Intra-articular injection of a nutritive mixture solution protects articular cartilage from osteoarthritic progression induced by anterior cruciate ligament transection in mature rabbits: a randomized controlled trial

The Effect of NSAID Use on Dextrose Prolotherapy in Patients With Knee Osteoarthritis: A Prospective Case Series

Objective

The objective was to determine whether oral non-steroidal anti-inflammatory drugs (NSAIDs) affect the efficacy of dextrose prolotherapy (DPT) in patients with knee osteoarthritis, and if the combination of these treatments is safe and well-tolerated.

Methods

Five patients with symptomatic knee osteoarthritis were included in this prospective case series. Participants underwent a series of three DPT injections at four-week intervals in their symptomatic knee(s) and were immediately prescribed a seven-day course of Ibuprofen after each injection. The main outcome measures included changes in the Knee Injury in Osteoarthritis (KOOS) questionnaire subscales (pain, symptoms, quality of life, sports and recreation function, and activities of daily living) and the Numeric Pain Rating Scale (NPRS).

Results

There was a statistically significant improvement in the KOOS subscales of pain (P < 0.0001), Symptoms (P = 0.01), and Quality of Life (P = 0.001) after 12 weeks. The KOOS subscales for Sports and Recreation function (P = 0.06) and Activities of Daily Living (P = 0.10) showed numerical improvement over time that fell short of statistical significance. There was a statistically significant improvement in the NPRS scores compared with baseline NPRS scores after 12 weeks (P < 0.0001). In addition, NPRS scores were significantly lower at one-week follow-up after each DPT injection (P = 0.01); (P = 0.025); (P < 0.0001). There were no reported adverse events.

Conclusions

Concomitant use of NSAIDS with dextrose prolotherapy injections is safe and well-tolerated with no adverse events and results in improvements in pain, symptoms, and overall quality of life associated with chronic knee OA. Controlled trials of this treatment are warranted.

Intra-articular Therapies for Hand Osteoarthritis: A Systematic Review and Network Meta-analysis

OBJECTIVE

Intra-articular injection therapy for hand osteoarthritis has inconclusive evidence regarding the effectiveness of different regimens. A systematic review and network meta-analysis of randomized controlled trials was conducted to examine the effectiveness of different injectants.

DESIGN

The PubMed, Cochrane Library, Embase, ClinicalKey, and Scopus databases were searched for studies from inception to July 15, 2023. Randomized controlled trials that applied intra-articular injection to hand osteoarthritis patients were included, and the outcomes of pain scores and functional scales were assessed.

RESULTS

Fourteen randomized controlled trials with 674 patients met the inclusion criteria; 11 randomized controlled trials were included in the network meta-analysis. Intra-articular injected platelet-rich plasma and dextrose significantly improved pain scores (mean difference = -4.03, 95% confidence interval = -6.51 to -1.56 for platelet-rich plasma; mean difference = -1.06, 95% confidence interval = -2.1 to -0.02 for dextrose) and hand function (standard mean difference = -0.93, 95% confidence interval = -1.81 to -0.05 for platelet-rich plasma; standard mean difference = -0.84, 95% confidence interval = -1.58 to -0.09 for dextrose) in the long-term (≥6 mos after treatment completion). The ranking probabilities revealed the highest effectiveness of platelet-rich plasma, followed by dextrose. No major adverse effects were reported.

CONCLUSIONS

Intra-articular injected platelet-rich plasma and dextrose can be recommended for treating hand osteoarthritis.

Biopuncture, A Multitarget Therapy in the Treatment of Individuals with Knee Osteoarthritis: state of the art

Objectives

The objective of this manuscript was to carry out a comprehensive review of the published information on the use of Biopuncture in patients with knee osteoarthritis.

Methods

A scientific search was performed using online databases following the terms (Biopuncture) and (Knee Osteoarthritis) to identify scientific manuscripts that were related to the use of Biopuncture in the treatment of individuals with knee osteoarthritis.

Results

With the information found, a theoretical framework was integrated that describes the components of Biopuncture, its mechanism of action and practical topics for the application of the technique.

Conclusion

Biopuncture appears to be a potential, simple and low-risk therapeutic strategy in the treatment of knee osteoarthritis, which is applied through periarticular subcutaneous injections, with multitarget mechanisms of action at various physiopathological levels such as the modulation of the inflammatory process, decreased peripheral sensitization, and stimulation of antidegenerative and trophic mechanisms. Perhaps it can be part of the integrative treatments for knee osteoarthritis.

The healing effects of L-carnitine and spongostan on cartilage defect in rat model

PURPOSE

We aimed to determine the effect of L-carnitine and spongostan on cartilage healing in an experimental animal model with a full-thickness cartilage defect.

