Original Research Article
Year: 2014 | Month: July | Volume: 1 | Issue: 1 | Pages: 42-47
Study on Role of Viscosupplementation in Primary Osteoarthritis
of Knee in Elderly Population
Asit
Ranjan Gosai
Physician,
Jodhpur Park, Kolkata, West Bengal, India.
ABSTRACT
Introduction: Knee
osteoarthritis is a common and progressive joint disease. With an estimated
incidence rate of 240 per 100,000 populations per year, it is a major public
health problem in the US and often results in early retirement and joint
replacement.
Methodology: This study was
conducted among 30 elderly (60 years & above) patients attending
out-patient department of Orthopaedics of Medical College & Hospital,
Kolkata with primary osteoarthritis of knee.
Result: By age->
Although not an inevitable consequence of ageing, OA is strongly age related;
this may reflect the cumulative effect of insults to the joint, aggravated by
decline in neuromuscular function or senescence of homeostatic repair
mechanisms.
By gender-> Women have a higher
prevalence and radiographic severity of OA knee. Women are also more likely to
have symptoms if radiographic OA is present.
By occupation-> Labors and weight
bearers are mostly affected, of which again homemakers (women) are involved in
this study.
Conclusion: This study was
conducted to establish the effective implementation of intra-articular
hyaluronic acid injection therapy in osteoarthritis of knee in comparison with
the results of conservative therapy and intra-articular steroids injection
therapy. We come into conclusion that injection Hylan G-F 20, if its cost is
reduced, might be at least used for the treatment of primary OA knee very early
to better avoid the costly surgical intervention like prosthesis or total joint
replacement.
Key words:
Viscosupplementation,
Primary Osteoarthritis, Knee, Elderly Population.
INTRODUCTION
Knee osteoarthritis
is a common and progressive joint disease. With an estimated incidence rate of
240 per 100,000 population per year, it is a major public health problem in the
US and often results in early retirement and joint replacement. In the absence
of effective disease modifying medical interventions for knee osteoarthritis,
treatments are primarily symptomatic in nature, often including intraarticular
injections of a corticosteroid or hyaluronic acid. Corticosteroids have been
employed for years in treatment of osteoarthritis, and as a result,
rheumatologists have substantial clinical experience of their utility and
effectiveness. Consensus statements widely recommend corticosteroids as useful
adjunctive treatment in the management of knee osteoarthritis. Clinical trials
and meta-analyses have demonstrated their efficacy. Hyaluronic acid, a large
viscoelastic glycosaminoglycan that is naturally present in healthy joint fluid
is a relatively new intervention that is now widely used. It confers to joint
fluid a number of protective properties, including shock absorption, traumatic
energy dissipation, protective coating of the articular cartilage surface and
lubrication. The original biologic rationale for the therapeutic use of synthetic
hyaluronic acid in knee osteoarthritis was its potential to increase the
viscosity of synovial fluid. Therefore, the basis for the Food and Drug
Administration’s approval for hyaluronic acid was a medical device rather than
a pharmaceutical, and despite many placebo-controlled trials of hyaluronic acid
products, contention remains regarding their effecvtiveness. Although numerous
clinical trials reported durable benefits on knee Osteoarthritis, others failed
to show benefits compared with placebo.
This raised the
question about the magnitude of therapeutic effects of hyaluronic acid products and stimulated a number of meta-analyses . However the
conclusions of meta-analyses were also inconsistent: 2 analyses drew strongly
positive conclusions but had potential conflicts of interest; 2 reported a
small effect; and 2 others inferred that hyaluronic acid is not more effective
than saline as a placebo. In the trace of this controversy, we aim to
re-examine the clinical usefulness of hyaluronic acid products from the
perspective of their relative efficacy when compared with intraarticular
corticosteroids conservative treatment.
Aims and Objectives
Purpose of our study is to compare the
results of conservative therapy, intra-articular corticosteroids injection therapy and
intra-articular hyaluronic acid injection therapy in primary osteoarthritis of
knee.
