Evaluation of quality-of-life following treatment with Hymovis in patients with knee osteoarthritis and/or meniscal tear

doi:10.21203/rs.3.rs-1368674/v2

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Evaluation of quality-of-life following treatment with Hymovis in patients with knee osteoarthritis and/or meniscal tear

https://doi.org/10.21203/rs.3.rs-1368674/v2

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Background: Knee osteoarthritis (KOA) and meniscal tears (MT) are the two most common types of knee injuries having an important impact on the quality of life of patients (QoL). The objective is to evaluate the impact on the QoL, physical activity and satisfaction degree of patients with KOA, MT or both conditions after intraarticular Hymovis infiltration.

Methods: Non-interventional, prospective, multicenter study of 165 patients with KOA and/or a MT treated with two injections of Hymovis.

Results: Patients in all three groups (KOA, MT and mixed) reported a high percentage of global QoL improvement (>80 %). KOOS and WOMAC change from baseline improved (p<0.001) for all patients. Physical, sports and recreational activities and Satisfaction with the treatment increased after treatment. (p<0.001). Pain also improved in the three groups (p<0.05).

Conclusion: Intra-articular injections of Hymovis improves QoL, physical function and clinical condition of patients suffering KOA, MT or both conditions.

Orthopedics

Sports Medicine and Kinesiology

Osteoarthritis

Meniscus tear

Hyaluronic acid

Viscosupplementation

Osteoarthritis is a common degenerative joint disease, and the main type of arthritis in industrialized countries¹. Its prevalence increases with age, particularly after the age of 60, and it is more common in women². It affects mobile joints (mainly the hips and knees) and is characterized by cartilage degradation, synovial inflammation, and abnormal subchondral bone remodelling³ producing not only a reduced physical function of the knee but also pain and a decrease in their quality of life (QoL)⁴. Due to the impact of osteoarthritis on quality of life, many therapies are used to improve symptoms in these patients, although no treatment delays or prevents osteoarthritis or provides long-term relief of symptoms⁵. Meniscus tears are the second most common type of knee injury and are more common in men⁶. They are classified as traumatic or degenerative. The first is frequently caused by acute trauma and is more common in younger patients, while the second is more common in older patients and are due to intrasubstance degeneration within the menisci⁷. Conventional treatments include physical therapy, pharmacologic treatments (local and systemic), and surgery. The goal of pharmacologic treatment is to alleviate symptoms and, while more difficult to achieve, slow progression. Paracetamol is effective in the short term, but it can result in hepatoxicity if used for long periods or at high doses⁸. Long-term use of non-steroidal anti-inflammatory drugs, in turn, can cause severe adverse effects⁹. Intra-articular corticosteroid injections have an anti-inflammatory effect and are used to treat acute flares, but their effectiveness is limited by their anti-regenerative effects¹⁰. Hyaluronic acid (HA) viscosupplementation is listed as a recommended conservative treatment in guidelines and consensus statements published by professional societies in the fields of rheumatology and orthopaedics, sports medicine, and geriatrics¹¹. HAs are classified by molecular weight and type of chemical modifications. They include 1) low-molecular–weight HA, which penetrates the synovial membrane more easily but has inferior mechanical properties; 2) high-molecular–weight HA, which enhances lubrication but has lower biologic interactivity; and 3) High molecular weigth cross-linked HA, which offers greater resistance and high viscosity, but can cause pain and/or edema when injected¹². A different type of HA is commertilized in the market under the brand name of Hymovis (Fidia Farmaceutici). It consists of a non-cross-linked, partially hydrophobized derivative of hyaluronic acid (HYADD 4), containing a low number of C16 side-chains per polysaccharide backbone¹³. It has been used for treating patients with symptomatic knee osteoarthritis¹⁴, meniscal lesions¹⁵ and hip osteoarthritis¹⁶. However, it has not been performed ant study evaluating the QoL after the treatment with this type of HA. The aim of the study was to evaluate the quality of life, physical activity and treatment satisfaction of patients who received intraarticular injections Hymovisfor the conservative treatment of meniscus tear, knee osteoarthritis or both conditions.

Study design

Prospective, non-interventional, post-marketing, observational, descriptive, multicentre study of retrospective and prospective information collection in 17 private clinics in Spain from 2018 to Sept 2020. The study was conducted in accordance with the principles of the “Declaration of Helsinki” and in compliance with Good Clinical Practice (GCP) principles for Medical Devices (ISO14155:2011). The study protocol was approved by the local ethics committee at the lead participating centre (16/2018 CEICEGC). All patients provided written informed consent.

