AB0873 ULTRASOUND GUIDED INTRA-ARTICULAR INJECTION WITH HYALURONIC ACID AGENTS IN MODERATE HIP OSTEOARTHRITIS
Authors: M. Micu, A. Micu, S. Bolboacă
Journal: Annals of the Rheumatic Diseases (2020)

Background: Current guidelines usually only include hyaluronic acid (HA) intra-articular injection as an alternative therapy option for knee osteoarthritis (OA). When compared to the blind approach, ultrasound guided intra-articular injections (USGIA) have shown a higher efficacy and reduced number of adverse events due to injection techniques [1]. This has allowed targeting deep joints like the hip. The objective of the study is to evaluate the short and long term efficacy and safety of HA-USGIA in moderate hip OA. Methods: Patients with Kellgren-Lawrence II and III hip OA (refractory to NSAIDs, pain killers and chondroprotective agents) were prospectively recruited to receive 3 consecutive weekly doses of HA- USGIA using free hand technique [2]. Informed written consent was signed. VAS pain scale and WOMAC score was performed at baseline and at 3 and 6 months after the end of treatment. The first injection was performed after a 1-month wash out. X ray assessment was made at baseline and after 6 months. Ultrasound evaluation was made at baseline and at each visit. Results: Fifteen patients (median age 67 years, IQR 63-69 years, 13/15 women) with hip OA were enrolled and 28 hip joints were injected (Fig 1a,b). None of the hips presented ultrasound detected capsular distension (suggesting inflammation) during the study. Table 1 presents the results on medication efficacy at 3 and 6 months. The pain evaluated by VAS score showed a significant and progressive decrease from baseline to 3 and 6 months respectively (Table 1). Indeed, a significant and sustained decrease of total WOMAC scores and its separate domains- pain, stiffness and function was recorded from baseline to 3 and 6 months (Fig 2a,b). No significant changes were observed regarding the WOMAC score stiffness and function domains when comparing results at 3 and 6ms. Moreover, WOMAC-pain score was significantly lower at 6ms as compared to 3ms (Table 1), highlighting the dramatic and sustained medication impact on the most relevant parameter for clinical practice, in patients with hip OA. Neither drug-related nor injection technique related adverse effects were recorded. No patient developed signs of hip osteonecrosis or inflammatory lesions during follow-up. Table 1. The trends of the scores expressed as medians and comparisons between follow-ups Score Median (Q1 to Q3) P-values Baseline (b) 3 ms 6 ms all* b vs. 3ms^ b vs. 6ms^ 3ms vs. 6ms^ VAS pain 8 (7 to 8) 3 (2 to 4) 2 (2 to 3) &lt;0.0001 &lt;0.0001 &lt;0.0001 0.2472 WOMAC total 57 (45.5 to 64.5) 9 (6.8 to 16.3) 7 (4.8 to 12.0) &lt;0.0001 &lt;0.0001 &lt;0.0001 0.1671 WOMAC pain 10.5 (8.0 to 13.5) 2 (1 to 2.3) 0.5 (0 to 2) &lt;0.0001 &lt;0.0001 &lt;0.0001 0.0123 WOMAC stiffness 3.5 (3 to 5) 0 (0 to 1) 0 (0 to 0) &lt;0.0001 &lt;0.0001 &lt;0.0001 0.1118 WOMAC function 42 (32 to 49) 7 (3.8 to 16) 6 (4 to 11.5) &lt;0.0001 &lt;0.0001 &lt;0.0001 0.4279 Q1 = first quartile; Q3 = third quartile; * Friedman test; ^ Wilcoxon test; 3 ms-3 months, 6ms-6 months, b-baseline Fig.1. Legend: a.) Longitudinal scanning at hip joint level. F- femoral head, arrows showing the hyperechoic needle penetrating the muscles and arriving inside the anterior join recess. b.) Post-procedural longitudinal scanning at the hip joint level. Arrowheads- showing the hyperechoic intra-articular drug moving anti-gravitational and distending the capsule. Fig 2. ab Legend. a.) Evolution of VAS for pain over time; b.) Evolution of WOMAC total score and its components over time. The line in the box is the value of median, the box is the first and the third quartile, the wishers are the minimum and maximum and the × is the value of mean. 3ms- 3 months, 6ms- 6 months, WOMAC T- WOMAC total. Conclusion: The results suggest that HA – USGIA may be an effective and safe treatment for moderate hip OA, due to its short and long term benefits. This treatment should not be delayed until advanced OA is diagnosed. Longitudinal controlled studies on larger cohorts are warranted to confirm these preliminary results. References: [1]Migliore A, Giovannangeli F, Granata M and Lagana B. Hyalgan G-F 20: Review of its Safety and Efficacy in the Management of Joint Pain in Osteoarthritis. Clinical Medical Insights: Arthritis and Musculoskeletal Disorders 2010;3: 55-68. [2]Micu MC, Fodor D. Musculoskeletal ultrasound guided interventional manoeuvres. Musculoskeletal Ultrasonography in Rheumatic Diseases. Ed. Springer 2015, ISBN 978-3-319-15723-8. Disclosure of Interests: None declared