Comparative Effectiveness of Intra-Articular Hyaluronic Acid and Corticosteroid Injections on the Time to Surgical Knee Procedures

J Arthroplasty. 2017 Dec;32(12):3591-3597.e24. doi: 10.1016/j.arth.2017.07.007. Epub 2017 Jul 14.


Background: Use of intra-articular hyaluronic acid (HA) injections to manage knee osteoarthritis (OA) remains controversial because of weak and conflicting evidence. The objective was to evaluate the effectiveness of intra-articular HA injections for knee OA management.

Methods: A nested cohort of persons with knee OA seeing a specialist was created using a 10% random sample of LifeLink Plus claims (2010-2015) to compare the risk of composite (any) knee surgical interventions, total (TKA)/unicompartmental knee arthroplasty (UKA) and TKA only among HA users and 2 comparison groups: corticosteroid (CS) users and HA/CS nonusers. A high-dimensional propensity score (hdPS) was used to match HA users with CS users and with HA/CS nonusers on background covariates. The risk of surgical interventions among HA users relative to the comparison groups was assessed using Cox proportional hazard models.

Results: Among 13,849 patients, 797 were HA users, 5327 were CS users, and 7725 were HA/CS nonusers. After hdPS matching, the risk of composite surgical interventions did not differ between HA users and HA/CS nonusers (hazard ratio [HR], 0.88; 95% confidence interval [CI], 0.67-1.16) and CS users (HR, 0.89; 95% CI, 0.65-1.12). Seven of the 8 sensitivity analyses demonstrated no significant benefit among HA users compared to CS users and HA/CS nonusers. A sensitivity analysis that restricted the study cohort to those who ultimately have knee surgery showed a lower risk of surgery of HA (HR, 0.87; 95% CI, 0.79-0.95).

Conclusion: There were no significant differences in the risk of surgical interventions among HA users compared to HA/CS nonusers and CS users after accounting for residual confounding using an hdPS.

Keywords: arthroplasty; comparative effectiveness; corticosteroids; hyaluronic acid; knee arthroplasty; knee osteoarthritis.

Publication types

  • Comparative Study

MeSH terms

  • Adrenal Cortex Hormones / administration & dosage*
  • Adult
  • Aged
  • Arthroplasty, Replacement, Knee / statistics & numerical data*
  • Cohort Studies
  • Female
  • Humans
  • Hyaluronic Acid / administration & dosage*
  • Injections, Intra-Articular
  • Knee Joint / surgery
  • Male
  • Middle Aged
  • Orthopedic Procedures
  • Osteoarthritis, Knee / drug therapy*
  • Osteoarthritis, Knee / surgery
  • Propensity Score
  • Time Factors
  • Viscosupplements / administration & dosage*


  • Adrenal Cortex Hormones
  • Viscosupplements
  • Hyaluronic Acid