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

A Low Transition Temperature Mixture-based viscosupplementation complemented with celecoxib for osteoarthritis treatment

Viscosupplementation consists of hyaluronic acid (HA) intra-articular injections, commonly applied for osteoarthritis treatment while non-steroidal anti-inflammatory drugs (NSAIDs) are widely administered for pain relief. Here, HA and a NSAID (celecoxib) were combined in a formulation based on a low transition temperature mixture (LTTM) of glycerol:sorbitol, reported to increase celecoxib's solubility, thus rendering a potential alternative viscosupplement envisioning enhanced therapeutic efficiency. The inclusion of glucosamine, a cartilage precursor, was also studied. The developed formulations were assessed in terms of rheological properties, crucial for viscosupplementation: the parameters of crossover frequency, storage (G') and loss (G'') moduli, zero-shear-rate viscosity, stable viscosity across temperatures, and shear thinning behaviour, support viscoelastic properties suitable for viscosupplementation. Additionally, the gels biocompatibility was confirmed in chondrogenic cells (ATDC5). Regarding drug release studies, high and low clearance scenarios demonstrated an increased celecoxib (CEX) release from the gel (6 to 73-fold), compared to dissolution in PBS. The low clearance setup presented the highest and most sustained CEX release, highlighting the importance of the gel structure in CEX delivery. NMR stability studies over time demonstrated the LTTM+HA+CEX (GHA+CEX) gel as viable candidate for further in vivo evaluation. In sum, the features of GHA+CEX support its potential use as alternative viscosupplement.

Demonstrating the effectiveness of intra-articular prolotherapy combined with peri-articular perineural injection in knee osteoarthritis: a randomized controlled trial

BACKGROUND

This study aimed to compare the efficacy of intra-articular prolotherapy (IG) combined with peri-articular perineural injection (PG) in the management of knee osteoarthritis (KOA).

METHODS

A total of 60 patients with the diagnosis of KOA were included in this double-blinded randomized controlled clinical trials. The inclusion criteria were as follow: (1) 48-80 years old; (2) the diagnose of KOA; (3) the grade 2 and 3 of the Kellgern-Lawrence grading scale; (4) the pain, crepitation, and knee joint stiffness continuing for 3 months at least. The main exclusion criteria were as follow: (1) any infection involving the knee skin; (2) history of any Influencing factors of disease. All patients were divided into three groups and received either IG, PG and I + PG under the ultrasound guidance and the 2, 4 and 8 weeks follow-up data of patients were available. (IG n = 20 or PG n = 20, I + PG n = 20). Visual Analogue Scale (VAS), The Western Ontario McMaster University Osteoarthritis Index (WOMAC) and the pressure pain threshold (PPT) were used as outcome measures at baseline, 2, 4 and 8 weeks.

RESULTS

There were no statistically significant differences in terms of age, sex, BMI, duration of current condition and baseline assessments of pain intensity, WOMAC scores and PPT. After treatment, the improvement of VAS activity, WOMAC and PPT values was showed compared with pre-treatment in all groups (p < 0.05). At 4 and 8 weeks after treatment, the VAS and WOMAC scores of the I + PG were significantly lower than those of the PG or IG, and the difference was statistically significant (p < 0.05). The PPT values of PG and I + PG were significantly improved compared to IG at 2, 4, and 8 weeks after treatment.

CONCLUSION

The ultrasound guided I + PG of 5% glucose seem to be more effective to alleviate pain and improve knee joint function than single therapy in short term. Clinical rehabilitators could clinically try this combination of I + PG to improve clinical symptoms in patients with KOA.

