Is intra-articular hyaluronic acid effective in treating osteoarthritis of the hip joint?

Viscosupplementation Is Effective for the Treatment of Osteoarthritis in the Hip: A Systematic Review

PURPOSE

To assess the efficacy of intra-articular viscosupplementation as a therapeutic intervention for hip osteoarthritis (OA), as well as to assess the duration of efficacy, effect of dose, composition and number of injections of the viscosupplement, and the incidence of adverse effects.

METHODS

We performed a systematic review using the literature search from the following databases: Embase, Medline, PubMed, Web of Science, and Scopus. Quality assessment of the included studies was performed using the Modified Newcastle-Ottawa Quality Assessment Scale. Random-effects meta-analysis and mixed-effects subgroup analysis were carried out, but due to the high heterogeneity, low level of evidence, and high risk of bias of the included studies after analyzing the data, weighted means and pooled estimates have not been provided. Instead, we have provided a subjective synthesis of the results.

RESULTS

Forty studies were included in the analysis from an initial search of 3,265 studies, with data from a total of 3,350 patients. The level of available evidence was low with an overall high risk of bias. Nearly all studies showed a reduction in mean pain at 1 month, 3 months, and 6 months of follow-up, as well as at the end point, and an improvement in mean patient-reported function was also seen at these time points. However, heterogeneity was extremely high at all time points and remained despite attempts at removing outliers. Subgroup analyses looking at the effects of dose, volume, composition of viscosupplement, and number of injections were carried out, but substantial heterogeneity still remained. There were no lasting adverse effects.

CONCLUSIONS

Weak evidence suggests that viscosupplementation improves patient-reported pain and function at end point 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.

LEVEL OF EVIDENCE

Level IV, systematic review of level I to IV studies.

Risk of Infection After Total Knee or Hip Arthroplasty After Receipt of Multiple Corticosteroid or Hyaluronic Acid Injections

BACKGROUND

Few studies have assessed the relationship between the quantity of preoperative corticosteroid injections (CSIs) or hyaluronic acid injections (HAIs) and postoperative infection risk after total knee or hip arthroplasty (TKA, THA). We aimed to (1) determine whether the number of injections administered before TKA/THA procedures is associated with postoperative infections and (2) establish whether infection risk varies by injection type.

METHODS

This retrospective cohort study included 230,487 THAs and 371,511 TKAs from the 2017 to 2018 Medicare Limited Data Set. The quantity of CSI or HAI, defined as receiving either CSI or HAI ≤2 years before TKA/THA, was identified and categorized as 0, 1, 2, or >2. The primary outcome was 90-day postoperative infection. Multivariable regression models measured the association between the number of injections and 90-day postoperative infection. Odds ratios and 95% confidence intervals were reported.

RESULTS

The percentage of THA patients receiving 1, 2, and >2 preoperative CSIs was 6.1%, 1.6%, and 0.8%, respectively. Receiving >2 CSIs within 2 years before THA was associated with higher odds of 90-day postoperative infection (odds ratios = 1.74, 95% CI = 1.11 to 2.74, P = 0.02). The percentage of TKA patients receiving 1, 2, and >2 CSIs was 3.0%, 1.2%, and 1.1%, respectively. For HAIs in TKA patients, percentage receiving injections was 98.3%, 0.6%, 0.2%, and 0.9%, respectively. Quantity of CSIs or HAIs administered was not associated with postoperative infection among TKA patients.

CONCLUSION

Patients receiving >2 injections before THA had higher odds of 90-day postoperative infection. This finding was not observed in TKA patients. These results suggest that the use of >2 injections within 2 years of THA should be avoided.

The value of injectable viscoelastic supplements for joints

Intra-articular viscoelastic supplements are commonly administered by musculoskeletal radiologists for the treatment of symptomatic osteoarthritis (OA). This article provides an overview of the putative mechanism of action of the agents, a brief review of the evidence base underlying the practice, a commentary on some of the major society guidelines regarding the treatment, and a description of the adverse events that are associated with intra-articular hyaluronic acid administration.

Radiologically Guided Versus Blinded Intra-articular Injection in Patients With Hip Osteoarthritis: A Retrospective Comparative Study

Objectives:

The aim of this study was to present the clinical results of patients with Kellgren-Lawrence (KL) stage 2-4 hip osteoarthritis who were administered intra-articular corticosteroid (CS) or hyaluronic acid (HA), with or without fluoroscopy.

