Is Viscosupplementation (VS) effective, or no better than placebo?

The question regarding the efficacy of sodium hyaluronate (or hyaluronic acid, HA) injections for the treatment of osteoarthritis, remains a hotly debated topic amongst Orthopaedic fraternities on both sides of the Atlantic. One of the main points of contention – if not the main point - relates to the “Value for money” realised by paying bodies when commissioning clinical professionals to administer VS. Government Health spending restriction bodies such as NIHCE in the UK, and professional organisations such as the AAOS (American Academy of Orthopaedic Surgeons) currently do not recommend the use of HA in the treatment of knee OA. 

However, does the evidence which health authorities use against VS actually bear up to scrutiny? This very issue was addressed in a letter sent in November 2017 by the President of the “Arthroscopy Association of North America”, Mr Robert Hunter, MD, to an American insurer. 

In his letter, Mr Hunter argues that in spite of countless studies and review articles showing, e.g. “improvement from baseline post injection from 30% to 69%”, and the most recent Cochrane review finding “overall benefits to VS in comparison to placebo for pain, function & patient global assessment scores”, the AAOS still chose to ignore these positive findings and to exclude VS from their OA treatment guidelines. 

Mr Hunter concludes that “From an economic perspective, there is clear supporting evidence that HA can in fact delay the need for knee replacement making thousands of patients more “age-appropriate” for their first and only knee replacement sparing the system and the patient from revision knee replacement surgery during their lifetime.” This evidence, along with other contemporaneous data which supports VS both clinically and economically, will hopefully be taken into consideration here in the UK when NIHCE’s Guideline CG177 comes up for review in due course.