This is title irrigation in practice

24 April of 2008

This is title irrigation in practice. There’s really not much to it. Anesthetizing the joint and the skin and putting in a 14-gauge needle that’s hooked up to a device that lets you run fluid through it, a liter, and about 60 cc aliquots. In the early 90’s we tested this prospectively in 15 different centers and these are the outcome measures. The dark lines are people who underwent irrigation, the light lines are the people who had ongoing medical management, close attention only. And there’s a significant trend towards pain relief after these various activities at 12 weeks of follow-up. Trying to expand on the lavage effect, analysis of the lavage effect, and also look at what arthroscopy tells us in early knee OA. Less than a year of symptoms, less than grade II on x-ray, but satisfying ACR criteria.

There were some surprises in this group. One of them was that a number of patients, practically one-third or more in UCLA, had findings like this. This is cartilage above and this is synovium and what’s embedded here – we think – are crystals. Now patients with crystals were excluded from the study and yet even with normal synovial fluids and normal x-rays it is not showing any calcium deposits. We do see quite a bit of crystals in these patients with OA knees. It may be why they did better. At the close we had trouble showing a difference between whether they got 3 liters of lavage or just enough lavage to clear out the joint, which is less than 250 cc. Although in both groups there was a reduction in pain. It was a bit more of a reduction in the 3 liter lavage group, but all the patients who had crystals had much greater improvement than those who did not.

The French have been at this for a long time and consider it part of their standard practice in knee OA. This is French lavage in practice. They use two entry points and they do it in a closed procedure. You may recall earlier this year seeing the results of their prospective study where they compared either placebo injection, joint lavage with placebo, cortisone or joint lavage with cortisone. What we see here first off is that anything done at the beginning, right away, plummets the pain scores. The puncture is still therapeutic. But then retaining that fact is much more likely in patients who underwent lavage with a cortisone injection. What’s missing here and what’s coming from Indiana very shortly is a comparison of joint lavage versus a sham lavage.

There are other things we can do to the knee, of course. For the past year we’ve had this stuff, although this is from a veterinary flyer. This is hyaluronate. High viscosity material that comprises synovial fluid that’s purified from rooster combs and can be injected repeatedly into knees with some effect. There have been a number of trials. This is again thanks to Kerwin, showing that in general there are two things this complicated graph says. First off, it confirms what Miller saw 40 years ago. That if you keep injecting a knee – now, with hyaluronate you have to inject the knee either three or five times in succession once a week – but if you keep injecting the knee, regardless of what you do, you reduce the pain score. Because on this graph are solid lines and dotted lines and the solid lines are hyaluronates and the dotted lines are placebo, and all of those things reduce pain scores. But in general the trend is – and it’s usually significant – is that even with that phenomenon you get more pain relief after their hyaluronate injection than after the saline injection.

With this 33-year-old man, I’m sure he’s happy to know that we have a cure for his disease. But seriously, I think that the data that is beginning to accumulate about glucosamine and chondroitin sulfate do warrant its use, particularly in young folks who have what really amounts to osteoarthritis and want to do something that might modify the long-term outcomes. It’s safe, it’s not very expensive, and this is what we recommended to our fellow. He is going to hold off on the hyaluronate and on the repeat joint lavage. But he does need more attention from a physical therapist. Actually, he went for the hyaluronate for his knees, he would take that. But he also went on glucosamine. So he had his knee joint effusion reduced and went back and I encouraged him to continue the therapy program that was prescribed to him. Because what he has to do over the long term is do whatever he can to modify the various processes that he has going on.

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