Efficacy of intra-articular hyaluronic acid in patients with osteoarthritis of the ankle: a prospective study

The Ankle Joint: Non-Operative Updates in Ankle Arthritis, Are Biologics Working?

The vast majority of ankle arthritis is post-traumatic in nature, with rates of 60% to 80%. Symptoms include pain, decreased range of motion, and joint effusion. Diagnostic imaging is helpful in determining the degree of joint degeneration, with MRI and CT scan being the most sensitive. Conservative treatment modalities are targeted at reducing symptoms and improving function. Injectable therapy has gained popularity over the last few decades, with advancements in biologic treatments. Corticosteroids, hyaluronic acid, platelet-rich plasma, and amniotic tissue-derived products can be used to reduce inflammation in the joint, as well as prevent cartilage degeneration.

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.

May the Symptomatic Subtalar Joint Be Conservatively Treated With Intra-Articular Hyaluronic Acid Injections After a Calcaneus Fracture?

BACKGROUND

Subtalar pain following intra-articular calcaneus fractures may be associated with disability, pain, and a negative impact on the quality of life. Salvage procedures as subtalar fusion are associated with further consequences as stiffness, altered ankle biomechanics, and adjacent articular overloading with degenerative changes. The objective of the present study is to evaluate the short-term effects of viscosupplementation with intra-articular hyaluronic acid (HA) on function and pain, in patients with painful subtalar joint after calcaneus fracture.

METHODS

We searched for patients who underwent osteosynthesis of intra-articular calcaneus fracture between January 2011 and July 2015 and were diagnosed during the follow-up with pain and subtalar osteoarthritis. Between January and December of 2018, 13 patients (50 ± 10 years) accepted to participate in this study and received intra-articular HA injections. Three consecutive doses of 20 mg of HA were administered within a week interval, through anterolateral injections into the subtalar joint. We prospectively evaluated the function using the ankle/hindfoot American Orthopaedic Foot & Ankle Society score (AOFAS) and level of pain using the visual analog scale (VAS) before the intervention and 4, 12, and 24 weeks after the first injection.

RESULTS

Hindfoot function improved with an increase of AOFAS from 55 ± 19 before the intervention to 88 ± 20 at the 24th week (P = .001). Similarly, we observed relief of pain during the 24 weeks following intra-articular hyaluronic acid injection, with a decrease in VAS from 8.3 ± 1.3 before treatment to 2.2 ± 3.0 at the 24th week (P = .001).

CONCLUSION

For patients experiencing pain and dysfunction with subtalar osteoarthritis after intra-articular calcaneus fracture, viscosupplementation with intra-articular HA may be associated with improvement in function and pain in the short term. Furthermore, patients with higher grades of osteoarthritis may have limited benefit in pain relief and function improvement.

LEVEL OF EVIDENCE

IV, Case series.

[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 Effect of a Single Hyaluronic Acid Injection in Ankle Arthritis: A Prospective Cohort Study

Nonoperative measures are often used as first line treatment in ankle osteoarthritis. One of these measures consists of hyaluronic acid injections in the affected ankle joint, but efficiency of this treatment is uncertain. The purpose of the study was to evaluate the effect on Self-reported Foot and Ankle Score, visual analog scale score at rest, and visual analog scale score at activity 6 months after a single dose of hyaluronic acid in patients with ankle osteoarthritis. Patients were included from December 2017 to March 2019. A single intra-articular injection of Cingal or MonoVisc was administered. Age, gender, osteoarthritis-grade, Self-reported Foot and Ankle Score, visual analog score at activity, and at rest before injection and after 6 months was registered. A total of 33 patients were included, with 14 lost to follow-up. Four were treated with MonoVisc and were excluded to reduce confounding. The remaining 15 patients were included for analysis. Median Self-reported Foot and Ankle Score remained unchanged (p = .06), whereas visual analog score at activity went from 7 to 6 (.02) and visual analog score at rest was reduced from 4 to 3 (.02). Subgroup analysis on arthrosis grade (grade I-II and III-IV) showed no statistically significant changes for all variables even though patients with grade III-IV arthrosis seemed to benefit more from the treatment. The results indicate that a single injection of hyaluronic acid is insufficient to produce at clinically relevant response after 6 months even though there is a high risk of underpowering because of a small patient population.

The use of intra-articular injection of autologous micro-fragmented adipose tissue as pain treatment for ankle osteoarthritis: a prospective not randomized clinical study

PURPOSE

The objective of this study was to evaluate the safety and the efficacy of intra-articular injections of autologous micro-fragmented adipose tissue in patients affected by early or moderate ankle osteoarthritis (AOA).

METHODS

A total of 31 symptomatic patients, aged 28-71 years, affected by AOA, were treated with 5 ml of autologous micro-fragmented adipose tissue. Clinical evaluations before the treatment and after six, 12, and 24 months were performed through American Orthopaedic Foot and Ankle Society (AOFAS) scale, the Foot and Ankle Disability Index (FADI), and Visual Analogue Scale (VAS) scores. Adverse events were recorded.

RESULTS

No severe complications were noted during the treatment and the follow-up period. A statistically significant improvement from basal evaluation to the six, 12-, and 24-month follow-up visit was observed, whereas a statistically significant worsening from the 12-month to the 24-month follow-up visit was showed.

