US guided hyaluronic acid intra-articular injections · study with fluoroscopy-guided injections. Arthroscopy. 2014 Jan;30(1):42-6 ... reducing pain in patients affected by hip arthritis

www.dottorvalent.it US guided hyaluronic acid intra-articular injections Dr. Alessandro Valent

Dr. Alessandro Valent

▪ Specialista in Medicina Fisica e Riabilitativa▪ Direttore Sanitario Poliambulatorio Fisioclinics,Formigine (MO)▪ Consulente Fisiatra Azimut Modena Volley▪ Membro ISMuLT (Italian Society of Muscles,legaments and Tendons)

US guidedhyaluronic acid intra-articular

injections


Hoeber S, Aly AR, Ashworth N, Rajasekaran S.Ultrasound-guided hip joint injections are moreaccurate than landmark-guided injections: asystematic review and meta-analysis. Br JSports Med. 2014 Jun 10.

This systematic review and meta-analysis has revealed that US-guided hip joint injections are significantly more accurate (close to100% Vs 72%) than those that are landmark guided.


ULTRASOUND-GUIDE TECHNIQUE

Ultrasound-guide allows:

▪ A real-time visualization of the needle placement,

▪ The identification of neurovascular bundle and soft tissuestructures and the aspiration of intra or peri-articular effusions (forexample iliopsoas bursitis),

▪ Ultrasound technique is simpler and less painful than fluoroscopy-guided injections and it produces no ionizing radiation,

▪ Ultrasound device is more portable and less costly than fluoroscopyor CT device,

▪ Smith J et Al. Sonographically Guided Hip Injection. J Ultrasound Med 2009; 28:329–335▪ Byrd JW, Potts EA, Allison RK, Jones KS. Ultrasound-guided hip injections: a comparativestudy with fluoroscopy-guided injections. Arthroscopy. 2014 Jan;30(1):42-6


ULTRASOUND-GUIDE TECHNIQUE

Ultrasound-guide allows:

▪ To detect joint effusion, joint capsule distension and synovialhyperemia,

▪ Follow-up of US-guided intra-articular HA injections.

▪ Klauser AS, Faschingbauer R, Kupferthaler K, Feuchnter G, Wick MC, Jaschke WR, Mur E.Sonographic criteria for therapy follow-up in the course of ultrasound-guided intra-articularinjections of hyaluronic acid in hand osteoarthritis. Eur J Radiol. 2012 Jul;81(7):1607-11.


HYALURONIC ACID INDICATIONS

▪ OSTEOARTHRITIS

▪ FEMOROACETABULAR IMPINGEMENT

▪ OSTEONECROSIS

▪ POST-TRAUMATIC HIP PAIN

▪ HIP DYSPLASIA


CONTRAINDICATIONS

▪ ACUTE INFLAMMATION WITH JOINTEFFUSION

▪ AUTOIMMUNITY

▪ SEPTIC CONDITIONS


HYALURONIC ACID EFFECTS

▪ Restoration of elastic and viscous properties of thesynovial fluid,

▪ Anti-inflammatory (reduce the production of proinflammatory mediators and MMPs) and antinociceptiveeffects,

▪ Normalization of hyaluronan synthesis by synoviocytes,

▪ Delayed onset, but prolonged duration of clinical effects(6-12 months)

▪ Axe JM, Snyder-Mackler L, Axe MJ. The role of viscosupplementation. Sports Med Arthrosc. 2013Mar; 21(1):18-22▪ Migliore A, Procopio S. Effectiveness and utility of hyaluronic acid in osteoarthritis. Clinical Casesin Mineral and Bone Metabolism 2015; 12(1): 31-33


Migliore A. etal, 2016

▪ 24 STUDIES▪ 15 RCT S▪ 9 COHORT S▪ 14 US-G▪ 2 NONE

Migliore, 2014 Jonexa® 41 24 None 1 injection US Pain, Lequesne, NSAID None


VS OF THE HIP: CURRENT EVIDENCE

▪ Studies suggest that VS of the hip is effective in reducing pain andincreasing function. Only 2 trials (1 under US and 1 underfluoroscopic guidance) showing no difference compared with placebo(Qvistgaard E. et al, 2005; Atchia I et al, 2011 ),

▪ VS appears to be a safe and reasonable alternative to NSAIDs orintra-articular steroids for the treatment of osteoarthritis pain,

▪ Ultrasound guided HA injections seem to reduce the consumptionof NSAIDs,

▪ Migliore A, Granata M, Tormenta S, Laganà B, Piscitelli P, Bizzi E, Massafra U, Alimonti A, Maggi C, De Chiara R,Iannessi F, Sanfilippo A, Sotera R, Scapato P, Carducci S, Persod P, Denaro S, Camminiti M, Pagano MG, Bagnato G,Iolascon G. Hip viscosupplementation under ultra-sound guidance riduces NSAID consumption in symptomatic hiposteoarthritis patients in a long follow-up. Data from Italian registry. Eur Rev Med Pharmacol Sci. 2011 Jan

▪ Mulvaney SW. A review of viscosupplementation for osteoarthritis of the hip and a description of an ultrasound-guided hip injection technique. Curr. Sports Med. Rep., Vol. 8, No. 6, pp. 291Y294, 2009.

