Improved Knee Function after Intraarticular Administration of a New Drug Combination : a Case Series Report

Degradation of the articular cartilage in arthritis involves both the cellular, functional component (chondrocytes, etc.) and the structural component (extracellular matrix with collagen, etc.) via distinct molecules and cross-talking pathways; this makes it diffi cult to re-establish physiological status after the pathological processes have begun. Minimally invasive procedures intraarticular injections, IAI were shown to be superior to oral medication, however the effi cacy of current intraarticular injections is limited, probably because of their narrowed focus on one of the two pathological processes: cellular inflammation (steroids) or extracellular matrix diminution (hyaluronic acid). Here we describe for the fi rst time the intraarticular administration of a combination of medicinal products with pleiotropic actions, which simultaneously addresses these processes. Starting in November 2015, 5 patients with arthritis were treated with 64 IAIs (50 knee, 14 ankle) and followed up for up to 2 years. Signifi cant and sustained improvement in articular pain, stiffness and function was observed in these patients; this was quantifi ed with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Likert scale version. Xrays showed no deterioration after 2 years in a patient with grade I osteoarthritis, and improvement of the knee cartilage in a patient with grade III osteoarthritis.


INTRODUCTION
Pathological modifi cations of the large joints (knee, hip, shoulder, ankle) due to trauma and/or infl ammation are a common occurrence, which increases as the general population gets simultaneously older and more active 1 .Progress in this therapeutic area has not kept up with the increased need for more effi cient treatments, an overall consideration which includes effi cacy in reducing discomfort, cost of treatments, presence of adverse reactions and the long term eff ects on the function and structure of the joints, which may prompt the need for repeated or diff erent treatments.
Systemic drugs (NSAIDS, steroids, diacerein, acetaminophen, etc) have important analgesic and antiinfl ammatory eff ects in osteoarthritis (OA), but there are limitations in their effi cacy and they have welldocumented gastrointestinal and cardiovascular side eff ects 2 .Good results were obtained in some patients with supplements containing chondroitine sulfate, glucosaminoglycans, collagen, Curcuma, Boswellia, Harpagophytum, Uncaria, etc.; homeopathic treatments, both systemic and injectable, are also available with variying degree of success 3,4 .
Intraarticular injections (IAIs, infi ltrations) are a less invasive, less risky and less expensive treatment option.Th e drugs most commonly used for such infi ltrations are steroids and hyaluronic acid, and both seem to have important limitations: steroids rapidly reduce joint pain, but do not improve signifi cantly stiff ness or physical function 2 and have important short -(Tachon syndrome 5 ) and long-term side eff ects (more cartilage and joint degradation when compared to saline 6 ), while hyaluronic acid has much less side eff ects when properly injected (ultrasound guidance is recommended by some clinicians) but their long-term effi cacy is questioned 7 .Good results were reported more recently after IAIs with PRP (platelet rich plasma 3 , autologous stem cells 8,9 , autologous protein solution 10 , ozone 11 , and interleukin 1 receptor antagonists 12 , however their cost is much higher than drug IAIs, leaving them out-ofreach for many patients. Infi ltrations using biological ultrafi ltrates (marine -Afl utop or veal -Actovegin) were previously done with various degrees of success 13,14 etc.We propose that their benefi cial actions can be signifi cantly enhanced by the addition of substances with known, important and complementary actions: ascorbic acid (vit C) and dimethylsulfoxide (DMSO).Vit C is essential for collagen synthesis and modulation of mitochondrial activity in the hypoxic conditions of cartilage via hypoxia-inducible factor 1 (HIF-1), as well as an essential an-tioxidant cofactor for the ferrous-dependent enzymes mono-and di-oxygenases 15 , while DMSO is excellent for permeabilising tissues and cells to various substances, while at the same time having protective eff ects on stem cells which may mature in functional chondrocytes 16,17 , and also signifi cant antiinfl ammatory and antioxidant actions [18][19][20] .
Here we report the successful administration through IAI of a new combination of three pharmaceutical products already available for medical use: deproteinated veal serum (Actovegin, Act) or fi sh extract (Afl utop, Afl ), together with vitamin C (vit C) and dimethylsulfoxide (DMSO).

