Viscosupplementation for osteoarthritis of the knee: a systematic review and meta-analysis

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

Background

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

Methods

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

Results

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

Conclusion

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

Bioinspired Bottlebrush Polymers Effectively Alleviate Frictional Damage Both In Vitro and In Vivo

Bottlebrush polymers (BB) have emerged as compelling candidates for biosystems to face tribological challenges, including friction and wear. This study provides a comprehensive assessment of an engineered triblock BB polymer's affinity, cell toxicity, lubrication, and wear protection in both in vitro and in vivo settings, focusing on applications for conditions like osteoarthritis and dry eye syndrome. Results show that the designed polymer rapidly adheres to various surfaces (e.g., cartilage, eye, and contact lens), forming a robust, biocompatible layer for surface lubrication and protection. The tribological performance and biocompatibility are further enhanced in the presence of hyaluronic acid (HA) both in vitro and in vivo. The exceptional lubrication performance and favorable interaction with HA position the synthesized triblock polymer as a promising candidate for innovative treatments addressing deficiencies in bio-lubricant systems.

Evaluation of single and multiple hyaluronic acid injections at different concentrations with high molecular weight in the treatment of knee osteoarthritis

BACKGROUND

Knee osteoarthritis is severe progressive and most commonly diagnosed articular disease and its incidence is increasing around the world depending on age. This pathologic condition which limits daily activity of patients can be characterized by degeneration of cartilage and inflammation. Although non-steroidal anti-inflammatory (NSAII) agents and other analgesics are routinely used treatment options, the potential effects of intraarticular injections including hyaluronic acid (HA) have also been demonstrated by various studies. However, few studies compare the efficacy of a single high molecular weight (HMW) high dose and a triple HMW low dose. This study aimed to compare the efficacy of single high molecular weight (HMW) high dose (2 mL / 60 mg) and triple HMW low dose (2 mL /30 mg) intra-articular injection of HA in knee osteoarthritis (OA) patients by evaluating function and pain parameters during 12 months.

METHODS

This is a single-center, retrospective clinical study that included and involved 128 patients. Group I (n=64) patients received triple 30 mg HA injections (SEMICAL®) with one-week intervals, while Group II (n=64) patients received a single 60 mg HA injection (SEMICAL®). Lequesne Index, WOMAC and VAS scores were recorded to assess pain and function during a 12-month period.

RESULTS

There was no significant difference in characteristics of patient demographics. Our finding indicate that WOMAC, VAS score, and Lequesne Index values during follow-up visits exhibited a decrease, signifying improvement in the clinical condition. Notably, scores were significantly more favorable with the 30 mg of HA injection compared to the 60 mg of HA injection.

CONCLUSION

This study suggests that the triple low-dose injection of HMW HA is more effective in improving WOMAC, VAS scores and Lequesne Index values than a single high-dose injection.

Predictors of Placebo Response to Local (Intra-Articular) Therapy In Osteoarthritis: An Individual Participant Data Meta-Analysis

OBJECTIVE

We undertook this study to evaluate potential predictors of placebo response with intra-articular (IA) injections for knee/hip osteoarthritis (OA) using individual participant data (IPD) from existing trials.

METHODS

Randomized placebo-controlled trials evaluating IA glucocorticoid or hyaluronic acid published to September 2018 were selected. IPD for disease characteristics and outcome measures were acquired. Potential predictors of placebo response included participant characteristics, pain severity, intervention, and trial design. Placebo response was defined as at least a 20% reduction in baseline pain. Logistic regression models and odds ratios were computed as effect measures to evaluate patient and pain mechanisms and then pooled using a random effects model. Generalized mixed-effect models were applied to intervention and trial characteristics.

RESULTS

Of 56 eligible trials, 6 shared data, and these were combined with the existing 4 OA Trial Bank studies, yielding 10 studies with IPD of 621 placebo participants for analysis. In the total placebo population, at short-term follow-up, the use of local anesthetic and ultrasound guidance were associated with reduced odds of placebo response. At midterm follow-up, mid- to long-term trial duration was associated with increased odds of placebo response, and worse baseline function scores were associated with reduced odds of a placebo response.

CONCLUSION

The administration of local anesthetics or ultrasound guidance may reduce IA placebo response at short-term follow-up. At midterm follow-up, participants with worse baseline function scores may be less likely to respond to IA placebo, and mid- to long-term trial duration may enhance the placebo response. Further studies are required to corroborate these potential predictors of IA placebo response.

Risk of metabolic abnormalities in osteoarthritis: a new perspective to understand its pathological mechanisms

Although aging has traditionally been viewed as the most important risk factor for osteoarthritis (OA), an increasing amount of epidemiological evidence has highlighted the association between metabolic abnormalities and OA, particularly in younger individuals. Metabolic abnormalities, such as obesity and type II diabetes, are strongly linked to OA, and they affect both weight-bearing and non-weight-bearing joints, thus suggesting that the pathogenesis of OA is more complicated than the mechanical stress induced by overweight. This review aims to explore the recent advances in research on the relationship between metabolic abnormalities and OA risk, including the impact of abnormal glucose and lipid metabolism, the potential pathogenesis and targeted therapeutic strategies.

Intra-articular Hyaluronic Acid Treatments for Knee Osteoarthritis: A Systematic Review of Product Properties

INTRODUCTION

There are many intra-articular hyaluronic acid (IA-HA) products on the market that have known intrinsic differences in molecular size, source, and structure. The current review summarizes existing evidence describing and assessing these differences, while also identifying whether these differences have an impact on clinical outcomes.

METHODS

This systematic review summarized all literature that specifically addresses IA-HA product differences. Included studies summarized basic science and mechanism of action comparisons of IA-HA product differences, or systematic reviews that assess differences in clinical outcomes between IA-HA product differences.

RESULTS

A total of 20 investigations assessed basic science differences between IA-HA products, while 20 investigations provided assessments of the clinical outcome differences between IA-HA product characteristics. The published basic science literature provided a differentiation between low molecular weight (LMW) and high molecular weight (HMW) HA with regard to changes within the synovial fluid, driven by the interactions that these molecules have with receptors in the joint space. These differences in receptor interaction manifest within clinical outcomes, as meta-analyses comparing pain relief after IA-HA suggest that pain reduction is superior in patients who receive HMW HA as opposed to LMW HA.

CONCLUSION

This review highlights differences between IA-HA characteristics, and how important the molecular weight, derivation of the product, and structure are to variances in reported clinical outcomes to treat osteoarthritis (OA) of the knee. HMW IA-HAs have shown greater efficacy compared to the alternative of LMW products, while avian-derived and cross-linked products have potentially demonstrated an increase in inflammatory events over non-avian-derived, non-cross-linked HAs.

Efficacy and safety of corticosteroids, hyaluronic acid, and PRP and combination therapy for knee osteoarthritis: a systematic review and network meta-analysis

OBJECTIVE

There are many injectable treatments for knee osteoarthritis with different characteristics and effects, the aim is to understand which one can lead to better and safer results.

METHODS

The PRISMA principles were followed when doing the literature search. Web of Science databases, Embase, the Cochrane Library, PubMed, and the Wanfang database were searched to identified randomized controlled trials that assessed the efficacy of corticosteroids (CSC), platelet-rich plasma (PRP), hyaluronic acid (HA), and combination therapy in treating KOA. Risk of bias was assessed using the relevant Cochrane tools (version 1.0). The outcome measure included the visual analog scale (VAS) score, the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) score, and treatment-related adverse events. The network meta-analysis was performed using STATA17 software and a Bayesian stratified random effects model.

