Knee osteoarthritis: Should your patient opt for hyaluronic acid injection?

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Applied Evidence

Knee osteoarthritis: Should your patient opt for hyaluronic acid injection?

J Fam Pract. 2006 August;55(8):669-674

By

Jennifer M. Medina, PhD, MS, ATC, CSCS

A meta-analysis of hyaluronic acid’s effects on pain, stiffness, and disability.

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References

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9. Huskisson EC, Donnelly S. Hyaluronic acid in the treatment of osteoarthritis of the knee. Rheumatology 1999;38:602-607.

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Practice recommendations

Hyaluronic acid (HA) injection may provide short-term relief of pain and improved functionality for patients with osteoarthritis of the knee, but benefits do not last beyond 6 months.
Examine the HA option from a cost-benefit perspective on a case-by-case basis. Based on our meta-analysis, there is no sufficient reason to recommend or not recommend HA injection for treatment of osteoarthritis of the knee.
You may want to help select patients weigh the possible benefit of HA therapy against its cost.

Though hyaluronic acid may reduce symptoms related to osteoarthritis of the knee, the relatively small and transient response in the population studied in our analysis does not provide sufficient reason to recommend or not recommend this therapy.

Those who might want to opt for hyaluronic acid injections

With the relatively low risk of complications, some patients may still opt to try hyaluronic acid injections as opposed to other osteoarthritis management strategies. Potential candidates include those whose only other option is surgery, in the hope that HA injection might postpone having to make that decision. Also, those whose pain or stiffness have not been relieved with other therapies might want to consider HA.

Two instruments for assessing osteoarthritis

There are many claims to the efficacy of hyaluronic acid injections for decreasing the pain associated with osteoarthritis of the knee. This meta-analysis was an attempt to collapse the data for hyaluronic acid treatment, using a reduction in score on the Western Ontario McMaster Universities Index (WOMAC) or the Lequesne index as its outcome measurement.

The WOMAC is a disease-specific, self-administered instrument for patients with osteoarthritis of the knee or hip. It has 3 separate dimensions (with 24 individual scenarios), measuring pain (5 scenarios), stiffness (2 scenarios), and physical function (17 scenarios). It may be administered using a 100 mm/10 cm visual analog scale (VAS) (where 0=none, 100 or 10=extreme) or a Likert scale (0 to 4, where 0=none, 4=extreme). These results are then scored on a 0 to 20 scale for pain, a 0 to 8 scale for stiffness, and a 0 to 68 scale for physical function. Lower scores for both scales indicate a lesser degree of pain, stiffness, or physical dysfunction. In a double-blind, randomized controlled trial, WOMAC was found to be a valid and reliable tool for determining self-reported status for osteoarthritis of the knee or hip.¹²

Osteoarthritis and hyaluronic acid

Osteoarthritis is a degenerative, debilitating disease that affects approximately 20.7 million adults in the United States.¹ It is the degeneration of the articular cartilage at synovial joints. There seems to be a genetic predisposition to developing osteoarthritis, although most people tend to experience some pain in their joints as they age, usually starting in their 30s or 40s.² Some elite athletes have even been reported as having arthritic changes in their 20s.³ Unfortunately, many factors may contribute to the pathological state of each person affected, making each case unique. It can be the result of general wear and tear at the joint, structural malalignments, or injury.⁴ With the surge in the elderly population, a more effective management strategy for osteoarthritis will improve quality of life and reduce health costs for many.

Hyaluronic acid, a normal component of synovial joints, the linear repeating polysaccharide that forms the central axis of proteoglycan aggregates, which are necessary for functional integrity of the articular cartilage.⁵ It is involved in joint lubrication and nutrition. Native hyaluronic acid increases the viscosity of the extracellular matrix, thereby increasing the load-dispersion properties of the articular cartilage. Arthritic articular cartilage tends to have a decreased concentration of naturally occurring hyaluronic acid.

Unfortunately, injection of hyaluronic acid does not appear to restore the properties that native hyaluronic acid provides to the articular cartilage. A treatment series of intra-articular injections of hyaluronic acid has been reported to decrease the pain associated with osteoarthritis and provide patient relief.⁶ It has also been reported that residual benefits may last for months after the last injection.^7-9 One of the first reported trials of hyaluronic acid injections for treatment of osteoarthritis came in 1974.¹⁰ Subsequently, in 1982, a report was published on the therapeutic effect as a result of hyaluronic acid injection into the knee.¹¹ By 1991, some of the first randomized, controlled trials of hyaluronic acid were reported.

Several different chemical compositions of hyaluronic acid are used for the treatment. Though similar, dosage depends on the specific chemical properties of each. A usual dosage is 3 to 5 injections, with the patient receiving 1 injection per week.