Patient 1 (November 2015 -January 2018)
First patient was a 68 year old female with HT, chronic sinusitis, obese (BMI -35.4,who had difficulties walking, bending the knees, climbing stairs, for which she was taking NSAIDS and advised to lower body weight (which she tried repeatedly but unsuccessfully).She was taking 400 mg Ibuprofen daily for the previous 2 months, but still was unable to walk up the stairs and was severely restricted by pain during household chores, with left knee being especially painful and stiff .WOMAC score was 27 total, 6 for pain subscale, 3 stiff ness, 18 physical function.
A radiography of the knee done in 2015, showed bilateral femoro-tibial arthrosis with incipient reduction of the articular interline, especially on the internal aspect of the knees; also incipient femoro-patellar arthrosis.
Clinical evaluation showed both knees with mild periarticular swelling; left knee being more painful to palpation and with moderate periarticular tension (fibrosis), especially of the peripatellar ligaments.
In November 2015 7 IAIs were administered in both knees (4 in left, 3 in right knee) all with Afl utop only.Xilin 1 mg was administered prior to IAI, and afterwards a topical cream was applied, which contained plant extracts, plant fat and DMSO.
After the fi rst IAI which was done in the left knee, the patient reported less pain and discomfort and decided to continue with infi ltrations in both knees.After 3 series of bilateral infi ltrations administered in an 18 day interval the patient felt better, much less pain and discomfort and was able to walk up two fl ight of stairs and needed no more ibuprofen.
After 6 months -May 2016 -4 more IAIs were administered (2 in each knee with 3 days in between) also with Afl utop; at this visit there was much less contrac-tion, swelling and tenderness in the articular capsules of both knees.
WOMAC score was 6 total -1 for pain subscale, 0 for stiff ness, 5 for physical function.
In November 2016 were administered 6 more IAIs (3 in each knee), all with Act+DMSO +Vit C) and in May 2017 were performed the fi nal 6 IAIs, 2 with Afl u+DMSO+Vit C, and 4 with Act+DMSO +Vit C.
A bilateral knee radiograph was done in May 2017 which showed minimal narrowing of the femoro-tibial articular space present in the median part of articulation.Th e patient stated she has no pain, stiff ness or alteration of physical function (WOMAC 0).
Patient was seen again in October 2017, again stated that she had no discomfort and no IAIs were administered.As of January 2018 the patient was still pain-free, with no discomfort or limitation of physical function of the knees.
Notable for this patient with grade 1 osteoarthritis is the rapid improvement (after the fi rst 2 injections) and sustained eff ect both in reducing knee discomfort as well as stopping further deterioration of knee in 2 years.

Patient 2 (March 2016-February 2018)
75 year old male with heart failure NYHA class II, atrial fi brillation, stage II hypertension, stroke history, hypercholesterolemia, and postraumatic osteoarthritis of the left knee stage II-III (fell while playing with grandkid).His medication included Pradaxa, Concor, Pramistar and Tertensif.
Magnetic resonance imaging (MRI) of the knee was done in July 2014, and showed:  narrowed tibio-femural space;  left and right knee meniscus with greatly reduced dimensions and heterogenous structure;  subcortical erosions of the internal femural condilus;  moderate intraarticular liquid; suprapatelar bursa fused at transverse ligament.

