Skip to main content
SpringerLink
Log in

Hyaluronic Acid for the Treatment of Osteoarthritis in all Joints Except the Knee

What is the Current Evidence?

  • Systematic Review
  • Published:
BioDrugs Aims and scope Submit manuscript

Abstract

Background

The use of intra-articular hyaluronic acid (HA) is a well known treatment in patients with knee osteoarthritis (OA). In other joints, less evidence is available about the efficacy of treatment with intra-articular HA. HA is also used intra-articularly in the metatarsophalangeal-1 joint, the ankle, the hip, the sacroiliac joint, the facet joints, the carpometacarpal-1 joint, the shoulder and the temporo-mandibular joint. In this systematic review we include all prospective studies about the effects of intra-articular HA in the above-mentioned joints. Its use in the knee joint, however, will be discussed in a separate article in this journal.

Methods

A systematic review was conducted using databases including MEDLINE, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register, and EMBASE.

Results

After performing a solid systematic review using a rigid methodology and trying to pool the outcomes of different studies, we noticed that, compared with baseline, there is statistical evidence for a positive effect of intra-articular HA. However, there is limited evidence HA is superior to placebo and no evidence that intra-articular HA is better than corticosteroids or other conservative therapies.

Conclusion

Our recommendation for future research is that one should focus on adequately powered randomized trials comparing HA treatment with other types of intra-articular or conservative treatment. We think it is useless to further perform and publish (large) non-comparative prospective studies about the use of HA in the treatment of problems caused by OA. It is well perceived that HA exerts positive effects in the treatment of OA, but up to now there is no (strong) evidence available that HA is superior to other treatments of OA such as corticosteroids, physiotherapy or other conservative measures.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Table I
Table II
Table III
Table IV
Table V

Similar content being viewed by others

References

  1. Felson D. Epidemiology of hip and knee osteoarthritis. Epidemiol Rev 1988; 10: 1–28

    PubMed  CAS  Google Scholar 

  2. Balazs E. The physical properties of the synovial fluid and the special role of hyaluronic acid. In: Helfet J, editor. Disorders of the knee. 2nd ed. Philidelphia: Lippincott, 1982: 61–74

    Google Scholar 

  3. Sostres C, Cargallo C, Arroyo M, et al. Adverse effects of non-steroidal anti-inflammatory drugs (NSAIDs, aspirin and coxibs) on upper gastrointestinal tract. Best Pract Res Clin Gastroenterol 2010; 24: 121–32

    Article  PubMed  CAS  Google Scholar 

  4. Brophy J. Cardiovascular effects of cyclooxygenase-2 inhibitors. Curr Opin Gastroenterol 2007; 23: 617–24

    PubMed  CAS  Google Scholar 

  5. Zhang W, Moskowitz RW, Nuki G, et al. OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthritis Cartilage 2008; 16 (2): 137–62

    Article  PubMed  CAS  Google Scholar 

  6. Gibbs D, Merrill E, Smith K, et al. Rheology of hyaluronic acid. Biopolymeres 1968; 6: 777–91

    Article  CAS  Google Scholar 

  7. Balazs E. Viscoelastic properties of hyaluronic acid and biological lubrification. Unic Mich Med Ctr J 1968; 9: 255–9

    Google Scholar 

  8. Punzi L, Schiavon F, Cavasin F, et al. The influence of intra-articular hyaluronic acid on PGE2 and cAMP of synovial fluid. Clin Exp Rheumatol 1989; 7 (3): 247–50

    PubMed  CAS  Google Scholar 

  9. Smith M, Ghosh P. The synthesis of hyaluronic acid by human synovial fibroblasts is influenced by the nature of the hyaluronate in the extracellular environment. Rheumatol Int 1987; 7: 113–22

    Article  PubMed  Google Scholar 

  10. Homandberg G, Hui F, Wen C, et al. Hyaluronic acid suppresses fibronectin fragment mediated cartilage chondrolysis: I. in vitro. Osteoarthritis Cartilage 1997; 5 (5): 309–19

