Marc Darrow MD,JD

Typically before someone diagnosed with hip osteoarthritis is recommended to surgery, they will be offered various injections that may help them delay or prolong the need for the replacement surgery. The reasons for delaying hip replacements are many. You have to work, you are a primary caregiver, you are waiting until you retire, you simply do not want the surgery. For the people with hip pain there are choices.

In the following recent research we will examine comparisons between routinely administered hip osteoarthritis injections.

Discussed in this article:

  • Cortisone injection
  • Hyaluronic acid injections
  • Platelet rich plasma
  • Botox injections
  • Cooled radiofrequency ablation

Injections and other non-surgical treatments for hip osteoarthritis

Reviewing the treatments

A March 2022 (14) study reviews the various hip osteoarthritis injections. The researchers of this paper write: “Corticosteroids and hyaluronic acid gel are the two most common agents injected into the hip. Off late, platelet-rich plasma (PRP), mesenchymal stem cell (MSC), bone marrow aspirate concentrate (BMAC), local anesthetic (LA) agents, non-steroidal anti-inflammatory drugs (NSAIDs) and their different combinations have also been injected in hips to provide desired pain relief. However, there is a group of clinicians who vary of these injections.”

In comparing these injections the authors write: “Intraarticular Corticosteroids are effective in providing the desired pain relief in osteoarthritis hip, but repeated injections should be avoided and the interval between hip injections and hip arthroplasty must be kept for more than three months. Methylprednisolone or triamcinolone are combined with 1% lidocaine or 0.5% bupivacaine. Chondrotoxic effects of local anesthetic is a concern. Although national guidelines do not favor the use of hyaluronic acid for hip osteoarthritis, numerous publications have favored its usage for a moderate grade of osteoarthritis. The PRP, MSC, and BMAC are treatment options with great potential; however, currently, the evidence is conflicting on their role in hip osteoarthritis.”

A November 2021 review study which evaluated previously published findings in the medical literature (1) compared hyaluronic acid with platelet rich plasma, with corticosteroids and with saline solution. The researchers of this study concluded of their comparisons: “we have observed that intra-articular injections of platelet-rich plasma seem to decrease pain at short term and disability at long term, in patients affected by hip osteoarthritis better than hyaluronic acid. The association of hyaluronic acid and corticosteroids could give better results compared to hyaluronic acid alone, while the use of intra-articular ketorolac and saline solution requires more studies.”

Cortisone effective for 12 weeks, better than hyaluronic acid injections

Many people are offered a cortisone injection to help with pain relief, inflammation, and in some cases to help their doctors identify where the source of their pain is coming from. Because of the well documented side-effects of cortisone, I cover this topic at length in my article Systemic effects of cortisone injections including cartilage damage, doctors have become less anxious to rush to these injections and in the past years alternatives including hyaluronic acid injections have been developed. But are the hyaluronic acid injections a better option?

The use of corticosteroid injections for hip osteoarthritis and compared these injections to hyaluronic acid injections

An August 202o study (2) made these observations concerning the use of corticosteroid injections for hip osteoarthritis and compared these injections to hyaluronic acid injections:

  • “Intraarticular corticosteroid injections have been used for decades, although evidence is quite scarce, and many controversies remain.”
  • “Available randomized controlled trials show that intraarticular corticosteroid injections provide pain relief and functional improvement in hip osteoarthritis. This efficacy has not been shown with intraarticular hyaluronic acid injections.”
  • “This review shows that intraarticular corticosteroid injections are efficacious in hip osteoarthritis and that this benefit can last up to 12 weeks.”

Summary: Cortisone injections are effective for 12 weeks and they are a better option than hyaluronic acid injections.

The side-effects of cortisone

But again, we come back to the problem of cortisone’s know side-effects and the basic question, what does it cost to get 12 weeks worth of pain relief in the long-term aspect of hip osteoarthritis treatment?

One of the side-effects if corticosteroid injections given into the hip is the concern, as pointed out in a  June 2021 study (3) is “that these injections may increase the risk of postoperative infection if a subsequent total hip arthroplasty (hip replacement) is performed. This study found that “there appears to be both a time and dose-dependent association of hip corticosteroid injection and postoperative infection following hip replacement. Surgeons should consider delaying elective hip replacement if a corticosteroid injection has been administered within the four months prior to the planned procedure.”

