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Lotsikas PJ. Intra-articular Injectates: What to Use and Why. Vet Clin North Am Small Anim Pract 2022:S0195-5616(22)00033-X. [PMID: 35562212 DOI: 10.1016/j.cvsm.2022.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Intra-articular injections are a nonsurgical treatment modality that can be used to manage osteoarthritis, naturally occurring or surgically induced acute synovitis, and intra-articular ligamentous or tendon injury. This option may be assistive for patients in which other conservative modalities are ineffective, or in conjunction with other forms of treatment. It may also be used as the primary treatment. Injectates labeled for use in companion animal joints include corticosteroids and viscosupplements. Additional injectates, that are not specifically approved for use in companion animals are but are reported in the literature, include orthobiologics and a radioisotope of Tin-117m.
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Abstract
BACKGROUND Osteoarthritis is a common degenerative musculoskeletal disease of synovial joints. It is characterized by a metabolic imbalance resulting in articular cartilage degradation, reduced elastoviscosity of synovial fluid and an altered chondrocyte phenotype. This is often associated with reduced mobility, pain and poor quality of life. Subsequently, with an ageing world population, osteoarthritis is of increasing concern to public health. Nuclear magnetic resonance (NMR) spectroscopy can be applied to characterize the metabolomes of biofluids, determining changes associated with osteoarthritis pathology, identifying potential biomarkers of disease and alterations to metabolic pathways. SOURCES OF DATA A comprehensive search of PubMed and Web of Science databases using combinations of the following keywords: 'NMR Spectroscopy', 'Blood', 'Plasma', 'Serum', 'Urine', 'Synovial Fluid' and 'Osteoarthritis' for articles published from 2000 to 2020. AREAS OF AGREEMENT The number of urine metabolomics studies using NMR spectroscopy to investigate osteoarthritis is low, whereas the use of synovial fluid is significantly higher. Several differential metabolites have previously been identified and mapped to metabolic pathways involved in osteoarthritis pathophysiology. AREAS OF CONTROVERSY Conclusions are sometimes conservative or overinflated, which may reflect the variation in reporting standards. NMR metabolic experimental design may require further consideration, as do the animal models used for such studies. GROWING POINTS There are various aspects which require improvement within the field. These include stricter adherence to the Metabolomics Standards Initiative, inclusive of the standardization of metabolite identifications; increased utilization of integrating NMR metabolomics with other 'omic' disciplines; and increased deposition of raw experimental files into open access online repositories, allowing greater transparency and enabling additional future analyses. AREAS TIMELY FOR DEVELOPING RESEARCH Overall, this research area could be improved by the inclusion of more heterogeneous cohorts, reflecting varying osteoarthritis phenotypes, and larger group sizes ensuring studies are not underpowered. To correlate local and systemic environments, the use of blood for diagnostic purposes, over the collection of synovial fluid, requires increased attention. This will ultimately enable biomarkers of disease to be determined that may provide an earlier diagnosis, or provide potential therapeutic targets for osteoarthritis, ultimately improving patient prognosis.
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Affiliation(s)
- Emily J Clarke
- Institute of Life Course and Medical Sciences, Musculoskeletal and Ageing Science, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK
| | - James R Anderson
- Institute of Life Course and Medical Sciences, Musculoskeletal and Ageing Science, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK
| | - Mandy J Peffers
- Institute of Life Course and Medical Sciences, Musculoskeletal and Ageing Science, William Henry Duncan Building, 6 West Derby Street, Liverpool L7 8TX, UK
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Lee MI, Kim JH, Kwak HH, Woo HM, Han JH, Yayon A, Jung YC, Cho JM, Kang BJ. A placebo-controlled study comparing the efficacy of intra-articular injections of hyaluronic acid and a novel hyaluronic acid-platelet-rich plasma conjugate in a canine model of osteoarthritis. J Orthop Surg Res 2019; 14:314. [PMID: 31533754 PMCID: PMC6749694 DOI: 10.1186/s13018-019-1352-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/29/2019] [Indexed: 02/07/2023] Open
Abstract
Background The objective of this study was to assess the efficacy of intra-articular injections of hyaluronic acid (HA) and a novel, on-site conjugate of HA with autologous fibrinogen in platelet-rich plasma (HA-PRP) in a canine model of osteoarthritis (OA) Methods Twelve beagle dogs underwent a unilateral resection of the cranial cruciate ligament (CrCL) of the stifle joint. Clinical and radiographic signs of OA were confirmed in all dogs 8 weeks following CrCL resection and prior to treatment. The dogs were randomized into three groups: saline (n = 4), HA (n = 4), and HA-PRP (n = 4). Each dog received intra-articular injections of the respective substance into the affected joint at pre-determined time points. The dogs were assessed for adverse effects for 3 days after each injection and for lameness, pain, range of motion, kinetics, and radiographic OA severity prior to treatment and 3 months after injection. OA severity as determined by radiographic examination was not significantly different among the groups at any time point. The dogs were then humanely euthanatized and the stifle joint assessed by gross and histological examinations. Results Dogs treated with four weekly injections of HA or two biweekly injections of HA-PRP were significantly (p < 0.05) better than dogs treated with four weekly injections of saline at 2-, 4-, and 12-week time points based on a comfortable range of motion (CROM) and clinical lameness score. Gait analysis measuring symmetry and weight distribution on pressure sensor walkway showed significantly (p < 0.05) improved limb function for dogs treated with HA and HA-PRP compared with dogs treated with saline yet with better clinical outcome for the HA-PRP-treated group at 12 and 20 weeks follow-up. Gross and histological analysis of synovium and articular cartilage demonstrated significant (p < 0.05) improvement by both treatments groups compared to controls. There was however significantly (p < 0.05) less damage to the cartilage in the HA-PRP group compared to the HA-treated group. Conclusions These data suggest that while injection of HA and HA-PRP may be sufficient for short-term amelioration of the symptoms associated with OA, treatment with HA-PRP conjugates may be superior, providing significantly better long-term cartilage preservation.
