Intra-articular Infiltration Research Articles

Effectiveness of intra-articular analgesia in reducing postoperative pain after minimally invasive sacroiliac joint fusion: a double-blind randomized controlled trial

During the first postoperative days following minimally invasive sacroiliac joint fusion (MISJF), patients often report serious pain, which contributes to high utilization of painkillers and prevention of early mobilization. This prospective, double-blind randomized controlled trial investigates the effectiveness of intraoperative SIJ infiltration with bupivacaine 0.50% versus placebo (NaCl 0.9%) in 42 patients in reducing postoperative pain after MISJF. The primary outcome was difference in pain between bupivacaine and placebo groups, assessed as fixed factor in a linear mixed model. Secondary outcomes were opioid consumption, patient satisfaction, adverse events, and length of hospital stay. We found that SIJ infiltration with bupivacaine did not affect postoperative pain scores in comparison with placebo, neither as group-effect (p = 0.68), nor dependent on time (group*time: p = 0.87). None of the secondary outcome parameters were affected in the postoperative period in comparison with placebo, including opioid consumption (p = 0.81). To conclude, intra-articular infiltration of the SIJ with bupivacaine at the end of MISJF surgery is not effective in reducing postoperative pain. Hence, we do not recommend routine use of intraoperative SIJ infiltration with analgesia in MISJF.

Actualización en el manejo de gonartrosis: Revisión bibliográfica

Gonarthrosis is a chronic-degenerative disease that involves the entire joint and its components, mainly affecting the articular cartilage, producing its degeneration and bone hyperplasia. About 50-60% of older adults experience symptoms of OA. The objective of this research is to discover new therapeutic options for gonarthrosis, in addition to expanding knowledge about intra-articular infiltration by describing the substances available for this therapy. An electronic search of scientific articles published from January 2018 to April 2024 was carried out in the PubMed, Scopus, Web of Science and ScieLO databases. Currently there are several options for the treatment of OA, from physiotherapy, pharmacotherapy to surgery. Intra-articular drug administration is a new therapeutic approved by the FDA, among its advantages are local bioavailability, reduced systemic drug exposure, fewer adverse events and reduced costs. Some of the substances used are glucocorticoids, hyaluronic acid, ozone and platelet-rich plasma, which reduce pain and inflammation, increasing the patient's quality of life. It is concluded that botulinum toxin decreases central and peripheral sensitivity, reducing pain in the short term. The use of hyaluronic acid as a vehicle for the application of gold microparticles has decreased symptoms in the short and long term, however, further studies are required to evaluate its effectiveness on the control of other symptoms.

Clinical effectiveness of polynucleotide TMJ injection compared with physiotherapy: a 3-month randomised clinical trial

Joint visco-supplementation is an effective therapeutic approach against the degenerative signs and symptoms of osteoarthrosis/osteoarthritis of the mandibular condyle. Supplements of choice are usually delivered inside the temporomandibular joint (TMJ) by intra-articular infiltration. The present study aimed to assess the clinical effectiveness of pericapsular injection of polinucleotides (PN) and hyaluronic acid (HA). Sixty patients suffering from TMJ osteoarthrosis were recruited and divided into two groups (test group: n = 30, pericapsular injection; control group: n = 30, self-delivered physiotherapeutic exercises). For each patient, maximum opening, right and left lateral excursion, and visual analogue scale (VAS) scores were recorded at four different timepoints by a blinded investigator. Paired Student’s t tests were used to compare consecutive measurements of the parameters evaluated within the groups, and unpaired Student’s t tests were used for between-group comparisons. All investigated parameters displayed a progressive clinical improvement in both groups, which was more accentuated in the test group. The decrease in VAS score differed significantly between groups (p < 0.0001). Maximum opening showed a continuous increase from baseline (mean (SD) 37.70 (8.33) mm) to T3 (39.68 (7.64) mm), reflecting a progressive improvement, but it was not statistically significant (p = 0.089 at T3 with respect to T0). PN HA pericapsular injection is a minimally invasive treatment that effectively reduces pain and improves mandibular kinematics.

The Efficacy of Intra-articular Platelet-Rich Plasma Injection Versus Corticosteroid Injection in the Treatment of Knee Osteoarthritis: A Prospective Comparative Analysis.

