Efficacy, Safety, and Accuracy of Intra-articular Therapies for Hand Osteoarthritis: Current Evidence.

The lifetime risk of symptomatic hand osteoarthritis (OA) is 39.8%, with one in two women and one in four men developing the disease by age 85 years and no disease-modifying drug (DMOAD) available so far. Intra-articular (IA) therapy is one of the options commonly used for symptomatic alleviation of OA disease as it can circumvent systemic exposure and potential side effects of oral medications. The current narrative review focuses on the efficacy and safety profiles of the currently available IA agents in hand OA (thumb-base OA or interphalangeal OA) such as corticosteroids and hyaluronic acid (HA), as well as the efficacy and safety of IA investigational injectates in phase 2/3 clinical trials such as prolotherapy, platelet-rich plasma, stem cells, infliximab, interferon-? and botulinum toxin, based on the published randomized controlled trials on PubMed database. The limited published literature revealed the short-term symptomatic benefits of corticosteroids in interphalangeal OA while long-term data are lacking. Most of the short-term studies showed no significant difference between corticosteroids and hyaluronic acid in thumb-base OA, usually with a faster onset of pain relief in the corticosteroid group and a slower but greater (statistically insignificant) pain improvement in the HA group. The majority of studies in investigational agents were limited by small sample size, short-term follow-up, and presence of serious side effects. In addition, we reported higher accuracy rates of drug administrations under imaging guidance than landmark guidance (blind method), and then briefly describe challenges for the long-term efficacy and prospects of IA therapeutics.

Cell-free stem cell-derived extract formulation for treatment of knee osteoarthritis: study protocol for a preliminary non-randomized, open-label, multi-center feasibility and safety study.

BACKGROUND: Musculoskeletal conditions are highly prevalent, and knee OA is most common. Current treatment modalities have limitations and either fail to solve the underlying pathophysiology or are highly invasive. To address these limitations, attention has focused on the use of biologics. The efficacy of these devices is attributed to presence of growth factors (GFs), cytokines (CKs), and extracellular vesicles (EVs). With this in mind, we formulated a novel cell-free stem cell-derived extract (CCM) from human progenitor endothelial stem cells (hPESCs). A preliminary study demonstrated the presence of essential components of regenerative medicine, namely GFs, CKs, and EVs, including exosomes, in CCM. The proposed study aims to evaluate the safety and efficacy of intraarticular injection of the novel cell-free stem cell-derived extract (CCM) for the treatment of knee OA. METHODS AND ANALYSIS: This is a non-randomized, open-label, multi-center, prospective study in which the safety and efficacy of intraarticular CCM in patients suffering from grade II/III knee OA will be evaluated. Up to 20 patients with grade II/III OA who meet the inclusion and exclusion criteria will be consented and screened to recruit 12 patients to receive treatment. The study will be conducted at up to 2 sites within the USA, and the 12 participants will be followed for 24 months. The study participants will be monitored for adverse reactions and assessed using Numeric Pain Rating Scale (NPRS), Patient-Reported Outcomes Measurement Information System (PROMIS) Score, Knee Injury and Osteoarthritis Outcome Score Jr. (KOOS Jr.), 36-ietm short form survey (SF-36), Single Assessment Numeric Evaluation (SANE), physical exams, plain radiography, and magnetic resonance imaging (MRI) with Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) score for improvements in pain, function, satisfaction, and cartilage regeneration. DISCUSSION: This prospective study will provide valuable information into the safety and efficacy of intraarticular administration of cell-free stem cell-derived extract (CCM) in patients suffering with grade II/III knee OA. The outcomes from this initial study of novel CCM will lay the foundation for a larger randomized, placebo-controlled, multi-center clinical trial of intraarticular CCM for symptomatic knee OA. TRIAL REGISTRATION: Registered on July 21, 2021. ClinicalTrials.gov NCT04971798.

PLA-coated Imwitor® 900 K-based herbal colloidal carriers as novel candidates for the intra-articular treatment of arthritis.