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Affiliation(s)
- Mun-Ik Lee
- College of Veterinary Medicine and Institute of Veterinary Science, Kangwon National University, Chuncheon, 24341, Korea
| | - Jun-Hyung Kim
- College of Veterinary Medicine and Institute of Veterinary Science, Kangwon National University, Chuncheon, 24341, Korea
| | - Ho-Hyun Kwak
- College of Veterinary Medicine and Institute of Veterinary Science, Kangwon National University, Chuncheon, 24341, Korea
| | - Heung-Myong Woo
- College of Veterinary Medicine and Institute of Veterinary Science, Kangwon National University, Chuncheon, 24341, Korea
| | - Jeong-Hee Han
- College of Veterinary Medicine and Institute of Veterinary Science, Kangwon National University, Chuncheon, 24341, Korea
| | - Avner Yayon
- ProCore-biomed, Ltd., Weizmann Science Park, 76400, Ness Ziona, Israel
| | | | - Jin-Man Cho
- Research Institute, Green Cross Veterinary Products Co., Ltd., Yongin, 17066, Korea
| | - Byung-Jae Kang
- College of Veterinary Medicine and Institute of Veterinary Science, Kangwon National University, Chuncheon, 24341, Korea. .,Department of Veterinary Clinical Sciences, College of Veterinary Medicine and Research Institute for Veterinary Science, Seoul National University, 1 Gwanak-ro, Gwanak-gu, Seoul, 08826, Korea.
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Abstract
Hyaluronic acid (also known as hyaluronan or hyaluronate) is naturally found in many tissues and fluids, but more abundantly in articular cartilage and synovial fluid (SF). Hyaluronic acid (HA) content varies widely in different joints and species. HA is a non-sulfated, naturally occurring non-protein glycosaminoglycan (GAG), with distinct physico-chemical properties, produced by synoviocytes, fibroblasts, and chondrocytes. HA has an important role in the biomechanics of normal SF, where it is partially responsible for lubrication and viscoelasticity of the SF. The concentration of HA and its molecular weight (MW) decline as osteoarthritis (OA) progresses with aging. For that reason, HA has been used for more than four decades in the treatment of OA in dogs, horses and humans. HA produces anti-arthritic effects via multiple mechanisms involving receptors, enzymes and other metabolic pathways. HA is also used in the treatment of ophthalmic, dermal, burns, wound repair, and other health conditions. The MW of HA appears to play a critical role in the formulation of the products used in the treatment of diseases. This review provides a mechanism-based rationale for the use of HA in some disease conditions with special reference to OA.
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Affiliation(s)
- Ramesh C Gupta
- Toxicology Department, Breathitt Veterinary Center, Murray State University, Hopkinsville, KY, United States
| | - Rajiv Lall
- Vets Plus, Inc., Menomonie, WI, United States
| | | | - Anita Sinha
- Vets Plus, Inc., Menomonie, WI, United States
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Chen LH, Xue JF, Zheng ZY, Shuhaidi M, Thu HE, Hussain Z. Hyaluronic acid, an efficient biomacromolecule for treatment of inflammatory skin and joint diseases: A review of recent developments and critical appraisal of preclinical and clinical investigations. Int J Biol Macromol 2018; 116:572-584. [DOI: 10.1016/j.ijbiomac.2018.05.068] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Revised: 04/29/2018] [Accepted: 05/12/2018] [Indexed: 11/29/2022]
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Kyostio-Moore S, Berthelette P, Cornell CS, Nambiar B, Figueiredo MD. Hyaluronic acid synthase-2 gene transfer into the joints of Beagles by use of recombinant adeno-associated viral vectors. Am J Vet Res 2018; 79:505-517. [DOI: 10.2460/ajvr.79.5.505] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Pashuck TD, Kuroki K, Cook CR, Stoker AM, Cook JL. Hyaluronic acid versus saline intra-articular injections for amelioration of chronic knee osteoarthritis: A canine model. J Orthop Res 2016; 34:1772-1779. [PMID: 26867692 DOI: 10.1002/jor.23191] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 02/08/2016] [Indexed: 02/04/2023]
Abstract
The objective of this study was to assess the safety and efficacy of intra-articular injections of hyaluronic acid (HA) versus saline for symptomatic treatment of osteoarthritis (OA). Twenty-five adult purpose-bred dogs underwent meniscal release of one knee. Clinical, arthroscopic, and radiographic signs of OA were confirmed in all dogs prior to treatment. Dogs were randomized into five groups: HA-1 (n = 5), HA-3 (n = 5), HA-5 (n = 5), Saline-1 (n = 5), and Saline-3 (n = 5). Each dog received intra-articular injections of the respective substance into the affected knee at the pre-determined time points. Dogs were assessed for heat, swelling, and erythema after each injection and for lameness, pain, effusion, range of motion, kinetics, radiographic OA scoring, and arthroscopic scoring prior to treatment and for 6 months after injection. Dogs were then humanely euthanatized and the knees assessed grossly and histologically. Only mild heat, swelling, and/or erythema were noted in some dogs following injection and resolved within 1 week. Dogs treated with HA-1, HA-3, and HA-5 were significantly (p < 0.05) better than dogs treated with Saline-1 and Saline-3 at the 4, 8, and 12 week time points based on at least one outcome measure. OA severity was not significantly different among groups at any time point, but increased in severity over time in all groups. Gross and histologic OA scores were not significantly different among groups. These data suggest the three HA injection protocols were safe, superior to saline for short-term amelioration of symptoms associated with chronic OA, and can be translated to human OA treatment. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1772-1779, 2016.
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Affiliation(s)
- Troy D Pashuck
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri
| | - Keiichi Kuroki
- Comparative Orthopaedic Laboratory, University of Missouri, Missouri Orthopaedic Institute (4028A), 1100 Virginia Ave., Columbia, 65212, Missouri
| | - Cristi R Cook
- Comparative Orthopaedic Laboratory, University of Missouri, Missouri Orthopaedic Institute (4028A), 1100 Virginia Ave., Columbia, 65212, Missouri
| | - Aaron M Stoker
- Comparative Orthopaedic Laboratory, University of Missouri, Missouri Orthopaedic Institute (4028A), 1100 Virginia Ave., Columbia, 65212, Missouri
| | - James L Cook
- Department of Orthopaedic Surgery, University of Missouri, Columbia, Missouri. .,Comparative Orthopaedic Laboratory, University of Missouri, Missouri Orthopaedic Institute (4028A), 1100 Virginia Ave., Columbia, 65212, Missouri.
