Hyaluronic Acid and Other Conservative Treatment Options for Osteoarthritis of the Ankle


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BackgroundOsteoarthritis (OA) is a chronic, degenerative condition that affects a significant proportion of the general population. The way the condition progresses can be variable; however, there is no doubt that it has a negative impact on the quality of life of individuals due to associated pain and loss of function in the affected joint. Typically, patients present with OA in major joints such as the hip and knee, with cartilage degradation usually attributed to an underlying inflammatory process (Stott & Wells, 2016). In contrast, in patients with OA of the ankle, the cause of the disease is different. These patients tend to be younger and typically present with pain and loss of function following fracture of the ankle or lower leg. It is well recognized that in the younger population, ankle trauma due to sporting injury is a common occurrence. As a result, these patients can expect to experience pain and loss of function for a much longer period of time, which has a significant impact on their quality of lifeFrom a clinical management perspective, there are a number of treatment options available. For example, for those patients with end-stage OA, surgical treatment is available. This includes arthrodesis, ankle replacement, or osteotomy. However, this treatment is viewed as a “last resort” due to high complication rates such as delayed wound-healing, infection, delayed union, and OA of associated joints. For patients who present with symptomatic ankle OA in its early stages, interventions tend to be conservative and focus on preventing further deterioration of the joint and managing symptoms such as pain and stiffness. Currently, conservative management interventions include the use of nonpharmacological and pharmacological treatments. Nonpharmacological interventions include providing education on the value of weight reduction, physiotherapy, and occupational therapy such as shoe adjustment, which use inlays to offload the joint, thus resulting in reduced pain. Generally, these interventions are supplemented with the use of analgesics such as acetaminophen, opioids, and nonsteroidal anti-inflammatory drugs. In the clinical environment, when simple analgesics are unsuccessful, the use of hyaluronic acid (HA) can be used as a means of reducing pain in those patients with ankle OA. Hyaluronic acid is a natural component of synovial fluid, and injections help lubricate the joint and act as a shock absorber for joint loads.There is no doubt that OA has a significant biopsychosocial impact on those patients with ankle OA, and nurses are well placed to deliver evidence-based treatment strategies aimed at improving their quality of life. The problem is, however, that despite having a number of interventions available, unlike OA of the hip and knee, which have clear evidence-based treatment guidelines, there is no evidence-based treatment guidelines for ankle OA (Witteveen, Hofstad, & Kerkhoffs, 2015).ObjectiveThe purpose of this systematic review was to assess the benefits and harms of any conservative treatment of ankle OA in adults in order to provide a synthesis of the evidence as a base for future treatment guidelines.Intervention/MethodsThe researchers undertook a comprehensive search of the literature up to September 2014 to identify randomized controlled trials (RCTs) and controlled clinical trials that investigated the efficacy of nonsurgical treatment for adults (older than 18 years) with a diagnosis of symptomatic ankle OA. Specifically, the researchers were seeking to assess the effect of the intervention on outcome measures such as pain, safety, physical function, and quality of life. Despite a comprehensive search of relevant databases, the only evidence eligible for inclusion in this review were six RCTs that investigated the efficacy of the use of HA.

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