This page is for my current patients only
此網頁只供我現時病人閱讀
Background 背景
Hyaluronic acid is a natural ingredient of the joint fluid that helps lubricate and cushion our joints. It turns the normal fluid into a “non-Newtonian” fluid, which have an interesting character. When the joint slides slowly, it acts as lubricant. When the motion became sudden, it instantaneously form a jelly and absorb shock. With such a special feature, it helps our joints work smoothly.
When we have degenerative joint, osteoarthritis (OA), the hyaluronic acid in the affected joint thins. And the molecular size of the Hyaluronic acid became smaller. It is like the engine oil of a Mercedes versus a taxi.
Hyaluronic acid injections add to our body’s natural supply. Sometimes your doctors might refer to these injections as “viscosupplementation,” which literally means they help the fluid in your joints.
Should You Try Hyaluronic Acid Injections?
Doctors can’t predict who will benefit from hyaluronic acid injections. But for patients with degenerative knees whose symptoms did not get better with painkillers or non-drug treatments such as heat or ice, injection is a valid option. And many of these patients improve significantly.
Hyaluronic injections are also often tried by people who cannot take painkillers due to various side effects, or who have conditions not severe enough to warrant (or not yet ready psychologically) total knee replacement surgery.
How Effective Are Hyaluronic Acid Injections for Osteoarthritis?
Studies show Hyaluronic acid injections may work better than painkillers for some people with degenerative knees. Other studies have shown they also may work as well as corticosteroid injections. But it is almost universally accepted that Hyaluronic Acid had therapeutic effect, that last for a significant period of time.
Hyaluronic acid injections seem to work better in some people than others. They may be less effective in older adults and people with severe degeneration (OA).
透明質酸 (也有人稱它為玻尿酸) 是關節液中的天然成分，有助於潤滑關節和吸收衝擊力。透明質酸分子能把普通液體轉化為具有有趣特徵的“非牛頓”流體。當關節緩慢滑動時，它充當液態潤滑劑。當運動突然發生時，它立即形成啫哩一樣的半固態並吸收震動。有了這樣的特殊功能，我們的關節才能正常使用。
當我們患有退化性關節炎（英文OsteoArthritis簡稱OA）時，受影響關節中的透明質酸會變得黏度不足。透明質酸的分子結構變小。就像Benz與的士的機油一樣，雖然同是機油，但效果可以是天與地。
注射透明質酸（打啫喱針）可增加關節的自然供應。您的醫生可能會將這些注射劑稱為“啫哩”，這實際上“打啫哩”是指”透明質酸這注射非牛頓流體”。
您應該嘗試注射透明質酸嗎？
醫生無法預測誰會在打透明質酸針後有理想改善。但是對於患有膝關節退化病的患者，如果使用止痛藥或非藥物療法（例如熱敷，冰敷或穿戴護膝）後症狀並未好轉，則注射是一種有效的選擇。很多患者在注射透明質酸後都匯報許多明顯改善。
對於因為副作用而無法服用止痛藥，或者病情不是嚴重到需要（或尚未有心理準備）做全膝關節置換手術的病人，也可嘗試使用透明質酸作緩時處理。
透明質酸補充液對骨關節炎有效嗎？
醫學研究發現，對於某些膝蓋退化的病人，打透明質酸針劑 可能比止痛藥更有效。部份研究表明透明質酸針劑可能與注射類固醇一樣有效止痛但沒有類固醇的風險。現在醫學界普遍認為，透明質酸具有治療作用並持續相當長的時間。
透明質酸注射劑似乎在某些人中比其他人更有效。它們在老年人和嚴重變性（OA）患者中可能無效。
Indication 適應症
Application can be done for 在以下情況下可以考慮使用透明質酸
- Degenerative Knee 退化性膝關節炎
- Knee Crepitation 膝蓋活動有聲
- Wrist Osteoarthritis 手腕退化性關節炎
- Hallux rigidus 大腳趾退化性關節炎
- After knee arthroscopy膝關節鏡手術後
Preparation 預備
- Avoid anti-inflammatory drug for 2 weeks 注射前2星期避免服用消炎藥
- Keep moving the limb to avoid stiffness 堅持多活動，避免僵化
- Continue usual medication on injection day 注射當天照常食藥
- No need for fasting 注射前無需禁食
- If injection is over the lower limb, bring a hiking stick 如果注射位置是下肢，帶備行山手仗
Risk 風險
While all medical and nursing professionals endeavor to provide best and safest practice, complications still would occur.
