Many people today are on waiting lists for surgeries. Some surgeries have been delayed days, some weeks, some months, some longer. During this time doctors and patients struggled with treatments that would help with managing the patient’s pain until the surgery could be performed. One such treatment was cortisone injection.
If you have two tools to help a patient with a more advanced knee osteoarthritis and those tools are cortisone injections and surgery and one tool was being delayed, a situation develops that puts the patient in a difficult situation. Doctors during the COVID pandemic found themselves trying to navigate through this situation where they had to balance the two treatments in the most effective way if surgery was to be postponed or delayed.
Corticosteroid or cortisone has well known side-effects and in the research below, we will see that cortisone injection before knee replacement surgery can cause complications. The question then became, how much cortisone can a patient’s knee take?
Extended Cortisone treatments
People get cortisone injections because they have pain and swelling that interfere with function. Injections are given for knee bursitis, knee tendinitis, rheumatoid arthritis and osteoarthritis. They were told at the time of the first injection that they should experience a near immediate relief as the anti-inflammatory action of the cortisone took effect. The next most common question people asked was “how long with this cortisone injection last?” The effect of a cortisone injection is temporary. Cortisone shots do not offer cures but reduce inflammation and pain enough that doctors can pursue other treatments.
Some people will only need one cortisone injection, some people will need more until they are eligible or can get surgery. For some people cortisone can last for days, weeks, or months. For others the cortisone has no effect at all.
Many people who were scheduled for a total knee replacement saw appointments cancelled and postponed as hospitals stopped elective surgeries to free up beds and staff to deal with COVID-19 patients. Some of these waiting for knee replacement people became COVID-19 patients themselves and used that same hospital bed that they were hoping to use to recover from their knee procedure.
As delays in knee replacement surgery continued many people were left with the choice of more painkillers, more cortisone, or more coping to help them deal with severe pain and limited mobility and reduced daily function.
Even as elective surgeries resumed, more delays occurred as the Delta and Omicron variants caused sickness among the healthcare workforce. It is estimated that hundreds of thousands of people in the United States have been waiting more than a year for surgery and the surgical backlog may reach over one million cases in mid-2022.
Delays in surgery cause more complicated surgeries, increased use of medications, more difficult recovery, and worse outcomes
The delays in surgery have caused obvious problems for patients. The biggest is that they have to be pain managed longer. In February 2022 an editorial in the medical journal The Lancet wrote:(1)
“Orthopaedists and rheumatologists caution that delaying surgery in patients with the most severe disease can lead to more complicated surgeries, increased use of medications, more difficult recovery, and worse outcomes, including increased rates of revision surgery and reduced quality of life. A recent study projected 50% greater odds of worse outcomes when surgery is delayed by more than 6 months—far less time than thousands of patients have already waited. Another concern is increased use of opioids, which even before the COVID-19 pandemic was reported in up to one fifth of patients awaiting arthroplasty, despite evidence that this leads to poorer outcomes. “
Cortisone before meniscus surgery
A November 2022 paper (11) examined at what point would pre-surgery cortisone injections be considered a high risk factor for infections post-surgery (4). Here is what the study found: “Consensus guidelines recommend administering a corticosteroid injection for patients with a symptomatic degenerative meniscus lesion prior to arthroscopic partial meniscectomy. A recent study found that corticosteroid injection administered within 1 month prior to meniscectomy is associated with an increased risk of postoperative infection. However, infections may range in severity from superficial infections to serious infections requiring surgical interventions. Serious infections requiring a surgical intervention are rare after a meniscectomy, occurring in 0.1% of arthroscopic partial meniscectomy in a matched cohort of patients over 35. Patients were five times more likely to return to the operating room for infection after arthroscopic partial meniscectomy if they had a corticosteroid injection in the month before or had multiple corticosteroid injection in the year before surgery. The risk of infection was no longer significant if there was at least a 2-month interval between preoperative corticosteroid injection and arthroscopic partial meniscectomy.”