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Abstract
This article presents the spectrum of indications for the use of hyaluronic acid (HA) based on the recommendations of the European League Against Rheumatism (EULAR), the American College of Rheumatology (ACR), the Osteoarthritis Research Society International (OARSI), the International Institute for Health and Clinical Excellence (NICE) and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) taking the reality of patient care in Europe into account.
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Affiliation(s)
- J Jerosch
- Klinik für Orthopädie, Unfallchirugie und Sportmedizin, Johanna Etienne Krankenhaus, Am Hasenberg 46, 40416, Neuss, Deutschland.
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Moreau M, Pelletier JP, Lussier B, d'Anjou MA, Blond L, Pelletier JM, del Castillo JR, Troncy E. A posteriori comparison of natural and surgical destabilization models of canine osteoarthritis. Biomed Res Int 2013; 2013:180453. [PMID: 24288664 DOI: 10.1155/2013/180453] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 09/10/2013] [Indexed: 02/07/2023]
Abstract
For many years Canis familiaris, the domestic dog, has drawn particular interest as a model of osteoarthritis (OA). Here, we optimized the dog model of experimental OA induced by cranial cruciate ligament sectioning. The usefulness of noninvasive complementary outcome measures, such as gait analysis for the limb function and magnetic resonance imaging for structural changes, was demonstrated in this model. Relationships were established between the functional impairment and the severity of structural changes including the measurement of cartilage thinning. In the dog model of naturally occurring OA, excellent test-retest reliability was denoted for the measurement of the limb function. A criterion to identify clinically meaningful responders to therapy was determined for privately owned dogs undergoing clinical trials. In addition, the recording of accelerometer-based duration of locomotor activity showed strong and complementary agreement with the biomechanical limb function. The translation potential of these models to the human OA condition is underlined. A preclinical testing protocol which combines the dog model of experimental OA induced by cranial cruciate ligament transection and the Dog model of naturally occurring OA offers the opportunity to further investigate the structural and functional benefits of disease-modifying strategies. Ultimately, a better prediction of outcomes for human clinical trials would be brought.
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Vincent HK, Percival SS, Conrad BP, Seay AN, Montero C, Vincent KR. Hyaluronic Acid (HA) Viscosupplementation on Synovial Fluid Inflammation in Knee Osteoarthritis: A Pilot Study. Open Orthop J 2013; 7:378-84. [PMID: 24093052 PMCID: PMC3788189 DOI: 10.2174/1874325001307010378] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 06/27/2013] [Accepted: 08/24/2013] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE This study examined the changes in synovial fluid levels of cytokines, oxidative stress and viscosity six months after intraarticular hyaluronic acid (HA) treatment in adults and elderly adults with knee osteoarthritis (OA). DESIGN This was a prospective, repeated-measures study design in which patients with knee OA were administered 1% sodium hyaluronate. Patients (N=28) were stratified by age (adults, 50-64 years and elderly adults, ≥65 years). Ambulatory knee pain values and self-reported physical activity were collected at baseline and month six. MATERIALS AND METHODS Knee synovial fluid aspirates were collected at baseline and at six months. Fluid samples were analyzed for pro-inflammatory cytokines (interleukins 1β, 6,8,12, tumor necrosis factor-α, monocyte chemotactic protein), anti-inflammatory cytokines (interleukins 4, 10 13), oxidative stress (4-hydroxynonenal) and viscosity at two different physiological shear speeds 2.5Hz and 5Hz. RESULTS HA improved ambulatory knee pain in adults and elderly groups by month six, but adults reported less knee pain-related interference with participation in exercise than elderly adults. A greater reduction in TNF-α occurred in adults compared to elderly adults (-95.8% ± 7.1% vs 19.2% ± 83.8%, respectively; p=.044). Fluid tended to improve at both shear speeds in adults compared to the elderly adults. The reduction in pain severity correlated with the change in IL-1β levels by month six (r= -.566; p=.044). CONCLUSION Reduction of knee pain might be due to improvements in synovial fluid viscosity and inflammation. Cartilage preservation may be dependent on how cytokine, oxidative stress profiles and viscosity change over time.
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Affiliation(s)
- Heather K Vincent
- Department of Orthopaedics and Rehabilitation, Interdisciplinary Center for Musculoskeletal Training and Research
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Nganvongpanit K, Boonsri B, Sripratak T, Markmee P. Effects of one-time and two-time intra-articular injection of hyaluronic acid sodium salt after joint surgery in dogs. J Vet Sci 2013; 14:215-22. [PMID: 23814475 PMCID: PMC3694194 DOI: 10.4142/jvs.2013.14.2.215] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2012] [Revised: 08/14/2012] [Accepted: 08/30/2012] [Indexed: 11/28/2022] Open
Abstract
Thirty-one dogs with patellar luxation (grades 2 and 3) were categorized into three groups. Group 1 (G.1; n = 12) had sodium hyaluronate (SHA) intra-articularly injected into the stifle joint that received surgery. Group 2 (G.2; n = 10) received SHA twice: first after surgery and then 1 week later. Group 3 (G.3; n = 9) served as a control, without injection. Blood was collected before injection and then once a week for 4 weeks after injection for evaluation of chondroitin sulfate (CS-WF6) and hyaluronan (HA). The results revealed significantly (p < 0.05) improved clinical scores by the end of week 4 in G.1 and G.2 relative to G.3; however, there was no significant difference between G.1 and G.2. There was a significant decrease (p < 0.05) in serum CS-WF6 levels beginning at week 2 in G.1 and G.2. At weeks 3 and 4, serum HA in G.1 and G.2 differed from that in G.3 (p < 0.05). No significant difference (p > 0.05) was observed in serum biomarkers between G.1 and G.2. In conclusion, intra-articular injection with SHA after joint surgery may improve homeostasis of the joint, retarding the process of OA.
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Affiliation(s)
- Korakot Nganvongpanit
- Animal Bone and Joint Research Laboratory, Department of Veterinary Biosciences and Public Health, Faculty of Veterinary Medicine, Chiang Mai University, Chiang Mai 50100, Thailand.
