LATERAL EPICONDYLE SLIDING OSTEOTOMY IN KNEE ARTHROPLASTIES WITH VALGUS DEFORMITY.

OBJECTIVE: To evaluate the efficacy and safety of sliding osteotomy of the lateral epicondyle in correcting rigid valgus deformity in knee arthroplasty. METHODS: A retrospective study of patients undergoing total knee arthroplasty with lateral epicondyle sliding osteotomy between 2006 and 2018. The main outcome was the incidence of complications and adverse events. Secondary outcomes were Visual Analog Scale for Pain, varus stress test, and varus knee thrust during gait. RESULTS: 19 knees (19 participants) were included in the study. The mean follow-up was 4.2 years. There were no cases of infection or reoperation due to instability. Two participants (10.5%) had mild or moderate knee pain (VAS pain = 4.6 ± 1.9). Two arthroplasties (10.5%) had mild varus stress. No participant presented varus thrust. CONCLUSION: Sliding osteotomy of the lateral epicondyle allows fast and safe ligament balance of knee valgus deformities. Level of Evidence I, Case series.

Avaliar a eficácia e a segurança da osteotomia de deslizamento do epicôndilo lateral na correção da deformidade em valgo rígida na artroplastia de joelho. Métodos: Estudo retrospectivo de pacientes submetidos à artroplastia total do joelho com osteotomia de deslizamento do epicôndilo lateral entre 2006 e 2018. O principal desfecho foi a incidência de complicações e eventos adversos. Os desfechos secundários foram escala visual analógica para dor, teste de estresse em varo e flambagem em varo do joelho durante a marcha. Resultados: Foram incluídos no estudo 19 joelhos (19 participantes). O seguimento médio foi de 4,2 anos. Não houve nenhum caso de infecção ou reoperação devido à instabilidade. Dois participantes (10,5%) apresentaram algum tipo de dor leve ou moderada no joelho (EVA = 4,6 ± 1,9). Duas artroplastias (10,5%) apresentaram estresse em varo leve. Nenhum participante apresentou flambagem em varo. Conclusão: A osteotomia de deslizamento do epicôndilo lateral possibilitou o balanço ligamentar das deformidades em valgo do joelho de forma rápida e segura. Nível de Evidência IV, Série de Casos.

Challenges of Implementing a Human Multi-Tissue Bank in a Public Hospital in the Interior of São Paulo: Under the Light of the Quality Management System.

BACKGROUND: Human multi-tissue banks (HMTB) are important health institutions specialized in the capture, processing, and distribution of human tissues for transplants and research, aiming for safety and quality in the supply of their products, intended for reconstructive surgeries and injury repair, in addition to contributing to the advancement of research developed in regenerative medicine. This study aims to report and share the experience of implementing an HMTB, as well as creating an institution's own quality management system. METHODS: This is a descriptive study, an experience report type, which identifies historical aspects of an HMTB's actions in the 5 years of implementing and operating the service. RESULTS: Initially, a musculoskeletal tissue bank was established in collaboration with the Department of Orthopedics at the State University of Campinas, São Paulo, Brazil, in June 2018. In 2023, through a management model and associated technologies, the banks of human musculoskeletal and ocular tissues at the institution established the HC-UNICAMP Human Multi-tissue Bank. CONCLUSIONS: The implementation of the HMTB with modern and technological infrastructure, associated with the development and operation of the quality management system, allowed us to provide excellent organization of work processes, as well as obtain the necessary health license to begin activities. It is believed that this report can be an important source of information and recommendations applicable to the implementation of other human HMTBs.

Efficacy and Safety of Hylan G-F 20 Versus Intra-Articular Corticosteroids in People with Knee Osteoarthritis: A Systematic Review and Network Meta-Analysis.

