The challenge of the definition of early symptomatic knee osteoarthritis: a proposal of criteria and red flags from an international initiative promoted by the Italian Society for Rheumatology.

The aim of this study was to establish consensus for potential early symptomatic knee osteoarthritis (ESKOA) clinical definition and referral criteria from primary care to rheumatologists, based on available data from literature and a qualitative approach, in order to perform studies on patients fulfilling such criteria and to validate the obtained ESKOA definition. A complex methodological approach was followed including: (1) three focus groups (FG), including expert clinicians, researchers and patients; (2) a systematic literature review (SLR); (3) two discussion groups followed by a Delphi survey. FG and SLR were performed in parallel to inform discussion groups in order to identify relevant constructs to be included in the modified Delphi survey. ESKOA is defined in the presence of: (a) two mandatory symptoms (knee pain in the absence of any recent trauma or injury and very short joint stiffness, lasting for less than 10 min, when starting movement) even in the absence of risk factors, or (b) knee pain, and 1 or 2 risk factors or (c) three or more risk factors in the presence of at least one mandatory symptom, with symptoms lasting less than 6 months. These criteria are applicable in the absence of active inflammatory arthritis, generalized pain, Kellgren-Lawrence grade >0, any recent knee trauma or injury, and age lower than 40 years. Knee pain in the absence of any recent trauma lasting for less than 6 months was considered as the referral criterion to the rheumatologist for the suspicion of ESKOA. This consensus process has identified provisional clinical definition of ESKOA and defined potential referral criterion to rheumatologist, in order to test ESKOA obtained definition in prospective validation studies.

Therapeutic efficacy of three hyaluronic acid formulations in young and middle-aged patients with early-stage meniscal injuries.

[Purpose] To investigate and compare the efficacy of three hyaluronic acid formulations in patients with early-stage meniscal injuries. [Subjects and Methods] Male and female patients who were admitted to our clinic between January 2013 and December 2013, diagnosed with early-stage meniscus lesions of the knee, and given a hyaluronic acid treatment were included in this retrospective study. Patients were categorized into 3 groups according to their treatments: MONOVISC, OSTENIL PLUS, or ORTHOVISC. Scores from a Visual Analog Scale and the Western Ontario and McMaster Universities Arthritis Index were evaluated at baseline and one, three, and six months after baseline. [Results] A total of 55 patients were included in this study. Most of the patients were female (55%), and the mean age of the patients was 42.4 (± 8.1) years. Based on the pre- and post-injection data, there was significant reductions both in the Visual Analog Scale score and the Western Ontario and McMaster Universities Arthritis Index score after the injections for all groups. According to intergroup comparisons, no significant difference was observed in terms of efficacy. [Conclusion] Three hyaluronic acid formulations produced a similar efficacy in patients with meniscal injuries, and further studies are needed to evaluate long-term results.

Effect of platelet concentration on clinical improvement in treatment of early stage-knee osteoarthritis with platelet-rich plasma concentrations.

[Purpose] To compare two platelet-rich plasma kits with different platelet concentrations for treatment of knee osteoarthritis. [Subjects and Methods] Male and female patients with knee osteoarthritis who had confirmed diagnosis with X-ray and magnetic resonance imaging were included in this retrospective study. Eligible patients were divided into two groups: Group I, which received platelet-rich plasma kit I, and Group II, which received platelet-rich plasma kit II. Platelet concentrations of both kits were measured by manual counting. For each group, platelet-rich plasma kit was injected twice with a one-month interval between injections. The Western Ontario and McMaster Universities Osteoarthritis Index and the Visual Analog Scale were applied for clinical evaluation before the first injection and one, three and six months after the second injection. [Results] Kits I and II contained 1,000,000 and 3,000,000 platelets/µl respectively. In both groups, initial Western Ontario and McMaster Universities Osteoarthritis Index and Visual Analog Scale scores were significantly higher compared to the latter evaluations. However, no significant difference was observed between groups in terms of clinical evaluations. [Conclusion] Similar clinical results were found in groups receiving different platelet concentrations, therefore, a concentration of 1,000,000 platelet/µl is considered sufficient for pain relief and functional recovery.

