NHS England: Even Longer Delays for Total Joint Replacements! What’s the solution?

A recent statement issued by NHS England’s Simon Stevens has caused concern that some patients awaiting elective knee and hip replacement operations may have to wait longer than is presently recommended to receive treatment. Current constraints on NHS funding and an increase in demand means budgets are having to be redirected to focus on A&E and cancer care.  The NHS has also stipulated that GPs should considerably reduce the number of people being referred to secondary care Consultants. 

Here are links to articles on this issue:

http://www.bbc.co.uk/news/health-39420662?

https://www.theguardian.com/society/2017/apr/02/labour-challenges-hunt-over-dropping-nhs-waiting-times-target

Are there any therapeutic options open to clinicians which may help alleviate the problems that some patients will face as a result of these changes?

It has been recognised for many years that Viscosupplementation can offer a valuable bridge between conservative care and surgery. Clinical studies have consistently shown intra-articular hyaluronic acid (HA) injections to be safe, efficacious and cost-effective (1-3). 

Before the introduction of the single injection HA OSTENIL® PLUS, OSTENIL® injections were usually administered as a course of up to 5 weekly injections. Mathies et al - in a seminal examination of the relationship between Viscosupplementation and the quality of synovial fluid - showed that Viscosupplementation could delay total knee replacements (TKR) by 4.5 to 6 months, and for some patients up to 12 months. His study also demonstrated that “OSTENIL® was safe and significantly improved symptoms in patients with painful advanced knee OA who were awaiting TKR, and that it improved the quality of life of these patients.” (4) In a larger study which examined the potential of HA for delaying knee arthroplasty, Altman demonstrated that “HA injection in patients with knee OA is associated with a dose-dependent increase in time-to-TKR” (7).

Since the introduction of OSTENIL® PLUS, patients have garnered the same symptom-reducing benefits from a single injection, and for the administering clinician - as well as the patient - the process is a lot more convenient. Significant symptomatic reduction and functional improvement was demonstrated in patients suffering moderate knee OA for up to 6 months following a single injection of OSTENIL® PLUS. (5,6). 

So why aren’t more OA patients in the UK being offered the option to help alleviate symptoms and potentially delay their joint replacement?

One of the major obstacles at present is the “Do not recommend intra-articular HA to treat osteoarthritis” in the current NIHCE guidelines on Knee OA. Although it is important to understand that the NIHCE Guidelines (CG177) DO NOT prohibit clinicians from using OSTENIL. In fact, OSTENIL® PLUS DOES meet the QLY cost to benefit criteria quoted by CG177.

Given the current climate in relation to treating degenerative joint change, clinicians and their patients have a limited number of options left open to them: simple analgesics, NSAIDs, and corticosteroid injections, none of which are entirely benign with prolonged use. Physiotherapy alone is not always an option if the joint has degenerated to such an extent that it makes exercise too painful. All this means that the impact on quality of life due to longer waiting times will be felt even more by an ageing and increasingly overweight population.

If you as an injecting physiotherapist/MSk specialist are receiving an increasing number of referrals of patients suffering symptomatic OA from GPs, have you considered Viscosupplementation as an option?

OSTENIL® injections do not require a Consultant to administer. Instead, local MSk triage services can offer a cost effective solution, providing GPs with an alternative patient treatment pathway, helping avoid unnecessary secondary care referrals - and the associated tariff fee - which would more than cover the cost of an OSTENIL® PLUS injection. As a result, not only would the ever growing demand on secondary care be ameliorated, patient waiting times could be reduced, and clinical outcomes improved. 

If you would like more information or chat to one of our representatives, please contact us on info@trbchemedica.co.uk. You can also visit our website here: ostenil.trbchemedica.co.uk, or call us on 0845 330 7556. 


REFERENCES:

1. Möller I et al. Presented at the 6th World Conference of the Osteoarthritis Research Society International 2001; poster PB22
2. Tsvetkova E et al. Ann Rheum Dis 2010;69(Suppl3):281
3. Funk L et al. Presented at the 9th World Conference of the Osteoarthritis Research Society International 2004; poster P338
4. Mathies B et al. Presented at the 5th Symposium of the International Cartilage Repair Society. May 26–29, 2004; poster 397.
5. Borràs Verdera A et al. Poster presented at the XXV triennial world congress of the International Society of Orthopedic and Traumatology. September 6-9, 2011.
6. K Frobenius “A new high-dose treatment with intra-articular hyaluronic acid facilitates the management of osteoarthritis”. Orthopädische Praxis 46, 5, 2009
7. Altman R, Lim S, Steen RG, Dasa V (2015) “Hyaluronic Acid Injections Are Associated with Delay of Total Knee Replacement Surgery in Patients with Knee Osteoarthritis: Evidence from a Large U.S. Health Claims Database. PLoS ONE 10(12): e0145776. doi:10.1371/journal.pone.0145776

Why consider topical Sodium Hyaluronate (HA) in the treatment of tendinopathy?

