Viscosupplementation, PRP Steroids-Consensus in OA-Dr. M.S.Dhillon

1. ICS Session: IAS congress 2014
Viscosupplementation, PRP,
Steroids - Consensus in OA
MS Dhillon
Chandigarh
12-Oct-14 Prof M S Dhillon 1

2. Injections for Osteoarthritis
Preffered as the last non
operative modality
• Initial injections were
steroids, with multi
purpose use: Pain relief,
Anti inflammatory,
Instinct?
Raynauld JP et al. Safety and efficacy of long term intraarticular steroid
injections in OA knee: a randomized, double blind, placebo controlled trial.
Arthritis Rheum 2003;48(2):370-377.
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3. What are the recommendations?
In 2012
“…Strong evidence supports the use of intra-articular
Injections as a valuable intervention in the continuum
of management of arthritis……..”
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4. BUT: Which type of injections?
“…Steroids help……. But not for long term..
Help reduce synovial inflammation, but
No effect on cartilage wear”
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5. • Steroids have both anti inflammatory and
immunosuppressive effect, but mech of action
is complex
• Ideal during OA flare; effusion in early
radiological
• Rare side effects
Arden NK et al. A randomised controlled trial of tidal irrigation vs corticosteroid
injection in knee OA:the KIVIS Study. Osteoarthritis Cartilage 2008; 16:733-739
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6. In 2013
Positive Recommendation: when treatment meets the
minimum clinically important improvement thresholds
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7. In 2013
Jones A, Doherty M. Intra-articular corticosteroids are effective in osteoarthritis but
there are no clinical predictors of response. Ann Rheum Dis 1996;55(11):829-832
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8. Consensus
• Adjunct to core treatments!
• Relieves moderate to severe pain in some
cases
• Joint effusion aspiration with injection in
Grades 2/3 OA gives short term relief
• Does NOT degrade cartilage further
National Collaborating Centre for Chronic Conditions (UK). Osteoarthritis: National clinical
guideline for care a&management in adults. London: Royal College of Physicians (UK), 2008
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9. Changing thought process
In the 1990s
Balazs EA, Denlinger JL. Viscosupplementation: a new concept in the
treatment of osteoarthritis. J Rheumatol Suppl 1993; 39: 3-9
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10. Joint Lubrication/
Vissco supplementation
“…generated significant interest in 1995-2014
years worldwide….”
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11. Hyaluronic Acid Injections have been
used extensively
“…patient activity and functional levels…….
…improve significantly as compared to placebo….”
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12. Vissco Supplements
• Designed as Synovial
fluid Prosthetic device
to lubricate the joint
• Different Molecular wts,
provide different levels
of lubrication
Maneiro E, et al. The biological action of hyaluronan on human osteoarthritic articular
chondrocytes: the importance of molecular weight. Clin Exp Rheumatol 2004; 22: 307-312
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13. Mechanism of Vissco-supplementation
Restores visco
elastic properties
of pathologically
altered synovial
fluids
Synvisc One GENZYME Video
Wang C et al. Therapeutic effects of hyaluronic acid on osteoarthritis of the knee. A
meta-analysis of randomized controlled trials. J Bone Joint Surg Am 2004; 86-A: 538-545
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14. Mechanism of Vissco-supplementation
Direct analgesic
activity by reducing
Bradykinin &
Substance P synthesis
• Forms envelope
around nociceptive
receptors, reduces
pain
Synvisc One GENZYME Video
Moreland LW. Intra-articular hyaluronan (hyaluronic acid) and hylans for the treatment
of osteoarthritis: mechanisms of action. Arthritis Res Ther 2003; 5: 54-67
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15. What about the current evidence?
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16. In 2013
AAOS has changed its guideline given in 2008
where it had medium evidence in support
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17. Consensus
• Research evidence suggests that IA HA
injections are safe, have potential efficacy,
• Provide pain reduction in EARLY OA for upto
24 weeks
• COST effectiveness is a concern.
• Patient must be aware of the limitations
Rutjes AW,et al. Viscosupplementation for osteoarthritis of the knee: a systematic
review and meta-analysis. Ann Intern Med 2012; 157: 180-191
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18. Can we actually help in
Healing Cartilage?????
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19. Lot of discussion on
“regenerative” injections?
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20. Disease Modifying Agents ?
Biological
products CAN
influence Cartilage
healing !
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21. PLATELETS: A SOURCE OF GROWTH
PLATELETS IN RESTING STATE
Discoid shape
ACTIVATED PLATELETS
inductive FACTORS
Provide a rich source of multiple
GROWTH FACTORS that serve a
CRITICAL function in WOUND
and FRACTURE Healing
These factors have a direct
Chemotactic and Mitogenic effect
on Cell precursors (MSC)
PRE-CLINICAL ANIMAL STUDIES
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22. One emerging Trend………….
Use PRP to stimulate tissue healing
2011
• Patel, Dhillon et al: PRP in early Knee OA
• Behera, Dhillon et al: PRP In intractable tennis elbow
• Shetty, Dhillon et al: PRP in Planter fascitis
Prof M S Dhillon
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23. Why PRP in Osteoarthritis?
• Aim is to restore
anabolic-catabolic
imbalance seen in OA
• Growth factors
released from Alpha
Granules of activated
Platelets may
influence OA
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24. Pubmed Search: Osteoarthritis AND PRP
A Lot of focused
Work is actually
going on
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25. Does PRP help knee OA?
Spate of publications in 2011-14
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26. Positive Exptal
evidence 2009
• Stimulated Chondrocyte GAG
Synthesis
• Suppressed progression of
OA in rabbit model
Stimulation of
Cartilage Matrix
metabolism by growth
factors in PRP
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27. Kon E, Buda R, Filardo G et
al Knee Surg Sports
Traumatol Arthrosc
2010;18:472–479
European
publications
Prof M S Dhillon
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28. 2013 Feb
issue AJSM
12-Oct-14
1st RCT
With controls
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29. What we concluded about PRP in
Knee OA
PRP is safe, gives symptomatic relief in early OA knees.
• Improvement noted by 2 to 3 weeks, which gradually
improves over 3 months
• Early OA fares better than late OA
• One injection is as effective as 2
Patel S, Dhillon MS, Aggarwal S, Marwaha N, Jain A.TREATMENT
WITH PLATELET-RICH PLASMA IS MORE EFFECTIVE THAN PLACEBO
FOR KNEE OSTEOARTHRITIS: A PROSPECTIVE, DOUBLE-BLIND,
RANDOMIZED TRIAL. Am J Sports Med. 2013 Feb;41(2):356-64
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30. Cited in 62 publications
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31. Comparison with Hyaluronate Acid
PRP may actually help
cartilage defects to heal better !
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32. Prof M S Dhillon
Where do we stand today?
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33. In 2013
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34. We are in an Era of EBM!
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35. Evidence for and against many things
is equivocal
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36. New Technology
Many times it
is a Leap of
faith
Sometimes
into darkness
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37. Our Understanding of PRP role in OA
Many issues in
relation to OA
are still undefined
? etio-pathogenesis
? factors controlling
progression
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38. What do we
Know today?
PRP works
…through
various factors
… influences
multiple
processes
inside joints
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39. Consensus?
• PRP is safe in OA
• Improvement by 2 to 3 wks,
improves over 3 months
• Improvement tapers off by 6 mo
Early OA fares better than late OA
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40. What we are still Unsure about?
• What formulation is more
effective, and at what conc?
• Will it work in Ahalback’s Type 3?
• How many (1,2 or 3) injections?
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41. Email me for a pdf copy
drdhillon@gmail.com
Thank You For Your Attention
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