High molecular weight sodium hyaluronate (hyalectin) in osteoarthritis of the knee: a 1 year placebo-controlled trial

Pain management of hip osteoarthritis with corticosteroids vs injection therapies: a systematic review and meta-analysis

INTRODUCTION

Osteoarthritis (OA) is the most common degenerative joint disease, characterized by chronic pain and articular cartilage damage. Hip OA is characterized by the progressive breakdown of articular cartilage within the hip, particularly the hip joints ball and socket structure, Hip OA leads to joint pain, stiffness and causes functional limitations.

AIM

To analyse the effectiveness of intra-articular corticosteroids (IA CS) use against other injection therapies for the symptomatic management of hip OA.

METHODS

PROSPERO registered-CRD42024526221. Medline, Embase, Scopus and Web of Science were searched for trials.

INCLUSION CRITERIA

Adults with symptomatic hip OA, randomised trials for treatment of hip OA with IA injection methods. Studies must involve comparators and the outcome measure must include a measurement of pain such as Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) or the visual analogue scale (VAS). Cochrane risk of bias and JBI critical appraisal tools assessed risk of bias. RevMan was used for creation of statistical figures within the meta-analysis.

RESULTS

Data extracted in the systematic review presented improvements on pain, function, stiffness, and overall scores using WOMAC and VAS scales. However, data from the meta-analysis indicates that there is no statistical significance (significance is a p value < 0.05) between corticosteroids and placebo or hyaluronic acid (HA). Meta-analyses produced p values of 0.05 when comparing CS and placebo WOMAC pain scores at 2 months, CS and HA overall WOMAC at 6 months-p value of 0.46. WOMAC stiffness and function scores between CS and placebo at 2 months-p value of 0.05 and 0.08, thus statistically insignificant.

CONCLUSION

This meta-analysis shows that IA corticosteroid injections for hip OA don't provide statistically significant symptomatic improvement for patients compared to placebo. Showing the urgent need to assess other therapies in hip OA treatment.

Long-term effectiveness of intra-articular injectables in patients with knee osteoarthritis: a systematic review and Bayesian network meta-analysis

BACKGROUND

Intra-articular injectables are proposed as a solution for pain relief and functional improvement in knee osteoarthritis (OA), however most studies involving intra-articular knee injectables are focused on short-term relief, leaving the recommendations regarding long-term management unclear. This network meta-analysis aimed to evaluate the mid- to long-term effectiveness of intra-articular knee injection of platelet-rich plasma (PRP), hyaluronic acid (HA), corticosteroids (CS), and their combinations for management of knee OA.

METHODS

Relevant studies were searched through PubMed, EMBASE, Scopus, and Cochrane Register of Trials databases from inception to 20th October, 2024 for randomized controlled trials (RCTs) of knee OA patients who had taken intra-articular injectable treatment with a follow-up duration of at least one year. The study included 37 RCTs involving 5089 patients. The outcomes assessed were pain relief and functional improvement of knee joint. The random effects Bayesian model was carried out for network meta-analysis. The surface under the cumulative ranking (SUCRA) curve demonstrated the rank probability of each injectable therapy for different outcomes.

RESULTS

Analysis revealed that, in terms of both knee pain relief and improvement of functional outcomes, the combined intra-articular injection of PRP and HA was ranked ahead of the isolated administration of PRP, followed by combination of HA with CS, HA alone, placebo, and CS at the end of one year.

CONCLUSION

These findings emphasize the sustained efficacy of PRP, particularly when combined with HA, in providing superior long-term pain relief and functional improvement in knee OA compared to other intra-articular injectables, highlighting its potential as a preferred treatment modality.

G-protein-coupled estrogen receptor 30 regulation of signaling downstream of protein kinase Cε mediates sex dimorphism in hyaluronan-induced antihyperalgesia

ABSTRACT

High molecular weight hyaluronan (HMWH) inhibits hyperalgesia induced by diverse pronociceptive inflammatory mediators and their second messengers, in rats of both sexes. However, the hyperalgesia induced by ligands at 3 pattern recognition receptors, lipopolysaccharide (a toll-like receptor 4 agonist), lipoteichoic acid (a toll-like receptor 2/6 agonist), and nigericin (a NOD-like receptor family, pyrin domain containing 3 activator), and oxaliplatin and paclitaxel chemotherapy-induced peripheral neuropathy are only attenuated in males. After gonadectomy or intrathecal administration of an antisense to G-protein-coupled estrogen receptor 30 (GPER) mRNA, HMWH produces antihyperalgesia in females. In nociceptors cultured from rats that had been treated with oxaliplatin, HMWH reverses nociceptor sensitization from male and GPER antisense-treated female, but not from gonad intact females. G-protein-coupled estrogen receptor-dependent sex dimorphism for HMWH-induced antihyperalgesia was also observed for the prolongation of prostaglandin E 2 (PGE 2 )-induced hyperalgesia in primed nociceptors. While in primed rats, HMWH inhibits early, protein kinase A-dependent hyperalgesia, 30 minutes post PGE 2 injection, in both sexes; measured 4 hours post-PGE 2 , HMWH inhibits the protein kinase Cε (PKCε)-dependent prolongation of PGE 2 hyperalgesia only in males and GPER antisense-treated females. In females, hyperalgesia induced by PKCε agonist, ψεRACK, in control but not in primed nociceptors, was inhibited by HMWH. Inhibitors of 2 GPER second messengers, extracellular-regulated kinase 1/2 and nonreceptor tyrosine kinase, also unmasked HMWH antihyperalgesia in females with oxaliplatin chemotherapy-induced peripheral neuropathy, a condition in which nociceptors are primed as well as sensitized. Our results support GPER-dependent sex dimorphism in HMWH-induced antihyperalgesia for pain induced by pattern recognition receptor agonists, and chronic inflammatory and neuropathic pain, mediated by changes in signaling downstream of PKCε in primed nociceptors.

Exploring the Potential of Non-Cellular Orthobiologic Products in Regenerative Therapies for Stifle Joint Diseases in Companion Animals

Stifle joint diseases present a significant challenge in companion animals that often lead to hind limb lameness, with osteoarthritis being a prevalent degenerative condition causing pain and reduced mobility. Regenerative medicine offers a promising avenue for improving treatment outcomes, with a range of emerging therapies showing potential to alleviate symptoms and promote joint health. Among these, hyaluronic acid and platelet-rich plasma have been widely used as intra-articular treatments to enhance joint lubrication, reduce inflammation, and provide symptomatic relief. Interleukin-1 receptor antagonist protein, autologous conditioned serum, and autologous protein solution represent the next generation of regenerative therapies, offering more disease-modifying effects by inhibiting key mediators of joint inflammation. More recently, the MSC-derived secretome has emerged as an innovative, cell-free approach that leverages the diverse bioactive factors secreted by MSCs to support tissue repair and modulate inflammation. This review highlights the evidence base behind these non-cellular orthobiologic treatments for stifle joint disease, aiming to inform veterinary practitioners and owners about available options and their efficacy in supporting conventional treatments.

Clinical efficacy of cell-free fat extract and its effects on bone marrow edema in patients with early to mid-stage knee osteoarthritis: a clinical trial in comparison with hyaluronic acid

BACKGROUND

Previous studies have shown that hyaluronic acid can delay the progression of knee osteoarthritis. Existing research has extracted a bright red fluid called cell-free fat extract from human adipose tissue, which may play an important role in delaying the progression of osteoarthritis. By comparing with intra-articular injection of hyaluronic acid, this study aimed to evaluate the effects of intra-articular injection of CEFFE on both clinical efficacy and the reduction of bone marrow edema in patients with early to mid-stage knee osteoarthritis.

METHODS

A total of 48 patients with KOA (Kellgren-Lawrence grade II-III) symptoms were randomly divided into CEFFE group (24 cases) and HA group (24 cases). The patients in the CEFFE group received five injections of CEFFE (2 ml, 1 time/week), and the patients in the HA group received five injections of HA (2 ml, 1 ml/10 mg, 1 time/week). All the patients underwent clinical assessments using rating scales, including VAS, WOMAC and Lysholm Knee Score. These assessments were conducted at pre-treatment and at 3-week, 6-week, 3-month, and 6-month follow-up timepoints post-treatment. The clinical efficacy was evaluated at the 6-month follow-up after the treatment. The changes in subchondral bone marrow edema before and 6 months after treatment were assessed by grading BME on MRI of the affected knees.

