The OA Trial Bank: meta-analysis of individual patient data from knee and hip osteoarthritis trials show that patients with severe pain exhibit greater benefit from intra-articular glucocorticoids

Associations of dexamethasone's effect on morphine consumption after total knee arthroplasty-Subgroup analyses

The DEXamethasone twice for pain treatment after Total Knee Arthroplasty (DEX-2-TKA) trial showed that adding one and two doses of 24 mg intravenous dexamethasone to paracetamol, ibuprofen and local infiltration analgesia, reduced morphine consumption (primary outcome) within 48 h after TKA. We aimed to explore the differences in the effect of dexamethasone on morphine consumption in different subgroups. Quantile regression adjusted for site was used to test for significant interaction between the predefined dichotomised subgroups and treatment group. The subgroups were defined based on baseline data: sex (male/female), age (≤65 years/>65 years), American Society of Anaesthesiologists (ASA)-score (ASA I + II/III), visual analogue score of preoperative pain at rest (≤30 mm/>30 mm), pain during mobilisation (≤30 mm/>30 mm), type of anaesthesia (spinal anaesthesia/general anaesthesia and spinal converted to general anaesthesia), and prior daily use of analgesics (either paracetamol and/or NSAID/neither). These analyses were supplemented with post hoc multivariate linear regression analyses. Test of interaction comparing sex in the pairwise comparison between DX2 (dexamethasone [24 mg] + dexamethasone [24 mg]) versus placebo (p = .02), showed a larger effect of dexamethasone on morphine consumption in male patients compared to females. Test of interaction comparing age in the pairwise comparison between DX1 (dexamethasone [24 mg] + placebo) versus placebo (p = .04), showed a larger effect of dexamethasone on morphine consumption in younger patients (≤65 years) compared to older. All remaining subgroup analyses showed no evidence of a difference. The supplemental multivariate analyses did not support any significant interaction for sex (p = .256) or age (p = .730) but supported a significant interaction with the type of anaesthesia (p < .001). Our results from the quantile regression analyses indicate that the male sex and younger age (≤65 years) may be associated with a larger analgesic effect of dexamethasone than the effects in other types of patients. However, this is not supported by post-hoc multivariate linear regression analyses. The two types of analyses both supported a possible interaction with the type of anaesthesia.

Network-based cytokine inference implicates Oncostatin M as a driver of an inflammation phenotype in knee osteoarthritis

Inflammatory cytokines released by synovium after trauma disturb the gene regulatory network and have been implicated in the pathophysiology of osteoarthritis. A mechanistic understanding of how aging perturbs this process can help identify novel interventions. Here, we introduced network paradigms to simulate cytokine-mediated pathological communication between the synovium and cartilage. Cartilage-specific network analysis of injured young and aged murine knees revealed aberrant matrix remodeling as a transcriptomic response unique to aged knees displaying accelerated cartilage degradation. Next, network-based cytokine inference with pharmacological manipulation uncovered IL6 family member, Oncostatin M (OSM), as a driver of the aberrant matrix remodeling. By implementing a phenotypic drug discovery approach, we identified that the activation of OSM recapitulated an "inflammatory" phenotype of knee osteoarthritis and highlighted high-value targets for drug development and repurposing. These findings offer translational opportunities targeting the inflammation-driven osteoarthritis phenotype.

Predictors of Placebo Response to Local (Intra-Articular) Therapy In Osteoarthritis: An Individual Participant Data Meta-Analysis

OBJECTIVE

We undertook this study to evaluate potential predictors of placebo response with intra-articular (IA) injections for knee/hip osteoarthritis (OA) using individual participant data (IPD) from existing trials.

METHODS

Randomized placebo-controlled trials evaluating IA glucocorticoid or hyaluronic acid published to September 2018 were selected. IPD for disease characteristics and outcome measures were acquired. Potential predictors of placebo response included participant characteristics, pain severity, intervention, and trial design. Placebo response was defined as at least a 20% reduction in baseline pain. Logistic regression models and odds ratios were computed as effect measures to evaluate patient and pain mechanisms and then pooled using a random effects model. Generalized mixed-effect models were applied to intervention and trial characteristics.

RESULTS

Of 56 eligible trials, 6 shared data, and these were combined with the existing 4 OA Trial Bank studies, yielding 10 studies with IPD of 621 placebo participants for analysis. In the total placebo population, at short-term follow-up, the use of local anesthetic and ultrasound guidance were associated with reduced odds of placebo response. At midterm follow-up, mid- to long-term trial duration was associated with increased odds of placebo response, and worse baseline function scores were associated with reduced odds of a placebo response.

CONCLUSION

The administration of local anesthetics or ultrasound guidance may reduce IA placebo response at short-term follow-up. At midterm follow-up, participants with worse baseline function scores may be less likely to respond to IA placebo, and mid- to long-term trial duration may enhance the placebo response. Further studies are required to corroborate these potential predictors of IA placebo response.

Is it possible to predict which patients are most likely to benefit from intra-articular corticosteroid injections? A systematic review

AIM

Intra-articular corticosteroid injections (IACIs) can reduce osteoarthritis-related pain, with differing levels of response across patient groups. This systematic review investigates what is known about the positive and negative predictors of outcomes in patients with osteoarthritis who undergo IACIs.

METHODS

We systematically searched the Medline, Embase, and Cochrane databases to May 2023 for studies that evaluated patients undergoing IACIs for osteoarthritis and reported on predictors of outcomes in these patients.

RESULTS

Eight studies were included. Two were placebo-controlled trials, six were observational studies. Due to the heterogeneity of outcomes and variables between the studies, it was not possible to pool the results for formal meta-analysis. Higher baseline pain, older age, higher BMI, lower range of movement, higher Kellgren-Lawrence radiographic score, joint effusion, and aspiration were shown to be predictors of a positive response to IACIs in some of the included studies. However, other studies showed no difference in response with these variables, or a negative correlation with response. Sex, smoking, mental health status, hypertension/ischaemic heart disease, diabetes mellitus, duration of symptoms, and socioeconomic status did not demonstrate any correlation with the prediction of positive or negative outcomes after IACIs.

CONCLUSION

Several patient features have been identified as positive predictors of outcomes following IACIs. However, this systematic review has identified inconsistent and variable findings across the existing literature. Further research with standardization of IACI administration and outcome measures is required to facilitate further analysis of the reliability and significance of predictive factors for response to IACIs.

NOD2 attenuates osteoarthritis via reprogramming the activation of synovial macrophages

OBJECTIVE

Synovial inflammation, which precedes other pathological changes in osteoarthritis (OA), is primarily initiated by activation and M1 polarization of macrophages. While macrophages play a pivotal role in the inflammatory process of OA, the mechanisms underlying their activation and polarization remain incompletely elucidated. This study aims to investigate the role of NOD2 as a reciprocal modulator of HMGB1/TLR4 signaling in macrophage activation and polarization during OA pathogenesis.

DESIGN

We examined NOD2 expression in the synovium and determined the impact of NOD2 on macrophage activation and polarization by knockdown and overexpression models in vitro. Paracrine effect of macrophages on fibroblast-like synoviocytes (FLS) and chondrocytes was evaluated under conditions of NOD2 overexpression. Additionally, the in vivo effect of NOD2 was assessed using collagenase VII induced OA model in mice.

RESULTS

Expression of NOD2 was elevated in osteoarthritic synovium. In vitro experiments demonstrated that NOD2 serves as a negative regulator of HMGB1/TLR4 signaling pathway. Furthermore, NOD2 overexpression hampered the inflammatory paracrine effect of macrophages on FLS and chondrocytes. In vivo experiments revealed that NOD2 overexpression mitigated OA in mice.

CONCLUSIONS

Supported by convincing evidence on the inhibitory role of NOD2 in modulating the activation and M1 polarization of synovial macrophages, this study provided novel insights into the involvement of innate immunity in OA pathogenesis and highlighted NOD2 as a potential target for the prevention and treatment of OA.

Musculoskeletal corticosteroid injection and risk of acute coronary syndrome: a case control study

BACKGROUND

Musculoskeletal corticosteroid injection (CSI) is a frequently used treatment, considered safe with a low incidence of minor side effects.

OBJECTIVE

To investigate whether the incidence of acute coronary syndrome (ACS) is increased following corticosteroid injection for musculoskeletal conditions.

METHODS

Data were reviewed from 41,276 patients aged over 40 years and hospitalised with ACS between January 2015 and December 2019. Each ACS case was allocated up to 10 control patients from their primary care clinic, matched for age and sex. The cases and controls were reviewed for orthopaedic or rheumatological consultation including a CSI procedure and occurring prior to the hospital admission date. The incidence of CSI was compared between the case and control groups.

