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Letters to the Editor to:

Scientific Articles:
Seth S Leopold, Brigham B Redd, Winston J Warme, Paul A Wehrle, Patrick D Pettis, and Susan Shott
Corticosteroid Compared with Hyaluronic Acid Injections for the Treatment of Osteoarthritis of the Knee: A Prospective, Randomized Trial
J Bone Joint Surg Am 2003; 85: 1197-1203 [Abstract] [Full text] [PDF]
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[Read Letter to the Editor] Dr. Leopold responds to Dr. Charalambous
Seth S. Leopold, Brigham B. Redd, Winston J. Warme, Paul A. Wehrle, Patrick D. Pettis, Susan Shott   (20 October 2003)
[Read Letter to the Editor] Corticosteroid Compared with Hyaluronic Acid Injections of the Knee
Charalambos P Charalambous   (15 October 2003)

Dr. Leopold responds to Dr. Charalambous 20 October 2003
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Seth S. Leopold,
Orthopaedic Surgeon (Hip and Knee Replacement)
University of Washington Medical Center,
Brigham B. Redd, Winston J. Warme, Paul A. Wehrle, Patrick D. Pettis, Susan Shott

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Re: Dr. Leopold responds to Dr. Charalambous

leopold{at}u.washington.edu Seth S. Leopold, et al.

Thank you for your letter. You are correct in noting that in our Hylan G-F 20 (Synvisc) group we aspirated any detectable effusions prior to injecting the product, while in the corticosteroid group, aspirations were not performed prior to injection.

As you point out, and as the reference you indicated suggests (1), the aspiration of joint effusions may produce some relief of symptoms, and this may indeed have had some impact on our results.

Our goal was to perform each study intervention as it is commonly used in practice, and as the manufactuer of the drug/device directs. The manufacturer's directions (on the package insert) for Synvisc call for joint aspiration prior to injection, and we felt it was important to follow this directive carefully. The package insert for the corticosteroid used in the study does not mandate joint aspiration, and there is inconsistent performance of joint aspiration before injection of corticosteroids in the literature, including in the article you referenced, which apparently aspirated only very large effusions (ones in which the "bulge sign" or positive patellar tap was present) (1).

In any case, we used corticosteroid injection as the "control" group, against which the newer, more expensive product was tested. There were no consequential differences in efficacy observed between corticosteroid and Synvisc in our study. Since this appears to be the case, despite what you -- perhaps correctly -- perceive to be a bias favoring the Synvisc group, this would tend to support our conclusion: "we do not consider Hylan G-F 20 a first-line treatment for patients with osteoarthritis who are considering intra-articular knee injections for palliation of symptoms."

Thank you again for your interest in our work.

1. Gaffney K, Ledingham J, Perry JD Intra-articular triamcinolone hexacetonide in knee osteoarthritis: factors influencing the clinical response. Ann Rheum Dis 1995; 54: 379-381
Corticosteroid Compared with Hyaluronic Acid Injections of the Knee 15 October 2003
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Charalambos P Charalambous,
SPR in Orthopaedics
MRCS

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Re: Corticosteroid Compared with Hyaluronic Acid Injections of the Knee

bcharalambos{at}hotmail.com Charalambos P Charalambous

To the Editor:

I read with interest the article by Leopold et al. I am writing regarding the methodology of this study.

The aim of the study was to compare Hylan with steroid injections. However, the group that received Hyalan also underwent aspiration of effusions while the group that had steroid injections did not. Aspiration of effusions alone may influence symptomatology(1). It is thus possible that part of the response attributed to Hylan may have been due to aspiration of the effusion.

In the article, no justification was given for not performing aspirations in the steroid group.

Sincerely,

1. Gaffney K, Ledingham J, Perry JD Intra-articular triamcinolone hexacetonide in knee osteoarthritis: factors influencing the clinical response. Ann Rheum Dis 1995; 54: 379-381