METHODS

In the study 32 Sprague-Dawley rats were divided into four groups in equal numbers. A cartilage defect with a diameter of 1 mm and a depth of 3 mm was created in the femoral intercondylar region of rats in groups A, B, and C. Group A received no treatment in the defective area. Group B received treatment with spongostan. Group C received treatment with spongostan soaked in L-carnitine. Group D served as the healthy control group. The rats were euthanized 6 weeks after the treatment. Histological evaluation of the condyles was done with the modified Mankin scoring.

RESULTS

In the histopathological imaging of the cartilage structure, it was observed that in group A, there was complete disorganization and cellular structure was completely absent up to the subchondral bone. In group B, moderate structural improvement, partially intact appearance in border integrity and mostly diffuse hypercellularity were observed. In group C, a near-normal healing, a completely intact appearance in boundary integrities and normal or hypercellularity in cellular structure were observed. The total score of the modified Mankin decreases numerically from A to D. There was no statistically significant difference observed between the A-B (p = 0.176), C-D (p = 0.145), and C-B (p = 0.580) groups, while significant differences were detected between the A-C (p = 0.004), B-D (p = 0.007), and A-D (p = 0.000) groups.

CONCLUSION

It has been known that mitochondrial activity is reduced in the osteoarthritis, and as a result, decrease in cellular activity occurs with ATP synthesis. For this reason, we found that L-carnitine, which we expect to stimulate cell proliferation by stimulating ATP synthesis, makes a positive contribution to cartilage healing, as expected. It has been found that combining spongostan with L-carnitine for the treatment of cartilage healing, instead of applying spongostan alone, provides near-normal healing.

Galactose Enhances Chondrogenic Differentiation of ATDC5 and Cartilage Matrix Formation by Chondrocytes

Galactose, an important carbohydrate nutrient, is involved in several types of cellular metabolism, participating in physiological activities such as glycosaminoglycan (GAG) synthesis, glycosylation, and intercellular recognition. The regulatory effects of galactose on osteoarthritis have attracted increased attention. In this study, in vitro cell models of ATDC5 and chondrocytes were prepared and cultured with different concentrations of galactose to evaluate its capacity on chondrogenesis and cartilage matrix formation. The cell proliferation assay demonstrated that galactose was nontoxic to both ATDC5 cells and chondrocytes. RT-PCR and immunofluorescence staining indicated that the gene expressions of cartilage matrix type II collagen and aggrecan were significantly upregulated with increasing galactose concentration and the expression and accumulation of the extracellular matrix (ECM) protein. Overall, these results indicated that a galactose concentration below 8 mM exhibited the best effect on promoting chondrogenesis, which entitles galactose as having considerable potential for cartilage repair and regeneration.

Meta-analysis of clinical trials focusing on hypertonic dextrose prolotherapy (HDP) for knee osteoarthritis

Hypertonic dextrose prolotherapy (HDP) is an injection of a concentrated dextrose solution for the purpose of local treatment of musculoskeletal pain and possible enhancement of repair mechanisms. This systematic review and meta-analysis examines the clinical utility of HDP injection for treatment of knee osteoarthritis (OA). Randomized controlled trials (RCTs) utilizing HDP to treat knee OA were retrieved from MEDLINE, EMBASE, and Cochrane Library (CENTRAL). Identification and inclusion of RCTs utilizing intra-articular and extra-articular administration of HDP vs administration of other injectate or physical therapy as control for knee OA were included. Primary clinical outcomes were changes in knee WOMAC, pain and function score. Secondary outcomes were adverse events related to HDP. For continuous outcomes with same or different measurements, we calculated, respectively the weighted mean difference (WMD) or the standardized mean difference (SMD), respectively. Results were pooled using DerSimonian and Laird random effect models across the included studies and heterogeneity between studies was estimated using the I² index. Five studies comprising a total of 319 treated patients met inclusion criteria and were included in the final analysis. At a mean of 22.8 weeks follow-up, HDP treatment significantly improved total WOMAC score (WMD = 13.77, 95% CI: 6.75-20.78; p < 0.001; I² = 90%), pain (SMD = 1.33, 95% CI: 0.49-2.17; p < 0.001; I² = 91%) and knee function (SMD = 1.30, 95% CI: 0.45-2.14; p < 0.001; I² = 91%) compared with control group. There were no severe adverse events related to dextrose injection reported in all the included studies. HDP is a promising treatment for knee OA with a reasonable safety profile. Further research in mechanism of HDP activity and long-term follow-up study will be needed for exploring this novel therapy modality.

Effectiveness, Compliance, and Safety of Dextrose Prolotherapy for Knee Osteoarthritis: A Meta-Analysis and Metaregression of Randomized Controlled Trials

OBJECTIVES

This study assessed the effectiveness, compliance, and safety of dextrose prolotherapy for patients with knee osteoarthritis.

