Gait patterns after intraarticular treatment of patients with osteoarthritis of the knee--hyaluronan versus triamcinolone: a prospective, randomized, doubleblind, monocentric study

The effects of allogeneic and autologous blood transfusion on immune function in patients receiving total hip replacement

OBJECTIVE

To evaluate the effects of allogeneic and autologous blood transfusion on immune function and postoperative inflammation in patients after total hip replacement.

METHODS

In this retrospective study, the clinical data of 60 patients undergoing total hip arthroplasty through a posterolateral approach were analyzed. The patients were grouped into an autologous blood transfusion group (allo group) (n = 30) and an autologous blood transfusion group (auto-group) (n = 30) according to the treatment they received. All patients did not receive preoperative and intraoperative blood transfusion. The blood collected in the operation area was transfused to the patients in the auto-group with the autotransfusion device and the allogeneic blood was transfused to the patients in the allo-group after the operation. The average amount of blood transfusion was 400 ml. The immune function after blood transfusion was mainly evaluated by natural killer cell cytotoxicity (NKCC) and interleukin-2 (IL-2) using ELISA kits, meanwhile the changes of cellular immune factor levels (differentiation cluster of differentiation, CD) (CD3+, CD4+) and humoral immune factor levels (Immunoglobulin E, IgE) after blood transfusion were determined by flow cytometry. The secondary outcome was postoperative inflammatory response measured by white blood cell (WBC) count, neutrophil percentage (NP) and C-reactive protein (CRP).

RESULTS

The parameters of both groups of patients were comparable. The auto-group significantly outperformed the Allo-group in the following laboratory parameters: NKCC (%, E:T = 10:1) at day 2 [26.1 (Auto) vs 19.3 (Allo); P = 0.0025], NKCC (%, E:T = 5:1) at day 2 [20.0 (Auto) vs 17.3 (Allo); P = 0.0094], CD3+ (%) at day 2 [50.5 (Auto) vs 40.8 (Allo); P = 0.0233], CD4+ (%) at day 2 [41.2 (Auto) vs 26.3 (Allo); P = 0.0122], IgE (U/mL) at day 2 [157.8 (Auto) vs 319.8 (Allo); P = 0.0064].

CONCLUSION

Autotransfusion can safely replace allogeneic blood transfusion and reduce the damage of postoperative immune function after total hip arthroplasty.

Changes in biomechanics, strength, physical function, and daily steps after extended-release corticosteroid injections in knee osteoarthritis: a responder analysis

INTRODUCTION/OBJECTIVE

To determine changes in gait biomechanics, quadricep strength, physical function, and daily steps after an extended-release corticosteroid knee injection at 4 and 8 weeks post-injection in individuals with knee osteoarthritis as well as between responders and non-responders based on changes in self-reported knee function.

METHOD

The single-arm, clinical trial included three study visits (baseline, 4 weeks, and 8 weeks post-injection), where participants received an extended-release corticosteroid injection following the baseline visit. Time-normalized vertical ground reaction force (vGRF), knee flexion angle (KFA), knee abduction moment (KAM), and knee extension moment (KEM) waveforms throughout stance were collected during gait biomechanical assessments. Participants also completed quadricep strength, physical function (chair-stand, stair-climb, 20-m fast-paced walk) testing, and free-living daily step assessment for 7 days following each visit.

RESULTS

All participants demonstrated increased KFA excursion (i.e., greater knee extension angle at heel strike and KFA at toe-off), increased KEM during early stance, improved physical function (all p < 0.001), and increased quadricep strength at 4 and 8 weeks. KAM increased throughout most of stance at 4 and 8 weeks post-injection (p < 0.001) but appears to be driven by gait changes in non-responders. Non-responders demonstrated lesser vGRF during late stance and lesser KEM and KFA throughout stance compared to responders at baseline.

CONCLUSIONS

Extended-release corticosteroid injections demonstrated short-term improvements in gait biomechanics, quadricep strength, and physical function for up to 4 weeks. However, non-responders demonstrated gait biomechanics associated with osteoarthritis progression prior to the corticosteroid injection, suggesting that non-responders demonstrate more deleterious gait biomechanics prior to corticosteroid injection. Key Points • Individuals with knee osteoarthritis who were treated with extended-release corticosteroid injections demonstrated improvements in gait biomechanics and physical function for 8 weeks. • Individuals with knee osteoarthritis, who walked with aberrant walking biomechanics before treatment, failed to respond to extended-release corticosteroid treatment. • Future research should determine the mechanisms contributing to the short-term changes in gait biomechanics and physical function such as reduced inflammation.

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.

