Steroid Injections of the Hip, Knee May Damage Joints

This is for our readers that treat chronic pain patients.

Corticosteroid injections used to treat osteoarthritis (OA) pain in the hip and knee may be more dangerous than previously thought, according to a study published in Radiology.

Researchers suggested that injection-associated risks like rapid progressive OA, which may eventually lead to joint collapse, should be integrated into consent forms so that patients are aware of the potential risks associated with these treatments.

“We have been telling patients that even if these injections do not relieve your pain, they are not going to hurt you,” said Ali Guermazi, MD, Boston University School of Medicine, Boston, Massachusetts. “But now we suspect that this is not necessarily the case.”

For the study, Andrew Kompel, MD, Boston University School of Medicine, and colleagues conducted a review of existing literature on complications after treatment with corticosteroid injections.

The researchers identified 4 main adverse findings: accelerated OA progression with loss of the joint space, subchondral insufficiency fractures, complications from osteonecrosis, and rapid joint destruction including bone loss.

Based on these findings, the researchers recommend careful scrutiny of patients with mild or no OA 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 OA after injections.

They also stated that physicians may want to reconsider a planned injection when a patient has an acute change in pain not explained by x-rays, as an underlying condition affecting joint health may be ongoing.

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,” said Dr. Guermazi. “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, he added.

“Intra-articular joint injection of steroids is a very common treatment for OA-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 concluded. “What we wanted to do with our [study] is to tell physicians and patients to be careful, because these injections are likely not as safe as we thought.”