Are the side-effects and adverse reaction to cortisone over-reported?

The continuing controversy surrounding the use of cortisone injections for hip pain includes the debate over side-effects.

An August 2022 paper (10) suggested that there is conflicting data about the benefits and complications of  Intraarticular corticosteroid injections and a lack of large studies with follow-up. This makes it difficult to determine the extent of the side-effect problem. In this study the researchers set out to determine the number of patients with complications after hip and knee Intraarticular corticosteroid injections in a large study sample with long-term follow-up.

In this study 500 patients who had corticosteroid injection in the hip and 500 patients who had corticosteroid injection in the knee were assessed for complication between one and 12 months after injection.

  • Of the 1000 patients (mean age, 57 years old; 545 women),
    • 10 patients (1%) developed severe complications.
    • Four patients developed osteonecrosis;
    • three, insufficiency fractures; and
    • three, rapid progressive osteoarthritis.
    • All 10 complications occurred between 2 and 9 months after injection: six (60%) in the hip and four (40%) in the knee.
    • Of the included 1000 patients, 545 (54%) were women, but they had nine of the 10 (90%) complications
    • Conclusion Intraarticular steroid injection had a substantially lower complication rate than that reported in previous smaller studies. The rate of severe complications was disproportionally higher in women than in men.

The risks of intra-articular corticosteroid injections pain relief versus the possibility that the injections were accelerating the need for hip replacement.

A June 2022 paper (12) assessed the risks of intra-articular corticosteroid injections pain relief versus the possibility that the injections were accelerating the need for hip replacement. In this study patients with a diagnosis of hip pain without femoroacetabular osteoarthritis who were administered an intra-articular corticosteroid injection of the hip. This large data base included  25,073 patients who received a corticosteroid injection. The incidence of total hip arthroplasty (THA) at 5-year-follow up was significantly higher for the corticosteroid cohort compared to controls. The incidence and risk of total hip arthroplasty increased along with number of injections, the highest risk being for patients who had three or more cortisone injections.

Hyaluronic acid injections not specifically favored over other treatments

Returning then to options, while some people get good short-term benefit from hyaluronic acid injections, researchers have not found them to be any better than cortisone or other injections types. A June 2021 study (4)  suggests Intra-articular intra-articular high molecular weight hyaluronic acid injection provided pain relief, functional improvement, and no severe complications on immediate short term basis. However, the results do not favor treatment with intra-articular high molecular weight hyaluronic acid over other treatment methods.

One injection of hyaluronic acid helps up to six weeks

One reason we see many patients with hip pain is that they have tried other injection treatments and they “wear out” or more specifically loss effectiveness. A September 2021 study (5)  assessed the safety and efficacy of ultrasound guided injection of a high molecular weight, non-animal derived, stabilized hyaluronic acid (Durolane) in patients with mild to moderate hip osteoarthritis. They found that in their 87 patient study group, one injection of hyaluronic acid provided meaningful clinical benefit at six weeks after injection.

A September 2021 study (6) looked at Hymovis injections and patient response 24 months after treatment. The study found “treatment of hip osteoarthritis in active sportsmen with Hymovis seems a safe and effective approach for the management of osteoarthritis symptoms, by potentially protecting cartilage and subchondral bone from further damage.

A November 2021 review study (7) suggested patients undergoing treatment for hip osteoarthritis with either PRP or hyaluronic acid injections can expect to experience similarly beneficial short-term clinical outcomes. 

hyaluronic acid injections show good outcomes at three to six months

An August 2022 study (11) look at patients with stage 2 and stage 3 hip osteoarthritis that failed standard of care therapy and received 3 consecutive ultrasound-guided intra-articular hyaluronic acid injections while other hip osteoarthritis were treated according to current guidelines

In the hyaluronic acid case group, 15 patients were enrolled and 28 hip joints were injected. The control group consisted of 17 hip osteoarthritis patients. In the hyaluronic acid case group group, pain and function were significantly and progressively improved from baseline up to 3 and 6 months. The case group also showed a significantly lower NSAIDs/pain killer average intake at 3 months from baseline.