Methods:

This retrospective comparative study was conducted in the clinics where the authors worked between 2010 and 2018. Patients with stage 2-4 hip osteoarthritis according to KL criteria were included in the study. Age, body mass index, American Society of Anesthesiologists stages, and Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores (3rd, 6th, and 12th months) were recorded. Two groups were created as patients who underwent injection with or without fluoroscopy guidance. In group 1, CS (triamnisolone) was administered, and in group 2, sodium hyaluronate 88 mg/4 mL was administered. Obtained parameters were compared.

Results:

The WOMAC scores at 3 months of both the CS and HA groups were statistically significantly better than before the application, with the improvement in the CS group found to be significantly better than in the HA group (P = .047). At 6 months, the mean WOMAC scores of the CS and HA groups were better than prior to the application, and there was a statistically significant difference (P < .001). No significant difference was found in either the CS or HA group in the comparison of 12-month WOMAC scores with the baseline scores (P = .744 and P = .054).

Conclusion:

In symptomatic hip OA patients, intra-articular administration of CS and HA was seen to be effective at 3 and 6 months after administration. However, the effectiveness was determined to have disappeared within 1 year. Furthermore, in hip OA intra-articular drug applications, it was determined that the blinded technique without radiological guidance performed in the outpatient clinic is as effective and safe as the radiologically guided technique administered in the operating room.

Intra-Articular Hyaluronic Acid Injections Less Than 6 Months Before Total Hip Arthroplasty: Is It Safe? A Retrospective Cohort Study in 565 Patients

BACKGROUND

Intra-articular hyaluronic acid (IAHA) can be injected into an osteoarthritic hip joint to reduce pain and to improve functionality. Several studies report IAHA to be safe, with minor adverse effects that normally disappear spontaneously within a week. However, intra-articular corticosteroids prior to total hip arthroplasty (THA) have been associated with increased infection rates. This association has never been investigated for IAHA and THA. We aimed to assess the influence of IAHA on the outcome of THA, with an emphasis on periprosthetic joint infection (PJI).

METHODS

At a mean follow-up of 52 months (±18), we compared complication rates, including superficial and deep PJIs, of THA in patients who received an IAHA injection ≤6 months prior to surgery (injection group) with that of patients undergoing THA without any previous injection in the ipsilateral hip (control group). One hundred thirteen patients (118 hips) could be retrospectively included in the injection group, and 452 patients (495 hips) in the control group.

RESULTS

No differences in baseline characteristics nor risk factors for PJI between the 2 groups were found. The clinical outcomes in terms of VAS pain scores (1.4 vs 1.7 points, P = .11), modified Harris Hip Scores (77 vs 75 points, P = .09), and Hip disability and Osteoarthritis Outcome Scores (79 vs 76 points, P = .24) did not differ between the injection group and the control group. Also, complications in terms of persistent wound leakage (0% vs 1.2%, P = .60), thromboembolic events (0% vs 0.6%, P = 1.00), periprosthetic fractures (1.7% vs 1.2%, P = .65), and dislocations (0% vs 0.4%, P = 1.00) did not differ. However, in the injection group there was a higher rate of PJIs (4% vs 0%, P < .001) and postoperative wound infections (9% vs 3%, P = .01), compared to the control group.

CONCLUSION

Our findings suggest that IAHA performed 6 months or less prior to THA may pose a risk for increased rates of PJI. We recommend refraining from performing THA within 6 months after IAHA administration.

Efficacy and safety of viscosupplementation with hyaluronic acid for hip osteoarthritis: results from a cross-sectional study with a minimum follow-up of 4 years

Background and aim of the work:

Osteoarthritis is the most common cause of disability in elderly. Hip osteoarthritis is the second most frequent form affecting a large joint and the social and economic impact on society of its related disability is expected to increase. The purpose of this study was to verify the efficacy and safety of ultrasound-guided viscosupplementation with high weight hyaluronic acid in hip osteoarthritis.

Methods:

183 patients with painful hip OA (Kellgren-Lawrence 1-2-3) were treated from January 2014 to December 2016 with viscosupplementation. Patients were evaluated before injection (T0) and after 1,2,3,4 (T1-T2-T3-T4) years through the VAS scale and Harris Hip Score (HHS). Patients who underwent to subsequent injections were followed and assessed. Subjects who underwent prosthesis were analyzed for a minimum of 6 months in order to detect any early postoperative complication.

