hyaluronic acid in football players affected by knee osteoarthritis seems efficacious and safe and resulted, in our experience, a stable improvement of symptoms; moreover, it allowed a rapid restart of sports activity. Larger studies on larger populations are needed to confirm these findings.

Intra-articular Injections in the Treatment of Symptoms from Ankle Arthritis: A Systematic Review

BACKGROUND

Intra-articular (IA) injections are commonly used to treat knee arthritis pain; however, whether their efficacy generalizes to ankle arthritis remains debatable. We aimed to evaluate the evidence for IA therapies in the management of this patient population.

METHODS

We performed a literature search for observational and randomized controlled trials (RCTs). Treatments included corticosteroids (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and mesenchymal stem cells (MSC). We extracted study details, patient demographics, treatment characteristics, efficacy outcomes, and safety. When feasible, data from RCTs were meta-analyzed using a random-effects model and 95% confidence intervals (CIs) were calculated. A P value <.05 was considered statistically significant.

RESULTS

We identified 27 studies (1085 patients). Ankle OA, rheumatoid arthritis (RA), and hemophilic arthropathy populations were examined. The majority of studies were observational (20 studies); the only RCTs were those evaluating HA. Case series demonstrated favorable results in terms of symptomatic relief with CS, HA, PRP, and MSC injections; however, the effects of CS may only be short term and the evidence on MSCs was limited to 1 study with 6 ankle OA patients. Pooled results (3 RCTs, 109 patients) suggested significantly improved Ankle Osteoarthritis Scale scores with HA over saline at 6 months, with a mean difference of 12.47 points (95% CI 1.18-23.77, P = .03).

CONCLUSION

Evidence from small trials favors HA and PRP injections for the treatment of pain associated with ankle osteoarthritis. However, the relative efficacy of all injectable therapies is far from definitive and warrants further high-quality comparative trials.

LEVEL OF EVIDENCE

Level III, systematic review.

Prospective Evaluation of Intra-Articular Sodium Hyaluronate Injection in the Ankle

Viscosupplementation by injection of hyaluronic acid into the ankle can be used to provide pain relief and to delay the need for surgery in patients with osteoarthritis of the ankle. In the present investigation, we prospectively evaluated 50 consecutive patients (25 males and 25 females) undergoing a 3-injection protocol of sodium hyaluronate viscosupplementation in the ankle from January 2014 to January 2015. The Foot and Ankle Outcomes Score was used to compare the patients' pre- and post-treatment opinions about their ankle problems. The mean pretreatment Foot and Ankle Outcomes Score was 48 ± 6.3 (range 25 to 84) and the 6-month post-treatment score was 78 ± 5.8 (range 48 to 100). This difference was statistically significant (p = .003). From our findings in the present prospective cohort study, we have concluded that intra-articular injection of sodium hyaluronate viscosupplementation is a useful conservative therapy for osteoarthritis of the ankle.

Imaging Guidance Improves the Results of Viscosupplementation with HANOX-M-XL in Patients with Ankle Osteoarthritis: Results of a Clinical Survey in 50 Patients Treated in Daily Practice

BACKGROUND

The objective of this survey was to assess retrospectively the interest of performing viscosupplementation using imaging guidance in patients suffering from ankle osteoarthritis (OA).

PATIENTS AND METHODS

This is a multicenter retrospective survey using a standardized questionnaire. Fifty patients suffering from ankle OA and treated, in daily clinical practice, with a single intra-articular injection of a novel viscosupplement made of a combination of a non-animal cross-linked hyaluronan and mannitol, HANOX M-XL, were included in the survey. The injection procedure (imaging or landmark guidance), demographic data, patient’s self-evaluation of pain, satisfaction, treatment efficacy, and tolerability were collected. Predictive factors of both efficacy and patient’s satisfaction were investigated.

RESULTS

The percentages of patients very satisfied/satisfied and not really satisfied/dissatisfied with the treatment were 68% and 32%, respectively. Efficacy was rated as very good, good, moderate, and poor by 38%, 30%, 12%, and 20% of the cases, respectively. Efficacy was unrelated to gender and age and was highly correlated with pain score (P < 0.0001). In satisfied patients, the decrease in consumption of analgesics/non-steroidal anti-inflammatory drugs was >75% in 64% of the cases. Efficacy was significantly different with regard to imaging guidance. There was a statistically significant difference in efficacy and satisfaction between landmark-guided and imaging-guided injections (P = 0.02). The success rate was 2.3 times higher in the imaging-guided group than in the landmark-guided group. No significant difference was found between patients injected under fluoroscopy or ultrasound guidance, despite a trend favoring ultrasound (P = 0.09). Tolerability was rated as very good/good in 47 patients, moderate in two, and poor in one and was unrelated to the type of guidance.