How much cortisone can I get in my knee while I wait for knee replacement?
We see many patients who had concerns about cortisone injection. Most recently we have been seeing many patients concerned about frequent recommendations to cortisone while they wait for knee surgery. Initially their doctors advised them that cortisone injections can be effective and safe if used in moderation or as a one time treatment.
But as this knee replacement recommended patient continued to wait for a surgery, decisions had to be made as to how cortisone could be used to provide comfort until the surgical date.
This was a difficult question for doctors to answer. A number of new research studies began to appear to try to offer medical professionals some basis for continued cortisone use.
(Corticosteroid has) limited short-term effectiveness, there are multiple potential adverse effects including toxicity
A January 2021 (2) study lead by Northwestern University McGaw Medical Center issued this statement:
“(Corticosteroid has) limited short-term effectiveness, there are multiple potential adverse effects including toxicity to articular cartilage and numerous systemic side effects such as increases in blood glucose levels, a reduction in immune function, and an increased risk of infections.”
A December 2020 paper in the medical journal Radiology (3) says this:
“Recent case series suggested that negative structural outcomes including accelerated osteoarthritis progression, subchondral insufficiency fracture (stress fractures in the bone beneath cartilage), complications of pre-existing osteonecrosis, and rapid joint destruction (including bone loss) may be observed in patients who received Intra-articular corticosteroid injections.
A December 2022 review paper (12) examined previously published medical research on the use of image-guided corticosteroid injections for knee. The researchers observed in the literature consistent findings suggesting cortisone “knee injections were found either to have little or no impact or were similar or inferior to comparison injections (intra-articular hyaluronic acid, PRP, NSAIDs, normal saline, adductor canal blocks). ”
Adverse joint events after intra-articular corticosteroid injection, including accelerated osteoarthritis progression
Here is a study published in the journal Radiology from the Department of Radiology, Boston University School of Medicine (4) :
“Adverse joint events after intra-articular corticosteroid injection, including accelerated osteoarthritis progression, subchondral insufficiency fracture, complications of osteonecrosis, and rapid joint destruction with bone loss, are becoming more recognized by physicians, including radiologists, who may consider adding these risks to the patient consent.”
How much cortisone can I get in my knee while I wait for knee replacement? What about low-dose cortisone?
Which brings us back to the question, how much cortisone can I get in my knee?
In the HSS journal : the musculoskeletal journal of Hospital for Special Surgery, (5) doctors discussed pre-surgery low-dose cortisone and its benefits and impact on patient recovery after knee replacement.
“Short-term benefits of perioperative corticosteroid injections for bilateral total knee replacement include suppressed inflammation, improved knee motion, and reduced pain. Very little is known about the long-term benefits, complications, and safety of corticosteroids administered in the perioperative period. (The doctors) sought to compare 3-year follow-up outcomes of bilateral total knee replacement patients who received perioperative corticosteroid injections with those who received placebo.”
The goal of this study according to the study’s authors was to test the hypothesis that there would be no statistically significant differences in functional outcomes or adverse events based on whether or not corticosteroid injections were administered in the perioperative period. That, in fact, low-dose cortisone could help a patient before surgery and its long-term effects would not impact the patients after surgery.
The doctors followed patients with had both knees replaced and assessed them at at 6 and 12 weeks and at 1, 2, and 3 years.
Low-dose corticosteroids can be administered in selected patients who undergo bilateral total knee replacement without increasing the risk of adverse events
The results where that Low-dose corticosteroids did not cause infections post-operatively in the knee replacement patients. Patients in the Low-dose corticosteroids group experienced reductions in pain and stiffness, though these results were not statistically significant compared to the placebo.
Conclusions: Low-dose corticosteroids can be administered in selected patients who undergo bilateral total knee replacement without increasing the risk of adverse events. At 3-year follow-up, administration of low-dose corticosteroids did not result in superior clinical outcomes scores when compared with placebo.