Study population

The study population comprised patients (male or female) older than 18 years seen at one of the participating clinics between December 2018 and July 2019 for their first follow-up visit after intra-articular injection of Hymovis due to:

mild to moderate symptomatic knee osteoarthritis responding to clinical and radiological criteria of ACR (American College of Rheumatology) and a Kallgren and Lawrence (KL) score II/III evidenced by radiography and/or MRI. Patients received 2 consecutive intra articular injections of Hymovis (3 mL syringe with 8 mg of non-cross-linked HA alkylamida HYADD4; FIDIA Farmaceutici, Italy) given at 1-week interval according to the prospect (group KOA).
Degenerative knee meniscal tear identifiable by MRI. Patients received 2 consecutive intra articular injections of Hymovis given at 2-week interval according to the prospect (group MT).
Mild to moderate symptomatic knee osteoarthritis with meniscal tear. Patients received 2 consecutive intra articular injections of Hymovis given at 1-week interval (mixed group).

Patients were excluded if they presented the following conditions: a) history of previous viscosupplementation or corticosteroid therapy in the last 6 months, b) concomitant diseases that could interfere with the tests during the data collection period or that could lead to erroneous results (i.e., rheumatoid arthritis, metabolic bone diseases, gout, Paget's disease of bone, symptomatic chondrocalcinosis), c) knee arthroplasty or other knee surgery in the last 12 months, d) any scheduled surgery during the data collection period, e) evidence or suspicion of infection in the affected joint or skin diseases of the knee, such as dermatitis or psoriasis, f) patients with bilateral knee OA.

Primary outcome

The main objective of the study has been to evaluate the patient's quality of life, physical activity and satisfaction degree with the HA treatment in all groups of patients. QoL was determined using several instruments, including a) KOOS score, b) WOMAC score, c) Patient's Global Improvement Impression Scale (PGI-I)¹⁷ and d) ad hoc QoL single question. Physical activity was determined using specific subdimensions from KOOS: a) activities of daily living (ADL) and b) sport and recreation (Sport/Rec). Satisfaction degree with the treatment was evaluated using a) visual analogue scale of satisfaction and b) an ad-hoc questionary.

Secondary outcome

The secondary outcome measures were pain (VAS score) and tolerability. Local tolerability at the site of injection of the viscosupplementation product was assessed through retrospective collection considering redness and pain occurring in the minutes following treatment sessions. Systemic adverse events were recorded during the follow-up visits. Patients were asked for the level of pain in the previous 7 days to the visit.

Data collection

Information was collected longitudinally for 3 months for patients with meniscal tear and 6 months for patients with knee OA. At the inclusion visit (10 days after the last injection of Hymovis), the pain and functionality of the knee that the patients had before undergoing the treatment were evaluated using the VAS score (Visual Analog Scale)¹⁸, WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index)¹⁹ and KOOS (Knee Injury and Osteoarthritis Outcome Score)²⁰ questionnaires. Follow up visits were 1, 2 and 3 months for the MT group and 1, 2, 3, 6 months for the KOA and mixed group. Patients completed at all follow up visits written questionnaires of VAS, WOMAC and KOOS. Written questionaries of QoL and patient satisfaction were given at 3 months follow up (MT group) and 6 months (KOA and mixed group). During the inclusion and follow up visits, the researchers collected sociodemographic and objective and subjective clinical data, as well as the use of concomitant medication. The evaluations could be performed within a time window of ± 7 days. Participants agreed to interrupt NSAIDs consumption at least 24 h before each visit for the entire study.

Quality of life

The evaluation of QoL consisted of single question that asks the patient to rate the QoL improvement since the hyaluronic acid was injected into its knee according to a five-point Likert scale (1 – has impaired; 5 – has improved).

Health related QoL aspects instruments

It was evaluated using the KOOS and WOMAC scores. The KOOS score has five subscales comprising a total of 42 items, each rated on a 5-point Likert scale, with lower scores indicating worse symptoms. The five subscales are pain (9 items), symptoms (7 items), activities of daily living (ADL, 17 items), sport and recreation (Sport/Rec, 5 items), and quality of life (QoL, 4 items).

