Hyaluronic Acid Injections (HA Injections), also known as Viscosupplementation, are a nonsurgical treatment option of osteoarthritis symptoms. Hyaluronic Acid is a naturally occurring compound that is found throughout the human body, and has been isolated and purified by manufacturers into an injectable form.
In osteoarthritis, HA chains are shortened and the viscosity of joint fluid decreases. Viscosupplementation injections work through a complex mechanism, and are thought to increase the lubrication of the arthritic joint fluid, decrease inflammation and pain, and improve function.
HA injections have been shown to decrease synovial inflammation and have been FDA approved since 1997 for the treatment of knee osteoarthritis. Improvement from the injections often last 6-12 months or longer. Viscosupplementation injections are typically covered by commercial insurance; however, we always recommend checking with your insurance provider to confirm coverage. Our office will obtain pre-certification when required.
Recent studies have also shown benefit in shoulder arthritis and ankle arthritis, but HA injections into the shoulder are not FDA approved. Our billing department can answer questions regarding cost.
What is osteoarthritis?
Osteoarthritis (OA), also known as degenerative joint disease, is the most common form of arthritis in the United States, affecting 522.7% of the adult population (Barbour et al, 2017). The knee is the most common joint affected in OA (Felson & Zhang, 1998).
How does viscosupplementation injections work?
Hyaluronic acid is a naturally occurring and integral part of maintaining healthy cartilage. Viscosupplementation injections consists of an injection of hyaluronic acid into affected joints, and are intending to restore the physiologic viscoelasticity in the synovial
fluid (de Rezende & de Campos, 2012). Synovial fluid is a solution found in the cavity of synovial joints, with the primary role of minimizing friction between the cartilage during movement. In addition to its lubricant properties, hyaluronic acid has many chondroprotective biochemical functions (Wang et al, 2006; Yasuda, 2010; Sasaki et al, 2004).
What does the Evidence Say?
Available guidelines and reviews have conflicting recommendations. The latest
guidelines published by the American Academy of Orthopaedic Surgeons
(AAOS) in 2013 state that hyaluronic acid for patients with symptomatic knee osteoarthritis cannot be recommended noting that most of the studies on viscosupplementation injections had a significant degree of publication
bias (McGrory et al, 2016).
While previous studies have demonstrated variable results, more evidence is available and is generally supportive of viscosupplementation injections for knee osteoarthritis (Peck et al, 2021). Studies show that viscosupplementation injections are effective at reducing pain, increasing functionality, and delaying surgery in knee osteoarthritis.
How does intra-articular hyaluronic acid compare to intra-articular corticosteroids?
Intra-articular
hyaluronic acid and intra-articular corticosteroids are
both used for treating knee osteoarthritis (OA), but they differ in
terms of efficacy and safety.
- Efficacy:
- Short-term relief:
Corticosteroids provides superior pain relief in the short term (up to 1 month)
compared to intra-articular hyaluronic acid. This is supported by a meta-analysis showing that corticosteroids
significantly reduces pain more effectively than intra-articular hyaluronic acid within the first
month [He et al, 2017].
- Long-term relief:
intra-articular hyaluronic acid is more effective for long-term pain relief and functional
improvement. By 6 months, intra-articular hyaluronic acid shows greater efficacy in reducing pain
and improving function compared to corticosteroids [He et al, 2017; Tammachote et al, 2016; Ran et al, 2018].
- Safety:
- Adverse effects: intra-articular hyaluronic acid is associated with more local adverse effects, such as injection-site pain and swelling, compared to corticosteroids. However, these adverse effects are generally mild and transient [He et al, 2017].
- Systemic effects: Corticosteroids can have systemic side effects, including potential impacts on blood glucose levels and increased risk of joint infection with repeated use. intra-articular hyaluronic acid has a more favorable long-term safety profile, with fewer systemic adverse effects [He et al, 2017; Ran et al, 2018; Housman et al, 2014].
