Rethinking Viscosupplementation: Ultrasound‐ Versus Landmark‐Guided Injection for Knee Osteoarthritis

Abstract

Objectives-Viscosupplementation, intra-articular injection of hyaluronic acid (HA), for knee osteoarthritis has fallen somewhat out of favor, with studies failing to show consistent benefits in pain reduction. Hyaluronic acid must enter the joint space to be beneficial; however, landmark-guided injection can be substantially inaccurate, especially in obese patients. We aimed to determine whether ultrasound (US) guidance to ensure needle placement for HA knee injection resulted in improved outcomes as reflected by surgery-free survival compared to landmark-guided HA knee injection.Methods-All community-dwelling patients in 6 contiguous surrounding counties receiving HA knee injection either by landmark guidance (n = 647) or by US guidance (n = 500) were analyzed for the degree of arthritis, body mass index, follow-up injection, and subsequent need for knee arthroplasty. A subgroup analysis of obese patients was also performed.Results-The US-and landmark-guided HA injection cohorts were similar with respect to sex, body mass index, and the degree of arthritis. Of 1147 patients receiving knee HA injection, 462 subsequently underwent knee arthroplasty. Significantly fewer patients in the US-guided HA injection cohort went to surgery (33.2%) compared to the landmark-guided cohort (45.8%; P < .001). The subgroup analysis for obese patients showed even larger differences (34.8% versus 51.8%; P < .001).Conclusions-Knee osteoarthritis treatment by viscosupplementation can be optimized by US guidance, ensuring intra-articular needle placement. Using an objective surgical outcome, our study shows that rethinking viscosupplementation to ensure intra-articular delivery improves effectiveness. Patients receiving US-guided knee HA injection were significantly less likely to undergo subsequent knee arthroplasty than patients receiving landmark-guided HA injection.

Safety and efficacy of a single intra-articular injection of hyaluronic acid in osteoarthritis of the hip: a case series of 87 patients

“…It is hypothesised that non-animal derived HA is associated with decreased rates of allergic response and pseudoseptic arthritis and our results support this [ 1 , 18 , 22 ]. The use of ultrasound guidance also reduces the negative outcomes of misplaced injection [ 8 , 25 ].…”

Value of imaging to guide interventional procedures in rheumatic and musculoskeletal diseases: a systematic literature review informing EULAR points to consider

“…19-22 27 28 32 55 In one retrospective cohort study with high RoB, an even worse outcome for US versus palpation-guided injection was found with a higher percentage of patients requiring an additional knee reinjection with hyaluronic acid in the US group (20.3% vs 15%, respectively). 18 In the palpation-guided group, however, more patients received an additional GC injection (34% vs 27.4%, respectively). In another study, it was observed that patients with knee osteoarthritis and US-guided injection had a worse quality of life at 3 months than patients with palpation-guided injections, while walking and standing tests were better in the former than in the latter group.…”

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 V, knee

“…US guidance improved injection accuracy and clinical outcomes at 6-and 12-week follow-up compared with palpation-guided injections in a randomized trial [24]. Long-term, precise intra-articular injection of HA by US guidance was associated with a reduced knee arthroplasty rate compared to the palpation-guided approach, particularly in obese patients [25,32].…”

“…Randomized trials comparing US-guided and palpation-guided corticosteroid intra-articular injections [17,22] reported pain reduction at 2-week follow-up, 107% increase in the responder rate, and 36% increase in therapeutic duration with subsequent cost reduction, using US guidance [22]. In knee osteoarthritis treated with HA injections, the use of US guidance resulted in enhanced functional and pain-score improvement after 6 and 12 weeks [24], with long-term decreased knee arthroplasty rate [25] when compared to palpation guidance. In emergency settings, both blind and US-guided arthrocentesis were successful, although the latter led to higher volume aspiration for novice practitioners [26].…”