Specific Objectives of This Study
1. To compare the results between
conservative, intra-articular corticosteroids and intra-articular hyaluronic
acid injection in primary osteoarthritis of knee.
2. To evaluate the functional outcomes
of the three modes of treatment in primary osteoarthritis of knee.
Study area: Medical
College, Kolkata
Study period: Six months
Sample size: 30 patients
total:- 10- conservative treatment; 10-i.a. steroids injection; 10-i.a. hyaluronic acid injections.
Sample design
1. Patient selection:
This study was conducted among the
elderly (60 years & above) patients attending out-patient department of
Orthopaedics of Medical College & Hospital, Kolkata with primary
osteoarthritis of knee.
2. Inclusion criteria:
Patients above 60 years with knee joint
pain including both male and female.
3. Exclusion criteria:
·
Age below 60 years
·
Pain in knee after trauma
·
Local infections in and around
knee joint
·
Uncontrolled diabetes mellitus
·
Severe joint deformity
·
Patient on anticoagulant therapy
·
Patient with history of surgery
in and around the knee
Study design:
Institutional based prospective study.
Study tools:
Ø
20-ml, 10-ml and 3-ml disposable syringes
Ø
20-gauge 1 ½-inch needles
Ø
22-gauge 1-inch or 1 ½-inch
needles
Ø
Paper towels or drapes,
disposable gloves
Ø
Forceps, alcohol sponges
Ø
Povidone-iodine solution (or
equivalent) or other antimicrobial solution
Ø
Lidocaine 1% (without
epinephrine)
Ø
Adhesive bandages
§
Corticosteroids injections
(methyl prednisolone)
§
Hyaluronic acid injections
Parameters to be studied:
Core outcomes to be identified in
accordance with the recommendations of the Outcome Measures in Arthritis
Clinical Trials (OMERACT) III consensus conference.
1. Pain
2. Physical function
3. Patient global assessment
Plan for data analysis:
Details of demographic features,
occupation and outcome measures of different treatment options from the schedules were verified, sorted and tabulated in appropriate
tables. Relevant findings of different treatment types implemented in causation
of alleviation of symptoms and their clinical variables were discussed.
RESULTS AND
DISCUSSIONS
Overview:
i) Osteoarthritis (OA) is the most
common form of arthritis
ii) Symptoms of OA are often episodic
iii) The goals of treatment are to
relieve pain, minimize disability and improve quality of life
iv) Non-pharmacologic treatments are as
important as pharmacologic treatment for OA
v) The effect of corticosteroids is
largely absent by the 26-week time point, but the absolute effect of hyaluronic
acid at this time point is modest
vi) Criteria of joint replacement
include uncontrolled pain and severe impairment of function despite
conservative treatment
1. Guidelines for management of
OA:
i) Conservative treatment [ education,
exercise programme, advice to reduce adverse mechanical factors, thermo
therapy, weight loss of obese, acupuncture, electrotherapy, paracetamol,
topical NSAIDs, topical capsaicin, oral NSAIDs, opioids,
chondroitin-glucosamine preparations, walking aids, braces, assistive devices
etc.]
ii) Intra articular corticosteroid
injection [methyl prednisolone]
iii) Intra articular hyaluronic acid
injection
TABLE-1:
Distribution of types of treatment options
Type
of treatment
|
No.
of patient
|
Percentage
( % )
|
CONSERVATIVE
|
10
|
33.33
|
I-A
CORTICOSTEROIDS
|
10
|
33.33
|
I-A
HYALURONAN
|
10
|
33.33
|
2. Demographic Profile
By age-> Although not an inevitable
consequence of ageing, OA is strongly age related; this may reflect the
cumulative effect of insults to the joint, aggravated by decline in
neuromuscular function or senescence of homeostatic repair mechanisms.
By gender-> Women have a higher
prevalence and radiographic severity of OA knee. Women are also more likely to
have symptoms if radiographic OA is present.