Conclusion-Stage III gonarthrosis with degenerative modifi cations of menisci and ligaments
WOMAC initial total score was 23; with subscalespain 8, stiff ness 2, physical function 13.
Patient used topical treatment with plant extracts for 2 years, which brought some relief, and he was administered 3 IAIs in left knee in March 7, 28, April 5 2016.Xilin 1 ml and afterwards Afl utop was administered with all 3 IAIs; patient stated that he had much less pain and discomfort in left knee, improved painfree range of movement.
Approximately 3 months after last IAI the patient injured again his left knee while playing with grandkid; and afterwards IAIs were not repeated.
Both knees and ankles were severely swollen, with important fi brosis and large, deforming osteophytes (Fig 1A, B and C).WOMAC initial total score was 52: with 12 on pain subscale, 4 for stiff ness and 36 for physical function.
IAIs were done without anesthesic due to concerns about cardiac function (presence of bradycardic episodes with frequent ventricular and supraventricular extrasystole) and was monitored with Holter during the IAIs.Th is patient had severe pain during injection in the right knee, radiating upwards on the thigh, and also had 3 episodes of emesis immediately after Actovegin administration.After the patient reported being sensitive to and not consuming veal meat, Actovegin, was replaced with Afl utop and emesis did not happen again.Th e pain felt during IAIs subsided in minutes following the application of a plant-based topical cream with plant extracts.An improvement in pain, stiff ness and physical function was reported starting with the day after IAIs.Th ere was no increase in the frequency of extrasystole on the Holter EKG recorded during and 30 minutes after the IAIs on both patient knees and ankles.
Th ere were 7 series of 4 IAIs each (both knees and ankles) administered to this patient; with variable intervals between them, noted in the brackets: I (27 days) II (7 days) III (67 days) IV (16 days) V (52 days) VI (87 days) VII.
Th e initial "on demand" strategy made it possible to estimate which administration schedule would give the best results, and it showed that at least 2 IAIs spaced at 1 week interval were needed for longer term relief of discomfort (at least 60 days relief ).
Patient was evaluated again in February 2018 (9 months after last IAIs) because of complaints about right knee discomfort.Pain in the right knee was causing most of the reported discomfort ("blocking" of the knee after standing for more than a few minutes -ex.waiting for the bus).At this time WOMAC total score was 22: pain 4, stiff ness 2, and physical function 16.Patient requested and received an IAI in right knee only (Act+DMSO+vit C; patient had moderate pain during and about 15 minutes after injection but no emesis) Patient 4 ( July-February 2018) 71 year old male in otherwise good health (BMI 25.6), presented with bilateral grade III knee osteoarthritis.Th is was the most severe case of osteoarthritis of the 5 presented here; Beginning with 2014 he had discomfort in both knees, and he received IAIs with hyaluronic acid, which was painful when administered and did not bring much relief (probably was not administered intraarticular).Afterwards he received IAI with ketoprofen, which relieved pain for about 10-12 months, but after that the pain was more severe than before, and the status of both knees deteriorated rapidly.Patient had severe pain at night which prevented and the improvement in right knee discomfort and physical function was prompt.
Pictures from Figure 1A, B, C were taken after 2 series of treatments (IAI on August 3 and 30, 2016), and those in Figure 2 A, B and C were taken after 3 treatments (IAIs on Sept 7, 2016); no signifi cant changes in the respective articulations were noted since.Importantly, this patient allowed a direct comparison of the Afl utop-based and Actovegin-based IAIs.In this patient, the combination Actovegin+DMSO+vit C, resulted in a much greater diminution of edema than those containing Afl utop (right knee vs left knee and to a lesser degree right ankle vs left ankle).(including ski, specialized dancing, aikido, etc).Prior to IAIs the discomfort became continuous, impeding her in regular activities and diffi cult to relieve with medication.She had a MRI done 1 week prior to the IAI which showed bilateral tear of internal meniscus and bursitis.
One IAI was administered in each knee, both IAIs with Act + DMSO + vit C. Patient had discomfort in the right knee immediately after the procedure; a cream with plant extracts applied topically helped relieve this discomfort.Next day patient reported no pain and improvement in stiff ness and physical function; she needed no other treatments for knee discomfort and she restarted regular activities, including regular aikido training.
WOMAC fi nal total score was 3: pain 1, stiff ness 0, physical function 2, and stayed the same 3 months after the IAI.
In Figure 4 are charted the patients' initial and fi nal WOMAC scores (before and after IAIs).Statistical signifi cance was calculated with the t-test for all the WOMAC scores (total, as well as subscales: pain, stiffness, physical function).Th ere was a statistically signifi cant overall improvement when comparing the initial and fi nal WOMAC scores in all 5 patients, for total WOMAC as well as subscale scores.For WOMAC total scores the two-tailed t-test value of t is -4.692858.
him from sleeping and had extreme pain while bending knees, which made standing up very painful, and was able to walk only by keeping the knees straight (not bending the knees at all placed extra strain on hip joints).
6 IAIs were administered in July, August and October 2017, 2 in each knee.First series was Afl alone, and the patient reported very little to no improvement, and was followed by two series of Act+DMSO+vit C. Patient reported improvement in pain (no more pain at night) after the fi rst Act+DMSO+vit C injection, and had considerable less discomfort at walking after the second Actovegin-containing IAI (was able to bend the knee more easily).
Figure 3A and 3B show X-rays of the left knee in 2014 and 2016 respectively; there is a great reduction in the cartilage volume between the 2014 and 2016 radiograph.After 3 series of IAIs, an Xray of left knee done in February 2018 (shown in Figure 3C) showed an improvement in the area corresponding to the medial meniscus.
Patient 5 (September -December 2017) 49 year old female with history of gastritis, surgery for hiatal hernia repair, BMI 27.1, with episodic knee discomfort after minor but repeated traumatic events Figure 3A.
Furthermore we are detailing those aspects in four important processes, even though they overlap and simultaneously interact: infl ammation; mitochondrial damage and apoptosis due to reactive oxygen species; collagen and extracellular matrix degradation; and availability of active substances at cellular level.Th e 4 processes mentioned are therapeutically addressed by the administration of the combination of substances via IAIs, and they are drawn together in Figure 5.As we are trying to present them as concise as possible, some of the molecules and paths linked to the ones represented are not mentioned in Figure 5.