RESULTS

Data from a total of 413,063 patients were reviewed, 41,276 ACS cases and 371,787 controls. The mean age was 68.1, standard deviation (SD) = 13.1, 69.4% male. In the week prior to their hospital admission, 118 ACS patients were treated with CSI compared with 495 patients in the control group; odds ratio (OR) = 1.95 (1.56-2.43). In total, 98% of CSI procedures were carried out by orthopaedic specialists. An association between ACS and prior CSI was strongest in the days immediately prior to hospitalisation: OR = 3.11 (2.10-4.61) for patients who were injected 1 day before ACS. The association between ACS and CSI declined with increasing time between injection and hospital admission: at 90 days OR = 1.08 (0.98-1.18). The association remained robust when cardiovascular risk factors, history of rheumatological disease, and other co-morbidity were taken into consideration.

CONCLUSIONS

Musculoskeletal corticosteroid injection appears to substantially increase the risk of acute coronary syndrome.

Advancing drug delivery to articular cartilage: From single to multiple strategies

Articular cartilage (AC) injuries often lead to cartilage degeneration and may ultimately result in osteoarthritis (OA) due to the limited self-repair ability. To date, numerous intra-articular delivery systems carrying various therapeutic agents have been developed to improve therapeutic localization and retention, optimize controlled drug release profiles and target different pathological processes. Due to the complex and multifactorial characteristics of cartilage injury pathology and heterogeneity of the cartilage structure deposited within a dense matrix, delivery systems loaded with a single therapeutic agent are hindered from reaching multiple targets in a spatiotemporal matched manner and thus fail to mimic the natural processes of biosynthesis, compromising the goal of full cartilage regeneration. Emerging evidence highlights the importance of sequential delivery strategies targeting multiple pathological processes. In this review, we first summarize the current status and progress achieved in single-drug delivery strategies for the treatment of AC diseases. Subsequently, we focus mainly on advances in multiple drug delivery applications, including sequential release formulations targeting various pathological processes, synergistic targeting of the same pathological process, the spatial distribution in multiple tissues, and heterogeneous regeneration. We hope that this review will inspire the rational design of intra-articular drug delivery systems (DDSs) in the future.

Debate: Intra-articular steroid injections for osteoarthritis - harmful or helpful?☆,☆☆

Intra-articular corticosteroids injections are a widely used treatment for pain from symptomatic osteoarthritis. Systematic reviews show that the treatment effect is modest compared with intra-articular saline (often considered as placebo) and lasts for 2-4 weeks on average. Potentially as a consequence of limited therapeutic duration, repeated injections are often given up to 4 injections annually. In this context of repeat injections, recent evidence has emerged that intra-articular corticosteroids might be associated with more MRI-assessed quantitative cartilage thickness loss than saline injections. Guidelines vary in the recommendation for use of intra-articular corticosteroids. Given the frequency with which intra-articular corticosteroids injections are used, the size and scale of the population with osteoarthritis, it is critical to fully understand the benefits and drawbacks of intra-articular corticosteroids injections. That is the focus of this debate article.

Moderators of the effect of therapeutic exercise for knee and hip osteoarthritis: a systematic review and individual participant data meta-analysis

BACKGROUND

Many international clinical guidelines recommend therapeutic exercise as a core treatment for knee and hip osteoarthritis. We aimed to identify individual patient-level moderators of the effect of therapeutic exercise for reducing pain and improving physical function in people with knee osteoarthritis, hip osteoarthritis, or both.

METHODS

We did a systematic review and individual participant data (IPD) meta-analysis of randomised controlled trials comparing therapeutic exercise with non-exercise controls in people with knee osteoathritis, hip osteoarthritis, or both. We searched ten databases from March 1, 2012, to Feb 25, 2019, for randomised controlled trials comparing the effects of exercise with non-exercise or other exercise controls on pain and physical function outcomes among people with knee osteoarthritis, hip osteoarthritis, or both. IPD were requested from leads of all eligible randomised controlled trials. 12 potential moderators of interest were explored to ascertain whether they were associated with short-term (12 weeks), medium-term (6 months), and long-term (12 months) effects of exercise on self-reported pain and physical function, in comparison with non-exercise controls. Overall intervention effects were also summarised. This study is prospectively registered on PROSPERO (CRD42017054049).

FINDINGS

Of 91 eligible randomised controlled trials that compared exercise with non-exercise controls, IPD from 31 randomised controlled trials (n=4241 participants) were included in the meta-analysis. Randomised controlled trials included participants with knee osteoarthritis (18 [58%] of 31 trials), hip osteoarthritis (six [19%]), or both (seven [23%]) and tested heterogeneous exercise interventions versus heterogeneous non-exercise controls, with variable risk of bias. Summary meta-analysis results showed that, on average, compared with non-exercise controls, therapeutic exercise reduced pain on a standardised 0-100 scale (with 100 corresponding to worst pain), with a difference of -6·36 points (95% CI -8·45 to -4·27, borrowing of strength [BoS] 10·3%, between-study variance [τ2] 21·6) in the short term, -3·77 points (-5·97 to -1·57, BoS 30·0%, τ2 14·4) in the medium term, and -3·43 points (-5·18 to -1·69, BoS 31·7%, τ2 4·5) in the long term. Therapeutic exercise also improved physical function on a standardised 0-100 scale (with 100 corresponding to worst physical function), with a difference of -4·46 points in the short term (95% CI -5·95 to -2·98, BoS 10·5%, τ2 10·1), -2·71 points in the medium term (-4·63 to -0·78, BoS 33·6%, τ2 11·9), and -3·39 points in the long term (-4·97 to -1·81, BoS 34·1%, τ2 6·4). Baseline pain and physical function moderated the effect of exercise on pain and physical function outcomes. Those with higher self-reported pain and physical function scores at baseline (ie, poorer physical function) generally benefited more than those with lower self-reported pain and physical function scores at baseline, with the evidence most certain in the short term (12 weeks).

INTERPRETATION

There was evidence of a small, positive overall effect of therapeutic exercise on pain and physical function compared with non-exercise controls. However, this effect is of questionable clinical importance, particularly in the medium and long term. As individuals with higher pain severity and poorer physical function at baseline benefited more than those with lower pain severity and better physical function at baseline, targeting individuals with higher levels of osteoarthritis-related pain and disability for therapeutic exercise might be of merit.

FUNDING

Chartered Society of Physiotherapy Charitable Trust and the National Institute for Health and Care Research.

The OA Trial Bank: Update of individual patient data meta-analysis of intra-articular glucocorticoids in persons with knee and hip osteoarthritis

Objective

To evaluate the efficacy of intra--articular (IA) glucocorticoid for knee or hip osteoarthritis (OA) in specific subgroups of patients according to the baseline severity of pain and inflammatory signs using individual patient data (IPD) from existing trials. Furthermore, this study aims to assess if a baseline pain cut-off was associated with clinically important effectiveness of IA glucocorticoid. This is an update of an IA glucocorticoid IPD meta-analysis by the OA Trial Bank.

Method

Randomized trials evaluating one or more IA glucocorticoid preparations in hip and knee OA, published to May 2018 were selected. IPD of patient and disease characteristics and outcome measures were acquired. The primary outcome was pain severity at short-term follow-up (up to 4 weeks). Potential interaction effect of severe pain (≥70 points, 0-100 scale) and signs of inflammation at baseline were studied using a two-stage approach with general liner model followed by random effects model. Analysis of trend was conducted, assessing if a baseline pain cut-off was associated with the threshold for clinically important treatment effect of IA glucocorticoid compared to placebo.

Results

Four out of 16 eligible randomized clinical trials (n ​= ​641) were combined with the existing OA Trial Bank studies (n ​= ​620), yielding 1261 participants from eleven studies. Participants with severe baseline pain compared to those with less severe pain had greater pain reduction at mid-term (around 12 weeks) (mean reduction: -6.90 (95%CI -10.91; -2.90)), but not at short- and long-term. No interaction effects were found between inflammatory signs and IA glucocorticoid injections compared to placebo at all follow-up time-points. Analysis of trend demonstrated treatment response to IA glucocorticoid from baseline pain levels >50 (0-100 scale) and above.

Conclusion

This updated IPD meta-analysis demonstrated that participants with severe pain compared to those with less severe pain at baseline experienced significantly more pain relief with IA glucocorticoid compared with placebo at mid-term.

Recovery After Hip Arthroscopy in Patients With Combined Femoroacetabular Impingement and Labral Tears Compared With Isolated Pathology

Background

Outcomes for patients with femoroacetabular impingement (FAI) treated with hip arthroscopy can differ depending on whether there is underlying intra-articular pathology.

Purpose

To evaluate the outcomes of patients after undergoing hip arthroscopy depending on their underlying pathology (isolated FAI, isolated labral tear, or combined FAI and a labral tear) using the 12-Item International Hip Outcome Tool (iHOT-12).

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 75 patients diagnosed with FAI with or without labral tears and isolated labral tears who underwent hip arthroscopy performed by the same surgeon at a single institution from January 2014 to December 2019 were included in this study. All patients had at least 2 years of follow-up data. Patients were divided into 3 groups as follows: patients with FAI and an intact labrum; patients with an isolated labral tear; and patients with combined FAI and a labral tear. The iHOT-12 scores at 1.5, 3, 6, 12, 18, and >24 months postoperatively were compared and analyzed. Outcome scores were also evaluated in terms of the substantial clinical benefit (SCB) and the patient-acceptable symptomatic state (PASS).

