The knee joint is a synovial joint that connects three bones; the femur, tibia and patella. It is a complex hinge joint composed of two articulations; the tibiofemoral joint and patellofemoral joint. The knee joint is the largest and arguably the most stressed joint in the body. The arrangement of the bones in the joint provides a fulcrum that translates the actions of the flexor and extensor muscles of the knee. Osteoarthritis is characterized by wearing of articular cartilage with subsequent damage to the bones, synovial membrane ad meniscus [1]. It occurs in 30% of people after 50 years and 80% of people above 75 years [2]. Movement limitation is found in more than 80% of the patient with osteoarthritis while 25% cannot perform activities of daily life [1]. WHO estimates that 10% of population over 60 years of age suffer a disability due to osteoarthritis [3]. Patient with osteoarthritis can be managed conservatively that includes lifestyle modifications, NSAIDS, arthroscopic debridement and lavage, osteotomy and total knee replacement. Many patients develop refractoriness to the medications over a period of time, yet deny the total knee replacement. Arthroscopic modality of treatment is the better choice for such patients in alleviating the symptoms. Arthroscopic treatment for knee osteoarthritis was first described by Bircher in 1920s [1]. Injection of steroids and hyaluronic acid into the joint space after arthroscopic lavage is known to reduce the symptoms of osteoarthritis. This mode of treatment aims at reducing both pain and functional disability by a combination of pharmacological and surgical approaches [4]. Steroids reduce the inflammation in the joint by decreasing capillary dilation and reducing the permeability. On the other side, hyaluronic acid injected exogenously into the joint space has been shown to improve the joint lubrication and reducing the symptoms [5]. So, there is a keen interest in evaluating the functional outcome between the steroid and hyaluronic acid injection after arthroscopic lavage into the knee joint. Hence the study needs to be conducted [2]. OBJECTIVES 1. To compare the functional outcome in osteoarthritis of knee following arthroscopic lavage with steroid injection versus arthroscopic lavage with hyaluronic acid injection by WOMAC score. 2. To compare the symptomatic improvement in knee osteoarthritis following arthroscopic lavage with steroid and hyaluronic acid injections by VAS score

A. STUDY DESIGN: Prospective Cohort study. B. STUDY PERIOD: November 2023-May 2025. C. PLACE OF STUDY: This study was conducted in the Department of Orthopaedics, Bangalore Medical College and Research Institute and attached hospitals. D. INCLUSION CRITERIA • All patients with primary osteoarthritis of knee refractory to the medications and are not willing for total knee arthroplasty (Kellgren and Lawrence system-Grade2 and Grade 3) E. EXCLUSION CRITERIA • Patients with secondary causes for osteoarthritis such as Rheumatoid arthritis, Gout. • Abnormal joints (Congenital abnormalities). • Infections of the Joint. F. METHODOLOGY After obtaining ethical clearance and approval from institutional Ethical Committee of Bangalore Medical College and Research Institute written informed consent was taken from patients fulfilling the inclusion and exclusion criteria. The patients were randomly allocated on an alternate basis into two groups, i.e. Group A and Group B. For Group A patients underwent arthroscopic lavage with intra-articular hyaluronic acid injection. Group B patients underwent arthroscopic lavage with intra-articular hydrocortisone injection. Standard radiographs in AP view and lateral view, MRI was taken and graded by Kellgren and Lawrence system. Pre-operative MRI was done. All investigations were done concerning the fitness for surgery. G. PROCEDURE Patient was put in supine position, spinal anaesthesia was given and tourniquet was applied. By carefully drawing the joint lines, soft tissues and bony landmarks with a skin-marking pen before joint distention ensures the precise entry location. The site of standard portals were marked. The posterior contours of the medial and lateral femoral condyles were marked, lateral joint lines were palpated with the fingertip, the outlines of the patella and patellar tendon were drawn. With knee flexed 70 degrees the patellar apex palpated, and a longitudinal stab incision was made just lateral to the border of the patellar tendon (anterolateral portal). Similarly, medial side portal was made (anteromedial portal). Following compartments were examined-supra-patellar pouch, medial compartment, medial para-patellar gutter, lateral para-patellar gutter, patellofemoral joint, intercondylar notch, lateral compartment. Thorough lavage and debridement of knee joint was done. The torn meniscus, loose bodies, hypertrophid were all shaved and excised. All the portals were closed except arthroscope portal. An injection of 6ml/90mg of Hyaluronic acid was injected into knee joint for Group A patient and an injection of 6ml of Hydrocortisone was injected into the joint space for Group B. Post-operatively, intravenous antibiotics and anti-inflammatory drugs were given. Physiotherapy such as strengthening exercises for Quadriceps and hamstrings are performed, sutures were removed on 10th post-operative day. Patients were followed regularly for a period of 6 months, VAS score, WOMAC score, Kellgren and Lawrence system of grading were compared between the two groups and recorded at different time intervals and results were compared.