Effect of platelet-rich plasma injections versus placebo on pain and quality of life in patients with hip osteoarthritis: A double-blind, randomized clinical trial.

Objectives: This study aims to compare the efficacy of intra-articular platelet-rich plasma (PRP) injections over a saline placebo in terms of reduction of pain and impact on quality of life among patients with hip osteoarthritis. Patients and methods: A total of 60 patients (29 males, 31 females, mean age: 57.9±7.3 years; range, 47 to 69 years) with known hip osteoarthritis of Kellgren-Lawrance (KL) Grades 2/3 were randomized into placebo (n=30) and PRP groups (n=30) between June 2014 and June 2015. Both groups received intra-articular injections into the hip joint under ultrasound guidance for three consecutive weeks. The patients were followed for six months, and pain reduction was assessed using the Visual Analog Scale (VAS), Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire, and Short Form Health Survey-36 (SF-36). Results: Intra-articular PRP treatment showed no advantage over a saline placebo in terms of VAS scores during activity. Both groups showed a significant improvement in VAS activity scores at one and six months. The placebo group showed improvements in VAS resting scores, whereas the PRP group did not. Both groups showed no improvement in WOMAC-total scores. Both groups showed no significant improvement across most SF-36 domains with the exception of improved physical role functioning at one month and general health at one and six months in the placebo group. Conclusion: Intra-articular injections of PRP show no significant difference compared to a saline placebo over a period of six months on pain, function, and quality of life scores in patients with hip osteoarthritis.

Different doses of hyaluronic acid injections in patients with knee osteoarthritis: A multicenter, randomized, prospective, single-blind, clinical study.

BACKGROUND: Many formulations and dosing regimens are available for hyaluronic acid (HA). OBJECTIVE: To compare different doses of linear, high-molecular weight (HMW) HA injections among patients with knee osteoarthritis (OA). METHODS: Hundred patients were included in this randomized, single-blinded trial and randomly divided into three HA injection groups. The first group received five weekly 20 mg HA injections, the second group received three weekly 32 mg HA injections, and the third group received a single 48 mg HA injection. Patients were evaluated at baseline, 1, 3, and 6 months after the last injection for pain, stiffness, and function using the visual analog scale (VAS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. Quality of life, patient's global assessment, and Timed Up and Go (TUG) test scores were also evaluated. RESULTS: There was significant improvement in the WOMAC, VAS-pain, quality of life, patient's global assessment, and TUG test mean scores at all follow-up time points (p< 0.001). However, the groups showed no significant differences in WOMAC, VAS-activity pain, and patient global scores at any follow-up point. CONCLUSION: Intra-articular injections of different doses of linear HMW HA can improve pain, stiffness, function, and quality of life in patients suffering from knee OA over a six-month period.

The role of ultrasound imaging of temporomandibular joint condyle-disc complex disorders.

OBJECTIVE: This study aimed to determine the diagnostic value of ultrasonography (US) in internal derangements of temporomandibular joint (TMJ) and to compare its efficacy with magnetic resonance imaging (MRI). METHODS: Fifty patients with MRI indications due to a TMJ disorder were enrolled. Findings of the clinical examination, US examination and MRI examination were noted by seperate clinicians and the sensitivity, specificity and diagnostic accuracies of all examinations were compared. RESULTS: When compared with MRI, the sensitivity, specificity and diagnostic accuracy of the clinical examination for the internal derangements were 73%, 37%, and 70%, respectively and 75.7%, 33.3% and 73.0% for US examination, respectively. CONCLUSION: US can be considered as an alternative to MRI as it can be used to detect the disc position, internal derangements, intraarticular fluid accumulations and superficial condyle changes with minimally better results than clinical examination.

EUROVISCO Good Practice Recommendations for a First Viscosupplementation in Patients with Knee Osteoarthritis.

