Guided or blind injections? What does the evidence say? This blog explores the evidence around accuracy and safety in relation to ultrasound guided vs unguided hip joint injections.
What is hydrodistension? This blog explains the principle behind hydrodistension injections. It also looks at the evidence for its benefit when compared with regular steroid injections.
A recent study by McAlindon et al (2017) wanted to determine the effects of intra-articular injection of 40 mg of triamcinoloneacetonide every 3 months for 2 years on progression of cartilage loss and knee pain.
Design: Two-year, randomized, placebo-controlled, double-blind trial of intra-articular triamcinolone vs saline for symptomatic knee osteoarthritis with ultrasonic features of synovitis in 140 patients.
Key findings: The 2-year change in the index compartment cartilage thickness was greater in the triamcinolone group with a between-group difference of −0.11 (95% CI, −0.20 to −0.03), which corresponds to a moderate effect size of 0.46 mm. Increased progression was not detected in other osteoarthritis features, structurally or clinically. These results contrast with a previous smaller trial that tested a similar regimen and found no difference in the rate of radiographic joint space loss and detected a benefit on knee pain in some secondary (but not primary) end points Wernecke et al (2015). In this study x-rays were used to determine cartilage loss rather than MRI. Guermazi (2011) showed that X-rays do not image cartilage directly and are insensitive to change. MRI used in this study enabled direct quantitation of cartilage.
CONCLUSIONS 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.
Potential Implications for clinical practice:
Previous In vivo and clinical evidence Wernecke (2012) showed the catabolic effects of corticosteroids. Eckstein (2014) showed that rates of cartilage loss are associated with higher rates of arthroplasty.
McAlindon’s study seems to indicate that cartilage loss does occur with 40mg Triamcinolone Acetonide given every three months for 2 years which amounts to 8 steroid injections in total over this period of time. Anecdotally In my area of work many practioners would stop repeating steroid injections after 3 or 4 injections. In many cases due to the concern of the potential for detrimental effects on the joint. In addition to that there is also a notion that repeat steroid injections often appear to have shorter lasting benefits after each subsequent injection. This personal experience does not seem to be supported though by a research study (Raynauld, 2003) which showed longterm clinical benefit from steroid injections over a two year period.
In any case for me the objective evidence that cartilage volume significantly reduced in the steroid group compared with a saline control group would make me more cautious still to continue with repeat injections beyond 3. I can think of clinical justifications to continue injecting (i.e an Older person with severe and severly painful OA who is unsuitable for surgery and who has had significant benefit from steroid injection (which in this scenario often times in my experience is not the case) then perhaps there is an argument to continue with injections.
However in younger patients, particularly those who are active and involved in high impact activities. In this category of patients I would very early on (after as few as 1 or 2 steroid injections) be thinking of alternatives such as Hyaluronic Acid injections in order to avoid progression of cartilage loss.
Eckstein, F., Boudreau, R.M., Wang, Z., Hannon, M.J., Wirth, W., Cotofana, S., Guermazi, A., Roemer, F., Nevitt, M., John, M.R. and Ladel, C., 2014. Trajectory of cartilage loss within 4 years of knee replacement–a nested case–control study from the Osteoarthritis Initiative. Osteoarthritis and cartilage, 22(10), pp.1542-1549.
Guermazi, A., Roemer, F.W., Burstein, D. and Hayashi, D., 2011. Why radiography should no longer be considered a surrogate outcome measure for longitudinal assessment of cartilage in knee osteoarthritis. Arthritis research & therapy, 13(6), p.247.
McAlindon, T.E., LaValley, M.P., Harvey, W.F., Price, L.L., Driban, J.B., Zhang, M. and Ward, R.J., 2017. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. Jama, 317(19), pp.1967-1975.
Raynauld, J.P., Buckland‐Wright, C., Ward, R., Choquette, D., Haraoui, B., Martel‐Pelletier, J., Uthman, I., Khy, V., Tremblay, J.L., Bertrand, C. and Pelletier, J.P., 2003. Safety and efficacy of long‐term intraarticular steroid injections in osteoarthritis of the knee: A randomized, double‐blind, placebo‐controlled trial. Arthritis & Rheumatology, 48(2), pp.370-377.
Wernecke, C., Braun, H.J. and Dragoo, J.L., 2015. The effect of intra-articular corticosteroids on articular cartilage: a systematic review. Orthopaedic journal of sports medicine, 3(5), p.2325967115581163.
Many will have heard of steroid injections often in relation to musculoskeletal disorders. Many people know someone who has received a steroid injection for an osteoarthritic knee a frozen shoulder or for any other musculokeletal condition.
Fewer people might have heard of Hyaluronic Acid injections and maybe still fewer might have heard of Hydrodistension injections. In this blog I will try to to give a brief summary of the differences between these injection options and indicate when they are likely to be most beneficial.
Often times patients are referred by their GP for a steroid injection when their shoulder, knee or whatever other joint or soft tissue problem they might be suffering with, is peristent, causing a lot of pain and is not responding to the usual first line treatments such as: relative rest, Non steroidal Antinflamatory drugs (NSAIDs) and or exercise therapy +/- physiotherapy.
Steroid injections when given appropriately are generally very safe and cause very litle side effects. Please see our steroid information leaflet for some more information on steroid injections and their risks and side effects.
