Efficacy Of Hyaluronic Acid Injections Research Articles

(050) Safety and Efficacy of Hyaluronic Acid Injections Using the UroFill™ Technique for Penile Girth Enhancement

Abstract Introduction Penile girth enhancement (PGE) has gained significant popularity and is in high demand among individuals seeking to improve their sexual experiences and self-confidence. Perception of penile length and girth are integral components of the male psyche. Unfortunately, current treatment options for motivated patients looking to enhance penile girth fall short of patient and clinical expectations. While the safety of penile augmentation methods has been a subject of debate, hyaluronic acid (HA) fillers have demonstrated proven efficacy and safety, offering potential solutions for those interested in PGE. Advancements in the field of penile cosmetics with HA has led to the development of the UroFill™ patented technique for PGE. Objective To assess the safety and efficacy of injecting HA using the UroFill™ technique for PGE. Methods We performed a retrospective analysis of men undergoing penile girth enhancement with FDA-approved HA fillers between October 2021 and March 2023. Patients completed a series of validated questionnaires including the COPS-P, IIEF, and BAPS. Peri- and post-procedure adverse events were closely monitored. Physician follow-up appointments and patient questionnaires were utilized to identify and document these events. The determination of unsatisfactory cosmetic outcomes and the need for revision was made by the treating physician in consultation with the patient. The UroFill™ standardized technique was employed for all injections. Results A total of 300 men (mean age: 37, range 21-80) received treatment using the UroFill™ standardized technique. 4,879 injections were performed over this time. Mean injection volume was 16.5 cc (range: 4-78cc) of HA once treatment had been completed. The study observed an average of 3.85 injection sessions (range: 1-44 sessions) and 5.25 post-injection modeling sessions (range 0-55) per patient. After receiving HA dermal fillers, patients experienced local injection site reactions such as bruising, tenderness, swelling, and erythema. These events were generally mild in intensity, and no patient reported bruising lasting longer than 7 days. None of the patients in this cohort required removal of filler. Adverse reactions were limited to 8 cases of localized skin infections which were successfully treated with conservative antibiotic therapy. All localized skin infections were a result of premature sexual intercourse or shaving in the area following injection. Patients reported high levels of satisfaction with 272/300 (91%) reporting “completely satisfied” or “mostly satisfied”. Mean filler retention was 90% after 12 months. Conclusions This study provides evidence that the UroFill™ standardized technique for penile girth enhancement using HA fillers is both safe and efficacious. With no instances of filler removal and successful management of adverse reactions, the safety profile of HA fillers is further supported. These findings reinforce HA’s potential for sustainable penile enhancement. It is essential these procedures be performed in the described fashion by qualified urological professionals. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast, Boston Scientific, UroFill.

The Efficacy of Hyaluronic Acid Injections in Soft Tissue Foot and Ankle Pathology: A Systematic Review

Category: Ankle; Basic Sciences/Biologics Introduction/Purpose: The purpose of this systematic review was to evaluate the clinical outcomes, complication rates and failure rates at short-term follow-up following hyaluronic acid (HA) injection for the management of various soft tissue foot and ankle pathologies. Methods: During January 2023, the PubMed, Embase and Cochrane library databases were systematically reviewed to identify clinical studies examining outcomes following HA injection for the management of various soft tissue foot and ankle pathologies. Data regarding study characteristics, patient demographics, pathological characteristics, subjective clinical outcomes, radiological outcomes, complications and failure rates were extracted and analysed. In addition, the level of evidence and quality of evidence for each individual study was also assessed. Results: Studies examining outcomes following HA injection included the following pathologies: Achilles tendinopathy (AT) (6 studies, 126 patients, weighted mean follow-up of 2.9 months), plantar fasciitis (PF) (2 studies, 54 patients, 4.3), lateral ankle sprains (LAS) (2 studies, 119 patients, follow-up of 11.4 months) and Morton's neuroma (MN) (1 study, 83 patients, follow-up of 12 months). Seven different HA formulations were utilised across 10 studies. Weighted mean pain and functional scores improved significantly in all 4 cohorts. The complication rates for the AT cohort, PF cohort, LAS cohort and MN include: 3.2%, 1.9%, 2.5% and 20.5%, respectively. The failure rates for the AT cohort, PF cohort, LAS cohort and MN include: 1.6%, 0%, 0% and 0%, respectively. Conclusion: This systematic review demonstrated improvements in subjective clinical outcomes together with low complication and failure rates following HA injections for various soft tissue foot and ankle pathologies at short term follow-up. However, the heterogeneity between the studies, low number of high quality studies and short-term follow-up limits the generation of any robust conclusions. Further research is warranted to assess the optimal role of HA in the management of foot and ankle soft tissue pathologies.

