Knee OA - The therapeutic trajectory of corticosteroids and hyaluronic acid

Study Type: Meta-analysis/Systematic Review
OE Level of Evidence: 1
Journal Level of Evidence: N/A
7 randomized controlled trials (RCTs) were included in this systematic review and meta-analysis comparing conservative treatment methods of intra-articular hyaluronic acid injections and corticosteroid injections. Pain scores were pooled at 2, 4, 8, 12, and 26 weeks post-injection. At early follow-up Please login to view the rest of this report. Please login to view the rest of this report.
Funding: Not Reported
Conflicts: None disclosed
Why was this study needed now?
Knee osteoarthritis is a progressive joint disease that leads to the gradual degradation of the joint. This condition is a leading cause of disability in the adult population that is associated with immense direct and indirect societal costs, which are projected to increase significantly with an aging population. Corticosteroid and hyaluronic acid injections are two forms of intra-articular injection therapies that mitigate the symptoms experienced by patients and are popular in the management of knee osteoarthritis. A number of randomized controlled trials have been conducted that have identified that the therapeutic trajectories of these treatments may differ. A systematic review and meta-analysis was needed to provide an estimate of effect for these two popular injection therapies at different time points to determine if there are significant differences in their therapeutic trajectories and if these differences are of clinical importance.
What was the principal research question?
How do hyaluronic acid and corticosteroid injections compare in symptomatic relief of knee osteoarthritis?
Data Source: Medline, Embase, CINAHL, BIOSIS, and the Cochrane Controlled Trials Register were searched for relevant articles published up to February 2009. Reference lists of identified articles, as well as conference proceedings from relevant meetings (American College of Rheumatology, British Society for Rheumatology, Osteoarthritis Research Society International) from 1990 to February 2009, were hand search for possible studies otherwise missed by the electronic search.
Index Terms: Search terms included: "osteoarthritis", "osteoarthrosis", "gonarthrosis", "degenerative arthritis", "hyaluronic acid", "hyaluronan", "hyaluronate", "viscosupplementation", and "corticosteroids". Trade names of injection drugs were also featured in the search.
Study Selection: Inclusion criteria were randomized clinical trial design, conducted in patients with knee osteoarthritis, and compared intraarticular injections of hyaluronic acid with corticosteroids. Additionally, one of the following outcomes had to have been reported: Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale, index joint pain when walking (either as a visual analog scale [VAS] or Likert scale), index joint pain during activity (VAS or Likert), or spontaneous index joint pain (VAS or Likert). The search and selection were performed independently by two reviewers. In total, 7 randomized controlled trials with 606 patients were selected for final inclusion.
Data Extraction: Data extracted was performed independently by two reviewers, with disagreement resolved by discussion and consensus.
Data Synthesis: Statistical analyses were conducted using SAS, version 9.1 and R, version 2.7.2. A pooled effect size was calculated using Hedges's G statistic at each time point using a random effects model. A negative Hedges's G favours corticosteroid treatment and a positive Hedge's G favours hyaluronic acid. Statistical heterogeneity was assessed using the I-squared statistic.
What were the important findings?
What should I remember most?
How will this affect the care of my patients?
The authors responsible for this critical appraisal and ACE Report indicate no potential conflicts of interest relating to the content in the original publication.