- In summary, IACS provides better short-term pain relief, while IAHA offers superior long-term benefits in terms of pain relief and functional improvement. Both treatments are relatively safe, but IAHA is associated with more local adverse effects, whereas IACS has potential systemic risks.
Why Boston Sports & Biologic ?
Boston Sports & Biologics specializes in minimally invasive
procedures and orthobiologics. At Boston Sports & Biologics viscosupplementation injections are done under ultrasound guidance to ensure
that the medication is placed into the joint, which offers patients the best chance of success.
Boston Sports & Biologics and is one of only a handful of clinics
in New England that Is accredited by the the American Institute of
Ultrasound Medicine (AIUM) in diagnostic ultrasound and ultrasound
guided procedures. AIUM ultrasound practice accreditation is a voluntary
peer review process that allows practices to demonstrate that they meet
or exceed nationally recognized standards in the performance and
interpretation of diagnostic ultrasound examinations.
References:
- Barbour KE, Helmick CG, Boring M, Brady TJ. Vital Signs: Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity Limitation - United States, 2013-2015. MMWR Morb Mortal Wkly Rep. 2017;66(9):246-253.
- de Rezende MU, de Campos GC. Viscosupplementation. Rev Bras Ortop (English Ed). 2012;47(2):160-164.
- Felson DT, Zhang Y. An update on the epidemiology of knee and hip osteoarthritis with a view to prevention. Arthritis Rheum. 1998;41(8):1343-1355.
- He WW, Kuang MJ, Zhao J, Sun L, Lu B, Wang Y,Ma JX, Ma XL. Efficacy and safety of intraarticular hyaluronic acid andcorticosteroid for knee osteoarthritis: A meta-analysis. Int J Surg. 2017 Mar;39:95-103.
- Housman L, Arden N, Schnitzer TJ, Birbara C, Conrozier T, Skrepnik N, Wei N, Bockow B, Waddell D, Tahir H, Hammond A,Goupille P, Sanson BJ, Elkins C, Bailleul F. Intra-articular hylastan versus steroid for knee osteoarthritis. Knee Surg Sports Traumatol Arthrosc. 2014 Jul;22(7):1684-92.
- McGrory B, Weber K, Lynott JA, et al. The American Academy of Orthopaedic Surgeons Evidence-Based Clinical Practice Guideline on Surgical Management of Osteoarthritis of the Knee. J Bone Joint Surg Am. 2016;98(8):688-692.
- Peck J, Slovek A, Miro P, et al. A Comprehensive Review of Viscosupplementation in Osteoarthritis of the Knee. Orthop Rev (Pavia). 2021 Jul 10;13(2):25549.
- Ran J, Yang X, Ren Z, Wang J, Dong H. Comparison of intra-articular hyaluronic acid and methylprednisolone for pain management in knee osteoarthritis: A meta-analysis of randomized controlled trials. Int J Surg. 2018 May;53:103-110.
- Sasaki A, Sasaki K, Konttinen YT, et al. Hyaluronate inhibits the interleukin-1beta-induced expression of matrix metalloproteinase (MMP)-1 and MMP-3 in human synovial cells. Tohoku J Exp Med. 2004;204(2):99-107.
- Tammachote N, Kanitnate S, Yakumpor T, Panichkul P. Intra-Articular, Single-Shot Hylan G-F 20 Hyaluronic Acid Injection Compared with Corticosteroid in Knee Osteoarthritis: A Double-Blind, Randomized Controlled Trial. J Bone Joint Surg Am. 2016 Jun 1;98(11):885-92.
- Wang CT, Lin YT, Chiang BL, Lin YH, Hou SM. High molecular weight hyaluronic acid down-regulates the gene expression of osteoarthritis-associated cytokines and enzymes in fibroblast-like synoviocytes from patients with early osteoarthritis. Osteoarthr Cartil. 2006;14(12):1237-1247.
- Yasuda T. Hyaluronan inhibits prostaglandin E2 production via CD44 in U937 human macrophages. Tohoku J Exp Med. 2010;220(3):229-235.
