Avaliação dos resultados do uso do hialuronato de sódio intra-articular no pós-operatório da artroscopia do joelho

w w w . r b o . o r g . b r

Original

Article

Results

evaluation

of

the

use

of

intra-articular

sodium

hyaluronate

in

the

post-operative

knee

arthroscopy

夽

,

夽夽

Ayrton

de

Paula

Pereira

Junior

_,

_Ricardo

_Pozzi

_Fasolin

_,

_Felipe

_Ayusso

_Correa

_Sossa

_,

Ozorio

de

Almeida

Lira

Neto

_,

_Marcelo

_Schmidt

_Navarro

_,

_Antonio

_Milani

b_{DepartamentodeOrtopediaeTraumatologia,UniversidadeFederaldeSãoPaulo,SãoPaulo,SP,Brazil} c_{DisciplinadeOrtopedia,FaculdadedeMedicinadoABC,SantoAndré,SP,Brazil}

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received3September2012 Accepted7December2012

Keywords: Arthroscopy Knee

Hyaluronicacid Viscosuplementation

a

b

s

t

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a

c

t

Objective:to evaluate the efficacy of hyaluronic acid in the post-operative of knee arthroscopy.

Methods:wehaveevaluated49patientsundergoingarthroscopicprocedurewiththeuseof intra-articularhyaluronicacid(Group1)and49patientsundergoingarthroscopicprocedure withouttheuseofhyaluronicacid(Group2).PatientswereevaluatedbasedontheVisual AnalogueScale,householdanalgesia,assessmentoftheRangeofMotionwithagoniometer, andtheLysholmquestionnaire.

Results:therewerenosubstantialadverseeffectsoneithergroup.

Conclusion: theuseofhyaluronicacidinthepost-operativeofkneearthroscopyisjustified due/becauseitleadstoadecreaseinpainintheearlystage,enablingfasterrecoveryofthe patient.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Avaliac¸ão

dos

resultados

do

uso

do

hialuronato

de

sódio

intra-articular

no

pós-operatório

da

artroscopia

do

joelho

Palavras-chave: Artroscopia Joelho

Ácidohialurônico Viscossuplementac¸ão

r

e

s

u

m

o

Objetivo:avaliaraeficáciadousodoácidohialurôniconopós-operatóriodeartroscopiade joelho.

Métodos:foramavaliados49pacientessubmetidosaoprocedimentoartroscópico associ-ado aousodoácidohialurônico intra-articular(GrupoI) e49 pacientessubmetidosao procedimentoartroscópicosemusodoácido hialurônico(GrupoII).Ospacientesforam avaliadoscombasenaEscalaVisualAnalógicadedor(EVA),analgesiadomiciliar,amplitude domovimentodojoelhocomgoniômetroenoquestionárioLysholm.

Resultados: nãoocorreramefeitosadversossignificativosemnenhumdosdoisgrupos.

夽

Pleasecitethisarticleas:dePaulaPereiraJuniorA,FasolinRP,SossaFAC,deAlmeidaLiraNetoO,NavarroMS,MilaniA.Avaliac¸ãodos resultadosdousodohialuronatodesódiointra-articularnopós-operatóriodaartroscopiadojoelho.RevBrasOrtop.2014;49:37–43.

夽夽

StudyconductedattheHospitalIfor,SãoBernardodoCampo,SP,Brazil.

∗ _{Correspondingauthor.}

E-mail:pilot@osite.com.br(A.Milani).

2255-4971/$–seefrontmatter©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

Conclusão:ousodoácidohialurôniconopós-operatóriodeartroscopiadejoelhoéjustificado porlevaraumadiminuic¸ãodadornafaseinicialepossibilitarumarecuperac¸ãomaisrápida dopaciente.

©2014SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevier EditoraLtda.Todososdireitosreservados.

