By Nathan Wei

Among the many treatment options available for people with osteoarthritis are injections of glucocorticoids… commonly known as cortisone injections.

Glucocorticoids, also called corticosteroids or steroids, are anti-inflammatory compounds that are synthetic copies of what the body’s adrenal glands make. When properly injected, these corticosteroids reduce the swelling, redness, heat, and pain that commonly accompany arthritis.

Traditionally, the use of glucocorticoid injections for the hip have been perceived to not work well… or at least not work as well as they do for the knee. However, the hip joint is one of the most difficult joints in the body to inject accurately.

A new study reported in Arthritis and Rheumatism (Lambert RGW, Hutchings EJ, Grace MGA, Jhangri GS, Conner-Spady B, Maksymowych WP. Steroid injection for osteoarthritis of the hip: A randomized, Double-blind, Placebo-controlled Trial. Arthritis Rheum. 2007;56:2278-2287) has demonstrated that correctly placed steroid injections can produce considerable improvement in patients with osteoarthritis (OA) of the hip.

What the researchers wanted to answer was whether the steroid was less effective because of the way it was injected. They wanted to ensure entry of the therapeutic agent into the synovial space. As a result they used fluoroscopic guidance. Fluoroscopy is a type of real time x-ray.

The investigators studied 52 symptomatic patients with hip OA who were randomized in a double-blind fashion to fluoroscopically guided intra-articular injection of bupivacaine (an anesthetic agent) and 40 mg triamcinolone (a type of long-acting glucocorticoid) or to bupivacaine and saline.

At 2 months, Western Ontario and McMaster Universities OA Index (WOMAC) pain scores fell by 49.2% in the active treatment group and by 2.5% in the placebo group. The WOMAC is considered the cornerstone of patient response in osteoarthritis clinical trials so that this response was critical to determining the effectiveness of the therapies.

In addition, 67.7% of the corticosteroid group showed a 20% WOMAC improvement, compared to 23.8% of the placebo group. Findings were similar for a 50% WOMAC improvement (61.3% versus 14.3%).

These differences were maintained at 3 months.

The trial confirmed that when the steroid is injected under image guidance and can be certain that the steroid is in the right place, the steroids work very well for most patients with moderately advanced or severe hip OA.

A potentially even more useful technique for localization of the hip joint is ultrasound (US). US has the advantages of being fast, of showing soft tissue as well as bone, and of having no radiation associated with it. Fluoroscopy has comparatively much radiation exposure both to the patient as well as to the physician doing the injection.

In our clinic we use US as opposed to fluoroscopy. In any event, though, one or the other should be used to ensure proper placement of the needle.

Cortisone injection into the hip is also a procedure that should be done using sterile techniques.

In patients who respond to corticosteroid injections, these can be repeated as often as three times per year. Another therapeutic option is injection of viscosupplements into the hip. These are gel-like lubricants that also help reduce pain and allow the joint to glide better. Examples of these are compounds such as Supartz, Hyalgan, and Synvisc. In patients who are not considered surgical candidates or who do not want surgery, this is a viable option to consider.

About the Author: Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. For more info: Cortisone Shot Side Effects

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