DATA SOURCES

PubMed, EMBASE, the Cochrane Library Database, and the Scopus database from their inception to December 31, 2021.

METHODS

This study was conducted in accordance with the guidelines recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Randomized controlled trials regarding the effectiveness of dextrose prolotherapy in knee osteoarthritis were identified. The included trials were subjected to meta-analysis. Risk of bias was assessed using the Cochrane risk of bias tool. Subgroup and random-effects metaregression analyses were performed to explore any heterogeneity (I²) of treatment effects across studies.

RESULTS

A total of 14 trials enrolling 978 patients were included in the meta-analysis. Compared with placebo injection and noninvasive control therapy, dextrose prolotherapy had favorable effects on pain, global function, and quality of life during the overall follow-up. Dextrose prolotherapy yielded greater reductions in pain score over each follow-up duration than did the placebo. Compared with other invasive therapies, dextrose prolotherapy generally achieved comparable effects on pain and functional outcomes for each follow-up duration.Subgroup results indicated that combined intra-articular and extra-articular injection techniques may have stronger effects on pain than a single intra-articular technique.

CONCLUSIONS

Dextrose prolotherapy may have dose-dependent and time-dependent effects on pain reduction and function recovery, respectively, in patients with knee osteoarthritis. Due to remarkable heterogeneity and the risk of biases across the included trials, the study results should be cautiously interpreted.

Hypertonic Dextrose Prolotherapy, an alternative to intra-articular injections with Hyaluronic Acid in the treatment of knee osteoarthritis: systematic review and meta-analysis

ABSTRACT

Intra-articular injections with hyaluronic acid are recommended in the treatment of knee osteoarthritis (KOA); however, hypertonic dextrose prolotherapy (HDP) has been reported as effective and safe. The aim was to evaluate the effectiveness of HDP for pain reduction and improvement of function in individuals with KOA in comparison with hyaluronic acid by meta - analysis. The search was performed in electronic databases. Six studies were included (395 participants). No statistically significant differences were found between prolotherapy and hyaluronic acid in pain control in the short term, however, in the sub-analysis where included only the studies that used intra-articular injection within the prolotherapy scheme, an effect was found in favor of the prolotherapy groups (d = -1.33, 95% CI -2.50 to -0.16, p (z) 0.03). Also, an effect was found in favor of the prolotherapy group in the improvement in function (d = -1.05, 95% CI -2.03 to -0.08, p (z) 0.03). No major adverse reactions or side effects were reported in any of the studies. HDP appears to be an effective intervention to decrease pain and improve function in KOA, with efficacy similar to intra-articular injections with hyaluronic acid in the short-term follow-up. Nonetheless, better-quality clinical trials are necessary.

Utility of Prolotherapy for Upper Extremity Pathology

Prolotherapy is a method of treatment of painful musculoskeletal conditions whereby a sclerosing agent is injected into an area of tendinosis or osteoarthritis to strengthen and repair painful connective tissue. It is a safe, effective, and relatively inexpensive nonsurgical treatment modality. This article provides a history of prolotherapy, discusses its proposed mechanisms of action, and provides a review of the existing literature on prolotherapy as a treatment for upper extremity pathologies, specifically, hand osteoarthritis, lateral epicondylitis, and rotator cuff disease.

Antinociceptive effects of hyaluronic acid on monoiodoacetate-induced ankle osteoarthritis in rats

Purpose

Ankle osteoarthritis (OA) causes significant pain and debilitation; yet, its underlying mechanisms remain unclear. Clinically, hyaluronic acid (HA) is widely used to treat OA. The present study aimed to investigate the roles of HA in pain-related behavior, joint function, swelling, and pathological changes in cartilage in a rat model of monoiodoacetate (MIA)-induced ankle OA.

Materials and methods

Male Sprague Dawley rats were assigned to three experimental groups as follows: 1) MIA rats injected with 1 mg MIA in the right tibiotarsal joint for two consecutive days; 2) sham rats injected with saline instead of MIA; and 3) MIA-HA rats injected with HA in the tibiotarsal joint at 7, 14, and 21 days after MIA injection. Joint swelling, range of motion (ROM), and pain-related behavior were evaluated 1 day before and on the 7th, 14th, 21st, and 28th day after MIA or saline injection. Pathological changes in the ankle joint were assessed 28 days after MIA or saline injection.

Results

No significant difference in the degree of ankle swelling or ROM reduction was observed between MIA rats and MIA-HA rats. However, compared with those in MIA rats, mechanical and thermal hypersensitivity was significantly reduced and stride length significantly improved in MIA-HA rats. Histologic analysis revealed that cartilage degeneration was significantly suppressed in MIA-HA rats compared with that in MIA rats, reflecting the chondroprotective effects of HA.

