COMMENTARY

The Utility of Corticosteroid Injections in Postmeniscectomy Patients With Osteoarthritis of the Knee

Joseph K. Lee, MD

Disclosures

August 06, 2009

Introduction

Intra-articular corticosteroid injection has been a common method of treatment in patients with osteoarthritis of the knee.[1,2] Patients undergoing nonoperative management have often seen short-term improvement in symptoms and function.[1,2] Patients with concomitant osteoarthritis of the knee and meniscal tears pose a different challenge because of the potential for accelerated arthritic changes, particularly after meniscectomy.[3,4] More recently, the use of postoperative corticosteroid injections in postmeniscectomy patients with knee osteoarthritis has been a growing trend as part of the treatment process.[5,6,7]

A Randomized, Prospective, Double-Blind Study to Investigate the Effectiveness of Adding DepoMedrol to a Local Anesthetic Injection in Postmeniscectomy Patients With Osteoarthritis of the Knee

Koyonos L, Yanke AB, McNickle AG, et al
Am J Sports Med. 2009;37:1077-1082

Koyonos and colleagues performed a randomized, double-blinded, controlled trial to investigate the utility of intra-articular corticosteroid with lidocaine injection therapy on postmeniscectomy patients with underlying osteoarthritis of the knee. These patients were compared with a similar patient population that received intra-articular normal saline and lidocaine injection. The steroid group received a 10-mL intra-articular injection consisting of 1 mL of 40-mg Depo-Medrol® (methylprednisolone) and 9 mL of 1% lidocaine. The second group received a 10-mL injection consisting of 1 mL of 0.9% normal saline and 9 mL of 1% lidocaine.

Inclusion criteria for this study were the following:

  • Age 18-85 years at time of surgery

  • Written informed consent; and

  • Arthroscopic meniscectomy with chondral changes noted (modified Outerbridge grade ≥ 2 in the ipsilateral compartment).

Exclusion criteria were the following:

  • Presence of or suspected allergy to agents used in the study;

  • Corticosteroid injection within the preceding 2 months; and

  • Insufficient follow-up data for analysis.

Of the 72 patients who were initially screened for the study, 14 patients were excluded because of failure to complete any follow-up visits (8 patients) or completion of only 1 follow-up visit (6 patients). The final study sample consisted of 58 patients (59 knees).

After the initial preoperative evaluation, patients underwent standardized follow-up evaluations at 6 weeks and then at 6, 9, and 12 months after surgery. Outcome metrics included the following: International Knee Documentation Committee (IKDC); Knee Injury and Osteoarthritis Outcome Score (KOOS); and Lysholm, Tegner, Noyes, and Short-Form 12 (SF-12) scales. Duration of pain medication use and time to return to work were also assessed. Objective measures also included knee range of motion (ROM) and quadriceps size.

Preoperative scores on the subjective knee measures showed no statistically significant difference between the steroid and saline groups. At 6 weeks after surgery, the steroid group showed higher improved scores over the saline group in the IKDC, KOOS Sport, KOOS quality of life, and treatment satisfaction measures. Subsequent follow-up at 6 months and thereafter, however, showed no significant difference between the 2 groups. Overall, scores improved for both treatment groups over time on the IKDC, KOOS, and Noyes scale (steroid group only).

No significant difference was seen in the Tegner activity scale or SF-12 scale scores at any point during the study. In addition, return to work and duration of pain medication use were similar in both groups. There was no statistically significant difference in quadriceps size before or after surgery. Knee ROM was higher in the steroid group before surgery only.

Three patients in the steroid group underwent repeated knee injection (1 corticosteroid, 2 viscosupplementation) at an average of 7.6 months. Two other patients decided to undergo additional surgery (1 medial meniscus transplantation, 1 additional meniscectomy). In the saline group, 4 patients underwent repeated corticosteroid knee injection (0 viscosupplementation) at an average of 8 months. One patient underwent total knee arthroplasty, and another underwent a unicompartmental arthroplasty before completion of the study.

At the end of the 12-month study, 86% of the steroid group and 63% of the saline group reported satisfaction with the procedure and would have the surgery performed on the contralateral side if needed. No adverse events occurred during this study.

Viewpoint

The results of this well-designed study suggest a short-term benefit to giving corticosteroid injections after meniscectomy in patients with knee osteoarthritis. These results are similar to those of previous studies that used intra-articular corticosteroid injections as part of conservative management for osteoarthritis of the knee.[1,2] The study also provides longer-term data supporting use of these injections in postmeniscectomy patients compared with previous studies.[5,6,7] Several limitations were noted in this study. First, because of preoperative randomization, the authors could not delineate outcomes on the basis of the severity of osteoarthritis. In addition, despite the use of randomization, notable differences existed in each treatment group. The steroid group tended to have a wider age range and better preoperative knee ROM. The saline group, on the other hand, had more severe disease and a higher prevalence of tricompartmental osteoarthritis, as well a higher rate of bilateral meniscectomies (37% vs. 21%). Moreover, as the authors also commented, it would have been interesting to see whether the steroid group had extended effects past 6 weeks, at a 2- or 3-month follow-up.

The authors caution that the study was not designed to focus on adverse effects of corticosteroid injections, and such conclusions should not be drawn from the article. The adverse effects of intra-articular corticosteroid use have been well documented and include endocrine/hormonal, metabolic, hematologic, vascular, allergic (including anaphylaxis), visual, musculoskeletal (including osteonecrosis), and psychological side effects.[8,9,10,11,12,13]

Funding for this study was supported by a grant from Pfizer, Inc.

Abstract

Comments

3090D553-9492-4563-8681-AD288FA52ACE
Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

processing....