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Intra-articular joint injections for

Osteoarthritis

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A 60-year-old man presents for evaluation ofworsening knee pain. He was diagnosed withosteoarthritis 5 years ago and has been takingmeloxicam 7.5 mg daily along with Tylenol 500

mg twice daily for pain control. The patient statesthat these medications are no longer effectiveand 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 toknow more information.

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Background question

What types of injections are available forosteoarthritis?

Corticosteroids

Hyaluronic Acids

Autologous platelet rich plasma

Mesenchymal stem cells

Botulinum type A toxin

Growth factors and growth hormone

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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?

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Search Strategy

Ovid Medline

Searched Osteoarthritis of Knee,

limited to human studies, english, andrandomized control trial, comparative trial,

from 2008-present

Combined with intra-articular injections andcorticosteroids

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Methods

This was a multicenter, prospective, randomized study

Inclusion criteria comprised: (1) age 60 years; (2) pain inthe tibiofemoral and/or patellofemoraljoint persisting 6months; (3) hydroarthrosis; (4) OA fi ndings on radiography

and Kellgren-Lawrence grade 2 or 316; and (5) notreatment including NSAID administration within 3 months.

Exclusion criteria were (1) intra-articular injection into theknee within 1 year; (2) knee arthritis associated withcollagen diseases including rheumatoid arthritis,pseudogout, or infection; (3)arthroplasty in the affectedlower 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 ligamentdysfunction

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Methods

All patients were allocated to the Na-HA or CS group byrandom sampling using a table of random numbers

Treatment effects were evaluated before, at 5 weeks,and at 6 months after treatment. At each evaluationpoint, a visual analog scale (VAS) of pain during walkingand the clinical assessment score reported by Gotoh etal.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), andchondroitin 6-sulfate(Ch6S), MMP-9 and TIMP-1

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Results

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Results

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Results

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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 werentmeasured at 6 months also

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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.