    Article  PubMed  CAS  Google Scholar 

  11. Williams J, Plaza V, Hui F, et al. Hyaluronic acid suppresses fibronectin fragment mediated cartilage chondrolysis: II. in vivo. Osteoarthritis Cartilage 1997; 5 (4): 235–40

    Article  PubMed  CAS  Google Scholar 

  12. Belomonte C, Pozo M, Balazs E. Modulation by hyaluronan and its derivates (hylans) of sensory nerve activity signaling articular pain. In: Laurent T, editor. The chemistry, biology and medical applications of hyaluronan and its derivates. London: Portland Press, 1999: 205–17

    Google Scholar 

  13. Frizziero L, Govoni E, Bacchini P. Intra-articular hyaluronic acid in the treatment of osteoarthritis of the knee: clinical and morphological study. Clin Exp Rheumatol 1998; 16: 441–9

    PubMed  CAS  Google Scholar 

  14. Kikuchi T, Yamada H, Fujikawa K. Effects of high molecular weight hyaluronan on the distribution and movement of proteoglycan around chondrocytes cultured in alginate beads. Osteoarthritis Cartilage 2001; 9: 351–6

    Article  PubMed  CAS  Google Scholar 

  15. Bagga H, Burkhardt D, Sambrook P, et al. Long-term effects of intraarticular hyaluronan on synovial fluid in osteoarthritis of the knee. J Rheumatol 2006; 33: 946–50

    PubMed  CAS  Google Scholar 

  16. Stroup DF, Berlin JA, Morton SC, et al. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008–12

    Article  PubMed  CAS  Google Scholar 

  17. Jadad AR, Moore RA, Carroll D, et al. Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 1996; 17: 1–12

    Article  PubMed  CAS  Google Scholar 

  18. Schulz KF, Chalmers I, Grimes DA, et al. Assessing the quality of randomization from reports of controlled trials published in obstetrics and gynecology journals. JAMA 1994; 272: 125–8

    Article  PubMed  CAS  Google Scholar 

  19. Verhagen AP, De Vet HC, De Bie RA, et al. Balneotherapy and quality assessment: interobserver reliability of the Maastricht criteria list and the need for blinded quality assessment. J Clin Epidemiol 1998; 51: 335–41

    Article  PubMed  CAS  Google Scholar 

  20. Mulrow CD, Oxman AD, editors. Cochrane Collaboration Handbook. In: The Cochrane Library [database on disk and CDROM]. Oxford: Cochrane Collaboration. Update Software: 1999

  21. Bragantini A, Molinaroli F. A pilot clinical evaluation of the treatment of hip osteoarthritis with hyaluronic acid. Clin Ther Res 1994; 55: 319–30

    Article  Google Scholar 

  22. Brocq O, Tran G, Breuil V, et al. Hip osteoarthritis: short-term efficacy and safety of viscosupplementation by hylan G-F 20. An open-label study in 22 patients. Joint Bone Spine 2002; 69: 388–91

    Article  PubMed  Google Scholar 

  23. Migliore A, Martin LS, Alimonti A, et al. Efficacy and safety of viscosupplementation by ultrasound-guided intra-articular injection in osteoarthritis of the hip. Osteoarthritis Cartilage 2003; 11 (4): 305–6

    Article  PubMed  CAS  Google Scholar 

  24. Vad VB, Sakalkale D, Sculco TP, et al. Role of hylan G-F 20 in treatment of osteoarthritis of the hip joint. Arch Phys Med Rehabil 2003; 84 (8): 1224–6

    Article  PubMed  Google Scholar 

  25. Conrozier T, Bertin P, Mathieu P, et al. Intra-articular injections of hylan G-F 20 in patients with symptomatic hip osteoarthritis: an open-label, multicentre, pilot study. Clin Exp Rheumatol 2003; 21 (5): 605–10

    PubMed  CAS  Google Scholar 

  26. Caglar-Yagci H, Unsal S, Yagci I, et al. Safety and efficacy of ultrasound-guided intra-articular hylan G-F 20 injection in osteoarthritis of the hip: a pilot study. Rheumatol Int 2005; 25 (5): 341–4