RESULTS

A total of 52 knees from 46 patients were included in the final analysis. Comparison of VAS score, WOMAC score, and Lysholm score between the two groups revealed that the differences between pre-treatment and 3 weeks post-treatment were not statistically significant (P > 0.05). For the VAS score and WOMAC score at 6 weeks, 3 months, and 6 months post-treatment, the CEFFE group was lower than the HA group (P < 0.05). For the Lysholm score, the CEFFE group was higher than the HA group (P < 0.05). Compared with pre-treatment, VAS scores and WOMAC scores were lower and Lysholm scores were higher at all post-treatment time points (P < 0.05). At 6 months post-treatment, the clinical efficacy of the CEFFE group was significantly better than that of the HA group (P < 0.05). At 6 months post-treatment, MRI grading showed that subchondral BME was reduced to different degrees in both groups, with the reduction being more pronounced in the CEFFE group (P < 0.05).

CONCLUSION

This study demonstrated that intra-articular injection of CEFFE into the knee joint could enhance the durability of tissue-specific cells (especially chondrocytes) and improve cellular metabolic processes, preventing the continued progression of osteoarthritis. Both CEFFE and HA were found to improve clinical symptoms and reduced subchondral bone marrow edema in the treatment of early to mid-stage knee osteoarthritis. However, CEFFE was more effective than HA in achieving these outcomes.

Comparison of Different Molecular Weights of Intra-Articular Hyaluronic Acid Injections for Knee Osteoarthritis: A Level I Bayesian Network Meta-Analysis

Background: The present Bayesian network meta-analysis compared the efficacy of intra-articular injections of different molecular weights of hyaluronic acid (HA) in patients with knee osteoarthritis. Methods: In November 2024, the following databases were accessed: PubMed, Web of Science, Google Scholar, and Embase. All randomised controlled trials investigating the efficacy of intra-articular HA injections for knee osteoarthritis were accessed. The outcome of interest was to evaluate pain according to the visual analogue scale (VAS). The groups included for comparison were the ultra-high molecular weight (UHMW), high molecular weight (HMW), medium molecular weight (MMW), and low molecular weight (LMW). Results: Data from 9822 patients were collected. The mean age of the patients was 62.1 ± 5.0 years with given comparability at baseline. Different follow-up periods were compared. The longest control period ranged from four to six months, and the UHMW and HMW injections were the interventions associated with the greatest reduction in the VAS. LMW HA was the intervention associated with the lowest decrease in VAS, falling short of the control group. Conclusions: The main findings of the present Bayesian network meta-analysis, with a current level I of evidence, suggests that the UHMW and HMW HA has a beneficial effect on pain at 6 months post intervention in patients with knee osteoarthritis.

Less Pain with Intra-Articular Hyaluronic Acid Injections for Knee Osteoarthritis Compared to Placebo: A Systematic Review and Meta-Analysis of Randomised Controlled Trials

The present meta-analysis investigated the efficacy of intra-articular hyaluronic acid (HA) injections for knee osteoarthritis. The outcomes of interest were the visual analogue scale (VAS) and Western Ontario McMaster Osteo-Arthritis Index (WOMAC) scores. This study was conducted according to the 2020 PRISMA statement. All the randomised controlled trials (RCTs) comparing the efficacy of intra-articular HA injections versus placebo injections for knee osteoarthritis were accessed in September 2024. Data from 3851 patients were collected. In total, 64% (2467 of 3851 patients) were women, and the mean age of the patients was 63.5 ± 4.9 years. At baseline, good comparability was found for the mean age, BMI, percentage of women, and patient-reported outcome measures (PROMs). Studies which reported data from two to four weeks of follow-up evidenced a lower value of the subscales pain (p < 0.0001) and stiffness (p = 0.01) of the WOMAC score. No difference was observed in VAS at rest (p = 0.4), VAS at exercise (p = 0.1), and subscale function (p = 0.4) of the WOMAC score. Studies which reported data from five to eight weeks of follow-up evidenced lower VAS at rest in favour of the HA group (p = 0.01). No difference in the other PROMs of interest was observed: VAS at exercise (p = 0.1), and the subscales pain (p = 0.3), function (p = 0.4), and stiffness (p = 0.4) of the WOMAC score. The current level I of evidence suggests that intra-articular HA injections in the knee might reduce pain in the short term.

Effectiveness of a Single Intra-articular Injection of High-Molecular-Weight Hyaluronic Acid Versus NSAIDs on the Visual Analog Pain Scale and Western Ontario and McMaster Universities Osteoarthritis Index Scores in Patients With Knee Osteoarthritis

OBJECTIVE

This study aimed to determine the effectiveness of a single intra-articular injection of high-molecular-weight (HMW) hyaluronic acid (HA) at a dose of 4 mL/60 mg to reduce pain in people with knee osteoarthritis (OA) over 12 months.

METHODOLOGY

This retrospective study was conducted after obtaining ethical approval from Dhaka Medical College and Hospital, Bangladesh. From July 2020 to June 2021, a medical professional conducted the investigation. The investigation encompassed patients aged 40 to 70 hospitalized at our facility and diagnosed with Grade 2 or Grade 3 knee OA according to the Kellgren-Lawrence grading method. We divided the patients into two categories based on the treatments they received. Patients in Group A received a single injection of HMW HA (60 mg/4 mL) into the joint, along with instructions on activities of daily living, exercise, and painkillers. Group B patients received conservative therapy, which involved the use of nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, therapeutic exercises, and a knee brace during physical activity.

RESULTS

This study compared the efficacy of a single injection of HMW HA in the joint versus NSAIDs for managing OA-related symptoms over 12 weeks. The HA group initially scored similarly to the comparison group. By week three, however, the group receiving HA had considerably higher Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (p=0.019). This pattern continued through weeks 6 (p=0.044), 9 (p=0.016), and 12 (p<0.001). Similarly, by week 3 (p=0.029), the visual analog scale (VAS) scores, which were initially identical (p=0.120), demonstrated a significant preference for HA, and this preference persisted through weeks 6, 9, and 12 (all p<0.001). The results show that by the third week, HA is more effective than NSAIDs at relieving pain and improving symptoms.

CONCLUSION

The study's results indicated that over 12 weeks, the use of HMW HA led to statistically significant reductions in pain intensity, as measured by the VAS. Furthermore, HMW HA demonstrated a more significant improvement in WOMAC ratings, which assess physical function, stiffness, and pain, compared to NSAIDs. The findings suggest that administering HMW HA injections can significantly reduce symptoms and improve functionality in individuals with knee OA.

Can Hyaluronic Acid Combined with Chondroitin Sulfate in Viscosupplementation of Knee Osteoarthritis Improve Pain Symptoms and Mobility?

The objective of the present study was to assess the effect of intra-articular Hyaluronic acid (HA) and Chondroitin sulfate (CS) supplementation (Hialurom® Hondro (HH)) on pain symptoms and joint mobility. In total, 60 mg/mL sodium hyaluronate and 90 mg/mL CS were administered to 21 patients (17 females and 4 males) respecting the in-force requirements, excluding patients with some specific comorbidities. In addition to the clinical study (where the pain intensity (severity) and joint mobility were assessed), rheological characterization was conducted evaluating the following parameters: elastic modulus (G'), loss modulus (G″) oscillatory frequency (fc) at 0.5 Hz and 2.5 Hz, crossover frequency (fc), relaxation time (λ) where it was noticed that the addition of chondroitin sulfate (CS) to sodium hyaluronate (SH) significantly enhances and improves the viscoelastic properties, particularly at higher shear frequencies. A significant decrease in pain intensity felt by the subjects was found, from 7.48 (according to Wong-Baker scale)-pain close to 8 (the patient is unable to perform most activities), to more reduced values of 5.86-at 6 weeks after injection, 4.81-at 3 months after injection, and 5.24-at 6 months after injection, improvements in symptoms was fast and durable. Data related to the evolution of joint mobility show that at 6 weeks after injection, the mobility of joints increased by 17.8% and at 6 months by 35.61%. No serious adverse events were reported with undesired effects so that they would impose additional measures. Better resistance to enzymatic degradation and free radicals could be expected from the synergic combination of sodium hyaluronate and chondroitin sodium sulfate, this having a special importance for the patients, granting them the ability to perform more ample movements and reducing dependency on attendants, thus increasing quality of life.

EFFECTIVENESS OF VISCOSUPPLEMENTATION IN THE TREATMENT OF HEMOPHILIC ARTHROPATHY: A SYSTEMATIC REVIEW

Objective

To describe the efficacy of using viscosupplementation in patients with hemophilic arthropathy (HA), on pain, limb functionality, and quality of life.

Methods

A systematic review of the literature was performed following the PRISMA guidelines without limitations of language or year of publication. The search was performed on the following medical databases: PubMed, Cochrane Library, EMBASE, BVS/BIREME, Scopus, Web of Science, EBSCOhost, and PROQUEST in April 2020. The search used the following word: (hemophilia AND joint diseases) OR (haemophilic arthropathy OR hemophilic arthropathy) AND viscosupplementation.

Results

The systematic review identified 127 articles, 10 of which were selected for data extraction and qualitative analysis. The 10 selected articles included 297 joints with HA in 177 hemophilic subjects. Our review showed positive results in alleviating pain and improving functional capacity, and quality of life. No major adverse effects were observed.

