Case reports on the use of viscosupplementation
David D. Waddell, MD
From A Special Report: Osteoarthritis of the Knee
Keeping Aging Adults Active
Case report No. 1A 45-year-old man had a long history of strenuous athletic participation, including long-distance running and competitive tennis. He underwent arthroscopic meniscectomy on the right knee in 1995 and on the left knee in 192021. In 192021 he had a torn left medial meniscus and chondromalacia of the patella and femoral groove. The chondromalacia was significant because it was full thickness on both patellar and femoral grooves in their contact zones. After the first arthroscopy, the patient did well for a short time and resumed his competitive tennis. He gradually had increased symptoms leading to repeat arthroscopy on the left knee in March 1999. At the time of that arthroscopy, he was found to have a large osteophyte, which had grown in the femoral groove. This osteophyte was debrided. At that time, the patient's knee pathology was diagnosed as patellofemoral degenerative joint disease.
Following the second arthroscopy, the patient did well for a short time, but in June 1999, his symptoms increased to the point where he could no longer play tennis or run. Range of motion in July 1999 was 0° to 130° on the left knee. He had 2+ to 3+ crepitus, skin was clear, and neurovascular status was good. There were no meniscal signs. The patient had been trying nonsteroidal medications in the form of oxaprozin, celecoxib, and glucosamine sulfate, with no relief of symptoms.1 He then underwent a series of hylan G-F 20 injections into the left knee on July 6, 13, and 23, 1999. Ten days after receiving hylan G-F 20, the patient had a 3+ effusion. He had played tennis the weekend before. The effusion was aspirated, and 45 cc of clear yellow fluid were obtained. Xylocaine and dexamethasone were injected into the joint, and the patient was seen again the following week.
The effusion had cleared completely, and he was asymptomatic the following week. Two months after receiving hylan G-F 20, he returned to full sports activity. The patient has a range of motion of 0° to 140°. There is trace crepitus, no effusion, skin is clear, and neurovascular status is good.
Case report No. 2
A 50-year-old male physician with osteoarthritis of the knee participates in recreational sports including tennis, hiking, and hunting. He had a football injury at age 17 that was treated with cast immobilization, crutches, and physical therapy. Previous treatment for osteoarthritis included oxaprozin, naproxen, nabumetone, and sulindac. None of these oral therapies provided enough symptomatic relief to allow the activities desired by the patient. X-rays showed osteoarthritis at the femorotibial and patellofemoral joints. Range of motion was 0° to 135° bilaterally. There were no meniscal signs, skin was clear, and neurovascular status was good. There was 1+ anterior cruciate ligament laxity in the right knee, with no pivot shift. No other ligamentous instability was noted on either knee. In May 192021, the patient underwent bilateral hylan G-F 20 therapy. After therapy his visual analog scale of pain went from 7 to 0 on activities of daily living, and from 9 to 10 to 1 to 2 on attempted sports and strenuous activity or work. His response has been maintained for 17 months with no evidence of recurrence of symptoms. He has noticed a minor increase in symptoms with strenuous activities: his visual analog scale of pain is now at a level of 3 to 4 after several hours of either strenuous sports or work.
Case report No. 3
A 35-year-old man participates in a strenuous weight-lifting program and bodybuilding. He underwent arthroscopy in both knees in January 1997. In May 1997, arthroscopy on the left knee had to be repeated. The patient had significant patellofemoral and femoral groove degenerative changes.
In a 1.5-cm area of the femoral groove there was a full-thickness lesion bilaterally. The patient improved after arthroscopy, but he still had limitations on the amount of weight he could lift. He took oral anti-inflammatory medications, including naproxen, oxaprozin, and nabumetone. He never regained full activity following the surgery, so in 1997 he underwent viscosupplementation on the left knee with sodium hyaluronate. The left knee moderately improved with with sodium hyaluronate therapy. He underwent hylan G-F 20 treatment on the right knee in November 1997. He noticed improved function on the right knee compared with the left knee, and in December 1997, he requested hylan G-F 20 treatment for the left knee. After this treatment he reported significant improvement.
He was functional in both work and sports activities until October 192021, when repeat hylan G-F 20 therapy on both knees was performed. His score on the visual analog scale before that treatment was 7 to 8, and after treatment it decreased to 0 to 1. Following the second course of hylan G-F 20 he had a minor synovitis reaction, which responded to conservative treatment. At follow-up 1 month after treatment with hylan G-F 20, the patient was back at full activity, including weight-lifting. His range of motion was 0° to 140°. There was no crepitus or effusion. He had excellent pain relief. Follow-up 6 months after bilateral treatment with hylan G-F 20 showed excellent, complete pain relief at full activity. There was no effusion. Range of motion was 0° to 150°. There was excellent quadriceps tone. There was trace crepitus. One month later, he noticed some increase in pain, and he returned to the clinic requesting repeat hylan G-F 20 treatment. Skin was clear. He had 1+ to 2+ crepitus and some pain with range of motion. Repeat hylan G-F 20 therapy was performed on May 25, 1999, and June 1 and 8, 1999.
Follow-up in October 1999 showed that the patient is having no problems and is still at full activity, including weight-lifting.
Viscosupplementation is widely known for pain relief during activities of daily living. To many people, activities of daily living include strenuous sports activities. Experience has shown that treatment with viscosupplementation can return people to a significant level of sports participation including golf, tennis, and running. The above case reports illustrate improvement in visual analog scale scores from 8 to 9 to 0 and maintained for 1 to 1 1/2 years. Viscosupplementation has proved to be a significant adjunct in the treatment of osteoarthritis.2 Further studies will clarify the usefulness of viscosupplementation in terms of patient selection, repeat treatment cycles, and even its possible use after arthroscopic surgery in which osteoarthritis is found.
David D. Waddell, MD is affiliated with Orthopedic Specialists of Louisiana Inc, Shreveport, Louisiana. Dr Waddell declares that he has no relationships with companies that manufacture products used to treat the patients under discussion.
Address for correspondence: David D. Waddell, MD, 3900 Hearn Ave. Shreveport, LA 71103.
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