Identification, Prevention, and Management of Adverse Reactions Associated with the Intra-Articular Hyaluronic Acid Therapeutic Class: A Delphi Approach

OBJECTIVE: The purpose of this study was to obtain expert consensus on the identification, management, and treatment of adverse reactions associated with the use of intra-articular hyaluronic acid (viscosupplementation) in any joint. DESIGN: A Delphi approach was used to establish expert consensus between February and October 2024. SETTING: The Delphi study was conducted virtually using the Welphi survey platform and Qualtrics. PARTICIPANTS: An expert panel of 33 panelists was created after an open call to sports medicine physicians who were members of The American Medical Society for Sports Medicine. Snowball sampling was conducted to recruit additional experts outside of The American Medical Society for Sports Medicine. MAIN OUTCOME MEASURES: Outcome measures consisted of demographic characteristics and clinical experience and beliefs of the expert panelists, and items that achieved and did not achieve consensus after the Delphi study. RESULTS: In total, 32 of 33 physicians completed all rounds of the Delphi study (97% completion rate). Most adverse reactions were agreed to be because of the administration of the injection rather than the substance itself. Severe adverse reactions including joint infection, pseudoseptic reaction, and large increase in pain at the injection site were deemed rare or very rare by the Delphi panel. Numerous prevention and treatment strategies were identified for mild and moderate adverse reactions. The only time discontinuation of viscosupplementation was recommended was in cases of pseudoseptic reactions and joint infections. CONCLUSIONS: This study provides expert guidance to clinicians on ways to identify and manage adverse reactions associated with viscosupplementation in their clinical practice.