Conclusion

There is a lack of scientific evidence regarding viscosupplementation with hyaluronic acid, but the results presented in this research suggest that it is an effective and safe therapeutic option to alleviate pain and improve functional capacity in patients with HA. Level of Evidence II, Systematic Review.

Topical coapplication of hyaluronan with transdermal drug delivery enhancers attenuates inflammatory and neuropathic pain

ABSTRACT

We have previously shown that intradermal injection of high-molecular-weight hyaluronan (500-1200 kDa) produces localized antihyperalgesia in preclinical models of inflammatory and neuropathic pain. In the present experiments, we studied the therapeutic effect of topical hyaluronan, when combined with each of 3 transdermal drug delivery enhancers (dimethyl sulfoxide [DMSO], protamine or terpene), in preclinical models of inflammatory and neuropathic pain. Topical application of 500 to 1200 kDa hyaluronan (the molecular weight range used in our previous studies employing intradermal administration), dissolved in 75% DMSO in saline, markedly reduced prostaglandin E 2 (PGE 2 ) hyperalgesia, in male and female rats. Although topical 500- to 1200-kDa hyaluronan in DMSO vehicle dose dependently, also markedly, attenuated oxaliplatin chemotherapy-and paclitaxel chemotherapy-induced painful peripheral neuropathy (CIPN) in male rats, it lacked efficacy in female rats. However, following ovariectomy or intrathecal administration of an oligodeoxynucleotide antisense to G-protein-coupled estrogen receptor (GPR30) mRNA, CIPN in female rats was now attenuated by topical hyaluronan. Although topical coadministration of 150 to 300, 300 to 500, or 1500 to 1750 kDa hyaluronan with DMSO also attenuated CIPN, a slightly lower-molecular-weight hyaluronan (70-120 kDa) did not. The topical administration of a combination of hyaluronan with 2 other transdermal drug delivery enhancers, protamine and terpene, also attenuated CIPN hyperalgesia, an effect that was more prolonged than with DMSO vehicle. Repeated administration of topical hyaluronan prolonged the duration of antihyperalgesia. Our results support the use of topical hyaluronan, combined with chemically diverse nontoxic skin penetration enhancers, to induce marked antihyperalgesia in preclinical models of inflammatory and neuropathic pain.

A composite device for viscosupplementation treatment resistant to degradation by reactive oxygen species and hyaluronidase

Osteoarthritis (OA) is one of the most common musculoskeletal disorders in the world. OA is often associated with the loss of viscoelastic and tribological properties of synovial fluid (SF) due to degradation of hyaluronic acid (HA) by reactive oxygen species (ROS) and hyaluronidases. Viscosupplementation is one of the ways how to effectively restore SF functions. However, current viscosupplementation products provide only temporal therapeutic effect because of short biological half-life. In this article we describe a novel device for viscosupplementation (NV) based on the cross-linked tyramine derivative of HA, chondroitin sulfate (CS), and high molecular weight HA by online determination of viscoelastic properties loss during degradation by ROS and hyaluronidase. Rheological and tribological properties of developed viscosupplement were compared with HA solutions with different molecular weights in the range 500-2000 kDa, which are currently commonly used as medical devices for viscosupplementation treatment. Moreover, based on clinical practice and scientific literature all samples were also diluted by model OA SF in the ratio 1:1 (vol/vol) to better predict final properties after injection to the joint. The observed results confirmed that NV exhibits appropriate rheological properties (viscosity, elastic, and viscous moduli) comparable with healthy SF and maintain them during degradation for a significantly longer time than HA solutions with molecular weight in the range 500-2000 kDa and cross-linked material without CS.

Second messengers mediating high-molecular-weight hyaluronan-induced antihyperalgesia in rats with chemotherapy-induced peripheral neuropathy

ABSTRACT

High-molecular-weight hyaluronan (HMWH) is an agonist at cluster of differentiation (CD)44, the cognate hyaluronan receptor, on nociceptors, where it acts to induce antihyperalgesia in preclinical models of inflammatory and neuropathic pain. In the present experiments, we studied the CD44 second messengers that mediate HMWH-induced attenuation of pain associated with oxaliplatin and paclitaxel chemotherapy-induced peripheral neuropathy (CIPN). While HMWH attenuated CIPN only in male rats, after ovariectomy or intrathecal administration of an oligodeoxynucleotide (ODN) antisense to G protein-coupled estrogen receptor (GPR30) mRNA, female rats were also sensitive to HMWH. Intrathecal administration of an ODN antisense to CD44 mRNA markedly attenuated HMWH-induced antihyperalgesia in male rats with CIPN induced by oxaliplatin or paclitaxel. Intradermal administration of inhibitors of CD44 second messengers, RhoA (member of the Rho family of GTPases), phospholipase C, and phosphatidylinositol (PI) 3-kinase gamma (PI3Kγ), attenuated HMWH-induced antihyperalgesia as does intrathecal administration of an ODN antisense to PI3Kγ. Our results demonstrated that HMWH induced antihyperalgesia in CIPN, mediated by its action at CD44 and downstream signaling by RhoA, phospholipase C, and PI3Kγ.

Time to Total Knee Arthroplasty after Intra-Articular Hyaluronic Acid or Platelet-Rich Plasma Injections: A Systematic Literature Review and Meta-Analysis

Intra-articular (IA) hyaluronic acid (HA) and platelet-rich plasma (PRP) injections are increasingly being prescribed for knee osteoarthritis (KOA). However, failure of the medical treatment may result in total knee arthroplasty (TKA). We wondered if IA HA or PRP injections (intervention) may delay the time to TKA (outcome) among KOA patients (population), compared to KOA patients not receiving these injections (comparator). For this systematic literature review (SLR) and meta-analysis, we selected observational studies with at least one group of patients receiving IA HA or PRP and with TKA data available. The main outcome was time from the diagnosis of KOA to TKA. We included 25 articles in the SLR (2,824,401 patients) and four in the meta-analysis. The mean strengthening the reporting of observational studies in epidemiology (STROBE) score was 63%. For patients receiving versus not receiving HA injections, the delay between a declared diagnosis of KOA to TKA was increased by 9.8 months (95% CI (8.2-11.4)). As compared with standard of care, the effect size of HA injections for this outcome was 0.57 (95% CI (0.36-0.76)). Only one study described a median time from PRP injections to TKA of 4.1 years (range 0.3-14.7). IA HA injections were associated with increased time to TKA. Causality cannot be concluded because of missing confounder factors as comorbidities. Data were insufficient to conclude any effect of PRP injections on TKA delay.

Intraarticular Hyaluronic Acid Preparations for Knee Osteoarthritis: Are Some Better Than Others?

OBJECTIVE

This literature review summarizes evidence on the safety and efficacy of intraarticular hyaluronic acid (IAHA) preparations approved in the United States for the treatment of osteoarthritis of the knee.

DESIGN

A systematic literature search was performed in PubMed, Ovid MEDLINE, and SCOPUS databases. Only studies in which clinical outcomes of individual IAHA preparations alone could be assessed when compared to placebo, no treatment, other standard knee osteoarthritis treatments, and IAHA head-to-head studies were selected.

RESULTS

One hundred nine articles meeting our inclusion criteria were identified, including 59 randomized and 50 observational studies. Hylan G-F 20 has been the most extensively studied preparation, with consistent results confirming efficacy in placebo-controlled studies. Efficacy is also consistently reported for Supartz, Monovisc, and Euflexxa, but not for Hyalgan, Orthovisc, and Durolane. In the head-to-head trials, high-molecular-weight (MW) Hylan G-F 20 was consistently superior to low MW sodium hyaluronate preparations (Hyalgan, Supartz) up to 20 weeks, whereas one study reported that Durolane was noninferior to Supartz. Head-to-head trials comparing high versus medium MW preparations all used Hylan G-F 20 as the high MW preparation. Of the IAHA preparations with strong evidence of efficacy in placebo-controlled studies, Euflexxa was found to be noninferior to Hylan G-F 20. There are no direct comparisons to Monovisc. One additional IAHA preparation (ie, Synovial), which has not been assessed in placebo-controlled studies, was also noninferior to Hylan G-F 20.

CONCLUSION

IAHA efficacy varies widely across preparations. High-quality studies are required to assess and compare the safety and efficacy of IAHA preparations.

Safety of Intra-Articular Hyaluronic Acid for Knee Osteoarthritis: Systematic Review and Meta-Analysis of Randomized Trials Involving More than 8,000 Patients

OBJECTIVE

The objective of this systematic review and meta-analysis was to report the safety of intra-articular hyaluronic acid (IAHA) in patients with symptomatic knee osteoarthritis (OA).