Background Knee osteoarthritis (KOA) is the most typical cause of knee pain and impairment worldwide. It is typified by slow and progressive degeneration of the articular cartilage of the knee joint. Although KOA is being managed with a variety of therapies, the comparison of the effectiveness of different intra-articular injections in KOA treatment in Pakistan is still not thoroughly investigated. Therefore, the purpose of this current study is to compare the efficacy of intra-articular administration of platelet-rich plasma (PRP) and corticosteroids (CSs) in the treatment of KOA. Methods This prospective comparative study was performed among one hundred patients diagnosed with KOA in Benazir Bhutto Hospital, Rawalpindi, for one year from April 2022 to March 2023. Specified inclusion and exclusion criteria were employed for patient enrollment. Patients were divided into two equal groups through simple random sampling. Group A patients received an intra-articular injection of PRP solution whereas group B patients received an intra-articular injection of CSs. Informed consent and ethical approval were also acquired prior to data collection. A self-designed proforma based on interviews was used to collect data. The data analysis in Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 25.0, Armonk, NY) was carried out via descriptive statistics and an independent t-test. Results Women (N=71, 71%) had a higher prevalence of KOA than men (N=29, 29%). The means of study variables like age, Visual Analog Scale (VAS) score, and Western Ontario and McMaster Universities (WOMAC) score were 56.10 ± 8.70 years, 8.08 ± 1.6, and 70.08 ± 8.76 respectively. The frequency of KOA on the right side was 62% (N=62) while it was 38% (N=38) on the left side. In the study population,69% (N=69) patients had grade II KOA, and 31% (N=31) patients had grade III KOA. At the first-month, second-month, and third-month follow-up visits, there were statistically significant differences in the mean scores of the WOMAC and VAS between the study groups. However, at the first-month follow-up visit, mean scores of VAS and WOMAC were lower in group B than in group A while these were lower in group A as compared to group B, at the second-month and third-month follow-up appointments. Conclusions Intra-articular infiltration of both PRP and CSs was efficacious in the treatment of KOA-related pain and functional limitations; however, overall improvement in the PRP group was higher than CSgroup.

THERAPEUTIC OPTIONS IN CALCIFIC ROTATOR CUFF TENDINOPATHY OF THE SHOULDER

Calcific tendinopathy in the tendons of the rotator cuff muscles of the shoulder is an increasingly common and disabling pathology. Calcific tendinopathy is a common disease that mainly affects people aged between 40 and 60. Women seem to be more affected than men. It has been suggested that various factors play a role in the condition, such as abnormal thyroid gland activity, metabolic diseases (e.g. gout, diabetes) and genetic predisposition. Various aetiological hypotheses have been put forward: the degenerative and multiphasic theories are the two most widely accepted. Clinically, calcific tendonitis is characterised by severe, disabling pain, often occurring spontaneously, usually in the morning or following exertion disproportionate to subsequent symptoms. There may be concomitant stiffness, giving rise to a clinical picture resembling frozen shoulder or hyperalgesic painful shoulder. Conventional radiography of the shoulder is the most appropriate imaging approach, but perfectly complemented by soft tissue ultrasound. Most acute painful episodes resolve spontaneously symptomatically. Numerous conservative treatments have been reported in the literature with varying levels of evidence of efficacy. In the present study we tried to evaluate which therapeutic option could give superior results both from a functional, lesional architectural and causal point of view in terms of reduction of callus size, but also from an imaging point of view. The use of various therapeutic protocols have shown a significant benefit of the association of ESWT with conventional FKT, and intra-articular infiltration, with a plus for the association of Corticosteroids and Sodium Hyaluronate regarding the speed of achieving the desired results. Similar results were obtained with the intra-articular shoulder PRP technique, but with slower achievement of the desired results. Arthroscopic surgery is the orthopaedic specialist's last option. Keywords: Calcific tendinopathy, rotator cuff muscles, shoulder, intra-articular infiltration.

Adductor Canal Block + Local Infiltration Versus Local Infiltration Alone in Post-Operative Pain Management in Total Knee Replacement