CONCLUSION

This preliminary study suggests that the use of imaging guidance significantly optimizes the success rate of ankle viscosupplementation. No safety concern was observed.

LEVEL OF EVIDENCE

III.

Intra-Articular Injections in Patients with Femoroacetabular Impingement: a Prospective, Randomized, Double-blind, Cross-over Study

We evaluated and compared the effectiveness of intra-articular injection of hip joint using hyaluronic acid and steroid in patients with femoroacetabular impingement (FAI). Thirty patients with FAI clinically and radiologically were enrolled and underwent hip injection using steroid (TA) or hyaluronic acid (HA) at 0-weeks with cross-over injection at 2-weeks in patients without clinical response of decrease of pain intensity less than 2-point. Patients were followed up to 12-weeks for pain intensity (Numeric rating scale, NRS: 0-10), hip disability score (HOOS), oral medication and adverse events. In 17 patients without cross-over, HOOS at 2-weeks was improved significantly in patients with HA injection (mean increase of HOOS = 13.8 with HA vs. -2.2 with TA, P = 0.031) without difference of NRS (P = 0.943). In 13 patients with cross-over, NRS was significantly improved at 2-weeks with first TA injection (mean decrease of NRS= 1.7 with first TA vs. 0.3 with first HA, P = 0.036), without difference of HOOS (P = 0.431). At 4-weeks, NRS and HOOS were significantly different according to injection drugs (NRS: 0.9 with TA first and HA later vs. 2.7 with HA first and TA later, P = 0.001; mean increase of HOOS: 5.3 with TA first and HA later vs. 10.2 with HA first and TA later, P = 0.032). Intra-articular hip injection may be effective in FAI, with faster effect of pain improvement by TA and more delayed effect of function improvement by HA.

VISCOSUPPLEMENTATION IN ANKLE OSTEOARTHRITIS: A SYSTEMATIC REVIEW

To evaluate the efficacy of viscosupplementation in patients with osteoarthritis of the ankle. A systematic review to evaluate the evidence in the literature on the use of viscosupplementation for osteoarthritis of the ankle. For this review, we considered blind randomized prospective studies involving the use of viscosupplementation for osteoarthritis of the ankle. A total of 1,961 articles were identified in various databases. After examining each of the articles, five articles were included in this review. Treatment with intraarticular hyaluronic acid is a safe treatment modality that significantly improves functional scores of patients, with no evidence of superiority in relation to other conservative treatments. Further clinical trials with larger numbers of patients are needed so that we can recommend its use and address unanswered questions. Systematic Review of Randomized Clinical Trials.

Hyaluronic acid and other conservative treatment options for osteoarthritis of the ankle

BACKGROUND

The cause of ankle osteoarthritis (OA) is usually trauma. Patients are relatively young, since ankle trauma occurs at a relatively young age. Several conservative treatment options are available, evidence of the benefits and harms of these options are lacking.

OBJECTIVES

To assess the benefits and harms of any conservative treatment for ankle OA in adults in order to provide a synthesis of the evidence as a base for future treatment guidelines.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2014, issue 9), MEDLINE (Ovid) (1946 up to 11 September 2014), EMBASE (1947 to September 2014), PsycINFO (1806 to September 2014), CINAHL (1985 to September 2014), PEDro (all years till September 2014), AMED until September 2014, ClinicalTrials.gov, Current Controlled Trials, The Dutch Register. To identify potentially relevant studies we screened reference lists in retrieved review articles and trials.