Results:

The mean improvement of HHS and VAS between T0 and T1 was statistically significant. Patients who underwent subsequent injections showed a higher improvement even if statistical significance was not observed. Results showed that patients with grade 2 of osteoarthritis had the higher change in the scores. No adverse effects were registered. No early complications were reported in those patients who needed prosthesis.

Discussion and Conclusions:

Results observed confirm that ultrasound-guided viscosupplementation with high weight hyaluronic acid could be a possibility in the treatment of hip osteoarthritis, especially in patients with Kellgren-Lawrence grade 2 of disease. Subsequent injections are not characterized by similar positive effects. Outcomes of prosthetic surgery are not influenced by viscosupplementation.

Viscosupplementation for hip osteoarthritis: Does systematic review of patient-reported outcome measures support use?

INTRODUCTION

Osteoarthritis of the hip is one of the leading causes of disability worldwide. There is lack of agreement among providers and governing agencies regarding the efficacy of hyaluronic acid (HA) for the management of hip osteoarthritis (OA). Therefore, the purpose of this systematic review was to determine how HA administration impacts 1) patient reported outcome measures (PROMs) and 2) rates of conversion to THA.

METHODS

The PubMed, EBSCO host, and Google Scholar electronic databases were queried for all studies published between January 1st, 2000 and January 1st, 2020 that reported on outcomes following HA administration for treatment of hip OA. The following keywords were implemented with AND and OR Boolean operators: "hip"; "osteoarthritis"; "arthritis"; "viscosupplementation"; "hyaluronic acid." Our final analysis included 39 studies and reported on a total of 5,864 patients receiving injections of HA.

RESULTS

All studies reporting on visual analog scale (VAS), patient global assessment, and total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores demonstrated improvements following HA administration. For the Lequesne Index (LI), WOMAC pain, WOMAC function, and Harris Hip Score (HHS) values, a majority of studies reported that HA would prove beneficial, with one analysis suggesting a lack of improvement. There was inconsistent evidence across studies regarding the effectiveness of HA compared to other intra-articular injections. The formulation of the administered viscosupplementation did not appear to influence outcomes. Furthermore, rates of conversion to THA were relatively low when evaluating 1- to 4-year follow-up intervals.

DISCUSSION

Non-comparative studies consistently demonstrated that HA can achieve satisfactory pain reduction and functional improvement. However, there was not enough evidence in the current literature regarding whether HA is superior to placebo or other types of intra-articular injections. Future studies should continue to compare HA to other treatment modalities in randomized controlled trials with larger sample sizes.

Increased Use of Intra-Articular Steroid Injection to Treat Osteoarthritis is Associated With Chronic Opioid Dependence After Later Total Knee Arthroplasty But Not Total Hip Arthroplasty

BACKGROUND

Intra-articular (IA) injections of corticosteroid (CO) and hyaluronic acid (HA) are commonly used for osteoarthritis. The efficacy of these interventions is controversial. Furthermore, research regarding the potential association of IA injection with later postoperative pain trajectories is lacking.

METHODS

We performed analysis on Truven Health MarketScan database (2012-2016) in total hip arthroplasty (THA) and total knee arthroplasty (TKA). Trends over time were assessed. Multivariable logistic regression analyses were executed to evaluate the impact of IA injections on postoperative chronic opioid use.

RESULTS

Preoperative CO and HA injections decreased throughout the study period in both THA and TKA. Preoperative CO and HA injections, regardless of frequency, had no significant impact on the odds of THA patients becoming chronic opioid users postoperatively. TKA patients who had 1 CO injection in the year before surgery experienced lower odds of postoperative chronic opioid use (odds ratio [OR], 0.89; 95% confidence interval [95% CI], 0.82-0.97), whereas patients who had 2 or more CO injections experienced significantly greater odds (OR, 1.14; 95% CI, 1.04-1.24). TKA patients who received 2 or more HA injections before surgery had significantly lower odds of chronic opioid use (OR, 0.90; 95% CI, 0.81-0.99).

CONCLUSION

The utilization of IA injections in patients with hip and knee osteoarthritis appears to be decreasing over time. TKA patients who received 2 or more preoperative CO injections experienced greater odds of chronic opioid utilization, whereas TKA patients with 2 or more HA injections in the year before surgery had decreased odds of chronic opioid use.

Different Intra-articular Injections as Therapy for Hip Osteoarthritis: A Systematic Review and Network Meta-analysis

PURPOSE

This systematic review and network meta-analysis aimed to compare the clinical outcomes between 4 intra-articular injections (platelet-rich plasma [PRP], hyaluronic acid [HA], corticosteroid [CS], and HA plus PRP) for hip osteoarthritis (OA).

METHODS

We performed a systematic literature search in PubMed, Embase, Web of Science, and the Cochrane database through April 2018 to identify any randomized controlled trials that evaluated the clinical efficacy of HA, PRP, CS, HA-plus-PRP, and control treatments for hip OA. Baseline information-country, mean age, number of patients, and Kellgren-Lawrence grade of hip OA in the treatment and control groups-was collected. The primary outcome was the visual analog scale (VAS) score at 1, 3, 6, and 12 months after injection.

RESULTS

We included 11 randomized controlled trials with a total of 1,060 patients. The Kellgren-Lawrence grades of the treatment and control groups were similar in individual studies. The pair-wise meta-analysis indicated that CS and HA were superior to the control group in reducing the VAS score at 1 month and 3 months (P < .05) and that CS was superior to HA in reducing the VAS score at 1 month (P < .05). The network meta-analysis results indicated that HA and CS exhibited a beneficial role in reducing the VAS score at 1 month. CS achieved the lowest value for the surface under the cumulative ranking curve (SUCRA) for the VAS score at 1 month (0.23), and the SUCRA values of the 5 interventions showed that PRP achieved the lowest SUCRA value for the VAS score at 6 months (0.53).

CONCLUSIONS

CS injections are recommended as the most efficient agent in hip OA patients in the short term. Moreover, PRP is reported to have the highest rank for pain relief for up to 6 months. Considering the limitations of this meta-analysis, future direct comparisons with more samples are needed.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II studies.

Intra-Articular Viscosupplementation for Patients with Hip Osteoarthritis: A Meta-Analysis and Systematic Review

BACKGROUND The aim of this study was to review the efficacy and safety of intra-articular (IA) viscosupplementation (VS) for hip osteoarthritis (OA). MATERIAL AND METHODS We searched Medline, Clinical Trial Register Center, EMBASE, and Cochrane databases for randomized controlled trials (RCTs) comparing VS with placebo injection for hip OA. We included suitable studies, assessed the quality of studies, and extracted data on pain reduction, function improvement at different time points, and safety profiles. The comparisons of pain and function outcome were performed by meta-analysis. RESULTS Five high-quality randomized controlled studies trials (RCTs) with 591 patients with hip OA were identified. Although several trials demonstrated a significant decline in pain in VS groups during follow-up compared to baseline, without severe adverse events, the pooled analysis did not show VS was superior to placebo at any time windows [7-14 days: standardized mean difference (SMD): -0.18; 95% CI, -0.47 to 0.10, p=0.21; 28-30 days: 0.02 (-0.15, 0.19), p=0.82; or at final visit: -0.14 (-0.46, 0.18), p=0.38]. Similar results were also observed in the combined data of functional results. CONCLUSIONS IA VS does not reduce pain or improve function significantly better than placebo in a short-term follow-up. The benefits and safety of VS should be further assessed by sufficiently-sized, methodologically sound studies with validated assessment of more clinically relevant end-points.

Corticosteroids and Hyaluronic Acid Injections

Osteoarthritis is a common condition that affects many individuals resulting in pain, reduced mobility, and decreased function. Corticosteroids have been a mainstay of osteoarthritis treatment. Studies have shown that they provide short-term pain improvement and can be used for osteoarthritis flares. Hyaluronic acid injections have extensively been studied in knee osteoarthritis but to a lesser degree in other joints. Despite some debate between societies, a large number of recent studies have shown hyaluronic acid to be a viable treatment option showing longer-term improvement in both pain and function.

PPAR-δ Agonist With Mesenchymal Stem Cells Induces Type II Collagen-Producing Chondrocytes in Human Arthritic Synovial Fluid

Osteoarthritis (OA) is an inflammatory joint disease characterized by degeneration of articular cartilage within synovial joints. An estimated 27 million Americans suffer from OA, and the population is expected to reach 67 million in the United States by 2030. Thus, it is urgent to find an effective treatment for OA. Traditional OA treatments have no disease-modifying effect, while regenerative OA therapies such as autologous chondrocyte implantation show some promise. Nonetheless, current regenerative therapies do not overcome synovial inflammation that suppresses the differentiation of mesenchymal stem cells (MSCs) to chondrocytes and the expression of type II collagen, the major constituent of functional cartilage. We discovered a synergistic combination that overcame synovial inflammation to form type II collagen-producing chondrocytes. The combination consists of peroxisome proliferator–activated receptor (PPAR) δ agonist, human bone marrow (hBM)-derived MSCs, and hyaluronic acid (HA) gel. Interestingly, those individual components showed their own strong enhancing effects on chondrogenesis. GW0742, a PPAR-δ agonist, greatly enhanced MSC chondrogenesis and the expression of type II collagen and glycosaminoglycan (GAG) in hBM-MSC-derived chondrocytes. GW0742 also increased the expression of transforming growth factor β that enhances chondrogenesis and suppresses cartilage fibrillation, ossification, and inflammation. HA gel also increased MSC chondrogenesis and GAG production. However, neither GW0742 nor HA gel could enhance the formation of type II collagen-producing chondrocytes from hBM-MSCs within human OA synovial fluid. Our data demonstrated that the combination of hBM-MSCs, PPAR-δ agonist, and HA gel significantly enhanced the formation of type II collagen-producing chondrocytes within OA synovial fluid from 3 different donors. In other words, the novel combination of PPAR-δ agonist, hBM-MSCs, and HA gel can overcome synovial inflammation to form type II collagen cartilage within human OA synovial fluid. This novel articularly injectable formula could improve OA treatment in the future clinical application.

Efficacy of a single intra-articular injection of ultra-high molecular weight hyaluronic acid for hip osteoarthritis: a randomized controlled study

BACKGROUND

Viscosupplementation with hyaluronic acid (HA) is increasingly used for the treatment of hip osteoarthritis (OA). The purpose of this study was to compare the efficacy of intra-articular injections of an ultra-high molecular weight viscosupplement (UHMW-HA, Fermathron S) with a medium molecular weight hyaluronan (MMW-HA, Hyalubrix 60) in hip OA.

METHODS

Fifty-four patients with hip OA grade 3 on the Kellgren/Lawrence scale were randomized. All infiltrations were performed under ultrasound guidance. Evaluation was performed preoperatively and at 1, 3, 6 and 12 months after infiltration. Patients were clinically evaluated using Lequesne index, VAS and WOMAC score.

RESULTS

Fifty patients, including 27 in the MMW-HA group and 23 in the UHMW-HA group, completed the follow-up. No significant difference was found between the two groups in terms of VAS, WOMAC or Lequesne index preoperatively or at 1, 3, 6 and 12 months after viscosupplementation. A stratified analysis was performed to study the development over time of Lequesne index of patients aged ≤ 55 years, > 55 and, ≤ 70 years and > 70 years and Lequesne index was different between the three age-stratified subgroups only in the MMW-HA group. The subgroup of older patients showed a higher Lequesne index than the subgroups of younger patients (p < 0.05).

CONCLUSIONS

UHMW-HA is a safe and effective treatment for hip osteoarthritis. A single dose of UHMW-HA was as effective as two doses of MMW-HA resulting in similar reductions of pain and disability.

STUDY DESIGN

Multicenter, independent, prospective, randomized controlled trial with level of evidence 1.

Hip Pain and Mobility Deficits-Hip Osteoarthritis: Revision 2017

The Orthopaedic Section of the American Physical Therapy Association (APTA) has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). The purpose of these revised clinical practice guidelines is to review recent peer-reviewed literature and make recommendations related to hip pain and mobility deficits. J Orthop Sports Phys Ther. 2017;47(6):A1-A37. doi:10.2519/jospt.2017.0301.

No Effects of Early Viscosupplementation After Arthroscopic Partial Meniscectomy: A Randomized Controlled Trial

BACKGROUND

The management of the postoperative period after knee arthroscopic surgery may be challenging because surgical trauma deeply alters the joint microenvironment, causing the release of several catabolic molecules and proinflammatory factors that might slow down functional recovery. The possibility of using hyaluronic acid (HA) to promote postoperative pain relief and expedite functional improvement seems attractive, considering its biological properties.

