Hyaluronic Acid Intra-Articular Injections in Patients Affected by Moderate to Severe Glenohumeral Osteoarthritis: A Prospective Randomized Study

Harms reporting in randomized controlled trials underpinning the American Academy of Orthopaedic Surgeons clinical practice guidelines for glenohumeral osteoarthritis

BACKGROUND

Glenohumeral osteoarthritis is one of the most common causes of shoulder pain. As such, the American Academy of Orthopaedic Surgeons (AAOS) has developed clinical practice guidelines (CPGs) to address the management of glenohumeral osteoarthritis. These CPG recommendations stem from the findings of randomized controlled trials (RCTs), which have been shown to influence clinical decision making and health policy. Therefore, it is essential that trial outcomes, including harms data (ie, adverse events), are adequately reported. We intend to evaluate the reporting quality of harms-related data in orthopedic literature specifically relating to AAOS CPG recommendations on the management of glenohumeral osteoarthritis.

METHODS

We adhered to the Preferred Reporting Items for Systematic Reviews (PRISMA) as well as guidance for reporting meta-research. The AAOS CPGs for glenohumeral osteoarthritis were obtained from orthoguidelines.org, and 2 authors independently screened the guidelines for the RCTs referenced. A total of 14 studies were identified. Data were extracted from the 14 included studies independently by the same 2 authors. Adherence to the Consolidated Standards of Reporting Trials (CONSORT) Extension for Harms Checklist was assessed using an 18-item scoring chart, with 1 point being awarded for meeting a checklist item and 0 points being awarded for not meeting a checklist item. Descriptive statistics, such as frequencies, percentages, and 95% confidence intervals were used to summarize RCT adherence to the CONSORT checklist.

RESULTS

The average score among the studies included was 7.36/18 items (39% adherence). No study adhered to all criteria, with the highest-performing study meeting 11 of 18 items (58%) and the lowest meeting 3 of 18 items (16%). A positive correlation between checklist score and year of publication was observed, with studies published more recently receiving a higher score on the CONSORT checklist (P < .05). Studies that disclosed funding information received a higher score than those that did not (P < .05), but there was no significant difference when the different funding sources were compared. Finally, double-blinded studies scored higher on the checklist than those with lower levels of blinding (single or no blinding, P < .05).

CONCLUSION

Adverse events are poorly reported amongst RCTs cited as supporting evidence for AAOS Management of Glenohumeral Osteoarthritis CPGs, evidenced by a CONSORT checklist compliance rate of only 41% in this study. We recommend the development of an updated checklist with information that makes it easier for authors to recognize, evaluate, and report on harms data. Additionally, we encourage authors to include information about adverse events or negative outcomes in the abstract.

Clinical and Biochemical Implications of Hyaluronic Acid in Musculoskeletal Rehabilitation: A Comprehensive Review

Hyaluronic acid (HA) naturally occurs as a biopolymer in the human body, primarily in connective tissues like joints and skin. Functioning as a vital element of synovial fluid, it lubricates joints, facilitating fluid movement and diminishing bone friction to protect articular well-being. Its distinctive attributes encompass notable viscosity and water retention capacities, ensuring flexibility and absorbing shock during motion. Furthermore, HA has gained significant attention for its potential benefits in various medical applications, including rehabilitation. Ongoing research explores its properties and functions, especially its biomedical applications in several clinical trials, with a focus on its role in improving rehabilitation outcomes. But the clinical and biochemical implications of HA in musculoskeletal rehabilitation have yet to be fully explored. This review thoroughly investigates the properties and functions of HA while highlighting its biomedical applications in different clinical trials, with a special emphasis on its role in rehabilitation. The presented findings provide evidence that HA, as a natural substance, enhances the outcomes of musculoskeletal rehabilitation through its exceptional mechanical and biochemical effects.

Efficacy of intra-articular injections of hyaluronic acid in patients with glenohumeral joint osteoarthritis: A systematic review and meta-analysis