BACKGROUND: Direct injection of corticosteroids into the joint is a standard treatment for knee osteoarthritis (OA). However, the treatment is somewhat controversial with regard to the benefit of both single and repeated injections; evidence that they are beneficial comes from small studies that show only modest improvements. The aim of this study was to estimate the short- and long-term clinical efficacy and safety of hylan G-F 20 versus intra-articular corticosteroids (IACS) for the treatment of pain in knee OA using Bayesian network meta-analysis. METHODS: Based on a pre-specified protocol, MEDLINE, Embase, and CENTRAL were searched from inception to June 2018 to identify randomized controlled trials. The Cochrane Collaboration's tool for assessing risk of bias in randomized trials was used to assess the included studies. Hylan G-F 20 and IACS were compared using Bayesian network meta-analysis. Efficacy was evaluated at 1, 3, and 6 months, and at the final follow-up for safety outcomes. A pain hierarchy was used to select 1 pain outcome per study. RESULTS: Forty-two trials were included for analysis. The network meta-analysis of pain showed that hylan G-F 20 may be equivalent to IACS in the short-term, but by 6 months the benefit relative to IACS was statistically significant, standardized mean difference (95% credible interval): -0.13 (-0.26, -0.01). There were no statistical differences in adverse events. CONCLUSIONS: Hylan G-F 20 may perform better in relieving pain at 6 months post-injection compared to IACS. Both agents were relatively well tolerated, with no clear differences in safety.

Anterior Knee Pain After Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Anterior knee pain is a frequent condition after anterior cruciate ligament reconstruction (ACLR), but its origin remains uncertain. Studies have suggested that donor site morbidity in autologous bone-patellar tendon-bone reconstructions may contribute to patellofemoral pain, but this does not explain why hamstring tendon reconstructions may also present with anterior pain. PURPOSE: To evaluate the prevalence of anterior knee pain after ACLR and its predisposing factors. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: We evaluated the records of all patients who underwent ACLR between 2000 and 2016 at a private facility. The prevalence of anterior knee pain after surgery was assessed, and possible risk factors (graft type, patient sex, surgical technique, range of motion) were evaluated. RESULTS: The records of 438 patients (mean age, 30 years) who underwent ACLR were analyzed. Anterior knee pain was found in 6.2% of the patients. We found an increased prevalence of anterior knee pain with patellar tendon graft, with an odds ratio of 3.4 (P = .011). Patients who experienced extension deficit in the postoperative period had an odds ratio of 5.3 of having anterior pain (P < .001). Anterior knee pain was not correlated with patient sex or surgical technique. CONCLUSION: The chance of having anterior knee pain after ACLR was higher when patellar tendon autograft was used compared with hamstring tendon graft, as well as in patients who experienced extension deficit in the postoperative period.

CURRENT PANORAMA OF ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION SURGERY IN BRAZIL.

OBJECTIVE: This study aims to establish the current panorama of the anterior cruciate ligament reconstruction surgery in Brazil. METHODS: A survey that consisted of a 24-item questionnaire including surgeon's demographics, preferred technique, graft selection, graft positioning, use of braces, drains, antibiotic prophylaxis and most common complications was conducted at the last three editions of a national knee surgery event. RESULTS: Six hundred eight questionnaires were analyzed. Brazilian knee surgeons are mostly male, with mean age of 42 years (26-68) and are affiliated to at least one orthopedic society. Thirty-six percent (36%) perform more than 50 reconstructions per year. The preferred graft is the hamstring tendons graft (64%). The frequency of use of anatomical technique increased approximately from 55% from 2011 to 2013, to 85.5% in 2015 (p<0.001). From 2011 to 2015, there was a progressive reduction from 56.8% to 18.1% in the frequency of use of transtibial femoral tunnel drilling (p<0.001). CONCLUSION: Our findings show that Brazilian knee surgeons' preferences are evolving according to the current world practice. Level of Evidence V, Economic and Decision analysis study.

OBJETIVO: O presente estudo tem como objetivo estabelecer o panorama atual da cirurgia de reconstrução do ligamento cruzado anterior no Brasil. MÉTODOS: Nas últimas três edições de um evento nacional de cirurgia do joelho, realizou-se uma pesquisa que consistiu em um questionário de 24 itens incluindo dados demográficos do cirurgião, técnica preferida, seleção do enxerto, posicionamento do enxerto, uso de órteses, drenos, profilaxia antibiótica e complicações mais comuns. RESULTADOS: Seiscentos e oito questionários foram analisados. O cirurgião brasileiro de joelho é majoritariamente do sexo masculino, tem idade média de 42 anos (26-68) e é afiliado a pelo menos uma sociedade ortopédica. Trinta e seis por cento (36%) realizam mais de 50 reconstruções por ano. O enxerto preferido é o enxerto de tendões isquiotibiais (64%). A frequência de uso da técnica anatômica aumentou de 55% nos anos de 2011 e 2013 para 85,5% em 2015 (p<0,001). Após 2011, também foi observada redução progressiva de 56,8% para 18,1% até 2015 na frequência de uso da técnica de perfuração do túnel femoral transtibial (p<0,001). CONCLUSÃO: Nossos achados mostram que os cirurgiões brasileiros de joelho estão evoluindo de acordo com a prática mundial atual. Nível de evidência V, Análise econômica e de decisão.