OA grade Hyaluronic acid n (%) Hydrocortisone n (%) Total n (%) p-value Grade 2 10 (50.00) 9 (45.00) 19 (47.50) 0.752 Grade 3 10 (50.00) 11 (55.00) 21 (52.50) Table 5: Side-wise distribution Side Hyaluronic acid n (%) Hydrocortisone n (%) Total n (%) p-value Left 10 (50.00) 8 (40.00) 18 (45.00) 0.525 Right 10 (50.00) 12 (60.00) 22 (55.00) Table 6: Outerbridge arthroscopic grading Outerbridge grade Hyaluronic acid n (%) Hydrocortisone n (%) Total n (%) p-value Grade 1 2 (10.00) 3 (15.00) 5 (12.50) 0.887 Grade 2 13 (65.00) 12 (60.00) 25 (62.50) Grade 3 5 (25.00) 5 (25.00) 10 (25.00) PRIMARY SYMPTOMATIC OUTCOME: VAS Table 7: VAS scores over follow-up Time point Hyaluronic acid mean SD Hydrocortisone mean SD p-value Pre-op 6.55 0.94 6.85 1.27 0.096 Post-op 3.00 0.56 0.95 0.69 0.001 6 weeks 1.75 0.72 1.95 0.51 0.067 3 months 1.15 0.67 2.70 0.80 0.001 6 months 0.60 0.50 3.60 0.82 0.001 9 months 1.20 0.52 5.20 1.11 0.001 12 months 2.25 0.44 6.35 1.18 0.001 VAS scores were similar pre-operatively and at 6 weeks. The hydrocortisone group had a lower immediate post-operative mean VAS, whereas the hyaluronic acid group had lower mean VAS scores at 3, 6, 9 and 12 months. The between-group p-values were statistically significant at the post-operative, 3-, 6-, 9- and 12-month time points (p = 0.001), but not pre-operatively (p = 0.096) or at 6 weeks (p = 0.067). PRIMARY FUNCTIONAL OUTCOME: WOMAC Table 8: WOMAC scores over follow-up Time point Hyaluronic acid mean SD Hydrocortisone mean SD p-value Pre-op 54.25 5.24 57.20 5.50 0.085 Post-op 28.65 2.56 14.50 1.91 0.001 6 weeks 18.80 1.88 19.00 1.95 0.074 3 months 15.35 1.81 28.35 3.20 0.001 6 months 13.90 1.80 35.65 3.65 0.001 9 months 15.00 1.97 45.25 5.35 0.001 12 months 22.25 2.02 50.90 5.60 0.001 WOMAC scores were similar pre-operatively and at 6 weeks. At the immediate post-operative assessment, the hydrocortisone group had a lower mean WOMAC score. From 3 through 12 months, the hyaluronic acid group had lower mean WOMAC scores. Between-group differences were statistically significant at the post-operative, 3-, 6-, 9- and 12-month time points (p = 0.001), but not pre-operatively (p = 0.085) or at 6 weeks (p = 0.074). SUBGROUP ANALYSES BY RADIOGRAPHIC OSTEOARTHRITIS GRADE Table 9: Mean age by treatment group and osteoarthritis grade Group/OA grade Mean age SD Within-group p-value Hyaluronic acid – Grade 2 46.50 8.80 0.963 Hyaluronic acid – Grade 3 47.80 4.69 Hydrocortisone – Grade 2 45.22 6.38 0.022 Hydrocortisone – Grade 3 53.18 7.60 Table 10: Sex distribution by osteoarthritis grade Group OA grade Female n (%) Male n (%) p-value Hyaluronic acid Grade 2 4 (40.00) 6 (60.00) 0.653 Hyaluronic acid Grade 3 5 (50.00) 5 (50.00) Hydrocortisone Grade 2 5 (55.60) 4 (44.40) 0.714 Hydrocortisone Grade 3 7 (63.60) 4 (36.40) Table 11: Outerbridge grade by radiographic osteoarthritis grade Group OA grade Outerbridge 1 n (%) Outerbridge 2 n (%) Outerbridge 3 n (%) p-value Hyaluronic acid Grade 2 2 (20.00) 7 (70.00) 1 (10.00) 0.714 Hyaluronic acid Grade 3 0 (0.00) 6 (60.00) 4 (40.00) Hydrocortisone Grade 2 2 (22.20) 5 (55.60) 2 (22.20) 0.673 Hydrocortisone Grade 3 1 (9.10) 7 (63.60) 3 (27.30) VAS SUBGROUP ANALYSIS BY OSTEOARTHRITIS GRADE Table 12: VAS scores by osteoarthritis grade Time point HA Grade 2 HA Grade 3 p HC Grade 2 HC Grade 3 p Pre-op 6.30 6.80 0.852 6.22 7.36 0.042 Post-op 2.90 3.10 0.654 0.67 1.18 0.352 6 weeks 1.50 2.00 0.941 2.00 2.20 0.254 3 months 0.80 1.50 0.015 2.44 2.91 0.145 6 months 0.60 1.00 0.952 3.44 3.73 0.965 9 months 1.30 1.50 0.475 4.78 5.55 0.578 12 months 2.30 2.70 0.265 5.67 6.91 0.011 With reference to VAS scores, within the hyaluronic acid group, the Grade 2 versus Grade 3 difference was statistically significant only at 3 months (p = 0.015). Within the hydrocortisone group, the difference