New evidence: Hip, knee steroid injections more dangerous than thought

A new study reveals that commonly given hip and knee steroid intra-articular injections may be harmful in some patients with at-risk conditions or may cause complications that are not well understood. These findings appear online in the journal Radiology.

Study: Accelerated arthritis can be caused by intra-articular corticosteroid injections, Kompel AJ, Roemer FW, Murakami AM, et al. 2019. Boston University School of Medicine. Posted on Youtube Oct 15, 2019

Boston University School of Medicine October 15, 2019

BUSM researchers have found accelerated arthritis and joint destruction can be the unintended result of intra-articular corticosteroid injections.

Osteoarthritis of the hip and knee is among the most common joint disorders. A frequently (thousands per day worldwide) performed treatment for osteoarthritis and other joint related pain syndromes are intra-articular corticosteroid injections, yet there is conflicting evidence on their potential benefit.

The researchers conducted a search on patients they had injected during (2018) in the hips and knees and found out that eight percent had complications, with 10 percent in the hips and four percent in the knees.

Figure 3. Subchondral insufficiency fracture in a 69-year-old woman who presented with acutely worsening knee pain without known trauma.
a. Anteroposterior radiograph of the right knee shows possible medial compartment joint space narrowing (arrows) without osteophytes. There are no signs of osteonecrosis or subchondral insufficiency fracture.
b. Coronal intermediate-weighted fat-suppressed MRI obtained at the same time as a shows a subchondral insufficiency fracture of the medial femoral condyle, without collapse of the articular surface (arrow). In addition, there is marked femoral and tibial bone marrow edema (*). This patient was not treated with conservative measures (ie, switch to non–weight-bearing activity) and received an intra-articular corticosteroid injection.
c. Eleven months later, she returned with continued right knee pain. Repeat anteroposterior radiograph of the right knee shows collapse of the medial femoral condyle articular surface (arrows).
d. Coronal intermediate-weighted MRI acquired at the same time as (c) demonstrates deformity of the articular surface (short arrow) of the medial femoral condyle in the area of a previously noted subchondral insufficiency fracture (long arrow). In addition, there is marked bone marrow edema (*). Kompel AJ, Roemer FW, Murakami AM, et al. 2019

“We are now seeing these injections can be very harmful to the joints with serious complications such as osteonecrosis, subchondral insufficiency fracture and rapid progressive osteoarthritis,” said corresponding author Ali Guermazi MD PhD, chief of radiology at VA Boston Healthcare System and professor of radiology at BUSM. “Intra-articular corticosteroid injection should be seriously discussed for pros and cons. Critical considerations about the complications should be part of the patient consent which is currently not the case right now,” he added.

Given that intra-articular corticosteroid injections are increasingly performed for treatment of pain in hip and knee osteoarthritis, researchers suggest that the radiologic community should actively engage in high-quality research about this topic, to better understand potential at-risk conditions prior to intervention and to better understand potential adverse joint events following these procedures to avoid possible complications.

Source Boston University School of Medicine

  References
Intra-articular Corticosteroid Injections in the Hip and Knee: Perhaps Not as Safe as We Thought? Andrew J. Kompel, Frank W. Roemer, Akira M. Murakami, Luis E. Diaz, Michel D. Crema, Ali Guermazi. Radiology. 2019. Published Online Oct 15 2019. DOI: 10.1148/radiol.2019190341. Full text

Risks and Benefits of Intra-articular Corticosteroid Injection for Treatment of Osteoarthritis: What Radiologists and Patients Need to Know, Richard Kijowski. Radiology. Published Online Oct 15 2019. DOI: 10.1148/radiol.2019192034.

  Further reading
Are patients more likely to have hip osteoarthritis progression and femoral head collapse after hip steroid/anesthetic injections? A retrospective observational study, Simeone FJ, Vicentini JRT, Bredella MA, Chang CY. Skeletal Radiol. 2019 Sep;48(9):1417-1426. doi: 10.1007/s00256-019-03189-x. Epub 2019 Mar 6.

Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial, McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, Ward RJ. JAMA. 2017 May 16;317(19):1967-1975. doi: 10.1001/jama.2017.5283. Full text

Intra-articular corticosteroid for knee osteoarthritis, Jüni P, Hari R, Rutjes AW, Fischer R, Silletta MG, Reichenbach S, da Costa BR. Cochrane Database Syst Rev. 2015 Oct 22;(10):CD005328. doi: 10.1002/14651858.CD005328.pub3. Review. Full text

The Intensive Diet and Exercise for Arthritis (IDEA) trial: design and rationale, Messier SP, Legault C, Mihalko S, Miller GD, Loeser RF, DeVita P, Lyles M, Eckstein F, Hunter DJ, Williamson JD, Nicklas BJ. BMC Musculoskelet Disord. 2009 Jul 28;10:93. doi: 10.1186/1471-2474-10-93. Full text

Also see
Orthopaedic surgeons on the common knee procedure that may cause more harm than good in Evidence Network
Could a common treatment for joint pain do more harm than good? in CBC Health
Steroid Injections of Hip and Knee May Damage Joints in Radiological Society of North America
Knee, Hip Steroid Injections May Speed Joint Damage in Some Patients in Medscape
Steroid Shots for Painful Joints May Make It Worse in WebMD
Steroid injections to treat arthritis pain may worsen joint damage in National Health Service UK
Alternative to cortisone shots in Caring Medical Regenerative Medicine Clinics

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