Results

Of 75 patients who underwent hip arthroscopy, 14 had FAI, 23 had labral tears, and 38 had both. All groups showed significant improvements on the iHOT-12 from preoperative to the final follow-up (FAI, from 37.64 ± 3.77 to 93.64 ± 1.50; labral tear, from 33.70 ± 3.55 to 93 ± 1.24; combined, from 28.55 ± 3.15 to 93.03 ± 0.88) (P < .001 for all). However, compared with other groups, the patients with FAI and a labral tear had lower scores at 1.5, 3, 6, and 12 months postoperatively (P < .001), highlighting a slower rate of recovery. For all groups, recovery to normal function according to the SCB was 100% at 12 months, and satisfaction according to the PASS was 100% at 18 months postoperatively.

Conclusion

The final iHOT-12 scores were similar at 18 months regardless of the pathology treated; however, patients with FAI and a labral tear took longer to reach their plateau.

Multiple Injections of Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Current Evidence in Randomized Controlled Trials

In recent years, various clinical trials have focused on treating knee osteoarthritis (KOA) with multiple injections of platelet-rich plasma (PRP). However, compared with the multiple hyaluronic acid (m-HA) injections, the clinical efficacy of multiple PRP (m-PRP) injections for KOA still remains controversial among these studies. Therefore, we aimed to compare the clinical effectiveness of m-PRP injections with m-HA injections in the treatment of KOA in this systematic review. Relevant clinical trials were searched via bibliographic databases, including Medline, PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials, to compare the m-PRP and m-HA injections in the treatment of KOA. Finally, fourteen randomized controlled trials, including 1512 patients, showed the postoperative VAS, WOMAC, IKDC, or EQ-VAS scores and were enrolled in this systematic review. Compared with the group of intra-articular m-HA injections, the group of intra-articular m-PRP injections was lower in the VAS scores at 3-month (WMD = −0.25; 95%CI, −0.40 to −0.10, p = 0.0009) and 12-month (WMD = −0.64; 95%CI, −0.79 to −0.49, p < 0.00001) follow-ups. In addition, the group of intra-articular m-PRP injections was also lower in the WOMAC scores at 1-month (WMD = −1.23; 95%CI, −2.17 to −0.29, p = 0.01), 3-month (WMD = −5.34; 95%CI, −10.41 to −0.27, p = 0.04), 6-month (WMD = −11.02; 95%CI, −18.09 to −3.95, p = 0.002), and 12-month (WMD = −7.69; 95%CI, −12.86 to −2.52, p = 0.004) follow-ups. Furthermore, compared with the group of intra-articular m-HA injections, the group of intra-articular m-PRP injections was higher in the IKDC scores at 3-month (WMD = 7.45; 95%CI, 2.50 to 12.40, p = 0.003) and 6-month (WMD = 5.06; 95%CI, 1.94 to 8.18, p = 0.001) follow-ups. However, the long-term adverse side of m-PRP injections for KOA still needs more large-scale trials and long-term follow-ups.

Effects of recurrent intra-articular corticosteroid injections for osteoarthritis at 3 months and beyond: a systematic review and meta-analysis in comparison to other injectables

OBJECTIVE

Intra-articular corticosteroid injections (IACIs) provide temporary symptom relief in osteoarthritis (OA). This meta-analysis investigated the effects of recurrent IACIs at 3 months and beyond.

DESIGN

We searched Medline, Embase and Cochrane from inception to January 2021 for randomised controlled trials (RCTs) of patients with OA who received recurrent IACIs compared with other injectables, placebo or no treatment (primary outcomes: pain, function). Mean differences (MDs) with 95% confidence intervals were reported.

RESULTS

Ten RCTs were included (eight knee OA (n = 763), two trapeziometacarpal OA (n = 121)). Patients received between 2 and 8 injections, varying by trial. Trials compared recurrent IACIs with hyaluronic acid (HA), platelet-rich plasma (PRP), saline or orgotein (follow-up 3-24 months). Greater improvements in pain, function and QoL at 3-24 months were noted for the comparators than with IACIs, with comparators demonstrating an equal or superior effect, or the intervention effect attenuated during follow-up. Recurrent IACIs demonstrated no benefits in pain or function over placebo at 12-24 months. No serious adverse events were recorded. No studies reported on time-to-future interventions, risk of future prosthetic joint infection or other adverse events associated with subsequent joint replacement.

CONCLUSIONS

Recurrent IACIs often provide inferior (or non-superior) symptom relief compared with other injectables (including placebo) at 3 months and beyond. Other injectables (HA, PRP) often yielded greater improvements in pain and function up to 24 months post-injection. Existing RCTs on recurrent IACIs lack sufficient follow-up data to assess disease progression and time-to-future interventions.

Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience

Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from – unfortunately, there is no consensus on which treatments are “better” and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.

Meta-analysis Integrated With Multi-omics Data Analysis to Elucidate Pathogenic Mechanisms of Age-Related Knee Osteoarthritis in Mice

Increased mechanistic insight into the pathogenesis of knee osteoarthritis (KOA) is needed to develop efficacious disease-modifying treatments. Though age-related pathogenic mechanisms are most relevant to the majority of clinically presenting KOA, the bulk of our mechanistic understanding of KOA has been derived using surgically induced posttraumatic OA (PTOA) models. Here, we took an integrated approach of meta-analysis and multi-omics data analysis to elucidate pathogenic mechanisms of age-related KOA in mice. Protein-level data were integrated with transcriptomic profiling to reveal inflammation, autophagy, and cellular senescence as primary hallmarks of age-related KOA. Importantly, the molecular profiles of cartilage aging were unique from those observed following PTOA, with less than 3% overlap between the 2 models. At the nexus of the 3 aging hallmarks, advanced glycation end product (AGE)/receptor for AGE (RAGE) emerged as the most statistically robust pathway associated with age-related KOA. This pathway was further supported by analysis of mass spectrometry data. Notably, the change in AGE-RAGE signaling over time was exclusively observed in male mice, suggesting sexual dimorphism in the pathogenesis of age-induced KOA in murine models. Collectively, these findings implicate dysregulation of AGE-RAGE signaling as a sex-dependent driver of age-related KOA.

Clinical effectiveness of one ultrasound guided intra-articular corticosteroid and local anaesthetic injection in addition to advice and education for hip osteoarthritis (HIT trial): single blind, parallel group, three arm, randomised controlled trial

OBJECTIVE

To compare the clinical effectiveness of adding a single ultrasound guided intra-articular hip injection of corticosteroid and local anaesthetic to advice and education in adults with hip osteoarthritis.

DESIGN

Pragmatic, three arm, parallel group, single blind, randomised controlled trial.

SETTING

Two community musculoskeletal services in England.

PARTICIPANTS

199 adults aged ≥40 years with hip osteoarthritis and at least moderate pain: 67 were randomly assigned to receive advice and education (best current treatment (BCT)), 66 to BCT plus ultrasound guided injection of triamcinolone and lidocaine, and 66 to BCT plus ultrasound guided injection of lidocaine.

INTERVENTIONS

BCT alone, BCT plus ultrasound guided intra-articular hip injection of 40 mg triamcinolone acetonide and 4 mL 1% lidocaine hydrochloride, or BCT plus ultrasound guided intra-articular hip injection of 5 mL 1% lidocaine. Participants in the ultrasound guided arms were masked to the injection they received.

MAIN OUTCOME MEASURES

The primary outcome was self-reported current intensity of hip pain (0-10 Numerical Rating Scale) over six months. Outcomes were self-reported at two weeks and at two, four, and six months.

RESULTS

Mean age of the study sample was 62.8 years (standard deviation 10.0) and 113 (57%) were women. Average weighted follow-up rate across time points was 93%. Greater mean improvement in hip pain intensity over six months was reported with BCT plus ultrasound-triamcinolone-lidocaine compared with BCT: mean difference -1.43 (95% confidence interval -2.15 to -0.72), P<0.001; standardised mean difference -0.55 (-0.82 to -0.27). No difference in hip pain intensity over six months was reported between BCT plus ultrasound-triamcinolone-lidocaine compared with BCT plus ultrasound-lidocaine (-0.52 (-1.21 to 0.18)). The presence of ultrasound confirmed synovitis or effusion was associated with a significant interaction effect favouring BCT plus ultrasound-triamcinolone-lidocaine (-1.70 (-3.10 to -0.30)). One participant in the BCT plus ultrasound-triamcinolone-lidocaine group with a bioprosthetic aortic valve died from subacute bacterial endocarditis four months after the intervention, deemed possibly related to the trial treatment.

CONCLUSIONS

Ultrasound guided intra-articular hip injection of triamcinolone is a treatment option to add to BCT for people with hip osteoarthritis.

TRIAL REGISTRATION

EudraCT 2014-003412-37; ISRCTN50550256.