Introduction

Theuseofintra-articularmedicationintheimmediate post-operativeperiodintheareaofarthroscopickneesurgeriesis controversial,withprospectsfornewbehaviorsandroutines, andwithauthorsforandagainsttheuseofhyaluronicacid post-operatively.1,2

A knee arthroscopy is a medicalprocedure moreusual inthe UnitedStates ofAmerica (USA), and iseffective for symptomreliefinpatientswithintra-articularloosebodies, chondralinjuryandmeniscalpathology.2

Theperformanceofhumanjointsisstrictlyrelatedtothe viscoelasticpropertiesofsynovialfluid,whichdeterminesthe strengthtransmission,lubricationandprotectionofarticular cartilage.Thisviscoelasticitydependsontheconcentrationof hyaluronicacidinthesinovialfluid.3

Other actions of hyaluronic acid would be an anti-inflammatoryeffect(decreasedgeneexpressionofcytokines, prostaglandinproduction,andintra-articularconcentrationof metalloproteinases)andanalgesic(inhibitionofnociceptors), stabilization ofcartilaginous matrix,chondrocyte prolifera-tion,increasedproductionoftypeIIcollagenanditsdecreased degradation.4–6

Someauthorsbelievethatexogenoushyaluronicacidalso stimulates the production of endogenous hyaluronic acid, whichwouldexplainitslong-termeffect.7_{Withrespecttothe}

analgesiceffectofintra-articularhyaluronicacid,itisbelieved that,initially,itwouldbesmallerthantheintra-articular cor-ticosteroidinjection,butwithpersistenceforlongerperiods.8

Anothersourceofdebateisthediscussionregardingthe numberofdosesofhyaluronicacidtobeeffective,butthere wasnodifferenceinthecomparisonbetweenthreeandsix dosesatweeklyintervals.9

Some authors claim that, during an arthroscopic knee surgery,adecreaseinintra-articularhyaluronicacid concen-trationmay occur and,as immediatetherapy, recommend intra-articular applications of sodium hyaluronate 20mg after surgery, and subsequently four injections at weekly intervals.10

Theaimofthisstudywastocomparetheresultsoftheuse ofintra-articularsodiumhyaluronateinagroupofpatients undergoingarthroscopicsurgeryduetomeniscallesions ver-susresultsobservedinagroupofpatientsnottreatedbythis complementarytherapy.

Materials

and

methods

Ninety-eight patients with meniscal lesions were studied. ThesepatientsweretreatedfromMarchtoNovember2005by arthroscopicsurgerywithpartialmeniscectomyofthemedial meniscus,alwaysbythesamesurgicalteam.

Their agesrangedfrom 18to65 years(mean:34 years). Sixty-five(63%)weremenand33(37%),women.

Theparticipantswererandomlydividedintotwogroups of49.Thefirstgroupwastreatedwithintra-articularsodium hyaluronate20mg(Polireumim, TRBPharma) inthe imme-diatepost-operativeperiodand,subsequently,withaweekly applicationforfourconsecutiveweeks.Inthesecondgroup, thistreatmentwasnotdone.Thesurgeonwasunawareofthe grouptowhicheachpatientbelonged,havingbeeninformed onlyafterskinsuture,atthetimeofcompletion(ornot)ofthe infiltration(Table1).

Allpatientswererehabilitatedaccordingtothesame pro-tocol,withevaluationsafterthree,eight,15,30and60days, andwereinstructedtoreturntosportpracticeafter60daysof surgery.

Allpatientsunderwentthesamesurgicaltechnique,with theuseofonlytwoinfrapatellarportals(medialandlateral) and,onaverage,withjointinfusion(6Lofsaline0.9%),using aninfusionpumpatameanpressureof50mmHg.All ran-domizedpatientsshowednosignificantchangesincartilage and,inthis study,onlycasesofOuterbridgegradeIand II chondropathy(Table1)wereincluded.

Allpatientswereanesthetizedbysubarachnoidblockwith bupivacaine0.5%associatedwithglucose12.5to15mg, with-outopioids.Apneumatictourniquetwasalsoused,withan averagetimeof35min.

Afterhospitaldischarge(mean:12haftertheintervention), bothgroupsweretreatedwithcephalexin500mgPO6/6hfor sevendaysand,incaseofpain,dipyrone50dropstothelimit of6/6h.Theuseofanalgesicswascontrolledinaform,in whichthepatienthadtocheckthedateandtimeofuseuntil theeighthday.

InGroup1,afterskinsuturetheinfiltrationsweremadein thelateralsuprapatellararea,(onceaweekforfour consec-utiveweeks).Besidesthecontrolontheformwiththedate andtimeofuseofanalgesics,patientsunderwentVAS.Inall reviews,therangeofmotionofthekneewasalsomeasured witha goniometer;theLysholm questionnairewasapplied inthepreoperatoryonthe dayofsurgeryandonthe 15th, 30thand60thdayspost-operatively.Allevaluationswere per-formedbythe sameexaminerwho didnotknowatwhich groupthepatientbelonged.