Symptomatic primary glenohumeral (GH) joint osteoarthritis (OA) can be challenging to treat. Hyaluronic acid (HA) has emerged as a promising treatment for the nonsurgical management of GH-OA. In this systematic review with meta-analysis, we aimed to evaluate the current evidence regarding the efficacy of intra-articular HA on pain relief in patients suffering from GH-OA. A total of 15 studies (only randomized controlled trials providing data at the end of the intervention) were included. The relevant studies were selected based on the following PICO model: P: patients with diagnosis of shoulder OA; I: HA infiltrations as therapeutic intervention administered; C: no restriction for comparators assessed; O: pain, in terms of visual analog scale (VAS) or numeric rating scale. The risk of bias among the included studies was estimated using the PEDro scale. A total of 1023 subjects were analyzed. Comparing HA injections combined with physical therapy (PT) compared to PT alone resulted in superior scores, showing an overall effect size (ES) of 4.43 (p = 0.00006). Moreover, pooled analysis of VAS pain scores demonstrated a significant improvement in the ES of the HA in comparison with corticosteroid injections (p = 0.002). On average, we reported a PEDro score of 7.2. A total of 46.7% of studies showed probable signs of a randomization bias. The findings of this systematic review and meta-analysis showed that IA injections of HA might be effective on pain relief with significant improvements compared to baseline and compared to corticosteroid injections in patients affected by GH-OA.

Efficacy of Ultrasound-Guided Glenohumeral Joint Injections of Leukocyte-Poor Platelet-Rich Plasma Versus Hyaluronic Acid in the Treatment of Glenohumeral Osteoarthritis: A Randomized, Double-Blind Controlled Trial

OBJECTIVE

To compare the efficacy of ultrasound-guided hyaluronic acid (HA) versus leukocyte-poor platelet-rich plasma (LP-PRP) injection in the treatment of glenohumeral osteoarthritis.

DESIGN

Double-blind randomized controlled trial.

SETTING

Academic institution.

PATIENTS

Seventy patients with chronic glenohumeral osteoarthritis were randomly assigned to receive a single injection of HA (n = 36) or LP-PRP (n = 34).

INTERVENTIONS

Leukocyte-poor platelet-rich plasma was processed using Harvest/TerumoBCT Clear PRP kits. Ultrasound-guided injections of 6 mL HA or 6 mL LP-PRP into the glenohumeral joint were performed. Patients, the injecting physician, and outcomes assessor were blinded to treatment assignments.

MAIN OUTCOME MEASURES

Shoulder Pain and Disability Index (SPADI), American Shoulder and Elbow Surgeons (ASES) score, current/average numerical rating scale (NRS) pain scores, satisfaction, and side effects were assessed at the 5 follow-up time points over 12 months.

RESULTS

Baseline characteristics were similar between groups. There were no significant between-group differences regarding SPADI, ASES, and current/average NRS pain scores at any time point up to 12 months postinjection ( P > 0.05). However, significant improvements in SPADI, ASES, and current/average NRS pain scores were observed in both groups starting at 1 or 2 months ( P < 0.01, P < 0.01, P < 0.001, and P < 0.01, respectively). These improvements were observed regardless of osteoarthritis severity. For patients who received LP-PRP, there was no effect of platelet yield on outcomes. Side effect and satisfaction rates were similar between groups.

CONCLUSIONS

There were no differences in pain and functional outcomes after a single injection of LP-PRP versus HA. However, significant improvements in pain and function were observed after both treatments in patients with glenohumeral osteoarthritis.

Review of Extraosseous Applications of Thermal Ablation in the Treatment of Moderate to Severe Large Joint Osteoarthritis

Osteoarthritis (OA) is the most common joint disease worldwide, leading to significant pain, restricted range of motion, and disability. A gap exists between short- and long-term symptom-relieving therapies. Although arthroplasty is an effective treatment for symptomatic end-stage disease, most patients ultimately do not receive a joint replacement due to suboptimal surgical qualifications, comorbidities, or an aversion to surgery. The lack of additional treatment options in this setting makes opioid agonists a commonly used pharmacologic agent, contributing to the addiction epidemic that greatly afflicts our communities. Cooled radiofrequency ablation (CRFA) has arisen as a treatment modality in the setting of moderate to severe OA among patients refractory to conservative management, generally showing greater efficacy compared with other existing strategies. This review focuses on the benefits of CRFA and its technical feasibility as a management option among patients experiencing debilitating large joint OA with limited clinical options.

Hyaluronic acid injections for treatment of pediatric sickle cell avascular necrosis of the humeral head

BACKGROUND

Avascular necrosis (AVN) can impact up to 50% of patients with sickle cell disease (SCD) and can result in significant pain, decline in physical function and decreased quality of life. While hyaluronic acid (HA) has been used in the adult population for shoulder osteoarthritic pain, we present the first published pediatric case of HA injections in the glenohumeral joint, used to improve function and pain control.

