A Comparative Study on Effectiveness of Intra-articular Injection of High Molecular Weight Hyaluronate, Steroid and High Molecular Weight Hyaluronate plus Steroid in Osteo-arthritis Knee
Authors: Pramanik R , Basak A , Ballav A 
Published: July 2019

Abstract

Background
Although primary osteo-arthritis is well known as a benign degenerative condition, the impact of this disease course is becoming terribly disabling day to day in our community possibly because of increasing life expectancy. After lots of search regarding the role of intra-articular hyaluronic acid plus steroid in osteo-arthritis knee it is noted that scarcity of literature regarding conclusive evidence for the above. There is a grey zone regarding the combined role of these two agents in patients with primary osteo-arthritis. This project is a humble sincere attempt to find out the role of high molecular weight hyaluronate plus steroid in osteo-arthritis knee and to compare the effectiveness of this with intra-articular steroid, and intraarticular HMW hyaluronic acid.

Methods and Design
This is a single blind randomised controlled parallel group study conducted in the department of physical medicine and rehabilitation, IPGME & R, SSKM Hospital, Kolkata for a period of 18 months taking 27 subjects in each group. All patients with primary osteo-arthritis knee with grade two or grade three were included in the study group. And those who did not want to get incorporated in the study, patients with secondary osteo-arthritis knee, grade one or grade four osteo-arthritis knee, with gross knee instability, patients with contra-indications of intra-articular injections or intra-articular injection of steroid or with history of allergy to a viscosupplementation solution and patients received intra-articular injection in knee within last one year were excluded from the study. WOMAC pain, stiffness and functional subscales, VAS pain, ROM of knee joint, 50 feet walk time, Patients global assessment scale, Physicians global assessment scale were the parameters studied. After taking clearance from the institutional ethical committee, patients were selected based on the inclusion and exclusion criteria, and baseline (visit-1) assessment was done on the parameters. The selected patients have been divided into three groups randomly. Written informed consent was taken from all patients before interventions. One group received intra-articular injection of methylprednisolone, second group received intra-articular injection of high molecular weight hyaluronoic acid, and third group received intra-articular injection of high molecular weight hyaluronate plus methylprednisolone in the knee joint. The injections administered under strict aseptic condition. After administering injections, the patients assessed at the interval of 6 weeks (visit-2) and 12 weeks (visit-3) using the parameters mentioned above. The results have been analysed according to the standard statistical methods to fulfill the aims and objectives of the study.

Discussion
Majority of patients were female and more than 50 years of age with K-L radiological grade of 3. At the baseline visit, the WOMAC pain was comparable in all the three groups. It has been seen that, there was statistically significant improvement in all the parameters at the 2nd visit (6 weeks) from the baseline in all groups, and at the 3rd visit (12 weeks) though there was improvement on all the parameters from the 2nd visit in all groups, it was not statistically significant. Steroid, high molecular weight hyaluronate and steroid plus HMW hyaluronate all are effective in osteo-athritis knee in terms of reduction of pain, reduction of stiffness of knee joint, increase of range of motion of knee joint, reduction of 50 feet walking time, reduction of patients and physicians global assessment score. No treatment regime is statistically significantly better than the other group after 6 and 12 weeks of postinjection. Adverse effects of any treatment regime is negligible.