Toavoidbiasintheresultsbecause ofthepainof infil-tration,theassessmentsinthe8th,15thand30thdayswere alwaysmadebeforethisprocedure.

Inthestatisticalanalysis,analysisofvariancewithtwo fac-torsand repeatedmeasuresonthetimefactorwere made, assuming a first-order autoregressive correlation matrix betweentimepoints.11_{Aftertheanalysis,Tukeymultiple}

com-parisonsweremade12_{toseebetweenwhichgroupsortime}

pointsoccurreddifferencesinscales.

Table1–Characterizationofsample.

Variables n=98 Group1=49 Group2=49

Age(years)–mean(SD) 34(12.1) 36(11.3) 33(12.1)

Minimum–maximum 18–65 20–65 18–61

Gender–n(%)

Female 33(37) 15(30.6) 18(36.7)

Male 65(63) 34(69.4) 31(63.3)

Operatedsite–n(%)

Right 58(59.2) 26(53) 32(65.3)

Left 40(40.8) 23(47) 17(34.7)

Chondrallesiona_–n(%)

Withoutlesion 43(43.9) 22(44.9) 21(42.9)

GradeI 31(31.6) 14(28.6) 17(34.7)

GradeII 24(24.5) 13(26.5) 11(22.4)

a _Outerbridge.

Results

ConsideringtheassessmentsbyVAS,theresultssuggestmore rapidreductionofpaininGroup1versusGroup2.Theanalysis showedthatthemeanbehaviorofVASwasstatistically differ-entbetweengroupsovertheevaluationtimepoints(p<0.001) (Fig.1).

Incomparingthedifferentevaluationtimepoints,thedata

inTable2showthatbothgroupshadameanreductioninVAS

withstatisticalsignificanceatallevaluationtimepoints,when comparedto the previous timepoint (p<0.001),but inthe eighthand15thdays,Group1showed,onaverage,statistically lowerVASversusGroup2(p<0.001andp<0.001)andinother timepoints,therewasnostatisticallysignificantdifferencein VASbetweengroups(p>0.05)(Table2).

Withrespecttotheneedforuseofhomeanalgesia,there was no statistical difference between the groups until the eighthday.

Withregardtoassessmentsmadewiththegoniometer,it wasobservedthatafter15daystheGroup1hadgreaterrange ofmotionversusGroup2.After30days,thisdifferencecould stillbeobserved,toalesserextent,butwithoutstatistical sig-nificance.Intheassessmentmadeonthe60thday,theresults weresimilarinbothgroups.

0 1 2 3 4 5 6 7 8

0 10 20 30 40 50 60 70

Dia

VAS

Groups 1 Groups 2

Fig.1–Graphicalrepresentationofthemeanprofilesand respectivestandarderrorsofVAS,accordingtogroups.

IntheevaluationwiththeLysholmquestionnaire (excel-lent:patientsbetween95and100points,good:94–84;regular: 83–65,andpoorscore:<64),wenotedinthepreoperativethat theGroups1and2hadanaverageof46and48points, respec-tively,classifiedthenaspoor(Table3).

Table 3shows that inboth Groups(1 and 2), themean

Lysholmscoredecreasedstatisticallyfromthepreoperatoryto 15dayspost-operatively(p=0.003andp<0.001,respectively), with“poor”ratinginbothgroups.However,intheevaluation ofthequestions,wefoundthatthelargestdifferencebetween groupswasobservedintheitems “pain”and “swelling”,in whichtheGroup1hadbetterresultsversusGroup2.Inother questions,theresultsweresimilarbetweengroups.

Inthe30thdaytheresultsshowedthegreateststatistical differencebetweengroups.Group1averaged90points, clas-sifiedasgood,andGroup2averaged77points,classifiedas regular. Weperceived agreater difference inthe questions about claudication,instability, swelling and squatting, and noticedthat,justasthatinthe15thday,theswellingwasalso animportantfactor.

Atthelastevaluationperiod,60daysafterthesurgery,the twogroupsdifferedstatistically,with94pointsinGroup1and 90pointsinGroup2,bothclassifiedasgood.Inthisevaluation, werealizedthatthetwogroupsdifferedprimarilyintheitem “climbing stairs”,but withoutstatisticaldifferencebetween values.

