How cortisone injections accelerate the need for a joint replacement

Marc Darrow MD,JD  Thank you for reading my article. To answer some of your questions:
Stem cell and PRP injections for musculoskeletal conditions are NOT FDA APPROVED. We do not treat disease. We do not offer stem cell IV treatments. There are no guarantees that these treatments will help you. Prior to our treatment, seek advice from your medical physician. There is controversy in the medical community about whether umbilical cord blood stem cells are alive or dead, and which type of stem cell may be appropriate. If you have questions please call our office at 310-231-7000

“Adverse joint events after intra-articular corticosteroid injection, including accelerated osteoarthritis progression, subchondral insufficiency fracture, complications of osteonecrosis, and rapid joint destruction with bone loss, are becoming more recognized by physicians, including radiologists, who may consider adding these risks to the patient consent.” This comes from a brand new study from the Department of Radiology, Boston University School of Medicine, published in the journal Radiology (1) Research October 15, 2019.

“What we wanted to do with our paper is to tell physicians and patients to be careful, because these injections are likely not as safe as we thought.”

In the accompanying press release issued by the Radiological Society of North America, the publishers of the journal Radiology, lead researcher of the study Ali Guermazi, M.D., Ph.D., professor of radiology and medicine at Boston University School of Medicine, found that corticosteroid injections may be associated with complications that potentially accelerate the destruction of the joint and may hasten the need for total hip and knee replacements.

“We’ve been telling patients that even if these injections don’t relieve your pain, they’re not going to hurt you,” Dr. Guermazi said. “But now we suspect that this is not necessarily the case.”

In a review of existing literature on complications after treatment with corticosteroid injections, Dr. Guermazi and colleagues identified four main adverse findings: accelerated osteoarthritis progression with loss of the joint space, subchondral insufficiency fractures (stress fractures that occur beneath the cartilage), complications from osteonecrosis (death of bone tissue), and rapid joint destruction including bone loss.

The researchers recommend careful scrutiny of patients with mild or no osteoarthritis on X-rays who are referred for injections to treat joint pain, especially when the pain is disproportionate to the imaging findings. Prior research has shown that these patients are at risk of developing rapid progressive joint space loss or destructive osteoarthritis after injections. Physicians may also want to reconsider a planned injection when the patient has acute change in pain not explained by X-rays as some underlying condition affecting joint health may be ongoing, the researchers said. Most importantly, younger patients and patients earlier in the course of the disease need to be told of the potential consequences of a corticosteroid injection before they receive it.

“Physicians do not commonly tell patients about the possibility of joint collapse or subchondral insufficiency fractures that may lead to earlier total hip or knee replacement,” Dr. Guermazi said. “This information should be part of the consent when you inject patients with intra-articular corticosteroids.”

With corticosteroid injections so widely used, the potential implications of the study are enormous, according to Dr. Guermazi.

“Intra-articular joint injection of steroids is a very common treatment for osteoarthritis-related pain, but potential aggravation of pre-existing conditions or actual side effects in a subset of patients need to be explored further to better understand the risks associated with it,” Dr. Guermazi said. “What we wanted to do with our paper is to tell physicians and patients to be careful, because these injections are likely not as safe as we thought.”

In a study in the Journal of the American Medical Association (JAMA) doctors found that among patients with knee osteoarthritis, an injection of a corticosteroid every three months over two years resulted in significantly greater cartilage volume loss and no significant difference in knee pain compared to patients who received a placebo injection.

Timothy E. McAlindon, D.M., M.P.H., of Tufts Medical Center, Boston, and colleagues randomly assigned 140 patients with symptomatic knee osteoarthritis with features of synovitis to injections in the joint with the corticosteroid triamcinolone (70 patients) or saline (70 patients) every 12 weeks for two years. The researchers found that injections with triamcinolone resulted in significantly greater cartilage volume loss than did saline and no significant difference on measures of pain. The saline group had three treatment-related adverse events compared with five in the triamcinolone group.(2)

In another new study scientists released their findings on the damaging effects of cortisone on cartilage and the inability of hyaluronic acid to repair this damage when used in combination.

The idea of combining cortisone and hyaluronic acid is that the intra-articular injection of corticosteroids can treat the inflammatory pain of arthritis and the hyaluronic acid can treat the deleterious effect of these steroids on chondrocyte cells (it disintegrates cartilage).

