A recent study by McAlindon et al (2017) wanted to determine the effects of intra-articular injection of 40 mg of triamcinoloneacetonide every 3 months for 2 years on progression of cartilage loss and knee pain.
Design: Two-year, randomized, placebo-controlled, double-blind trial of intra-articular triamcinolone vs saline for symptomatic knee osteoarthritis with ultrasonic features of synovitis in 140 patients.
Key findings: The 2-year change in the index compartment cartilage thickness was greater in the triamcinolone group with a between-group difference of −0.11 (95% CI, −0.20 to −0.03), which corresponds to a moderate effect size of 0.46 mm. Increased progression was not detected in other osteoarthritis features, structurally or clinically. These results contrast with a previous smaller trial that tested a similar regimen and found no difference in the rate of radiographic joint space loss and detected a benefit on knee pain in some secondary (but not primary) end points Wernecke et al (2015). In this study x-rays were used to determine cartilage loss rather than MRI. Guermazi (2011) showed that X-rays do not image cartilage directly and are insensitive to change. MRI used in this study enabled direct quantitation of cartilage.
CONCLUSIONS Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain.
Potential Implications for clinical practice:
Previous In vivo and clinical evidence Wernecke (2012) showed the catabolic effects of corticosteroids. Eckstein (2014) showed that rates of cartilage loss are associated with higher rates of arthroplasty.
McAlindon's study seems to indicate that cartilage loss does occur with 40mg Triamcinolone Acetonide given every three months for 2 years which amounts to 8 steroid injections in total over this period of time. Anecdotally In my area of work many practioners would stop repeating steroid injections after 3 or 4 injections. In many cases due to the concern of the potential for detrimental effects on the joint. In addition to that there is also a notion that repeat steroid injections often appear to have shorter lasting benefits after each subsequent injection. This personal experience does not seem to be supported though by a research study (Raynauld, 2003) which showed longterm clinical
benefit from steroid injections over a two year period.
In any case for me the objective evidence that cartilage volume significantly reduced in the steroid group compared with a saline control group would make me more cautious still to continue with repeat injections beyond 3. I can think of clinical justifications to continue injecting (i.e an Older person with severe and severly painful OA who is unsuitable for surgery and who has had significant benefit from steroid injection (which in this scenario often times in my experience is not the case) then perhaps there is an argument to continue with injections.
However where for me this study has potentially made me change my practice is in the treatment of younger patients, particularly those who are active and involved in high impact activities. In this category of patients I would very early on (after as few as 1 or 2 steroid injections) be thinking of alternatives such as Hyaluronic Acid injections in order to avoid progression of cartilage loss.
Eckstein, F., Boudreau, R.M., Wang, Z., Hannon, M.J., Wirth, W., Cotofana, S., Guermazi, A., Roemer, F., Nevitt, M., John, M.R. and Ladel, C., 2014. Trajectory of cartilage loss within 4 years of knee replacement–a nested case–control study from the Osteoarthritis Initiative. Osteoarthritis and cartilage, 22(10), pp.1542-1549.
Guermazi, A., Roemer, F.W., Burstein, D. and Hayashi, D., 2011. Why radiography should no longer be considered a surrogate outcome measure for longitudinal assessment of cartilage in knee osteoarthritis. Arthritis research & therapy, 13(6), p.247.
McAlindon, T.E., LaValley, M.P., Harvey, W.F., Price, L.L., Driban, J.B., Zhang, M. and Ward, R.J., 2017. Effect of intra-articular triamcinolone vs saline on knee cartilage volume and pain in patients with knee osteoarthritis: a randomized clinical trial. Jama, 317(19), pp.1967-1975.
Raynauld, J.P., Buckland‐Wright, C., Ward, R., Choquette, D., Haraoui, B., Martel‐Pelletier, J., Uthman, I., Khy, V., Tremblay, J.L., Bertrand, C. and Pelletier, J.P., 2003. Safety and efficacy of long‐term intraarticular steroid injections in osteoarthritis of the knee: A randomized, double‐blind, placebo‐controlled trial. Arthritis & Rheumatology, 48(2), pp.370-377.
Wernecke, C., Braun, H.J. and Dragoo, J.L., 2015. The effect of intra-articular corticosteroids on articular cartilage: a systematic review. Orthopaedic journal of sports medicine, 3(5), p.2325967115581163.