CONCLUSION

The autologous micro-fragmented adipose tissue for the treatment of pain in ankle osteoarthritis seems safe and able to provide positive clinical outcomes, potentially offering a new minimally invasive therapeutic option for patients who are not eligible for more invasive approaches. Further high-quality studies are needed to confirm these findings.

Intra-articular Injections of Hyaluronic Acid on Osteochondral Lesions of the Talus After Failed Arthroscopic Bone Marrow Stimulation

BACKGROUND

The purpose of the study was to compare clinical and functional outcomes before and after hyaluronic acid (HA) injections in patients with osteochondral lesions of the talus who experienced a failure of their primary treatment with arthroscopic microfracture surgery.

METHODS

A total of 40 patients were included in the final study. These patients had received microfracture surgery but continued to experience postoperative pain over an average of 13.0 months (range, 0-81 months) and were available for investigation with a mean follow-up for 29.1 months (SD 14.7; range 2.6-79.6 months). All patients received intra-articular injections of HA once per week for 3 weeks. We assessed clinical and functional outcomes before and after injection using the American Orthopaedic Foot & Ankle Society (AOFAS) score, Foot and Ankle Outcome Score (FAOS), Short Form Health Survey (SF-36), the visual analog scale (VAS) for pain, and the Alexander subjective scale.

RESULTS

The AOFAS score significantly increased from 50.7 ± 13.8 to 79.9 ± 13.8 and the FAOS scores for symptom, pain, daily living, and sports were significantly higher postinjection compared to preinjection (all P < .001). Similarly, the mean VAS for pain was significantly decreased after 6 weeks following injection and continued to decrease over the follow-up period; the mean VAS was significantly lower postinjection compared to preinjection at 12 months (P < .001).

CONCLUSION

Intra-articular HA injections on average significantly improved clinical and functional scores after failed primary operative treatment. HA injections may provide an alternative to secondary operative treatment and provide better clinical outcomes than other conservative treatments.

LEVEL OF EVIDENCE

Level II, prospective observational cohort study.

A review on the wide range applications of hyaluronic acid as a promising rejuvenating biomacromolecule in the treatments of bone related diseases

Hyaluronic acid (HA) is a multifunctional high molecular weight polysaccharide produced by synoviocytes, fibroblasts, and chondrocytes, and is naturally found in many tissues and fluids, and more abundantly in articular cartilage and synovial fluid. Naturally occurring HA is thought to participate in many biological processes, such as regulation of cell adhesion and cell motility, manipulation of cell differentiation and proliferation, and providing mechanical properties to tissues (Girish and Kemparaju, 2007). Due to its excellent physicochemical properties such as high viscosity, elasticity, biodegradability, biocompatibility, nontoxicity, and nonimmunogenicity, HA based formulations have a wide range of applications and serves as a promising rejuvenating biomacromolecule in biomedical applications. In recent decades, HA is currently a popular topic, and has been widely used in bone related diseases for its remarkable efficacy in articular cartilage lubrication, analgesia, anti-inflammation, immunomodulatory, chondroprotection, anti-cancer and etc. Moreover, the safety and tolerability of HA based formulations have also been well-documented for treatment of various types of bone related diseases (Chen et al., 2018). This review gives a deep understanding on the special benefits and provides a mechanism-based rationale for the use of HA in bone related diseases conditions with special reference to osteoarthritis (OA), rheumatoid arthritis (RA), bone metastatic cancers.

Evidence on ankle injections for osteochondral lesions and osteoarthritis: a systematic review and meta-analysis

PURPOSE

To evaluate the evidence supporting safety and effectiveness of intra-articular injective treatments for ankle lesions ranging from osteochondral lesions of the talus (OLT) to osteoarthritis (OA).

METHODS

A systematic review and a meta-analysis were performed on PubMed, Embase, and Cochrane Library in March 2020. Safety was evaluated through the reported side effects and effectiveness through the scores used. The quality of the studies was assessed using the Cochrane Collaboration Risk of Bias 2.0 tool and the Downs and Black checklist. For each outcome, the quality of evidence was graded according to GRADE guidelines.

RESULTS

Twenty-four studies (21 for OA, 3 for OLT) were included on hyaluronic acid (HA), platelet-rich plasma (PRP), saline, methylprednisolone, botulinum toxin type A (BoNT-A), mesenchymal stem cells (MSCs), and prolotherapy. No severe adverse events were reported. For OLT, a comparison was possible between HA and PRP showing no significant difference. For ankle OA, a significant difference favouring HA versus saline was documented at six months (p < 0.001). The GRADE level of evidence was very low.

CONCLUSION

This meta-analysis supports the safety of intra-articular treatment for ankle OA and OLT, while only a very low evidence supports the efficacy of HA in terms of better results versus placebo for the treatment of ankle OA, and other conclusions are hindered by the scarcity of the available literature. This urges further and stronger trials to specifically investigate potential and limitations of these different injective approaches for the treatment of OLT and ankle OA.