METHODS

We identified randomized controlled trials reporting the safety of IAHA versus IA saline in adults with symptomatic knee OA. Main safety outcomes were adverse events (AEs), local AEs, serious adverse events (SAEs), study withdrawals, and AE-related study withdrawals.

RESULTS

A total of 35 randomized controlled trials with 38 group comparisons comprising 8,078 unique patients (IAHA: 4,295, IA saline: 3,783) were included in the meta-analysis. Comparing IAHA with IA saline over a median of 6 months follow-up, there were no differences in the risk of AEs (42.4% vs. 39.7%, risk ratio [RR] = 1.01, 95% CI = 0.96-1.07, P = 0.61), SAEs (1.8% vs. 1.2%, RR = 1.44, 95% CI = 0.91-2.26, P=0.12), study withdrawals (12.3% vs. 12.7%, RR = 0.99, 95% CI = 0.87-1.12, P = 0.83), or AE-related study withdrawals (2.7% vs. 2.1%, RR = 1.37, 95% CI = 0.97-1.93, P = 0.08). Local AEs, all of which were nonserious, were more common with IAHA vs. IA saline (14.5% vs. 11.7%, RR = 1.21, 95% CI = 1.07-1.36, P = 0.003) and typically resolved within days.

CONCLUSION

IAHA was shown to be safe for use in patients with symptomatic knee OA. Compared with IA saline, IAHA is associated with an increased risk of nonserious, transient local reactions. There was no evidence to suggest any additional safety risks of IAHA.

Exploring the application and mechanism of sodium hyaluronate in cryopreservation of red blood cells

The cryopreservation of red blood cells (RBCs) is essential for transfusion therapy and maintaining the inventory of RBCs units. The existing cryoprotectants (CPAs) have many defects, and the search for novel CPAs is becoming a research hotspot. Sodium hyaluronate (SH) is polymerized from sodium glucuronate and N-acetylglucosamine, which has good water binding capacity and biocompatibility. Herein, we reported for the first time that under the action of medium molecular weight sodium hyaluronate (MSH), the thawed RBCs recovery increased from 33.1 ​± ​5.8% to 63.2 ​± ​3.5%. In addition, RBCs functions and properties were maintained normally, and the residual MSH could be removed by direct washing. When MSH was used with a very low concentration (5% v/v) of glycerol (Gly), the thawed RBCs recovery could be increased to 92.3 ​± ​4.6%. In general, 40% v/v Gly was required to achieve similar efficiency. A mathematical model was used to compare the performance of MSH, PVA and trehalose in cryopreservation, and MSH showed the best efficiency. It was found that MSH could periodically regulate the content of intracellular water through the “reservoir effect” to reduce the damages during freezing and thawing. Moreover, MSH could inhibit ice recrystallization when combined with RBCs. The high viscosity and strong water binding capacity of MSH was also conducive to reducing the content of ice. This works points out a new direction for cryopreservation of RBCs and may promote transfusion therapy in clinic.

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MSH improved the RBCs recovery in cryopreservation.

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MSH can be removed directly after thawing.

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The properties and functions of RBCs were protected by MSH.

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High RBCs recovery is found using MSH with 5% v/v glycerol.

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The mathematical model is studied for the cryopreservation.

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The mechanism is proposed for cryopreservation using MSH.

PI3Kγ/AKT Signaling in High Molecular Weight Hyaluronan (HMWH)-Induced Anti-Hyperalgesia and Reversal of Nociceptor Sensitization

High molecular weight hyaluronan (HMWH), a well-established treatment for osteoarthritis pain, is anti-hyperalgesic in preclinical models of inflammatory and neuropathic pain. HMWH-induced anti-hyperalgesia is mediated by its action at cluster of differentiation 44 (CD44), the cognate hyaluronan receptor, which can signal via phosphoinositide 3-kinase (PI3K), a large family of kinases involved in diverse cell functions. We demonstrate that intrathecal administration of an oligodeoxynucleotide (ODN) antisense to mRNA for PI3Kγ (a Class I PI3K isoform) expressed in dorsal root ganglia (DRGs), and intradermal administration of a PI3Kγ-selective inhibitor (AS605240), markedly attenuates HMWH-induced anti-prostaglandin E₂ (PGE₂) hyperalgesia, in male and female rats. Intradermal administration of inhibitors of mammalian target of rapamycin (mTOR; rapamycin) and protein kinase B (AKT; AKT Inhibitor IV), signaling molecules downstream of PI3Kγ, also attenuates HMWH-induced anti-hyperalgesia. In vitro patch-clamp electrophysiology experiments on cultured nociceptors from male rats demonstrate that some HMWH-induced changes in generation of action potentials (APs) in nociceptors sensitized by PGE₂ are PI3Kγ dependent (reduction in AP firing rate, increase in latency to first AP and increase in slope of current ramp required to induce AP) and some are PI3Kγ independent [reduction in recovery rate of AP afterhyperpolarization (AHP)]. Our demonstration of a role of PI3Kγ in HMWH-induced anti-hyperalgesia and reversal of nociceptor sensitization opens a novel line of research into molecular targets for the treatment of diverse pain syndromes.SIGNIFICANCE STATEMENT We have previously demonstrated that high molecular weight hyaluronan (HMWH) attenuates inflammatory hyperalgesia, an effect mediated by its action at cluster of differentiation 44 (CD44), the cognate hyaluronan receptor, and activation of its downstream signaling pathway, in nociceptors. In the present study, we demonstrate that phosphoinositide 3-kinase (PI3K)γ and downstream signaling pathway, protein kinase B (AKT) and mammalian target of rapamycin (mTOR), are crucial for HMWH to induce anti-hyperalgesia.

Sexually Dimorphic Role of Toll-like Receptor 4 (TLR4) in High Molecular Weight Hyaluronan (HMWH)-induced Anti-hyperalgesia

High molecular weight hyaluronan (HMWH), a prominent component of the extracellular matrix binds to and signals via multiple receptors, including cluster of differentiation 44 (CD44) and toll-like receptor 4 (TLR4). We tested the hypothesis that, in the setting of inflammation, HMWH acts at TLR4 to attenuate hyperalgesia. We found that the attenuation of prostaglandin E2 (PGE2)-induced hyperalgesia by HMWH was attenuated by a TLR4 antagonist (NBP2-26245), but only in male and ovariectomized female rats. In this study we sought to evaluated the role of the TLR4 signaling pathway in anti-hyperalgesia induced by HMWH in male rats. Decreasing expression of TLR4 in nociceptors, by intrathecal administration of an oligodeoxynucleotide (ODN) antisense to TLR4 mRNA, also attenuated HMWH-induced anti-hyperalgesia, in male and ovariectomized female rats. Estrogen replacement in ovariectomized females reconstituted the gonad-intact phenotype. The administration of an inhibitor of myeloid differentiation factor 88 (MyD88), a TLR4 second messenger, attenuated HMWH-induced anti-hyperalgesia, while an inhibitor of the MyD88-independent TLR4 signaling pathway did not. Since it has previously been shown that HMWH-induced anti-hyperalgesia is also mediated, in part by CD44 we evaluated the effect of the combination of ODN antisense to TLR4 and CD44 mRNA. This treatment completely reversed HMWH-induced anti-hyperalgesia in male rats. Our results demonstrate a sex hormone-dependent, sexually dimorphic involvement of TLR4 in HMWH-induced anti-hyperalgesia, that is MyD88 dependent. PERSPECTIVE: The role of TLR4 in anti-hyperalgesia induced by HMWH is a sexually dimorphic, TLR4 dependent inhibition of inflammatory hyperalgesia that provides a novel molecular target for the treatment of inflammatory pain.

Intra-Articular Injections of Platelet-Rich Plasma, Adipose Mesenchymal Stem Cells, and Bone Marrow Mesenchymal Stem Cells Associated With Better Outcomes Than Hyaluronic Acid and Saline in Knee Osteoarthritis: A Systematic Review and Network Meta-analysis

PURPOSE

To perform a network meta-analysis to evaluate clinical efficacy and treatment-related adverse events (AEs) of intra-articular hyaluronic acid (HA), leukocyte-poor platelet-rich plasma (LP-PRP), leukocyte-rich platelet-rich plasma (LR-PRP), bone marrow mesenchymal stem cells (BM-MSCs), adipose mesenchymal stem cells (AD-MSCs), and saline (placebo) during 6 and 12 months of follow-up.

METHODS

Six databases were searched for randomized controlled trials. Outcome assessment included the visual analog scale (VAS) score, Western Ontario and McMaster Universities Osteoarthritis (WOMAC) pain subscore, WOMAC score, International Knee Documentation Committee (IKDC) subjective score, and treatment-related AEs. Main inclusion criteria were at least one of the aforementioned outcome measurements, a minimum follow-up period of 5 months, and >80% patient follow-up. Treatments combined with the use of other operations or drugs were excluded.

