Hyaluronic acid or platelet-rich plasma in the treatment of hip osteoarthritis?

Ross A. Hauser, MD, Danielle R. Steilen-Matias, MMS, PA-C

In your quest to avoid hip replacement surgery, you may have been recommended hyaluronic acid injections. The thinking behind this, as we will see, is that by injecting a lubricant (hyaluronic acid) into the hip, bone on bone pressure can be relieved. Surprisingly there is not a lot of research on the effectiveness of this treatment. One could speculate that the reasoning for this is that the treatment will probably help in the short term, but it does not represent a treatment that can prevent the eventual need for a hip replacement. In essence, with hyaluronic acid injections for hip osteoarthritis, you are simply buying time and stalling the need for the surgery. Worse, the injections may offer no help and your hip condition will continue to worsen.

Buying time is appealing to those who work at physically demanding jobs, those who want to continue with sports, or those who are caregivers for others with worse medical problems than their own. Solving their hip pain problems without surgery is of course the ultimate goal. Unfortunately, hyaluronic acid injections for hip osteoarthritis have not been shown to be an effective treatment for the avoidance of surgery and provide that ultimate goal.

“But my doctor says to get the gel shots”

Some people do very well with hyaluronic acid injections for their hip problems. In the short term. We usually do not see these short-term benefits people in our office. We see the people who are now beyond the short-term and the useful effectiveness of hyaluronic acid injections. In other words, they have “outgrown” the treatment.

Gel shots or “viscosupplementation,” are usually not the first, second, or even third-line treatment for hip osteoarthritis. They are usually given when other treatments have failed to alleviate your hip pain. These treatments include the typical conservative care of corticosteroid injections, pain medications, and anti-inflammatory medications. In some instances, physical therapy and yoga are recommended for hip pain patients.

But I have no cartilage in my hips

No cartilage in hip

As just discussed, someone will usually consider hyaluronic acid injections for their hip problem as the fourth or fifth or more treatment. It is usually not the first-line choice and the reasoning is pointed out in the research below.

A typical patient story as to how they were recommended for hyaluronic acid injections for their hips goes something like this:

My doctor told me there was no cartilage left in both hips and I should have my hips replaced. She sent me to an orthopedist who told me the same thing, nothing could be done, and I needed a bilateral hip replacement. I was faced with two options, if I got the surgery I would have to wait months to get it and I would still be in pain, try something else. As a compromise, the orthopedist recommended that I try the hyaluronic acid injections. When I asked, “Will this help me avoid the hip replacement, the answer was no, “It will help me until I get the surgeries.” 

In theory, the idea of replacing or supplementing the protective and lubricating fluids of the hip sounds like a good idea. Conflicting research.

The idea that hyaluronic acid injections will help is based on a good idea. In theory, the idea of replacing or supplementing the protective and lubricating fluids of the hip sounds like it can be a solution. So why is it not the first line of treatment for hip osteoarthritis and why do leading research centers suggest that the treatments do not work as well as hoped? Because it really does not help.

In January 2019, research led by doctors at Northwestern University Feinberg School of Medicine in Chicago wrote these opinions in the medical journal Osteoarthritis and Cartilage. (1)

  • “Hip osteoarthritis is difficult to treat. Steroid injections reduce pain with a short duration. With the widespread adoption of office-based, image-guided injections, hyaluronic acid is a potentially relevant therapy. In the largest clinical trial to date, we compared the safety/efficacy of a single, 6-mL image-guided injection of Hylan G-F 20 (Synvisc) to saline (injections) in painful hip osteoarthritis.”
    • 357 patients.
    • All over the age of 35.
    • Patients suffered from mild to moderate hip osteoarthritis with “pain on walking.”

CONCLUSION: No better than the Placebo

  • “A single 6-mL Hylan G-F 20 injection or saline for painful hip osteoarthritis resulted in similar, statistically significant/clinically relevant pain and function improvements up to 6 months following injection; no differences between Hylan G-F 20 and saline placebo were observed.”

