Typically, before someone diagnosed with hip osteoarthritis is recommended to arthroscopic hip surgery or hip replacement, 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
Reviewing the treatments
A common theme among researchers is that these injections currently used for hip osteoarthritis seem to work, however, there is too much variation on how these treatments are given and there is not sufficient medical research to support their widespread uses.
In an assessment of available treatments, a November 2023 paper (1) suggested that there is a lot to understand as to which treatment could be considered the best treatment for hip osteoarthritis. The authors wrote: “Non-steroidal anti-inflammatory drugs and corticosteroid injections are the most supported and recommended options for hip osteoarthritis; other medications with potential benefits for short-term pain relief include acetaminophen and tramadol. Most (medical) societies recommend against the use of glucosamine, typical opioids, and viscosupplementation injections. Platelet-rich plasma has potential benefits, but evidence of its effectiveness is incomplete.”
A March 2022 (2) study also reviewed the available research about the 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 (steroid) 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, mesenchymal stem cell (MSC) and bone marrow aspirate concentrate (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 (3) 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.”
The effectiveness of PRP versus Hyaluronic Acid in terms of pain relief and functional outcomes
An October 2023 study (4) assessed the effectiveness of PRP versus Hyaluronic Acid in terms of pain relief and functional outcomes for the management of hip osteoarthritis. The authors summarized their findings: “. . . this analysis indicate that PRP therapy may provide potential benefits and pose few risks for the treatment of hip osteoarthritis. PRP demonstrates a relatively greater effectiveness in relieving symptoms of hip osteoarthritis, particularly during the mid-term phase of a 12-month follow-up period (than hyaluronic acid.) After six months of treatment, PRP exhibits notable improvements in pain reduction, surpassing the outcomes observed with hyaluronic acid treatment. During the initial two months of treatment and at the 12-month mark, no significant benefits of using PRP over hyaluronic acid are observed. Moreover, the administration of intra-articular injections of PRP and hyaluronic acid to patients with hip osteoarthritis has been demonstrated to be safe with no significant risks of major adverse events or long-term complications.”
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 (5) 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.
A December 2022 paper (6) examined previously published studies on the use of image-guided corticosteroid injections in the treatment of patients with hip osteoarthritis. The authors observed “hip injections were found to be effective in treating short- and long-term pain and more effective than hyaluronic acid, Mepivacaine, NSAIDs, and normal saline in terms of improvement in pain and/or function.”
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 (7) 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 (8) 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 (9) 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 (10) 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 (11) 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 (12) 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 (13) 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 (14) 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.
A November 2023 paper (15) assessed the various aspects of effectiveness of hyaluronic acid “as a therapeutic intervention for hip osteoarthritis, as well as to assess the duration of efficacy, effect of dose, composition and number of injections of the viscosupplement, and the incidence of adverse effects.” What the study team found was that clinically speaking “Weak evidence suggests that viscosupplementation improves patient-reported pain and function at endpoint compared to baseline, regardless of dose, volume, composition and number of injections. However, due to the high heterogeneity, low level of evidence and high risk of bias in the current available literature, the strength of our conclusions is limited.”
Botox addresses muscle spasms and seizure
A 2019 study (16) 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 (17) 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.
Treating Hip Osteoarthritis Injection Therapy
Can Bone Marrow Aspirate injections and Platelet-Rich Plasma Therapy be effective in treating hip arthritis and in helping you avoid a hip replacement surgery? The answer in many cases is yes. However, success is dependent on a physical examination and a practice of best diagnosis. The hip is a tricky and complex area filled with many pain generator suspects beyond arthritis. The causes of hip pain can be many this is why an extensive physical examination should be part of the diagnostic process.
A March 2022 study (18) examined the use of hip injections. The paper writes:
“Hip injection for osteoarthritis are in vogue nowadays. 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 agents, non-steroidal anti-inflammatory drugs (NSAIDs) and their different combinations have also been injected in hips to provide desired pain relief. . .
. . . Intraarticular corticosteroids are effective in providing the desired pain relief in the osteoarthritis hip, but repeated injections should be avoided and the interval between hip injection and hip arthroplasty must be kept for more than three months.
Chondrotoxic effects of local anesthetic agents 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, mesenchymal stem cell (MSC), and bone marrow aspirate concentrate (BMAC) are treatment options with great potential; however, currently, the evidence is conflicting on their role in hip osteoarthritis.”
Research on corticosteroids
A February 2020 paper (19) suggested that corticosteroid injections had significant efficacy on both immediate and delayed pain relief until 12 weeks after injection, though the injections effectiveness decreased over time. In addition, based on the current evidence, the longer than 12 weeks follow-up data of efficacy are still rarely reported. Previous research failed to demonstrate significant outcomes on pain reduction at both immediate and delayed intervals up to six months after injection. The researchers noted that they found these results surprising in that they had hypothesized the corticosteroid would be more effective.