    Article  PubMed  CAS  Google Scholar 

  27. Berg P, Olsson U. Intra-articular injection of non-animal stabilized hyaluronic acid (NASHA) for osteoarthritis of the hip: a pilot study. Clin Exp Rheumatol 2004; 22: 300–6

    PubMed  CAS  Google Scholar 

  28. Tikiz C, Unlü Z, Sener A, et al. Comparison of the efficacy of lower and higher molecular weight viscosupplementation in the treatment of hip osteoarthritis. Clin Rheumatol 2005; 24 (3): 244–50

    Article  PubMed  Google Scholar 

  29. Pourbagher MA, Ozalay M, Pourbagher A. Accuracy and outcome of sonographically guided intra-articular sodium hyaluronate injections in patients with osteoarthritis of the hip. J Ultrasound Med 2005; 24 (10): 1391–5

    PubMed  Google Scholar 

  30. Migliore A, Tormenta S, Valente C, et al. Intra-articular treatment with Hylan G-F 20 under ultrasound guidance in hip osteoarthritis. Clinical results after 12 months follow-up. Reumatismo 2005; 57 (1): 36–43

    PubMed  CAS  Google Scholar 

  31. Migliore A, Tormenta S, Massafra U, et al. Repeated ultrasound-guided intra-articular injections of 40 mg of Hyalgan® may be useful in symptomatic relief of hip osteoarthritis. Osteoarthritis Cartilage 2005; 13: 1126–7

    Article  PubMed  CAS  Google Scholar 

  32. Migliore A, Tormenta S, Martin LS, et al. Open pilot study of ultrasound-guided intra-articular injection of hylan G-F 20 (Synvisc) in the treatment of symptomatic hip osteoarthritis. Clin Rheumatol 2005; 24: 285–9

    Article  PubMed  Google Scholar 

  33. Migliore A, Tormenta S, Martin LS, et al. The symptomatic effects of intra-articular administration of hylan G-F 20 on osteoarthritis of the hip: clinical data of 6 months follow-up. Clin Rheumatol 2006; 25: 389–93

    Article  PubMed  Google Scholar 

  34. Van Den Bekerom MP, Mylle G, Rys B, et al. Viscosupplementation in symptomatic severe hip osteoarthritis: a review of the literature and report on 60 patients. Acta Orthop Belg 2006 Oct; 72 (5): 560–8

    Google Scholar 

  35. Conrozier T, Bertin P, Bailleul F, et al. Clinical response to intra-articular injections of hylan G-F 20 in symptomatic hip osteoarthritis: the OMER-ACT-OARSI criteria applied to the results of a pilot study. Joint Bone Spine 2006; 73 (6): 705–9

    Article  PubMed  CAS  Google Scholar 

  36. Qvistgaard E, Christensen R, Torp-Pedersen S, et al. Intra-articular treatment of hip osteoarthritis: a randomized trial of hyaluronic acid, corticosteroid, and isotonic saline. Osteoarthritis Cartilage 2006 Feb; 14 (2): 163–70

    Article  PubMed  CAS  Google Scholar 

  37. Migliore A, Tormenta S, Massafra U, et al. 18 month observational study on efficacy of intraarticular hyaluronic acid (Hylan G-F 20) injections under ultrasound guidance in hip osteoarthritis. Reumatismo 2006; 58 (1): 39–49

    PubMed  Google Scholar 

  38. Gaston MS, Tiemessen CH, Philips JE. Intra-articular hip viscosupplementation with synthetic hyaluronic acid for osteoarthritis: efficacy, safety and relation to pre-injection radiographs. Arch Orthop Trauma Surg 2007; 127 (10): 899–903

    Article  PubMed  CAS  Google Scholar 

  39. Migliore A, Tormenta S, Massafra U et al. Intra-articular administration of hylan G-F 20 in patients with symptomatic hip osteoarthritis: tolerability and effectiveness in a large cohort study in clinical practice. Curr Med Res Opin 2008; 24 (5): 1309–16