Firstly, the difference between HA and other glycosaminoglycans is that it is non-sulfated, forms in the plasma membrane instead of the Golgi apparatus, and can be very large, with its molecular weight often reaching the millions1. HA is considered to be a key molecule in the tissue regeneration process. It has been shown to modulate via specific HA receptors, inflammation, cellular migration, and angiogenesis, which are the main phases of wound healing7.

In relation to tendinopathies, hyaluronic acid modulates a variety of cellular functions: anti-inflammatory activity, enhanced cellular proliferation and collagen deposition. Studies have shown a link between the inhibition of fibroblast proliferation, with a reduction in the formation of adhesions at the tendon healing site; by limiting the proliferation of fibroblasts, HA may reduce the risk of adhesions.2

It has sometimes been assumed, in relation to tendinopathic change, that because there is an excess of GAGs detectable within the local bio-chemical environment, there is an excess of hyaluronan, which is not necessarily the case. For example, the activity of hyaluronidase (enzymes that catalyse the degradation of hyaluronan) has been shown to increase during the healing of equine superficial digital flexor tendon injuries6.

Multiple studies analysing tendon healing have confirmed that HA reduces the formation of scars and granulation tissue, and also prevents adhesions2. Importantly, HA forms part of the extracellular matrix as a major component of ground substance, giving structure for other GAGs and proteoglycans3. In tendon healing, the GAGs provide a temporary structure in the early stages of the wound4. So without the presence of HA, there is evidence to suggest that other GAGs are of limited use. Also, high levels of HA are thought to be instrumental in scar-less healing by facilitating the movement and proliferation of fibroblasts, and by regulating the production and type of collagen5.

HA also plays an important role as a hydrating agent, being able to absorb 3,000 times its own weight in water4. HA appears to inhibit the expression of key intermediaries for the inflammatory signalling pathways (NF-kB), by reducing the expression of pro inflammatory factors, exogenous HA may reduce the fragmentation of endogenous HA and further stimulate synthesis of endogenous HA.7,8.

References

1.       Fraser JR, Laurent TC, Laurent UB (1997). "Hyaluronan: its nature, distribution, functions and turnover" (PDF). J. Intern. Med. 242 (1): 27–33. doi:10.1046/j.1365-2796.1997.00170.x. PMID 9260563.
2.       Michele Abate, Cosima Schiavone, and Vincenzo Salini, “The Use of Hyaluronic Acid after Tendon Surgery and in Tendinopathies,” BioMed Research International, vol. 2014, Article ID 783632, 6 pages, 2014. doi:10.1155/2014/783632.
3.       Bertolami, C.N. (1984)Glycosaminoglycan interactions in early wound repair. In: Hunt, T.K., Heppenstall, R.B., Pines., Rovee, D. (eds). Soft and Hard Tissue Repair: Biological and clinical aspects. Eastbourne: Praeger Scientific.
4.       Snyder, R.J. (1999)Wound management: a global perspective. Ostomy/Wound Management 45: 9, 26-30.
5.       Desai, H. (1997)Ageing and wounds, part 2: healing in old age. Journal of Wound Care 6: 5, 237-239.
6.       J. W. Foland, G. W. Trotter, B. E. Powers, R. H. Wrighley, and F. W. Smith, “Effect of sodium hyaluronate in collagenase-induced superficial digital flexor tendinitis in horses,” American Journal of Veterinary Research, vol. 53, no. 12, pp. 2371–2376, 1992.
7.       Litwiniuk M., Krejner A., Grzela T. (2016). Hyaluronic acid in inflammation and tissue regeneration. Wounds 28, 78–88.
8.       Litwiniuk, Malgorzata, Alicja Krejner, and Tomasz Grzela. "Hyaluronic Acid In Inflammation And Tissue Regeneration". Wounds 28.3 (2016): n. pag. Print.

New Guidelines Offer Hope for Older UK Osteoarthritis Sufferers

A report on how people suffering with symptomatic Osteoarthritis (OA) of the knee may still be able to remain active in sport has just been published in the Clinical Journal of Sport Medicine. Clinical Journal of Sport Medicine: January 2016 - Volume 26 - Issue 1 - p 1–11 doi: 10.1097/JSM.0000000000000274

The authors – who are all members of The American Medical Society for Sport Medicine (AMSSM), an organisation which represents over 2100 nonsurgical sports medicine physicians - carried out a detailed meta-analysis (a process where the results of many different studies are pooled and then subjected to sensitive statistical testing) of all relevant clinical investigations relating to the use of Viscosupplementation published between 1960 and 2014.  Viscosupplementation is an internationally recognised treatment modality for Osteoarthritis of the knee. The process involves injecting Hyaluronic Acid (HA) or Sodium Hyaluronate as it is often referred to, directly into the affected joint. HA is a viscous fluid which closely resembles the natural synovial fluid found in all healthy articular joints...

Continue here: http://www.trbchemedica.co.uk/news/new-guidelines-offer-hope-to-older-oa-sufferers

What to do after joint injections

You have just had an injection with hyaluronic acid to treat osteoarthritis, but what else can you do?

