Marc Darrow MD, JD 

“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)

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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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