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Family Medicine

Training Level

Resident PGY 3


Henry Ford Macomb


Background: Osteoarthritis (OA) is one of the most common forms of arthritis affecting a significant population worldwide potentially leading to long term disability. Osteoarthritic joints contain synovial fluid that has become less concentrated and viscous over time which often leads to less absorption and protection. Synovial fluid also contains Hyaluronic Acid (HA), although the mechanism is unclear this seems to inhibit inflammation, decrease cartilage degradation, and promote cartilage development. It has been proposed that HA injections help preserve OA joints and act as an acceptable alternative treatment option to corticosteroid injections, NSAIDs, or opioids. Project Purpose: Hyaluronic Acid (HA) Injections have been identified as a valuable treatment option to help patients with mild to moderate osteoarthritis (OA); however, the ability to order and perform these injections at our family medicine clinic faces constraints due to cost/storage and staff and resident training requirements. Due to the limited amount of injections performed annually, ordering the medication in bulk is not a viable option due to risk of waste and unavailable storage space. Formulating a standardized protocol for performing the HA injections and providing additional training to staff and residents was required. Patient acceptance of this treatment is also a challenge, seeing that less invasive options such as NSAIDs or opioid medications are sometimes preferred to control pain. After systems were in place to order the medication, it was hypothesized that self-reported pain and symptoms would improve after receiving HA injections. Methods: A pre-ordering system was implemented to obtain injections at a lower cost, avoid issues with storage, and prevent waste. Patient selection was determined through both physical examinations and surveys. Candidates who qualify must also receive insurance approval before the medication orders can be submitted. The timing of the treatment must be coordinated between the staff and patient, concurrent with when the medication orders are submitted. Staff and resident experience levels with HA injections were assessed throughout the study using surveys. To address knowledge gaps in applying and using HA injections, a lecture on treatment options for OA highlighting HA injection as well as a wet lab were provided to residents. The lecture and other training information has been uploaded to online filing service for future reference. Furthermore, codes for the medication and procedure were posted on the whiteboard in our resident office for convenience and easy-access. After patients were identified, the KOOS questionnaire was administered prior to and after receiving HA injection as a measure to assess effectiveness of HA injections. Results and Conclusions: Five patients received HA injections. Four of these patients completed both pre and post injection KOOS questionnaire. The mean KOOS questionnaire score prior to injection was 79.25 with a standard deviation of 17.69 compared to a mean after injection of 42.00 with a standard deviation of 19.43. The p value was 0.0697. Future goals will be to expand the number of patients in the study and continue to follow KOOS questionnaire to evaluate the effectiveness of HA injections. Associated with this goal will be to continue to educate residents on the indications and benefits of HA injections.

Presentation Date


A Systematic Way of Ordering Hyaluronic Acid for Knee Injections in the Primary Care Setting