Intra-articular Corticosteroid Injections for the Treatment of Hip and Knee Osteoarthritis-related Pain: Considerations and Controversies with a Focus on Imaging—Radiology Scientific Expert Panel

Abstract

O steoarthritis (OA) is a highly prevalent, disabling, and costly condition that has been recognized by the United States Food and Drug Administration as a serious disease with unmet medical need (1-3). OA is understood as a disease of the whole joint, involving structural damage of the articular cartilage, subchondral bone, ligaments, capsule, synovial membrane, and periarticular muscles (4,5). Pain is the predominant symptom and is a major driving force in clinical decision making and health service attention (6). Current management of OA is primarily focused on symptom control. Intra-articular corticosteroid (IACS) injections are often used for pain management of hip and knee OA in patients who have not responded to oral or topical analgesics and are frequently intended to delay total joint replacement surgery if patients are young or hesitant to undergo surgery right away (7). A recent case series presented data on possible negative outcomes of IACS injection as perceived from a radiologic perspective (8). These findings included accelerated OA progression, subchondral insufficiency fracture, complications of pre-existing osteonecrosis, and rapid joint destruction including bone loss. Another recent uncontrolled retrospective observational study that focused on IACS injection of the hip and subsequent joint events reported that almost half of the patients treated with IACS injections exhibited signs of radiographic progression

New developments in osteoarthritis pharmacological therapies

“…Other single-centre case series have suggested structural associations include subchondral insufficiency fracture, osteonecrosis, and rapid joint destruction [ 49 ]. However, confounding factors exist with such data, and a recent expert consensus group suggested no benefit of pre-injection imaging screening [ 50 ]. Local anaesthetic may play a role in developing increased joint damage [ 51 ].…”

How close are disease‐modifying drugs for osteoarthritis?

“…Osteoarthritis arises from complex and mutually reinforcing structural changes that can involve the whole joint -including articular cartilage, subchondral bone, ligaments, capsule, synovial membrane and periarticular muscles 3,5 -which we can only outline here. (See the reviews by Vincent 5 and Hunter et al 4 for more details.…”

“…There's little healthcare professionals can do pharmacologically to stem the almost inevitable decline. Drug treatment focuses on controlling symptoms, especially pain 3 . But healthcare professionals’ efforts are often in vain.…”

“…For example, intra-articular corticosteroid injections do not effectively alleviate pain, even transiently, in 20% to 30% of people with knee osteoarthritis. 3 Even joint replacement does not guarantee freedom from pain and disability: up to 25% of patients still complain of pain and disability a year after total joint replacement. 4 In any case, analgesia closes the symptomatic door long after the degenerative horse has bolted.…”

Effect of a Single-Shot of a High-Density Viscoelastic Solution of Hyaluronic Acid in Patients with Symptomatic Primary Knee Osteoarthritis: The No-Dolor Study

“…Knee OA is characterized by diverse pathophysiological changes, including decreased synovial uid elastoviscosity and hyaluronan concentration [3]. The treatment of knee OA is only focused on the control of symptoms, especially pain [4]. Treatment guidelines recommend the use of nonoperative treatments before surgery [2].…”