Injections for knee arthritis

[injuryupdate]

Editorial in the BMJ this week suggests that cortisone injections are under-used for short-term pain relief in knee osteoarthritis.

I think they can be used for special occasions, but they probably break down the lining cartilage even further when they get used.

From this weeks' BMJ:

Managing osteoarthritis of the knee
NSAIDs and other measures offer only short term benefits—up to surgery


A slightly swollen and aching knee. Walking is difficult, the stairs are almost impossible, and so begins the downward spiral of inactivity, immobility, and weight gain. Osteoarthritis of the knee is a familiar picture, presenting usually when it is too painful to ignore but too early for surgery. Patients have often already made the diagnosis themselves and seek a solution. They want pain relief so they can walk, kneel, climb a ladder, shop, or simply get around in comfort. Most patients have tried paracetamol, hot water bottles, someone else's great new tablets, a cabbage leaf, various herbal or homoeopathic medications, prayer, copper bracelets, and many other remedies before asking for help. Most general practitioners would reach for the keyboard tapping out their favourite non-steroidal anti-inflammatory (NSAID).

NSAIDs do not seem to offer a long term solution. In a comprehensive systematic review and meta-analysis of randomised placebo controlled trials in this issue of the journal, we learn that NSAIDs can reduce short term pain only slightly better than placebo (p 1317). 1 This study does not support the long term use of NSAIDs in osteoarthritis of the knee, and our prescriptions may, in fact, be doing harm. Good scientific reasons exist for this—prostaglandin inhibitors reduce the immediate inflammatory response in the acutely injured joint but may inhibit long term healing. Good medical reasons also exist—the gastrointestinal side effects are well known, but patients with osteoarthritis are older and the British National Formulary recommends that NSAIDs be used with caution in elderly people, who are more likely to have cardiac, hepatic, or renal impairment.2 The EULAR guidelines recommend both pharmacological and non-pharmacological measures but advise simple analgesia at first.w1 w2 Another recent systematic review concludes that paracetamol is an effective agent for relieving pain due to osteoarthritis and, although safer, is less effective than NSAIDs. They recommend paracetamol as a first line treatment for reasons of safety.3

What are the alternatives? An osteoarthritic knee is often a weak knee. Muscle dysfunction may be as important a cause as wear and tear.4 Physical training may relieve symptoms, and both strengthening and endurance exercise is of benefit to patients with mild and moderate osteoarthritis. Referral to exercise training appears to be the most useful option but home based programmes are effective too.5 6 Training improves muscle strength and joint mobility, but the condition is progressive and training offers only a temporary respite in the inevitable decline in function.7 Facilities for getting people started and providing support through a programme of exercise training are not commonly available in the United Kingdom so referral is rarely an option. Acupuncture may reduce pain and improve both physical function and health related quality of life.w3 Taping may also be a useful short term and intermittent intervention, although arranging weekly taping by a physiotherapist might prove difficult in the NHS.8 Topical anti-inflammatory applications are of some help, and patients often try glucosamine and chondroitin, which have been shown to be of benefit and can be sold directly to patients.9-11

Intra-articular injections are effective. Notable improvements are seen in the short term (two weeks), and in some longer term studies (16-24 weeks).12 But the short term benefits can be important. Normal lives are a patchwork of work, leisure, holidays, weddings, and other life events. Short term benefit from an intra-articular injection may give sufficient temporary improvement to allow a patient to go on holiday, take part in a family event, or simply enjoy getting outdoors during summer. The pain relief can be almost immediate and the improvement in mobility magical. The benefit, however short term, can make such a difference. No one knows the long term effects of repeated injections although they seem to be safe over two years. Surgery is ultimately the preferred option. But, for most patients the most difficult period is between onset of the symptoms and the point when surgery becomes necessary.

