- Joined
- Nov 21, 1998
- Messages
- 12,547
- Reaction score
- 6,931
Is it finally time for pain doctors to admit that we're at the end of the corticosteroid era in pain management?? Next up polymethyl methacrylate.
Inter-articular Steroids Not As Safe As We Thought
- Thread starter drusso
- Start date
- Joined
- May 30, 2005
- Messages
- 21,235
- Reaction score
- 12,347
A review or reviews by Radiologists.
GIGO.
GIGO.
I agree with what they're saying as the agents are often off label, ineffective, and systemically if not locally harmful in a lot of states where we use them, but I suspect this is part of their push towards distal vessel embolization for joint pain rather than ablation/steroids.
- Joined
- Apr 6, 2016
- Messages
- 926
- Reaction score
- 570
I had no idea distal vessel embolization for joint pain existed !!
- Joined
- Apr 6, 2013
- Messages
- 847
- Reaction score
- 415
how is that supposed to help someone’s pain...in terms of mechanism?
isn’t there a risk of increased cartilage loss or other such complication given the decreased blood flow?
D
deleted993114
Lots of articles in the internal med literature recently about this. Hip and knee injections are kaput in that realm.
I just talked to several ortho guys in their late 50s and early 60s. They have done 1000's of injections into the knees shoulders etc. they state they will continue to do it as they feel it is beneficial and the risks are overstated in that article. one guy told me he does around 15-20 various steroid injections a day for 30 years and sees no problem with it
- Joined
- Nov 21, 1998
- Messages
- 12,547
- Reaction score
- 6,931
"Sometimes wrong; never in doubt."
- Joined
- Nov 21, 1998
- Messages
- 12,547
- Reaction score
- 6,931
Here's another doctor who has done 1000's of steroid injections...
"As a specialist in joint pain, Guermazi has done thousands of steroid injections over decades of work. He has trained other doctors as he was trained: to believe that the injections are safe as long as they aren’t overused. But now he has come to believe that the procedure is more dangerous than he knew. And he and a group of his Boston University colleagues are raising a warning flag for doctors and patients alike."
A Warning From a Doctor Who Has Done Thousands of Steroid Injections for Arthritis
The extremely common treatment might be causing more harm than previously thought.
Do you think that inter-articular steroid injections will be the next major "medical reversal?"
Medical reversal - Wikipedia
What's the over/under that autologous orthobiologics are the next disruptive innovation in medicine like Netflix or Uber?
- Joined
- Apr 20, 2018
- Messages
- 2,168
- Reaction score
- 1,659
Depo and 0.9% NS for me.
Anesthetic is what is killing your joint. Not that cortisone is great but the surgeons I work with routinely use lido + bupi + Kenalog.
Anesthetic is what is killing your joint. Not that cortisone is great but the surgeons I work with routinely use lido + bupi + Kenalog.
- Joined
- Nov 4, 2004
- Messages
- 1,250
- Reaction score
- 598
I would think common sense wise:
Joint degenerated >> joint feels bad move less >> inject joint >> Joint feels better >> move more, wear down already degenerated joint more >> get studies from radiologist point the blame on steroids themselves degenerating joint
The same will be said of any treatment that allows someone to continue to use a Broken down joint more.
**except “stem cells” because they turn back time on everything**
Sent from my iPhone using SDN
Joint degenerated >> joint feels bad move less >> inject joint >> Joint feels better >> move more, wear down already degenerated joint more >> get studies from radiologist point the blame on steroids themselves degenerating joint
The same will be said of any treatment that allows someone to continue to use a Broken down joint more.
**except “stem cells” because they turn back time on everything**
Sent from my iPhone using SDN
- Joined
- May 30, 2010
- Messages
- 1,651
- Reaction score
- 1,607
In young people who are getting an initial/diagnostic injection, I use dexamethasone and bupivicaine so it answers the question and hopefully gives them enough relief to participate in therapy. If those people come back, I continue to use dex if its effective but skip the local for repeat injections.
For old people who are just trying to get by until their hip replacement, I use particulate and bupivicaine each time.
