Meta-analysis| Volume 36, ISSUE 5, P1452-1464.e2, May 2020

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

Published:January 13, 2020DOI:


      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).


      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.


      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).


      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.
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        • Brooks P.M.
        The burden of musculoskeletal disease—A global perspective.
        Clin Rheumatol. 2006; 25: 778-781
        • Bennell K.L.
        • Hunter D.J.
        • Paterson K.L.
        Platelet-rich plasma for the management of hip and knee osteoarthritis.
        Curr Rheumatol Rep. 2017; 19: 24
        • Leite V.F.
        • Daud Amadera J.E.
        • Buehler A.M.
        Viscosupplementation for hip osteoarthritis: A systematic review and meta-analysis of the efficacy on pain and disability, and the occurrence of adverse events.
        Arch Phys Med Rehabil. 2018; 99: 574-583.e1
        • da Costa B.R.
        • Reichenbach S.
        • Keller N.
        • et al.
        Effectiveness of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoarthritis: A network meta-analysis.
        Lancet. 2017; 390: e21-e33
        • Pereira L.C.
        • Kerr J.
        • Jolles B.M.
        Intra-articular steroid injection for osteoarthritis of the hip prior to total hip arthroplasty: Is it safe? A systematic review.
        Bone Joint J. 2016; 98-B: 1027-1035
        • National Collaborating Centre for Chronic Conditions (UK)
        Osteoarthritis: National clinical guideline for care and management in adults.
        National Institute for Health and Clinical Excellence: guidance. Royal College of Physicians (UK), London2008
        • Conaghan P.G.
        • Dickson J.
        • Grant R.L.
        Care and management of osteoarthritis in adults: Summary of NICE guidance.
        BMJ. 2008; 336: 502-503
        • Zhang W.
        • Moskowitz R.W.
        • Nuki G.
        • et al.
        OARSI recommendations for the management of hip and knee osteoarthritis, part II: OARSI evidence-based, expert consensus guidelines.
        Osteoarthritis Cartilage. 2008; 16: 137-162
        • Lieberman J.R.
        • Engstrom S.M.
        • Solovyova O.
        • Au C.
        • Grady J.J.
        Is intra-articular hyaluronic acid effective in treating osteoarthritis of the hip joint?.
        J Arthroplasty. 2015; 30: 507-511
        • Sanchez M.
        • Guadilla J.
        • Fiz N.
        • Andia I.
        Ultrasound-guided platelet-rich plasma injections for the treatment of osteoarthritis of the hip.
        Rheumatology (Oxford). 2012; 51: 144-150
        • Battaglia M.
        • Guaraldi F.
        • Vannini F.
        • et al.
        Efficacy of ultrasound-guided intra-articular injections of platelet-rich plasma versus hyaluronic acid for hip osteoarthritis.
        Orthopedics. 2013; 36: e1501-e1508
        • Dallari D.
        • Stagni C.
        • Rani N.
        • et al.
        Ultrasound-guided injection of platelet-rich plasma and hyaluronic acid, separately and in combination, for hip osteoarthritis: A randomized controlled study.
        Am J Sports Med. 2016; 44: 664-671
        • Margules K.R.
        Fluoroscopically directed steroid instillation in the treatment of hip osteoarthritis: Safety and efficacy in 510 cases.
        Arthritis Rheum. 2001; 44 (author reply 2455-2446): 2449-2450
        • Flanagan J.
        • Casale F.F.
        • Thomas T.L.
        • Desai K.B.
        Intra-articular injection for pain relief in patients awaiting hip replacement.
        Ann R Coll Surg Engl. 1988; 70: 156-157
        • Plant M.J.
        • Borg A.A.
        • Dziedzic K.
        • Saklatvala J.
        • Dawes P.T.
        Radiographic patterns and response to corticosteroid hip injection.
        Ann Rheum Dis. 1997; 56: 476-480
        • Sparling M.
        • Malleson P.
        • Wood B.
        • Petty R.
        Radiographic followup of joints injected with triamcinolone hexacetonide for the management of childhood arthritis.
        Arthritis Rheum. 1990; 33: 821-826
        • Hutton B.
        • Salanti G.
        • Caldwell D.
        • et al.
        The PRISMA extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: Checklist and explanations.
        Ann Intern Med. 2015; 162: 777-784
        • Atchia I.
        • Kane D.
        • Reed M.R.
        • Isaacs J.D.
        • Birrell F.
        Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis.
        Ann Rheum Dis. 2011; 70: 110-116
        • Qvistgaard E.
        • Christensen R.
        • Torp-Pedersen S.
        • Bliddal H.
        Intra-articular treatment of hip osteoarthritis: A randomized trial of hyaluronic acid, corticosteroid, and isotonic saline.
        Osteoarthritis Cartilage. 2006; 14: 163-170
