Clinical outcome of intra-articular hyaluronic acid injection for knee joint osteoarthritis: a prospective interventional study from a tertiary care hospital


  • Urampath Sudheer Department of Orthopedics, Amala Institute of Medical Sciences, Amala Nagar, Thrissur, Kerala
  • Chundarathil Jayaprakash Department of Orthopedics, Amala Institute of Medical Sciences, Amala Nagar, Thrissur, Kerala



Intra-articular hyaluronic acid, Viscosupplementation, Knee osteoarthritis, Non-steroidal anti-inflammatory drugs


Background: The prevalence of knee osteoarthritis (OA) is estimated to be 14% and 6% in rural and urban areas of India, respectively. In severe cases, the American Academy of Orthopedics Surgeons recommends non-steroidal anti-inflammatory drugs (NSAIDs). A prospective interventional study was conducted to evaluate the effectiveness of intra-articlular hyaluronic acid injection (IAHA) in knee OA patients.

Methods: Medical records of 29 patients with knee OA, who were treated with IAHA injection, were analyzed using a 24 item WOMAC scale for the pain, stiffness, and physical function scores. Furthermore, the patients’ quality of life was evaluated based on the SF-12 scale and a global status assessment of knee OA was performed using the Likert scale and visual analogue scale (VAS). The data were analysed statistically.

Results: The overall WOMAC pain, stiffness, and physical function scores decreased following the IAHA administration in patients with knee OA. The mean pain scores decreased from 10.82 to 3.62 and stiffness scores dropped from 4.34 to 2.03. The mean physical function scores decreased from 36.75 to 17.1 (p<0.0001). The Likert scale and VAS demonstrated statistically significant (P < 0.0001) improvement in the patient’s health status. Overall, nearly 80% of the patients expressed little-to-none physical or emotional problems four weeks after IAHA treatment.

Conclusions: A single IAHA injection provided statistically significant improvement in pain, disability, and quality of life in knee OA patients. 

Author Biography

Chundarathil Jayaprakash, Department of Orthopedics, Amala Institute of Medical Sciences, Amala Nagar, Thrissur, Kerala

Prof. and HOD,

Department of Orthopedics,

Amala Institute of Medical Sciences,

Amala Nagar, Thrissur-680 555, Kerala, India


Radha MS, Gangadhar MR. Prevalence of knee osteoarthritis patients in Mysore city, Karnataka. Int J Recent Sci Res. 2015;6:3316-20.

Sharma MK, Swami HM, Bhatia V, Verma A, Bhatia SPS, Kaur G. An epidemiological study of correlates of osteo-arthritis in geriatric population of UT Chandigarh. Indian J Community Med. 2007;32:77-8.

Fransen M, Bridgett L, March L, Hoy D, Penserga E, Brooks P. The epidemiology of osteoarthritis in Asia. Int J Rheum Dis. 2011;14(2):113-21.

Salve H, Gupta V, Palanivel C, Yadav K, Sngh B. Prevalence of knee osteoarthritis amongst perimenopausal women in an urban resettlement colony in South Delhi. Indian J Pub Health. 2010;54:155-7.

Sowers MR, Karvonen-Gutierrez CA. The evolving role of obesity in knee osteoarthritis. Curr Opin Rheumatol. 2010;22:533–7.

Singh AK, Kalaivani M, Krishnan A, Aggarwal PK, Gupta SK. Prevalence of osteoarthritis of knee among elderly persons in urban slums using American College of Rheumatology (ACR) Criteria. J Clin and Diagnostic Res. 2014;8:JC09-11.

Chan KW, Wu R. Principles of Osteoarthritis - Its definition, character, derivation and modality-related recognition. Edited by Bruce M. Rothschild. InTech, 2012.

Brown GA. AAOS clinical practice guideline: treatment of osteoarthritis of the knee: evidence-based guideline, 2nd edition. J Am Acad Orthop Surg. 2013;21:577-9.

