Orthopaedists frequently treat knee osteoarthritis with hyaluronic acid (HA) or corticosteroid injections, but which works better?
The 99 patients in a double-blinded randomized controlled trial by Tammachote et al. in the June 1, 2016 Journal of Bone & Joint Surgery received a single intra-articular injection of either 6 mL of hylan G-F 20, or 1 mL of 40-mg triamcinolone acetonide plus 5 mL of 1% lidocaine. At the six-month follow-up, both groups experienced significant and similar improvements in knee pain, function, and range of motion, without complications. But there were short-term distinctions: Triamcinolone relieved pain better and faster in the first week, after which the effect became similar to that of HA. Similarly, triamcinolone provided better functional improvement than HA at two weeks post-injection, but the effects of the two drugs were not statistically distinguishable after that.
In commenting on this study, Paul Levin, MD, says that its findings “support the [AAOS] clinical practice guideline of a strong recommendation against the use of hyaluronic acid.” He goes on to do a quick cost analysis showing that if 1.2 million people received a single cortisone injection (approximately $10 each) and another 1.2 million people received a single HA injection (per-injection prices ranging from $250 to more than $1000), the yearly medication cost would be $300 million to $1.2 billion for HA, versus $12 million for corticosteroid.
Dr. Levin says explaining both clinical and cost considerations to patients can be challenging. “It is easier, more efficient, and less acrimonious to comply with our patient’s request for [HA],” he writes. But he reminds orthopaedists that “bioethical principles along with the concept of shared decision-making do require a physician to spend the necessary time to educate his or her patients.”