Clinical Orthopaedics and Related Research®

, Volume 471, Issue 2, pp 613–620

Adding Triamcinolone Improves Viscosupplementation: A Randomized Clinical Trial

  • Gustavo Constantino de Campos
  • Marcia U. Rezende
  • Alexandre F. Pailo
  • Renato Frucchi
  • Olavo Pires Camargo
Clinical Research

Abstract

Background

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.

Questions/Purposes

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?

Methods

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.

Results

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.

Conclusions

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.

References

  1. 1.
    Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, Christy W, Cooke TD, Greenwald R, Hochberg M et al. 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. 1986;29:1039–1049.PubMedCrossRefGoogle Scholar
  2. 2.
    Balazs EA, Watson D, Duff IF, Roseman S. Hyaluronic acid in synovial fluid: I. Molecular parameters of hyaluronic acid in normal and arthritis human fluids. Arthritis Rheum. 1967;10:357–376.PubMedCrossRefGoogle Scholar
  3. 3.
    Bannuru RR, Natov NS, Dasi UR, Schmid CH, McAlindon TE. Therapeutic trajectory following intra-articular hyaluronic acid injection in knee osteoarthritis: meta-analysis. Osteoarthritis Cartilage. 2011;19:611–619.PubMedCrossRefGoogle Scholar
  4. 4.
    Bannuru RR, Natov NS, Obadan IE, Price LL, Schmid CH, McAlindon TE. Therapeutic trajectory of hyaluronic acid versus corticosteroids in the treatment of knee osteoarthritis: a systematic review and meta-analysis. Arthritis Rheum. 2009;61:1704–1711.PubMedCrossRefGoogle Scholar
  5. 5.
    Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW. 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. 1988;15:1833–1840.PubMedGoogle Scholar
  6. 6.
    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.Google Scholar
  7. 7.
    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.Google Scholar
  8. 8.
    Chevalier X, Jerosch J, Goupille P, van Dijk N, Luyten FP, Scott DL, Bailleul F, Pavelka K. 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. 2010;69:113–119.PubMedCrossRefGoogle Scholar
  9. 9.
    Conaghan PG, Hunter DJ, Maillefert JF, Reichmann WM, Losina E. Summary and recommendations of the OARSI FDA osteoarthritis Assessment of Structural Change Working Group. Osteoarthritis Cartilage. 2011;19:606–610.PubMedCrossRefGoogle Scholar
  10. 10.
    DiBattista JA, Martel-Pelletier J, Wosu LO, Sandor T, Antakly T, Pelletier JP. Glucocorticoid receptor mediated inhibition of interleukin-1 stimulated neutral metalloprotease synthesis in normal human chondrocytes. J Clin Endocrinol Metab. 1991;72:316–326.PubMedCrossRefGoogle Scholar
  11. 11.
    Divine JG, Zazulak BT, Hewett TE. Viscosupplementation for knee osteoarthritis: a systematic review. Clin Orthop Relat Res. 2007;455:113–122.PubMedCrossRefGoogle Scholar
  12. 12.
    Goldberg VM, Coutts RD. Pseudoseptic reactions to hylan viscosupplementation: diagnosis and treatment. Clin Orthop Relat Res. 2004;419:130–137.PubMedCrossRefGoogle Scholar
  13. 13.
    Gomis A, Miralles A, Schmidt RF, Belmonte C. 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. 2009;17:798–804.PubMedCrossRefGoogle Scholar
  14. 14.
    Guidolin DD, Ronchetti IP, Lini E, Guerra D, Frizziero L. 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. 2001;9:371–381.PubMedCrossRefGoogle Scholar
  15. 15.
    Hepper CT, Halvorson JJ, Duncan ST, Gregory AJ, Dunn WR, Spindler KP. The efficacy and duration of intra-articular corticosteroid injection for knee osteoarthritis: a systematic review of level I studies. J Am Acad Orthop Surg. 2009;17:638–646.PubMedGoogle Scholar