Although there are several treatments for rheumatoid arthritis (RA), outcomes are unsatisfactory and often associated with many side effects. We attempted to improve RA therapeutic outcomes by intra-articular administration of dual drug-loaded poly(lactic) acid (PLA)-coated herbal colloidal carriers (HCCs). Curcumin (CU) and resveratrol (RES) were loaded into HCCs because of their safety and significant anti-inflammatory activity. HCCs were prepared using a high-pressure, hot homogenization technique and evaluated in vitro and in vivo using a complete Freund's adjuvant-induced arthritis model. Transmission electron microscope (TEM) evaluated coating selected formulations with PLA, which increased particle sizes from 52 to 89.14 nm. The entrapment efficiency of both formulations was approximately 76%. HCCs significantly increased the amount of RES and CU released compared with the drug suspensions alone. The in vivo treated groups showed a significant improvement in joint healing. PLA-coated HCCs, followed by uncoated HCCs, yielded the highest reductions in knee diameter, myeloperoxidase (MPO) levels, and tumor necrosis factor-alpha (TNFα) levels. Histological examination of the dissected joints revealed that PLA-coated HCCs followed by uncoated HCCs exhibited the most significant joint healing effects. Our results demonstrate the superiority of intra-articularly administered HCCs to suppress RA progression compared with RES or CU suspensions alone.

Changes in levels of cartilage oligomeric proteinase and urinary C-terminal telopeptide of type II collagen in subjects with knee osteoarthritis after dextrose prolotherapy: A randomized controlled trial.

OBJECTIVE: To assess the effects of dextrose prolotherapy in patients with knee osteoarthritis on the levels of serum cartilage oligomeric proteinase and urinary C-terminal telopeptide of type II collagen, and on the Western Ontario McMaster Universities Index and numerical rating scale score for pain. METHODS: A randomized controlled trial, in which participants were randomly allocated into 2 groups, receiving injections of either hyaluronic acid or dextrose prolotherapy. The hyaluronic acid group received 5 injections, 1 each on weeks 1, 2, 3, 4 and 5, and the dextrose prolotherapy group received 3 injections, 1 each on weeks 1, 5 and 9. Serum cartilage oligomeric proteinase, urinary C-terminal telopeptide of type II collagen, Western Ontario McMaster Universities Index score, and numerical rating scale score for pain were measured at baseline and 3 weeks after the last injection. Comparative analysis was conducted using Wilcoxon test within groups and analysis of covariance (ANCOVA) test between groups. RESULTS: A total of 47 participants (21 allocated to hyaluronic acid, 26 allocated to dextrose prolotherapy) completed the protocol. Both interventions resulted in significant improvements in numerical rating scale scores for pain, total Western Ontario McMaster Universities Index scores, and its subscales score. However, the dextrose prolotherapy outperformed hyaluronic acid in numerical rating scale score for pain and level of urinary C-terminal telopeptide of type II collagen, with score changes differences of 0.93 (p = 0.042) and 0.34 (p = 0.048), respectively. No significant changes in level of serum cartilage oligomeric proteinase were found in either group. CONCLUSION: Dextrose prolotherapy is an alternative injection therapy for knee osteoarthritis, which was found to be associated with a significant reduction in urinary C-terminal telopeptide of type II collagen compared with hyaluronic acid injection. Neither injection method resulted in reduced serum cartilage oligomeric proteinase.

Development of a novel intraarticular injection of diclofenac for the treatment of arthritis: a preclinical study in the rabbit model.

PURPOSE: To develop a novel intraarticular injection of diclofenac for the treatment of arthritis. METHOD: Diclofenac loaded nanoparticles were prepared by a nanoprecipitation technique using Eudragit L 100 as the polymer and polyvinyl alcohol as the surfactant. The nanoparticles were evaluated for particle size, zeta potential, scanning electron microscopy, drug release, encapsulation efficiency, and loading efficiency studies. The optimized nanoparticulate formulation was developed for intra articular injection. Intraarticulate injection was evaluated for pH, appearance, viscosity, osmolarity and syringability studies. The optimized injection formulation was tested in an arthritic model consisting of 25 rabbits. RESULT: Nanoprecipitation method was found to be suitable for diclofenac nanoparticles. The shape of the prepared nanoparticles was found to be spherical and devoid of any cracks and crevices. The average particle size of a diclofenac nanoparticle was found to range from 87±0.47 to 103±0.26 nm. The zeta potential of the prepared nanoparticles was found to be in the range of 0.598±0.34 to 0.826±0.25 mV. The encapsulation efficiency was found to be between 73.45% to 99.03%, while the drug loading was observed between 10.34 to 35.32%. The percentage drug release at 12 hours was found to range from 73.45% to 99.03%. CONCLUSION: The developed intraarticular injection was found to be within the physically and chemically accepted limits. Animals treated with the intra articular injection of diclofenac showed a significant reduction in swelling as compares to the other groups.