Conclusion

HA improved pain-related behavior and stride length and suppressed MIA-induced cartilage degeneration. HA may thus inhibit OA progression and suppress peripheral and/or central sensitization.

Chondroprotective effect of Nigella sativa oil in the early stages of osteoarthritis: an experimental study in rabbits

PURPOSE

Nigella sativa oil possesses a well-known ability to protect certain organs from oxidative, neoplastic, and inflammatory damage. This study investigated the potential chondroprotective effects of intraarticular injections of Nigella sativa oil in a rabbit osteoarthritis model.

METHODS

Osteoarthritis models were created by performing anterior cruciate ligament transections in 20 New Zealand rabbits. Rabbits were randomly divided into two groups of 10 and given intraarticular injections in their right knees weekly for 5 weeks, beginning in the third week post-operation. Injections given to the first group contained whole Nigella sativa oil, whereas the second group was injected with a saline solution. Knee joints were harvested 8 weeks after surgery. Knee joint surfaces were examined macroscopically, and medial femoral condyle sections were examined microscopically.

RESULTS

There was a statistically significant difference in the macroscopic grading results of the groups, with the Nigella sativa group having better results (p=0.001). The Nigella sativa group also received significantly better total Osteoarthritis Research Society International (OARSI) scores (p=0.035).

CONCLUSIONS

Intraarticular administration of Nigella sativa oil has the potential to protect cartilage from degeneration in the early stages of osteoarthritis.

Shear-thinning hyaluronan-based fluid hydrogels to modulate viscoelastic properties of osteoarthritis synovial fluids

Hyaluronan-based injectable fluid hydrogel was prepared and used as an artificial synovial fluid for the treatment of osteoarthritis.

The comparison of the effects of a novel hydrogel compound and traditional hyaluronate following micro-fracture procedure in a rat full-thickness chondral defect model

PURPOSE

The aim of this experimental study was to investigate the impact of HA-CS-NAG compound (hyaluronate, sodium chondroitin sulfate, N-acetyl-d-glucosamine) on the quality of repair tissue after micro-fracture and to compare it with HA (hyaluronat), in a rat full-thickness chondral defect model.

METHODS

Full-thickness chondral defects were created in a non-weight bearing area by using a handle 2.7-mm drill bit, in the right knees of 33 Sprague-Dawley rats. Each specimen then underwent micro-fracture using a needle. Two weeks after surgery, 3 groups were randomly formed among the rats (n = 33). In Group 1, 0.2 mL of sterile saline solution (0.9%) was injected. In Group 2, 0.2 mL HA with a mean molecular weight of 1.2 Mda was injected. In Group 3, 0.2 mL of HA-CS-NAG compound (hyaluronate, sodium chondroitin sulfate, N-acetyl-d-glucosamine) was injected. The injections were applied on the 14th, the 21st and the 28th postoperative days. All rats were sacrificed on the 42nd postoperative day. Histological analysis of the repair tissue was performed for each specimen by two blinded observers using Wakitani scoring system.

RESULTS

There was significantly improved repair tissue in both Group 3 and Group 2 when compared with Group 1. Group 3 showed statistically significant improvement in terms of 'cell morphology' and 'integration of donor with host' when compared to Group 2 (p < 0.001).

CONCLUSION

Intra-articular injection of HA-CS-NAG compound after micro-fracture results in significantly improved repair tissue in rats' chondral defects when compared to HA regarding the donor integration and cell morphology.

Accuracy of computed tomographic arthrography for assessment of articular cartilage defects in the ovine stifle

Articular cartilage defects are one of the features of osteoarthritis in animals and humans. Early detection of cartilage defects is a challenge in clinical veterinary practice and also in translational research studies. An accurate, diagnostic imaging method would be desirable for detecting and following up lesions in specific anatomical regions of the articular surface. The current prospective experimental study aimed to describe the accuracy of computed tomographic arthrography (CTA) for detecting cartilage defects in a common animal model used for osteoarthritis research, the ovine stifle (knee, femoropatellar/femorotibial) joint. Joints in cadaver limbs (n = 42) and in living animals under anesthesia (n = 13) were injected with a contrast medium and imaged using a standardized CT protocol. Gross anatomy and histological assessment of specific anatomic regions were used as a gold standard for the evaluation of sensitivity, specificity, negative predictive value, and positive predictive value for CTA identification of articular cartilage defects in those regions. Pooled estimated sensitivity and specificity were 90.32% and 97.30%, respectively, in cadaver limbs, and 81.82% and 95.24%, respectively, in living animals. Pooled estimated positive predictive value and negative predictive values were 98.25% and 85.71%, respectively, in cadaver limbs, and 81.82% and 95.24%, respectively, in living animals. The delineation of cartilage surface was good for anatomical regions most frequently affected by cartilage defects in the ovine stifle: medial femoral condyle, medial tibial condyle, and patella. This study supported the use of CTA as an imaging technique for detecting and monitoring articular cartilage defects in the ovine stifle joint.

