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Hyaluronic Acid Injection – How Effective Is It?

Hyaluronic Acid injection, which is known as Hyaluronan, is a type of naturally occurring substance found in the synovial joints in the body. The main function of this viscoelastic substance is that it acts as a shock absorber in the joints and helps dissipate energy after a trauma. Hyaluronic Acid is also called viscosupplementation, acts as a lubricant and helps in the lubrication of the joint, hence promoting the joint movement and aiding in pain relief. (1) It also improves the health of the joint. It can be produced by a process called fermentation where bacteria undergo a specialized method to uptake the formation of HA or it can be derived by animal proteins by the rooster comb method( this involves filtration, drying, and conditioning method).

Studies have shown when viscosupplementation injections were injected directly to treat advanced arthritis under ultrasound guidance, HA significantly prevented the death of the cartilage cells caused by arthritis, and improved the health of knee joints and the quality of life of patients. (2)

Osteoarthritis and Hyaluronic Acid Content

It has been found that patients with Osteoarthritis have a reduced concentration and molecular weight of Hyaluronic Acid in the synovial fluid of the joints. Since the functioning of the synovial fluid is highly dependent on the Hyaluronic acid content, a reduction in this substance leads to a reduction in the viscoelastic properties of the joint fluid and hence leading to the development of arthritis. (3) This is what led to the initial suggestion that Hyaluronic Acid treatment by an Orthopedic specialist might be effective at restoring the viscoelastic and natural protective function of the synovial fluid in the knee joint space and can also improve joint health.

These injections help the patient by increasing their joint lubrication and acting as the shock absorber, allowing them to reduce pain levels and lead to a healthy joint. This treatment option is particularly suggested for those who have undergone other treatment modalities like taking pain medications like Acetaminophen, and physical therapy had not seen any positive results.

Studies indicate that hyaluronic acid shots may be more effective than analgesics for some OA patients. Other studies have demonstrated that they may also be as effective as corticosteroid knee shots.

Some individuals may respond better than others to hyaluronic acid inoculations. They may be less beneficial for the elderly and those with severe OA.

Are HA supplements beneficial for patients with osteoarthritis?

Previous researches indicate that  HA supplementation may assist some individuals with osteoarthritis symptoms. For instance,  a  2014 study found that a 3-month course of HA supplements alleviated the symptoms of knee osteoarthritis in obese individuals.

At the completion of the treatment, the researchers observed an increased HA concentration in the joint fluid and a decrease in inflammatory cytokines. However, there were only forty participants in this investigation.

According to a 2015 study, oral HA supplementation exhibited similar findings.  The 72 participants with knee osteoarthritis who took oral HA reported less pain and better sleep quality than those who undergo placebo treatment, Additionally, they used fewer pain drugs.

Overall, additional large-scale studies are required to determine the efficacy of HA supplementation in treating osteoarthritis.

How Long Do Hyaluronic Acid Knee Injections Last?

It has generally been suggested that Hyaluronic Acid injections for knee with higher molecular weight can last up to 1 year. This treatment may also be repeated safely every six months to a year for the management of Osteoarthritis. However, the exact longevity of these knee injections is still being investigated in musculoskeletal systematic reviews and meta-analyses. One recent study showed they last for more than 450 days in some individuals, while for the others, They lasted for more than 1000 days. (4)

Another study, which included 223 individuals, showed positive results after the injection of Hyaluronic Acid treatment. It was found that the patients who had been treated with these shots reported lower joint pain and stiffness levels than those who were not injected. The study concluded by stating that the HA knee inoculations were effective for mild to moderate knee pain and as well as for other arthritis symptoms for at least 13 weeks after the injection period. (5)

What Are The Side Effects of Hyaluronic Acid Knee Injections?

The benefits of hyaluronic acid outweigh the risks. The very few side effects associated with Hyaluronic Acid Knee shots are almost always mild and self-limiting. Among these, the most common side effects include injection site reaction or a mild flare-up in less than 2% of individuals. This may include symptoms like pain, swelling, and redness, which can be corrected with icing, anti-inflammatory pills, and rest. There have been no reports of joint infections after Hyaluronic Acid Inoculations in clinical trials that have been conducted to study the subject matter. Evidence also indicates that systemic side effects like skin rashes, myalgia, nausea, and body muscle cramps are also very rare and reported in less than 2% of the participants in the clinical trials. (6) Additionally, an individual must not inject hyaluronic acid on their own, it must be administered as per professional medical advice. Because if an individual injects hyaluronic acid into soft tissue, he/ she may feel inflammation and severe pain.

What Is the Best Injection For Knees?

Experts have generally suggested that Hyaluronic Acid injections with a higher molecular weight like Hyalgan are considered better as they are much more long-lasting. This is because they are FDA-approved and more cross-linked and have a higher viscosity, making their degradation much slower as compared to other forms of Hyaluronan injections, which are less cross-linked and have a lower molecular weight.

What to Expect After Getting the Hyaluronic acid injection

Depending on the type your doctor prescribes, you may receive a single injection. Alternately, you will receive three to five shots every week. The injection is administered identically for all types. The doctor first cleans the area. If your knee is swollen due to extra joint fluid, your physician may inject a local anesthetic and then put a needle into the joint to remove the excess fluid build-up. Typically, the doctor can inject hyaluronic acid into the knee joint using the same needle. After one or two days of treatment, non-strenuous weight-bearing activity can be started according to the doctor advice. Aside from that, you should be able to continue your regular activities.