“Intraarticular glucocorticoid injections for symptomatic knee osteoarthritis did not significantly increase the 5-year risk of incident total knee replacement.”
An August 2022 study (9) questioned whether glucocorticoid injections increase the risk of knee osteoarthritis progression over 5 years? Here is what the study authors wrote: “Recent findings have demonstrated that intraarticular glucocorticoid injections can be deleterious (harmful) for knees with osteoarthritis. This study was undertaken to assess, in a real-life setting, the risk of knee osteoarthritis progression in patients who received intraarticular glucocorticoid injections over a 5-year follow-up period.
- Among the 564 patients with knee osteoarthritis included in the study sample, 51 (9.0%) and 99 (17.5%) received intraarticular glucocorticoid injections or intraarticular hyaluronic acid injections, respectively, and 414 (63.1%) did not receive any injection during follow-up.
- Compared to untreated knees, those treated with intraarticular glucocorticoid injections had a similar risk of incident total knee replacement or osteoarthritis grade worsening. Intraarticular hyaluronic acid injections had no effect on the risk of total knee replacement or osteoarthritis grade worsening.
Conclusion: “In this study, intraarticular glucocorticoid injections for symptomatic knee osteoarthritis did not significantly increase the 5-year risk of incident total knee replacement or radiographic worsening. These findings should be interpreted cautiously. . . ”
Options to waiting for knee replacement or cortisone injections
There are a number of options you can try to avoid knee replacement or manage your pain beyond cortisone. Most people I see have already visited these treatments.
- More and more potent anti-inflammatories.
- Renewed physical therapy sessions – if you can get it.
- Reluctantly, more painkillers.
- Bigger, better braces.
- Better coping skills.
PRP Injections
In our office we offer PRP or Platelet Rich Plasma injections. PRP treatments involve collecting a small amount of your blood and spinning it in a centrifuge to separate the platelets from the red cells. The collected platelets are then injected back into the injured area to stimulate healing and regeneration.
The platelets contain healing agents, or “growth factors.” including Platelet-derived growth factor (PDGF), Transforming growth factor beta (or TGF-β, Insulin-like growth factors, Vascular endothelial growth factor (VEGF) and Epidermal growth factors .
An introduction to PRP injections
Here is a simple introduction to PRP treatments from an editorial commentary in the April 2021 issue of the journal Arthroscopy.(6)
“Injections for the pain caused by knee osteoarthritis have been the focus of significant research for the last few decades. Systematic reviews and meta-analyses suggest that platelet-rich plasma (PRP) can provide up to 12 months of pain relief in these patients, superior to both cortisone and hyaluronic acid.”
Research: PRP, Intra-articular hyaluronic acid injections and Intra-articular cortisone
A February 2021 (7) study also assed the effectiveness of PRP injections and compared them to cortisone and hyaluronic acid.
In addition to providing the growth factors necessary for healing mentioned above, the researchers also noted: “PRP was proven to halt chondrocytes catabolic activity (breakdown and death of cartilage cells), which is important for the reduction of the chondrocyte apoptosis (death) rate, also resulting in a decrease in the loss of the cartilage matrix secreted by cartilage cells and an increase in cartilage height. Further, compared to other injective therapies (hyaluronic acid, cortisone, and saline), treatment with PRP was found to be clinically superior in reducing osteoarthritis-related pain symptomatology and increasing the functional outcomes with similar or less risks of adverse events. ”
Direct comparison between PRP injections and cortisone for knee pain
An October 2020 study (8) compared the effectiveness of platelet-rich plasma in pain complaints reduction and functional improvement of knee osteoarthritis compared with the standard treatment with injectable corticosteroid, such as triamcinolone.
The study was performed on 50 patients with knee osteoarthritis randomly divided into equivalent samples for each therapy (25 patients each).
