- Email: [email protected]
Role of hylan G-F 20 in treatment of osteoarthritis of the hip joint1
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Role of Hylan G-F 20 in Treatment of Osteoarthritis of the Hip Joint Vijay B. Vad, MD, Durgadas Sakalkale, MD, Thomas P. Sculco, MD, Thomas L. Wickiewicz, MD ABSTRACT. Vad VB, Sakalkale D, Sculco TP, Wickiewicz TL. Role of hylan G-F 20 in treatment of osteoarthritis of the hip joint. Arch Phys Med Rehabil 2003;84:1224-6. Objective: To study the efficacy of hylan G-F 20 in the treatment of osteoarthritis (OA) of the hip joint. Design: Prospective within-group study. Setting: Musculoskeletal rehabilitation clinic. Participants: Twenty-two patients (25 hips) with hip joint OA who had failed to find pain relief from conservative methods such as physical therapy, exercises, and steroid injections. Demographics included 14 men and 11 women (mean age, 56.4y), 21 of whom had mild to moderate OA and 4 of whom had severe OA of the hips. Intervention: Each hip joint was injected with 2mL of hylan G-F 20 at 2, 3, and 4 weeks and fluoroscopic lavage with 100mL of normal saline at week 1. All patients had standard hip exercise regimen after the injection. Main Outcome Measures: American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Core Scale score and visual numeric pain score. Results: At 1-year follow-up, the AAOS Lower Limb Core Scale score improved from a preinjection mean of 44.2 to a follow-up mean of 86.1 (P⬍.05). The mean visual numeric pain score improved from a preinjection mean of 8.7 (range, 6.4 –10) to a follow-up mean of 2.3 (range, 0 –7.2). The overall success rate was 84%. In patients with mild to moderate OA, the mean pain score decreased from a preinjection value of 7.8 to a follow-up value of 1.7. The success rate was 90.5% in that subgroup. In patients with severe OA, the mean pain score decreased from a preinjection value of 9.1 to a follow-up value of 3.8. The success rate was 50% in that subgroup. There were no complications related to the injection. Conclusion: Use of hylan G-F 20 injection is a viable option for treatment of mild to moderate OA of the hip joint. Key Words: Hip; Hylan G-F 20; Osteoarthritis; Rehabilitation. © 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation STEOARTHRITIS (OA) IS THE MOST common cause of arthritic conditions that requires medical or surgical O interventions. With the increasing longevity of the general population, this condition adds to the enormous health care
From the Department of Rehabilitation Medicine, Cornell University Medical Center, New York (Vad); Department of Physical Medicine and Rehabilitation, New York University Medical Center, New York (Sakalkale); and Department of Orthopaedic Surgery, Hospital for Special Surgery, New York (Sculco, Wickiewicz), NY. Presented as a poster at the American Academy of Orthopaedic Surgeons’ 68th Annual Meeting, February 28 –March 4, 2001, San Francisco, CA. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or any organization with which the authors are associated. Reprint requests to Vijay B. Vad, MD, 535 E 70th St, New York, NY 10021. 0003-9993/03/8408-7604$30.00/0 doi:10.1016/S0003-9993(03)00140-0
Arch Phys Med Rehabil Vol 84, August 2003
costs involved. With total joint replacement procedures generally reserved for severe arthritis, the general treatment approach has been conservative or medicinal for mild to moderate arthritis.1,2 The idea behind these measures is to manage the arthritic process. The traditional approach of physical therapy and anti-inflammatory medications has shown limited success.1,2 Biomolecular studies3-7 have revealed a chondroprotective role of synovial fluid. Studies3-7 have noted decreased viscosity and a decreased chondroprotective role of synovial fluid in OA. Hyaluronic acid, a normal component of synovial fluid, has been found to contribute to the viscosity and to the chondroprotective effect of synovial fluid.3-7 European and North American clinical trials of intra-articular