Evaluation of the Effect of Hyaluronic Acid Injection on the Reconstruction of Reduced Interdental Papillae in Patients Referred to Shiraz School of Dentistry.

The occurrence of papillary defects adjacent to teeth or dental implants causes both the dental staff and the patients to be concerned about the esthetic issues. Interdental papilla reconstruction surgery is one of the most difficult and unpredictable mucogingival surgeries. The present study aimed to investigate the efficacy of hyaluronic acid injection in the reconstruction of the interdental papilla. This clinical trial study was conducted on four patients with 20 deficient interdental papillae who met the inclusion criteria. At first, local anesthesia was applied. Afterward, 0.2 mL of 1.6% hyaluronic acid (HA) gel was injected (at the tip of the papilla and 2-3 mm below the tip of the papilla) three times every two weeks. At baseline, three, and six months later, clinical photography was taken under standard conditions. The papilla height (the distance between the interdental papilla tip and the basis), black triangle area, and the distance between the interdental papilla tip and contact point of adjacent teeth were all measured using Image J software. The effectiveness of using HA gel in reducing the black triangle area was 85.06%. Furthermore, the papilla length increased by 70.256% while contact to papilla distance decreased by 83.026%. At different times, the values of the studied variables in the three levels were significantly different (p< 0.05). Injection of HA with 1.6% concentration at two points of the interdental papilla was effective in interdental papilla reconstruction at the aesthetic zone, especially in long-term, follow-ups (especially 6 months).

Concurrent Imaging and Clinical Study of the Efficacy of Hyaluronic Acid Injection for Knee Osteoarthritis: A Synovial Membrane Investigation with Ultrasound Imaging.

We investigated whether hyaluronic acid (HA) injections can ameliorate ultrasound-detected synovitis in knee osteoarthritis (OA). We recruited 103 patients with symptomatic knee OA and ultrasound-detected synovitis and performed two ultrasound-guided fluid drainage procedures, followed by the administration of a low-molecular-weight HA injection (2.5 mL) in the subpatellar bursa, at a 2-week interval. Knee ultrasound imaging evaluations were performed before injection (baseline) and at 1 and 6 months after the second injection and included the measurements of synovial vascularity by using color Doppler ultrasound, synovial fluid depth over the suprapatellar bursa (SF), and synovial hypertrophy (SH). Initial clinical assessments included a visual analog scale (VAS) and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). VAS scores decreased significantly at both 1-month and 6-month evaluations (p < 0.001). WOMAC scores also significantly decreased at 1 month (p < 0.001), but not at 6 months (p = 0.23). The ultrasound parameters did not significantly change, except color Doppler grading, which tended to decrease at the 6-month evaluation (p = 0.059). Our findings revealed that two ultrasound-guided HA injections following fluid drainage improved pain and knee function but did not considerably influence imaging-detected synovitis in patients with knee OA.