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Iannitti T, Elhensheri M, Bingöl AO, Palmieri B. Preliminary histopathological study of intra-articular injection of a novel highly cross-linked hyaluronic acid in a rabbit model of knee osteoarthritis. J Mol Histol 2013; 44:191-201. [PMID: 23389746 PMCID: PMC3617354 DOI: 10.1007/s10735-012-9457-4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Accepted: 10/07/2012] [Indexed: 11/30/2022]
Abstract
Osteoarthritis is a degenerative joint disease mostly occurring in the knee and commonly seen in middle-aged and elderly adults. Intra-articular injection of hyaluronic acid has been widely used for treatment of knee osteoarthritis. The aim of this study was to evaluate the efficacy of intra-articular injection of a novel highly cross-linked hyaluronic acid, alone or in combination with ropivacaine hydrochloride and triamcinolone acetonide, on knee articular cartilage in a rabbit model of collagenase-induced knee osteoarthritis. After induction of experimental osteoarthritis by intra-articular injection of collagenase, adult New Zealand white rabbits (n = 12) were divided into 3 groups. Group 1 (control group) received 0.3 ml phosphate buffered saline into the right knee joint. Group 2 received 0.3 ml cross-linked hyaluronic acid (33 mg/ml) into the right knee joint. Group 3 received a mixture of 0.15 ml cross-linked hyaluronic acid (33 mg/ml), 0.05 ml ropivacaine hydrochloride 1 % and 0.1 ml triamcinolone acetonide (10 mg/ml) into the right knee joint. Intra-articular injections were given 4 weeks after first collagenase injection and were administered once a week for 3 weeks. Gross pathology and histological evaluation of rabbits’ knee joints were performed after 16 weeks following initial collagenase injection. Histological analysis of sections of right knee joints at lesion sites showed a significant decrease in Mankin’s score in groups treated with hyaluronic acid alone or in combination with ropivacaine hydrochloride and triamcinolone acetonide versus control group (p < 0.05 and p < 0.01 respectively). This evidence was consistent with strong articular degenerative changes in control right knee joints (grade III osteoarthritis), while the treated groups revealed less severe articular degenerative changes (grade II osteoarthritis). The present results show that cross-linked hyaluronic acid, alone or in combination with ropivacaine hydrochloride and triamcinolone acetonide, produces a significant improvement in knee articular cartilage degeneration in a rabbit model of collagenase-induced osteoarthritis.
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Affiliation(s)
- Tommaso Iannitti
- Department of Physiology, School of Medicine, University of Kentucky Medical Center, 800 Rose Street, Lexington, KY 40536-0298, USA.
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Li P, Raitcheva D, Hawes M, Moran N, Yu X, Wang F, Matthews GL. Hylan G-F 20 maintains cartilage integrity and decreases osteophyte formation in osteoarthritis through both anabolic and anti-catabolic mechanisms. Osteoarthritis Cartilage 2012; 20:1336-46. [PMID: 22809835 DOI: 10.1016/j.joca.2012.07.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2012] [Revised: 06/04/2012] [Accepted: 07/02/2012] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To perform a molecular mechanism-based investigation of the chondroprotective potential of hylan G-F 20. METHOD The effects of hylan G-F 20 on IL-1β-induced glycosaminoglycan (GAG) depletion and matrix metalloproteinase (MMP) expression in bovine and human cartilage explants were evaluated. Three weekly intra-articular hylan G-F 20 or control injections were administered 4 weeks post-operatively to rabbits with surgically induced osteoarthritis (OA). Cartilage histopathologic scores and osteophyte size were evaluated at 1, 4, and 8 weeks post-injections. Histomorphometry and immunostaining were used to quantify cartilage area and type II collagen (Col II) intensity, and real-time polymerase chain reaction (PCR) was used to examine the mRNA levels of Col2A1, MMP-13, -16 and IL-1β at 1 week. RESULTS Hylan G-F 20 retained GAG in IL-1β-exposed bovine and human cartilage explants and abrogated IL-1β-mediated increases in MMP-1, -3, and -13 in human explant culture. Hylan G-F 20‒treated OA joints had significantly better cartilage integrity at 1 and 4 weeks post-treatment and significantly smaller osteophytes at 4 weeks compared with control. Col2A1 mRNA increased with hylan G-F 20 treatment, which correlated with a trend toward increased Col II immunostaining. MMP-13 and -16 mRNAs increased in OA cartilage, but were not significantly altered by hylan G-F 20. IL-1β mRNA was undetectable in cartilage and unaltered in the synovium. CONCLUSIONS Hylan G-F 20 improved cartilage integrity and decreased osteophyte formation in the rabbit model of OA. Our results suggest that hylan G-F 20 may stimulate cartilage repair by increasing Col II, and inhibit IL-1β-mediated matrix degradation by decreasing MMPs.
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Affiliation(s)
- P Li
- Department of Orthopaedic Research, Genzyme Corporation, Framingham, MA 01701, USA.
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McArthur BA, Dy CJ, Fabricant PD, Valle AGD. Long term safety, efficacy, and patient acceptability of hyaluronic acid injection in patients with painful osteoarthritis of the knee. Patient Prefer Adherence 2012; 6:905-10. [PMID: 23271899 PMCID: PMC3526887 DOI: 10.2147/ppa.s27783] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The increasing prevalence of painful knee osteoarthritis has created an additional demand for pharmacologic management to prevent or delay surgical management. Viscosupplementation, via intraarticular injection of hyaluronic acid (HA), aims to restore the favorable milieu present in the nonarthritic joint. The safety profile of intraarticular HA injections for painful knee osteoarthritis is well established, with the most common adverse effect being a self-limited reaction at the injection site. Although acceptance of the early literature has been limited by publication bias and poor study quality, more recent and rigorous meta-analysis suggests that intraarticular HA injection is superior to placebo injection for pain relief and matches, if not surpasses, the effect size of other nonoperative treatments, such as nonsteroidal anti-inflammatory medication. Intraarticular HA injection is effective in providing temporary pain relief in patients with painful knee osteoarthritis. Future investigations should focus on optimizing the composition and administration of HA agents to provide prolonged relief of painful osteoarthritis in the knee and other joints.