Orthobiologics

Use of orthobiologics in sports medicine and musculoskeletal surgery has gained significant interest. However, many of the commercially available and advertised products are lacking in clinical evidence. Widespread use of products before fully understanding their true indications may result in unknown adverse outcomes and may also lead to increased health care costs. As more products become available, it is important to remain judicial in use and to practice evidence-based medicine. Likewise, it is important to continue advances in research in hopes to improve surgical outcomes. This article reviews clinical evidence behind common orthobiologics in the treatment of foot and ankle pathology.

Nonanimal Hyaluronic Acid for the Treatment of Ankle Osteoarthritis: AProspective, Single-Arm Cohort Study

Ankle osteoarthritis (OA) can cause disabling symptoms, and some patients prefer to be treated with minimally invasive procedures. Nonanimal hyaluronic acid (NASHA) is a cross-linked hyaluronic acid product that has a prolonged intra-articular residence time. The authors report the first study of NASHA for the treatment of ankle OA. Thirty-seven patients with Kellgren-Lawrence grade II or III ankle OA received an intra-articular injection of NASHA (1 mL). Outcomes included visual analogue scale (VAS) scores for pain and disability. At baseline, the mean VAS pain score was 50.1 ± 14.5mm. During the 26-week follow-up period, the least squares (LS) mean change from baseline in the ankle OA VAS pain score was -20.5mm (95% confidence interval [CI] -25.5 to -15.6 mm), an LS mean percentage reduction of 40.0% (95% CI 30.2% to 49.9%). The LS mean change from baseline in the VAS disability score during 26 weeks was -19.2mm (95% CI -24.8 to -13.6 mm), a percentage reduction of 34% (95% CI 22.3% to 45.7%). Five participants experienced a total of 7 adverse events considered to be related to study treatment (injection site pain, n = 3; injection site joint pain, n = 3; plantar fasciitis, n = 1). This study shows promise for viscosupplementation with NASHA in the treatment of ankle OA. A single injection was associated with clinically meaningful reductions in pain and disability during a 26-week period and, in general, was well tolerated.

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.

Hyaluronic Acid Influence on Normal and Osteoarthritic Tissue-Engineered Cartilage

The aim of this study is to identify gene expression profiles associated with hyaluronic acid (HA) treatment of normal and osteoarthritis (OA)-like tissue-engineered cartilage. 3D cartilage micromasses were treated with tumour necrosis factor-α (TNF-α) (OA-inducer) and/or HA for 7 days. Viability was examined by PI/FDA staining. To document extracellular matrix (ECM) formation, glycosaminoglycans (GAG) were stained with Safranin-O and cartilage-specific type II collagen was detected immunohistochemically. Genome-wide gene expression was determined using microarray analysis. Normal and OA-like micromasses remained vital and showed a spherical morphology and homogenous cell distribution regardless of the treatment. There was no distinct difference in immunolabeling for type II collagen. Safranin-O staining demonstrated a typical depletion of GAG in TNF-α-treated micromasses (−73%), although the extent was limited in the presence of HA (−39%). The microarray data showed that HA can influence the cartilage metabolism via upregulation of TIMP3 in OA-like condition. The upregulation of VEGFA and ANKRD37 genes implies a supportive role of HA in cartilage maturation and survival. The results of this study validate the feasibility of the in vitro OA model for the investigation of HA. On the cellular level, no inhibiting or activating effect of HA was shown. Microarray data demonstrated a minor impact of HA on gene expression level.

Recent advances in hyaluronic acid based therapy for osteoarthritis

Osteoarthritis is a debilitating disease that has increased in prevalence across the world due to the aging population. Currently, physicians use a plethora of treatment strategies to try and slow down the progression of the disease, but none have been shown to ubiquitously treat and cure the disease. One of the strategies uses the high molecular weight molecule hyaluronic acid as either an injectable or oral supplement for treatment. Hyaluronic acid (HA) is a relatively new treatment that has shown varied results through several clinical trials. It can be used as a scaffold for engineering new treatments and several new preparations have just been added to the market. A comprehensive search was conducted through several search databases according our inclusion and exclusion criteria. This review included 44 prospective clinical trial investigating the feasibility and efficacy of HA injection for knee, hip, and ankle osteoarthritis. This review will take a closer look at hyaluronic acid and its properties, as well clinical effectiveness and future options.

No superior treatment for primary osteochondral defects of the talus

PURPOSE

The purpose of this systematic literature review is to detect the most effective treatment option for primary talar osteochondral defects in adults.

METHODS

A literature search was performed to identify studies published from January 1996 to February 2017 using PubMed (MEDLINE), EMBASE, CDSR, DARE, and CENTRAL. Two authors separately and independently screened the search results and conducted the quality assessment using the Newcastle-Ottawa Scale. Subsequently, success rates per separate study were calculated. Studies methodologically eligible for a simplified pooling method were combined.

RESULTS

Fifty-two studies with 1236 primary talar osteochondral defects were included of which forty-one studies were retrospective and eleven prospective. Two randomised controlled trials (RCTs) were identified. Heterogeneity concerning methodological nature was observed, and there was variety in reported success rates. A simplified pooling method performed for eleven retrospective case series including 317 ankles in the bone marrow stimulation group yielded a success rate of 82% [CI 78-86%]. For seven retrospective case series investigating an osteochondral autograft transfer system or an osteoperiosteal cylinder graft insertion with in total 78 included ankles the pooled success rate was calculated to be 77% [CI 66-85%].

