Osteoarthritis- a systematic review of long-term safety implications for osteoarthritis of the knee.

BACKGROUND: There is no cure for knee osteoarthritis (KOA) and typically patients live approximately 30-years with the disease. Most common medical treatments result in short-term palliation of symptoms with little consideration of long-term risk. This systematic review aims to appraise the current evidence for the long-term (≥12 months) safety of common treatments for knee osteoarthritis (KOA). METHODS: Cochrane Database of Systematic Reviews, Medline and PubMed were systematically searched from 1990 to July 2017, inclusive. Inclusion criteria were 1) peer-reviewed publications investigating treatments for KOA referred to in the Australian Clinical Care Standard and/or Therapeutic Guidelines: Rheumatology 2) specifically addressing safety of the treatments 3) with ≥12 months of follow-up and 4) Downs and Black quality score ≥ 13. RESULTS: Thirty-four studies fulfilled the inclusion criteria. Lifestyle modifications (moderate exercise and weight loss), paracetamol, glucosamine, Intraarticular Hyaluronic Acid (IAHA) and platelet-rich-plasma (PRP) injections have a low risk of harm and beneficial ≥12 month outcomes. Although Nonsteroidal Anti-inflammatory Drugs (NSAIDs) provide pain relief, they are associated with increased risk of medical complications. Cortisone injections are associated with radiological cartilage degeneration at > 12 months. Arthroscopy for degenerative meniscal tears in KOA leads to a 3-fold increase in total knee arthroplasty (TKA). TKA improves primary outcomes of KOA but has a low rate of significant medical complications. CONCLUSIONS: Given the safety and effectiveness of lifestyle interventions such as weight loss and exercise, these should be advocated in all patients due to the low risk of harm. The use of NSAIDs should be minimized to avoid gastrointestinal complications. Treatment with opioids has a lack of evidence for use and a high risk of long-term harm. The use of IAHA and PRP may provide additional symptomatic benefit without the risk of harm. TKA is associated with significant medical complications but is justified by the efficacy of joint replacement in late-stage disease. TRIAL REGISTRATION: PROSPERO International prospective register for systematic reviews; registration number CRD42017072809 .

Actitud terapéutica de los tutores y residentes de cuarto año de Medicina Familiar y Comunitaria de Girona frente a las infiltraciones periarticulares / Therapeutic attitude of tutors and fourth year residents of Family and Community Medicine from Girona towards peri-articular infiltration

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Eficacia y seguridad de una única inyección intraarticular de ácido hialurónico al 2 por ciento más manitol en artrosis de rodilla durante un periodo de 6 meses / Efficacy and safety of a single intra-articular injection of 2 percent hyaluronic acid plus mannitol in knee osteoarthritis over a 6-month period

Objetivo. Evaluar la eficacia y seguridad de una única inyección intraarticular de ácido hialurónico (AH)+manitol en artrosis de rodilla (AR). Material y método. Estudio prospectivo, abierto, no-comparativo con 80 pacientes diagnosticados de AR, de los cuales 79 finalizaron el estudio. Recibieron una inyección intraarticular de 2ml de AH al 2%+manitol al 0,5% (día 0) y fueron monitorizados durante 6 meses. Los días 0, 15, 30, 60, 90, 120, 150 y 180 se evaluaron dolor y funcionalidad articular mediante una escala analógica visual (EAV) y el índice WOMAC, eficacia y seguridad según médico y paciente, y medicación de rescate como medida indirecta del dolor. Resultados. Disminución significativa del dolor articular, rigidez e incapacidad funcional en comparación con el valor inicial en todas las visitas (p<0,001). La funcionalidad articular mejoró un 38,7% 30 días tras la inyección, alcanzando un 47,5% el día 180. El consumo de medicación de rescate descendió desde un 58,2%, inicial, hasta un 2,5% el día 90, aumentando en las últimas visitas. Investigadores y pacientes valoraron positivamente eficacia y seguridad. Solamente se reportaron efectos adversos leves en 4 pacientes (dolor leve e inflamación en la zona de infiltración). Discusión. Está demostrado que inyecciones intraarticulares repetidas de AH mejoran los síntomas en AR. Sin embargo, estudios con una única inyección de AH han proporcionado resultados mixtos. Este estudio demuestra que una inyección intraarticular de AH no crosslinked mejora el dolor y la funcionalidad articular en pacientes con AR durante un periodo mínimo de 6 meses (AU)

Objective. To evaluate the safety and efficacy of a single intra-articular injection of 2% hyaluronic acid (HA)+mannitol in symptomatic knee osteoarthritis (KOA). Material and methods. Pilot, multicentre, open, non-comparative study performed in eighty patients with painful KOA, of whom 79 completed the study. They received one injection of 2ml of 2% HA+0.5% mannitol (Day 0) and were followed-up for 6 months. On Days 0, 15, 30, 60, 90, 120, 150 and 180, pain and joint function were assessed using a visual analogue scale (VAS) and WOMAC index. Efficacy and safety by investigator and patient, and rescue medication, as an indirect measure of pain, were also recorded. Results. A significant reduction in joint pain, stiffness and functional disability compared with baseline was observed at every follow-up visit (P<.001). Joint function improved by 38.7% on Day 30, reaching 47.5% on Day 180. Rescue medication use decreased from 58.2% at baseline to 2.5% on Day 90, increasing in the last visits. Efficacy and safety were positively evaluated by investigators and patients. No serious adverse events were observed. Mild side effects were reported in 4 patients (local pain and swelling in the infiltration area). Discussion. There is evidence that repeated intra-articular injections of HA improve symptoms in KOA. However, studies with a single injection of HA have shown mixed results. This study demonstrates that one single intra-articular injection of non-cross-linked HA reduces joint pain and increases function in patients with KOA over a period of at least 6 months (AU)

The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee.

