Rodilla/Knee: en la gonartrosis mejor pinchar, peor el paracetamol

Pharmacologic Interventions for Knee OA

Raveendhara R, Christopher H,  David M, Elizaveta E,  John B,  Timothy E,

Ann Intern Med. 6 January 2015,162(1):46-54

Background: The relative efficacy of available treatments of knee osteoarthritis (OA) must be determined for rational treatment algorithms to be formulated.

Purpose: To examine the efficacy of treatments of primary knee OA using a network meta-analysis design, which estimates relative effects of all treatments against each other.

Data Sources: MEDLINE, EMBASE, Web of Science, Google Scholar, Cochrane Central Register of Controlled Trials from inception through 15 August 2014, and unpublished data.

Study Selection: Randomized trials of adults with knee OA comparing 2 or more of the following: acetaminophen, diclofenac, ibuprofen, naproxen, celecoxib, intra-articular (IA) corticosteroids, IA hyaluronic acid, oral placebo, and IA placebo.

Data Extraction: Two reviewers independently abstracted study data and assessed study quality. Standardized mean differences were calculated for pain, function, and stiffness at 3-month follow-up.

Data Synthesis: Network meta-analysis was performed using a Bayesian random-effects model; 137 studies comprising 33 243 participants were identified. For pain, all interventions significantly outperformed oral placebo, with effect sizes from 0.63 (95% credible interval [CrI], 0.39 to 0.88) for the most efficacious treatment (hyaluronic acid) to 0.18 (CrI, 0.04 to 0.33) for the least efficacious treatment (acetaminophen). For function, all interventions except IA corticosteroids were significantly superior to oral placebo. For stiffness, most of the treatments did not significantly differ from one another.

Limitation: Lack of long-term data, inadequate reporting of safety data, possible publication bias, and few head-to-head comparisons.

Conclusion: This method allowed comparison of common treatments of knee OA according to their relative efficacy. Intra-articular treatments were superior to nonsteroidal anti-inflammatory drugs, possibly because of the integrated IA placebo effect. Small but robust differences were observed between active treatments. All treatments except acetaminophen showed clinically significant improvement from baseline pain. This information, along with the safety profiles and relative costs of included treatments, will be helpful for individualized patient care decisions.

Rodilla/Knee/Knie/Genou: Rx de pie pero con las rodillas dobladas

Sensitivity of Standing Radiographs to Detect Knee Arthritis: A Systematic Review of Level I Studies.

Duncan, Khazzam, Burnham, Spindler, Dunn, Wright.

Arthroscopy. 2014 Oct 10. doi: 10.1016/j.arthro.2014.08.023. [Epub ahead of print]

Abstract

PURPOSE:

The purpose of this study was to perform a systematic review of the available literature to define the level of quality evidence for determining the sensitivity and specificity of different radiographic views in detecting knee osteoarthritis and to determine the impact of different grading systems on the ability to detect knee osteoarthritis.

METHODS:

A systematic review of the literature was conducted to identify studies that evaluated the standing anteroposterior (AP) and 45° posteroanterior (PA) views for tibiofemoral and patellofemoral arthritis and those comparing the use of the Kellgren-Lawrence versus the joint space narrowing (JSN) radiographic grading systems using arthroscopy as the gold standard. A comprehensive search of PubMed, Scopus, CINAHL, the Cochrane Database, Clinicaltrial.gov, and EMBASE was performed using the keywords "osteoarthritis," "knee," "x-ray," "sensitivity," and "arthroscopy."

RESULTS:

Six studies were included in the evaluation. The 45° flexion PA view showed a higher sensitivity than the standing AP view for detecting severe arthritis involving either the medial or lateral tibiofemoral compartment. There was no difference in the specificities for the 2 views. The direct comparison of the Kellgren-Lawrence and the JSN radiographic grading systems found no clinical difference between the 2 systems regarding the sensitivities, although the specificity was greater for the JSN system.

CONCLUSIONS:

The ability to detect knee osteoarthritis continues to be difficult without using advanced imaging. However, as an inexpensive screening tool, the 45° flexion PA view is more sensitive than the standing AP view to detect severe tibiofemoral osteoarthritis. When evaluating the radiograph for severe osteoarthritis using either the Kellgren-Lawrence or JSN grading system, there is no clinical difference in the sensitivity between the 2 methods; however, the JSN may be more specific for ruling in severe osteoarthritis in the medial compartment.

LEVEL OF EVIDENCE:

Level I, systematic review of Level I studies.

