Re: In-office management of knee osteoarthritis

Drs Sidhu, Sheridan, Badii, and Masri’s article “In-office management of knee osteoarthritis” [BCMJ 2024;65:118-121] provides an excellent detailed overview of the in-office diagnosis and management of knee osteoarthritis that is relevant to so many physicians. The article was very informative, and we wish to affirm the points of discussion, as several important treatment options for knee osteoarthritis were outlined and reviewed. The article was brought to our attention because an important injection therapy was overlooked: prolotherapy.

Prolotherapy is a common in-office procedure that has been around (in its current form) for at least 70 years. Prolotherapy is most often a compounded solution consisting of dextrose, saline, and local anesthetic (procaine/lidocaine). The concentration of dextrose in the solution generally ranges from 10% to 25%. Although the mechanism of action is not entirely understood, it is thought that a neuromodulatory effect precedes a proliferative response.

With respect to pharmacologic interventions for knee osteoarthritis, several meta-analyses have demonstrated that prolotherapy has a very favorable safety profile and appears to be a promising treatment option. A 2021 meta-analysis suggests that prolotherapy for knee osteoarthritis is associated with improved Western Ontario and McMaster Universities Arthritis Index (WOMAC) composite score, pain relief, and knee function performance when compared with conventional methods such as corticosteroids, viscosupplementation, and physical therapy.[1] Similarly, a 2024 systematic review and meta-analysis of interventional studies showed that prolotherapy injections provided statistically significant improvements in pain, stiffness, and function in knee osteoarthritis.[2] When compared with physiotherapy, a systematic review and meta-analysis found that prolotherapy alone provided greater improvement in visual analog scale scores, WOMAC total values, and range of motion at 1 and 3 months posttreatment.[3,4] Further, a 2013 methodologically rigorous randomized controlled trial showed that prolotherapy resulted in safe, significant, progressive improvement of knee pain, function, and stiffness scores among most participants through a mean follow-up of 2.5 years.[5] The authors also wish to acknowledge the superiority of a combination of both pharmacological and exercise interventions rather than a single therapeutic approach.

Complications related to prolotherapy injection are rare, typically self-limited, and similar to those of other injections, such as mild pain or stiffness and localized swelling and bruising in the treated areas. Prolotherapy also has a better safety profile than corticosteroids (i.e., it is not associated with osteonecrosis, rapidly progressive osteoarthritis, systemic side effects, or tendon rupture). Prolotherapy contraindications include acute infections such as local abscess or cellulitis, septic arthritis, and acute gouty arthritis. Prolotherapy is not currently covered by MSP but is available through private pay in some settings.

Evidence suggests that prolotherapy provides effective pain reduction and increased functional improvement and is recommended based on high-quality evidence for knee osteoarthritis. Due to easily accessible ingredients, relatively low cost, tolerability, and efficacy, prolotherapy should be considered as a potential treatment option and early intervention in mild to moderate knee osteoarthritis.
—W. Francois Louw, CCFP(EM), FCFP, MBChB(Pret), DA(SA), PgCPain, Adv Dipl Pain Mgt
Clinical Associate Professor, UBC Department of Family Practice
—Adrian Gretton, MD, LMCC, CCFP
Clinical Assistant Professor, University of Calgary Department of Family Medicine
—MJ Atkins, ND
Victoria

This letter was submitted in response to “In-office management of knee osteoarthritis.”

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References

1.    Wang J, Liang J, Yao J, et al. Meta-analysis of clinical trials focusing on hypertonic dextrose prolotherapy (HDP) for knee osteoarthritis. Aging Clin Exp Res 2022;34:715-724.

2.    Khateri S, Nejad FB, Kazemi F, et al. The effect of dextrose prolotherapy on patients diagnosed with knee osteoarthritis: A comprehensive systematic review and meta-analysis of interventional studies. Health Sci Rep 2024;7:e2145.

3.    Yildiz KM, Guler H, Ogut H, et al. A comparison between hypertonic dextrose prolotherapy and conventional physiotherapy in patients with knee osteoarthritis. Med Int 2023;3:45.

4.    Sit RWS, Chung VCH, Reeves KD, et al. Hypertonic dextrose injections (prolotherapy) in the treatment of symptomatic knee osteoarthritis: A systematic review and meta-analysis. Sci Rep 2016;6:25247.

5.    Rabago D, Patterson JJ, Mundt M, et al. Dextrose prolotherapy for knee osteoarthritis: A randomized controlled trial. Ann Fam Med 2013;11:229-237.