Intra-Articular Injections to Treat Joint Disorders

Musculoskeletal Injections: A Review of the Evidence

Intra-Articular Injections to Treat Joint Disorders

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Joint Injections: Are They Worth the Risk?

Intra-Articular Injections to Treat Joint Disorders

Intra-articular injections of corticosteroids for relief of the pain of hip or knee osteoarthritis (OA) may have adverse long-term consequences, researchers suggested.

These injections are commonly performed and have been “conditionally” recommended by the American College of Rheumatology and “should be considered,” according to the Osteoarthritis Research Society International.

The American Academy of Orthopedic Surgeons, however, has advised clinicians to be on the lookout for emerging evidence for or against the use of intra-articular injections in the knee, explained Ali Guermazi, MD, PhD, of Boston University School of Medicine, and colleagues.

However, a review of the outcomes following 459 injection procedures performed during 2018 in a single center now has identified four potential adverse events that should raise concerns, particularly for certain patients:

  • Accelerated OA progression, reported in 6% of patients
  • Subchondral insufficiency fractures, seen in 0.9%
  • Complications of osteonecrosis, in 0.7%
  • Rapid joint destruction including bone loss, also in 0.7% of patients

These findings were published in Radiology.

The Background

A Cochrane meta-analysis evaluated 27 trials that included more than 1,767 patients found moderate improvements in pain and slight benefits for physical function following intra-articular corticosteroid injections for knee OA. However, the review noted that the quality of evidence was low, concluding that the results were inconclusive.

“Whether there are clinically important benefits of intra-articular corticosteroids after 1 to 6 weeks remains unclear in view of the overall quality of the evidence, considerable heterogeneity between trials, and evidence of small-study effects,” the Cochrane reviewers wrote.

In an editorial accompanying the Boston University report, Richard Kijowski, MD, of the University of Wisconsin in Madison, wrote, “The use of intra-articular corticosteroid injection to treat OA remains commonplace in clinical practice despite the lack of strong evidence supporting its efficacy.”

In vitro and animal research has revealed that corticosteroids actually can have negative effects on cartilage. “The action by which corticosteroids are chondrotoxic is complex, but it seems to affect cartilage proteins (especially aggrecan, type II collagen, and proteoglycan) by mediating protein production and breakdown,” Guermazi and colleagues explained.

Moreover, the local anesthetics often combined with the steroids also have been linked with chondrolysis.

And a recent retrospective study of 70 patients with hip OA found that 44% of patients who were given injections of triamcinolone with ropivacaine had radiographic progression and 17% experienced collapse of the articular surface.

“Thus, there is a growing body of evidence to suggest that intra-articular corticosteroid injection can accelerate the progression of joint degeneration,” Kijowski observed.

The Events

The injection protocol used at Boston University involved 40 mg triamcinolone, 2 mL of 1% lidocaine, and 2 mL of 0.25% bupivacaine.

Accelerated OA progression, characterized by rapid loss of radiographic joint space, was first observed in trials of nerve growth inhibitors, wherein some patients required joint replacement earlier than had been expected. Some experts have suggested that a loss of joint space exceeding 2 mm within a year can be considered accelerated progression, which can be accompanied by effusions, synovitis, and local soft tissue changes.

This accelerated OA progression was seen in 26 patients, following hip injections in 21 patients and knee injections in five.

Subchondral insufficiency fractures were the second type of adverse outcome observed, and were seen in four patients undergoing intra-articular hip injections. This event was previously thought to occur in elderly patients with osteopenia, but has now been reported in younger, active patients who present with acute pain but no apparent trauma.

The affected area often is weight-bearing and may involve loss of cartilage and meniscal tearing.

Radiographic findings can be normal or subtle, while on magnetic resonance imaging (MRI) subchondral hypointensity may be detected.

If the condition is identified early, before articular collapse has occurred, healing can occur, but once the articular surface has collapsed, the joint must be replaced.

Early identification of subchondral insufficiency fractures also is crucial before intra-articular injections, because the steroid may interfere with resolution of the fracture. Moreover, if an injection is performed and results in pain alleviation, the patient may increase weight-bearing and worsen the insufficiency fracture, hastening collapse.

The third type of event the researchers identified involved complications of osteonecrosis, which typically present with insidious onset of pain or can be asymptomatic. MRI is required for the diagnosis, and can help predict collapse by the extent of osteonecrosis and bone marrow edema. Once collapse has occurred, the only option is joint replacement.

The fourth adverse outcome, rapid joint destruction including bone loss (also referred to as rapidly progressive OA type 2), occurred in two patients with hip injections and one following a knee injection. Some previous authors ned this event to accelerated osteonecrosis, and others have hypothesized that the joint destruction results from undiagnosed subchondral insufficiency fractures.

The Advice

There are currently no recommendations regarding imaging before performing an intra-articular corticosteroid injection, and in some cases, findings may be subtle.

“However, given the relative ease of performance and the low cost of radiography, there should be a low threshold to obtain radiographs before performing an intra-articular corticosteroid injection, as the intervention may affect the disease course (i.e., it may result in accelerated progression),” Guermazi and colleagues wrote.

Of particular concern are patients who have no apparent OA or very mild changes on radiographs who have been referred for injections because of pain. In these cases, the indication for injection should be “closely scrutinized,” as destructive or rapidly progressive joint space loss tends to develop in patients with severe pain but minimal structural change on radiographs.

“Clinicians should consider obtaining a repeat radiograph before each subsequent intra-articular injection to evaluate for progressive narrowing of the joint space and any interval changes in the articular surface that can indicate subchondral insufficiency fracture or type 1 or 2 rapidly progressive OA,” the authors advised.

