0
Commentary and Perspective   |    
A Firmer Base for Clinical Judgment About Hyaluronic Acid InjectionCommentary on an article by Henry DeGroot III, MD, et al.: “Intra-Articular Injection of Hyaluronic Acid Is Not Superior to Saline Solution Injection for Ankle Arthritis. A Randomized, Double-Blind, Placebo-Controlled Study”
Timothy R. Daniels, MD, FRCS(C); Ellie Pinsker, BA&Sc
View Disclosures and Other Information
  • Disclosure statement for author(s): PDF

The authors did not receive payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

University of Toronto and St. Michael's Hospital, Toronto, Ontario, Canada

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2012 Jan 04;94(1):e4 1-2. doi: 10.2106/JBJS.K.01335
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case
For most patients, the natural history of osteoarthritis of a lower extremity joint is one of insidious onset and gradual deterioration. The symptoms wax and wane over time, with the frequency of the painful episodes gradually increasing in both intensity and duration. It takes time and personal reflection for patients to decide that a surgical opinion is necessary. The primary role of the treating surgeon is not only to identify the best mode of treatment but also to discuss the limitations of the proposed interventions. With many surgical options, the recovery time can be substantial and the outcomes variable. The entire process can take years by the time the patient decides to proceed with surgery.
During the interval between the onset of symptoms and surgical intervention, many patients seek effective and affordable treatments to manage their worsening condition. Patients often ask if there is a way to rejuvenate or grow the cartilage that has been lost in the joint. The option of injecting a lubricant into the joint makes sense to the patient and is often embraced with enthusiasm. At this point, they are relying on their treating physician to consider all aspects of the proposed intervention, including the risks, benefits, reliability, cost, effectiveness, and duration of the pain relief. It has been our experience that it does not take much time or effort to convince a patient to agree with the option of having his or her arthritic ankle joint injected with a hyaluronic acid-containing solution.
Unfortunately, many physicians themselves have not required much convincing either. Studies supporting the safety and effectiveness of hyaluronic acid-containing injections for the treatment of knee arthritis along with favorable results from many of the initial investigations of its utility for treating ankle osteoarthritis have been met with optimistic enthusiasm by our profession. To our knowledge, nine previous studies have investigated the effects of hyaluronic injections in arthritic ankles. They have looked at single and multiple-dose hyaluronic acid regimens, as well as a variety of hyaluronic acid, or similar, substances, but most of the studies are not considered high-quality by virtue of being underpowered, uncontrolled, nonblinded, noncomparative, and/or industry funded1-9.
The current study is adequately powered, randomized, and prospective, with validated outcomes; thus, it meets the criteria of a Level-I study. This clinical study demonstrates that the use of a single intra-articular injection of low-molecular-weight, non-cross-linked hyaluronic acid for the treatment of symptomatic ankle arthritis does not produce significantly superior outcomes compared with a single intra-articular injection of saline solution. To a scientist, the outcomes are not surprising since injecting a biologic substance regardless of its function is not likely to work unless it can promote development of a normal articular surface, with resorption of the osteophytes and restoration of joint motion—a goal that is not achievable by hyaluronic acid or similar substances. This does not in any way definitively close the door on the subject; we still need equally well-designed studies to investigate multi-injection regimens and other hyaluronic acid-type substances. However, this study does provide us with a firmer base from which we can make important clinical judgments and advise patients of their treatment options.
In the current climate of upward-spiraling medical costs, record national debt, and uncertain economic future, we believe that physicians have a moral obligation to manage the health-care dollar with prudence, regardless of whether its source is government, insurance, or personal. Given the state of the current evidence base for hyaluronic acid-containing injections for the treatment of ankle arthritis, we encourage a healthy skepticism regarding its benefits and will wait for more evidence before recommending it to patients.
Carpenter  B;  Motley  T. The role of viscosupplementation in the ankle using hylan G-F 20. J Foot Ankle Surg.  2008;47:377-84.
 
Cohen  MM;  Altman  RD;  Hollstrom  R;  Hollstrom  C;  Sun  C;  Gipson  B. Safety and efficacy of intra-articular sodium hyaluronate (Hyalgan) in a randomized, double-blind study for osteoarthritis of the ankle. Foot Ankle Int.  2008;29:657-63.
 
Karatosun  V;  Unver  B;  Ozden  A;  Ozay  Z;  Gunal  I. Intra-articular hyaluronic acid compared to exercise therapy in osteoarthritis of the ankle. A prospective randomized trial with long-term follow-up. Clin Exp Rheumatol.  2008;26:288-94.
 
Pleimann  JH;  Davis  WH;  Cohen  BE;  Anderson  RB. Viscosupplementation for the arthritic ankle. Foot Ankle Clin.  2002;7:489-94.
 