    Article  PubMed  CAS  Google Scholar 

  40. Van den Bekerom MP, Rys B, Mulier M. Viscosupplementation in the hip: evaluation of hyaluronic acid formulations. Arch Orthop Trauma Surg 2008 Mar; 128 (3): 275–80

    Article  PubMed  Google Scholar 

  41. Rennesson-Rey B, Rat AC, Chary-Valckenaere I, et al. Does joint effusion influence the clinical response to a single Hylan GF-20 injection for hip osteoarthritis? Joint Bone Spine 2008; 75 (2): 182–8

    Article  PubMed  Google Scholar 

  42. Diraço D, Alptekin K, Teksöz B, et al. Knee vs hip single-joint intra-articular hyaluronic acid injection in patients with both hip and knee osteoarthritis: a pilot study. Clin Rheumatol 2009; 28 (9): 1021–4

    Article  Google Scholar 

  43. Richette P, Ravaud P, Conrozier T, et al. Effect of hyaluronic acid in symptomatic hip osteoarthritis: a multicenter, randomized, placebo-controlled trial. Arthritis Rheum 2009 Mar; 60 (3): 824–30

    Article  PubMed  CAS  Google Scholar 

  44. Conrozier T, Couris CM, Mathieu P, et al. Safety, efficacy and predictive factors of efficacy of a single intra-articular injection of non-animal-stabilized-hyaluronic-acid in the hip joint: results of a standardized follow-up of patients treated for hip osteoarthritis in daily practice. Arch Orthop Trauma Surg 2009; 129 (6): 843–8

    Article  PubMed  Google Scholar 

  45. Migliore A, Massafra U, Bizzi E, et al. Comparative, double-blind, controlled study of intra-articular hyaluronic acid (Hyalubrix) injections versus local anesthetic in osteoarthritis of the hip. Arthritis Res Ther 2009; 11 (6): R183

    Article  PubMed  Google Scholar 

  46. Migliore A, Massafra U, Bizzi E, et al. Intra-articular injection of hyaluronic acid (MW 1.500–2.000 kDa; HyalOne®) in symptomatic osteoarthritis of the hip: a prospective cohort study. Arch Orthop Trauma Surg 2011; 131 (12): 1677–85

    Article  PubMed  Google Scholar 

  47. Atchia I, Kane D, Reed MR, et al. Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis. Ann Rheum Dis 2011 Jan; 70 (1): 110–6

    Article  PubMed  Google Scholar 

  48. Leardini G, Perbellini A, Franceschini M, et al. Intra-articular injections of hyaluronic acid in the treatment of painful shoulder. Clin Ther 1988; 10 (5): 521–6

    PubMed  CAS  Google Scholar 

  49. Silverstein E, Leger R, Shea KP. The use of intra-articular hylan G-F 20 in the treatment of symptomatic osteoarthritis of the shoulder: a preliminary study. Am J Sports Med 2007; 35 (6): 979–85

    Article  PubMed  Google Scholar 

  50. Blaine T, Moskowitz R, Udell J, et al. Treatment of persistent shoulder pain with sodium hyaluronate: a randomized, controlled trial. A multicenter study. J Bone Joint Surg Am 2008; 90 (5): 970–9

    Article  PubMed  Google Scholar 

  51. Noël E, Hardy P, Hagena FW, et al. Efficacy and safety of Hylan G-F 20 in shoulder osteoarthritis with an intact rotator cuff. Open-label prospective multicenter study. Joint Bone Spine 2009; 76 (6): 670–3

    Article  PubMed  Google Scholar 

  52. Brander VA, Gomberawalla A, Chambers M, et al. Efficacy and safety of hylan G-F 20 for symptomatic glenohumeral osteoarthritis: a prospective, pilot study. PM R 2010; 2 (4): 259–67

    Article  PubMed  Google Scholar 

  53. Tagliafico A, Serafini G, Sconfienza LM, et al. Ultrasound-guided viscosupplementation of subacromial space in elderly patients with cuff tear arthropathy using a high weight hyaluronic acid: prospective open-label non-randomized trial. Eur Radiol 2011; 21 (1): 182–7

