Use of Exogenous Hyaluronic Acid for the Treatment of Patellar Chondropathy– A Six-Month Randomized Controlled Trial^[*]

Abstract

Objective To evaluate the clinical and radiological benefits of intra-articular exogenous hyaluronic acid for the treatment of chondral patellar injury.

Method Randomized clinical trial with 70 patients divided into 2 groups: those submitted to physical therapy for 3 months, and those submitted to physical therapy associated with the intra-articular administration of 2 mL of hyaluronic acid for the same period, who had anterior knee pain and patellar cartilage injury of grades II or III with no significant bone abnormalities. The functional scores and the characteristics of the physical and imaging exams were evaluated before and 3 and 6 months after the treatment.

Result The average age of the patients was 32 ± 7.6 years. Patients from the hyaluronic acid group had better Kujala et al and Lysholm scores, and lower pain scores after 3 and 6 months of treatment when compared to the control group. The incidence of positive Clarke maneuver was lower in the treated group, but there was no difference in the magnetic resonance imaging classification.

Conclusion Patients with patellar chondropathy of grades II or III treated with hyaluronic acid and physical therapy had less pain (visual analogue scale, VAS), and better functional results in the Lysholm and Kujala et al questionnaires after 3 and 6 months of treatment compared to patients undergoing physical therapy alone. In addition, the number of cases with a negative Clarke maneuver was larger in the treated group after 6 months of treatment.

Keywords

cartilage diseases - hyaluronic acid - chondrocytes - patella

^* Work developed by the Knee Group, Sports Traumatology Center, Orthopedics and Traumatology Department, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil.

