Arthritis

Updated 08 April 2016

Can viscosupplements alleviate arthritic knee pain?

Osteoarthritis sufferers have less hyaluronic acid in their joints than other people and many doctors believe that injecting hyaluronic acid into the affected joint will provide relief from arthritic symptoms.

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There are more than 100 kinds of arthritis, but the three most common kinds are osteoarthritis, rheumatoid arthritis and psoriatic arthritis.

Osteoarthritis is often referred to as “wear and tear” arthritis and affects a large part of the population. It happens as people grow older, but can also be caused by obesity or joint injuries.

No cure for osteoarthritis

Weight-bearing joints like the hips, feet, spine and knees are the areas that are most affected by osteoarthritis.

According to the American National Institutes of Health (NIH) osteoarthritis mostly affects cartilage. Cartilage is the slippery tissue that covers the ends of bones in a joint, allowing bones to glide over each other. In osteoarthritis, the top layer of cartilage wears away, which causes bones under the cartilage to rub together.

Read: Knee cartilage regrown

This rubbing motion can cause symptoms like pain, swelling, tenderness, stiffness, loss of flexibility, “grating” and bone spurs.

Apart from joint replacement surgery there is no cure for osteoarthritis, but a lot can be done to alleviate symptoms and prevent the situation from becoming worse. Some ways to relieve the pain of osteoarthritis and improve mobility are:

- Exercise

- Weight loss

- Anti-inflammatory medication

- Pain relievers

- Steroid injections

- Corticosteroid injections

- Hyaluronic acid injections/viscosupplementation

- Alternative medicine

- Physical devices

- Physical therapy

Hyaluronic acid injections

When nothing else has worked, many doctors are willing to give hyaluronic acid injections a try before turning to surgery (knee replacement), especially if the patient can’t take painkillers like ibuprofen and paracetamol. The side effects are mild, recovery time is short, and there is a lot of anecdotal evidence for the effectiveness of viscosupplementation.  

Read: Total knee replacement

Hyaluronic acid is a natural substance in the synovial fluid surrounding joints where it lubricates bones, enabling them to move smoothly over each other. Osteoarthritis sufferers have less hyaluronic acid in their joints than other people and the idea is that injecting hyaluronic acid into the affected joint will provide relief from arthritic symptoms.

According to SANOFI, to prepare your knee for injection your doctor may:

- Clean your knee with alcohol and/or iodine

- Apply a local anaesthetic to your knee

- Insert a needle into your joint

- Withdraw any excess fluid from your joint

- Inject the viscosupplement into your knee joint (intra-articular injection)

The procedure only takes a few minutes and you can go home directly afterwards. At home the patient is advised to rest and to avoid putting strain on the knee. Any pain may be alleviated with an ice pack. Side effects are usually mild and temporary.

Sanofi says that for people with osteoarthritis of the knee relief has been shown to last up to a year with three viscosupplement injections. Success varies from person to person and repeat treatment is safe and effective. 

Hyaluronic acid is often made from rooster combs, and patients who are allergic to chicken products should avoid viscosupplements from avian sources.     

'Minimal or nonexistent benefit'

Viscosupplementation is widely used for symptomatic knee osteoarthritis to improve biomechanical function, and the FDA approved it in 1997.  

Although popular, the therapy is controversial, and Anne W.S. Rutjes, PhD, with the Institute of Social and Preventive Medicine, at the University of Bern, in Bern, Switzerland, and colleagues reported their findings regarding the practice online June 12, 2012 in the Annals of Internal Medicine.

The conclusion of the authors’ meta-analysis was: “The benefit of viscosupplementation on pain and function in patients with symptomatic osteoarthritis of the knee is minimal or nonexistent." They also found that the procedure increased the risk for “serious adverse events”.

The American Academy of Orthopaedic Surgeons (AAOS) also recently stated in their guidelines for the treatment of osteoarthritis of the knee that they cannot recommend using hyaluronic acid (HA) for patients with symptomatic osteoarthritis of the knee.  (This is bad news for companies like SANOFI that sell hyaluronic acid [HA].)

Health24 asked Cape Town rheumatologist Dr David Gottlieb about the use of viscosupplementation for osteoarthritis. He replied via email that he has no strong belief in the therapy and doesn’t “think it works any better than a cheap cortisone injection” and doesn’t use it anymore. 

For some it works

There are however influential organisations that strongly advocate the use of viscosupplementation.

An article by the American Arthritis Foundation gives what is probably the best assessment of the situation, stating that the weight of evidence suggests that a (hyaluronic acid) shot in the knee may bring some osteoarthritis patients relief. And although studies of viscosupplementation have yielded some disappointing results, many doctors who treat osteoarthritis say that, in their clinical experience, hyaluronic acid can produce significant relief for some patients. 

Arthritis Research UK also sends out a generally positive message: “Hyaluronan injections are most useful in  osteoarthritis  when the smooth, highly polished surfaces of the joint have become roughened but there’s no significant inflammation.” 

Cost of viscosupplementation

According to The Journal of Family Practice the cost of one hyaluronic acid (30 mg/mL) injection is approximately $230 (R3 500). If you receive a course of three to five weekly knee injections, your total cost per treatment could be more than $1 000 (R15 500) per knee. This is a lot of money and the benefit of viscosupplementation must be carefully compared with other therapies. 

Read more:  

Study shows the value of alternative knee replacement treatment

Arthritis and exercise

Knee pain may run in the family

 

Ask the Expert

Arthritis expert

Professor Asgar Ali Kalla completed his MBChB (Bachelor of Medicine and Bachelor of Surgery) degree in 1975 at the University of Cape Town and his FRCP in 2003 in London. Professor Ali Kalla is the Isaac Albow Chair of Rheumatology at the University of Cape Town and also the Head of Division of Rheumatology at Groote Schuur Hospital. He has participated in a number of clinical trials for rheumatology and is active in community outreach. Prof Ali Kalla is an expert in Arthritis for Health24.

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