Page 28 - 2020 ISAKOS Newsletter Volume I

CURRENT CONCEPTS
State of the Art for Injections in Orthopaedics
Additional studies are needed to identify optimal formulations and in defining the ideal dose and timing of injections for various orthopaedic conditions. In this state of the art article, you will find a critical review of the latest high-level evidence-based medicine for the clinical use of injections in orthopaedics.
Injections for Osteoarthritis (OA)
Corticosteroids
Corticosteroids have been reported to be more effective than placebo in pain reduction and clinical scores until three weeks post-injection. However, after one-month post-injection, there were no significant differences when compared to placebo. There are some patient factors, such as obesity and OA severity, that affects its effectiveness. Due to the lack of long-term benefit, patients often request multiple injections. The AAOS clinical practice guidelines for non-surgical management of knee OA updated in 2013 was unable to recommend for or against its use for knee OA. Thus, evidence of using corticosteroids for the treatment of symptomatic knee OA was determined to be inconclusive.
Hyaluronic Acid (HA)
HA has been shown to reduce the symptoms of OA and provide a superior safety profile when compared to the use of NSAIDs. It has also been shown to postpone the time of knee arthroplasty from the diagnosis of OA. Recent OARSI guidelines for the treatment of osteoarthritis suggest “good” level of evidence for the treatment of symptomatic mild to moderate OA of the knee with intra-articular HA. The European Viscosupplementation Consensus Group recommended the use of HA injections in young patients at high risk of progression of OA and competitive athletes in an attempt to slow the progression of OA. Recently, a new type of HA has been brought in to the market. It consists of a mixture of two hyaluronates, one of medium molecular weight (1200-1500 kDa), which promotes viscosupplementation, the other of low molecular weight (200-400 kDa), which contributes to the resolution of OA articular damages. The main innovation is the excipient, trehalose, a sugar that seems to act as a protector of HA, delaying the degradation from hyaluronidases. Pre-clinical studies demonstrated that this new formulation lasts longer than three months, and a new clinical trial is in progress to analyze the effect in patients suffering from OA.
Platelet Rich Plasma (PRP)
PRP has been the center of attention regarding non- surgical injectable therapies. It is known to contain a high concentration of -granules with growth factors and anti- inflammatory cytokines such as insulin-like growth factor 1 (IGF-1), IGF-2, vascular endothelial growth factor (VEGF), transforming growth factor- (TGF- ), fibroblast growth factor (FGF), endothelial growth factor, and platelet-derived growth factors (PDGF).
Abstract
Ignacio Dallo, MD
O.A.S.I Bioresearch Foundation Gobbi Onlus, Milano, ITALY
Email: info@drignaciodallo.com.ar
Eleonora Irlandini
O.A.S.I Bioresearch Foundation Gobbi Onlus, Milano, ITALY
Email: e.irlandini@gmail.com
Vetri Kumar, MS
O.A.S.I Bioresearch Foundation Gobbi Onlus, Milano, ITALY
Email: fellow@oasiortopedia.it
There is a growing interest in orthopaedics and sports medicine in non-surgical treatment with the advent of injectable therapies, such as viscosupplementation, injections using endogenous growth factors and cells directly into the tissue to facilitate healing, decrease inflammation and subsequently provoke an analgesic effect after an injury or illness. Injections have the advantage of being ‘‘minimally invasive’’ with relatively low risk of complications. Commonly used biological approaches include platelet- rich plasma (PRP), bone marrow aspirate concentrate (BMAC), adipose tissue, and allogenic amniotic fluid. These injectable treatments may contribute to a regenerative microenvironment with the potential to improve healing rates and function in patients with musculoskeletal problems; however to date, only symptomatic improvements have been reported clinically. The American Academy of Orthopaedic Surgeons (AAOS) defined these biological as substances that can be found naturally in the body that aid in injury healing. Several clinical trials are currently being performed evaluating these non-invasive therapies despite limited understanding of the underlying pathologic basis of the disease and without a complete characterization of their components.
26 ISAKOS NEWSLETTER 2020: VOLUME I