Abstract Background: Adductor canal blocks (ACBs) are an emerging concept for post-operative pain management in total knee replacement (TKR). The present study was designed to evaluate the duration of analgesia, patient satisfaction, use of opioids, pain score, and ease of ambulation after ACB + intra-articular local infiltration for TKR surgery and compare it with local infiltration alone. Materials and Methods: This retrospective observational study included a total of 260 cases of TKR selected as per inclusion/exclusion criteria. All patients underwent surgery under spinal, epidural, or general anesthesia. For post-operative analgesia, intra-articular local infiltration of a cocktail [12.5 mL of 0.5% sensocaine + 2 mL ketorolac + 0.5 mg adrenaline + 95 mL normal saline] was administered to all patients, with some patients also receiving ACB (15 mL of 0.2% ropivacaine + 1 mcg/kg dexmedetomidine) by random selection. Thus, two groups of patients were formed: (i) those who received ACB and local infiltrative analgesia and (ii) those who received only local infiltrative analgesia. The two groups were matching in terms of demography, comorbidities, and complexity of osteoarthritis. Variables were compared between these two groups by using outcome measures, including (i) time to attain SLR (straight leg raise), (ii) the total amount of opioid doses given in 24 h, (iii) the pain score by visual analogue score (VAS) at 24 h, (iv) success of early ambulation, and (v) complications. Results: Out of the 260 cases of TKR, 126 were of Group 1 and 134 were of Group 2. In the local infiltration alone group, the average VAS at 24 h was 3.8, the average amount of opioid doses given in 24 h was 1.54, the average time of ambulation was 3 h post-surgery, and the average time to attain SLR was 3 h post-surgery. In the adductor canal plus local infiltration group, the average VAS was 3.32, the average amount of opioid use was 0.9, the average time for ambulation was 3 h post-surgery, and the average time to attain SLR was 3 h post-surgery. No major complications were noted in either group. Conclusion: According to our study, ACB is certainly a useful tool in reducing the post-operative pain and increasing ambulation and patient satisfaction. However, a larger study is required to establish its effectiveness conclusively.

Perioperative Intra-articular Infiltration of Tranexamic Acid and Ropivacaine Cocktail in Bilateral Total Knee Replacement

Objective: This study evaluated the efficacy and safety of perioperative intra-articular infiltration with a tranexamic acid and ropivacaine cocktail in patients undergoing bilateral total knee replacement (TKR). Methods: A randomized controlled trial was conducted involving 50 patients scheduled for elective bilateral TKR. Participants were randomly assigned to receive either intra-articular infiltration of a tranexamic acid and ropivacaine cocktail (intervention group) or standard care (control group). Outcome measures included postoperative blood loss, pain scores, range of motion, and adverse events. Results: Among the enrolled patients (n=50), the intervention group demonstrated reduced postoperative blood loss, evidenced by higher hemoglobin levels and lower drain output than the control group. Additionally, the intervention group exhibited consistently lower pain scores at various postoperative time points and greater improvements in range of motion. Conclusion: Intra-articular infiltration with a tranexamic acid and ropivacaine cocktail in bilateral TKR patients showed promising outcomes, including reduced blood loss, improved pain control, and enhanced range of motion. These findings suggest the potential of this adjunctive therapy in optimizing perioperative care for patients undergoing bilateral TKR. However, further research with larger sample sizes is warranted to validate these preliminary results and establish this intervention’s long-term efficacy and safety.

Comparison of the Effectiveness of Intra-articular Infiltration of Hyaluronic Acid and Corticosteroids in the Management of Knee Osteoarthritis: A Prospective Comparative Study.

Background Knee osteoarthritis (KOA) is a chronic and progressive disease of the knee joint characterized by articular cartilage destruction. It is the most common cause of knee disability and pain globally. Various treatments are used for the management of KOA; however, the role of intra-articular injections in KOA management in Pakistan remains understudied. Therefore, this study aims to evaluate the effectiveness of intra-articular injections of hyaluronic acid (HA) and corticosteroids in the management of KOA. Methodology This randomized, prospective, comparative study was conducted among 88 patients diagnosed with KOA in the outpatient department clinic of orthopedics in Benazir Bhutto Hospital, Rawalpindi, from January 2022 to January 2023. For patient enrolment, structured inclusion and exclusion criteria and a simple random sampling technique were used. Before data collection, ethical approval and informed consent were obtained. Data collection was done via a self-structured and interview-based proforma. Data analysis was performed through descriptive statistics and independent t-tests using SPSS version 25 (IBM Corp., Armonk, NY, USA). Results KOA was more prevalent in women (60, 68.18%) than men (28, 31.82%). The means for study variables such as age, Visual Analog Scale (VAS) score, and Western Ontario and McMaster Universities (WOMAC) score were 58.08 ± 7.89 years, 7.66 ± 1.8, and 71.86 ± 8.90, respectively. The incidences of right-sided and left-sided KOA were 57 (64.77%) and 31 (35.23%), respectively. Likewise, the frequency of grade II KOA was 55 (62.50%), while the frequency of grade III KOA was 33 (37.50%). Differences in the mean scores of both VAS and WOMAC between study groups were statistically significant at the second-week, sixth-week, and third-month follow-up visits. However, the mean scores of VAS and WOMAC were lower in group B than in group A at the second-week follow-up visit, whereas the scores were lower in group A compared to group B after the sixth week and third month of intra-articular injections. Conclusions Intra-articular injections of both HA and corticosteroids were adequately effective in the management of KOA-associated pain and functional restrictions; nevertheless, the benefits of corticosteroids were acute and short-term, whereas the outcomes of HA were gradual and long-term.

