Evaluating the use of intra-articular injections as a treatment for painful hip osteoarthritis: a randomized, double-blind, multicenter, parallel-group study comparing a single 6-mL injection of hylan G-F 20 with saline.

OBJECTIVE: Hip osteoarthritis (OA) is difficult to treat. Steroid injections reduce pain with short duration. With widespread adoption of office-based, image-guided injections, hyaluronic acid is a potentially relevant therapy. In the largest clinical trial to-date, we compared safety/efficacy of a single, 6-mL image-guided injection of hylan G-F 20 to saline in painful hip OA. METHOD: 357 patients were enrolled in a multicenter, double-blind, randomized saline placebo- controlled trial. Subjects were ≥35 years of age, with painful (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]-A1:5.0-8.0; numeric rating scale [NRS]: 0-10) mild-to-moderate hip OA (Kellgren-Lawrence grade II/III) and minimal contralateral hip pain (WOMAC-A1 < 4). Outcome measures included "pain on walking" (WOMAC-A1 and -A), Patient Global Self-Assessment (PTGA), WOMAC-A1 responder rate (+≥2 points on NRS), and adverse events (AEs) over 26 weeks. RESULTS: 357 patients (hylan G-F 20 single:182; saline:175) were enrolled. Both groups demonstrated significant pain improvement from baseline over 26 weeks (P < 0.0001); saline-induced pain reduction was a remarkable 35%. WOMAC-A and PTGA scores also significantly improved (P < 0.0001). No statistically significant difference was observed between groups in WOMAC-A1 scores (hylan G-F 20 single:-2.19 ± 0.16; saline:-2.26 ± 0.17) or WOMAC-A1 responders (41-52%). Treatment-related AE rates at target hip were similar (hylan G-F 20 single:23 patients [12.8%]; saline:12 [7.0%]). Posthoc analysis found, despite protocol requirements, many patients had psychological (31%) or potential neuropathic pain (27.5%) conditions. CONCLUSION: A single 6-mL hylan G-F 20 injection or saline for painful hip OA resulted in similar, statistically significant/clinically relevant pain and function improvements up to 6 months following injection; no differences between hylan G-F 20 and saline placebo were observed.

Rehabilitation of orthopedic and rheumatologic disorders. 1. Osteoporosis.

This self-directed learning module reviews and summarizes recent literature on osteoporosis. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The areas covered include pathophysiology of primary and secondary osteoporosis, effects of various pharmacologic treatments on bone metabolism, and the utility of available diagnostic tests. Management strategies for perimenopausal women as compared with postmenopausal women with established osteoporosis are discussed. This is followed by an evaluation and management plan for the older man with acute osteoporotic fracture.

Rehabilitation of orthopedic and rheumatologic disorders. 2. Connective tissue diseases.

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with connective tissue diseases. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. New advances covered in this article include the management of patients who have polymyalgia rheumatica, juvenile rheumatoid arthritis, ankylosing spondylitis, rheumatoid cervical spine, and rheumatoid hand.

Rehabilitation of orthopedic and rheumatologic disorders. 3. Degenerative joint disease.

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with osteoarthritis. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. New advances covered in this article include updates on conservative and operative treatment of lumbar spinal stenosis and pediatric hip diseases, prophylactic therapy for thromboembolic disease after lower limb joint replacement, new therapies for osteoarthritis, and the impact of exercise on outcome following hip replacement in active persons.

Rehabilitation of orthopedic and rheumatologic disorders. 4. Musculoskeletal disorders.

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with orthopedic and musculoskeletal disorders. It is part of the chapter on rehabilitation of orthopedic and rheumatologic disorders in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses new advances in such topics as idiopathic scoliosis, nontraumatic shoulder pain, rotator cuff tendinitis, and Dupuytren's disease.

Rehabilitation advances in the treatment of arthritis and musculoskeletal disease.

The current literature is reviewed related to three disease processes commonly encountered by the physiatrist, rheumatologist, and internist in clinical practice, including osteoarthritis, rheumatoid arthritis, and osteoporosis. These diseases often have effects beyond the pathology that has an impact on the individual's function and integration into society. Emphasis is on the specific rehabilitative approach to the individual.

Outcome of hip and knee arthroplasty in persons aged 80 years and older.