Scale-Dependent Rheology of Synovial Fluid Lubricating Macromolecules

Synovial fluid (SF) is the complex biofluid that facilitates the exceptional lubrication of articular cartilage in joints. Its primary lubricating macromolecules, the linear polysaccharide hyaluronic acid (HA) and the mucin-like glycoprotein proteoglycan 4 (PRG4 or lubricin), interact synergistically to reduce boundary friction. However, the precise manner in which these molecules influence the rheological properties of SF remains unclear. This study aimed to elucidate this by employing confocal microscopy and multiscale rheometry to examine the microstructure and rheology of solutions containing recombinant human PRG4 (rhPRG4) and HA. Contrary to previous assumptions of an extensive HA-rhPRG4 network, it is discovered that rhPRG4 primarily forms stiff, gel-like aggregates. The properties of these aggregates, including their size and stiffness, are found to be influenced by the viscoelastic characteristics of the surrounding HA matrix. Consequently, the rheology of this system is not governed by a single length scale, but instead responds as a disordered, hierarchical network with solid-like rhPRG4 aggregates distributed throughout the continuous HA phase. These findings provide new insights into the biomechanical function of PRG4 in cartilage lubrication and may have implications in the development of HA-based therapies for joint diseases like osteoarthritis.

Three once-weekly intra-articular injections of Hylan G-F 20 significantly improve pain relief compared with placebo in patients with chronic idiopathic knee osteoarthritis: a single-centre, evaluator-blinded and patient-blinded, randomized controlled trial

Background

Clinical trials on the use of viscosupplementation with hyaluronic acid (HA) in patients with knee osteoarthritis (KOA) are inconsistent, making it challenging to determine its value in clinical practice. One issue is the availability of various HA products on the market; differences in their chemical features can impact patient outcomes. Herein, we assess the efficacy and safety of three once-weekly intra-articular (IA) injections of Hylan G-F 20, a high-molecular-weight and highly crosslinked HA product, in patients with KOA. We hypothesized that Hylan G-F 20 would provide significant pain relief with no increased safety risk compared with IA saline (placebo).

Methods

This was a 26-week, patient-blinded and evaluator-blinded, single-centre, randomized placebo- controlled trial. Men or women ≥18 years of age with Larsen grade II or III KOA were included. Patients received IA injections of either Hylan G-F 20 or placebo once a week for 3 weeks. The primary endpoints were the week 12 and 26 visits. Primary efficacy outcomes included visual analogue scale (VAS) pain scores, patient activity level and an overall assessment of clinical condition. Secondary outcomes included adverse events (AEs) that emerged during treatment. The primary analysis included the intention-to-treat population. An alpha level of 0.05 was used in the statistical analysis.

Results

Thirty patients were included in the intention-to-treat population (15 per group). All efficacy outcomes were statistically significant in favour of Hylan G-F 20, except night pain and inactivity stiffness, for both patient- assessed (all p=0.0001 at week 12) and evaluator-assessed (all p=0.0001 at week 12 and p=0.0004-0.0180 at week 26) measurements. There was also a greater proportion of symptom-free patients and those with a >50% improvement in their VAS scores, except night pain, in the Hylan G-F 20 group (p=0.001-0.003 in patient-assessed scores and p<0.0001 to 0.002 in evaluator-assessed scores at week 12). Two patients, one in each group, experienced an AE; no sequelae occurred, and no special treatment was required for either AE. No patients withdrew from the study prematurely due to an AE.

Conclusion

In patients with chronic idiopathic KOA, Hylan G-F 20 provides significant improvements in pain relief compared with placebo with no added safety concerns.

Effectiveness of gonarthrosis treatment via intra-articular injections of linear vs. cross-linked hyaluronic acids

OBJECTIVES

The study aimed to compare the outcomes of single-dose cross-linked hyaluronic acid and the linear regimen of three doses of HA knee injections among patients with gonarthrosis.

PATIENTS AND METHODS

This single-center, retrospective study was conducted with 60 patients (47 females, 13 males; mean age: 57.9±4.29 years; range, 50 to 65 years) with Kellgren-Lawrence Grade 2 or 3 gonarthrosis between February 2020 and February 2022. Patients were either subjected to intra-articular cross-linked hyaluronic acid (n=30) or linear hyaluronic acid (n=30) injection treatments. Comprehensive assessments of the patients were conducted prior to the injections, as well as at three and six months after injection. The two injection groups were compared regarding the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Oxford Knee Score.

