Are Hyaluronic injections for Knee Osteoarthritis low-value health care?

It should be noted that we see many patients who have tried hyaluronic acid injections. These injections have worked for these people in the short-term. These patients are now in our office because the short-term has not transpired to the long-term and now  a different treatment approach needs to be undertaken.

The idea behind hyaluronic acid injections is to protect the knee by reintroducing lost or diminished hyaluronic acid in the knee’s synovial fluid or “providing a cushion.” The synovial fluid is a thick gel-like liquid that helps cushion the knee and acts to absorb the daily impact of walking and running and stair climbing our knees are subjected to.

The treatment of Hyaluronic Acid Injections is also called Viscosupplementation – supplementing the “viscosity” or the thick, sticky, gel-like properties of the synovial fluid.

In our office we also find patients calling Viscosupplementation “rooster comb injections,” “rooster shots,” “chicken shots,” as well as by trade names Euflexxa ®, Supartz ® Supartz FX ®, Synvisc-One ®, Synvisc ®, Hyalgan ®, Orthovisc ®, et al. All these products offer subtle differences in their treatment goals including the number of injections – however none of them offer a permanent solution. This is what the American Academy of Orthopaedic Surgeons posted on their website:

“The theory is that adding hyaluronic acid to the arthritic joint will facilitate movement and reduce pain. The most recent research, however, has not found viscosupplementation to be effective at significantly reducing pain or improving function. Although some patients report pain relief with the procedure, some people are not helped by the injections.” (1)

This should be enough for anyone considering Hyaluronic Acid Injections to seek alternatives. However many people do not understand that there are alternatives, especially if their doctor does not tell them there are.

Alternatives to Hyaluronic Acid Injections – Just get a knee replacement stop the delay

You are going to see in the research below that surgeons are writing that patients should not waste time and money with hyaluronic acid injections. The best alternative to these injections is knee replacement surgery. While we agree that there are better options to hyaluronic acid injections, we differ with the surgeons, we recommend regenerative medicine surround the use of H3 Prolotherapy, Platelet Rich Plasma injections, and stem cell therapy. This is all discussed below.

But I don’t want a knee replacement!

Doctors in Germany, writing in the medical journal The Orthopedist, (2) give a good summary of the patient with knee pain heading into “conservative” treatments.

  • In an effort to delay major surgery, patients with knee instability and osteoarthritis are offered a variety of nonsurgical options such as weight loss, exercise, physiotherapy, bracing, orthoses, nonsteroidal anti-inflammatory drugs (NSAIDs) and intra-articular viscosupplementation or corticosteroid injection.
  • In general, the goals of these therapeutic options are to decrease pain and improve function. Some of these treatments  may also have a disease-modifying effect by altering the mechanical environment of the knee. In the case of hyaluronic acid the therapeutic effects and procedure remain uncertain.

The German doctors were uncertain that hyaluronic acid had any benefit. The doctors in the research below were more certain.

Two studies are in conflict over the benefits of Hyaluronic Acid Injections

One study suggests that Hyaluronic Acid are a waste of time, money, and resources.

  • The first study, lead by the University of California Los Angeles (UCLA) agrees with the current beliefs that Hyaluronic Acid Injections are a treatment best used to help delay inevitable total knee replacement.(3)
  • The second study suggests that Hyaluronic Acid Injections that delay inevitable knee replacement are a waste of time, money, and resources. Some patients should proceed directly to the knee replacement. The research from the journal American Health and Drug Benefits suggest that patients over the age of 70 should proceed to total knee replacement as opposed to intra-articular injections of steroids or hyaluronic acid  to save on national health care costs.(4)

In the first study from UCLA on the benefits of delaying surgery with Hyaluronic Acid Injections doctors found:

  • Patients who did not receive Hyaluronic Acid Injections went on to knee replacement  by 114 days post-diagnosis of knee osteoarthritis
  • Patients who only had  one course of Hyaluronic Acid Injections, the mean time to Knee Replacement was 1.4 years – a delay of about 1 year
  • Patients who received more than 5 courses of Hyaluronic Acid Injections courses delayed Knee Replacement by 3.6 years.

Now from the second study: Hyaluronic Acid Injections is of no help.