RESULTS

Forty-three studies meeting the eligibility criteria were included. At 6 months, VAS scores and WOMAC pain subscores showed that AD-MSCs were the best treatment option (surface under the cumulative ranking curve [SUCRA] = 96.7%, SUCRA = 85.3%, respectively). According to WOMAC scores and subjective IKDC scores, LP-PRP was the most effective treatment (SUCRA = 86.0%, SUCRA = 80.5%, respectively). At 12 months, only AD-MSCs were associated with improved VAS scores compared with the placebo (weighted mean difference [WMD] = -20.93, 95% credibility interval [CrI], -41.71 to -0.78). Both LP-PRP and AD-MSCs were more beneficial than the placebo for improving WOMAC pain subscores (WMD = -30.08; 95% CrI, -53.59 to -6.25; WMD = -34.85; 95% CrI, -68.03 to -4.86, respectively). For WOMAC scores, LP-PRP and LR-PRP were significantly associated with improved WOMAC scores compared with the placebo after sensitivity analysis was performed (WMD = -35.26; 95% CrI, -64.99 to -6.01; WMD = -38.69; 95% CrI, -76.21 to -2.76). LP-PRP exhibited relatively better efficacy in improving subjective IKDC scores than the placebo (WMD = 13.67; 95% CrI, 4.05-23.39). Regarding safety, all treatments except for LP-PRP (relative risk = 1.83; 95% CrI, 0.89-4.64) increased treatment-related AEs compared with the placebo.

CONCLUSIONS

Based on the results of current research findings, during 6 months of follow-up, AD-MSCs relieved pain the best; LP-PRP was most effective for functional improvement. During the 12-month follow-up, both AD-MSCs and LP-PRP showed potential clinical pain relief effects; functional improvement was achieved with LP-PRP. Unfortunately, AD-MSC/LP-PRP functional comparisons were only based on WOMAC scores due to missing IKDC scores. BM-MSCs seem to have potentially beneficial effects, but the wide credibility interval makes it impossible to draw a well-supported conclusion. HA viscosupplementation clinical efficacy was lower than that of biological agents during follow-up, which may be related to the properties of the drugs. Considering the evaluation of treatment-related AEs, LP-PRP is the most advisable choice; although the AEs of these treatments are not serious, they may affect treatment compliance and satisfaction.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II studies.

Recent Progress in Cartilage Lubrication

Healthy articular cartilage, covering the ends of bones in major joints such as hips and knees, presents the most efficiently-lubricated surface known in nature, with friction coefficients as low as 0.001 up to physiologically high pressures. Such low friction is indeed essential for its well-being. It minimizes wear-and-tear and hence the cartilage degradation associated with osteoarthritis, the most common joint disease, and, by reducing shear stress on the mechanotransductive, cartilage-embedded chondrocytes (the only cell type in the cartilage), it regulates their function to maintain homeostasis. Understanding the origins of such low friction of the articular cartilage, therefore, is of major importance in order to alleviate disease symptoms, and slow or even reverse its breakdown. This progress report considers the relation between frictional behavior and the cellular mechanical environment in the cartilage, then reviews the mechanism of lubrication in the joints, in particular focusing on boundary lubrication. Following recent advances based on hydration lubrication, a proposed synergy between different molecular components of the synovial joints, acting together in enabling the low friction, has been proposed. Additionally, recent development of natural and bio-inspired lubricants is reviewed.

Injection-Based Management of Osteoarthritis of the Knee: A Systematic Review of Guidelines

Osteoarthritis (OA) is a leading cause of disability among older adults. Numerous pharmaceutical and nonpharmaceutical interventions have been described. Intra-articular injections are commonly the first line treatment. There are several articles, reporting the outcome of corticosteroids (CS), hyaluronic acid (HA) and platelet rich plasma (PRP). The aim of the study is to highlight the usefulness, indication and efficacy of the intra-articular injection of principal drugs. CSs have been shown to reduce the severity of pain, but care should be taken with repeated injections because of potential harm. HA reported good outcomes both for pain reduction and functional improvement. Different national societies guidelines do not recommend the PRP intra-articular injection in the management of knee OA for lack of evidence. In conclusion, the authors affirm that there is some evidence that intra-articular steroids are efficacious, but their benefit may be relatively short lived (<4 weeks). Most of the positive outcome were limited to the studies or part of the studies that considered the injection of high molecular weight as visco-supplementation, with a course of two to four injections a year.

Mechanisms Mediating High-Molecular-Weight Hyaluronan-Induced Antihyperalgesia

We evaluated the mechanism by which high-molecular-weight hyaluronan (HMWH) attenuates nociceptor sensitization, in the setting of inflammation. HMWH attenuated mechanical hyperalgesia induced by the inflammatory mediator prostaglandin E2 (PGE₂) in male and female rats. Intrathecal administration of an oligodeoxynucleotide antisense (AS-ODN) to mRNA for cluster of differentiation 44 (CD44), the cognate hyaluronan receptor, and intradermal administration of A5G27, a CD44 receptor antagonist, both attenuated antihyperalgesia induced by HMWH. In male rats, HMWH also signals via Toll-like receptor 4 (TLR4), and AS-ODN for TLR4 mRNA administered intrathecally, attenuated HMWH-induced antihyperalgesia. Since HMWH signaling is dependent on CD44 clustering in lipid rafts, we pretreated animals with methyl-β-cyclodextrin (MβCD), which disrupts lipid rafts. MβCD markedly attenuated HMWH-induced antihyperalgesia. Inhibitors for components of intracellular signaling pathways activated by CD44, including phospholipase C and phosphoinositide 3-kinase (PI3K), also attenuated HMWH-induced antihyperalgesia. Furthermore, in vitro application of HMWH attenuated PGE₂-induced sensitization of tetrodotoxin-resistant sodium current, in small-diameter dorsal root ganglion neurons, an effect that was attenuated by a PI3K inhibitor. Our results indicate a central role of CD44 signaling in HMWH-induced antihyperalgesia and suggest novel therapeutic targets, downstream of CD44, for the treatment of pain generated by nociceptor sensitization.SIGNIFICANCE STATEMENT High-molecular-weight-hyaluronan (HMWH) is used to treat osteoarthritis and other pain syndromes. In this study we demonstrate that attenuation of inflammatory hyperalgesia by HMWH is mediated by its action at cluster of differentiation 44 (CD44) and activation of its downstream signaling pathways, including RhoGTPases (RhoA and Rac1), phospholipases (phospholipases Cε and Cγ1), and phosphoinositide 3-kinase, in nociceptors. These findings contribute to our understanding of the antihyperalgesic effect of HMWH and support the hypothesis that CD44 and its downstream signaling pathways represent novel therapeutic targets for the treatment of inflammatory pain.

Comparison of patient-reported outcomes of treatment with low- and intermediate molecular weight hyaluronic acid in Japanese patients with symptomatic knee osteoarthritis: A prospective, randomized, single-blind trial

Objectives

The objective of this study was to compare the clinical outcomes of treatment with low- or intermediate-molecular-weight hyaluronic acid (HA) in patients with knee osteoarthritis (OA).

Methods

In total, 59 patients with OA who fulfilled the criteria of the American College of Rheumatology for OA were enrolled. Patients were randomly assigned in a 1:1 ratio to the low- or intermediate-molecular-weight HA group. An intraarticular injection of HA into the knee joint was performed five times per week. The visual analog scale for pain (pain VAS) and Japanese Knee Osteoarthritis Measure (JKOM) score were analyzed at baseline and week 6 to assess the outcomes.

Results

Pain VAS and JKOM score were significantly improved in both groups. At follow-up, there were no significant between-group differences in pain VAS or total JKOM score. Moreover, reduction in pain VAS and JKOM score was not significantly different between the two groups.

Conclusions

Both low- and intermediate-molecular-weight HA have significant efficacy in the first-line treatment of patients with knee OA as indicated by patient-reported outcomes. However, there does not appear to be any difference between the efficacy of low- and intermediate-molecular-weight HA as indicated by the JKOM score. We believe that the results of this study provide important insights into the clinical management of Japanese patients with knee OA.

Arthrocentesis and Sodium Hyaluronate Infiltration in Temporomandibular Disorders Treatment. Clinical and MRI Evaluation

Arthrocentesis in temporomandibular joint disorders can be associated with the intra-articular infiltration of various drugs with the objective of increase treatment efficacy. The aim of this study was to evaluate the clinical indexes variation in patients affected by temporomandibular joint disorders treated with arthrocentesis and sodium hyaluronate (SH) injections. A total of 28 patients suffering from temporomandibular joint disorders underwent one cycle of five arthrocentesis and infiltrations of sodium hyaluronate. Spontaneous mouth opening improved from 36.3 ± 7.5 mm to 45.1 ± 1.9 mm at six months follow-up. A significant reduction in the pain at rest and during mastication mean values emerged at follow-up (p < 0.0001). The mean masticatory efficiency, evaluated through a visual analogic scale, showed improvement at the follow-up period, highlighted by the increase of mean value from a baseline of 3.1 ± 1.2 to a mean value of 8.5 ± 1.2 (p < 0.0001). The mean severity of the joint damage at baseline time was 2.4 ± 0.9 and decreased to 0.4 ± 0.3 at the end of the follow-up period. The decrease in values is confirmed by statistical test (p < 0.05). Our data show how arthrocentesis integrated with sodium hyaluronate infiltrations performed under local anesthesia is a valid method of treating temporomandibular joint disorders.