Thankfully, surgery does offer the ultimate answer in the severely osteoarthritic knee.w4 The results are good in about 90% of patients, with improvement in pain, functional status, and overall health related quality of life, and 85% of patients are satisfied with the outcome. The strongest evidence is in studies with two years' follow up, but the results are also positive in studies with five to 10 years' follow up. The overall complication rate of 5.5% includes infection, deep vein thrombosis, and poor wound healing and a further 0.5% die during surgery. The revision rate after five or more years is 2%.w5 Total knee replacement is a good option when other strategies fail, in patients with chronic pain and functional limitation.

The slightly swollen aching knee usually gets worse. We may slow the inevitable decline in function and provide short term symptomatic relief. Prescription medicines offer some benefit, but patients may be justified in self medication with glucosamine and chondroitin. Intra-articular injections do offer short term benefit and, although general practitioners have been reluctant to inject, perhaps improved training may encourage a more active approach. Exercise training, guided by a physiotherapist, may also delay decline.

Domhnall MacAuley, general practitioner

[hhh]

It begs the question, what is the best form of management for osteoarthritis of the knee.

A controlled trial of arthroscopic surgery for osteoarthritis of the knee.

Moseley JB, O'Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP.

BACKGROUND: Many patients report symptomatic relief after undergoing arthroscopy of the knee for osteoarthritis, but it is unclear how the procedure achieves this result. We conducted a randomized, placebo-controlled trial to evaluate the efficacy of arthroscopy for osteoarthritis of the knee. METHODS: A total of 180 patients with osteoarthritis of the knee were randomly assigned to receive arthroscopic debridement, arthroscopic lavage, or placebo surgery. Patients in the placebo group received skin incisions and underwent a simulated debridement without insertion of the arthroscope. Patients and assessors of outcome were blinded to the treatment-group assignment. Outcomes were assessed at multiple points over a 24-month period with the use of five self-reported scores--three on scales for pain and two on scales for function--and one objective test of walking and stair climbing. A total of 165 patients completed the trial. RESULTS: At no point did either of the intervention groups report less pain or better function than the placebo group. For example, mean (+/-SD) scores on the Knee-Specific Pain Scale (range, 0 to 100, with higher scores indicating more severe pain) were similar in the placebo, lavage, and debridement groups: 48.9+/-21.9, 54.8+/-19.8, and 51.7+/-22.4, respectively, at one year (P=0.14 for the comparison between placebo and lavage; P=0.51 for the comparison between placebo and debridement) and 51.6+/-23.7, 53.7+/-23.7, and 51.4+/-23.2, respectively, at two years (P=0.64 and P=0.96, respectively). Furthermore, the 95 percent confidence intervals for the differences between the placebo group and the intervention groups exclude any clinically meaningful difference. CONCLUSIONS: In this controlled trial involving patients with osteoarthritis of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no better than those after a placebo procedure.

[hhh]

My evidence based guidelines for the management of chronic knee osteoarthritis:

1. Glucosamine/chondroitin etc.
2. Positive reinforcement to patient to continue ADLs; include rehab exercises etc
3. Sham cortisone and/or NSAIDs
4. Refer to point 2
5. Sham lavage and debridement
6. Refer to point 2.
7. Sham joint replacement surgery
8. Refer to point 2.
7. Back to point 1.

[injuryupdate]

Agree with most of this but have to disagree about the sham joint replacement surgery. Joint replacement surgery is one of the major medical advances of the 20th Century - I think it would seriously make a top 10 list, along with antibiotics, lifestyle changes to prevent cardiovascular disease etc. When a joint replacement is successful, it would literally add years to a patient's life because of the extra exercise tolerance it gives them. I once visited a knee surgeon's practice in the week before Christmas and he had cases of wine stacked up in his PA's office, all from joint replacement patients who were prepared to tip in an extra Christmas present on top of the lucrative fee they had parted with earlier in the year, just to show that they though they got more than their money's worth.