Comparison of Treatments for Frozen Shoulder: A Systematic Review and Meta-analysis.

Importance: There are a myriad of available treatment options for patients with frozen shoulder, which can be overwhelming to the treating health care professional. Objective: To assess and compare the effectiveness of available treatment options for frozen shoulder to guide musculoskeletal practitioners and inform guidelines. Data Sources: Medline, EMBASE, Scopus, and CINHAL were searched in February 2020. Study Selection: Studies with a randomized design of any type that compared treatment modalities for frozen shoulder with other modalities, placebo, or no treatment were included. Data Extraction and Synthesis: Data were independently extracted by 2 individuals. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Random-effects models were used. Main Outcomes and Measures: Pain and function were the primary outcomes, and external rotation range of movement (ER ROM) was the secondary outcome. Results of pairwise meta-analyses were presented as mean differences (MDs) for pain and ER ROM and standardized mean differences (SMDs) for function. Length of follow-up was divided into short-term (≤12 weeks), mid-term (>12 weeks to ≤12 months), and long-term (>12 months) follow-up. Results: From a total of 65 eligible studies with 4097 participants that were included in the systematic review, 34 studies with 2402 participants were included in pairwise meta-analyses and 39 studies with 2736 participants in network meta-analyses. Despite several statistically significant results in pairwise meta-analyses, only the administration of intra-articular (IA) corticosteroid was associated with statistical and clinical superiority compared with other interventions in the short-term for pain (vs no treatment or placebo: MD, -1.0 visual analog scale [VAS] point; 95% CI, -1.5 to -0.5 VAS points; P < .001; vs physiotherapy: MD, -1.1 VAS points; 95% CI, -1.7 to -0.5 VAS points; P < .001) and function (vs no treatment or placebo: SMD, 0.6; 95% CI, 0.3 to 0.9; P < .001; vs physiotherapy: SMD 0.5; 95% CI, 0.2 to 0.7; P < .001). Subgroup analyses and the network meta-analysis demonstrated that the addition of a home exercise program with simple exercises and stretches and physiotherapy (electrotherapy and/or mobilizations) to IA corticosteroid may be associated with added benefits in the mid-term (eg, pain for IA coritocosteriod with home exercise vs no treatment or placebo: MD, -1.4 VAS points; 95% CI, -1.8 to -1.1 VAS points; P < .001). Conclusions and Relevance: The findings of this study suggest that the early use of IA corticosteroid in patients with frozen shoulder of less than 1-year duration is associated with better outcomes. This treatment should be accompanied by a home exercise program to maximize the chance of recovery.

Needle knife therapy plus sodium hyaluronate injection for knee osteoarthritis: A protocol for a systematic review and meta-analysis.

BACKGROUND: Knee osteoarthritis (KOA) is a worldwide disease and more and more people are suffered from it. With the increasing number of patients, it brings a huge burden on social economy and security system. There are varieties of methods to cure KOA, such as Traditional Chinese Medicine and surgery. Needle knife therapy plus Sodium hyaluronate Injection is one of the prevalent treatments for KOA. Therefore, we perform a systematic review and meta-analysis to evaluate the evidence for the treatment of needle knife therapy plus sodium hyaluronate Injection. METHODS: Randomized controlled trials will be used to compare the effect of needle knife therapy plus sodium hyaluronate injection with needle knife alone for KOA patients. Six studies will be included in this meta-analysis, and the relative risk and weight mean difference with 95% CI for the Lysholm knee score, visual analogue scale, and effective rate will be evaluated by using RevMan 5.3 software. Besides, the bias assessment of the included studies will be evaluated using the Cochrane risk of bias tool, and the Grading of Recommendations, Assessment Development, and Evaluation system will be applied to assess the overall quality of the evidence. RESULTS: From the study we will assess the effectiveness, safety of needle knife therapy plus sodium hyaluronate injection on joint pain relief and functional improvement in patients with KOA. CONCLUSION: The study will provide a new evidence to confirm the effect of needle knife therapy plus sodium hyaluronate injection on KOA, which can further guide the selection of therapy. PROSPERO REGISTRATION NUMBER: CRD42020169602.

Intra-Articular Route for the System of Molecules 14G1862 from Centella Asiatica: Pain Relieving and Protective Effects in a Rat Model of Osteoarthritis.