injections of hyaluronic acid preparations (hylan G-F 20) have shown promising results in osteoarthritic knees.7-15 Despite reports of the success of hylan G-F 20 in knees,7-15 the clinical data on its use in osteoarthritic hips have been sparse.16,17 We have not found any study on the use of hyaluronic acid preparations in osteoarthritic hip joints reported in the literature from North America. We present our experience of early results with its use in treating OA of the hip joint. METHODS Twenty-five osteoarthritic hip joints in 22 patients were selected for study from the patient population at the rehabilitation clinic at our institution from 1998 to 2000. The demographics included 14 men and 11 women, with a mean age of 56.4 years (range, 39 –72y). Inclusion criteria were demonstration of hip OA on plain radiography and magnetic resonance imaging (MRI) and failure of all conservative methods, including physical therapy, anti-inflammatory medications, and fluoroscopically guided intra-articular steroid injections. The exclusion criterion was any previous hip surgery. Based on the extent of joint involvement, patients were divided into 2 groups: (1) those with mild to moderate OA (ie, evidence of some preservation of joint space; 21 hips) and (2) those with severe OA (ie, complete loss of joint space; 4 hips). A standard technique of fluoroscopically guided hip injection was used in all patients.18 With the patient lying supine, the femoral artery was palpated and an entry site mark was placed, under fluoroscopic guidance, on the skin lateral to the femoral vessels, directly anterior to the midportion of the femoral neck. Using a sterile technique and local anesthetic (1% lidocaine), a 20-gauge 3.5-in spinal needle was directed to the lateral aspect of the junction of the femoral head and neck. One milliliter of iodinated contrast medium was injected to confirm an intraarticular position of the needle tip (fig 1). Each patient underwent hip lavage, with 100mL of normal saline, using fluoroscopic guidance during the first week of treatment. Routine aseptic precautions and a combination of local anesthesia with sedation was used during the lavage procedure. This was followed by a 2mL intra-articular injection of hylan G-F 20 (Synvisc) at 2, 3, and 4 weeks, under fluoroscopic guidance. All patients received 4 to 6 weeks of a hip exercise program (3 times a week) that is standard at our institution. A typical exercise session consisted of 5 repetitions of knee to chest
HYLAN G-F 20 AND HIP JOINT OA, Vad
Fig 1. Intra-articular injection of the hip joint under fluoroscopy, with confirmation using dye.
positioning, positioning in the flexion abduction external rotation, iliotibial band stretching, active straight-leg raising, and side-leg raising, with each of these sustained for 20 seconds. This was followed by a 15-minute session of recumbent bicycle exercise. Follow-up was performed at 1 year. The outcome measures included the American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Core Scale19 score and visual numeric pain score.20 Patient satisfaction was rated as poor, fair, good, or excellent. Successful outcome was defined as having both greater than 50% reduction in pain score after treatment and good or excellent patient satisfaction. Statistical analysis was performed using the Student t test and calculation of 95% confidence interval. RESULTS The mean AAOS Lower Limb Core Scale score improved from a preinjection mean of 44.2 (range, 29.1–57.2) to a follow-up mean of 86.1 (range, 71.3–99) (P⬍.05). Mean visual numeric pain score improved from a preinjection mean of 8.7 (range, 6.4 –10) to a follow-up mean of 2.3 (range, 0 –7.2). The overall success rate was 84%. In patients with mild to moderate OA, the mean pain score decreased from a preinjection value of 7.8 to a follow-up value of 1.7. The success rate was 90.5%. In patients with severe OA, the mean pain score decreased from a preinjection value of 9.1 to a follow-up value of 3.8. The success