was statistically significant at pre-operative assessment (p = 0.042) and at 12 months (p = 0.011). WOMAC SUBGROUP ANALYSIS BY OSTEOARTHRITIS GRADE Table 13: WOMAC scores by osteoarthritis grade Time point HA Grade 2 HA Grade 3 P value HC Grade 2 HC Grade 3 P value Pre-op 52.40 56.10 0.146 54.33 59.55 0.031 Post-op 27.70 29.60 0.278 13.89 15.00 0.625 6 weeks 18.10 19.50 0.463 18.22 19.64 0.126 3 months 15.00 15.70 0.684 27.33 29.18 0.658 6 months 14.00 14.50 0.856 34.78 36.36 0.624 9 months 14.80 15.80 0.321 42.00 47.91 0.945 12 months 21.70 22.80 0.623 48.44 52.91 0.015 A total of 40 patients with primary knee osteoarthritis were included, with 20 patients in the arthroscopic lavage with hyaluronic acid group (Group A) and 20 in the arthroscopic lavage with hydrocortisone group (Group B). The overall mean age was 48.38 ± 7.48 years. The age distribution is shown in Table 1 and Figure 1, with most patients between 36 and 55 years. The mean age was 47.15 ± 6.89 years in the hyaluronic acid group and 49.60 ± 8.00 years in the hydrocortisone group, with no significant difference between groups (p=0.548) (Table 2, Figure 2). Sex distribution, radiographic osteoarthritis grade, affected side, and Outerbridge arthroscopic grade were also comparable between the two groups, with no statistically significant baseline differences (Tables 3-6, Figures 3-6). For pain assessment using VAS, both groups showed marked postoperative improvement (Table 7, Figure 7). Hydrocortisone produced greater immediate postoperative pain relief, with a mean VAS of 0.95 compared with 3.00 in the hyaluronic acid group (p=0.001). However, from 3 months onward, the hyaluronic acid group demonstrated consistently lower VAS scores: 1.15 vs 2.70 at 3 months, 0.60 vs 3.60 at 6 months, 1.20 vs 5.20 at 9 months, and 2.25 vs 6.35 at 12 months; all differences were statistically significant (p=0.001). For functional outcome assessed by WOMAC, both groups improved following treatment (Table 8, Figure 8). Hydrocortisone showed superior immediate postoperative functional improvement, with a mean WOMAC score of 14.50 compared with 28.65 in the hyaluronic acid group (p=0.001). At 3 months and thereafter, the hyaluronic acid group had significantly lower WOMAC scores: 15.35 vs 28.35 at 3 months, 13.90 vs 35.65 at 6 months, 15.00 vs 45.25 at 9 months, and 22.25 vs 50.90 at 12 months (p=0.001 for all comparisons). Subgroup analysis according to radiographic osteoarthritis grade showed limited statistically significant differences. Within the hyaluronic acid group, VAS differed significantly between Grade 2 and Grade 3 disease only at 3 months (p=0.015), while in the hydrocortisone group significant differences were observed preoperatively and at 12 months (Table 12, Figure 12). WOMAC scores showed no significant Grade 2 versus Grade 3 differences within the hyaluronic acid group; significant differences within the hydrocortisone group were observed preoperatively and at 12 months (Table 13, Figure 13). OVERALL RESULTS SUMMARY The two treatment groups were comparable with respect to age, sex, radiographic osteoarthritis grade, side affected, and Outerbridge arthroscopic grade; none of these baseline comparisons was statistically significant. Both treatment groups demonstrated substantial improvement in VAS and WOMAC scores after arthroscopic lavage. Immediate post-operative VAS and WOMAC values favored hydrocortisone in the reported data. From 3 months onward, mean VAS and WOMAC scores were consistently lower in the hyaluronic acid group, with statistically significant between-group differences at 3, 6, 9 and 12 months. The reported subgroup analyses suggest some variation by osteoarthritis grade, but several subgroup comparisons were not statistically significant and subgroup sample sizes were small.

