How Corticosteroid Injections Increases The Risk Of Undergoing Knee Arthroplasty

i

Prajakta Shendge

July 13, 2021

Have you been prescribed a corticosteroid injection for your joint pain?

Read on to find out how these same injections, will increase the risk of requiring a knee arthroplasty.

We have summarized a recent (2020) research paper finding, the scientific discussions, research outcomes, and how these injections have been scientifically proven to increase other side effects as well as, not forgetting how much pain and inconvenience it might bring along.

Intra-articular corticosteroid injections increase the risk of requiring knee arthroplasty
Corticosteroids are a class of drugs that lowers inflammation; they are typically used to treat diseases like arthritis and vasculitis (inflammation of the blood vessels). Intra-articular Corticosteroid injections may be used for the management of pain, although the effect is often temporary. Corticosteroids have a time and dose-dependent effect on articular cartilage. High doses, frequent injections, or both, such as > 3 mg per injection or a cumulative dose of 18 to 24 mg, have been shown to be associated with gross cartilage damage and chondrocyte toxicity. Low doses, such as < 2 mg to 3 mg per injection or a cumulative dose of 8 to 12 mg, have been shown to increase cell growth and recovery from cartilage damage. Corticosteroids are having short-term effects and have many side effects. The safety of recurrent corticosteroid injections, however, remains unknown. Studies dealing with the long-term complications of intra-articular injections have reported contradictory findings.

corticosteriod injection for joint paint

Methods
Study Design

This study used data from the Osteoarthritis Initiative (OAI), It is a multicentre, longitudinal cohort study that included patients with, or at risk of developing, symptomatic OA of the knee. Patients were enrolled between February 2004 and May 2006 in four centres and were followed up for nine years. The present study was conducted and reported according to STROBE guidelines. The patients in the OAI cohort were divided into a progression cohort and an incidence cohort. The progression cohort consisted of patients with symptomatic OA of the knee, defined as having tibial-femoral osteophytes (OARSI (Osteoarthritis Research Society International) atlas grade 1 to 3; definite osteophytes and mild to severe joint space narrowing) at baseline and pain, aching, or stiffness on most days of the month during the previous year. The incidence cohort consisted of patients without symptomatic OA of the knee (OARSI atlas grade 0; no osteophytes or joint space narrowing), but with an increased risk of developing symptomatic OA in one or both knees.

Result

Each injection increased the absolute risk of arthroplasty by 9.4% at nine years’ follow-up compared with patients who did not receive injections. Sensitivity analysis of the unmatched cohort showed a hazard ratio of 2.15 (95% confidence interval 1.96 to 2.38; p < 0.001) for each cumulative injection. The increased risk was defined as either frequent symptoms without radiological evidence of OA, the presence of osteophytes in one or both knees but not in combination with frequent symptoms in the same knee, or at least two additional risk factors for OA.

Treatment regimens for intra-articular injections and arthroplasty might have changed during the study period, which might reduce the generalizability of the findings. We noticed a small increase in the rate of injections and arthroplasty with the passage of time during the study period of nine years. However, this could also be due to the increasing age of the cohort and the progression of OA.

Discussion

Corticosteroid injections seem to be associated with an increased risk of knee arthroplasty in patients with, or at risk of developing, symptomatic OA of the knee. These findings suggest that a conservative approach to injections of corticosteroids into the knee joint to treat symptoms related to OA should be recommended.

Long-lasting, crystalline suspensions of injectable corticosteroids have been used to treat joint and soft-tissue disorders for many years; they decrease inflammation by reducing local infiltration of inflammatory cells and mediators. Depot formulations differ in their characteristics. Compounds with low solubility are thought to have the longest duration of action but may cause tissue atrophy when used in soft tissues. Intra-articular corticosteroids are commonly used to treat osteoarthritis and inflammatory arthritis. Post-injection flare, facial flushing, and skin and fat atrophy are the most common side effects. Systemic complications of injectable corticosteroids are rare. Septic arthritis is the most feared complication following an intra-articular corticosteroid injection.

Hyperglycemia occurs after corticosteroid injections in diabetic patients. Menstrual disturbances are a potential side effect associated with oral corticosteroid administration, and although their occurrence following an intra-articular injection has been suggested, this has not been substantiated by controlled studies. Iatrogenic adrenal suppression may occur following a single intraarticular or soft tissue corticosteroid injection and may last up to 2 weeks, putting patients at risk for an adrenal crisis in cases of trauma, infection, or surgery (1).

Joint sepsis is of the greatest concern, with reported incidences ranging from 1 in 3,000 to 1 in 50,000. Case reports have documented the occurrence of tendon ruptures in patients after corticosteroid injections. The ability of intra-articular injections to suppress the hypothalamicpituitary-adrenal (HPA) axis is well documented. Post-injection pain and flares may be caused by the needle puncture but more commonly are thought to result from chemical synovitis in response to the injected crystals. Facial flushing occurs in up to 15% of patients and is particularly common in women(2).

One week after injection, treated patients were less likely to have continuing pain and had significantly lower scores on a visual analogue scale (VAS) for pain. Three to 4 weeks after injection, treated patients still had significantly less pain, but their VAS scores were no longer significantly lower than scores in the control group. Six to 8 weeks after injection, neither pain reduction nor VAS scores were significantly different between groups. Intra-articular corticosteroid injection results in clinically and statistically significant reduction in osteoarthritic knee pain 1 week after injection. The beneficial effect could last for 3 to 4 weeks but is unlikely to continue beyond that.(3)

Adverse Effects
Systemic
  • Facial flushing
  • Hyperglycemic effect (in diabetic patients
  • Adrenal suppression
  • Menstrual disturbances
Adverse Effects
Local
  • Postinjection flare
  • Postinjection pain
  • Subcutaneous atrophy
  • Skin depigmentation
  • Soft tissue calcifications
Potential Complications
Local
  • Facial flushing
  • Hyperglycemic effect (in diabetic patients
  • Adrenal suppression
  • Menstrual disturbances

References:
1. Injectable Corticosteroids in Modern Practice
Brian J. Cole, MD, MBA, and H. Ralph Schumacher, Jr, MD
2. Injectable Corticosteroids: Take Precautions and Use Caution
Véronique Freire, MD, FRCPC, Nathalie J. Bureau
3. Intra-articular steroid injections for painful knees Systematic review with meta-analysis
Marshall Godwin, MD, MSC, CCPF, FCFP Martin Dawes, MD, FRCGP

Book Your Consultation Today

More From Our Blog