Non-operative management of shoulder osteoarthritis: Current concepts

Glenohumeral osteoarthritis (OA) is one of the most common causes of shoulder pain. Conservative treatment options include physical therapy, pharmacological therapy, and biological therapy. Patients with glenohumeral OA present shoulder pain and decreased shoulder range of motion (ROM). Abnormal scapular motion is also seen in patients as adaptation to the restricted glenohumeral motion. Physical therapy is performed to (1) decrease pain, (2) increase shoulder ROM, and (3) protect the glenohumeral joint. To decrease pain, it should be assessed whether the pain appears at rest or during shoulder motion. Physical therapy may be effective for motion pain rather than rest pain. To increase shoulder ROM, the soft tissues responsible for the ROM loss need to be identified and targeted for intervention. To protect the glenohumeral joint, rotator cuff strengthening exercises are recommended. Administration of pharmacological agents is the major part next to physical therapy in the conservative treatment. The main aim of pharmacological treatment is the reduction of pain and diminution of inflammation in the joint. To achieve this aim, non-steroidal anti-inflammatory drugs are recommended as first-line therapy. Additionally, the supplementation of oral vitamin C and vitamin D can help to slow down cartilage degeneration. Depending on the individual comorbidities and contraindications, sufficient medication with good pain reduction is thus possible for each patient. This interrupts the chronic inflammatory state in the joint and, in turn, enables pain-free physical therapy. Biologics such as platelet-rich plasma, bone marrow aspirate concentrate, and mesenchymal stem cells have gathered increased attention. Good clinical outcomes have been reported, but we need to be aware that these options are helpful in decreasing shoulder pain but neither stopping the progression nor improving OA. Further evidence of biologics needs to be obtained to determine their effectiveness. In athletes, a combined approach of activity modification and physical therapy can be effective. Oral medications can provide patients with transient pain relief. Intra-articular corticosteroid injection, which provides longer-term effects, must be used cautiously in athletes. There is mixed evidence for the efficacy of hyaluronic acid injections. There is still limited evidence regarding the use of biologics.

Are We Actually Guided by Clinical Practice Guidelines?: Commentary on an article by Kevin Y. Zhu, BS, et al.: "Hyaluronic Acid Injections for Knee Osteoarthritis. Has Utilization Among Medicare Beneficiaries Changed Between 2012 and 2018?"

Commentary Medical practitioners are presented with substantial data regarding potential interventions for musculoskeletal problems. The American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines (CPGs) organize and summarize the available data regarding numerous nonoperative and operative treatments for musculoskeletal problems, including the management of knee osteoarthritis (OA). While the recommendations of the CPGs are often somewhat limited by the lack of quality research, the 2013 AAOS CPG cited moderate evidence against the routine use of hyaluronic acid (HA) injections for the management of symptomatic knee OA. The study by Zhu et al. provides an excellent evaluation of the use of HA injections in Medicare patients, both before and after the CPG was published, as well as an analysis of the financial impact of continued HA use. Knee OA remains highly prevalent and is a substantial economic burden in the United States. Intra-articular injections have long been a mainstay in the nonoperative treatment of the disease; however, recent publications have demonstrated some concerns with corticosteroid injections, particularly when they are performed close to the time of total knee arthroplasty (TKA)1. Unfortunately, similar risk has been demonstrated with HA injections2. The data surrounding the clinical efficacy of HA injections also are quite variable, but in most comparative studies, little benefit is seen over the use of nonsteroidal anti-inflammatory drugs, corticosteroid injections, biologics, or even normal saline solution3,4. The most important finding of the present study is that despite the moderate recommendation against the routine use of HA in the 2013 AAOS CPG, as well as its high cost and questionable clinical efficacy when compared with numerous other treatments, there has not been a significant decline in the use of HA in Medicare beneficiaries. This finding is supported by and expands on an earlier survey study that reported HA to be the most popular choice for management of moderate-grade knee OA5. This finding, while not surprising, is disappointing as it is clear that either the message of the CPG is not being effectively disseminated to the practitioners who are managing knee OA with HA injections, or the evidence is simply being ignored due to a lack of other options for this challenging population of patients. A second important finding of this study is the substantial financial burden that HA injections continue to pose on the health-care system. A cost averaging >$300 million a year is significant and worthy of highlighting. Zhu et al. demonstrated that this cost steadily increased throughout the study period and likely will continue to increase. Given the lack of demonstrated clinical efficacy in large systematic reviews and high-level studies, it is hard to justify these costs for HA use. Recent studies have shown that even emerging treatments such as biologics and platelet-rich plasma (PRP) may be more cost-effective than HA injections6. A finding of the study that may explain some of the discordance between the AAOS recommendations and HA utilization is that advanced practice providers (APPs) contributed significantly to the national increase in utilization that was seen over the study period. Many practices have transitioned interventions such as injections to APPs. It is very possible that evidence from the CPG has not effectively been distributed to APPs. The true cause is likely multifactorial. There are many patients with advanced knee OA who are simply not ready for TKA or are not good candidates for TKA since the requirements for optimization of medical comorbidities continue to become stricter. Many patients will not find any relief from corticosteroid injections, and as long as HA injections are available, they represent another possible therapeutic option, despite the evidence against the routine use of HA. While biologics such as PRP have shown promising benefits in the management of knee OA, insurance companies still do not cover this cost, and many patients cannot afford cash payments for prolonged treatment. Value-based care continues to be the focus of health-care practitioners, health systems, and insurers. When CPGs offer conclusive recommendations based on available evidence, it is worthwhile to evaluate their effects on practice patterns. The trends observed in the study by Zhu et al. demonstrated that despite the high cost and low clinical efficacy of HA injections, in addition to a CPG recommending against its routine use, there has been no appreciable decline in the use of HA injections among Medicare beneficiaries within the 5 years following publication of the CPG. This highlights the importance of wide dissemination of CPGs to physicians and APPs, as well as the need for more cost-effective treatments for knee OA.

