- Email: [email protected]
Optimizing the effectiveness of viscosupplementation in non-knee osteoarthritis
G Model BONSOI-4228; No. of Pages 2
ARTICLE IN PRESS Joint Bone Spine xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Editorial
Optimizing the effectiveness of viscosupplementation in non-knee osteoarthritis
a r t i c l e
i n f o
Keywords: Hyaluronic acid Viscosupplementation Intraarticular injection Hip Ankle Shoulder Trapeziometacarpal joint Recommendations
The usefulness of viscosupplementation in the treatment of knee osteoarthritis is finally receiving support from a rapidly increasing number of recommendations and metaanalyses [1,2]. A far less convincing body of literature exists about hyaluronic acid injections into other joints. After the knee, the joints most often treated with viscosupplementation are the hip, ankle, shoulder, and trapeziometacarpal joint, for which the published data are therefore most abundant. Most studies were done in small populations, often with fewer than 100 patients per group. The wide variations in treatment protocols and products across studies generate considerable heterogeneity in the results. In addition, an open-label design was generally used, and, among the few controlled studies, the vast majority fail to meet the quality criteria needed to obtained valid results. Finally, not all studies used, or clearly defined, fluoroscopy or ultrasonography to guide the injections, which is crucial to ensure delivery-site accuracy. As a result, published data do not form a sound basis on which to build an assessment of the effectiveness of viscosupplementation at sites other than the knee. In particular, the few published metaanalyses and systematic reviews provide no firm conclusions, for the reasons described above [3,4]. Nevertheless, a closer look at these studies teaches a number of very interesting lessons, which should help clinicians to make treatment decisions and to participate in developing high-quality, large-scale, controlled studies with sufficiently long follow-ups. The first essential lesson that can be drawn from a careful review of the literature is that the number of injections needed to obtain a significant therapeutic effect is dependent, not on the joint, but on the product. In other words, a joint that is smaller than the knee will not necessarily require fewer injections. The simple explanation to this fact is that one of the main factors limiting the effectiveness of viscosupplementation is the short residence time of hyaluronic acid in the joint, of 2–3 days at the most for linear
hyaluronic acid and 1–4 weeks for cross-linked hyaluronic acid [5,6]. A highly likely (albeit as yet unproven) hypothesis is that the effectiveness of viscosupplementation depends, at least in part, on the duration of contact between the hyaluronic acid and the tissues involved by the osteoarthritis process (chiefly the cartilage and synovial membrane). Consequently, the recommended number of injections is 5 for linear hyaluronic acids with a molecular weight of less than 1 MDa, 3 for linear hyaluronic acids with a molecular weight of 1 to 3 MDa, 1 to 3 for hylan prepared from partly cross-linked high-molecular-weight hyaluronic acid, and 1 for fully cross-linked hyaluronic acid [7]. Thus, the need to repeat the injections is not dependent on the size of the joint to be treated. Even for very small joints such as the trapeziometacarpal joint, to obtain a significant clinical effect with a linear form of hyaluronic acid 3 injections must be given, at 1-week intervals, as recommended for the knee. Abundant support for this strategy exists in the literature. In patients with mild-to-moderate hip osteoarthritis, Richette et al. [8] found no significant difference between 1% low-molecularweight hyaluronic acid and saline. The same form of hyaluronic acid given according to the standard regimen of 3 injections 1 week apart had a far larger treatment effect in a study by Eyigör et al. which, however, used an open-label design [9]. Again using the same form of hyaluronic acid, DeGroot et al. [10] found no evidence of efficacy of a single injection compared to a placebo in talocrural osteoarthritis; whereas in a comparable study, 5 injections of a very similar hyaluronic acid preparation was markedly more effective than saline [11]. In a study by Roux et al. [12] of patients with trapeziometacarpal osteoarthritis, a single injection had no detectable therapeutic effect, whereas three injections produced a decrease in pain intensity; however, the groups were too small to allow definitive conclusions. Several studies evaluated viscosupplementation products designed to be administered as a single injection. With these products, in osteoarthritis of the hip [13,14], shoulder [15], or ankle [16], the effect was considerably greater than with a single injection of a linear product. Unfortunately, no controlled trials of these products are available. The second key piece of information that emerges from the literature makes simple sense: hyaluronic acid must be injected directly into the joint cavity if it is to be effective. Glucocorticoids may have some measure of efficacy even when injected outside the joint, as they exert systemic effects. Hyaluronic acid, in contrast, is not effective when injected extraarticularly and may even increase the frequency of pain or induce the development of granulomas. Studies evaluating delivery-site accuracy consistently showed extremely high failure rates of 40% to 80% when
http://dx.doi.org/10.1016/j.jbspin.2015.08.009 1297-319X/© 2015 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Conrozier T. Optimizing the effectiveness of viscosupplementation in non-knee osteoarthritis. Joint Bone Spine (2015), http://dx.doi.org/10.1016/j.jbspin.2015.08.009
G Model BONSOI-4228; No. of Pages 2
ARTICLE IN PRESS Editorial / Joint Bone Spine xxx (2015) xxx–xxx
2
radiological or ultrasonographic guidance was not used [17]. This point is crucial, although highly experienced operators may obtain lower failure rates. Therefore, a reasonable recommendation is that hyaluronic acid injections into joints other than the knee be performed only under radiological or ultrasonographic guidance, in order to optimize the success rates. In a cohort study of 50 patients with talocrural osteoarthritis whose outcomes were reported at the 27th meeting of the French Society for Rheumatology, the success rate was 100% with ultrasound guidance compared to only 50% without guidance. Finally, the last point that deserves emphasis reflects the medical truism that the outcome of any treatment depends primarily on good patient selection. Given that viscosupplementation probably acts by allowing de novo production of endogenous hyaluronic acid (viscoinduction), whose main properties combat tissue degradation and inflammation [18], this treatment strategy is best indicated in early to moderate osteoarthritis. Thus, viscosupplementation should not be viewed as a valid alternative to surgery in severe osteoarthritis, although in a small minority of cases it may be of some help when surgery is contraindicated or not accepted by the patient. Although a number of uncertainties remain, most studies indicate that the main predictor of the efficacy of viscosupplementation is the radiological grade of osteoarthritis. The same highly cross-linked hyaluronic acid produced very promising results in patients with early-to-moderate hip osteoarthritis but was not different from the placebo in candidates for hip replacement surgery [13,19]. Similarly, in a recent study we showed that the proportion of patients satisfied with viscosupplementation was very low in a group awaiting hip replacement surgery but was greater than two-thirds in a group with moderate hip osteoarthritis [20]. In glenohumeral osteoarthritis, hyaluronic acid was effective in patients with an intact rotator cuff [15] but not in those with cuff tears or adhesive capsulitis [21]. A detailed analysis of the symptoms and signs is therefore essential to select patients for viscosupplementation. Pain from joints with osteoarthritis may result from many different mechanisms including an inflammatory flare, a neuropathic component, bone microcracks, and major deformities. None of these mechanisms responds to viscosupplementation. Although many gray areas persist and the exact indications and therapeutic regimens need to be determined, viscosupplementation deserves a place in the therapeutic weaponry against symptomatic osteoarthritis of the hip, shoulder, ankle, or trapeziometacarpal joint, provided three crucial rules are scrupulously applied: • the therapeutic regimen recommended for the viscosupplement used should be followed; thus, even a joint that is small or difficult to access should receive the recommended number of injections or be treated with a product designed for administration as a single injection; • an effective guidance system must be used to ensure that the product is delivered strictly within the joint cavity; • physicians must give careful consideration to the source of the pain and offer viscosupplementation only to those patients in whom the likelihood of success is high. Viscosupplementation, whether used at the knee or elsewhere, is indicated based on positive arguments and not as a treatment of last resort when no other alternatives are available. Disclosure of interest Thierry Conrozier has received honoraria as a regular consultant for Labrha and Aptissen and as an occasional consultant for Genevrier.