RESULTS

Network meta-analysis using the Bayesian random-effects model revealed 35 studies with 3104 participants. PRP showed the best WOMAC score at a 3-month follow-up, followed by PRP + HA, HA, placebo, and CSC; PRP + HA scored the highest VAS, followed by PRP, CSC, HA, and placebo. PRP, CSC, HA, and placebo had the highest WOMAC scores six months following treatment; PRP + HA showed the best VAS scores. PRP showed the best WOMAC score at 12 months, followed by PRP + HA, HA, placebo, and CSC; The best VAS score was obtained with PRP, followed by PRP + HA, HA, and CSC. No therapy demonstrated a rise in adverse events linked to the treatment in terms of safety.

CONCLUSIONS

The current study found that PRP and PRP + HA were the most successful in improving function and alleviating pain after 3, 6, and 12 months of follow-up. CSC, HA, PRP, and combination therapy did not result in an increase in the incidence of treatment-related side events as compared to placebo.

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

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

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Non-operative Treatment Options for Osteoarthritis in the Hip

With the increased disability associated with osteoarthritis (OA) progression, and the significant socioeconomic burden of joint replacement surgeries, there is a need for more reliable conservative treatments for patients presenting with hip OA. Most studies of OA treatments involve the knee. We conducted a literature search and reviewed non-operative hip OA treatment recommendations by the Osteoarthritis Research Society International, the American College of Rheumatology, American Academy of Orthopedic Surgeons, and European Alliance of Associations for Rheumatology, as well as Cochrane Reviews. Non-steroidal anti-inflammatory drugs and corticosteroid injections are the most supported and recommended options for hip OA; other medications with potential benefits for short-term pain relief include acetaminophen and tramadol. Most societies recommend against the use of glucosamine, typical opioids, and viscosupplementation injections. Platelet-rich plasma has potential benefits, but evidence of its effectiveness is incomplete. Further research is needed to better inform and guide clinicians who create treatment plans for patients with symptomatic hip OA.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

2023 American College of Rheumatology and American Association of Hip and Knee Surgeons Clinical Practice Guideline for the Optimal Timing of Elective Hip or Knee Arthroplasty for Patients With Symptomatic Moderate-to-Severe Osteoarthritis or Advanced Symptomatic Osteonecrosis With Secondary Arthritis for Whom Nonoperative Therapy Is Ineffective

OBJECTIVE

To develop evidence-based consensus recommendations for the optimal timing of hip and knee arthroplasty to improve patient-important outcomes including, but not limited to, pain, function, infection, hospitalization, and death at 1 year for patients with symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis of the hip or knee who have previously attempted nonoperative therapy, and for whom nonoperative therapy was ineffective, and who have chosen to undergo elective hip or knee arthroplasty (collectively referred to as TJA).

METHODS

We developed 13 clinically relevant population, intervention, comparator, outcomes (PICO) questions. After a systematic literature review, the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used to rate the quality of evidence (high, moderate, low, or very low), and evidence tables were created. A Voting Panel, including 13 physicians and patients, discussed the PICO questions until consensus was achieved on the direction (for/against) and strength (strong/conditional) of the recommendations.

RESULTS

The panel conditionally recommended against delaying TJA to pursue additional nonoperative treatment including physical therapy, nonsteroidal antiinflammatory drugs, ambulatory aids, and intraarticular injections. It conditionally recommended delaying TJA for nicotine reduction or cessation. The panel conditionally recommended delay for better glycemic control for patients who have diabetes mellitus, although no specific measure or level was identified. There was consensus that obesity by itself was not a reason for delay, but that weight loss should be strongly encouraged, and the increase in operative risk should be discussed. The panel conditionally recommended against delay in patients who have severe deformity or bone loss, or in patients who have a neuropathic joint. Evidence for all recommendations was graded as low or very low quality.

CONCLUSION

This guideline provides evidence-based recommendations regarding the optimal timing of TJA in patients who have symptomatic and radiographic moderate-to-severe osteoarthritis or advanced symptomatic osteonecrosis with secondary arthritis for whom nonoperative therapy was ineffective to improve patient-important outcomes, including pain, function, infection, hospitalization, and death at 1 year. We acknowledge that the evidence is of low quality primarily due to indirectness and hope future research will allow for further refinement of the recommendations.

Guidelines for the diagnosis and treatment of knee osteoarthritis with integrative medicine based on traditional Chinese medicine

Knee osteoarthritis (KOA) is a common geriatric disease in middle-aged and elderly people. Its main pathological characteristics are articular cartilage degeneration, changes in subchondral bone reactivity, osteophyte formation at joint edges, synovial disease, ligament relaxation or contracture, and joint capsular contracture. The prevalence rate of symptomatic KOA in middle-aged and elderly people in China is 8.1%, and this is increasing. The main clinical manifestations of this disease are pain and limited activity of the knee joint, which seriously affect the quality of life of patients and may cause disability, posing a huge burden on society and the economy. Although the pathogenesis of KOA is not clear, the treatment of KOA is diverse, and Chinese medicine, which mainly relies on plant-based natural products, has a relatively stable and reliable curative effect. This guideline aims to emphasize the evidence-based staging and stepped treatment of KOA and the therapeutic effect of integrative medicine based on traditional Chinese medicine on KOA. We make recommendations that include the adoption of manual therapy, acupuncture, external application of herbs, herbal plasters, exercise therapy, and other integrative medicine based on traditional Chinese medicine. Users of the above guidelines are most likely to include clinicians and health managers in healthcare settings.

A Review of Cyclic Phosphatidic Acid and Other Potential Therapeutic Targets for Treating Osteoarthritis

Osteoarthritis (OA), a chronic degenerative joint disease, is the most common form of arthritis. OA occurs when the protective cartilage that cushions the ends of bones gradually breaks down. This leads to the rubbing of bones against each other, resulting in pain and stiffness. Cyclic phosphatidic acid (cPA) shows promise as a treatment for OA. In this article, we review the most recent findings regarding the biological functions of cPA signaling in mammalian systems, specifically in relation to OA. cPA is a naturally occurring phospholipid mediator with unique cyclic phosphate rings at the sn-2 and sn-3 positions in the glycerol backbone. cPA promotes various responses, including cell proliferation, migration, and survival. cPA possesses physiological activities that are distinct from those elicited by lysophosphatidic acid; however, its biochemical origin has rarely been studied. Although there is currently no cure for OA, advances in medical research may lead to new therapies or strategies in the future, and cPA has potential therapeutic applications.

Autologous micro-fragmented adipose tissue in the treatment of atherosclerosis patients with knee osteoarthritis in geriatric population: A systematic review and meta-analysis

BACKGROUND

Atherosclerosis and osteoarthritis are closely related. However, no high-quality studies have investigated the potential of micro-fragmented adipose tissue to treat patients with atherosclerosis accompanied by osteoarthritis.

METHODS

PubMed, Embase, the Cochrane Library, Web of Science, China National Knowledge Infrastructure, WANFANG DATA, and CQVIP were searched for potentially eligible studies published before October 13, 2022. Due to the statistical limitations of the existing relevant literature, it is not possible to make direct statistics on the patients with osteoarthritis accompanied by atherosclerosis treated by micro-fragmented adipose tissue. The primary outcome consisted of two parts: 1) Correlation between atherosclerosis and osteoarthritis; 2) Scores of the Knee injury and Osteoarthritis Outcome Score (KOOS). And secondary outcomes were pain assessed by visual analog scale (VAS) or numeric rating scale (NRS), quality of life (QoL) (assessed using tools apart from the KOOS), and adverse events (AEs). Random meta-analysis was conducted using STATA 14.0.

