This clinical practice guideline is based on a systematic review of published studies on the treatment of glenohumeral osteoarthritis in the adult patient population. Of the 16 recommendations addressed, nine are inconclusive. Two were reached by consensus-that physicians use perioperative mechanical and/or chemical venous thromboembolism prophylaxis for shoulder arthroplasty patients and that total shoulder arthroplasty not be performed in patients with glenohumeral osteoarthritis who have an irreparable rotator cuff tear. Four options were graded as weak: the use of injectable viscosupplementation; total shoulder arthroplasty and hemiarthroplasty as treatment; avoiding shoulder arthroplasty by surgeons who perform fewer than two shoulder arthroplasties per year (to reduce the risk of immediate postoperative complications); and the use of keeled or pegged all-polyethylene cemented glenoid components. The single moderate-rated recommendation was for the use of total shoulder arthroplasty rather than hemiarthroplasty. Management of glenohumeral osteoarthritis remains controversial; the scientific evidence on this topic can be significantly improved.

Antecedentes: La ecografía se ha utilizado cada vez más para ayudar a la comprensión y manejo de las enfermedades reumáticas. En los últimos años ha habido un foco en la validez y utilidad de la ecografía en la demostración de patología de la articulación, aunque se ha centrado principalmente en la artritis inflamatoria. Objetivos: Realizar una revisión sistemática de la literatura publicada que evalúa la ecografía como herramienta de evaluación en la artrosis. MÉTODOS: En Medline y PubMed se buscó identificar los manuscritos originales, publicados antes de junio de 2008, donde se utilizó la ecografía para evaluar las articulaciones de cohortes de pacientes con osteoartritis. Los datos se extrajeron de los manuscritos que cumplen los criterios de inclusión, con un enfoque particular sobre la imagen formada de la patología, las definiciones utilizadas, los sistemas de puntuación y sus propiedades métricas. RESULTADOS: Se identificaron cuarenta y siete estudios que utilizan la ecografía para evaluar la patología estructural de la osteoartritis. La función Doppler sólo se evaluó en 10 estudios y medios de contraste en uno. Hubo heterogeneidad en cuanto a la patología de examinados, la definición de la patología, la cuantificación y la denuncia de estos factores. También hubo una falta de validez de constructo y de criterio y los datos que demuestran la fiabilidad y sensibilidad al cambio. Conclusiones: Considerando que existe una creciente evidencia de la validez de la ecografía en la detección de patología estructural en la artritis inflamatoria, se requiere más trabajo para desarrollar definiciones estandarizadas de la patología y demostrar la validez de la ecografía en la artrosis.

Introducción: la gonartrosis es una enfermedad frecuente en la actualidad debido al envejecimiento de la población y la necesidad en este grupo de enfermos de una mejor capacidad funcional. Objetivo: profundizar sobre la utilidad de las escalas evaluativas en pacientes con gonartrosis. Desarrollo: en la presente revisión se utilizaron las bases de datos Medline, Hinari y Pubmed con más de 200 artículos sobre el tema de los que fueron seleccionados 51. Se abordan las escalas más usadas en pacientes que sufren de artrosis de la rodilla, entre las que se encuentran las dependientes en su totalidad de lo referido por los enfermos. Por otra parte, se hace referencia a la utilidad de la escala cuantitativa de Rasmussen, ya que se relaciona con aspectos muy importantes de la enfermedad que necesitan de valoración y evolución. En la última parte de la investigación se hace referencia a la nueva clasificación propuesta por la American Knee Society, donde por primera vez en una escala se combinan elementos subjetivos y objetivos. Conclusiones: la gradación de pacientes que sufren de artrosis de la rodilla es de vital importancia para determinar los resultados del tratamiento, tanto conservador como quirúrgico a corto y largo plazo; y de esta manera trazar estrategias efectivas que den respuesta a pacientes que padecen de esta enfermedad.