RATIONALE: Viscosupplementation (VS) with hyaluronic acid is widely used in the management of knee osteoarthritis. There is no clear recommendation on the decision-making to achieve VS. DESIGN: Based on extensive research of the literature and expert opinion, the members of the EUROVISCO (European Viscosupplementation Consensus Group) task force were asked to give their degree of agreement with 60 issues, using a Delphi method. RESULTS: The expert panel achieved unanimous agreement in favor of the following statements: It is recommended to assess pain on a visual or 10-point numeric scale before considering VS. VS can be considered for patients with pain scores between 3 and 8. A standard x-ray must be obtained before the decision of VS. If the x-ray is normal, osteoarthritis must be confirmed by MRI or computed tomography (CT) arthrogram before considering VS. The aims of VS are relieving pain, improving function, and reducing non-steroidal anti-inflammatory drug (NSAID) consumption. The use of VS must not be considered for treating an osteoarthritis flare. VS can be envisaged as a first-line pharmacological treatment in patients having a contra-indication to NSAIDs or analgesics. VS can be considered in patients with contra-indications to arthroplasty. In the case of severe comorbidities (diabetes, hypertension, gastrointestinal disorders, renal failure), VS can avoid the use of potentially dangerous treatments. VS can be considered in patients receiving antiplatelet agents, vitamin K antagonists, and direct factor Xa or thrombin inhibitors. Five other statements obtained a high level of consensus. CONCLUSION: These recommendations, illustrated in a decision algorithm, have been established to help practitioners in the decision-making of knee VS.

Evaluation of disease burden, patient journey, unmet diagnosis and treatment needs of patients with HIP and knee osteoarthritis in Turkey: A study through Delphi Methodology.

Objective: To get information-driven insights from expert physicians regarding multiple aspects of the patient journey in knee and hip OA and establish a consensus for future studies and decision tree models in Turkey. Design: 157 questions were asked in total during this three-round modified Delphi-method panel to 10 physical medicine and rehabilitation specialists (2 have rheumatology and 3 have algology subspeciality), one orthopaedic surgeon and one algology specialist from anaesthesia specialty background. A consensus was achieved when 80% of the panel members agreed with an item. Contradictions between different disciplines were accepted as a non-consensus factor. Results: Panellists agreed that American College of Rheumatology classification criteria is mostly sufficient to provide an OA diagnosis in clinical practice, OA patients with ≥5 Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain or physical function score can be defined as moderate-to-severe OA if they have an additional ≥2 Kellgren-Lawrence (KL) score, a minimum improvement of 30% from baseline in WOMAC pain or function subscales or in PGA score can be accepted as moderate treatment response where ≥50% improvement from baseline in those scores as substantial response. Panellists stated that arthroplasty procedures need to be delayed as long as possible, but this delay should not jeopardize a beneficial and successful operation. Conclusions: These findings show that there is a significant disease burden, unmet treatment needs for patients with moderate-to-severe OA in Turkey from experts' perspective. Therefore, an updated systematic approach and decision tree models are needed to be implemented.

What We Should Expect from an Innovative Intra-Articular Hyaluronic Acid Product: Expert Opinion Based on a Comprehensive Review of the Literature.

BACKGROUND: Intra-articular hyaluronic acid (IAHA) products are often used in the treatment of adults with mild-to-moderate knee osteoarthritis (KOA). The International Symposium on Intra-Articular Treatment (ISIAT) convened a multidisciplinary technical expert panel to define characteristics for an innovative IAHA product that should answer unmet needs in the clinical management of adults with mild-to-moderate KOA. METHODS: An initial set of evidence-based statements was developed based on data extracted from articles identified through a comprehensive literature search. A Delphi panel comprising 19 experts in KOA voted in 3 rounds to rate their degree of agreement with accepted statements. RESULTS: The final set of 13 accepted statements focus on the effect of an innovative IAHA across 5 key domains of nociceptive pain, joint function, quality of life, joint structure and integrity, and adverse effects. The statements set thresholds for clinically meaningful improvements that exceed those generally achievable by currently available IAHA products. CONCLUSION: The characteristics described by these statements from the ISIAT set new standards for what should be expected from an innovative IAHA. These statements should serve as a framework for driving the development of innovative IAHA products that will surpass the actual outcomes achieved by current viscosupplements in patients with mild-to-moderate KOA.