▪ Chandrasekaran S, Lodhia P, Suarez-Ahedo C, Vemula SP, Martin TJ, Domb BG. Symposium: evidence for the use of intra-articular cortisone or hyaluronic acid injection in the hip. J Hip Preserv Surg. 2015 Mar 31;3(1):5-15▪ Mulvaney SW. A review of viscosupplementation for osteoarthritis of the hip and a description of an ultrasound-guided hip injection technique. Curr. Sports Med. Rep., Vol. 8, No. 6, pp. 291Y294, 2009.


▪ VS may reduce or delay the need for hip replacement surgery,

▪ VS appears to work better in patients with fewer radiographicchanges of osteoarthritis.

▪ Placement of HA in the hip under real-time ultrasound guidance issafe and well tolerated, with few and only local side effects (5-10%).

▪ Migliore A, Bizzi E, Massafra U, Bella A, Piscitelli P, Laganà B, Tormenta S. The impact of treatment with hylan G-F 20 onprogression to total hip arthroplasty in patients with symptomatic hip OA: a retrospective study. Curr Med Res Opin. 2012May;28(5):755-60.▪ Migliore A, Bella A, Bisignani M, Calderaro M, De Amicis D, Logroscino G, Mariottini F, Moreschini O, Massafra U, Bizzi E,Laganà B, Piscitelli P, Tormenta S. Total hip replacement rate in a cohort of patients affected by symptomatic hip osteoarthritisfollowing intra-articular sodium hyaluronate (MW 1,500-2,000 kDa) ORTOBRIX study. Clin Rheumatol. 2012 Aug;31(8):1187-96.

VS OF THE HIP: CURRENT EVIDENCE

▪ Smith J et Al. Sonographically Guided Hip Injection. J Ultrasound Med 2009; 28:329–335▪ Byrd JW, Potts EA, Allison RK, Jones KS. Ultrasound-guided hip injections: a comparative study with fluoroscopy-guidedinjections. Arthroscopy. 2014 Jan;30(1):42-6▪ Migliore A et al. Safety of intra-articular hip injection of hyaluronico acid products by ultrasound guidance: an open studyfrom ANTIAGE register. Eur Rev Med Pharmacol Sci 2013; 17: 1752-1759


The Author studied a patient's gait after ultrasound guided hipinjections with HA:▪ The patient showed an early clinical and biomechanicalimprovement during walking after a single intra articular injection ofhyaluronic acid.▪ Gait analysis parameters obtained suggest that the pre-treatmentslower speed may be caused by antalgic walking patterns, the needfor pain control and muscle weakness.▪ After hip viscosupplementation, the joint displayed differenttemporal, kinetic and kinematic parameters associated withimproved pain patterns.

Di Lorenzo L. Gait analysis in hipviscosupplementation for osteoarthritis: a casereport. Reumatismo. 2013 Oct 31;65(4):199-202


Although the literature has unequivocally proven the possibility ofreducing pain in patients affected by hip arthritis the molecularweight and density, the number of infiltrations required for long-termresults, and the most appropriate indications for infiltrationtreatment have yet to be clarified. Selecting the patient is the firstobstacle to be overcome.

▪ Rivera F. Can viscosupplementation be used in the hip? An Italian perspective. Orthopedics. 2014 Jan;37(1):48-55.


HA vs CORTICOSTEROIDS

▪ 2 Studies (Qvistgaard E. et al, 2005; Atchia I et al, 2011) suggest reduced efficacyof HA compared with CS at 8-12 weeks.

▪ Spitzer et al. (2010) in a prospective randomized study of 313 patients,highlighted that functional scores for Hylan G-F 20 were higher thanmethylprednisolone for patients with more severe OA (Grade 3) and similar forless severe OA (Grade 2) at 6 months.

▪ Atchia I, Kane D, Reed MR, Isaacs JD, Birrell F. Efficacy of a single ultrasound-guided injection for the treatment of hiposteoarthritis. Ann Rheum Dis 2011; 70: 110–6.▪ Qvistgaard E, Christensen R, Torp-Pedersen S et al. Intra-articular treatment of hip osteoarthritis: a randomized trialof HA, corticosteroid, and isotonic saline. Osteoarthritis Cartilage 2006; 14: 163–70.▪ Spitzer AI, Bockow BI, Brander VA et al. Hylan g-f 20 improves hip osteoarthritis: a prospective, randomized study.Phys Sportsmed 2010; 38: 35–47.