Improved range of motion after manipulation under anesthesia versus physiotherapy for stage two frozen shoulder: a randomized controlled trial

BackgroundFrozen shoulder (FS) is a common cause of shoulder pain and stiffness. Conservative treatment is sufficient for the majority of patients with recovery of shoulder function at long term. Manipulation under anesthesia (MUA) is known as a well-established treatment option if conservative treatment fails. It is unknown whether MUA does indeed shorten the duration of symptoms or leads to a superior outcome compared to conservative treatment. The objective of the current trial is to evaluate the effectiveness of MUA followed by a physiotherapy program (PT) compared to a PT program alone in patients with stage two FS. MethodsA prospective, single center randomized controlled trial was performed. Patients between 18 and 70 years old with a stage two FS were deemed eligible if an initial course of conservative treatment, consisting of physiotherapy and an intra-articular corticosteroid infiltration was considered unsatisfactory. Patients were randomized and data was collected with an online data management platform (CASTOR). MUA was performed by a single surgeon under interscalene block and an intensive physiotherapy treatment protocol was started within 4 hours after MUA. In the PT group patients were referred to instructed physiotherapist, and treatment was guided by tissue irritability. The primary outcome was the SPADI score. Secondary outcomes were pain, range of motion, OSS, quality of life and ability to work. ResultsIn total, 82 patients were included, 42 in the PT group and 40 in the MUA group. There was a significant improvement in SPADI, OSS, pain, range of motion and quality of life in both groups at 1 year follow-up. SPADI scores at three months were significantly improved in favor of MUA. MUA showed a significant bigger increase in anteflexion and abduction compared to PT at all points of follow-up. No significant differences between both groups were found for all other parameters. No fractures, dislocations or brachial plexus injuries occurred in this trial. ConclusionMUA in stage 2 FS can be considered safe and results in a faster recovery of range of motion and improved functional outcome, measured with SPADI scores, compared to PT alone at short term. After 1 year, except for slightly better range of motion scores for MUA, the result of MUA is equal to PT.

Observational study of ropivacaine and compound betamethasone mixture for analgesia after triangular fibrocartilage complex repair under wrist arthroscopy: A single-center randomized double-blind controlled trial

BackgroundThe purpose of this study was to investigate the clinical effect of an intra-articular and local infiltration injection of a compound analgesic mixture of ropivacaine and compound betamethasone on the repair of the triangular fibrocartilage complex under wrist arthroscopy. MethodsThis prospective, double-blind, randomized study involved 20 patients with Atzei type 2 or 3 injuries of the triangular fibrocartilage complex who underwent repair under wrist arthroscopy. Patients were divided into two groups (n = 10) according to the systematic random sampling method. The test group was injected with a “cocktail” mixture for pain relief. The control group was injected with normal saline. The visual analog scale (VAS) pain score, pinch force, wrist joint mobility, wrist joint function score (PRWE score), occurrence of adverse reactions and dosage of analgesic drugs were evaluated before and after the operation in the two groups. ResultsThe resting pain of the patients in the test group was less severe than that of the control group at 12 h, 24 h and 48 h after the operation (P < 0.05), and the pinch force of the patients in the test group was significantly greater than that of the control group at 1 d, 2 d and 3 d after the operation (P < 0.01). The amount of postoperative analgesics used in the test group was significantly lower than that in the control group (P < 0.01), and the patient satisfaction rate in the test group was higher than that in the control group (P < 0.05). There were no postoperative adverse effects in either group. ConclusionAn intra-articular and local infiltration injection of a “cocktail” analgesic mixture in the repair of triangular fibrocartilage complex under wrist arthroscopy can provide good pain control in the early postoperative period and reduce the amount of postoperative analgesic drugs administered, thus improving clinical safety. Level of evidenceLevel II; Randomized Controlled Trial; Treatment Study.

