Premier Orthopaedics and Sports Medicine, 300 Evergreen Drive, Suite 200, Glen Mills, PA, 19342, USA.
Research Department, Rehabilitation Clinic ('RehaClinic'), Bad Zurzach, Switzerland.
BMC Musculoskelet Disord. 2020 Oct 23;21(1):702. doi: 10.1186/s12891-020-03729-w.
The 2013 American Academy of Orthopaedic Surgeons (AAOS) guidelines made strong recommendations against intraarticular hyaluronic acid (IAHA) for patients with knee osteoarthritis (OA), as evidence supporting improvements in pain did not meet the minimal clinically important improvement (MCII) threshold. However, there may be important distinctions based on IAHA molecular weight (MW). Hence our objective was to evaluate the efficacy of IAHAs in knee OA based on molecular weight.
Randomized controlled trials were searched within MEDLINE, Embase, and CENTRAL and selected based on AAOS criteria. A pain measure hierarchy and longest follow-up were used to select one effect size from each trial. Mean differences between interventions were converted to standardized mean differences (SMDs) and incorporated into a random-effects Bayesian network meta-analysis. High MW (HMW) was defined as ≥6000 kDa, and low MW (LMW) as < 750 kDa.
HMW IAHA was associated with a statistically significant and possibly clinically significant improvement in pain (SMD - 0.57 (95% credible interval [Crl]: - 1.04, - 0.11), exceeding the - 0.50 MCII threshold. LMW IAHA had a lesser, non-significant improvement (- 0.23, 95% Crl: - 0.67, 0.20). Back-transforming SMDs to the WOMAC pain scale indicated a 14.65 (95% CI: 13.93, 15.62) point improvement over IA placebo, substantially better than the 8.3 AAOS MCII threshold.
Unlike LMW IAHA, HMW IAHA exceeded the MCII threshold for pain relief, suggesting that improvements can be subjectively perceived by the treated patient. Amalgamation of LMW and HMW may have blurred the benefits of IAHA in the past, leading to negative recommendations. Differentiation according to MW offers refined insight for treatment with IAHA.
2013 年美国矫形外科医师学会（AAOS）指南强烈反对膝关节骨关节炎（OA）患者关节内透明质酸（IAHA）治疗，因为支持疼痛改善的证据未达到最小临床重要改善（MCII）阈值。然而，根据 IAHA 分子量（MW）可能存在重要区别。因此，我们的目的是根据分子量评估 IAHA 在膝骨关节炎中的疗效。
在 MEDLINE、Embase 和 CENTRAL 中搜索随机对照试验，并根据 AAOS 标准进行选择。使用疼痛测量层次和最长随访时间从每个试验中选择一个效应量。干预措施之间的均值差异转换为标准化均数差（SMD），并纳入随机效应贝叶斯网络荟萃分析。高 MW（HMW）定义为≥6000 kDa，低 MW（LMW）定义为<750 kDa。
HMW IAHA 与疼痛的统计学显著和可能具有临床意义的改善相关（SMD -0.57（95%可信区间 [Crl]：-1.04，-0.11），超过-0.50 MCII 阈值。LMW IAHA 的改善较小，无统计学意义（-0.23，95% Crl：-0.67，0.20）。将 SMD 反转为 WOMAC 疼痛量表，与 IA 安慰剂相比，IAHA 治疗可改善 14.65（95%CI：13.93，15.62）点，明显优于 8.3 AAOS MCII 阈值。
与 LMW IAHA 不同，HMW IAHA 超过了疼痛缓解的 MCII 阈值，这表明治疗患者可以主观感受到改善。过去，LMW 和 HMW 的混合可能模糊了 IAHA 的益处，导致负面建议。根据 MW 进行区分可提供 IAHA 治疗的精细见解。
