The document discusses different injection treatments for osteoarthritis (OA), including corticosteroids, hyaluronic acid injections, and platelet-rich plasma (PRP). It provides an overview of the mechanisms of action and evidence for each treatment. For PRP specifically, it summarizes that PRP is safe for treating OA and can provide symptomatic relief for up to 3 months, though more research is still needed to determine optimal formulations and treatment protocols.

1. ICS Session: IAS congress 2014
Viscosupplementation, PRP,
Steroids - Consensus in OA
MS Dhillon
Chandigarh
12-Oct-14 Prof M S Dhillon 1

2. Injections for Osteoarthritis
Preffered as the last non
operative modality
• Initial injections were
steroids, with multi
purpose use: Pain relief,
Anti inflammatory,
Instinct?
Raynauld JP et al. Safety and efficacy of long term intraarticular steroid
injections in OA knee: a randomized, double blind, placebo controlled trial.
Arthritis Rheum 2003;48(2):370-377.
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3. What are the recommendations?
In 2012
“…Strong evidence supports the use of intra-articular
Injections as a valuable intervention in the continuum
of management of arthritis……..”
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4. BUT: Which type of injections?
“…Steroids help……. But not for long term..
Help reduce synovial inflammation, but
No effect on cartilage wear”
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5. • Steroids have both anti inflammatory and
immunosuppressive effect, but mech of action
is complex
• Ideal during OA flare; effusion in early
radiological
• Rare side effects
Arden NK et al. A randomised controlled trial of tidal irrigation vs corticosteroid
injection in knee OA:the KIVIS Study. Osteoarthritis Cartilage 2008; 16:733-739
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6. In 2013
Positive Recommendation: when treatment meets the
minimum clinically important improvement thresholds
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7. In 2013
Jones A, Doherty M. Intra-articular corticosteroids are effective in osteoarthritis but
there are no clinical predictors of response. Ann Rheum Dis 1996;55(11):829-832
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8. Consensus
• Adjunct to core treatments!
• Relieves moderate to severe pain in some
cases
• Joint effusion aspiration with injection in
Grades 2/3 OA gives short term relief
• Does NOT degrade cartilage further
National Collaborating Centre for Chronic Conditions (UK). Osteoarthritis: National clinical
guideline for care a&management in adults. London: Royal College of Physicians (UK), 2008
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9. Changing thought process
In the 1990s
Balazs EA, Denlinger JL. Viscosupplementation: a new concept in the
treatment of osteoarthritis. J Rheumatol Suppl 1993; 39: 3-9
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10. Joint Lubrication/
Vissco supplementation
“…generated significant interest in 1995-2014
years worldwide….”
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11. Hyaluronic Acid Injections have been
used extensively
“…patient activity and functional levels…….
…improve significantly as compared to placebo….”
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12. Vissco Supplements
• Designed as Synovial
fluid Prosthetic device
to lubricate the joint
• Different Molecular wts,
provide different levels
of lubrication
Maneiro E, et al. The biological action of hyaluronan on human osteoarthritic articular
chondrocytes: the importance of molecular weight. Clin Exp Rheumatol 2004; 22: 307-312
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13. Mechanism of Vissco-supplementation
Restores visco
elastic properties
of pathologically
altered synovial
fluids
Synvisc One GENZYME Video
Wang C et al. Therapeutic effects of hyaluronic acid on osteoarthritis of the knee. A
meta-analysis of randomized controlled trials. J Bone Joint Surg Am 2004; 86-A: 538-545
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14. Mechanism of Vissco-supplementation
Direct analgesic
activity by reducing
Bradykinin &
Substance P synthesis
• Forms envelope
around nociceptive
receptors, reduces
pain
Synvisc One GENZYME Video
Moreland LW. Intra-articular hyaluronan (hyaluronic acid) and hylans for the treatment
of osteoarthritis: mechanisms of action. Arthritis Res Ther 2003; 5: 54-67
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15. What about the current evidence?
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16. In 2013
AAOS has changed its guideline given in 2008
where it had medium evidence in support
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17. Consensus
• Research evidence suggests that IA HA
injections are safe, have potential efficacy,
• Provide pain reduction in EARLY OA for upto
24 weeks
• COST effectiveness is a concern.
• Patient must be aware of the limitations
Rutjes AW,et al. Viscosupplementation for osteoarthritis of the knee: a systematic
review and meta-analysis. Ann Intern Med 2012; 157: 180-191
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18. Can we actually help in
Healing Cartilage?????
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19. Lot of discussion on
“regenerative” injections?
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20. Disease Modifying Agents ?
Biological
products CAN
influence Cartilage
healing !
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21. PLATELETS: A SOURCE OF GROWTH
PLATELETS IN RESTING STATE
Discoid shape
ACTIVATED PLATELETS
inductive FACTORS
Provide a rich source of multiple
GROWTH FACTORS that serve a
CRITICAL function in WOUND
and FRACTURE Healing
These factors have a direct
Chemotactic and Mitogenic effect
on Cell precursors (MSC)
PRE-CLINICAL ANIMAL STUDIES
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22. One emerging Trend………….
Use PRP to stimulate tissue healing
2011
• Patel, Dhillon et al: PRP in early Knee OA
• Behera, Dhillon et al: PRP In intractable tennis elbow
• Shetty, Dhillon et al: PRP in Planter fascitis
Prof M S Dhillon
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23. Why PRP in Osteoarthritis?
• Aim is to restore
anabolic-catabolic
imbalance seen in OA
• Growth factors
released from Alpha
Granules of activated
Platelets may
influence OA
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24. Pubmed Search: Osteoarthritis AND PRP
A Lot of focused
Work is actually
going on
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25. Does PRP help knee OA?
Spate of publications in 2011-14
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26. Positive Exptal
evidence 2009
• Stimulated Chondrocyte GAG
Synthesis
• Suppressed progression of
OA in rabbit model
Stimulation of
Cartilage Matrix
metabolism by growth
factors in PRP
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27. Kon E, Buda R, Filardo G et
al Knee Surg Sports
Traumatol Arthrosc
2010;18:472–479
European
publications
Prof M S Dhillon
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28. 2013 Feb
issue AJSM
12-Oct-14
1st RCT
With controls
Prof M S Dhillon 28