These findings were also confirmed by researchers in August 2019 in the journal Medical Science Monitor. (2) The researchers here wrote: wrote: “Intra-articular viscosupplementation does not reduce pain or improve function significantly better than placebo in a short-term follow-up. The benefits and safety of viscosupplementation should be further assessed by sufficiently-sized, methodologically sound studies with validated assessment of more clinically relevant end-points.”

So why do doctors keep offering hyaluronic acid injections for hip pain? Because it may help someone.

In March 2020 Orthopaedics, (3) doctors at the Department of Orthopaedic Surgery at the Cleveland Clinic wrote:

“There is a lack of agreement among providers and governing agencies regarding the efficacy of hyaluronic acid for the management of hip osteoarthritis.” As the doctors point out that is clearly demonstrated in the research. What the Cleveland Clinic’s doctors want to demonstrate in this research paper is how hyaluronic acid injections impact 1) patient-reported outcome measures and (do people say they are getting better?) 2) rates of conversion to total hip replacement.

In this research, the doctors examined 39 published outcome studies that included 5,864 patients receiving injections of hyaluronic acid. What did they find?

“There was inconsistent evidence across studies regarding the effectiveness of hyaluronic acid compared to other intra-articular injections. The formulation of the administered viscosupplementation did not appear to influence outcomes. Furthermore, rates of conversion to total hip replacement were relatively low when evaluating 1- to 4-year follow-up intervals.

Non-comparative studies consistently demonstrated that hyaluronic acid injections can achieve satisfactory pain reduction and functional improvement. However, there was not enough evidence in the current literature regarding whether hyaluronic acid is superior to placebo or other types of intra-articular injections.”

Ultrasound guidance can also be debated

The benefits of ultrasound-guided injections are also debated. A May 2022 paper in the Clinical Medicine Insights. Arthritis and musculoskeletal disorders (4) summarized that “In symptomatic hip osteoarthritis patients, intra-articular administration of corticosteroid and hyaluronic acid was seen to be effective at three and six months after administration. However, the effectiveness was determined to have disappeared within 1 year. Furthermore, in hip osteoarthritis intra-articular drug applications, it was determined that the blinded technique (no ultrasound) without radiological guidance performed in the outpatient clinic is as effective and safe as the radiologically guided technique administered in the operating room.”

Opposing views – Hyaluronic acid injections provided pain relief, functional improvement, and no severe complications on an immediate short-term basis. However, the results do not favor treatment with high molecular weight hyaluronic acid injection over other treatment methods.

An August 2022 paper in the journal Clinical Rheumatology (5) evaluated the short- and medium-term effectiveness and safety of ultrasound-guided hyaluronic acid injections in moderate hip osteoarthritis and to determine if patients could reduce their NSAIDs/pain killer intake.

The researchers looked at patients who had Grade II or Grade III hip osteoarthritis and who had failed standard of care therapy. In the case or treatment group, 15 patients had their hips injected. Thirteen of the patients had both hips injected.

In the case group, pain scores were significantly and progressively decreased and patients showed a significantly lower NSAIDs/pain killer average intake at 3 months from baseline. The researchers concluded: “Our data suggest that ultrasound-guided hyaluronic acid injections in moderate hip osteoarthritis may be an effective and safe treatment for moderate hip osteoarthritis with short- and medium-term benefits.”

In the Pakistani Journal of Ayub Medical College, (6) doctors treating hip pain patients made these observations on the different molecular weights gels available. Was thicker better? There seemed to be no research on that. Here is what they wrote:

“A multitude of conservative treatments is used for pain relief and functional improvement including acetaminophen, NSAID, intra-articular corticosteroid, and viscosupplementation. Different preparations of viscosupplementation based on different molecular weights are commercially available.” The researchers then examined the use of intra-articular high molecular weight hyaluronic acid injection for the hip joint by reviewing four previous studies on Hyaluronic acid injection effectiveness.

