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Combined intra-articular injection of corticosteroid and hyaluronic acid reduces pain compared to hyaluronic acid alone in the treatment of knee osteoarthritis

Knee Surgery, Sports Traumatology, Arthroscopy volume 27, pages 1974–1983 (2019)Cite this article

Abstract

Purpose

Intra-articular injections of corticosteroid (CS) and hyaluronic acid (HA) have individually demonstrated efficacy for knee osteoarthritis (OA); however, both treatments are limited by the trajectory of symptom relief. The combination of CS and HA in the management of knee OA may provide improved symptomatic relief for patients who are candidates for intra-articular therapies.

Methods

Electronic databases Medline, EMBASE and Cochrane Library were used to identify relevant publications. Randomized controlled trials (RCT) that evaluated intra-articular injections of combined CS and HA in comparison to HA alone were included. Outcomes eligible for meta-analysis were WOMAC pain, WOMAC total, OMERACT-OARSI responder rate, and treatment-related adverse events. Standardized mean differences (SMD) were calculated for continuous outcomes using an inverse variance method and a random-effects model. Odds ratios (OR) were calculated for dichotomous outcomes using the Mantel–Haenszel method and a random-effects model. Heterogeneity was assessed using the I2 statistic.

Results

Eight trials (n = 751 patients) were included. Reduction in WOMAC pain scores at 2–4 weeks favoured the combined CS and HA group compared to HA alone [SMD 0.60, 95% CI (0.23, 0.97); p = 0.002, I2 = 75%]. Longer term improvements at 24–26 and 52 weeks WOMAC pain scores also favoured the combined CS and HA group {[SMD 0.25, 95% CI (0.09, 0.41); p = 0.002, I2 = 0%] and [SMD 0.39, 95% CI (0.01, 0.77); p = 0.05, I2 = 0%]} compared to HA alone, respectively. There were no significant differences in WOMAC total scores, OMERACT-OARSI responder rate, or treatment-related adverse events.

Conclusion

Combined intra-articular injections of CS and HA led to reductions in pain at 2–4, 24–26 and 52 weeks compared to HA injections alone.

Level of evidence

Level II—meta-analysis.

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Funding

This study was not funded.

Author information

Affiliations

  1. OrthoEvidence, 3228 South Service Rd, Burlington, ON, Canada

    Christopher Smith, Christopher Vannabouathong & Brendan Sales

  2. McMaster University, 1280 Main St W, Hamilton, ON, Canada

    Rahil Patel, Alexander Rabinovich & Mohit Bhandari

  3. University of British Columbia, 2329 West Mall, Vancouver, BC, Canada

    Robert McCormack

  4. University Laval, 1050 Avenue de la Medecine, Quebec City, QC, Canada

    Etienne L. Belzile

Authors
  1. Christopher Smith
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  2. Rahil Patel
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  3. Christopher Vannabouathong
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  4. Brendan Sales
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  5. Alexander Rabinovich
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  7. Etienne L. Belzile
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  8. Mohit Bhandari
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Corresponding author

Correspondence to Christopher Smith.

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Conflict of interest

Authors Christopher Smith, Rahil Patel, Christopher Vannabouathong, and Brendan Sales declare they have no conflicts of interest. Author Mohit Bhandari declares research funding and grants from Sanofi, Pendopharm, Ferring, DJO, and Acumed. Author Alexander Rabinovich declares consulting for Sanofi and Pendopharm, Author Robert McCormack declares receiving speaker honorariums from Sanofi and Pendopharm and is on an advisory board for Sanofi and Pendopharm, Author Etienne L. Belzile declares receiving funding from the Canadian Institute of Health and Research, speaking honoraria from Stryker, Smith & Nephew, and Victhom, and has a position on an advisory board for Amgen, Pendopharm, and BodyCad.

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This is a systematic review and meta-analysis no ethical approval is required.

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Smith, C., Patel, R., Vannabouathong, C. et al. Combined intra-articular injection of corticosteroid and hyaluronic acid reduces pain compared to hyaluronic acid alone in the treatment of knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc 27, 1974–1983 (2019). https://doi.org/10.1007/s00167-018-5071-7

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  • DOI: https://doi.org/10.1007/s00167-018-5071-7

Keywords

  • Knee osteoarthritis
  • Corticosteroid
  • Hyaluronic acid
  • Combination therapy