Abstract:
Background: Osteoarthritis (OA) is the most prevalent chronic
joint disorder worldwide and is associated with significant pain
and disability. We looked into the therapeutic efficacy and
safety of intra-articular injection of hyluronic acid for
management of osteoarthritis of knee.
Method: Questionnaire was sent to patients retrospectively and
their pain score was assessed along with improvement in mobility
and reduction in their analgesic use following the injection.
Result: The treatment was well tolerated overall. Majority of
patients benefited from the injection. Pain relief was best
appreciated at the end of six weeks and in most of the patients
the effect weaned off at six month.
Conclusion: Intra-articular HA or hylan has proven to be an
effective, safe, and tolerable treatment for symptomatic knee
OA.
J.Orthopaedics 2010;7(2)e4
Keywords:
Synvisc; Hyluronic acid; Osteoarthritis; Intra articular.
Introduction:
Osteoarthritis (OA) is the most prevalent chronic joint disorder
worldwide and is associated with significant pain and
disability.(1)
It is a chronic degenerative disease of synovial joints that is
characterized by the deterioration of hyaluronan and other
constituents of hyaline cartilage, resulting in intermittent
pain, swelling, inflammation and varying degrees of functional
loss.(2).
There are several options for treating osteoarthritis of
the knee, including simple analgesics, nonsteroidal
anti-inflammatory drugs, intra-articular injection of
glucocorticoids, exercise, physiotherapy,
weight-relieving braces, and knee arthroplasty.
Hyaluronan is critical for the homeostasis of the joint as an
organ, in part, because it provides the rheological properties
(viscosity and elasticity) of the synovial fluid. These
properties depend upon both the concentration and the molecular
weight of the hyaluronan in the synovial fluid. In
osteoarthritis, the hyaluronan is both smaller in size and lower
in concentration. Thus, it is rational and physiologically
meaningful to treat osteoarthritis with viscosupplementation,
i.e. injection of material designed to increase the rheological
properties of the synovial fluid. (3)
In addition, it has been found that injected hyaluronic acid
can augment the flow of synovial fluid, normalize the
synthesis and inhibit the degradation of endogenous
hyaluronic acid, and relieve joint pain.
Studies have demonstrated that the
anti-inflammatory, anabolic, and chondroprotective actions of
hyaluronic acid reduce pain and improve patient function (4)
There are studies that have evaluated the efficacy and safety of
hylan G-F 20 in patients with knee osteoarthritis.
We looked into how patients responded to treatment as far as
pain management, decreased analgesic use and better mobility is
concerned in our DGH.
Materials
and Methods:
The study was conducted retrospectively.
In our study we included patients who had 3 doses of intra-articular
synvisc injection in knee from January 2007 to January 2008.
These patients were seen in our knee clinic for the first time
and were diagnosed clinically to be having osteoarthritis which
was confirmed by radiograph..
The inclusion criterion
was:
1.
Mild to moderate OA not
responding to traditional pharmacological and non-
pharmacological treatment.
2.
Patients who are
intolerant to traditional treatment due to gastrointestinal
problems related to anti-inflammatory treatment.
3.
Severe OA when any
surgical intervention is not contemplated due to associated
medical problem.
Patients with
hypersensitive to hyluronate preparations and allergy to
feathers, egg, poultry and avian proteins, patients with large
effusion of joints or patients with any suspicion of infection
in or around the joint were excluded from this study.
Hylan G-F 20 (Synvisc)
was administered in accordance with the manufacturer's
recommendations as a course of three weekly injections.
This was
given in a sterile environment of operation theatre.
Each
injection was given with use of the manufacturer's prefilled
2-ml syringe, which contained 16 mg of hydrated gel in
buffered physiologic sodium chloride solution of pH
7.2.
A questionnaire was send by post to these patients in July 2008
with a request for completing and
returning the questionnaire in the enclosed envelope.