Early Osteoarthritis Questionnaire (EOAQ): a tool to assess knee osteoarthritis at initial stage.

Background: Early stage of osteoarthritis (OA) is characterized by joint stiffness and pain as well as by subclinical structural changes that may affect cartilage, synovium, and bone. At the moment, the lack of a validated definition of early osteoarthritis (EOA) does not allow to make an early diagnosis and adopt a therapeutic strategy to slow disease progression. Also, no questionnaires are available to evaluate the early stage, and therefore this remains an unmet need. Objective: Therefore, the purpose of the technical experts panel (TEP) of 'International Symposium of intra-articular treatment' (ISIAT) was to create a specific questionnaire to evaluate and monitor the follow-up and clinical progress of patients affected by early knee OA. Design: The items for the Early Osteoarthritis Questionnaire (EOAQ) were identified according to the following steps: items generation, items reduction, and pre-test submission. Methods: During the first step, literature has been reviewed and a comprehensive list of items about pain and function in knee EOA was drafted. Then, during the ISIAT (5th edition 2019), the draft has been discussed by the board, which reformulated, deleted, or subdivided some of the items. After the ISIAT symposium, the draft was submitted to 24 subjects affected by knee OA. A score based on the importance and the frequency was created and the items with a score ⩾0.75 were selected. After intermediate evaluation made by a sample of patients, the second and final version of the questionnaire EOAQ was submitted to the whole board for final analysis and acceptance in a second meeting (29 January 2021). Results: After an exhaustive elaboration, the final version of the questionnaire contains two domains (Clinical Features and Patients Reported Outcome) with respectively 2 and 9 questions, for a total of 11 questions. Questions mainly explored the fields of early symptoms and patients reported outcomes. Marginally, the need of the symptoms treatment and the use of painkillers were investigated. Conclusions: Adoption of diagnostic criteria of early OA is strongly encouraged and a specific questionnaire for the whole management of the clinical features and patients' outcome might really improve the evolution of OA in the early stages of the disease, when the treatment is expected to be more effective.

Ultrasound-guided cervical selective nerve block: A case series.

BACKGROUND: Cervical radiculopathy is characterized by pain, numbness, tingling, and weakness, mostly in an affected extremity, reflecting compression of a nerve in the neck is compressed or irritated where it emerges from the spinal cord. Diagnosis requires a detailed anamnesis, physical examination, and imaging. Physical therapy, exercise, medical therapy, and injections are the preferred treatments, but injections into the cervical region are only indicated if conservative treatment is ineffective. OBJECTIVE: This study explored the utility of selective cervical nerve root blocks (SNRBs) performed at various levels under ultrasound guidance (USG). METHODS: We evaluated patients diagnosed with cervical radiculopathy via physical examination and magnetic resonance imaging from November 2019 to March 2020. We included those who did not respond to conservative treatment and therefore received SNRBs at various levels. Sixty-three patients were evaluated over 6 months in terms of pain, functional status, and complications. RESULTS: We retrospectively evaluated patients with cervical herniated discs who received SNRBs at various levels between C4-7 under USG. Pain and functional status improved in month 1 and was maintained until at least month 6. CONCLUSION: SNRB injections performed under USG effectively treated pain and poor functional status in selected patients. The procedure is safe (especially) for patients who do not respond to conservative treatment.

Caudal epidural steroid injection for chronic low back pain: A prospective analysis of 107 patients.