Botox addresses muscle spasms and seizure

A 2019 study (8) examined the use of the application of botulinum toxin type A (BoNT-A) in hip osteoarthritis patients. the researchers write that Botox “produces a temporary, delimitable and reversible flaccid paralysis of the muscle (it lessens spasms and tightness), which applied in a strategic way achieves to reduce mechanical stress and pain. The researchers evaluated the effect on pain perception, functionality and rigidity and changes in flexibility, internal and external rotation, before and 90 days after the application of botulinum toxin type A.” They found that the treatment with botulinum toxin type A provides a conservative and safe option for the management of symptoms and physical restraint caused by hip osteoarthritis at 90 days after treatment. 

Cooled radiofrequency ablation – for patients who cannot have hip replacement surgery or do not want it.

A May 2022 study (9) looked at the effectiveness of cooled radiofrequency ablation in managing hip pain from osteoarthritis at six months after receiving treatment in patients who failed conservative treatments and are not surgical candidates due to comorbidities or unwillingness to undergo arthroplasty surgery. In cooled radiofrequency ablation, the nerve branches that bring pain sensations from the hip are heated in a form of nerve block. The treatment is called “cooled” because water is used to cool the surrounding tissues to prevent tissue damage. In this study’s conclusion, the researchers said 11 advanced osteoarthritis patients who received cooled radiofrequency ablation showed significant improvement in pain and stiffness scores.

Other injection treatments

In our office we use biologic-type injections. These would include platelet rich plasma injections and bone marrow derived stem cell therapy. I have post related articles below which are more extensive and detailed.

A September 2022 paper (13) examined the effectiveness of intra articular injections of PRP, hyaluronic acid and a combination of PRP and hyaluronic acid in patients with hip osteoarthritis. The paper notes: “Hyaluronic acid and PRP are two intra articular interventions that can be used in osteoarthritis in the preoperative stages. Due to the different mechanisms of action, these two are proposed to have a synergistic effect by combining.”

  • In this study, patients with grade 2 and 3 hip osteoarthritis were included, and were randomly divided into three injection groups: PRP, hyaluronic acid and a combination of PRP and hyaluronic acid. All three groups, PRP, hyaluronic acid and a combination of PRP and hyaluronic acid, showed significant improvement in the pain and disability scores at 2 months and 6 months compared with baseline. The authors concluded: “Although all 3 interventions were associated with improvement of pain and function in patients with hip osteoarthritis, the therapeutic effects of PRP and PRP and hyaluronic acid injections lasted longer (6 months), and the effects of these two interventions on patients’ performance, disability, and activities of daily living were superior to hyaluronic acid in the long run. Moreover, the addition of hyaluronic acid to PRP was not associated with a significant increase in the therapeutic results.”

Treatment of Hip Osteoarthritis with Platelet-Rich Plasma Injections

Research: Stem cell therapy for a bone on bone hip and alterative to hip replacement surgery

Summary of a case we will see

Recently we had a young 61 year-old woman in our office for right hip pain that had plagued her following a traumatic skiing since the age of 19. She said her pain had been “low grade” and just nagging for most of her life, but in the four years previous to her visit with us, it began to get progressively worse.

A visit to an orthopedic specialist prompted an MRI of the hip. The scan revealed moderately advanced osteoarthritis of her right hip, severe atrophy of the right gluteus minimus, and osteoarthritis of the left hip. Her doctor began treatment that included a synvisc injection into her right hip, and given percocet and oxycontin, to offer some improvement in the pain.

When she visited us she described her right hip pain as constant, aggravated with prolonged sitting, and driving, and also worsened at night- preventing her from getting a good night’s sleep. Over the years we have seen many patients in similar situation and given the patient’s history of right hip pain and osteoarthritis she was an appropriate candidate for treatments.

Two weeks, three treatments later the patient reported being completely pain free in the right hip and overall improvement.

Of course every patient is unique and positive results like those above may not be typical. When the patient comes in, we do a physical examination and we see if surgery or prolonged narcotic use can be avoided.