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Affiliation(s)
| | - Christopher J Dy
- Correspondence: Christopher J Dy, 535 E 70th Street, New York, NY, USA, Tel +1 212 606 1466, Fax +1 212 606 1477, Email
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Wang Y, Hall S, Hanna F, Wluka AE, Grant G, Marks P, Feletar M, Cicuttini FM. Effects of Hylan G-F 20 supplementation on cartilage preservation detected by magnetic resonance imaging in osteoarthritis of the knee: a two-year single-blind clinical trial. BMC Musculoskelet Disord 2011; 12:195. [PMID: 21861935 PMCID: PMC3201041 DOI: 10.1186/1471-2474-12-195] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Accepted: 08/24/2011] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Although viscosupplementation is an effective symptomatic treatment for knee osteoarthritis (OA), the effect of longer term administration on articular cartilage has not been fully explored. We examined the effect of viscosupplementation with Hylan G-F 20 on knee cartilage over 2 years in patients with knee OA. METHODS In this prospective, single-blind, parallel control group pilot study, 78 patients with symptomatic knee OA (Kellgren-Lawrence grade II and III) were assigned to either intervention group (n = 39 receiving 4 courses of 3 × 2.0 ml of intra-articular Hylan G-F 20 injections at 6 month intervals) or control group (n = 39 receiving usual care for knee OA without injections). Magnetic resonance imaging of the study knee was performed at baseline, 12 and 24 months. Cartilage volume and defects were assessed using validated methods. RESULTS Fifty-five subjects (71%) completed 24 month follow up. Over 24 months, the intervention group had a reduced annual percentage rate of medial and lateral tibial cartilage volume loss (mean ± SD, -0.3 ± 2.7% and -1.4 ± 4.3%) compared with the control group (2.3 ± 2.6% and 1.4 ± 2.6%, P = 0.001 and 0.005 for difference, respectively). The intervention group also showed reduced cartilage defect score increment in the medial tibiofemoral compartment (0.1 ± 1.3) compared with the control group (0.8 ± 1.5, P = 0.05). CONCLUSIONS Six monthly intra-articular injections of Hylan G-F 20 administered to patients with symptomatic knee OA have a beneficial effect on knee cartilage preservation measured by both cartilage volume and cartilage defects. Hylan G-F 20 warrants further evaluation in larger clinical trials as a possible disease-modifying agent in the treatment of knee OA. TRIAL REGISTRATION The study was registered with ClinicalTrials.gov (NCT00393393).
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Affiliation(s)
- Yuanyuan Wang
- Department of Epidemiology and Preventive Medicine, Monash University, Alfred Hospital, Melbourne, Australia
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Smith MM, Cake MA, Ghosh P, Schiavinato A, Read RA, Little CB. Significant synovial pathology in a meniscectomy model of osteoarthritis: modification by intra-articular hyaluronan therapy. Rheumatology (Oxford) 2008; 47:1172-8. [PMID: 18565987 PMCID: PMC2468886 DOI: 10.1093/rheumatology/ken219] [Citation(s) in RCA: 71] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Objective. IA therapy with hyaluronan (HA) is reported to provide symptomatic relief and disease modification in OA. This study assessed the pathological changes in the synovium of an ovine model of OA and evaluated the effects of two HA preparations on this pathology. Methods. Eighteen sheep had bilateral lateral meniscectomy to induce OA. Four months post-surgery animals received IA saline or HA (Hyalgan®) weekly for 5 weeks or three injections of an amide derivative of HA (HYADD®4-G) every 2 weeks (n = 6 per group). Six months after meniscectomy, sheep were killed, knee joint synovium processed, scored for pathological change and compared with synovium from non-operated animals. Sections of synovium from normal and treated joints were also immunostained for TNF-α, HSP-47, TGF-β, CD44, connective tissue growth factor (CTGF) or iNOS. HA synthesis by synovial fibroblasts isolated from each OA joint was quantified. Results. Aggregate scores of pathological change were higher in OA joint synovia compared with controls, with individual measures of subintimal fibrosis and vascularity predominantly affected. Depth of intimal fibrosis was also significantly higher in meniscectomized joints. IA treatment with Hyalgan® decreased aggregate score, vascularity and depth of fibrosis. HYADD®4-G treatment decreased vascularity, intimal hyperplasia and increased high-molecular weight HA synthesis by synovial fibroblasts. CD44, CTGF or iNOS expression was increased in the synovial lining of OA joints compared with normal, but there was no significant modulation of this increase by either HA preparation. Conclusion. Increased fibrosis and vascularity are hallmarks of pathological change in synovium in this meniscectomy model of OA. Both the IA HA and an amide derivative of HA reduced aspects of this pathology thus providing a potential mechanism for improving joint mobility and function in OA.
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Affiliation(s)
- M M Smith
- Raymond Purves Bone and Joint Research Laboratories, Institute of Bone and Joint Research, Kolling Institute of Medical Research, University of Sydney, Royal North Shore Hospital, St Leonards, NSW, Australia.
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Affiliation(s)
- Todd P Stitik
- Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, New Jersey 07103, USA
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19
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Abstract
Lameness remains an important source of reduced performance in many types of horses. Pain referable to joints is among the most common causes, and intra-articular injections remain a common and important means of addressing lameness referable to joints in horses.
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Affiliation(s)
- John P Caron
- Department of Large Animal Clinical Sciences, College of Veterinary Medicine, G-351 VMC, Michigan State University, East Lansing, MI 48824, USA.
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20
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Abstract
Treatment of the knee with unicompartmental osteoarthritis remains a challenging clinical problem. Despite pharmacologic advances and surgical innovations, the ideal strategy for the patient who has single-compartment degenerative disease can be complicated. The understanding and management of this problem are further confounded by the fact that so much of the data are unreliable. Given these constraints, this article outlines the current alternatives available in nonoperatively managing the symptomatic unicompartmental arthritic knee.
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Affiliation(s)
- Bryan T Hanypsiak
- Orthopaedic Associates of Long Island, 6 Technology Drive, Suite 100, East Setauket, New York 11733, USA.
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21
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Abstract
PURPOSE The aim of this study was to assess whether intra-articular hyaluronan viscosupplementation after osteochondral grafting (mosaic arthroplasty) of the knee allowed better graft integration and function in a sheep model. TYPE OF STUDY Experimental study. METHODS Twelve adult sheep underwent a mosaic arthroplasty procedure to a standardized osteochondral defect on the medial femoral condyle. One week after surgery the animals were randomized to receive a course of weekly intra-articular injections for 5 weeks of either sodium-hyaluronate solution 25 mg/2.5 mL (HA group) or of a 2.5 mL buffer solution (control group). Synovial fluid samples were taken preoperatively, preceding each injection, and at 8 and 12 weeks. The animals were euthanized at 12 weeks, the knees dissected out, and biomechanical and histologic assessments were made. RESULTS There was no difference in the synovial fluid leukocyte or total protein concentration between the groups, but the hyaluronan concentration was statistically higher in the HA group. Aggregate moduli of the articular surface were statistically higher in the graft articular cartilage in the HA group than in the control group, as were the sulphated glycosaminoglycan levels. Histologic assessment found more articular cartilage flow in the HA group, whereas there was more interstitial tissue present in the interstices between the grafts in the control group. CONCLUSIONS Results from this study suggest that hyaluronan viscosupplementation following osteochondral grafting does convey some beneficial effects on graft cartilage in the early postoperative period in an ovine model. CLINICAL RELEVANCE This study suggests that, in the early postoperative period, hyaluronan supplementation improves articular cartilage survival after osteochondral grafting.