Effect of Intramuscular vs Intra-articular Glucocorticoid Injection on Pain Among Adults With Knee Osteoarthritis: The KIS Randomized Clinical Trial

IMPORTANCE

Intra-articular (IA) glucocorticoid injection is widely used in patients with knee osteoarthritis (OA), but the safety of this technique is in question among physicians. Intramuscular (IM) glucocorticoid injection could be an alternative approach.

OBJECTIVE

To investigate whether an IM glucocorticoid injection is noninferior to an IA glucocorticoid injection in reducing knee pain for patients with knee OA in primary care.

DESIGN, SETTING, AND PARTICIPANTS

The KIS trial, a multicenter, open-label, randomized clinical noninferiority trial including patients with symptomatic knee OA, was conducted in 80 primary care general practices in the southwest of the Netherlands. The study was conducted from March 1, 2018, to July 28, 2020.

INTERVENTIONS

Patients were randomly allocated to receive an injection of triamcinolone acetonide, 40 mg, either IM in the ipsilateral ventrogluteal region or IA in the knee joint. All patients were followed up for 24 weeks.

MAIN OUTCOMES AND MEASURES

The pain score at 4 weeks measured with Knee Injury and Osteoarthritis Outcome Score (range, 0-100; 0 indicates extreme pain), with a noninferiority margin of -7 (IM minus IA). A per-protocol analysis was prespecified as the primary analysis.

RESULTS

A total of 145 patients (94 women [65%]; mean [SD] age, 67 [10] years) were included; of these, 138 patients (IM, 72; IA, 66) were included in the per-protocol analysis. Clinically relevant improvements in knee pain were reached up to 12 weeks after the injection in both groups. At 4 weeks, the estimated mean difference in the Knee Injury and Osteoarthritis Outcome Score between the 2 groups was -3.4 (95% CI, -10.1 to 3.3). Noninferiority could not be declared because the lower limit exceeded the noninferiority margin. Intramuscular injection was noninferior to IA injection at 8 (mean difference, 0.7; 95% CI, -6.5 to 7.8) and 24 (mean difference, 1.6; 95% CI, -5.7 to 9.0) weeks. No significant difference was found among all the secondary outcomes. These results were similar for the sensitivity analysis in an intention-to-treat population. The most frequently reported adverse events were hot flush (IM, 7 [10%] vs IA, 14 [21%]) and headache (IM, 10 [14%] vs IA, 12 [18%]), and all events were classified as nonserious.

CONCLUSIONS AND RELEVANCE

Based on the findings of this trial, among patients with knee OA in primary care, IM glucocorticoid injection could present an inferior effect in reducing pain at 4 weeks compared with IA injection. Noninferiority of an IM injection was observed at 8 and 24 weeks after injection. This trial provides data for shared decision-making, taking into account the advantages and disadvantages of both types of injections.

TRIAL REGISTRATION

Dutch Trial Registry: NTR6968.

Joint synovial macrophages as a potential target for intra-articular treatment of osteoarthritis-related pain

Osteoarthritis is the most common form of joint disease and is one of the leading causes of chronic pain. Given the multi-factorial nature, numerous efforts have been made to clarify the multiple factors impacting the pain symptoms and joint pathology, including synovial macrophages in particular. Accumulating evidence from studies involving human participants and experimental animal models suggests that accumulating macrophages in synovial tissue are implicated in peripherally mediated pain sensitization of affected joints in osteoarthritis. Crosstalk between synovial macrophages and the innervating primary nociceptive neurons is thought to contribute to this facilitated pain processing by the peripheral nervous system. Due to high plasticity and complexity of synovial macrophages in the joint, safe therapies targeting single cells or molecules are currently lacking. Using advanced technologies (such as single-cell RNA sequencing and mass cytometry), studies have shown that diverse subpopulations of synovial macrophages exist in the distinct synovial microenvironments of specific osteoarthritis subtypes. Considerable progress has been made in delineating the molecular mechanisms of various subsets of synovial macrophages in the development of osteoarthritis. To develop a novel intra-articular treatment paradigm targeting synovial macrophages, we have summarized in this review the recent advances in identifying the functional consequences of synovial macrophage sub-populations and understanding of the molecular mechanisms driving macrophage-mediated remodeling.

Osteoarthritis year in review 2021: epidemiology & therapy

This "Year in review" presents a selection of research themes and individual studies from the clinical osteoarthritis (OA) field (epidemiology and therapy) and includes noteworthy descriptive, analytical-observational, and intervention studies. The electronic database search for the review was conducted in Medline, Embase and medRxiv (15th April 2020 to 1st April 2021). Following study screening, the following OA-related themes emerged: COVID-19; disease burden; occupational risk; prediction models; cartilage loss and pain; stem cell treatments; novel pharmacotherapy trials; therapy for less well researched OA phenotypes; benefits and challenges of Individual Participant Data (IPD) meta-analyses; patient choice-balancing benefits and harms; OA and comorbidity; and inequalities in OA. Headline study findings included: a longitudinal cohort study demonstrating no evidence for a harmful effect of non-steroidal anti-inflammatory drugs (NSAIDs) in terms of COVID-19 related deaths; a Global Burden of Disease study reporting a 102% increase in crude incidence rate of OA in 2017 compared to 1990; a longitudinal study reporting cartilage thickness loss was associated with only a very small degree of worsening in pain over 2 years; an exploratory analysis of a non-OA randomised controlled trial (RCT) finding reduced risk of total joint replacement with an Interleukin -1β inhibitor (canakinumab); a significant relationship between cumulative disadvantage and clinical outcomes of pain and depression mediated by perceived discrimination in a secondary analysis from a RCT; worsening socioeconomic circumstances were associated with future arthritis diagnosis in an innovative natural experiment (with implications for unique research possibilities arising from the COVID-19 pandemic context).

Platelet-rich plasma outcomes do not correlate with patient satisfaction or perceived cost-effectiveness

BACKGROUND

As platelet-rich plasma injection for knee osteoarthritis (OA) has increased in popularity, it has become more important to assess its effectiveness and satisfaction with its use in the context of its high cost. The purpose of this study was to determine satisfaction, commercial appeal, and effectiveness of platelet-rich plasma (PRP) for the treatment of knee OA.

METHODS

A retrospective review of patients who underwent PRP injection in the knee from 2016 to 2019 was performed. Various patient-reported outcomes were collected, including: satisfaction with the PRP injection (out of 100), whether the patient would want to undergo PRP injection again, whether they would recommend the injection and whether they felt that the injection was worth the cost was collected. VAS pain scores were collected and measured out of 100. Demographics and radiographical information were obtained via chart review. Statistical analyses were conducted including descriptive statistics and binary logistic and linear regressions.

RESULTS

Overall, 114 patients were included. The mean pre-injectionpain score was 70.4, and the mean pain level decreased after injection to 36.8. Patients rated their satisfaction on average as neutral along the aforementioned continuous scale (49.2), , 50.9% stated that they would get the PRP injection again, 60.5% would recommend to a friend, and 50.9% felt the injection was worth the cost. Younger age and improved post-injection pain correlated with increasing likelihood of desiring further PRP injection.

CONCLUSIONS

Patients on average rated satisfaction slightly below average, indicating net neutrality in terms of satisfaction with their injection. Furthermore, only half of the patients indicated that it was worth the cost and that they would receive it again. Younger age and post-injection pain relief increased desire for further injection, but pain-relief did not correlate with patients saying that the injection was worth the cost.

Subgroup effects of non-surgical and non-pharmacological treatment of patients with hand osteoarthritis: a protocol for an individual patient data meta-analysis

INTRODUCTION

Hand osteoarthritis (OA) is a common joint disorder in the adult population. No cure for hand OA is known yet, but treatment aims to reduce symptoms. Non-surgical and non-pharmacological therapy interventions can include splinting, patient education, and strengthening and range of movement exercises. However, it is still unclear which treatment is most beneficial for which patient. This study aims to identify subgroups of patients with hand OA that benefit most from the different non-surgical and non-pharmacological treatments.

METHODS AND ANALYSIS

We will conduct an individual patient data (IPD) meta-analysis by extracting IPD of eligible published randomised controlled trials (RCTs). A systematic literature search through Embase, Medline and Cochrane was performed on 8 February 2021. The primary outcome will be hand pain, and our secondary outcomes are objective and subjective hand physical functions. Subgroups include age, sex, body mass index, hypermobility and other comorbidities, pain medication, occupation, baseline pain, erosive OA, type and the number of hand joints involved, radiological severity of OA, and duration of symptoms. IPD of RCTs with homogeneous treatment interventions will be pooled and analysed using a two-stage approach to evaluate treatment effect on different subgroups.

ETHICS AND DISSEMINATION

No new data will be collected, so research ethical or governance approval is exempt. Findings will be disseminated via national and international conferences, publications in peer-reviewed journals, and summaries posted on websites accessed by the public and clinicians.