Efficacy and safety of hyaluronic acid fillers for lip augmentation in a Chinese population.

Hyaluronic acid (HA) is an effective dermal filler for facial rejuvenation. This study aimed to observe the clinical efficacy of HA injection for lip augmentation in Chinese patients. From May 2019 to April 2020, 70 patients with lip fullness scale (LPS) ≤3 underwent local HA injection using the "three-point" injection technique. All patients were followed up to observe the clinical efficacy, LPS, adverse events, and complications. All 70 patients were followed up for 12months. Statistically significant improvements were observed in the height of lips within 6-9months post-treatment (p<0.05). The LFS improved significantly at follow-up compared with baseline (p<0.05). Local redness occurred in two patients, and serious swelling occurred in three patients. These adverse events were generally tolerated and disappeared gradually within 1week. No other serious adverse events and complications were reported in the remaining patients. Hyaluronic acid injection can be used for lip augmentation in the Chinese population. The "three-point" technique is simple, safe, and effective and does not cause serious complications.

Efficacy of Hyaluronic Acid Injections in the Treatment of Osteoarthritis of the Knee

Background: Hyaluronic acid injections for treatment of osteoarthritis of the knee are a widely used yet highly controversial therapy. Many societal guidelines recommend against the use of such injections. Objective: This review aims to investigate efficacy of intra-articular hyaluronic acid injections for treatment of osteoarthritis of the knee. Conclusion: There are many factors impacting the efficacy of intra-articular hyaluronic acid injections. This can include source of hyaluronic acid, dosing regimen, molecular weight of the product, and patient characteristics. Overall, hyaluronic acid injections can be effective in reducing pain and improving physical function in patients with osteoarthritis of the knee. These injections may also prolong time between diagnosis and arthroplasty. Adverse events after injection are rare and can be product-related. Radiologic findings and severity of disease can be predictive of successful treatment outcomes. More consistent research will be necessary to overturn societal guideline recommendations to support treatment with intra-articular hyaluronic acid products.