- At 180 days after treatment the research team was able to verify, through standardized scoring systems that the patients receiving the PRP had reduced pain and better function in their knees.
- In direct comparison between the two treatments the study concludes: “Although both platelet-rich plasma and corticosteroid therapies have been shown to be effective in the reduction pain complaints and functional recovery, there was a statistically significant difference between them at 180 days. According to the results obtained, platelet-rich plasma presented longer-lasting effects within 180 days in the treatment of knee osteoarthritis.”
A September 2022 study (10) examined the data from ten randomized control studies (eight knee osteoarthritis papers with 763 patients among them.) Patients received between 2 and 8 injections, varying by trial. Trials compared recurrent cortisone injections, hyaluronic acid, platelet-rich plasma (PRP), saline or orgotein (as an anti-inflammatory drug). The average follow up was three to 24 months).
- Greater improvements in pain, function and quality of life at 3-24 months were noted for the other treatments over cortisone.
- Recurrent cortisone injections demonstrated no benefits in pain or function over placebo at 12-24 months.
- No serious adverse events were recorded.
- Recurrent cortisone injections often provide inferior (or non-superior) symptom relief compared with other injectables (including placebo). Other injectables (hyaluronic acid, platelet-rich plasma (PRP)) often yielded greater improvements in pain and function up to 24 months post-injection.
- Existing randomized control studies on recurrent cortisone injections lack sufficient follow-up data to assess disease progression and complications.
Bone Marrow Concentrate Injections – Stem Cell Injections
In 2018, our team published the results of four case studies in the journal Clinical Medicine Insights: Arthritis and Musculoskeletal Disorders June 18, 2018 (4)
Preliminary research suggests that bone marrow concentrate (BMC), which contains mesenchymal stem cells and platelets, is a promising treatment for knee osteoarthritis. In our paper we reported on the short-term progress of 15 patients (20 knees) with knee osteoarthritis through 4 BMC (bone marrow derived stem cell treatments.)
The timetable of the four treatments:
- First treatment
- Second treatment approximately 14 days after first treatment.
- Third treatment, approximately 21 days after second treatment, 35 days after first treatment
- Fourth treatment, approximately 34 days after the third treatment. Approximately 69 days on average after first treatment
- The last follow-up was conducted a mean 86 days after the first treatment.
What we measured: Overall improvement percentage was compared after each treatment for the following:
- pain at rest
- pain during activity
- functionality scale scores
What we found:
- Patients experienced statistically significant improvements in active pain and functionality score after the first treatment.
- Additionally, patients experienced a mean decrease in resting pain after the first treatment, yet outcomes were not statistically significant until after the second treatment.
- On average, patients experienced:
- an 84.31% decrease in resting pain,
- a 61.95% decrease in active pain,
- and a 55.68% increase in functionality score at the final follow-up.
- Patients also reported a mean 67% total overall improvement at study conclusion. Outcomes at the final follow-up after the fourth treatment were statistically significant compared to outcomes at baseline, after first treatment, after second treatment, and after third treatment.
In this study we concluded: “These results are promising, and additional research with a larger sample size and longer follow-up is needed to further examine the treatment effectiveness of multiple BMC injections for knee osteoarthritis.”
Recent research on bone marrow derived stem cell therapy
A February 2021 study, (5) citing our above research, among other research studies investigated the available literature on the use of bone marrow aspirate concentrate (BMAC) and summarize the current evidence supporting its potential for the stem cell injective treatment of joints affected by osteoarthritis. They noted that the “publication trend (of bone marrow aspirate concentrate research) remarkably increased over time. A total of 22 studies were included in the qualitative data synthesis: four preclinical studies and 18 clinical studies, for a total number of 4626 patients. Safety was documented by all studies, with a low number of adverse events. An overall improvement in pain and function was documented in most of the studies.” This study team concluded: “There is a growing interest in the field of bone marrow aspirate concentrate injections for the treatment of osteoarthritis, with promising results in preclinical and clinical studies in terms of safety and effectiveness.”
