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Viscosupplementation Can Relieve Pain & Protect Your Knee
 

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Viscosupplementation Can Relieve Pain & Protect Your Knee byDennis Armstrong, M.D.

We bend our knees a million times in a year. The lubricating fluid, called synovial fluid, helps this process acting like a lubricant and shock absorber to protect your knee. To understand viscosupplemention and its benefits, let's take a look at the normal knee and osteoarthritis (OA).    The knee joint is where the femur (thigh bone) and tibia (shin bone) come together. A third bone, the triangular-shaped patella (kneecap), lies across the front of the joint to protect it. As in our other joints, a layer of protective cartilage covers the ends of the bones to allow smooth movement. Special to the knee are two pads of protective tissue called menisci. The entire joint is encased is a capsule lined with a membrane called the synovium which generates a fluid that acts as both a lubricant and a shock absorber. This fluid is called synovial fluid. Various ligaments and muscles support, stabilize and power the joint.    Although there are many problems associated with knee pain, the most prevalent joint disorder is osteoarthritis. Osteoarthritis can be due to a predisposition to its development but also often is a result of repetitive micro traumas over many years, an injury left untreated such as a torn meniscus and being overweight. The end result of osteoarthritis of the knee is often severe cartilage loss resulting in significant pain particularly while weight bearing (walking), getting up from a chair and sometimes at night.    Through this process of progressive osteoarthritis, the components of the synovial fluid often breakdown, resulting in diminished shock absorbing characteristics. This loss of shock absorption results in less protection of the knee during movement. One such component of the synovial fluid is hyaluronic acid (HA), which is responsible for the synovial fluid's ability to lubricate and act as a shock absorber in the knee. When one has knee OA, the concentration of HA in the synovial fluid is reduced causing a loss of shock absorbing and lubricating properties. This results in increased joint pain, stiffness and possibly an onset or worsening of osteoarthritis. What is Hyaluronic Acid?    Hyaluronic acid (HA) is a substance natural in the body and is present not only in the synovial fluid but also in the eyeballs, skin and cartilage. When isolated, it is a thick, viscous solution. Viscosupplements, which are designed to replace osteoarthritic synovial fluid with a more normal prosthetic synovial fluid, use purified HA derived from either rooster combs or genetically engineered cells to add to the natural HA in the knee joint. The Role of Viscosupplementation    Viscosupplementation is an option of treatment for those with moderate to moderately severe osteoarthritis of the knee. Through a series of injections, supplemental HA can be added to the knee joint. It is believed that by replacing the osteoarthritic synovial fluid with a product made of HA that is closer to normal synovial fluid, the patient experiences pain relief due to the presence of a new "lubricant" in the knee that is also acting as a shock absorber. The result is increased protection of the knee joint itself and a soothing of the nerve endings exposed by the degraded cartilage of the osteoarthritic knee. Could You Benefit?    Viscosupplementation is given to people with knee osteoarthritis who have not responded to traditional therapies, such as oral anti-inflammatory or analgesic medications or exercise. It is also can be considered for those who are trying to delay or simply are not candidates for total knee replacement surgery. This treatment has not been approved for other joints, although there are studies underway for hip arthritis. How Is It Administered?    Viscosupplementation therapy is only available through injection into the knee. The injection is given directly into the knee from a point on the side and under the kneecap. Synvisc is a viscosupplementation product that is specifically designed to be closest to healthy young synovial fluid and provides relief that can last for months. It is given in a series of three injections, one each week. It can take up to 12 weeks to take full effect. Is There Any Risk?    If you have had any allergic reaction to any hyaluronate preparations or are allergic to poultry products, you are not a candidate for these injections. You also should not receive these injections if you have an infection or skin disease around the injection area. Sometimes one can experience some swelling, heat, redness or itching around the joint, but this is temporary. Any reaction is usually mild and short-lived. Does Viscosupplemention Work?    HA viscosupplemention is a safe and effective treatment for osteoarthritis of the knee. Depending on the severity of the knee arthritis, these injections can be 72-75% effective for six months to a year.    If you wonder whether you are a candidate or could benefit from viscosupplemention, see your orthopaedic surgeon or rheumatologist for an evaluation of your options. About the Author:    Arizona orthopaedic surgeon, Dennis Armstrong, M.D., is board certified in orthopaedic surgery and specializes in arthritis reconstructive surgery. He received his medical degree from the Wayne State School of Medicine and completed his orthopaedic residency at Henry Ford Hospital in Detroit, Michigan. Dr. Armstrong has been involved in several clinical investigative studies researching the surgery and care of those undergoing total joint replacement, and has authored numerous talks/papers on options for knee and hip pain.   © Copyright 2002. Arthritis Education by Professionals, Inc.