The WOMAC scale consists of 24 items, also scored on a 5-point Likert scale. There are three subscales: joint pain (5 items), stiffness (2 items), and physical function (17 items). To normalize the WOMAC index to a 0-100 scale all single scores in each subscale were summed, multiplied by 100 and divided by the possible maximum score for the relevant subscale. The questions refer to the previous 48 hours and higher scores indicate worsening.

Patient Global Impression of Improvement (PGI-I)

It consists of single question that asks the patient to rate the relief obtained with the treatment according to a five-point Likert scale.

Patient satisfaction with the treatment

It was estimated using a visual analogue scale of satisfaction (0 to 100 mm) with viscosupplementation where 0 corresponds to ‘Minimal Satisfaction” and 100 to ‘Maximum satisfaction”. Additionally, and an ad-hoc questionary evaluating how the treatment improved their normal activities was included. The patients were asked for “thinking about some of the usual activities and since the last intra-articular injection of hyaluronic acid, you a) work/study, b) practice sport c) do leisure activities d) has a social life (relationship with family and friends). Evaluation was done using a 5-point categorical scale (1 – much worse; 5 - much better).

Sample size calculation

The sample size calculation was based on the minimally important change (MIC) recommended for the KOOS^{20, 21}. We estimated a sample size of 89 patients per group (total of 178 patients) to provide at least 80 % power to detect differences in the KOOS symptoms scale equal or superior to 5 (lowest value to detect from the symptoms subscale), with a 2-sided significance level of 5%, a beta risk of 20%, a standard deviation of 15 points and taking in consideration 20 % of possible losses.

Statistical analysis

Categorical variables are expressed as number and percentage of patients in each category, while continuous variables are expressed as mean and SD. Two-sided non-parametric tests (Kolmogorov-Smirnov with 95% CI) were used to check for normal distribution of data. Bivariate non-parametric bilateral tests (McNemar and Wilcoxon) with 95% confidence intervals were used for statistical inference where appropriate. Paired data were used for all comparisons between baseline and the final evaluation (6 months for patients with osteoarthritis and 3 months for those with only meniscus tear). All analyses were performed in IBM SPSS Statistics 25.0.

Demographic and baseline clinical characteristics

A total of 165 patients were included: 76 in the osteoarthritis group (KOA), 58 in the meniscus tear group (MT) and 31 in the mixed group (patients with both types of lesions, KOA + MT). Of the 165 patients originally enrolled, 3 did not complete the entire study. Two withdrew from the KOA group and one from the MT group. The reasons for the 3 patients who left the study prematurely were: voluntary withdrawal of the patient, clinical conditions of the patient that prevent their continuity and loss of follow-up. The patients’ sociodemographic and clinical characteristics are summarized in Table 1. 80.3 % of the patients in the osteoarthritis group (KOA) were older than 50 years and 55.3% were men. 63.3% of the patients referred to had chronical mechanical pain which limited their activities of daily living (38.3 %). Patients form the meniscus tear group (MT) had lower mean age of 51.8 (12.7) years and 79.3% were men and 72.5% engaged in physical activity or sport several times a week or month. In the mixed group, patients had a mean age of 59.2 (8.4) years, 45.2% were men and 51.7% engaged in physical activity or sport several times a week or month. Most of the lesions in the meniscus tear group were traumatic tears (91.4%) sustained during the practice of sport.

Effect of Hymovis on quality of life, physical activity and satisfaction

The QoL showed a high percentage of global improvement (>80 %) in all groups (Figure 1) and only a few percentages considered that had impaired or had no change (KOA, 4.8 %, MT, 6.8 % and mixed group, 7.4 %).

Clinical changes before the treatment and at the final evaluation (6 months for patients with osteoarthritis and mixed group and 3 months for the meniscal tear group) are shown in table 2 (KOOS) and Table 3 (WOMAC). There was a statistically significant improvement is all KOOS and WOMAC individual dimensions and global score evaluation (P<0.001).

The assessment of the ability of the participants to move around and to look after themselves (activities of daily living) showed statistically significant rates of improvements for the KOA group (34 %, p<0.001), MT (28 %, p<0.001) and mixed group (34 %, p<0.001).

Sports and recreational activities had also statistically significant percentages of improvements for the KOA group (104 %, p<0.001), MT (105 %, p<0.001) and mixed group (137 %, p<0.001).

The PGI-I instrument also showed high rates of perceived improvement after treatment (Figure 2). 92.2% of participants in the osteoarthritis group, 95.6% of those in the meniscus tear group, and 88.8% of those in the mixed group reported that they felt that their condition had become a little better or much better after treatment.