CONCLUSIONS

For primary talar osteochondral defects, none of the treatment options showed any superiority over others.

LEVEL OF EVIDENCE

IV.

Nonsurgical Treatment of Ankle Arthritis

Nonsurgical treatment of ankle arthritis can be a short-term fix or a long-term solution. An understanding of the biomechanics of the ankle is helpful in the successful use of orthotics and bracing. Pharmacologic and/or biologic treatments can be used exclusively or in concert with mechanical interventions to decrease pain, improve function, and potentially extend the life span of an arthritic ankle.

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.

Bone Healing Improvements Using Hyaluronic Acid and Hydroxyapatite/Beta-Tricalcium Phosphate in Combination: An Animal Study

The purpose of this study was to investigate whether the use of HLA as an aqueous binder of hydroxyapatite/beta-tricalcium phosphate (HA-βTCP) particles can reduce the amount of bone graft needed and increase ease of handling in clinical situations. In this study, HA/βTCP was loaded in commercially available crosslinking HLA to form a novel HLA/HA-βTCP composite. Six New Zealand White rabbits (3.0-3.6 kg) were used as test subjects. Four 6 mm defects were prepared in the parietal bone. The defects were filled with the HLA/HA-βTCP composite as well as HA-βTCP particle alone. New bone formation was analyzed by micro-CT and histomorphometry. Our results indicated that even when the HA-βTCP particle numbers were reduced, the regenerative effect on bone remained when the HLA existed. The bone volume density (BV/TV ratio) of HLA/HA-βTCP samples was 1.7 times larger than that of the control sample at week 2. The new bone increasing ratio (NBIR) of HLA/HA-βTCP samples was 1.78 times higher than the control group at week 2. In conclusion, HA-βTCP powder with HLA contributed to bone healing in rabbit calvarial bone defects. The addition of HLA to bone grafts not only promoted osteoconduction but also improved handling characteristics in clinical situations.

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.

Differences Regarding Branded HA in Italy, Part 2: Data from Clinical Studies on Knee, Hip, Shoulder, Ankle, Temporomandibular Joint, Vertebral Facets, and Carpometacarpal Joint

OBJECTIVES

The aim of the current study is to collect scientific data on all branded hyaluronic acid (HA) products in Italy that are in use for intra-articular (IA) injection in osteoarthritis (OA) compared with that reported in the leaflet.

METHODS

An extensive literature research was performed for all articles reporting data on the IA use of HA in OA. Selected studies were taken into consideration only if they are related to products based on HAs that are currently marketed in Italy with the specific joint indication for IA use in patients affected by OA.

RESULTS

Sixty-two HA products are marketed in Italy: 30 products are indicated for the knee but only 8 were proved with some efficacy; 9 products were effective for the hip but only 6 had hip indication; 7 products proved to be effective for the shoulder but only 3 had the indication; 5 products proved effective for the ankle but only one had the indication; 6 products were effective for the temporomandibular joint but only 2 had the indication; only 2 proved effective for vertebral facet joints but only 1 had the indication; and 5 products proved effective for the carpometacarpal joint but only 2 had the indication.

CONCLUSIONS

There are only a few products with some evidences, while the majority of products remain without proof. Clinicians and regulators should request postmarketing studies from pharmaceuticals to corroborate with that reported in the leaflet and to gather more data, allowing the clinicians to choose the adequate product for the patient.

Clinical and MRI outcomes of HA injection following arthroscopic microfracture for osteochondral lesions of the talus

PURPOSE

The purpose of this study was to compare the clinical and magnetic resonance imaging (MRI) outcomes of arthroscopic microfracture surgery alone or in combination with hyaluronic acid (HA) injection in the treatment of osteochondral lesions of the talus.

METHODS

Thirty-five patients with osteochondral lesions of the talus who underwent arthroscopic microfracture were included and followed up for at least 9 months post-operatively. The patients were randomly divided into non-injection group (n = 17) who received treatment with microfracture surgery alone and injection group (n = 18) who also accepted intra-articular injection of HA post-operatively. Quantitative MRI was used to evaluate the cartilage repair after surgery. American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hind foot Scale scores and Visual Analogue Scale (VAS) scores were used to evaluate clinical outcomes.

RESULTS

After operation, the MRI outcomes showed that the thickness index was higher (0.8 ± 0.1 vs. 0.7 ± 0.1) and the T2 index was lower (1.2 ± 0.1 vs. 1.4 ± 0.1) in the injection group than in the non-injection group (P < 0.01). As for the volumes of subchondral bone marrow oedema, there are no significant differences between groups (n.s.). Compared with the non-injection group, the AOFAS score and the VAS score yielded a higher level of improvement in injection group at final follow-up post-operatively (P < 0.05).

CONCLUSIONS

Arthroscopic microfracture is a safe and effective procedure for osteochondral lesions of the talus. Intra-articular HA injection as an adjunct to arthroscopic microfracture might offer better functional recovery than microfracture alone.

LEVEL OF EVIDENCE

II.