References [1] Bruyère O, Cooper C, Pelletier JP, et al. An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arthritis Rheum 2014;44: 253–63. [2] Bannuru RR, Schmid CH, Kent DM, et al. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Ann Intern Med 2015;162:46–54. [3] van den Bekerom MP, Lamme B, Sermon A, et al. What is the evidence for viscosupplementation in the treatment of patients with hip osteoarthritis? Systematic review of the literature. Arch Orthop Trauma Surg 2008;128: 815–23. [4] Migliore A, Giovannangeli F, Bizzi E, et al. Viscosupplementation in the management of ankle osteoarthritis: a review. Arch Orthop Trauma Surg 2011;131:139–47. [5] Lindenhayn K, Heilmann HH, Niederhausen T, et al. Elimination of tritiumlabelled hyaluronic acid from normal and osteoarthritic rabbit knee joints. Eur J Clin Chem Clin Biochem 1997;35:355–63. [6] Lindqvist U, Tolmachev V, Kairemo K, et al. Elimination of stabilised hyaluronan from the knee joint in healthy men. Clin Pharmacokinet 2002;4:603–13. [7] Agerup B, Berg P, Akermark C. Non-animal stabilized hyaluronic acid: a new formulation for the treatment of osteoarthritis. BioDrugs 2005;19:23–30. [8] Richette P, Ravaud P, Conrozier T, et al. Effect of hyaluronic acid in symptomatic hip osteoarthritis: a multicenter, randomized, placebo-controlled trial. Arthritis Rheum 2009;60:824–30. [9] Eyigör C, Pirim A, Eyigör S, et al. Efficacy of intraarticular hyaluronic acid injection through a lateral approach under fluoroscopic control for advanced hip osteoarthritis. Agri 2010;22:139–44. [10] DeGroot 3rd H, Uzunishvili S, Weir R, et al. Intra-articular injection of hyaluronic acid is not superior to saline solution injection for ankle arthritis: a randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am 2012;94: 2–8. [11] Cohen MM, Altman RD, Hollstrom R, et al. Safety and efficacy of intraarticular sodium hyaluronate (hyalgan) in a randomized, double-blind study for osteoarthritis of the ankle. Foot Ankle Int 2008;29:657–63. [12] Roux C, Fontas E, Breuil V, et al. Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb in osteoarthritis. A prospective evaluation of efficacy. Joint Bone Spine 2007;74:368–72. [13] Conrozier T, Couris CM, Mathieu P, et al. Safety, efficacy and predictive factors of efficacy of a single intra-articular injection of non-animal-stabilizedhyaluronic-acid in the hip joint: results of a standardized follow-up of patients treated for hip osteoarthritis in daily practice. Arch Orthop Trauma Surg 2009;129:843–8. [14] Conrozier T, Bertin P, Bailleul F, et al. Clinical response to intra-articular injections of hylan G-F 20 in symptomatic hip osteoarthritis: the OMERACT-OARSI criteria applied to the results of a pilot study. Joint Bone Spine 2006;73: 705–9. [15] Noël E, Hardy P, Hagena FW, et al. Efficacy and safety of Hylan G-F 20 in shoulder osteoarthritis with an intact rotator cuff. Open-label prospective multicenter study. Joint Bone Spine 2009;76:670–3. [16] Witteveen AG, Giannini S, Guido G, et al. A prospective multi-centre, open study of the safety and efficacy of hylan G-F 20 (Synvisc) in patients with symptomatic ankle osteoarthritis. Foot Ankle Surg 2008;14:145–52. [17] Hall MM. The accuracy and efficacy of palpation versus image-guided peripheral injections in sports medicine. Curr Sports Med Rep 2013;12:296–303. [18] du Souich P. Absorption, distribution and mechanism of action of SYSADOAS. Pharmacol Ther 2014;142:362–74. [19] Atchia I, Kane D, Reed MR, et al. Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis. Ann Rheum Dis 2011;70:110–6. [20] Conrozier T, Bossert M, Walliser-Lohse A, et al. Viscosupplementation with HANOX-M-XL is effective in moderate hip osteoarthritis but is not an alternative to hip joint surgery in patients with severe disease. Results of a clinical survey in 191 patients treated in daily practice. EMJD 2015;3:49–55. [21] Kwon YW, Eisenberg G, Zuckerman JD. Sodium hyaluronate for the treatment of chronic shoulder pain associated with glenohumeral osteoarthritis: a multicenter, randomized, double-blind, placebo-controlled trial. J Shoulder Elbow Surg 2013;22:584–94.