Definitely THR and TKR are magnificent procedures in the right patient with the right surgeon, and I don't believe that RCTs are needed because the results are so obvious. I LOVE the Moseley study you have listed above showing that arthroscopic washout and chondroplasty are essentially sham procedures in moderate O/A (or of such minimal benefit that the study was underpowered to show any). I can't see why the HIC continues to pay for surgery that is so discredited, and have written an editorial along these lines.

http://www.injuryupdate.com.au/images/research/JSMSeditinsur.PDF

I think that, of the other major orthopaedic operations, ACL surgery in low level athletes needs to be justified further.

The question now obviously needs to be answered about making sure that success rates for THR and TKR are as high as possible. A failure of these operations (infection, DVT, premature loosening of prosthesis, fractured femur) can be an unmitigated disaster. The best surgeons for primary replacement probably have failure rates of 1-5%, but, knowing the variance in quality of surgeons, I would be almost sure that there are surgeons out there who have failure rates (early on) in the league of 10-20%. There are total joint registers in Australia, and you can bet that the orthopods will keep the data very quiet and will allow surgeons who are getting bad results to keep charging $2000 for a 90 minute procedure and won't do anything about making sure that only those with proven good results can keep doing these difficult operations. It could be the stuff of lawsuits over the next few years.

One other semi-sham intervention you forgot to add was sham Synvisc injection, which probably gives minimal help (but not much) and is of course very expensive. I am glad the government doesn't pay for this, but again I don't understand why they pay for chondroplasty which is probably worse. (OK, I really do understand, the real reason being the surgeons have a magnificent power base and will defend the right to forever get fully funded to do whatever operations they want, whether or not they work).

I have used Aprotinin in joints for moderate O/A and it gives bloody good pain relief (similar to cortisone), with hopefully long-term chondroprotective rather than catabolic effects that cortisone has on articular cartilage. However, I don't want to make a big deal of it yet because I am scared stiff of allergic reaction to it. I have had some bad ones come on quickly after Aprotinin tendon injections, but I would be scared that the reactions might occur hours later with Aprotinin in a joint.

[hhh]

Agree that I probably took the sham joint replacement option a bit too far, but it would make an interesting pilot study. If the sham option costs $100 and you can put off a few replacement surgeries with a positive result, everyone is going to be a winner.

I heard a case report of an older guy with a severely arthritic knee. Instead of a replacement they put a full knee brace on to essentially totally fuse the joint. He lost use of his knee, but was also pain free. He can still get around with a limp so there is no major impact on his quality of life.

I think other options need to be explored as with the increasing rates of childhood obesity and inactivity the average age of replacement surgery patients will surely come down. The other thing that should be emphasized is that one replacement is not life-long. Correct my figures but I understand the first one will last 15 years and the second one about 10 years.

PS: I'm sure Moseley is Mr Popularity at the surgical conventions going round!

[hhh]

PSS: after reading your editorial you must be giving Moseley a run for his money...at least you'll have someone to set next to at these conventions.

When is the ACSP going to have an uprising for more respect from the general medical community and government or is it going to be left to a few rogue editorials here an there to create a change?

[Gibbo]

Can you complete your top 10 medical advances??

Then maybe follow this up with the top 10 medical flops

[injuryupdate]

I heard a case report of an older guy with a severely arthritic knee. Instead of a replacement they put a full knee brace on to essentially totally fuse the joint. He lost use of his knee, but was also pain free. He can still get around with a limp so there is no major impact on his quality of life.



Fusions have an even worse long-term prognosis than total joint replacements. To walk around you need to create moments around joints, so if your knee is fused, pretty soon you will have an arthritic hip and ankle, which you can't fuse because you need the movement somewhere.

This is why spinal fusions have such a bad name. You fuse L4-S1, then what happens when you get intractable pain from the upper lumbar segments which get arthritis 5 years later?

Total replacement gives you the movement with a replacable part. Shelf-life is probably 10-15 years I agree, but still the gold standard.