rate was 50%. In 4 patients, the improvement in pain score was less than 50%. These included 2 patients with severe OA, 1 patient with significant subchondral edema of the femoral head on MRI, and 1 patient with hip flexor strength of less than 3/5. DISCUSSION Hyaluronic acid is an integral part of the connective tissue system. In synovial joints, it forms an important component of the synovial fluid, which contributes to its viscosity, protection of the superficial layer of articular cartilage, and mechanical shock absorption.5 These properties led to the favorable results of intra-articular injections of hyaluronic acid in osteoarthritic knees.2-12 Results
1225
of hyaluronic acid substitutes like hylan G-F 20 have been quite consonant with earlier results.8,10,13,14 In a Canadian multicenter trial of hylan G-F 20 injections for OA of the knee joint, Adams et al10 reported significantly better outcomes at 26-week follow-up in the group receiving the injections than in the group receiving nonsteroidal anti-inflammatory drugs alone. Lussier et al15 reported a 77% success rate 8 months after injection of hylan G-F 20 in OA of the knee. In their 26-week controlled trial of viscosupplementation with hylan G-F 20 in osteoarthritic knees, up to 57% of patients were free of weight-bearing pain at 10 to 24 weeks after the course of injections. Goorman et al8 reported measurable improvement in function at 6 months in osteoarthritic knees after injections of hylan G-F 20. Most of the published literature on hylan G-F 20 has focused its use in OA of the knee joint. The literature on its use in OA of the hip joint has been sparse. We found only 2 such reports.16,17 Ohshima et al16 reported 50% efficacy with use of sodium hyaluronate in 20 patients with OA of the hip joint. Bragantini and Molinaroli17 analyzed 50 osteoarthritic knees treated with hyaluronic acid injections and found 49% of patients reporting excellent efficacy and 24% reporting moderate efficacy at 6-month follow-up. In our series of 25 osteoarthritic hips, the success rate was 84% at an average follow-up of 1 year after intra-articular hylan G-F 20 injection. The beneficial effect of hylan G-F 20 appears due not only to its effect of viscosupplementation, which improvises lubrication, but also to its chondroprotective properties. Frizerrio et al7 demonstrated histologic improvement using the microarthroplasty technique to obtain cartilage and synovial tissue in osteoarthritic knees. The greater potential of the cross-linked hyaluronans, which result from their larger molecular size, improved rheotic properties and longer intra-articular retention.4 Moreover, hylan therapy might retard the progression of OA, particularly when used in early arthritis.5 The experiments of Marshall et al6 lend further credence to these presumptions. In their study of intra-articular hylan therapy in canine OA, hylan G-F 20 was found to be cleared from joints by lymphatics within 4 weeks of injection, which suggests (1) that hylan therapy can retard progression of OA for periods of time extending beyond the intra-articular residence time of injected molecules, and (2) that hylan injections given at relatively early stages of OA may have a chondroprotective effect. Despite success with hylan G-F 20 injections in osteoarthritic joints, it has not been without flaws. Many authors21,22 have reported adverse reactions with the use of hylan injections, ranging from increased pain at the injection site to attacks of gout in the injected joint. Our use of the fluoroscopically guided injection technique likely contributed to the lack of adverse reactions. Biologic interventions such as hylan G-F 20 injection require proper patient selection, precise injection technique under fluoroscopic guidance, and properly structured rehabilitation protocol. The astonishing success rate seen in our series appears to be due to the cumulative effect of these determinants. Based on our high success rate, it might be possible to conclude that the use of the hylan G-F 20 injection is a safe and effective option for treatment of early to moderate OA of the hip joint. CONCLUSION Hyaluronic acid compounds such as hylan G-F 20 may benefit select patients with mild to moderate OA of the hip joint, when combined with a structured exercise regimen. More studies, including randomized controlled trials, are required to further substantiate the efficacy of this form of treatment. Arch Phys Med Rehabil Vol 84, August 2003
