Saturday, November 12, 2016

Synvisc - does it benefit patients with arthritis more than a cortisone shot?

Intra-Articular, Single-Shot Hylan G-F 20 Hyaluronic Acid Injection Compared with Corticosteroid in Knee Osteoarthritis: A Double-Blind, Randomized Controlled Trial.

These authors compared the efficacy of hyaluronic acid (hylan G-F 20)(Synvisc) with triamcinolone acetonide as a single intra-articular injection for knee osteoarthritis using a prospective, randomized, double-blind clinical trial. Participants with symptomatic knee osteoarthritis were randomized to receive a single-shot, intra-articular injection of either 6 mL of hylan G-F 20 or 6 mL of a solution comprising 1 mL of 40-mg triamcinolone acetonide and 5 mL of 1% lidocaine with epinephrine.

At the 6-month follow-up, compared with patients who took hylan G-F 20, patients who took triamcinolone acetonide had similar improvement in knee pain, knee function, and range of motion. 

The difference in mean outcome scores between groups was, with regard to knee pain, a visual analog scale (VAS) score of 3 points (95% confidence interval [95% CI], -6 to 11 points); with regard to knee function, a modified Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score of 0 points (95% CI, -8 to 6 points); and, with regard to range of motion, flexion of -1° (95% CI, -5° to 2°) and extension of 0° (95% CI, -0.5° to 0.5°). However, patients who took triamcinolone acetonide had better pain improvement from 24 hours until 1 week after injection; the mean difference between groups with regard to the VAS score was 12 points (95% CI, 5 to 20 points; p = 0.002) at 24 hours and 9 points (95% CI, 1 to 15 points; p = 0.018) at 1 week. At 2 weeks after injection, patients who took triamcinolone acetonide also had better knee functional improvement; the mean difference between groups for the modified WOMAC score was 6 points (95% CI, 0.7 to 12 points; p = 0.03). Both groups had improvement in pain, knee function, and range of motion during the 6-month follow-up (p < 0.0001).
Here's an example of their data comparing triamcinolone acetonide (TA) with Hylan.

Comment:  It is surely wonderful to see a solid Level I study in orthopaedics - congratulations to the authors.

See this related article for a prior similar randomized study coming to the same conclusion:
Corticosteroid compared with hyaluronic acid injections for the treatment of osteoarthritis of the knee. A prospective, randomized trial. These authors also found no differences between patients treated with intra-articular injections of Hylan G-F 20 and those treated with the corticosteroid with respect to pain relief or function at six months of follow-up. 

Like many shoulder surgeons, we are asked regularly about the value of HA in managing arthritis of the shoulder. As is often the case, the shoulder literature is not as high quality as that from the knee literature. However, it seems unlikely that the shoulder results would be any better than what is shown here for the knee.

In our practice we do not use intraarticular injections to manage shoulder symptoms because of the lack of evidence on their cost-effectiveness and out of concern for introducing Propionibacterium into the joint. 

See also these posts: 
Are shoulder injections safe before shoulder joint replacement and arthroscopy?
Effectiveness of hyaluronic acid injections - placebo?