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Osteoarthritis of the knee

1997; Elsevier BV; Volume: 350; Issue: 9087 Linguagem: Inglês

10.1016/s0140-6736(05)62494-4

1474-547X

Paul Creamer, Marc C. Hochberg,

Proteoglycans and glycosaminoglycans research

Author's reply Sir—Our statement about the efficacy of hyaluronic acid versus intra-articular steroids was made on the basis of Jones' and colleagues' randomised, double-blind comparative study1Jones AC Pattrick M Doherty S Doherty M Intra-articular hyaluronic acid compared to intra-articular triamcinolone hexacetonide in inflammatory knee osteoarthritis.Osteoarthritis Cart. 1995; 3: 269-273Summary Full Text PDF PubMed Scopus (133) Google Scholar that compared hyaluronic acid with 20 mg triamcinolone hexacetonide. Although there was a high drop-out rate in both groups, intention-to-treat analysis showed a greater reduction in pain in the hyaluronic acid group, over a 6-month period. We agree with Margaret-Mary Gordan and colleagues that the older published research on this treatment is confused by several short-term, poorly designed, or uncontrolled studies. Nevertheless, since 1993 studies have been published that compared hyaluronic acid with placebo,2Dougados M Nguyen M Listrat V Amor B High molecular weight sodium hyaluronate (hyalectin) in osteoarthritis of the knee: a 1 year placebo-controlled trial.Osteoarthritis Cart. 1993; 1: 97-103Summary Full Text PDF PubMed Scopus (267) Google Scholar, 3Lohmander LS Dalen N Englund G et al.Intra-articular hyaluronan injections in the treatment of osteoarthritis of the knee: a randomised, double blind, placebo controlled multicentre trial. Hyaluronan Multicentre Trial Group.Ann Rheum Dis. 1996; 55: 424-431Crossref PubMed Scopus (253) Google Scholar, 4Henderson EB Smith EC Pegley F Blake DR Intra-articular injections of 750 kD hyaluronan in the treatment of osteoarthritis: a randomised single centre double-blind placebo-controlled trial of 91 patients demonstrating lack of efficacy.Ann Rheum Dis. 1994; 53: 529-534Crossref PubMed Scopus (147) Google Scholar as well as studies comparing hyaluronic acid with intra-articular triamcinolone hexacetonide and non-steroidal anti-inflammatory drugs (NSAIDs).5Adams ME Atkinson MH Lussier AJ et al.The role of viscosupplementation with hylan G-F 20 (Synvisc) in the treatment of osteoarthritis of the knee: a Canadian multicenter trial comparing hylan G-F 20 alone, hylan G-F 20 with non-steroidal anti-inflammatory drugs (NSAIDs) and NSAIDs alone.Osteoarthritis Cart. 1995; 3: 213-225Summary Full Text PDF PubMed Scopus (350) Google Scholar All but one4Henderson EB Smith EC Pegley F Blake DR Intra-articular injections of 750 kD hyaluronan in the treatment of osteoarthritis: a randomised single centre double-blind placebo-controlled trial of 91 patients demonstrating lack of efficacy.Ann Rheum Dis. 1994; 53: 529-534Crossref PubMed Scopus (147) Google Scholar of these large, well-designed studies showed a slight but significant benefit for hyaluronic acid, at least in some subgroups. We agree that hyaluronic acid has not, as yet, been accepted as a standard or routine treatment for knee osteoarthritis and that optimum guidelines for its use have yet to be established. However, we believe that the product may have a role in a small group of patients: for example, older individuals in whom surgery is not contemplated and whose pain is uncontrolled by other measures, or patients with isolated knee osteoarthritis with contraindications to NSAIDs. Two preparations of hyaluronic acid have been approved by the US Food and Drug Administration for use in the treatment of knee osteoarthritis. We thank Madhur Bhattaral for sharing his experience of the bicycle ergometer as a means to provide exercise for patients with knee osteoarthritis. Most intervention studies focus on strengthening the quadriceps, since that is believed to be the muscle which contributes most to functional loss in knee osteoarthritis. Bicycling involves many other muscles and also requires greater degrees of knee flexion than are used in everyday activities. However, compliance is likely to be an issue with any exercise programme and, if bicycling is well tolerated, we see no reason why it should not be encouraged, if only as an adjunct to weight reduction. Osteoarthritis of the kneePaul Creamer and Marc Hochberg's seminar on osteoarthritis (Aug 16, p 503)1 provides a comprehensive overview, including treatment strategies and options. They suggest that intra-articular hyaluronic acid is more efficacious than a single injection of intra-articular steroid in patients with knee osteoarthritis. As far as we can see, the only comparative studies have compared intra-articular 6-methyl prednisolone acetate (6-MPA), a short-acting corticosteroid with a half life of only 7 days, with intra-articular hyaluronic acid, rather than the more commonly used preparation of triamcinolone hexacetonide, which has a half life of 26–60 days. Full-Text PDF Osteoarthritis of the kneePaul Creamer and Marc Hochberg1 rightly highlight the important role of physical therapy in the management of osteoarthritis. In case of osteoarthritis of the knee, walking or jogging is not recommended as an exercise because such activity tends to increase joint loading.2 Exercises to strengthen the quadriceps—for example, quadriceps-setting exercise and straight-leg raises—are effective in reducing pain and improving function in patients with knee osteoarthritis.1,3 But patients may not continue to exercise regularly. Full-Text PDF