BACKGROUND: Osteoarthritis (OA) is the most prevalent chronic joint disorder worldwide and is associated with significant pain and disability. OBJECTIVES: To assess the effects of viscosupplementation in the treatment of OA of the knee. The products were hyaluronan and hylan derivatives (Adant, Arthrum H, Artz (Artzal, Supartz), BioHy (Arthrease, Euflexxa, Nuflexxa), Durolane, Fermathron, Go-On, Hyalgan, Hylan G-F 20 (Synvisc Hylan G-F 20), Hyruan, NRD-101 (Suvenyl), Orthovisc, Ostenil, Replasyn, SLM-10, Suplasyn, Synject and Zeel compositum). SEARCH STRATEGY: MEDLINE (up to January (week 1) 2006 for update), EMBASE, PREMEDLINE, Current Contents up to July 2003, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Specialised journals and reference lists of identified randomised controlled trials (RCTs) and pertinent review articles up to December 2005 were handsearched. SELECTION CRITERIA: RCTs of viscosupplementation for the treatment of people with a diagnosis of OA of the knee were eligible. Single and double-blinded studies, placebo-based and comparative studies were eligible. At least one of the four OMERACT III core set outcome measures had to be reported (Bellamy 1997). DATA COLLECTION AND ANALYSIS: Each trial was assessed independently by two reviewers for its methodological quality using a validated tool. All data were extracted by one reviewer and verified by a second reviewer . Continuous outcome measures were analysed as weighted mean differences (WMD) with 95% confidence intervals (CI). However, where different scales were used to measure the same outcome, standardized mean differences (SMD) were used. Dichotomous outcomes were analyzed by relative risk (RR). MAIN RESULTS: Seventy-six trials with a median quality score of 3 (range 1 to 5) were identified. Follow-up periods varied between day of last injection and eighteen months. Forty trials included comparisons of hyaluronan/hylan and placebo (saline or arthrocentesis), ten trials included comparisons of intra-articular (IA) corticosteroids, six trials included comparisons of nonsteroidal anti-inflammatory drugs (NSAIDs), three trials included comparisons of physical therapy, two trials included comparisons of exercise, two trials included comparisons of arthroscopy, two trials included comparisons of conventional treatment, and fifteen trials included comparisons of other hyaluronans/hylan. The pooled analyses of the effects of viscosupplements against 'placebo' controls generally supported the efficacy of this class of intervention. In these same analyses, differential efficacy effects were observed for different products on different variables and at different timepoints. Of note is the 5 to 13 week post injection period which showed a percent improvement from baseline of 28 to 54% for pain and 9 to 32% for function. In general, comparable efficacy was noted against NSAIDs and longer-term benefits were noted in comparisons against IA corticosteroids. In general, few adverse events were reported in the hyaluronan/hylan trials included in these analyses. AUTHORS' CONCLUSIONS: Based on the aforementioned analyses, viscosupplementation is an effective treatment for OA of the knee with beneficial effects: on pain, function and patient global assessment; and at different post injection periods but especially at the 5 to 13 week post injection period. It is of note that the magnitude of the clinical effect, as expressed by the WMD and standardised mean difference (SMD) from the RevMan 4.2 output, is different for different products, comparisons, timepoints, variables and trial designs. However, there are few randomised head-to-head comparisons of different viscosupplements and readers should be cautious, therefore, in drawing conclusions regarding the relative value of different products. The clinical effect for some products, against placebo, on some variables at some timepoints is in the moderate to large effect-size range. Readers should refer to relevant tables to review specific detail given the heterogeneity in effects across the product class and some discrepancies observed between the RevMan 4.2 analyses and the original publications. Overall, the analyses performed are positive for the HA class and particularly positive for some products with respect to certain variables and timepoints, such as pain on weight bearing at 5 to 13 weeks postinjection.In general, sample-size restrictions preclude any definitive comment on the safety of the HA class of products; however, within the constraints of the trial designs employed no major safety issues were detected. In some analyses viscosupplements were comparable in efficacy to systemic forms of active intervention, with more local reactions but fewer systemic adverse events.In other analyses HA products had more prolonged effects than IA corticosteroids. Overall, the aforementioned analyses support the use of the HA class of products in the treatment of knee OA.

La artrosis es la enfermedad articular crónica que presenta mayor prevalencia, en la cual el dolor es uno de los principales síntomas y el mayor determinante de la pérdida de funcionalidad. Se han planteado múltiples opciones terapéuticas, entre ellas la glucosamina, pero su real utilidad aún no ha sido claramente establecida. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos, identificamos 11 revisiones sistemáticas que en conjunto incluyen 35 estudios aleatorizados que responden la pregunta de este resumen. Extrajimos la información relevante, realizamos un metanálisis y preparamos tablas de resumen de los resultados utilizando el método GRADE. Concluimos que no está claro que la glucosamina disminuya el dolor o mejore la funcionalidad en la artrosis porque la certeza de la evidencia es muy baja.