The research appearing is the publication American Health and Drug Benefits has this to say about Hyaluronic Acid Injections

Given the dramatic increase in total knee and hip replacement procedures among the US population aged 45 years and older, there is a need to compare the downstream healthcare utilization and costs between patients who undergo joint replacement and those who receive injections as a low-cost alternative.

Medicare members over the age of 45 who were diagnosed with osteoarthritis were identified for this study. Data were compared for patients who underwent primary knee or hip replacement surgery between July 1, 2007, and June 30, 2012, and those receiving injection of pain-relief medication during the same period.

  • The overall results showed a greater decrease in healthcare utilization and costs for the members with joint replacement than for those receiving steroid or viscosupplementation injection.

“(the study) findings indicate that members without significant comorbid conditions who underwent knee or hip replacement procedure had a greater decrease in osteoarthritis-related healthcare resource utilization and costs after they recovered from surgery, compared with presurgery, and compared with the members who received Hyaluronic Acid Injections and cortisone.

These results are consistent with the American Academy of Orthopaedic Surgeons’ recent  change in evidence-based guidelines for viscosupplementation for symptomatic osteoarthritis pain of the knee, from “inconclusive” to “recommend against.”

A review of 14 studies that assessed outcomes of Hyaluronic Acid Injections demonstrated that the overall effect was not clinically meaningful.

But I don’t want knee replacement: Comparing Platelet Rich Plasma, H3 Prolotherapy injections, and hyaluronic acid injections

Comprehensive H3 Prolotherapy utilizes various ingredients in the injections to induce inflammation in the joint in order to mimic an injury and bring rebuilding immune cells and healing factors to the area to repair and rebuild the injured and degenerated soft tissue of the knee.

Caring Medical doctors investigated Prolotherapy in patients with unresolved knee pain at a charity clinic in rural Illinois. Eighty patients, representing a total of 119 knees, were treated every three months with Prolotherapy. On average, 15 months following their last Prolotherapy session, patients were contacted and asked numerous questions in regard to their levels of pain and a variety of physical and psychological symptoms, as well as activities of daily living, before and after their last Prolotherapy treatment. The results of this study showed that patients had:

  • A statistically significant decline in their level of pain, stiffness, crunching sensation, and improvement in their range of motion with Prolotherapy.
  • More than 82% showed improvements in walking ability, medication usage, athletic ability, anxiety, depression, and overall disability with Prolotherapy.
  • Ninety-six percent of patients felt Prolotherapy improved their life overall.(5)

Platelet Rich Plasma Therapy is a “blood injection” taken from the patient’s own blood and “reduced” down to plasma that is heavy with platelets. Blood plasma platelets hold and encourage many healing growth factors that stimulate healing in degenerated tissues. PRP has also been shown to be superior to hyaluronic acid injections in many studies documented below.

  • In research published in the Medical science monitor: international medical journal of experimental and clinical research, PRP was shown to provide significant healing of the meniscus (5as well as out out-perform hyaluronic acid in patients with knee joint cartilage degeneration as documented by National Taiwan University College of Medicine researchers.(21)

In the medical journal Arthroscopy, Spanish researchers noted: “Plasma rich in growth factors showed superior short-term results when compared with hyaluronic acid in a randomized controlled trial, in alleviating symptoms of mild to moderate osteoarthritis of the knee.”(6)

Here is a summary of further research findings:

  • Dutch doctors writing in the British Journal of Sports Medicine wrote: Platelet Rich Plasma injections for knee osteoarthritis were more effective at reducing pain and increasing range of movement than hyaluronic acid injections.(7)
  • In the medical journal Clinical medicine insights, doctors wrote: PRP injection is more effective  than hyaluronic acid injections in reducing symptoms and improving quality of life and is a therapeutic option in select patients with knee osteoarthritis who have not responded to conventional treatment.(8)
  • Research in the journal Knee surgery, sports traumatology, arthroscopy documented that in short-term patient outcomes of one year or less PRP injection improved functional outcomes when compared to hyaluronic acid and placebo, reducing symptoms and improving function and quality of life. This research suggests that PRP has the potential to be the treatment of choice in patients with mild-to-moderate osteoarthritis of the knee who have not responded to conventional treatment.(9)
  • In the Journal of Arthroplasty, Dutch researchers found no clinical outcome significance in comparing Hyaluronic Acid and Placebo.(10)
  • Doctors in Italy wrote in the European Journal of Orthopaedic Surgery & Traumatology that combining platelet-rich plasma and hyaluronic acid has the same efficacy of platelet-rich plasma only, administered in higher volume.(11)
  • Doctors at the University of California at Davis report that PRP contributes to articular cartilage lubrication.(12)
  • Doctors writing in the World Journal of Orthopedics found “hyaluronic acid injections might have efficacy and might provide pain reduction in mild osteoarthritis of knee up to 24 weeks. But for hyaluronic acid injections, the cost-effectiveness is an important concern that patients must be informed about the efficacy of these preparations. Although more high-quality evidence is needed, recent studies indicate that platelet rich plasma injections are promising for relieving pain, improving knee function and quality of life, especially in younger patients, and in mild osteoarthritis cases. “(13)