Comparison between intra-articular infiltrations of placebo, steroids, hyaluronic and PRP for knee osteoarthritis: a Bayesian network meta-analysis

INTRODUCTION

Regarding the efficacy of intra-articular injections of platelet-rich plasma, hyaluronic acid and corticosteroids, current evidence is controversial. The superiority of one technique over another is questioned and debates are ongoing. The purpose of the present study was to compare and investigate the efficacy of these intra-articular infiltrations in patients with knee osteoarthritis (OA). A Bayesian network meta-analysis of randomized clinical trials (RCTs) was conducted comparing patient outcomes at 3, 6 and 12-months of follow-up.

MATERIALS AND METHODS

This Bayesian network meta-analysis was conducted according to the PRISMA extension statement for reporting systematic reviews incorporating network meta-analyses of health care interventions. All the RCTs comparing the outcomes of two or more intra-articular infiltrations of interest for knee OA were considered for inclusion. The outcomes of interest were the WOMAC and VAS scores. The network meta-analyses were performed using the STATA routine for Bayesian hierarchical random-effects models.

RESULTS

Data from 30 RCTs (3463 patients) were collected. At 3-months follow-up, PRP showed the best WOMAC scores, followed by the Placebo, CCS and HA. At 6-months follow-up, PRP showed the best WOMAC scores, followed by HA, CCS and Placebo. At 12-months follow-up, PRP showed the best WOMAC scores, followed by the Placebo, HA and CCS. At 3-months follow-up, the PRP showed the best VAS scores, followed by CCS, HA and Placebo. At 6-months follow-up, PRP showed the best VAS scores, followed by CCS, Placebo and HA. At 12-months follow-up, the PRP showed the best VAS scores, followed by CCS, Placebo and HA.

CONCLUSION

Intra-articular injections of PRP demonstrated the best overall outcome compared to steroids, hyaluronic acid and placebo for patients with knee osteoarthrosis at 3, 6 and 12-months follow-up. Among CCS, hyaluronic acid and placebo, no discrepancies were detected.

LEVEL OF EVIDENCE

I, Bayesian network meta-analysis of RCTs.

Assessing Site Specificity of Osteoarthritic Gait Kinematics with Wearable Sensors and Their Association with Patient Reported Outcome Measures (PROMs): Knee versus Hip Osteoarthritis

There is a great need for quantitative outcomes reflecting the functional status in patients with knee or hip osteoarthritis (OA) to advance the development and investigation of interventions for OA. The purpose of this study was to determine if gait kinematics specific to the disease—i.e., knee versus hip OA—can be identified using wearable sensors and statistical parametric mapping (SPM) and whether disease-related gait deviations are associated with patient reported outcome measures. 113 participants (N = 29 unilateral knee OA; N = 30 unilateral hip OA; N = 54 age-matched asymptomatic persons) completed gait analysis with wearable sensors and the Knee/Hip Osteoarthritis Outcome Score (KOOS/HOOS). Data were analyzed using SPM. Knee and hip kinematics differed between patients with knee OA and patients with hip OA (up to 14°, p < 0.001 for knee and 8°, p = 0.003 for hip kinematics), and differences from controls were more pronounced in the affected than unaffected leg of patients. The observed deviations in ankle, knee and hip kinematic trajectories from controls were associated with KOOS/HOOS in both groups. Capturing gait kinematics using wearables has a large potential for application as outcome in clinical trials and for monitoring treatment success in patients with knee or hip OA and in large cohorts representing a major advancement in research on musculoskeletal diseases.

Efficacy of intra-articular corticosteroid injections in knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

Knee osteoarthritis (OA) is a frequent degenerative disease representing an important health and economic burden. Symptomatic medical treatments available include intra-articular (IA) injections of corticosteroids (GC) but their efficacy and safety profile are debated.

METHODS

We performed a systematic literature review (SLR) and a meta-analysis (MA) of randomized controlled trials (RCTs) assessing the effect of IA GC injections for knee OA. The effect of the interventions on pain and function was extracted from the single studies and pooled. Standardized mean differences (SMD) are reported.

RESULTS

Of 520 studies screened, 23 were included in the SLR and 15 subsequently included in the MA. IA GC showed a trend towards a superior effect compared to control on both pain (SMD -0.61 (95% CI: -1.25, 0.03)) and function (SMD -1.02 (95% CI: -2.14, 0.10)) in short term follow-up (≤6 weeks), while long term follow-up (≥24 weeks) analysis showed a trend towards superiority of controls (IA HA, IA NSAID, physiotherapy) for pain (SMD 0.68 (95% CI: -0.11, 1.47)) and function (SMD 0.88 (95% CI: -0.36, 2.12). There were no differences between interventions in medium term (>6 weeks &<24 weeks).

CONCLUSION

In this work, IA GC injections reduced pain and improved function early after administration (≤6 weeks) compared to placebo; while this result was no longer statistically significant with other comparators (IA hyaluronic acid or physiotherapy). Other interventions seem to be more efficient in the long term (≥24 weeks) but this effect was largely driven by single studies with large effect sizes.