Effects of Intraperitoneal Hyaluronan on Peritoneal Fluid and Solute Transport in Peritoneal Dialysis Patients

← Background

Hyaluronan (HA) is a glycosaminoglycan found in connective tissues and tissue spaces, including the peritoneal cavity. In vivo studies in a rat model of peritoneal dialysis (PD) have shown that addition of HA to PD solution during an intraperitoneal dwell can alter peritoneal fluid transport and protect the peritoneal membrane from the effects of inflammation and repeated infusions of dialysis solution. The current study sought to evaluate the safety of intraperitoneal HA and its effect on peritoneal fluid and solute transport when administered during a dialysis dwell in humans.

← Methods

13 PD patients were enrolled in a prospective, randomized crossover study involving three dialysis treatments using the following PD solutions: ( 1 ) a commercially available PD solution (Dianeal PD-4, 1.36% glucose; Baxter Healthcare Corporation, Alliston, Ontario, Canada); ( 2 ) Dianeal PD-4 containing 0.1 g/L HA, and ( 3 ) Dianeal PD-4 containing 0.5 g/LHA. Each 6-hour dialysis exchange was separated from the other exchanges by a 2-week washout period. Radioiodinated human serum albumin (RISA) was administered with the dialysis solution to evaluate intraperitoneal volume, net ultrafiltration (UF), and fluid reabsorption. Peritoneal clearances, dialysate/plasma ratios (D/P), and mass transfer area coefficients (MTACs) were determined for sodium, urea, creatinine, albumin, and glucose. Safety was evaluated by monitoring adverse events and changes in serum chemistries. Ten patients completed all three dialysis exchanges and two additional patients completed at least one treatment exchange.

← Results

There were no reported adverse events related to HA administration and no significant changes in serum chemistries. There were no significant differences in net UF or peritoneal volume profiles among the three treatments. Mean net UF calculated using residual volumes, estimated by RISA dilution, tended to be slightly higher during treatment with solution containing 0.1 g/L HA and 0.5 g/L HA [74 ± 86 (SE) and 41 ± 99 mL, respectively] compared to control treatment (–58 ± 129 mL). Although not statistically significant, there was a trend toward decreased fluid reabsorption during treatment with HA. Solute clearances, D/P ratios, and MTACs were similar for the three treatments. Serum levels of HA were also unaffected by the two treatment solutions.

← Conclusions

These data support the acute safety of HA when administered intraperitoneally with the dialysis solution to PD patients. Due to the small sample size and variability in net UF and fluid reabsorption, statistically significant differences were not demonstrated for these parameters. However, a trend toward decreased fluid reabsorption was observed, suggesting that HA may act by a mechanism similar to that observed in animal studies. Further studies are necessary to evaluate whether the beneficial effects of HA observed in animal studies can be shown in humans.

Safety of Intra-articular Hyaluronic Acid Injections in Osteoarthritis: Outcomes of a Systematic Review and Meta-Analysis

BACKGROUND

Some controversy exists regarding the safety of intra-articular hyaluronic acid (IAHA) in the management of osteoarthritis (OA).

OBJECTIVE

The objective of this study was to re-assess the safety profile of IAHA in patients with OA, through a comprehensive meta-analysis of randomized, placebo-controlled trials.

METHODS

A comprehensive literature search was undertaken in the databases MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus. Randomized, double-blind, placebo-controlled, parallel-group trials that assessed adverse events (AEs) with IAHA in patients with OA were eligible for inclusion. Authors and/or study sponsors were contacted to obtain the full report of AEs. The primary outcomes were overall severe and serious AEs, as well as the following MedDRA System Organ Class (SOC)-related AEs: gastrointestinal, cardiac, vascular, respiratory, nervous system, skin and subcutaneous tissue disorders, musculoskeletal, renal and urinary disorders, infections and infestations, and hypersensitivity reaction.

RESULTS

Database searches initially identified 1481 records. After exclusions according to the selection criteria, 22 studies were included in the qualitative synthesis, and nine studies having adequate data were ultimately included in the meta-analysis. From the studies excluded according to the pre-specified selection criteria, 21 with other pharmacological OA treatments permitted during the trials were a posteriori included in a parallel qualitative synthesis, from which eight studies with adequate data were finally included in a parallel meta-analysis. Since this meta-analysis was designed to assess safety, the exclusion criterion on concomitant anti-OA medication was crucial. However, due to the high number of studies that allowed mainly concomitant oral non-steroidal anti-inflammatory drugs (NSAIDs), we decided to include them in a post hoc parallel analysis in order to compare the results from the two analyses. No statistically significant difference in odds was found between IAHA and placebo for all types of SOC-related disorders, except for infections and infestations, for which significantly lower odds were found with IAHA compared with placebo, both overall (odds ratio [OR] = 0.61, 95% confidence interval [CI] 0.40-0.93; I² = 0%) and in studies without concomitant anti-OA medication (OR = 0.49, 95% CI 0.27-0.89). There were significant increased odds of reporting serious AEs with IAHA compared with placebo, both overall (OR = 1.78, 95% CI 1.21-2.63; I² = 0%) and in studies with concomitant anti-OA medication (OR = 1.78, 95% CI 1.10-2.89), but not in studies without concomitant anti-OA medication (OR = 1.78, 95% CI 0.92-3.47).

CONCLUSIONS

Using the available data on studies without any concomitant anti-OA medication permitted during clinical trials, IAHA seems not to be associated with any safety issue in the management of OA. However, this evidence was associated with only a "low" to "moderate" certainty. A possible association with increased risk of serious AEs, particularly when used with concomitant OA medications, requires further investigation.

A comparative review of network meta-analysis models in longitudinal randomized controlled trial

Network meta-analysis (NMA) technique extends the standard meta-analysis methods, allowing pairwise comparison of all treatments in a network in the absence of head-to-head comparisons. Traditional NMA models consider a single endpoint for each trial. However, in many cases, trials in the network have different durations and/or report data at multiple time points. Moreover, these time points are often not the same for all trials. In this work, we review the most relevant methods that incorporate multiple time points and allow indirect comparisons of treatment effects across different longitudinal studies. In particular, we focus on the mixed treatment comparison developed by Dakin et al,[10] on the Bayesian evidence synthesis techniques-integrated two-component prediction developed by Ding et al,[11] and on the more recent method based on fractional polynomials by Jansen et al.[12] We highlight the main features of each model and illustrate them in simulations and in a real data application. Our study shows that methods based on fractional polynomials offer a flexible modeling strategy in most applications.

Does Hyaluronan improve pain or function following Arthroscopic Subacromial decompression (ASD) surgery of Shoulder? Results of a level 1 RCT

BACKGROUND

Sodium hyaluronate (hyaluronan) can be used as a synovial fluid substitute following arthroscopic surgery. In this study, we examined its effect on pain and function following arthroscopic subacromial arthroscopic decompression (ASAD).

METHODOLOGY

A prospective, randomized, and single-blinded design was used (13/LO0427) to compare the effect of a single postprocedure subacromial instillation of 10 ml hyaluronan, against 10 ml saline control. All patients had interscalene block along with general anesthesia and followed standard postoperative rehabilitation protocol. A power calculation for a 6-point difference in Oxford Shoulder Score (OSS) indicated a minimum sample size of 44. Participants were assessed preoperatively, and at 12 weeks using the following outcome measures -Oxford Shoulder Score (OSS), visual analog score (VAS), European quality of life score (EUROQOL), and Disability of the arm, shoulder, and hand (DASH) scores.

RESULTS

46 patients were included for analysis. Both groups showed a mean improvement in OSS of 9 points (P = 0.0001), DASH (10 points, P < 0.05), and EUROQOL (0.13, P < 0.05). No significant difference was observed between groups in any of the recorded outcomes. Apart from one case of frozen shoulder in each group, no other complications were noted.

CONCLUSION

While both groups showed improved pain and function scores after ASAD, no significant difference was seen between groups receiving placebo or hyaluronan. The intervention is safe but, in this study, has not been shown to improve postoperative pain or function over ASAD alone. Level of evidence: I.