        • Richette P.
        • Ravaud P.
        • Conrozier T.
        • et al.
        Effect of hyaluronic acid in symptomatic hip osteoarthritis: A multicenter, randomized, placebo-controlled trial.
        Arthritis Rheum. 2009; 60: 824-830
        • Kullenberg B.
        • Runesson R.
        • Tuvhag R.
        • Olsson C.
        • Resch S.
        Intraarticular corticosteroid injection: Pain relief in osteoarthritis of the hip?.
        J Rheumatol. 2004; 31: 2265-2268
        • Lambert R.G.
        • Hutchings E.J.
        • Grace M.G.
        • Jhangri G.S.
        • Conner-Spady B.
        • Maksymowych W.P.
        Steroid injection for osteoarthritis of the hip: A randomized, double-blind, placebo-controlled trial.
        Arthritis Rheum. 2007; 56: 2278-2287
        • Migliore A.
        • Massafra U.
        • Bizzi E.
        • et al.
        Comparative, double-blind, controlled study of intra-articular hyaluronic acid (Hyalubrix) injections versus local anesthetic in osteoarthritis of the hip.
        Arthritis Res Ther. 2009; 11: R183
        • Dias S.
        • Welton N.J.
        • Caldwell D.M.
        • Ades A.E.
        Checking consistency in mixed treatment comparison meta-analysis.
        Stat Med. 2010; 29: 932-944
        • Chaimani A.
        • Higgins J.P.
        • Mavridis D.
        • Spyridonos P.
        • Salanti G.
        Graphical tools for network meta-analysis in STATA.
        PloS One. 2013; 8e76654
        • Veroniki A.A.
        • Vasiliadis H.S.
        • Higgins J.P.
        • Salanti G.
        Evaluation of inconsistency in networks of interventions.
        Int J Epidemiol. 2013; 42: 332-345
        • Salanti G.
        • Marinho V.
        • Higgins J.P.
        A case study of multiple-treatments meta-analysis demonstrates that covariates should be considered.
        J Clin Epidemiol. 2009; 62: 857-864
        • Salanti G.
        • Ades A.E.
        • Ioannidis J.P.
        Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: An overview and tutorial.
        J Clin Epidemiol. 2011; 64: 163-171
        • Higgins J.P.
        • Altman D.G.
        • Gotzsche P.C.
        • et al.
        The Cochrane Collaboration's tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343: d5928
        • Di Sante L.
        • Villani C.
        • Santilli V.
        • et al.
        Intra-articular hyaluronic acid vs platelet-rich plasma in the treatment of hip osteoarthritis.
        Med Ultrason. 2016; 18: 463-468
        • Doria C.
        • Mosele G.R.
        • Caggiari G.
        • Puddu L.
        • Ciurlia E.
        Treatment of early hip osteoarthritis: Ultrasound-guided platelet rich plasma versus hyaluronic acid injections in a randomized clinical trial.
        Joints. 2017; 5: 152-155
        • Spitzer A.I.
        • Bockow B.I.
        • Brander V.A.
        • et al.
        Hylan G-F 20 improves hip osteoarthritis: A prospective, randomized study.
        Phys Sportsmed. 2010; 38: 35-47
        • Wu B.
        • Li Y.M.
        • Liu Y.C.
        Efficacy of intra-articular hyaluronic acid injections in hip osteoarthritis: A meta-analysis of randomized controlled trials.
        Oncotarget. 2017; 8: 86865-86876
        • Jüni P.
        • Hari R.
        • Rutjes A.W.
        • et al.
        Intra-articular corticosteroid for knee osteoarthritis.
        Cochrane Database Syst Rev. 2015; : CD005328
        • He W.W.
        • Kuang M.J.
        • Zhao J.
        • et al.
        Efficacy and safety of intraarticular hyaluronic acid and corticosteroid for knee osteoarthritis: A meta-analysis.
        Int J Surg. 2017; 39: 95-103
        • Dai W.L.
        • Zhou A.G.
        • Zhang H.
        • Zhang J.
        Efficacy of platelet-rich plasma in the treatment of knee osteoarthritis: A meta-analysis of randomized controlled trials.
        Arthroscopy. 2017; 33: 659-670.e1
        • Ye Y.
        • Zhou X.
        • Mao S.
        • Zhang J.
        • Lin B.
        Platelet rich plasma versus hyaluronic acid in patients with hip osteoarthritis: A meta-analysis of randomized controlled trials.
        Int J Surg. 2018; 53: 279-287

      Linked Article

      • Editorial Commentary: Intra-articular Injection for Osteoarthritis—Is It Hip or Not?
        ArthroscopyVol. 36Issue 5
        • Preview
          Intra-articular injections are commonly used in the treatment algorithm for osteoarthritis of the hip. A number of different adjuvants can be used, such as corticosteroids, hyaluronic acid, and platelet-rich plasma, but there is no consensus regarding indications for or anticipated outcomes of each of these interventions. Recent data suggest that corticosteroids provide the best relief in the short term whereas platelet-rich plasma may be more beneficial in the mid term, but the results are variable.
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