Consensus statement on viscosupplementation with hyaluronic acid for the management of osteoarthritis

https://doi.org/10.1016/j.semarthrit.2015.04.011Get rights and content

Abstract

Viscosupplementation (VS) with hyaluronic acid is currently used by physicians to treat osteoarthritis. However, many aspects of this treatment remain questionable and subject of controversy. A group of 8 experts in this field, from European countries, met to debate on 24 statements previously listed by the group members. Based on an extensive research of the literature and expert opinion, a consensus position has been proposed for each statement. Agreement was achieved on some recommendations. In particular, the expert achieved unanimous agreement in favor of the following statements: VS is an effective treatment for mild to moderate knee OA; VS is not an alternative to surgery in advanced hip OA; VS is a well-tolerated treatment of knee and other joints OA; VS should not be used only in patients who have failed to respond adequately to analgesics and NSAIDs; VS is a “positive” indication but not a “lack of anything better” indication; the dosing regimen must be supported by evidence-based medicine; cross-linking is a proven means for prolonging IA residence time of HA; the best approach to inject accurately knee joint is the lateral mid-patellar one; when VS is performed under fluoroscopy, the amount of radiopaque contrast agent must be as low as possible to avoid viscosupplement dilution. These clear recommendations have been established to help practitioners in the use of viscosupplementation.

Introduction

In the early 1990s, Balazs hypothesized that intra-articular (IA) injections of exogenous hyaluronic acid (HA) could restore visco-elasticity of the osteoarthritic synovial fluid (SF). This concept of “viscosupplementation” (VS) [1], [2] has been developed, based on the finding that the visco-elastic properties characterizing the healthy SF are altered in osteoarthritis (OA), and that these changes were directly related to the quantitative and qualitative HA decline in SF. Indeed, HA plays a major role in lubrication, shock absorption, and visco-elastic behavior of SF [3] as a result of HA molecules and proteins/HA electrostatic interactions. The visco-elastic property of SF, which is directly related to both molecular weight (MW) and concentration of HA [3], [4], [5], gives it the ability to reduce mechanical stress on the joint. At low shear, such as occurs during a slow movement, the linear chains of HA align slowly in the direction of flow and behave like a viscous fluid. When the joint is subjected to fast impact (i.e., running or jumping) HA molecules do not have time enough to realign and exhibit elastic behavior, thus, allowing shock absorption. In OA, SF visco-elasticity and consequently its ability to protect cartilage is dramatically lowered because of the decrease of both HA molecular weight (MW) and concentration [2]. Beside these physical properties, HA also exerts biological activities such as promotion of endogenous high MW HA production [6], interaction with pain receptors, and inhibition of pro-inflammatory mediators synthesis by joint cells [7], [8], [9], [10], [11], [12], [13].

After more than 20 years of use, VS is usually recognized as a safe and effective treatment of knee OA [14], [15], [16], [17], [18], [19], [20], [21], safety being a major issue in the treatment of this condition. However, despite this positive assessment by practitioners and a high level of evidence, recent guidelines fail to recommend this therapeutic modality. This is mainly due to conflicting results of meta-analyses [22], [23], [24] that may arise from methodological differences and from possible differences in efficacy between products that widely vary in concentration, molecular weight, molecular organization (linear or cross-linked HA), and protocol of injection. Furthermore the indications, protocol of injecting and economic impacts of VS have yet to be specified [25], [26].

To provide clarification to prescribers and users of VS, a task force of European experts on OA has been brought together in order to propose a consensual approach on VS in knee and other joints OA.

Section snippets

Experts

Eight European experts from Belgium, France, Germany, Italy, and UK, were selected according to their expertise in the field of OA and especially VS and were invited to participate at a task force on VS with HA (Lyon, France, June 2014). The expert panel was made of 5 rheumatologists (A.M., H.B., P.R., T.C., and X.C.), 2 orthopedic surgeons (J.J. and R.R.) and 1 physiotherapist (Y.H.). The board members have experience in both academic medicine and private practice and have expertise in

Results

For each of the 24 issues, the average voting score, standard deviation, median, range, and global opinion (Disagree, Agree under condition, and Agree) are given.

Discussion

Viscosupplementation is booming, with an annual growth estimated at 7.1% and more than 17 million treatments sold so far [111]. Nevertheless, major controversies persist regarding its efficacy, safety, and cost-effectiveness. This reflects a huge gap between those who doubt—some academics, methodologists, and health authorities, and those who believe—practitioners, for whom there is little doubt that VS is a very useful therapeutic modality in the management of OA.

It thus seemed logical to

Conclusion

In conclusion, this task force has helped to create consensus on critical points of the use of VS in OA management including the route of injection, the indication, the efficacy and the tolerability. These recommendations should contribute to a better use of VS in the daily practice of physicians.

Acknowledgment

The authors acknowledge Laboratoire de Rhumatologie Appliquée (LABRHA SAS) and Sandra CAVAGNA for the meeting organization and Dr. Pierre Mathieu, Carole Bergougnoux, and Josepha Roques for their participation to the meeting content.

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