SELECTION CRITERIA

We considered randomised or controlled clinical trials investigating any non-surgical intervention for ankle OA for inclusion.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

No other RCT concerning any other conservative treatment besides the use of hyaluronic acid (HA) for ankle OA was identified. Six randomised controlled trials (RCTs) were included.A total of 240 participants diagnosed with ankle OA were included in this review. The primary analysis included three RCTs (109 participants) which compared HA to placebo. One study compared HA to exercise therapy, one compared HA combined with exercise therapy to an intra-articular injection of botulinum toxin and one compared four different dosages of HA.Primary analysis: a pooled analysis of two trials (45 participants) found that the Ankle Osteoarthritis Scale (AOS) total score (measuring pain and physical function) was reduced by 12% (95% CI -24% to -1%) at six months (mean difference (MD) -12.53 (95% CI -23.84 to -1.22) on a scale of 0 to 100; number needed to treat for an additional beneficial outcome (NNTB) = 4 (95% CI 2 to 205); this evidence was graded as low quality, due to limitations in study design (unclear risk of selection bias for two studies and unclear risk for attrition bias for one study) and imprecision of results: a small population size (45 participants). It is not known if a mean difference of 12.53 points on a 100 point scale is clinically relevant. No minimal important clinical difference is known for this score. Pain and function outcomes were not reported separately. Radiographic joint structure changes were not investigated. For the mean quality of life at six months (two trials; 45 participants) no meta-analysis could be performed due to missing data. No serious adverse events (SAEs) were noted and no participants withdrew because of an adverse event. There were a few adverse events (AEs) 5/63 (8%) in the HA group and 2/46 (4%) in the placebo group. The Peto odds ratio (Peto OR) to have an adverse event was 2.34 higher compared to the control group (95% CI 0.45 to 12.11). This evidence is inconclusive because of a wide CI and a small number of events.For comparing HA to exercise therapy (30 participants) the results for pain on a Visual Analogue Scale (VAS 0 to 10) at 12 months are inconclusive (MD 0.70, 95% CI -2.54 to 1.14). The American Orthopedic Foot and Ankle Society score (AOFAS score) was 13.10 points (MD) higher in favour of HA (95% CI 2.97 to 23.23) on a scale of 0 to 100. The evidence was graded as low. No adverse events were found. Radiographic structure changes were not measured; no participants withdrew due to AEs; no SAEs were found.For the comparison of HA injection combined with exercise therapy to an intra-articular injection of botulinum toxin A (BoNT-A) (75 participants), the outcome of the AOS pain score of the affected joint at six months is inconclusive (MD 0.10, 95% CI -0.42 to 0.62). The physical function (the AOS disability score) at six months is inconclusive (MD 0.20, 95% CI -0.34 to 0.74). The same number of AEs were found in both groups; HA 2/37 (5.9%), BoNT-A 2/38 (5.8%) (risk ratio (RR) 1.03, 95% CI 0.15 to 6.91). Radiographic changes were not examined, no SAEs were found and no participants withdrew because of an AE. The evidence was graded as low.The RCT comparing four different dosing schedules for HA (26 participants) showed the best median decrease in pain on walking VAS (on a scale of 0 to 100) for 3 x 1 ml at 27 weeks with a median decrease of 30. Physical function, radiographic changes and quality of life were not measured.Twenty-seven percent of all participants had AEs, most of them in the 2ml group (57% in this group). No participants withdrew due to an AE and no SAEs were noted.Overall the quality of the evidence showed some serious limitations. The evidence was graded low for the primary analysis comparing HA to placebo. This was based on a limitation in design and implementation: sample sizes were small (45 to 92 participants) and and imprecision in results: there was an unclear risk of bias for several items concerning the three studies used in the meta analysis.

AUTHORS' CONCLUSIONS

Currently, there is insufficient data to create a synthesis of the evidence as a base for future guidelines for ankle OA. Since the aetiology of ankle OA is different, guidelines that are currently used for hip and knee OA may not be applicable for ankle OA. Simple analgesics as recommended for hip and knee OA seem however a reasonable first step to treat ankle OA. It is unclear if there is a benefit or harm for HA as treatment for ankle OA compared to placebo at six months based on a low quality of evidence. Inconclusive results were found comparing HA to other treatments. HA can be conditionally recommended if patients have an inadequate response to simple analgesics. It remains unclear which patients (age, grade of ankle OA) benefit the most from HA injections and which dosage schedule should be used.