RESULTS

Both injections showed a statistically significant improvement from baseline in both WOMAC and Oxford Knee Score at three and six months (p<0.001). There was no notable distinction in the alteration of WOMAC knee scores between the two injection types. However, a notable discrepancy was observed in the elevation of Oxford Knee Score among patients who received cross-linked knee injections compared to those who underwent linear hyaluronic acid knee injections, signifying a significant increase in the former group (p<0.001).

CONCLUSION

The advantage of a single-dose administration of cross-linked HA knee injections, as opposed to the three-dose regimen required for linear hyaluronic acid, translates into reduced time and cost for the injection process. Moreover, this approach minimizes injection-associated discomfort for patients due to the singular dose administration.

Large Variations in Resistance to Degradation between Hyaluronic Acid Viscosupplements: A Comparative Rheological Study

AIM

To compare the resistance to degradation of linear and cross-linked viscosupplements using a rheological model combining mechanical and oxidative stresses, mimicking what happens inside the joint following HA injection.

METHODS

The rheological properties of 8 HAs were measured using a stress-imposed Rheometer DHR3. Strain sweeps were carried out to evaluate the rheological properties at rest from 0.001 to 3000% at a frequency of 1 Hz. The complex modulus G*, in Pa, and the phase tangent tan δ, dimensionless, in the linear viscoelastic domain (LVED) were extracted. The oxidation tests were conducted by exposing the product to H2O2 for 30 minutes. The effect of oxidation was evaluated by measuring variations of G* and tan δ, using an oscillation time sweep. Those tests were carried out at a frequency of 1 Hz and at 1% strain in the LVED.

RESULTS

At rest, the different samples exhibited various viscous behaviors. During mixing process, G* decreased from -6.4% to -31.3%. G* of low-molecular-weight HAs decreased more than that of medium molecular weight (MW) and cross-linked products. After oxidative stress, G* variation ranged from -10.1% to -46.3%. Cross-linked HAs and those containing mannitol resisted the best to degradation.

CONCLUSIONS

We showed large variations in resistance to degradation between viscosupplements. The duration of effectiveness of these products deserves to be compared in randomized clinical studies.

Efficacy of intra-articular injections of hyaluronic acid in patients with glenohumeral joint osteoarthritis: A systematic review and meta-analysis

Symptomatic primary glenohumeral (GH) joint osteoarthritis (OA) can be challenging to treat. Hyaluronic acid (HA) has emerged as a promising treatment for the nonsurgical management of GH-OA. In this systematic review with meta-analysis, we aimed to evaluate the current evidence regarding the efficacy of intra-articular HA on pain relief in patients suffering from GH-OA. A total of 15 studies (only randomized controlled trials providing data at the end of the intervention) were included. The relevant studies were selected based on the following PICO model: P: patients with diagnosis of shoulder OA; I: HA infiltrations as therapeutic intervention administered; C: no restriction for comparators assessed; O: pain, in terms of visual analog scale (VAS) or numeric rating scale. The risk of bias among the included studies was estimated using the PEDro scale. A total of 1023 subjects were analyzed. Comparing HA injections combined with physical therapy (PT) compared to PT alone resulted in superior scores, showing an overall effect size (ES) of 4.43 (p = 0.00006). Moreover, pooled analysis of VAS pain scores demonstrated a significant improvement in the ES of the HA in comparison with corticosteroid injections (p = 0.002). On average, we reported a PEDro score of 7.2. A total of 46.7% of studies showed probable signs of a randomization bias. The findings of this systematic review and meta-analysis showed that IA injections of HA might be effective on pain relief with significant improvements compared to baseline and compared to corticosteroid injections in patients affected by GH-OA.

Ex Vivo Functional Benchmarking of Hyaluronan-Based Osteoarthritis Viscosupplement Products: Comprehensive Assessment of Rheological, Lubricative, Adhesive, and Stability Attributes

While many injectable viscosupplementation products are available for osteoarthritis (OA) management, multiple hydrogel functional attributes may be further optimized for efficacy enhancement. The objective of this study was to functionally benchmark four commercially available hyaluronan-based viscosupplements (Ostenil, Ostenil Plus, Synvisc, and Innoryos), focusing on critical (rheological, lubricative, adhesive, and stability) attributes. Therefore, in vitro and ex vivo quantitative characterization panels (oscillatory rheology, rotational tribology, and texture analysis with bovine cartilage) were used for hydrogel product functional benchmarking, using equine synovial fluid as a biological control. Specifically, the retained experimental methodology enabled the authors to robustly assess and discuss various functional enhancement options for hyaluronan-based hydrogels (chemical cross-linking and addition of antioxidant stabilizing agents). The results showed that the Innoryos product, a niacinamide-augmented linear hyaluronan-based hydrogel, presented the best overall functional behavior in the retained experimental settings (high adhesivity and lubricity and substantial resistance to oxidative degradation). The Ostenil product was conversely shown to present less desirable functional properties for viscosupplementation compared to the other investigated products. Generally, this study confirmed the high importance of formulation development and control methodology optimization, aiming for the enhancement of novel OA-targeting product critical functional attributes and the probability of their clinical success. Overall, this work confirmed the tangible need for a comprehensive approach to hyaluronan-based viscosupplementation product functional benchmarking (product development and product selection by orthopedists) to maximize the chances of effective clinical OA management.

A green-based approach for noninvasive skin rejuvenation: Potential application of hyaluronic acid

Gradually, loss of skin elasticity and elastic properties occurs after 30 years of age and will be associated with several changes, including creating wrinkles, skin laxity (sagging skin), and skin blemishes. In general, people all over the world are looking for ways to keep their facial skin young over time. There are several strategies to skin rejuvenate, including invasive and non-invasive methods. However, invasive methods have less popularity than non-invasive methods due to their need for specialist physicians (medical expertise), localized neuropathic pains for patients, the prevalence and incidence of skin infections, and high-cost clinical services. In the meantime, skin hydration is one of the simplest non-invasive methods for skin rejuvenation, and HA, with anti-aging and skin collagen-stimulating properties, has been introduced as a natural skin moisturizing agent. Therefore, since this composition maintains facial skin moisture and radiance, and improves its elasticity, it has always been considered by experts and specialist physicians. On the other hand, due to its lipophilic properties, hydrophilic macromolecules containing HA cannot pass through the stratum corneum. However, they have temporary and superficial softening effects on the skin. Hence, some nanocarriers have been suggested to overcome this problem and develop the properties and positive influences of HA on skin rejuvenation. Therefore, the present study aimed to introduce some new non-invasive approaches in facial skin rejuvenation, including applying liposomes, niosomes, ethosomes, and ionic liquids, to transport HA into the inner and deeper layers of the skin, including Dermis. In this review article, we examine non-invasive methods using nanoparticles to deliver HA to the epidermis and dermis of the skin for skin rejuvenation.

Is the Rate of Responders to Hyaluronic Acid Injection for Patients with Knee Osteoarthritis Stable Over Time? Post hoc Analyses of a 6-Month Follow-Up Study

INTRODUCTION

Recently, a study showing the non-inferiority of a single injection of sodium hyaluronate plus sorbitol (Synolis VA®) compared to hylan G-F20 (Synvisc-One®) over a 24-week period in patients with knee osteoarthritis was published. The objective of the present study is to assess if a short-term response to a single injection of sodium hyaluronate plus sorbitol can be maintained over a 6 month-period and if the maintenance of the response to treatment is dependent on the functional status at baseline.

METHODS

Responders to treatment at days 28, 84, and 168 were evaluated according to the responder criteria proposed by the OMERACT-OARSI. The Western Ontario and McMaster Universities Arthritis Index (WOMAC) was used to assess functional status at baseline. All analyses were adjusted for age, gender, BMI, and baseline WOMAC total score using data from the intention-to-treat (ITT) population.

