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Hyaluronic acid injections for osteoarthritis of the knee: predictors of successful treatment



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.

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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.

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Corresponding author

Correspondence to Fredrick M. Azar.

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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.

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Bowman, E.N., Hallock, J.D., Throckmorton, T.W. et al. Hyaluronic acid injections for osteoarthritis of the knee: predictors of successful treatment. International Orthopaedics (SICOT) 42, 733–740 (2018).

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  • Osteoarthritis
  • Knee
  • Hyaluronic acid
  • Injection
  • Viscosupplementation