The Journal of Bone and Joint Surgery (American) 84:1142-1147 (2002)
© 2002 The Journal of Bone and Joint Surgery, Inc.
Granulomatous Inflammation After Hylan G-F 20 Viscosupplementation of the Knee
A Report of Six Cases
Andrew L. Chen, MD, MS,
Panna Desai, MD,
Edward M. Adler, MD and
Paul E. Di Cesare, MD
Investigation performed at the New York University-Hospital for
Joint Diseases, New York, NY
Andrew L. Chen, MD, MS
Panna Desai, MD
Edward M. Adler, MD
Paul E. Di Cesare, MD
Departments of Orthopaedic Surgery (A.L.C., E.M.A., and P.E.D.C.)
and Pathology (P.D.), New York University-Hospital for Joint Diseases,
301 East 17th Street, New York, NY 10003. E-mail address for P.E.
Di Cesare: pedicesare{at}aol.com
The authors did not receive grants or outside funding in support
of their research or preparation of this manuscript. They did not
receive payments or other benefits or a commitment or agreement
to provide such benefits from a commercial entity. No commercial
entity paid or directed, or agreed to pay or direct, any benefits
to any research fund, foundation, educational institution, or other
charitable or nonprofit organization with which the authors are
affiliated or associated.
Background:
Recently, intra-articular viscosupplementation with hyaluronate-derived
products has gained popularity as a palliative modality for the
treatment of osteoarthritis of the knee. Mild pain or swelling at
the site of injection may occur in up to 20% of patients, although
severe local inflammation, warmth, and joint effusion are rare.
We present a series of six cases in which granulomatous inflammation
of the synovium was observed after hyaluronate viscosupplementation
of the knee.
Methods:
Six knees (five patients) treated with intra-articular Hylan G-F
20 viscosupplementation underwent a surgical procedure because of
persistent symptoms. Routine histopathological evaluation, supplemented
by alcian-blue staining and hyaluronidase digestion, was performed
in each case.
Results:
Chronically inflamed synovium with areas of histiocytic and foreign-body
giant-cell reaction was observed surrounding acellular, amorphous
material. The material stained with alcian blue, a stain for hyaluronate,
which disappeared after hyaluronidase digestion.
Conclusions:
We believe that the injected hyaluronate (Hylan G-F 20) may have
been responsible for the synovitis in our patients and thus may
be a pathological cause of recalcitrant symptoms after such injection.
It is not known whether the responsible pathological agent was the
hyaluronate derivative, a contaminant of the purification process,
or a component of the carrier substance. Importantly, it appears
that the findings in these patients most likely represent a previously
unreported pathological response to a viscosupplementation product.
This report should raise clinical awareness about this potential complication.
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