RESULTS

Out of the 96 patients included in the study who were receiving Synolis VA®, 59.38% were responders at day 28 according to the OMERACT/OARSI responder criteria, 59.78% at day 84, and 64.52% at day 168. Among the responders at D28, the probability of being responder at D84 and D168 was significantly higher than among non-responders, with corresponding odds ratio (95% CI) of 2.85 (1.07-7.59) and 7.28 (2.53-20.93), respectively. Patients with a poorer physical function at baseline were more likely to respond to the treatment at all time points, compared to those with a better physical function (OR 3.74 [1.37-10.21]).

CONCLUSIONS

An early response of a single injection of sodium hyaluronate plus sorbitol is predictive of long-term response, up to 24 weeks. Patients with a poorer physical function may best benefit from the treatment.

Designing polymers for cartilage uptake: effects of architecture and molar mass

Osteoarthritis (OA) is a progressive disease, involving the progressive breakdown of cartilage, as well as changes to the synovium and bone. There are currently no disease-modifying treatments available clinically. An increasing understanding of the disease pathophysiology is leading to new potential therapeutics, but improved approaches are needed to deliver these drugs, particularly to cartilage tissue, which is avascular and contains a dense matrix of collagens and negatively charged aggrecan proteoglycans. Cationic delivery vehicles have been shown to effectively penetrate cartilage, but these studies have thus far largely focused on proteins or nanoparticles, and the effects of macromolecular architectures have not yet been explored. Described here is the synthesis of a small library of polycations composed of N-(2-hydroxypropyl)methacrylamide (HPMA) and N-(3-aminopropyl)methacrylamide (APMA) with linear, 4-arm, or 8-arm structures and varying degrees of polymerization (DP) by reversible addition fragmentation chain-transfer (RAFT) polymerization. Uptake and retention of the polycations in bovine articular cartilage was assessed. While all polycations penetrated cartilage, uptake and retention generally increased with DP before decreasing for the highest DP. In addition, uptake and retention were higher for the linear polycations compared to the 4-arm and 8-arm polycations. In general, the polycations were well tolerated by bovine chondrocytes, but the highest DP polycations imparted greater cytotoxicity. Overall, this study reveals that linear polymer architectures may be more favorable for binding to the cartilage matrix and that the DP can be tuned to maximize uptake while minimizing cytotoxicity.

The role of intraarticular injections of hyaluronic acid in joint pain relief in hemophilic arthropathy

INTRODUCTION

Chronic pain in hemophilic patients is due to joint degeneration associated with hemophilic arthropathy. In addition to appropriate hematological treatment (primary prophylaxis), pharmacologic management and Physical Medicine and Rehabilitation should be indicated. When such measures are not sufficient, intraarticular injections (IAIs) of hyaluronic acid (HyA) may be considered.

AREAS COVERED

In order to determine whether IAIs of HyA are effective in terms of pain relief in individuals with painful moderate hemophilic arthropathy, a PubMed and Cochrane Library search using 'hemophilia hyaluronic acid' as keywords was performed on 18 July 2023.

EXPERT OPINION

In a study of individuals with hemophilic arthropathy (elbows, knees and ankles), 91% of them improved pain after a mean follow-up of 6 years. In another study of individuals with knee arthropathy, after a 7-year follow-up 82% reported an improvement in pain. As for hemophilic ankle arthropathy, in a study 67% of patients showed relief of joint pain at 6-month follow-up. Although the literature on the subject is very heterogeneous and difficult to interpret, it appears that IAIs of HyA can relieve the joint pain of painful moderate hemophilic arthropathy for months. Moreover, the IAIs can be repeated every 6-12 months.

Efficacy and safety of platelet-rich plasma injections for the treatment of osteoarthritis: a systematic review and meta-analysis of randomized controlled trials

Background

In recent years, platelet-rich plasma (PRP) injections for osteoarthritis (OA) have been widely promoted in clinical practice, but their effectiveness is controversial. Therefore, we conducted a meta-analysis of relevant randomized controlled trials (RCTs) to determine the efficacy and safety of PRP injections for the treatment of OA.

Methods

We searched databases including Embase, Web of Science, Medline, PubMed, and the Cochrane Library for relevant studies. Two researchers (YQX and CG) performed literature screening, baseline data extraction, literature quality assessment, and heterogeneity analysis of RCTs from the retrieved studies. Based on the magnitude of heterogeneity I², random-effects or fixed-effects models were selected for the meta-analysis.

