Patients Continue to Receive Hyaluronic Acid Injections for Knee OA

    The use of hyaluronic acid injections to treat knee osteoarthritis (OA) among Medicare beneficiaries has increased in recent years despite recommendations against the injections, according to a study from Cleveland Clinic published online ahead of print by The Journal of Bone & Joint Surgery.

    In 2013, the American Academy of Orthopaedic Surgeons (AAOS) published clinical practice guidelines recommending against the use of hyaluronic acid injections for patients with knee OA, citing a lack of high-quality data to support the effectiveness of this intervention. The available evidence, the guideline says, does not meet the minimum clinically important improvement thresholds for patients with knee OA.

    RELATED: An Update on the Clinical Practice Guideline for Knee OA

    The researchers from Cleveland Clinic wanted to know what effect – if any – this recommendation had on clinical practice. To do so, they analyzed data on Medicare Part B claims made between 2012 and 2018, assessing utilization rates and associated costs of hyaluronic acid injections for knee OA.

    Study Results

    They found that despite the AAOS recommendation, “[hyaluronic acid] services continued to be widely implemented among [the Medicare] patient population.” The data showed a significant increase in the overall use of HA services during the study period: from 1,090,503 services in 2012 to 1,209,489 in 2018.

    Consistent with the updated guidelines, the numbers of primary care physicians, rheumatologists, and orthopaedic surgeons who provided hyaluronic acid services decreased after 2013. However, the number of nurse practitioners and physician assistants offering hyaluronic acid injections significantly increased. In an overall trends analysis excluding these advanced practice providers, there was no significant change in total use of HA injections.

    Adjusted for inflation, costs for hyaluronic acid formulations increased from about $226 million in 2012 to $267 million in 2018. These costs increased among nurse practitioners and physician assistants, as well as among pain and rehabilitation physicians.

    The total costs associated with hyaluronic acid services increased from $290 million in 2012 to $325 million in 2018. Costs for services increased among nurse practitioners and physician assistants while decreasing among rheumatologists.

    Concluding Thoughts

    The AAOS recently released an updated version of its clinical practice guideline on knee OA, reaffirming its recommendation against the use of hyaluronic acid injections. In fact, the guideline downgrades the recommendation “due to a lack of generalized results.”

    Further studies are needed to identify the value of hyaluronic acid injections for knee OA and to determine which patients may benefit from this therapy, the researchers said.

    They added that “future studies should evaluate the efficacy of specific interventions that can help limit inappropriate [hyaluronic acid] use among orthopaedic surgeons, advanced practice providers, and other healthcare providers who manage knee osteoarthritis.”


    Zhu KY, Acuña AJ, Samuel LT, Grits D, Kamath AT. Hyaluronic acid injections for knee osteoarthritis: has utilization among Medicare beneficiaries changed between 2012 and 2018? J Bone Joint Surg Am. December 13, 2021. Online ahead of print. doi: 10.2106/JBJS.21.00832