Jacobson JA, Girish G, Jiang Y, Sabb BJ. Radiographic evaluation of arthritis: degenerative joint disease and variations. Radiology. 2008;248:737-47.

Saadat E, Link TM. Current Radiographic Diagnosis for Osteoarthritis of the Knee. In: Majumdar S, editor. Advances in MRI of the Knee for Osteoarthritis. World Scientific; 2010: 69-71.

Veena C, Kumar GA, Niranjan K. Diagnostic Radiology: Musculoskeletal and Breast Imaging. Jaypee Brothers Medical Publishers Pvt. Ltd, 2012:169.

Braun HJ, Gold GE. Diagnosis of Osteoarthritis: Imaging. Bone. 2012;51:278–88.

Fibel KH, Hillstrom HJ, Halpern BC. State-of-the-Art management of knee osteoarthritis. World J Clin Cases. 2015;3:89-101.

American Family Physician. NSAID Prescribing Physician. Available at: afp/2009/1215/p1371.html Accessed on 30 Aug 2016.

Recommendations for the medical management of osteoarthritis of the hip and knee. Arthritis & Rheumatism. 2000;43:1905–15.

Harirforoosh S, Asghar W, Jamali F. Adverse effects of nonsteroidal antiinflammatory drugs: an update of gastrointestinal, cardiovascular and renal complications. J Pharm Sci. 2013;16:821-47.

Hippisley-Cox J, Coupland C. Risk of myocardial infarction in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: population based nested case-control analysis. BMJ. 2005;330:1366.

Richmond J, Hunter D, Irrgang J, Jones MH, Levy B, Marx R, et al. Treatment of OA Knee (Nonarthroplasty). J Am Acad Orthop Surg. 2009;17:591–600.

Wen DY. Intra-articular hyaluronic acid injections for knee osteoarthritis. Am Fam Physician. 2000;62:565-70.

American College of Rheumatology. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Available at: http://www. Research/Clinician-Researchers/Western-Ontario-McMaster-Universities-Osteoarthritis-Index-WOMAC. Accessed on 30 Aug 2016.

Hunter DJ, Neogi T, Hochberg MC. Quality of osteoarthritis management and the need for reform in the US. Arthritis Care Res (Hoboken). 2011;63:31-8.

Trigkilidas D, Anand A. The effectiveness of hyaluronic acid Intra-articular injections in managing osteoarthritic knee pain. Ann R Coll Surg Engl. 2013;95:545-51.

McGrath AF, McGrath AM, Jessop MA, Gandham S, Datta G, Dawson-Bowling S et al. A Comparison of Intra-articular Hyaluronic Acid Competitors in the Treatment of Mild to Moderate Knee Osteoarthritis. J Arthritis. 2013;2:1.

Altman R, Manjoo A, Fierlinger A, Niazi F, Nicholls M. The mechanism of action for hyaluronic acid treatment in the osteoarthritic knee: a systematic review. BMC Musculoskeletal Disorders. 2015;16:321.

Moreland LW. Intra-articular hyaluronan (hyaluronic acid) and hylans for the treatment of osteoarthritis: mechanisms of action. Arthritis Res Ther. 2003;5:54-67.

Bannuru RR. Comparative effectiveness of pharmacologic interventions for knee osteoarthritis: a systematic review and network meta-analysis. Ann Intern Med. 2015;162:46-54.

Altman R, Lim S, Steen RG, Dasa V. Hyaluronic acid injections are associated with delay of total knee replacement surgery in patients with knee osteoarthritis: evidence from a large U.S. health claims database. PLOS One. 2015;10:e0145776.

Divine JG, Shaffer MD. Use of viscosupplementation for knee osteoarthritis: an update. Curr Sports Med Rep. 2011;10:279-84.

McNabb JW. A Practical Guide to Joint and Soft Tissue Injection and Aspiration: An Illustrated Text for Primary care. Lippincott Williams and Wilkins, 2012:12.






Original Research Articles