BRAZILIAN CONSENSUS STATEMENT ON VISCOSUPPLEMENTATION OF THE KNEE (COBRAVI).

OBJECTIVE: The aim of this consensus statement on viscosupplementation is to serve as a reference document based on relevant literature and clinical experience in the treatment of knee osteoarthritis using an intra-articular injection of hyaluronic acid, covering key aspects such as clinical indications, effectiveness, and tolerability. METHODS: A multidisciplinary panel including two sports medicine physicians, six orthopedists, four physiatrists, and two rheumatologists were selected based on their clinical and academic experience of viscosupplementation. Sixteen statements were prepared and discussed, after which a vote was held. Each member of the panel gave a score between 0 and 10 on a Likert scale, specifying their level of agreement with the statement. RESULTS: The panel reached a consensus on several issues. Specifically, the panel agreed that the best indication is for mild to moderate knee arthrosis; prior or concomitant use of intraarticular triamcinolone hexacetonide may optimize the effect of hyaluronic acid; viscosupplementation should not be performed as an isolated procedure but in conjunction with other rehabilitative and pharmacological measures; viscosupplementation has analgesic, anti-inflammatory, and chondroprotective effects; and viscosupplementation is cost-effective. CONCLUSION: This consensus statement provides clear information and guidance for both individuals and payers. Level of evidence V, Consensus statement.

OBJETIVO: O Consenso Brasileiro de Viscossuplementação visa gerar uma fonte referencial e consensual, a partir de levantamentos bibliográficos relevantes, do conhecimento teórico e da experiência clínica de especialistas de áreas afins para tratamento de viscossuplementação na osteoartrite do joelho, mitigando pontos críticos desse procedimento, como via de aplicação, indicação, eficácia e tolerabilidade. MÉTODOS: Um painel multidisciplinar foi formado com dois médicos do esporte, seis ortopedistas, quatro fisiatras e dois reumatologistas, com base nas experiências clínica e acadêmica no uso da viscossuplementação. Foram elaboradas, discutidas e votadas 16 afirmativas. Cada membro do painel deu um valor entre zero e 10, em uma escala tipo Likert, especificando seu nível de concordância com a afirmação. RESULTADOS: O painel chegou a um consenso sobre diversos aspectos da viscossuplementação, com destaque para as seguintes afirmativas: a melhor indicação é para artrose de joelhos leve a moderada; o uso prévio ou concomitante de hexacetonido de triancinolona intra-articular pode otimizar o efeito do ácido hialurônico; a viscossuplementação não deve ser realizada como procedimento isolado no tratamento da OA, mas em conjunto com outras medidas reabilitadoras e farmacológicas; promove efeito analgésico; anti-inflamatório; condroprotetor; e é custo-efetiva. CONCLUSÃO: Este consenso traz informações claras e servirá, como guia tanto para médicos quanto para as fontes pagadoras. Nível de evidência V, Consenso de especialistas.

Treat-to-target strategy for knee osteoarthritis. International technical expert panel consensus and good clinical practice statements.

BACKGROUND: In this work, we aimed to establish a clinical target in the management of knee osteoarthritis (KOA) and to propose good clinical practice (GCP) statements for carrying out a treat-to-target strategy. METHODS: A steering committee of seven experts had formulated a provisional set of recommendations that were exposed for discussion and modification to a technical expert panel (TEP) of 25 multidisciplinary experts from Europe, North America, South America and Asia. The level of evidence and strength of each recommendation was discussed. The TEP formulated overarching principles and GCP statements based on the level of agreement for each item with a vote using a 10-point numerical scale. RESULTS: Two overarching principles and 10 GCP statements were formulated by the TEP. These GCP statements suggest: treatment should achieve clinical improvement bringing the patient to the Patient Acceptable Symptom State (PASS); pharmacological and nonpharmacological treatment should begin as early as possible, with an early diagnosis of symptomatic KOA; the patient should be evaluated every 3-6 months; risk factors of KOA progression should be identified and managed with patients at the beginning of the treatment and monitored regularly; treatment should be adapted according to patient phenotype and disease severity; healthy lifestyle must be promoted and monitored. The level of agreement average ranged from 8.7 to 9.6 on scale. CONCLUSIONS: The proposed overarching principles and GCP statements have the aim of involving patients, general practitioners and multidisciplinary specialists in sharing a therapeutic treat-to-target strategy for KOA management based on the best evidence and expert opinions.