For old people who are just trying to get by until their hip replacement, I use particulate and bupivicaine each time.
- Joined
- Apr 20, 2018
- Messages
- 2,168
- Reaction score
- 1,659
FYI, lido and bupi are the worst for chondrocytes. If you're going to put local in there I'd recommend ropi.
Also what's your thought process for dex over particulate? Out of curiosity...
Also what's your thought process for dex over particulate? Out of curiosity...
- Joined
- May 30, 2010
- Messages
- 1,651
- Reaction score
- 1,607
If I'm going to inject something that's potentially chondrotoxic (corticosteroids), I would rather put in something that doesn't stick around forever.
Ropivicaine is definitely a better option. The reason I dont use it for options is purely logistical(its in short supply in my clinic and I use a lot of it for SGBs). I'll definitely look into it some more, though.
Ropivicaine is definitely a better option. The reason I dont use it for options is purely logistical(its in short supply in my clinic and I use a lot of it for SGBs). I'll definitely look into it some more, though.
- Joined
- Oct 12, 2007
- Messages
- 485
- Reaction score
- 224
Second, cultures containing Methylprednisolone acetate and Triamcinolone acetonide exhibited a significant decrease in chondrocyte viability when combined with 1% lidocaine, but demonstrated no increased cell death when combined with 0.25% bupivacaine.
It is hypothesized that benzalkonium chloride, a preservative in the Betamethasone sodium phosphate and Betamethasone acetate solution, is responsible for the negative impact on cell viability when administered alone. While Betamethasone sodium phosphate and Betamethasone acetate did not show significant cell death when analyzed independently, a solution containing both Betamethasone combination and benzalkonium chloride began to be significantly chondrotoxic at levels 5% of standard clinical doses. The crystalline structure of Betamethasone sodium phosphate and Betamethasone acetate preparations may also be responsible for its chondrotoxicity
Graph shows Depomedrol +Bup was lower chondrotoxicity than dexamethasone or kenalog with bup; also depomedrol + bup lower than just bup
It is hypothesized that benzalkonium chloride, a preservative in the Betamethasone sodium phosphate and Betamethasone acetate solution, is responsible for the negative impact on cell viability when administered alone. While Betamethasone sodium phosphate and Betamethasone acetate did not show significant cell death when analyzed independently, a solution containing both Betamethasone combination and benzalkonium chloride began to be significantly chondrotoxic at levels 5% of standard clinical doses. The crystalline structure of Betamethasone sodium phosphate and Betamethasone acetate preparations may also be responsible for its chondrotoxicity
Graph shows Depomedrol +Bup was lower chondrotoxicity than dexamethasone or kenalog with bup; also depomedrol + bup lower than just bup
- Joined
- Jun 3, 2007
- Messages
- 4,693
- Reaction score
- 3,095
It's not new news that steroids are a horrible choice.
But there isn't a good alternative that is cheap.
I always try steroids before AmnioFix or PRP - because I'm not reaching for the $800 fix, when $30 will do (even though the $800 is really a better choice).
- Joined
- Nov 21, 1998
- Messages
- 12,547
- Reaction score
- 6,931
I took a lot flack last year by predicting an end to the corticosteroid era...
Bone Joint J. 2020 May;102-B(5):586-592. doi: 10.1302/0301-620X.102B5.BJJ-2019-1376.R1.
Intra-articular Corticosteroid Injections Increase the Risk of Requiring Knee Arthroplasty
Stan R W Wijn 1, Maroeska M Rovers 1 2, Tony G van Tienen 3 4, Gerjon Hannink 1
Affiliations expand
PMID: 32349592 DOI: 10.1302/0301-620X.102B5.BJJ-2019-1376.R1
Abstract
Aims: Recent studies have suggested that corticosteroid injections into the knee may harm the joint resulting in cartilage loss and possibly accelerating the progression of osteoarthritis (OA). The aim of this study was to assess whether patients with, or at risk of developing, symptomatic osteoarthritis of the knee who receive intra-articular corticosteroid injections have an increased risk of requiring arthroplasty.
