Abstract Perspective: Differential characteristics and management of pseudoseptic arthritis following hyaluronic acid injection is a rare complication: a systematic review

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As the variety of available injectable treatments for osteoarthritis increases, it is important for practitioners to be aware of potential product specific side effects. This is especially important in the context of COVID-19 as many patients seek to prolong conservative treatments to avoid hospital stays and where access to operating room resources has become scarce. When one of our patients returned following a hyaluronic acid (HA) injection within 12 hours with symptoms mirroring septic arthritis we found a paucity of literature to guide our treatment plan. This systematic review details common characteristics that can help delineate management and diagnosis of acute pseudoseptic arthritis. This local inflammatory response may present following HA injections and can be associated with severe joint pain (100%), effusion (100%), inability to weight bear, fevers (22.2%), elevated CRP, ESR (71.4% and 85.7%) and serum leukocytosis (50%) – very similar to septic arthritis. Interestingly, multiple reported cases were associated with a synovial leukocyte count above 50,000. While it is important to start patients on antibiotics empirically following arthrocentesis, our findings would suggest that with negative synovial cultures and symptom improvement with anti-inflammatories in patients who present within 72 hours of HA injection, a diagnosis of pseudoseptic arthritis should be considered.

Dr. Khan, Study Author