Hyaluronic Acid vs Corticosteroid Injection in the treatment of Symptomatic OA Knee
Date First Published:
November 4, 2015
Last Updated:
November 4, 2015
Report by:
Kristin Moat & Rachel Wynne, Clinical Specialist Physiotherapist / ESP Physiotherapist (Northumbria Healthcare NHS Trust / Frimley Park Hospital NHS Foundation Trust)
Search checked by:
Kristin Moat, Northumbria Healthcare NHS Trust / Frimley Park Hospital NHS Foundation Trust
Three-Part Question:
In [adults with OA knee], is [Intra-articular Hyaluronic Acid (HA) injection better than Corticosteroid (CS) injection] in [reducing pain and improving function]?
Clinical Scenario:
A 52 year old male presents to the orthopaedic knee service with gradual onset of knee pain and effusion. He finds walking is now limited to 2 hrs and he struggles to play a full round of golf. Knee X-ray findings confirm moderate signs of degenerative joint disease. He is not yet at the stage to consider a joint replacement. He has tried physiotherapy and relative rest but now is keen for an ‘injection’. Should he be offered a corticosteroid or hyaluronic acid injection?
Search Strategy:
Using the Health Databases Search via the NHS Library interface (library.nhs.uk) the following databases were interrogated: AMED (1985-present), BNI (1992 – present), CINAHL (1981-present), EMBASE (1974-present), MEDLINE (1946-present). Searches were also carried out in the Cochrane Library and the PEDro database. Internal References from papers.
Search Details:
{knee} AND {OA OR osteoarthritis} AND {corticosteroid} AND {hyaluron*} AND {Systematic* OR Meta*}
Outcome:
22 papers found. 2 meta-analyses chosen. 19 excluded as they were not systematic reviews or meta-analyses. One was excluded due to directly using one of the chosen references as its data source (Same author repeating previous analyses of results).
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Intra-articular hyaluronic acid and corticosteroids in the treatment of knee osteoarthritis: A meta‑analysis Wang, F. and He, X., 2015 China | Pooled from 7 RCT: 583 patients (222 males, 361 females) with knee OA. Mean ages ranged from 49.5 to 70.5 years. Intervention: intra articular injection of either CS or HA. Follow up ranged from 12 weeks to 6 months |
Meta-analysis | VAS | at 1/12 CS better than HA | No comparison to placebo in RCT studies 1 study is methodologically weak (JADAD and PEDro - Used Jadad scoring system initially, which is criticised as being simplistic.) Variety of HA and CS agents evaluated. |
| VAS | at 3/12 HA better than CS | ||||
| VAS | at 6/12 HA better than CS | ||||
| Lequesne | No difference at 3/12 | ||||
| KSS | No difference at 3/12 | ||||
| Maximum Flexion | No difference at 3/12 | ||||
| Adverse Effects | No difference at 3/12 | ||||
| Therapeutic Trajectory of Hyaluronic Acid Versus Corticosteroids in the Treatment of Knee Osteoarthritis: A Systematic Review and Meta-Analysis Bannuru, R.R., Natov,N.S., Obadan, I.E., Price, L.L., Schmid, C.H., and McAindon, T.E. 2009 USA | Pooled from 7 RCT (published 1987-2004): 606 patients (610 knees). HA group: 312 (101 males and 211 females) CS group:294 (298 knees, 99 male and 195 females) Follow up at 2,4,12, and 26 weeks |
Systematic Review and Meta-Analysis |
Pooled Effect Size | at 2/52 CS better than HA | Degree of OA for participants? Repeated weekly injections, reflects practice? Also, when does the follow up period start? After all injections? Differing drugs used and treatment protocols Are results statistically significant? HA sponsorship Trial quality wasn’t tested with PEDRO or equivalent. No placebo, are long term effects of HA better than nothing? Allowed participants to use pain medication in 6 studies |
| Pooled Effect Size | at 4/52 No difference | ||||
| Pooled Effect Size | at 8/52 HA better than CS | ||||
| Pooled Effect Size | at 12/52 HA better than CS | ||||
| Pooled Effect Size | at 26/52 HA better than CS |
Author Commentary:
These are good meta–analyses looking at published RCT’s where HA was compared with CS in the treatment of symptomatic OA of the knee in adults. Both groups of authors evaluated the quality of the papers by assessing them against the PEDro quality score and with Wang et al, also the JADAD score. Both author groups requested further data from authors if there was not adequate data in the studies. Both papers tested for publication bias.
Bottom Line:
Corticosteroid injection is more effective at relieving pain within the first month after administration but then following that, Hyaluronic acid injection gives better symptomatic benefit up to 6 months after administration. There were few adverse effects documented with either injection.
References:
- Wang, F. and He, X., . Intra-articular hyaluronic acid and corticosteroids in the treatment of knee osteoarthritis: A meta‑analysis
- Bannuru, R.R., Natov,N.S., Obadan, I.E., Price, L.L., Schmid, C.H., and McAindon, T.E.. Therapeutic Trajectory of Hyaluronic Acid Versus Corticosteroids in the Treatment of Knee Osteoarthritis: A Systematic Review and Meta-Analysis