PREVALENCE OF JOINT PAIN AND OSTEOARTHRITIS IN OBESE BRAZILIAN POPULATION.

BACKGROUND: High body mass index, as well as maintaining this condition for a long period of time, are important risk factors for the development of osteoarthritis. AIM: To determine joint pain and osteoarthritis prevalence in patients referred to bariatric surgery. METHODS: Morbidly obese patients referred to bariatric surgery responded to the visual analogue pain scale (VAS) and the WOMAC questionnaire. X-rays of the hips and knees were evaluated. The primary endpoints were self-reported joint pain and the diagnosis of osteoarthritis by clinical and radiological criteria of the American College of Rheumatology. RESULTS: 141 patients were interviewed (85.1% women) with a mean age of 40 years. The mean body mass index was 46. The lumbar spine and knee joint were the most commonly reported as painful (77.9% and 73.2% respectively). Prevalence of knee osteoarthritis was 63.1% and hip osteoarthritis was 40.8%. Age, mean VAS and WOMAC scores were higher in the osteoarthritic individuals. CONCLUSION: There is prevalence of 90.1% of pain symptoms in morbidly obese patients referred to bariatric surgery. The prevalence of knee osteoarthritis was 63.1% and hip osteoarthritis was 40.8% in this sample.

Prevalence of joint pain and osteoarthritis in obese brazilian population / Prevalência de dor articular e osteoartrite na população obesa brasileira

ABSTRACT Background: High body mass index, as well as maintaining this condition for a long period of time, are important risk factors for the development of osteoarthritis. Aim: To determine joint pain and osteoarthritis prevalence in patients referred to bariatric surgery. Methods: Morbidly obese patients referred to bariatric surgery responded to the visual analogue pain scale (VAS) and the WOMAC questionnaire. X-rays of the hips and knees were evaluated. The primary endpoints were self-reported joint pain and the diagnosis of osteoarthritis by clinical and radiological criteria of the American College of Rheumatology. Results: 141 patients were interviewed (85.1% women) with a mean age of 40 years. The mean body mass index was 46. The lumbar spine and knee joint were the most commonly reported as painful (77.9% and 73.2% respectively). Prevalence of knee osteoarthritis was 63.1% and hip osteoarthritis was 40.8%. Age, mean VAS and WOMAC scores were higher in the osteoarthritic individuals. Conclusion: There is prevalence of 90.1% of pain symptoms in morbidly obese patients referred to bariatric surgery. The prevalence of knee osteoarthritis was 63.1% and hip osteoarthritis was 40.8% in this sample.

RESUMO Racional: Alto índice de massa corpórea, assim como a manutenção desta condição por longo período de tempo, são importantes fatores de risco para o desenvolvimento de osteoartrite. Objetivo: Determinar a prevalência de dor articular e osteoartrite em pacientes aguardando cirurgia bariátrica. Métodos: Pacientes obesos mórbidos responderam à escala e questionário (VAS e WOMAC) de dor e função. Radiografias dos quadris e joelhos foram avaliadas. Os desfechos primários foram dor articular referida nos questionários e o diagnóstico de osteoartrite feito através dos critérios clinicoradiológicos do Colégio Americano de Reumatologia. Resultados: Cento e quarenta e um pacientes foram entrevistados (85,1% mulheres) com idade média de 40 anos. A média do índice de massa corpórea foi de 46. Coluna lombar e joelhos foram as regiões mais comumente referidas com dor (77,9% e 73,2% respectivamente). A prevalência de osteoartrite dos joelhos foi de 63,1% e dos quadris foi de 40,8%. Idade, média da escala visual de dor e resultados do questionário de WOMAC foram maiores nos indivíduos com osteoartrite. Conclusão: Há prevalência de 90,1% de sintomas dolorosos nos pacientes obesos mórbidos encaminhados para cirurgia bariátrica. A osteoartrite dos joelhos foi de 63,1% e de quadris de 40,8%.

Femoral positioning influences ipsi-and contralateral anterior cruciate ligament rupture following its reconstruction: Systematic review and meta-analysis.

