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Poster 377 Viscosupplementation With Hyaluronic Acid for Advanced Knee Osteoarthritis: Follow Up Assessment of a Case Series
PM&R
Chennyfer P. Paim, PhD; Herison H. Vaz, Medical Student. Disclosures: F. V. Borges, No Disclosures. Objective: Review the potential role of local anesthetics and injections to decrease pain in knee osteoarthritis. Design: MEDLINE database (PubMed) and Cochrane Library were screened up to January 2012. The search strategy used was based on structured questions as PICO (The initials “Patient,” “Intervention,” “Control,” “Outcome”): “Knee Osteoarthritis” and “nerve block” OR “Bupivacaine” OR “Lidocaine” OR “ropivacaine” [Supplementary Concept] OR “Anesthesia”, Spinal. Studies were included for adults diagnosed with knee osteoarthritis, randomized controlled trials (RCTs), published in any date, in humans, in the English language and using intra-articular or periarticular injections. Methodological quality was assessed by the Jadad and Van Tulder scores. Setting: Clinical research center. Main Outcome Measures: Pain, function and quality of life related outcomes. Results: We retrieved 89 citations and included 10 RCTs, all low risk of bias, with 873 patients, aged 63.9 years. Intra-articular injection of bupivacaine 0.25-0.5% provides similar results than hyaluronic acid, morphine or saline. Superior short term, but not long term improvement on pain and function is achieved with the association of methylprednisolone (1mL, 40mg) and lidocaine 1% (9mL) than lidocaine 1% (9mL) and saline 0.9% (1mL). The effect of multimodal intra-articular injection of bupivacaine 0.5%, morphine 10mg, methylprednisolone 40mg and epinephrine is still controversial. Periarticular injection of bupivacaine 2mg/mL, fentanyl and methylprednisolone is more beneficial than no infiltration. Intradermal injections of lidocaine 1% at periarticular trigger points provide similar results than injections of sterile saline at periarticular trigger points. The association of lidocaine 1% injections intraarticularly (10mL) and at soft tissues (5-10mL) is similar to intraarticular injection of triancinolone (40mg) and lidocaine. Conclusions: The benefits of most local anesthetics and injections are similar to morphine, hyaluronic acid and placebo. Efficacy of the association of medications is still controversial and should be further investigated. Poster 377 Viscosupplementation With Hyaluronic Acid for Advanced Knee Osteoarthritis: Follow Up Assessment of a Case Series. Gabriel T. Kubota, Medical Student (University of São Paulo School of Medicine, São Paulo, Brazil); Erik Halex Barone dos Santos, Student of Medicine; Raul Bolliger; Fernando Hong, Medical Student; Marta Imamura, MD, PhD; Erico M. Rodenbeck, Medical Student; Leandro H. Yoshioka, College. Disclosures: G. T. Kubota, No Disclosures. Objective: To report the follow up assessments of the viscosupplementation with hyaluronic acid for severe knee osteoarthritis in pain reduction and functional improvement. Design: Case series. Setting: Tertiary care orthopaedic hospital. Participants: Our study included 47 patients (65 knees), 43 female, aged 67.4⫾12.2 years, with severe refractory knee pain due to osteoarthritis. Mean pain duration was 136.5⫾97.3 months.