Hyaluronic acid  injections has been suggested as a means to counteract negative side effects through replenishment of synovial fluid that can decrease pain in affected joints. However, combination treatments of steroid and hyaluronic acid have not been completely understood or standardized and are still a matter of concern.(3)  It may be better to avoid this treatment because results are lacking is what the study suggested.

Corticosteroids, like cortisone, are powerful anti-inflammatory substances. They are not used to relieve pain, but rather reduce inflammation, which in turn can lessen a patient’s level of discomfort.

Examples of conditions for which local cortisone injections are used include inflammation of a bursa (bursitis), a tendon (tendonitis), and a joint (arthritis). Knee arthritis, hip bursitis, painful foot conditions such as plantar fasciitis, rotator cuff tendinitis and many other conditions may be treated with cortisone injections.

In a new study from Italy, researchers noted that local  glucocorticoids have shown positive results in some tendinopathies but not in others. moreover, worsening of symptoms, reduction of native healing stem cells in joints , and even spontaneous tendon ruptures has been reported. Several experimental studies suggest that the direct action of glucocorticoids on tendons is detrimental.(4)

Do you have questions? Ask Dr. Darrow



A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. There is controversy in the medical community about whether umbilical cord blood stem cells are alive or dead, and which type of stem cell may be appropriate.

Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

References:

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

2 From the JAMA news department, May 16, 2017

3. Siengdee P, Radeerom T, Kuanoon S, Euppayo T, Pradit W, Chomdej S, Ongchai S, Nganvongpanit K. Effects of corticosteroids and their combinations with hyaluronanon on the biochemical properties of porcine cartilage explants. BMC Vet Res. 2015 Dec 4;11(1):298. doi: 10.1186/s12917-015-0611-6.

4 Abate M, Salini V, Schiavone C, Andia I. Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies. Expert Opin Drug Saf. 2017 Mar;16(3):341-349. doi: 10.1080/14740338.2017.1276561. Epub 2016 Dec 28.

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Patellar tendinopathy treatments

Marc Darrow MD,JD  Thank you for reading my article. To answer some of your questions:
Stem cell and PRP injections for musculoskeletal conditions are NOT FDA APPROVED. We do not treat disease. We do not offer stem cell IV treatments. There are no guarantees that these treatments will help you. Prior to our treatment, seek advice from your medical physician. There is controversy in the medical community about whether umbilical cord blood stem cells are alive or dead, and which type of stem cell may be appropriate. If you have questions please call our office at 310-231-7000

Over the years we have seen a lot of people with knee problems. Many of them with problems of the patellar tendon. They have had many treatments including, cortisone, physical therapy, rest, some of the them wear big braces on their knees. They are doing a consult with me because they are still looking for help. Can stem cell therapy and Platelet Rich Plasma Therapy help them? After an email or a phone call we assesses the person’s situation. If we feel they are a realistic candidate for treatment, they come in for a consultation where we can do an examination and come up with a healing program.

  • PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration. PRP utilizes the blood’s platelets and their healing and tissue repair factors.
  • Stem cell therapy involves the use of your own bone marrow derived stem cells or donated umbilical cord blood derived stem cells. These are explained further in the research below.

Published research on Patellar tendinopathy treatments

A December 2018 study examined the role of mesenchymal stem cells in the treatment of tendinopathies.(1) The investigators of this study wrote: “Although attention was mainly focused on their ability to differentiate and to directly participate to the regeneration process in the past, mesenchymal stem cells (MSCs) have more recently been demonstrated to have further and probably more important therapeutic functions in response to injury like immune modulation and trophic (promoting cellular growth) activities. That is why that they have been defined as “drugstores”. Indeed, they can home in on sites of inflammation or tissue injury and they start to secrete immunomodulatory and trophic agents such as cytokines and growth factors aimed to re-establish physiological homeostasis in response to that environment. (In simpler terms act and an anti-inflammatory and pro-healing agent). So, either as direct player in the process or/and bioactive molecules “drugstores”, mesenchymal stem cells may enhance tissue repair and regeneration and thereby restore normal joint homeostasis.” This research does suggest further studies to validate these positive findings.

A well referenced and cited study from 2012 (2) followed eight mid-20s aged athletes with chronic patellar tendon degeneration. These patients received bone marrow stem cell therapy. The stem cells were taken from the patient’s iliac bone crest and injected into the problem knee. These patients were then followed for 5 years to measure the long-term results of the treatment. Here were the published results:

  • “At 5-year followup, statistically significant improvement was seen for most clinical scores.
  • Seven of eight patients said they would have the procedure again if they had the same problem in the opposite knee and were completely satisfied with the procedure.
  • Seven of 8 patients thought that the results of the procedure were excellent. According to our results, (bone marrow stem cells should be) considered as a potential therapy for those patients with chronic patellar tendinopathy refractory to nonoperative treatments.”