Can Early Rehabilitation Prevent Posttraumatic Osteoarthritis in the Patellofemoral Joint after Anterior Cruciate Ligament Rupture? Understanding the Pathological Features

Knee instability resulting from anterior cruciate ligament (ACL) rupture is a high-risk factor for posttraumatic osteoarthritis (PTOA) in the patellofemoral joint (PFJ). However, whether non-weight-bearing and weight-bearing treatments have chondroprotective effects remains unclear. Twenty-four adult New Zealand White male rabbits were employed in this study. All animals received ACL transection in the right knee and sham surgery in the left knee. The rabbits were randomly assigned to the following groups: (I) In the sedentary (SED) group, the rabbits (n = 6) were simply kept in their cage; (II) In the continuous passive motion (CPM) group, the rabbits (n = 6) performed CPM exercise for 7 days, starting from the first postoperative day; (III) In the active treadmill exercise (TRE) group, the rabbits (n = 6) performed TRE for 2 weeks; (IV) In the CPM + TRE group, the rabbits (n = 6) executed CPM exercise, followed by TRE. Two joint surfaces (the retropatella and femoral trochlear groove) were assessed at 4 weeks after operation. Although the gross appearance in each group was comparable, histological examination revealed significant differences in the articular cartilage status. The CPM group exhibited a greater thickness of articular cartilage, maintenance of tidemark continuity, abundant glycosaminoglycan (GAG), and significantly lower inflammatory cytokine 9, e.g., tumor necrosis factor-alpha (TNF-α) 0 levels, with modest cell apoptosis (i.e., caspase-3). By contrast, the TRE group displayed the worst pathological features: an irregular cartilage surface and chondrocyte disorganization, reduced cartilage thickness, breakdown of the tidemark, depletion of collagen fibers, loss of GAG, and the highest levels of TNF-α and caspase-3 expression. Furthermore, the CPM + TRE group had more favorable outcomes than the SED group, indicating that suitable exercise is needed. The sham treatment displayed no variance in the changes in the two joint surfaces among groups. These data indicate that the application of early CPM rehabilitation is suggested for subjects in order to decrease the risk of PTOA without ACL reconstruction in the PFJ compartment in rabbits. The early TRE program, however, had harmful outcomes. Additionally, inactivity was discovered to initiate the development of PTOA.

Prospective Evaluation of Intra-Articular Dextrose Prolotherapy for Treatment of Osteoarthritis in Dogs

The objective of this study was to evaluate intra-articular dextrose prolotherapy for osteoarthritis of the elbow or stifle in dogs in a randomized, double-blind, placebo-controlled, prospective pilot study. Seventeen dogs were evaluated with 10 meeting inclusion criteria for this study. Evaluations included orthopedic exam, visual lameness scoring, Canine Brief Pain Inventory (CBPI), goniometry, kinetic gait analysis, and radiography. Initial lameness score, age, body weight, duration of lameness, and CBPI scores did not differ between groups. Change in CBPI pain severity score in the prolotherapy group from wk 6-12 was significantly less improved than in the placebo group, with no other significant differences in pain severity or pain interference scores between groups. Range of motion and radiographic scores did not differ between groups at any time. Mean kinetic forces improved in prolotherapy dogs but were not significantly different between treatment groups at any time. Although easily performed and well-tolerated, there were no statistically significant benefits of dextrose prolotherapy for treatment of osteoarthritis of the elbow and stifle in dogs. Post hoc power analysis of these sample means and standard deviations found that 29-106 animals per group would be necessary to demonstrate significant differences in kinetic forces, providing useful guidance for future studies.

Comparison of the chondroprotective effect of a novel hydrogel compound and traditional hyaluronate on rat cartilage in a papain-induced osteoarthritis model

Purpose

The aim of this experimental study is to evaluate the efficacy of a novel intraarticular drug in a papain induced osteoarthritis (OA) rat model and compare with the traditional hyaluronat (HA) visco supplementation.

Methods

An early stage OA model was induced by the intra-articular injection of papain enzyme in the right knee joints of 44 Sprague-Dawley rats. Eleven rats (eleven right knees: papain group, 11 left knees: control group) were chosen randomly 28 days after the last injection and sacrificed for verifying OA. The remaining rats (n = 33) were randomly divided into 3 groups. Group 1 was injected 0,2 mL of sterile saline solution (0,9%), group 2 was injected 0,2 mL HA and the group 3 was injected 0,2 mL of HA-CSNAG (hyaluronat, chondritin sulfate, N-acetyl-d-glucosamine) combination in the right knees. Injections were performed on the 35th, the 42nd and the 49th days consecutively. Two weeks after the last injection, all groups were sacrificed to evaluate the severity of OA according to Mankin system.