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Today's News

Friday, February 5, 1999

Viscosupplementation found useful for osteoarthitis pain

Edward H. Miller, MD, principal exhibitor, assistant volunteer professor, department of orthopaedics, University of Cincinnati College of Medicine, and colleagues said viscosupplementation is useful in patients who fail NSAID and intra-articular corticosteroid injection. Benefits are radiological grade dependent, being less effective in the higher (worse) grades of osteoarthritis.

The authors said viscosupplementation has been shown to be superior to continuous NSAID therapy and can delay the necessity of total knee replacement in up to one-third of patients. There is a significantly higher incidence of adverse effects of acute inflammatory reaction than previously reported; these are self-limiting.

Sixteen patients, who received a series of five injections with hyaluronan, were compared to 92 patients receiving three injections of Hylan G-F 20 at one week intervals. The standard dose of 2 ccs. was used in all cases. The patients included 52 men and 56 women. The average age was 62 years. The average follow-up was 1.3 years (range: 12 to 18 months). The patients had radiological Stages I through IV in at least one compartment of the knee. All patients had failed control of symptoms with NSAIDs and intra-articular corticosteroids.

All knees with effusions at the initial injection were aspirated. The Hospital for Special Surgery knee rating scale and the SF-36 surveys were performed pretreatment, at one-month, 12-weeks, 26-weeks and one-year posttreatment. Results and degree of improvement shown by the HSS Scale were correlated with the radiological stage of osteoarthritis.

The most significant adverse effect, which occurred in 7.4 percent of the patients, was an acute inflammatory reaction that can occur at any time up to 10 days after any of the three injections. It was characterized by severe pain and marked effusion. Treatment consisted of serial arthrocenteses for culture and analysis, analgesics and antiinflammatory medications. A short course of antibiotics was prescribed until the bacteriological studies were determined to be negative (all were negative).

Joint fluid analysis revealed high polymorphonuclear leukocyte counts (ranging from 9,000 to 28,000), a normal mucin clot test, normal glucose and a normal string test. Resolution is spontaneous, occurring in three to seven days and did not jeopardize the ultimate results of the treatment. Two patients required treatment with short course systemic prednisone (six day decreasing dose).

In addition to Dr. Miller, study co-authors, all of the department of orthopaedics, University of Cincinnati College of Medicine, are Mark A. Snyder, MD, assistant volunteer professor; Robert S. Heidt Jr., MD, assistant volunteer professor; and Michael Welch, MD, associate clinical professor.

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Granulomatous inflammation after Hylan G-F 20 viscosupplementation of the knee : a report of six cases.

Chen AL, Desai P, Adler EM, Di Cesare PE.

Department of Orthopaedic Surgery, New York University-Hospital for Joint Diseases, New York, NY 10003, USA.

BACKGROUND: Recently, intra-articular viscosupplementation with hyaluronate-derived products has gained popularity as a palliative modality for the treatment of osteoarthritis of the knee. Mild pain or swelling at the site of injection may occur in up to 20% of patients, although severe local inflammation, warmth, and joint effusion are rare. We present a series of six cases in which granulomatous inflammation of the synovium was observed after hyaluronate viscosupplementation of the knee. METHODS: Six knees (five patients) treated with intra-articular Hylan G-F 20 viscosupplementation underwent a surgical procedure because of persistent symptoms. Routine histopathological evaluation, supplemented by alcian-blue staining and hyaluronidase digestion, was performed in each case. RESULTS: Chronically inflamed synovium with areas of histiocytic and foreign-body giant-cell reaction was observed surrounding acellular, amorphous material. The material stained with alcian blue, a stain for hyaluronate, which disappeared after hyaluronidase digestion. CONCLUSIONS: We believe that the injected hyaluronate (Hylan G-F 20) may have been responsible for the synovitis in our patients and thus may be a pathological cause of recalcitrant symptoms after such injection. It is not known whether the responsible pathological agent was the hyaluronate derivative, a contaminant of the purification process, or a component of the carrier substance. Importantly, it appears that the findings in these patients most likely represent a previously unreported pathological response to a viscosupplementation product. This report should raise clinical awareness about this potential complication.

PMID: 12107313 [PubMed - indexed for MEDLINE]

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