Dry Needling
A December 2023 study (x) suggested that dry needling may provide more patient hip pain relief than several types of pain intervention (including corticosteroid injections, laser, and no treatment.) The study’s authors reviewed medical data of 273 patients who suffered from hip osteoarthritis, greater trochanteric pain syndrome or piriformis syndrome and healthy athletes. The researchers found dry needling may be “safe and effective at relieving hip pain and improving hip function.” However, strong evidence to the point is still lacking.
Research on Platelet-Rich Plasma Therapy for Hip Repair
Platelet-rich plasma (PRP), obtained by withdrawing the patient’s blood and concentrating the platelets, represents a safe, economical, easy to prepare, and easy to inject source of growth factors. Platelets contain numerous growth factors, and a large number of them have specific activity in cartilage regeneration. PRP is able to significantly reduce pain and improve physical joint function.(20)
A study done in 2012 examined patient safety and symptomatic changes among 40 patients receiving Platelet-Rich Plasma (PRP) Therapy for osteoarthritis of the hip. In the study, each joint received three injections of PRP, administered once a week. The primary end point was meaningful pain relief, which was described as a reduction in pain intensity of at least 30% at six months post-treatment.
Secondary end points included reduction in the level of disability of at least 30% and the percentage of positive responders—that is, the number of patients who achieved a greater than 30% reduction in pain and disability.
The results were statistically significant reductions in pain and improvement in function as reported at seven weeks and again at six months.
- Twenty-three patients (58%) reported a clinically relevant reduction of pain (45%).
- Sixteen (40%) of these patients were classified as excellent responders and showed an early pain reduction at six or seven weeks that was sustained at 6 months, accompanied by a parallel
reduction of disability. (21)
From a January 2016 paper: “Results indicated that intra-articular PRP injections offer a significant clinical improvement in patients with hip osteoarthritis without relevant side effects.”(22)
In other research, doctors followed patients who received Stem Cell Therapy for hip, knee, or ankle osteoarthritis and documented such therapeutic benefits as increased walking distance, increased function, and reduced pain.(23)
Bone marrow concentrate injection treatment improves short-term outcomes in patients suffering from hip osteoarthritis
A December 2020 paper (24) suggested that bone marrow concentrate injection treatment improves short-term outcomes in patients suffering from hip osteoarthritis.
In this study a total of 24 patients diagnosed with symptomatic hip osteoarthritis elected to undergo a single bone marrow concentrate injection to see if the injection would help their hip pain. A total of 18 hips from 16 patients (7 male and 9 female) (average age, 58 mean body mass index, about 26 or a little overweight) were used in the final analysis.
- Significant improvements were observed in pain scores with activity and without activity over 6 months. At 6 months, all patients maintained their improvements and did not return to preprocedure status.
- Conclusion: A single bone marrow concentrate injection can significantly improve subjective pain and function scores up to 6 months in patients with symptomatic hip osteoarthritis. Further studies are warranted to evaluate osteoarthritis treatment against other therapeutics in a larger sample size and compare the biological signature profiles that may be responsible for the therapeutic effect.
- Doctors in Argentina and Seton Hall University in New Jersey combined to suggest that in their research in patients receiving bone marrow aspirate intra-articular injections for the treatment of early knee or hip osteoarthritis were found to be safe and demonstrated satisfactory results in 63.2% of patients. It should be pointed out that this was a single injection treatment. (25)
A September 2022 paper (26) 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.”
how bone marrow stem cell therapy or whole bone marrow aspirate concentrate (BMAC) works to repair damage in an osteoarthritic hip
An April 2021 paper (27) examined how bone marrow stem cell therapy or whole bone marrow aspirate concentrate (BMAC) works to repair damage in an osteoarthritic hip.
“Potentially, these (stem cells from bone marrow aspirate concentrate) are able to provide a direct cell source for repair. (The injected cells themselves become building blocks to fill lesions). In addition, (the stem cells) may have a significant paracrine (advanced cell to cell communication) effect, releasing and delivering a myriad of cytokines and growth factors to orchestrate tissue repair processes.
The use of BMAC has been suggested to restore joint harmony (changing the joint environment from breakdown to regenerative) and minimize further chondral deterioration. As I just mentioned above, stem cells injected into the joint can initiate a healing environment.
One advantage of this orthobiologic is that MSCs are ideal for the chondrolabral junction, since these cells are able to differentiate into both fibrocartilage (this is the very tough cartilage found at the insertion or attachment points where ligaments and tendons attach themselves to the bone) and hyaline-like tissue products. (The stem cells morph into the different types of cartilage).
The study authors noted: “The results of BMAC in bone, cartilage and tendon injuries are encouraging. . . The use of BMAC especially in the early stages of hip diseases resulted in positive results for pain and function, and could represent a promising contemporary treatment strategy.”
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.
References
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