Scientific Article   |    
Granulomatous Inflammation After Hylan G-F 20 Viscosupplementation of the Knee A Report of Six Cases
Andrew L. Chen, MD, MS; Panna Desai, MD; Edward M. Adler, MD; Paul E. Di Cesare, MD
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Investigation performed at the New York University-Hospital for Joint Diseases, New York, NY

Andrew L. Chen, MD, MS
Panna Desai, MD
Edward M. Adler, MD
Paul E. Di Cesare, MD
Departments of Orthopaedic Surgery (A.L.C., E.M.A., and P.E.D.C.) and Pathology (P.D.), New York University-Hospital for Joint Diseases, 301 East 17th Street, New York, NY 10003. E-mail address for P.E. Di Cesare: pedicesare@aol.com

The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2002 Jul 01;84(7):1142-1147
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Background: Recently, intra-articular viscosupplementation with hyaluronate-derived products has gained popularity as a palliative modality for the treatment of osteoarthritis of the knee. Mild pain or swelling at the site of injection may occur in up to 20% of patients, although severe local inflammation, warmth, and joint effusion are rare. We present a series of six cases in which granulomatous inflammation of the synovium was observed after hyaluronate viscosupplementation of the knee.

Methods: Six knees (five patients) treated with intra-articular Hylan G-F 20 viscosupplementation underwent a surgical procedure because of persistent symptoms. Routine histopathological evaluation, supplemented by alcian-blue staining and hyaluronidase digestion, was performed in each case.

Results: Chronically inflamed synovium with areas of histiocytic and foreign-body giant-cell reaction was observed surrounding acellular, amorphous material. The material stained with alcian blue, a stain for hyaluronate, which disappeared after hyaluronidase digestion.

Conclusions: We believe that the injected hyaluronate (Hylan G-F 20) may have been responsible for the synovitis in our patients and thus may be a pathological cause of recalcitrant symptoms after such injection. It is not known whether the responsible pathological agent was the hyaluronate derivative, a contaminant of the purification process, or a component of the carrier substance. Importantly, it appears that the findings in these patients most likely represent a previously unreported pathological response to a viscosupplementation product. This report should raise clinical awareness about this potential complication.

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    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.
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    Granulomatous inflammation after Hylan G-F 20 viscosupplementation of the knee. J Bone Joint Surg Am 2003;85-A(10):2051-2; author reply 2052-3.
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