Adding Triamcinolone Improves Viscosupplementation: A Randomized Clinical Trial
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Intraarticular injections, mainly using long-lasting corticosteroid suspensions, have long been used to treat knee osteoarthritis. Viscosupplementation is a relatively new approach with injection of a variety of agents. When comparing viscosupplementation with intraarticular injections of corticosteroids from baseline to the fourth week, steroids have been more effective for pain relief. By the fourth week they provide similar relief, but beyond that viscosupplementation appears to provide greater pain reduction. The delayed onset of symptomatic improvement combined with reports of reactive synovitis may discourage physicians and patients.
We therefore addressed three questions: Does the addition of triamcinolone to viscosupplementation (1) improve first-week pain and function compared with viscosupplementation alone, (2) diminish adverse effects of viscosupplementation alone, and (3) alter 6-month pain and function of viscosupplementation alone?
We prospectively enrolled 104 patients with knee osteoarthritis and randomized them to receive either a single intraarticular injection (6 mL) of hylan GF-20 (Group viscosupplementation [Group VS]), or a single intraarticular injection of hylan GF-20 (6 mL) and 1 mL (20 mg) of triamcinolone hexacetonide (Group VS + T). VAS, WOMAC™, and Lequesne questionnaires were completed at baseline and at Weeks 1, 4, 12, and 24.
At Week 1 the WOMAC and VAS scores were lower in Group VS + T, compared with Group VS. There was no difference regarding the adverse effects. At Weeks 4, 12, and 24 there were no differences in the groups.
The addition of triamcinolone hexacetonide improves first-week symptom and functional scores of viscosupplementation, but not beyond. It does not seem to increase the likelihood of adverse effects.
Level of Evidence
Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
- Altman, R, Asch, E, Bloch, D, Bole, G, Borenstein, D, Brandt, K, Christy, W, Cooke, TD, Greenwald, R, Hochberg, M (1986) Development of criteria for the classification and reporting of osteoarthritis: classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 29: pp. 1039-1049 CrossRef
- Balazs, EA, Watson, D, Duff, IF, Roseman, S (1967) Hyaluronic acid in synovial fluid: I. Molecular parameters of hyaluronic acid in normal and arthritis human fluids. Arthritis Rheum. 10: pp. 357-376 CrossRef
- Bannuru, RR, Natov, NS, Dasi, UR, Schmid, CH, McAlindon, TE (2011) Therapeutic trajectory following intra-articular hyaluronic acid injection in knee osteoarthritis: meta-analysis. Osteoarthritis Cartilage. 19: pp. 611-619 CrossRef
- Bannuru, RR, Natov, NS, Obadan, IE, Price, LL, Schmid, CH, McAlindon, TE (2009) Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Arthritis Rheum. 61: pp. 1704-1711 CrossRef
- Bellamy, N, Buchanan, WW, Goldsmith, CH, Campbell, J, Stitt, LW (1988) Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol. 15: pp. 1833-1840
- Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Intraarticular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;CD005328.
- Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;CD005321.
- Chevalier, X, Jerosch, J, Goupille, P, Dijk, N, Luyten, FP, Scott, DL, Bailleul, F, Pavelka, K (2010) Single, intra-articular treatment with 6 ml hylan G-F 20 in patients with symptomatic primary osteoarthritis of the knee: a randomised, multicentre, double-blind, placebo controlled trial. Ann Rheum Dis. 69: pp. 113-119 CrossRef
- Conaghan, PG, Hunter, DJ, Maillefert, JF, Reichmann, WM, Losina, E (2011) Summary and recommendations of the OARSI FDA osteoarthritis Assessment of Structural Change Working Group. Osteoarthritis Cartilage. 19: pp. 606-610 CrossRef
- DiBattista, JA, Martel-Pelletier, J, Wosu, LO, Sandor, T, Antakly, T, Pelletier, JP (1991) Glucocorticoid receptor mediated inhibition of interleukin-1 stimulated neutral metalloprotease synthesis in normal human chondrocytes. J Clin Endocrinol Metab. 72: pp. 316-326 CrossRef
- Divine, JG, Zazulak, BT, Hewett, TE (2007) Viscosupplementation for knee osteoarthritis: a systematic review. Clin Orthop Relat Res. 455: pp. 113-122 CrossRef
- Goldberg, VM, Coutts, RD (2004) Pseudoseptic reactions to hylan viscosupplementation: diagnosis and treatment. Clin Orthop Relat Res. 419: pp. 130-137 CrossRef
- Gomis, A, Miralles, A, Schmidt, RF, Belmonte, C (2009) Intra-articular injections of hyaluronan solutions of different elastoviscosity reduce nociceptive nerve activity in a model of osteoarthritic knee joint of the guinea pig. Osteoarthritis Cartilage. 17: pp. 798-804 CrossRef