Lower limb kinematics improvement after genicular nerve blockade in patients with knee osteoarthritis: a milestone study using inertial sensors

Background

Genicular nerve blockade is a possible treatment for patients with knee osteoarthritis. Pain relief and improvement in functioning is expected. This procedure could be of major interest for patients in low-income countries where total knee arthroplasty is not available for the population. This study aims at assessing the immediate benefits on pain, gait, and stairs kinematics after a genicular nerve blockade in patients suffering from knee osteoarthritis in Cameroun.

Methods

A prospective study was carried out on 26 subjects in Cameroun. A genicular nerve blockade was performed on 14 women with painful knee osteoarthritis grade 2–4. Lower limb joint angles were recorded with inertial sensors before and 1 h after injection. Patient-reported outcomes of pain and perceived difficulty were collected, as well as 10 m and 6 min walking tests. A reliability analysis of inertial sensors was performed on a sample of 12 healthy subjects by calculating the intraclass correlation coefficient and the standard error of measurement.

Results

Pain and perceived difficulty decreased significantly (p < 0.001). Cadence increased significantly in stairs climbing (upstairs: + 7.7 steps/min; downstairs: + 7.6 steps/min). There was an improvement for hip sagittal range of motion during gait (+ 9.3°) and pelvis transverse range of motion in walking upstairs (− 3.3°). Angular speed range of the knee in the sagittal plane and of the hip in the frontal plane increased significantly in stairs descent (+ 53.7°/s, + 94.5°/s).

Conclusions

This study quantified improvement of gait and stair climbing immediately after a genicular nerve blockade in patients suffering from knee OA in Cameroon. This is the first study objectifying this effect, through wearable sensors.

Trial registration

Pan African Clinical Trial Registry, PACTR202004822698484. Registered 28 March 2020 - Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-020-03836-8.

Efficacy and Safety of Hylan G-F 20 Versus Intra-Articular Corticosteroids in People with Knee Osteoarthritis: A Systematic Review and Network Meta-Analysis

Background:

Direct injection of corticosteroids into the joint is a standard treatment for knee osteoarthritis (OA). However, the treatment is somewhat controversial with regard to the benefit of both single and repeated injections; evidence that they are beneficial comes from small studies that show only modest improvements. The aim of this study was to estimate the short- and long-term clinical efficacy and safety of hylan G-F 20 versus intra-articular corticosteroids (IACS) for the treatment of pain in knee OA using Bayesian network meta-analysis.

Methods:

Based on a pre-specified protocol, MEDLINE, Embase, and CENTRAL were searched from inception to June 2018 to identify randomized controlled trials. The Cochrane Collaboration’s tool for assessing risk of bias in randomized trials was used to assess the included studies. Hylan G-F 20 and IACS were compared using Bayesian network meta-analysis. Efficacy was evaluated at 1, 3, and 6 months, and at the final follow-up for safety outcomes. A pain hierarchy was used to select 1 pain outcome per study.

Results:

Forty-two trials were included for analysis. The network meta-analysis of pain showed that hylan G-F 20 may be equivalent to IACS in the short-term, but by 6 months the benefit relative to IACS was statistically significant, standardized mean difference (95% credible interval): –0.13 (–0.26, –0.01). There were no statistical differences in adverse events.

Conclusions:

Hylan G-F 20 may perform better in relieving pain at 6 months post-injection compared to IACS. Both agents were relatively well tolerated, with no clear differences in safety.

Histological Comparison of Nanocomposite Multilayer Biomimetic Scaffold, A Chondral Scaffold, and Microfracture Technique to Repair Experimental Osteochondral Defects in Rats

Objective

We used biomimetic scaffolds, chondral scaffolds, and microfractures to repair experimentally created osteochondral defects in rat knees and then compared the results of each method.

Materials and Methods

We used a total of 56 female Wistar albino rats. The rats were grouped into 4 groups, with 14 rats each: biomimetic scaffold, chondral scaffold, microfracture, and control groups. Cylindrical full-thickness osteochondral defects 2.5 mm in diameter and 2 mm in depth were drilled into the right knees with the rats under general anesthesia. The knees of all rats were operated again after 4 weeks. Biomimetic and chondral scaffolds were classified into two groups. Microfractures 0.5 mm in diameter and 0.8 mm in depth were created in the rats of the microfracture group. The control group received no treatment. All the rats were observed for 6 weeks and then sacrificed, with samples subjected to macroscopic and histopathological examinations.

Results

The macroscopic and histopathological results in the biomimetic scaffold group differed significantly from those of the other treatment groups (p<0.05). When we compared the 3 treatment groups, the results of the chondral scaffold group were better than those of the microfracture group. The results of the microfracture group were somewhat better than those of the control group, but the result was not statistically significant (p>0.05).

Conclusions

Nanocomposite multilayer biomimetic scaffolds were better than chondral scaffolds and microfractures when used to treat osteochondral defects.

