Hyaluronic acid injections for osteoarthritis of the knee: predictors of successful treatment
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This study aimed to identify patient and treatment factors that predict a favourable response to intra-articular hyaluronic acid (HA) treatment to better guide patient and treatment selection.
This prospective, observational study evaluated patients with mild-to-moderate (Kellgren–Lawrence grades 1–3) primary knee osteoarthritis treated between March 2013 and May 2016. Patient function and pain scores were assessed by the Western Ontario and McMaster Universities Arthritis Index/Knee Injury and Osteoarthritis Outcome Score (WOMAC/KOOS) and visual analogue scale (VAS) surveys, with response to treatment defined according to the Osteoarthritis Research Society International (OARSI) 2004 criteria. Surveys were completed at each injection and three months post-treatment. Patients were followed an average of 27 months.
Of 102 patients, 57% had a positive response. Those at least twice as likely to respond were patients with grades 1–2 osteoarthritis or a positive response to the first injection and those who were ≥60 years. Gender, race, body mass index (BMI), smoking status, HA brand, and initial VAS and WOMAC/KOOS scores were not significant predictors of success. Mean time to arthroplasty following injection series was 11 months (30% of nonresponders, 12% of responders). The VAS strongly correlated with KOOS pain scores and successful outcomes.
Patients with mild-to-moderate osteoarthritis (grades 1–2) and those responding positively to the first injection were twice as likely to respond positively to the injection series, as were patients ≥60 years. Patients who did not respond positively were more likely to proceed to arthroplasty. The VAS appears to be a reliable method of defining and monitoring treatment success. Judicious patient selection and counseling may improve outcomes associated with intra-articular HA injections.
KeywordsOsteoarthritis Knee Hyaluronic acid Injection Viscosupplementation
Source of funding
This study received no financial assistance or incentives from pharmaceutical or other industry sources. The Campbell Foundation provided US$1300 for patient stipends. No author received direct or indirect financial support related to this study.
Compliance with ethical standards
Conflict of interest
Authors Bowman and Hallock declare that they have no conflict of interest. Author Azar has received consultant fees from 98point6, Iovera, and Zimmer and publishing royalties from Elsevier; he serves on the governing/editorial board/committee of the ABOS, Am J Sports Med, Orthop Clin N Am, and St. Jude Children’s Research Hospital. Author Throckmorton has received consultant and speaker fees, IP royalties, and research support from Biomet and Zimmer; he receives publishing royalties from Elsevier, and serves on the governing/editorial board/committee of the AAOS, Am J Orthop, American Shoulder & Elbow Surgeons, J Orthop Trauma, Mid-America Orthop Assoc, Orthop Clin No Am, and Tech in Shoulder & Elbow Surgery.
- 6.Adams ME, Atkinson MH, Lussier AJ, Schulz JI, Siminovitch KA, Wade JP et al (1995) The role of viscosupplementation with hylan G-F 20 (Synvisc) in the treatment of osteoarthritis of the knee: a Canadian multicenter trial comparing hylan G-F 20 alone, hylan G-F 20 with nonsteroidal anti-inflammatory drugs (NSAIDs) and NSAIDs alone. Osteoarthr Cartil 3:213–225CrossRefPubMedGoogle Scholar
- 14.Bellamy N, Buchanan WW, Goldsmith CH, Campbell J, Stitt LW (1988) Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. J Rheumatol 15:1833–1840PubMedGoogle Scholar
- 24.Newberry SJ, Fitzgerald JD, Maglione MA, O’Hanlon CE, Booth M, Motala A et al (2015) Systematic review for effectiveness of hyaluronic acid in the treatment of severe degenerative joint disease (DJD) of the knee. AHRQ Technology Assessments, RockvilleGoogle Scholar
- 31.Bruyere O, Cooper C, Pelletier JP, Maheu E, Rannou F, Branco J et al (2016) A consensus statement on the European Society for Clinical and Economic Aspects of osteoporosis and osteoarthritis (ESCEO) algorithm for the management of knee osteoarthritis-from evidence-based medicine to the real-life setting. Semin Arthritis Rheum 45:S3–11CrossRefPubMedGoogle Scholar
- 36.Lohmander LS, Dalen N, Englund G, Hämäläinen M, Jensen EM, Karlsson K et al (1996) Intra-articular hyaluronan injections in the treatment of osteoarthritis of the knee: a randomised, double blind, placebo controlled multicentre trial. Hyaluronan multicentre trial group. Ann Rheum Dis 55:424–431CrossRefPubMedPubMedCentralGoogle Scholar
- 40.Saltzman BM, Leroux T, Meyer MA, Basques BA, Chahal J, Bach BR Jr et al (2016) The therapeutic effect of intra-articular normal saline injections for knee osteoarthritis. Am J Sports Med Dec 1:363546516680607Google Scholar
- 43.Miller LE, Block JE (2013) US-approved intra-articular hyaluronic acid injections are safe and effective in patients with knee steoarthritis: systematic review and meta-analysis of randomized, saline-controlled trials. Clin Med Insights Arthritis Musculoskelet Disord 6:57–63CrossRefPubMedPubMedCentralGoogle Scholar
- 45.Campbell KA, Erickson BJ, Saltzman BM, MascarenhasR BBR Jr, Cole BJ et al (2015) Is local viscosupplementation injection clinically superior to other therapies in the treatment of osteoarthritis of the knee: a systematic review of overlapping meta-analyses. Arthroscopy 31:2036–2045CrossRefPubMedGoogle Scholar