Current pharmacological therapies for the management of chronic articular diseases are far from being satisfactory, so new strategies need to be investigated. We tested the intra-articular pain relieving properties of a system of molecules from a characterized Centella asiatica extract (14G1862) in a rat model of osteoarthritis induced by monoiodoacetate (MIA). 14G1862 (0.2-2 mg mL-1) was intra-articularly (i.a.) injected 7 days after MIA, behavioural and histological evaluations were performed 14, 30 and 60 days after treatments. Moreover, the effect of 14G1862 on nitrate production and iNOS expression in RAW 264.7 macrophages stimulated with LPS was assessed. In vitro, 14G1862 treatment attenuated LPS-induced NO production and iNOS expression in a comparable manner to celecoxib. In vivo, 14G1862 significantly reduced mechanical allodynia and hyperalgesia, spontaneous pain and motor alterations starting on day 14 up to day 60. The efficacy was higher or comparable to that evoked by triamcinolone acetonide (100 µg i.a.) used as reference drug. Histological evaluation highlighted the improvement of several morphological parameters in MIA + 14G1862-treated animals with particularly benefic effects on joint space and fibrin deposition. In conclusion, i.a. treatment with Centella asiatica is a candidate to be a novel effective approach for osteoarthritis therapy.

Extracorporeal Shock Wave Therapy for the Treatment of Osteoarthritis: A Systematic Review and Meta-Analysis.

BACKGROUND: Osteoarthritis is the most common musculoskeletal disease. Extracorporeal shockwave therapy had shown an effect on osteoarthritis in both some animal experiments and clinical studies, but there was no systematic review to confirm the value of shockwave therapy in the treatment of all types of osteoarthritis and compare it with other traditional therapies (especially traditional Chinese medicine). METHOD: PubMed, Medline, the Cochrane Central Register of Controlled Trials, Web of Science, Chinese National Knowledge Infrastructure, WANFANG database, and VIP database were searched up to December 10, 2019, to identify randomized controlled trials comparing shockwave therapy and other treatments for osteoarthritis. Visual analogue scale and the Western Ontario and McMaster Universities Osteoarthritis Index were extracted and analyzed by RevMan and STATA software as outcomes of pain reduction and functional improvement. Adverse reactions were recorded to evaluate the safety of shockwave therapy. RESULTS: Shockwave therapy had significant improvement in both pain reduction and functional improvement compared with placebo, corticosteroid, hyaluronic acid, medication, and ultrasound (P < 0.05). In functional improvement, shockwave therapy showed statistical improvement compared with kinesiotherapy and moxibustion (P < 0.05) but not with acupotomy surgery (P = 0.24). A significant difference between shockwave therapy and platelet-rich plasma was observed in pain reduction (P < 0.05) but not in functional improvement (P = 0.89). Meanwhile, a statistical difference was found between shockwave therapy and fumigation in functional improvement (P < 0.05) but not in pain reduction (P = 0.26). Additionally, there was no statistically significant difference between shockwave therapy and manipulation in both pain reduction (P = 0.21) and functional improvement (P = 0.45). No serious adverse reaction occurred in all of studies. CONCLUSIONS: Extracorporeal shockwave therapy could be recommended in the treatment of osteoarthritis as a noninvasive therapy with safety and effectiveness, but the grade of recommendations needs to be discussed in a further study.

A report on the use of a single intra-articular administration of autologous platelet therapy in a naturally occurring canine osteoarthritis model - a preliminary study.