Injections intra articulaires (IA) d'acide hyaluronique (AH) dans le traitement symptomatique de la gonarthrose : une méta-analyse des injections uniques (mono-injections)

Introduction

La viscosupplémentation du liquide synovial par injections intra articulaires (IA) d'acide hyaluronique (AH), est un traitement symptomatique bien connu dans la gonarthrose. La question se pose de savoir si les traitements par injection unique (mono-injection) peuvent présenter autant d'efficacité que les multi-injections (3 à 5).

Méthodes

Une méta-analyse des résultats publiés pour les essais de mono-injections IA de AH a été réalisée. Le critère d'efficacité retenu a été le sous-score douleur de l'indice Western Ontario and MacMaster universities (WOMAC A). Toutes les conceptions d'études ont été admises, depuis les essais randomisés contrôlés jusqu'aux études observationnelles ouvertes à simple bras. Une recherche extensive a été effectuée à partir de PubMed, Google, Google Scholar, et des listes de références trouvées dans les méta-analyses récentes, pour obtenir tous les articles publiés avant fin avril 2018. Les profils des populations furent analysés en termes d'âge, de sexe, d'indice de masse corporelle (IMC) et de stade radiologique selon Kellgren-Lawrence (KL). Les résultats d'injection IA unique de placebo, ont été pris en compte pour créer une base permettant des comparaisons post-hoc. Chaque bras AH IA étudié a été comparé à un bras placebo IA (seul ou mixé), de manière à présenter un profil KL similaire, contrôlé à l'aide du test Chi². Les tailles de l'effet (ES) avec intervalles de confiance (IC 95%) et p-valeurs furent calculées et synthétisées pour chacune des visites de contrôle à 1, 2, 3 et 6 mois. En parallèle, une approche globale a été utilisée afin de représenter les variations par rapport à la baseline, pour chacun des sous-groupes étudiés.

Résultats

En partant de 1 547 citations, 28 études ont été incluses dans la méta-analyse, décrivant 4 129 patients traités par mono-injection: 3 360 ont reçu de l'AH IA et 769 patients ont reçu du placebo IA. Le patient moyen (SD) traité par AH IA était âgé de 61,2 (9,6) ans dont 63% de femmes, avec un IMC de 28,0 (4,1) kg/m², et un stade radiologique à 47% KL III pour 3% KL IV. Un bon appariement du profil KL a été obtenu pour 26 des 31 bras AH IA. Sur l'ensemble de la population AH IA, ES = 0,30 (0,25; 0,35) à 3 mois et ES = 0,39 (0,33; 0,44) à 6 mois. Dans une analyse restreinte, après élimination des cas aberrants, des KL mal appariés et des bras actifs < 30 patients, les résultats sont restés inchangés, ES = 0,29 (0,23; 0,34) et ES = 0,40 (0,34; 0,45) à 3 et 6 mois respectivement, tandis que l'hétérogénéité était améliorée.

Discussion

Il existe certainement des limites à la méthode de comparaison post-hoc versus placebo, appliquée à des essais individuels. Mais pour chaque synthèse par sous-groupe ou groupe, les résultats ont été confirmés en utilisant plusieurs approches statistiques et différentes méthodes de pondération. Cette méta-analyse suggère que les résultats des mono-injections sont similaires à ceux des multi-injections d'acide hyaluronique intra articulaire en termes de soulagement de la douleur, dans le traitement de la gonarthrose.

Combined intra-articular injection of corticosteroid and hyaluronic acid reduces pain compared to hyaluronic acid alone in the treatment of knee osteoarthritis

PURPOSE

Intra-articular injections of corticosteroid (CS) and hyaluronic acid (HA) have individually demonstrated efficacy for knee osteoarthritis (OA); however, both treatments are limited by the trajectory of symptom relief. The combination of CS and HA in the management of knee OA may provide improved symptomatic relief for patients who are candidates for intra-articular therapies.

METHODS

Electronic databases Medline, EMBASE and Cochrane Library were used to identify relevant publications. Randomized controlled trials (RCT) that evaluated intra-articular injections of combined CS and HA in comparison to HA alone were included. Outcomes eligible for meta-analysis were WOMAC pain, WOMAC total, OMERACT-OARSI responder rate, and treatment-related adverse events. Standardized mean differences (SMD) were calculated for continuous outcomes using an inverse variance method and a random-effects model. Odds ratios (OR) were calculated for dichotomous outcomes using the Mantel-Haenszel method and a random-effects model. Heterogeneity was assessed using the I² statistic.

RESULTS

Eight trials (n = 751 patients) were included. Reduction in WOMAC pain scores at 2-4 weeks favoured the combined CS and HA group compared to HA alone [SMD 0.60, 95% CI (0.23, 0.97); p = 0.002, I² = 75%]. Longer term improvements at 24-26 and 52 weeks WOMAC pain scores also favoured the combined CS and HA group {[SMD 0.25, 95% CI (0.09, 0.41); p = 0.002, I² = 0%] and [SMD 0.39, 95% CI (0.01, 0.77); p = 0.05, I² = 0%]} compared to HA alone, respectively. There were no significant differences in WOMAC total scores, OMERACT-OARSI responder rate, or treatment-related adverse events.

