Joint Injections: Are They Worth the Risk?

Joint Injections: Are They Worth the Risk? | Medpage Today – Oct 2019

Patients no longer allowed to receive effective pain medications (opioids) may become desperate enough to allow these procedures despite the known dangers.

Intra-articular injections of corticosteroids for relief of the pain of hip or knee osteoarthritis (OA) may have adverse long-term consequences, researchers suggested.

I’ve been warning about this for years, especially when they are done near the spine: The Pain Industry’s New & Dangerous Fall-Back

You can see all my previous posts about this hazard using the tag epidural-injection

The American Academy of Orthopedic Surgeons, however, has advised clinicians to be on the lookout for emerging evidence for or against the use of intra-articular injections in the knee, explained Ali Guermazi, MD, PhD, of Boston University School of Medicine, and colleagues.

However, a review of the outcomes following 459 injection procedures performed during 2018 in a single center now has identified four potential adverse events that should raise concerns, particularly for certain patients:

  • Accelerated OA progression, reported in 6% of patients
  • Subchondral insufficiency fractures, seen in 0.9%
  • Complications of osteonecrosis, in 0.7%
  • Rapid joint destruction including bone loss, also in 0.7% of patients

The Background

A Cochrane meta-analysis evaluated 27 trials that included more than 1,767 patients found moderate improvements in pain and slight benefits for physical function following intra-articular corticosteroid injections for knee OA.

However, the review noted that the quality of evidence was low, concluding that the results were inconclusive.

In vitro and animal research has revealed that corticosteroids actually can have negative effects on cartilage.

“The action by which corticosteroids are chondrotoxic is complex, but it seems to affect cartilage proteins (especially aggrecan, type II collagen, and proteoglycan) by mediating protein production and breakdown,”

For those of us with EDS and already defective connective tissue proteins, this could be devastating.

And a recent retrospective study of 70 patients with hip OA found that

  • 44% of patients who were given injections of triamcinolone with ropivacaine had radiographic progression and
  • 17% experienced collapse of the articular surface.

These numbers are so large that I wonder how such injections are even legal, let alone recommended, in place of opioids.

The Events

The injection protocol used at Boston University involved

  • 40 mg triamcinolone,
  • 2 mL of 1% lidocaine, and
  • 2 mL of 0.25% bupivacaine.

Accelerated OA progression, characterized by rapid loss of radiographic joint space, was first observed in trials of nerve growth inhibitors, wherein some patients required joint replacement earlier than had been expected.

I’ve long been concerned about such “nerve growth inhibitors”, which were being investigated for possible pain-relieving qualities. Any substances that inhibit nerve growth sound very undesirable to me, especially when the actions are systemic.

Luckily, there were enough problems found to halt any further investigation of such drugs for pain relief.

Subchondral insufficiency fractures were the second type of adverse outcome observed, and were seen in four patients undergoing intra-articular hip injections. T

his event was previously thought to occur in elderly patients with osteopenia, but has now been reported in younger, active patients who present with acute pain but no apparent trauma.

If the condition is identified early, before articular collapse has occurred, healing can occur, but once the articular surface has collapsed, the joint must be replaced.

Early identification of subchondral insufficiency fractures also is crucial before intra-articular injections, because the steroid may interfere with resolution of the fracture.

The third type of event the researchers identified involved complications of osteonecrosis, which typically present with insidious onset of pain or can be asymptomatic.

The fourth adverse outcome, rapid joint destruction including bone loss (also referred to as rapidly progressive OA type 2), occurred in two patients with hip injections and one following a knee injection.

The Advice

There are currently no recommendations regarding imaging before performing an intra-articular corticosteroid injection, and in some cases, findings may be subtle.

Of particular concern are patients who have no apparent OA or very mild changes on radiographs who have been referred for injections because of pain. In these cases, the indication for injection should be “closely scrutinized,” as destructive or rapidly progressive joint space loss tends to develop in patients with severe pain but minimal structural change on radiographs.

“Clinicians should consider obtaining a repeat radiograph before each subsequent intra-articular injection to evaluate for progressive narrowing of the joint space and any interval changes in the articular surface that can indicate subchondral insufficiency fracture or type 1 or 2 rapidly progressive OA,” the authors advised.

So, no more “cowboy-ing” it free-hand at a moment’s notice.

A new doctor did this to my mother during a routine appointment. She complained of persistent hip pain, so he simply grabbed a needle and gave a cortisone injection right then and there. 

I was furious that she allowed this, but at her age, she still assumes “doctor knows best”. The injection didn’t help at all and possibly even worsened her pain over time.

Primary Source
Source Reference: Kompel A, et al “Intra-articular corticosteroid injections in the hip and knee: perhaps not as safe as we thought?” Radiology 2019;doi:10.1148/radiol.2019190341.
Secondary Source
Source Reference: Kijowski R “Risks and benefits of intra-articular corticosteroid injection for treatment of osteoarthritis: what radiologists and patients need to know” Radiology 2019; doi:10.1148/radiol.2019192034.

2 thoughts on “Joint Injections: Are They Worth the Risk?

  1. Kathy C

    These injections are profitable, and they don’t require any pain management or opioids. One of the more undisclosed side effects is the effect these drugs have on the mind. Many people who get these injections suffer severe depression and mood swings. The immuno supressive effects of these shots are not considered either. Of course they are not warned by their physicians, which causes even more distress. These shots are offered as the first line of treatment for most painful conditions, yet most of the time, people getting these injections do not report a benefit.

    Plenty of these “Pain Clinics” are essentially an assembly line of injections, have sprung up in areas where untreated pain is a real problem. It is another example of how they turned the opioid “epidemic” into a profitable marketing campaign. Physicians can charge a lot more for these procedures, and include imaging services too. Our corrupt healthcare system, and the drive for profit, made these dangerous and ineffective shots a widespread “option,” for pain relief. Once again the adverse events, side effects and interactions are kept from the people, who out of desperation turn to these “options.”

    Liked by 1 person


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