The VAS satisfaction resulted in mean 7.5 ± 1.9 for the OA group, 7.2 ± 2.7 for the MT group and 7.5 ± 2.2 for the mixed group. The evaluation of the ability to perform usual activities since the last intraarticular injection of Hymovis (Satisfaction - Table 4) revealed that 80.6 % ± 9.2 (KOA), 78.1 % ± 3.1 (MT) and 73.7 % ± 4.8 (Mixed) of the participants declared little or much improvement in performing usual activities such as work, study, sports, outdoor and leisure activities and social life. The percentage of participants that declared no improvement (much worse, little worse or no change) in performing usual activities at the final of the study was 19.4 %± 9.2 (KOA), 21.9 % ± 3.1 (MT) and 26.3 % ± 4.8 (mixed).

Pain assessment

Perceived pain intensity also improved in the three groups (Figure 3). In all groups, comparison between pre-injection scores and scores at the end of follow-up yielded a p-value of ≤0.05; The percentage of participants who experienced moderate or severe pain decreased from 35. % (24 of 67 participants) at baseline to 4.8 % (3 of 63 participants) at the final visit for the KOA group; MT group: 21.6. % (11 of 56 participants) at baseline to 2.4 % (1 of 42 participants) at the final visit.; Mixed group, 34.6. % (9 of 26 participants) at baseline to 0 % (26 of 26 participants) at the final visit. The percentage of change in the perceived pain at the final visit based on the disease duration was -89.8 % (0-2 years), -66.2 % (2-5 years), -64.0 % (5-8 years) and -54.5 % (<8 years) for the KOA group, suggesting a better pain improvement with lower disease duration. The percentage of change in the perceived pain at the final visit based in the history of previous tear was -81.1 % (participants having a previous tear) and -60.7 % (participant without a previous tear)

Tolerability and safety

No serious adverse effects attributable to Hymovis or adverse reactions to any of the drugs prescribed for the treatment of the underlying conditions were observed in any of the groups. Six adverse events—all moderate inflammatory injection site reactions—were described and they all resolved.

This multicentric study conducted a thorough analysis of QoL in patients with KOA, MT and both conditions in 17 different heath centres in Spain. Our study demonstrated that two administrations of Hymovis not only reduced the clinical symptoms but also, improved the QoL of patients having KOA (alone or combined) or MT, respectively. Up to our knowledge, this is the first study to analyse the effects of Hymovis in the QoL of patients with KOA and MT. Our results also showed 85 % and 77% improvement in different aspects of quality of life for the osteoarthritis group and meniscus tear and mixed groups respectively. Most of the research on knee OA and Meniscal tear has attempted to quantify the magnitude of clinical symptoms associated with this disease and the impact of various treatments on outcomes such as pain severity and physical functioning²². The physical manifestations of these two pathologies have direct impact on other aspects of patient’s lives such as social interactions, mental functioning, and sleep quality²³. In fact, limitations in walking, stair climbing, and squatting are common patient complaints that greatly interfere with activities of daily living and recreation. For this reason, this study included not only clinical related outcomes but also, evaluated different aspects of the QoL of the participants. Health related quality of life measures are relevant and important extra outcomes that help quantify the physical, social, and emotional impact of patients suffering KOA and/or MT.

