Abstract
BACKGROUND: Knee osteoarthritis (KOA) is a prevalent degenerative joint disorder causing significant pain and functional impairment. Intra-articular injections (IAI) under ultrasound (US) guidance have emerged as a key treatment for early-to-mid stage KOA due to enhanced precision and localized therapeutic effects. However, the relative efficacy of various injectable agents remains unclear. METHODS: A Bayesian network meta-analysis (BNMA) was conducted following PRISMA guidelines using the following databases: ClinicalTrials.gov, EMBASE, PubMed, Web of Science, Cochrane Library, and the WHO International Clinical Trials Registry Platform (WHO ICTRP), we searched incorporating 14 randomized controlled trials (RCTs) involving 934 patients. Interventions included US-guided injections of platelet-rich plasma (PRP), hyaluronic acid (HA), corticosteroids (CS), ozone (O3), dexamethasone (DX), autologous adipose tissue (AAT), and placebo (PL). Primary outcomes were Visual Analog Scale (VAS) and WOMAC subscale scores. Model consistency, transitivity, and robustness were rigorously assessed. RESULTS: The analysis demonstrated that all active interventions provided significant symptom relief. PRP consistently ranked highest across multiple outcomes, with surface under the cumulative ranking curve (SUCRA) values of 85.86% for total WOMAC score, 78.55% for pain, 93.24% for stiffness, and 90.9% for function. HA showed significant superiority over ozone in pain reduction (SMD: -1.48, 95% CI: -2.71 to -0.24). Model consistency was confirmed (p > 0.05 for all node-splitting tests), and sensitivity analyses supported result stability. No significant publication bias was detected. CONCLUSION: IAI under US-guided has shown good therapeutic effect in the treatment of KOA in the early and middle stages, and PRP has been proved to have the highest therapeutic possibility, followed by HA and CS. These findings support the use of US-guided biologic interventions as part of a comprehensive KOA management strategy, though standardization of protocols and long-term outcomes require further investigation.