Saturday, July 7, 2012

News Flash: Injections of Hyaluronic Acid May Do Your Knees More Harm Than Good

For anyone thinking of having Synvisc, or some other artificial lubricant that uses hyaluronic acid, injected into their decaying knee joints, there’s a new study out that will give you pause.

Apparently the shots have little effect on pain and none on function. And that’s the good news.

The bad news is the procedure may lead to cardiovascular and gastrointestinal problems.

Products such as Synvisc treat bad knees through viscosupplementation. In unhealthy or diseased joints, the synovial fluid becomes thin and watery, less capable of effectively doing its job (healthy fluid has the consistency of egg whites and both lubricates the knee joint and cushions it from impacts).

Viscosupplementation injections (approved by the FDA in 1997) are intended to artificially boost the viscosity and performance of your ailing synovial fluid. The cost can be more than $1,800 (based on 2006 prices), according to this article.

Here are some details about the study (here’s another article that’s a bit more granular about the results):

* It was a meta-analysis, which means that no new research was conducted. Rather, the conclusions and methodologies of existing studies were examined. The findings of such broad, sweeping meta-studies are typically more powerful because of their much greater reach (in this case, 89 clinicial trials and more than 12,600 participants).

* A weakness was the poor quality of many trials. Also, some studies were unpublished (thus not vigorously vetted) and funded by pharmaceutical companies. The funding point, though, makes it likely that the results overstated the efficacy of viscosupplementation, if anything.

* 18 large-scale trials with 5,094 subjects found the injections made so little difference for pain as to be “clinically irrelevant.”

Okay, now my 2 cents: As I’ve said before, my reading of message boards (which I did a lot of when I was trying to fix my own knees) led me to conclude that about half of Synvisc takers claim an improvement, while half say the shots worsened their condition or hurt a lot or did nothing -- and unfortunately, beforehand you can’t tell which group you’ll be in. And even if you get the improvement, it’s only temporary, wearing off in as little as 4 weeks, it appears.

I know a shot seems simple. I know we’re frequently conditioned, when in chronic pain, to look to a deft surgeon’s hand or the miracle of 21st century medical technology. But just be careful. Often there are no good shortcuts to fixing a hard problem.


  1. Richard: I had a Synvisc shot (3 in 1) November 30 and had virtually no relief. Regular PT of the quad strengthening type did not help. As of end of April of this year I was certain I needed TKR (4 surgeons concurred I have patellofemoral arthritis of my left knee). By chance, I found your little ebook on Amazon at that time and read it in a couple of hours. I actually scoffed at the idea that I could recover as you had done because I couldn't really walk at all on hard ground without excessive pain. I had a limp. I had almost fainted from the pain at the market the week before. But I said what do I have to lose--nothing else had worked--so I started padding around my apt. wood floors in my bare feet, since barefoot had always felt better than shoes. At that time I was so close to scheduling TKR surgery that I had grab bars put in my shower in beginning of May. Believe it or not, within a couple of days of starting to walk 60 steps every hour or so around my apartment, I started to feel much better--almost right away, really. Then within a week or so by a great stroke of luck I met a woman who had been scheduled for TKR with my same surgeon (coincidence), and she had found a physical trainer very near where I live in Santa Monica, CA, at a place called Drive Cardio (for others who might be in the area--I am not a PR person for him, believe me). This guy she said had virtually cured her--she was leaving the next day on a 3-week hiking trip in Turkey. I started seeing him and told him that walking small steps had started to help me. He said "closed chain" (I don't know this stuff) and I have continued to see him once a week. He does different things every time--uses a bosu ball, a stability ball (small "micropushes" with it against a wall), etc. Every week is usually a new series of movements in different order and different intensity. He says what's important is increasing "vascularity." I am doing more strengthening stuff each week but it's been very gradual. But certainly not the kind of quad strengthening I had been doing before. I continue to walk around my apt. but I can also walk outside now without pain and use cardio machines which I couldn't use before. All I know is I am getting better and better. My recovery was so fast after reading your book, maybe because I didn't have a long history of pain--only since Nov. 2011. Last week I went on a short trip to Vegas and walked pretty much all day for 3 days. I still have a tiny bit of pain in my knee here and there but it's more like a 1/10 versus 6/10. Am even feeling well enough to plan a trip to Europe this fall. I have a real passion for tennis, and am even getting hopeful that I might go back to it in some limited way--have somebody hit the ball to me so I don't try to run. Anyway I have been wanting to write you for the last two months really-- I feel so grateful for having chanced upon your book. I've recommended it to others. By the way, I'm a 66-year-old woman. I should say I was quite flexible and athletic for my age before my knee pain. Thanks again, Richard!