Results

We included 24 RCTs comprising 1344 patients with OA who met the inclusion criteria, with the main types of morbidity being knee osteoarthritis (KOA), hip osteoarthritis (HOA), ankle osteoarthritis (AOA), and temporomandibular joint osteoarthritis (TMJOA). Our results indicate that PRP injections were effective in improving Visual Analog Scale (VAS) pain scores in patients with KOA, HOA, and AOA compared to controls (AOA, MD = -1.15, CI = 95% [-1.74, -0.56], I² = 40%, P < 0.05; KOA, MD = -1.03, CI = 95% [-1.16, -0.9], I² = 87%, P < 0.05; TMJOA, MD = -1.35, CI = 95% [-1.74, -0.97], I² = 92%, P < 0.05) but showed no significant efficacy in patients with HOA (MD = -0.27, CI = 95% [-0.8, 0.26], I² = 56%, P>0.05). Compared to controls, PRP injections were effective in improving Knee Injury and Osteoarthritis Outcome Score (KOOS), including the patient's pain symptoms, activities of daily living (ADL), and adhesion symptomatology, but not for that of sports function (KOOS-pain, MD = 2.77, CI = 95% [0, 5.53], I² = 0%, P < 0.05; KOOS-symptoms, MD = 3.73, CI = 95% [0.76, 6.71], I² = 0%, P < 0.05; KOOS-ADL, MD = 3.61, CI = 95% [0.79, 6.43], I² = 0%, P < 0.05; KOOS-QOL, MD = 4.66, CI = 95% [0.98, 8.35], I² = 29%, P < 0.05, KOOS-sport, MD = 0.48, CI = 95% [-3.02, 3.98], I² = 0%, P > 0.05). PRP injections were effective in improving Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores, including pain, stiffness, and functional joint motion, in patients with OA compared with the control group (WOMAC-pain, MD = -1.08, CI = 95% [-1.62, -0.53], I² = 87%, P < 0.05; WOMAC-stiffness, MD = -1.17, CI = 88% [-1.72, -0.63], I² = 87%, P < 0.05; WOMAC-function, MD = -1.12, CI = 95% [-1.65, -0.58], I² = 87%, P < 0.05). In addition, subgroup analysis showed that leukocyte-poor (LP) PRP injections were more effective than leukocyte-rich (LR) PRP injections in improving pain symptoms in patients with OA (VAS, LR-PRP, MD = -0.81, CI = 95% [-1.65, -0.03], I² = 83%, P = 0.06 > 0.05; LP-PRP, MD = -1.62, CI = 95% [-2.36, -0.88], I² = 92%, P < 0.05). A subgroup analysis based on injection sites showed that no statistical difference in efficacy between intra-articular (IA) combined with intra-osseous (IO) simultaneous PRP injections. IA PRP injections only improved VAS pain scores in patients with OA (IA+IO PRP injections, MD = -0.74, CI =95% [-1.29, -0.18], I² = 61%, P < 0.05; IA PRP injections, MD = -1.43, CI = 95% [-2.18, -0.68], I² = 87%, P < 0.05, test for subgroup differences, P > 0.05, I² = 52.7%).

Conclusion

PRP injection therapy can safely and effectively improve functional activity in patients with OA and produce positive analgesic effects in patients with KOA, TMJOA, and AOA. However, PRP injection therapy did not significantly reduce pain symptoms in patients with HOA. In addition, the analgesic effect of LP-PRP was greater than that of LR-PRP.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier: CRD42022362066.

EUROVISCO Good Practice Recommendations for a First Viscosupplementation in Patients with Knee Osteoarthritis

RATIONALE

Viscosupplementation (VS) with hyaluronic acid is widely used in the management of knee osteoarthritis. There is no clear recommendation on the decision-making to achieve VS.

DESIGN

Based on extensive research of the literature and expert opinion, the members of the EUROVISCO (European Viscosupplementation Consensus Group) task force were asked to give their degree of agreement with 60 issues, using a Delphi method.