Efficacy of Hyaluronic Acid Injections versus Steroid Injections on Painful Tendinopathies

Background: Tendinopathies are manifested by pain, swelling, and limited mobility functions.Corticosteroid injections have been a mainstay in the treatment of tendinopathy, and are widely used despite the controversy regarding their usefulness and safety.The peri-tendinous administration of hyaluronic acid (HA) has shown promising results in the management of tendinopathy. Objectives: The aim of the current study was to evaluate the efficacy of peri-tendinous injections of hyaluronic acid versus steroid injections on pain reduction in patients with painful tendinopathies. Patients and methods: A prospective study, including a total of 90 patients with tendinopathy who were recruited from the Rheumatology and Rehabilitation Outpatient Clinic at Sohag University Hospital. Demographic data including age, disease duration, and tendon affected were evaluated. Patients were divided into three groups, each group contained 30 patients. First group received peritendinous steroid injection, second group received peritendinous hyaluronic acid injection, and the third group received both peritendinous hyaluronic acid and steroid injections. Groups were compared using in visual analogue scale, tenderness and range of motion after one week, one month and after 3 months from injection. Results: Best improvement was seen in the group of combined hyaluronic acid and steroid; followed by the group of steroid injection alone, which showed early response better than hyaluronic acid alone. Conclusion: Local injection for tendinopathies by combined hyaluronic acid and steroid gives significantly better and more long standing effect compared to either hyaluronic acid or steroid alone. On the other hand, monotherapy showed non-significant difference between steroid and hyaluronic acid.

Evaluation of Arthrocentesis with hyaluronic acid injections for management of temporomandibular disorders: a systematic review and case series.

Although arthrocentesis is an accepted safe treatment modality for the management of temporomandibular disorders (TMD) in symptomatic patients, the benefit of hyaluronic acid (HA) injections remains uncertain. The aim of this study was to evaluate whether intra-articular HA injections adjunctive to arthrocentesis can be more effective than other medications for the improvement of TMD associated symptoms. Additionally, the impact of HA injections on quality of life of TMD patients was assessed with SF-36® questionnaire in a cohort of patients. An electronic search of Medline, Scopus and Cochrane databases was performed up to March 2020. The following search terms were used: "arthrocentesis", "hyaluronic acid", "intra-articular injections", "visco-supplementation", "temporomandibular disorders". Prospective and retrospective studies that reported the application of HA injections compared to other intra-articular drugs for the treatment of temporomandibular disorders were included. Systematic or narrative reviews and pre-clinical studies were excluded. Additionally, a retrospective clinical study was performed for evaluation of changes in quality of life before and after arthrocentesis with HA injections. In the systematic review, the initial search yielded 1327 articles. After screening of the titles, abstracts, and full texts, 29 studies were selected (26 randomized studies, 2 controlled clinical trials, 1 retrospective report). In the clinical study, 12 patients were included. Intra-articular injections of HA and other medications together with arthrocentesis seemed to be beneficial for improvement of functional symptoms of TMD and pain. The case series also supported the efficacy of HA injections showing an improvement of quality of life of these patients. However, from literature review, it was impossible to identify an optimum drug or a protocol for predictably improving the pain and/or functional symptoms of temporomandibular problems, due to different etiologies, diversity of treatment modalities and conflicting results. In conclusion, there is no consensus in the literature that HA injections shows better results in comparison with other treatment modalities. According to the results of the present clinical study, HA injections with/without arthrocentesis seems to be beneficial in terms of clinical symptoms and quality of life of the TMD patients.

Effect of ultrasound-detected synovitis on therapeutic efficacy of hyaluronic acid injection for symptomatic knee osteoarthritis.

ObjectiveTo determine whether ultrasound (US)-detected synovitis affects the therapeutic efficacy of hyaluronic acid (HA) injection for treating knee OA.MethodsPatients with symptomatic knee OA were recruited. All the patients received HA injection two times at 2-week intervals. Clinical assessments were performed using a visual analogue scale (VAS) and the Western Ontario and McMaster Universities OA Index (WOMAC) at baseline and 1 and 6 months after treatment. Imaging evaluation was based on complete knee US examination and the Kellgren–Lawrence grading. Suprapatellar synovial fluid (SF) depth, synovial hypertrophy (SH) and vascularity were measured through US.ResultsIn total, 137 patients who fulfilled the inclusion criteria were included in the analysis. All patients demonstrated improvement in VAS and WOMAC scores at 1 and 6 months after treatment (P < 0.001). Moreover, regression model-based analysis revealed significant associations of SF depth with the VAS and WOMAC scores in all patients. Each centimetre increase in the effusion diameter was associated with a decrease in the 1-month post-treatment VAS improvement percentage (15.26; 95% CI: 0.05, 29.5; P = 0.042) and 6-month post-treatment WOMAC improvement (37.43; 95% CI: 37.68, 50.69; P < 0.01). However, SH and vascularity were not significantly associated with VAS or WOMAC scores.ConclusionUltrasound detected suprapatellar effusion predicts reduced efficacy of HA injection in knee OA

Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections.

Consequences on Private Insurance Coverage: The AAOS Clinical Practice Guidelines and Hyaluronic Acid Injections.

Efficacy of Hyaluronic Acid in the Treatment of Internal Derangement – Clinical Study

Introduction: Hyaluronic acidis known as Sodium hyaluronate or hyaluronan is an essential component of the synovial fluid. It enables the fluid to act as a lubricant, a shock absorber and a filter controlling the movement of cells and large molecules within the joint.The present study presents a case series on the efficacy of hyaluronic acid injections for the treatment of temporomandibular joint pain by providing patient evaluations. Study Design: Thirty-one temporomandibular joints in 23 patients were evaluated in this study. Six males and 17 females aged 18 to 55 years with chief complaints of limited mouth opening, TMJ pain, and clicking sounds in the TMJ. The TMJ was examined clinically and radiographically. Patients were randomly divided into two groups, were one group received only arthrocentesis and the other group received arthrocentesis plus hyaluronic acid. Both the groups contained patients with disc displacement with reduction with closed lock. Results: Descriptive analysis showed improvements which were maintained over time for all the study parameters. Permutation tests evidenced the significance of changes which occurred in many clinical parameters over three months. Differences with baseline levels remained significant at the end of the follow-up period, particularly for the jaw movements, masticatory efficiency, clicking and pain at mastication parameters. Conclusion: Data from the clinical study support findings from studies on other joints, which prove the efficacy of hyaluronic acid after arthrocentesis to reduce symptoms of osteoarthritis and to maintain improvements over time.

Effectiveness of hyaluronic acid injection after failed arthroscopic microfracture in osteochondral lesion of the talus

Category: Ankle, Arthroscopy Introduction/Purpose: Non-operative treatment options with symptomatic OLT after failed primary arthroscopic treatment may be treated by various methods such as analgesics, anti-inflammatory drug, steroid injection, Platelet rich plasma (PRP) injection and hyaluronic acid (HA) injection. HA injection could be treated OLT besides osteoarthritis on knee or ankle joint. Effect of HA is viscoelastic and lubricating properties primarily, and other biomechanical effect can be considered. Purpose of this study is to evaluate the clinical outcomes of intra-articular HA injection in the patients with recurrent pain after the arthroscopic microfracture for OLT Methods: This study included 20 patients who received three weekly injections of intra-articular HA after arthroscopic microfracture for OLT between June 2014 and August 2016. All patients had persistent pain for more than 3 months after the index surgery. The patients were followed for 16.7 months (range: 4.6-30.9). At each visit, the efficacy of HA injection in reducing pain was evaluated by a Visual Analog Scale (VAS). In addition, subjective satisfactions were assessed by the Alexander scale. Results: The mean period from the arthroscopic microfracture to the intra-articular HA injection was 26.5 months (range: 6.0- 87.0). Mean VAS scores decreased from 6.7 ± 1.1 at a pre-injection to 3.8 ± 2.3 at post-injection six months (p = 0.02). According to the Alexander scale, there were 65.0% (13/20) good, 25.0% (5/20) fair, and 10.0% (2/20) poor results at post-injection six months. There was no severe adverse effect. Conclusion: The HA injection may be a useful treatment option after failed arthroscopic microfracture in OLT. Further studies will be needed to evaluate long-term results.