Comparison of Four Treatment Protocols with Intra-Articular Medium Molecular Weight Hyaluronic Acid in Induced Temporomandibular Osteoarthritis: An Experimental Study.

The aim was to compare the effect between a single intra-articular infiltration (1i) and two infiltrations (2i) of medium molecular weight hyaluronic acid (MMW-HA) of high viscosity (HV) and low viscosity (LV) on the histopathological characteristics of temporomandibular joint (TMJ) osteoarthritis (OA) induced in rabbits. An experimental study was conducted on Oryctolagus cuniculus rabbits, including 42 TMJs, distributed between (1) TMJ-C, control group; (2) TMJ-OA, group with OA; (3) TMJ-OA-wt, group with untreated OA; (4) group treated with HA-HV-1i; (5) group treated with HA-HV-2i; (6) group treated with HA-LV-1i; and (7) group treated with HA-LV-2i. The results were evaluated using the Osteoarthritis Research Society International (OARSI) scale and descriptive histology considering the mandibular condyle (MC), the articular disc (AD), and the mandibular fossa (MF). The Kruskal-Wallis test was used for the statistical analysis, considering p < 0.05 significant. All treated groups significantly decreased the severity of OA compared to the TMJ-OA-wt group. The HA-HV-2i group showed significant differences in the degree of OA from the TMJ-OA group. The degree of OA in the HA-HV-2i group was significantly lower than in the HA-LV-1i, HA-LV-2i, and HA-HV-1i groups. The protocol that showed better results in repairing the joint was HA-HV-2i. There are histological differences depending on the protocol of the preparation used: two infiltrations seem to be better than one, and when applying two doses, high viscosity shows better results.

Post-Operative Analgesic Effect of Intra-Articular Local Anesthetic Infiltration versus Adductor Canal Block after Knee Arthroscopic Surgeries

Abstract Background Knee arthroscopic surgery is one of the most common orthopaedic procedures. Postoperative pain after Knee arthroscopy is caused by irritation of free nerve endings of synovial tissue, anterior fat pad, and joint capsule during surgical excision and resection. Aim of the Work To compare between intra-articular local anaesthetic infiltration and ultrasound guided adductor canal block to achieve effective and safe postoperative analgesia after knee arthroscopic surgeries as regarding duration of postoperative analgesia, need for analgesic supplements postoperatively, patient satisfaction, time of ambulation, and presence of any associated complications or side effects. Patients and Methods A prospective randomized comparative study was conducted in Ain Shams University hospitals, on patients aged from 20 to 60 years, ASA class I-II-III assigned for knee arthroscopic surgeries. For six to eight months started after approval from ethical committee of Ain Shams University. A written informed consent had been obtained from all patients. Every patient received an explanation for the purpose of the study and research results only used for scientific purposes. Results The study showed that adductor canal group had lower Pain perception (VAS-10) at rest, but the differences were statistically significant beginning from hour-8. Also, adductor canal group had lower Pain perception (VAS-10) during movement, but the differences were statistically significant beginning from hour-8. Rescue analgesia was significantly less frequent in adductor canal group. High satisfaction (Good/excellent) grades were significantly more frequent in adductor canal group. Conclusion The findings of our study revealed that ACB Provides better postoperative analgesia after knee arthroscopic surgeries than intra-articular local anaesthetic infiltration at rest and movement. Furthermore it facilitated earlier mobility than local anaesthetic infiltration. However, in clinical practice intra-articular local anaesthetic infiltration is easier to perform than ACB which requires experienced anaesthesiologist.

Office-Based Intraosseous Infiltrations of PRGF as an Effective Treatment for Knee Osteoarthritis: A Retrospective Observational Clinical Study.

The aim of this study was to explore and assess office-based ultrasound-guided intraosseous and intra-articular infiltrations of plasma rich in growth factors (PRGF) in patients with moderate and severe knee osteoarthritis (KOA). Seventy-nine patients (30 women and 49 men) with grade 3-4 KOA according to the Kellgren-Lawrence classification participated in the study. All patients were treated with a minimally invasive technique using local anesthesia WALANT (wide-awake local anesthesia no tourniquet) in the ambulatory setting. A PRGF intra-articular infiltration and two intraosseous infiltrations in the tibial plateau and femoral condyle were performed weekly for a total of three sessions. The evaluation of the results was carried out using knee injury and osteoarthritis outcome score (KOOS) at baseline and post-treatment. After a follow-up period of 11 months (median) [interquartile range, 7-14], all the KOOS domains showed statistically significant improvement (p < 0.001). Moreover, 88% of the patients showed a pain reduction of at least 10 points (minimally clinically important improvement) from pre- to post-treatment. Our retrospective study using the in-office procedure of ultrasound-guided combination of intra-articular and intraosseous infiltrations of PRGF is a safe and efficacious approach for the treatment of grade 3-4 knee osteoarthritis.