Results

Early stage of OA was verified regarding total Mankin scores (p < 0.05). There was statistically significant difference between Group 1 and Group 2 (p < 0.05), between Group 1 and Group 3 (p < 0.05) on the 63th day regarding total Mankin scores. Group 3 showed statistically significant improvement in terms of proteoglycan content of matrix when compared to Group 2 (p < 0,05).

Conclusion

HA-CS-NAG compound in hydrogel form is more chondroprotective to rats' cartilage when compared to HA during the early stages of OA.

Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis

Hypertonic dextrose injections (prolotherapy) is an emerging treatment for symptomatic knee osteoarthritis (OA) but its efficacy is uncertain. We conducted a systematic review with meta-analysis to synthesize clinical evidence on the effect of prolotherapy for knee OA. Fifteen electronic databases were searched from their inception to September 2015. The primary outcome of interest was score change on the Western Ontario and McMaster Universities Arthritis Index (WOMAC). Three randomized controlled trials (RCTs) of moderate risk of bias and one quasi-randomized trial were included, with data from a total of 258 patients. In the meta-analysis of two eligible studies, prolotherapy is superior to exercise alone by a standardized mean difference (SMD) of 0.81 (95% CI: 0.18 to 1.45, p = 0.012), 0.78 (95% CI: 0.25 to 1.30, p = 0.001) and 0.62 (95% CI: 0.04 to 1.20, p = 0.035) on the WOMAC composite scale; and WOMAC function and pain subscale scores respectively. Moderate heterogeneity exists in all cases. Overall, prolotherapy conferred a positive and significant beneficial effect in the treatment of knee OA. Adequately powered, longer-term trials with uniform end points are needed to better elucidate the efficacy of prolotherapy.

Chondrogenic Effect of Intra-articular Hypertonic-Dextrose (Prolotherapy) in Severe Knee Osteoarthritis

BACKGROUND

Dextrose injection is reported to improve knee osteoarthritis (KOA)-related clinical outcomes, but its effect on articular cartilage is unknown. A chondrogenic effect of dextrose injection has been proposed.

OBJECTIVE

To assess biological and clinical effects of intra-articular hypertonic dextrose injections (prolotherapy) in painful KOA.

DESIGN

Case series with blinded arthroscopic evaluation before and after treatment.

SETTING

Physical medicine and day surgery practice.

PARTICIPANTS

Symptomatic KOA for at least 6 months, arthroscopy-confirmed medial compartment exposed subchondral bone, and temporary pain relief with intra-articular lidocaine injection.

INTERVENTION

Four to 6 monthly 10-mL intra-articular injections with 12.5% dextrose.

MAIN OUTCOME MEASURES

Visual cartilage growth assessment of 9 standardized medial condyle zones in each of 6 participants by 3 arthroscopy readers masked to pre-/postinjection status (total 54 zones evaluated per reader); biopsy of a cartilage growth area posttreatment, evaluated using hematoxylin and eosin and Safranin-O stains, quantitative polarized light microscopy, and immunohistologic cartilage typing; self-reported knee specific quality of life using the Western Ontario McMaster University Osteoarthritis Index (WOMAC, 0-100 points).

RESULTS

Six participants (1 female and 5 male) with median age of 71 years, WOMAC composite score of 57.5 points, and a 9-year pain duration received a median of 6 dextrose injections and follow-up arthroscopy at 7.75 months (range 4.5-9.5 months). In 19 of 54 zone comparisons, all 3 readers agreed that the posttreatment zone showed cartilage growth compared with the pretreatment zone. Biopsy specimens showed metabolically active cartilage with variable cellular organization, fiber parallelism, and cartilage typing patterns consistent with fibro- and hyaline-like cartilage. Compared with baseline status, the median WOMAC score improved 13 points (P = .013). Self-limited soreness after methylene blue instillation was noted.

CONCLUSIONS

Positive clinical and chondrogenic effects were seen after prolotherapy with hypertonic dextrose injection in participants with symptomatic grade IV KOA, suggesting disease-modifying effects and the need for confirmation in controlled studies. Minimally invasive arthroscopy (single-compartment, single-portal) enabled collection of robust intra-articular data.

LEVEL OF EVIDENCE

IV.