In this article I presented evidence to suggest that cortisone injections for people waiting for knee replacement can be detrimental. Other doctors suggest the same. Some research alludes to a lower dose cortisone to help patients until surgery. If you have a question about these treatments. Ask me.
References
1 Too long to wait: the impact of COVID-19 on elective surgery. www.thelancet.com/rheumatology Vol 3 February 2021
2 Malanga GA. Corticosteroids: Review of the history, the effectiveness, and adverse effects in the treatment of joint pain. Pain Physician. 2021;24:S233-46.
3 Guermazi A, Neogi T, Katz JN, Kwoh CK, Conaghan PG, Felson DT, Roemer FW. Intra-articular corticosteroid injections for the treatment of hip and knee osteoarthritis-related pain: considerations and controversies with a focus on imaging—Radiology scientific expert panel. Radiology. 2020 Dec;297(3):503-12.
4 Kompel AJ, Roemer FW, Murakami AM, Diaz LE, Crema MD, Guermazi A. Intra-articular corticosteroid injections in the hip and knee: perhaps not as safe as we thought?. Radiology. 2019 Dec;293(3):656-63.
5 McLawhorn AS, Poultsides LA, Sakellariou VI, Kunze KN, Fields KG, Jules-Elysée K, Sculco TP. Low-Dose Perioperative Corticosteroids Can Be Administered Without Additional Morbidity in Patients Undergoing Bilateral Total Knee Replacement: A Retrospective Follow-up Study of a Randomized Controlled Trial. HSS Journal®. 2022 Feb;18(1):48-56.
6 Dwyer T, Chahal J. Editorial Commentary: Injections for Knee Osteoarthritis: Doc, You Gotta Help Me!. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021 Apr 1;37(4):1288-9.
7 Testa G, Giardina SM, Culmone A, Vescio A, Turchetta M, Cannavò S, Pavone V. Intra-articular injections in knee osteoarthritis: A review of literature. Journal of functional morphology and kinesiology. 2021 Mar;6(1):15.
8 Freire MR, da Silva PM, Azevedo AR, Silva DS, da Silva RB, Cardoso JC. Comparative effect between infiltration of platelet-rich plasma and the use of corticosteroids in the treatment of knee osteoarthritis: a prospective and randomized clinical trial. Revista Brasileira de Ortopedia. 2020 Oct;55(5):551-6.
9 Latourte A, Rat AC, Omorou A, Ngueyon‐Sime W, Eymard F, Sellam J, Roux C, Ea HK, Cohen‐Solal M, Bardin T, Beaudreuil J. Do Glucocorticoid Injections Increase the Risk of Knee Osteoarthritis Progression Over 5 Years?. Arthritis & Rheumatology. 2022 Aug;74(8):1343-51.
10 Donovan RL, Edwards TA, Judge A, Blom AW, Kunutsor SK, Whitehouse MR. Effects of recurrent intra-articular corticosteroid injections for osteoarthritis at three months and beyond: a systematic review and meta-analysis in comparison to other injectables. Osteoarthritis and Cartilage. 2022 Sep 13.
11 Forsythe B, Berlinberg EJ, Forlenza EM, Oeding JF, Patel HH, Mascarenhas R. Corticosteroid injections 2 months before arthroscopic meniscectomy increases the rate of postoperative infections requiring surgical irrigation and debridement. Knee Surgery, Sports Traumatology, Arthroscopy. 2022 May 27:1-9.
12 Chang CY, Mittu S, Da Silva Cardoso M, Rodrigues TC, Palmer WE, Gyftopoulos S. Outcomes of imaging-guided corticosteroid injections in hip and knee osteoarthritis patients: a systematic review. Skeletal Radiology. 2022 Dec 15:1-2. / 4949