BACKGROUND: Patients with unicompartmental osteoarthritis of the knee can be treated with an osteotomy. The goal of an osteotomy is to unload the diseased compartment of the knee. This is the second update of the original review published in The Cochrane Library, Issue 1, 2005. OBJECTIVES: To assess the benefits and harms of an osteotomy for treating patients with knee osteoarthritis, including the following main outcomes scores: treatment failure, pain and function scores, health-related quality of life, serious adverse events, mortality and reoperation rate. SEARCH METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE (Current Contents, HealthSTAR) were searched until November 2013 for this second update. SELECTION CRITERIA: Randomised and controlled clinical trials comparing an osteotomy with other treatments for patients with unicompartmental osteoarthritis of the knee. DATA COLLECTION AND ANALYSIS: Two review authors independently selected trials, extracted data and assessed risk of bias using the domains recommended in the 'Risk of bias' tool of The Cochrane Collaboration. The quality of the results was analysed by performing overall grading of evidence by outcome using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach. MAIN RESULTS: Eight new studies were included in this update, for a total of 21 included studies involving 1065 people. In four studies, the randomised sequence was adequately generated and clearly described. In eight studies, allocation concealment was adequately generated and described. In four studies, the blinding procedures were sufficient. In six studies, incomplete outcome data were not adequately addressed. Furthermore, in 11 studies, the selective outcome reporting item was unclear because no study protocol was provided. Follow-up of studies comparing different osteotomy techniques was too short to measure treatment failure, which implicates revision to a knee arthroplasty. Four studies evaluated a closing wedge high tibial osteotomy (CW-HTO) with another high tibial osteotomy (aHTO). Based on these studies, the CW-HTO group had 1.8% (95% confidence interval (CI) -7.7% to 4.2%; low-quality evidence) more pain compared with the aHTO group; this finding was not statistically significant. Pooled function in the CW-HTO group was 0.5% (95% CI -3.8% to 2.8%; low-quality evidence) higher compared with the aHTO group; this finding was not statistically significant. No data on health-related quality of life and mortality were presented. Serious adverse events were reported in only four studies and were not significantly different (low-quality evidence) between groups. The reoperation rate were scored as early hardware removal because of pain and pin track infection due to the external fixator. Risk of reoperation was 2.6 (95% CI 1.5 to 4.5; low-quality evidence) times higher in the aHTO group compared with the CW-HTO group, and this finding was statistically significant. The quality of evidence for most outcomes comparing different osteotomy techniques was downgraded to low because of the numbers of available studies, the numbers of participants and limitations in design. Two studies compared high tibial osteotomy versus unicompartmental knee replacement. Treatment failure and pain and function scores were not different between groups after a mean follow-up of 7.5 years. The osteotomy group reported more adverse events when compared with the unicompartmental knee replacement group, but the difference was not statistically significant. No data on health-related quality of life and mortality were presented. No study compared an osteotomy versus conservative treatment. Ten included studies compared differences in perioperative or postoperative conditions after high tibial osteotomy. In most of these studies, no statistically significant differences in outcomes were noted between groups. AUTHORS' CONCLUSIONS: The conclusion of this update did not change: Valgus high tibial osteotomy reduces pain and improves knee function in patients with medial compartmental osteoarthritis of the knee. However, this conclusion is based on within-group comparisons, not on non-operative controls. No evidence suggests differences between different osteotomy techniques. No evidence shows whether an osteotomy is more effective than alternative surgical treatment such as unicompartmental knee replacement or non-operative treatment. So far, the results of this updated review do not justify a conclusion on benefit of specific high tibial osteotomy technique for knee osteoarthritis.

OBJETIVOS: Dadas las definiciones contradictorias de "osteoartritis generalizada" (GOA) en la literatura, se realizó una revisión sistemática de las definiciones, factores de riesgo y los resultados respecto a esta. MÉTODOS: Se realizaron búsquedas en la literatura en MEDLINE con los términos osteoartritis generalizada, poliarticular, articulación múltiple, y multi-articular para obtener artículos relacionados con GOA, siguiendo directrices basadas en la evidencia. Se revisó los títulos y resúmenes de 948 artículos, con la revisión del texto completo de 108. Los datos fueron obtenidos en base a criterios predefinidos para 74 artículos más 24 identificados a través de revisión bibliográfica (n = 98). RESULTADOS: Veinticuatro grandes cohortes (n ~ 30.000) estaban representados junto con numerosas series clínicas (n ~ 9000), a través de 22 países y 60 años (1952-2012). Se dieron no menos de 15 definiciones de GOA en 30 estudios que tenían una definición GOA establecida; al menos 6 grupos utilizaron una puntuación sumada de las articulaciones o los grados radiográficos. Las estimaciones de prevalencia en base a estas definiciones GOA fueron 1-80%, aunque la mayoría eran 5.25%. El aumento del riesgo y la progresión de GOA se asoció con la edad, el sexo femenino, y los factores genéticos/familiares. Asociaciones con el aumento del índice de masa corporal o la densidad mineral ósea no fueron consistentes. Un estudio estimó la heredabilidad de GOA en el 42%. Los niveles de biomarcadores colágeno aumentaron con el número de articulaciones afectadas. El aumento de la carga de OA se asoció con mayor mortalidad y discapacidad, peor salud y función. CONCLUSIÓN: Si bien no queda ninguna definición estándar de GOA, este término se utiliza comúnmente. El impacto en la salud puede ser mayor cuando la OA está en más de una articulación. Se recomienda utilizar un término descriptivo, como multi-articular u OA poliarticular, designando OA de múltiples articulaciones o grupos de articulaciones.