A. infl ammation
It was shown that the OA cartilage produces more TNF-alpha and TNF alpha convertase enzyme (TACE) than normal cartilage; and also that neutralizing TNF-alpha suppressed cartilage degradation in arthritis 21 .
IL-1-induced phosphorylation of the mitogen-activated protein (MAP) kinases extracellular-signal regulated kinase (ERK), protein 38 (p38) and c-Jun Nterminal kinase ( JNK), results in down-regulation of MMP gene expression in chondrocyte.Th rough various pathways, IL-1 stimulates prostaglandin E2, nitric oxide synthase, and matrix metalloproteases, inhibits collagen synthesis, augments activation of T and B lymphocytes and production of further pro-infl ammatory cytokines, causes macrophages to release proteoly-and the value of p is 0.009.For the pain subscale the value of t is -7.839295 and the value of p is 0.001.For the stiff ness subscale, the value of t is -9.797959 and the value of p is 0.0006.For the physical function subscale, the value of t is -3.436407, and the value of p is 0.026.
After considering the results in the 5 patients treated with combination IAIs, the following observations are made:  a minimum of 2 IAIs at 1 week interval are needed for initial long-term pain relief and discomfort; best results are given by a series of 3 IAIs spaced at 4-7 days interval;  the eff ects of IAIs seem to be cumulative; the need for injections decreases over time;  even though Afl utop had good results when administered by itself, the addition of DMSO and vitamin C increased its effi cacy in reducing edema and pain;  Afl utop and Actovegin had comparable results when used in combination with DMSO and Vitamin C.

DISCUSSION
Even though the pathological processes in the OA joint are taking place simultaneously and are closely interlinked via direct or more complex molecular pathways, below we will focus on two main aspects: I. cellular-level modifi cations, most importantly of chondrocyte function and structure, and II.degradation of the extracellular matrix of the cartilage (collagen, GAGs, etc).

B. Mitochondrial damage and apoptosis due to reactive oxygen and nitrogen species
As is the case with all cells, mitochondria are of fundamental importance and they need to be protected from stressors, especially ROS, for preserving normal function of chondrocytes.Th e following observations were made 24 about mitochondria from OA chondrocyte  they were more susceptible to damage induced by pro-infl ammatory cytokines then mitochondria from normal chondrocytes; tic enzymes and chemotactic factors, and also stimulates osteoclasts to resorb bone, all of which promote joint degradation 23 .
As much as infl ammation plays a major role in many cases of OA, in some forms of osteoarthritis it is neither the incipient nor the predominant factor, as is the case with the collagenase induced OA 23 , and this can be explained by the next two important types of processes which take place in the OA cartilage.

C. Extracellular matrix degradation
Th is is the most visible process on radiography and MRI and can have multiple causes: infl ammation including infection and immune imbalance, mechanical trauma, oxidative stress, defi cient DNA repair associated with stress and senescence, endocrine imbalance, defi cit of vit C, ferrous iron, nitrogen-or sulphur rich molecules and possibly other microelements.
Regeneration of the cartilage starts with the availability of the necessary components, both inside the chondrocytes where aminoacids (from Act/Afl ) are assembled in the endoplasmic reticulum for collagen protofi brils, (also GAG, chondroitine sulfate, etc) under the epigenetic infl uence of growth factors and vit C, as well as in the extracellular matrix, where vitamin C is essential cofactor for a variety of enzymes, including prolyl-3-hydroxylase (P3H), prolyl-4-hydroxylase (P4H), and lysyl hydroxylase (LH), all which mediate collagen maturation and transformation of collagen protofi brills into full-strength collagen fi bers.
Also important is the trans-membrane transport of these substances into chondrocytes.In the case of vit C it is estimated that suboptimal plasma concentrations (30 μmol or less) are present in a signifi cant proportion of population, linked to improper nutrition or smoking or chronic conditions such as diabetes, which decrease its cellular availability.Complicating matters is the possibility of an impaired function of the sodium-dependent vitamin C transporter 2 (SVCT2), which ensures that vit C enters cells.Polymorphism in SVCT2 (Single Nuclear Polymorphysm in the SLC23A2 gene) is relatively frequent in the caucasian population and so far was linked to premature termination of pregnancy, neurodegeneration, head and neck squamous cell carcinoma, acute coronary syndrome in women 29 .