CONCLUSION

Combined intra-articular injections of CS and HA led to reductions in pain at 2-4, 24-26 and 52 weeks compared to HA injections alone.

LEVEL OF EVIDENCE

Level II-meta-analysis.

Gait analysis following single-shot hyaluronic acid supplementation: a pilot randomized double-blinded controlled trial

Objectives

Viscosupplementation with new-generation, polyol-containing, cross-linked hyaluronic acid (HA) gels reduces joint inflammation in patients with knee osteoarthritis. Gait analysis is a complementary outcome measure to standard patient-reported scores and physical measures for testing the effect of HA injection. This three-arm, prospective, randomized, controlled, double-blind, feasibility pilot study investigated which gait parameters are more sensitive following a single bolus injection of polyol-containing HA for knee osteoarthritis.

Methods

Twenty-two patients with Ahlbäck grade II-III knee osteoarthritis were randomly allocated into three groups: (1) HA + mannitol (n = 9), (2) HA + sorbitol (n = 5), and (3) saline placebo (n = 8). Patients were assessed by blinded observers prior to injection and at 4 weeks post-injection (4W). Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Knee Society score (KSS), EuroQol in five-dimensions (EQ-5D), VAS pain, and VAS stiffness. Gait was assessed over 30 m using a portable inertial-based data logger (Physilog®).

Results

Differences between 4W and baseline were statistically significant for the mannitol-containing viscosupplement, with a median increase of 0.076 m/s on gait speed (p = 0.039), 0.055 m on stride length (p = 0.027), and 15 points on the KSS (p = 0.047). In contrast, the HA + sorbitol and saline groups demonstrated no significant changes from baseline to 4W in any gait parameters or self-reported outcome measures (all p > 0.3). The observed increase in gait speed is approximately 13% greater than the mean difference between healthy subjects and those with knee osteoarthritis, is clinically important, and thus is a sensitive gait parameter.

Conclusions

This study demonstrated gait speed and stride length are the most relevant gait parameters to investigate when assessing the effect of polyol-containing HA viscosupplementation. This study supports the need for a larger, randomized, controlled, clinical trial to assess the effect of a single-bolus HA injection versus multiple injections in people with knee osteoarthritis using both gait performance and self-reported parameters of knee function.

Trial registration

This study was retrospectively registered at clinicaltrials.gov on August 20, 2018, and assigned #NCT03636971.

Level of evidence

I.

Intra-Articular Hyaluronic Acid in the Symptomatic Treatment of Knee Osteoarthritis: A Meta-Analysis of Single-Injection Products

Background

Viscosupplementation of the synovial fluid with intra-articular hyaluronic acid (IA HA) is a well-known symptomatic treatment of knee osteoarthritis. The question arises whether a monoinjection (ie, single injection) could be as efficient as multi-injection (ie, 3-5 injections) regimens.

Methods

A meta-analysis of published studies relating to IA HA monoinjection trials was performed. The efficacy criterion was the Western Ontario and MacMaster Universities pain subscore. Any study design was accepted, from randomized control trials to single-arm observational open-label studies. An extensive search was performed using PubMed, Google, Google Scholar, and references found in recent meta-analyses, for all articles published before end of April 2018. Population profiles were analyzed in terms of age, sex, body mass index (BMI), and Kellgren-Lawrence (KL) radiology grades. Results of intra-articular single injection of placebo were collected to create a database allowing post hoc comparisons. Each IA HA study arm was compared to an IA placebo arm (either pooled or not), to present a similar KL profile controlled with the χ² test. The effect size (ES) (95% CI) and P values were calculated and synthesized for each follow-up visit at 1, 2, 3, and 6 months. In parallel, a global approach was used to represent the variations from baseline for each group or subgroup studied.

Results

From 1547 citations, 28 studies were included in the meta-analysis, representing 4129 patients treated with monoinjection: 3360 received IA HA and 769 patients received IA placebo. The mean (SD) IA HA patient was 61.2 (9.6) years, 63% women, BMI 28.0 (4.1), 47% KL III, and 3% KL IV. A good placebo KL profile matching was obtained for 26 of the 31 IA HA arms. For the whole IA HA population, ES = 0.30 (95% CI, 0.25-0.35) at 3 months and ES = 0.39 (95% CI, 0.33-0.44) at 6 months. In a restricted analysis, after removal of outliers, poorly KL matched and active arms <30 patients, results remained unchanged, ES = 0.29 (95% CI, 0.23-0.34) and ES = 0.40 (95% CI, 0.34-0.45) at 3 and 6 months respectively, whilst heterogeneity was improved.