All the physical function aspects evaluated using the different scales improved from baseline in the three groups, and the improvements remained significant at the end of follow-up (6 months in the osteoarthritis and mixed groups and 3 months in the meniscus tear group). Similarly, All the patients in our series reported a marked and significant reduction in pain, with significant improvements from baseline. It is noteworthy that improvements in pain correlated with disease duration in the osteoarthritis group, where patients with a shorter time since onset were more likely to report significant improvements in pain. In the meniscus tear group, by contrast, patients with a previous history of a tear were more likely to report pain reduction, raising the question of whether restoring the biomechanical properties of synovial fluid alters the course of these lesions. The results of the present study are also comparable with those achieved using HYMOVIS to manage symptoms of KOA or MT patients. Priano et al. (2017) analysed the retrospective data concerning 698 patients with moderate-severe KOA who received two infiltrations of HYMOVIS (24 mg/3 mL), 1 week apart. The mean WOMAC scores and VAS score were reduced by 56.3% and 56.8 % from baseline at 6 months, respectively. Additionally, 88 % of the patients reported an improvement of subjective patient satisfaction and only 14 % declared no improvement or no change at 6 months of observation²⁴. In our study, we obtained higher average pain and WOMAC reduction of 61 % and 70 % from baseline at 6 months with similar percentage of patient improvement satisfaction of 81 %. Bisicchia et al. (2016) conducted a single-center, single-blind, prospective randomized controlled clinical study with 1-year follow-up, and showed that 2 (24 mg/ 3 mL) HYMOVIS injections did not have significantly higher side effects when compared to corticosteroid injections and provided better short-term control of symptoms in patients with mild to moderate knee osteoarthritis²⁵. The reasons that may be behind the positive clinical and QoL results are possibly based on the improved rheological properties of Hymovis compared to other types of HA. The HYMOVIS is an optimal viscosupplementation and shock absorbing agent²⁶. Besides, it has been reported that this type of HA can enhanced type II collagen turnover of the knee joint and cartilage volume in lateral knee compartment²⁷. Similarly, the efficacy of HYMOVIS in meniscal healing and pain improvement has been described in preclinical models²⁸. Zorzi et al. (2015) investigated the efficacy of 2 IA injections (2 weeks apart) of Hymovis in 50 patients with meniscal tear in a prospective randomized clinical trial. Patients were found to significantly improve knee function and reduced VAS pain (87 %) and the length and depth of the meniscal lesion after 2 months treatment, together with an improvement in 27 % in the mental health score (evaluated with the SF-36 questionnaire)¹⁵. In comparison, we obtained a minor VAS pain reduction (51 %) at 2 months after treatment. Berton et al. (2020) reported in a pilot study of 40 patients that two administrations of Hymovis at a distance of 1 week improved clinical outcomes up to 60 days of patients with degenerative meniscus lesion, demonstrating also a potential correlation with a T2 mapping healing effect²⁹. Our findings demonstrated the clinical effectiveness of HA injections for the conservative treatment of meniscus tears in a larger population followed for a longer time. Exposure of articular cartilage to meniscus tears can severely impair the lubricating activity of synovial fluid, which may be diluted by intra-articular bleeding or plasma extravasation, reducing natural concentrations of the two major joint lubricants: hyaluronic acid (HA) and lubricinin³⁰. As consequence, the decreased concentrations of HA in degenerative knee joint diseases (osteoarthritis and meniscus tears) finally contribute to symptoms impairment. In conclusion, our findings lend support to the effectiveness of Hymovis intra-articular injections for the conservative treatment of meniscus tears, knee osteoarthritis and patients having simultaneously meniscus tear and knee osteoarthritis. We showed that this treatment is clinically effective, improves both physical function and quality of life, is associated with high patient satisfaction, with a good safety profile. Further, our study was conducted in a clinical practice setting and thus reflects real-world conditions. Our study has some limitations, including the absence of a placebo control group. Double blind randomized controlled trial on bigger cohort of patients would be useful to improve the evidence of effectiveness of this treatment. The results of this study correspond to follow-up periods of 3 months and 6 months. Hence, an additional study, suitably designed for long-term assessment, is necessary to validate the long-term effects of Hymovis.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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(30) Elsaid, K. A.; Fleming, B. C.; Oksendahl, H. L.; Machan, J. T.; Fadale, P. D.; Hulstyn, M. J.; Shalvoy, R.; Jay, G. D. Decreased lubricin concentrations and markers of joint inflammation in the synovial fluid of patients with anterior cruciate ligament injury. Arthritis Rheum 2008, 58 (6), 1707-1715. DOI: 10.1002/art.23495 From NLM.

Table 1. Demographic and clinical data. Patients with knee osteoarthritis (KOA); Patients with meniscal tear (MT); patients with both type of lesions (KOA + MT). ^aPrimary osteoarthritis: associated to in joints without a previous abnormality and an inciting trauma or agent. Secondary osteoarthritis: associated to previous joint abnormalities.