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Affiliation(s)
- Graham Tytherleigh-Strong
- Division of Orthopaedics, Addenbrooke's Hospital, Cambridge University Teaching Hospitals Trust, Cambridge, England.
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22
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Henrotin Y, Sanchez C, Balligand M. Pharmaceutical and nutraceutical management of canine osteoarthritis: present and future perspectives. Vet J 2005; 170:113-23. [PMID: 15993795 DOI: 10.1016/j.tvjl.2004.08.014] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2004] [Indexed: 12/01/2022]
Abstract
Osteoarthritis (OA) is one of the most common chronic musculoskeletal diseases and causes of lameness in the dogs. The osteoarthritic disease process involves the entire synovial joint, encompassing the synovium, cartilage and underlying bone. Joint failure results from an abnormal mechanical strain causing damage to normal tissue or failure of pathologically impaired articular cartilage and bone under the influence of normal physiological strain or a combination of both. In both cases, the end point is cartilage loss and joint impairment. Osteoarthritic chondrocytes show an altered phenotype characterised by an excess production of catabolic factors, including metalloproteinases and reactive oxygen species. These factors constitute potential therapeutic targets and some new drugs and nutraceuticals have been proposed to promote the return to homeostasis. Until now, the therapeutic management of OA in dogs has been dominated by nonsteroidal anti-inflammatory drugs, but some new compounds, including diacerhein, with potential structure-modifying effects, are already used to treat OA in humans and could be helpful to manage OA in the dog. In addition, novel nutraceuticals, such as avocado/soybean unsaponifiable substances, have shown symptomatic effects in knee OA in humans, and could offer an alternative to prevent OA progression. This paper provides an overview of recent discoveries in the pathophysiology and in the therapeutic management of osteoarthritis in dogs.
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Affiliation(s)
- Yves Henrotin
- Bone and Cartilage Research Unit, Institute of Pathology, Level +5, CHU Sart-Tilman, 4000 Liège, Belgium.
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23
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Goldberg VM, Buckwalter JA. Hyaluronans in the treatment of osteoarthritis of the knee: evidence for disease-modifying activity. Osteoarthritis Cartilage 2005; 13:216-24. [PMID: 15727888 DOI: 10.1016/j.joca.2004.11.010] [Citation(s) in RCA: 174] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2004] [Accepted: 11/29/2004] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Although available nonsurgical pharmacotherapies for treatment of osteoarthritis (OA) are considered to be solely symptom-modifying agents, recent advances have been made in the search for agents that may modify disease progression. Intra-articular hyaluronan (HA) therapy is one symptom-modifying approach that has been found to be safe and effective for reducing pain due to OA of the knee. Presented here is a review of the evidence that HAs may also modify the rate of OA disease progression in addition to providing symptomatic efficacy. DESIGN A review of the literature based on a MEDLINE search through June 2004, using the terms HA, sodium hyaluronate, hyaluronic acid, hylan, hylan G-F 20, OA, disease modification, structure modifying and joint structure. RESULTS Evidence for disease-modifying activity of HAs stems from 1) the complex biochemical effects of HAs in the synovium and extracellular matrix of the articular cartilage, including interactions between exogenously administered HA and articular cartilage, subchondral bone, matrix proteoglycans, and collagens; 2) the effects of HA administration in animal models of OA, including total or partial meniscectomy and anterior cruciate ligament transectomy; 3) results of clinical trials using one HA, Hyalgan (sodium hyaluronate, molecular weight 500-730 kDa) that evaluated structural outcomes, such as joint-space width, chondrocyte density and vitality, and arthroscopic evaluation of chondropathy. DISCUSSION Growing preclinical and clinical evidence supports the notion that, in addition to relieving the symptoms of OA, HAs also modify the structure of the diseased joint and the rate of OA disease progression, at least early in the evolution of the disease process.
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Affiliation(s)
- V M Goldberg
- Case Western Reserve University, University Hospitals of Cleveland, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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24
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Abstract
Hyaluronic acid (HA) is a major component of human synovial fluid, providing the rheologic properties (elasticity and viscosity) that enable the synovial fluid to perform lubricating and shock-absorbing functions within the healthy joint. Over the last 2 decades, HA preparations have become established in intra-articular therapy of osteoarthritis (OA), particularly OA of the knee. Existing HA preparations, both cross-linked and non-cross-linked, are all administered by courses of multiple injections, and all have been associated with variable success rates. The clinical profile of an HA preparation is inextricably linked to the product's physicochemical properties. For example, the molecular structure of the HA affects the intra-articular residence time, which should in turn influence the duration of action post-injection. Non-animal stabilized hyaluronic acid (NASHA) is a new-generation HA preparation, produced wholly from non-animal sources. NASHA is stabilized using a carefully controlled cross-linking process, which increases the intra-articular residence time from hours to weeks. This facilitates single-injection treatment for OA without affecting the biocompatibility of HA. This review evaluates the properties of NASHA, including the available clinical data, in the context of previously developed HA preparations.
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Abstract
The current study investigated whether hyaluronate exerts a beneficial effect on articular cartilage repair. Nineteen rabbits had bilateral knee arthrotomies, and 2-mm full-thickness cartilage defects were created on each medial femoral condyle. Rabbits received intraarticular injections (0.5 mL) of hyaluronic acid once a week for 3 weeks in the right knee, started at either 1 or 3 weeks after injury. The left knees, which served as controls, were injected with 0.5 mL normal saline. Cohorts of each group were euthanized at 2 and 6 months, and histologic sections of the injury sites were evaluated for repair tissue. No significant differences were seen in the quantity or quality of the repair tissue at either 2 or 6 months. Hyaluronate and saline-treated defects showed persistent fibrillation, poor matrix staining, and incomplete void filling, irrespective of the injection timing. Hyaluronate did not provide protection to zones peripheral to the injury site, and did not significantly alter the healing process in this model of acute full-thickness cartilage injuries.