D. Cellular availability of the medication through tissue permeation
Th e dense, negatively charged matrix of cartilage is a major hurdle to the transport of potential therapeutics and the availability of medication to chondrocytes in the middle parts of the cartilage.
To this extent, the positively charged glycoprotein avidin was used as nanocarier for dexamethasone (Dex) and single intra-articular injections of Dex/low dose avidin-Dex were evaluated in rabbits, where it was observed that avidin-Dex suppressed injury-induced joint swelling and catabolic gene expression to a greater extent than free Dex 30 .
It is worth noting that neither treatment (Dex alone or Dex-avidin) restored the loss of cartilage stiff ness following cartilage tear, and the author suggested the  cytokines increase reactive oxygen and nitrogen species within chondrocytes as well as mitochondrial superoxide production;  increased NO production is the key factor responsible for accumulation of mtDNA damage after cytokine exposure;  Pro-infl ammatory cytokines IL-1 and TNF- induce mitochondrial DNA damage, decrease energy production and mitochondrial transcription, and fi nally induce apoptosis;  maintaining mitochondrial DNA integrity is necessary to prevent chondrocytes from apoptosis induced by IL-1 and TNF-.Protection of human chondrocytes from mtDNA damage by the mitochondria-targeted DNA repair enzyme hOGG1 rescued mtDNA integrity, preserved ATP levels, reestablished mitochondrial transcription, and signifi cantly diminished apoptosis following IL-1 and TNF- exposure.
A more direct correlation between oxidative damage and articular cartilage degeneration was shown in cartilage explants from QA patients, and that the presence of oxidative stress induces telomere genomic instability, replicative senescence and dysfunction of chondrocytes in the OA cartilage 25 .Furthermore, treatment of cultured chondrocytes with reactive oxygen species decreased telomere length, replicative capacity and GAG production.
Th e same author 24 established that in articular cartilages from human OA patients, the expression of hypoxia-inducible factor-1 (HIF-1) mRNA was higher in the degenerated regions than in the intact regions, and that HIF-1 expression in the OA cartilage is associated with the progression of articular cartilage degeneration.Catabolic-stresses, IL-1beta, and oxidative stress induce the expression of HIF-1 in chondrocytes, while inhibitors for phosphatidylinositol 3-kinase and p38 kinase cause a signifi cant decrease in catabolic-factor-induced HIF-1 expression.
HIF-1 protein activates the transcription of genes that are of fundamental importance for oxygen homeostasis at the mitochondrial level, including genes involved in energy metabolism, angiogenesis, vasomotor control, apoptosis, proliferation, and matrix production, under hypoxic conditions.HIF-1 is also involved in the up-regulation of microsomal prostaglandin E synthase 1 (mPGES-1) and cyclooxygenase 2 (COX-2), while treatment with 2-methoxyestradiol lowers its activity 27 .
HIF-1 protein is rapidly degraded by higher oxygen concentrations and most importantly its actions are inhibited by vit C 28 .
Ca, Mg, Fe, Cu, Zn), and maximum 5mg/100ml phenol as preservative.According to data from the summary of the medicinal product, it reduces infl ammation, inhibits hyaluronidase excess; restores chondrocytes homeostasis in damaged tissues; stimulates regenerative processes of the cartilage; modulates synthesis of synovial fl uid; stimulates superoxide dismutase; lowers formation of ROS.Intra-articular (IA) injections with Afl utop were shown to be eff ective in clinical trials.Th e recommended administration is 1-2 amps every third day into the joint for 21 days 33 .
Vitamin C plays essential roles in cartilage physiology, with major actions on both the cellular component (modulates functions of mitochondria and nuclei of chondrocytes, and consequently their function, maturation and apoptosis) and also on the extracellular matrix, where it acts as essential cofactor in collagen formation.Vit C protects chondrocyte mitochondria against oxidative damage and apoptosis, as well as nucleus by epigenetic modifi cations of nuclear DNA 34 .
In this regard, it is possible that the comparatively higher amounts of vit C present in the marine extract (Afl ) makes it more eff ective for cartilage healing than the veal ultrafi ltrate (Act).
Th e direct protective eff ect of Vit C on chondrocytes was observed after OA cartilage explants were treated with reactive oxygen species or vit C (100.0 micromol/l).Treatment of cultured chondrocytes with reactive oxygen species shortened telomere length and replicative lifespan of chondrocytes, while treatment with vit C had opposite, benefi cial eff ect on chondrocytes 23 .
Th e important epigenetic actions of Vit C on nuclear DNA is due to being an essential cofactor for reducing iron to Fe(II), a redox reaction which restores the catalytic activity of important enzymes: several histone-and DNA-modifying enzymes are Fe(II) 2oxoglutarate-dependent oxidases, as well as Jumonji C ( JmjC)-domain-containing histone demethylases which catalyze the removal of methyl groups from lysine residues of histone proteins in a two-step mechanism; the fi rst step, an oxidative reaction requires Fe(II) and 2oxoglutarate 15 .

