Study Links Hip Steroid Injections to Rapidly Destructive Hip Disease

Corticosteroids (also called glucocorticoids; hereafter referred to as steroids) are used to prevent and treat inflammatory conditions. Some doctors commonly perform intra-articular hip steroid injections — which entail injecting a steroid drug directly into the hip-joint space — in patients with osteoarthritis who are unresponsive to other, less invasive forms of treatment to relieve hip pain and to delay the need for total hip arthroplasty (joint replacement surgery).[1]

Although limited evidence suggests that intra-articular hip steroids may provide short-term pain relief in certain patients with hip osteoarthritis, their long-term effectiveness is not well-established.[2] Therefore, some treatment guidelines (such as those by the Osteoarthritis Research Society International) do not recommend intra-articular hip steroid injections.[3]

Some patients may choose to undergo intra-articular hip steroid injections thinking that even if these injections may not be helpful for relieving hip pain, they are not harmful. However, evidence from a recent observational study shows that intra-articular steroid injections for hip osteoarthritis are associated with an increased risk of rapidly destructive hip disease,[4] a serious long-term condition that involves rapid joint destruction and bone loss.[5]

The study was published in the Nov. 17, 2021, issue of the Journal of Bone and Joint Surgery.

The new study[6]

The study researchers used data pertaining to patients who were members of a geographically isolated Hawaiian health-maintenance organization in which members received all their health care and radiographic imaging within an integrated health care system. They divided the study into two retrospective parts: a case-control analysis that aimed to assess whether an association exists between intra-articular steroid injections and rapidly destructive hip disease and a cohort analysis that aimed to determine the rate of, and risk factors for, rapidly destructive hip disease after intra-articular steroid injections.

In the case-control analysis, the researchers compared data for hips of adult patients who were treated for rapidly destructive hip disease from 2013 and 2016 (case group) with those for patients who were at risk of this complication but did not develop it (control group). Specifically, the control group comprised all patients who underwent total hip arthroplasty for diagnoses other than rapidly destructive hip disease (or fracture) during the same period. The researchers considered history of receiving any injection with either low-dose (40 milligram [mg] or less) or high-dose (80 mg or more) intra-articular triamcinolone — a steroid drug — as the exposure of interest in the case group. All such injections had been performed by certified radiologists under fluoroscopy (real-time X-ray imaging) guidance.

There were 40 hips in the case group and 717 hips in the control group (the median age among the overall patients was 66 years). Whereas 88% of the hips pertaining to the case group had received at least one intra-articular triamcinolone injection, only 45% of hips in the control group had received such injections. Overall, the researchers estimated that intra-articular triamcinolone injections increased the odds of rapidly destructive hip disease by approximately ninefold. Also, there was a dose-response effect: low-dose injections increased the odds of rapidly destructive hip disease by fivefold whereas high-dose injections increased these odds by 10-fold.

In the cohort analysis, the researchers limited their data to the hips that were injected with triamcinolone during the study period. Overall, out of 688 hips that received such injections, 37 (5%) developed rapidly destructive hip disease.

On average, rapidly destructive hip disease was diagnosed five months after the steroid injection, and all patients who developed this complication were treated with total hip arthroplasty.

The study researchers noted that they no longer perform hip injections using high-dose steroids and have revised the informed consent for steroid hip injections to alert patients about the increased risk of rapidly destructive hip disease.

Because the study was not a randomized, controlled clinical trial, its findings infer — but do not prove — a causal link between steroid hip injections and rapidly destructive hip disease. However, its findings, along with similar supportive evidence from prior case series studies,[7],[8] raise concerns that should be heeded by patients who are considering this treatment option.

What You Can Do

If you have hip osteoarthritis, especially if you have a mild-to-moderate form of this condition, it is best to rely on physical therapy, exercise and tai chi to manage your condition.[9] Also, try to lose weight if you are obese or overweight.

If you are considering intra-articular hip steroid injections, discuss this article with your doctor. Based on current evidence, it is especially important to avoid high-dose intra-articular steroids because they are potentially associated with higher risk of rapidly destructive hip disease than smaller doses.

Also, avoid opioid analgesics because of their limited effectiveness for hip osteoarthritis and their substantial adverse effects, such as addiction, respiratory depression and somnolence.[10]

If you have severe hip osteoarthritis and structural hip damage, discuss with your doctor whether you are a good candidate for total joint replacement.
 

References

[1] Hernigou P. Primum non nocere: Is it really true with corticosteroid hip injections? J Bone Jt Surg Am. 2021;103(22):e92.

[2] Zhong HM, Zhao GF, Lin T, et al. Intra-articular steroid injection for patients with hip osteoarthritis: A systematic review and meta-analysis. Biomed Res Int. 2020;2020(February 24):6320154.

[3] Bannuru RR, Osani MC, Vaysbrot EE, et al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthritis Cartilage. 2019;27(11):1578-1589.

[4] Okike K, King RK, Merchant JC, et al. Rapidly destructive hip disease following intra-articular corticosteroid injection of the hip. J Bone Joint Surg Am. 2021;103(22):2070-2079.

[5] Kompel AJ, Roemer FW, Murakami AM, et al. Intra-articular corticosteroid injections in the hip and knee: Perhaps not as safe as we thought? Radiology. 2019;293(3):656-663.

[6] Okike K, King RK, Merchant JC, et al. Rapidly destructive hip disease following intra-articular corticosteroid injection of the hip. J Bone Joint Surg Am. 2021;103(22):2070-2079.

[7] Kompel AJ, Roemer FW, Murakami AM, et al. Intra-articular corticosteroid injections in the hip and knee: Perhaps not as safe as we thought? Radiology. 2019;293(3):656-663.

[8] Batra S, Batra M, Mcmurtrie A, Sinha AK. Rapidly destructive osteoarthritis of the hip joint: a case series. J Orthop Surg Res. 2008;3(January 11):3.

[9] Kolasinski SL, Neogi T, Hochberg MC, et al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Care Res. 2020;72(2):149-162.

[10] Katz JN, Arant KR, Loeser RF. Diagnosis and treatment of hip and knee osteoarthritis. A review. JAMA. 2021;325(6):568-578.