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Affiliation(s)
- Stephen Mendelson
- Department of Orthopaedic Surgery, Wayne State University School of Medicine, 10475 Elgin, Huntington Woods, MI 48070, USA.
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26
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Shaffer B, Hanypsiak B. Nonoperative and arthroscopic approaches to the postmeniscectomy arthritic knee. Arthroscopy 2003; 19 Suppl 1:122-8. [PMID: 14673431 DOI: 10.1016/j.arthro.2003.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Kelly MA, Goldberg VM, Healy WL, Pagnano MW, Hamburger MI. Osteoarthritis and beyond: a consensus on the past, present, and future of hyaluronans in orthopedics. Orthopedics 2003; 26:1064-79; quiz 1080-1. [PMID: 14577532 DOI: 10.3928/0147-7447-20031001-19] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Michael A Kelly
- Insall Scott Kelly Institute for Orthopaedics and Sports Medicine, Department of Orthopedic Surgery, Beth Israel Medical Center, New York, NY 10128, USA
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Abstract
OBJECTIVE To study the efficacy of hylan G-F 20 in the treatment of osteoarthritis (OA) of the hip joint. DESIGN Prospective within-group study. SETTING Musculoskeletal rehabilitation clinic. PARTICIPANTS Twenty-two patients (25 hips) with hip joint OA who had failed to find pain relief from conservative methods such as physical therapy, exercises, and steroid injections. Demographics included 14 men and 11 women (mean age, 56.4y), 21 of whom had mild to moderate OA and 4 of whom had severe OA of the hips. INTERVENTION Each hip joint was injected with 2mL of hylan G-F 20 at 2, 3, and 4 weeks and fluoroscopic lavage with 100mL of normal saline at week 1. All patients had standard hip exercise regimen after the injection. MAIN OUTCOME MEASURES American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Core Scale score and visual numeric pain score. RESULTS At 1-year follow-up, the AAOS Lower Limb Core Scale score improved from a preinjection mean of 44.2 to a follow-up mean of 86.1 (P<.05). The mean visual numeric pain score improved from a preinjection mean of 8.7 (range, 6.4-10) to a follow-up mean of 2.3 (range, 0-7.2). The overall success rate was 84%. In patients with mild to moderate OA, the mean pain score decreased from a preinjection value of 7.8 to a follow-up value of 1.7. The success rate was 90.5% in that subgroup. In patients with severe OA, the mean pain score decreased from a preinjection value of 9.1 to a follow-up value of 3.8. The success rate was 50% in that subgroup. There were no complications related to the injection. CONCLUSION Use of hylan G-F 20 injection is a viable option for treatment of mild to moderate OA of the hip joint.
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Affiliation(s)
- Vijay B Vad
- Department of Rehabilitation Medicine, Cornell University Medical Center, New York, NY, USA
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30
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Abstract
Viscosupplementation, in which hyaluronan derivatives are injected into the intra-articular space of osteoarthritic joints, is now widely used to treat knee osteoarthritis (OA). No viscosupplements have been approved for osteoarthritic joints other than the knee. To date, no clinical trials using viscosupplements to treat ankle or foot OA have been published. However, the mechanisms thought to be responsible for viscosupplementation's therapeutic effects would likely apply in any synovial joint. A goal of this article is to stimulate interest in research to assess the potential role of viscosupplementation in treating foot and ankle OA.
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Affiliation(s)
- K Wayne Marshall
- Division of Orthopaedic Surgery, University of Toronto, Toronto, Ontario, Canada.
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31
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Abstract
OBJECTIVE The addition of exogenous high molecular weight hyaluronic acid (HA) reverses cartilage damage caused by fibronectin fragments (Fn-fs) added to explant cultures of bovine and human cartilage and by Fn-fs in an experimental in vivo model of rabbit knee joint damage. Our objective was to test whether HA was also effective in an IL-1 damage model and whether this repair was stable and occurred in older bovine cartilage. DESIGN Bovine cartilage explants from 18-month-old or 6-year-old bovines in 10% serum/Dulbecco's modified Eagle's medium were exposed to Fn-f or to IL-1 and the ability of 1mg/ml HA of 800 kDa to block damage or promote restoration of proteoglycan (PG) after the damage was measured. The damage phase as well as the exposure to HA were varied. RESULTS Exposure of exogenous HA decreased Fn-f-mediated damage, but did not decrease IL-1 beta-induced cartilage damage. If explants from 18-month-old bovines were damaged by a 7-day exposure to Fn-f or IL-1 beta and then exposed for 7 days to HA, PG was restored. This reparative activity persisted up to 4 weeks after the removal of HA from the culture medium. The restoration of PG did not occur in 0.1% serum-free cultures, was less when the exposure to the Fn-f was doubled and failed when exposure to IL-1 beta was doubled. In explants from 6-year-old bovines damaged with IL-1 beta for 7 days, HA fully restored PG content to normal levels. CONCLUSIONS The reparative activities of HA occur not only in a Fn-f damage model, but also in an IL-1 damage model and occur with older bovine cartilage.
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Affiliation(s)
- Gene A Homandberg
- Department of Biochemistry, Rush Medical College at Rush-Presbyterian-St. Luke's Medical Center, 1653 West Congress Parkway, Chicago, IL 60612-3864, USA.
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Moreland LW. Intra-articular hyaluronan (hyaluronic acid) and hylans for the treatment of osteoarthritis: mechanisms of action. Arthritis Res Ther 2003; 5:54-67. [PMID: 12718745 PMCID: PMC165033 DOI: 10.1186/ar623] [Citation(s) in RCA: 390] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2002] [Revised: 11/07/2002] [Accepted: 12/12/2002] [Indexed: 11/10/2022] Open
Abstract
Although the predominant mechanism of intra-articular hyaluronan (hyaluronic acid) (HA) and hylans for the treatment of pain associated with knee osteoarthritis (OA) is unknown, in vivo, in vitro, and clinical studies demonstrate various physiological effects of exogenous HA. HA can reduce nerve impulses and nerve sensitivity associated with the pain of OA. In experimental OA, this glycosaminoglycan has protective effects on cartilage, which may be mediated by its molecular and cellular effects observed in vitro. Exogenous HA enhances chondrocyte HA and proteoglycan synthesis, reduces the production and activity of proinflammatory mediators and matrix metalloproteinases, and alters the behavior of immune cells. Many of the physiological effects of exogenous HA may be a function of its molecular weight. Several physiological effects probably contribute to the mechanisms by which HA and hylans exert their clinical effects in knee OA.