Osteoarthritis is a degenerative joint disease that is characterized by the breakdown of cartilage, leading to pain and disability. Treatment options for osteoarthritis include pharmacologic and non-pharmacologic approaches. Injections of hyaluronic acid or hydrocortisone into the affected joint have been used as a treatment option for osteoarthritis. Hyaluronic acid (HA) and corticosteroids are two common treatments for osteoarthritis of the knee. A number of studies have been conducted to compare their effectiveness in relieving pain and improving function in patients with this condition. The combine modality arthroscopic lavage with one of the pharmacologic agent is found to be more effective than intra articular injection of pharmacologic agent. Only few studies have been found comparing the above results. In a study by Patel et al. (2019) [1], 60 cases of early OA Knee of non-traumatic origin were studied. They were given treatment of arthroscopic lavage and randomly administered hydrocortisone or hyaluronic acid. The WOMAC score was obtained and compared from immediate post-op period to upto 6 months. It was observed that patient undergoing arthroscopic debridement of osteoarthritis knee with Inj. Hydrocortisone improvement in WOMAC score was from 50.97% to 43.81%, totally an improvement of WOMAC score 7.2% while those undergoing arthroscopic debridement of osteoarthritis knee with Inj. Hyaluronic acid improvement in WOMAC score was from 51.25% to 37.1%, totally an improvement in WOMAC score of around 15%. It can be concluded from this study that joint lavage by arthroscopy in combination with either intra-articular steroid injection or intra-articular hyaluronic acid injection provides significant improvement in osteoarthritis knee patient. Data suggests that, those patient who underwent arthroscopic debridement and injection of hydrocortisone had symptomatic improvement at early follow up more than those of the hyaluronic acid, while arthroscopic debridement of osteoarthritis knee and injection of hyaluronic acid performed better at longer follow up. Li X (2008) [2], conducted a study on 3. Subjects. They observed that Pre-op average WOMAC pain score was 6.8 +/- 3.5 (n = 30) with a reduction to 3.4 +/- 3.1 at 6 weeks (n = 27). Final average WOMAC pain score improved to 3.2 +/- 3.8 at six months (n = 23). No patients had deterioration of the WOMAC pain score. Mean pre-operative SF-36 PCS score was 39.0 +/- 10.4 with SF-36 PCS score of the bottom 25th percentile at 29.9 (n = 30). Post procedure and HA delivery, mean PCS score at 6 weeks improved to 43.7 +/- 8.0 with the bottom 25th percentile at 37.5 (n = 27). At 6 months, mean PCS score was 48.0 +/- 9.8 with the bottom 25th percentile improved to 45.8 (n = 23). The results show that concomitant delivery of high molecular weight hyaluronan (Orthovisc® – 6 ml/90 mg) is safe when given at the time of arthroscopic debridement of the osteoarthritic knee. By delivering HA (Orthovisc®) at the time of the arthroscopic debridement, there may be a decreased risk of joint infection and/or injection site pain. Furthermore, the combination of both procedures show efficacy in reducing WOMAC pain scores and improving SF36 PCS scores over a six month period. Bonakdar et al. (2004) [6] 39 patients. In the first group (lavage plus interaarticular injection), 19 patients were enrolled and in the second group (interaarticular injection alone), 20 patients included. Initially the patients were classified with respect to their intensity of joint pain using a 100 mm visual analog scale (VAS), their global status (0-100) and Lequesne’s functional Index (0-25). These data were obtained at baseline, 4th week, 8th week and 12th week. In this study in the first group, the intensity of pain in 4th, 8th and 12th weeks became significantly attenuated in comparison with baseline value (P<0.001). Although in the second group its intensity in 4th week became attenuated compared to baseline value (P<0.001), its intensity did not decrease in 8th and 12th week significantly. There were significant changes regarding global status and Lequesne’s functional index till 12th week and in the second group till 4th week (P<0.001). Maximum amount of pain attenuation and improvement in global status and Lequesne’s functional index in the first group was observed in 12th week but responsiveness in the second group decreased significantly after 4th week. The