  • Results: Four studies comprising 185 and 189 patients in high molecular weight hyaluronic acid injection and control groups were included, respectively.
  • Conclusions: “Intra-articular high molecular weight hyaluronic acid injection provided pain relief, functional improvement, and no severe complications on an immediate short-term basis. However, the results do not favor treatment with high molecular weight hyaluronic acid injection over other treatment methods”

Doctors writing in the Archives of Physical Medicine and Rehabilitation say: “We do not recommend viscosupplementation for hip osteoarthritis”

Researchers in Brazil published in the August 2017 edition of Archives of Physical Medicine and Rehabilitation (7) had this to say about using hyaluronic acid injections for hip osteoarthritis:

  • “We do not recommend viscosupplementation for hip osteoarthritis. Compared to placebo, data shows scarce evidence of its efficacy up to 3 months, and suggests no difference at 6 months.”
  • BUT, future random control studies could present hyaluronic acid injections as an alternative to methylprednisolone (steroid) for short-term symptom relief.

That recommendation is because the steroid and viscosupplementation both showed the same small benefit of pain relief over the short term. But if you don’t recommend viscosupplementation, how can you recommend viscosupplementation over steroids? Why not recommend the placebo?

This research was cited and referenced in an August 2019 study published in the journal Medical Science Monitor (8) where a similar conclusion was reached:

  • “Our analysis was not able to show that Intra-Articular Viscosupplementation reduces pain and improves function significantly better than placebo in a short-term follow-up. The benefits and safety of Intra-Articular Viscosupplementation should be further assessed by sufficiently sized, methodologically sound studies with validated assessment of more clinically relevant end-points.”

More on high molecular weight hyaluronic acid

In the use of hyaluronic acid injections, the greater the molecular weight, (in simplest terms density or thickness), the better the hoped for results. The hyaluronic acid derived from animal sources has a greater molecular weight. Rooster combs are one of the highest molecular weights and why for years hyaluronic acid injections were called “rooster shots.”

A September 2021 study led by Australian researchers and published in the journal BioMed Central Musculoskeletal Disorders (9) found that in 87 patients treated with high molecular weight hyaluronic acid, one injection would provide benefit in many patients assessed at six weeks after the injection. A December 2020 paper from Italian researchers also found that more injections did not provide a more positive effect. (10)

Hymovis treatment

Italian researchers writing in the Journal of Clinical Orthopaedics and Trauma (11) investigated the safety and performance of Hymovis injection, a hyaluronic acid-derivative, used to manage symptomatic hip osteoarthritis in active middle-aged sportsmen over a 24-month observation period.

Patient profile:

  • Thirty active sportsmen, sixteen cyclists, and 14 tennis players, aged between 40 and 65 years, and suffering from symptomatic Grade II to III hip osteoarthritis
  • They were treated with two Hymovis injections, two weeks apart, every 3-4 months, for two years.
  • Conclusion: “Treatment of hip osteoarthritis in active sportsmen with Hymovis seems a safe and effective approach for the management of osteoarthritis symptoms, by potentially protecting cartilage and subchondral bone from further damage.”

A November 2023 paper in the journal Arthroscopy (18) from the University of Cambridge, School of Clinical Medicine tried to determine which factors would make hyaluronic acid injections less or more effective. The factors the researchers looked at were, how long the patient was treated with hyaluronic acid injections, the doses given, the number of injections they received, and if adverse or side-effects played a role in lesser outcomes. The researchers looked at forty previously published studies and found “level of available evidence was low with an overall high risk of bias. Nearly all studies showed a reduction in (average) pain at 1 month, 3 months and 6 months follow-up. . . ” Their conclusion? “Weak evidence suggests that viscosupplementation improves patient-reported pain and function at endpoint compared to baseline, regardless of dose, volume, composition and number of injections. However, due to the high heterogeneity, low level of evidence and high risk of bias in the current available literature, the strength of our conclusions is limited.”

Hyaluronic acid injections, Cortisone, and Saline Lavage

December 2020 (12) study examined a more aggressive approach to helping patients avoid a hip replacement. Here the doctors tested the idea that Hylan G-F20 (Synvisc) improves saline lavage (the injection of large amounts of saline solution into the hip and then draining it out to in essence “power-wash” away inflamed synovial fluid, floated pieces of cartilage, and other impurities floating in the hip) and triamcinolone injection.