1226
HYLAN G-F 20 AND HIP JOINT OA, Vad
References 1. Simon LS. Osteoarthritis: a review. Clin Cornerstone 1999;2:2637. 2. Helfet AJ. Management of osteoarthritis of the knee joint. In: Helfet AJ, editor. Disorders of the knee. Philadelphia: Lippincott; 1974. p 175. 3. Rosier RN, O’Keefe RJ. Hyaluronic acid therapy. Inst Course Lect 2000;49:495-502. 4. Adams ME. An analysis of clinical studies of the use of crosslinked hyaluronan, hylan, in the treatment of osteoarthritis. J Rheumatol Suppl 1993;39:16-8. 5. Balazas EA. The physical properties of synovial fluid and the special role of hyaluronic acid. In: Helfet AJ, editor. Disorders of the knee. Philadelphia: Lippincott; 1974. p 63. 6. Marshall KW, Manolopoulos V, Mancer K, Staples J, Damyanovich A. Amelioration of disease severity by intraarticular hylan therapy in bilateral canine osteoarthritis. J Orthop Res 2000;18: 416-25. 7. Frizziero L, Govani E, Bachin P. Intraarticular hyaluronic acid in the treatment of osteoarthritis of the knee: clinical and morphological study. Clin Exp Rheumatol 1998;16:441-9. 8. Goorman SD, Watanabe TK, Miller EH, Perry C. Functional outcome in knee osteoarthritis after treatment with hylan G-F 20: a prospective study. Arch Phys Med Rehabil 2000;81:479-83. 9. Hyaluronan or hylans for knee osteoarthritis? Drug Ther Bull 1999;37:71-2. 10. Adams ME, Atkinson MH, Lussier AJ, et al. The role of viscosupplementation with hylan G-F 20 (Synvisc) in the treatment of osteoarthritis of the knee: a Canadian multicenter trial comparing hylan G-F 20 alone, hylan G-F 20 with non-steroidal anti-inflammatory drugs (NSAIDs) and NSAIDs alone. Osteoarthritis Cartilage 1995;3:213-25. 11. Wen DY. Intra-articular hyaluronic acid injections for knee osteoarthritis. Am Fam Physician 2000;62:565-70.
Arch Phys Med Rehabil Vol 84, August 2003
12. Peyron JG, Balazas EA. Preliminary clinical assessment of NaHyaluronate injection into human arthritic knee joints [abstract]. Pathol Biol 1974;22:731. 13. Wobig M, Bach G, Beks P, et al. The role of elastoviscosity in the efficacy of viscosupplementation for osteoarthritis of the knee: a comparison of hylan G-F 20 and a lower-molecular-weight hyaluronan. Clin Ther 1999;21:1549-62. 14. Wobig M, Dickhut A, Maier R, Vetter G. Viscosupplementation with hylan G-F 20: a 26-week controlled trial of efficacy and safety in the osteoarthritic knee. Clin Ther 1998;20:410-23. 15. Lussier A, Cividino AA, McFarlane CA, Olszynski WP, Potashner WJ, De Medicis R. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol 1996;23:1579-85. 16. Ohshima Y, Higashi H, Mamiki O, et al. A study of the effect of intraarticular injection of high molecular weight sodium hyaluronate on osteoarthritis of the hip. Jpn Pharmacol Ther 1987;15: 1337-47. 17. Bragatini A, Molinaroli F. A pilot clinical evaluation of the treatment of hip osteoarthritis with hyaluronic acid. Clin Ther Res 1984;55:3319-30. 18. Erb RE. Current concepts in imaging the adult hip. Clin Sports Med 2001;20:661-96. 19. American Academy of Orthopaedic Surgeons. AAOS Outcomes Survey: lower limb instrument. Rosemont: AAOS; 1994. 20. De Conno F, Caraceni A, Gamba A, et al. Pain measurement in cancer patients: a comparison of six methods. Pain 1994;57:161-6. 21. Kroesen S, Schmid W, Theiler R. Induction of an acute attack of calcium pyrophosphate dihydrate arthritis by intra-articular injection of hylan G-F 20 (Synvisc). Clin Rheumatol 2000;19: 147-9. 22. Yacyshyn EA, Matteson EL. Gout after intraarticular injection of hylan GF-20 (Synvisc) [letter]. J Rheumatol 1999;26:2717.