Steroid injections for musculoskeletal conditions should not to be confused with oral steroid (steroid pills) treatment. Usually the negative reports one hears about steroids refer to the side-effects associated with long term (usually oral) systemic steroid therapy (steroid pills). This tends to be for chronic conditions. For doctors to decide that the benefits outweigh the significant risks and side effects associated with long term steroid therapy it usually reflects the seriousness of the conditions that these people might be taking it for.
In what situation is a steroid injection most beneficial ?
Corticosteroids are synthetic drugs that resemble cortisol, a hormone that you produce in your adrenal glands. Corticosteroids have powerful anti-inflammatory effects. As a rule steroid injections are most useful for conditions where the pain, caused by a musculoskeletal condition, is a dominating feature and where there is a big impact on functional activities. Injections allow for an optimum dosage to a specific area of the body. Steroid injections tend to give pain relief relatively quickly, usually within one week following administration. Note that these are not the same drugs that some athletes use (illegally) to gain muscle strength.
Hyaluronic acid injections
Hyaluronic acid injections are also called viscosupplementation injections. Hyaluronic acid injections are most commonly used to treat symptoms of symptoms of knee osteoarthritis. Hyaluronic acid is an important component of the joint fluid in healthy joints, but is found in lower concentrations in osteoarthritic joints. By adding hyaluronic acid to the existing joint fluid the aim is to facilitate better joint movement, reduce pain and maybe slow down the progression of osteoarthritis.
In what situation is a hyaluronic injection most beneficial ?
Often good candidates for viscosupplementation are those with osteoarthritis who have failed to improve with other non-surgical treatments including steroid injections. Steroid injections can only be repeated for a limited number of times due to their potential side-effects. So regardless of the benefits of steroid injections hyaluronic acid injection might be a more suitable alternative in these circumstances.
Generally people who benefit from hyaluronic acid injections are active people for whom good movement in their joints is important. They should not be in severe acute pain as hyaluronic acid does not have the strong anti-inflammatory effects of a steroid injection and therefore might not provide enough pain relief in these more acute states.
Hyaluronic acid gives the joint fluid its viscous, slippery quality, which enables the bones’ cartilage-covered surfaces to glide against each other, thereby reducing joint friction. It adds cushion to protect joints during impact (e.g. weight-bearing activity).
joints have lower concentrations of hyaluronic acid in their joint fluid than healthy joints, and therefore have less protection against joint friction and impact.
By injecting a synthetically made hyaluronanic acid into the knee the aim is to temporarily lubricate the knee joint, thereby decreasing pain improving function and hopefully slowing the degeneration process.
Hydrodistension or High Volume injections are performed under ultrasound guidance with the aim of precisely depositing anti-inflammatory steroid, local anaesthetic and saline to give pain relief whilst also deliberately stretching the lining of the joint (joint capsule). This procedure is increasingly used in the treatment of ‘frozen shoulder’ (adhesive capsulitis) and has been shown to be effective in the majority of patients by giving pain relief and also helping them to regain movement. These injections can give rapid and effective reduction in pain and inflammation; however, improvements are usually temporary. As with all medicines, some people may experience side effects.
In what situation is a hydrodistension injection most beneficial ?
Clinically hydrodistension appears to be most useful in frozen shoulders where restriction rather than pain is the most dominant feature. As the injected volume is higher the procedure is likely to be slightly more uncomfortable when compared with a “normal” steroid injection under ultrasound guidance. This makes the procedure a good choice in “stiffness dominated” frozen shoulders.
Some research (Yoon et al. 2016) appears to support the above notion. Their study showed that hydrodistension plus steroid resulted in a bigger reduction in pain and a greater improvement of shoulder movement when compared to steroid injection alone in the first 3 months post injection. However patients in this study due to inclusion citeria were more likely to be in the more chronic stage (froze stage) of frozen shoulder when pain levels are reduced and the dominant problem is restriction of movement.
No such differences have been shown in other studies which included patients in the more acute earlier stages of frozen shoulder (Sharma, 2016; Lee, 2016). This might suggest that hydrodistension is more effective in those with significant shoulder stiffness but who are not in severe pain. More research is needed to evaluate this further.
Lee, D.H., Yoon, S.H., Lee, M.Y., Kwack, K.S. and Rah, U.W., 2017. Capsule-Preserving Hydrodilatation With Corticosteroid Versus Corticosteroid Injection Alone in Refractory Adhesive Capsulitis of Shoulder: A Randomized Controlled Trial. Archives of physical medicine and rehabilitation, 98(5), pp.815-821.
Sharma, S.P., Bærheim, A., Moe-Nilssen, R. and Kvåle, A., 2016. Adhesive capsulitis of the shoulder, treatment with corticosteroid, corticosteroid with distension or treatment-as-usual; a randomised controlled trial in primary care. BMC musculoskeletal disorders, 17(1), p.232.
Yoon, J.P., Chung, S.W., Kim, J.E., Kim, H.S., Lee, H.J., Jeong, W.J., Oh, K.S., Lee, D.O., Seo, A. and Kim, Y., 2016. Intra-articular injection, subacromial injection, and hydrodilatation for primary frozen shoulder: a randomized clinical trial. Journal of shoulder and elbow surgery, 25(3), pp.376-383.