Rodilla/Knee/Knie/Genou: Una buena rodillera para la artrosis

Strength and Functional improvement using Pneumatic Brace with Extension Assist for End-Stage Knee Osteoarthritis: A Prospective, Randomized trial
Jeffrey J. Cherian, Anil Bhave, Bhaveen H. Kapadia, Roland Starr, Mark J. McElroy, Michael A.
The Journal of Arthroplasty
Published Online: November 28, 2014
DOI: http://dx.doi.org/10.1016/j.arth.2014.11.036
Publication stage: In Press Accepted Manuscript

Abstract

Pneumatic unloader bracing with extension assists have been proposed as a non-operative modality that may delay the need for knee surgery by reducing pain and improving function.

This prospective, randomized, single blinded trial evaluated 52 patients who had knee osteoarthritis for changes in: (1) muscle strength; (2) objective functional improvements; (3); subjective functional improvements; (4) pain; (5) quality of life; and (6) conversion to total knee arthroplasty (TKA) compared to standard of care.

Patient outcomes were evaluated at a minimum 3 months. Braced patient’s demonstrated significant improvements in muscle strength, several functional tests, and patient reported outcomes when compared to the matched cohort.

These results are encouraging and suggest that this device may represent a promising alternative to standard treatment methods for knee osteoarthritis.

Rodilla/Knee/Knie/Genou: Abrir o cerrar la osteotomía de tibia; hay diferencias

Comparison of Closing-Wedge and Opening-Wedge High Tibial Osteotomy for Medial Compartment Osteoarthritis of the Knee: A Randomized Controlled Trial with a Six-Year Follow-up.

Duivenvoorden T, Brouwer RW, Baan A, Bos PK, Reijman M, Bierma-Zeinstra SM, Verhaar JA.
J Bone Joint Surg Am. 2014 Sep 3;96(17)

Abstract

BACKGROUND:

Varus deformity increases the risk of progression of medial compartment knee osteoarthritis. The aim of this study was to investigate the clinical and radiographic mid-term results of closing-wedge and opening-wedge high tibial osteotomy when used to treat this condition.

METHODS:

From January 2001 to April 2004, ninety-two patients were randomized to receive either a closing-wedge or an opening-wedge high tibial osteotomy. The clinical outcome and radiographic results were examined preoperatively; at one year; and, for the present study, at six years postoperatively. The outcomes that we reviewed included maintenance of the achieved correction, progression of osteoarthritis (based on the Kellgren and Lawrence classification), severity of pain (as assessed on a visual analog scale [VAS]), knee function (as measured with the Hospital for Special Surgery [HSS] score and Knee injury and Osteoarthritis Outcome Score [KOOS]), walking distance, complications, and survival with conversion to a total knee arthroplasty as the end point. The results were analyzed on the basis of the intention-to-treat principle.

RESULTS:

Six years postoperatively, the mean hip-knee-ankle (HKA) angle (and standard deviation) was 3.2° ± 4.1° of valgus after a closing-wedge high tibial osteotomy and 1.3° ± 5.0° of valgus after an opening-wedge high tibial osteotomy (p = 0.343). In both groups, the six-year postoperative HKA angles did not differ from the respective one-year postoperative angles. No difference in the severity of pain or in knee function was found between the two groups. Four complications (9%) occurred in the closing-wedge group and seventeen (38%), in the opening-wedge group. Ten (22%) of the patients in the closing-wedge group and three (8%) in the opening-wedge group needed conversion to a total knee arthroplasty within the six-year period (p = 0.05). The difference in the percentage of cases with conversion to total knee arthroplasty was 14% (95% confidence interval [CI] = 21.7 to 0.2).

CONCLUSIONS:

In the group of patients without conversion to a total knee arthroplasty, there was no difference between the high tibial closing-wedge and opening-wedge osteotomies in terms of clinical outcomes or radiographic alignment at six years postoperatively. Opening-wedge osteotomy was associated with more complications, but closing-wedge osteotomy was associated with more early conversions to total knee arthroplasty.

LEVEL OF EVIDENCE:

Therapeutic Level I

Rodilla/Knee/Ginocchio: Más estudios apuntando al PRP para la gonartrosis inicial

Platelet-rich plasma vs hyaluronic acid to treat knee degenerative pathology: study design and preliminary results of a randomized controlled trial.

Filardo G, Kon E, Di Martino A, Di Matteo B, Merli ML, Cenacchi A, Fornasari PM, Marcacci M

BMC Musculoskelet Disord 2012.:229.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532098/pdf/

Abstract

BACKGROUND

Platelet rich plasma (PRP), a blood-derived product rich in growth factors, is a promising treatment for cartilage defects but there is still a lack of clinical evidence. The aim of this study is to show, through a randomized double blind prospective trial, the efficacy of this procedure, by comparing PRP to Hyaluronic Acid (HA) injections for the treatment of knee chondropathy or osteoarthritis (OA).