In a remarkable piece of research, doctors found that if you want to increase your hyaluronic acid in knees naturally – stem cells may be the answer.

When the researchers introduced bone marrow-derived stem cells into knees, the stem cells started “talking” to the cartilage cells – when the hyaluronan (Hyaluronic Acid) heard this “cross-talk” they started the production of molecules – this is the phenomena of “signalling” that I discuss at length in my article Stem cell therapy for bone repair in osteoarthritis.(14)

In other words, the stem cells started the repair by alerting the cartilage cells that “we need more cartilage,” the hyaluronan heard it and said, “if they are making more cartilage, we need more Hyaluronic Acid”. A curative environment is being rallied.

 Are Hyaluronic injections low-value health care? Using Medicare Data to Understand Low-Value Health Care: The Case of Intra-articular Hyaluronic Acid Injections.

In the Canadian Medical Association Journal, a study led by Austrian researchers found that “according to the currently available evidence, intra-articular hyaluronic acid has not been proven clinically effective and may be associated with a greater risk of adverse events.”(15)

Using Medicare Data to Understand Low-Value Health Care: The Case of Intra-articular Hyaluronic Acid Injections.

This research letter (the title above) backed that up with “based on high-quality evidence that hyaluronic acid injections were not associated with clinically meaningful improvement in symptoms compared with placebo injections.”(16)

Side-Effects and Reactions

A more recent study compiled 89 studies on hyaluronic acidThis study found that hyaluronic acid supplementation to the knee produced minimal to non-existent results when it came to pain and function in knee osteoarthritis patients.(17)

In this systematic review of 89 randomized medical trials that was summarized in the medical publication Medscape, doctors compared hyaluronic acid injections to a sham or to non-intervention patients. There were a total of 12,667 patients where the primary measure was pain intensity and the secondary measure was physical functioning.

“Viscosupplementation, the intra-articular injection of hyaluronic acid, produced “minimal or nonexistent” effects on pain and function in patients with knee osteoarthritis but did increase the risks for serious adverse events and local adverse reactions, according to a systematic review and meta-analysis in the Annals of Internal Medicine.

A flare-up in the injected knee within 24 to 72 hours of injection was the primary safety outcome. Secondary safety outcomes were serious adverse events, withdrawals or dropouts because of adverse events, adverse events overall, effusions at the injected knee, any local adverse event in the injected knee, and dropouts and withdrawals overall (regardless of reason).”

That means thousands of patients in numerous studies received minimal results in pain relief and non-existent results in function.

Hyaluronic Acid Injections cause accelerated knee degeneration

Doctors revealed that while Hyaluronic Acid Injections injections can provide significant pain relief and improvement in activity of daily living function for patients with knee osteoarthritis, the reduction in pain WITHOUT SUPPORTIVE REPAIR can increase in knee adduction movement and cause excessive loading on the knee joints, which may further accelerate the rate of knee degeneration.(18)

Hyaluronic Acid Injections Alternatives

Caring Medical Prolotherapy Research and wrap up

In research published in the Journal of Prolotherapy, we identified many of the problems with the above-listed stopgap treatments and why we do not employ their use in our practice.