Visual Analog pain score was used to assess pain relief
following
Hylan G-F 20 (synvisc)
injection. Patients were asked to score there pain before
injection, 1 week following injection, 6 weeks following
injection and 6 months following injection respectively.
The questions were related to 3 main issues- pain, reduction in
analgesic use and mobility.
Results :
A total of 60 questionnaires were sent to 57 patients. 3 had
both there knees injected at different settings.
A total of 40 patients replied (response rate 66%).
The response is tabulated.
__ָ__
A
____ָ____
B
____ָ___
C
____ָ____
D
|
1 2 3 4 5 6 7
8 9 10
Graph A before injection
Graph B 1 week after injection
Graph C 6 weeks after injection
Graph D 6 months after injection
VAS Score
Comparision of visual analog pain score in patients having
synvisc injection
Graph |
Mean VAS |
Standard Deviation (S.D) |
95% Confidence interval for the mean |
A |
8.47 |
1.63 |
+/- 0.51 |
B |
6.85 |
2.62 |
+/- 0.81 |
C |
4.85 |
2.74 |
+/- 0.85 |
D |
6.87 |
3.10 |
+/- 0.95 |
Analgesic Use
Of the 40 participants 16 patients reduced the amount of
analgesic that they were taking before the injection.
Mobility
Of the 40 participants 18 had better mobility after the
injections.
Discussion :
Hyaluronic acid has been the subject of interest for centuries
i.e from the time of Paracelsius who compared joint fluid with
eggwhite to Virchow who isolated it from the vitreous humour. It
was Mayer who coined the term hyaluronic acid in the 1930's. The
first medical use of hyaluronic acid was as a vitreous
replacement in ophthalmology. In the late 1960's animal studies
were carried out for its use in osteoarthritis (4) following
joint injuries in horses. Human trials in the joint have shown
its beneficial effects and it has been in clinical use since
1987 when it was first used in Japan and Italy (5). The term
Viscosupplementation was proposed in 1993(6)
The most common symptom with which patient with osteoarthritis
of knee presents to a clinician is pain. As pain is the main
concern for patients suffering from this disease we did this
study to see how patients response to
Hylan G-F 20 (synvisc)
injection. As patient starts getting pain his mobility
decreases. Along with this most of them start taking pain
killers. We also looked into these two factors in our study.
From our survey we found out that most of the patients do well
with synvisc injection. The response to
Hylan G-F 20
(synvisc) injection starts appearing 1 week after injection and
peaks at 6 weeks.The mean visual analog score came down from 8.4
before the start of therapy to to 5.1six weeks after surgery.
In mean pain was score again increased to 7.1 6 months
following surgery.
Majority of patients were very satisfied with the treatment.Half
of them were happy to have further doses of injection.
Small number of patients did not get any benefit from this
injection. As with previous studies (7) we are not sure about
the factors
predictive
of a good response to Hylan GF-20.
However all of our non-responders were patients who had high VAS
before the therapy started.
Hylan G-F20 has been reported to be well tolerated in the
management of chronic idiopathic OA. (8).
Our study also reconfirms this fact as none of the patients had
any adverse effect.
Cost is a major factor in more widespread use of these
injections. Taking into account the fallingprices and the
long-term benefit in the form of postponing or doing away with
the need for surgery, the viability of these injections cannot
be denied. We believe that viscosupplementation is a useful mode
of treatment in the spectrum of arthritis treatment from NSAIDs
to total arthroplasty.
In conclusion Hylan
G-F 20 (Synvisc)
is a good treatment for primary osteoarthritis of knee for a
short period of time. It relieves the pain, and with relief of
pain there is better mobility and reduced analgesic intake.
There was no adverse reaction to this treatment in our study and
most of the patients were very pleased with the outcome.In an effort to limit cardiovascular, gastrointestinal, and renal
safety concerns with COX-2 selective and nonselective NSAIDs and
maximize HA efficacy, the authors proposed using HA earlier in
the treatment paradigm for knee OA and also as part of a
comprehensive treatment strategy. (9)
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