OBJECTIVE: To conduct a systematic review of evidence supporting the efficacy and safety profiles of nonsteroidal anti-inflammatory drugs (NSAIDs) introduced in the last decade for the treatment of patients with osteoarthritis (OA), including their analgesic effects, ability to improve function, and adverse event profiles relative to current standards of care. RESEARCH DESIGN AND METHODS: Systematic search of the literature for NSAIDs approved by the FDA (2000-2010). RESULTS: One new orally-administered NSAID molecule (meloxicam), two orally-administered NSAID formulations (naproxen plus lansoprazole; oxycodone/ibuprofen), and three topical NSAID formulations (diclofenac patch, gel, and solution) were approved by the FDA (2000-2010). A systematic literature review found evidence to support efficacy in treating patients with OA for all agents except oxycodone/ibuprofen, which has not been studied in this patient population, although ibuprofen and immediate-release oxycodone have been studied individually for OA pain. Evidence quality was inconsistent, with several agents lacking long-term, controlled trials against active comparators, and functional end points inconsistently met. Although low-dose meloxicam and naproxen plus lansoprazole offer a reduced risk of adverse gastrointestinal (GI) events, cardiovascular and renal risks remain similar to traditional oral NSAID therapy. Further, only lower doses of meloxicam appear to carry a reduced risk of GI events. Diclofenac patch, gel, and solution preparations offer the potential for reduced GI, cardiovascular, and renal adverse events. The level of evidence available to support the efficacy and safety of these agents for long-term treatment of patients with OA differs, with some having only short-term trials, while others have longer-duration trials with active comparators. CONCLUSIONS: By expanding the treatment armamentarium, newly-approved NSAID agents may improve the ability of clinicians to tailor analgesic therapy for their diverse patient populations and to achieve realistic functional improvements. The comparisons in this article were limited to drugs that received approval after 2000 and should be considered accordingly.

INTRODUCTION: Osteoarthritis (OA) is a disease of synovial joints and is the most common cause of chronic pain. Viscosupplementation (VS) with hyaluronic acid (HA) is largely used for knee osteoarthritis therapy but the evidence for its usefulness in ankle osteoarthritis is limited. The objective of this review is to assess the efficacy of viscosupplementation treatment of ankle osteoarthritis in the current literature. METHODS: The following databases were searched: Medline (period 2006-2008), Database of Abstract on Reviews and Effectiveness and Cochrane Database of Systematic Reviews. Reference lists of relevant articles were controlled for additional references. The search terms Review, Viscosupplementation (VS), Osteoarthritis (OA), Hyaluronic acid (HA), Hyaluronan, Sodium hyaluronate, Ankle OA, Ankle joint were used to identify all studies relating to the use of VS therapy for the ankle OA. Methodological quality of included studies was assessed by assigning level of evidence as previously defined by the Centre for Evidence Based Medicine (CEBM). RESULT: Seven articles concerning the efficacy of a total of 275 patients undergoing VS treatment for ankle OA were included. One European study, one Taiwanese study, one Italian study, one Turkish study and three American studies with level of evidence ranging from I to IV evaluated the following products: Hyalgan, Synvisc, Supartz, Adant. CONCLUSION: Viscosupplementation is used widely in knee OA and is included in the professional guidelines for treatment of the disease in this joint. The potential for treating osteoarthritis of the ankle joint by viscosupplementation has been suggested in the literature, however, no dosing studies have been published to date, and dosing in the ankle joint remains an area for discussion. Viscosupplementation could potentially provide an useful alternative in treating such patients with painful ankle OA.

La artrosis es la enfermedad articular crónica que presenta mayor prevalencia, en la cual el dolor es uno de los principales síntomas y el mayor determinante de la pérdida de funcionalidad. Se han planteado múltiples opciones terapéuticas, entre ellas el condroitín sulfato, pero su real utilidad aún no ha sido claramente demostrada. Para aclarar esta interrogante utilizamos la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples fuentes de información. Identificamos 13 revisiones sistemáticas que en conjunto incluyen 50 estudios aleatorizados que responden la pregunta de este resumen. Extrajimos la información relevante, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE. Concluimos que no está claro si el uso de condroitín sulfato produce una mejoría en el dolor o la funcionalidad en la artrosis porque la certeza de la evidencia es muy baja.