Methods: We used data from the Osteoarthritis Initiative (OAI), a multicentre observational cohort study that followed 4,796 patients with, or at risk of developing, osteoarthritis of the knee on an annual basis with follow-up available up to nine years. Increased risk for symptomatic OA was defined as frequent knee symptoms (pain, aching, or stiffness) without radiological evidence of OA and two or more risk factors, while OA was defined by the presence of both femoral osteophytes and frequent symptoms in one or both knees. Missing data were imputed with multiple imputations using chained equations. Time-dependent propensity score matching was performed to match patients at the time of receving their first injection with controls. The effect of corticosteroid injections on the rate of subsequent (total and partial) knee arthroplasty was estimated using Cox proportional-hazards survival analyses.
Results: After removing patients lost to follow-up, 3,822 patients remained in the study. A total of 249 (31.3%) of the 796 patients who received corticosteroid injections, and 152 (5.0%) of the 3,026 who did not, had knee arthroplasty. In the matched cohort, Cox proportional-hazards regression resulted in a hazard ratio of 1.57 (95% confidence interval (CI) 1.37 to 1.81; p < 0.001) and each injection increased the absolute risk of arthroplasty by 9.4% at nine years' follow-up compared with those who did not receive injections.
Conclusion: 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 regarding the treatment of these patients with corticosteroid injections should be recommended. Cite this article: Bone Joint J 2020;102-B(5):586-592.
Keywords: Corticosteroid injection; Intra-articular injection; Osteoarthritis; Osteoarthritis initiative; Total knee arthroplasty.
Bone Joint J. 2020 May;102-B(5):586-592. doi: 10.1302/0301-620X.102B5.BJJ-2019-1376.R1.
Intra-articular Corticosteroid Injections Increase the Risk of Requiring Knee Arthroplasty
Stan R W Wijn 1, Maroeska M Rovers 1 2, Tony G van Tienen 3 4, Gerjon Hannink 1
Affiliations expand
PMID: 32349592 DOI: 10.1302/0301-620X.102B5.BJJ-2019-1376.R1
Abstract
Aims: Recent studies have suggested that corticosteroid injections into the knee may harm the joint resulting in cartilage loss and possibly accelerating the progression of osteoarthritis (OA). The aim of this study was to assess whether patients with, or at risk of developing, symptomatic osteoarthritis of the knee who receive intra-articular corticosteroid injections have an increased risk of requiring arthroplasty.
Methods: We used data from the Osteoarthritis Initiative (OAI), a multicentre observational cohort study that followed 4,796 patients with, or at risk of developing, osteoarthritis of the knee on an annual basis with follow-up available up to nine years. Increased risk for symptomatic OA was defined as frequent knee symptoms (pain, aching, or stiffness) without radiological evidence of OA and two or more risk factors, while OA was defined by the presence of both femoral osteophytes and frequent symptoms in one or both knees. Missing data were imputed with multiple imputations using chained equations. Time-dependent propensity score matching was performed to match patients at the time of receving their first injection with controls. The effect of corticosteroid injections on the rate of subsequent (total and partial) knee arthroplasty was estimated using Cox proportional-hazards survival analyses.
Results: After removing patients lost to follow-up, 3,822 patients remained in the study. A total of 249 (31.3%) of the 796 patients who received corticosteroid injections, and 152 (5.0%) of the 3,026 who did not, had knee arthroplasty. In the matched cohort, Cox proportional-hazards regression resulted in a hazard ratio of 1.57 (95% confidence interval (CI) 1.37 to 1.81; p < 0.001) and each injection increased the absolute risk of arthroplasty by 9.4% at nine years' follow-up compared with those who did not receive injections.
Conclusion: 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 regarding the treatment of these patients with corticosteroid injections should be recommended. Cite this article: Bone Joint J 2020;102-B(5):586-592.
Keywords: Corticosteroid injection; Intra-articular injection; Osteoarthritis; Osteoarthritis initiative; Total knee arthroplasty.