Role of Hylan G-F 20 in Treatment of Osteoarthritis of the Hip Joint Vijay B. Vad, MD, Durgadas Sakalkale, MD, Thomas P. Sculco, MD, Thomas L. Wickiewicz, MD ABSTRACT. Vad VB, Sakalkale D, Sculco TP, Wickiewicz TL. Role of hylan G-F 20 in treatment of osteoarthritis of the hip joint. Arch Phys Med Rehabil 2003;84:1224-6. Objective: To study the efficacy of hylan G-F 20 in the treatment of osteoarthritis (OA) of the hip joint. Design: Prospective within-group study. Setting: Musculoskeletal rehabilitation clinic. Participants: Twenty-two patients (25 hips) with hip joint OA who had failed to find pain relief from conservative methods such as physical therapy, exercises, and steroid injections. Demographics included 14 men and 11 women (mean age, 56.4y), 21 of whom had mild to moderate OA and 4 of whom had severe OA of the hips. Intervention: Each hip joint was injected with 2mL of hylan G-F 20 at 2, 3, and 4 weeks and fluoroscopic lavage with 100mL of normal saline at week 1. All patients had standard hip exercise regimen after the injection. Main Outcome Measures: American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Core Scale score and visual numeric pain score. Results: At 1-year follow-up, the AAOS Lower Limb Core Scale score improved from a preinjection mean of 44.2 to a follow-up mean of 86.1 (P⬍.05). The mean visual numeric pain score improved from a preinjection mean of 8.7 (range, 6.4 –10) to a follow-up mean of 2.3 (range, 0 –7.2). The overall success rate was 84%. In patients with mild to moderate OA, the mean pain score decreased from a preinjection value of 7.8 to a follow-up value of 1.7. The success rate was 90.5% in that subgroup. In patients with severe OA, the mean pain score decreased from a preinjection value of 9.1 to a follow-up value of 3.8. The success rate was 50% in that subgroup. There were no complications related to the injection. Conclusion: Use of hylan G-F 20 injection is a viable option for treatment of mild to moderate OA of the hip joint. Key Words: Hip; Hylan G-F 20; Osteoarthritis; Rehabilitation. © 2003 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation STEOARTHRITIS (OA) IS THE MOST common cause of arthritic conditions that requires medical or surgical O interventions. With the increasing longevity of the general population, this condition adds to the enormous health care
From the Department of Rehabilitation Medicine, Cornell University Medical Center, New York (Vad); Department of Physical Medicine and Rehabilitation, New York University Medical Center, New York (Sakalkale); and Department of Orthopaedic Surgery, Hospital for Special Surgery, New York (Sculco, Wickiewicz), NY. Presented as a poster at the American Academy of Orthopaedic Surgeons’ 68th Annual Meeting, February 28 –March 4, 2001, San Francisco, CA. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the authors or any organization with which the authors are associated. Reprint requests to Vijay B. Vad, MD, 535 E 70th St, New York, NY 10021. 0003-9993/03/8408-7604$30.00/0 doi:10.1016/S0003-9993(03)00140-0
Arch Phys Med Rehabil Vol 84, August 2003
costs involved. With total joint replacement procedures generally reserved for severe arthritis, the general treatment approach has been conservative or medicinal for mild to moderate arthritis.1,2 The idea behind these measures is to manage the arthritic process. The traditional approach of physical therapy and anti-inflammatory medications has shown limited success.1,2 Biomolecular studies3-7 have revealed a chondroprotective role of synovial fluid. Studies3-7 have noted decreased viscosity and a decreased chondroprotective role of synovial fluid in OA. Hyaluronic acid, a normal component of synovial fluid, has been found to contribute to the viscosity and to the chondroprotective effect of synovial fluid.3-7 European and North American clinical trials of intra-articular injections of hyaluronic acid preparations (hylan G-F 20) have shown promising results in osteoarthritic knees.7-15 