    Article  PubMed  Google Scholar 

  54. Salk RS, Chang TJ, D’Costa WF, et al. Sodium hyaluronate in the treatment of osteoarthritis of the ankle: a controlled, randomized, double-blind pilot study. J Bone Joint Surg Am 2006; 88 (2): 295–302

    Article  PubMed  Google Scholar 

  55. Sun SF, Chou YJ, Hsu CW, et al. Efficacy of intra-articular hyaluronic acid in patients with osteoarthritis of the ankle: a prospective study. Osteoarthritis Cartilage 2006; 14 (9): 867–74

    Article  PubMed  Google Scholar 

  56. Cohen MM, Altman RD, Hollstrom R, et al. Safety and efficacy of intra-articular sodium hyaluronate (Hyalgan) in a randomized, double-blind study for osteoarthritis of the ankle. Foot Ankle Int 2008; 29 (7): 657–63

    Article  PubMed  Google Scholar 

  57. Witteveen AG, Giannini S, Guido G, et al. A prospective multi-centre, open study of the safety and efficacy of hylan G-F 20 (Synvisc) in patients with symptomatic ankle (talo-crural) osteoarthritis. Foot Ankle Surg 2008; 14 (3): 145–52

    Article  PubMed  Google Scholar 

  58. Karatosun V, Unver B, Ozden A, et al. Intra-articular hyaluronic acid compared to exercise therapy in osteoarthritis of the ankle. A prospective randomized trial with long-term follow-up. Clin Exp Rheumatol 2008; 26 (2): 288–94

    PubMed  CAS  Google Scholar 

  59. Luciani D, Cadossi M, Tesei F, et al. Viscosupplementation for grade II osteoarthritis of the ankle: a prospective study at 18 months’ follow-up. Chir Organi Mov 2008; 92 (3): 155–60

    Article  PubMed  Google Scholar 

  60. Witteveen AG, Sierevelt IN, Blankevoort L, et al. Intra-articular sodium hyaluronate injections in the osteoarthritic ankle joint: effects, safety and dose dependency. Foot Ankle Surg 2010; 16 (4): 159–63

    Article  PubMed  Google Scholar 

  61. Mei-Dan O, Kish B, Shabat S, et al. Treatment of osteoarthritis of the ankle by intra-articular injections of hyaluronic acid: a prospective study. J Am Podiatr Med Assoc 2010; 100 (2): 93–100

    PubMed  Google Scholar 

  62. Fuchs S, Mönikes R, Wohlmeiner A, et al. Intra-articular hyaluronic acid compared with corticoid injections for the treatment of rhizarthrosis. Osteoarthritis Cartilage 2006; 14 (1): 82–8

    Article  PubMed  CAS  Google Scholar 

  63. Stahl S, Karsh-Zafrir I, Ratzon N, et al. Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints. J Clin Rheumatol 2005; 11 (6): 299–302

    Article  PubMed  Google Scholar 

  64. Coaccioli S, Pinoca F, Puxeddu A. Short term efficacy of intra-articular injection of hyaluronic acid in osteoarthritis of the first carpometacarpal joint in a preliminary open pilot study. Clin Ter 2006; 157 (4): 321–5

    PubMed  CAS  Google Scholar 

  65. Karalezli N, Ogun TC, Kartal S, et al. The pain associated with intraarticular hyaluronic acid injections for trapeziometacarpal osteoarthritis. Clin Rheumatol 2007; 26 (4): 569–71

    Article  PubMed  Google Scholar 

  66. Roux C, Fontas E, Breuil V, et al. Injection of intra-articular sodium hyaluronidate (Sinovial) into the carpometacarpal joint of the thumb (CMC1) in osteoarthritis: a prospective evaluation of efficacy. Joint Bone Spine 2007; 74 (4): 368–72

    Article  PubMed  CAS  Google Scholar 

  67. Heyworth BE, Lee JH, Kim PD, et al. Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial. J Hand Surg Am 2008; 33 (1): 40–8

    Article  PubMed  Google Scholar 

  68. Bahadir C, Onal B, Dayan VY, et al. Comparison of therapeutic effects of sodium hyaluronate and corticosteroid injections on trapeziometacarpal joint osteoarthritis. Clin Rheumatol 2009; 28 (5): 529–33