Exercising helps to prolong the benefit
of hyaluronic acid joint injections

After your injection with OSTENIL® hyaluronic acid (or: sodium hyaluronate) into your knee joint, or other synovial joint, you may want to utilise and prolong the positive effects of the treatment and get your joints moving again. Your Physiotherapist or GP can give you some helpful advice on which exercises and type of activity would be most suitable to further improve and stabilise your joints.
Here are some ideas:

Knee, shoulder and hip:

• Frequent exercising that won't put too much pressure on the joints: e.g. swimming, walking, cycling
• Specific physiotherapy exercises to strengthen the muscles surrounding the joint
• Reducing weight

Fingers and toes:

• Regular movement exercises to maintain joint flexibility
• Bathing fingers and toes in warm water to reduce pain
• Stretching fingers and toes as far as pain allows

Back joints:

• Strengthening and stretching abdominal muscles (back and stomach muscles)
• Relaxing painful back muscles by applying warmth, e.g. hot water bottle

What can you do to keep your eyes healthy?

What can you do yourself to keep your eyes healthy?

Here are some ideas:

• Drink sufficient amounts of water, particularly during times of stress and in old age
  
• Spend plenty of time outside in fresh air
  
• Avoid smoke-filled rooms
  
• Get an air moisturiser when the central heating is on and the air indoors is too dry
  
• Protect your eyes from draughts, wind and too much sun, perhaps by using goggles or sun glasses
• Give your eyes time to rest and blink while working at a computer screen
  
• In the evening, carefully remove all make-up from your eyes
  
• Have your eyes checked regularly to ensure there are no serious underlying causes, and to keep your prescription glasses or contact lenses up-to-date
  
• Regularly clean and change your contact lenses
  
• A healthy diet will be good for your eyes, too

An eye lubricant may also be helpful. Solutions containing sodium hyaluronate can be particularly effective and are well tolerated. Sodium hyaluronate is an important component of healthy eyes. (Click here to read more about sodium hyaluronate).

Ask your GP, optometrist (optician), or ophthalmologist, whether you might suffer from a breakdown of the tear film, and what he might recommend to reduce your discomfort.

Sodium hyaluronate: an important component of a healthy tear film!

Shoulders and Elbows

TRB Chemedica (UK) Ltd supported another event this summer related to sports medicine: the BESS Annual Scientific Meeting held in Torquay (15-17 June 2012). BESS stands for British Elbow and Shoulder Society.

The annual meeting in June attracted many delegates from all parts of the UK, to attend lectures and seminars on the techniques and latest developments in shoulder and elbow surgery and other treatment options.

TRB Chemedica (UK) Ltd had a stand at the trade exhibition during the congress, and TRB staff talked to many stand visitors about the benefits of sodium hyaluronate treatments for traumatic and degenerative joint disease in the shoulder and elbow.

OSTENIL^® is the only Sodium Hyaluronate product recommended in the formulary for the world-wide sports event in England this year. This fact, coupled with the experience that many of the delegates already had with OSTENIL^® and OSTENIL^® PLUS, helped to promote the OSTENIL^® range as a valid treatment option.

OSTENIL^® and OSTENIL^® PLUS come in the form of syringes which can be injected into the synovial joint either to prevent or to postpone surgery.

Sodium hyaluronate can also be used post-arthroscopy: VISCOSEAL^® replaces the lost synovial fluid that was washed out during the arthroscopic procedure and helps to promote joint homeostasis.

We look forward to supporting other conferences later on in 2012 where we can talk to sports physicians and medical specialists about the benefits of the OSTENIL^® range, and on how it can help rehabilitate our sporting champions.

New Packaging

We at TRB Chemedica are currently in the process of updating the packaging of our products. Our customers will have already noticed the new Vismed multi bottle which now comes in a new easy-to-use "Just squeeze" dispenser bottle. Vismed single-dose vials as well as Vismed light have also changed their appearance. Vismed gel will follow in 2-3 months' time.

In the orthopaedic product range used for the treatment of osteoarthritis, Ostenil Plus and Ostenil mini have also been transformed in appearance, with Ostenil to follow shortly. Ostenil Tendon is an exciting new product used for the treatment of tendinitis and already reflects the new packaging style.

Last but not least, Viscoseal now comes in a totally new presentation: in syringe form, which makes it easier to handle in the operating theatre.
Visit our website or contact us on info@trbchemedica.co.uk for more details.

Viscoseal Roundtable Meeting

Synovial fluid replacement after arthroscopy

Arthroscopic procedures in shoulder, knee and hip are nowadays established as minimally invasive methods. However, post-operative pain, swelling and restricted mobility induced by tissue lesion cannot be completely avoided. Those post-operative symptoms can be alleviated with VISCOSEAL®, a solution of hyaluronic acid.

In January of 2011, Dr S Egger (Austria), Dr Muthu Jeyam (UK), Prof C Erggelet (Switzerland) and Dr W Weissenbacher (Austria) gathered together in Austria for a roundtable meeting, to discuss their experiences in arthroscopic surgery. A report on this meeting is now available on our website. Click here to read more...>>>