CONCLUSIONS
IAIs with marine or veal extract in combination with DMSO and vitamin C produced signifi cant and sustained reductions in pain, stiff ness and improved physical function in patients with osteoarthritis, and also in patients with cartilage tear.need for a combinational therapy with a pro-anabolic factor for enhancing matrix biosynthesis 30 .
Th e therapeutic actions of the substances administered in our combination via IAI are numerous: DMSO has excellent tissue penetration capabilities and ensures that the chondrocytes at the center of the cartilage receive useful concentrations of the medication injected in the joint.Besides being an excellent aprotic solvent and permeabilising membranes for other molecules (similar to nanocarriers), DMSO has direct and important cellular actions:  inhibition of infl ammation, specifi cally the NF-B pathways, which lead to chondrocyte apoptosis.In OA, DMSO signifi cantly suppresses the expression of many pro-infl ammatory cytokines, chemokines and prostaglandin E2 (PGE2).viaERK1/2, p38, JNK and Akt phosphorylation 20 ;  the anti-infl ammatory actions of DMSO also are seen in attenuation of NLRP3 infl ammasome activation, IL-1 maturation, Caspase 1 acti vity, and ASC pyroptosome formation and mediates inhibition of IL-1s transcription 19 ;  in the human chondrocyte cell line C-28/I2, DMSO exhibits strong anti-infl ammatory properties by blocking IL-6 and IL-8 expression, both constitutive as well as IL-1-induced 18 .
Actovegin is a deproteinated ultrafi ltrate of calf blood, composed of more than 200 biological substances 31 .Besides being an important source of peptides, minerals and growth factors, preclinical studies have shown that Actovegin increases glucose uptake and improves oxygen uptake in ischemic conditions; mitigates the eff ects of irradiation and stimulates wound healing; and also has anti-oxidative and anti-apoptotic mechanisms of action by inhibiting poly (ADP-ribose) polymerase (PARP) activity (which may trigger events leading to apoptosis).
Actovegin also stimulates production of the extracellular matrix components: hexosamine, uronic acid, hyaluronic acid, chondroitinsulfate and heparin, which contribute to regeneration of cartilage 13 .
Finally, Actovegin was shown to improve clinical outcomes and reduce return to sport time in professional players, most likely by modulating infl ammation via CD68+ (which are elevated in OA synovial cells), and repair via CD163+ macrophages 32 .
Afl utop (Biotehnos, Romania) contains a marine fi sh bioactive concentrate (amino acids, low molecular mass peptides, mucopolysaccharides, trace elements: Na, K, tions, etc.), due to the essential roles played by ascorbic acid and DMSO described above, as well as in cell reprogramming (mesenchimal-to-somatic transition -Chen, 2013, and somatic into induced pluripotent stem cells -Wang, 2011 -all of which translate into therapeutic redress and makes possible the regeneration of the cartilage in the arthritic or traumatic joint.
Addition of vit C and DMSO to Afl utop resulted in improved eff ects, so that IAIs could be reduced to 2 or 3 spaced at 1 week, from the recommended 7 done every 3 days, when only Afl utop is administered.
Finally, the addition of vit C and DMSO is also proposed for improving the therapeutic success of other substances or cell suspensions injected intraarticularly (platelet rich plasma, autologous plasma, cell prepara-

Figure 4 .
Figure 4. WOMAC scale scores with subscales for pain, stiffness and physical func tion, initially and after IAIs for 5 patients.

Table 1 .
Dates and types of IAIs administered in Patient 3