BACKGROUND: Osteoarthritis (OA) represents a significant burden to societies, as it affects quality of life, performance and poses a large healthcare cost. We aimed to describe the use of a single intra-articular (IA) injection of an autologous platelet therapy in the management of osteoarthritis (OA) in a naturally occurring canine model. METHODS: Fifteen police working dogs with bilateral hip OA were treated with 3 ml of platelet concentrate per hip joint, produced with the V-PET kit. Response to treatment was measured by the Canine Brief Pain Inventory (CBPI, divided in pain interference score - PIS, and Pain Severity Score - PSS), Liverpool Osteoarthritis in Dogs (LOAD), Canine Orthopedic Index (COI, divided in four dimensions: function, gait, stiffness and quality of life - QOL) and the Hudson Visual Analogue Scale (HVAS). Seven different time points were considered: T0 (before treatment), T1 (after 15 days), T2, T3, T4, T5 and T6 (after 1, 2, 3, 4 and 5 months respectively). Results from each evaluation moment were compared with T0 with a Paired Samples T-Test, and a p < 0.05 was set. RESULTS: Significant differences were observed at T1 (p < 0.01 for HVAS, PSS, COI, Gait and QOL; p = 0.01 for PIS; p = 0.02 for Function; and p < 0.05 for Stiffness), T2 (p < 0.01 for PSS, PIS and Gait; p = 0.01 for COI; p = 0.02 for HVAS, Function and QOL; and p = 0.04 for Stiffness), T3 (p < 0.01 for HVAS, PSS, PIS, Function and Gait; p = 0.01 for COI; and p = 0.02 for QOL), T4 (p < 0.01 for PSS; p = 0.03 for PIS and Gait), T5 (p < 0.01 for COI, Function and Gait; p = 0.03 for PSS, PIS and Stiffness), T6 (p < 0.01 for PSS, Function and Gait; p = 0.04 for PIS; p < 0.05 for COI) and T7 (p < 0.01 for PSS, Function and Gait; p = 0.01 for COI; and p < 0.05 for PIS). CONCLUSIONS: Autologous platelet therapy was used without apparent harm in the subjects. A single administration produced significant improvements, which lasted several months, and therefore warrants further study.

Intra-articular ozone therapy efficiently attenuates pain in knee osteoarthritic subjects: A systematic review and meta-analysis.

OBJECTIVES: Ozone (O3) gas is being used for chronic pain relief in knee osteoarthritis (KOA). However, there are controversies whether this gas can be medically useful in KOA pain treatments. The aim of this study was to evaluate the effectiveness of intra-articular ozone therapy for pain relief in KOA subjects using a systematic review and meta-analysis and standardized mean difference (SMD) as the effect size. METHOD: Using specialized biomedical online databases of Pubmed Central, Pubmed, Medline, Google scholar, Scopus and Embase databases without the beginning date restriction until July 2018, the systematic review retrieved 10 studies for meta-analysis after fulfilling the inclusion and exclusion criteria. RESULTS: Analysis of Q and I2% indices showed a high heterogeneity in the selected studies (2600.330 and 99.654, respectively), thus, the random-effects model was chosen for SMD calculation. The primary analysis for the main hypothesis found that the weighted pooled effect size for the impact of intra-articular ozone therapy for pain reduction was as follows: SMD= -28.551 (95% confidence interval, -32.553 to -24.549). The P-value for the significance of the combined SMD examined by the z-test was 0.000 and thus, it was clearly considered statistically significant. CONCLUSION: This meta-analysis presents evidence that intra-articular ozone therapy is an effective way for chronic pain management in KOA.

Comparative Effectiveness of Injection Therapies in Rotator Cuff Tendinopathy: A Systematic Review, Pairwise and Network Meta-analysis of Randomized Controlled Trials.

OBJECTIVE: To compare the effectiveness of diverse injections in patients with rotator cuff tendinopathy using pairwise and network meta-analysis. DATA SOURCES: PubMed, EMBASE, Scopus, and Cochrane Library were searched for studies published up to September 31, 2017. STUDY SELECTION: We included all published or unpublished randomized controlled trials (RCTs) comparing diverse injections including corticosteroid, nonsteroidal anti-inflammatory drugs, hyaluronic acid, botulinum toxin, platelet-rich plasma (PRP), and prolotherapy in patients with rotator cuff tendinopathy. Among the 1495 records screened, 18 studies were included in the meta-analysis. DATA EXTRACTION: The quality of RCTs was assessed with Cochrane Risk of Bias Tool by 2 independent raters. The primary outcome was pain reduction, and the secondary outcome was functional improvement. DATA SYNTHESIS: Standardized mean difference (SMD) was used for pairwise and network meta-analysis. In pairwise meta-analysis, corticosteroid was more effective only in the short term in both pain reduction and functional improvement. Network meta-analysis indicated that prolotherapy significantly reduced pain compared with placebo in the long term (over 24wk; SMD: 2.63; 95% confidence interval [CI], 1.88-3.38); meanwhile PRP significantly improved shoulder function compared with placebo in the long term (over 24wk; SMD: 0.44; 95% CI, 0.05-0.84). CONCLUSIONS: For patients with rotator cuff tendinopathy, corticosteroid plays a role in the short term (3-6wk) but not in long-term (over 24wk) pain reduction and functional improvement. By contrast, PRP and prolotherapy may yield better outcomes in the long term (over 24wk). On account of heterogeneity, interpreting these results with caution is warranted.