METHODS

109 patients (55 treated with HA and 54 with PRP) were treated and evaluated at 12 months of follow-up. The patients were enrolled according to the following inclusion criteria: age > 18 years, history of chronic (at least 4 months) pain or swelling of the knee and imaging findings of degenerative changes of the joint (Kellgren-Lawrence Score up to 3). A cycle of 3 weekly injections was administered blindly. All patients were prospectively evaluated before and at 2, 6, and 12 months after the treatment by: IKDC, EQ-VAS, TEGNER, and KOOS scores. Range of motion and knee circumference changes were measured over time. Adverse events and patient satisfaction were also recorded.

RESULTS

Only minor adverse events were detected in some patients, such as mild pain and effusion after the injections, in particular in the PRP group, where a significantly higher post-injective pain reaction was observed (p=0.039). At the follow-up evaluations, both groups presented a clinical improvement but the comparison between the two groups showed a not statistically significant difference in all scores evaluated. A trend favorable for the PRP group was only found in patients with low grade articular degeneration (Kellgren-Lawrence score up to 2).

CONCLUSIONS

Results suggest that PRP injections offer a significant clinical improvement up to one year of follow-up. However, conversely to what was shown by the current literature, for middle-aged patients with moderate signs of OA, PRP results were not better than those obtained with HA injections, and thus it should not be considered as first line treatment. More promising results are shown for its use in low grade degeneration, but they still have to be confirmed.

Rodilla/Knee/Knie: infiltraciones de PRP para la gonartrosis incipiente

The effects of repeated intra-articular PRP injections on clinical outcomes of early osteoarthritis of the knee.

Gobbi ALad DKarnatzikos G

Knee Surg Sports Traumatol Arthrosc 2014 Apr 20.

Abstractc

PURPOSE

To assess the outcome of intra-articular platelet-rich plasma (PRP) injections into the knee in patients with early stages of osteoarthritis (OA) and to determine whether cyclical dosing would affect the end result.

METHODS

This is a prospective, randomized study in which 93 patients (119 knees) were followed up for a minimum of 2 years. Fifty knees were randomly selected prior to the first injection, to receive a second cycle at the completion of 1 year. A cycle consisted of three injections, each given at a monthly interval. The outcome was assessed using Knee Injury and Osteoarthritis Outcome Score (KOOS), Visual Analogue Scale (VAS), Tegner and Marx scoring systems, recorded prior to the first injection and then at 12, 18 and 24 months.

RESULTS

There was a significant improvement in all scores over time compared to the pre-treatment value (p < 0.001). At 12 months, both groups showed similar and significant improvement. At 18 months, except for KOOS (Symptoms) and Tegner score, all other parameters showed a significant difference between the two groups in favour of the patients who had received the second cycle (p < 0.001). At 2 years, the scores declined in both groups but remained above the pre-treatment value with no significant difference between the groups despite the patients with two cycles showing higher mean values for all the scores.

CONCLUSION

Intra-articular PRP injections into the knee for symptomatic early stages of OA are a valid treatment option. There is a significant reduction in pain and improvement in function after 12 months, which can be further improved at 18 months by annual repetition of the treatment. Although the beneficial effects are ill sustained at 2 years, the results are encouraging when compared to the pre-treatment function.

LEVEL OF EVIDENCE: II.

Rodilla/Knee: artrosis y combinar PRP con ácido hialurónico

Knee osteoarthritis: hyaluronic acid, platelet-rich plasma or both in association?

Expert Opinion on Biological Therapy 2014 February 17
Isabel Andia, Michele Abate

Introduction: Bidirectional interactions between cells and fluidic surroundings regulate cellular functions and maintain tissue or organ architecture. Accordingly, the synovial fluid is the primary source of environmental signals and determines to a great extent the molecular interactions within the joint capsule, both in homeostasis and pathology.

Areas covered: We provided an update on hyaluronic acid (HA) and platelet-rich plasma (PRP) concepts necessary to build the rationale for creating a combined treatment. The information is based on a PubMed search using the terms 'platelet-rich plasma', 'hyaluronic acid', 'knee pathology', 'knee osteoarthritis' (OA). 

Expert opinion: In OA, a deleterious fluidic microenvironment is established, with presence of HA fragments, catabolic enzymes and inflammatory molecules. The central concept underlying intra-articular injection is to modify deleterious fluidic microenvironments. PRP administration has shown pain remission and function improvement, but less than half of the patients showed clinically significant improvement. PRP exceeds HA, the comparator used in PRP clinical trials, albeit both HA and PRP alleviate symptoms in mild-to-moderate OA patients. Combining PRP and HA may benefit from their dissimilar biological mechanisms and help in controlling delivery and presentation of signaling molecules. Three armed randomized studies, using both HA and PRP as comparators, will provide information about the impact of this approach.