A 72 year old woman presented with severe pain at her knees for over 5 years. She had history of chronic obstructive pulmonary disease for 10 years, diabetes mellitus for 20 years, and hypertension for 30 years. In addition to physiotherapy, intra-articular steroid two years ago and hyaluronic acid injections one year ago had been applied, and her complaints had not resolved with these treatments, although she used 500 mg paracetamol, 30 mg caffeine, 10 mg codein every six hour and 25 mg dexketoprofen trometamol every eight hour.
The last physician patient was referred had recommended total knee prosthesis but stated that surgical intervention would be unfavorable due to her irregular chronic diseases. After all, the patient was referred to our clinic.
Physical examination revealed tenderness at medial and lateral collateral ligaments, pes anserius, patellar ligament, and coronary ligament. There was a decrease at joint flexion angle, range of motion (ROM = 90 degree) and stress tests were positive.
Visual Analog Scale (VAS), established by Price et al. (
4), was used to measure the pain level of the patient. Pain level was detected as close to the most severe pain level (Scala 1).
The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale (
5) was applied to measure the osteoarthritis level of the patient: Pain level; 25 points, stiffness level; 10 points, Physical function loss; 80 points, and total WOMAC 115 points.
At radiological evaluation, the patient was diagnosed as grade IV osteoarthritis due to significant osteophyte presence and complete joint space narrowing (
Table 1) ( Figure 1).
Table 1. Radiological Knee Staging of Gonarthrosis Patients
Stage Explanation 1 Minimal osteophyte, normal joint space 2 Significant osteophyte, suspicious joint space narrowing 3 Significant osteophyte and significant joint space narrowing 4 Significant osteophyte and complete joint space narrowing
Figure 1. Knee Radiography Before Prolotherapy
Blood analysis and biochemical tests were reported as normal. Administration of prolotherapy protocol was decided after getting the written informed consent from the patient.
2.1. Therapy Protocol
Six sessions of knee prolotherapy protocol was applied to the patient, one session monthly.
The patient was monitored with ECG, arterial blood pressure and pulse oximeter measurements. 50 mcg fentanyl, 1 mg midazolam, and 50 mg propofol were given to the patient in divided doses for sedoanalgesia.
Tenderness points at examination were marked after sterilizing the injection area. 4 cc of 25% dextrose + 4 cc of 0.2% lidocaine solution was injected intra-articularly. Lateral knee injections.
0.5 cc of 15% dextrose + 0.5 cc of 0.2% lidocaine solution was injected to per certain points around the joint (joint capsule, insertion of medial coronary ligament, insertion of medial collateral ligament, teno-periosteal junction, insertion of pes anserious semimembranosus point over tibia, insertion of gastrocnemius and adductor magnus points over femur, fibro-osseous junction, insertion of arcuate and oblique ligaments, insertion of lateral coronary ligament, insertion of lateral collateral ligament, teno-periosteal junction, iliotibial tract at tibia, insertion of biceps femoris point at fibular head, insertion of gastrocnemius and popliteus points at femur).
We administered five times the skin attempt for 15 point injections and used 22 cc solutions totally.
Nonsteroidal anti-inflammatory drugs and steroids have been lost. Weight loss, decreasing the weight bearing on the joint, stretching exercises and physiotherapy was continued.