    Article  PubMed  Google Scholar 

  69. Salini V, De Amicis D, Abate M, et al. Ultrasound-guided hyaluronic acid injection in carpometacarpal osteoarthritis: short-term results. Int J Immunopathol Pharmacol 2009; 22 (2): 455–60

    Google Scholar 

  70. Mandl LA, Hotchkiss RN, Adler RS, et al. Injectable hyaluronan for the treatment of carpometacarpal osteoarthritis: open label pilot trial. Curr Med Res Opin 2009; 25 (9): 2103–8

    Article  PubMed  CAS  Google Scholar 

  71. Fuchs S, Erbe T, Fischer HL, et al. Intraarticular hyaluronic acid versus glucocorticoid injections for nonradicular pain in the lumbar spine. J Vasc Interv Radiol 2005; 16 (11): 1493–8

    Article  PubMed  Google Scholar 

  72. Cleary M, Keating C, Poynton AR. Viscosupplementation in lumbar facet joint arthropathy: a pilot study. J Spinal Disord Tech 2008; 21 (1): 29–32

    Article  PubMed  Google Scholar 

  73. DePalma MJ, Ketchum JM, Queler ED, et al. Prospective pilot study of painful lumbar facet joint arthropathy after intra-articular injection of hylan G-F 20. PM R 2009; 1 (10): 908–15

    Article  PubMed  Google Scholar 

  74. Srejic U, Calvillo O, Kabakibou K. Viscosupplementation: a new concept in the treatment of sacroiliac joint syndrome: a preliminary report of four cases. Reg Anesth Pain Med 1999; 24 (1): 84–8

    PubMed  CAS  Google Scholar 

  75. Pons M, Alvarez F, Solana J, et al. Sodium hyaluronate in the treatment of hallux rigidus: a single-blind, randomized study. Foot Ankle Int 2007; 28 (1): 38–42

    Article  PubMed  Google Scholar 

  76. Colen S, van den Bekerom MP, Bellemans J, et al. Comparison of intra-articular injections of hyaluronic acid and corticosteroid in the treatment of osteoarthritis of the hip in comparison with intra-articular injections of bupivacaine: design of a prospective, randomized, controlled study with blinding of the patients and outcome assessors. BMC Musculoskelet Disord 2010; 16 (11): 264

    Article  Google Scholar 

Download references

Acknowledgments

The authors thank Atchia et al.[47] for providing additional data. In November 2010 our team received funding from TRB Chemedica AG, Haar, Germany to pay the article processing charge for their protocol “Comparison of intra-articular injections of Hyaluronic Acid and Corticosteroid in the treatment of Osteoarthritis of the hip in comparison with intra-articular injections of bupivacaine. Design of a prospective, randomized, controlled study with blinding of the patients and outcome assessors”. TRB Chemedica AG had absolutely no role in the design of this review, in the inclusion of articles in this review, in the analysis and interpretation of the data from this study, in the writing of the manuscript, or in the decision to submit the manuscript for publication.

Author information

Authors and Affiliations

  1. Department of Orthopaedic Surgery, University Hospitals Leuven, Pellenberg site, Weligerveld 1, 3212, Pellenberg, Belgium

    Sascha Colen & Michiel Mulier

  2. Department of Orthopaedic Surgery, Slotervaart Hospital, Amsterdam, The Netherlands

    Daniel Haverkamp

  3. Department of Orthopaedic Surgery, Spaarne Hospital, Hoofddorp, The Netherlands

    Michel P. J. van den Bekerom

Authors
  1. Sascha Colen
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Daniel Haverkamp
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Michiel Mulier
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Michel P. J. van den Bekerom
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sascha Colen.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Colen, S., Haverkamp, D., Mulier, M. et al. Hyaluronic Acid for the Treatment of Osteoarthritis in all Joints Except the Knee. BioDrugs 26, 101–112 (2012). https://doi.org/10.2165/11630830-000000000-00000

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.2165/11630830-000000000-00000

Keywords

Search

Navigation