RESULTS

The expert panel achieved unanimous agreement in favor of the following statements: It is recommended to assess pain on a visual or 10-point numeric scale before considering VS. VS can be considered for patients with pain scores between 3 and 8. A standard x-ray must be obtained before the decision of VS. If the x-ray is normal, osteoarthritis must be confirmed by MRI or computed tomography (CT) arthrogram before considering VS. The aims of VS are relieving pain, improving function, and reducing non-steroidal anti-inflammatory drug (NSAID) consumption. The use of VS must not be considered for treating an osteoarthritis flare. VS can be envisaged as a first-line pharmacological treatment in patients having a contra-indication to NSAIDs or analgesics. VS can be considered in patients with contra-indications to arthroplasty. In the case of severe comorbidities (diabetes, hypertension, gastrointestinal disorders, renal failure), VS can avoid the use of potentially dangerous treatments. VS can be considered in patients receiving antiplatelet agents, vitamin K antagonists, and direct factor Xa or thrombin inhibitors. Five other statements obtained a high level of consensus.

CONCLUSION

These recommendations, illustrated in a decision algorithm, have been established to help practitioners in the decision-making of knee VS.

Ginsenoside Rg1/ADSCs supplemented with hyaluronic acid as the matrix improves rabbit temporomandibular joint osteoarthrosis

OBJECTIVE

To investigate whether and how ginsenoside Rg1/ADSCs supplemented with hyaluronic acid as the matrix can improve rabbit temporomandibular joint osteoarthrosis.

METHOD

Isolate and culture adipose stem cells, measure the activity of differentiated chondrocytes by MTT assay and expression of type II collagen in these cells by immunohistochemistry, in order to evaluate the effect of ginsenoside Rg1 on adipose stem cell proliferation and differentiation into chondrocytes.32 New Zealand white rabbits were randomly divided into four groups: blank group, model group, control group and experimental group, 8 in each group. Osteoarthritis model was established by intra-articular injection of papain. Two weeks after successful model building, medication was given for the rabbits in control group and experimental group. 0.6 mL ginsenoside Rg1/ ADSCs suspension was injected into superior joint space for the rabbits in control group, once a week; 0.6 mL ginsenoside Rg1/ ADSCs complex was injected for the rabbits in experimental group, once a week.

RESULTS

Ginsenoside Rg1 can promote ADSCs-derived chondrocytes' activity and expression of type II collagen. Scanning electron microscopy histology images showed cartilage lesions of the experimental group was significantly improved in comparison with control group.

CONCLUSION

Ginsenoside Rg1 can promote ADSCs differentiate into chondrocytes, and Ginsenoside Rg1/ADSCs supplemented with hyaluronic acid as the matrix can significantly improve rabbit temporomandibular joint osteoarthrosis.

Different molecular weights of hyaluronan research in knee osteoarthritis: A state-of-the-art review

Osteoarthritis (OA), the most common form of arthritis, is characterized by progressive cartilage destruction, concomitant adaptive osteogenesis, and loss of joint function. The progression of OA with aging is associated with a decrease in native hyaluronan (HA, hyaluronate or hyaluronic acid) with a high molecular weight (HMW) in synovial fluid and a subsequent increase in lower MW HA and fragments. As HMW HA possesses numerous biochemical and biological properties, we review new molecular insights into the potential of HA to modify OA processes. Different MWs in the formulation of products appear to have varying effects on knee OA (KOA) pain relief, improved function, and postponing surgery. In addition to the safety profile, more evidence indicates that intraarticular (IA) HA administration may be an effective option to treat KOA, with a particular emphasis on the use of HA with fewer injections of higher MW, including potential applications of HA of very HMW. We also analyzed published systemic reviews and meta-analyses of IA HA in treating KOA in order to discuss their conclusions and consensus statements. According to its MW, HA may offer a simple way to refine therapeutic information in selective KOA.