RESULTS

Nineteen studies were included. The metaanalysis evidenced a positive association between atherosclerosis and osteoarthritis (OR 1.17, CI 1.01-1.36). The mean absolute difference in KOOS subscale scores between pre- and post-treatment (mean with 95% confidence interval [CI]) was 19.65 (13.66, 25.63), 14.20 (4.64, 23.76), 19.95 (13.02, 26.89), 25.23 (14.80, 35.66), and 26.01 (13.68, 38.35) for pain, symptoms, activities of daily living (ADL), sports/recreation, and quality-of-life (QOL), respectively. The mean differences in VAS, resting VAS, activity VAS, and NRS between pre- and post-treatment was -8.24 (-10.66, -5.82), -3.61 (-4.49, -2.72), -4.17 (-4.89, -3.44), and -2.17 (-4.06, and -0.28), respectively. The mean difference in score of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), EQ-5D, and University of California in Los Angeles (UCLA) between pre- and post-treatment was -24.81 (-40.80, -8.82), 0.07 (0.02, 0.12), and 0.30 (-0.42, 1.02), respectively. The mean difference in Tegner score and the International Knee Documentation Committee (IKDC) score between pre- and post-treatment was 0.67 (-0.62, 1.97) and 13.70 (6.35, 21.04), respectively. The use of micro-fragmented adipose tissue was associated with risk of bruising, bleeding, hematoma, drainage, infection, soreness, swelling, pain, and stiffness in harvest and injection sites.

CONCLUSION

Atherosclerosis and osteoarthritis share common risk factors and comorbidity. And the use of micro-fragmented adipose tissue may benefit for improving symptoms of knee osteoarthritis accompanied by atherosclerosis although may lead to some mild adverse events. Randomized controlled trials with long-term follow-up are necessary for further evaluation because many limitations of this meta-analysis cannot be ignored.

Hyaluronic Acid in Rheumatology

Hyaluronic acid (HA), also known as hyaluronan, is an anionic glycosaminoglycan widely distributed throughout various tissues of the human body. It stands out from other glycosaminoglycans as it lacks sulfation and can attain considerable size: the average human synovial HA molecule weighs about 7 million Dalton (Da), equivalent to roughly 20,000 disaccharide monomers; although some sources report a lower range of 3-4 million Da. In recent years, HA has garnered significant attention in the field of rheumatology due to its involvement in joint lubrication, cartilage maintenance, and modulation of inflammatory and/or immune responses. This review aims to provide a comprehensive overview of HA's involvement in rheumatology, covering its physiology, pharmacology, therapeutic applications, and potential future directions for enhancing patient outcomes. Nevertheless, the use of HA therapy in rheumatology remains controversial with conflicting evidence regarding its efficacy and safety. In conclusion, HA represents a promising therapeutic option to improve joint function and alleviate inflammation and pain.

Three Weekly Intra-Articular Injections of Hylan G-F 20 vs Arthrocentesis in Patients with Chronic Idiopathic Knee Osteoarthritis: A Multicenter, Evaluator- and Patient-Blinded, Randomized Controlled Trial

Background

Knee osteoarthritis is a leading cause of disability worldwide. Symptoms can vary over time, leading to episodes of worsened symptoms known as flares. Intra-articular injection of hyaluronic acid has demonstrated long-term symptomatic relief in the broader knee osteoarthritis population, although its use in the flare population has not been extensively examined.

Objective

To assess the efficacy and safety of 3 once-weekly intra-articular injections of hylan G-F 20 (as single and repeat courses) in patients with chronic knee osteoarthritis, including a subpopulation that experienced flare.

Methods

Prospective randomized controlled, evaluator- and patient-blinded, multicenter trial with 2 phases: hylan G-F 20 vs arthrocentesis only (control) and 2 courses vs single-course hylan G-F 20. Primary outcomes were visual analog scale (0-100 mm) pain scores. Secondary outcomes included safety and synovial fluid analysis.

Results

Ninety-four patients (104 knees) were enrolled in Phase I, with 31 knees representing flare patients. Seventy-six patients (82 knees) were enrolled in Phase II. Long-term follow-up was 26 to 34 weeks. In flare patients, hylan G-F 20 showed significantly more improvement than the controls for all primary outcomes except pain at night (P = 0.063). Both 1 and 2 courses of hylan G-F 20 showed significant improvements from baseline for primary outcomes with no differences in efficacy between groups in the intention-to-treat population at the end of Phase II. Two courses of hylan G-F 20 showed better improvement in pain with motion (P = 0.0471) at long-term follow-up. No general side effects were reported, and local reactions (pain/swelling of the injected joint) resolved within 1 to 2 weeks. Hylan G-F 20 was also associated with reduced effusion volume and protein concentration.

Conclusions

Hylan G-F 20 significantly improves pain scores vs arthrocentesis in flare patients with no safety concerns. A repeat course of hylan G-F 20 was found to be well tolerated and efficacious.

Ozone Therapy versus Hyaluronic Acid Injections for Pain Relief in Patients with Knee Osteoarthritis: Preliminary Findings on Molecular and Clinical Outcomes from a Randomized Controlled Trial

Ozone therapy (OT) is used for the treatment of multiple musculoskeletal disorders. In recent years, there has been a growing interest in its use for the treatment of osteoarthritis (OA). The aim of this double-blind randomized controlled trial was to evaluate the efficacy of OT compared with hyaluronic acid (HA) injections for pain relief in patients with knee OA. Patients with knee OA for at least three months were included and randomly assigned to receive three intra-articular injections of ozone or HA (once a week). Patients were assessed at baseline and at 1, 3, and 6 months after the injections for pain, stiffness, and function using the WOMAC LK 3.1, the NRS, and the KOOS questionnaire. Out of 55 patients assessed for eligibility, 52 participants were admitted to the study and randomly assigned into the 2 groups of treatment. During the study, eight patients dropped out. Thus, a total of 44 patients, reached the endpoint of the study at 6 months. Both Group A and B consisted of 22 patients. At 1-month follow-up after injections, both treatment groups improved statistically significantly from baseline in all outcomes measured. At 3 months, improvements remained similarly consistent for Group A and Group B. At 6-month follow-up, the outcomes were comparable between the 2 groups, showing only a worsening trend in pain. No significant differences were found between the two groups in pain scores. Both therapies have proven to be safe, with the few recorded adverse events being mild and self-limiting. OT has demonstrated similar results to HA injections, proving to be a safe approach with significant effects on pain control in patients affected by knee OA. Due to its anti-inflammatory and analgesic effects, ozone might be considered as a potential treatment for OA.

Funding has no effect on studies evaluating viscosupplementation for knee osteoarthritis: A systematic review of bibliometrics and conflicts of interest

Background

Viscosupplementation for knee osteoarthritis (OA) may raise concerns regarding conflicts of interest (COI). Evidence of inconclusive study results and publication bias in previous studies has led to concern that financial COI have influenced viscosupplementation outcomes. It is critical to ensure that clinical practice is guided by informed decision making and evidence-based medicine.

Methods

A systematic review was conducted following PRISMA guidelines. PubMed, MEDLINE, and Web of Science databases were searched for articles pertaining to hyaluronic acid (or similarly derived) injections to native knees with primary OA only. Bibliometric data, financial COI, and study outcomes were assessed.

Results

67 studies met inclusion criteria for analysis, 53 of which (79.1%) presented Level I evidence, and 21 of which (31.3%) reported at least one author with COI. All studies reporting COI also disclosed industry funding. There were no relationships between reported COI and study outcomes (Χ 2  = 0.31, P = 0.577), levels of evidence (Χ 2  = 3.48, P = 0.176), or relative citation ratio (RCR) (S = 743, P = 0.591). Studies reporting COIs/industry funding tended to be published in journals with significantly higher impact factors (IF) (reporting COI: IF = 3.5 ± 2.0; no COI: IF = 1.8 ± 1.1; S = 950, P < 0.001). Study outcomes were not related to the probability of being published in an open access journal (Χ 2  = 0.01, P = 0.960), nor to level of evidence (Χ 2  = 2.67, P = 0.263), RCR (S = 618, P = 0.835), or IF (S = 563, P = 0.655).

Conclusions

Investigator COIs (and commercial funding of studies) have not significantly influenced the frequency of favorable outcomes or study level of evidence regarding contemporary viscosupplementation for the treatment of knee OA. Studies reporting COIs/industry funding tended to be published in journals with significantly higher impact factors. Results overwhelmingly supported using viscosupplementation to treat knee OA.