Evaluation of the Therapeutic Effects of Hyaluronic Acid Injections on Football Players’ Articular Cartilage Using an Immunochromatographic Urine Strip

Early detection and diagnosis of knee osteoarthritis (OA) in football players and preventive measures to delay cartilage degeneration are crucial to prolong football players’ careers and to reduce the waste of coaching and medical resources. In this study, we intended to use the immunochromatographic urine strip together with the International Knee Documentation Committee (IKDC) subjective knee evaluation form and the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index to assess the therapeutic efficacy of intra-articular injections of hyaluronic acid (HA) on knee OA in football players. The 18 football players showed lower IKDC and WOMAC scores compared to the 42 healthy subjects. The players demonstrated significantly improved IKDC scores and WOMAC scores, signifying that the improvement of knee function after the injections of HA. Importantly, 70% of the player’s improvements of OA can be detected and reflected from this urine strip. The results revealed that combined the immunochromatographic urine strip with the IKDC and WOMAC could be used to assess the therapeutic efficacy of HA injections on OA.

Efficacy of hyaluronic acid injection in superior joint space for the treatment of temporomandibular disorder in Taiwan

Efficacy of hyaluronic acid injection in superior joint space for the treatment of temporomandibular disorder in Taiwan

Hyaluronic Acid Injection After Failed Arthroscopic Microfracture in Osteochondral Lesion of the Talus

Category: Ankle Introduction/Purpose: The optimal treatment for symptomatic osteochondral lesion of the talus (OLT) after failed arthroscopic microfracture has been a controversial issue. The use of viscosupplementation for treatment of OLT has been gradually increasing. The hyaluronic acid (HA) injection is believed to play an important role in reducing pain and inflammation, and promoting tissue repair. The purpose of this study is to evaluate the clinical outcomes of intra-articular HA injection for the patients with failed arthroscopic microfracture in OLT. Methods: This study included 12 patients who received three weekly injections of intra-articular HA after arthroscopic microfracture for OLT between October 2014 and October 2015. Five men and seven women were included in this study. The average age at the time of injection was 41 years (range, 19-63 years). All patients had recurrent pain for at least 6 months after the index surgery. The patients were followed for 6.1 months (range: 5.0-7.0). At each visit, the efficacy of HA injection was evaluated by a Visual Analog Scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score and Foot and Ankle Outcome Score (FAOS) pain subscale. In addition, subjective satisfactions were assessed by the Alexander scale. Results: The mean period from the arthroscopic microfracture to the intra-articular HA injection was 26.5 months (range: 6.0- 87.0). Mean VAS decreased from 6.7 ± 1.1 at pre-injection to 2.4 ± 1.6 at post-injection six weeks (p &lt; 0.001), 3.1 ± 1.5 at three months (p = 0.002) and 3.8 ± 2.3 at six months (p = 0.02). Mean AOFAS score improved from 61.0 ± 9.1 at pre-injection to 85.3 ± 11.3 at post-injection six weeks (p &lt; 0.001), 82.9 ± 10.4 at three months (p &lt; 0.001) and 80.4 ± 13.8 at six months (p = 0.001). Mean FAOS pain subscale also improved from 53.2 ± 4.2 at pre-injection to 71.1 ± 9.4 at post-injection six weeks (p &lt; 0.001), 66.7 ± 7.2 at three months (p = 0.001) and 64.4 ± 9.5 at six months (p = 0.036). According to the Alexander scale, there were 58.3% (7/12) good, 25.0% (3/12) fair, and 16.7% (2/12) poor results at post-injection six months. There was no adverse effect. Conclusion: In this study, we found that the main improvement in clinical outcomes occurred during the first six weeks and significantly maintained until at least three or six months. We believe that the HA injection could be a useful treatment option after failed arthroscopic microfracture in OLT.

Unraveling the confusion behind hyaluronic acid efficacy in the treatment of symptomatic knee osteoarthritis.