Intra-articular injection of triamcinolone acetonide sustains macrophage levels and aggravates osteophytosis during degenerative joint disease in mice

BACKGROUND AND PURPOSE

Corticosteroids such as triamcinolone acetonide (TAA) are potent drugs administered intra-articularly as an anti-inflammatory therapy to relieve pain associated with osteoarthritis (OA). However, the ability of early TAA intervention to mitigate OA progression and modulate immune cell subsets remains unclear. Here we sought to understand the effect of early intra-articular injection of TAA towards OA progression, local macrophages and peripheral blood monocytes.

EXPERIMENTAL APPROACH

Degenerative joint disease was induced by intra-articular injection of collagenase into the knee joint of C57BL/6 mice. After one week, TAA or saline was injected intra-articularly. Blood was taken throughout the study to analyse monocyte subsets. Mice were euthanised at day 14 and 56 post-induction of collagenase-induced OA (CiOA) to examine synovial macrophages and structural OA features.

KEY RESULTS

The percentage of macrophages relative to total live cells present within knee joints was increased in collagenase- compared to saline-injected knees at day 14 and was not altered by TAA treatment. However, at day 56 post-induction of CiOA TAA-treated knees had increased levels of macrophages compared with the knees of untreated CiOA-mice. The distribution of monocyte subsets present in peripheral blood was not altered by TAA treatment during the development of CiOA. Osteophyte maturation was increased in TAA-injected knees at day 56.

CONCLUSION AND IMPLICATIONS

Intra-articular injection of TAA increases long-term synovial macrophage numbers and osteophytosis. Our findings suggest that TAA accentuates the progression of osteoarthritis-associated features when applied to an acutely inflamed knee.

Injectable therapies for knee osteoarthritis

Knee osteoarthritis is a degenerative arthritis that mainly affects older adults. Over time, osteoarthritis can result in significant and sustained discomfort, pain, and disability. Current treatment focuses on the alleviation of pain and functional impairment. While arthroplasty is the definitive management option, it subjects patients to surgical complications, and the possibility of surgical revisions. In addition, many patients are not surgical candidates. Instead, pharmacological therapy is recommended first-line for most patients. On top of pharmacological therapy, there are a range of non-operative procedural options available. However, leading professional guidelines vary in their recommendations for these agents. Therefore, we present a review of recent randomized controlled trials and meta-analyses on injectable corticosteroids, hyaluronic acid (HA), platelet-rich plasma (PRP), mesenchymal stem cell injections, and ozone therapy. The preliminary data reveal the strongest evidence in favour of corticosteroid injections, although there are promising findings regarding the long-term efficacy of HA and PRP.

The efficacy of intra-articular injections in the treatment of knee osteoarthritis: A network meta-analysis of randomized controlled trials

PURPOSE

Osteoarthritis (OA) is a debilitating joint disease characterized by progressive loss of articular cartilage. Intra-articular injections are a mainstay of nonoperative treatment, however, there is controversy as to the optimal injectable for these patients. The purpose of the current study is to perform a network meta-analysis of the randomized control trials in the literature to ascertain whether there is a superior injectable nonoperative treatment for knee OA.

METHODS

The literature search was conducted based on the PRISMA guidelines. Randomized control trials (RCTs) evaluating intra-articular injectables in osteoarthritic knees were included. Data was extracted and Visual Analogue Scale (VAS) scores and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, where available were analyzed at 1, 3, 6 and 12 months. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-Score.

RESULTS

Seventy-nine RCTs with 8761 patients were included in this review. Intra-articular injectables evaluated included autologous conditioned serum (ACS), bone marrow aspirate concentrate (BMAC), botulinum toxin, corticosteroids (CS), hyaluronic acid (HA), mesenchymal stem cells (MSC), ozone, saline placebo, platelet-rich plasma (PRP), plasma rich in growth factor (PRGF), and stromal vascular fraction (SVF). At 4-6 weeks and 3 months of follow-up, the treatment with the highest P-Score for WOMAC score was high molecular weight (HMW) HA + CS [P-Score = 0.9500 and 8503, respectively]. At 6-months follow-up, the treatment with the highest P-Score for WOMAC score was PRP [P-Score = 0.7676]. At all post-injection time points, the treatment with the highest P-Score for VAS score [P-Score Range = 0.8631-9927] and Womac score at 12 Months [P-Score = 0.9044] was SVF.

CONCLUSIONS

The current evidence shows that SVF injections result in the greatest improvement in pain and functional outcomes in patients with knee OA at up to 1 year of follow-up.

Identifying predictors of response to oral non-steroidal anti-inflammatory drugs and paracetamol in osteoarthritis: a hypothesis-driven protocol for an OA Trial Bank individual participant data meta-analysis

INTRODUCTION

Symptomatic treatments for osteoarthritis (OA) provide only small-to-moderate efficacy over placebo in randomised controlled trials (RCTs). Treatment guidelines therefore have emphasised the need to identify predictors of treatment response through subgroup and multiple regression analysis. Individual participant data (IPD) meta-analysis is recommended as an efficient approach for this purpose. To our knowledge, this has not been undertaken for oral non-steroidal anti-inflammatory drugs (NSAIDs), including paracetamol, in OA. In this IPD meta-analysis, we aim to identify RCTs with specific mechanistic features related to OA pain, such as joint inflammation. We hypothesise that NSAIDs may work better for participants with joint inflammation, whereas paracetamol may not.

METHODS AND ANALYSIS

A comprehensive literature search will be conducted on the databases of Web of Science, Embase, Medline, CINAHL, AMED and the Cochrane Library from 1 January 1998 to 1 December 2020. All RCTs related to oral NSAIDs or paracetamol including placebo-controlled trials in people with OA that have evaluated pain-related peripheral risk factors (eg, clinically detected knee effusion, synovial hypertrophy or effusion on imaging, knee morning stiffness, elevated serum C-reactive protein (CRP) level) and/or central pain risk factors (eg, pain elsewhere, depression, anxiety, sleep disturbance) will be retrieved. The outcome will be change in pain from baseline. Change in function and patient global assessment will also be included as outcomes if available. Investigators of all eligible trials will be contacted for IPD. Multilevel regression models will be used to identify predictors for the specific (active-placebo) and the overall treatment effect (change from baseline in active group).

ETHICS AND DISSEMINATION

No identifiable data will be included in this study and no formal ethics approval is required as no new data collection will be processed. Results of this hypothesis-driven IPD meta-analysis will be disseminated through conference presentations and publication in peer-reviewed journals.

PROSPERO REGISTRATION NUMBER

CRD42020165098.

Predicting outcomes in patients undergoing intra-articular corticosteroid hip injections

OBJECTIVE

To investigate the associations between clinical, procedural, and radiographic factors and outcomes of steroid hip injections, including long-term and immediate pain reduction, time to arthroplasty, time to reinjection, and the total number of injections.

MATERIALS AND METHODS

All intra-articular anesthetic and steroid injections of the hip under fluoroscopic guidance between January 2014 and March 2016 were retrospectively reviewed. Hip radiographs were scored using the Kellgren-Lawrence (KL) and Osteoarthritis Research Society International (OARSI) scores. Immediate pain relief and response were evaluated using a change in visual analog scale and OMERACT-OARSI criteria respectively. Long-term pain relief was evaluated at 2‑7 months after injection by reviewing the medical records. Correlation between patient characteristics, procedural variations, and radiographic factors with injection outcomes was analyzed by using linear and logistic regression models.

RESULTS

Of 361 injections, 79.8% showed an immediate pain response and 32.7% had subjective long-term pain relief (> 2 months). There was no significant correlation between immediate pain relief and response with long-term pain relief and other outcomes. Older age and higher KL score, OARSI-central joint space narrowing (JSN), and inferior acetabular osteophyte were correlated with long-term pain relief (p = 0.01‑0.03). Higher KL and OARSI grades, particularly JSN, were significantly correlated with increased immediate pain relief and total number of injections but decreased time to arthroplasty. Baseline pain positively correlated with immediate pain response (p < 0.001).

CONCLUSIONS

Older patients with higher grades of radiographic OA and high baseline pain were good candidates for steroid injections, particularly for those patients awaiting hip arthroplasty.

Calcyclin (S100A6) Attenuates Inflammatory Response and Mediates Apoptosis of Chondrocytes in Osteoarthritis via the PI3K/AKT Pathway

OBJECTIVE

To clarify the regulatory effect of Calcyclin (S100A6) on chondrocytes apoptosis and its relationship with progression of osteoarthritis in an effort to explore potential therapeutic targets for osteoarthritis.

METHOD

Immunofluorescence assay was produced to identify the rat chondrocyte sample and western blots assay was detected the expression changes of S100A6 between control group and osteoarthritis model which induced by interleukin-1β. Adenovirus were transfected into the chondrocytes in vitro, in order to regulate the S100A6 expression. The influence of S100A6 on inflammatory reaction of osteoarthritis was detected by RT-PCR. Also, Caspase-3 activity assay and TUNEL assay were performed to evaluate the apoptosis changes. In addition, RT-PCR and western blots were performed to verify that S100A6 mediated the PI3K/AKT signaling pathway. Through the usage of pathway regulator, we detected S100A6 produced the effect by mediating the PI3K/AKT pathway.