Level of evidence

Level V Systematic Review.

Pharmaceutical treatment of osteoarthritis

OBJECTIVE

To review the current state of pharmaceutical treatment recommendations for the management of osteoarthritis.

METHOD

A narrative review was drafted to describe treatment guidelines, mechanism of action, pharmacokinetics, and toxicity for nine classes of pharmaceuticals: 1) oral nonsteroidal anti-inflammatory drugs (NSAIDs), 2) topical NSAIDs, 3) COX-2 inhibitors, 4) duloxetine, 5) intra-articular corticosteroids, 6) intra-articular hyaluronic acid, 7) acetaminophen (paracetamol), 8) tramadol, and 9) capsaicin.

RESULTS

In general, oral and topical NSAIDs, including COX-2 inhibitors, are strongly recommended first-line treatments for osteoarthritis due to their ability to improve pain and function but are associated with increased risks in patients with certain comorbidities (e.g., heightened cardiovascular risks). Intra-articular corticosteroid injections are generally recommended for osteoarthritis management and have relatively minor adverse effects. Other treatments, such as capsaicin, tramadol, and acetaminophen, are more controversial, and many updated guidelines offer differing recommendations.

CONCLUSION

The pharmaceutical management of osteoarthritis is a constantly evolving field. Promising treatments are emerging, and medicines that were once considered conventional (e.g., acetaminophen) are gradually becoming less acceptable based on concerns with efficacy and safety. Clinicians need to consider the latest evidence and recommendations to make an informed decision with their patients about how to optimize treatment plans for patients with knee, hip, polyarticular, or hand osteoarthritis.

Patient Reported Outcomes Following Intraarticular Hyaluronic Acid for Knee Osteoarthritis

BACKGROUND

Intraarticular hyaluronic acid (IAHA) has been commonly used in the management of knee osteoarthritis (OA). This study sought to assess patient reported outcomes (PRO) following different formulations of HA injections for patients who have knee OA.

METHODS

A retrospective analysis was performed on patients who have knee OA and received IAHA knee injections from October 2018 to May 2022 in sports medicine (SM) and adult reconstructive (AR) clinics. Patients completed PRO measures including the Patient-Reported Outcome Measurement Information System (PROMIS ®) Mobility, Pain Interference, and Pain Intensity at baseline, 6-week, 6-month, and 12-month follow-up. Univariate and multivariate analyses were used to evaluate changes in PRO measures between baseline and follow-up periods and to evaluate differences between the SM and AR divisions. A total of 995 patients received IAHA for knee OA and completed PRO assessments.

RESULTS

There was no difference in the PROMIS® measures based on molecular weight at 6-weeks, 6-months, and 12-months. Except for 6-month Mobility scores between the SM and AR patients (-0.52 ± 5.46 vs 2.03 ± 6.95; P = 0.02), all other PROMIS® scores were similar. Mobility scores at 6-months were significantly different based on KL (Kellgren and Lawrence) grade (P = 0.005) but all other PROMIS® scores were similar.

CONCLUSION

Average change in PROMIS® scores were significantly different only for 6-month Mobility scores based on divisions and KL grade, but did not achieve minimally clinical important difference in most timepoints. Further studies are needed to investigate whether improvement is observed in specific patient populations.

Relationship Between the Underlying Factors and the Treatment Results of Platelet-Rich Plasm (PRP) Injection in Degenerative Knee Disease; A Blinded Randomized Study

Background: To investigate the therapeutic effects of PRP injection + conservative treatment as the intervention group versus normal saline injection + conservative treatment as the control group. Objectives: This study we determined the effects of underlying factors, including age, gender, and Body Mass Index (BMI), on the therapeutic effects of PRP. Methods: In this single-blinded randomized clinical trial, 60 patients with grade 2 knee OA with an age of 40 - 65 years were enrolled. In the intervention group, leukocyte-poor PRP with double spinning, and in the control group, normal saline was injected with a similar protocol. All patients in both groups were also provided with a conservative protocol, including oral celecoxib 100 mg BID for four weeks, modifying physical activity, and 15 sessions of physiotherapy. Results: Demographic characteristics (age, gender, and BMI) and pre-treatment scores were similar between the two groups (all P > 0.05). The WOMAC score was improved from pre-treatment to first week post-treatment in both groups (from 54.89 ± 3.4 to 64.9 ± 3.7 in the intervention group and from 53.7 ± 3.1 to 63.8 ± 3.9 in the control group). It means that PRP + conservative treatment was effective, similar to normal saline + conservative treatment. After adjusting BMI as an underlying variable, it was indicated that in the patients with lower BMI, PRP + conservative provided a better outcome in comparison to saline + conservative treatment (P = 0.014 and P = 0.019, respectively). Also, the comparison of functional scores changes with age as an underlying variable, demonstrating that younger cases obtained a better response from PRP + conservative rather than normal saline + conservative (P = 0.012 and P = 0.007, respectively). Conclusions: PRP seems to be an appropriate choice for treatment of moderate osteoarthritis, especially in younger patients and those with lower BMI.

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

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

New insights in osteoarthritis diagnosis and treatment: Nano-strategies for an improved disease management

Osteoarthritis (OA) is a common chronic joint pathology that has become a predominant cause of disability worldwide. Even though the origin and evolution of OA rely on different factors that are not yet elucidated nor understood, the development of novel strategies to treat OA has emerged in the last years. Cartilage degradation is the main hallmark of the pathology though alterations in bone and synovial inflammation, among other comorbidities, are also involved during OA progression. From a molecular point of view, a vast amount of signaling pathways are implicated in the progression of the disease, opening up a wide plethora of targets to attenuate or even halt OA. The main purpose of this review is to shed light on the recent strategies published based on nanotechnology for the early diagnosis of the disease as well as the most promising nano-enabling therapeutic approaches validated in preclinical models. To address the clinical issue, the key pathways involved in OA initiation and progression are described as the main potential targets for OA prevention and early treatment. Furthermore, an overview of current therapeutic strategies is depicted. Finally, to solve the drawbacks of current treatments, nanobiomedicine has shown demonstrated benefits when using drug delivery systems compared with the administration of the equivalent doses of the free drugs and the potential of disease-modifying OA drugs when using nanosystems. We anticipate that the development of smart and specific bioresponsive and biocompatible nanosystems will provide a solid and promising basis for effective OA early diagnosis and treatment. This article is categorized under: Diagnostic Tools > In Vivo Nanodiagnostics and Imaging Implantable Materials and Surgical Technologies > Nanotechnology in Tissue Repair and Replacement.

Lubricants for osteoarthritis treatment: From natural to bioinspired and alternative strategies

Osteoarthritis is the most common degenerative and highly prevalent joint disease, characterized by progressive loss and destruction of articular cartilage. The damaged cartilage surface has an increased friction, which causes patients to suffer from serious pain. Restoring the lubrication ability of the joint is central to the treatment of osteoarthritis, a key topic in medical research. A variety of lubricants have been designed to reduce friction in joints and promote cartilage tissue repair to alleviate the symptoms of osteoarthritis. Herein, we review the recent progress of lubricants from the three perspectives of natural, bioinspired, and alternative strategies for osteoarthritis treatment, as well as the structural characterization and lubrication properties of such lubricants. Specifically, natural lubricants include glycosaminoglycans, lubricin and lipids in joints, bioinspired lubricants include scaffolds mimicking hyaluronic acid or lubricin, and alternative lubricants include modified lubricants based on hyaluronic acid, lipids, nanoparticles, and peptides. We also discuss the current challenges and long-term perspectives for further research in this area.