  16. 16.
    Hollander JL, Brown EM Jr, Jessar RA, Brown CY. Hydrocortisone and cortisone injected into arthritic joints: comparative effects of and use of hydrocortisone as a local antiarthritic agent. JAMA. 1951;147:1629–1635.CrossRefGoogle Scholar
  17. 17.
    Hunter DJ, Zhang W, Conaghan PG, Hirko K, Menashe L, Li L, Reichmann WM, Losina E. Systematic review of the concurrent and predictive validity of MRI biomarkers in OA. Osteoarthritis Cartilage. 2011;19:557–588.PubMedCrossRefGoogle Scholar
  18. 18.
    Kellgren JH, Lawrence JS. Radiological assessment of rheumatoid arthritis. Ann Rheum Dis. 1957;16:485–493.PubMedCrossRefGoogle Scholar
  19. 19.
    Kemper F, Gebhardt U, Meng T, Murray C. 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. 2005;21:1261–1269.PubMedCrossRefGoogle Scholar
  20. 20.
    Lequesne MG. The algofunctional indices for hip and knee osteoarthritis. J Rheumatol. 1997;24:779–781.PubMedGoogle Scholar
  21. 21.
    Lussier A, Cividino AA, McFarlane CA, Olszynski WP, Potashner WJ, De Medicis R. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol. 1996;23:1579–1585.PubMedGoogle Scholar
  22. 22.
    Navarro-Sarabia F, Coronel P, Collantes E, Navarro FJ, de la Serna AR, Naranjo A, Gimeno M, Herrero-Beaumont G. 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. 2011;70:1957–1962.PubMedCrossRefGoogle Scholar
  23. 23.
    Ozturk C, Atamaz F, Hepguler S, Argin M, Arkun R. The safety and efficacy of intraarticular hyaluronan with/without corticosteroid in knee osteoarthritis: 1-year, single-blind, randomized study. Rheumatol Int. 2006;26:314–319.PubMedCrossRefGoogle Scholar
  24. 24.
    Papachristou G, Anagnostou S, Katsorhis T. The effect of intraarticular hydrocortisone injection on the articular cartilage of rabbits. Acta Orthop Scand Suppl. 1997;275:132–134.Google Scholar
  25. 25.
    Prieto JG, Pulido MM, Zapico J, Molina AJ, Gimeno M, Coronel P, Alvarez AI. Comparative study of hyaluronic derivatives: rheological behaviour, mechanical and chemical degradation. Int J Biol Macromol. 2005;35:63–69.PubMedCrossRefGoogle Scholar
  26. 26.
    Raynauld JP, Buckland-Wright C, Ward R, Choquette D, Haraoui B, Martel-Pelletier J, Uthman I, Khy V, Tremblay JL, Bertrand C, Pelletier JP. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 2003;48:370–377.PubMedCrossRefGoogle Scholar
  27. 27.
    Reichmann WM, Maillefert JF, Hunter DJ, Katz JN, Conaghan PG, Losina E. Responsiveness to change and reliability of measurement of radiographic joint space width in osteoarthritis of the knee: a systematic review. Osteoarthritis Cartilage. 2011;19:550–556.PubMedCrossRefGoogle Scholar
  28. 28.
    Wang CT, Lin YT, Chiang BL, Lin YH, Hou SM. 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. 2006;14:1237–1247.PubMedCrossRefGoogle Scholar
  29. 29.
    Wang Y, Hall S, Hanna F, Wluka AE, Grant G, Marks P, Feletar M, Cicuttini FM. 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. 2011;12:195.PubMedCrossRefGoogle Scholar
  30. 30.
    Yasuda T. Hyaluronan inhibits prostaglandin E2 production via CD44 in U937 human macrophages. Tohoku J Exp Med. 2010;220:229–235.PubMedCrossRefGoogle Scholar
  31. 31.
    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. 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. 2010;18:476–499.PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • Gustavo Constantino de Campos
    • 1
  • Marcia U. Rezende
    • 1
  • Alexandre F. Pailo
    • 1
  • Renato Frucchi
    • 1
  • Olavo Pires Camargo
    • 1
  1. 1.Orthopaedics and Traumatology DepartmentUniversity of São Paulo General HospitalSão PauloBrazil

Personalised recommendations