Conclusions

There are certainly limits to the post hoc placebo comparison method, for individual studies. But for each synthesis per subgroup or group, the results were properly confirmed using multiple statistical approaches and weighing methods. This meta-analysis suggests that monoinjections produce results similar to multi-injections of IA HA in terms of pain relief in the treatment of knee osteoarthritis. (Curr Ther Res Clin Exp. 2019; 80:XXX-XXX).

Systematic clinical evidence review of NASHA (Durolane hyaluronic acid) for the treatment of knee osteoarthritis

Background

Pain and limitations in joint mobility associated with knee osteoarthritis (OA) are clinically challenging to manage, and advanced progression of disease can often lead to total knee arthroplasty. Intra-articular injection of hyaluronic acid (HA), also referred to as viscosupplementation, is a non-surgical treatment approach for OA, the effectiveness of which may depend on the HA composition, and the length of time over which it resides in the joint. One of the available options for such therapies includes NASHA (Durolane HA), a non-animal, biofermentation-derived product, which is manufactured using a process that stabilizes the HA molecules to slow down their rate of degradation and produce a unique formulation with a terminal half-life of ~1 month. The objectives of the current review were to assess, in patients with OA of the knee, the efficacy and safety of intra-articular treatment with NASHA relative to control (saline) injections, other HA products, and other injectables (corticosteroids, platelet-rich plasma, mesenchymal stem cells).

Methods

This systematic evidence review examines patient outcomes following NASHA treatment as described in published data from studies conducted in subjects with knee OA. A Preferred Reporting Items for Systematic Reviews and Meta-analyses-compliant literature search strategy yielded 11 eligible clinical studies with a variety of comparator arms. Outcomes assessed at various time points following intra-articular treatment included measures of pain, function, quality of life, and incidence of treatment-related adverse events (AEs).

Results

The available evidence reported for the clinical studies assessed demonstrates sustained and effective relief of knee OA symptoms following a single injection of NASHA. In addition, an excellent biocompatibility profile is observed for NASHA as an intra-articular therapy for OA, as reflected by the low rate of AEs associated with treatment.

Conclusion

Treatment with NASHA is an effective and safe single-injection procedure, which can be beneficial in the clinical management of knee OA.

Injections for Knee Osteoarthritis: Corticosteroids, Viscosupplementation, Platelet-Rich Plasma, and Autologous Stem Cells

This article reviews the benefits of corticosteroid, viscosupplementation, platelet-rich plasma, and autologous mesenchymal stem cell injections for the treatment of patients with knee osteoarthritis. Integrating injections into both clinical and surgical practices is complicated given existing health insurance reimbursement policies. This review describes the outcomes associated with these interventions and appropriate methods of navigating the existing reimbursement pathways to help providers implement these treatments into their practices.

Intra-Articular Hyaluronic Acid Compared to Traditional Conservative Treatment in Dogs with Osteoarthritis Associated with Hip Dysplasia

The purpose of this study was to compare the efficacy of the intra-articular (IA) hyaluronic acid injection to traditional conservative treatment (TCT) in dogs with osteoarthritis (OA) induced by hip dysplasia. Sixteen dogs were distributed into two groups: Hyal: IA injection of hyaluronic acid (5-10 mg), and Control: IA injection with saline solution (0.5-1.0 mL) in combination with a TCT using an oral nutraceutical (750-1000 mg every 12 h for 90 days) and carprofen (2.2 mg/kg every 12 h for 15 days). All dogs were assessed by a veterinarian on five occasions and the owner completed an assessment form (HCPI and CPBI) at the same time. The data were analyzed using unpaired t test, ANOVA, and Tukey's test (P < 0.05). Compared with baseline, lower scores were observed in both groups over the 90 days in the veterinarian evaluation, HCPI, and CPBI (P < 0.001). The Hyal group exhibited lower scores from 15 to 90 and 60 to 90 days, in the CBPI and in the veterinarian evaluation, respectively, compared to the Control group. Both treatments reduced the clinical signs associated with hip OA. However, more significant results were achieved with intra-articular hyaluronic acid injection.

Product Differences in Intra-articular Hyaluronic Acids for Osteoarthritis of the Knee

BACKGROUND

Knee osteoarthritis (OA) is a common and often disabling joint disorder among adults that may result in impaired activity and daily function. A variety of treatment options are currently available and prescribed for knee OA depending on the severity of the disorder and physician preference. Intra-articular hyaluronic acid (IA-HA) injection is a treatment for knee OA that reportedly provides numerous biochemical and biological benefits, including shock absorption, chondroprotection, and anti-inflammatory effects within the knee. Clarity is needed as to whether the available IA-HA products should be considered for therapy as a group or whether there are significant differences in the products that need to be considered in treatment of OA of the knee.

PURPOSE

To determine whether there are differences in efficacy and safety with respect to intrinsic properties of available IA-HA injections for knee OA.