Comparison of the Effects of Different Molecular Weight Hyaluronic Acid Application in Knee Osteoarthritis

Objective: The objective of this study was to evaluate the effect of different molecular weight (MW) hyaluronic acid (HA) application on pain and functional parameters in knee osteoarthritis (OA). Methods: This study was designed as retrospectively. Hospital records of the patients who received intraarticular HA injection therapy in our center were screened. The patients were divided into 3 categories according to the MW of the preparates as the follows; Group 1: 0,6-1,2 Milion Da of MW (N=26); Group 2: 1,1- 2,2 Million Da of MW (N=25); and Group 3: 1,7-2,1 Million Da of MW (N=25). All patients were assessed using Visual Analogue Scale (VAS) and Western Ontario and McMaster Universities Arthritis Index (WOMAC) before the treatment and one month after the injection. Results: A total of 76 patients (61 females, 15 males) with a mean age of 62,1 years (minimum-maximum: 50-70 years) were included. VAS and WOMAC scores did improve significantly in all groups (all for p

Harnessing hyaluronic acid for the treatment of osteoarthritis: A bibliometric analysis

Background: Osteoarthritis (OA) is a common disease which usually occurs in middle-aged and elderly people. Hyaluronic acid (HA) has been widely used to treat OA and related researches on the efficacy and safety of HA in the treatment of OA have been published. Therefore, the purpose of this research was to investigate the subject characteristics of harnessing HA for the treatment of OA and to analyse the relevant trends and hotspots by using a bibliometric approach.

Methods: The articles published from 1 January 2002 to 31 December 2021 were searched in the Web of Science Core Collection (WoSCC) and the relevant information of HA for the treatment of OA was extracted after screening. Then, a total of 2438 publications were analysed by using Microsoft Excel, CiteSpace 5.8.R3, VOSviewer 1.6.18 and the Online Analysis Platform of Literature Metrology (http://bibliometric.com/).

Results: A total of 2438 articles were finally included for analysis. The number of publications increased year by year. A total of 83 coutries and 3319 institutions published 2438 manuscripts in the field of use HA for the treatment of OA. The most productive country was United States with total 689 publications and League of European Research Universities Leru (Belgium) was the leading institution with total 126 publicatios. In terms of authors, the most prominent author was KrausVB, who published 28 papers with the highest H-index (19). In addition, Osteoarthritis and Cartilage had the highest number of publications (152 articles) and the highest number of citations (6450 citations). The co-cited references analysis indicated that the article published by McAlindon in 2014 had the most highest number of citations (91co-citations). What’s more, most research hotspots focused on the efficacy and safety of HA, and regenerative medicine researches such as platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs) have attracted more and more attentions of researchers.

Conclusion: This study visually analyzed the historical evolution and future trends of HA for the treatment of OA, and discussed the research priorities. At present, there are still different views on the efficacy of HA for the treatment of OA. Gradually, research hotspots of this field have focused on the regenerative medicine.

Relative Efficacy of Intra-articular Injections in the Treatment of Knee Osteoarthritis: A Systematic Review and Network Meta-analysis

BACKGROUND

In younger patients and those without severe degenerative changes, the efficacy of intra-articular (IA) injections as a nonoperative modality for treating symptomatic knee osteoarthritis (OA)-related pain while maintaining function has become a subject of increasing interest.

PURPOSE

To assess and compare the efficacy of different IA injections used for the treatment of knee OA, including hyaluronic acid (HA), corticosteroids (CS), platelet-rich plasma (PRP), and plasma rich in growth factors (PRGF), with a minimum 6-month patient follow-up.

STUDY DESIGN

Meta-analysis of randomized controlled trials; Level of evidence, 1.

METHODS

A systematic review was performed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed/MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Google Scholar. Mean or mean change from baseline and standard deviation for outcome scores regarding pain and function were recorded at the 6-month follow-up and converted to either a 0 to 100 visual analog scale score for pain or a 0 to 100 Western Ontario and McMaster Universities Osteoarthritis Index score for function. A frequentist network meta-analysis model was developed to compare the effects of HA, CS, PRP, PRGF, and placebo on patient-reported outcomes.

RESULTS

All IA treatments except CS were found to result in a statistically significant improvement in outcomes when compared with placebo. PRP demonstrated a clinically meaningful difference in function-related improvement when compared with CS and placebo due to large effect sizes. Studies evaluating outcomes of PRGF reported significant improvement when compared with placebo due to large effect sizes, whereas a potential clinically significant difference was detected in the same comparison parameters in pain evaluation. With regard to improvements in pain, function, and both combined, PRP was found to possess the highest probability of efficacy, followed by PRGF, HA, CS, and placebo.

CONCLUSION

PRP yielded improved outcomes when compared with PRGF, HA, CS, and placebo for the treatment of symptomatic knee OA at a minimum 6-month follow-up. Further investigations evaluating different IA and other nonoperative treatment options for patients with knee OA are warranted to better understand the true clinical efficacy and long-term outcomes of nonsurgical OA management.

Racial and ethnic differences in the pharmacologic management of osteoarthritis: rapid systematic review

Background

Racial and ethnic disparities in osteoarthritis (OA) patients' disease experience may be related to marked differences in the utilization and prescription of pharmacologic treatments.

Objectives

The main objective of this rapid systematic review was to evaluate studies that examined race/ethnic differences in the use of pharmacologic treatments for OA.

Data sources and methods

A literature search (PubMed and Embase) was ran on 25 February 2022. Studies that evaluated race/ethnic differences in the use of OA pharmacologic treatments were included. Two reviewers independently screened titles and abstracts and abstracted data from full-text articles. Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed.

Results

The search yielded 3880 titles, and 17 studies were included in this review. African Americans and Hispanics were more likely than non-Hispanic Whites to use prescription non-selective non-steroidal anti-inflammatory drugs (NSAIDs) for OA. However, compared to non-Hispanic Whites with OA, African Americans and Hispanics with OA were less likely to receive a prescription for cyclooxygenase-2-selective NSAIDs and less likely to report the use of joint health supplements (i.e. glucosamine and chondroitin sulfate). There were minimal/no significant race/ethnic differences in the patient-reported use of the following OA therapies: acetaminophen, opioids, and other complementary/alternative medicines (vitamins, minerals, and herbs). There were also no significant race differences in the receipt of intra-articular therapies (i.e. glucocorticoid or hyaluronic acid). However, there is limited evidence to suggest that African Americans may be less likely than Whites to receive opioids and intra-articular therapies in some OA patient populations.

Conclusion

This systematic review provides an overview of the current pharmacologic options for OA, with a focus on race and ethnic differences in the use of such medical therapies.

Viscosupplementation for knee osteoarthritis: systematic review and meta-analysis

OBJECTIVE

To evaluate the effectiveness and safety of viscosupplementation for pain and function in patients with knee osteoarthritis.

DESIGN

Systematic review and meta-analysis of randomised trials.

DATA SOURCES

Searches were conducted of Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to 11 September 2021. Unpublished trials were identified from the grey literature and trial registries.

ELIGIBILITY CRITERIA FOR STUDY SELECTION

Randomised trials comparing viscosupplementation with placebo or no intervention for knee osteoarthritis treatment.

MAIN OUTCOME MEASURES

The prespecified primary outcome was pain intensity. Secondary outcomes were function and serious adverse events. Pain and function were analysed as standardised mean differences (SMDs). The prespecified minimal clinically important between group difference was -0.37 SMD. Serious adverse events were analysed as relative risks.

METHODS

Two reviewers independently extracted relevant data and assessed the risk of bias of trials using the Cochrane risk of bias tool. The predefined main analysis was based only on large, placebo controlled trials with ≥100 participants per group. Summary results were obtained through a random effects meta-analysis model. Cumulative meta-analysis and trial sequential analysis under a random effects model were also performed.