Ultrasound guided intra-articular ketorolac versus corticosteroid injection in osteoarthritis of the hip: a retrospective comparative study

OBJECTIVE

Intra-articular steroid injection has been widely used in the management of symptomatic osteoarthritis; however, its frequent use is avoided since there is an increase in the incidence of articular infection and several mechanical side effects such as cartilage breakdown and loss of elasticity of the articular cartilage. For these reasons, nonsteroidal anti-inflammatory drugs instead of corticosteroids can be considered for intra-articular injection. On this basis, we investigated the effects and safety of ultrasound-guided intra-articular ketorolac versus corticosteroid injection for patients with osteoarthritis of the hip.

MATERIALS AND METHODS

This retrospective study included 98 patients with diagnoses of hip osteoarthritis who underwent ultrasound-guided intra-articular ketorolac or corticosteroid injection. Fifty patients who received ultrasound-guided intra-articular corticosteroid injection were administered a mixture of 0.5% lidocaine and triamcinolone. Forty-eight patients who received ultrasound-guided intra-articular ketorolac injection were administered 0.5% lidocaine and ketorolac. Outcome measurement was assessed using the Harris hip score and verbal numeric pain scale, which were evaluated before the injections and at 1, 3 and 6 months following the injection. Univariate analysis (using the x (2) test) and multiple logistic regression analysis were performed to evaluate the relationship between the possible outcome predictors (injected medications, patients' age, gender, pain duration and Kellgren-Lawrence classification) and the therapeutic effects.

RESULTS

The Harris hip score and verbal numeric pain scale were improved at 1, 3 and 6 months after the injection in both groups. No statistical differences in the Harris hip score and verbal numeric pain scale were observed between the groups. The success rate was also not significantly different among the time periods of 1, 3 and 6 months. Multiple logistic regression and univariate analysis showed that injected medications patients' age, gender, pain duration and Kellgren-Lawrence classification were not independent predictors of successful outcome at midterm follow-up.

CONCLUSION

The treatment of osteoarthritis of the hip with intra-articular ketorolac injection is as effective as that with intra-articular corticosteroid injection. Intra-articular ketorolac injection can be considered useful for patients with contraindications to using corticosteroids.

Current Concepts in the Management of Ankle Osteoarthritis: A Systematic Review

Ankle osteoarthritis is less common than hip or knee osteoarthritis; however, it is a relatively common presentation and is predominantly related to previous trauma. Treatments have traditionally consisted of temporizing measures such as analgesia, physiotherapy, and injections until operative treatment in the form of arthrodesis is required. More recently, interest has been increasing in both nonoperative and alternative operative options, including joint-sparing surgery, minimal access arthrodesis, and new arthroplasty designs. The present systematic instructional review has summarized the current evidence for the treatment options available for ankle osteoarthritis.

Prevalence of osteoarthritis in former elite athletes: a systematic overview of the recent literature

The aim of this study was to systematically review the recent scientific literature to explore the prevalence of osteoarthritis (OA) in former elite athletes from team and individual sports. A systematic review of observational studies was conducted. Based on three categories of keywords (and synonyms), a sensitive search strategy was built in order to search MEDLINE and SPORTDiscus from 2000 to 2014. The data from included studies presenting a prevalence rate of OA as an outcome measure were extracted using a standardised extraction form, and their methodological quality was described. Fifteen studies were identified through our search strategy, studies being rather heterogeneous with regard to their study population and to the definition and assessment of OA. Hip OA ranged from 2 to 60%, and knee OA from 16 to 95%. Prevalence rates of general, lower limbs or hip/knee OA ranged from 1 to 59%. Prevalence of neck, back, shoulder and ankle OA was reported only in single studies (16, 18, 33 and 3%, respectively). This study showed that prevalence of OA, especially in their lower limbs, seems to be high among former elite athletes from team and individual sports compared to the general population and other occupational sectors.

Prognostic factors after intra-articular hyaluronic acid injection in ankle osteoarthritis

PURPOSE

The goal of this study was to identify baseline prognostic factors of outcome in ankle osteoarthritis patients after intra-articular hyaluronic acid injection.

MATERIALS AND METHODS

Patients with ankle osteoarthritis who received hyaluronic acid injection therapy were retrospectively reviewed. Each patient received weekly intra-articular hyaluronic acid injections (2 mL) for 3 weeks. Six predictors including gender, age, symptom duration, radiographic osteoarthritis stage, radiographic subchondral cyst, and fracture history were evaluated. Visual analogue scale (VAS) and patient satisfaction were evaluated as outcome measures. These predictors and outcome measurements were included in a logistic regression model for statistical analysis.