- Joined
- May 30, 2005
- Messages
- 21,235
- Reaction score
- 12,347
Intra-articular steroid injections and total knee arthroplasty are not going away. You can tell grandma to suck it up and get a cane but that is not the American thing to do. You can say your magic beans and voodoo stem cells with PRP are the answer but the literature does not yet there this out. Maybe if we stop treating orthopedic surgeons we would illuminate all knee surgeries in the future. Yeah that’s the ticket
- Joined
- Nov 21, 1998
- Messages
- 12,547
- Reaction score
- 6,931
Arthroscopy. 2019 Jan;35(1):106-117. doi: 10.1016/j.arthro.2018.06.035.
Intra-articular Injection of Platelet-Rich Plasma Is Superior to Hyaluronic Acid or Saline Solution in the Treatment of Mild to Moderate Knee Osteoarthritis: A Randomized, Double-Blind, Triple-Parallel, Placebo-Controlled Clinical Trial.
Lin KY1, Yang CC2, Hsu CJ3, Yeh ML4, Renn JH5.
Author information
Abstract
PURPOSE:
To prospectively compare the efficacy of intra-articular injections of platelet-rich plasma (PRP) and hyaluronic acid (HA) with a sham control group (normal saline solution [NS]) for knee osteoarthritis in a randomized, dose-controlled, placebo-controlled, double-blind, triple-parallel clinical trial.
METHODS:
A total of 87 osteoarthritic knees (53 patients) were randomly assigned to 1 of 3 groups receiving 3 weekly injections of either leukocyte-poor PRP (31 knees), HA (29 knees), or NS (27 knees). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score and International Knee Documentation Committee (IKDC) subjective score were collected at baseline and at 1, 2, 6, and 12 months after treatment. Data were analyzed using generalized estimating equations.
RESULTS:
All 3 groups showed statistically significant improvements in both outcome measures at 1 month; however, only the PRP group sustained the significant improvement in both the WOMAC score (63.71 ± 20.67, increased by 21%) and IKDC score (49.93 ± 17.74, increased by 40%) at 12 months. For the intergroup comparison, except for the first month, there was a statistically significant difference between the PRP and NS groups in both scores throughout the study duration (regression coefficients of 8.72 [P = .0015], 7.94 [P = .0155], and 11.92 [P = .0014] at 2, 6, and 12 months, respectively, for WOMAC score, and 9.1 [P = .0001], 10.28 [P = .0002], and 13.97 [P < .0001], respectively, for IKDC score). There was no significant difference in both functional outcomes between the HA and NS groups at any time point. Only the PRP group reached the minimal clinically important difference in the WOMAC score at every evaluation (15%, 21%, 18%, and 21% at 1, 2, 6, and 12 months, respectively) and the minimal clinically important difference in the IKDC score at 6 months (improvement of 11.6).
CONCLUSIONS:
Intra-articular injections of leukocyte-poor PRP can provide clinically significant functional improvement for at least 1 year in patients with mild to moderate osteoarthritis of the knee.
LEVEL OF EVIDENCE:
Level I, randomized controlled single-center trial.
Copyright © 2019 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.
D
deleted993114
This is somewhat old news from the internal med literature. Many internal medicine groups stopped referring for joint injections a few years ago. Just say "no" to intra-articular steroids for hips and knees (and hopefully to whatever plasma de jour of the day may be).
Nothing beats a total joint arthroplasty. For patients pre-op or who have medical conditions which preclude arthroplasty, think genicular rfa and or IOVERA.
- Joined
- Aug 16, 2007
- Messages
- 5,368
- Reaction score
- 2,509
Isn't this an example of correlation does not equal causation? Perhaps those who received steroid injections had more severe pain, inflammation and arthritis thus leading them to be more likely to require corticosteroids and ultimately surgery for adequate pain relief. No?
- Joined
- Apr 13, 2016
- Messages
- 2,651
- Reaction score
- 2,625
Perhaps even more broadly than that - those who sought more medical care got it. Would be interesting to compare rates of TKA in those who got PRP vs no injections. Not saying there aren’t issues with steroids - basic science demonstrates toxicity, but this study doesn’t do much to move the needle.