Ultrasound-Guided Interventional Procedures in Pain Medicine: A Review of Anatomy, Sonoanatomy, and Procedures: Part VI: Ankle Joint

Ultrasound-guided injections in pain medicine are emerging as a popular technique for pain interventions. Ultrasound can be applied for procedures of the ankle joint and surrounding structures. This review describes the anatomy and sonoanatomy of the ankle joint, subtalar joint, and surrounding extra-articular structures relevant for intra-articular injection. Second, it reviews injection techniques and the accuracy and efficacy of these intra-articular ankle injections.

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.

[Injection treatment with hyaluronic acid]

This article presents the spectrum of indications for the use of hyaluronic acid (HA) based on the recommendations of the European League Against Rheumatism (EULAR), the American College of Rheumatology (ACR), the Osteoarthritis Research Society International (OARSI), the International Institute for Health and Clinical Excellence (NICE) and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) taking the reality of patient care in Europe into account.

Clinical Effects of Platelet-Rich Plasma and Hyaluronic Acid as an Additional Therapy for Talar Osteochondral Lesions Treated with Microfracture Surgery: A Prospective Randomized Clinical Trial

BACKGROUND

Osteochondral ankle injuries commonly affect the dome of the talus, and these injuries are a common cause of athletic disability. Various treatment options are available for these injuries including intra-articular hyaluronic acid (HA) and platelet-rich plasma (PRP) injections. The purpose of this study was to compare the effects of HA and PRP as adjunct therapies after arthroscopic microfracture in osteochondral lesions (OCLs) of the talus.

METHODS

In this prospective, randomized blinded study, 40 patients with talar OCLs in their ankle joints were treated with arthroscopic debridement and a microfracture technique. Thirteen randomly selected patients received PRP, 14 patients received HA, and the remaining 13 patients received saline as a control group. The participants were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) and visual analog pain scale (VAS) scores after a 15.3-month (range, 11-25 months) follow-up.

RESULTS

Postoperatively, all the groups exhibited significantly increased AOFAS scores and decreased VAS scores compared with their preoperative results (P < .005). The AOFAS scores were significantly increased in the PRP group versus the HA and control groups (P < .005), although the increased AOFAS scores in the HA group versus the control group were also significant (P < .005). Similar to the AOFAS scores, the decrease in the VAS scores was significantly lower in the PRP group versus the HA and control groups (P < .005). In addition, the HA group had significantly lower VAS scores than the control group (P < .005).

CONCLUSION

Both PRP and HA injections improved the clinical outcomes of patients who underwent operation for talar OCLs in the midterm period and can be used as adjunct therapies for these patients. Because a single dose of PRP provided better results, we recommend PRP as the primary adjunct treatment option in the talar OCL postoperative period.

LEVEL OF EVIDENCE

Level I, prospective randomized study.

Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis

Viscosupplementation (VS) with hyaluronic acid is currently used by physicians to treat osteoarthritis. However, many aspects of this treatment remain questionable and subject of controversy. A group of 8 experts in this field, from European countries, met to debate on 24 statements previously listed by the group members. Based on an extensive research of the literature and expert opinion, a consensus position has been proposed for each statement. Agreement was achieved on some recommendations. In particular, the expert achieved unanimous agreement in favor of the following statements: VS is an effective treatment for mild to moderate knee OA; VS is not an alternative to surgery in advanced hip OA; VS is a well-tolerated treatment of knee and other joints OA; VS should not be used only in patients who have failed to respond adequately to analgesics and NSAIDs; VS is a "positive" indication but not a "lack of anything better" indication; the dosing regimen must be supported by evidence-based medicine; cross-linking is a proven means for prolonging IA residence time of HA; the best approach to inject accurately knee joint is the lateral mid-patellar one; when VS is performed under fluoroscopy, the amount of radiopaque contrast agent must be as low as possible to avoid viscosupplement dilution. These clear recommendations have been established to help practitioners in the use of viscosupplementation.

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.

Ankle arthritis: review of diagnosis and operative management

The diagnostic and therapeutic options for ankle arthritis are reviewed. The current standard of care for nonoperative options include the use of nonsteroidal antiinflammatory drugs, corticosteroid injections, orthotics, and ankle braces. Other modalities lack high-quality research studies to delineate their appropriateness and effectiveness. The gold standard for operative intervention in end-stage degenerative arthritis remains arthrodesis, but evidence for the superiority in functional outcomes of total ankle arthroplasty is increasing. The next few years will enable more informed decisions and, with more prospective high-quality studies, the most appropriate patient population for total ankle arthroplasty can be identified.

Efficacy of intraarticular botulinum toxin A and intraarticular hyaluronate plus rehabilitation exercise in patients with unilateral ankle osteoarthritis: a randomized controlled trial

Background

There was an increasing requirement for novel treatments of osteoarthritis (OA). The aim was to compare the efficacy of intraarticular Botulinum toxin type A (BoNT-A) and intraarticular hyaluronate plus rehabilitation exercise in patients with ankle OA.