Mechanical overloading causes mitochondrial superoxide and SOD2 imbalance in chondrocytes resulting in cartilage degeneration

Mechanical stress and aging are major risk factors of cartilage degeneration. Human studies have previously reported that oxidative damage increased, while SOD2 protein was reciprocally downregulated in osteoarthritic degenerated cartilage. However, it remains unclear whether mitochondrial superoxide imbalance in chondrocytes causes cartilage degeneration. We herein demonstrate that mechanical loading promoted mitochondrial superoxide generation and selective Sod2 downregulation in chondrocytes in vivo and that mitochondrial superoxide inducer also downregulated Sod2 expression in chondrocytes in vitro. A genetically manipulated model revealed that Sod2 deficiency in chondrocytes also resulted in mitochondrial superoxide overproduction and dysfunction, thus leading to cartilage degeneration. Intra-articular injection of a permeable antioxidant effectively suppressed the mechanical loading-induced mitochondrial superoxide generation and cartilage degeneration in mice. Our findings demonstrate that mitochondrial superoxide plays a pivotal role in the development and progression of osteoarthritis, and the mitochondrial superoxide balance may therefore be a promising target for the treatment of cartilage degeneration.

Development and evaluation in vitro and in vivo of injectable hydrolipidic gels with sustained-release properties for the management of articular pathologies such as osteoarthritis

This study aimed to evaluate glycerol monooleate (GMO) as a carrier to develop viscoelastic and injectable sustained-release drug delivery systems. The potential pro- and antioxidant activity of the developed hydrolipidic gels were evaluated by measuring the production of ROS by polymorphonuclear leukocytes (PMNs). In addition, the biocompatibility and effectiveness of two selected gel candidates were evaluated in vivo by evaluating the benefit of a single intraarticular injection of these new treatments in a model of osteoarthritis in rabbits. The in vitro study demonstrated that the carrier F1 did not have a pro-oxidative effect and even protected PMNs against natural auto-activation, regardless of the incorporation of either clonidine chlorhydrate or betamethasone dipropionate. The in vivo study demonstrated that F1 and F1-BDP induced a loss of cartilage quality in comparison to the control and reference groups but that the lesions of cartilage observed were generally mild, with not much full-depth erosion. Moreover, no exacerbating inflammation was observed when considering the synovial membranes and the PGE2 and CRP levels. These results seemed to demonstrate that the sustained-release formulation based on GMO could be well-tolerated after intraarticular injection. Moreover, it could have the potential to prevent inflammatory conditions while sustaining drug activity locally over weeks.

Nondestructive assessment of sGAG content and distribution in normal and degraded rat articular cartilage via EPIC-microCT

OBJECTIVE

The objective of this study was to evaluate the feasibility of quantifying the Equilibrium Partitioning of an Ionic Contrast agent via Microcomputed Tomography (EPIC-microCT) to nondestructively assess sulfated glycosaminoglycan (sGAG) content and distribution in rat articular cartilage ex vivo, and in doing so to establish a paradigm for extension of this technique to other small animal models.

DESIGN

After determination of an appropriate incubation time for the anionic contrast agent, EPIC-microCT was used to examine age-related differences in cartilage sGAG content between 4-, 8-, and 16-week old (n=5 each) male Wistar rats and to evaluate sGAG depletion in the right femora of each age group after 60 min of digestion with chondroitinase ABC. The EPIC-microCT measurements were validated by histological safranin-O staining, and reproducibility was evaluated by triplicate scans of six femora.

RESULTS

Cartilage attenuation gradually increased with cumulative digestion time and reached a plateau at approximately 60 min with a 16.0% temporal increase (P<0.01). Average femoral articular cartilage attenuation increased by 14.2% from 4- to 8-weeks of age (P<0.01) and further increased by 2.5% from 8 to 16 weeks (P<0.05). After 60 min of digestion, femoral articular cartilage attenuations increased by 15-17% in each age group (P<0.01). Correspondingly, sGAG optical density decreased with age and digestion, and showed a linear correlation (r=-0.88, slope=-1.26, P<0.01, n=30) with EPIC-microCT cartilage attenuation. High reproducibility was indicated by a low coefficient of variation (1.5%) in cartilage attenuation.

CONCLUSIONS

EPIC-microCT imaging provides high spatial resolution and sensitivity to assess sGAG content and three-dimensional distribution in rat femoral articular cartilage.

Care of the geriatric rabbit

The average life span reported in laboratory and lay literature for the domestic rabbit is 5 to 10 years. The author and other veterinarians are now regularly seeing rabbits living to 9 or 10 years, the oldest reported in the author's practice being 14 years. Rabbits are herbivorous prey species with continually growing (elodont) teeth. This feature allows the geriatric rabbit to possess teeth that are essentially "new", a distinct advantage over geriatric carnivores. Expanded longevity, while generally desirable, necessarily accompanies an increase in geriatric disorders. This article examines the spectrum of disease that can affect the geriatric rabbit as well as crucial factors concerning the clinical management of the animal up to the end of its life. An improved understanding of geriatric disorders in pet rabbits allows early recognition and the opportunity to improve quality of life.