- Joined
- Nov 11, 2012
- Messages
- 1,945
- Reaction score
- 1,203
Another possible explanation. Patients receiving steroid injection had excellent pain relief and thus were unwilling to live with the pain when it returned. The other patients basically don't remember what it was like not to have pain and they accept a higher level of discomfort before opting for surgery.
- Joined
- Nov 21, 1998
- Messages
- 12,547
- Reaction score
- 6,931
Steroid Shot Side Effects: Steroid Injections are BAD NEWS - Regenexx
Steroid shot side effects are very real and problematic. Dr. Centeno reviews the issues with steroid shots and discusses alternatives.
regenexx.com
"The new research on knees is also not good for patients who get steroid shots. In this study, the authors looked at almost four thousand patients who were part of a government-funded arthritis study (15). Each steroid shot in the knee increased the likelihood of needing a knee replacement by 9%. Meaning if you got 4 steroid shots to help arthritis pain, this increased the likelihood that you needed a knee replacement by about 36%!"
@Ducttape
Steroid Shot Side Effects: Steroid Injections are BAD NEWS - Regenexx
Steroid shot side effects are very real and problematic. Dr. Centeno reviews the issues with steroid shots and discusses alternatives.
"The new research on knees is also not good for patients who get steroid shots. In this study, the authors looked at almost four thousand patients who were part of a government-funded arthritis study (15). Each steroid shot in the knee increased the likelihood of needing a knee replacement by 9%. Meaning if you got 4 steroid shots to help arthritis pain, this increased the likelihood that you needed a knee replacement by about 36%!"
@Ducttape
im not a statistician, but im pretty sure you cant just add the percentages. so if you get 11 shots, there is a 99% chance you will get a knee replacement?
- Joined
- Apr 20, 2018
- Messages
- 2,168
- Reaction score
- 1,659
Knee pain increases the risk of TKR.
- Joined
- Oct 7, 2011
- Messages
- 14,638
- Reaction score
- 5,932
from that study: Intra-articular corticosteroid injections increase the risk of requiring knee arthroplasty. - PubMed - NCBI
2. interestingly, only 796 out of 3822 patients got steroid shots. seems low
3. the main take home message was to do conservative care and endpoint of the study was to avoid surgery.
4. some of the patients were determined to have OA based on symptoms only which I thought seemed presumptuous
other issues were noted by the authors:
in addition, they did not use radiologic evidence as an independent marker of needing surgery.
that being said.... I cant remember the last time I did an intraarticular knee injection.
1. observational cohort study...
2. interestingly, only 796 out of 3822 patients got steroid shots. seems low
3. the main take home message was to do conservative care and endpoint of the study was to avoid surgery.
4. some of the patients were determined to have OA based on symptoms only which I thought seemed presumptuous
other issues were noted by the authors:
in addition, they did not use radiologic evidence as an independent marker of needing surgery.
that being said.... I cant remember the last time I did an intraarticular knee injection.
- Joined
- Apr 20, 2018
- Messages
- 2,168
- Reaction score
- 1,659
It's ridiculous to say we should do away with CSI for chronic osteoarthritic knee pain. They're effective in a huge percentage of pts and they're easy/quick.
I use Depo and saline, and many of my pts do well for several months.
I use Depo and saline, and many of my pts do well for several months.
- Joined
- Nov 21, 1998
- Messages
- 12,547
- Reaction score
- 6,931
It's never too late to admit when you were wrong...
- Joined
- Jun 1, 2005
- Messages
- 3,861
- Reaction score
- 1,194
or alternatively
It's never to late to bash an old treatment when you can make More money with a new treatment
- Joined
- Oct 12, 2007
- Messages
- 485
- Reaction score
- 224
see previous post above
Graph shows Depomedrol +Bup was lower chondrotoxicity than dexamethasone or kenalog with bup; also depomedrol + bup lower than just bup
Graph shows Depomedrol +Bup was lower chondrotoxicity than dexamethasone or kenalog with bup; also depomedrol + bup lower than just bup
D
deleted131481
Interesting post, thanks for the article. The differences among steroid shown besides betamethasone are insignificant though.