CASE PRESENTATION

The patient is a 12-year-old woman with SCD, who suffered from chronic pain due to AVN of the humeral and femoral head. Despite engaging in a multidisciplinary pain management plan, she continued to have severe decline in physical functioning and became a wheelchair user. As a result, she was scheduled for a right total hip arthroplasty, which necessitated aggressive postoperative therapies using the glenohumeral joint. To improve this pain and to facilitate postoperative recovery, the patient underwent 4 weekly HA injections into the glenohumeral joint. Over a 2-month period, the patient was able to improve physical functioning, decrease opiate use and participate in all postoperative therapies.

CONCLUSION

Conservative options to improve functioning and pain are especially important in pediatric patients where it may be desirable to delay surgical interventions until skeletal maturity. Our case report demonstrates the benefits of intra-articular HA as part of a multidisciplinary pain management plan to improve function and decrease pain related to AVN of the humeral head. Future studies should assess the long-term benefits of HA injections for AVN in the setting of SCD.

NASHA hyaluronic acid for the treatment of shoulder osteoarthritis: a prospective, single-arm clinical trial

Background: Osteoarthritis of the shoulder or glenohumeral joint is a painful condition that can be debilitating. Intra-articular injection with hyaluronic acid should be considered for patients not responding adequately to physical therapy or anti-inflammatory medication.

Methods: This was a single-arm, open-label, prospective study of a single intra-articular injection of NASHA (non-animal hyaluronic acid) in patients with symptomatic glenohumeral osteoarthritis. Patients were followed up for 26 weeks post-treatment, during which time rescue medication with acetaminophen was permissible. The study objective was to demonstrate that a single injection of NASHA is well tolerated with an over-6-month 25% reduction in shoulder pain on movement, assessed using a 100-mm visual analog scale.

Results: Forty-one patients were enrolled, all of whom received study treatment. The mean decrease in shoulder pain on movement score over the 6-month study period was −20.1 mm (95% CI: −25.2, −15.0 mm), corresponding to a mean reduction of 29.5% (22.0, 37.0%). Statistically significant improvements were also observed in shoulder pain at night and patient global assessment. There was no clear change over time in the percentage of patients using rescue medication and mean weekly doses were below 3500 mg. Seventeen patients (41.5%) experienced adverse events, all of which were mild or moderate. Two adverse events (both shoulder pain) were deemed related to study treatment.

Conclusion: This study provides preliminary evidence that a single injection of NASHA may be efficacious over 6 months and well tolerated in patients with symptomatic glenohumeral osteoarthritis. Larger studies are needed for confirmation.

Outcomes of hyaluronic acid injections for glenohumeral osteoarthritis: a systematic review and meta-analysis

BACKGROUND

Hyaluronic acid (HA) is an analgesic and chondroprotective agent often used for the nonoperative treatment of osteoarthritis (OA). The effects of HA injections are well studied in the treatment of knee OA, but the effects in glenohumeral OA remain unclear. This study evaluated the efficacy of HA to reduce pain in patients with glenohumeral OA.

METHODS

PubMed, MEDLINE, CENTRAL, and Embase were searched from the database inception date through January 16, 2018. Two reviewers independently screened articles for eligibility and extracted data for analysis. A methodological quality assessment was completed for all included studies, including assessment of risk of bias. The primary outcome was change in visual analog scale for pain. The secondary outcomes were functional outcome and adverse events.

RESULTS

In the HA arm, the reduction of visual analog scale pain score at 3 months was 26.2 mm (95% confidence interval, 22.0-30.3 mm; I² = 31%) and at 6 months was 29.5 mm (95% confidence interval, 25.5-33.4 mm; I² = 19%). All studies reported an improvement in functional outcome. Similar clinical improvements were reported in the intervention and control groups, suggesting that these improvements may not be directly related to HA. Commonly reported adverse events were rare and included swelling and mild pain at the injection site, local effusion, lethargy, and face rash.

CONCLUSION

Intra-articular HA injection is safe and improves pain for patients with glenohumeral OA. Pain improvements also reported in the control group suggest that a significant placebo effect may be present with respect to intra-articular shoulder injection. Further randomized controlled trials are necessary to evaluate the efficacy of HA and identify optimal dosing and route of administration.

Corticosteroids and Hyaluronic Acid Injections

Osteoarthritis is a common condition that affects many individuals resulting in pain, reduced mobility, and decreased function. Corticosteroids have been a mainstay of osteoarthritis treatment. Studies have shown that they provide short-term pain improvement and can be used for osteoarthritis flares. Hyaluronic acid injections have extensively been studied in knee osteoarthritis but to a lesser degree in other joints. Despite some debate between societies, a large number of recent studies have shown hyaluronic acid to be a viable treatment option showing longer-term improvement in both pain and function.