Long-Term Outcomes of Single versus Multiple Courses of Viscosupplementation for Osteoarthritic Knee Pain: Real-World, Multi-Practice Experience Over a Six-Year Period

Predictors of Clinical Benefit with Intra-articular Hyaluronic Acid in Patients with Knee Osteoarthritis - A Narrative Review

BACKGROUND

There is conflicting evidence regarding the efficacy of viscosupplementation with intra-articular hyaluronic acid injections in knee osteoarthritis. One possible explanation for the inconsistent findings on its efficacy is that only certain subpopulations of patients benefit from this therapy.

OBJECTIVE

The purpose of this narrative review is to succinctly summarize the existing data on the predictive factors of clinical response to intra-articular hyaluronic acid to identify the patient profile most likely to benefit from this therapy.

METHODS

For this narrative review, a PubMed search was conducted in January 2023, with no date limits, to identify publications reporting predictive factors of response to viscosupplementation using the following terms: hyaluronic acid OR viscosupplem* AND osteoarthritis AND knee AND predict*. Searches were limited to randomized controlled trials, systematic reviews and meta- analyses, or observational studies written in English. Other relevant references were identified by searching the references of retrieved articles.

RESULTS

The disease severity was found to reliably predict response to intra-articular hyaluronic acid injections; patients with less severe disease consistently had a more robust therapeutic response than those with more severe disease. Other clinical variables such as level of baseline pain did not reliably predict response. Body mass index, and possibly age, may also be independent predictors of the response.

CONCLUSION

A review of the existing literature suggests that patients with less severe clinical symptoms and radiological findings, who are younger, and with a lower or normal body mass index are the best candidates for intra-articular hyaluronic acid therapy.

Effects of Hyaluronic Acid With Intra-articular Corticosteroid Injections in the Management of Subtalar Post-traumatic Osteoarthritis - Randomized Comparative Trial

We investigated the potential of exogenous hyaluronic acid (HA) associated with corticosteroid injections to improve pain and function for the treatment of post-traumatic subtalar osteoarthritis, in comparison with isolated intra-articular corticosteroid. Twenty-five symptomatic participants (50 ± 8 years) with a minimum follow-up of 1 year after surgery for calcaneus fractures were enrolled. Participants were randomly assigned into a therapeutic group that underwent isolated corticosteroid intra-articular subtalar injection (Corticosteroid Group, n = 12) or a combination of HA plus corticosteroid (HA+C Group, n = 13). All participants underwent three repeated injections with intervals of 1 week. We assessed the visual analog scale of pain (VAS) and the AOFAS scores at 4 moments: before treatment (pre), 4-, 12-, and 24-weeks following the last injection. HA+C Group showed lower VAS at the 12th (p = .003) and 24th weeks (p = .003) and greater AOFAS at the 4th (p = 0.040), 12th (p = .014), and 24th weeks (p = .021), in comparison to Corticosteroid Group. We observed a reduction in VAS in the Corticosteroid Group only at the 4th week (p = .007), compared with pretreatment values. In the HA+C Group, VAS presented lower levels at the 4- (p < .001), 12- (p < .001), and 24 weeks (p < .001). In the Corticosteroid Group, participants presented higher AOFAS score only at the 4th week (p < .001), while in the HA+C Group, the AOFAS scores were greater at the 4th, 12th, and 24th weeks compared to baseline (p < .001). The combination of exogenous HA and corticosteroid showed greater and longer analgesic effects and function improvement in comparison with isolated intra-articular corticosteroids.

May the Symptomatic Subtalar Joint Be Conservatively Treated With Intra-Articular Hyaluronic Acid Injections After a Calcaneus Fracture?

BACKGROUND

Subtalar pain following intra-articular calcaneus fractures may be associated with disability, pain, and a negative impact on the quality of life. Salvage procedures as subtalar fusion are associated with further consequences as stiffness, altered ankle biomechanics, and adjacent articular overloading with degenerative changes. The objective of the present study is to evaluate the short-term effects of viscosupplementation with intra-articular hyaluronic acid (HA) on function and pain, in patients with painful subtalar joint after calcaneus fracture.

METHODS

We searched for patients who underwent osteosynthesis of intra-articular calcaneus fracture between January 2011 and July 2015 and were diagnosed during the follow-up with pain and subtalar osteoarthritis. Between January and December of 2018, 13 patients (50 ± 10 years) accepted to participate in this study and received intra-articular HA injections. Three consecutive doses of 20 mg of HA were administered within a week interval, through anterolateral injections into the subtalar joint. We prospectively evaluated the function using the ankle/hindfoot American Orthopaedic Foot & Ankle Society score (AOFAS) and level of pain using the visual analog scale (VAS) before the intervention and 4, 12, and 24 weeks after the first injection.

RESULTS

Hindfoot function improved with an increase of AOFAS from 55 ± 19 before the intervention to 88 ± 20 at the 24th week (P = .001). Similarly, we observed relief of pain during the 24 weeks following intra-articular hyaluronic acid injection, with a decrease in VAS from 8.3 ± 1.3 before treatment to 2.2 ± 3.0 at the 24th week (P = .001).

CONCLUSION

For patients experiencing pain and dysfunction with subtalar osteoarthritis after intra-articular calcaneus fracture, viscosupplementation with intra-articular HA may be associated with improvement in function and pain in the short term. Furthermore, patients with higher grades of osteoarthritis may have limited benefit in pain relief and function improvement.

LEVEL OF EVIDENCE

IV, Case series.

Intra-Articular Hybrid Hyaluronic Acid Injection Treatment in Overweight Patients with Knee Osteoarthritis: A Single-Center, Open-Label, Prospective Study

Background: A BMI > 25 is the most decisive, albeit modifiable, risk factor for knee osteoarthritis (KOA). This study aimed at assessing the efficacy of intra-articular injections of hybrid hyaluronic acid (HA) complexes (Sinovial® H-L) for the treatment of KOA in overweight patients in terms of disease severity, cardiocirculatory capacity, and quality of life. Materials: In this single-site, open-label, prospective trial, 37 patients with symptomatic knee OA were assessed at baseline and 3 months after ultrasound-guided intra-articular injection of hybrid HA complexes (Sinovial® H-L). Results: Primary variables displaying a statistically significant improvement after treatment were pain (VAS), disease severity (WOMAC), and cardiopulmonary capacity (6 min walk test). Among secondary variables, quality of life (SF-12) improved significantly, as did analgesic intake for pain control. No statistically significant difference was observed in body fat and muscle mass percentage measured by bioelectrical impedance analysis. Conclusions: Intra-articular hybrid HA injections are significantly effective in improving OA-related disease severity, cardiopulmonary function, and analgesic intake. This supports the role of hybrid HA viscosupplementation as a nonpharmacological treatment to relieve pain, reduce disability, improve quality of life, and limit the risk of polypharmacy in overweight patients with knee OA.