IntheallocationoftheresultsoftheLysholmetal. ques-tionnaireonagraph,earlierimprovementoffunctioninGroup 1versusGroup2wasnotedinallassessments(p<0.001)(Fig.2). Inthisstudy,somecomplicationsoccurred:eightpatients inGroup1reportedaneedforanalgesiaafterinfiltration.Insix ofthesecases,twopatientsrequiredonlyonedoseofdipyrone 50drops,andintwoofthem,twodaysofdipyrone50drops 8/8hwererequired.

Noneofthepatientshadpost-operativeinfections,joint stiffness,orscarchanges.

Discussion

Table2–ResultofmultiplecomparisonsofVASamonggroupsandtimepoints.

Group/timepoint Comparison Meanestimated

difference

Standarderror tvalue gL p

Group1 3days–8days 3.86 0.10 38.60 384 <0.001

3days–15days 5.20 0.13 41.05 384 <0.001

3days–30days 6.22 0.14 44.25 384 <0.001

3days–60days 7.02 0.15 47.27 384 <0.001

8days–15days 1.35 0.10 13.48 384 <0.001

8days–30days 2.37 0.13 18.67 384 <0.001

8days–60days 3.16 0.14 22.49 384 <0.001

15days–30days 1.02 0.10 10.21 384 <0.001

15days–60days 1.82 0.13 14.33 384 <0.001

30days–60days 0.80 0.10 7.97 384 <0.001

Group2 3days–8days 2.27 0.10 22.67 384 <0.001

3days–15days 4.33 0.13 34.12 384 <0.001

3days–30days 6.37 0.14 45.26 384 <0.001

3days–60days 7.06 0.15 47.55 384 <0.001

8days–15days 2.06 0.10 20.63 384 <0.001

8days–30days 4.10 0.13 32.35 384 <0.001

8days–60days 4.80 0.14 34.09 384 <0.001

15days–30days 2.04 0.10 20.42 384 <0.001

15days–60days 2.73 0.13 21.57 384 <0.001

30days–60days 0.69 0.10 6.94 384 <0.001

3days Group1–Group2 −0.10 0.16 −0.64 384 >0.999

8days Group1–Group2 −1.69 0.16 −10.59 384 <0.001

15days Group1–Group2 −0.98 0.16 −6.12 384 <0.001

30days Group1–Group2 0.04 0.16 0.26 384 >0.999

60days Group1–Group2 −0.06 0.16 −0.38 384 >0.999

matrixandispresentinhighconcentrationsincartilageand synovialfluid.10

Some authors claimthat sodium hyaluronate, which is a defined fraction of hyaluronic acid, has analgesic and anti-inflammatoryproperties,contributestothe normaliza-tion of fluidity or viscoelasticity of the synovial fluid and totheactivation oftissueregenerationintheaffected car-tilage, and restores the functional balance of the joint. Therefore, they recommend its use for the treatment of osteoarthritis.4,13,14

Somestudieshavereportedthat,inadditiontorelieving painandimprovingfunction,theuseofhyaluronicacidcould

alterthecourseofosteoarthrosisandimprove qualitatively and quantitativelythearticularcartilage.Theseindications are based on studies of imaging such as X-ray and MRI, in which therewas an increase incartilage volume and a decrease injoint space afterthe treatment versus placebo. Thesebenefitsarealsobasedonthebestqualityofthematrix andonahigherdensityofchondrocytesinbiopsystudiesafter theimplementationoftreatment.4

Inanimalstudies,Plaasetal.15_{concludedthathyaluronic}

acid suppresses synovialhyperplasia and the development ofperiarticularfibrosis,andprotectagainstcartilageerosion, andalsoactstorelievepainintheshortterm(dilutionofjoint

Table3–ResultofmultiplecomparisonsofLysholmquestionnaireamonggroupsandtimepoints.

