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Dec 17, 2023

Journal Watch: Ultrasound Guided Viscosupplementation Injections Delay Total Knee Replacement Surgery Compared to Traditional Injections

Knee osteoarthritis (OA) is common, and nonsurgical options are limited. Viscosupplementation injections have been used to provide lubrication to the knee joint and provide sustained benefits by effecting the physiology of the knee joint (Altman et al.; Altman et al.; Bowman et al.).

In many clinics, knee injections are performed using landmark guidance (i.e. without confirming that the injection is going into the knee with imaging such as x-ray or ultrasound). In a large systematic review, these landmark-guided injections were accurate in only 70 to 74% of cases when the patient was seated on a table with the knee bent (Maricar et al.). In contrast, with image guidance the joint injection accuracy substantially improved to 98% (Maricar et al.; Daniels et al.).

Viscosupplementation injections have been associated with delaying total knee replacement surgery (Altman et al.; Altman et al.; Delbarre et al.; Ong et al.; Waddell et al.). For viscosupplementation injections to be effective the medication must be placed within the joint, and an inadvertent injection into the tissue outside of the knee joint does not provide any benefit. Ultrasound is one form of visualization that ensures accuracy of needle placement into the knee joint to optimize benefits.

In a study by Lundstrom et al., ultrasound-guided viscosupplementation injections were compared to landmark guided injections and the study examined whether the use of guidance impacted the rate of knee replacement surgery. The authors did not distinguish between which brand of viscosupplementation injection was used.

In the 1147 patients enrolled in the study, 647 of the procedures were landmark guided and 500 were ultrasound guided. The rate of a total knee replacement was significantly less in the patients whose injection was ultrasound guided and fewer patients in the ultrasound group needed subsequent injections.

Ensuring that the viscosupplementation or hyaluronic acid injection was accurately injected into the joint significantly reduced knee replacement rates.

Learn more about viscosupplementation injections here.


Altman RD, Dasa V, Takeuchi J. Review of the Mechanism of Action for Supartz FX in Knee Osteoarthritis. Cartilage. 2018 Jan;9(1):11-20.

Altman R, Fredericson M, Bhattacharyya SK, Bisson B, Abbott T, Yadalam S, Kim M. Association between Hyaluronic Acid Injections and Time-to-Total Knee Replacement Surgery. J Knee Surg. 2016 Oct;29(7):564-570.

Altman R, Lim S, Steen RG, Dasa V. Hyaluronic Acid Injections Are Associated with Delay of Total Knee Replacement Surgery in Patients with Knee Osteoarthritis: Evidence from a Large U.S. Health Claims Database
PLoS One. 2015 Dec 22;10(12):e0145776.

Altman RD, Manjoo A, Fierlinger A, Niazi F, Nicholls M. The mechanism of action for hyaluronic acid treatment in the osteoarthritic knee: a systematic review. BMC Musculoskelet Disord. 2015 Oct 26;16:321.

Bowman S, Awad ME, Hamrick MW, Hunter M, Fulzele S. Recent advances in hyaluronic acid based therapy for osteoarthritis. Clin Transl Med. 2018 Feb 16;7(1):6.

Delbarre A, Amor B, Bardoulat I, Tetafort A, Pelletier-Fleury N. Do intra-articular hyaluronic acid injections delay total knee replacement in patients with osteoarthritis - A Cox model analysis. PLoS One. 2017 Nov 20;12(11):e0187227.

Lundstrom ZT, Sytsma TT, Greenlund LS. Rethinking Viscosupplementation: Ultrasound- Versus Landmark-Guided Injection for Knee Osteoarthritis. J Ultrasound Med. 2020 Jan;39(1):113-117.

Maricar N, Parkes MJ, Callaghan MJ, Felson DT, O'Neill TW. Where and how to inject the knee--a systematic review. Semin Arthritis Rheum. 2013 Oct;43(2):195-203.

Ong KL, Anderson AF, Niazi F, Fierlinger AL, Kurtz SM, Altman RD. Hyaluronic Acid Injections in Medicare Knee Osteoarthritis Patients Are Associated With Longer Time to Knee Arthroplasty. J Arthroplasty. 2016 Aug;31(8):1667-73.

Waddell DD, Bricker DC. Total knee replacement delayed with Hylan G-F 20 use in patients with grade IV osteoarthritis. J Manag Care Pharm. 2007 Mar;13(2):113-121.

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