A 2017 study (3) featured the role of umbilical cord blood-mesenchymal stem cells in tendon repair. Here the researchers suggested:

“Emerging cell sources for tendon repair include peripheral blood MSC, umbilical cord blood-mesenchymal stem cells (UCB-MSCs), and periodontal ligament cells. Studies have shown:

  • Allogeneic UCB-MSCs injected into naturally occurring tendinitis of the superficial digital flexor tendon led to higher performance and strength, as well as improved healing as assessed by ultrasound imaging
  • Efficacy of UCB-MSCs in improving tendon-bone healing following anterior cruciate ligament reconstruction has also been demonstrated in a rabbit model.
  • Injection of UCB-MSCs into the interface between the bone tunnel and tendon graft improved the histologic appearance in the bone-tendon interface.

More research is called for, including that which examines the benefit of stem cells for the patella tendon.

PRP RESEARCH

There is limited research as well in the role of PRP in helping patients with patellar tendinopathy. However a 2017 study (4) stated: “These limited studies are encouraging and indicate that PRP injections have the potential to promote the achievement of a satisfactory clinical outcome, even in difficult cases with chronic refractory tendinopathy after previous classical treatments have failed.” One of the studies reviewed was a study from researchers in the Netherlands. In this study, outcomes of patients with patellar tendinopathy treated with platelet-rich plasma injections (PRP) were evaluated to determine whether certain characteristics, such as activity level or previous treatment affected the results. What they found was: “After PRP treatment, patients with patellar tendinopathy showed a statistically significant improvement. In addition, these improvements can also be considered clinically meaningful.”

As stated at the top of this article. We have been offering regenerative medicine injections for more than 20 years. Empirical and in office data shows a benefit for many. Will these treatments work for everyone? No. Email me with the form below so we can assess whether or not these treatments would be viable for you.

Do you have questions? Ask Dr. Darrow



A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
11645 WILSHIRE BOULEVARD SUITE 120, LOS ANGELES, CA 90025

PHONE: (800) 300-9300 or 310-231-7000

Stem cell and PRP injections for musculoskeletal conditions are not FDA approved. We do not treat disease. We do not offer IV treatments. There are no guarantees that this treatment will help you. Prior to our treatment, seek advice from your medical physician. There is controversy in the medical community about whether umbilical cord blood stem cells are alive or dead, and which type of stem cell may be appropriate.

Neither Dr. Darrow, nor any associate, offer medical advice from this transmission. This information is offered for educational purposes only. The transmission of this information does not create a physician-patient relationship between you and Dr. Darrow or any associate. We do not guarantee the accuracy, completeness, usefulness or adequacy of any resource, information, product, or process available from this transmission. We cannot be responsible for the receipt of your email since spam filters and servers often block their receipt. If you have a medical issue, please call our office. If you have a medical emergency, please call 911.

1 Abat F, Alfredson H, Cucchiarini M, Madry H, Marmotti A, Mouton C, Oliveira JM, Pereira H, Peretti GM, Spang C, Stephen J, van Bergen CJA, de Girolamo L. Current trends in tendinopathy: consensus of the ESSKA basic science committee. Part II: treatment options. J Exp Orthop. 2018 Sep 24;5(1):38. doi: 10.1186/s40634-018-0145-5. PMID: 30251203; PMCID: PMC6153202.
2 Pascual-Garrido C,et al. Treatment of chronic patellar tendinopathy with autologous bone marrow stem cells: a 5-year-followup. Stem Cells Int. 2012;2012:953510. doi: 10.1155/2012/953510. Epub 2011 Dec 18.
3 Liu L, Hindieh J, Leong DJ, Sun HB. Advances of stem cell based-therapeutic approaches for tendon repair. J Orthop Translat. 2017 Apr 13;9:69-75. doi: 10.1016/j.jot.2017.03.007. PMID: 29662801; PMCID: PMC5822968.
4. Gosens T, Den Oudsten BL, Fievez E, van ‘t Spijker P, Fievez A. Pain and activity levels before and after platelet-rich plasma injection treatment of patellar tendinopathy: a prospective cohort study and the influence of previous treatments.Int Orthop. 2012 Apr 27. [Epub ahead of print]