Salk  RS;  Chang  TJ;  D'Costa  WF;  Soomekh  DJ;  Grogan  KA. Sodium hyaluronate in the treatment of osteoarthritis of the ankle: a controlled, randomized, double-blind pilot study. J Bone Joint Surg Am.  2006;88:295-302.
 
Sun  SF;  Chou  YJ;  Hsu  CW;  Hwang  CW;  Hsu  PT;  Wang  JL;  Hsu  YW;  Chou  MC. Efficacy of intra-articular hyaluronic acid in patients with osteoarthritis of the ankle: a prospective study. Osteoarthritis Cartilage.  2006;14:867-74.
 
Valiveti  M;  Reginato  AJ;  Falasca  GF. Viscosupplementation for degenerative joint disease of shoulder and ankle. J Clin Rheumatol.  2006;12:162-3.
 
Witteveen  AG;  Giannini  S;  Guido  G;  Jerosch  J;  Lohrer  H;  Vannini  F;  Donati  L;  Schulz  A;  Scholl  J;  Sierevelt  IN;  van Dijk  CN. A prospective multi-centre, open study of the safety and efficacy of hylan G-F 20 (Synvisc) in patients with symptomatic ankle (talo-crural) osteoarthritis. Foot Ankle Surg.  2008;14:145-52.
 
Witteveen  AG;  Sierevelt  IN;  Blankevoort  L;  Kerkhoffs  GM;  van Dijk  CN. Intra-articular sodium hyaluronate injections in the osteoarthritic ankle joint: effects, safety and dose dependency. Foot Ankle Surg.  2010;16:159-63.
 

Submit a comment

References

Carpenter  B;  Motley  T. The role of viscosupplementation in the ankle using hylan G-F 20. J Foot Ankle Surg.  2008;47:377-84.
 
Cohen  MM;  Altman  RD;  Hollstrom  R;  Hollstrom  C;  Sun  C;  Gipson  B. Safety and efficacy of intra-articular sodium hyaluronate (Hyalgan) in a randomized, double-blind study for osteoarthritis of the ankle. Foot Ankle Int.  2008;29:657-63.
 
Karatosun  V;  Unver  B;  Ozden  A;  Ozay  Z;  Gunal  I. Intra-articular hyaluronic acid compared to exercise therapy in osteoarthritis of the ankle. A prospective randomized trial with long-term follow-up. Clin Exp Rheumatol.  2008;26:288-94.
 
Pleimann  JH;  Davis  WH;  Cohen  BE;  Anderson  RB. Viscosupplementation for the arthritic ankle. Foot Ankle Clin.  2002;7:489-94.
 
Salk  RS;  Chang  TJ;  D'Costa  WF;  Soomekh  DJ;  Grogan  KA. Sodium hyaluronate in the treatment of osteoarthritis of the ankle: a controlled, randomized, double-blind pilot study. J Bone Joint Surg Am.  2006;88:295-302.
 
Sun  SF;  Chou  YJ;  Hsu  CW;  Hwang  CW;  Hsu  PT;  Wang  JL;  Hsu  YW;  Chou  MC. Efficacy of intra-articular hyaluronic acid in patients with osteoarthritis of the ankle: a prospective study. Osteoarthritis Cartilage.  2006;14:867-74.
 
Valiveti  M;  Reginato  AJ;  Falasca  GF. Viscosupplementation for degenerative joint disease of shoulder and ankle. J Clin Rheumatol.  2006;12:162-3.
 
Witteveen  AG;  Giannini  S;  Guido  G;  Jerosch  J;  Lohrer  H;  Vannini  F;  Donati  L;  Schulz  A;  Scholl  J;  Sierevelt  IN;  van Dijk  CN. A prospective multi-centre, open study of the safety and efficacy of hylan G-F 20 (Synvisc) in patients with symptomatic ankle (talo-crural) osteoarthritis. Foot Ankle Surg.  2008;14:145-52.
 
Witteveen  AG;  Sierevelt  IN;  Blankevoort  L;  Kerkhoffs  GM;  van Dijk  CN. Intra-articular sodium hyaluronate injections in the osteoarthritic ankle joint: effects, safety and dose dependency. Foot Ankle Surg.  2010;16:159-63.
 
Accreditation Statement
These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
CME Activities Associated with This Article
Submit a Comment
Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field
(if multiple authors, separate names by comma)
Example: John Doe





Related Content
The Journal of Bone & Joint Surgery
JBJS Case Connector
Topic Collections
Related Audio and Videos
PubMed Articles
Clinical Trials
Readers of This Also Read...
JBJS Jobs
04/16/2014
Connecticut - Yale University School of Medicine
12/04/2013
New York - Icahn School of Medicine at Mount Sinai
04/02/2014
W. Virginia - Charleston Area Medical Center