Recent studies have established the cost effectiveness and safety of total joint arthroplasties. As the population ages, it is important to determine whether these procedures are equally beneficial in the elderly. The short term safety and efficacy of total hip and knee arthroplasties in subjects 80 years of age and older was evaluated. Between 1988 and 1993, preoperative and postoperative physical and functional information was collected on 99 consecutive elective hip and knee arthroplasties in subjects 80 years of age or older. These data were compared with those derived from a younger otherwise matched control group. Data collected included subject demographics and characteristics, information concerning the acute and postacute hospital stay, comorbid conditions, postoperative complications, discharge disposition, Hospital for Special Surgery knee and Harris hip scores, pain scores, and functional capacity. The average age of the subjects was 83 years; osteoarthritis was the most common diagnosis; and the average followup was 25 months. Complication rates and length of stay in acute care facilities were not significantly different than for the control group. Mean preoperative Hospital for Special Surgery knee and Harris hip scores were 58 and 60, respectively, with postoperative scores of 77 and 88, respectively. Pain dramatically improved with 98% of total knee arthroplasty and 100% of total hip arthroplasty subjects reporting mild or no pain at followup. Preoperatively, none of the knee or hip subjects could walk unlimited distances. Postoperatively 51% of the total knee arthroplasty and 54% of the total hip arthroplasty subjects could walk more than five blocks; 71% of the total knee arthroplasty and 86% of the total hip arthroplasty subjects walked with a cane or no assistive device. The most dramatic postoperative functional gains were seen in the most disabled subjects. Total charges of care for patients 80 years of age and older was slightly greater than for a younger group. It was established that total joint arthroplasty can be performed safely in patients 80 years of age and older, promising excellent pain relief and improved functional outcome.

Selective muscle activation following electrical stimulation of the collateral ligaments of the human knee joint.

The objective of this study was to establish the presence of a local neurosensory reflex are from mechanoreceptors in human collateral ligaments and joint capsule to knee muscles and to determine if these muscles could be selectively activated as varus or valgus stabilizers using randomized trials. All studies were performed in the research department laboratories. Eleven subjects were recruited from the university staff and students based on no prior history of knee ailments. Subjects laid supine on an experimentation table as a current-modulated electrical stimulation was provided through the medial (MCL) or lateral collateral (LCL) knee ligaments. Latency of activation was measured for seven muscles, four by surface electrodes (semitendinosus, biceps femoris long head, vastus medialis, and lateralis), and three by intramuscular electrodes (sartorius, gracilis, tensor fascia lata). In the protocol, selective activation was defined as the relative increase in the activity of four muscles with medial moment arms following MCL stimulation compared with corresponding activity following LCL stimulation. For lateral muscles, the opposite was assumed (ie, that more activity would follow LCL than MCL stimulation). Monte Carlo simulations were performed on the data to determine significant selective muscle activation (p < .05). Statistically significant increases in activation were observed, most consistently, in the vastus medialis following MCL stimulation and in the vastus lateralis following LCL stimulation. These results suggest that a neurosensory reflex are from ligament mechanoreceptors may provide varus and valgus stabilization and knee muscles may be selectively activated to counter varus or valgus loads.

Rehabilitation in joint and connective tissue diseases. 1. Systemic diseases.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in joint and connective tissue diseases in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses treatment and outcome in rheumatoid arthritis, musculoskeletal involvement in human immunodeficiency virus infection, scleroderma, systemic lupus erythematosus, and intraarticular injection of corticosteroids.

Rehabilitation in joint and connective tissue diseases. 2. Inflammatory and degenerative spine diseases.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in joint and connective tissue diseases in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses ankylosing spondylitis and spinal stenosis, including differential features, diagnostic strategy, rehabilitation management, spinal complications of ankylosing spondylitis, and pathophysiology of spinal stenosis.

Rehabilitation in joint and connective tissue diseases. 3. Limb disorders.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on rehabilitation in joint and connective tissue diseases in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This article discusses the following: differential features, diagnostic strategy, and rehabilitation management of hip, knee, foot, and shoulder pain; indications, contraindications, and postsurgical management for joint arthroplasty; management of gout and chondrocalcinosis; and rehabilitation issues related to hip and shoulder fracture.

Rehabilitation and biomechanics.

In this review, we discuss large epidemiologic and focused clinical and laboratory studies published over the past year that advanced our current knowledge of the physical and functional impairments, societal handicaps, and disability related to the rheumatic diseases. Studies of rehabilitative methods appropriate for patients with a variety of rheumatic and musculoskeletal disorders are presented.

Rehabilitation and biomechanics.

Advances in our understanding of disability is important to the development of new rehabilitation ideas for patients with rheumatic disease. Large epidemiologic and focused clinical and laboratory studies that deal with risk factors and treatment for physical and social disability, exercise, gait analysis, and biomechanics are reviewed.

Updates on the diagnosis and management of posttraumatic hydrocephalus.

Posttraumatic hydrocephalus is a vital subject for the practitioner caring for patients with traumatic encephalopathy, as a large number of brain trauma patients develop ventricular enlargement. The managing physician should understand which ventriculomegalic patients are suffering from hydrocephalus, which have cerebral atrophy and which stand a reasonable chance of improvement on surgical placement of a ventricular shunt. This paper highlights this decision process in two patients, and offers the physician a practical overview of posttraumatic hydrocephalus and its management.