Change of site of intra-articular injection of hypertonic dextrose resulted in different effects of treatment.

Most minimally invasive treatments for dysfunction of the temporomandibular joint (TMJ) are empirical, and aimed at the painful trigger points with the purpose of preventing muscular spasm and restoring normal function. In this prospective study I investigated whether the choice of site of injection of hypertonic dextrose affected the benefits of treatment of internal derangement and pain. I studied 72 patients with pain and clicking as a result of dysfunction of the TMJ. Patients were divided into four groups with four separate sites for intra-articular injection. Dextrose was injected into the superior joint space, inferior joint space, retrodiscal tissue, and anterior capsule injection. Results showed that the retrodiscal site was the most effective for reducing clicking and subsequently improving derangement, while the inferior joint space was the best site for the relief of pain, and the extracapsular site should be used in cases of hypermobility. In conclusion, the injection site should be selected according to the symptoms being treated, and could be used as an adjunct to other sites to improve outcome.

Oral Glucosamine Hydrochloride Combined With Hyaluronate Sodium Intra-Articular Injection for Temporomandibular Joint Osteoarthritis: A Double-Blind Randomized Controlled Trial.

PURPOSE: Temporomandibular joint (TMJ) disorders occur in many people and osteoarthritis (OA) is a severe form of this disease. Glucosamine has been used to treat OA of the large joints for many years and has been proved effective. A double-blinded randomized controlled trial was designed to investigate the effectiveness and safety of oral glucosamine hydrochloride pills combined with hyaluronate sodium intra-articular injection in TMJ OA. PATIENTS AND METHODS: One hundred forty-four participants with TMJ OA were randomized to 4 hyaluronate sodium injections and oral glucosamine hydrochloride (1.44 g/day) for 3 months (group A) or 4 hyaluronate sodium injections and oral placebo for 3 months (group B). All participants were followed for 1 year. Eighteen participants were lost to follow-up. RESULTS: The intention-to-treat analysis showed that group A had similar maximal interincisal mouth opening and pain intensity during TMJ function at months 1 and 6 (P > .05). However, during long-term follow-up, group A had significantly greater maximal interincisal mouth opening compared with group B at month 12 (41.5 vs 37.9 mm; P < .001). For pain intensity, group A showed obviously lower visual analog scale scores than group B at month 6 (20.6 vs 29.2 mm; P = .007) and month 12 (17.4 vs 28.6 mm; P = .001). Twenty-four participants had gastrointestinal tract side effects, fatigue, and rash. Of these, 23 had slight side effects that were not correlated with glucosamine. There was no significant difference between the 2 groups (P > .05). CONCLUSION: The results of this study suggest that, compared with hyaluronate sodium injection alone, glucosamine hydrochloride pills added to hyaluronate sodium injection had no meaningful effect on TMJ OA in the short-term but did relieve the pain caused by TMJ OA and improved TMJ functions in the long-term.

Evaluation of the Short- and Long-Term Effectiveness of Pulsed Radiofrequency and Conventional Radiofrequency Performed for Medial Branch Block in Patients with Lumbar Facet Joint Pain.

Background: Diagnosis of lumbar facet joint disease is the sum of the combinations consisting of history, physical activity, and diagnostic imaging frequently including computed tomography and magnetic resonance imaging scans. Prevalence of facet-based chronic low back pain is 15-45%. Intra-articular injections with corticosteroid or medial branch block are traditionally used prevalently in the management of chronic low back pain due to lumbar facet joints. However, the evidence levels of these procedures are at either a low or a medium level. Radiofrequency neurolysis of the lumbar medial branch can be used as an alternative in the management of lumbar facet joint pain. There are two types of radiofrequency applications for radiofrequency neurolysis as pulsed radiofrequency and conventional radiofrequency. Materials and Methods: Patients with lumbar facet pain were separated into 2 groups. Group 1 (n=75): patients were given pulsed radiofrequency under fluoroscopy. Group 2 (n=43): patients were given conventional radiofrequency under fluoroscopy. Pre-op and post-op 1st, 3rd, and 6th month and 1st and 2nd year Visual Analogue Scale values of all patients were asked, recorded, and statistically compared. Visual Analogue Scale values of the groups in the same months were compared as well. At the end of the second year, Odom criteria of both groups were recorded and statistically compared. Results: Preoperation Visual Analogue Scale values and postoperation 1st, 3rd, and 6th month and 1st and 2nd year Visual Analogue Scale values were compared in Group 1 and Group 2, and there was a statistically significant difference between preoperation Visual Analogue Scale values and postoperation 1st, 3rd, and 6th month and 1st and 2nd year Visual Analogue Scale values in both groups. However, the number of repetitions of the operation was higher in Group 1. In the comparison of Odom criteria for both groups at the end of the second year, it was observed that the patients in Group 2 were more satisfied with the treatment. Conclusion: Conventional radiofrequency in patients with lumbar facet joint pain for medial branch neurolysis effectively decreases Visual Analogue Scale values in both short and long term. The quality of life and daily activities of patients were better at conventional radiofrequency.