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33
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Affiliation(s)
- Keiichi Kuroki
- Comparative Orthopaedic Laboratory, University of Missouri, Columbia 65211, USA
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Ghosh P, Guidolin D. Potential mechanism of action of intra-articular hyaluronan therapy in osteoarthritis: are the effects molecular weight dependent? Semin Arthritis Rheum 2002; 32:10-37. [PMID: 12219318 DOI: 10.1053/sarh.2002.33720] [Citation(s) in RCA: 237] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Hyaluronan, or hyaluronic acid (HA), is the major hydrodynamic nonprotein component of joint synovial fluid (SF). Its unique viscoelastic properties confer remarkable shock absorbing and lubricating abilities to SF, while its enormous macromolecular size and hydrophilicity serve to retain fluid in the joint cavity during articulation. HA restricts the entry of large plasma proteins and cells into SF but facilitates solute exchange between the synovial capillaries and cartilage and other joint tissues. In addition, HA can form a pericellular coat around cells, interact with proinflammatory mediators, and bind to cell receptors, such as cluster determinant (CD)44 and receptor for hyaluronate-mediated motility (RHAMM), where it modulates cell proliferation, migration, and gene expression. All these physicochemical and biologic properties of HA have been shown to be molecular weight (MW) dependent. OBJECTIVE Intra-articular (IA) HA therapy has been used for the treatment of knee osteoarthritis (OA) for more than 30 years. However, the mechanisms responsible for the reported beneficial clinical effects of this form of treatment remain contentious. Furthermore, there are a variety of pharmaceutic HA preparations of different MW available for the treatment of OA, but the significance of their MWs with respect to their pharmacologic activities have not been reviewed previously. The objective of the present review is to redress this deficiency. METHODS We reviewed in vitro and in vivo reports to identify those pharmacologic activities of HA that were considered relevant to the ability of this agent to relieve symptoms and protect joint tissues in OA. Where possible, reports were selected for inclusion when the pharmacologic effects of HA had been studied in relation to its MW. In many studies, only a single HA preparation had been investigated. In these instances, the experimental outcomes reported were compared with similar studies undertaken with HAs of different MWs. RESULTS Although in vitro studies have generally indicated that high MW-HA preparations were more biologically active than HAs of lower MW, this finding was not confirmed using animal models of OA. The discrepancy may be partly explained by the enhanced penetration of the lower MW HA preparation through the extracellular matrix of the synovium, thereby maximizing its concentration and facilitating its interaction with target synovial cells. However, there is accumulating experimental evidence to show that the binding of HAs to their cellular receptors is dependent on their molecular size; the smaller HA molecular species often elicits an opposite cellular response to that produced by the higher MW preparations. Studies using large animal models of OA have shown that HAs with MWs within the range of 0.5 x 10(6)-1.0 x 10(6) Da were generally more effective in reducing indices of synovial inflammation and restoring the rheological properties of SF (visco-induction) than HAs with MW > 2.3 x 10(6) Da. These experimental findings were consistent with light and electron microscopic studies of synovial membrane and cartilage biopsy specimens obtained from OA patients administered 5 weekly IA injections of HA of MW = 0.5 x 10(6)-0.73 x 10(6) Da in which evidence of partial restoration of normal joint tissue metabolism was obtained. CONCLUSIONS By mitigating the activities of proinflammatory mediators and pain producing neuropeptides released by activated synovial cells, HA may improve the symptoms of OA. In addition, HAs within the MW range of 0.5 x 10(6)-1.0 x 10(6) Da partially restore SF rheological properties and synovial fibroblast metabolism in animal models. These pharmacologic activities of HA could account for the reported long-term clinical benefits of this OA therapy. However, clinical evidence has yet to be described to support the animal studies that indicated that HAs with MW > 2.3 x 10(6) Da may be less effective in restoring SF rheology than HAs of half this size.
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Affiliation(s)
- Peter Ghosh
- Institute of Bone and Joint Research, Department of Surgery, University of Sydney, Royal North Shore Hospital, New South Wales, Australia.
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35
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Abstract
Injections, especially of corticosteroids but also of hyaluronan, are widely used in the treatment of osteoarthritis. The various joints - knee, hip, hand - affected by OA are accessible to these local treatments. This chapter concentrates on the evidence for efficacy of these treatments and attempts to delimit their respective indications and optimal doses. The side-effects of corticosteroid injections are reviewed, and the potential interest in post-injection rest is discussed. Finally, the potential structure-modifying effect of hyaluronan is investigated.
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Affiliation(s)
- X Ayral
- Department of Rheumatology B, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université René Descartes, Paris Cedex 14, 75679, France
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36
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Abstract
Characterization of transgenic murine osteoarthritis (OA) models and analysis of anterior cruciate ligament and meniscectomy models in various species, including rodents, has provided insight into pathogenic mechanisms and impact of loading. Development of a transgenic murine OA model by postnatal expression in hyaline cartilage of constitutively expressed human matrix metalloproteinase-13 emphasizes the potential role of this enzyme. On the other hand, collagenase involvement in OA models seems a confined focal process, complicating therapeutic approaches. The potential role of interleukin-1 still needs further confirmation. Apart from destructive cytokines, disturbed growth factor responses seems obvious. Transforming growth factor-beta is a crucial mediator in osteophyte formation, but its role in cartilage destruction has not yet been clarified. Nitric oxide appears involved in chondrocyte apoptosis and blocking of nitric oxide provides protection against joint pathology in OA models. Treatment with a range of disease-modifying drugs showed some efficacy in a number of OA models, but its predictive value for human OA remains obscure.
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Affiliation(s)
- W B van den Berg
- Rheumatology Research and Advanced Therapeutics, University Medical Center, Nijmegen Geert Grooteplein 26-28 6500 HB, Nijmegen, The Netherlands.
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