TABLE-2:
Age-wise distribution of respondents
Age group
|
Conservative
|
I-A corticosteroids
|
I-A hyaluronan
|
Total
|
60-64 years
|
03
|
03
|
03
|
09
|
65-74 years
|
03
|
06
|
06
|
15
|
75 years+
|
04
|
01
|
01
|
06
|
Total
|
10
|
10
|
10
|
30
|
By occupation-> Labors and weight bearers are mostly affected, of which
again homemakers (women) are involved in this study.
Table-3:
Distribution according to occupation
Occupation
|
Conservative
|
I-A corticosteroid
|
I-A hyaluronan
|
Total
|
Labour
|
02
|
03
|
01
|
06
|
Athelets
|
01
|
0
|
0
|
01
|
Retired
|
05
|
0
|
01
|
06
|
Homemakers
|
02
|
07
|
08
|
17
|
Total
|
10
|
10
|
10
|
30
|
3. Outcome measures in arthritis
clinical trials
By subsidence of pain and swelling->
Table-4: Showing distribution of
symptomatic relief of pain and swelling.
Treatment
options
|
Outcome
measures initiation
|
Time
point of relief
|
Conservative
|
Instant
|
Very
short lasting
|
I-A
corticosteroid
|
4
weeks (approx)
|
<
8 weeks
|
I-A
hyaluronan
|
4
weeks (approx)
|
>12
weeks
|
By restoration of Physical function/
limiting disability->Achieving Activity Daily Living (ADL) and/or
Instrumental Activity Daily Living (IADL)
ADL i.e., person himself is capable of
dressing, bathing, eating, toileting, walking and climbing a plight of stairs
in his or her daily activities and able to take care of own.
IADL i.e., person himself is also
capable of shopping, financing, banking, attending telephones, cooking,
laundering, washing etc. which require little skill. Analgesics or braces are
usually very quickly omitted after treatment with hyaluronan injection.
Table-5:
Showing restoration of physical function (ADL/ IADL).
Treatment
options
|
Time
elapsed since restoration
|
Effectivity
of restoration
|
Conservative
|
Nothing
suggestive
|
Nothing
suggestive
|
I-A
corticosteroid
|
6
weeks (approx)
|
<
20 weeks
|
I-A
hyaluronan
|
4
weeks (approx)
|
>24
weeks
|
By patient global assessment->
U.S. study=> age-wise: 45-64
years----21.3 million
65 & older-------18.4
million (Rarely below 40 years)
gender-wise:
women-------38.2 million
men------25.7 million
The importance of a multi disciplinary
care pathway in the management of osteoarthritis is now well recognized
globally. A community-wide approach encompassing the involvement and education
of both patient and primary care physician will lead to earlier diagnosis,
speedier and more appropriate secondary care referrals, quicker treatment and
ultimately improved clinical outcomes.
SUMMARY
Osteoarthritis
is defined as a heterogeneous group of conditions that leads to joint symptoms
and signs which are associated with defective integrity of articular cartilage
in addition to related changes in the underlying bone at the joint margins. It
refers to a clinical syndrome of joint pain accompanied by varying degrees of
functional limitations and reduced quality of life. It is the most common form
of arthritis and one of the leading causes of pain and disability worldwide.
Knees, hips and small joints of hands are most commonly affected. Although
pain, reduced function and participation restriction can be important
consequences of osteoarthritis, structural changes often occur without
accompanying symptoms.
