INTRA-ARTICULAR

JOURNAL
CORTICOSTEROID INJECTION
READING
FOR SYMPTOMATIC KNEE
OSTEOARTHRITIS : WHAT THE
ORTHOPAEDIC PROVIDER
NEEDS TO KNOW
Cody L. Martin, MD
James A. Browne, MD
abstract
Intra-articular corticosteroid
injections have been used for
decades in the management of
symptomatic osteoarthritis of
the knee and remain a common
practice.
The pain relief from a steroid
injection, substantial variability
remains among providers with The success of steroid injections
regard to the technique used to most often occurs in the short
perform the procedure, including term. The efficacy varies within
the site of the injection, the the published literature.
medications injected, and the
level of sterility.

American Academy of
Orthopaedic Surgeons guideline
does not support conclusive Should be aware of the adverse
recommendations about the use effects and potential
of intra-articular corticosteroid complications.
injections for symptomatic knee
osteoarthritis.
 01 introduction 04 Location & methods
for injection and site
preparation &
technique

02 Type and dose of 05 Subsequent injections

corticosteroid

TABLE OF 03 Combination with 06 outcomes

CONTENTS local anesthetics

07 Adverse effects and

complication
INtroduction
52.5 millions

Intra-articular steroid injections are work

Standard treatment, including intra- Indications for their use are short-term
by reducing inflammation within the joint
articular steroid injections, focus symptomatic relief after failure of other
and synovium, althougt the
symptomatic relief. nonsurgical measures
exactmechanism is not know

The Osteoarthritis Research Society

International group published an
update of evidence-based, consensus
recommendations on knee osteoarthritis
in 2014 in which they recommended
that intra-articular steroid injections
are appropriate for patients with knee
and multijoint osteoarthritis with or
without comorbidities for short-term pain
relief
83% disability burden of
osteoarthritis
The American Academy of
Orthopaedic Surgeons, on the other
hand, was unable to support
conclusive recommendations
concerning the use of intra-articular
corticosteroids for patients with
symptomatic osteoarthritis of the
knee
 Type of corticosteroid
TRIAMNICOLONE
• More efective than another
• (TRIAMNICOLONE HEXACETONIDE) Has low
solubility, which allows for longer maintained
levels of the medication in the joint an synovium.

A survey of American College of Rheumatology

• Methylprednisolone acetate 34.6%
• Triamnicolone hexacetonide 31.2%
• Triamnicolone acetonide 21.7%
Dose of Corticosteroids
• Depends on the potency and solubility of the • Effective to improving pain for up to 24 weeks.
drug
• The lowest possible dose to achieve the
desired outcome is a rule for medication use
in general.
 Combinaton with local
anesthetics
positive
● Pain relief from intra-articular pathology
● Diluting the steroid preparation
● Moderating or eliminating the postinjecton
flare
● For diagnostic the patien’s predominant cause
of pain it is multifactorial (that sometimes
wrongfully attributed to osteoarthritis pain.)
Potential drawbacks exist
● Chondrotoxic
● Toxicity to the cartilage
● Crystallization / flocculation
● Decrease the bioavailability of the local
anesthetic or affect the efficacy of the
corticosteroid
 Location for Injection and
Likelihood of Injecting Within the Joint
Location Potition Disadvantage
Peripatellar Knee extended Potential injury to the
patellar cartilage.
(Mid-patellar) Potential
injury to the patellar
cartilage (the needle
must pass under the
patella to access the
knee joint)

Superior Suprapatellar puch, the

patellar needle does not have to
pass under the patella
Anterior Knee bent  sitting
*No bencmark location exists for injection
Methods for increasing the accuracy of
intra-articular injection
Sibbitt et al
Hussein (RCT of 94 osteoarthritic knees without effusion comparing intra-
articular corticosteroid treatment
USG guidance VS anatomic guidance)

• Aspirating fluid before • Absence of effusion and • USG 48% less needle
injection without the need of introduction pain, 36%
• Imaging such as imaging increase in therapeutic
ultrasonography or duration and 42% less
fluoroscopy knee pain at 2 weeks
(but no difference at 6
months)
 Aspiration
Site Preparation and Technique indications for
fluid analysis
include concern
With
Looking for inflammatory
Aseptics sterile/nonsterile
venipuncture arthritis or crystal
gloves
arthropathy

Blood culture contamination rate 2% alcoholic 10% aqueous povidone-

chlorhexidine iodine
3.2% 6.9%
Blood culture contamination 70% isopropyl alcohol 2% chlorhexidine
(Martínez et al) 0.9% 1.9%
Maximum antiseptic effect Chlorhexidine povidone-iodine
30 seconds 1.5 to 2 minutes
Culture growth from skin samples After alcohol preparation After alcohol preparation
(Polishchuk et al) before ethyl chloride 3% after ethyl chloride 5%
Benefit from aspiration, followed by steroid Aspiration No aspiration
injection 92% 61%
At 1 week 66% 44%
At 6 weeks (Gaffney et al)
Subsequent injections

Little data are available to guide

• No more than 3 to 4 steroid injections int a knee be performed within a year.

• Long-term repetitive use of intra-articular steroid injections to be ineffecttive.

Liu et al

• 59% who received an initial corticosteroid injection in the knee did not receive additional injections.
• 20% of patients after receiving their first corticosteroid injection need subsequent steroid injections
outcomes
Corticosteroid injections for
management of osteoarthritis
Hepper et al
have been shown to be significant pain relief
statistically and clinically
significant at reducing pain
at 1 week after
in the short term injection

A Cochrane Review Maricar et al (cohort 207

Injections remained patients)
73.4% responded to treatment
unclear at 1 to 6 weeks
Outcomes (2)
McAlindon et al (controlled Raynauld et al
double blind trial of 140 patient)
Who received steroid injection
Who received steroid injection
every 3 months for 2 years 
every 3 months for 2 years 
increased knee cartilage volume 1 year f/u and 2 year f/u no
loss (MRI) significant difference.

Hirsch et al Meta-analysis (137 studies with

Subsequent injections have less pain 33,243 patients)
relief or decreased duration of efficacy Intra-articular significantly better pain
Who had previous intra-articular relief than oral
Adverse effects and complications
Intra-articular corticosteroid injections in the knee are considered to be a relatively safe
procedure
 ● Intra-articular steroid injections are a relatively safe
treatment for short-term symptomatic osteoarthritis of the
knee.
● Should not be given on a scheduled basis but instead used
only when patients have substantial symptoms.
● Should be discontinued if previous injections fail to provide
substantial relief.

CONCLUSIO● Cartilage loss may occur in those who receive multiple

subsequent injections.
NS ● Should be aware of the risks and potential complications of
this common treatment.
Thank you