Despite reports of the success of hylan G-F 20 in knees,7-15 the clinical data on its use in osteoarthritic hips have been sparse.16,17 We have not found any study on the use of hyaluronic acid preparations in osteoarthritic hip joints reported in the literature from North America. We present our experience of early results with its use in treating OA of the hip joint. METHODS Twenty-five osteoarthritic hip joints in 22 patients were selected for study from the patient population at the rehabilitation clinic at our institution from 1998 to 2000. The demographics included 14 men and 11 women, with a mean age of 56.4 years (range, 39 –72y). Inclusion criteria were demonstration of hip OA on plain radiography and magnetic resonance imaging (MRI) and failure of all conservative methods, including physical therapy, anti-inflammatory medications, and fluoroscopically guided intra-articular steroid injections. The exclusion criterion was any previous hip surgery. Based on the extent of joint involvement, patients were divided into 2 groups: (1) those with mild to moderate OA (ie, evidence of some preservation of joint space; 21 hips) and (2) those with severe OA (ie, complete loss of joint space; 4 hips). A standard technique of fluoroscopically guided hip injection was used in all patients.18 With the patient lying supine, the femoral artery was palpated and an entry site mark was placed, under fluoroscopic guidance, on the skin lateral to the femoral vessels, directly anterior to the midportion of the femoral neck. Using a sterile technique and local anesthetic (1% lidocaine), a 20-gauge 3.5-in spinal needle was directed to the lateral aspect of the junction of the femoral head and neck. One milliliter of iodinated contrast medium was injected to confirm an intraarticular position of the needle tip (fig 1). Each patient underwent hip lavage, with 100mL of normal saline, using fluoroscopic guidance during the first week of treatment. Routine aseptic precautions and a combination of local anesthesia with sedation was used during the lavage procedure. This was followed by a 2mL intra-articular injection of hylan G-F 20 (Synvisc) at 2, 3, and 4 weeks, under fluoroscopic guidance. All patients received 4 to 6 weeks of a hip exercise program (3 times a week) that is standard at our institution. A typical exercise session consisted of 5 repetitions of knee to chest
HYLAN G-F 20 AND HIP JOINT OA, Vad
Fig 1. Intra-articular injection of the hip joint under fluoroscopy, with confirmation using dye.
positioning, positioning in the flexion abduction external rotation, iliotibial band stretching, active straight-leg raising, and side-leg raising, with each of these sustained for 20 seconds. This was followed by a 15-minute session of recumbent bicycle exercise. Follow-up was performed at 1 year. The outcome measures included the American Academy of Orthopaedic Surgeons (AAOS) Lower Limb Core Scale19 score and visual numeric pain score.20 Patient satisfaction was rated as poor, fair, good, or excellent. Successful outcome was defined as having both greater than 50% reduction in pain score after treatment and good or excellent patient satisfaction. Statistical analysis was performed using the Student t test and calculation of 95% confidence interval. RESULTS The mean AAOS Lower Limb Core Scale score improved from a preinjection mean of 44.2 (range, 29.1–57.2) to a follow-up mean of 86.1 (range, 71.3–99) (P⬍.05). Mean visual numeric pain score improved from a preinjection mean of 8.7 (range, 6.4 –10) to a follow-up mean of 2.3 (range, 0 –7.2). The overall success rate was 84%. In patients with mild to moderate OA, the mean pain score decreased from a preinjection value of 7.8 to a follow-up value of 1.7. The success rate was 90.5%. In patients with severe OA, the mean pain score decreased from a preinjection value of 9.1 to a follow-up value of 3.8. The success rate was 50%. In 4 patients, the improvement in pain score was less than 50%. These included 2 patients with severe OA, 1 patient with significant subchondral edema of the femoral head on MRI, and 1 patient with hip flexor strength of less than 3/5. DISCUSSION Hyaluronic acid is an integral part of the connective tissue system. In synovial joints, it forms an important component of the synovial fluid, which contributes to its viscosity, protection of the superficial layer of articular cartilage, and mechanical shock absorption.5 These properties led to the favorable results of intra-articular injections of hyaluronic acid in osteoarthritic knees.2-12 Results
