- In this randomized observational study, 141 hips treated with corticosteroid/anesthetic injection (CSI) were matched with 141 untreated hips based on age, sex, BMI and severity of osteoarthritis (OA)
- 48 pairs of hips were excluded because of preexisting avascular necrosis (AVN) or subchondral insufficiency fracture (SIF), leaving 93 pairs
- In both the treated and untreated groups, the rate of OA progression was 3.2%, and in the CSI group the rate of new AVN/SIF was 1.1%
- Of the three cases of new femoral head collapse in the CSI group, two were classified as femoral head remodeling secondary to OA, leaving only one (1.1%) definitive femoral head collapse secondary to AVN or SIF
- There were no differences in these complication rates between patients treated with methylprednisolone and those who received triamcinolone acetonide
No definitive level I evidence exists about the safety of hip corticosteroid/anesthetic injection (CSI). However, two recent retrospective case series, one published in Radiology and the other in Skeletal Radiology, suggest steroid injection into the hip is associated with increased risk of avascular necrosis (AVN), femoral head collapse, subchondral insufficiency fracture (SIF) and accelerated osteoarthritis progression.
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Paul Abraham, MD, research fellow at Massachusetts General Hospital, and Scott D. Martin, MD, director of the Joint Preservation Service and the Sports Medicine Fellowship within the Department of Orthopaedics at Massachusetts General Hospital, and colleagues have performed the largest-ever study of this issue. Unlike the two earlier series, theirs accounted for preinjection OA severity and preexisting AVN/SIF. In the Orthopaedic Journal of Sports Medicine, they report low, similar complication rates in patients who underwent CSI and matched controls.
The researchers began with two cohorts:
- 141 hips that underwent fluoroscopic-guided CSI performed between May 2007 and December 2019 and had preinjection hip MRI (within 12 months previously), preinjection hip radiography (within 12 months previously) and postoperative hip radiography (within 12 months)
- 141 control hips, matched on age, sex, body mass index and OA presence/severity, that had never undergone CSI but had undergone hip radiography, then hip MRI within 12 months and hip radiography within 12 months after MRI
Radiographs in each group were reviewed independently by two musculoskeletal radiologists, and a third for arbitrating discrepancies. All readers were blinded to group and time points. 48 matched pairs were excluded because of preexisting AVN or SIF, leaving 93 pairs for final analysis.
All complication rates were low and were statistically similar in the two groups:
- Progression of OA—3 hips (3.2%) in each group (within expectation for natural disease progression)
- New AVN or SIF—1 (1.1%) in the CSI group and 0 in the control group
- New femoral head collapse—3 (3.2%) and 2 (2.2%); 2 of the 3 cases in the CSI group were secondary to OA
- Diagnosis of septic arthritis within 12 months after CSI—0 and 0
There were no differences in these complication rates between patients treated with methylprednisolone and those who received triamcinolone acetonide.
According to a post hoc calculation, this study had 80% power to detect a difference in OA progression incidence of <12% between groups. Therefore, it's not possible to rule out a small (<12%) increase in OA progression, but hip CSI does not appear to increase the short-term rate of OA progression substantially in most patients.
Even if a small difference in OA progression exists, the risk–benefit tradeoff for CSI may be positive for selected patients. Multiple randomized controlled trials have demonstrated significantly greater short-term pain and functional improvements with CSI than with placebo.
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