These authors asked, "What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on progression of cartilage loss and knee pain in patients with osteoarthritis?".
In a randomized clinical trial of 140 patients with symptomatic knee osteoarthritis they used annual knee magnetic resonance imaging for the quantitative evaluation of cartilage volume. They found that the use of intra-articular triamcinolone compared with intra-articular saline resulted in greater cartilage volume loss (i.e. worsening of the arthritis). There was no significant difference on knee pain severity between treatment groups.
They concluded that among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.
Comment: Many physicians try to delay the need for arthroplasty through the use of injections (steroids, PRP, hylaluronic acid) The safety and efficacy of these injections is unclear (see this link, this link, this link, this link, this link, and this link). Laboratory investigations, such as Lidocaine Potentiates the Chondrotoxicity of Methylprednisolone (see this link), may be of relevance.
Not infrequently we'll see patients in whom the first or second injection helped, but from #3 on, there was no appreciable benefit. Occasionally we see shoulders that have had multiple injections and changes in the shoulder radiographs that are not typical of osteoarthritis.
Here's a recent example.
A very active young man sustained a hard fall on his shoulder. He received a series of intra articular injections as he documented for us here:
His current shoulder radiographs are shown here:
While this use of injections is common practice, we were struck by the cystic changes in the bone on both sides of the joint - changes that are not typical of post-traumatic arthritis in our experience. It is surely not possible to know if there was an association between these changes and the injections.
For comparison, the x-rays below show the more typical appearance of osteoarthritis.
Here are some quotes from the American Academy of Orthopaedic Surgeons 2013 guidelines (see this link) regarding the use of injections for arthritis of the knee:
Procedural Treatments: Recommendations 8-11
RECOMMENDATION 8
We are unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.
RECOMMENDATION 9
We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Strong
Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supportingevidenceishigh. Aharmsanalysisonthisrecommendationwasnotperformed.
Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
RECOMMENDATION 8
We are unable to recommend for or against the use of intraarticular (IA) corticosteroids for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.
RECOMMENDATION 9
We cannot recommend using hyaluronic acid for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Strong
Description: Evidence is based on two or more “High” strength studies with consistent findings for recommending for or against the intervention. A Strong recommendation means that the quality of the supportingevidenceishigh. Aharmsanalysisonthisrecommendationwasnotperformed.
Implications: Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present.
RECOMMENDATION 10
We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.
Here is an interesting recent post about platelet rich plasma (see this link).
The bottom line is that we do not know (1) how injections affect the natural history of shoulder arthritis or (2) what regimen of injections is likely to maximize safety and efficacy.
The patients we most commonly see in our office have advanced arthritis with virtually complete loss of the cartilage over the glenoid and humeral head. In such cases it seems unlikely that injections will change the subsequent course of the disease.
We are unable to recommend for or against growth factor injections and/or platelet rich plasma for patients with symptomatic osteoarthritis of the knee.Strength of Recommendation: Inconclusive
Description: Evidence from a single low quality study or conflicting findings that do not allow a recommendation for or against the intervention. An Inconclusive recommendation means that there is a lack of compelling evidence that has resulted in an unclear balance between benefits and potential harm.
Implications: Practitioners should feel little constraint in following a recommendation labeled as Inconclusive, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role.
Here is an interesting recent post about platelet rich plasma (see this link).
The bottom line is that we do not know (1) how injections affect the natural history of shoulder arthritis or (2) what regimen of injections is likely to maximize safety and efficacy.
The patients we most commonly see in our office have advanced arthritis with virtually complete loss of the cartilage over the glenoid and humeral head. In such cases it seems unlikely that injections will change the subsequent course of the disease.
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