RESULTS

Total of 40 consecutive patients (21 male, 19 female) were included in this study. Mean age was 60.6. Average follow up period was 13 months. The mean VAS recorded 3, 6, and 12 months after the first injection was 3.6 (SD 2.54, p<0.001), 4.33 (SD 2.9, p<0.001), and 5.3 (SD 2.7, p=0.0071), respectively, when compared to baseline VAS. Early stage disease was identified as an independent predictor associated with 'positive VAS outcome' at 3 and 6 months. Early stage disease and duration of pain less than 1 year were independent predictors associated with higher satisfaction.

CONCLUSION

While hyaluronic acid injection for ankle osteoarthritis is a safe and effective treatment, careful selection of patients should be made according to the above prognostic predictors.

Viscosupplementation of the ankle: a prospective study with an average follow-up of 45.5 months

INTRODUCTION

Providing pain relief for ankle osteoarthritis and delaying the need for a radical surgery procedure is difficult to achieve with analgesics that have limited efficacy or are not devoid of substantial side effects.

HYPOTHESIS

The goals of this study were to evaluate the efficacy of viscosupplementation, explore which factors better predict Patient's response and propose an injection protocol.

MATERIALS AND METHODS

Eighteen patients (26 ankles) with ankle osteoarthritis were included, with seven of them having received multiple series of injections. The average age was 60 years. Series of three injections, performed in the operating room under fluoroscopy-guidance, were evaluated after 4 and 12 months and then annually with the AOFAS score; patient satisfaction was also assessed.

RESULTS

The average AOFAS score increased significantly from 61.8 ± 15 before the injections to 74.4 ± 14.5 and 73.7 ± 16.6 after 4 and 12 months, respectively. The average follow-up was 45.5 months and 73% of patients were satisfied or very satisfied. There were no adverse effects or intolerance. In patients receiving more than one series of injections, the average delay between series was 27.8 (range 15-43) months. Five patients had a radical surgery procedure after an average of 27 months of effective viscosupplementation.

DISCUSSION

This prospective study showed that viscosupplementation had a significant positive effect (P<0.05) in patients with ankle osteoarthritis when a three-injection protocol was used every two years on average. Neither etiology nor severity of the osteoarthritis was predictive of the response. In our opinion, fluoroscopy-guidance is essential for these injections.

LEVEL OF EVIDENCE

Level IV cohort study.

Osteochondral lesions of the talus: size, age, and predictors of outcomes

In this article, our research on osteochondral lesions of the talus (OLTs) is summarized, the orthopedic literature is reviewed, and the direction of future research and treatment trends are discussed. Our research has explored the role of lesion size, significance of marrow edema, relationship of patient age, importance of lesion containment, and role of a stable cartilage lesion cap in the prognosis and outcomes of these lesions. We have identified smaller sized lesions, younger patients and contained lesions as independent predictors of success for the operative treatment of OLTs. Our data should facilitate the development of a more comprehensive treatment algorithm to more accurately predict success in operative management of these lesions.

Knee and ankle osteoarthritis in former elite soccer players: a systematic review of the recent literature

OBJECTIVES

To investigate the prevalence of knee and/or ankle osteoarthritis in former elite soccer player.

DESIGN

Systematic review.

METHODS

Medline, Embase and SPORTDiscus (2000 to January 2012) were used. To be included, studies were required to be a primary study, written in English, Dutch, French or German, former elite soccer players had to be the study population, and presenting knee or ankle OA had to be the outcome measure.

RESULTS

The search strategy resulted in four studies. Two studies, evaluated as having a high methodological quality, found a prevalence rate of knee OA between 60 and 80%. Both studies used radiographic examination as their measurement instrument to diagnose OA; the presence of ankle OA was not determined. The other two studies, evaluated as having a moderate methodological quality, found a prevalence rate of knee OA between 40 and 46% and a prevalence rate of ankle OA between 12 and 17%. These studies used a questionnaire as their measurement instrument wherein players were asked if they had ever been diagnosed with OA by a medical specialist.

CONCLUSIONS

The prevalence of knee and ankle OA in former elite soccer players can be considered high compared to the general population and to other occupations. To identify players at risk for OA, a health surveillance program should be implemented in elite soccer as a preventive measure. Further research should be conducted to determine if the risk of developing OA varies among different subgroups of elite soccer players and what the consequences of this high OA prevalence are.