1225
of hyaluronic acid substitutes like hylan G-F 20 have been quite consonant with earlier results.8,10,13,14 In a Canadian multicenter trial of hylan G-F 20 injections for OA of the knee joint, Adams et al10 reported significantly better outcomes at 26-week follow-up in the group receiving the injections than in the group receiving nonsteroidal anti-inflammatory drugs alone. Lussier et al15 reported a 77% success rate 8 months after injection of hylan G-F 20 in OA of the knee. In their 26-week controlled trial of viscosupplementation with hylan G-F 20 in osteoarthritic knees, up to 57% of patients were free of weight-bearing pain at 10 to 24 weeks after the course of injections. Goorman et al8 reported measurable improvement in function at 6 months in osteoarthritic knees after injections of hylan G-F 20. Most of the published literature on hylan G-F 20 has focused its use in OA of the knee joint. The literature on its use in OA of the hip joint has been sparse. We found only 2 such reports.16,17 Ohshima et al16 reported 50% efficacy with use of sodium hyaluronate in 20 patients with OA of the hip joint. Bragantini and Molinaroli17 analyzed 50 osteoarthritic knees treated with hyaluronic acid injections and found 49% of patients reporting excellent efficacy and 24% reporting moderate efficacy at 6-month follow-up. In our series of 25 osteoarthritic hips, the success rate was 84% at an average follow-up of 1 year after intra-articular hylan G-F 20 injection. The beneficial effect of hylan G-F 20 appears due not only to its effect of viscosupplementation, which improvises lubrication, but also to its chondroprotective properties. Frizerrio et al7 demonstrated histologic improvement using the microarthroplasty technique to obtain cartilage and synovial tissue in osteoarthritic knees. The greater potential of the cross-linked hyaluronans, which result from their larger molecular size, improved rheotic properties and longer intra-articular retention.4 Moreover, hylan therapy might retard the progression of OA, particularly when used in early arthritis.5 The experiments of Marshall et al6 lend further credence to these presumptions. In their study of intra-articular hylan therapy in canine OA, hylan G-F 20 was found to be cleared from joints by lymphatics within 4 weeks of injection, which suggests (1) that hylan therapy can retard progression of OA for periods of time extending beyond the intra-articular residence time of injected molecules, and (2) that hylan injections given at relatively early stages of OA may have a chondroprotective effect. Despite success with hylan G-F 20 injections in osteoarthritic joints, it has not been without flaws. Many authors21,22 have reported adverse reactions with the use of hylan injections, ranging from increased pain at the injection site to attacks of gout in the injected joint. Our use of the fluoroscopically guided injection technique likely contributed to the lack of adverse reactions. Biologic interventions such as hylan G-F 20 injection require proper patient selection, precise injection technique under fluoroscopic guidance, and properly structured rehabilitation protocol. The astonishing success rate seen in our series appears to be due to the cumulative effect of these determinants. Based on our high success rate, it might be possible to conclude that the use of the hylan G-F 20 injection is a safe and effective option for treatment of early to moderate OA of the hip joint. CONCLUSION Hyaluronic acid compounds such as hylan G-F 20 may benefit select patients with mild to moderate OA of the hip joint, when combined with a structured exercise regimen. More studies, including randomized controlled trials, are required to further substantiate the efficacy of this form of treatment. Arch Phys Med Rehabil Vol 84, August 2003
