I have been regularly using viscosupplementation for OA knee ( Three injection course) for the last four years with good results. I feel that one should not blindly follow the recommendations based on experiences of Western authors in their particular population. If something supported by research works in my patients, makes  them more mobile and pain free without causing any harm, I will continue to use it.

They are inferior to steroids in short term duration, but with likely improved benefit in longer term results. Good therapy for Grade II/III OA and not for grade IV

Thanks Dr Rathore and Dr Vaishya.

In KL grade 2 or 3, the ordinary patients, in my practice rarely agreed to spend for this injection due to low grade symptoms. The professional sportspersons do agree and I have injected the knees of national/ international players in grade 2 or grade 3. They did get relief in symptoms. But what happens in long term needs to be seen.

In my practice I used it more often in grade 4 OA  into the non-operated knees as well as after arthroscopic surgery for degenerative knee. I usually mix them with depomedral. The results are mixed. Some of them are doing really very well. While there are a few patients who did not get any relief or got only temporary relief.

Dear Ravi, The literature does not support its use in KL grade IV and hence I do not use it (so no experience). Mixing with Depomedrol is also questionable and its product monograph does not mention about it. What are your views??

If the results are mixed, then the indications should be made clear. I never use viscosupplemenation injectoins in advanced OA (i.e.grade 4 ) because in the majority of these patients it fails, and the patients are disappointed.

Thanks Dr Vaishya, Dr Tanchev and Dr Mahmud.

I agree with Dr Mahmud that the patients who are grade 4 symptomatic OA, and are not candidates for surgery for one or the other reason, can be given this injection.

We all know that hyaluronidase has shock absorbing properties and gives cushioning effect. In addition, it has antiinflammatory properties and also stimulates the synovial membrane to secret normal synovial fluid, So the patients who do not have much mechanical symptoms,  are the candidates (in my practice).

Regarding combination with depomedral, we do not mix the solutions in one syringe. They are injected through different syringes at the same time. There are a number of trials in the literature where people have used them in combination. 

I agree that this therapy have very limited effect in decompensated knee OA. It is very important that 's no adverse effects, but we have to respect asepsis and antisepsis. 

Yes Dr Rathore, I agree. Even the definition of EBM says that the use of a treatment based on scientific evidence according to the local needs of the patients in accordance with the experience of the treating physician.

The product manual of Depomedrol clearly mentions that Depomedrol should not be mixed with any agent. Whether it is mixed outside the knee or get mixed within the knee with Sod Hyaluronate is the same. In this era of EBM, we should try to avoid experimenting on our patients and go against the established evidence, because of their demands!

I agree with Ravi Gupta; there are quite a good number of patients who feel significant improvement in their symptoms but only in low degrees (Allback 2 or 1) and results are sustained only if there is no axis misalignment (to have to be corrected)

Dear Ravi, thank you for the question. I have used the Hyaluronic acid injections in the past (years ago). In all knees an arthroscopy was performed prior to injection so the grade of degeneration was recorded. I am reminding the indications given by the companies according to their research; they are useful to patients with grade 1 or 2 of degeneration and they are not recommended for grades 4 or 5. I did an audit and my findings were the opposite. Patients of 1 or 2 had no benefit but 4 and 5 were delighted. This was a surprise and against the recommendations. Companies had no answer to this. In a second audit where I was injecting only local anaesthetic to some patients and visco-supplementation in others. The results were similar and I am talking in the long run. This "confusion" made me to stop. There are other surgeons who have the same experiences and the results do not follow a pattern. The injections were far more expensive than the benefit. Insurance providers learn about this and stop paying, but before this NHS managers were not accepting the patients on the waiting lists. I can say that for years I have not injected a knee as I prefer to replace it, if it is indicated, or send the patient to physio and dietician. In case of a very sick patient who is impossible due to comorbidities to be operated (this is rare as I have a great anaesthetist who can give safe anaesthesia in almost all cases) I administer steroids every six months.

Sir

Does anybody have experience of using Univestin. I mean oral medication for long term use.

Thanks Dr Vaishya,

The literature of Pfizer company with the trade name of Depomedral does not permit its use as epidural injection.

Many surgeons across the globe use it.

Similarly, when there is enough scientific evidence in the literature of having it successfully used in combination with visco-supplementation, the mention of a statement by the company literature without any scientific support takes a back seat for me. Yes, the company literature should be in our knowledge, but at the same time scientific evidence should also be paid attention to.

In my 34 years experience visco-supplementation is an effective treatment of osteoarthrits (OA) of the knee joint with beneficial effects on pain and function especially after 4 to 12 weeks post injection period. I agree with George Safiropoulos that they are specially useful to patient with OA gr 1 and 2.

Dear Ravi,

Thank you for this very interesting question. I've been using them for a long time - mostly for grade 2 & 3 OA with rather satisfying but short term results? Patients often come back for the same problem after an unpredictable delay... It's so rather hard to find a real issue for them as well as satisfying rules or ideal indications; the better results are often the unexpected ones and I still can't say why... Their efficiency look shorter - to me at least - compared to steroids but they really improve pain and function! No doubt that insurances companies were happy with such results! So the question now might be, in these specific situations, which treatment for early Knee OA (up to grade 3): visco-supplementation, steroids, arthroscopy or any association of them? It's effectively still uncertain to me which part should be allowed to good results obtained after arthroscopy with "house cleaning": washing, minimal mechanical improvement, synovectomy if associated, end-procedure injections (with steroids and/or local anesthesia and/or morphin), ... Could we so imagine to build up an international study comparing all these techniques, isolated and associated?

Thanks Thierry for bringing in another important issue of arhroscopic surgery in degenerative knee. I shall ask it as a separate question to get the attention of more surgeons from globe.