In Reply

Letter to the Editor regarding the article Methods of Conservative Intra-Articular Treatment for Osteoarthritis of the Hip and Knee by Dr. med. Robert Ossendorff, Dr. Dominik Thimm, Univ.-Prof. Dr. med. Dieter C. Wirtz, and PD Dr. rer. nat. Frank A. Schildberg in issue 35–36/2023

We are pleased about the extensive feedback on our article entitled “Methods of Conservative Intra-Articular Treatment for Osteoarthritis of the Hip and Knee” (1). This shows how important and topical the subject is in a society shaped by demographic change.

Osteoarthritis as a degenerative joint disorder requires differentiated diagnostic evaluation before specific treatment can be initiated. The main emphasis of our article was, however, a detailed explanation of current therapeutic approaches; the topic of diagnostic evaluation was only slightly touched upon. Diagnostic evaluation is unquestionably an important basis for a differentiated decision on treatment and will continue to be a decisive factor in the quality of clinical studies, but also—especially—in the context of targeted care provision for osteoarthritis.

Some procedures that are not primarily ascribed to treating osteoarthritis were not included in the article for reasons of space. These include radiosynoviorthesis (RSO). By contrast to osteoarthritis, which is known as a degenerative disorder with mild inflammation, a multitude of chronic inflammatory articular disorders exist that are categorized as rheumatic disorders. These are typically associated with synovitis, which can be treated in a targeted way by means of radiosynoviorthesis, by applying appropriate radionuclides. RSO can also be successfully deployed to prevent bleeds in hemophilic arthropathy. In certain cases, RSO is credited with positive effects in activated osteoarthritis with accompanying synovitis, and it is therefore undertaken as a therapeutic alternative for local pain control (2, 3). Because of pathogenetic differences, however, and the current evidence base, RSO in osteoarthritis is not recommended by the German Society for Rheumatology at this time and is therefore not included as an indication in the S1 guideline. An additional intra-articular therapeutic method is the application of local anesthetics and opioids. It should be borne in mind that local anesthetics have chondrotoxic potential and accordingly can accelerate the progression of osteoarthritis if applied repeatedly (4). This should be considered accordingly when using these substances. As regards intra-articular injection of opioids, there are indications that results regarding pain reduction are comparable to those of intra-articular injection of corticosteroids (5). However, the evidence is limited and no unequivocal conclusions can be drawn.

Like every scientific article, our review article presents only a moment’s snapshot of the evidence (1). At this time, a multitude of novel therapeutic approaches exist in the area of intra-articular treatment of osteoarthritis, which our review article described in detail. Furthermore, combination therapies may influence future therapeutic successes in a decisive manner, in the sense of individualized therapy. It remains to be seen, however, how the evidence develops and how guidelines will be adapted in future.

DOI: 10.3238/arztebl.m2023.0258

Corresponding authors:

Dr. med. Robert Ossendorff, Univ.-Prof. Dr. med. Dieter C. Wirtz, Univ.-Prof. Dr. rer. nat. Frank A. Schildberg; Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Bonn, [e-mail]

Dr. Dominik Thimm, Pharmazeutisches Institut, Pharmazeutische & Medizinische Chemie, Rheinische Friedrich-Wilhelms-Universität Bonn:

Competing interest statement

The authors of all contributions declare that no conflict of interest exists.

References

1. Ossendorff R, Thimm D, Wirtz DC, Schildberg FA: Methods of conservative intra-articular treatment for osteoarthritis of the hip and knee. Dtsch Arztebl Int 2023; 120: 575–81

2. Szerb I, Gál T, Kiss D, Nagy V, Hangody L: Efficacy assessment of radiosynoviorthesis on the progression of radiological osteoarthritic features of hip and ankle joint in patients with osteoarthritis and rheumatoid arthritis. Nuklearmedizin 2020; 59: 269–75

3. Rau H, Lohmann K, Franke C, et al.: Multizenterstudie zur Radiosynoviorthese: klinische Ergebnisse bei aktivierten Arthrosen und anderen Gelenkerkrankungen mit chronischer Synovialitis im Vergleich zur rheumatoiden Arthritis. Nuklearmedizin 2004; 43: 57–62

4. Jayaram P, Kennedy DJ, Yeh P, Dragoo J: Chondrotoxic effects of local anesthetics on human knee articular cartilage: a systematic review. PM R 2019; 11: 379–400

5. Beyaz SG: Comparison of efficacy of intra-articular morphine and steroid in patients with knee osteoarthritis. J Anaesthesiol Clin Pharmacol 2012; 28: 496–500