Parameters	KOA	MT	KOA + MT
N	76	58	31
Mean (SD) age	59.4 (13.1)	51.8 (12.7)	59.2 (8.4)
Mean (SD) body mass index	25.5 (3.9)	24.3 (3.7)	25.4 (3.3)
Gender
Male [N (%)]	42 (55.3)	46 (79.3)	14 (45.2)
Female [N (%)]	34 (44.7)	12 (20.7)	17 (54.8)
Affected knee
Right [N (%)]	58 (77.3)	28 (48.3)	17 (56.7)
Left [N (%)]	17 (22.7)	30 (51.7)	13 (43.3)
Type of knee OA lesion^a
Primary [N (%)]	67 (89.3)	-	25 (86.2)
Secondary [N (%)]	8 (10.7)	-	4 (13.8)
Current type of meniscus tear
Traumatic [N (%)]	-	53 (91.4)	8 (26.7)
Degenerative due to knee osteoarthritis [N (%)]	-	5 (8.6)	22 (73.3)
Previous knee injury explaining current tear [N (%)]	-	22 (37.9)	11 (36.7)

Table 2. Health-related quality of life – KOOS scores between the perception before the infiltration and the last visit. Scores range from 0-100 where 100 indicates improvement. P-value calculated using Wilcoxon signed rank test with a confidence level of 95%.

	KOA			MT			KOA + MT
KOOS score [Mean(SD)]	Before injection	6 months	P-value	Before injection	3 months	P-value	Before injection	6 months	P-value
Pain	46.1 (15.4)	68.8 (10.4)	0.000	50.0 (13.3)	69.1 (10.2)	0.000	46.4 (15.1)	71.8 (8.3)	0.000
Symptoms	41.5 (8.7)	51.4 (7.8)	0.000	44.7 (10.4)	50.9 (8.7)	0.000	39.0 (9.7)	50.9 (6.6)	0.000
Activities of daily living	53.0 (16.2)	71.5 (10.4)	0.000	55.9 (14)	71.4 (10.4)	0.000	52.8 (14.5)	70.7 (9.9)	0.000
Sport and recreation	27.9 (20)	57.1 (18.3)	0.000	28.4 (16.6)	56.7 (16.7)	0.000	24.3 (17.8)	57.7 (17.5)	0.000
Quality of life	30.3 (14.1)	55.3 (17.1)	0.000	29.5 (13.6)	51.3 (20.6)	0.000	33.7 (13.8)	62.4 (15)	0.000
Global	43.0 (14.4)	64.1 (10.7)	0.000	47.1 (11.9)	64.4 (10.1)	0.000	43.9 (13.7)	64.4 (10.2)	0.000

Table 3. Health-related quality of life – WOMAC scores between the perception before the infiltration and the last visit. Scores range from 0-100 where 0 indicates improvement. P-value calculated using Wilcoxon signed rank test with a confidence level of 95%.

	KOA			MT				KOA + MT
WOMAC score [Mean(SD)]	Before injection	6 months	P-value	Before injection	3 months	P-value	Before injection		6 months	P-value
Pain	6.5 (3.7)	1.9 (2.3)	0.000	5.1 (3.3)	1.9 (2.3)	0.000	6.0 (4.2)		1.4 (2.0)	0.000
Stiffness	2.6 (1.7)	0.8 (1.2)	0.000	1.7 (1.3)	0.9 (1.1)	0.000	2.3 (1.5)		0.4 (0.8)	0.000
Physical Function	21.1 (13.5)	6.6 (8.3)	0.000	17.5 (10.9)	6.6 (7.6)	0.000	21.0 (11.1)		7.5 (8.3)	0.000

Table 4. Satisfaction – Ad Hoc questions. Assessment of the ability to perform usual activities since the last intraarticular injection of Hymovis® at the last follow up visit (6 months for the KOA and mixed group; 3 months for the MT group). Percentages of patients for each categorical dimension for the following question “Thinking about some of the usual activities and since the last intra-articular injection of hyaluronic acid, you: a) work/ study, b) you do sports / does outdoor activities, c) do leisure activities, e) has a social life (relationship with family and friends). A = Group KOA; B = group MT, C = mixed group

	Work/Study (%)			Sports/outdoor activities (%)			Leisure activities (%)			Social life (%)
Groups	A	B	C	A	B	C	A	B	C	A	B	C
Much worse	8,3	0	16	8,3	2,4	7,7	1,6	2,3	0	0	3,2	0
Little worse	0	0	0	2,8	2,4	7,7	0	4,5	3,8	0	0	5,9
No change	13,9	17,2	8	22,2	17,1	19,2	9,7	15,9	19,2	10,8	22,6	17,6
Little better	19,4	27,6	24	38,9	39	30,8	29	25	23,1	27	22,6	11,8
Much better	58,3	55,2	52	27,8	39	34,6	59,7	52,3	53,8	62,2	51,6	64,7

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Evaluation of quality-of-life following treatment with Hymovis in patients with knee osteoarthritis and/or meniscal tear

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