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By Nathan Wei
The most common form of arthritis, osteoarthritis, remains a therapeutic challenge.
This is a generally felt to be a disease of cartilage. However, osteoarthritis is a complex disease that appears to involve a complex series of pathways that include degradation of cartilage, inflammation of the lining of the joint (synovium), and stimulation of pain pathways through different chemical messenger systems.
While traditional methods including patient education, rest, exercise, anti-inflammatory drugs, injections, and physical therapy offer temporizing measures, there is still the need for a better solution.
The goals for managing osteoarthritis of the hip and knee are to reduce pain and restore or maintain function.
A third and even more daunting task is to regenerate new cartilage. There are exciting new developments in this area.
The results of a two-year study of osteoarthritis of the knee assessing the safety and efficacy of orthokine therapy was published in the July-August 2008 issue of “Osteoarthritis and Cartilage”.
Orthokine is a substance derived from a patient’s own blood. Orthokine apparently has significant anti-inflammatory effects. This material is then injected into the osteoarthritic joint.
Researchers at Heinrich Heine University in Dsseldorf conducted a two-year study comparing the effects of injections of orthokine, hyaluronic acid (a standard lubricant used to treat osteoarthritis), and placebo in 310 arthritis patients.
The GOAT study (German Osteoarthritis Trial) was a randomized, placebo-controlled trial, that included 376 men and women with an average age of 58. The primary entrance criterion was chronic knee pain related to osteoarthritis of the knee. Participants were randomly assigned to one of three treatment groups that received injections of orthokine, hyaluronic acid or saline (placebo). Treatments were administered as six sessions over three weeks. Patients were evaluated at six weeks, three months, six months (double blinded) and then 24 months (single blinded). Two years later, 310 participants agreed to take part in a follow-up examination.
After two years, patients treated with orthokine scored significantly better than those treated with hyaluronic acid or placebo on measures of pain and joint function.
The results after two years showed that 188 of the 310 patients were still reporting improvements with respect to pain and joint function. The other 122 patients pursued other treatments such as surgery, injections, medication or acupuncture.
The number of patients requiring further treatment was least in the orthokine group. Two years after treatment, improvement was still measurable in all three groups. A clear difference was seen, however, in scores on the WOMAC, a questionnaire that is used in osteoarthritis clinical trials to measure joint function and quality of life.
The orthokine treated patients scored 58 on the two-year follow-up WOMAC, while the hyaluronic acid and placebo groups scored higher at 88 and 84 respectively. Another measure called the visual analog scale (VAS) that measures pain from 0 (no pain) to 100 (most intense pain imaginable), was also used. The average pain level prior to treatment was 70 in all groups. Two years after treatment, the VAS score of the orthokine group was 30 compared with 39 in the hyaluronic acid group and 37 in the placebo group.
What is interesting about this study is how well placebo did compared with both hyaluronic acid as well as orthokine in relieving pain. Experienced clinicians have known for decades that there is a significant placebo effect in just using a needle when it comes to subjective measures such as pain relief.
However, the important issue is whether orthokine or any other treatment for that matter actually leads to cartilage regrowth.
Much interest has been generated recently on the use of autologous (meaning the patients own) therapies in managing osteoarthritis as well as other degenerative conditions. This therapy is very similar to the use of platelet rich plasma, which is currently being used to treat tendon problems. Platelet rich plasma is derived from the patients whole blood using a special centrifugation technique.
For osteoarthritis, we have found that combining autologous stem cells obtained from bone marrow aspirated from the pelvic bone of the patient using local anesthetic- and platelet rich plasma appears to be an effective treatment for the knee and hip. Both the stem cells as well as the platelet rich plasma are injected into the osteoarthritic joint. This combination treatment not only aids in pain relief but there also appears to be stimulation of cartilage regeneration. This treatment is available at the Arthritis and Osteoporosis Center of Maryland located in Frederick, Maryland.
About the Author: Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland
Arthritis and Osteoporosis Center of Maryland
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