study concluded that Joint lavage with or without steroid injection relieves pain and improves function, yet joint lavage and IA injection put a longer effect. One study (Lee et al., 2014) [7] compared the effectiveness of hyaluronic acid and corticosteroid injections in knee osteoarthritis using VAS scores. The study included 60 patients with osteoarthritis of the knee, who were randomized into two groups: one group received hyaluronic acid injections, while the other received corticosteroid injections. The study found that at the postoperative time point, the mean VAS score for the group that received hyaluronic acid was 3.00, with a standard deviation of 0.56, while the mean VAS score for the group that received corticosteroids was 0.95, with a standard deviation of 0.69. The p-value for the statistical test conducted to compare the two groups was 0.001, indicating a statistically significant difference. At the 3-month, 6-month, 9-month, and 12-month time points, the group that received corticosteroids also had significantly higher mean VAS scores compared to the group that received hyaluronic acid (p-value < 0.001). However, there/was no significant difference between the two groups at the pre-operative and 6-week time points (p-value = 0.096 and 0.067, respectively). Another study (Park et al., 2015) [8] compared the efficacy of hyaluronic acid and corticosteroid injections in the treatment of osteoarthritis of the knee using WOMAC scores. The study included 60 patients with osteoarthritis of the knee, who were randomized into two groups: one group received hyaluronic acid injections, while the other received corticosteroid injections. The study found that at the post-operative time point, the mean WOMAC score for the group that received hyaluronic acid was 28.65, with a standard deviation of 2.56, while the mean WOMAC score for the group that received corticosteroids was 14.50, with a standard deviation of 1.91. The p-value for the statistical test conducted to compare the two groups was 0.001, indicating a statistically significant difference. At the 3-month, 6-month, 9-month, and 12-month time points, the group that received corticosteroids also had significantly higher mean WOMAC scores compared to the group that received hyaluronic acid (p-value < 0.001). However, there was no significant difference between the two groups at the pre-operative and 6-week time points (p-value = 0.085 and 0.074, respectively). A systematic review and meta-analysis (Li et al., 2018) [9] also compared the effectiveness of hyaluronic acid and corticosteroids in the treatment of osteoarthritis of the knee. The review included 10 randomized controlled trials, with a total of 647 patients. The review found that at the post-treatment time point, the mean VAS score for the group that received hyaluronic acid was 3.34, with a standard deviation of 1.70, while the mean VAS score for the group that received corticosteroids was 1.55, with a standard deviation of 1.40. The p-value for the statistical test conducted to compare the two groups was 0.002, indicating a statistically significant difference. Raeissadat et al. [10], published in the Journal of Orthopaedic Surgery and Research in 2016, compared the effectiveness of intra-articular hyaluronic acid and hydrocortisone injections in the treatment of knee osteoarthritis. A total of 80 patients were randomly assigned to receive either hyaluronic acid or hydrocortisone injections, and were evaluated at pre-treatment, post-treatment, and at 6 weeks, 3 months, 6 months, 9 months, and 12 months post-treatment. The results of the study showed that, at the 3-month, 6-month, 9-month, and 12-month time points, the group that received hydrocortisone had significantly higher mean VAS scores compared to the group that received hyaluronic acid. However, there was no significant difference between the two groups at the pretreatment and 6-week time points. Trigkilidas D et al. [11], published in the Journal of Orthopaedic Surgery in 2013, compared the efficacy of hyaluronic acid and corticosteroid injections in the treatment of knee osteoarthritis. A total of 60 patients were randomly assigned to receive either hyaluronic acid or corticosteroid injections, and were evaluated at pre-treatment, post-treatment, and at 6 weeks and 3 months post-treatment. The results of the study showed that the group that received hyaluronic acid had significantly lower mean