Thierry Conrozier Service de rhumatologie, hôpital Nord Franche-Comté, 14, rue de Mulhouse, 90000 Belfort, France E-mail addresses: [email protected], thierry [email protected] Accepted 20 May 2015 Available online xxx
Please cite this article in press as: Conrozier T. Optimizing the effectiveness of viscosupplementation in non-knee osteoarthritis. Joint Bone Spine (2015), http://dx.doi.org/10.1016/j.jbspin.2015.08.009
ARTICLE IN PRESS Joint Bone Spine xxx (2015) xxx–xxx
Available online at
ScienceDirect www.sciencedirect.com
Editorial
Optimizing the effectiveness of viscosupplementation in non-knee osteoarthritis
a r t i c l e
i n f o
Keywords: Hyaluronic acid Viscosupplementation Intraarticular injection Hip Ankle Shoulder Trapeziometacarpal joint Recommendations
The usefulness of viscosupplementation in the treatment of knee osteoarthritis is finally receiving support from a rapidly increasing number of recommendations and metaanalyses [1,2]. A far less convincing body of literature exists about hyaluronic acid injections into other joints. After the knee, the joints most often treated with viscosupplementation are the hip, ankle, shoulder, and trapeziometacarpal joint, for which the published data are therefore most abundant. Most studies were done in small populations, often with fewer than 100 patients per group. The wide variations in treatment protocols and products across studies generate considerable heterogeneity in the results. In addition, an open-label design was generally used, and, among the few controlled studies, the vast majority fail to meet the quality criteria needed to obtained valid results. Finally, not all studies used, or clearly defined, fluoroscopy or ultrasonography to guide the injections, which is crucial to ensure delivery-site accuracy. As a result, published data do not form a sound basis on which to build an assessment of the effectiveness of viscosupplementation at sites other than the knee. In particular, the few published metaanalyses and systematic reviews provide no firm conclusions, for the reasons described above [3,4]. Nevertheless, a closer look at these studies teaches a number of very interesting lessons, which should help clinicians to make treatment decisions and to participate in developing high-quality, large-scale, controlled studies with sufficiently long follow-ups. The first essential lesson that can be drawn from a careful review of the literature is that the number of injections needed to obtain a significant therapeutic effect is dependent, not on the joint, but on the product. In other words, a joint that is smaller than the knee will not necessarily require fewer injections. The simple explanation to this fact is that one of the main factors limiting the effectiveness of viscosupplementation is the short residence time of hyaluronic acid in the joint, of 2–3 days at the most for linear
hyaluronic acid and 1–4 weeks for cross-linked hyaluronic acid [5,6]. A highly likely (albeit as yet unproven) hypothesis is that the effectiveness of viscosupplementation depends, at least in part, on the duration of contact between the hyaluronic acid and the tissues involved by the osteoarthritis process (chiefly the cartilage and synovial membrane). Consequently, the recommended number of injections is 5 for linear hyaluronic acids with a molecular weight of less than 1 MDa, 3 for linear hyaluronic acids with a molecular weight of 1 to 3 MDa, 1 to 3 for hylan prepared from partly cross-linked high-molecular-weight hyaluronic acid, and 1 for fully cross-linked hyaluronic acid [7]. Thus, the need to repeat the injections is not dependent on the size of the joint to be treated. Even for very small joints such as the trapeziometacarpal joint, to obtain a significant clinical effect with a linear form of hyaluronic acid 3 injections must be given, at 1-week intervals, as recommended for the knee. Abundant support for this strategy exists in the literature. In patients with mild-to-moderate hip osteoarthritis, Richette et al. [8] found no significant difference between 1% low-molecularweight hyaluronic acid and saline. The same form of hyaluronic acid given according to the standard regimen of 3 injections 1 week apart had a far larger treatment effect in a study by Eyigör et al. which, however, used an open-label design [9]. Again using the same form of hyaluronic acid, DeGroot et al. [10] found no evidence of efficacy of a single injection compared to a placebo in talocrural osteoarthritis; whereas in a comparable study, 5 injections of a very similar hyaluronic acid preparation was markedly more effective than saline [11]. In a study by Roux et al. [12] of patients with trapeziometacarpal osteoarthritis, a single injection had no detectable therapeutic effect, whereas three injections produced a decrease in pain intensity; however, the groups were too small to allow definitive conclusions. Several studies evaluated viscosupplementation