1226
HYLAN G-F 20 AND HIP JOINT OA, Vad
References 1. Simon LS. Osteoarthritis: a review. Clin Cornerstone 1999;2:2637. 2. Helfet AJ. Management of osteoarthritis of the knee joint. In: Helfet AJ, editor. Disorders of the knee. Philadelphia: Lippincott; 1974. p 175. 3. Rosier RN, O’Keefe RJ. Hyaluronic acid therapy. Inst Course Lect 2000;49:495-502. 4. Adams ME. An analysis of clinical studies of the use of crosslinked hyaluronan, hylan, in the treatment of osteoarthritis. J Rheumatol Suppl 1993;39:16-8. 5. Balazas EA. The physical properties of synovial fluid and the special role of hyaluronic acid. In: Helfet AJ, editor. Disorders of the knee. Philadelphia: Lippincott; 1974. p 63. 6. Marshall KW, Manolopoulos V, Mancer K, Staples J, Damyanovich A. Amelioration of disease severity by intraarticular hylan therapy in bilateral canine osteoarthritis. J Orthop Res 2000;18: 416-25. 7. Frizziero L, Govani E, Bachin P. Intraarticular hyaluronic acid in the treatment of osteoarthritis of the knee: clinical and morphological study. Clin Exp Rheumatol 1998;16:441-9. 8. Goorman SD, Watanabe TK, Miller EH, Perry C. Functional outcome in knee osteoarthritis after treatment with hylan G-F 20: a prospective study. Arch Phys Med Rehabil 2000;81:479-83. 9. Hyaluronan or hylans for knee osteoarthritis? Drug Ther Bull 1999;37:71-2. 10. Adams ME, Atkinson MH, Lussier AJ, et al. The role of viscosupplementation with hylan G-F 20 (Synvisc) in the treatment of osteoarthritis of the knee: a Canadian multicenter trial comparing hylan G-F 20 alone, hylan G-F 20 with non-steroidal anti-inflammatory drugs (NSAIDs) and NSAIDs alone. Osteoarthritis Cartilage 1995;3:213-25. 11. Wen DY. Intra-articular hyaluronic acid injections for knee osteoarthritis. Am Fam Physician 2000;62:565-70.
Arch Phys Med Rehabil Vol 84, August 2003
12. Peyron JG, Balazas EA. Preliminary clinical assessment of NaHyaluronate injection into human arthritic knee joints [abstract]. Pathol Biol 1974;22:731. 13. Wobig M, Bach G, Beks P, et al. The role of elastoviscosity in the efficacy of viscosupplementation for osteoarthritis of the knee: a comparison of hylan G-F 20 and a lower-molecular-weight hyaluronan. Clin Ther 1999;21:1549-62. 14. Wobig M, Dickhut A, Maier R, Vetter G. Viscosupplementation with hylan G-F 20: a 26-week controlled trial of efficacy and safety in the osteoarthritic knee. Clin Ther 1998;20:410-23. 15. Lussier A, Cividino AA, McFarlane CA, Olszynski WP, Potashner WJ, De Medicis R. Viscosupplementation with hylan for the treatment of osteoarthritis: findings from clinical practice in Canada. J Rheumatol 1996;23:1579-85. 16. Ohshima Y, Higashi H, Mamiki O, et al. A study of the effect of intraarticular injection of high molecular weight sodium hyaluronate on osteoarthritis of the hip. Jpn Pharmacol Ther 1987;15: 1337-47. 17. Bragatini A, Molinaroli F. A pilot clinical evaluation of the treatment of hip osteoarthritis with hyaluronic acid. Clin Ther Res 1984;55:3319-30. 18. Erb RE. Current concepts in imaging the adult hip. Clin Sports Med 2001;20:661-96. 19. American Academy of Orthopaedic Surgeons. AAOS Outcomes Survey: lower limb instrument. Rosemont: AAOS; 1994. 20. De Conno F, Caraceni A, Gamba A, et al. Pain measurement in cancer patients: a comparison of six methods. Pain 1994;57:161-6. 21. Kroesen S, Schmid W, Theiler R. Induction of an acute attack of calcium pyrophosphate dihydrate arthritis by intra-articular injection of hylan G-F 20 (Synvisc). Clin Rheumatol 2000;19: 147-9. 22. Yacyshyn EA, Matteson EL. Gout after intraarticular injection of hylan GF-20 (Synvisc) [letter]. J Rheumatol 1999;26:2717.