What is the evidence for intra-articular (viscosupplementation) injections of hyaluronic acid in patients with hip osteoarthritis for pain reduction and functional improvement?
AMSTAR Rating
Summary
Patient Population:
8 randomized controlled trials (RCTs) met eligibility criteria, encompassing a total sample size of n = 807 patients with primary hip osteoarthritis diagnosed per American College of Rheumatology (ACR) criteria. Patient age averages across trials spanned a range from 53 to 73 years old, and disease baseline severity captured Kellgren-Lawrence grades (KLG) 1 through 4.
Intervention:
Various intra-articular hyaluronic acid (HA) formulations and delivery protocols were utilized. Single injections of Durolane (~90 MDa molecular weight) or Synvisc-One (~6 MDa); two injections of Hylan G-F 20 (~6 MDa); or three sequential injections of Hyalubrix (1.5–3.2 MDa) or Hyalgan (0.5–0.73 MDa). Most treatment arms specified injection tracking using dynamic ultrasound or fluoroscopic imaging guidance.
Comparison:
Viscosupplementation was compared independently against both inactive and active controls across multi-arm trials, consisting of Placebo saline water (4 RCTs, n = 542), Corticosteroid injections at a consistent standard dose of 60 mg methylprednisolone acetate per application (3 RCTs, n = 405), Platelet-Rich Plasma (PRP) biologic preparations (3 RCTs, n = 223), or Local Anesthetic mepivacaine control (1 RCT, n = 42).
Outcome:
Quantitative random-effects meta-analysis demonstrated that HA was not statistically superior to placebo for pain relief at 3 months (Standardized Mean Difference [SMD] = -0.06; 95% CI, -0.38 to 0.25; p = 0.69, graded as very low-certainty evidence).
Safety profiles showed no significant differences in adverse event rates between HA and placebo controls (Risk Ratio [RR] = 1.21; 95% CI, 0.79 to 1.86; p = 0.38, high-certainty evidence).
For comparisons with active treatments, high-certainty data demonstrated that HA was no different from methylprednisolone for pain at 1 month (SMD = 0.02; 95% CI, -0.18 to 0.22; p = 0.85) or for adverse events (RR = 1.21; 95% CI, 0.79 to 1.87; p = 0.38).
Comparisons against PRP showed broad confidence intervals indicating no clear superiority for HA at 1, 6, or 12 months.
A pooled quantitative meta-analysis for functional disability or quality of life was precluded due to absent or sparse data in primary study reports.
Guideline Recommendations
| Source | Recommendation |
|---|---|
| AAOS, 2023 | Strong Recommendation AGAINST Use |
| NICE, 2022 | Recommendation AGAINST Use |
Outcomes Assessed
- Benefit
- Harm
- Inconclusive
Pain
v. Placebo at 3 months
v. Cortisone at 1 month
v. PRP at 1, 3, and 6 months
Safety
v. Placebo and Cortisone
Relevant Clinical Info
Spitzer AI, Bockow BI, Brander VA, et al. Hylan G-F 20 improves hip osteoarthritis: a prospective, randomized study. Phys Sportsmed. 2010;38(2):35-47.
Spitzer et al. (2010) was a prominent multi-center parallel-group RCT included in the meta-analysis, evaluating a total sample size of 312 patients with symptomatic hip osteoarthritis (KLG 2 or 3). Participants were randomized to receive either 2 injections of high molecular weight hylan G-F 20 or an active corticosteroid comparison arm (60mg methylprednisolone). While the trial observed significant short-term relief inside both application groups at a 1-month check, it uniquely demonstrated that patients categorized with more established KLG 3 baseline severity metrics sustained significantly more durable therapeutic improvements following viscosupplementation compared to the steroid arm at a longer-term 6-month tracking milestone.
Participant Information
The sample size was 807
There were 8 studies used.
