Osteoarthritis (OA) is a significant cause of disability. Considering the increasing diffusion of the viscosupplementation (VS) with hyaluronic acid (HA), the International Symposium Intra Articular Treatment (ISIAT) appointed a Technical Expert Panel (TEP) to identify the criteria for successful VS with a specific HA in OA; this through a systematic literature review (SLR), performed following the PRISMA guidelines interrogating Medline, Embase, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Grey Matters and American College of Rheumatology (ACR/EULAR) databases and the opinion of international experts. The research included only studies on adults and humans without limitations of language or time of publication. Researchers extracted both quantitative and qualitative data from each study. Mixed Methods Appraisal Tool (MMAT) was used to perform quality analysis for the level of evidence. The SLR retrieved 385 papers, 25 of which were suitable for the analysis. The TEP focused on the different formulations of the product Sinovial® [HA 0.8%, HA 1.6%, HA 2%, 800-1200 kDa, HA 3.2% (1400-2100 kDa/65-110 kDa)]. The choice was due to the vast amount of evidence available. The TEP weighed the evidence in two rounds of a Delphi survey; the results, and any disagreement, were discussed in a final session. Three domains were considered: 1) the patients' characteristics associated with the best results; 2) the contraindications and the conditions linked to increased risk of failure; 3) the clinical conditions in which VS is considered appropriate. The TEP concluded that VS with HA is safe and effective in the treatment of knee and hip OA of grades I to III and that it is possible to undertake VS in other situations (eg grade IV Kellgren-Lawrence - KL); a comprehensive examination of the patient should be performed before the procedure.

Center for Treatment Comparison and Integrative Analysis at Tufts Medical Center Boston MA USA

Department of Metabolic Diseases of Bone and Joints 5 A Nasonova Research Institute of Rheumatology Moscow Russian Federation

Department of Musculoskeletal Medicine and Sports Hospital Košice Šaca Kosice Saca Slovakia

Department of Orthopaedic Surgery Charles University and Motol University Hospital Prague Czech Republic

Department of Physical Medicine and Rehabilitation Istanbul University Istanbul Turkey

Department of Rheumatology Al Azhar University Cairo Egypt

Department of Rheumatology Belarusian State Medical University Minsk Belarus

Department of Rheumatology University of Ioannina Ioannina Greece

Division of Rheumatology University of Florence Florence Italy

Lubelskie Centrum Diagnostyczne Świdnik Poland

Rheumatology Division Henri Mondor Hospital Créteil France

Rheumatology Unit San Pietro Fatebenefratelli Hospital Rome Italy

Semmelweis University Department of Traumatology Uzsoki Hospital Department of Orthopaedics and Traumatology FIFA Medical Centre of Excellence Uzsoki u 29 41 Budapest Hungary

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