  2. Sorry for making it so hard to read. Can I put paragraphs in?

  3. What a great story, Pat! Thanks for writing. I'm going to comment on this in the blog soon. We love success stories here.

    Don't worry about the paragraphs; it read fine! ;)

  4. I had the series of three hyaluronic acid shots (Euflexxa brand) in my knee and had a horrible adverse reaction. Lots of pain and swelling that persisted for a long time. I don't think this happens to most people, but it is a known risk. Just fyi to everyone out there thinking about having this.

  5. I had one of these Synvisc type shots. My surgeon said it helps some people in her experience but for some people doesn't help at all. we decided to try it. I had this very unusual reaction starting the day after the shot I had stabbing pains sometimes when I moved. No discoloration or major swelling, just stabbing pains unexpectantly. Then finally several days after the shot my knee would sort of "catch" and would not bend. I fell down on the sidewalk the first time it happened, which was about 5 days after the shot. After that I was scared and walked with a cane because I never knew when it would catch and Stab and I didnt want to fall down again. I had to move really slowly. :(

    Now then, I don't know if the shot is what caused this. the timing certainly makes me suspect the shot caused this, bbut neither I nor my surgeon have ever heard anyone having that sort of reaction. Later I did go for arthroscopy which smoothed out the cartilage and we saw my cartiledge was all jagged in my knee groove. That Solved the knee locking problem. However, even after the surgery I continued to have knee pain and flare ups and setbacks, so, I still could not return to a normal active life. But. Only 2 years after the surgery I have had some success with the gentle movements in the water (not swimming or walking, but gentle movements while suspended in the deep end with a floatation belt). Now after reading Saving My Knees I think it was the gentle repetition that was helping heal my joint first and not focusing on strengthening the quads until my knee joint was in better shape. Also, now that in "Saving My Knees" I read bout how cartilage can be healthy and supple or can be brittle and flakey, I wonder if the injection stirred up brittle flakey cartilage in my knee and that is why my knee would suddenly decide it would not bend.

    I feel lucky my surgeon wanted to try the minimally invasive arthroscopy to smooth the cartilage (which did solve the locking problem) instead of what the second opinion surgeon wanted which was a patella realignment surgery which is a major surgery with a long recovery time. Now after reading Saving My Knees I wonder if I could have recovered without the arthroscopy, but I did not know about the book and the knee locking and screaming stabbing pain and falling down and hobbling around with my cane in fear of the next stan was really the last straw for me.

  6. Hauser: You are doing a study with stem cell therapy, correct?

    Wei: Yes, we are doing a study in order to get around this whole mystique. A whole lot is written about stem cells. If you go to a source like Google for instance, you get a lot of misinformation. Number one, people don’t know what stem cells are, and number two, when they’re told things, they’re told this is the next best thing since sliced bread. They are just not true. What we are doing is taking a select group of patients who range in age from about 25-75. We made that age cut off because we know stem cells in older patients respond less well to stimulus than those coming from younger patients. What we are looking at is osteoarthritis of the knee and we are measuring different parameters, including what is called the Visual Analog Scale (VAS), which is basically what a patient tells us is happening as far as are they feeling better or worse. That is coming from the patient perspective, as well as the physician perspective. We are having patients fill out a WOMAC questionnaire, which is a standard questionnaire used in osteoarthritis studies to describe a patient’s ability to perform activities of daily living (ADL’s). We measure the speed of a 50 ft walk. Finally, and most importantly in order to create objective data, we are measuring the thickness of cartilage growth in the knee joint, between the knee cap and the upper leg bone.

    This is called the patellofemoral joint. It is the only joint that is really accessible to ultrasound measurement. We have been able to demonstrate, over a one year period of time, significant improvement in cartilage thickness in most of our patients. Not all. We have had a couple patients not respond and that is to be expected. If you see a paper, and they report 100% success, there is something wrong. I mean there is no treatment in the world that works 100% of the time. The same thing is true with stem cells. But the data that we are getting, both subjective as well as objective, is very encouraging.

    - See more at: