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Patients Satisfaction following Intra articular Knee Injection of Hylan G-F 20 (Synvisc) for Osteoarthritis


*Department of Orthopaedic Surgery Royal Blackburn Hospital

Address for Correspondence

  Syed HAQUE
98 Humberstone Road
Luton LU4 9SS
United Kingdom
Tel: 0044-7799541732


Background: Osteoarthritis (OA) is the most prevalent chronic joint disorder worldwide and is associated with significant pain and disability. We looked into the therapeutic efficacy and safety of intra-articular injection of hyluronic acid for management of osteoarthritis of knee.

Method: Questionnaire was sent to patients retrospectively and their pain score was assessed along with improvement in mobility and reduction in their analgesic use following the injection.

Result: The treatment was well tolerated overall. Majority of patients benefited from the injection. Pain relief was best appreciated at the end of six weeks and in most of the patients the effect weaned off at six month.

Conclusion: Intra-articular HA or hylan has proven to be an effective, safe, and tolerable treatment for symptomatic knee OA.

J.Orthopaedics 2011;8(3)e1


Synvisc; Hyluronic acid; Osteoarthritis; Intra articular.


Osteoarthritis (OA) is the most prevalent chronic joint disorder worldwide and is associated with significant pain and disability.(1) It is a chronic degenerative disease of synovial joints that is characterized by the deterioration of hyaluronan and other constituents of hyaline cartilage, resulting in intermittent pain, swelling, inflammation and varying degrees of functional loss.(2). There are several options for treating osteoarthritis of the knee, including simple analgesics, nonsteroidal anti-inflammatory drugs, intra-articular injection of glucocorticoids, exercise, physiotherapy, weight-relieving braces, and knee arthroplasty.

Hyaluronan is critical for the homeostasis of the joint as an organ, in part, because it provides the rheological properties (viscosity and elasticity) of the synovial fluid. These properties depend upon both the concentration and the molecular weight of the hyaluronan in the synovial fluid. In osteoarthritis, the hyaluronan is both smaller in size and lower in concentration. Thus, it is rational and physiologically meaningful to treat osteoarthritis with viscosupplementation, i.e. injection of material designed to increase the rheological properties of the synovial fluid. (3)
In addition, it has been found that injected hyaluronic acid can augment the flow of synovial fluid, normalize the synthesis and inhibit the degradation of endogenous hyaluronic acid, and relieve joint pain. Studies have demonstrated that the anti-inflammatory, anabolic, and chondroprotective actions of hyaluronic acid reduce pain and improve patient function (4)
There are studies that have evaluated the efficacy and safety of hylan G-F 20 in patients with knee osteoarthritis. We looked into how patients responded to treatment as far as pain management, decreased analgesic use and better mobility is concerned in our DGH.

Material and Methods :

The study was conducted retrospectively.
In our study we included patients who had 3 doses of intra-articular synvisc injection in knee from January 2007 to January 2008.  These patients were seen in our knee clinic for the first time and were diagnosed clinically to be having osteoarthritis which was confirmed by  radiograph..

The inclusion criterion was:

  1. Mild to moderate OA not responding to traditional pharmacological and non- pharmacological treatment.
  2. Patients who are intolerant to traditional treatment due to gastrointestinal problems related to anti-inflammatory treatment.
  3. Severe OA when any surgical intervention is not contemplated due to associated medical problem.

Patients with hypersensitive to hyluronate preparations and allergy to feathers, egg, poultry and avian proteins, patients with large effusion of joints or patients with any suspicion of infection in or around the joint were excluded from this study.
Hylan G-F 20 (Synvisc) was administered in accordance with the manufacturer's recommendations as a course of three weekly injections. This was given in a sterile environment of operation theatre. Each injection was given with use of the manufacturer's prefilled 2-ml syringe, which contained 16 mg of hydrated gel in buffered physiologic sodium chloride solution of pH 7.2.

A questionnaire was send by post to these patients in July 2008 with a request for completing and returning the questionnaire in the enclosed envelope.

Visual Analog pain score was used to assess pain relief following Hylan G-F 20 (synvisc) injection. Patients were asked to score there pain before injection, 1 week following injection,  6 weeks following injection and 6 months following injection respectively.
The questions were related to 3 main issues- pain, reduction in analgesic use and mobility.

Results :

A total of 60 questionnaires were sent to 57 patients. 3 had both there knees injected at different settings.

A total of 40 patients replied (response rate 66%). The response is tabulated.
Pain Relief following Synvisc Injection


                                                                                        __ָ __   A
                                                 ____ָ ____     B
                           ____ָ ___   C
                                                ____ָ ____  D

Graph A before injection
Graph B 1 week after injection
Graph C 6 weeks after injection
Graph D 6 months after injection

               1        2        3        4        5        6        7        8        9       10
                                                                   VAS Score
      Comparision of visual analog pain score in patients having synvisc injection


Mean VAS

Standard Deviation (S.D)

95% Confidence interval for the mean




+/- 0.51




+/- 0.81




+/- 0.85




+/- 0.95

Analgesic Use

Of the 40 participants 16 patients reduced the amount of analgesic that they were taking before the injection.


Of the 40 participants 18 had better mobility after the injections.

