Intra-articular hip corticosteroid injections do not offer prolonged pain relief or time to THA
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For patients with advanced hip osteoarthritis, intra-articular hip corticosteroid injections will not provide a long-term solution for pain or prolong the time to total hip arthroplasty, according to study results.
Musa Zaid, MD, and colleagues from the department of orthopedic surgery at the University of California, San Francisco, separated patients who had primary hip OA from 2014 to 2019 into three groups: patients who received an image-guided hip corticosteroid injection (CSI) before an ipsilateral THA, patients who received the same hip CSI without ensuing THA, and a control group of patients who underwent THA with no history of hip CSI, according to the study abstract.
“This is the first study of its kind to determine if hip injections prolong the time to total hip arthroplasty for patients being evaluated for surgery,” Zaid told Healio Orthopedics.
After evaluating a total of 390 injections (240 CSI with THA, 150 CSI without THA), researchers found that, “patients who underwent an injection only received short-term pain relief, 47 days on average,” Zaid said. “For patients with advanced osteoarthritis, hip injections did not meaningfully prolong the time to hip replacement; patients who underwent a hip injection had surgery, on average, 4 months later than patients who did not have an injection (11.8 months vs. 7.6 months).” Yet, Zaid noted the 4-month difference may be accounted for by the time it took patients to schedule and receive the injection.
Zaid and colleagues also discovered 6.9% of patients who received hip CSI without a subsequent THA found the injections helpful.
Due to the low satisfaction rate, Zaid said CSI injections should only be considered for patients with medical comorbidities or other contraindications who are poor surgical candidates, as the injections themselves come with risk.
“Surgeons should re-consider offering this as a therapeutic option due to the known increased risk of prosthetic joint infections in patients with a history of previous injections,” Zaid said. “Data from this study may impact how surgeons utilize therapeutic intra-articular hip corticosteroid injections for patients with symptomatic hip osteoarthritis who are good surgical candidates.” – by Max R. Wursta
Disclosure: Zaid reports no relevant financial disclosures.
Reference:
Zaid M, et al. ePaper 016. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 24-28, 2020 (meeting canceled).
Perspective
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William Jiranek, MD, FACS
We read with interest the findings of Dr. Zaid and colleagues from the University of California, San Francisco Medical Center and agree that intra-articular cortisone injection for osteoarthritis of the hip often does not delay the progression to total hip replacement. In fact, we found in the study by Hess and colleagues that in more than 20% of the OA cohort the progression of OA changes was actually hastened by intra-articular injections.
Intra-articular cortisone injection (CSI) to the hip have become relatively common since Faber described the technique using fluoroscopy in 1964. A prior RCT of hip OA patients receiving intra-articular CSI vs. Marcaine (Pfizer) injection alone revealed a significant decrease in pain and stiffness at 3 months in the steroid group. A meta-analysis of the results of intra-articular cortisone injection for symptomatic hip OA concluded that there was limited evidence to support the routine use of intra-articular CSI for hip OA, due to inconsistent results and poor longevity. In addition, a relatively high cost, and an increased risk of bacterial infection weigh against its routine use for hip OA.
It is also not clear that intra-articular hip injection of any other substance, such as hyaluronate or “stem cells,” has successfully treated the symptoms of OA and improved patient outcomes. It is clear that without good data, the use of these injections should be within a well-designed, prospective studies with informed consent and appropriate controls.
As a diagnostic test, however, intra-articular injections (whether with local anesthetic alone, or in conjunction with steroids) of the hip can be very helpful to differentiate true hip pathology from other sources, as well as buying time in cases where more immediate surgery is not an option or comorbidities make surgery too risky. Delivering the medicine into the hip joint is difficult, and most authors recommend fluoroscopy or ultrasound guidance. I suspect that going forward, intra-articular steroid injections to the hip will become less common. Dr. Zaid and colleagues are to be commended for their careful study with important findings.
References:
Hess SR, et al. Arthroplast Today. 2017;doi:10.1016/j.artd.2017.12.002.
Faber U, et al. Med Klin. 1964;59:1348-1351.
Kullenberg B, et al. J Rheumatol. 2004;11:2265-2268.
Chandrasekaran S, et al. J Hip Preserv Surg. 2015;doi:10.1093/jhps/hnv020.
Duke University School of Medicine
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