Vol. 4, Iss. 10S, 2012
S319
Interventions: Ultrasound-guided intra-articular injections of 2.5 mL hyaluronic acid were performed for 3 consecutive weeks. The injections were applied to the suprapatellar bursa through the superolateral, inferolateral, superomedial or inferomedial portals, using adequate aseptic technique. Local anesthesia at the injection sites was not performed before the procedure. Main Outcome Measures: Patients were assessed by a Visual analogic scale (VAS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) before and at 1, 2, 3 and 6 months post intervention. Results: After the hyaluronic acid application, there was immediate pain reduction, as VAS and WOMAC pain scores varied from 7.62⫾2.08 to 3.22⫾2.79 (P⬍.001), and from 2.53⫾0.99 to 1.42⫾0.89 (P⬍.001), respectively. They were 3.82⫾2.66, 4.24⫾2.86, 4.58⫾2.90 and 4.32⫾3.03 for VAS, and, 1.63⫾0.97, 1.77⫾1.10, 1.59⫾1.02 and 1.74⫾1.08 for WOMAC, at 1, 2, 3 and 6 months, respectively. The difference between the scores before intervention and at the all follow-up evaluations were statistically significant (P⬍.001). The same was observed for WOMAC rigidity scores, which were 2.48⫾1.13, 1.32⫾1.32, 1.47⫾1.12, 1.77⫾1.26, 1.69⫾1.20 and 1.44⫾1.27, and for WOMAC functional difficulty scores, which were 2.5⫾0.76, 1.69⫾0.83, 1.83⫾0.91, 1.86⫾1.02, 1.86⫾0.92 and 1.96⫾0.95 at pre, post, 1, 2, 3 and 6 months follow-up evaluations. Differences between WOMAC rigidity (P⬍.001) and functional difficulty (P⬍.001) scores before intervention and at the last evaluation were also statistically significant. Conclusions: Intra-articular injections of hyaluronic injections under ultrasound guidance may be an efficient non-surgical, costeffective alternative for pain reduction and functional improvement for severe, long-lasting refractory knee pain due to osteoarthritis. Poster 378 Development of a Severity Score for Complex Regional Pain Syndrome (CRPS). Geneva L. Jacobs, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States); Joseph R. Graciosa; R. N. Harden, MD; Maxine M. Kuroda, PhD, MPH; Anjum Sayyad, MD. Disclosures: G. L. Jacobs, No Disclosures. Objective: The CRPS Severity Score (CSS) is a hybrid metric employing physician interpretation of the signs and symptoms in CRPS. This study tests the hypothesis that the CSS, as an adjunct to the dichotomous Budapest Criteria for diagnosing CRPS, can be used to monitor temporal fluctuations in the manifestation of this syndrome. Design: Observational, longitudinal study. Setting: Clinic environment. Participants: Patients diagnosed with CRPS as validated by the Budapest Criteria. Patient recruitment is ongoing. Interventions: Not applicable. Main Outcome Measures: Complex Regional Pain Syndrome Severity Score implemented at 2 clinic visits over a period of 3 months and compared to subject completed questionnaires that detail pain, emotional state and functional level: Patient Global Impression of Change (PGIC), McGill Pain Questionnaire-Short Form (MPQ-SF), Visual Analogue Scale for pain (VAS), Short Form-36 Health Assessment Tool (SF-36), Center for Epidemiologic Studies Depression Scale (CES-D10), Pain Disability Index (PDI), Pain Anxiety Symptoms Scale (PASS-20), Occupational Sta-
Chennyfer P. Paim, PhD; Herison H. Vaz, Medical Student. Disclosures: F. V. Borges, No Disclosures. Objective: Review the potential role of local anesthetics and injections to decrease pain in knee osteoarthritis. Design: MEDLINE database (PubMed) and Cochrane Library were screened up to January 2012. The search strategy used was based on structured questions as PICO (The initials “Patient,” “Intervention,” “Control,” “Outcome”): “Knee Osteoarthritis” and “nerve block” OR “Bupivacaine” OR “Lidocaine” OR “ropivacaine” [Supplementary Concept] OR “Anesthesia”, Spinal. Studies were included for adults diagnosed with knee osteoarthritis, randomized controlled trials (RCTs), published in any date, in humans, in the English language and using intra-articular or periarticular injections. Methodological quality was assessed by the Jadad and Van Tulder scores. Setting: Clinical research center. Main Outcome Measures: Pain, function and quality of life related outcomes. Results: We retrieved 89 citations and included 10 RCTs, all low risk of bias, with 873 patients, aged 63.9 years. Intra-articular injection of bupivacaine 0.25-0.5% provides similar results than hyaluronic acid, morphine or saline. Superior short term, but not long term improvement on pain and function is achieved with the association of methylprednisolone (1mL, 40mg) and lidocaine 1% (9mL) than lidocaine 1% (9mL) and saline 0.9% (1mL). The effect of multimodal intra-articular injection of bupivacaine 0.5%, morphine 10mg, methylprednisolone 40mg and epinephrine is still controversial. Periarticular injection of bupivacaine 2mg/mL, fentanyl and methylprednisolone is more beneficial than no infiltration. Intradermal injections of lidocaine 1% at periarticular trigger points provide similar results than injections of sterile saline at periarticular trigger points. The association of lidocaine 1% injections intraarticularly (10mL) and at soft tissues (5-10mL) is similar to intraarticular injection of triancinolone (40mg) and lidocaine. Conclusions: The benefits of most local anesthetics and injections are similar to morphine, hyaluronic acid and placebo. Efficacy of the association of medications is still controversial and should be further investigated. Poster 377 Viscosupplementation With Hyaluronic Acid for Advanced Knee Osteoarthritis: Follow Up Assessment of a Case Series. Gabriel T. Kubota, Medical Student (University of São Paulo School of Medicine, São Paulo, Brazil); Erik Halex Barone dos Santos, Student of Medicine; Raul Bolliger; Fernando Hong, Medical Student; Marta Imamura, MD, PhD; Erico M. Rodenbeck, Medical Student; Leandro H. Yoshioka, College. Disclosures: G. T. Kubota, No Disclosures. Objective: To report the follow up assessments of the viscosupplementation with hyaluronic acid for severe knee osteoarthritis in pain reduction and functional improvement. Design: Case series. Setting: Tertiary care orthopaedic hospital. Participants: Our study included 47 patients (65 knees), 43 female, aged 67.4⫾12.2 years, with severe refractory knee pain due to osteoarthritis. Mean pain duration was 136.5⫾97.3 months.