Association of Pharmacological Treatments With Long-term Pain Control in Patients With Knee Osteoarthritis: A Systematic Review and Meta-analysis

IMPORTANCE

Even though osteoarthritis is a chronic and progressive disease, pharmacological agents are mainly studied over short-term periods, resulting in unclear recommendations for long-term disease management.

OBJECTIVE

To search, review, and analyze long-term (≥12 months) outcomes (symptoms, joint structure) from randomized clinical trials (RCTs) of medications for knee osteoarthritis.

DATA SOURCES AND STUDY SELECTION

The databases of MEDLINE, Scopus, EMBASE, Web of Science, and the Cochrane Central Register of Controlled Trials were searched until June 30, 2018 (MEDLINE alerts through August 31, 2018) for RCTs of patients with knee osteoarthritis that had treatment and follow-up lasting 1 year or longer.

DATA EXTRACTION AND SYNTHESIS

Data at baseline and at the longest available treatment and follow-up of 12 months' duration or longer (or the change from baseline) were extracted. A Bayesian random-effects network meta-analysis was performed.

MAIN OUTCOMES AND MEASURES

The primary outcome was the mean change from baseline in knee pain. Secondary outcomes were physical function and joint structure (the latter was measured radiologically as joint space narrowing). Standardized mean differences (SMDs) and mean differences with 95% credibility intervals (95% CrIs) were calculated. Findings were interpreted as associations when the 95% CrIs excluded the null value.

RESULTS

Forty-seven RCTs (22 037 patients; mean age range, mostly 55-70 years; and a higher mean proportion of women than men, around 70%) included the following medication categories: analgesics; antioxidants; bone-acting agents such as bisphosphonates and strontium ranelate; nonsteroidal anti-inflammatory drugs; intra-articular injection medications such as hyaluronic acid and corticosteroids; symptomatic slow-acting drugs in osteoarthritis such as glucosamine and chondroitin sulfate; and putative disease-modifying agents such as cindunistat and sprifermin. Thirty-one interventions were studied for pain, 13 for physical function, and 16 for joint structure. Trial duration ranged from 1 to 4 years. Associations with decreases in pain were found for the nonsteroidal anti-inflammatory drug celecoxib (SMD, -0.18 [95% CrI, -0.35 to -0.01]) and the symptomatic slow-acting drug in osteoarthritis glucosamine sulfate (SMD, -0.29 [95% CrI, -0.49 to -0.09]), but there was large uncertainty for all estimates vs placebo. The association with pain improvement remained significant only for glucosamine sulfate when data were analyzed using the mean difference on a scale from 0 to 100 and when trials at high risk of bias were excluded. Associations with improvement in joint space narrowing were found for glucosamine sulfate (SMD, -0.42 [95% CrI, -0.65 to -0.19]), chondroitin sulfate (SMD, -0.20 [95% CrI, -0.31 to -0.07]), and strontium ranelate (SMD, -0.20 [95% CrI, -0.36 to -0.05]).

CONCLUSIONS AND RELEVANCE

In this systematic review and network meta-analysis of studies of patients with knee osteoarthritis and at least 12 months of follow-up, there was uncertainty around the estimates of effect size for change in pain for all comparisons with placebo. Larger RCTs are needed to resolve the uncertainty around efficacy of medications for knee osteoarthritis.

Intra-articular, single-shot co-injection of hyaluronic acid and corticosteroids in knee osteoarthritis: A randomized controlled trial

The aim of the present study was to investigate whether the co-injection of hyaluronic acid (HA) and corticosteroids (CS) was superior to HA alone in the treatment of knee OA. A total of 120 participants with symptomatic knee OA were recruited and formed the intention-to-treat population for a 6-month follow-up. In the HA group, patients received a single-shot injection of 4 ml HA. In the HA&CS group, patients received a co-injection of 3 ml compound betamethasone solution and 4 ml HA. Visual analog scale (VAS), Western Ontario and McMaster University Osteoarthritis Index (WOMAC) and knee flexion motion were assessed as primary outcomes. Patients in the HA&CS group exhibited better pain relief and knee function at the time points of week 1, month 1 and month 3 (P<0.05). For the last follow-up at month 6, the values did not differ significantly between these two groups. Patients in both groups exhibited improvement in pain, knee function, and range of motion following injection. For the final follow-up at month 6, the mean VAS score, WOMAC score and knee flexion motion were still superior to that prior to treatment, but the values did not differ significantly. The co-injection of HA and CS provided a rapid improvement in pain relief, knee function, and range of motion, but did not differ significantly from that of HA alone in the long term effect.

Hyaluronic Acid in the Third Millennium

Since its first isolation in 1934, hyaluronic acid (HA) has been studied across a variety of research areas. This unbranched glycosaminoglycan consisting of repeating disaccharide units of N-acetyl-d-glucosamine and d-glucuronic acid is almost ubiquitous in humans and in other vertebrates. HA is involved in many key processes, including cell signaling, wound reparation, tissue regeneration, morphogenesis, matrix organization and pathobiology, and has unique physico-chemical properties, such as biocompatibility, biodegradability, mucoadhesivity, hygroscopicity and viscoelasticity. For these reasons, exogenous HA has been investigated as a drug delivery system and treatment in cancer, ophthalmology, arthrology, pneumology, rhinology, urology, aesthetic medicine and cosmetics. To improve and customize its properties and applications, HA can be subjected to chemical modifications: conjugation and crosslinking. The present review gives an overview regarding HA, describing its history, physico-chemical, structural and hydrodynamic properties and biology (occurrence, biosynthesis (by hyaluronan synthases), degradation (by hyaluronidases and oxidative stress), roles, mechanisms of action and receptors). Furthermore, both conventional and recently emerging methods developed for the industrial production of HA and its chemical derivatization are presented. Finally, the medical, pharmaceutical and cosmetic applications of HA and its derivatives are reviewed, reporting examples of HA-based products that currently are on the market or are undergoing further investigations.

Changes in biomarkers in equine synovial fluid two weeks after intra-articular hyaluronan treatment: a randomised double-blind clinical trial

BACKGROUND

Inflammatory and degenerative activity inside the joint can be studied in vivo via analysis of synovial fluid (SF) biomarkers, which are molecular markers of inflammatory processes and tissue turnover. The aim of this study was to investigate the response of selected biomarkers in the SF after an intra-articular (IA) high-molecular-weight non-animal stabilized hyaluronic acid (NASHA) treatment. Our hypothesis was that prostaglandin E₂ (PGE₂), substance P, aggrecan chondroitin sulfate 846 epitope (CS846), and carboxypeptide of type II collagen (CPII) concentrations in SF would decrease more in the NASHA than in the placebo group. Twenty-eight clinically lame horses with positive responses to diagnostic IA anaesthesia of the metacarpophalangeal or metatarsophalangeal joints were randomized into treatment (n = 15) and control (n = 13) groups. After collection of baseline SF samples followed by IA diagnostic anaesthesia, horses in the treatment group received 3 ml of a NASHA product IA. Those in the placebo group received an equivalent volume of sterile 0.9% saline solution. The horses were re-evaluated and a second SF sample was obtained after a 2-week period.

RESULTS

CS846 concentration decreased in the NASHA group only (P = 0.010). Both PGE₂ and CPII concentrations decreased within the groups (PGE₂, P = 0.010 for the NASHA group; P = 0.027 for the placebo group; CPII, P < 0.001 for NASHA group; P = 0.009 for placebo group). No significant treatment effect for any biomarker was found between groups. NASHA induced an increase in white blood cell count; this was significant compared with baseline (P = 0.021) and the placebo group (P = 0.045).

CONCLUSIONS

Although the SF concentration of the cartilage-derived biomarker CS846 decreased in the NASHA group, no statistically significant treatment effect of any of the biomarkers were observed between treatment groups. The significant increase in SF white blood cell count after IA NASHA may indicate a mild inflammatory response. However, as no clinical adverse effects were observed, we conclude that IA NASHA was well tolerated.

