What makes a treatment worthwhile?

Editorial: Getting Evidence Into Practice – or Not: The Case of Viscosupplementation

We recently came across this editorial that pointed out the divergence between evidence and practice. In it the author points out that in spite of the substantial evidence that hyaluronate injections (viscosupplementation) are ineffective, the market value of these products is expected to exceed $2.6 Billion by 2021.

He points to three questions we should ask about any treatment we use: (1) is it effective? (2) is it safe? and (3) is it worth the cost? 

This editorial is recommended reading for all of us who are tempted by 'novel' approaches, drugs, and implants.

We could say that the burden of proof lies with the advocates for a new technology, perhaps restating the author's questions:  (1) is it more effective than what we are currently using? (2) is it safer than what we are currently using? and (3) is it worth the increased cost over what we are currently using?
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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?

Injections for shoulder arthritis

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Synvisc (hyaluronate), glucosamine, chondroitin,arthroscopy, BMI and arthritis

Treatment of Osteoarthritis of the Knee, 2nd Edition SUMMARY OF RECOMMENDATIONS

The American Academy of Orthopaedic Surgeons recently published clinical practice guideline on osteoarthritis (OA) of the knee.  These guidelines seem, in large part, to be applicable to osteoarthritis of the shoulder as well:

(1) Participate in self-management programs, exercises, and physical activity.

(2) Weight loss for patients with BMI ≥ 25
(3) Recognize that the evidence does not support the use of acupuncture
(4) Recognize that the evidence does not support the use of glucosamine or chondroitin
(5) Recognize that the evidence does not support the use of hyaluronic acid (Synvisc) injections
(6) Recognize that the evidence does not support arthroscopic lavage and debridement

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.


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