Clinical variants of
osteoarthritis
·
Monoarticular and pauciarticular
osteoarthritis
·
Polyarticular (Generalised) osteoarthritis
·
Osteoarthritis in unusual sites
·
Rapidly destructive
osteoarthritis
Osteoarthritis is a metabolically active
repair process that takes place in all joint tissues and involves localized
loss of cartilage and remodeling of adjacent bone. Osteoarthritis is aslow but
efficient repair process that often compensates for the initial trauma,
resulting in a structurally altered but symptom-free joint. In some people,
either because of overwhelming trauma or compromised repair potential, the
process can not compensate, resulting in continuing tissue damage and eventual
presentation with symptomatic osteoarthritis or ‘joint failure’. This explains
the extreme variability in clinical presentation and outcome that can be
observed between people and also at different joints in the same person. This
study was conducted to establish the effective implementation of
intra-articular hyaluronic acid injection therapy in osteoarthritis of knee in
comparison with the results of conservative therapy and intra-articular
steroids injection therapy. We come into conclusion that injection Hylan G-F
20, if it’s cost is reduced, might be at least used for the treatment of
primary OA knee very early to better avoid the costly surgical intervention
like prosthesis or total joint replacement. Also it may be attempted in cases
of oldest-old patients where surgery is contraindicated otherwise. However, if
we assume that the effect of corticosteroids is largely absent by the 26-week
time point, we might infer that the absolute effect of hyaluronic acid at this
time point is modest. I-A corticosteroid appear to be relatively more effective
for pain than I-A hyaluronic acid. By week 4, the 2 approaches have equal
efficacy, but beyond week 8, hyaluronic acid has greater efficacy.
Understanding this trend is useful to clinicians when treating knee OA.
Recommendations
The goals of medical management of Knee
OA in aged person are to:
(a) Provide patient education and
information access
(b) Relieve pain
(c) Optimize physical function and
(d) Minimize disease progression
Intra-articular
corticosteroids injection is a valuable treatment that often gives effective
quick relief of pain that may last just a few weeks to few months. It may be
particularly useful to tide a patient over an important event (e.g., family
wedding, holiday) and to improve pain during initiations of other interventions
such as an exercise programme.
But, nevertheless, a variety
of hyaluronan preparations are available, given as a single injection or a
course of one per week for 3-5 weeks, although a modest, relatively prolonged
(several months) improvement in pain may result, the cost and logistics of this
treatment are limiting. It may be regarded as an alternative management
guideline in respect of end-stage knee OA where surgical maneuvers like joint
replacement could be delayed or avoided,
if contraindicated, or as ihe latter is concerned with the issues of huge
funding, waiting times, choice of prosthesis and revision have to be faced.
Future scope of the study
It is hoped that
further exploration may be carried out in near future, since the structure of
an effective health education programme for this highly susceptible group would
depend to a large extent on the findings of such study to carry out initiation
of treatment at the outset rather than at a mature state, which is a major
stumble block to successful achievement of activity of daily living (ADL) in
elderly persons and to reduce the burden of the cost of financial budget of the
nation.
Recognition of
corticosteroids’ adverse effect, if absorbed in the system, has been entirely
neglected and variables leading to causation of the side effects have not been
enlightened.
The issues
discussed in this study have global application, as the burden of illness from
musculoskeletal conditions is high in both the developed world and developing
countries alike, particularly with an ever-increasing elderly population
worldwide. In developing countries, it is essential to involve local community
leaders and community health workers in the management of patients with these
conditions. For patients with osteoarthritis, optimal management depends on
developing an efficient triage system that include health care professionals,
governments and members of the public. In spite of a number of studies which
were conducted abroad no definite profile of non-pharmacological and
pharmacological treatment of
osteoarthritis has yet been defined.
I owe a great
debt of gratitude to Dr. P. Chatterjee, Asst. Prof. of Department of Orthopaedics,
Medical College, Kolkata without whose continuous inspiration, constructive
criticism, meticulous guidance & formulation my work was impossible.
My sincere
thanks to Dr. Wanlamkupar L Khongwir, MS (PGT), Orthopaedics, Medical College,
Kolkata for his valuable assistance to my field work.
Lastly, it would
be unforgiveable act on my part if I do not acknowledge the way my study
subjects, both the cases and control, helped me with their full co-operation.
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How to cite this
article: Gosai AR. Study on role of
viscosupplementation in primary osteoarthritis of knee in elderly population.
Int J Res Rev. 2014;1(1):42-47.
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