Clinical outcome after 36 months of treatment with injections of autologous blood for recurrent dislocation of the temporomandibular joint.

We investigated the prognosis after three years of treatment for recurrent dislocation of the temporomandibular joint with autologous blood given intravenously in 21 patients with a mean (range) age 64 (17-92) years of whom 16 had coexisting systemic disease. The mean (range) follow up from the first injection was 64 (41-99) months. Eighteen patients had no recurrence during the first 36 months after their first injection, which showed that this minimally-invasive treatment was effective, particularly for those who had conditions that made a mouthpiece or operation unsuitable.

Chitosan in viscosupplementation: in vivo effect on rabbit subchondral bone.

BACKGROUND: To investigate the effect of intra-articular injection of Chitosan (Cs) added to hyaluronic acid (HA) on subchondral bone during osteoarthritis (OA), microarchitectural parameters and mineral density were measured in a rabbit model of early OA. A novel hybrid hydrogel adding reacetylated Cs of fungal origin to HA was compared to high molecular weight HA commercial formulation. METHOD: Eighteen rabbits underwent unilateral anterior cruciate ligament transection (ACLT) and were divided into three groups (Saline-group, HA-group and Hybrid-group) depending on the intra-articular injection compound. Eight contralateral knees were used as non-operated controls (Contralateral-group). Micro-computed tomography was performed six weeks post-ACLT to study subchondral bone microarchitectural parameters and mineral density at an early stage of OA development. RESULTS: Cartilage thickness mean value was reduced only in Saline-group compared to Contralateral-group. When the Hybrid-group was compared to Saline-group, subchondral bone microarchitectural parameters (trabecular thickness and trabecular bone volume fraction) were significantly changed; subchondral bone plate and trabecular bone mineral densities (bone mineral density and tissue mineral density) were reduced. When the Hybrid-group was compared to HA-group, subchondral bone microarchitectural parameters (subchondral plate thickness and trabecular thickness) and trabecular bone mineral densities (bone mineral density and tissue mineral density) were significantly decreased. CONCLUSION: Conclusion: Compared to HA alone, the novel hybrid hydrogel, constituted of Cs added to HA, enhanced microarchitectural parameters and mineral density changes, leading to subchondral bone loss in a rabbit model of early experimental OA.

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

PURPOSE: The aim of this experimental study was to investigate the impact of HA-CS-NAG compound (hyaluronate, sodium chondroitin sulfate, N-acetyl-d-glucosamine) on the quality of repair tissue after micro-fracture and to compare it with HA (hyaluronat), in a rat full-thickness chondral defect model. METHODS: Full-thickness chondral defects were created in a non-weight bearing area by using a handle 2.7-mm drill bit, in the right knees of 33 Sprague-Dawley rats. Each specimen then underwent micro-fracture using a needle. Two weeks after surgery, 3 groups were randomly formed among the rats (n = 33). In Group 1, 0.2 mL of sterile saline solution (0.9%) was injected. In Group 2, 0.2 mL HA with a mean molecular weight of 1.2 Mda was injected. In Group 3, 0.2 mL of HA-CS-NAG compound (hyaluronate, sodium chondroitin sulfate, N-acetyl-d-glucosamine) was injected. The injections were applied on the 14th, the 21st and the 28th postoperative days. All rats were sacrificed on the 42nd postoperative day. Histological analysis of the repair tissue was performed for each specimen by two blinded observers using Wakitani scoring system. RESULTS: There was significantly improved repair tissue in both Group 3 and Group 2 when compared with Group 1. Group 3 showed statistically significant improvement in terms of 'cell morphology' and 'integration of donor with host' when compared to Group 2 (p < 0.001). CONCLUSION: Intra-articular injection of HA-CS-NAG compound after micro-fracture results in significantly improved repair tissue in rats' chondral defects when compared to HA regarding the donor integration and cell morphology.