After examining 82 patients in the study group for improvements in pain and range of motion at baseline, one month, three months, six months, and twelve months, post-injection the patients who had the lavage procedure, the cortisone, and the Synvisc had an improved external rotation since the first postoperative month and maintained the results up to a year. However, all groups showed clinically relevant improvements. No differences were found between the groups in any subjective evaluations

Conclusion: “Hip lavage and triamcinolone injection, with or without the use of (Synvisc), improves pain, function, and quality of life up to a year in hip osteoarthritis patients. Hylan may improve Range of motion up to one year.”

The point here is that these doctors are presenting an option for hip replacement. They are looking for ways to improve the treatments they offer. Here they suggested Synvisc may help achieve that goal, the understanding is the lavage and cortisone worked just as well without the Synvisc as with the Synvisc.

Eleven studies compare PRP to hyaluronic acid viscosupplementation

In this article, we will limit the discussion of PRP to a direct comparison to viscosupplementation.

  • PRP treatment re-introduces your own concentrated blood platelets into your hip
  • Your blood platelets contain growth and healing factors. When concentrated through simple centrifuging, your blood plasma becomes “rich” in healing factors, thus the name Platelet RICH plasma. Platelets play a central role in blood clotting and wound/injury healing.

Platelet Rich Plasma injections and Prolotherapy injections for Hip Osteoarthritis

Prolotherapy Hip Injection Sites

In basic terms, Platelet Rich Plasma injections are the application of concentrated blood platelets, which contain and release growth factors to stimulate recovery in non-healing injuries. The video describes the technique, and the research below describes the results. Prolotherapy is an injection technique utilizing simple sugar or dextrose.

We do not use PRP treatments in isolation. As we have discussed in this article, hip osteoarthritis and hip instability are problems that a single injection, for the most part, has not been shown to be effective in the long term as attested to in the research above.

Will PRP work for your hip osteoarthritis?

If you have come upon this page, it is likely that you have received a recommendation for Platelet Rich Plasma Injections for your hip pain and you are doing your research. We are going to try to offer help with that research, but first, we would like to take a moment to describe how we offer Platelet Rich Plasma Injections for your hip pain as opposed to how you may have been offered this treatment in other offices.

  • In Platelet Rich Plasma treatment, your blood is drawn from your arm, it is spun to concentrate the blood platelets which contain concentrated healing elements. The concentrated plasma “rich in healing platelets” solution is then injected into your hip.
  • In another office, Platelet Rich Plasma treatment may have been explained to you as a one-time injection treatment.
    • This “one-time,” treatment explanation may offer confusion in that many patients assume PRP injections are cortisone-like in that it is one injection offered at the time of treatment. The single injection PRP causes an inflammatory response, the opposite of the cortisone injection effect of causing an anti-inflammatory effect. The effects of the two injections could not be more opposite. Patients are often confused when the inflammation gets worse after PRP and they tell everyone they know that PRP does not work.
    • This “one time,” treatment may also confuse patients who have or had been suggested to Hyaluronic acid. This is typically seen in patients who ask about PRP injections “How long does this last?” Hyaluronic acid injections have a finite or limited beneficial effect and patients are typically told how long these types of injections will last.

There are some doctors who warn against PRP use. Doctors at the Keck School of Medicine of USC, wrote in the journal Current Reviews in Musculoskeletal Medicine, (13) December 2018, “PRP is a costly treatment not covered by insurance, and clinical trials have not demonstrated definitive efficacy, we recommend informing patients when providing PRP ‘off-label.” Like any medical treatment, PRP will not fix everything. For some patients, PRP will not work for their hip pain for various reasons, generally speaking, a condition of hip degenerative disease that is “too far gone.”

Further, doctors stress that patients be evaluated for the realistic candidacy of treatment. PRP should only be offered when there is a realistic expectation that the patient is considered a good candidate for treatment success. A multinational team of researchers also writing in the journal Current Reviews in Musculoskeletal Medicine (14) June 2019 suggested: “Although PRP is safe to use and it can be easily applied in the clinics, case-specific considerations are needed to determine whether PRP could be beneficial or not. If the use of PRP is favored, then, the configuration/optimization of the preparation and administration/delivery strategy with or without a concomitant treatment may further enhance the clinical outcomes and patients’ experience.”