- Guidolin, DD, Ronchetti, IP, Lini, E, Guerra, D, Frizziero, L (2001) Morphological analysis of articular cartilage biopsies from a randomized, clinical study comparing the effects of 500–730 kDa sodium hyaluronate (Hyalgan) and methylprednisolone acetate on primary osteoarthritis of the knee. Osteoarthritis Cartilage. 9: pp. 371-381 CrossRef
- Hepper, CT, Halvorson, JJ, Duncan, ST, Gregory, AJ, Dunn, WR, Spindler, KP (2009) The efficacy and duration of intra-articular corticosteroid injection for knee osteoarthritis: a systematic review of level I studies. J Am Acad Orthop Surg. 17: pp. 638-646
- Hollander, JL, Brown, EM, Jessar, RA, Brown, CY (1951) Hydrocortisone and cortisone injected into arthritic joints: comparative effects of and use of hydrocortisone as a local antiarthritic agent. JAMA. 147: pp. 1629-1635 CrossRef
- Hunter, DJ, Zhang, W, Conaghan, PG, Hirko, K, Menashe, L, Li, L, Reichmann, WM, Losina, E (2011) Systematic review of the concurrent and predictive validity of MRI biomarkers in OA. Osteoarthritis Cartilage. 19: pp. 557-588 CrossRef
- Kellgren, JH, Lawrence, JS (1957) Radiological assessment of rheumatoid arthritis. Ann Rheum Dis. 16: pp. 485-493 CrossRef
- Kemper, F, Gebhardt, U, Meng, T, Murray, C (2005) Tolerability and short-term effectiveness of hylan G-F 20 in 4253 patients with osteoarthritis of the knee in clinical practice. Curr Med Res Opin. 21: pp. 1261-1269 CrossRef
- Lequesne, MG (1997) The algofunctional indices for hip and knee osteoarthritis. J Rheumatol. 24: pp. 779-781
- Lussier, A, Cividino, AA, McFarlane, CA, Olszynski, WP, Potashner, WJ, Medicis, R (1996) Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol. 23: pp. 1579-1585
- Navarro-Sarabia, F, Coronel, P, Collantes, E, Navarro, FJ, Serna, AR, Naranjo, A, Gimeno, M, Herrero-Beaumont, G (2011) A 40-month multicentre, randomised placebo-controlled study to assess the efficacy and carry-over effect of repeated intra-articular injections of hyaluronic acid in knee osteoarthritis: the AMELIA project. Ann Rheum Dis. 70: pp. 1957-1962 CrossRef
- Ozturk, C, Atamaz, F, Hepguler, S, Argin, M, Arkun, R (2006) The safety and efficacy of intraarticular hyaluronan with/without corticosteroid in knee osteoarthritis: 1-year, single-blind, randomized study. Rheumatol Int. 26: pp. 314-319 CrossRef
- Papachristou, G, Anagnostou, S, Katsorhis, T (1997) The effect of intraarticular hydrocortisone injection on the articular cartilage of rabbits. Acta Orthop Scand Suppl. 275: pp. 132-134
- Prieto, JG, Pulido, MM, Zapico, J, Molina, AJ, Gimeno, M, Coronel, P, Alvarez, AI (2005) Comparative study of hyaluronic derivatives: rheological behaviour, mechanical and chemical degradation. Int J Biol Macromol. 35: pp. 63-69 CrossRef
- Raynauld, JP, Buckland-Wright, C, Ward, R, Choquette, D, Haraoui, B, Martel-Pelletier, J, Uthman, I, Khy, V, Tremblay, JL, Bertrand, C, Pelletier, JP (2003) Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 48: pp. 370-377 CrossRef
- Reichmann, WM, Maillefert, JF, Hunter, DJ, Katz, JN, Conaghan, PG, Losina, E (2011) Responsiveness to change and reliability of measurement of radiographic joint space width in osteoarthritis of the knee: a systematic review. Osteoarthritis Cartilage. 19: pp. 550-556 CrossRef
- Wang, CT, Lin, YT, Chiang, BL, Lin, YH, Hou, SM (2006) High molecular weight hyaluronic acid down-regulates the gene expression of osteoarthritis-associated cytokines and enzymes in fibroblast-like synoviocytes from patients with early osteoarthritis. Osteoarthritis Cartilage. 14: pp. 1237-1247 CrossRef
- Wang, Y, Hall, S, Hanna, F, Wluka, AE, Grant, G, Marks, P, Feletar, M, Cicuttini, FM (2011) Effects of Hylan G-F 20 supplementation on cartilage preservation detected by magnetic resonance imaging in osteoarthritis of the knee: a two-year single-blind clinical trial. BMC Musculoskelet Disord. 12: pp. 195 CrossRef
- Yasuda, T (2010) Hyaluronan inhibits prostaglandin E2 production via CD44 in U937 human macrophages. Tohoku J Exp Med. 220: pp. 229-235 CrossRef
- Zhang, W, Nuki, G, Moskowitz, RW, Abramson, S, Altman, RD, Arden, NK, Bierma-Zeinstra, S, Brandt, KD, Croft, P, Doherty, M, Dougados, M, Hochberg, M, Hunter, DJ, Kwoh, K, Lohmander, LS, Tugwell, P (2010) OARSI recommendations for the management of hip and knee osteoarthritis: Part III. Changes in evidence following systematic cumulative update of research published through January 2009. Osteoarthritis Cartilage. 18: pp. 476-499 CrossRef
- Adding Triamcinolone Improves Viscosupplementation: A Randomized Clinical Trial
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- 1. Orthopaedics and Traumatology Department, University of São Paulo General Hospital, Rua Ovídio Pires de Campos, 333, 3o. Andar, São Paulo, 05403-010, Brazil