29. What we concluded about PRP in
Knee OA
PRP is safe, gives symptomatic relief in early OA knees.
• Improvement noted by 2 to 3 weeks, which gradually
improves over 3 months
• Early OA fares better than late OA
• One injection is as effective as 2
Patel S, Dhillon MS, Aggarwal S, Marwaha N, Jain A.TREATMENT
WITH PLATELET-RICH PLASMA IS MORE EFFECTIVE THAN PLACEBO
FOR KNEE OSTEOARTHRITIS: A PROSPECTIVE, DOUBLE-BLIND,
RANDOMIZED TRIAL. Am J Sports Med. 2013 Feb;41(2):356-64
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30. Cited in 62 publications
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31. Comparison with Hyaluronate Acid
PRP may actually help
cartilage defects to heal better !
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32. Prof M S Dhillon
Where do we stand today?
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33. In 2013
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34. We are in an Era of EBM!
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35. Evidence for and against many things
is equivocal
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36. New Technology
Many times it
is a Leap of
faith
Sometimes
into darkness
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37. Our Understanding of PRP role in OA
Many issues in
relation to OA
are still undefined
? etio-pathogenesis
? factors controlling
progression
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38. What do we
Know today?
PRP works
…through
various factors
… influences
multiple
processes
inside joints
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39. Consensus?
• PRP is safe in OA
• Improvement by 2 to 3 wks,
improves over 3 months
• Improvement tapers off by 6 mo
Early OA fares better than late OA
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40. What we are still Unsure about?
• What formulation is more
effective, and at what conc?
• Will it work in Ahalback’s Type 3?
• How many (1,2 or 3) injections?
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41. Email me for a pdf copy
drdhillon@gmail.com
Thank You For Your Attention
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