Methods

This was a prospective, randomized, assessor-blinded study with a 6-month follow-up period, conducted in the outpatient rehabilitation department at a university-affiliated tertiary care medical center. Seventy-five patients with symptomatic ankle OA (Kellgren-Lawrence grade 2) were randomized to receive either a single 100-unit BoNT-A injection into the target ankle (n = 38) or a single hyaluronate injection plus 12 sessions of rehabilitation exercise (30 minutes/day, 3 times/week for 4 weeks) (n = 37). The primary outcome measure was the Ankle Osteoarthritis Scale (AOS). Secondary outcome measures included American Orthopedic Foot and Ankle Society (AOFAS) Ankle/Hindfoot Score, visual analog scale (VAS) for ankle pain, single leg stance test (SLS), Timed “Up-and-Go” test (TUG), consumption of rescue analgesics and global patient satisfaction.

Results

There were no significant between-group differences in total AOS scores, pain subscale and disability subscale scores (adjusted mean difference AMD = -0.2, 95% CI = (-0.5, 0.2), p = 0.39; AMD = -0.1, 95% CI = (-0.5, 0.3), p = 0.57; AMD = -0.2, 95% CI = (-0.6, 0.2), p = 0.36). The 2 groups showed no significant differences in AOFAS, VAS, SLS, TUG scores and consumption of rescue analgesics at each follow-up visit, except that the hyaluronate group improved more in SLS than the BoNT-A group at 1-month follow-up. Patients’ satisfaction rate was high, with no serious adverse events. There was no difference in adverse events between the two groups (p = 1.00).

Conclusions

Treatment with intraarticular BoNT-A or hyaluronate injection plus rehabilitation exercise was associated with improvements in pain, physical function and balance in patients with ankle OA. These effects were rapid at 2 weeks and might last for at least 6 months. There was no difference in effectiveness between the two interventions.

Trial registration

The trial was registered at clinical trials.gov (Registry number NCT01760577).

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.

Intra-articular injections of hyaluronic acid in osteoarthritis of the subtalar joint: a pilot study

We evaluated the efficacy of intra-articular viscosupplementation with sodium hyaluronate in the management of osteoarthritis of the subtalar joint. A total of 22 patients, aged 22 to 72 years (mean 53), with symptomatic subtalar joint osteoarthritis of 1 to 20 years' duration (mean 4.2) and a severity of Kellgren-Lawrence grade II to IV and Paley and Hall grade 1 to 3, were entered into the present study. Intra-articular injections of 10 mg sodium hyaluronate (Euflexxa) were administered weekly to the subtalar joint for 3 weeks. Clinical evaluations and objective scoring using the American Orthopaedic Foot and Ankle Society Ankle Hindfoot score, visual analog scale, maximum walking distance, pain frequency, and subjective global function were performed at baseline and 4, 12, and 28 weeks after treatment. Significant improvement occurred in the American Orthopaedic Foot and Ankle Society Ankle Hindfoot scores (baseline score 54.5, week 28 score 73.7; p < .01) and visual analog scale assessment (baseline pain, stiffness, and function score 5.4, 5.8, and 6.9; week 28 pain, stiffness, and function score 2.8, 3.1, and 3.8, respectively; p < .01). Global assessment showed improvement in 18 of 20 patients completing the study (p < .01). The tolerated walking distance significantly improved from 770 ± 886 m to 2,075 ± 1,500 m (p < .001). Improvement lasted for more than 6 months. Intra-articular injection of sodium hyaluronate should be considered in the conservative management of subtalar osteoarthritis.

Intra-articular delivery of liposomal celecoxib-hyaluronate combination for the treatment of osteoarthritis in rabbit model

Oral administration of celecoxib (Clx), which is the traditional treatment for osteoarthritis (OA), is accompanied by a high risk for cardiovascular events, while intra-articular injection of hyaluronate (HA) is a well-documented treatment for knee OA. To improve OA therapy while reducing the adverse effects, we formulate Clx-loaded liposomes embedded in HA gel, then administer the liposomal Clx-HA combination via intra-articular injection. Clx-loaded liposomes showed high efficiency encapsulation (>99%). In vitro release studies demonstrated that the release of Clx from lipsosomes was delayed by the combination of HA with liposomes. We examined the effect of intra-articular injection of liposomal Clx-HA combination on cartilage degeneration in rabbit knee OA model. The rabbits were treated with a single intra-articular injection of a single drug, either Clx liposome or HA, or liposomal Clx-HA combination. Using an incapacitance tester and the histopathological study, it was verified that the liposomal Clx-HA combination was more effective than a single drug in pain control and cartilage protection.

Treatment of osteochondral lesions of the talus with microfracture technique and postoperative hyaluronan injection

PURPOSE

The aim of this study is to report the outcomes of the treatment of talar osteochondral lesions with arthroscopic microfracture technique and postoperative intra-articular hyaluronan injection.

METHOD

Fifty-seven patients (29 men, 28 women) with osteochondral lesions of the talus were included in this prospective randomized clinical study between the years 2003 and 2009. The patients were treated with arthroscopic debridement and microfracture technique. Randomly selected 41 patients were injected intra-articular hyaluronan (injection group). The remaining 16 patients did not receive postoperative injection (non-injection group). Assessment of the pain and functional outcomes was performed using the Freiburg and AOFAS ankle/hindfoot scoring systems.