• Referências

• 1 Heintjes E, Berger M, Bierma-Zeinstra S, Bernsen R, Verhaar J, Koes B. Exercise therapy for patellofemoral pain syndrome. Hoboken, NJ: John Wiley & Sons; 2005
• 2 Collins NJ, Bierma-Zeinstra SM, Crossley KM, van Linschoten RL, Vicenzino B, van Middelkoop M. Prognostic factors for patellofemoral pain: a multicentre observational analysis. Br J Sports Med 2013; 47 (04) 227-233
• 3 Lankhorst NE, van Middelkoop M, Crossley KM. , et al. Factors that predict a poor outcome 5-8 years after the diagnosis of patellofemoral pain: a multicentre observational analysis. Br J Sports Med 2016; 50 (14) 881-886
• 4 Loudon JK, Gajewski B, Goist-Foley HL, Louden KL. The effectiveness of exercise in treating patellofemoral-pain syndrome. J Sport Rehabil 2004; 13: 323-342
• 5 Irrgang JJ, Anderson AF, Boland AL. , et al. Development and validation of the international knee documentation committee subjective knee form. Am J Sports Med 2001; 29 (05) 600-613
• 6 Coppack RJ, Etherington J, Wills AK. The effects of exercise for the prevention of overuse anterior knee pain: a randomized controlled trial. Am J Sports Med 2011; 39 (05) 940-948
• 7 Barton CJ, Lack S, Hemmings S, Tufail S, Morrissey D. The ‘Best Practice Guide to Conservative Management of Patellofemoral Pain’: incorporating level 1 evidence with expert clinical reasoning. Br J Sports Med 2015; 49 (14) 923-934
• 8 Plánka L, Starý D, Srnec R, Necas A, Gál P. [New options for management of posttraumatic articular cartilage defects]. Rozhl Chir 2008; 87 (01) 42-45
• 9 Richette P, Chevalier X, Ea HK. , et al. Hyaluronan for knee osteoarthritis: an updated meta-analysis of trials with low risk of bias. RMD Open 2015; 1 (01) e000071
• 10 Mathieu P, Conrozier T, Vignon E, Rozand Y, Rinaudo M. Rheologic behavior of osteoarthritic synovial fluid after addition of hyaluronic acid: a pilot study. Clin Orthop Relat Res 2009; 467 (11) 3002-3009
• 11 van der Heijden RA, Lankhorst NE, van Linschoten R, Bierma-Zeinstra SM, van Middelkoop M. Exercise for treating patellofemoral pain syndrome. Cochrane Database Syst Rev 2015; 1: CD010387
• 12 Lisignoli G, Grassi F, Zini N. , et al. Anti-Fas-induced apoptosis in chondrocytes reduced by hyaluronan: evidence for CD44 and CD54 (intercellular adhesion molecule 1) invovement. Arthritis Rheum 2001; 44 (08) 1800-1807
• 13 McAlindon TE, Bannuru RR, Sullivan MC. , et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 2014; 22 (03) 363-388
• 14 Kim SE, Lee JY, Shim KS. , et al. Attenuation of inflammation and cartilage degradation by sulfasalazine-containing hyaluronic acid on osteoarthritis rat model. Int J Biol Macromol 2018; 114: 341-348
• 15 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 (03) 410-423
• 16 Bellamy N, Campbell J, Robinson V, Gee T, Bourne R, Wells G. Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database Syst Rev 2006; (02) CD005321
• 17 Doberstein ST, Romeyn RL, Reineke DM. The diagnostic value of the Clarke sign in assessing chondromalacia patella. J Athl Train 2008; 43 (02) 190-196
• 18 Nakayama H, Iseki T, Kanto R. , et al. Physiologic knee joint alignment and orientation can be restored by the minimally invasive double level osteotomy for osteoarthritic knees with severe varus deformity. Knee Surg Sports Traumatol Arthrosc 2018; ;•••: DOI: 10.1007/s00167-018-5103-3.
• 19 International Cartilage Repair Society Clinical Cartilage Injury Evaluation System. Available from: www.cartilage.org/society/publications/icrs-score
• 20 Gracitelli GC, Pierami R, Tonelli TA. , et al. Assessment of patellar height measurement methods from digital radiography. Rev Bras Ortop 2015; 47 (02) 210-213
• 21 Schueda MA, Astur DC, Bier RS, Bier DS, Astur N, Cohen M. Use of computed tomography to determine the risk of patellar dislocation in 921 patients with patellar instability. Open Access J Sports Med 2015; 6: 55-62
• 22 Bhattacharya R, Kumar V, Safawi E, Finn P, Hui AC. The knee skyline radiograph: its usefulness in the diagnosis of patello-femoral osteoarthritis. Int Orthop 2007; 31 (02) 247-252
• 23 E Albuquerque RP, Giordano V, Calixto A. , et al. Analysis on the modified lysholm functional protocol among patients with normal knees. Rev Bras Ortop 2015; 46 (06) 668-674
• 24 Kujala UM, Jaakkola LH, Koskinen SK, Taimela S, Hurme M, Nelimarkka O. Scoring of patellofemoral disorders. Arthroscopy 1993; 9 (02) 159-163
• 25 He WW, Kuang MJ, Zhao J. , et al. Efficacy and safety of intraarticular hyaluronic acid and corticosteroid for knee osteoarthritis: A meta-analysis. Int J Surg 2017; 39: 95-103
• 26 Clarke S, Lock V, Duddy J, Sharif M, Newman JH, Kirwan JR. Intra-articular hylan G-F 20 (Synvisc) in the management of patellofemoral osteoarthritis of the knee (POAK). Knee 2005; 12 (01) 57-62
• 27 Fosco M, Dagher E. Proposal of a therapeutic protocol for selected patients with patellofemoral knee osteoarthritis: arthroscopic lateral retinacular release followed by viscosupplementation. Musculoskelet Surg 2016; 100 (03) 171-178
• 28 van Jonbergen HP, Poolman RW, van Kampen A. Isolated patellofemoral osteoarthritis. Acta Orthop 2010; 81 (02) 199-205
• 29 Wenz W, Graf J, Brocai DR. , et al. [Effectiveness of intra-articular application of hyaluronic acid on early forms of femoropatellar arthrosis--an experimental study in dogs]. Z Orthop Ihre Grenzgeb 1998; 136 (04) 298-303
• 30 Kon E, Filardo G, Gobbi A. , et al. Long-term Results After Hyaluronan-based MACT for the Treatment of Cartilage Lesions of the Patellofemoral Joint. Am J Sports Med 2016; 44 (03) 602-608
• 31 Magarelli N, Palmieri D, Ottaviano L. , et al. Evaluation of magnetic resonance signal modification induced by hyaluronic acid therapy in chondromalacia patellae: a preliminary study. J Biol Regul Homeost Agents 2008; 22 (04) 247-252