RESULTS

169 trials provided data on 21 163 randomised participants. Evidence of small study effects and publication biases was observed for pain and function (Egger's tests with P<0.001 and asymmetric funnel plots). Twenty four large, placebo controlled trials (8997 randomised participants) included in the main analysis of pain indicated that viscosupplementation was associated with a small reduction in pain intensity compared with placebo (SMD -0.08, 95% confidence interval -0.15 to -0.02), with the lower bound of the 95% confidence interval excluding the minimal clinically important between group difference. This effect corresponds to a difference in pain scores of -2.0 mm (95% confidence interval -3.8 to -0.5 mm) on a 100 mm visual analogue scale. Trial sequential analysis for pain indicated that since 2009 there has been conclusive evidence of clinical equivalence between viscosupplementation and placebo. Similar conclusions were obtained for function. Based on 15 large, placebo controlled trials on 6462 randomised participants, viscosupplementation was associated with a statistically significant higher risk of serious adverse events than placebo (relative risk 1.49, 95% confidence interval 1.12 to 1.98).

CONCLUSION

Strong conclusive evidence indicates that viscosupplementation leads to a small reduction in knee osteoarthritis pain compared with placebo, but the difference is less than the minimal clinically important between group difference. Strong conclusive evidence indicates that viscosupplementation is also associated with an increased risk of serious adverse events compared with placebo. The findings do not support broad use of viscosupplementation for the treatment of knee osteoarthritis.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021236894.

Osteoarthritis Treatment Guidelines from Six Professional Societies

Despite the high prevalence and burden of osteoarthritis (OA) worldwide, management of OA continues to primarily focus on symptom management due to the lack of approved pharmacologic agents that halt disease progression. Recent recommendations from 6 professional societies support the importance of education, self-management approaches, weight loss, and physical modalities in managing OA. These recent guidelines also highlight the paucity of effective and safe treatment options, with recommendations against ineffective therapies outnumbering those for effective ones. NSAIDs, oral and topical, remain the primary recommended pharmacologic management option for OA.

Efficacy of a Novel Intra-Articular Administration of Platelet-Rich Plasma One-Week Prior to Hyaluronic Acid versus Platelet-Rich Plasma Alone in Knee Osteoarthritis: A Prospective, Randomized, Double-Blind, Controlled Trial

Recent studies have suggested that the combined injection of platelet-rich plasma (PRP) and hyaluronic acid (HA) may have additive benefits for knee osteoarthritis over PRP alone, but there is insufficient evidence to support this combined injection. Moreover, the simultaneous injection of PRP and HA may offset the combined effect. Hence, the aim of this prospective, randomized, double-blind study was to assess their combined efficacy with a novel injection protocol. Forty-six study subjects with unilateral knee osteoarthritis were randomized to receive either a single-dose injection of HA (intervention group) or normal saline (control group) 1 week after a single-dose injection of leukocyte-poor PRP. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and static balance and the risk of falls measured by Biodex Balance System were, respectively, the primary and secondary outcome measures. Evaluations were performed at baseline, 1 month, 3 months, 6 months, and 12 months post-injection. The intervention group exhibited significant declines in WOMAC pain, stiffness, and total scores, as well as static balance, compared to the control group (p < 0.05). These randomized double-blind control trials, with novel protocol of intra-articular injection of PRP 1-week prior to HA, provide greater symptom relief and improve static balance compared to PRP alone in patients with knee osteoarthritis.

Hyaluronic Acid Injections for Knee Osteoarthritis: Has Utilization Among Medicare Beneficiaries Changed Between 2012 and 2018?

BACKGROUND

The utilization of hyaluronic acid (HA) for the management of knee osteoarthritis (OA) remains controversial, and more information is needed regarding how its utilization and financial burden have changed over recent years. The purpose of our analysis was to evaluate changes in overall utilization and health-care costs associated with HA injections among Medicare beneficiaries over a contemporary time frame.

METHODS

The 2012 to 2018 Medicare Fee-for-Service Provider Utilization and Payment Public Use Files (PUFs) were utilized for our analysis. Organized by Healthcare Common Procedure Coding System (HCPCS) codes, these files capture 100% of Medicare Part B claims. Payment and utilization data were collected for all HCPCS codes corresponding to injection of an HA formulation. The number of services involving HA as well as the total cost of HA administration in 2020 U.S. dollars were tabulated. Mann-Kendall trend tests were used to evaluate trends in utilization for providers nationally and when segregated by specialty.

RESULTS

Total HA utilization increased significantly from 2012 (n = 1,090,503) through 2018 (n = 1,209,489; p = 0.04). Although orthopaedic surgeons did not demonstrate significant changes in total utilization rates (p = 0.23), the average number of services per orthopaedic surgeon increased significantly (p = 0.02). Reflecting a substantial growth in the number of advanced practice providers (APPs) providing injections, there was a significant increase in utilization and associated costs among physician assistants (p < 0.01) and nurse practitioners (p < 0.01). Total costs associated with HA services increased significantly from $290.10 million to $325.02 million (p < 0.01).

CONCLUSIONS

Despite the 2013 American Academy of Orthopaedic Surgeons clinical practice guideline recommending against the clinical utility of these injections, HA services continued to be widely implemented among Medicare beneficiaries. Although there were variations across specialties when evaluating overall utilization rates as well as rates per provider, APPs largely contributed to the increase seen in the U.S. over this study period. More data are needed to support continued implementation and spending on this low-value care.

The Association Between Acupuncture Therapies and Reduced Fracture Risk in Patients with Osteoarthritis: A Nationwide Retrospective Matched Cohort Study

Objective: The aim of this study is to investigate the association between acupuncture therapy and the risk of fracture in patient with osteoarthritis (OA). Design: The authors performed a 1:1 propensity score-matched cohort study to analyze patient with OA between January 1, 1997 and December 31, 2010 through the Taiwanese National Health Insurance Research Database. Patients who received acupuncture therapy from the initial date of diagnosis of OA to December 31, 2010 were included in the acupuncture cohort. Patients who did not receive acupuncture during the same follow-up period were defined as the no-acupuncture cohort. A Cox regression model was used to adjust for sex, age, comorbidities, prescription, and surgical experiences. Hazard ratios (HRs) were compared between the two cohorts. Results: A total of 3416 patients were identified after 1:1 propensity score matching. The patients had similar basic characteristics. In the final analysis, 292 patients in the acupuncture cohort (30.06 per 1000 person-years) and 431 patients in the no-acupuncture cohort (56.08 per 1000 person-years) developed fractures (adjusted HRs 0.57, 95% confidence interval 0.49-0.67). A reduced cumulative incidence of fracture was found in the acupuncture cohort (log-rank test, p < 0.001). The association between acupuncture and reducing the fracture incidence was independent of sex, comorbidities, drugs use, and surgical experiences. Conclusion: Their results revealed the association between acupuncture therapies and a reduced incidence of fracture development in patients with OA. This finding provides noteworthy ideas for further research.

NSAIDs Reduce Therapeutic Efficacy of Mesenchymal Stromal Cell Therapy in a Rodent Model of Posttraumatic Osteoarthritis

BACKGROUND

Intra-articular injections of human mesenchymal stromal cells (hMSCs) have shown promise in slowing cartilage degradation in posttraumatic osteoarthritis (PTOA). Clinical use of cell therapies for osteoarthritis has accelerated in recent years without sufficient scientific evidence defining best-use practices. Common recommendations advise patients to avoid nonsteroidal anti-inflammatory drug (NSAID) use before and after cell injection over concerns that NSAIDs may affect therapeutic efficacy. Recommendations to restrict NSAID use are challenging for patients, and it is unclear if patients are compliant.

HYPOTHESIS

NSAIDs will reduce the efficacy of hMSC therapy in treating a preclinical model of PTOA.

STUDY DESIGN

Controlled laboratory study.

METHODS

Lewis rats underwent medial meniscal transection (MMT) surgery to induce PTOA or a sham (sham group) surgery that did not progress to PTOA. Rats received naproxen solution orally daily before (Pre-NSAID group) or after (Post-NSAID group) hMSC treatment, throughout the course of the experiment (Full-NSAID group), or received hMSCs without NSAIDs (No NSAID). Cartilage morphology and composition were quantified using contrast-enhanced micro-computed tomography and histology. Pain (secondary allodynia) was measured using a von Frey filament.

