Injections are considered an adjunct to core treatment (exercise, education, and weight management), not a replacement for core treatment.
There are discrepancies in the guidelines around injection recommendations
Intra-articular cortisone (IAC) injections are commonly used to provide short term pain relief, with most guidelines recommending as an adjunct to core treatments or if having a flare of pain.
A 2015 Cochrane review found:
-at 1-2 weeks-moderate benefit
-at 4-6 weeks small to moderate benefit
-at 13 weeks small benefit
-at 26 weeks no benefit
Effect on pain- 44% of people respond to IAC injection; however 31% respond to placebo
Effect on function: 36% or people respond to IAC injection, however 26% respond to placebo
Summary: IAC injections may cause short term moderate improvement in pain and small improvement in physical function, however whether there are clinically important benefits after 1 to 6 weeks remains unclear due to quality of evidence; highest quality trial found no benefit of IAC injections.
Concerns are being raised about effects of IAC injection:
-may lead to cartilage damage in knee OA,
-possible increased risk of TKR (9.4% increase in rate in recent study).
Also risk of insufficiency fracture, complications of osteonecrosis and rapid joint destruction (Kompel et al 2019)
IAC injection vs physiotherapy:
Recent RCT comparing physical therapy (physiotherapy) to intra-articular cortisone injections found more sustained benefits (measured at 12 months) with PT than with CSI. (NB-Physical therapy was combination of manual therapy and ROM exercises)
Risk factors/considerations:
Consider other factors such comorbidites e.g. unstable diabetes, mediation taking e.g. anti-coagulants, skin conditions and likely breakdown e.g. cellulitis.
Avoid if has insufficiency fracture as may delay healing-recommendation to avoid if acute change in pain not explained by using radiography, and no or mild OA on imaging.
**INSERT TABLE OF GUIDELINES HERE-see dropbox
Who does injections-some GPs do CSI, or refer to radiology departments, rheumatologists, orthopaedic sonsultants or sports physicians. If patient wishes to consider injection-refer back to GP in first instance-highlighting risks vs likely benefits and costs
Podcast discussing physiotherapy versus injection
RACGP OA Guidelines: Conditional For Recommendation, cautious of potential harms of repeated use
Platelet Rich Plasma (PRP injections) Evidence is mixed, RACGP guidelines state “most studies at serious risk of bias and inconsistency and small in size, and felt beneficial effects likely to be over inflated”. Issues with no consensus on eligible participant selection, number and frequency of injections, preparation technique or appropriate platelet concentration. Cost is high.
Guidelines reflect inconsistency-see table – 3 out of 6 against, 2 out of 6 inconclusive and 1 out of 6 conditionally for as an adjunct to treatment
Who does injections? Usually requires referral to orthopaedic or rheumatology consutlant or sports physicians. If patient wishes to consider injection-refer back to GP in first instance-highlighting risks vs likely benefits and costs -PRP usually series of injections usually costing minimum of $250-300 each (cost does vary)
RACGP OA guidelines: Neutral conditional recommendation -studies serious risk of bias, no consensus on eligible participant selection, number and frequency of injections, preparation technique or appropriate platelet concentration
HLA injection:
Cartilage and synovial fluid contain hyaluronate , which is believed to help the synovial fluid to act as a lubricant or shock absorber. The aim of HLA injections is to increase the visco elasticness of the synovial fluid and provide and maintain intra-articular lubrication; hence referred to as ‘viscosupplementation’. Thought may provide anti-inflammatory, analgesic and possibly chondroprotective effects on the articular cartilage and joint synovium, although the RACGP guidelines suggest a conditional against recommendation as the evidence was considered to be at serious risk of bias. The RACGP guidelines reported “an overall a positive effect that was small and not clinically relevant was found for pain and function”.
(Honvo, Reginster, et al., 2019) systematic review but not specific for hip and knee OA-most studies low quality and lacked transparency of date
Safety: adverse events: no significant difference in adverse events compared with placebo.
RACGP recommendation: conditional against
**INSERT TABLE GUIDELIENS Here
If patient wishes to consider injection-refer back to GP in first instance-highlighting risks vs likely benefits and costs – HLA injections also expensive several hundred dollars up to $700 and usually require referral to orthopaedic or rheumatology consultant or sports physician
RACGP OA Guidelines: Conditional against recommendation. Serious risk of bias in studies. Inconsistency in conclusions, appears to demonstrate a small and not clinically relevant positive effect on pain and function. However, risk of total and serious adverse events, cost and complexity of intervention resulted in conditional against recommendation.
Stem cells are cells that have the ability to divide and develop into many different types of cell in the body.
Currently, further trials are required to demonstrate safety and efficacy of stem cell treatment
RACGP OA Guidelines: Strong against recommendation
Animation of study ‘Intra-articular corticosteriod injections increase the risk of requiring knee arthroplasty from the The Bone & Joint Journal
Patient information sheet for HLA injections from Arthritis Australia (www.arthritisaustralia.com.au)