CD44 Signaling Mediates High Molecular Weight Hyaluronan-Induced Antihyperalgesia

We studied, in male Sprague Dawley rats, the role of the cognate hyaluronan receptor, CD44 signaling in the antihyperalgesia induced by high molecular weight hyaluronan (HMWH). Low molecular weight hyaluronan (LMWH) acts at both peptidergic and nonpeptidergic nociceptors to induce mechanical hyperalgesia that is prevented by intrathecal oligodeoxynucleotide antisense to CD44 mRNA, which also prevents hyperalgesia induced by a CD44 receptor agonist, A6. Ongoing LMWH and A6 hyperalgesia are reversed by HMWH. HMWH also reverses the hyperalgesia induced by diverse pronociceptive mediators, prostaglandin E₂, epinephrine, TNFα, and interleukin-6, and the neuropathic pain induced by the cancer chemotherapy paclitaxel. Although CD44 antisense has no effect on the hyperalgesia induced by inflammatory mediators or paclitaxel, it eliminates the antihyperalgesic effect of HMWH. HMWH also reverses the hyperalgesia induced by activation of intracellular second messengers, PKA and PKC_ε, indicating that HMWH-induced antihyperalgesia, although dependent on CD44, is mediated by an intracellular signaling pathway rather than as a competitive receptor antagonist. Sensitization of cultured small-diameter DRG neurons by prostaglandin E₂ is also prevented and reversed by HMWH. These results demonstrate the central role of CD44 signaling in HMWH-induced antihyperalgesia, and establish it as a therapeutic target against inflammatory and neuropathic pain.SIGNIFICANCE STATEMENT We demonstrate that hyaluronan (HA) with different molecular weights produces opposing nociceptive effects. While low molecular weight HA increases sensitivity to mechanical stimulation, high molecular weight HA reduces sensitization, attenuating inflammatory and neuropathic hyperalgesia. Both pronociceptive and antinociceptive effects of HA are mediated by activation of signaling pathways downstream CD44, the cognate HA receptor, in nociceptors. These results contribute to our understanding of the role of the extracellular matrix in pain, and indicate CD44 as a potential therapeutic target to alleviate inflammatory and neuropathic pain.

Appropriate Use Criteria for Hyaluronic Acid in the Treatment of Knee Osteoarthritis in the United States

OBJECTIVE

A workgroup of clinical experts has developed an Appropriate Use Criteria (AUC) for the use of hyaluronic acid (HA) in the treatment of osteoarthritis (OA) of the knee. The increasingly broad and varied use of HA injections, lack of published clinical guidance, and limited coverage for their use has created the imperative to establish appropriateness criteria.

METHODS

The experts of this workgroup represent rheumatology, orthopedic surgery, physiatry, sports medicine, and nursing clinicians with substantive knowledge of intra-articular HA therapy. This workgroup utilized the results of a systematic review of evidence, expert clinical opinion, and current evidence-based clinical practice guidelines to develop appropriateness criteria for the use of intra-articular HA for knee OA in 17 real-world clinical scenarios.

RESULTS

The workgroup scored the appropriateness of treatment of each patient scenario using a 9-point scale to designate a treatment as appropriate (7-9), uncertain (4-6), or inappropriate (1-3). Six scenarios were scored as appropriate, 10 scenarios were scored as uncertain, and 1 scenario was scored as inappropriate.

CONCLUSION

This article can assist clinicians in shared decision-making by providing best practices in considering HA injections for knee OA treatment. Moreover, this AUC article can aid payers and policy makers in determining reimbursement and preauthorization policies and more appropriately managing health care resources. It is clear that further research is still necessary-particularly in patient populations differentiated by OA severity-that may benefit the greatest from the use of HA injections for the treatment of knee OA.

Injectable hyaluronic acid down-regulates interferon signaling molecules, IGFBP3 and IFIT3 in the bovine intervertebral disc

Low back pain which is a major cause of disability for people aged between 20 and 50years imposes a serious socio-economic burden. The current focus of regenerative medicine is on identifying molecular markers to facilitate the design of targeted therapeutics. Previously, we have demonstrated that expression of the anti-proliferative interferon-induced protein with tetratricopeptide repeats 3 (IFIT3) and pro-apoptotic insulin-like growth factor-binding protein-3 (IGFBP3), are up-regulated as downstream targets of the inflammatory cytokine interferon α (IFNα) signaling pathway in the human annulus fibrosus (AF). Here, we hypothesised that injection of hyaluronic acid (HA) would have an anti-inflammatory and matrix modulatory effect on injured and IFNα₂β inflamed bovine intervertebral discs (IVD). Discs with an AF defect and challenged with IFNα₂β were used in a bovine IVD organ culture model to test the effect of HA on the IFNα₂β pathway, as well as the matrix proteins aggrecan and collagen I. qRT-PCR was used to assess the gene expression of IFNα₂β signaling molecules. Additionally, immunostaining was used to measure protein expression. Our results show that HA treatment significantly down-regulates IFNAR1, IFNAR2, STAT1/2, JAK1, IFIT3 and IGFBP3 mRNA expression in the inflamed groups. Protein analysis confirmed the PCR results. In the extracellular matrix, aggrecan and collagen I were up-regulated while ADAMTS4 was down-regulated upon treatment of the injured and inflamed discs with HA. Hence, HA demonstrates both an anti-inflammatory role, resulting in the down-regulation of IFIT3 and IGFBP3 in the AF, and a matrix modulatory effect by up-regulating aggrecan and collagen I expression.

STATEMENT OF SIGNIFICANCE

The pro-inflammatory environment of the degenerated IVD represents a challenge for regenerative therapies. The study demonstrates that hyaluronan acts as an anti-inflammatory molecule by down-regulating IFNAR1 and IFNAR2, the signaling molecules STAT1, STAT2, JAK1 and the downstream apoptotic targets IGFBP3 and IFIT3. We also demonstrated that hyaluronan modulates the disc matrix environment by increasing aggrecan and collagen I synthesis and down-regulating ADAMTS4 that degrades the matrix under inflammatory conditions. The significance of this work lies in the fact that hyaluronan acts as an anti-inflammatory molecule by shifting the disc environment towards a more anabolic state and by promoting native IVD matrix production.

Hyaluronic acid injection therapy for osteoarthritis of the knee: concordant efficacy and conflicting serious adverse events in two systematic reviews

BACKGROUND

The prevalence of knee osteoarthritis (OA)/degenerative joint disease (DJD) is increasing in the USA. Systematic reviews of treatment efficacy and adverse events (AEs) of hyaluronic acid (HA) injections report conflicting evidence about the balance of benefits and harms. We review evidence on efficacy and AEs of intraarticular viscosupplementation with HA in older individuals with knee osteoarthritis and account for differences in these conclusions from another systematic review.

METHODS

We searched PubMed and eight other databases and gray literature sources from 1990 to December 12, 2014. Double-blind placebo-controlled randomized controlled trials (RCTs) reporting functional outcomes or quality-of-life; RCTs and observational studies on delay/avoidance of arthroplasty; RCTs, case reports, and large cohort studies and case series assessing safety; and systematic reviews reporting on knee pain were considered for inclusion. A standardized, pre-defined protocol was applied by two independent reviewers to screen titles and abstracts, review full text, and extract details on study design, interventions, outcomes, and quality. We compared our results with those of a prior systematic review and found them to be discrepant; our analysis of why this discrepancy occurred is the focus of this manuscript.

RESULTS

Eighteen RCTs reported functional outcomes: pooled analysis of ten placebo-controlled, blinded trials showed a standardized mean difference of -0.23 (95 % confidence interval (CI) -0.45 to -0.01) favoring HA at 6 months. Studies reported few serious adverse events (SAEs) and no significant differences in non-serious adverse events (NSAEs) (relative risk (RR) [95 % CI] 1.03 [0.93-1.15] or SAEs (RR [95 % CI] 1.39 [0.78-2.47]). A recent prior systematic review reported similar functional outcomes, but significant SAE risk. Differences in SAE inclusion and synthesis accounted for the disparate conclusions.

CONCLUSIONS

Trials show a small but significant effect of HA on function on which recent systematic reviews agree, but lack of AE synthesis standardization leads to opposite conclusions about the balance of benefits and harms. A limitation of the re-analysis of the prior systematic review is that it required imputation of missing data.

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.

Hyaluronic acid compared with corticosteroid injections for the treatment of osteoarthritis of the knee: a randomized control trail

Background

Osteoarthritis (OA) is the most common chronic condition of the joints that takes place when the cartilage or a low friction surface between joints breaks down which leads to pain, stiffness and swelling. The purpose of the present study was to evaluate the therapeutic effect of intra-articular hyaluronic acid (HA) in comparison to corticosteroids (CS) for knee osteoarthritis.

Methods

140 patients with knee osteoarthritis, who were followed for 3 months, were randomized to receive intra-articular injection of either hyaluronic acid or corticosteroid. By receiving one injection of drug during the enrollment in the study, the patients were treated. With the Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee injury and Osteoarthritis Outcome Score (KOOS), and the visual analog pain scale, an independent, blinded evaluator assessed the patients three times.

Results

The mean age of the patients in the corticosteroid group were 57 ± 1.9 years and in Hyaluronic acid group were 58.5 ± 8.3 years. WOMAC score represented that pain and stiffness did not improve in neither groups at any time points after intervention (P > 0.05). KOOS score suggested that symptoms improved after 3 months in both CS and HA groups. Besides, daily activity improved in both groups (P < 0.05).

Conclusions

As a conclusion, it is argued that the most important difference between the two intervention groups is the duration of effectiveness. HA is suggested to be superior in the duration of pain relief when compared to CS. We can propose that HA can be administered every 3 months intra-articular for knee joint OA. Therefore, when CS has to be injected every 2 months, it will be more convenient to use HA.