Viscosupplementation / Hyaluronic Acid Injections

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.

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:

1. 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.
2. de Rezende MU, de Campos GC. Viscosupplementation. Rev Bras Ortop (English Ed). 2012;47(2):160-164.
3. 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.
4. 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.
5. 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.
6. 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.
7. 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.
8. Yasuda T. Hyaluronan inhibits prostaglandin E2 production via CD44 in U937 human macrophages. Tohoku J Exp Med. 2010;220(3):229-235.