A comprehensive review of intraarticular knee injection therapy, geniculate injections, and peripheral nerve stimulation for knee pain in clinical practice

The knee is the most common joint in adults associated with morbidity. Many pathologies are associated with knee damage, such as gout or rheumathoid arthritis, but the primary condition is osteoarthritis (OA). Not only can osteoarthritis cause significant pain, but it also can result in signficant disability as well. Treatment for this condition varies, starting off with oral analgesics and physical therapy to surgical total knee replacmenet. In the gamut of this various treatments, a conservative approach has included intra articular steroid injections. With time, researchers and clinicians determined that other components injected to the knee may additionally provide relief of this condition. In this investigation, we describe different types of knee injections such as platelet-rich plasma (PRP), hyaluronic acid, stem cells, and prolotherapy. Additionally, we describe the role of geniculate knee injections, radiofrequency, and periopheral nerve stimulation. These treatments should be considered for patients with knee pain refractory to conservative therapies.

Assessment of the Response Profile to Hyaluronic Acid Plus Sorbitol Injection in Patients with Knee Osteoarthritis: Post-Hoc Analysis of a 6-Month Randomized Controlled Trial

In a previous randomized trial, the non-inferiority of two hyaluronic acid injections (Synolis VA versus Synvisc-One) was assessed in patients with knee OA, with a response rate of 79% for Synolis VA. To assess whether a responder profile could be established for this treatment modality, we used the Synolis VA arm of a published 6-month prospective, multicenter, comparative, randomized, double-blinded trial. At baseline and during the study, pain and function were assessed using the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Ninety-six subjects from the intention-to-treat trial were included in the analysis. The 6-month change of WOMAC Pain with Synolis VA was not associated with any baseline clinical data. However, the change in WOMAC Function was significantly associated with its baseline level, even after adjustment for potential confounding variables (p = 0.028), i.e., a poorer physical function at baseline was associated with a better response. In conclusion, in addition to the high absolute response rate to Synolis VA, the probability of success is even increased if administered in patients with more limited physical function at baseline. Further research with other potential confounding clinical variables is warranted in order to better applicate the concept of personalized medicine.

Orthopedic Surgeons' Views of Hyaluronic Acid Formulations in the Management of Knee Osteoarthritis: A Questionnaire-Based Cross-Sectional Study

Background and Objectives: Multiple hyaluronic acid (HA) products were approved and marketed to manage osteoarthritis (OA). Although these products are widely prescribed by orthopedic surgeons to manage OA, especially knee OA, the therapeutic value of these products is highly uncertain. Few studies with significant limitations in their designs have indicated positive outcomes among OA patients treated with HA; however, their results were inconclusive. Thus, we aimed to explore the therapeutic value of different HA products in alleviating knee OA pain and improving patients’ physical function from the orthopedic surgeons’ perspective. Materials and Methods: This was a questionnaire-based cross-sectional study in which practicing orthopedic surgeons in two countries (e.g., Saudi Arabia and Jordan) were invited to participate. The 10-item, newly developed questionnaire inquired about the respondents’ sociodemographic characteristics (e.g., age, gender, country, years of experience), and their opinions regarding the efficacy of HA products in the management of OA (e.g., efficacy in improving mobility and alleviating pain). Results: Out of the 200 orthopedic surgeons who were invited to participate, 122 (61%) filled out the questionnaire. Most of the respondents were from Saudi Arabia (58%), aged 35 to 55 years (68%), had at least 10 years of experience (69%), and male (98%). About 80% of the respondents reported prescribing HA, such as Hyalgan^®, Orthovisc^®, Hyalubrix^®, and Crespine Gel^®. About 66% of the respondents believed that HA was moderately to highly effective in managing knee OA, and 34% believed that HA was either ineffective or mildly effective. Pain at the site of injection (44.3%) and rash or local skin reactions (22.1%) were the most commonly reported adverse events. Conclusions: The variations in the formulation of different HA brands (e.g., molecular weight and cross-linking) did not seem to offer any therapeutic advantage. HA might have value in the management of knee OA; however, its value is highly uncertain and necessitates more well-designed studies to further examine its therapeutic value.