Discussion :

Hyaluronic acid has been the subject of interest for centuries i.e from the time of Paracelsius who compared joint fluid with eggwhite to Virchow who isolated it from the vitreous humour. It was Mayer who coined the term hyaluronic acid in the 1930's. The first medical use of hyaluronic acid was as a vitreous replacement in ophthalmology. In the late 1960's animal studies were carried out for its use in osteoarthritis (4) following joint injuries in horses. Human trials in the joint have shown its beneficial effects and it has been in clinical use since 1987 when it was first used in Japan and Italy (5). The term Viscosupplementation was proposed in 1993(6)
The most common symptom with which patient with osteoarthritis of knee presents to a clinician is pain. As pain is the main concern for patients suffering from this disease we did this study to see how patients response to Hylan G-F 20 (synvisc) injection. As patient starts getting pain his mobility decreases. Along with this most of them start taking pain killers. We also looked into these two factors in our study.

From our survey we found out that most of the patients do well with synvisc injection. The response to Hylan G-F 20 (synvisc) injection starts appearing 1 week after injection and peaks at 6 weeks.The mean visual analog score came down from 8.4 before the start of therapy to to 5.1six  weeks after surgery.   In mean  pain was score again increased to 7.1 6 months following surgery.

Majority of patients were very satisfied with the treatment.Half of them were happy to have further doses of injection.

Small number of patients did not get any benefit from this injection.  As with previous studies (7) we are not sure about the factors predictive of a good response to Hylan GF-20. However all of our non-responders were patients who had high VAS  before the therapy started.

Hylan G-F20 has been reported to be well tolerated in the management of chronic idiopathic OA. (8). Our study also reconfirms this fact as none of the patients had any adverse effect.

Cost is a major  factor in more  widespread use of these  injections. Taking into account  the falling
prices and the long-term benefit in the form of postponing or doing away with the need for surgery, the viability of these injections cannot be denied. We believe that viscosupplementation is a useful mode of treatment in the spectrum of arthritis treatment from NSAIDs to total arthroplasty.

In conclusion Hylan G-F 20 (Synvisc) is a good treatment for primary osteoarthritis of knee for a short period of time. It relieves the pain, and with relief of pain there is better mobility and reduced analgesic intake. There was no adverse reaction to this treatment in our study and most of the patients were very pleased with the outcome.In an effort to limit cardiovascular, gastrointestinal, and renal safety concerns with COX-2 selective and nonselective NSAIDs and maximize HA efficacy, the authors proposed using HA earlier in the treatment paradigm for knee OA and also as part of a comprehensive treatment strategy. (9)

Patient’s Perception of Intra-articular (Knee) Hylan G-F 20 (Synvisc) injection

(1) Grade your pain before injection (Please circle your response)
      Minimum 0   1  2   3   4   5   6   7   8   9   10 worse
(2) Grade your pain 1 week after injection
      Minimum 0   1   2   3   4   5   6   7   8   9   10 worse
(3) Grade your pain 6 weeks after injection
      Minimum 0   1  2   3   4   5   6   7   8   9   10 worse
(4) Grade your pain 6 month after injection
     Minimum 0   1  2   3   4   5   6   7   8   9   10 worse
(5) Would you have liked to have a repeat course of therapy after 6 months?
     Yes        22/40                                                      No 18/40
(6) Do you think that it improved your mobility for some time?
      Yes       21/40                                                      No 19/40
(7) Did it helped in reducing your medications (pain killers) for some time?
     Yes        16/40                                                     No   24/40
(8) Was there any adverse reaction following injection?
      Yes       0/40                                                        No 40/40 

  Reference :

(1) Nicholas Bellamy1, Jane Campbell2, Vivian Welch3, Travis L Gee4, Robert Bourne2, George A Wells5  Viscosupplementation for the treatment of osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005321
(2) Stitik, Todd P; Kazi, Asad; Kim, Jong-Hyun Future Rheumatology, Volume 3, Number 3, June 2008 , pp. 215-222(8)
(3) Adams ME, Lussier AJ, Peyron JG ; A risk-benefit assessment of injections of hyaluronan and its derivatives in the treatment of osteoarthritis of the knee ; Drug Safety 2000-08 Volume: 23 Issue: 2 Pages: 115-30
(4) Strauss EJ. Hart JA. Miller MD. Altman RD. Rosen JE ; Hyaluronic acid viscosupplementation and osteoarthritis: current uses and future directions ; American Journal of Sports Medicine. 37(8):1636-44, 2009 Aug
(5)Rydell NW, Butler J, Balazs EA. Effect of intraarticular injection of hyaluronic acid on the clinical symptoms of arthritis in track horses. Acta Vet Scand 1970; 11:139-55  
(6)Marshall KW. Viscosupplementation for osteoarthritis: current status, unresolved issues and future directions. J Rheumatol 1998;25: 2056-8
(7) Balazs EA, Denlinger JL. Viscosupplementation: a new concept in the treatment of osteoarthritis. J Rheumatol 1993;20:3-9 
(8) Conrozier T. Mathieu P. Schott AM. Laurent I. Hajri T. Crozes P. Grand P. Laurent H. Marchand F. Meignan F. Noel E. Rozand Y. Savoye JF. Vignon E ; Factors predicting long-term efficacy of Hylan GF-20 viscosupplementation in knee osteoarthritis ; Joint, Bone, Spine: Revue du Rhumatisme. 70(2):128-33, 2003 Mar

(9) Wobig M. Dickhut A. Maier R. Vetter G ; Viscosupplementation with hylan G-F 20: a 26-week controlled trial of efficacy and safety in the osteoarthritic knee ; Clinical Therapeutics. 20(3):410-23, 1998 May-Jun


This is a peer reviewed paper 

Please cite as : Syed HAQUE,Patients Satisfaction following Intra articular Knee Injection of Hylan G-F 20 (Synvisc) for Osteoarthriti

J.Orthopaedics 2011;8(3)e1




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