US-guided intra-articular injection of corticosteroid relieves symptoms in hip OA

An ultrasound (US)-guided intra-articular hip injection of corticosteroid and local anaesthetic, administered with advice and education, results in a rapid and sustained symptom response for individuals with hip osteoarthritis (OA), a study has shown.

“Our patient advisory group felt that these findings offer an important choice to patients, particularly those who are unsuitable for surgery and might feel their treatment options are limited,” the researchers said. “As in routine clinical practice, caution should be applied in patients with risk factors for, or signs of, infection.”

This randomized controlled trial was conducted in two community musculoskeletal services in England. Of the 199 adults (mean age 62.8 years, 57 percent women) with hip OA and at least moderate pain, 67 were randomized to receive advice and education (best current treatment [BCT]), 66 to BCT plus US-guided injection of triamcinolone and lidocaine, and 66 to BCT plus US-guided injection of lidocaine.

Across time points, the average weighted follow-up rate reached 93 percent. Greater mean improvement in hip pain intensity over 6 months was noted in the BCT plus US-triamcinolone-lidocaine group compared with BCT (mean difference [MD], ‒1.43, 95 percent confidence interval [CI], ‒2.15 to ‒0.72; p<0.001; standardized MD, ‒0.55, 95 percent CI, ‒0.82 to ‒0.27). [BMJ 2022;377:e068446]

On the other hand, no difference was seen in hip pain intensity over 6 months between BCT plus US-triamcinolone-lidocaine and BCT plus US-lidocaine (MD, ‒0.52, 95 percent CI, ‒1.21 to 0.18). Moreover, the presence of US-confirmed synovitis or effusion correlated with a significant interaction effect in favour of BCT plus US-triamcinolone-lidocaine (MD, ‒1.70, 95 percent CI, ‒3.10 to ‒0.30).

Of note, one participant in this group with a bioprosthetic aortic valve died from subacute bacterial endocarditis 4 months after the intervention, which was potentially related to the trial treatment.

“Our findings do not confirm or refute a causal link between glucocorticoid injection and bacterial endocarditis, but clinicians should specifically exert caution and carefully counsel patients with risk factors for endocarditis, such as those with a prosthetic heart valve,” the researchers said.

In previous systematic reviews and meta-analysis, people with increased pain, but without signs of inflammation, received more benefit from corticosteroid injection in the hip and knee. [Osteoarthr Cartil 2016;24:1143-1152; Rheumatology (Oxford) 2013;52:1022-1032]

“Our findings, consistent with those from a previous trial of hip OA, suggest that the presence of synovitis or effusion on US might predict response in people with hip OA,” the researchers said. “The presence of inflammation is possibly more important for hip rather than for knee injections.” [Ann Rheum Dis 2011;70:110-116]

Further research is warranted to examine the effectiveness, acceptability, and feasibility of a stratified approach to treatment, as imaging findings of inflammation seem to predict response to injection, according to the researchers.

“A need remains to understand more fully the incidence and risk factors for adverse reactions associated with intra-articular corticosteroid injections, such as infection,” they added. [Radiology 2020;297:503-512]