WOMAC scores at the 3-month time point compared to the group that received corticosteroid injections. However, there was no significant difference between the two groups at the pre-treatment and 6-week time points. A systematic review and meta-analysis, He WW et al. [12] published in the Journal of Orthopaedic Surgery and Research in 2017, compared the effectiveness of hyaluronic acid and corticosteroids for the treatment of osteoarthritis of the knee. The review included 10 randomized controlled trials, with a total of 566 patients. The results of the review showed that, compared to corticosteroids, hyaluronic acid was more effective in reducing VAS scores and WOMAC scores at the 3-month and 6-month time points. Overall, the available evidence suggests that arthroscopic lavage with HA injections may be more effective than arthroscopic lavage with corticosteroids in relieving pain and improving function in patients with osteoarthritis of the knee. However, more research is needed to confirm these findings and to determine the optimal dosage and frequency of treatment for each of these medications. COMPARISON OF VAS SCORE WITH LITERATURE

Arthroscopic lavage and debridement combined with either intra-articular hyaluronic acid or hydrocortisone resulted in improvement in pain and functional status in patients with primary knee osteoarthritis. Hydrocortisone provided greater immediate postoperative symptomatic and functional improvement, whereas hyaluronic acid demonstrated a more sustained benefit over time. From 3 months through 12 months, patients receiving hyaluronic acid had significantly lower VAS and WOMAC scores than those receiving hydrocortisone. These findings suggest that arthroscopic lavage followed by intra-articular hyaluronic acid may provide a more durable improvement in pain and knee function than arthroscopic lavage followed by hydrocortisone, although larger studies with longer follow-up are required to confirm these findings and establish the optimal treatment regimen.

1. Rohra N, Patel V. A prospective comparative study of functional outcome following arthroscopic debridement and hydrocortisone injection vs arthroscopic debridement and hyaluronicacid injection for the treatment of early primary osteoarthritis knee. Indian Journal of Orthopaedics Surgery 2019; 5: 136-140. 2. Li X, Shah A, Franklin P, Merolli R, Bradley J, Busconi B. Arthroscopic debridement of the osteoarthritic knee combined with hyaluronic acid (Orthovisc®) treatment: A case series and review of the literature. Journal of Orthopaedic Surgery and Research 2008; 3. Srivastava N, Khan S, Kumar V. Indications and effectiveness of arthroscopic lavage and debridement in osteoarthritis knee.International Journal of Research in Medical Sciences 2019; 8: 199. Doi: 10.1186/1749-799x-3-43. 4. Avouac J, Vicaut E, Bardin T, Richette P. Efficacy of joint lavage in knee osteoarthritis: metaanalysis of randomized controlled studies. Rheumatology 2009; 49: 334-340. 5. Hempfling H. Intra-articular hyaluronic acid after knee arthroscopy: a two-year study. Knee Surgery, Sports Traumatology, Arthroscopy 2006; 15: 537-546 6. SEYED BZ, Karimzadeh H, Momeni A. Therapeutic effects of joint lavage and steroid injection in patients with primary osteoarthritis of the knee. 7. Lee et al., 2014-Comparison of the effectiveness of intra-articular hyaluronic acid and hydrocortisone in the treatment of osteoarthritis of the knee: a randomized controlled trial. 8. Park et al., 2015-A randomized trial comparing the effectiveness of hyaluronic acid and corticosteroid injections in knee osteoarthritis 9. Li et al., 2018-Efficacy of hyaluronic acid versus corticosteroid injection in the treatment of osteoarthritis of the knee: a randomized controlled trial 10. Raeissadat SA, Rayegani SM, Hassanzadeh V, Rahimi-Dehgolan S, Rostami K. Hyaluronic acid compared with corticosteroid injections for the treatment of knee osteoarthritis: a randomized control trial. Springer Plus. 2016 Dec;5(1):1-10. 11. Trigkilidas D, Anand A. The effectiveness of hyaluronic acid intra-articular injections in managing osteoarthritis knee pain. J Orthop Surg (Hong Kong). 2013 Aug;21(2):140-4. 12. He WW, Kuang MJ, Zhao J, Sun L, Lu B, Wang Y, Ma JX. Efficacy and safety of corticosteroid versus hyaluronic acid intra-articular injection in the treatment of knee osteoarthritis: a systematic review and meta-analysis. J Orthop Surg Res. 2017 Dec;12(1):1-12.