[injuryupdate]

Can you complete your top 10 medical advances??

Then maybe follow this up with the top 10 medical flops

Don't think I am well enough qualified to do the general medical list, but maybe you could suggest some sports medicine ones and start a new thread.

Include in the flops:
Artificial (Dacron) ACL reconstruction (these all broke down)
Preventative menisectomy for soccer players
Capsular shrinkage for unstable shoulders
Vioxx
Surgam
Cortisone for Achilles tendinopathy

In the advances:
ACL reconstruction
Arthroscopy
McConnell program for patellofemoral pain
Total joint replacement
MRI scanning
Local anaesthetic injections to get key players through Grand Finals.

[hhh]

The guy in my example is late 80s so it is a massive risk for a replacement. I've heard of a 100 year old lady going in for one. Arthritic change is going to take a long time to develop so for the guy I was mentioning it was a success. He didn't have a huge demand for knee function either ie: wasn't a golfer.

[Monica]

What this all boils down to is doctors STILL umming and ahhing over an arthritis treatment - let alone cure. My father has rheumatoid arthritis in both his ankles, knees, and knuckles especially. He has now had it for forty years, and I can tell you, the sham treatments number more than mentioned. At first he was diagnosed with gout, and following many more consultations with many more MDs, they finally got it right - about 3 years later. My father has never, in my living memory, been able to run or play sport. His knees are permanently bent and he walks with a limp, he can't get up steps in on go, his ankles balloon up every night, and his fingers have NEVER been straight - his hands are basically useless to him. The disformation of his body is torturous to ME, but he's given up hope of help and has had to commit to deteriorate in agony. He's had most of the treatments you've mentioned, and many more - gold injections, wax treatments, endless pills... Arava - one of the worst I've ever seen. The man is in pain every minute of every day of his life.

I'm sorry to sound how I do, but I feel that the efforts of gifted doctors should be focussed more on actual work towards a concrete resolution, than nicking the shin of patients to see if they can tell the difference.

p.s. hhh by the time arthritis patients accept the fact that they are severe enough to require surgical procedures, they've given up golf, and are looking more at quotes to have rails fitted on stairs. From my experience, they dont have a huge demand for knee function - but it would be bloody nice for a change! ... and that's what its really all about

[hhh]

Sorry to hear about you dad. I have been talking about degenerative arthritis which is more due to wear and tear and previous injury. The type your dad has is classified as an inflammatory arthirits and has a total different pathophysiology and needs to be managed totally different. It is a totally different form of arthritis. Unfortunately we still don't know why rheumatoid arthritis occurs but as it sounds like with your dad, it can results in massive damage to joint surfaces and physical deformities. Most suggestions of a cause involve an auto-immune mechanism where the body attacks itself, but there is likely to be a genetic component. Some have also suggested a viral cause, but we don't know.

Most people with severe RA tend to be on permanent corticosteroids. There will be periods or exacerbation and remission where cortisone injections may be trialled. There is a large selection of other pharmacological agents that can be prescribed. Unfortunately systemic effects are likely including malaise and fatigue

RA is not my area of expertise but I wish your dad all the best. RA is more common in females so he mustn't be having much luck.

[injuryupdate]

There is a good theory that a disease like Rheumatoid Arthitis should be caused by infectious agents. I think most of the rheumatolosits think that it is a viral agent that triggers a genetic predisposition. The problem is that no one really has nailed the agent yet. It means though that any treatment that could kill the virus more than it harms the body might work.

A full article on this theory:

A New Germ Theory
by Judith Hooper
The Atlantic Monthly: Feb 1999

Excerpts:

The dictates of evolution virtually demand that the causes of
some of humanity's chronic and most baffling "noninfectious"
illnesses will turn out to be pathogens -- that is the radical
view of a prominent evolutionary biologist

These Darwinian laws have led Ewald to a new theory: that diseases we
have long ascribed to genetic or environmental factors -- including some
forms of heart disease, cancer, and mental illness -- are in many cases
actually caused by infections.

