Purpose: Osteoarthritis (OA) is a debilitating joint disease characterized by progressive loss of articular cartilage. Intra-articular injections are a mainstay of nonoperative treatment, however, there is controversy as to the optimal injectable for these patients. The purpose of the current study is to perform a network meta-analysis of the randomized control trials in the literature to ascertain whether there is a superior injectable nonoperative treatment for knee OA.

Methods: The literature search was conducted based on the PRISMA guidelines. Randomized control trials (RCTs) evaluating intra-articular injectables in osteoarthritic knees were included. Data was extracted and Visual Analogue Scale (VAS) scores and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores, where available were analyzed at 1, 3, 6 and 12 months. Clinical outcomes were compared using a frequentist approach to network meta-analysis, with statistical analysis performed using R. The treatment options were ranked using the P-Score.

Results: Seventy-nine RCTs with 8761 patients were included in this review. Intra-articular injectables evaluated included autologous conditioned serum (ACS), bone marrow aspirate concentrate (BMAC), botulinum toxin, corticosteroids (CS), hyaluronic acid (HA), mesenchymal stem cells (MSC), ozone, saline placebo, platelet-rich plasma (PRP), plasma rich in growth factor (PRGF), and stromal vascular fraction (SVF). At 4-6 weeks and 3 months of follow-up, the treatment with the highest P-Score for WOMAC score was high molecular weight (HMW) HA + CS [P-Score = 0.9500 and 8503, respectively]. At 6-months follow-up, the treatment with the highest P-Score for WOMAC score was PRP [P-Score = 0.7676]. At all post-injection time points, the treatment with the highest P-Score for VAS score [P-Score Range = 0.8631-9927] and Womac score at 12 Months [P-Score = 0.9044] was SVF.

Conclusions: The current evidence shows that SVF injections result in the greatest improvement in pain and functional outcomes in patients with knee OA at up to 1 year of follow-up.