Intra-articular joint injections for Osteoarthritis

A 60-year-old man presents for evaluation of worsening knee pain. He was diagnosed with osteoarthritis 5 years ago and has been taking meloxicam 7.5 mg daily along with Tylenol 500 mg twice daily for pain control. The patient states that these medications are no longer effective and wishes to discuss other treatment options. He only wants surgery as a last resort. He wants to know if there are other effective medications. Hes heard about joint injections but wants to know more information.

Background question
What types of injections are available for osteoarthritis? Corticosteroids Hyaluronic Acids Autologous platelet rich plasma Mesenchymal stem cells Botulinum type A toxin Growth factors and growth hormone

PICO
In elderly patients with Osteoarthritis of the knee which type of intra-articular injection would better control pain and limit further joint damage, Hyalouronic acid or corticosteroids?

Search Strategy
Ovid Medline Searched Osteoarthritis of Knee, limited to human studies, english, and randomized control trial, comparative trial, from 2008-present Combined with intra-articular injections and corticosteroids

Methods
This was a multicenter, prospective, randomized study Inclusion criteria comprised: (1) age 60 years; (2) pain in the tibiofemoral and/or patellofemoral joint persisting 6 months; (3) hydroarthrosis; (4) OA fi ndings on radiography and Kellgren-Lawrence grade 2 or 316; and (5) no treatment including NSAID administration within 3 months. Exclusion criteria were (1) intra-articular injection into the knee within 1 year; (2) knee arthritis associated with collagen diseases including rheumatoid arthritis, pseudogout, or infection; (3)arthroplasty in the affected lower limb; (4) surgery including arthroscopy of the knee joint due to injury or meniscus injury within 1 year; and (5) marked instability associated with knee ligament dysfunction

Methods
All patients were allocated to the Na-HA or CS group by random sampling using a table of random numbers Treatment effects were evaluated before, at 5 weeks, and at 6 months after treatment. At each evaluation point, a visual analog scale (VAS) of pain during walking and the clinical assessment score reported by Gotoh et al.17 were used. The following joint biomarkers were measured in collected synovial fluid at 0 and 5 wks: Aggrecans, hyaluronan (HA), chondroitin 4-sulfate (Ch4S), and chondroitin 6-sulfate(Ch6S), MMP-9 and TIMP-1

Results

Results

Results

Strengths multicenter, prospective, randomized study Comparative study Looked at clinical outcomes as well as biomarkers of disease No conflicts of interest

Weaknesses Small study (no power analysis) Short study (only 6 months) Older population than our patient and predominantly female Biomarkers werent measured at 6 months also

Clinical Decision
Based on this paper and a review of the literature it would be beneficial to try Hyaluronic Acid injections first in our patient.