Juvenile Idiopathic Arthritis.

Juvenile idiopathic arthritis is the most common chronic rheumatic disease of unknown aetiology in childhood and predominantly presents with peripheral arthritis. The disease is divided into several subgroups, according to demographic characteristics, clinical features, treatment modalities and disease prognosis. Systemic juvenile idiopathic arthritis, which is one of the most frequent disease subtypes, is characterized by recurrent fever and rash. Oligoarticular juvenile idiopathic arthritis, common among young female patients, is usually accompanied by anti-nuclear antibodie positivity and anterior uveitis. Seropositive polyarticular juvenile idiopathic arthritis, an analogue of adult rheumatoid arthritis, is seen in less than 10% of paediatric patients. Seronegative polyarticular juvenile idiopathic arthritis, an entity more specific for childhood, appears with widespread large- and small-joint involvement. Enthesitis-related arthritis is a separate disease subtype, characterized by enthesitis and asymmetric lower-extremity arthritis. This disease subtype represents the childhood form of adult spondyloarthropathies, with human leukocyte antigen-B27 positivity and uveitis but commonly without axial skeleton involvement. Juvenile psoriatic arthritis is characterized by a psoriatic rash, accompanied by arthritis, nail pitting and dactylitis. Disease complications can vary from growth retardation and osteoporosis secondary to treatment and disease activity, to life-threatening macrophage activation syndrome with multi-organ insufficiency. With the advent of new therapeutics over the past 15 years, there has been a marked improvement in juvenile idiopathic arthritis treatment and long-term outcome, without any sequelae. The treatment of juvenile idiopathic arthritis patients involves teamwork, including an experienced paediatric rheumatologist, an ophthalmologist, an orthopaedist, a paediatric psychiatrist and a physiotherapist. The primary goals of treatment are to eliminate active disease, to normalize joint function, to preserve normal growth and to prevent long-term joint damage. Timely and aggressive treatment is important to provide early disease control. The first-line treatment includes disease-modifying anti-rheumatic drugs (methotrexate, sulphasalazine, leflunomide) in combination with corticosteroids, used in different dosages and routes (oral, intravenous, intra-articular). Intra-articular application of steroids seems to be an effective treatment modality, especially in monoarthritis. Biological agents should be added in the treatment of unresponsive patients. Anti-tumour necrosis factor agents (etanercept, infliximab, adalimumab), anti-interleukin-1 agents (anakinra, canakinumab), anti- interleukin-6 agents (tocilizumab) and T-cell regulatory agents (abatacept) have been shown to be safe and effective in childhood patients. Recent studies reported sustained reduction in joint damage with even complete clinical improvement in paediatric patients, compared to previous data.

Cervical Facet Joint Imaging-Guided Injections: A Comparison of Outcomes in Patients Referred Based on Imaging Findings Vs Palpation for Pain.

OBJECTIVES: The purpose of this study was to compare outcomes of patients referred for cervical facet joint injections by either a medical doctor (MD) primarily basing the selection of facet levels on structural changes found on imaging vs a doctor of chiropractic (DC) selecting the levels for injection based on palpation for pain. METHODS: This was a prospective cohort outcome study including 121 consecutive patients receiving cervical facet injections with completed outcomes questionnaires. Medical doctors referred 91 patients and DCs referred 30 patients. Baseline pain numerical rating scale (NRS) data were collected. Outcomes collected at 1 day, 1 week, and 1 month after injection included NRS pain levels and overall "improvement" using the Patient Global Impression of Change scale (primary outcome). The responses "much better" and "better" were considered "improved." The proportion improved was compared between the 2 groups using the χ(2) test. NRS change scores for the 2 groups were compared using the unpaired t test. RESULTS: At 1 day, "improvement" was reported in 44.8% of DC-and 29.7% of MD-referred patients (P = .17). At 1 week, 37.9% of DC-and 21.3% of MD-referred patients reported improvement (P = .03). At 1 month, 50.0% of DC-and 31.0% of MD-referred patients reported improvement (P = .1). CONCLUSIONS: A greater proportion of DC-referred patients (injection level based on palpation for pain) reported "improvement" at all follow-up time points. This finding reached statistical significance at 1 week. These findings may be because DCs use palpation for pain to determine injection level whereas MDs rely more on imaging findings. The results suggest that the reported moderate results of facet injections partially may be due to the inaccurate selection of the spinal level treated.