Highlights from

ACR 2020

ACR Convergence 2020

Virtual 5 - 9 November 2020

Steroid injections do not advance the need for joint replacement

Corticosteroid injections are a popular treatment for knee osteoarthritis, but a recent study found an increased risk of disease progression with this treatment. The current study found that corticosteroid injections do not speed up progression to a total knee replacement compared with hyaluronic acid injections.

A recent cohort study suggested a three-fold higher risk for knee osteoarthritis (OA) progression with the use of corticosteroid (CS) injections, a popular treatment recommended by guidelines. Recipients of CS injections might have more advanced knee OA, which in itself is a risk factor for OA progression, making a comparison of those undergoing CS injections to those who do not report injections questionable, despite statistical adjustments.

Therefore, the current study aimed to explore whether CS injections are associated with increased rates of knee OA progression compared with hyaluronic acid injections that have not been associated with cartilage loss [1]. “The treatment options for knee OA are limited. Steroid injections are considered a safe and effective intervention for relieving pain from knee OA. Clinicians and patients need to know if steroid injections are making knee OA worse,” Dr Justin J. Bucci (Boston University School of Medicine, USA) explained. Therefore, Dr Bucci and his co-workers used data from 2 large cohort studies of people with knee OA (MOST and OAI) who received either corticosteroid or hyaluronic acid injections. They reviewed the rates of radiographic progression and total knee replacement surgery. Patients in the first cohort had medical visits every 12 months, and those in the second cohort had visits every 30 months. Their exams included knee X-rays and questions about their steroid or hyaluronic acid injections over the previous 6 months. Knee OA progression was assessed with Kellgren and Lawrence grades (KL 0-4) and joint space narrowing (JSN 0-3) in both studies. In OAI, medial joint space (JWS250) was also measured.

Patients that had very advanced OA progression (baseline KL 4 score) and those who had received either CS or hyaluronic acid injections in the past were excluded from the study. X-rays from each patient’s medical visits before their first injection to those taken after their last injection were compared. Annualised deterioration rates were calculated for KL, JSN, and JWS250. Multivariable linear regression was used to adjust for known risk factors of OA like age, sex, BMI, and baseline KL grade.

The researchers analysed 792 knees, including 647 treated with CS injections and 145 with hyaluronic acid injections. They found that the rate of total knee replacement surgery was greater among patients with a single exam where they reported hyaluronic acid injection compared to those with a single exam where they reported CS injection (P=0.04). There was no difference between patients reporting injections at multiple exams. Multivariable analysis showed similar rates of X-ray progression for both kinds of injection treatment at either single or multiple medical exams.

The authors concluded that CS injections for knee OA were not associated with a higher rate of radiographic progression or progression to a total knee replacement compared with hyaluronic acid injections. Future research will focus on MRI of knees undergoing steroid injection treatment for OA to better understand the effect of CS injections.

  1. Bucci JJ, et al. Progression of knee OA with use of intra-articular corticosteroids (CS) vs hyaluronic acid (HA). P1652, ACR Convergence 2020 Virtual Annual Meeting, 5-9 November 2020.

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