We invite you to read our article The Evidence for Platelet Rich Plasma Therapy for Treating Hip Osteoarthritis for a further discussion of PRP treatments

Study: PRP showed significantly better results than hyaluronic acid groups.

A multi-national team of researchers from Israel, the United States, Italy, and Portugal published their findings in the medical journal Cartilage (15) which suggested beneficial results for PRP Platelet Rich Plasma therapy in the treatment of hip osteoarthritis. In this research 29, medical studies were evaluated. In eleven of them, a comparison was made between PRP and hyaluronic acid injections. The doctors noted that patients treated with PRP showed significantly better results than hyaluronic acid groups.

Doctors in Italy published in the American Journal of Sports Medicine (16) also evaluated the effectiveness of intra-articular platelet-rich plasma injections versus hyaluronic acid injections for hip osteoarthritis.

A total of 111 patients were randomly assigned to 3 different study groups and each received 3 weekly injections of either

  • PRP  (44 patients),
  • PRP + Hyaluronic Acid  (31 patients),
  • or Hyaluronic Acid alone(36 patients).
  • At all follow-ups, the PRP group had the lowest pain assessment scores
  • Significant improvements were achieved in reducing pain and improving quality of life and functional recovery.

“My doctor says he/she wants to give me both PRP and Hyaluronic Acid”

The idea is that while PRP rebuilds hip tissue, Hyaluronic Acid will act as a lubricant to help the PRP work better. As the research shows that did not happen.

The conclusion the doctors reached was that their results indicated that intra-articular PRP injections offer a significant clinical improvement in patients with hip osteoarthritis without relevant side effects.

The benefit was significantly more stable up to 12 months as compared with the other tested treatments. The addition of PRP + Hyaluronic Acid did not lead to a significant improvement in pain symptoms.

In another study in the medical journal Orthopedics, doctors said both PRP and Hyaluronic acid worked well for patients with hip osteoarthritis, these researchers however offered a conflicting assessment.

Intra-articular injections of platelet-rich plasma and hyaluronic acid represent effective medical treatments for osteoarthritis. This study’s goals were to compare the clinical efficacy of the platelet-rich plasma and hyaluronic acid at 12-month follow-up in hip osteoarthritis patients.

One hundred patients with chronic hip were consecutively enrolled and randomly assigned to 1 of 2 groups:

  • Group A received PRP and
  • Group B received hyaluronic acid
  • both administered via intra-articular ultrasound-guided injections.
  • Patients were evaluated at baseline and after 1, 3, 6, and 12 months
  • Despite a slightly progressive worsening between 6- and 12-month follow-ups, the final clinical scores remained higher compared with baseline with no significant differences between PRP and hyaluronic acid.

The conclusion these researchers reached was that intra-articular injections of PRP are effective in terms of functional improvement and pain reduction but are not superior to hyaluronic acid in patients with symptomatic hip osteoarthritis at 12-month follow-up. (17)

While these studies show good results, we find more effective results can be achieved by treating the whole hip joint and surrounding ligaments and tendons to stabilize hip instability. Please read our article The Evidence that Alternatives for a Hip Replacement May Work for you

The half-life of injections

One of the reasons your doctor may suggest multiple treatments is the potency of treatment. Doctors at the University Hospital Bonn write in their September 2023 paper (19): “Joints are surrounded by a joint capsule lined with a synovial membrane. The synovial membrane plays an important role by producing synovial fluid which is confined within the joint space. The synovial fluid is constantly renewed. This renewal must be taken into consideration when giving intra-articular injections because, within a short space of time, the injected substance is no longer present at an effective concentration. For example, hyaluronic acid is reported to have a half-life of around 26 hours, while the half-life for the topical application of glucocorticoids is only a few hours.”

Summary and contact us. Can we help you?

We hope you found this article informative and that it helped answer many of the questions you may have surrounding your hip problems.  If you would like to get more information specific to your challenges please email us: Get help and information from our Caring Medical staff

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References:

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This article was updated August 11, 2023

 

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