BACKGROUND: Low back pain affects 80% of people worldwide at least once in a lifetime and reduces the quality of life and causes absence from work. OBJECTIVE: To evaluate the pain and functional status of patients with lumbar disc disease who received blind caudal epidural injections (CEI) for pain relief. METHODS: The records of 107 patients who had been given CEI between September 2017 and January 2018 were retrospectively analyzed. The inclusion criteria were age > 18 years, > 3-month history of low back pain, and diagnosis of lumbar disc disease by magnetic resonance imaging. The epidural injection solution consisted of 2 mL of betamethasone sodium and 8 mL saline. Follow-up examinations were conducted 3 and 6 months post-injection and the patients were evaluated using a visual analog scale (VAS) and the Oswestry Disability Index (ODI). RESULTS: The most common disc pathology was at the L4-L5 level. The VAS and ODI scores indicated significantly reduced pain at 3 and 6 months compared with the pre-injection baseline. Two patients experienced total anesthesia and paresis of the lower limbs, but recovered fully after 2 weeks. Blood was aspirated during the injection in two patients, but second-attempt injections were successful in both cases. No other complications were observed. CONCLUSION: Our results suggest that the blind method is safe for administering CEI to patients with chronic low back pain in the absence of radiological screening and results in significant pain relief with improved functional capacity.

Effect of adenoid hypertrophy and adenoidectomy on bite force in children: Twelve month follow-up, case-control study.

OBJECTIVE: The effects of adenoid hypertrophy (AH) and adenoidectomy on maximal bite force (MBF) in patients were evaluated by comparing them with healthy controls. METHODS: A total of 118 children diagnosed with AH and undergoing adenoidectomy (Group A), and healthy controls (Group B) were included. The MBF and nasopharyngeal airway passage distance (NAPD) were recorded. RESULTS: There was a correlation between NAPD and MBF at the beginning of the study (r = -0.675 and p < 0.001). The initial mean MBF of Groups A and B were 318.37 ± 70.76 N and 344.04 ± 64.14 N, respectively (p = 0.041). However, there was no significant difference between the groups due to the increase in the MBF of Group A at 12 months (p = 0.165). CONCLUSION: The MBF may be negatively affected in proportion to decreased NAPD, and it could also be an indicator for monitoring the status of children with AH.

Effects of ultrasound-assisted botulinum neurotoxin-A injection in patients with bruxism and masseter hypertrophy.

OBJECTIVES: This study aims to explore effects of ultrasound-assisted injection of the botulinum neurotoxin-A (BoNT-A) on muscle thickness (MT) in patients with masseter hypertrophy. PATIENTS AND METHODS: Between December 2018 and December 2019, a total of 20 patients (3 males, 17 females; mean age: 28±6.9 years; range, 18 to 42 years) with bruxism who underwent BoNT-A injections were reviewed retrospectively. The patients were treated using individualized injection dosages and sites. Assessment methods included length between the tragus and the angle of the mouth, maximal bite force, and MT of the masseter muscle. Follow-up data were collected from the hospital electronic database. RESULTS: There were 26 masseter muscles with masseter hypertrophy in 20 patients. There was a significant difference in ultrasonographic measurements of the relaxed and contracted masseter muscles between the baseline and two weeks, one month and three months after the treatment (p<0.05). In the ultrasonographic measurement of the relaxed masseter muscle, post-treatment third month values significantly differed from the second week values. The differences in the measurement of the line between the tragus and the angle of the mouth between the baseline and two weeks, one month and three months after the treatment were statistically significant (p<0.05). In the maximal bite force measurements, no significant difference was observed between the baseline and post-intervention measurements (p>0.05). CONCLUSION: The MT decreases after a single dose of BoNT-A injection in patients with masseter muscle hypertrophy and ultrasonography is a convenient imaging modality for BoNT-A injection to the masseter.

Effects of mobilization treatment on sacroiliac joint dysfunction syndrome.