RESULTS

We determined the expression of S100A6 decreased in osteoarthritis model, the relative expression level in osteoarthritis model was about 0.5 fold compared with control group. Through adenovirus transfection we revealed that the inflammatory factors of osteoarthritis (interleukin-6 and matrix metalloproteinase-13) showed a negative correlation with the S100A6 expression. The relative expression level of interleukin-6 and matrix metalloproteinase-13 were 1.534 and 1.259 when S100A6 was up-regulated and the values were up to 2.445 and 2.074, respectively, when S100A6 was down-regulated. Also, the data verified the apoptosis could be reduced when the S100A6 was up-regulated and be activated when the S100A6 was down-regulated, the Caspase-3 activity was 16.512 U/μg and 24.45 U/μg respectively. Similar results were shown in TUNEL assay, the apoptosis index was 4.46% and 31.44%, respectively. Additionally, the results of polymerase chain reaction and western blots both demonstrated that the expression level of PI3K and AKT were increased when S100A6 was up-regulated, conversely the expression level of those two signal modules were reduced if the S100A6 was down-regulated. More importantly, the apoptosis triggered by S100A6 can be offset by the PI3K/AKT pathway inhibitor and activator (LY294002 and IGF-1), the values of Caspase-3 activity and apoptosis index became close to the untreated osteoarthritis group. The experimental results in this study were statistically significant.

CONCLUSION

We investigated that Calcyclin (S100A6) relieved the inflammation and mediated the chondrocyte apoptosis through PI3K/AKT pathway and we confirmed that S100A6 might be an attractive therapeutic target.

Meditation Monologue can Reduce Clinical Injection-Related Anxiety: Randomized Controlled Trial

Background.

Strategies to reduce anxiety prior to injection procedures are not well understood. The purpose is to determine the effect of a meditation monologue intervention delivered via phone/mobile application on pre-injection anxiety levels among patients undergoing a clinical injection. The following hypothesis was tested: patients who listened to a meditation monologue via phone/mobile application prior to clinical injection would experience less anxiety compared to those who did not.

Methods.

A prospective, randomized controlled trial was performed at an orthopedics and sports medicine clinic of a tertiary level medical center in the New England region, USA. Thirty patients scheduled for intra- or peri-articular injections were randomly allocated to intervention (meditation monologue) or placebo (nature sounds) group. Main outcome variables were state and trait anxiety inventory (STAI) scores and blood pressure (BP), heart rate, and respiratory rate.

Results.

There were 16 participants who were allocated to intervention (meditation monologue) while 14 participants were assigned to placebo (nature sounds). There was no interaction effect. However, a main time effect was found. Both state anxiety (STAI-S) and trait anxiety (STAI-T) scores were significantly reduced post-intervention compared to pre-intervention (STAI-S: p = 0.04, STAI-T: p = 0.04). Also, a statistically significant main group effect was detected. The pre- and post- STAI-S score reduction was greater in the intervention group (p = 0.028). Also, a significant diastolic BP increase between pre- and post-intervention was recorded in the intervention group (p = 0.028), but not in the placebo group (p = 0.999).

Conclusion.

Listening to a meditation monologue via phone/mobile application prior to clinical injection can reduce anxiety in adult patients receiving intra- and peri-articular injections. Registration:ClinicalTrials.gov NCT02690194

MicroRNA-200b relieves LPS-induced inflammatory injury by targeting FUT4 in knee articular chondrocytes in vitro

Osteoarthritis (OA), characterized by the degeneration of articular cartilage, is a major problem in aging populations, and cartilage chondrocytes have been indicated to serve a curial role in the progression of OA. MicroRNA-200b-3p (miR-200b) was preliminarily identified to participate in OA. However, its role and mechanism of action in injured chondrocytes in OA remain unclear to date. In the present study, lipopolysaccharide (LPS)-treated cells isolated from normal knee articular cartilage were used to mimic inflammatory injury of OA chondrocytes. Cell viability, apoptosis and inflammatory responses were detected using Cell Counting Kit-8, flow cytometry and enzyme-linked immunosorbent assay, respectively. The expression levels of miR-200b and fucosyltransferase-4 (FUT4) were measured by reverse transcription-quantitative PCR and western blotting. The association between miR-200b and FUT4 was verified using TargetScan software, dual-luciferase reporter assay and RNA immunoprecipitation. The results indicated that LPS treatment decreased cell viability of primary chondrocytes, and increased apoptosis rate and production of IL-1β, IL-6 and TNF-α. The expression level of miR-200b was downregulated, and that of FUT4 was upregulated in OA cartilage tissues and LPS-treated normal chondrocytes compared with normal cartilage tissues and chondrocytes. Overexpression of miR-200b via transfection with miR-200b mimic inhibited the apoptosis rate and reduced the levels of IL-1β, IL-6 and TNF-α in LPS-stimulated chondrocytes. However, the suppressive effect of miR-200b overexpression on the LPS-induced inflammatory injury in chondrocytes was reversed by the restoration of FUT4 levels. Notably, FUT4 was indicated to be a downstream target of miR-200b and was negatively regulated by miR-200b. Taken together, the results of the current study indicated that miR-200b protected chondrocytes from LPS-induced inflammatory injury in vitro by targeting FUT4. These findings revealed the miR-200b/FUT4 axis as a potential candidate to target the degeneration of cartilages, thereby inhibiting the progression of OA.

Effects of mechanical interventions in the management of knee osteoarthritis: protocol for an OA Trial Bank systematic review and individual participant data meta-analysis

INTRODUCTION

Knee osteoarthritis (OA) is a prevalent and disabling musculoskeletal condition. Biomechanical factors may play a key role in the aetiology of knee OA, therefore, a broad class of interventions involves the application or wear of devices designed to mechanically support knees with OA. These include gait aids, bracing, taping, orthotics and footwear. The literature regarding efficacy of mechanical interventions has been conflicting or inconclusive, and this may be because certain subgroups with knee OA respond better to mechanical interventions. Our primary aim is to identify subgroups with knee OA who respond favourably to mechanical interventions.

METHODS AND ANALYSIS

We will conduct a systematic review to identify randomised clinical trials of any mechanical intervention for the treatment of knee OA. We will invite lead authors of eligible studies to share individual participant data (IPD). We will perform an IPD meta-analysis for each type of mechanical intervention to evaluate efficacy, with our main outcome being pain. Where IPD are not available, this will be achieved using aggregate data. We will then evaluate five potential treatment effect modifiers using a two-stage approach. If data permit, we will also evaluate whether biomechanics mediate the effects of mechanical interventions on pain in knee OA.

ETHICS AND DISSEMINATION

No new data will be collected in this study. We will adhere to institutional, national and international regulations regarding the secure and confidential sharing of IPD, addressing ethics as indicated. We will disseminate findings via international conferences, open-source publication in peer-reviewed journals and summaries posted on websites serving the public and clinicians.

PROSPERO REGISTRATION NUMBER

CRD42020155466.

Predicting response to topical non-steroidal anti-inflammatory drugs in osteoarthritis: an individual patient data meta-analysis of randomized controlled trials

Objectives

To identify predictors of the specific (difference between treatment and placebo) and overall (change from baseline in treatment arm) treatment effects of topical NSAIDs in OA.

Methods

Randomized controlled trials (RCTs) of topical NSAIDs in OA were identified through systematic literature searching and inquiry to pharmaceutical companies. The raw, de-identified data were analysed in one-stage individual patient data meta-analysis (IPD-MA). Negative values for treatment effects (0–100 scale) indicate pain reduction.

Results

Of 63 eligible RCTs, 15 provided IPD (n = 1951 on topical NSAID), including 11 placebo-controlled RCTs (n = 1587 on topical NSAIDs, 1553 on placebo). Seven potential predictors of response were examined. Topical NSAIDs were superior to placebo [−6 (95% CI −9, −4)], with a small, but statistically significant greater effect in women than men [difference −4 (95% CI −8, −1)]. The overall treatment effect was 4-fold larger than the specific effect [−25 (95% CI −31, −19)] and increased with greater baseline pain severity (P < 0.001). No differences in efficacy were observed for age, BMI, features of inflammation, duration of complaints or radiographic OA severity.

Conclusion

Topical NSAIDs are effective for OA pain relief. Greater overall pain relief in individuals with more baseline pain might be due to contextual and non-specific effects, including regression to the mean. Additional factors that have been linked either mechanistically or through empirical evidence to outcomes should be selected for inclusion across future RCTs in order to facilitate the identification of response predictors through IPD-MA.

Critical appraisal of intra-articular glucocorticoid injections for symptomatic osteoarthritis of the knee

OBJECTIVE

Intra-articular (IA) injections of glucocorticoids (GCs) have been shown to decrease pain, increase mobility, and improve quality of life in patients with osteoarthritis (OA) of the knee. Concerns about cartilage loss with IA GCs have prompted reconsideration of their use in knee OA. This review has three objectives: 1) critically review the clinical, molecular, and structural effects of IA GCs in knee OA; 2) provide a design for a clinical trial aimed at improving our understanding of the long-term consequences of IA GCs; and 3) provide practical guidance on the use of IA GCs in patients with knee OA based on current information.