Hyaluronic acid (HA) is a commonly prescribed treatment for knee pain resulting from osteoarthritis (OA). Although numerous HA products have been approved for use by the US Food and Drug Administration, the efficacy of HA injections for knee OA remains disputed with meta-analyses and societal clinical guidelines drawing disparate conclusions. The American Academy of Orthopaedic Surgeons (AAOS) recently published a best-evidence systematic review and concluded that available data did not support the routine use of HA for knee OA. The purpose of the current article is to highlight issues that confound interpretation of meta-analyses on HA for knee OA, to provide realistic estimates of the true efficacy of HA injections in knee OA, and to provide commentary on the methods and conclusions from the AAOS systematic review. In general, the clinical benefit of HA is underestimated using conventional meta-analytic techniques. When accounting for differential control group effects in HA studies, it can be reasonably concluded that HA injections may be beneficial to an appreciable number of patients with knee OA. In addition, the systematic review methodology used by AAOS was questionable due to exclusion of numerous relevant studies and inclusion of studies that used HAs not approved for use in the US, both of which underestimated the true efficacy of HA injections. Overall, the efficacy of HA injections for knee OA is likely better than previously reported. Future clinical trials and meta-analyses should account for differential control group effects in order to avoid the continued confusion surrounding HA injection efficacy.

Multicenter Randomized Study of Obesity Treatment with Minimally Invasive Injection of Hyaluronic Acid Versus and Combined with Intragastric Balloon.

Research into minimally invasive techniques is worthwhile for greater acceptance in bariatric surgery, a useful first step being to evaluate the combination of these with current procedures. We suggest that intragastric balloon (IGB) can be performed with hyaluronic acid (HA) injections at the level of the gastroesophageal junction. A submucosal restriction is created by circular injection of an absorbable material within a defined area based on endoscopic anatomy. We included 101 patients in a prospective multicenter randomized trial, with average body mass index (BMI) 33.4 (range 27-44), treated from April 2010 to April 2012 by IGB and/or HA injection, sequentially, and followed for two more years. Patients were divided into group 1 (IGB alone), group 2 (IGB followed by HA at IGB removal, at 6months), and group 3 (HA and IGB at 6months). BMI loss at 6months was inferior in the HA group (32 patients) compared with the IGB groups (68 patients) (2.1 ± 0.4 versus 3.4 ± 0.3, p < 0.05). The efficacy of IGB alone compared with combined treatments (groups 2 and 3) was significantly inferior at 18months only, but the impact of the treatment sequence (HA before or after IGB) on BMI loss was not statistically significant, although in favor of HA first. This study did not demonstrate the efficacy of HA injections as an obesity treatment.

A Pilot Study to Compare Two Different Hyaluronic Acid Compounds for Treatment and Knee Osteoarthritis

Osteoarthritis is characterized by progressive articular cartilage degeneration, changes in subchondral bone and synovial inflammation, leading to pain and disability. Viscosupplementation with hyaluronic acid has been widely investigated due to the viscoelastic properties of this compound to manage pain improving the ability to perform daily activities in patients affected by osteoarthritis. In the present study we investigated the clinical effectiveness of viscosupplementation with a new highly cross-linked hyaluronic acid, Variofill, in patients affected by bilateral knee osteoarthritis in comparison with the widely used Synvisc. A total of 20 patients, aged between 24-74 years and affected by bilateral knee osteoarthritis, participated in this pilot randomized triple-blind clinical study. They received two injections (2 ml each) of Synvisc in their left knee and 2 injections (2 ml each) of Variofill in their right knee spaced 15 days apart. Visual Analogue Scale and Western Ontario McMaster Universities Osteoarthritis Index score were used to evaluate the efficacy of hyaluronic acid injections before and 3 and 6 months after treatment. Both treatment regimens resulted in a significant improvement vs baseline in all endpoints at 3 and 6 months (p less than 0.001). Treatment with Variofill resulted in a high percentage improvement in Visual Analogue Scale pain, Western Ontario McMaster universities Osteoarthritis Index score pain and physical activity, when compared to Synvisc viscosupplementation, at 6 months (p less than 0.05). These results are encouraging for larger clinical trials with Variofill in larger cohorts of patients affected by osteoarthritis of the knee.