Supartz injection techniques

Injection TechniqueInjection Techniqueforfor

Joint Fluid TherapyJoint Fluid Therapy

A Conservative Treatment of A Conservative Treatment of OsteoarthritisOsteoarthritis

AgendaAgenda

Overview of Osteoarthritis (OA) The Continuum of Care for OA The Role of Joint Fluid Therapy Intra-articular Injection Technique

The KneeThe Knee

The Anatomy of the KneeThe Anatomy of the Knee

CartilageCartilage

lamina splendens

superficial layer

deep layer

cortical bone

cancellous bone

2mm

CartilageCartilage

Proteoglycan aggregate

Chondrocyte

Collagen fibril

Hyaluronan

Cartilage MatrixCartilage Matrix

OsteoarthritisOsteoarthritis

Osteoarthritis of the KneeOsteoarthritis of the Knee

Superoxide Anion

ProteinaseCytokine

Synovitis

Cartilage degradation

Mechanical Stress

Age, Genetics, Gender

Increased Surface Fibrillation and Decreased Lubrication

Effects of OsteoarthritisEffects of Osteoarthritis

Decreased molecular weight of HADecreased molecular weight of HA Decreased concentration of HADecreased concentration of HA Less physical protection from shockLess physical protection from shock Less nerve protectionLess nerve protection Increased chemical breakdown of Increased chemical breakdown of

cartilagecartilage

Decreased molecular weight of HADecreased molecular weight of HA Decreased concentration of HADecreased concentration of HA Less physical protection from shockLess physical protection from shock Less nerve protectionLess nerve protection Increased chemical breakdown of Increased chemical breakdown of

cartilagecartilage

OA Cycle of DegradationOA Cycle of Degradation

F a u l t y S y n t h e s i so r D e g r a d a t i o no f H y a l u r o n a n

J o i n tI m m o b i l i t y

S t a g n a t i o n o fTr a n s s y n o vi a l

F l o w

A c c u m u l a t i o n o fC a t a b o l i t e s a n d

D i s r u p t i o n i nC e l l M e t a b o l i s m

L o w e r V i s c o c i t yo f t h e

I n t r a c e l l u l a rM a t r i x

F a u l t y S y n t h e s i so r D e g r a d a t i o no f H y a l u r o n a n

J o i n tI m m o b i l i t y

S t a g n a t i o n o fTr a n s s y n o vi a l

F l o w

A c c u m u l a t i o n o fC a t a b o l i t e s a n d

D i s r u p t i o n i nC e l l M e t a b o l i s m

L o w e r V i s c o c i t yo f t h e

I n t r a c e l l u l a rM a t r i x

Late Stage OALate Stage OA

Treating OATreating OA

Arthritis & Rheumatism Vol. 43, 9 Sept. 2000, 1905-1915

Recommendations Recommendations for the for the

Medical Management of Medical Management of Osteoarthritis Osteoarthritis

of the Hip And Kneeof the Hip And Knee

American College of American College of RheumatologyRheumatology

Subcommittee on Osteoarthritis Subcommittee on Osteoarthritis

GoalsGoals

Control of Pain Improvement of Function Avoidance of toxic effects

Management PathwayManagement Pathway

1. Non-Pharmacologic (NP)

2. Pharmacologic (P), in addition to maintained NP management.

3. Surgical, when pain is severely symptomatic and not responding to NP or P.

Non-PharmacologicNon-Pharmacologic Patient education

– Self management programs– Personalized social support via telephone– Weight loss– Exercise– Occupational Therapy– Joint Protection and Energy conservation

Non-PharmacologicNon-Pharmacologic

Physical Therapy– muscle strengthening exercises– Assistive devices for ambulation– Patellar taping– Wedged insoles– Bracing– Assistive devices for activities of

daily living

PharmacologicPharmacologic

Oral Intra-articular Topical


Oral– Acetaminophen, up to 4g per day– COX-2*– NSAID plus Gastroprotectant*– Nonacetylated salicylate*

* After careful assessment of upper GI adverse event risk factors:

Age, comorbidity, oral steroids, history of peptic ulcer and /or upper GI bleeding, anticoagulants


Intra-articular– Steroids

• Opioids, Glucocorticoids

– Hyaluronan


Topical– Capsaicin– Methylsalicylate

SurgicalSurgical

Lavage– Unproven

Debridement Osteotomy Total Joint Arthroplasty

Treating OA With Treating OA With Joint Fluid TherapyJoint Fluid Therapy

The Effect of Natural HA The Effect of Natural HA in the Jointin the Joint

Natural HA acts as combination matrix between many kinds of cells – Body fluid, skin, other organs

Joint cartilage– Aggregate to proteoglycan - keeps water.

– 1 g of aglycan can keep 50 mL of water = cartilage elasticity.

Joint fluid– Lubricant and viscous fluid.

– Exists in synovium and capsule. Natural HA

– Density : 2.7 (old) to 4 (young) mg/mL density in normal joint fluid.

– Decreased density and viscosity in the inflammatory joint.

Why use hyaluronan?Why use hyaluronan?

Potential long term problems with steroids.

Safe, clean, easy. Pure and natural. Effects are comfortable and

long-lasting. More attractive to patients

than TKR.

Captures analgesicmediator in synovial

fluid (viscosity, structure of randomcoil,anionic charge)

Inhibitscartilage

degeneration

Improvespathologicaljoint fluids

Covers sensory nerve

receptor of jointtissue

Pain relief and improvement of daily activities

Improveslubricatingfunction

Improvessensitivity

topain

mediator

Indirect Action

Pain Relief for HyaluronanPain Relief for HyaluronanDirect Action

Hyaluronan

SynovialMembraneCartilage

Inhibits proteoglycan release Covers pain receptors

Improves cartilage metabolism Suppresses pain

PENETRATION

Action of Hyaluronan on Joint TissueAction of Hyaluronan on Joint Tissue

The Effective Use of The Effective Use of Sodium HyaluronateSodium Hyaluronate Not a cure for OA. Slow-acting and long-lasting. Most effective for

early and middle stage OA.– Very good conservative treatment plan for older

patients with moderate OA! – The relief can be remarkable.

Consider the young athlete.

ConclusionConclusion

OA is an accelerating biochemical cycle causing cartilage degradation.

There is no cure for OA. Sodium hyaluronate is a safe,

effective, non-invasive treatment for mild to moderate stages of OA and patients of all ages.

Injection TechniqueInjection Technique


















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Supartz injection techniques