PURPOSE

The aim of the present double-blind randomized controlled trial was to evaluate the effects, in terms of pain control and functional recovery, provided by a single HA injection performed at the end of arthroscopic meniscectomy.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

A total of 90 patients, 18 to 55 years old, were included according to the following criteria: (1) chronic, symptomatic meniscal tears requiring partial resection; (2) a healthy contralateral knee; (3) no previous surgery on the index knee; and (4) no other concurrent articular lesions requiring surgical treatment (eg, cartilage or ligament injuries). Patients were randomized into 2 treatment groups: one underwent meniscectomy alone, whereas the other also received an injection of 3 mL HA at the end of the procedure. All patients were evaluated at baseline and then at 15, 30, 60, and 180 days using the following tools: International Knee Documentation Committee (IKDC) subjective, Knee injury and Osteoarthritis Outcome Score (KOOS), visual analog scale (VAS) for pain, VAS for general health status, and Tegner scores. The transpatellar circumference and active and passive ranges of motion were also recorded during the follow-up evaluations.

RESULTS

No major adverse events were reported using HA postoperatively. A statistically significant increase in all the clinical scores was reported in both treatment groups, but no significant intergroup difference was documented at any follow-up evaluation. No difference was observed also in the objective measurements. The mean time to return to full sports activity was not different between groups, and a comparable satisfaction rate was recorded in both treatment groups.

CONCLUSION

Early postoperative viscosupplementation did not provide significant clinical benefits after arthroscopic meniscectomy. Despite the lack of major adverse events, the administration of a single HA injection at the end of the surgical procedure is not a successful strategy to provide either faster functional recovery or symptomatic improvement after meniscectomy.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02629380.

Hip Osteoarthritis: Etiopathogenesis and Implications for Management

Highly prevalent among the elderly, hip osteoarthritis (OA) carries a heavy burden of disease. Guidelines for the management of hip OA are often extrapolated from knee OA research, despite clear differences in the etiopathogenesis and response to treatments of OA at these sites. We propose that hip OA requires specific attention separate from other OA phenotypes. Our understanding of the etiopathogenesis of hip OA has seen significant advance over the last 15 years, since Ganz and colleagues proposed femoroacetabular impingement (FAI) as an important etiological factor. This narrative review summarizes the current understanding of the etiopathogenesis of hip OA and identifies areas requiring further research. Therapeutic approaches for hip OA are considered in light of the condition’s etiopathogenesis. The evidence for currently adopted management strategies is considered, especially those approaches that may have disease-modifying potential. We propose that shifting the focus of hip OA research and public health intervention to primary prevention and early detection may greatly improve the current management paradigm.

Evaluation and Management of Hip and Pelvis Injuries

Injuries to the hip and pelvis among runners can be among the most challenging to treat. Advances in the understanding of running biomechanics as it pertains to the lumbopelvic and hip regions have improved the management of these conditions. Conservative management with an emphasis on activity modification and neuromuscular exercises should comprise the initial plan of care, with injection therapies used in a supportive manner.

Intra-articular Hyaluronic Acid in Treating Knee Osteoarthritis: a PRISMA-Compliant Systematic Review of Overlapping Meta-analysis

Numerous meta-analyses have been conducted aiming to compare hyaluronic acid (HA) and placebo in treating knee osteoarthritis (OA). Nevertheless, the conclusions of these meta-analyses are not in consistency. The purpose of the present study was to perform a systematic review of overlapping meta-analyses investigating the efficacy and safety of HA for Knee OA and to provide treatment recommendations through the best evidence. A systematic review was conducted based on the PRISMA guidelines. The meta-analyses and/or systematic reviews that compared HA and placebo for knee OA were identified. AMSTAR instrument was used to evaluate the methodological quality of individual study. The information of heterogeneity within each variable was fetched for the individual studies. Which meta-analyses can provide best evidence was determined according to Jadad algorithm. Twelve meta-analyses met the eligibility requirements. The Jadad decision making tool suggests that the highest quality review should be selected. As a result, a high-quality Cochrane review was included. The present systematic review of overlapping meta-analyses demonstrates that HA is an effective intervention in treating knee OA without increased risk of adverse events. Therefore, the present conclusions may help decision makers interpret and choose among discordant meta-analyses.