Do you have questions? Ask Dr. Darrow

Marc Darrow, MD. JD., discusses the treatment philosophy of the Darrow Stem Cell Institute. Transcript of video


A leading provider of stem cell therapy, platelet rich plasma and prolotherapy
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PHONE: (800) 300-9300 or 310-231-7000

 References

1 Ferrara PE, Codazza S, Coraci D, Malerba G, Ferriero G, Ronconi G. State of art in intra-articular hip injections of different medications for osteoarthritis: a systematic review. BMC Musculoskelet Disord. 2021 Nov 29;22(Suppl 2):997. doi: 10.1186/s12891-021-04866-6. PMID: 34844603.
2 Choueiri M, Chevalier X, Eymard F. Intraarticular Corticosteroids for Hip Osteoarthritis: A Review. Cartilage.:1947603520951634.
3 Forlenza EM, Burnett RA, Korrapati A, Yang J, Forsythe B, Della Valle CJ. Preoperative Corticosteroid Injections Demonstrate a Temporal and Dose-Dependent Relationship with the Rate of Postoperative Infection Following Total Hip Arthroplasty. The Journal of Arthroplasty. 2021 Jun 1;36(6):2033-7.
4 Ali SM, Farooqui SF, Sahito B, Ali M, Khan AA, Naeem O. Clinical Outcomes Of Intra-Articular High Molecular Weight Hyaluronic Acid Injection For Hip Osteoarthritis-A Systematic Review And Meta-Analysis. J Ayub Med Coll Abbottabad. 2021;33(2).
5 Long DM, Fitzpatrick J. Safety and efficacy of a single intra-articular injection of hyaluronic acid in osteoarthritis of the hip: a case series of 87 patients. BMC Musculoskeletal Disorders. 2021 Dec;22(1):1-7.
6 Rando G, Pastorino R. Intra-articular Hymovis injection for managing hip OA in active sportsmen. A 24-month observational retrospective clinical investigation. Journal of Clinical Orthopaedics and Trauma. 2021 Sep 14:101594.
7 Belk JW, Houck DA, Littlefield CP, Kraeutler MJ, Potyk AG, Mei-Dan O, Dragoo JL, Frank RM, McCarty EC. Platelet-Rich Plasma versus Hyaluronic Acid for Hip Osteoarthritis Yield Similarly Beneficial Short-Term Clinical Outcomes: A Systematic Review and Meta-Analysis of Level I and II Randomized Controlled Trials. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021 Nov 14.
8 Durán-Hernández S, Soto-Rodríguez JF, Allen-Bobadilla J, Durán-Hernández N, García-Mosco P. Osteoarthritis of the hip conservative treatment with type A botulinum toxin. Gaceta medica de Mexico. 2019 Jan 1;155(Suppl 1):S44-8.
9 Tran A, Reiter D, Wong PK, Fritz J, Cruz AR, Oskouei S, Gonzalez FM. Alternative treatment of hip pain from advanced hip osteoarthritis utilizing cooled radiofrequency ablation: single institution pilot study. Skeletal Radiology. 2022 May;51(5):1047-54.
10 Graf DN, Thallinger A, Zubler V, Sutter R. Intraarticular steroid injection in hip and knee with fluoroscopic guidance: reassessing safety. Radiology. 2022 May 10:210668.
11 Micu MC, Micu A, Bolboacă SD. Ultrasound-guided injection with hyaluronic acid in hip osteoarthritis: efficacy and safety in a real-life setting. Clinical Rheumatology. 2022 Apr 7.
12 Angotti ML, Burnett RA, Khalid S, Terhune EB, Della Valle CJ. Intra-articular corticosteroids associated with increased risk of total hip arthroplasty at 5 years. HIP International. 2022 Jun 19:11207000221107225.
13 Nouri F, Babaee M, Peydayesh P, Esmaily H, Raeissadat SA. Comparison between the effects of ultrasound guided intra-articular injections of platelet-rich plasma (PRP), high molecular weight hyaluronic acid, and their combination in hip osteoarthritis: A randomized clinical trial.
14 Rampal S, Jaiman A, Tokgöz MA, Arumugam G, Sivananthan S, Singh RS, Zazali SB, Mohaddes M. A review of the efficacy of intraarticular hip injection for patients with hip osteoarthritis: To inject or not to inject in hip osteoarthritis?. Joint Diseases and Related Surgery. 2022 Apr;33(1):255.

 

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