products designed to be administered as a single injection. With these products, in osteoarthritis of the hip [13,14], shoulder [15], or ankle [16], the effect was considerably greater than with a single injection of a linear product. Unfortunately, no controlled trials of these products are available. The second key piece of information that emerges from the literature makes simple sense: hyaluronic acid must be injected directly into the joint cavity if it is to be effective. Glucocorticoids may have some measure of efficacy even when injected outside the joint, as they exert systemic effects. Hyaluronic acid, in contrast, is not effective when injected extraarticularly and may even increase the frequency of pain or induce the development of granulomas. Studies evaluating delivery-site accuracy consistently showed extremely high failure rates of 40% to 80% when
http://dx.doi.org/10.1016/j.jbspin.2015.08.009 1297-319X/© 2015 Société franc¸aise de rhumatologie. Published by Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Conrozier T. Optimizing the effectiveness of viscosupplementation in non-knee osteoarthritis. Joint Bone Spine (2015), http://dx.doi.org/10.1016/j.jbspin.2015.08.009
G Model BONSOI-4228; No. of Pages 2
ARTICLE IN PRESS Editorial / Joint Bone Spine xxx (2015) xxx–xxx
2
radiological or ultrasonographic guidance was not used [17]. This point is crucial, although highly experienced operators may obtain lower failure rates. Therefore, a reasonable recommendation is that hyaluronic acid injections into joints other than the knee be performed only under radiological or ultrasonographic guidance, in order to optimize the success rates. In a cohort study of 50 patients with talocrural osteoarthritis whose outcomes were reported at the 27th meeting of the French Society for Rheumatology, the success rate was 100% with ultrasound guidance compared to only 50% without guidance. Finally, the last point that deserves emphasis reflects the medical truism that the outcome of any treatment depends primarily on good patient selection. Given that viscosupplementation probably acts by allowing de novo production of endogenous hyaluronic acid (viscoinduction), whose main properties combat tissue degradation and inflammation [18], this treatment strategy is best indicated in early to moderate osteoarthritis. Thus, viscosupplementation should not be viewed as a valid alternative to surgery in severe osteoarthritis, although in a small minority of cases it may be of some help when surgery is contraindicated or not accepted by the patient. Although a number of uncertainties remain, most studies indicate that the main predictor of the efficacy of viscosupplementation is the radiological grade of osteoarthritis. The same highly cross-linked hyaluronic acid produced very promising results in patients with early-to-moderate hip osteoarthritis but was not different from the placebo in candidates for hip replacement surgery [13,19]. Similarly, in a recent study we showed that the proportion of patients satisfied with viscosupplementation was very low in a group awaiting hip replacement surgery but was greater than two-thirds in a group with moderate hip osteoarthritis [20]. In glenohumeral osteoarthritis, hyaluronic acid was effective in patients with an intact rotator cuff [15] but not in those with cuff tears or adhesive capsulitis [21]. A detailed analysis of the symptoms and signs is therefore essential to select patients for viscosupplementation. Pain from joints with osteoarthritis may result from many different mechanisms including an inflammatory flare, a neuropathic component, bone microcracks, and major deformities. None of these mechanisms responds to viscosupplementation. Although many gray areas persist and the exact indications and therapeutic regimens need to be determined, viscosupplementation deserves a place in the therapeutic weaponry against symptomatic osteoarthritis of the hip, shoulder, ankle, or trapeziometacarpal joint, provided three crucial rules are scrupulously applied: • the therapeutic regimen recommended for the viscosupplement used should be followed; thus, even a joint that is small or difficult to access should receive the recommended number of injections or be treated with a product designed for administration as a single injection; • an effective guidance system must be used to ensure that the product is delivered strictly within the joint cavity; • physicians must give careful consideration to the source of the pain and offer viscosupplementation only to those patients in whom the likelihood of success is high. Viscosupplementation, whether used at the knee or elsewhere, is indicated based on positive arguments and not as a treatment of last resort when no other alternatives are available. Disclosure of interest Thierry Conrozier has received honoraria as a regular consultant for Labrha and Aptissen and as an occasional consultant for Genevrier.
