A recent US study has found that corticosteroid injections may hasten the progression of knee osteoarthritis, but that hyaluronic acid – an alternative injection – doesn’t have the same negative effect. So are cortisone injections safe? What is hyaluronic acid and is it a better alternative? And why might there still be room for both treatments? Alex Dodds explains.
To be clear, I use both types of injection at my Cheltenham hip and knee clinic, and the latest research isn’t likely to change that for several reasons, but first, let’s look at what each injection does.
What are cortisone injections?
Cortisone injections are steroid shots which have a proven ability to reduce the pain and inflammation of osteoarthritis (OA). The potential side effects (which now seem to include the progression of your OA) mean the number of injections you can have in any one year is limited. Cortisone injections are a ‘tried and tested’ non-operative way of managing OA in the hip and knee.
What is hyaluronic acid?
Hyaluronic acid (I use Durolane) is the relative new kid on the block and is designed to take a biological approach to delivering much the same result as cortisone. The acid ‘mimics’ natural lubricants within the joints and acts as a sort of shock absorber to reduce pain. In the study, hyaluronic acid delivered the same pain reducing effect as cortisone but didn’t lead to a degeneration of the knee after two years.
Are both injections available on the NHS?
No. Only cortisone is available on the NHS. Most insurance companies currently only cover cortisone injections too. If you want a hyaluronic acid injection, not only is it only available privately, but you’ll have to pay for it yourself.
For many, that’s a crucial factor in choosing between the two.
Why injections are important in managing osteoarthritis
The primary goal of the hip and knee surgeon is to reduce pain – not to carry out hip and knee replacements. Any surgical procedure carries risks, and although the risks involved in a hip or knee replacement are small, they are greater than with less invasive treatments such as injections.
Generally speaking, the longer we can manage your osteoarthritis without resorting to a joint replacement the better. What starts with entirely non-invasive approaches – over the counter painkillers, knee braces, physiotherapy and activity modification, for example – may eventually reach a point where something more impactful is required.
Injections are often that next step. For some patients, they may be the only viable next step, at least for the time being. If, for example, the patient is frail, a cortisone or hyaluronic acid injection may be the limit of treatment available. The same may be true if:
- You have significant medical comorbidities (that is, medical conditions or diseases in addition to OA)
- You don’t want a major operation now because of its impact on your life or work
- You are too young for a joint replacement currently (because there’s a limit to how many joint replacements anyone can have) so an injection helps to delay the procedure
Why room remains for cortisone
Those last two points are important, because for many patients a cortisone injection is seen as a way of delaying the inevitable. They know they will need a joint replacement at some point; it’s just that delaying the inevitable can have important benefits to their life and finances, as well as their health.
If, then, a steroid injection may eventually make the arthritis worse, those patients may ask whether that really matters when they’re planning on a joint replacement anyway.
It’s for this reason that I believe there’s remains room for both steroidal and hyaluronic acid treatments.
Steroid or hyaluronic acid?
So which treatment should you have? It really is a question that each patient must decide for themselves, once they have the facts.
Steroids such as cortisone are proven to be effective. They are available on the NHS or via health insurance. But they may hasten the progression of the arthritis in the longer term.
Hyaluronic acid is the less venerable treatment and is only available through self-pay, but it doesn’t appear to affect the progression of arthritis in the way steroids may.
Any injection brings a small but increased risk of joint infection, but this is rarely a significant issue.
If you would like to explore your options for managing your osteoarthritis, book an appointment at my Cheltenham hip and knee clinic now. Or call 01242 246549.