It is well established that damaged articular cartilage has a very limited potential for healing, and articular defects larger than two to four millimeters in diameter rarely heal even with such advances as the use of continuous passive motion26,36,70,98,101,128,130,138,162,163,208. Damage to articular cartilage is a common problem: in one study, it was associated with 16 percent (twenty-one) of 132 injuries of the knee that were sufficient to cause intra-articular bleeding88. Furthermore, damage to a joint surface can lead to premature arthritis128. Twyman et al. prospectively followed twenty-two knees in which osteochondritis dissecans had been diagnosed before skeletal maturity; at an average of thirty-four years, 32 percent had radiographic evidence of moderate or severe osteoarthritis235. Only 50 percent had a good or excellent functional result.

Elderly patients (those who are sixty-five years of age or older) who have an arthritic condition can obtain dramatic relief from pain and restoration of function after total joint replacement. However, such procedures have higher rates of failure in young and early-middle-aged patients (those who are less than forty years old and those who are forty to sixty years old, respectively) than in elderly patients194. This leaves a large group of patients spanning a broad age-group, many of whom are in their prime, for whom there is no currently acceptable and reliable treatment. A typical example is that of a young, healthy individual who has arthrosis or osteochondritis dissecans following an injury to a joint. It might be possible to solve this patient's problems if the lost or damaged segment of articular cartilage inside the involved joint could be regenerated. After it had been restored, the …

Current Concepts Review - The Healing and Regeneration of Articular Cartilage*

Importance Synovitis is common and is associated with progression of structural characteristics of knee osteoarthritis Intra-articular corticosteroids could reduce cartilage damage associated with synovitis but might have adverse effects on cartilage and periarticular bone Objective To determine the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on progression of cartilage loss and knee pain Design, setting, and participants Two-year, randomized, placebo-controlled, double-blind trial of intra-articular triamcinolone vs saline for symptomatic knee osteoarthritis with ultrasonic features of synovitis in 140 patients Mixed-effects regression models with a random intercept were used to analyze the longitudinal repeated outcome measures Patients fulfilling the American College of Rheumatology criteria for symptomatic knee osteoarthritis, Kellgren-Lawrence grades 2 or 3, were enrolled at Tufts Medical Center beginning February 11, 2013; all patients completed the study by January 1, 2015 Interventions Intra-articular triamcinolone (n = 70) or saline (n = 70) every 12 weeks for 2 years Main outcomes and measures Annual knee magnetic resonance imaging for quantitative evaluation of cartilage volume (minimal clinically important difference not yet defined), and Western Ontario and McMaster Universities Osteoarthritis index collected every 3 months (Likert pain subscale range, 0 [no pain] to 20 [extreme pain]; minimal clinically important improvement, 394) Results Among 140 randomized patients (mean age, 58 [SD, 8] years, 75 women [54%]), 119 (85%) completed the study Intra-articular triamcinolone resulted in significantly greater cartilage volume loss than did saline for a mean change in index compartment cartilage thickness of -021 mm vs -010 mm (between-group difference, -011 mm; 95% CI, -020 to -003 mm); and no significant difference in pain (-12 vs -19; between-group difference, -06; 95% CI, -16 to 03) The saline group had 3 treatment-related adverse events compared with 5 in the triamcinolone group and had a small increase in hemoglobin A1c levels (between-group difference, -02%; 95% CI, -05% to -0007%) Conclusions and relevance Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain These findings do not support this treatment for patients with symptomatic knee osteoarthritis Trial registration ClinicalTrialsgov Identifier: NCT01230424

/pdf/effect-of-intra-articular-triamcinolone-vs-saline-on-knee-4nnrdiquzn.pdf

Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial.

Alterations in Cartilage in Osteoarthritis The morphologic changes in joints affected by osteoarthritis were identified in writings of the Hunter brothers over 200 years ago.88 Over the intervening...

The Reaction of Articular Cartilage to Injury and Osteoarthritis

Osteoarthritis (OA) is a complex “whole joint” disease pursued by inflammatory mediators, rather than purely a process of “wear and tear”. Besides cartilage degradation, synovitis, subchondral bone remodeling, degeneration of ligaments and menisci, and hypertrophy of the joint capsule take parts in the pathogenesis. Pain is the hallmark symptom of OA, but the extent to which structural pathology in OA contributes to the pain experience is still not well known. For the knee OA, intraarticular (IA) injection (corticosteroids, viscosupplements, blood-derived products) is preferred as the last nonoperative modality, if the other conservative treatment modalities are ineffective. IA corticosteroid injections provide short term reduction in OA pain and can be considered as an adjunct to core treatment for the relief of moderate to severe pain in people with OA. IA hyaluronic acid (HA) injections might have efficacy and might provide pain reduction in mild OA of knee up to 24 wk. But for HA injections, the cost-effectiveness is an important concern that patients must be informed about the efficacy of these preparations. Although more high-quality evidence is needed, recent studies indicate that IA platelet rich plasma injections are promising for relieving pain, improving knee function and quality of life, especially in younger patients, and in mild OA cases. The current literature and our experience indicate that IA injections are safe and have positive effects for patient satisfaction. But, there is no data that any of the IA injections will cause osteophytes to regress or cartilage and meniscus to regenerate in patients with substantial and irreversible bone and cartilage damage.

http://drzprp.com/wp-content/uploads/2015/06/knee-prp2.pdf

Intraarticular injections (corticosteroid, hyaluronic acid, platelet rich plasma) for the knee osteoarthritis

is well recognized as an important therapeutic adjunct in the conservative treatment of local inflammatory conditions. Various steroid agents have been employed for more than twenty years to treat osteoarthritis, bursitis and tenosynovitis. The beneficial effects of pain relief and rapid rehabilitation make their frequent use desirable. However, in recent years serious complications, following local steroid use, have been brought to attention.

The effects of local steroid injections on tendons: a biomechanical and microscopic correlative study

This study demonstrates the effect of intra-articularly administered hydrocortisone acetate in doses of 0.16 and 1.6 milligrams per kilogram on the incorporation of glycine-H3 into articular cartilage of rabbits. The steroid was injected into one knee joint and, at intervals up to twety-four days, t

Karl A. Conger

Papers

The acute effects of intra-articular hydrocortisone on articular cartilage in rabbits.