Group/timepoint Comparison Meanestimated

difference

Standarderror tvalue gL p

Group1 Pre–15days 1.10 0.28 3.92 288 0.003

Pre–30days −43.47 0.33 −133.55 288 <0.001

Pre–60days −47.76 0.34 −140.79 288 <0.001

15days–30days −44.57 0.28 −158.49 288 <0.001

15days–60days −48.86 0.33 −150.11 288 <0.001

30days–60days −4.29 0.28 −15.24 288 <0.001

Group2 Pre–15days 12.02 0.28 42.74 288 <0.001

Pre–30days −28.88 0.33 −88.72 288 <0.001

Pre–60days −41.84 0.34 −123.34 288 <0.001

15days–30days −40.90 0.28 −145.43 288 <0.001

15days–60days −53.86 0.33 −165.47 288 <0.001

30days–60days −12.96 0.28 −46.08 288 <0.001

Pre Group1–Group2 −1.73 0.35 −5.01 288 <0.001

15days Group1–Group2 9.18 0.35 26.54 288 <0.001

30days Group1–Group2 12.86 0.35 37.16 288 <0.001

0 10 20 30 40 50 60 70 80 90 100

-10 0 10 20 30 40 50 60 70

Dia

Lysholm

Group 1 Group 2

Fig.2–Graphicalrepresentationofthemeanprofilesand respectivestandarderrorsofLysholmquestionnaire, accordingtogroups.

fluid)andinthelongterm(blockingofpainreceptors),and improvethegaitpatternoftheosteoarthrosisknee.

Currently,theuseofintra-articularhyaluronicacidisalso widelydiscussedbecauseofthedifferentformulations,with differentmolecular weightsand theresultsofsome meta-analyses.Thesestudiesalsodifferintheparameterusedand furtherincreasethediscussionastotheeffectivenessofits use.16

Huanget al.,13_{inarandomized,double-blind,}

multicen-terstudy,evaluatedinonesampleofthe Asianpopulation theuseofintra-articularhyaluronicacidversusplacebo.These authorsfoundstatisticallysignificantimprovementin reduc-ingthepainandinthekneefunction,especiallyafterthefifth weekoftreatment.Thesebenefitshaveremainedeffectivefor upto25weeks.Inthesubjectiveevaluation,favorableresults withitsusealsowerenoted.Regardingtheconsumptionof acetaminophenandthevolumeofjointfluid,therewasno statisticallysignificantdifferenceforanygroup.11

Theseresultsare consistentwiththe study by Navarro-Sarabiaetal.,17_{inwhichtherewasastatisticallysignificant}

difference in favor of hyaluronic acid in the categories of painrelief,improvedfunctionandoverallimprovementofthe patientversusplacebo.

Bannuruetal.,14_{inameta-analysiscomparativeoftheuse}

ofintra-articularhyaluronic acidversus placebo, concluded thathyaluronicacidiseffectiveasearlyasthefourthweek oftreatment, with peak effectiveness at eight weeks, and remainingbeneficialforupto24weeks.Theseauthors eval-uatedtheeffectivenessforpainrelief,improvedfunctionand decreasedjointstiffness.

Leeetal.18_{believethattheanalgesiceffectofhyaluronic}

acid in the first five weeksis equal tothat ofplacebo. In their prospective and randomized study, the authors con-cludedthattheuse ofcetorolac associatedwithhyaluronic acidshowedmorerapidanalgesiaversusmonotherapywith hyaluronic acid. In the fifth week this analgesia achieved equalintensityinbothgroups(hyaluronicacidwith cetoro-lac×hyaluronicacidalone).

Butit isworthbearinginmindthattheaforementioned studies evaluate the hyaluronic acid in the treatment of

osteoarthrosis;hence,itisinterestingtoquotethem,because they discuss the efficacy ofhyaluronicacid as ameans of improvingfunctionandpain.

Regardingtheuseofhyaluronicacidinthepost-operative ofarthroscopy,ForsterandStraw19_{comparedpainand}

func-tion in activities of daily living in patients with isolated arthroscopy versus arthroscopy associated with hyaluronic acid.Theseauthorsconcludedthattherewasimprovement offunctionwiththeuseofHA,butwithoutdifferenceinthe categoryofpain.

Heybeli et al.1 _{compared pain and function in patients}

with 40–65yearsold with mildtomoderate osteoarthrosis and whounderwent arthroscopywithand withoutthe use ofhyaluronicacid(HA)post-operatively.Therewasno statis-ticallysignificant differencewithrespecttopain,but there wasimprovementinfunctioninpatientswhousedHA.Inour study,weobservedthesameresultwithrespecttofunction improvement,mainlyuntilthe30thday,bothbytheLysholm questionnaireandbythegoniometermensuration.However, withregardtopain,untilthethirddaytheresultsconfirmthe literature,withnodifferencewiththeuseofthemedication inquestion;thereafter,patientstreatedwithhyaluronicacid hadlesspainversuscontrolgroup,andthisanalgesiaachieved equalintensityinthe30thday-evaluationandfromthenon.