Vol. 4, Iss. 10S, 2012
S319
Interventions: Ultrasound-guided intra-articular injections of 2.5 mL hyaluronic acid were performed for 3 consecutive weeks. The injections were applied to the suprapatellar bursa through the superolateral, inferolateral, superomedial or inferomedial portals, using adequate aseptic technique. Local anesthesia at the injection sites was not performed before the procedure. Main Outcome Measures: Patients were assessed by a Visual analogic scale (VAS) and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) before and at 1, 2, 3 and 6 months post intervention. Results: After the hyaluronic acid application, there was immediate pain reduction, as VAS and WOMAC pain scores varied from 7.62⫾2.08 to 3.22⫾2.79 (P⬍.001), and from 2.53⫾0.99 to 1.42⫾0.89 (P⬍.001), respectively. They were 3.82⫾2.66, 4.24⫾2.86, 4.58⫾2.90 and 4.32⫾3.03 for VAS, and, 1.63⫾0.97, 1.77⫾1.10, 1.59⫾1.02 and 1.74⫾1.08 for WOMAC, at 1, 2, 3 and 6 months, respectively. The difference between the scores before intervention and at the all follow-up evaluations were statistically significant (P⬍.001). The same was observed for WOMAC rigidity scores, which were 2.48⫾1.13, 1.32⫾1.32, 1.47⫾1.12, 1.77⫾1.26, 1.69⫾1.20 and 1.44⫾1.27, and for WOMAC functional difficulty scores, which were 2.5⫾0.76, 1.69⫾0.83, 1.83⫾0.91, 1.86⫾1.02, 1.86⫾0.92 and 1.96⫾0.95 at pre, post, 1, 2, 3 and 6 months follow-up evaluations. Differences between WOMAC rigidity (P⬍.001) and functional difficulty (P⬍.001) scores before intervention and at the last evaluation were also statistically significant. Conclusions: Intra-articular injections of hyaluronic injections under ultrasound guidance may be an efficient non-surgical, costeffective alternative for pain reduction and functional improvement for severe, long-lasting refractory knee pain due to osteoarthritis. Poster 378 Development of a Severity Score for Complex Regional Pain Syndrome (CRPS). Geneva L. Jacobs, MD (Rehabilitation Institute of Chicago, Chicago, IL, United States); Joseph R. Graciosa; R. N. Harden, MD; Maxine M. Kuroda, PhD, MPH; Anjum Sayyad, MD. Disclosures: G. L. Jacobs, No Disclosures. Objective: The CRPS Severity Score (CSS) is a hybrid metric employing physician interpretation of the signs and symptoms in CRPS. This study tests the hypothesis that the CSS, as an adjunct to the dichotomous Budapest Criteria for diagnosing CRPS, can be used to monitor temporal fluctuations in the manifestation of this syndrome. Design: Observational, longitudinal study. Setting: Clinic environment. Participants: Patients diagnosed with CRPS as validated by the Budapest Criteria. Patient recruitment is ongoing. Interventions: Not applicable. Main Outcome Measures: Complex Regional Pain Syndrome Severity Score implemented at 2 clinic visits over a period of 3 months and compared to subject completed questionnaires that detail pain, emotional state and functional level: Patient Global Impression of Change (PGIC), McGill Pain Questionnaire-Short Form (MPQ-SF), Visual Analogue Scale for pain (VAS), Short Form-36 Health Assessment Tool (SF-36), Center for Epidemiologic Studies Depression Scale (CES-D10), Pain Disability Index (PDI), Pain Anxiety Symptoms Scale (PASS-20), Occupational Sta-