“We believe that certain patient characteristics, including but not limited to acute change in pain not explained by using radiography and no or only mild OA at radiography, should lead to careful reconsideration of a planned intra-articular corticosteroid injection,” the authors concluded, adding that MRI may be helpful in these circumstances.

“Patients might be more than willing to take the small risk of an adverse joint event requiring eventual joint replacement for the possibility of at least some degree of pain relief after intra-articular corticosteroid injection,” wrote Kijowski.

“However, patients have the right to make this decision for themselves,” he stated.

Last Updated October 15, 2019

Source: https://www.medpagetoday.com/rheumatology/arthritis/82753

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Steroid injections to treat arthritis pain may worsen joint damage

Intra-Articular Injections to Treat Joint Disorders

“Cortisone injections for hip and knee pain are more dangerous than was thought,” reports The Telegraph.

The headline follows a study looking into the effects of steroid injections (also called corticosteroid injections) in the hip and knee.

Steroid injections in joints are intended to relieve joint pain by reducing inflammation. In the UK, you may be offered this type of injection if you have moderate to severe pain from osteoarthritis.

Doctors in the US reviewed results from a group of 459 patients who had a steroid injection into their hip or knee joint during 2018. They found 8% of patients had problems after an injection, including worsening pain and breakdown of cartilage in the joint.

They warn that steroid injections are “perhaps not as safe as we thought” and say that people should be warned about the possibility that a steroid injection might make their joint symptoms worse.

This research raises questions about how thoroughly the safety of steroid injections into hip and knee joints has been assessed, and about whether these injections are suitable for everyone.

However, this study has too many limitations to form any reliable conclusions. Large-scale, long-term studies are needed to give us an accurate picture of the possible risk of joint damage after injections.

Find out more about treatments for osteoarthritis

Where did the story come from?

The researchers who carried out the study were from Boston University School of Medicine in the US.

The study was published in the peer-reviewed medical journal Radiology on an open-access basis and is free to read online.

It was covered by several media outlets. Metro focused on potential risks to elite athletes, warning they “may suffer devastating long-term effects” from steroid injections. However, the treatment is used far more widely to treat joint pain in older people with osteoarthritis, and we do not know whether any of the people in the study were elite athletes.

The Telegraph included a section on rheumatoid arthritis, which is a different disease from that focused on in the study.

Mail Online provided a mostly accurate and balanced report, including expert comment that potential complications affected a minority of people.

What kind of research was this?

This was not a formal cohort-study, as the researchers did not do “before and after” scans of all patients, but only arranged for a scan of patients who returned to the hospital for further investigation or treatment after an earlier injection.

This means we cannot put much trust in the figures, as the study was not done according to a standard research protocol.

What did the research involve?

Doctors reviewed patient notes and scan (radiography) results, where available, from 459 patients who had received steroid injections in 2018 (307 hip injections and 152 knee injections). They looked for signs of worsening joint damage on radiography or MRI scans after the injections had been done.

They considered signs of accelerated progression of osteoarthritis, bone damage below the joint surface, complications from death of bone cells, and destruction of the joint, including bone loss.

The doctors described the joint problems they found in their patients after steroid injections, and reviewed the previous studies published on the subject.

What were the basic results?

Of the 459 people who had injections:

  • 218 had no follow-up joint scans
  • 30 of 307 (10%) people who received injections into their hip had a joint problem afterwards
  • 6 of 152 (4%) people who received steroid injections into their knee had a joint problem afterwards

The most common problem was accelerated progression of osteoarthritis (26 people), indicated by reduced joint space between the bones because of cartilage loss.

The researchers also found bone damage below the joint surface (4 people), complications from death of bone cells (3 people), and destruction of the joint through bone loss (3 people).

The 36 patients (8%) who had joint problems after the injection ranged from 37 to 79 years of age and had between 1 and 3 injections. Most (72%) had moderate osteoarthritis of the knee or hip.

The researchers said that they did not know whether the problems they found were caused by the injections, or if they were already happening but not obvious on scans when the injections were given.

How did the researchers interpret the results?

The researchers said there was insufficient research into the use of steroid joint injections in the hip or knee to be sure of their safety.

They said: “We believe that certain patient characteristics… should lead to careful reconsideration of a planned IACS [a corticosteroid injection into a joint].”

The characteristics they mention included pain that cannot be explained by radiographic images, no sign of osteoarthritis, or signs of mild osteoarthritis on scans. They also suggest more people should have radiographic or MRI images taken before joint injections, to be sure they do not have existing bone weakness that could be made worse by the injection.

Conclusion

Steroid injections into joints can be a useful way to help to manage joint pain for people with conditions such as osteoarthritis. They have been widely used for years. This study raises questions about how well their safety has been assessed in past research, and about whether they are suitable for everyone.

The study does not tell us that the injections were the cause of the joint damage found. As the researchers say, it is possible that the joint damage was already underway, but not visible at the time the injections were done.

The patients already had osteoarthritis or joint pain when they were referred to the hospital where the study was done. We do not know what would have happened to their joints if they had not received the injections.

The study does not give us an accurate picture of the possible risk of joint damage after steroid injections. This is because not everyone in the study had images taken before and after injections, and images taken after injections were only taken when and if the patient returned to the hospital, not at a set time according to a study protocol.

However, the study does demonstrate that some people who have joint injections go on to have joint damage at a faster rate than expected, which might be linked to the injection. We need large-scale, long-term studies to find out whether the injections are the cause of the damage, and if so, how common this problem is.

Analysis by Bazian
Edited by NHS Website

Source: https://www.nhs.uk/news/medication/steroid-injections/