What is the Difference between Hyaluronic Acid and Cortisone?

The effect of Hyaluronic Acid injections treatments for knee osteoarthritis is often compared to the effectiveness of Cortisone injections – however, they are not the same. Cortisone is an anti-inflammatory substance that is prescribed by doctors to treat arthritis of the knees. That is because it can improve osteoarthritis symptoms such as swelling, pain, and knee joint inflammation. Even though some evidence shows cortisone/steroid injections to work for up to 3 months, they are not effective in all cases. Moreover, unlike Intra Articular Hyaluronic shots which are considered safe to be re-injected, steroid injections may lead to joint cartilage loss on reinjection and can also cause an allergic reaction. It may also promote the degradation of joints until the individual requires joint replacement and has to undergo total knee replacement surgery.

Another difference between the two is that while the effectiveness of Cortisone may be immediate, it may take up to 4 weeks for the Hyaluronic injections to become effective. However, this also means that the effects of Hyaluronic Acid injections are much longer. (7)

Additionally, while treating osteoarthritis with cortisone injection, there is a risk of the development of other conditions such as GI bleeding, cataracts, and glaucoma. On the other hand, hyaluronic acid injections are quite safe, as no such risks have been found associated with these injections to treat osteoarthritis.

Prolotherapy – A more advanced alternative to Hyaluronic acid injections

Prolotherapy in the UK  has built a reputation for achieving results when all other treatments have failed. Studies have proven that it can relieve pain, repair, strengthen and regenerate the following structures: joints, cartilage, spinal discs, muscles, ligaments, tendons, meniscus, and bursa.

The treatment was named ‘Prolotherapy’ because it involves the injection of regenerative solution to proliferate cells in a weak or damaged region of the body. To proliferate cells means to multiply and increase the number of them.

Prolotherapy proliferates chondrocyte and collagen cells. Cartilage is formed mainly of chondrocytes. Spinal discs, muscles, ligaments, tendons, meniscus, and bursa are formed mainly of collagen. The treatment increases the number of these cells through activating chondroblasts and fibroblasts, which are the pre-curser building blocks to chondrocytes and collagen.

Prolotherapy has the ability to provide complete relief of symptoms, even in severe conditions that have been present for many years. Medical Ozone is naturally anti-bacterial, so deemed one of the safest injections on offer within medicine.

Conclusion

Hyaluronic Acid Knee Injections treatments have been discussed and investigated by numerous recent studies, the majority of which have found them to be effective compared to other treatments at managing the symptoms of mild to moderate knee osteoarthritis. They are ideal for individuals who don’t have significant swelling of the joint, as the injections take a few days to show results. Hence if you are someone who is looking for a quick fix, these injections might not be for you. On the other hand, if you are willing to wait a few days to have longer-lasting results, the Hyaluronic Acid Knee Injections are ideal for joint health. These are also suggested for individuals who show allergic reactions to steroids or may not be permitted to use them for certain medical conditions. They may also be the best option for patients who do not want to undergo surgery. They have no downtime, so the individual may go home right after getting their injection.

References:

    1. Altman, R. D., Akermark, C., Beaulieu, A. D., Schnitzer, T., & Durolane International Study Group (2004). Efficacy and safety of a single intra-articular injection of non-animal stabilized hyaluronic acid (NASHA) in patients with Osteoarthritis of the knee. Osteoarthritis and cartilage, 12(8), 642–649. https://doi.org/10.1016/j.joca.2004.04.010
    2. Larsen, N. E., Lombard, K. M., Parent, E. G., & Balazs, E. A. (1992). Effect of hylan on cartilage and chondrocyte cultures. Journal of orthopaedic research: official publication of the Orthopaedic Research Society, 10(1), 23–32. https://doi.org/10.1002/jor.1100100104
    3. Dahl, L. B., Dahl, I. M., Engström-Laurent, A., & Granath, K. (1985). Concentration and molecular weight of sodium hyaluronate in synovial fluid from patients with rheumatoid arthritis and other arthropathies. Annals of the rheumatic diseases, 44(12), 817–822. https://doi.org/10.1136/ard.44.12.817
    4. Carney, G., Harrison, A., & Fitzpatrick, J. (2021). Long-Term Outcome Measures of Repeated Non-Animal Stabilized Hyaluronic Acid (Durolane) Injection in Osteoarthritis: A 6-Year Cohort Study with 623 Consecutive Patients. Open access rheumatology : research and reviews, 13, 285–292. https://doi.org/10.2147/OARRR.S331562
    5. Day, R., Brooks, P., Conaghan, P. G., Petersen, M., & Multicenter Trial Group (2004). A double blind, randomized, multicenter, parallel group study of the effectiveness and tolerance of intraarticular Hyaluronan in Osteoarthritis of the knee. The Journal of rheumatology, 31(4), 775–782.
    6. Walker K, Basehore BM, Goyal A, et al. Hyaluronic Acid. [Updated 2021 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482440/
    7. Leopold, S. S., Redd, B. B., Warme, W. J., Wehrle, P. A., Pettis, P. D., & Shott, S. (2003). Corticosteroid compared with hyaluronic acid injections for the treatment of Osteoarthritis of the knee. A prospective, randomized trial. The Journal of bone and joint surgery. American volume, 85(7), 1197–1203. https://doi.org/10.2106/00004623-200307000-00003

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