Regeneration of Partial Anterior Cruciate Ligament Tears Using the Technique of Biologic Augmentation with Bone Marrow Concentrate and Platelet-Rich Plasma Under Arthroscopic Visualization

To present clinical outcomes in a preliminary patient cohort using a biologic augmentation technique consisting of intra-ligamentous and intra-articular infiltration of bone marrow aspirate concentrate (BMAC) and platelet-rich plasma (PRP) under arthroscopic visualization for treatment of isolated and acute partial anterior cruciate ligament (ACL) tears. Athletes with an acute symptomatic partial ACL injury with clinical examination findings of increased anterior tibial translation without rotational instability were treated with the biologic augmentation technique. Patients were followed for 2 years postoperatively. The Lysholm Knee Questionnaire, IKDC Objective score, physical examination findings, MRI, and the KT-1000 arthrometer were used to assess clinical outcomes. Five patients were included in the analysis with a median age of 22. All patients were determined to have a healed ACL on MRI 8 months postoperatively. The median Lysholm Score at the final follow-up of 99 was significantly increased from the median pre-operative score (p = 0.042). In addition, the objective IKDC score improved in all patients postoperatively, and no clinical examination findings of knee instability were identified at the final follow-up. The median side-to-side difference in KT-1000 arthrometer testing was 3 mm pre-operatively and 0 mm at the last follow-up (p = 0.038). The treatment of appropriately indicated partial ACL injuries in this study has demonstrated that restoration of ligamentous structure and function may be achieved by a biologic augmentation technique using intra-ligamentous and intra-articular infiltration of BMAC and PRP. This technique is performed with minimal technical difficulty, leading to excellent 2-year clinical outcomes in this preliminary series of patients.

A comparative study between intraarticular infiltration of platelet rich plasma and hyaluronic acid in osteoarthritis knee

Background: Osteoarthritis (OA) is the most common progressive musculoskeletal condition that can affect joints, but it mainly affects the hips and knees as predominant weight-bearing joints and is characterized by structural modifications to primarily articular cartilage and subchondral bone, Hoffa’s fat pad, synovia, ligaments and muscles, leading to the concept of OA as a whole joint disease. Hence the present study was undertaken to evaluate the outcomes of platelet rich plasma (PRP) and hyaluronic acid (HA) intra-articular injections in patients with OA in terms of pain by numerical pain score and VAS and to evaluate the outcomes of PRP and HA intra-articular injections in patients with OA in terms of functional outcome by WOMAC scores. Methods: The study was a prospective hospital-based study in Kempegowda Institute of Medical Sciences between 2020 to 2022. The study was conducted on 100 patients, more than the age of 50 years of either gender with grade I-III OA of the knee fulfilling the inclusion and exclusion criteria. Patients were followed up at 6, 12 and 24 weeks for data collection and data was analyzed after follow-up visits were completed for all patients. Results: On intragroup analysis, there was significant reduction in the mean WOMAC score in both the study groups across time-points (p&lt;0.05). On intragroup analysis, there was significant reduction in the mean VAS score in both the study groups across time-points (p&lt;0.05). On intergroup analysis at any time point of follow-up, the mean WOMAC score was noted to be statistically comparable between the study groups (p&gt;0.05). Conclusions: In patients with symptomatic knee OA, intra-articular HA and PRP provide short term improvement in pain and function. Both the therapy agents for OA were associated with equivalent safety, with no complications.