AIM: To systematically review the incidence of ipsilateral graft re-rupture and contralateral anterior cruciate ligament (ACL) rupture following its reconstruction, with special attention to the femoral drilling technique. METHODS: Systematic review and meta-analysis of high-level prospective studies searched in MEDLINE database following PRISMA statement. The rate of ipsilateral graft re-rupture and contralateral rupture in patients submitted to either transtibial (TT) technique (isometric) or anteromedial (AM) technique (anatomic) was compared. RESULTS: Eleven studies met the criteria and were included in final analysis. Reconstructions using the AM technique had a similar chance of contralateral ACL rupture when compared to the chance of ipsilateral graft failure (OR = 1.08, P = 0.746). In reconstructions using TT technique, the chance of contralateral ACL rupture was approximately 1.5 times higher than ipsilateral graft failure (OR = 1.49, P = 0.048). Incidence of contralateral lesions were similar among the techniques TT (7.4%) and AM (7.0%) (P = 0.963), but a trend could be noticed with a lower incidence of lesion in the ipsilateral limb when using the TT technique (4.9%) compared to the AM technique (6.5%) (P = 0.081). CONCLUSION: ACL reconstruction by TT technique leads to lower incidence of graft re-injury than contralateral ACL lesion. There is no difference between the chance of re-injury after AM technique and the chance of contralateral ACL lesion (native ligament) with either technique.

Association Between Meniscal and Chondral Lesions and Timing of Anterior Cruciate Ligament Reconstruction.

BACKGROUND: Rupture of the anterior cruciate ligament (ACL) is a common sports injury and is known to be associated with an increased risk of knee osteoarthritis. Several studies have indicated that the risk of additional injuries to the menisci and articular cartilage increases with delays in the treatment of ACL tears. However, no consensus has been reached regarding the ideal timing for ACL reconstruction in terms of preventing secondary lesions. PURPOSE: To determine how the time elapsed between an ACL lesion and its reconstruction affects the incidence of meniscal and chondral lesions. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Medical records of 764 patients who underwent primary ACL reconstruction were reviewed. Data from arthroscopic findings that included information about meniscal lesions and full-thickness articular cartilage lesions at the time of surgery were collected. The association between time elapsed between ACL lesion and reconstruction surgery and incidence of articular cartilage and meniscal lesions was analyzed by chi-square or Fisher exact test. The risk of secondary lesion was calculated by odds ratios (ORs) obtained from simple logistic regression analysis. RESULTS: A positive correlation was observed between time after injury and the presence of any articular lesions (P = .003), cartilage lesions (P = .01), and medial meniscus lesions (P < .001). When analyzing the risk of secondary lesion relative to the reference period (<2 months), it was observed that the odds of finding any articular injury at the time of ACL reconstruction increased when the time from ACL injury to surgery was between 12 and 24 months (OR = 2.62) and >24 months (OR = 5.88). Furthermore, the odds of lesions on the medial meniscus increased when the timing between injury and surgery was 6 to 12 months (OR = 2.71) and continued to increase when the timing was 12 to 24 months (OR = 3.78) and >24 months (OR = 9.07). CONCLUSION: Associated articular lesions are more common if ACL reconstruction is delayed by ≥6 months (medial meniscus lesion) and ≥1 year (chondral or any meniscal lesion).

One-Year Results of an Educational Program on Osteoarthritis: A Prospective Randomized Controlled Trial in Brazil.

INTRODUCTION: Knee osteoarthritis (KOA) is the most prevalent form of osteoarthritis. Low socioeconomic level, age, and obesity are directly correlated with the incidence of the disease. Education, exercise, and diet are the core recommendations of all KOA treatment guidelines. OBJECTIVE: To evaluate the impact of a multiprofessional educational program on patients with KOA. METHODS: Of a total of 198 participants, 150 patients with KOA attended 2 days of lectures (at 1- to 3-month intervals) and received educational material on osteoarthritis, and a control group (48 patients) received educational materials only. Body mass index (BMI), frequency, and intensity of physical activity, pain, function, and quality-of-life scores were assessed at baseline and at 4 and 12 months after the educational program. Bimonthly telephone calls were made to half of the participants. Correlations between BMI, level of education, coping skills, functional, and pain results was procured. RESULTS: The groups were similar in terms of race, gender, affected side, and osteoarthritis severity. The results were not affected by the telephone calls or the patients' level of education. At baseline, 25 performed physical activity, whereas 123 performed at 1 year. Seventy-two (36.36%) patients decreased BMI (45 by 1 point and 27 by more than 2 points). There were some weak correlations such as BMI reduction with pain and functional improvements and with coping results. Significant improvements in function and quality of life were found at 4 months. Quality of life remained improved at 1 year. CONCLUSION: The effect of this educational program in function and quality of life of patients with KOA is very subtle. Interval between classes (1, 2, or 3 months) is not an important issue.