Although intraarticular injections are important to the management of rheumatoid arthritis, there are few studies regarding the cost-effectiveness of alternative injection techniques. This randomized controlled study addressed the cost-effectiveness of two different low-cost, anatomic landmark palpation-directed intraarticular injection techniques. Ninety-six symptomatic rheumatoid knees were randomized to two different low-cost, palpation-guided intraarticular injection techniques utilizing (1) a conventional syringe or (2) a mechanical syringe, the RPD (the reciprocating procedure device). Three milliliters of 1% lidocaine were used to anesthetize the synovial membrane, followed by arthrocentesis and hydrodissection, and injection of 80 mg of triamcinolone acetonide utilizing the one-needle two-syringe technique. Baseline pain, procedural pain, aspirated fluid volume, pain at outcome (2 weeks and 6 months), responders, reinjection rates, cost/patient/year, and cost/responder/year were determined. Pain was measured with the 10 cm Visual Analogue Pain Scale (VAS). Both techniques significantly reduced pain scores at outcome from baseline (P < 0.001). The mechanical syringe technique resulted in a greater volume of aspirated fluid (P < 0.01), a 38% reduction in procedural pain (P < 0.001), a 24% reduction in pain scores at outcome (P < 0.03), an increase in the responder rate (P < 0.025), 33% increase in the time to next injection (P < 0.001), 23% ($35 US) reduction in cost/patient/year for a patient treated in a physician office (P < 0.001), 24% reduction ($26 US) in cost/patient/year for a hospital outpatient (P < 0.001), and 51% ($151 US) reduction in cost/responder/year (P < 0.001). The outcomes and cost-effectiveness of intraarticular injection of the rheumatoid knee can be improved significantly with low-cost alternations in technique.

Low back pain in older adults: are we utilizing healthcare resources wisely?

OBJECTIVES: 1) To examine recent change in prevalence and Medicare-associated charges for non-invasive/minimally invasive evaluation and treatment of nonspecific low back pain (LBP); and 2) to examine magnetic resonance imaging (MRI) utilization appropriateness in older adults with chronic low back pain (CLBP). DESIGN: Two cross-sectional surveys of 1) national (1991-2002) and Pennsylvania (2000-2002) Medicare data; and 2) patients aged >or= 65 years with CLBP. SETTING: Outpatient data. PARTICIPANTS: Patients aged >or= 65 years with LBP. MEASUREMENTS: Study 1: Outpatient national and Pennsylvania Part A Medicare data were examined for number of patients and charges for all patients, and for those with nonspecific LBP. Total number of visits and charges for imaging studies, physical therapy (PT), and spinal injections was also examined for Pennsylvania. Study 2: 111 older adults with CLBP were interviewed regarding presence of red flags necessitating imaging and history of having a lumbar MRI, neurogenic claudication (NC), and back surgery. RESULTS: Study 1: Between 1991 and 2002, there was a 42.5% increase in total Medicare patients, 131.7% increase in LBP patients, 310% increase in total charges, and 387.2% increase in LBP charges. In Pennsylvania (2000-2002), there was a 5.5% increase in LBP patients and 33.2% increase in charges (0.2% for PT, 59.4% for injections, 41.9% for MRI/CT, and 19.3% for X rays). Study 2: None of the 111 participants had red flags and 61% had undergone MRIs (29% with NC, 24% with failed back surgery syndrome). CONCLUSION: LBP documentation and diagnostic studies are increasing in Medicare beneficiaries, and evidence suggests that MRIs may often be ordered unnecessarily. Injection procedures appear to account for a significant proportion of LBP-associated costs. More studies are needed to examine the appropriateness with which imaging procedures and non-invasive/minimally invasive treatments are utilized, and their effect on patient outcomes.

Intra-articular steroid hip injection for osteoarthritis: a survey of orthopedic surgeons in Ontario.

BACKGROUND: Intra-articular steroid hip injection (IASHI) has been prescribed for painful hip arthritis since the 1950s, but with advances in medical and surgical management its role is less certain today. There are very few published data on the utility or prescribing patterns of IASHI. METHODS: We developed a questionnaire to seek expert opinion on IASHI that we distributed to practising Ontario-based members of the Canadian Orthopaedic Association. We systematically describe the current practices and expert opinion of 99 hip surgeons (73% response rate), focusing on indications, current use and complications experienced with IASHI. RESULTS: Only 56% of surgeons felt that IASHI was therapeutically useful, with 72% of surgeons estimating that 60% or less of their patients achieved even transient benefit from IASHI. One-quarter of the surgeons believe that IASHI accelerates arthritis progression, most of whom had stated that it would be no great loss if IASHI was no longer available. Nineteen percent of the surgeons believed that the infection rate related to total hip arthroplasty (THA) may be increased after IASHI, and this was associated with fewer IASHIs ordered per year, compared with the number prescribed by those who did not feel that infection rates would increase. CONCLUSIONS: This systematic collection of expert opinions demonstrates that substantial numbers of surgeons felt that, in their patients, IASHI was not therapeutically helpful, may accelerate arthritis progression or may cause increased infectious complications after subsequent THA.