Here is what we published in the Journal of Prolotherapy, “although steroid injections and nonsteroidal anti-inflammatory drugs (NSAIDs) have been shown to be effective in decreasing inflammation and pain of ligament injuries for up to six to eight weeks, the properties of ligament healing are inhibited. For this reason, their use is cautioned in athletes (and patients) who have ligament injuries. As such, NSAIDs are no longer recommended for chronic soft tissue (ligament) injuries, and for acute ligament injuries should be used for the shortest period of time, if used at all. Regenerative medicine techniques, such as Prolotherapy, have been shown in case series and clinical studies, to resolve ligament injuries of the spine and peripheral joints.”(19)

We recently published an article called “Ligament Injury’s Effect of Cartilage Breakdown” – which describes the very dominating influence of ligaments on knee cartilage. This research “Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics” also supports the view that the long-term consequence of non-healed ligament injury is osteoarthritis.(20)

So is it any wonder why the treatments mentioned above including hyaluronic acid do not last? The situation of osteoarthritis can only be remedied when the problem of ligament laxity is addressed. None of those above treatments address this problem. Comprehensive Prolotherapy for knee osteoarthritis does.

Do you have a question about Hyaluronic Acid Injections for knee osteoarthritis? Ask us get help and information from our Caring Medial staff.

1. Diehl P, Gerdesmeyer L, Schauwecker J, Kreuz PC, Gollwitzer H, Tischer T. Conservative therapy of osteoarthritis. Orthopade. 2013 Feb 1. [Google Scholar]
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3. Pasquale MK, Louder AM, Cheung RY, Reiners AT, Mardekian J, Sanchez RJ, Goli V. Healthcare Utilization and Costs of Knee or Hip Replacements versus Pain-Relief Injections. Am Health Drug Benefits. 2015 Oct;8(7):384-94.
4. Hauser RA, Hauser MA. A Retrospective Study on Dextrose Prolotherapy for Unresolved Knee Pain at an Outpatient Charity Clinic in Rural Illinois Journal of Prolotherapy. 2009;1(1):11-21.
5. Wei LC, Gao SG, Xu M, Jiang W, Tian J, Lei GH. A novel hypothesis: The application of platelet-rich plasma can promote the clinical healing of white-white meniscal tears. Med Sci Monit. 2012 Aug;18(8):HY47-50. [Google Scholar]
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8. Raeissadat SA, Rayegani SM, Hassanabadi H, Fathi M, Ghorbani E, Babaee M, Azma K. Knee Osteoarthritis Injection Choices: Platelet- Rich Plasma (PRP) Versus Hyaluronic Acid (A one-year randomized clinical trial). Clin Med Insights Arthritis Musculoskelet Disord. 2015 Jan 7;8:1-8. [Google Scholar]
9. Kanchanatawan W et al. Short-term outcomes of platelet-rich plasma injection for treatment of osteoarthritis of the knee. Knee Surg Sports Traumatol Arthrosc. 2015 Sep 19. [Google Scholar]
10. van der Weegen W, Wullems JA, Bos E, Noten H, van Drumpt RA. No Difference Between Intra-Articular Injection of Hyaluronic Acid and Placebo for Mild to Moderate Knee Osteoarthritis: A Randomized, Controlled, Double-Blind Trial. J Arthroplasty. 2014 Dec 13. pii: S0883-5403(14)00943-7. [Google Scholar]
11. Abate M, Verna S, Schiavone C, Di Gregorio P, Salini V. Efficacy and safety profile of a compound composed of platelet-rich plasma and hyaluronic acid in the treatment for knee osteoarthritis (preliminary results) Eur J Orthop Surg Traumatol. 2015 Sep 24. [Google Scholar]
12. Sakata R, Reddi AH. Platelet-Rich Plasma Modulates Actions on Articular Cartilage Lubrication and Regeneration. Tissue Eng Part B Rev. 2016 Oct;22(5):408-419. Epub 2016 Jun 27.Tissue Eng Part B Rev. 2016 Oct;22(5):408-419. [Google Scholar]
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19. Hauser RA. Ligament injury and healing: an overview of current clinical concepts. Journal of Prolotherapy. 2011;3(4):836-846.
20. Hauser RA., et al. Prolotherapy research: Ligament Injury and Healing: A Review of Current Clinical Diagnostics and Therapeutics. The Open Rehabilitation Journal, 2013, 6, 1-20.
21. Chang KV, Hung CY, Aliwarga F, Wang TG, Han DS, Chen WS. Comparative Effectiveness of Platelet-Rich Plasma Injections for Treating Knee Joint Cartilage Degenerative Pathology: A Systematic Review and Meta-Analysis. Arch Phys Med Rehabil. 2013 Nov 27. pii: S0003-9993(13)01212-4. [Google Scholar]



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