References [1] Bruyère O, Cooper C, Pelletier JP, et al. An algorithm recommendation for the management of knee osteoarthritis in Europe and internationally: a report from a task force of the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO). Semin Arthritis Rheum 2014;44: 253–63. [2] Bannuru RR, Schmid CH, Kent DM, et al. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Ann Intern Med 2015;162:46–54. [3] van den Bekerom MP, Lamme B, Sermon A, et al. What is the evidence for viscosupplementation in the treatment of patients with hip osteoarthritis? Systematic review of the literature. Arch Orthop Trauma Surg 2008;128: 815–23. [4] Migliore A, Giovannangeli F, Bizzi E, et al. Viscosupplementation in the management of ankle osteoarthritis: a review. Arch Orthop Trauma Surg 2011;131:139–47. [5] Lindenhayn K, Heilmann HH, Niederhausen T, et al. Elimination of tritiumlabelled hyaluronic acid from normal and osteoarthritic rabbit knee joints. Eur J Clin Chem Clin Biochem 1997;35:355–63. [6] Lindqvist U, Tolmachev V, Kairemo K, et al. Elimination of stabilised hyaluronan from the knee joint in healthy men. Clin Pharmacokinet 2002;4:603–13. [7] Agerup B, Berg P, Akermark C. Non-animal stabilized hyaluronic acid: a new formulation for the treatment of osteoarthritis. BioDrugs 2005;19:23–30. [8] Richette P, Ravaud P, Conrozier T, et al. Effect of hyaluronic acid in symptomatic hip osteoarthritis: a multicenter, randomized, placebo-controlled trial. Arthritis Rheum 2009;60:824–30. [9] Eyigör C, Pirim A, Eyigör S, et al. Efficacy of intraarticular hyaluronic acid injection through a lateral approach under fluoroscopic control for advanced hip osteoarthritis. Agri 2010;22:139–44. [10] DeGroot 3rd H, Uzunishvili S, Weir R, et al. Intra-articular injection of hyaluronic acid is not superior to saline solution injection for ankle arthritis: a randomized, double-blind, placebo-controlled study. J Bone Joint Surg Am 2012;94: 2–8. [11] Cohen MM, Altman RD, Hollstrom R, et al. Safety and efficacy of intraarticular sodium hyaluronate (hyalgan) in a randomized, double-blind study for osteoarthritis of the ankle. Foot Ankle Int 2008;29:657–63. [12] Roux C, Fontas E, Breuil V, et al. Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb in osteoarthritis. A prospective evaluation of efficacy. Joint Bone Spine 2007;74:368–72. [13] Conrozier T, Couris CM, Mathieu P, et al. Safety, efficacy and predictive factors of efficacy of a single intra-articular injection of non-animal-stabilizedhyaluronic-acid in the hip joint: results of a standardized follow-up of patients treated for hip osteoarthritis in daily practice. Arch Orthop Trauma Surg 2009;129:843–8. [14] Conrozier T, Bertin P, Bailleul F, et al. Clinical response to intra-articular injections of hylan G-F 20 in symptomatic hip osteoarthritis: the OMERACT-OARSI criteria applied to the results of a pilot study. Joint Bone Spine 2006;73: 705–9. [15] Noël E, Hardy P, Hagena FW, et al. Efficacy and safety of Hylan G-F 20 in shoulder osteoarthritis with an intact rotator cuff. Open-label prospective multicenter study. Joint Bone Spine 2009;76:670–3. [16] Witteveen AG, Giannini S, Guido G, et al. A prospective multi-centre, open study of the safety and efficacy of hylan G-F 20 (Synvisc) in patients with symptomatic ankle osteoarthritis. Foot Ankle Surg 2008;14:145–52. [17] Hall MM. The accuracy and efficacy of palpation versus image-guided peripheral injections in sports medicine. Curr Sports Med Rep 2013;12:296–303. [18] du Souich P. Absorption, distribution and mechanism of action of SYSADOAS. Pharmacol Ther 2014;142:362–74. [19] Atchia I, Kane D, Reed MR, et al. Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis. Ann Rheum Dis 2011;70:110–6. [20] Conrozier T, Bossert M, Walliser-Lohse A, et al. Viscosupplementation with HANOX-M-XL is effective in moderate hip osteoarthritis but is not an alternative to hip joint surgery in patients with severe disease. Results of a clinical survey in 191 patients treated in daily practice. EMJD 2015;3:49–55. [21] Kwon YW, Eisenberg G, Zuckerman JD. Sodium hyaluronate for the treatment of chronic shoulder pain associated with glenohumeral osteoarthritis: a multicenter, randomized, double-blind, placebo-controlled trial. J Shoulder Elbow Surg 2013;22:584–94.
Thierry Conrozier Service de rhumatologie, hôpital Nord Franche-Comté, 14, rue de Mulhouse, 90000 Belfort, France E-mail addresses: [email protected], thierry [email protected] Accepted 20 May 2015 Available online xxx
Please cite this article in press as: Conrozier T. Optimizing the effectiveness of viscosupplementation in non-knee osteoarthritis. Joint Bone Spine (2015), http://dx.doi.org/10.1016/j.jbspin.2015.08.009