Knowledge and appropriateness of care of family physicians and physiotherapists in the management of shoulder pain: a survey study in the province of Quebec, Canada

BackgroundShoulder pain is difficult to diagnose and treat with half of those affected still symptomatic six months after initial consultation. This may be explained by primary care management not conforming to evidence-based practice. This survey evaluated physiotherapists (PTs) and family physicians' (FPs) knowledge and appropriateness of care in shoulder pain management.MethodsA survey sent to PTs and FPs in the province of Quebec, Canada presented four clinical vignettes with cases of rotator cuff (RC) tendinopathy, acute full-thickness RC tear, adhesive capsulitis and traumatic anterior glenohumeral instability. Respondents indicated diagnosis, indications for imaging, specialists’ referrals, and choice of treatments. Answers were compared to recommendations from clinical practice guidelines (CPGs). Participants’ responses were compared between types of providers with Fisher’s exact test.ResultsRespondents (PTs = 175, FPs = 76) were mostly women with less than ten years of experience. More than 80% of PTs and 84% of FPs correctly diagnosed cases presented. Despite this practice not being recommended, more FPs than PTs recommended an imaging test in the initial management of RC tendinopathy (30% compared to 13%, p = 0.001) and adhesive capsulitis (51% compared to 22%, p = 0.02). For full-thickness RC tear and shoulder instability, up to 72% of FPs and 67% of PTs did not refer to a specialist for a surgical opinion, although recommended by CPGs. For RC tendinopathy, 26% of FPs and 2% of PTs (p < 0.001) would have prescribed a corticosteroid infiltration, which is not recommended in the initial management of this disorder. For adhesive capsulitis, significantly more FPs (76%) than PTs (62%) (p < 0.001) suggested an intra-articular corticosteroid infiltration, as recommended by CPGs. For all presented vignettes, up to 95% of family physicians adequately indicated they would refer patients for physiotherapy. In prioritizing rehabilitation interventions, up to 42% of PTs did not consider active exercises as a priority and up to 65% selected passive modalities that are not recommended for all shoulder pain vignettes.ConclusionsMost FPs and PTs were able to make adequate diagnoses and select appropriate treatments for shoulder pain, but practices opposed to evidence-based recommendations were chosen by several respondents. Further training of FPs and PTs may be needed to optimize primary care management of different shoulder disorders.

Remodeling articular immune homeostasis with an efferocytosis-informed nanoimitator mitigates rheumatoid arthritis in mice

Massive intra-articular infiltration of proinflammatory macrophages is a prominent feature of rheumatoid arthritis (RA) lesions, which are thought to underlie articular immune dysfunction, severe synovitis and ultimately joint erosion. Here we report an efferocytosis-informed nanoimitator (EINI) for in situ targeted reprogramming of synovial inflammatory macrophages (SIMs) that thwarts their autoimmune attack and reestablishes articular immune homeostasis, which mitigates RA. The EINI consists of a drug-based core with an oxidative stress-responsive phosphatidylserine (PtdSer) corona and a shell composed of a P-selectin-blocking motif, low molecular weight heparin (LMWH). When systemically administered, the LMWH on the EINI first binds to P-selectin overexpressed on the endothelium in subsynovial capillaries, which functions as an antagonist, disrupting neutrophil synovial trafficking. Due to the strong dysregulation of the synovial microvasculature, the EINI is subsequently enriched in the joint synovium where the shell is disassembled upon the reactive oxygen species stimulation, and PtdSer corona is then exposed. In an efferocytosis-like manner, the PtdSer-coroneted core is in turn phagocytosed by SIMs, which synergistically terminate SIM-initiated pathological cascades and serially reestablish intra-articular immune homeostasis, conferring a chondroprotective effect. These findings demonstrate that SIMs can be precisely remodeled via the efferocytosis-mimetic strategy, which holds potential for RA treatment.

Femoral Nerve Block and Local Instillation Analgesia Associated With More Reliable Efficacy in Regional Anesthesia Interventions Within 24 Hours Following Anterior Cruciate Ligament Reconstruction: A Network Meta-analysis