STUDY DESIGN

Meta-analysis.

METHODS

A comprehensive literature search of the Medline, EMBASE, and PubMed databases was conducted for all existing randomized trials of IA-HA. The primary outcome measure analyzed was the mean pain score at the reported follow-up nearest to 26 weeks after injection. Pooled efficacy and safety results were recorded for subgroupings of HA product characteristics.

RESULTS

A total of 68 studies were included for analysis. Products with an average molecular weight ≥3000 kDa provided favorable efficacy results when compared with products of an average molecular weight <3000 kDa. Products with a molecular weight ≥3000 kDa demonstrated significantly fewer discontinuations due to treatment-related adverse events than did ≤1500 kDa counterparts, while trial discontinuation rates were similar between biological fermentation-derived HA products and avian-derived HA. The results did not demonstrate a significant difference in the occurrence of effusion across molecular weight subgroups. Additionally, biological fermentation-derived HA had a significantly smaller incidence of effusion than did avian-derived HA. Biological fermentation-derived HA demonstrated fewer acute flare-ups at the injection site than did avian-derived HA products, while high-molecular-weight products demonstrated the highest rate of injection site flare-up.

CONCLUSION

Despite similarities, IA-HA products should not be treated as a group, as there are differences in IA-HA products that influence both efficacy and safety. In the available literature, IA-HA products with a molecular weight ≥3000 kDa and those derived from biological fermentation relate to superior efficacy and safety-factors that may influence selection an IA-HA product for OA of the knee.

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.

Effectiveness and Implications of Alternative Placebo Treatments: A Systematic Review and Network Meta-analysis of Osteoarthritis Trials

BACKGROUND

Placebo controls are essential in evaluating the effectiveness of medical treatments. Although it is unclear whether different placebo interventions for osteoarthritis vary in efficacy, systematic differences would substantially affect interpretation of the results of placebo-controlled trials.

OBJECTIVE

To evaluate the effects of alternative placebo types on pain outcomes in knee osteoarthritis.

DATA SOURCES

MEDLINE, EMBASE, Web of Science, Google Scholar, and Cochrane Database from inception through 1 June 2015 and unpublished data.

STUDY SELECTION

149 randomized trials of adults with knee osteoarthritis that reported pain outcomes and compared widely used pharmaceuticals against oral, intra-articular, topical, and oral plus topical placebos.

DATA EXTRACTION

Study data were independently double-extracted; study quality was assessed by using the Cochrane risk of bias tool.

DATA SYNTHESIS

Placebo effects that were evaluated by using a network meta-analysis with 4 separate placebo nodes (differential model) showed that intra-articular placebo (effect size, 0.29 [95% credible interval, 0.09 to 0.49]) and topical placebo (effect size, 0.20 [credible interval, 0.02 to 0.38]) had significantly greater effect sizes than did oral placebo. This differential model showed marked differences in the relative efficacies and hierarchy of the active treatments compared with a network model that considered all placebos equivalent. In the model accounting for differential effects, intra-articular and topical therapies were superior to oral treatments in reducing pain. When these differential effects were ignored, oral nonsteroidal anti-inflammatory drugs were superior.

LIMITATIONS

Few studies compared different placebos directly. The study could not decisively conclude whether disease severity and co-interventions systematically differed between trials evaluating different placebos.

CONCLUSION

All placebos are not equal, and some can trigger clinically relevant responses. Differential placebo effects can substantially alter estimates of the relative efficacies of active treatments, an important consideration for the design of clinical trials and interpretation of their results.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality.

Clinical efficacy of intra-articular injections in knee osteoarthritis: a prospective randomized study comparing hyaluronic acid and betamethasone

Background

Osteoarthritis (OA) is the most common joint disease and leading cause of disability. Intra-articular (IA) administration of hyaluronic acid (HA) or corticosteroids (CS) have been previously studied, though using insufficient number of patients or short follow-up periods.

Objective

We evaluate HA and CS in patients with knee OA in terms of clinical efficacy over 12 months.

Methods

We used a prospective, randomized study with parallel groups. Randomized patients received IA injections of HA or betamethasone (BM). The primary outcomes were improvement in pain using Visual Analog Scale and function in the Western Ontario and McMaster University Osteoarthritis Index (Likert scale). Follow-up visits were scheduled at 3 months, 6 months, 9 months, and 12 months.

Results

A total of 200 patients were included. Pain was significantly reduced in both groups at the first follow-ups. At 12 months, the mean pain reduction in the HA group was 33.6% (95% CI: 31.1–36.1) compared to 8.2% (95% CI: 5.2–11.1) in BM (P<0.0001). Function improvement was higher in HA through every visit, and mean improvement at 12 months was 47.5% (95% CI: 45.6–49.3) in HA patients vs 13.2% (95% CI: 11.4–14.9) in the BM group (P<0.0001). All patients from both groups achieved the Minimal Clinically Important Improvement (MCII) for both pain and function up to 6 months. At 9 months and 12 months, the MCII figures were higher in HA group with ≥80% compared to ≤10% in BM group (P<0.0001). Adverse reactions were rare and related to the administration procedure.