RESULTS

Injection of hMSCs attenuated cartilage degeneration associated with MMT. hMSCs prevented proteoglycan loss, maintained smooth cartilage surfaces, reduced cartilage lesions, reduced mineralized osteophyte formation, and reduced pain by week 7. The Pre-NSAID group had decreased proteoglycan levels compared with the hMSC group, although there were no other significant differences. Thus, pretreatment with NSAIDs had minimal effects on the therapeutic benefits of hMSC injections. The Post-NSAID and Full-NSAID groups, however, exhibited significantly worse osteoarthritis than the hMSC-only group, with greater proteoglycan loss, surface roughness, osteophyte volume, and pain.

CONCLUSION

Use of NSAIDs before hMSC injection minimally reduced the therapeutic benefits for PTOA, which included preservation of cartilage surface integrity as well as a reduction in osteophytes. Use of NSAIDs after injections, however, substantially reduced the therapeutic efficacy of cellular treatment.

CLINICAL RELEVANCE

Our data support the clinical recommendation of avoiding NSAID use after hMSC injection but suggest that using NSAIDs before treatment may not substantially diminish the therapeutic efficacy of cell treatment.

Improvement in condition specific and generic quality of life outcomes in patients with knee osteoarthritis following single intraarticular viscosupplementation injection

Background

Non-operative management of Osteoarthritis (OA) can be challenging. The intra-articular injection with hyaluronic acid (IAHA), corticosteroids and Platelet rich plasma are some of the popular modalities which are increasingly being employed as a stop-gap strategy before considering any surgical intervention for OA management. Among these, the intra-articular HA (IAHA) has been widely studied with variable and conflicting results.

Method

This was a prospective observational study conducted in adults with knee OA. Suitable patients were given IAHA (Synvisc-One®) on an out-patient basis. They were assessed in terms of VAS score, WOMAC score and SF36 scores at successive follow-up visits at 8, 24 and 52 weeks.

Results

50 patients were recruited in this study and followed for 52 weeks post injection of HA. Mean and SD values of VAS, WOMAC and SF36 scores were on a decreasing trend in each follow up visit. Percentage change between the visits was also statistically significant. The improvement in pain scores at successive visits was significant in KL grade 1 OA than grade 2 or 3 indicating strong association between them.

Conclusion

Short-term (up to one year) beneficial effects of intra-articular viscosupplementation with HA in early primary knee OA can be seen with a decreasing trend in the intensity of pain and an increasing trend in improving the physical functioning and health-related quality of life.

Cancer Cytotoxicity of a Hybrid Hyaluronan-Superparamagnetic Iron Oxide Nanoparticle Material: An In-Vitro Evaluation

While hyaluronic acid encapsulating superparamagnetic iron oxide nanoparticles have been reported to exhibit selective cytotoxicity toward cancer cells, it is unclear whether low-molecular-weight hyaluronic acid-conjugated superparamagnetic iron oxide nanoparticles also display such cytotoxicity. In this study, high-molecular-weight hyaluronic acid was irradiated with γ-ray, while Fe3O4 nanoparticles were fabricated using chemical co-precipitation. The low-molecular-weight hyaluronic acid and Fe3O4 nanoparticles were then combined according to a previous study. Size distribution, zeta potential, and the binding between hyaluronic acid and iron oxide nanoparticles were examined using dynamic light scattering and a nuclear magnetic resonance spectroscopy. The ability of the fabricated low-molecular-weight hyaluronic acid conjugated superparamagnetic iron oxide nanoparticles to target cancer cells was examined using time-of-flight secondary ion mass spectrometry and T2* weighted magnetic resonance images to compare iron signals in U87MG human glioblastoma and NIH3T3 normal fibroblast cell lines. Comparison showed that the present material could target U87MG cells at a higher rate than NIH3T3 control cells, with a viability inhibition rate of 34% observed at day two and no cytotoxicity observed in NIH3T3 normal fibroblasts during the three-day experimental period. Supported by mass spectrometry images confirming that the nanoparticles accumulated on the surface of cancer cells, the fabricated materials can reasonably be suggested as a candidate for both magnetic resonance imaging applications and as an injectable anticancer agent.

Emerging microfluidics-enabled platforms for osteoarthritis management: from benchtop to bedside

Osteoarthritis (OA) is a prevalent debilitating age-related joint degenerative disease. It is a leading cause of pain and functional disability in older adults. Unfortunately, there is no cure for OA once the damage is established. Therefore, it promotes an urgent need for early detection and intervention of OA. Theranostics, combining therapy and diagnosis, emerges as a promising approach for OA management. However, OA theranostics is still in its infancy. Three fundamental needs have to be firstly fulfilled: i) a reliable OA model for disease pathogenesis investigation and drug screening, ii) an effective and precise diagnostic platform, and iii) an advanced fabrication approach for drug delivery and therapy. Meanwhile, microfluidics emerges as a versatile technology to address each of the needs and eventually boost the development of OA theranostics. Therefore, this review focuses on the applications of microfluidics, from benchtop to bedside, for OA modelling and drug screening, early diagnosis, and clinical therapy. We first introduce the basic pathophysiology of OA and point out the major unfilled research gaps in current OA management including lack of disease modelling and drug screening platforms, early diagnostic modalities and disease-modifying drugs and delivery approaches. Accordingly, we then summarize the state-of-the-art microfluidics technology for OA management from in vitro modelling and diagnosis to therapy. Given the existing promising results, we further discuss the future development of microfluidic platforms towards clinical translation at the crossroad of engineering and biomedicine.

Acide hyaluronique intra-articulaire dans la gonarthrose: résultats cliniques d'une famille de produits (ARTHRUM), avec méta-analyses comparatives

Introduction

La viscosupplémentation est largement pratiquée, pour réduire la douleur dans l'arthrose (OA), par des injections intra articulaires (IA) d'acide hyaluronique (AH). En Europe, ces produits sont des dispositifs médicaux de classe III, pour lesquels la réglementation Medical Device Regulation (MDR) impose une évaluation clinique, basée sur des études spécifiques et/ou une revue bibliographique des dispositifs équivalents. L'objet de cet article est de présenter une revue comparative entre une famille de dispositifs (ARTHRUM, de LCA Pharmaceuticals, Chartres, France) et un groupe important de dispositifs AH IA présumés équivalents dont les résultats et ceux de leurs contrôles, ont fait l'objet de publications dans des journaux scientifiques.

Méthodes

Pour rejoindre les critères utilisés dans la plupart des études ARTHRUM, les sous-scores de l'indice Western Ontario and McMaster Universities ont été sélectionnés pour la douleur (WOMAC A), la raideur (WOMAC B) et la fonction (WOMAC C). Le critère principal était la variation du score WOMAC A depuis T0 (date d'inclusion) jusqu'à T6 (6 mois). Les autres critères WOMAC ont été évalués à T1, T3, T6 et complétés par les taux de répondeurs au traitement selon OMERACT-OARSI. Cinquante articles ont été sélectionnés, incluant des résultats portant sur plus de 12.000 patients. Ceux-ci ont été répartis en trois groupes: ARTHRUM, EQUIVALENTS et CONTROLES. Pour obtenir des comparaisons quantitatives, des méta-analyses furent réalisées pour chaque critère individuel. Les intervalles de confiance (CI) à 95% de chaque variation par rapport à l'inclusion, ont permis d'évaluer la pertinence clinique en se référant à un minimum validé dans la littérature de l'OA. L'investigation a été complétée par des comparaisons entre groupes et par l'évaluation de la tolérance.