HA vs PLATELET RICH PLASMA (PRP)

▪ 100 patients with chronic unilateral symptomatic hip OA were consecutivelyenrolled and randomly assigned to 1 of 2 groups: group A received PRP and group Breceived HA administered via intra-articular ultrasound-guided injections.▪ Patients were evaluated at baseline and after 1, 3, 6, and 12 months using theHarris Hip Score (HHS) and visual analog scale (VAS).

▪ Intra-articular injections of PRP are efficacious in terms of functional improvementand pain reduction but are not superior to HA in patients with symptomatic hip OAat 12-month follow-up.


HA & PLATELET RICH PLASMA (PRP)

D'Avola GM, Tropea S, Petralia A. Efficacy ofUltrasound-Guided Intra-Articular Injections of Platelet-Rich Plasma and Hyaluronic Acid for Hip Osteoarthritis.Ann Rheum Dis 2015;74:1186

The ultrasound-guided intra-articular treatment with platelet gel andafter ialuronan in patients with symptomatic hip osteoarthritisdemonstrates in almost all the treated patients (93.7% of cases) asignificant reduction of subjective pain (on a VAS scores) andconsumption of NSAIDs greater than the ialuronan or platelet gelalone.


▪ Dallari D, Stagni C, Giavaresi G, et al. Ultrasound-Guided Injection of Platelet-Rich Plasma and Hyaluronic Acid,Separately and in Combination, for Hip Osteoarthritis: A Randomized Controlled Study. The American Journal Of SportsMedicine. March 2016;44(3):664-671

Current results indicate that intra-articular PRP injections offer asignificant clinical improvement in hip OA, better than HA alone orcombined with HA, stable up to 12 months and without relevant sideeffects.

HA & PLATELET RICH PLASMA (PRP)


FEMOROACETABULAR IMPINGEMENT

Abate M, Scuccimarra T, Vanni D, Pantalone A,Salini V. Femoroacetabular impingement: ishyaluronic acid effective? Knee Surg SportsTraumatol Arthrosc. 2014 Apr;22(4):889-92.

▪ 23 hips (3 bilateral cases) were treated.▪ Each patient received a 2-ml intra-articular ultrasound-guidedinjection of HA at baseline and after 40 days; the same dosingschedule was repeated after 6 months. The clinical evaluation wasperformed at baseline and after 6 and 12 months of follow-up.▪ Hyaluronic acid is safe and effective in the treatment of mildfemoroacetabular impingement, with significant pain reduction andfunction improvement.


FEMOROACETABULAR IMPINGEMENT

Khan W, Khan M, Alradwan H, Williams R,Simunovic N, Ayeni OR. Utility of Intra-articular HipInjections for Femoroacetabular Impingement: ASystematic Review. Orthop J Sports Med. 2015 Sep1; 3(9):2325967115601030.

The results of this review suggest that (1) pain relief obtained froman intra-articular hip injection supports a diagnosis of FAI, (2)therapeutic relief at 12 months may be achieved, particularly withhyaluronic acid, and (3) a negative response to preoperativeinjections may predict poor short-term surgical outcomes.


ANTERO-SUPERIOR

ANTERO-INFERIOR

LATERAL

INJECTION TECNIQUE

Anterior parasagittal approach (superior or inferior) vs lateral approach


INJECTION TECNIQUE




Patients 88 (106 hips)

Sex Males 50Females 38

Age (mean) 59,4 (range 27-72 years)

BMI (mean) 25,8

Side affected Right 58 (55%)Left 48 (45%)Bilateral 18 (17%)

Radiological grade 1° 122° 44 (50%)3° 27 (32%)4° 5

Casistica personale


RESULTS

3 Injections:- T0- 15 days- 45 days

5,47

2,451,94

2,32

0

1

2

3

4

5

6

T0 T0 + 1 T0 + 3 T0 + 6

VAS mean values

**

*

Drugs:- Donegal HA 40 mg- Jointex 32 mg- Hyalubrix

61,85

84,72 81,92 80,02

0

20

40

60

80

100

T0 T0 + 1 T0 + 3 T0 + 6

Harris Hip Score mean values

* * *


RESULTS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

T0 T0 +1 T0 +3 T0 +6

70

5 4 6

36

14 1820

0

80 79 75

07 5 5

Harris Hip Score

Poor Fair Good Excelent


TAKE HOME MESSAGES

▪ Us guided viscosupplementation (US-GVS) of the hip appears to be safe, welltolerated and effective to reduce painand improve function up to 6-12months,

▪ US-G VS seems to reduce theconsumption of NSAIDs and the need forjoint replacement,

▪ US-G VS appears to work better inpatients with mild or moderate forms ofOA and FAI.


Documents

US guided hyaluronic acid intra-articular injections · study with fluoroscopy-guided injections. Arthroscopy. 2014 Jan;30(1):42-6 ... reducing pain in patients affected by hip arthritis