To assess the relative effectiveness of different regional anesthetic techniques (peripheral nerve blocks, local instillation analgesia, including intra-articular, subcutaneous, and periarticular infiltration) in patients undergoing anterior cruciate ligament reconstruction (ACLR). PubMed, Embase, Cochrane Library, and Web of Science databases were searched from their inception to December 31, 2020. The search was supplemented by manual review of relevant reference lists. Randomized controlled trials of participants after ACLR that compared regional anesthesia interventions were selected. The 2 coprimary outcomes were (1) rest pain scores and (2) cumulative oral morphine equivalent consumption on day 1 (24 hours) post-ACLR. Data were pooled using a Bayesian framework. Of 759 records identified, 46 trials were eligible, evaluating 9 interventions in 3,171 patients. Local instillation analgesia (LIA), including intra-articular, subcutaneous, and periarticular infiltration, had significant improvement in pain relief as compared with placebo (-0.91; 95% CrI -1.45 to -0.37). Femoral nerve block (FNB) also showed significant effects in relieving pain as compared with placebo (-0.70; 95% 95% credible interval [CrI] -1.28 to -0.12). Compared with placebo, a significant reduction in opioid consumption was found in LIA (mean difference -13.29 mg; 95% CrI -21.77 to -4.91) and FNB (mean difference -13.97 mg; 95% CrI -24.71 to -3.04). Femoral and sciatic nerve block showed the greatest ranking for pain relief and opioid consumption without significant evidence (P > .05) to support superiority in comparison with placebo, respectively. Our meta-analysis shows that FNB and LIA can significantly diminish postoperative pain and reduce opioid consumption following ACLR compared with placebo in the setting of regional anesthesia, and femoral and sciatic nerve block may be the number 1 top-ranked analgesic technique despite high uncertainty. I, Systematic review of Level I studies.

Comparative efficacy of ultrasonically guided infiltration of single shot of platelet-rich plasma and triamcinolone acetonide in adhesive capsulitis of shoulder joint - a prospective clinical study

Background: Adhesive capsulitis is also termed periarthritis of the shoulder joint or frozen shoulder. It is the most common cause of pain in and around the shoulder joint, extending up to the insertion of the deltoid muscle in the middle of the arm. The incidence of adhesive capsulitis ranges from 2% to 5%. It is prevalent in the middle-aged (40–60 years) group. Females suffer more from this condition. In the recent past, the infiltration of steroids into the shoulder joint was the mainstay of the treatment. Platelet-rich plasma (PRP) has appeared as a new hope for such patients, as it is believed to enhance the revascularization of the soft tissue and also increase the concentration of growth factors to improve and accelerate tendon healing. Aims and Objectives: This present study was done to evaluate the relative efficacy of ultrasonically guided infiltration of PRP and triamcinolone acetonide. Materials and Methods: The present clinical prospective study was conducted on 50 patients in a tertiary institute in Punjab, India, from June 2018 to December 2020 to evaluate the comparative efficacy of ultrasonically guided infiltration through the posterior approach of PRP and triamcinolone acetonide in the outdoor patient department of the department of orthopedics. The patients selected for the intra-articular infiltration were in their middle age (40–60 years), diagnosed as having adhesive capsulitis with non-resolution of signs and symptoms for the last 12 weeks. Results: PRP was a superior alternative to triamcinolone acetonide in the management of adhesive capsulitis as it resulted in long-term improvement in the visual analog score and disability of arm, shoulder, and hand scores with significant margins. Conclusion: PRP is definitively a newer, effective, cost-effective, autogenously derived alternative to the corticosteroids used till date, as it not only provides a long lasting effect but also helps in regenerative medicine.

Intra-osseous infiltration of adipose mesenchymal stromal cells and plasma rich in growth factors to treat acute full depth cartilage defects in a rabbit model: Serum osteoarthritis biomarkers and macroscopical assessment.

Intra-articular infiltration of plasma rich in growth factors (PRGF) and adipose mesenchymal stromal cells (AMSCs) are known to inhibit osteoarthritis progression. However, in severely affected patients, the treatment cannot reach the deeper layers of the articular cartilage; thus, its potential is limited. To overcome this limitation, intra-osseous infiltrations have been suggested. The purpose of this study is to assess the impact of intra-osseous infiltration therapies on serum biomarkers of osteoarthritis and to assess cartilage regeneration macroscopically. A total of 80 rabbits were divided into four groups based on the intra-osseous treatment administered on the day of surgery: control, PRGF, AMSCs and a combination of PRGF + AMSCs. In addition, all groups received a single intra-articular administration of PRGF on the same day. Serum biomarker levels were measured before infiltration and 28-, 56-, and 84-days post infiltration, and macroscopical assessment was conducted at 56- and 84-days follow-up post infiltration. In the PRGF + AMSCs group, significantly lower concentrations of hyaluronic acid and type II collagen cleavage neoepitope were recorded at all time points during the study, followed by PRGF, AMSCs and control groups. Regarding macroscopical assessment, lower scores were obtained in PRGF + AMSCs group at all study times. The results suggest that the combination of intra-articular PRGF with intra-osseous PRGF or AMSCs achieves better results in rabbits with acute chondral defects and that intra-osseous infiltration is a safe procedure.