Résultats

Pour les scores WOMAC A, B et C, l'intégralité de CI 95% était toujours supérieure à l'amélioration minimale cliniquement perceptible (MPCI), pour les groupes ARTHRUM et EQUIVALENTS, ce qui n'a pas été observé pour la totalité des critères, avec le groupe CONTROLES. Dans les comparaisons, les groupes ARTHRUM et EQUIVALENTS ont été significativement meilleurs que le groupe CONTROLES pour chaque critère. La taille de l'effet (ES) sur la douleur, pour les groupes ARTHRUM et EQUIVALENTS, a varié de 0,28 à 0,56 et de 0,23 to 0,27, respectivement. Globalement, ARTHRUM a toujours été évalué non-inférieur aux EQUIVALENTS, et parfois statistiquement et cliniquement supérieur.

Conclusions

La comparaison des études cliniques ARTHRUM, avec les études tirées de la recherche bibliographique, permet de conclure que l'efficacité clinique des dispositifs médicaux ARTHRUM, pour réduire la douleur et améliorer la fonction dans la gonarthrose, sur une période de six mois, est au moins aussi élevée que celle des dispositifs équivalents. Avec un bon profil de tolérance (taux plus faible d'effets indésirables, et aucun sévère), le rapport risque-bénéfice est en faveur de la viscosupplémentation avec ARTHRUM.

Acupuncture for the Treatment of Knee Osteoarthritis: An Overview of Systematic Reviews

Background

Acupuncture has been widely used in the clinical management of osteoarthritis of the knee (KOA). Many systematic reviews (SRs) and meta-analyses (MAs) have reported its effectiveness in relieving pain. This overview aimed to summarize SRs and MAs on the effectiveness and safety of acupuncture for KOA and evaluate their methodological and evidence quality of the included SRs and MAs.

Methods

We conducted a comprehensive literature search for SRs and MAs in four Chinese and four international databases from their inception until August 2021. Two researchers independently searched the reviews, extracted the data, and cross-checked the data. The Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) tool was used to evaluate the methodological quality of the included SRs and MAs. The Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the quality of evidence for the outcomes of the included SRs and MAs.

Results

A total of 14 SRs and MAs were included. The evaluation results of the AMSTAR 2 tool showed that the methodological quality of all the 14 SRs and MAs was critically low. The principal causes are the lack of a pre-registration proposal and a list of excluded studies and justify the exclusions, the report on the sources of funding, and the reasons for the study designs for inclusion. The results of the GRADE evaluation showed 25 of 46 outcomes were very low-level evidence. Seventeen were of low level, four were of moderate level and none were of high level. Most outcomes were downgraded in quality of evidence mainly because of publication bias and imprecision.

Conclusion

The existing evidence suggests that acupuncture seems to be an effective and safe therapy for KOA. However, the deficiencies in the methodological quality and quality of evidence of the included SRs/MAs have limited the reliability of the conclusions. Therefore, further rigorous and comprehensive studies are warranted to verify the effectiveness and safety of acupuncture in KOA.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Does the Presence of Neuropathic Pain Influence the Response to Hyaluronic Acid in Patients with Knee Osteoarthritis?

OBJECTIVES

Up to 50% of patients with symptomatic knee osteoarthritis (OA) present with neuropathic pain (NP) features. We assessed the impact of NP according to DN4 (Douleurs Neuropathiques 4 questions) score on the response to intra-articular (IA) hyaluronic acid (HA) injections and the effects of HA injections on NP.

MATERIALS AND METHODS

We conducted a post hoc analysis from a multicenter, randomized, double-blind, noninferiority trial comparing the efficacy of 2 HA in symptomatic knee OA at 24 weeks. At baseline, demographic, anthropometric, radiologic data, and symptoms were recorded. The symptomatic effect of HA was assessed by VAS pain, patient global assessment (PGA), WOMAC, DN4, and OMERACT-OARSI response.

RESULTS

A total of 187 patients were included. NP according to DN4 score was present in 20 patients (10.7%) at baseline. Most common positive DN4 items were tingling (36.9%) and burning (36.4%). NP was associated with WOMAC pain score (P = 0.02). The presence of NP at baseline did not affect the symptomatic improvement after HA injections according to the VAS pain (P = 0.71), PGA (P = 050), WOMAC pain (P = 0.89), WOMAC function (P = 0.52), and rate of OMERACT-OARSI responders (P = 0.21). The prevalence of patients with NP decreased by 50% (n = 10) at 24 weeks after HA injections. Most improved DN4 items were itching (90%), hypoesthesia to pinprick (88%), and burning (50%).

CONCLUSION

In our study, NP was associated with pain severity, but did not influence the response to IA HA. On the other hand, HA injections reduced some NP features, especially itching, sting hypoesthesia, and burning.

Molecular Weight of Hyaluronic Acid Has Major Influence on Its Efficacy and Safety for Viscosupplementation in Hip Osteoarthritis: A Systematic Review and Meta-Analysis

BACKGROUND

This study aimed to compare the efficacy and safety of intra-articular hyaluronic acid (HA) injection with different molecular weights (MWs) for treating hip osteoarthritis (OA).

METHODS

A systematic literature search for relevant studies was conducted in 3 electronic databases, including PubMed, BMJ Journals, and Cochrane Library, from inception to April 2020. Extracted outcomes included visual analogue scale (VAS) (1, 3, and 6 months), Lequesne index (3 and 6 months), and adverse effects. HAs were classified into low-molecular-weight (LMW), moderate-molecular-weight (MMW), high-molecular-weight (HMW), and ultra-high-molecular-weight (UHMW) groups. Meta-analysis was performed using Review Manager 5.3.

RESULTS

A total of 15 studies with 614 patients were included. Our meta-analysis showed that the HMW HA group had the best improvement in VAS and Lequesne index compared with other HA groups for all the follow-up visits. Moreover, the HMW group demonstrated significantly better improvement than the other groups in VAS at 6-month follow-up and in Lequesne index at 3- and 6-month follow-ups. Analysis for adverse effects revealed low rates of systemic adverse effects (≤0.6%) in all groups and similar rate of local adverse effects (around 10%) among the groups except for UHMW HA group (37.5%).

CONCLUSION

Among different MWs of HA for treating hip OA, HMW HA injection demonstrated the best efficacy for up to 6 months after treatment without increased risk of adverse effects. Further studies with more comprehensive data and a higher level of evidence are required to prove our results.

Increasing Concentration of Sinovial: Effect on Cartilage Protection in a Rabbit ACLT Model

OBJECTIVE

This study aimed to test the hypothesis that administration of increasing doses of Sinovial (hyaluronic acid [HA]), would exhibit a dose-dependent effect on the prevention of cartilage degradation, without local and systemic toxicity.

METHODS

Twenty-seven adult rabbits were subjected to anterior cruciate ligament transection (ACLT). Two Sinovial products containing HA concentrations of 1.6% and 2.4% were used as active treatment, and 0.9% saline was used as control and injected intra-articularly 7 days post ACLT. Radiographs were taken prior to surgery, at injection and sacrifice times. After euthanasia, 8 weeks postsurgery, knee joints were observed macroscopically using India ink staining with OARSI (Osteoarthritis Research Society International) scoring and histologically using modified Mankin scoring. The synovial membranes were analyzed using Cake classification.

RESULTS

No intraoperative complications were observed. One week postinjection, 4 animals in the HA 2.4% group developed subcutaneous nodules that disappeared spontaneously. No inflammation of the synovial membrane was ever observed. The control group exhibited the maximum uptake of India ink 2.22 ± 0.14. HA groups exhibited a dose-dependent (P = 0.02) reduction in India ink uptake: 1.75 ± 0.17 for HA 1.6% and 1.58 ± 0.14 for HA 2.4%. The most marked dose-dependent effect of this study was a reduction of modified Mankin score for HA groups, with the 2.4% treatment achieving a statistically significant improvement as compared with the control group (7.19 ± 0.85 for saline, 4.65 ± 0.66 for HA 1.6%, and 3.53 ± 0.59 for HA 2.4%; P = 0.005).

CONCLUSIONS

A dose-dependent protective effect on cartilage was observed after injection of both HA solutions.