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To the Editor: In their meta-analysis, Dr Lo and colleagues¹ concluded that intra-articular hyaluronic acid has a small beneficial effect compared with saline and suggested that publication bias had overestimated the therapeutic effect. We have several concerns about their methods.

First, the authors examined only 22 published studies, including some with products not approved for use in the United States, and did not account for excluded data. Sodium hyaluronate, however, has been evaluated in more than 60 trials, 55 of which have been published. These trials have involved more than 5000 patients. Many of these were randomized, saline-controlled trials that demonstrated a significant benefit for sodium hyaluronate.²

Second, as the authors noted, the effect size was equivalent to that seen with NSAIDs compared with acetaminophen in patients with OA, an effect the authors noted to be significant. Given that the effect size of the hyaluronans exceeded that of acetaminophen, an . . . [Full Text of this Article]

Roland Moskowitz, MD
rolliemoskowitz@aol.com
School of Medicine
Case Western Reserve University
Beachwood, Ohio

Roy Altman, MD
Division of Rheumatology and Immunology
David Geffen School of Medicine
University of California, Los Angeles

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Therapeutic Effects of Hyaluronic Acid on Osteoarthritis of the Knee * S.-M. Hou and C.-T. Wang reply:
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