"When diseases have been present in human populations for many
generations and still have a substantial negative impact on people's
fitness," he says, "they are likely to have infectious causes."

Although its fitness-reducing dimensions are difficult to calculate,
the ordinary stomach ulcer is the best recent example of a common
ailment for which an infectious agent -- to the surprise of almost
everyone -- turns out to be responsible.

When I visited him one afternoon, Ewald pulled off his shelves a
standard medical textbook from the 1970s and opened the heavy volume to
the entry on peptic ulcers. We squinted together at a gray field of
small print punctuated by subheads in boldface. Under "Etiology" we
scanned several pages: environmental factors ... smoking ... diet ...
ulcers caused by drugs ... aspirin ... psychonomic factors ... lesions
caused by stress. In the omniscient tone of medical texts, the authors
concluded, "It is plausible to hypothesize a wealth of these
factors...." There was no mention of infection at all.

In 1981 Barry J. Marshall was training in internal medicine at the Royal
Perth Hospital, in Western Australia, when he became interested in
incidences of spiral bacteria in the stomach lining. The bacteria were
assumed to be irrelevant to ulcer pathology, but Marshall and J. R.
Warren, a histopathologist who had previously observed the bacteria,
reviewed the records of patients whose stomachs were infected with large
numbers of these bacteria. They noticed that when one patient was
treated with tetracycline for unrelated reasons, his pain vanished, and
an endoscopy revealed that his ulcer was gone.

An article by Marshall and Warren on their culturing of "unidentified
curved bacilli" appeared in the British medical journal The Lancet in
1984, and was followed by other suggestive studies. For years, however,
the medical establishment remained deaf to their findings, and around
the world ulcer patients continued to dine on bland food, swear off
stress, and swill Pepto-Bismol. Finally Marshall personally ingested a
batch of the spiral bacteria and came down with painful gastritis,
thereby fulfilling all of Koch's postulates.

There is now little doubt that Helicobacter pylori, found in the
stomachs of a third of adults in the United States, causes inflammation
of the stomach lining. In 20 percent of infected people it produces an
ulcer. Nearly everyone with a duodenal ulcer is infected. H. pylori
infections can be readily diagnosed with endoscopic biopsy tests, a
blood test for antibodies, or a breath test. In 90 percent of cases the
infections can be cured in less than a month with antibiotics.
(Unfortunately, many doctors still haven't gotten the news. A Colorado
survey found that 46 percent of patients seeking medical attention for
ulcer symptoms are never tested for H. pylori by their physicians.)

Heart disease is now being linked to Chlamydia pneumoniae, a newly
discovered bacterium that causes pneumonia and bronchitis.

While examining coronary-artery tissues at autopsy in 1991, Allan Shor,
a pathologist in Johannesburg, saw "pear-shaped bodies" that looked like
nothing he'd ever seen before. He mentioned his observations to a
microbiologist colleague, who had read about a new species of chlamydia
with a peculiar pear shape. The colleague referred Shor to an expert on
the subject, Cho-Chou Kuo, of the University of Washington School of
Public Health, in Seattle. After Shor shipped Kuo the curious coronary
tissue, Kuo found that the clogged coronary arteries were full of C.
pneumoniae. Before long, others were reporting the presence of live C.
pneumoniae in arterial plaque fresh from operating tables. Everywhere
the bacterium lodges, it appears to precipitate the same grim sequence
of events: a chronic inflammation, followed by a buildup of plaque that
occludes the opening of the artery (or, in the case of venereal
chlamydia, a buildup of scar tissue in the fallopian tube). Recently a
team of pathologists at MCP-Hahnemann School of Medicine, in
Philadelphia, found the same bacterium in the diseased sections of the
autopsied brains of patients who had had late-onset Alzheimer's disease:
it was present in seventeen of nineteen Alzheimer's patients and in only
one of nineteen controls.