General operative risks including infection, bruises, persistent swelling, pain, stiffness and redness related to reflex sympathetic dystrophy, etc, is possibly encountered but extremely rare.
Transient inflammation of the joint is seen infrequently.
Blood vessel and nerve injury might cause loss of sensation or movement over the limb, but is extremely rare. Anatomical variants also carry more risk.
Recurrence or persistent of symptom is around 20%, but this might be the natural course of the disease rather than complication.
儘管醫生和護士都會盡最大努力提供最佳和最安全的治療，但併發症仍會發生。
一般手術可能會遇到的風險，包括感染，瘀血，關於區域性神經紊亂相關的患肢持續性紅腫僵硬疼痛等，這手術也不例外。
短暫性關節紅熱腫脹偶有發生，通常沒有後果。
血管及神經線損傷是很罕見的風險。可能會引致肢體觸感受損以及乏力。先天結構異常會有更高的風險。
持續病癥不改善或復發機率大概為20%，但這屬疾病的自然進程，不屬併發症。
Budget Estimation 預算費用
CPT code and RVU is as follows
- 20610 Injection of Hyaluronic Acid into joint, Arthrocentesis, aspiration, and/or injection; major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa] RVU 0.79
CPT碼和RVU如下
- 20610 注射透明質酸，RVU 0.79
Estimation based in Aug-2020,
- Surgeon fee $3,600 (3 injections); $1,300 (single injection)
- Consultation fee $1,200
- Drug cost $3,900 (3 injections); $5,200 (single injection)
Total $8,700 (3 injections); $7,700 (single injection) around
根據於2020年8月進行的估算，
- 外科醫生費$3,600 (3針); $1,300 (單針)
- 診金$1,200;
- 物料費 $3,900 (3針); $5,200 (單針)
總計$ 8,700 (3針); $7,700 (單針) 約數
Post-injection care 注射後料理
- The wound is covered by a waterproof dressing. You can shower with it. Keep the dressing intact for 1 day then remove it by yourself.
- Gently move the injected body part few times a day through the full motion range, to avoid stiffness.
- No exercise for the injected body part for 6 weeks. Avoid lift heavy things (for upper limb) or walking too much (for lower limb).
- 傷口已用防水敷料覆蓋。 你可以照常淋浴。保持敷料1天，然後自己將其移除。
- 每天把患肢全幅位運動幾次，以避免僵硬。
- 注射的身體部位在6週內不要運動。 避免舉重（對於上肢）或走太多路或樓梯（對於下肢）。
Early Post-op Complication 手術後早期併發症
Notify surgeon in case you have
- Persistent fever of more than 37.5 Celcius
- Chills and rigor
- Wound pain despite rest
- Wound redness and swelling
- Purulent discharge from wound
如發現以下情況，要立即通知醫生
- 持續高燒（口探高於攝氏37.5度）
- 發冷打顫
- 無論運動或休息時，傷口痛楚都持續增加
- 傷口持續發紅腫脹
- 傷口有膿液
Rehabilitation after 6 weeks 手術後6週復健
Range of Motion Exercise:
- Continue full range of motion exercise, gradual stretching to gain additional range.
Strengthening:
- Gradual increase in weight and number of repetition.
活動範圍運動:
- 全幅度活動，並逐漸拉伸，增加活動範圍。
肌力訓練：
- 逐漸增加重量及重複次數
- Roy Altman, Josh Hackel, Faizan Niaze, et al. Efficacy and safety of repeated courses of hyaluronic acid injections for knee osteoarthritis: A systematic review Semin Arthritis Rheum 2018 Oct 48(2):168-175
- Dongjun Shen, Maoxi Chen, Kai Chen, et al. Efficacy of hyaluronic acid after knee arthroscopy: A systematic review and meta-analysis. J Rehabil Med 2018 Nov 7;50(10)860-865