DESIGN

A narrative review of current literature on the use of IA GCs for OA of the knee.

RESULTS

Important questions remain to be fully answered with respect to IA GCs, including long-term effects on all aspects of the structural and molecular environment of the knee, and identification of factors that can reliably predict a positive or negative response to IA GCs.

CONCLUSIONS

While awaiting results from an appropriately designed study, several provisional statements regarding IA GCs can be put forward: 1) IA GCs appear to be a relatively safe option that is effective in specific patients with symptomatic knee OA; 2) there is no definitive evidence that IA GCs accelerate joint deterioration to an important extent or hastens the requirement for knee replacement; and 3) there are few contraindications to IA GCs and injection-associated complications are rare when IA GCs are delivered with proper technique.

IMPROVEMENTS IN HIP OSTEOARTHRITIS WITH LAVAGE, TRIAMCINOLONE AND HYLAN G-F20

Objective:

To verify whether the use of Hylan G-F20 improves saline lavage and triamcinolone injection results in the treatment of hip osteoarthritis (HOA).

Methods:

82 patients with HOA categorized as grades II and III severity, according to Kellgren and Lawrence criteria, were randomized into the groups: lavage and triamcinolone (G0); lavage, triamcinolone, and 2 mL of hylan G-F20 (G1); lavage, triamcinolone, and 4mL of hylan G-F20 (G2); lavage, triamcinolone, and 6mL of hylan G-F20 (G3). The VAS, range of motion (ROM), WOMAC, and Lequesne questionnaires were administered at baseline, one, three, six, and twelve months post-injection.

Results:

All groups showed clinically relevant improvements (> 20%) between baseline and first month post-injection, maintaining subjective results throughout the study period (p < 0.001). We found no differences between groups in any subjective evaluations (p > 0.05, for all). G2 and G3 obtained improved flexion results up to a year (p = 0.028). Hylan groups presented an improved external rotation since the first postoperative month and maintained the results up to a year (G1, p = 0.041; G2, p = 0.007), whereas G0 showed no improvement (p = 0.336).

Conclusion:

Hip lavage and triamcinolone injection, with or without the use of hylan, improves pain, function, and quality of life up to a year in HOA. Hylan may improve ROM up to one year. Level of Evidence IB, Randomized clinical trial.

Intra-articular Corticosteroid Injections for the Treatment of Hip and Knee Osteoarthritis-related Pain: Considerations and Controversies with a Focus on Imaging-Radiology Scientific Expert Panel

Current management of osteoarthritis (OA) is primarily focused on symptom control. Intra-articular corticosteroid (IACS) injections are often used for pain management of hip and knee OA in patients who have not responded to oral or topical analgesics. Recent case series suggested that negative structural outcomes including accelerated OA progression, subchondral insufficiency fracture, complications of pre-existing osteonecrosis, and rapid joint destruction (including bone loss) may be observed in patients who received IACS injections. This expert panel report reviews the current understanding of pain in OA, summarizes current international guidelines regarding indications for IACS injection, and considers preinterventional safety measures, including imaging. Potential profiles of those who would likely benefit from IACS injection and a suggestion for an updated patient consent form are presented. As of today, there is no established recommendation or consensus regarding imaging, clinical, or laboratory markers before an IACS injection to screen for OA-related imaging abnormalities. Repeating radiographs before each subsequent IACS injection remains controversial. The true cause and natural history of these complications are unclear and require further study. To determine the cause and natural history, large prospective studies evaluating the risk of accelerated OA or joint destruction after IACS injections are needed. However, given the relatively rare incidence of these adverse outcomes, any clinical trial would be challenging in design and a large number of patients would need to be included.

Target-based approach for osteoarthritis treatment

There is still no definitive treatment for knee osteoarthritis (OA). We are certainly far from a consensus on the best form of treatment or on an effective treatment recommendation. There are reasons for the current equivocal treatment recommendations in the face of this very serious health problem. The greatest of these reasons, undoubtedly, is the great complexity of the factors involved in the development and progression of knee OA and the complex pathophysiology including mechanical, inflammatory, metabolic, post-traumatic, molecular, genetic, and psychological changes. For several years, an attempt has been made to correlate different patient phenotypes to different patterns of response to treatment, thus creating the possibility of developing specific treatments for certain groups of patients and theoretically allowing better treatment efficacy. However, in practice we still find totally different responses and evolutions even in individuals belonging to the same phenotype. Thus, classification by phenotypes, despite being an advance, is not sufficient. The present article proposes a fragmented look at each of the many factors or targets involved in the genesis and evolution of OA. Therefore, we propose not the treatment of OA per se but the management of an individual set of targets to achieve personalized OA management. We believe that, paradoxically, by fragmenting the view of the disease we will be able to treat our patients more holistically in an individualized way.

Effect of vitamin D supplementation on pain and physical function in patients with knee osteoarthritis (OA): an OA Trial Bank protocol for a systematic review and individual patient data (IPD) meta-analysis

INTRODUCTION

Observational data suggest that vitamin D deficiency is associated with the onset and progression of knee osteoarthritis (OA). However, randomised controlled trials (RCTs) to date investigating the efficacy of vitamin D supplementation in knee OA have reported conflicting results. Further research is needed to clarify the effects of vitamin D on patient-reported outcomes and determine whether there are patient subgroups who may benefit from the supplementation. The aim of this individual patient data (IPD) meta-analysis is to identify patient-level predictors of treatment response to vitamin D supplementation on pain and physical function.

METHODS AND ANALYSIS

A systematic literature search will be conducted for RCTs of vitamin D supplementation on knee OA. Authors of original RCTs will be contacted to obtain the IPD. The primary outcomes will include long-term (≥12 months) pain and physical function. Secondary outcomes will include medium-term (≥6 months and <12 months) and short-term (<6 months) pain and physical function, as well as patient global assessment, quality of life and adverse events. Potential treatment effect modifiers to be examined in the subgroup analyses include age, gender, body mass index, baseline knee pain severity and physical function, baseline vitamin D level, radiographic stage, presence of bone marrow lesions on MRI, presence of clinical signs of local inflammation and concomitant depressive symptoms. Both one-step and two-step modelling methods will be used to determine the possible modifiable effect of each subgroup of interest.

ETHICS AND DISSEMINATION

Research ethical or governance approval is exempt for this study as no new data are being collected. This study will be the first IPD meta-analysis to clarify the effect of vitamin D supplementation on clinical symptoms in different subgroups of patients with knee OA. The findings will be disseminated through peer-review publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42018107740.

Effectiveness of intramuscular gluteal glucocorticoid injection versus intra-articular glucocorticoid injection in knee osteoarthritis: design of a multicenter randomized, 24 weeks comparative parallel-group trial

Background

The knee is symptomatically the most frequent affected joint in osteoarthritis and, in the Netherlands and other Western countries, is mainly managed by general practitioners (GPs). An intra-articular glucocorticoid injection is recommended in (inter) national guidelines for patients with knee osteoarthritis as an option for a flare of knee pain and/or for those who are not responding well to pain medication. An innovative approach that could replace the intra-articular injection is an intramuscular gluteal glucocorticoid injection. An intramuscular injection is easier to perform than an intra-articular injection with lesser risk of severe local adverse reactions. We hypothesize that intramuscular gluteal glucocorticoid injection is non-inferior in reducing knee pain compared to intra-articular glucocorticoid injection, with potentially a longer lasting effect than intra-articular injection.

Methods/design

The study will be a pragmatic randomized controlled non-inferiority trial with two parallel groups. A total of 140 patients aged 45 years and older with knee osteoarthritis who contacted their general practitioner and have persistent knee pain (score ≥ 3 on 0–10 numerical rating scale; 0 = no knee pain) will be included.

Patients will be randomly allocated (1:1) to an injection of 40 mg triamcinolone acetonide intra-articular in the knee joint or intramuscular in the ipsilateral ventrogluteal area.

The effect of treatment will be evaluated by questionnaires at 2, 4, 8, 12, and 24 weeks after injection. The primary outcome is patients’ reported severity of knee pain measured with the pain subscale of the Knee injury and Osteoarthritis Outcome Score 4 weeks after injection. Statistical analysis will be based on both the per-protocol and the intention-to-treat principle.

Discussion

This study will evaluate non-inferiority of intramuscular glucocorticoid injection compared to intra-articular glucocorticoid injection for knee osteoarthritis symptoms.

Trial registration

This trial is registered in the Dutch Trial Registry (number NTR6968) at 2018-01-22 (https://www.trialregister.nl/trial/6784). Issue date: 1 October 2019.

Trial sponsor

Erasmus MC University Medical Center Rotterdam.

PO-box 2040.

3000 CA Rotterdam.

The Netherlands.

Do Clinical Correlates of Knee Osteoarthritis Predict Outcome of Intraarticular Steroid Injections?