Hempfling10 _{also contrasted isolated arthroscopy versus}

arthroscopyassociatedwithHAinthe itemsofnightpain, pain when walking, and ability to walk 100 meters with-out pain. A clear symptomatic improvement occurred in bothgroups,comparedwithpreoperativevalues;butinthe group using HA this improvement lasted longer. In our study, therewas alsosignificant improvementin pain and function versus preoperative assessments, but this differ-ence wasobservedintheinitialevaluations.Afterthe60th day,animportantdifferencebetweentheratingsofGroups 1 and 2 was not observed, which can be justified by the lack ofassessmentof patientsover a longer period, when maybe we could observe results equivalent to the litera-ture.

In2007,Ulucayet al.20_{comparedtheuse ofthreetypes}

of HA in women40–60 years old with mild osteoarthrosis and degenerative meniscal lesion,after arthroscopy. These authors concluded that HA is effective therapy for these patients.

Alsoin2008,Atay etal.21 _{comparedthe effectofHAof}

high and lowmolecular weight versus placebo interms of pain,stiffnessandfunctionalabilityatsixand12monthsafter arthroscopicdebridementinpatientswithmildtomoderate osteoarthrosis. Aftersix months,there was nostatistically significantdifference,butthisoccurredafter12months.The authorsconcludedthattheuseofHAresultsbeneficialand improves the effectivenessof treatment, regardless of the substance’shighorlowmolecularweight.Inourstudy,pain improvement wasobserved untilthe 15th day, withbetter rangeofmotionandfunctionalcapacityuntilthe30thday. There was nostatistical differencefor theitems evaluated fromthe60thday.

Waddell andBert,2 _{inasystematicreviewconductedin}

decreasepainandimprovethefunctionofasignificant num-berofpatientspost-operatively.Inourstudy,theimprovement ofpain,function,andrangeofmotioninpatientswhowere treatedwithHAinfiltrationwasobserved.Theimprovement ofpainisobserved intheinitialstage, especiallyuntilthe 15thday;ontheotherhand,thefunctionandrangeofmotion improvedafterthisperiod.Webelieveinadirectrelationwith thiseffect:withlesspain,thepatientcanachieveafaster reha-bilitation,withmorequality,besidesafasterreturntohis/her dailyfunctions.

When interpreting more deeply the Lysholm question-naire,ourresultsdemonstrated,intheinitialevaluation,that although both groups were classified as poor, the superi-ority of the patients in Group 1 was justifiedby the best assessmentsin relation topain and swelling.This finding corroboratestheresultsofVASandcanbeexplainedbythe analgesic and anti-inflammatory effect of hyaluronic acid.

4,13,14

Inthe30thdayevaluation,wefoundthegreatestdifference betweenGroups1and2:90and77points,respectively.The maindifferencesareintheitem“swelling”,againbecausethe anti-inflammatoryeffectofHA.Asof“claudication”, “instabil-ity”and“squatting”,webelievethat,bythistime,withamore effectivetherapy and because ofalower intensity ofpain, itispossiblethatthepatientbesubmittedtomoreintense demands and achieve an earlier gain ofmuscle mass and proprioception.Thiswouldfacilitatetheactivitiesabove eval-uated.Fromthe 30th,the painwassimilarinbothgroups, andintheassessmentofthe60thdaybothgroupswere clas-sifiedasgood,withstatisticalsuperiorityinGroup1versus Group2(94×90,respectively).Thissuperioritywasduetothe

improvedabilitytoclimbstairsbyGroupHApatients,likely duetothebettermusclereservesacquired inthe initial60 days.

Conclusion

Giventhesubjective parametersevaluated, webelievethat theuseofintra-articularinfiltrationsofsodiumhyaluronate 20mgin proceduresof arthroscopicsurgery ofthe knee is fullyjustified,asthispracticeleadstoadecreaseinpainin theinitialphase,enablesfasterpatientrecoveryand gener-atesafasterreturnandbetterqualitytotheactivitiesofdaily living.

Ourstudyhassomelimitations:theshortperiodof eval-uation ofpatients (wewere unable toverify the effects of hyaluronicacidinthemediumandlongterm),andalsothe factofthesubjectivityoftheevaluationofpatients’function. Thisimpliesthatperhapsanisokineticevaluationwithcybex couldbetterdemonstrateamuscledifferencesbetweenthe twogroupsofindividuals.Webelievethatthis isthemain causeofimprovementofthefunctiononthe60thday. Unfor-tunately,wecould notproceedwiththis optionforlackof money.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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