By the mid-1990s a radical new view was emerging of atherosclerosis as
a chronic, lifelong arterial infection. "I am confident that this will
reach the level of certainty of ulcer and H. pylori," says Saikku, who
estimates that at least 80 percent of all coronary heart disease is
caused by the bacterium.

H. pylori, the ulcer pathogen, confers a sixfold greater risk of
stomach cancer, and accounts for at least half of all stomach cancers.
Also, the lymphoid tissue of the stomach can produce a low-grade gastric
lymphoma under the influence of this bacterium. Early reports indicate
that the lymphoma is cured in 50 percent of cases by resolving the H.
pylori infection -- which may mark the first time in medical history
that cancer has been cured with an antibiotic.
Hepatitis B and C, two of the ever-growing alphabet soup of hepatic
diseases, have been linked to liver cancer. Herpes virus 8 has recently
been discovered to be the cause of Kaposi's sarcoma. "There is no reason
to believe that this flurry of discovery has now completed the list of
infectious agents of cancer," Ewald says.
Among the many known animal cancer viruses is a closely studied
retrovirus known as mouse mammary tumor virus (MMTV), which causes
mammary-gland cancer in mice.

Microbes obviously can cause mental disorders -- as syphilitic
dementia, to name but one example, makes brutally clear.

Multiple sclerosis seems pretty clearly infectious, because you have
these island populations where there was no MS and then you see it
spread like a wave through the population. And you have this latitudinal
gradient ...

"Yes!" Cochran burst from the speaker phone. "The farther you get from
the Equator, the more common it is. It's three to four times more common
if you grow up in Ontario than if you grow up in Mississippi."

Of the top forty fitness-antagonistic diseases on the list, thirty-three
are known to be directly infectious and three are indirectly caused by
infection; Cochran believes that the others will turn out to be
infectious too. The most fitness-antagonistic diseases must be
infectious, not genetic, Ewald and Cochran reason, because otherwise
their frequency would have sunk to the level of random mutations. The
exceptions would be either diseases that could be the effect of some new
environmental factor (radiation or smoking, for example), or genetic
diseases that balance their fitness cost with a benefit. Sickle-cell
anemia is one example of the latter.

No doubt everywhere people look there will be more and more examples of
chronic diseases with infectious etiology," says Stephen S. Morse, an
expert in infectious diseases at the Columbia University School of
Public Health. "Helicobacter is probably the tip of the iceberg."
Although we have wielded the tools of microbial cultivation for a
hundred years, much of the microbial world is still as mysterious as an
alien planet. "It has been estimated that only 0.4 percent of all extant
bacterial species have been identified," David Relman has written. "Does
this remarkable lack of knowledge pertain to the subset of
microorganisms both capable of and accomplished in causing human
disease?" Even the germs that inhabit our bodies -- the so-called "human
commensal flora," such as the swarming populations of organisms that
live in the spaces between our teeth -- are largely unknown, he points
out. Most of them are presumably benign, up to a point. There are
disquieting suggestions in the literature of a link between bacteria in
dental plaque and coronary disease.

"Some people think it's scary to have these time bombs in our bodies,"
Ewald says, "but it's also encouraging -- because if it's a disease
organism, then there's probably something we can do about it. The
textbooks say, In 1900 most people died of infectious diseases, and
today most people don't die of infectious disease; they die of cancer
and heart disease and Alzheimer's and all these things. Well, in ten
years I think the textbooks will have to be rewritten to say,
"Throughout history most people have died of infectious disease, and
most people continue to die of infectious disease."

