Effectiveness and Tolerability of Repeated Courses of Viscosupplementation in Symptomatic Hip Osteoarthritis: A Retrospective Observational Cohort Study of High Molecular Weight vs. Medium Molecular Weight Hyaluronic Acid vs. No Viscosupplementation

Abstract

Background: Nonsurgical management of symptomatic hip osteoarthritis needs real-world evidence. We evaluated the effectiveness and tolerability of US-guided intra-articular treatment of two hyaluronic acids (HAs) commercially available in Italy and investigated predictors of response. Methods: Outpatient records including three cohorts: 122 subjects treated with medium (1,500–3,200 kDa; Hyalubrix®) molecular weight (MW) or high (hylan G-F20; Synvisc®) MW HAs and 20 controls taking NSAIDs/analgesics on demand were retrospectively analyzed. Pain VAS score, WOMAC, NSAID/analgesic consumption, and causes of suspension were available at 1, 6, 12, and 24 months after first administration. As selection bias usually affects observational retrospective studies, a quasi-randomization process was attained by performing propensity score approach. Results: Propensity score adjustment successfully allowed comparisons among balanced groups of treatments. VAS and WOMAC considerably decreased over time in treated groups independently of the radiological grade (p<0.001). On the other hand, the control group showed only a slight and rather uneven variation in VAS. Mean score changes were comparable in both HA cohorts from the earliest stages (ΔVAS(HA1,500–3,200kDa)T1vsT0 = −20%; ΔVAS(hylan G-F20)T1vsT0 = −23%/ΔWOMAC(HA1,500–3,200kDa)T1vsT0 = −17%; ΔWOMAC(hylan G-F20)T1vsT0 = −19%), reaching a further substantial reduction after 12 months (ΔVAS(HA1,500–3,200kDa)T12vsT0 = −52%; ΔVAS(hylan G-F20)T12vsT0 = −53%/ΔWOMAC(HA1,500–3,200kDa)T12vsT0 = −45%; and ΔWOMAC(hylan G-F20)T12vsT0 = −47%). Almost 11% (=13/122) of ineffectiveness and few moderate local side effects 3% (=4/122) were detected. Conclusions: Viscosupplementation in a real-life setting seems to provide a sound alternative in pain management in comparison to oral NSAIDs/analgesics, guaranteeing a reduced intake of pain killer medications. Analgesic effectiveness, functional recovery, and reduced joint stiffness extend and improve over 12 and 24 months, suggesting that repeated administrations achieve an additive effect.

Hybrid Hyaluronic Acid versus High Molecular Weight Hyaluronic Acid for the Treatment of Hip Osteoarthritis in Overweight/Obese Patients

“…Generally, one to four injections are recommended with the ultrasound-guided infiltration technique, which is the safest approach [28][29][30].…”

Intra-articular Injections of Cross-linked Hyaluronic Acid in Japanese Patients with Symptomatic Osteoarthritis of the Hip

“…A meta-analysis of HA injection into the knee showed that the improvement of pain and function compared to the placebo group depended on the type of HA, and that Hylan G-F 20 did result in such improvements. 41) Whereas most hip injection studies do not have a placebo group, [10][11][12][13][14][15] there are three studies of hip injection that compare the HA group with a placebo group and show no difference between them. 42) However, Brander et al evaluated the effects of HA-IA using the Western Ontario McMaster Universities Osteoarthritis Index, in which the pain score is classified into five levels and subtle differences at the same level could be neglected.…”

“…8) For hip OA, several studies have reported that pain is reduced in the short-term by IA-HA, and function disability is improved. [10][11][12][13][14][15][16] These reports are from Europe and the United States, because the use of HA for hip OA is not covered by insurance in Japan and is therefore rarely used. Hylan G-F 20 is a cross-linked sodium hyaluronate with a high average molecular weight of 6 million Dalton.…”

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)—part IV, hip

“…A meta-analysis found that intra-articular placebo is effective for osteoarthritis, particularly with regards to self-reported pain and functional outcome measurements, probably due to the dilution of proinflammatory cytokines by saline [72]. Regarding the different concoctions, published data showed that most hyaluronic acid formulations were not significantly different in terms of clinical and functional outcomes [73][74][75].…”

“…Indeed, studies using intra-articular corticosteroids in the hip suggest a short duration of action (4-12 weeks) [67,76,77]. In contrast, the effects of hyaluronic acid can last up to 6 months, although recent evidence also showed no difference at this time point for hyaluronic acid and corticosteroids [60,74,75,78]. A systematic review included five trials investigating the use of PRP in hip osteoarthritis, showing overall no significant differences between patients treated with PRP or hyaluronic acid alone [79].…”