OBJECTIVE

To determine whether clinical correlates of knee osteoarthritis (OA) affect the outcome of intraarticular steroid injections (IASI) in symptomatic knee OA.

METHODS

Men and women aged ≥ 40 years with painful knee OA who participated in an open-label trial of IASI completed questionnaires and clinical examination. The Outcome Measures in Rheumatology (OMERACT)-Osteoarthritis Research Society International (OARSI) criteria were used to assess response to therapy in the short term (within 2 weeks). Among those who initially responded, those whose pain had not returned to within 20% of the baseline Knee Injury and Osteoarthritis Outcome Score pain score at 6 months were characterized as longer-term responders. Log-binomial regression was used to examine factors associated with outcome.

RESULTS

One hundred ninety-nine participants were included, of whom 146 (73.4%) were short-term and 40 (20.1%) longer-term responders. Compared to short-term nonresponders, participants with these characteristics were more likely to be short-term responders: medial joint line tenderness [relative risk (RR) 1.42, 95% CI 1.10-1.82], medial and lateral joint line tenderness (RR 1.38, 95% CI 1.03-1.84), patellofemoral tenderness (RR 1.27, 95% CI 1.04-1.55), anserine tenderness (RR 1.27, 95% CI 1.06-1.52), and a belief that treatment would be effective [RR/unit increase (range 0-10) = 1.05 (1.01-1.09)]. Aspiration of joint fluid (RR 0.79, 95% CI 0.66-0.95) and previous ligament/meniscus injury (RR 0.63, 95% CI 0.44-0.91) were associated with a reduced risk of being a short-term responder. Compared to initial nonresponders and those whose pain recurred within 6 months, participants with a higher number of pain sites [RR/unit increase (range 0-10) = 0.83, 95% CI 0.72-0.97], chronic widespread pain (RR 0.32, 95% CI 0.10-0.98), perceived chronicity of disease [RR/unit increase (range 0-10) = 0.86, 95% CI 0.78-0.94], and a higher depression score [RR/unit increase (range 0-21) = 0.89, 95% CI 0.81-0.99] were less likely to be longer-term responders.

CONCLUSION

Among patients with symptomatic knee OA, tenderness around the knee was associated with better short-term outcome of IASI. However, clinical-related factors did not predict longer-term response, while those with chronic widespread pain and depressive symptoms were less likely to obtain longer-term benefits.

Intra-Articular Steroid Injection for Patients with Hip Osteoarthritis: A Systematic Review and Meta-Analysis

Purpose

The aim of this current review was to confirm the efficacy of intra-articular steroid therapy (IAST) for patients with hip osteoarthritis (OA) and discuss the duration and influential factors of IAST.

Methods

Online databases (Medline, EMBASE, and Web of Science) were searched from inception to May 2019. Both randomized controlled trials (RCTs) and noncontrolled trials assessing the efficacy of hip IAST on pain were included. Common demographics data were extracted using a standardized form. Quality was assessed on the basis of Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence.

Results

12 trials met the inclusion criteria. According to data from individual trials, IAST had significant efficacy on hip OA in both immediate and delay pain reduction, which persisted up to 12 weeks after IAST. The influences of the baseline severity of hip OA or synovitis and injection dose or volume on the clinical outcome of IAST were still controversial. The IAST appeared to be well tolerant by most of the participants.

Conclusion

IAST was proved to be an efficacious therapy in both immediate and delay pain reduction for hip OA patients within 12 weeks. The longer follow-up data of efficacy and safety and potentially influential factors are still unclear and needed further confirmation.

An updated algorithm recommendation for the management of knee osteoarthritis from the European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO)

OBJECTIVES

The European Society for Clinical and Economic Aspects of Osteoporosis, Osteoarthritis and Musculoskeletal Diseases (ESCEO) sought to revisit the 2014 algorithm recommendations for knee osteoarthritis (OA), in light of recent efficacy and safety evidence, in order to develop an updated stepwise algorithm that provides practical guidance for the prescribing physician that is applicable in Europe and internationally.

METHODS

Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) process, a summary of evidence document for each intervention in OA was provided to all members of an ESCEO working group, who were required to evaluate and vote on the strength of recommendation for each intervention. Based on the evidence collected, and on the strength of recommendations afforded by consensus of the working group, the final algorithm was constructed.

RESULTS

An algorithm for management of knee OA comprising a stepwise approach and incorporating consensus on 15 treatment recommendations was prepared by the ESCEO working group. Both "strong" and "weak" recommendations were afforded to different interventions. The algorithm highlights the continued importance of non-pharmacological interventions throughout the management of OA. Benefits and limitations of different pharmacological treatments are explored in this article, with particular emphasis on safety issues highlighted by recent literature analyses.

CONCLUSIONS

The updated ESCEO stepwise algorithm, developed by consensus from clinical experts in OA and informed by available evidence for the benefits and harms of various treatments, provides practical, current guidance that will enable clinicians to deliver patient-centric care in OA practice.

Pharmacodynamics, efficacy, safety and administration of intra-articular therapies for knee osteoarthritis

Introduction: Osteoarthritis (OA) is the leading cause of disability in the elderly, usually presenting with mono-or oligo-arthritis where local drug delivery by intra-articular (IA) injection may be more effective in terms of increased bioavailability, less systemic exposure and reduced adverse events. Several intra-articular medications for symptomatic are available on the market while the new disease-modifying drugs (DMOADs) are progressing into phase 3 pipeline of drug development.Areas covered: This narrative review covered the pharmacokinetic and pharmacodynamics of clinically available IA drugs which include corticosteroids, hyaluronic acid as well as injection techniques, efficacy, adverse effects and contraindications. In addition, the authors briefly describe the newer disease-modifying OA drugs (DMOAD) which are undergoing phase 3 pipeline of development such as Fibroblast growth factor (FGF-18) and Wnt inhibitor.Expert opinion: This is a rapidly evolving area with both new products and new trials regularly emerging. It is also a critically important area in a disease field that lacks for safe and effective treatments, where intra-articular delivery may enhance both local efficacy and reduce systemic toxicity.

Local controlled release of corticosteroids extends surgically induced joint instability by inhibiting tissue healing

Background and Purpose

Corticosteroids are intra‐articularly injected to relieve pain in joints with osteoarthritis (OA) or acute tissue damage such as ligament or tendon tears, despite its unverified contraindication in unstable joints. Biomaterial‐based sustained delivery may prolong reduction of inflammatory pain, while avoiding harmful peak drug concentrations.

Experimental Approach

The applicability of prolonged corticosteroid exposure was examined in a rat model of anterior cruciate ligament and medial meniscus transection (ACLT + pMMx) with ensuing degenerative changes.

Key Results

Intra‐articular injection of a bolus of the corticosteroid triamcinolone acetonide (TAA) resulted in enhanced joint instability in 50% of the joints, but neither instability‐induced OA cartilage degeneration, synovitis, nor the OA‐related bone phenotype was affected. However, biomaterial microsphere‐based extended TAA release enhanced instability in 94% of the animals and induced dystrophic calcification and exacerbation of cartilage degeneration. In healthy joints, injection with TAA releasing microspheres had no effect at all. In vitro, TAA inhibited cell migration out of joint tissue explants, suggesting inhibited tissue healing in vivo as mechanisms for enhanced instability and subsequent cartilage degeneration.

Conclusions and Implications

We conclude that short‐term TAA exposure has minor effects on surgically induced unstable joints, but its extended presence is detrimental by extending instability and associated joint degeneration through compromised healing. This supports a contraindication of prolonged corticosteroid exposure in tissue damage‐associated joint instability, but not of brief exposure.

Intra-Articular Viscosupplementation for Patients with Hip Osteoarthritis: A Meta-Analysis and Systematic Review

BACKGROUND The aim of this study was to review the efficacy and safety of intra-articular (IA) viscosupplementation (VS) for hip osteoarthritis (OA). MATERIAL AND METHODS We searched Medline, Clinical Trial Register Center, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) comparing VS with placebo injection for hip OA. We included suitable studies, assessed the quality of studies, and extracted data on pain reduction, function improvement at different time points, and safety profiles. The comparisons of pain and function outcome were performed by meta-analysis. RESULTS Five high-quality randomized controlled studies trials (RCTs) with 591 patients with hip OA were identified. Although several trials demonstrated a significant decline in pain in VS groups during follow-up compared to baseline, without severe adverse events, the pooled analysis did not show VS was superior to placebo at any time windows [7-14 days: standardized mean difference (SMD): -0.18; 95% CI, -0.47 to 0.10, p=0.21; 28-30 days: 0.02 (-0.15, 0.19), p=0.82; or at final visit: -0.14 (-0.46, 0.18), p=0.38]. Similar results were also observed in the combined data of functional results. CONCLUSIONS IA VS does not reduce pain or improve function significantly better than placebo in a short-term follow-up. The benefits and safety of VS should be further assessed by sufficiently-sized, methodologically sound studies with validated assessment of more clinically relevant end-points.