1. Comparative study of intraarticular STEROID and HYALURONIC ACID in Knee OA
Dr (Prof) RAJU VAISHYA
(MBBS, MS, MCh, FRCS)
Sr. Consultant Orthopaedic Surgeon
Indraprastha Apollo Hospitals
New Delhi

2. Goals of Treatment To Make Life Better!!! by Relieving pain
Increasing motion
Improving strength
The goals of treatment are to:
Relieve pain
Increase motion and
Improve strength

3. Visco-Supplementation Platelet rich plasma (PRP)
Next Rung of the Ladder
Injections
Cortisone (steroid)
Visco-Supplementation
Platelet rich plasma (PRP)
In some cases, when NSAIDs are ineffective, liquid cortisone may be injected into the joint; however, there can be potentially serious side effects with repeated treatments. Another promising drug in the treatment of Osteoarthritis is a cartilage extract called glucosamine sulfate. Early clinical trials suggest that when injected into the joint it may reduce the progression of the disease.

4. Intra-articular Corticosteroids
Most commonly used injection in knee OA
Five different steroid are approved by Food and Drug Administration.
Triamcinolone HA has rare flare reaction compared to other steroids.
THA has the highest potency, long duration of action in few trial compared to others
Five different steroid are approved by Food and Drug Administration that can be given in OA knee. These are methylprednisolone acetate, betamethasone acetate and betamethasone sodium phosphate, triamcinolone acetate (TA), triamcinolone hexacetonide (THA), and dexamethasone.

5. MOA and Side Effects of Steroids
Act on nuclear steroid receptors
Anti-inflammatory and immunosuppressive -interrupt the inflammatory and immune cascade
Clinically it decreases erythema, heat, swelling, and tenderness
S/E- Cortisone flare reaction, softening of the cartilage, increase in blood sugar level, infection, and development of Cushing’s syndrome in frequent user.

6. Goals of viscosupplementation
Improve lubrication
Decrease pain
Increase mobility of joint (?ROM)
Increase activity
Restore viscoelasticity of synovial hyaluronate

7. HA: Mechanism of Action
Increased synovial fluid HA concentration
Increased cartilage lubrication/elasticity
Chondrocyte proliferation
Decreased inflammatory mediators

8. Side effects ?Allergic reactions Redness Itching Inflammatory reaction
Swelling
?Allergic reactions
To eggs and chicken products

9. AAOS 2013 Recommendations
Cannot Recommend the Following (Strong Rating)
• Glucosamine and chondroitin
• Viscosupplementation - Hyaluronic acid
• Acupuncture
• Arthroscopy with lavage or debridement
Cannot Recommend (Moderate Rating)
• Needle lavage
• Lateral wedge insoles in patients with medial compartment osteoarthritis

10. AAOS 2013 Recommendations
Inconclusive Evidence to Support for or Against • Use of PRP • Medial compartment unloader brace • Arthroscopic partial meniscectomy in patients with knee osteoarthritis and torn meniscus • Intraarticular corticosteroids

11. Differences between 2008 and 2013 Recommendations
Viscosupplementation and injection of hyaluronic acid.
• In 2008 guidelines – rating: inconclusive.
• In 2013 with a "strong" rating against based on new evidences.

12. Aim of study
To compare the effect of both most commonly used intraarticular injections
To evaluate the effect of age and severity of OA on different injection
OBJECTIVE
Pain relief measured by VAS and KSS
The ROM and manual function as measured by KSS

13. Inclusion and Exclusion criteria
INCLUSION CRITERIA
Kellgren Lawrence grade 2 or 3
EXCLUSION CRITERIA
Kellgren Lawrence grade 1 & 4
Inflammatory arthritis e.g. Rheumatoid arthritis
Major axial deviation at knee joint (varus>5, valgus > 5)
Hematological diseases e.g. coagulopathy
Severe cardiovascular diseases
Any infective foci anywhere in the body
Immunosuppression
Malignancy
Age > 80 years
Previous IA injection

14. Methodology
Group 1 – 40 patients (68 knees) - Triamcinolone hexacetonate 40 mg
Group 2 – 42 patients (72 knees) – Synvisc-one 6 ml (Hylan polymer A and B, G-F 20)

15. Baseline Demographic and Clinical Parameters
Steroid group
HA group
No. of cases (%age)
Male
15 (37.5%)
13 (31%)
Female
25 (62.5%)
29 (69%)
Unilateral
11 (27.5%)
11 (26%)
Bilateral
29 (72.5%)
31 (74%)
KL Grade 2
22 (55%)
18 (43%)
KL Grade 3
18 (45%)
24 (57%)

16. Complications Complication STEROID HA Superficial Infection 1 _
Transient raise in blood sugar 3
Deep Infection
Acute inflammatory reaction
Increased Pain for 24 hours -

17. KSS for pain Baseline data both groups – statistically same
Pain relieved in both groups within first week
Steroid – KSS and VAS Score rapidly decrease after 4 weeks
HA - KSS and VAS Score decrease after 12 weeks but slowly
At 24 weeks – Both groups has significantly better result then base line.
At 24 weeks - HA is significantly better then Steroid.

18. KSS for function Baseline data both groups – statistically same
Trend of data was same as of KSS for pain
Both group remain statistically similar till 12 weeks post injection

19. VAS score
Trend of data was same as of KSS for function

20. Affect of age
In Steroid group both sub group had statistically similar result
In HA lower age subgroup has better result

21. Affect of severity of OA
Both groups had significantly better result in
Gr II OA than in Gr III

22. Conclusion
Both injections are safe and effective in relieving OA pain temporarily.
These are palliative agents and are not curative therapy.
Steroid given IA can give pain relief for about 12 weeks.
Hyaluronic acid provides significant pain relief until 6 months after the injection.
At 24 weeks HA was significantly better then steroid.
In younger age group and early OA, HA has better result.