OBJECTIVE: This study aims to reveal the short-term effects of exercise therapy and manual therapy plus exercise therapy on pain, quality of life, and physical examination results in the treatment of sacroiliac joint dysfunction syndrome (SIJDS). METHODS: In this study, 64 patients who were participated were divided into two groups. The first group (exercise group) was assigned with the sacroiliac joint (SIJ) home exercise program and the second group (mobilization group) with the combined SIJ manual therapy and home exercise program. Physical examination tests, visual analog scale, and SF-36 evaluation were performed at the beginning of the study, at 24 h, at 1 week, and 1 month after the treatment. RESULTS: Both groups showed that the rate of pain in the posttreatment, after the first week, and the first month; the presence of pain in the sacroiliac region; and VAS values of the patients with SIJDS compared to pretreatment values were clearly decreased (p<0.05). All tests performed in the SIJ physical examination showed significant improvement within both groups (p<0.05). However, there was no statistical difference between the two groups in 1-month period (p>0.05). CONCLUSIONS: We found that the home exercise program and the manual therapy plus exercise program significantly improved pain intensity, quality of life, and the findings of specific tests in patients with SIJDS. In addition, superiority between the two groups in terms of pain intensity, quality of life, and specific tests was not determined.

Comparison of platelet-rich plasma and extracorporeal shock wave therapy in patients with chronic lateral epicondylitis: A prospective, randomized-controlled study.

OBJECTIVES: In this study, we aimed to investigate the effectiveness or comparative therapeutic superiority of exercise, extracorporeal shock wave therapy (ESWT), and platelet-rich plasma (PRP) on pain, grip strength and functional activities in chronic lateral epicondylitis (LE). PATIENTS AND METHODS: Between January 2016 and February 2017, a total of 74 patients (14 males, 60 females; mean age; 49.7±7.6 years, range, 26 to 60 years) with chronic LE were included in this prospective, randomized-controlled study. All patients received stretching and eccentric strengthening exercises for three months. The patients were divided into three groups. The first group (Exercises group, n=24) was given home exercises. The second group (ESWT+Exercises group, n=25) received one session of ESWT added once a week for three weeks. The third group (PRP+Exercises group, n=25) received one session of PRP in addition to the exercise program. All patients were evaluated for pain by Visual Analog Scale (VAS), for functionality by Disabilities of Arm, Shoulder and Hand (DASH) questionnaire and Patient-Rated Tennis Elbow Evaluation (PRTEE), handgrip strength by a dynamometer, and extensor tendon thickness by ultrasonography (USG) at baseline and at one, two, three, and six months. RESULTS: A significant improvement was found in the VAS, DASH, PRTEE, handgrip strength values at six months compared to between in all groups (p<0.001). Extensor tendon thickness as assessed by USG indicated no significant difference (p>0.05). Regarding the VAS activity levels, there was a significant difference in the PRP+Exercises group compared to the Exercises group at six months of follow-up (p<0.001). The decrease in the DASH scores during six-month follow-up was significantly higher in the PRP+Exercises group compared to the Exercises group (p=0.004). For the PRTEE scores at six months, the PRP+Exercises group showed a statistically significant improvement than both Exercises (p<0.001) and ESWT+Exercises (p=0.007) groups. CONCLUSION: In the treatment of chronic LE, PRP combined with exercise seems to be superior to exercise or ESWT in terms of pain and functionality in chronic LE patients.

Viscosupplementation for the treatment of osteoarthritis. The contribution of EUROVISCO group.

Viscosupplementation (VS) is a symptomatic treatment for knee and other joint osteoarthritis (OA). Despite a long history of use, conflicting opinions remain on the best clinical indications and the most appropriate patients to be treated with intra-articular hyaluronic acid (IA-HA), the optimal dosing regimen and the modalities of retreatment. A multidisciplinary committee of European experts on OA (EUROVISCO) was constituted to formulate recommendations, aimed at helping physicians in the decision-making and the optimal achievement of VS. Before each session members were tasked to collate an exhaustive literature review. Level of evidence and strength of recommendation were based on the level of agreement for each item according to the Delphi method. In 2015, a consensus position was proposed for 24 statements. Among those that obtained a consensual agreement, the working group stressed that VS is effective in mild/moderate knee OA but is not an alternative to surgery in advanced OA, and that dosing regimen must be supported by controlled trials. In 2018, two decision algorithms for the retreatment with IA-HA in knee OA were published. Among the key recommendations, the experts recommended to re-treat every year patients with high risk of OA progression, even if not symptomatic. In 2020, EUROVISCO published two sets of recommendations for the design of clinical trials on the disease-modifying effect of VS and for optimizing the results of VS. The working group underlined that an accurate analysis of radiological features and symptoms and a careful clinical examination may improve the chances of success of VS, as well as good technique of injection and the use of imaging guidance. Based on the exhaustive analysis of the literature and their own clinical experience, the EUROVISCO experts offer a wide range of recommendations intended to help practitioners, particularly in certain cases where the specific characteristics of the patients make the therapeutic decision difficult.

