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Orthopedists debate the efficacy of viscosupplementation after meniscectomy
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WAILEA, Hawaii — Although some orthopedists contend that viscosupplementation relieves knee cartilage pathology symptoms after arthroscopy and preserves articular cartilage, others hold that the outcomes of viscosupplementation are inconclusive and that platelet-rich plasma may work better.
“Post-arthroscopy high molecular weight viscosupplementation improves symptoms and may be helpful to prevent further degeneration to the articular surface,” Jack M. Bert, MD, said during a debate on the topic with William R. Beach, MD, at Orthopedics Today Hawaii 2014.
The American Academy of Orthopaedic Surgeons (AAOS) recently released clinical practice guidelines noting that viscosupplementation should not be recommended after arthroscopy because the results of the adjuvant therapy are inconclusive, according to Bert.
Jack M. Bert
“They missed the mark on this as noted in the January issue of the Journal of Arthroscopy,” he said noting that viscosupplementation can prevent further degeneration of articular cartilage. Bert cited a level 1 study by Wang and Hall that compared 39 patients with knee osteoarthritis (OA) who received hyaluronic acid (HA) injections to 39 patients who did not. HA injections improved cartilage preservation as evidenced by T2 mapping at 2-year follow-up, whereas those who did not receive HA had progression of OA. He furthermore noted that HA may improve the proteoglycan content of articular cartilage as noted by a study in press by Shah and Kelly that used T1 Rho imaging at 6 weeks status post HA injection.
In two meta-analyses conducted with David D. Waddell, MD, Bert and colleagues found use of high molecular weight HA post-arthroscopy decreased pain, pain upon motion and crepitus at 3-month and 6-month follow-ups.
William R. Beach, MD, argued that because of the AAOS clinical practice guideline and the cost of viscosupplementation, platelet-rich plasma (PRP) may be the better alternative.
William R. Beach
“I do not think there is going to be much question that if it is not covered by insurers, we are not going to be doing hyaluronic acid injections for long,” Beach said. “There are several randomized clinical trials that show that platelet-rich plasma may be better than viscosupplementation.”
In a multicenter, double-blind, clinical trial of 176 patients knee OA, Mikel Sánchez, PhD, found PRP yielded better short-term results compared to HA, according to Beach.
In a comparison study of 60 gonarthrosis patients who received HA injections and 60 gonarthrosis patients who received autologous-conditioned plasma (ACP) injections, Fabio Cerza, MD, and others found that patients treated with ACP injections had better clinical outcomes than patients treated with HA injections.
Beach also pointed to a study by Elizaveta Kon, MD, that compared 150 OA patients with cartilage degenerative lesions. The researchers treated 50 patients with PRP injections, 50 patients with low-molecular-weight HA injections and 50 patients with high-molecular-weight HA injections. The patients injected with PRP had better, longer lasting pain and symptom reduction than patients injected with HA, according to the study. – by Renee Blisard Buddle
References:
Bert J. Ther Adv Musculoskelet Dis. 2010;doi: 10.1177/1759720X10370930.
Kon E. Arthroscopy. 2011;doi: 10.1016/j.arthro.2011.05.011.
Sanchez M. Arthroscopy. 2012;doi: 10.1016/j.arthro.2012.05.011.
Waddell D. Arthroscopy. 2010; doi: 10.1016/j.arthro.2009.05.009.
Wang Y. BMC Musculoskelet Disord. 2011; doi: 10.1186/1471-2474-12-195.
For more information:
Jack M. Bert, MD, can be reached at Minnesota Bone & Joint Specialists Ltd., 17 W. Exchange St., Ste. 110, St. Paul, MN. bertx001@umn.edu
Disclosures: Beach receives fellowship grants from Smith & Nephew, Arthrex, Synthes and Mitek, is a shareholder of Tuckahoe Surgery Center and St. Mary’s ASC and is on the Arthroscopy Association of North America Board of Directors and the American Academy of Orthopaedic Surgeons Coding, Coverage and Reimbursement Committee. Bert is a consultant for Smith & Nephew, Extactech, Wright Medical Technology, Tornier, Sanofi, Exscribe and Arthrex; and is the executive advisor of the Arthroscopy Association of North America Board of Directors.