[jellybean]

Agree with most of this but have to disagree about the sham joint replacement surgery. Joint replacement surgery is one of the major medical advances of the 20th Century - I think it would seriously make a top 10 list, along with antibiotics, lifestyle changes to prevent cardiovascular disease etc. When a joint replacement is successful, it would literally add years to a patient's life because of the extra exercise tolerance it gives them. I once visited a knee surgeon's practice in the week before Christmas and he had cases of wine stacked up in his PA's office, all from joint replacement patients who were prepared to tip in an extra Christmas present on top of the lucrative fee they had parted with earlier in the year, just to show that they though they got more than their money's worth.

Definitely THR and TKR are magnificent procedures in the right patient with the right surgeon, and I don't believe that RCTs are needed because the results are so obvious. I LOVE the Moseley study you have listed above showing that arthroscopic washout and chondroplasty are essentially sham procedures in moderate O/A (or of such minimal benefit that the study was underpowered to show any). I can't see why the HIC continues to pay for surgery that is so discredited, and have written an editorial along these lines.

http://www.injuryupdate.com.au/images/research/JSMSeditinsur.PDF

I think that, of the other major orthopaedic operations, ACL surgery in low level athletes needs to be justified further.

The question now obviously needs to be answered about making sure that success rates for THR and TKR are as high as possible. A failure of these operations (infection, DVT, premature loosening of prosthesis, fractured femur) can be an unmitigated disaster. The best surgeons for primary replacement probably have failure rates of 1-5%, but, knowing the variance in quality of surgeons, I would be almost sure that there are surgeons out there who have failure rates (early on) in the league of 10-20%. There are total joint registers in Australia, and you can bet that the orthopods will keep the data very quiet and will allow surgeons who are getting bad results to keep charging $2000 for a 90 minute procedure and won't do anything about making sure that only those with proven good results can keep doing these difficult operations. It could be the stuff of lawsuits over the next few years.

One other semi-sham intervention you forgot to add was sham Synvisc injection, which probably gives minimal help (but not much) and is of course very expensive. I am glad the government doesn't pay for this, but again I don't understand why they pay for chondroplasty which is probably worse. (OK, I really do understand, the real reason being the surgeons have a magnificent power base and will defend the right to forever get fully funded to do whatever operations they want, whether or not they work).

I have used Aprotinin in joints for moderate O/A and it gives bloody good pain relief (similar to cortisone), with hopefully long-term chondroprotective rather than catabolic effects that cortisone has on articular cartilage. However, I don't want to make a big deal of it yet because I am scared stiff of allergic reaction to it. I have had some bad ones come on quickly after Aprotinin tendon injections, but I would be scared that the reactions might occur hours later with Aprotinin in a joint.


Hi Injury Update (or anyone else!),

Could I ask what your thoughts are now (18 months down the track) re injections (specifically, cortisone vs aprotinin injections) into the knee joint as a means of reducing inflammation caused by arthritis?

I had my knee 'scoped nearly 11 weeks ago (partial menisectomy). During the 'scope grade 3 changes and chondral fissuring and flaps were noted on the superior patella and a chondroplasty was performed back to a stable base.

The op was beneficial in that I can now ride again (I'm a cyclist and couldn't complete a pedal stroke before the op) but I still have some swelling (particularly in the suprapatellar area) and stiffness and mild discomfort (I wouldn't call it pain). Cycling and other exercise is helping reducing the stiffness a little but it's still quite significant.

At a post op review last week my OS suggested I go back on anti-inflamm's. (I'd run out and wanted a break from them, 'have taken them alot over the last two years due to another injury). He also suggested that a cortisone injection into the knee joint might be indicated at the next visit (8 weeks) if there wasn't a substantial improvement.

I am not a big fan of cortisone and am keen to determine if there are other options. Is aprotinin still getting good raps? Are there any contraindications for its use? What is likely to cause an allergic reaction? (I am allergic to some sulphur containing meds).

The fact that an injection seems to offer only short term benefits has me wondering if it's worthwhile at all, especially given I have very little pain at the moment.

Thanks in advance.

Cheers,

Jellybean