RESULTS

In the injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). Similarly, for the patients in non-injection group, the mean postoperative Freiburg functional and pain scores were significantly higher compared to preoperative functional and pain scores (P < 0.001). The AOFAS functional and pain scores of the patients in the injection group were significantly higher (P < 0.001) postoperatively compared to preoperative scores. Scoring the patients in the non-injection group according to AOFAS system also revealed significantly higher (P < 0.001) postoperative functional and pain scores over preoperative scores. The increase in the postoperative scores was found to be significantly higher in the injection group compared to non-injection group in both Freiburg and AOFAS systems (P < 0.001).

CONCLUSION

Treatment of osteochondral lesions of the talus using microfracture technique significantly improved functional and pain scores postoperatively. Additional treatment with intra-articular hyaluronan injection as an adjunct to microfracture technique may offer better clinical outcomes over microfracture technique alone.

LEVEL OF EVIDENCE

Randomized, controlled trial, Level I.

Hyaluronic acid for the treatment of osteoarthritis in all joints except the knee: what is the current evidence?

BACKGROUND

The use of intra-articular hyaluronic acid (HA) is a well known treatment in patients with knee osteoarthritis (OA). In other joints, less evidence is available about the efficacy of treatment with intra-articular HA. HA is also used intra-articularly in the metatarsophalangeal-1 joint, the ankle, the hip, the sacroiliac joint, the facet joints, the carpometacarpal-1 joint, the shoulder and the temporo-mandibular joint. In this systematic review we include all prospective studies about the effects of intra-articular HA in the above-mentioned joints. Its use in the knee joint, however, will be discussed in a separate article in this journal.

METHODS

A systematic review was conducted using databases including MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, and EMBASE.

RESULTS

After performing a solid systematic review using a rigid methodology and trying to pool the outcomes of different studies, we noticed that, compared with baseline, there is statistical evidence for a positive effect of intra-articular HA. However, there is limited evidence HA is superior to placebo and no evidence that intra-articular HA is better than corticosteroids or other conservative therapies.

CONCLUSION

Our recommendation for future research is that one should focus on adequately powered randomized trials comparing HA treatment with other types of intra-articular or conservative treatment. We think it is useless to further perform and publish (large) non-comparative prospective studies about the use of HA in the treatment of problems caused by OA. It is well perceived that HA exerts positive effects in the treatment of OA, but up to now there is no (strong) evidence available that HA is superior to other treatments of OA such as corticosteroids, physiotherapy or other conservative measures.

Intra-articular injection of hyaluronic acid is not superior to saline solution injection for ankle arthritis: a randomized, double-blind, placebo-controlled study

BACKGROUND

Intra-articular injections of hyaluronic acid are potentially useful to treat ankle osteoarthritis, yet their effectiveness has not been proven. Both single and multiple-dose treatments for ankle arthritis with use of various hyaluronic acid products have been recommended, but few high-quality studies have been published. The aim of this study was to compare the effectiveness of a single intra-articular injection of hyaluronic acid with a single intra-articular injection of normal saline solution (placebo) for osteoarthritis of the ankle.

METHODS

Sixty-four patients with ankle osteoarthritis who met all study criteria were randomly assigned to a single intra-articular injection of 2.5 mL of low-molecular-weight, non-cross-linked hyaluronic acid or a single intra-articular injection of 2.5 mL of normal saline solution. The primary outcome measure was the change from baseline in the American Orthopaedic Foot & Ankle Society (AOFAS) clinical rating score at the six-week and twelve-week follow-up examination. Secondary outcome measures included the Ankle Osteoarthritis Scale score and patient-reported pain with use of a visual analog pain scale.

RESULTS

Of the sixty-four patients randomized and treated, eight patients withdrew, leaving fifty-six patients who completed the entire study. There was one mild adverse event (1.6%) among the sixty-four patients. At six weeks and twelve weeks, the mean AOFAS scores in the hyaluronic acid group had improved from baseline by 4.9 and 4.9 points, respectively, whereas the mean AOFAS scores in the placebo group initially worsened by 0.4 point at six weeks and then improved by 5.4 points at twelve weeks. While the change at twelve weeks from baseline was substantial for both groups, the between-group differences were not significant.

CONCLUSIONS

We found that a single intra-articular injection of low-molecular-weight, non-cross-linked hyaluronic acid is not demonstrably superior to a single intra-articular injection of saline solution for the treatment of osteoarthritis of the ankle.

The effect of three weekly intra-articular injections of hyaluronate on pain, function, and balance in patients with unilateral ankle arthritis

BACKGROUND

Ankle arthritis can cause substantial pain and functional limitation. Previous studies have indicated that five weekly intra-articular injections of hyaluronate were safe and effective in the treatment of ankle osteoarthritis. The purpose of this study was to evaluate the effect and safety of three weekly injections of hyaluronate in patients with unilateral ankle arthritis.

METHODS

Fifty patients who had had unilateral ankle pain for at least six months and were classified radiographically as having Kellgren-Lawrence grade-2 or 3 ankle arthritis were recruited for a prospective study. Patients received three weekly intra-articular injections of hyaluronate. The primary outcome was the change in the Ankle Osteoarthritis Scale score at six months after the third injection. Secondary outcomes included the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score, four clinical tests of balance, consumption of rescue analgesics, and global patient satisfaction.