Prevalence of osteoporosis in patients awaiting total hip arthroplasty.

OBJECTIVE: To evaluate the prevalence of osteoporosis in patients awaiting total hip arthroplasty. METHOD: Twenty-nine patients diagnosed with hip osteoarthritis awaiting primary total arthroplasty of the hip answered WOMAC questionnaire, VAS and questions about habits, osteoporosis and related diseases. Bone mineral densitometry of the lumbar spine and hips and laboratory tests (complete blood count and examination of calcium metabolism) were performed. Weight and height were measured to calculate body mass index (BMI). The evaluated quantitative characteristics were compared between patients with and without osteoporosis using the Mann-Whitney tests. RESULTS: Thirteen men and 16 women with a mean age of 61.5 years old, WOMAC 51.4; EVA 6.4 and BMI 27.6 were evaluated. The prevalence of osteoporosis was 20.7%, and 37.9% had osteopenia. Patients with osteoporosis were older than patients without osteoporosis (p=0.006). The mean bone mineral density of the femoral neck without hip osteoarthritis was lower than the affected side (p=0.007). Thirty-five percent of patients did not know what osteoporosis is. Of these, 30% had osteopenia or osteoporosis. CONCLUSION: osteoarthritis and osteoporosis may coexist and the population waiting for total hip arthroplasty should be considered at risk for the presence of osteoporosis. Level of Evidence III, Observational Study.

Obesity, ostearthritis and clinical treatment.

OBJECTIVE: To evaluate the relationship between BMI and pain and function in patients with OA undergoing medical treatment following OARSI recommendations. METHODS: Thirty-eight patients were classified according to their arthritis degree by X-ray and body mass index (BMI). All patients completed the WOMAC, Lequesne, and visual analogue pain scale (VAS) questionnaires at baseline and after six months treatment. All patients were treated with diacerhein and analgesics (according to pain), orthotics (when indicated), and an educational program on osteoarthritis. They were instructed on balanced diet and exercise at least three times a week. RESULTS: There was no significant BMI variation in this study. The higher the initial BMI, the lower the improvement in pain (p = 0.03). Pain did not improve significantly (p = 0.2). Function improved (p <0.001) in inverse ratio to the initial BMI. CONCLUSION: BMI determines how patients will improve pain and function.

Adding triamcinolone improves viscosupplementation: a randomized clinical trial.

BACKGROUND: Intraarticular injections, mainly using long-lasting corticosteroid suspensions, have long been used to treat knee osteoarthritis. Viscosupplementation is a relatively new approach with injection of a variety of agents. When comparing viscosupplementation with intraarticular injections of corticosteroids from baseline to the fourth week, steroids have been more effective for pain relief. By the fourth week they provide similar relief, but beyond that viscosupplementation appears to provide greater pain reduction. The delayed onset of symptomatic improvement combined with reports of reactive synovitis may discourage physicians and patients. QUESTIONS/PURPOSES: We therefore addressed three questions: Does the addition of triamcinolone to viscosupplementation (1) improve first-week pain and function compared with viscosupplementation alone, (2) diminish adverse effects of viscosupplementation alone, and (3) alter 6-month pain and function of viscosupplementation alone? METHODS: We prospectively enrolled 104 patients with knee osteoarthritis and randomized them to receive either a single intraarticular injection (6 mL) of hylan GF-20 (Group viscosupplementation [Group VS]), or a single intraarticular injection of hylan GF-20 (6 mL) and 1 mL (20 mg) of triamcinolone hexacetonide (Group VS + T). VAS, WOMAC™, and Lequesne questionnaires were completed at baseline and at Weeks 1, 4, 12, and 24. RESULTS: At Week 1 the WOMAC and VAS scores were lower in Group VS + T, compared with Group VS. There was no difference regarding the adverse effects. At Weeks 4, 12, and 24 there were no differences in the groups. CONCLUSIONS: The addition of triamcinolone hexacetonide improves first-week symptom and functional scores of viscosupplementation, but not beyond. It does not seem to increase the likelihood of adverse effects. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Is osteoarthritis a mechanical or inflammatory disease?