The effects of hypertonic dextrose injection on connective tissue and nerve conduction through the rabbit carpal tunnel

OBJECTIVE

To investigate the effects of hypertonic dextrose injection on the subsynovial connective tissue (SSCT) in a rabbit model. We hypothesized that dextrose injection would induce proliferation of the SSCT, hinder median nerve conduction, and alter SSCT mechanical properties, similar to what is observed in patients with carpal tunnel syndrome (CTS).

DESIGN

Randomized, controlled prospective study.

SETTING

Not applicable.

PARTICIPANTS

New Zealand white rabbits (N=28) weighing 4.0 to 4.5kg.

INTERVENTION

One forepaw was randomly injected with 0.1mL 10% dextrose solution. The contralateral paw was injected with a similar amount of 0.9% saline solution as a control. Animals were killed at 12 weeks after injection.

MAIN OUTCOME MEASURES

Animals were evaluated by electrophysiology (EP), mechanical testing, and histology. EP was evaluated by distal motor latency and amplitude. Shear force was evaluated when the middle digit flexor digitorum superficialis tendon was pulled out from the carpal tunnel. The ultimate tensile load and the energy absorption were also measured. Tissue for histology was evaluated qualitatively.

RESULTS

EP demonstrated significant prolongation of distal motor latency. The energy absorption and stiffness were also significantly increased in the dextrose group. Histologically, the dextrose group showed thickening of the collagen bundles and vascular proliferation within the SSCT compared with the saline group.

CONCLUSIONS

These results are consistent with the findings in patients with CTS and suggest that hypertonic dextrose injection has the potential to create a novel animal model in which to study the evolution of CTS.

Regenerative injection of elite athletes with career-altering chronic groin pain who fail conservative treatment: a consecutive case series

OBJECTIVE

To obtain multisport and long-term outcome data from the use of regenerative injection therapy on career-threatened athletes.

DESIGN

Consecutive enrollment of elite performance-limited athletes with chronic groin/abdominal pain who failed a conservative treatment trial. The treatment consisted of monthly injections of 12.5% dextrose in 0.5% lidocaine in abdominal and adductor attachments on the pubis. Injection of the nociceptive source was confirmed by repetition of resistive testing 5 mins after injection.

RESULTS

Seventy-five athletes were enrolled. Seventy-two athletes (39 rugby, 29 soccer, and 4 other) completed the minimum two-treatment protocol. Their data revealed a mean groin pain history of 11 (3-60) mos. Average number of treatments received was 3 (1-6). Individual paired t tests for Visual Analog Scale (VAS) of pain with sport (VAS Pain) and Nirschl pain phase scale measured at 0 and an average of 26 (6-73) mos indicated VAS Pain improvement of 82% (P < 10) and Nirschl pain phase scale improvement of 78% (P < 10). Six athletes did not improve following regenerative injection therapy treatment, and the remaining 66 returned to unrestricted sport. Return to unrestricted sport occurred in an average of 3 (1-5) mos.

CONCLUSIONS

Athletes returned to full elite-level performance in a timely and sustainable manner after regenerative injection therapy using dextrose.

Assessment of a goat model of posterolateral knee instability

The development of an in vivo animal model of posterolateral knee instability is desired for devising effective interventions for this injury. Sequential sectioning of the popliteus tendon, lateral collateral ligament, and lateral capsule was done in cadaveric goat knees to create knee joint instability, followed by in vivo studies (Studies 1 and 2) of 7 and 3 months duration, respectively. In Study 1, the popliteus tendon and lateral collateral ligament were sectioned; in Study 2, these structures as well as the lateral joint capsule were sectioned. Biomechanical testing and histological assessments were done to determine the severity of the instability and the morphological changes. Sectioning the lateral collateral ligament and popliteus tendon (Study 1) resulted in a significant increase in varus instability at 90 degrees . Sectioning the lateral collateral ligament, popliteus tendon, and lateral capsule (Study 2) resulted in significant varus instability at 30 degrees , 60 degrees , and 90 degrees , and significant internal-external rotation at 60 degrees and 90 degrees ; however, the lesions of osteoarthritis in the operated knees were similar to those in unoperated control knees. This study confirms that posterolateral knee instability can be created in a goat model, but we were unable to demonstrate lesions of osteoarthritis that were of sufficient severity to allow evaluation of disease reduction in future intervention procedures. Future studies will determine if further manipulation of the model results in sufficient morphological changes to allow its use in the assessment of intervention strategies.