Conclusion

Both treatments effectively controlled OA symptoms. BM showed higher short-term effectiveness, while HA showed better long-term effectiveness, maintaining clinical efficacy in a large number of patients 1 year after administration.

Intra-articular hyaluronic acid and corticosteroids in the treatment of knee osteoarthritis: A meta-analysis

The aim of the present study was to evaluate the therapeutic effect of intra-articular hyaluronic acid (HA) in comparison to corticosteroids (CS) for knee osteoarthritis (OA). The data sources included PubMed, EMBASE, The Cochrane Central Register of Controlled Trials and hand searched reviews. Randomized controlled trials that reported the effects of intra-articular HA and CS in the treatment of knee OA were selected based on specific inclusion criteria. A meta-analysis was performed for the visual analog scale (VAS), Lequesne index, Knee Society Clinical Rating System (KSS), maximum flexion and adverse events of knee OA. Sensitivity analysis was also conducted to avoid bias. The seven eligible trials included 583 participants and the majority of the trials were of high quality. After one month, the mean difference in the VAS was 1.66 [95% confidence interval (CI); -0.90, 4.23), indicating equal efficacy for HA and CS. However, after three months, the mean difference was -12.58 (95% CI; -17.76, -7.40), while after six months, the difference was -9.01 (95% CI; -12.62, -5.40), favoring HA. For the additional indicators, including the Lequesne index, the KSS, maximum flexion and adverse events, no statistically significant differences were observed between the two treatment approaches for knee OA. Therefore, the results of the meta-analysis highlight a therapeutic trajectory for intra-articular HA in knee OA pain, as compared with CS, over six months post-intervention. After one month, the two approaches exhibited equal efficacy; however, in the long term, HA was found to have an enhanced effect. No statistically significant difference was observed in the adverse events caused by the two interventions. Further investigation and understanding into the trend observed in the present study may aid clinicians in the treatment of knee OA.

NASHA hyaluronic acid vs. methylprednisolone for knee osteoarthritis: a prospective, multi-centre, randomized, non-inferiority trial

OBJECTIVE

To compare NASHA hyaluronic acid gel as single-injection intra-articular (IA) treatment for knee osteoarthritis (OA) against methylprednisolone acetate (MPA).

DESIGN

This was a prospective, multi-centre, randomized, active-controlled, double-blind, non-inferiority clinical trial. A unique, open-label extension phase (OLE) was undertaken to answer further important clinical questions. Subjects with painful unilateral knee OA were treated and followed for 26 weeks (blinded phase). All patients attending the clinic at 26 weeks were offered NASHA treatment, with a subsequent 26-week follow-up period (extension phase). The primary objective was to show non-inferiority of NASHA vs MPA in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain responder rate (percentage of patients with ≥40% improvement from baseline in WOMAC pain score and an absolute improvement of ≥5 points) at 12 weeks.

RESULTS

In total, 442 participants were enrolled. The primary objective was met, with NASHA producing a non-inferior response rate vs MPA at 12 weeks (NASHA: 44.6%; MPA: 46.2%; difference [95% CI]: 1.6% [-11.2%; +7.9%]). Effect size for WOMAC pain, physical function and stiffness scores favoured NASHA over MPA from 12 to 26 weeks. In response to NASHA treatment at 26 weeks, sustained improvements were seen in WOMAC outcomes irrespective of initial treatment. No serious device-related adverse events (AEs) were reported.

CONCLUSIONS

This study shows that single-injection NASHA was well tolerated and non-inferior to MPA at 12 weeks. The benefit of NASHA was maintained to 26 weeks while that of MPA declined. An injection of NASHA at 26 weeks conferred long-term improvements without increased sensitivity or risk of complications. STUDY IDENTIFIER: NCT01209364 (www.clinicaltrials.gov).

Gait analysis of knee arthritis treated with hyaluronic acid

Self-reported studies have demonstrated efficacy of hyaluronic acid (HA) therapy. Gait analysis may objectively demonstrate changes associated with HA therapy. Fifty-three consecutive patients with unilateral osteoarthritis (OA) of the knee were evaluated with a validated and sensitive gait laboratory previously used for gonarthrosis. Two 100-meter walks were performed before and after HA therapy. Nineteen parameters were measured. In addition, the subjective response to treatment was correlated with changes in gait parameters. Single-limb support time, velocity, fatigability, and swing phase were not improved. Only double-limb support time was found to be significantly different (P = .04). The remaining gait variables were not changed. Separately, the subset of patients that achieved greater than 70% subjective pain relief had no objective improvements in gait parameters. Hyaluronic acid therapy may result in a placebo effect for the treatment of gonarthrosis.