Traditionally considered "wear and tear" disease, the pathogenic mechanisms of osteoarthritis have not yet been elucidated. The increasing number of articles demonstrating the influence of inflammatory factors in the onset and progression of the disease currently raises great debate in the literature about the importance of each of the factors involved in the disease. Even the choice between the terms "Osteoarthritis" and "Osteoarthrosis" generates controversy, since the first term implies the presence of inflammation as the key generator of the disease, and the latter denotes a degenerative/mechanical causal factor. The aim of this revision article is to promote a debate on the influence of inflammatory factors and mechanical factors in the pathogenesis of OA.

Classicamente considerada uma doença de wear and tear (desgaste), a osteoartrite ainda não tem elucidados todos os seus mecanismos patogênicos. O crescente número de artigos que demonstram a influência dos fatores inflamatórios no surgimento e na evolução da doença suscita, atualmente, grande debate na literatura sobre a importância de cada um dos fatores envolvidos. Até mesmo a escolha dos termos osteoartrite e osteoartrose gera polêmica, uma vez que o primeiro implica a presença da inflamação como fator primordial gerador da doença e o último denota um fator causal degenerativo/mecânico. O objetivo deste artigo é promover um debate sobre a influência dos fatores inflamatórios e dos fatores mecânicos na patogênese da OA.

Current concepts in osteoarthritis.

Osteoarthritis (OA), the most common form of joint disease, affects mainly the hips, knees, hands and feet, leading to severe disability and loss of quality of life, particularly in the elderly population. Its importance grows every year with the aging of the population, with a large increase in the elderly population compared to younger patients. The progressive understanding of the pathophysiology of OA, the perception that the process is not purely mechanical and / or aging, and clarification of the inflammatory pathways involved led recently to the clinical application of various drugs and other measures. This update aims to expose the current concepts on the pathophysiology and treatment of OA.

Prospective randomized clinical trial: single and weekly viscosupplementation.

OBJECTIVE: To compare two different dosages of an intermediate molecular weight sodium hyaluronate (HA) (Osteonil(®)-TRB Pharma) assessing whether a single 6 ml application of this HA has the same effectiveness as the classical three-weekly 2 ml dose. METHODS: 108 patients with knee osteoarthritis were randomized into two groups of 54 patients each. The groups were designated "single" (S) and "weekly" (W). Patients in group S underwent a viscosupplementation procedure by application of only 6 ml of sodium hyaluronate and 1 ml triamcinolone hexacetonide. Patients in group W underwent the procedure of viscosupplementation through three applications with 2 ml sodium hyaluronate with a week interval between them, and the first application was also performed with the infiltration of 1 ml (20 mg) of Triamcinolone Hexacetonide. Both groups were assessed before, at one month and three months after application, by responding to the WOMAC, Lequesne, IKDC and VAS questionnaires. RESULTS: There was no statistical difference between the single application of 6 ml of sodium hyaluronate and classic application with three weekly injections. However, only the classical regime showed statistically significant improvement in baseline pain (WOMAC pain and VAS). CONCLUSION: Our results suggest that both application schemes improve application function, but the three-weekly regimen of 2 ml was more effective in reducing pain. Level of Evidence I, Prospective Randomized, Clinical Trial.

VISCOSUPPLEMENTATION.

With the aging of the world's population, the prevalence of age-related diseases is continually increasing, especially osteoarthritis, the most common form of joint disease. In addition to its high prevalence, osteoarthritis has been correlated with high medical and social costs. Among the treatment methods, viscosupplementation (intra-articular injection of hyaluronic acid derivatives) has been gaining more prominence. The substances used are high molecular weight polysaccharides that, in addition to mechanical functions of weight distribution and joint lubrication, have anti-inflammatory properties and physical-chemical action on a variety of joint characteristics. These effects are directly proportional to the molecular weight and concentration of the drug used and any cross-links that may be present in the drug. Viscosupplementation is a simple procedure and can be performed in outpatient clinics. It provides benefits regarding pain and function, and also favorably alters the course of the disease, through quantitatively and qualitatively improving the joint cartilage. It has a good safety profile and favorable cost-effectiveness relationship, and is indicated both for osteoarthritis cases and after an arthroscopic procedure.