Attached an article that suggests bupivacaine > lidocaine > ropivacaine (least) for chondrotoxicity. Betamethasone appears the worst steroid of the group.
We don't have ropivacaine readily available but may look into more now.
- Joined
- Nov 21, 1998
- Messages
- 12,547
- Reaction score
- 6,931
Excellent contribution to this discussion!
- Joined
- Oct 12, 2007
- Messages
- 485
- Reaction score
- 224
Dose related response is clear; take away appears don't use 0.5% bupivacaine but 0.25% does not significantly affect cell viability for some of the studies included in the article, don't use continues intraarticulater infusions of any locals. Still meta-analysis, so lot of variability in the studies here
From your article
- With regard to bupivacaine, they found that 0.25% bupivacaine did not affect cell viability at the time points analyzed up to 120 hours; however, 0.5% bupivacaine caused a detectable but not significant decrease in cell viability at 24 hours, and was found to have significant (P < .05)
- Breu et al exposed human articular chondrocytes to varying concentrations of bupivacaine, ropivacaine, mepivacaine, and buffered saline controls for 1 hour.18 They found that 0.5% bupivacaine caused a significant increase in apoptotic and necrotic cells and cell viability in a dose-dependent concentration after 24 hours and after 96 hours when compared with buffer saline controls (P < .01), but not with lesser concentrations 0.25%, 0.125%, 0.063%, and 0.031% of bupivacaine.18
- Given the varying concentrations of anesthetics involved, no one particular anesthetic seemed to be more significantly cytotoxic than the others. (levobupivicaine, bupivicaine, ropivicaine)
- Finally, the true duration of contact from a single local anesthetic injection into a peripheral joint in vivo is not clear.
- Joined
- Apr 20, 2018
- Messages
- 2,168
- Reaction score
- 1,659
Putting local into a joint adds nothing IMO, and significantly increases chondrotoxicity. Just don't do it.
- Joined
- May 30, 2005
- Messages
- 21,235
- Reaction score
- 12,347
Yes.
And we reviewed this same data on this forum 5+ years ago or so. Would need to search for it.
- Joined
- May 30, 2005
- Messages
- 21,235
- Reaction score
- 12,347
Scan up and down this old thread.
i only use Bupivacaine when i want to kill something, like RF. Toxicity of anesthetics is well known. The best thing about HA is that it isnt a steroid.
i disagree.....i add diluted lidocaine....it's another small indicator confirming the pain generator. For extra-articular pathology, an IA knee injection doesnt make the patient smile when they get off the table because their pain is gone.
Last edited:
- Joined
- Apr 20, 2018
- Messages
- 2,168
- Reaction score
- 1,659
Saline and Kool-aid would have the same effect.
I worded my post above wrong. But hopefully you get the gist of it. If I use lido and the pain is still there, I learned something.
- Joined
- Apr 20, 2018
- Messages
- 2,168
- Reaction score
- 1,659
Haha. I know what you mean and you're not wrong.
- Joined
- Dec 22, 2016
- Messages
- 26
- Reaction score
- 3
more neuromodulation techniques!!! yay, I'm just a resident applying to pain and am not sure if insurance companies deny modulation techniques (like RFA of genicular nerves, etc) but would this help push for these with less long term joint damage?
denervating a joint isnt the best way to preserve a joint. IE: charcot joint
- Joined
- May 30, 2005
- Messages
- 21,235
- Reaction score
- 12,347
Ever seen this?
as a matter of fact...... no.
- Joined
- May 30, 2005
- Messages
- 21,235
- Reaction score
- 12,347
It does not happen. As a pimply teenage doctor at SIS 2003 in Chicago, I was able to talk to Dr. Bogduk and ask him why RF of the facets does not cause Charcot. He smoked several cigarettes and explained with such intellect and enthusiasm, I choked on the fumes. But basically, there is still innervation of the joint as far as position based on muscle spindles surrounding the joint and such... and a fanboy was born.