RESULTS

Forty-six participants completed the study. A significant reduction in the mean Ankle Osteoarthritis Scale score was noted at one, three, and six months after the third injection (p < 0.05 for each follow-up visit compared with baseline). The mean AOFAS Ankle-Hindfoot Score improved from 60.5 points at baseline to 73.5, 75.5, and 76.7 points at one, three, and six months of follow-up, respectively (p < 0.05). The patients demonstrated significant improvement on all four balance tests at each follow-up visit (p < 0.05 for each test compared with baseline). Acetaminophen consumption dropped significantly following treatment (p < 0.05). The patients' satisfaction rate was high, and no serious adverse events were reported.

CONCLUSIONS

This study suggests that three weekly injections of hyaluronate are well-tolerated and can provide pain relief and improve function and balance in patients with unilateral ankle arthritis. Larger controlled trials with longer follow-up are necessary to verify the effects of hyaluronate in the treatment of ankle arthritis.

Efficacy of ultrasound-guided steroid injections for pain management of midfoot joint degenerative disease

OBJECTIVE

To examine the efficacy of ultrasound (US)-guided injections for midfoot joint degenerative changes.

MATERIALS AND METHODS

The US images and radiographs of 63 patients with midfoot joint degenerative changes were retrospectively reviewed. In those patients who had US-guided intra-articular steroid injection, the response to the injection was recorded by reviewing the 2-week pain diaries and clinical notes. Partial or complete pain relief was defined as a positive response and the same or increased level of pain as a negative response to the injection.

RESULTS

Fifty-nine (59/63, 93.6%) patients with midfoot joint degenerative changes received US-guided injection. The majority of patients had a positive response up to 3 months post-injection (78.4% still experiencing pain relief at 2 weeks, 57.5% at 3 months and fewer than 15% of patients further than 3 months post-injection). The number of positive therapeutic responses did not differ significantly between patients with diagnostic and non-diagnostic response (p = 0.2636).

CONCLUSIONS

US-guided intra-articular injections for midfoot degenerative changes can have a good therapeutic result in the majority of patients up to 3 months post-injection. Therapeutic response cannot be predicted by a positive diagnostic response.

Viscosupplementation in the management of ankle osteoarthritis: a review

INTRODUCTION

Osteoarthritis (OA) is a disease of synovial joints and is the most common cause of chronic pain. Viscosupplementation (VS) with hyaluronic acid (HA) is largely used for knee osteoarthritis therapy but the evidence for its usefulness in ankle osteoarthritis is limited. The objective of this review is to assess the efficacy of viscosupplementation treatment of ankle osteoarthritis in the current literature.

METHODS

The following databases were searched: Medline (period 2006-2008), Database of Abstract on Reviews and Effectiveness and Cochrane Database of Systematic Reviews. Reference lists of relevant articles were controlled for additional references. The search terms Review, Viscosupplementation (VS), Osteoarthritis (OA), Hyaluronic acid (HA), Hyaluronan, Sodium hyaluronate, Ankle OA, Ankle joint were used to identify all studies relating to the use of VS therapy for the ankle OA. Methodological quality of included studies was assessed by assigning level of evidence as previously defined by the Centre for Evidence Based Medicine (CEBM).

RESULT

Seven articles concerning the efficacy of a total of 275 patients undergoing VS treatment for ankle OA were included. One European study, one Taiwanese study, one Italian study, one Turkish study and three American studies with level of evidence ranging from I to IV evaluated the following products: Hyalgan, Synvisc, Supartz, Adant.

CONCLUSION

Viscosupplementation is used widely in knee OA and is included in the professional guidelines for treatment of the disease in this joint. The potential for treating osteoarthritis of the ankle joint by viscosupplementation has been suggested in the literature, however, no dosing studies have been published to date, and dosing in the ankle joint remains an area for discussion. Viscosupplementation could potentially provide an useful alternative in treating such patients with painful ankle OA.

Intra-articular sodium hyaluronate injections in the osteoarthritic ankle joint: effects, safety and dose dependency

BACKGROUND

To determine the efficacy, safety and dose dependency of intra-articular Orthovisc(®) hyaluronic acid injections in the ankle.

METHODS

A prospective single blinded study in patients with symptomatic ankle-osteoarthritis. Patients were randomly allocated to 1, 2, 3 ml, or 3 weekly injections of 1 ml (3 × 1 ml). Primary outcome was 'pain during walking' at 15 weeks measured on a 100mm VAS.

RESULTS

Twenty-six patients (ITT) participated. The 3 × 1 ml dose group showed statistically significant decreases at week 7 for 'pain during walking' and 'pain at rest' (p=0.046). At week 15 decreases were significant for 'pain at rest' (p=0.046). There was no significant decrease of VAS-scores in any of the single dose groups. Seven patients experienced temporary local swelling and increased pain in the injected ankle.

CONCLUSIONS

Orthovisc(®) viscosupplementation in the ankle joint is effective and well tolerated. The 3 × 1 ml dose regimen shows the best results.