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Rheumatology 2001; 40: 1425-1426
© 2001 British Society for Rheumatology
Letters to the Editor |
Systemic reaction to viscosupplementation for knee osteoarthritis
Department of Rheumatology, Eastbourne District General Hospital, Kings Drive, Eastbourne, East Sussex BN21 2UD, UK
SIR, Viscosupplementation is an increasingly popular form of treatment for knee osteoarthritis. Intra-articular injections of synthetic hyaluronan are given to restore the natural mechanical properties of synovial fluid and are promoted as safe alternatives to conventional therapy [1]. Four preparations of hyaluronan are available: Hyalgan, Orthovisc, Supatrz and Synvisc. We report a case of systemic reaction to knee injections of Synvisc (hylan G-F 20) which required a 7-day hospital admission.
A 79-yr-old lady presented to the rheumatology department with increasing difficulty in walking and climbing her stairs at home as a result of bilateral knee pain. Her medical history included hypertension and upper gastrointestinal bleeding whilst on meloxicam, requiring an acute admission in 1999. Bendrofluazide 2.5 mg was her sole medication. On examination she was overweight with crepitus, effusions and reduced range of movement of both knees, although her other joints were in good condition. Plain radiographs of the knees confirmed bilateral knee osteoarthritis. The full blood count and renal function were within normal limits. She was considered a good candidate for viscosupplementation and was placed on the waiting list for bilateral knee injections weekly for 3 weeks (there was no history of avian protein allergy, which is a contraindication to viscosupplementation).
The first two injections into each knee were performed without complication. Synovial fluid was aspirated but not sent for laboratory analysis. However, when the patient presented for the third and final injection she complained of increased pain, swelling and stiffness in her left knee. On examination she had a large effusion of the left knee. As infection could not be excluded, the left knee was aspirated and synovial fluid sent for microbiological assessment. Analysis was negative for Gram stain, culture and crystals.
One week later the swelling of the patient's left knee had subsided and the final injections were performed. Unfortunately, the patient was admitted as an emergency some 12 h later. She had increased swelling and pain in both knees and was unable to bear weight. She also had pyrexia of 39.8°C. Both knees were aspirated on admission; a total of 90 ml of fluid was withdrawn and this was sent for urgent microbiological analysis. She was placed on intravenous antibiotics pending blood and synovial fluid culture. The systemic upset was significant. Her C-reactive protein rose to 282 mg/l and her erythrocyte sedimentation rate peaked at 112 mm/h (baseline was 17). Her white cell count on admission was 12.0x109 and there was eosinophilia (1.6x109). Two further sets of knee aspirates were taken before antibiotics were stopped. All aspirates were confirmed as negative for both bacterial infection and crystals. X-rays of the knee taken during admission showed only soft tissue swelling and the existing osteoarthritis. Her temperature gradually settled but she required considerable assistance to mobilize. Intra-articular steroid injections into the knees were performed to aid recovery. She was discharged 7 days after admission, infection having been excluded, but her mobility at that time was not yet back to normal.
The management of osteoarthritis consists of non-pharmacological intervention, drug treatment (local and systemic) and surgical intervention [2]. Viscosupplementation offers a new way of treating knee OA but, as our case shows, it is not without systemic side-effects. However, the risks of viscosupplementation should be compared with the risks of conventional treatments. Recent evidence on the chronic use of NSAIDs, which is a popular treatment choice [3], suggests that 1 in 1200 patients taking NSAIDs for at least 2 months will die from gastroduodenal complications. This extrapolates to about 2000 deaths each year in the UK [4].
Our case is the first systemic reaction to Synvisc reported to the manufacturer. Whilst it was a serious reaction, both systemically and locally, it was not life-threatening. However, this is a potential complication of viscosupplementation.
Notes
Correspondence to: J. A. Wojtulewski. 
References
- Adams ME, Atkinson MH, Lussier AJ, Schulz JI, Siminovitch KA, Wade JP, Zummer M. The role of viscosupplementation with hylan G-F 20 (Synvisc) in the treatment of osteoarthritis of the knee. Osteoarthritis Cartilage1995;3:213–26.[Web of Science][Medline]
- Brandt KD, Lohmander LS, Doherty M. Management of osteoarthritis. In: Brandt KD, Lohmander LS, Doherty M, eds. Osteoarthritis. Oxford: Oxford Medical Publications, 1998:250–5.
- Griffin MR. Nonsteroidal anti-inflammatory drugs. In: Brandt KD, Lohmander LS, Doherty M, eds. Osteoarthritis. Oxford: Oxford Medical Publications, 1998:261–71.
- Tramer MR, Moore RA, Reynolds DJM, McQuay HJ. Quantitative estimation of rare adverse events which follow a biological progression: a new model applied to chronic NSAID use. Pain2000;85:169–82.[Web of Science][Medline]
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