Retreatment with Hyaluronic Acid Viscosupplementation in Knee Osteoarthritis: Agreement between EUROVISCO Guidelines and Current Medical Practice.

OBJECTIVES: This work studied if and how current clinical practice agrees with European Viscosupplementation Consensus Group (EUROVISCO) recommendations and how this agreement might be different according to physician's specialization. In addition, this work aimed to identify key decision factors that practitioners consider in their decision to retreat or not a patient with hyaluronic acid viscosupplementation. METHODS: Practitioners have been invited by e-mail to participate in an online exercise on viscosupplementation retreatment. They received a fictional patient case at random among a set of predefined fictional cases. The platform asked the practitioner if he/she would retreat the patient with viscosupplementation or not. To take a decision, the practitioner could select questions among a list of predefined questions. Among them, some were related to criteria used in the EUROVISCO decision tree and others served as confounding factors. RESULTS: A total of 506 practitioners participated to the exercise, of which 399 gave their decision about the case assigned to them by the platform. The observed agreement between practitioner decisions and EUROVISCO recommendations was 58.89 ± 4.95% (95% confidence interval [CI]). Overall, the decision to retreat was taken in 47.87% of the cases, while the EUROVISCO guidelines follow-up would have led to 55.89% retreatment for the same cases (P = 0.03). CONCLUSIONS: In current practice, physicians tended to reinject their patients less than recommended, although EUROVISCO guidelines for viscosupplementation retreatment consider decision criteria that clearly correspond to those of practitioners in real life. These include the patients' willingness to be treated or the patients' perception of the effectiveness of the treatment.

Systematic Literature Review and Expert Opinion for the Use of Viscosupplementation with Hyaluronic Acid in Different Localizations of Osteoarthritis.

Osteoarthritis (OA) is a significant cause of disability. Considering the increasing diffusion of the viscosupplementation (VS) with hyaluronic acid (HA), the International Symposium Intra Articular Treatment (ISIAT) appointed a Technical Expert Panel (TEP) to identify the criteria for successful VS with a specific HA in OA; this through a systematic literature review (SLR), performed following the PRISMA guidelines interrogating Medline, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Grey Matters and American College of Rheumatology (ACR/EULAR) databases and the opinion of international experts. The research included only studies on adults and humans without limitations of language or time of publication. Researchers extracted both quantitative and qualitative data from each study. Mixed Methods Appraisal Tool (MMAT) was used to perform quality analysis for the level of evidence. The SLR retrieved 385 papers, 25 of which were suitable for the analysis. The TEP focused on the different formulations of the product Sinovial® [HA 0.8%, HA 1.6%, HA 2%, 800-1200 kDa, HA 3.2% (1400-2100 kDa/65-110 kDa)]. The choice was due to the vast amount of evidence available. The TEP weighed the evidence in two rounds of a Delphi survey; the results, and any disagreement, were discussed in a final session. Three domains were considered: 1) the patients' characteristics associated with the best results; 2) the contraindications and the conditions linked to increased risk of failure; 3) the clinical conditions in which VS is considered appropriate. The TEP concluded that VS with HA is safe and effective in the treatment of knee and hip OA of grades I to III and that it is possible to undertake VS in other situations (eg grade IV Kellgren-Lawrence - KL); a comprehensive examination of the patient should be performed before the procedure.