Intra-Articular Corticosteroid Injections for Symptomatic Knee Osteoarthritis

What the Orthopaedic Provider Needs to Know

Cody L. Martin, MD; James A. Browne, MD


J Am Acad Orthop Surg. 2019;27(17):e758-e766. 

In This Article

Type of Corticosteroid

Many corticosteroids are available for use in intra-articular injections[4,9–13] (Table 1). However, clinical data comparing the different injectable steroids are limited. In 2009, Hepper et al[14] performed a systematic review and found four level I studies comparing three distinct corticosteroids: betamethasone, methylprednisolone, and triamcinolone. Their analysis found triamcinolone to be more effective, although not all outcome measures were validated, and the follow-up and steroid doses were not standardized among the studies.

Triamcinolone hexacetonide may be more effective because of its low solubility, which allows for longer maintained levels of the medication in the joint and synovium and lower systemic levels compared with more soluble compounds.[15] A survey of American College of Rheumatology physician members that focused on injectable corticosteroid use in the knee found that 34.6% used methylprednisolone acetate, 31.2% used triamcinolone hexacetonide, and 21.7% used triamcinolone acetonide, whereas the rest used other types of steroid for injections. The most common reason for methylprednisolone acetate (71.9%) and triamcinolone acetonide (51.9%) use was due to "availability" or out of "habit," whereas the most common reason for triamcinolone hexacetonide (76.3%) use was that it was "effective" or "longer acting."[16] However, the idea that triamcinolone hexacetonide may be more effective is lacking strong data and even contradicted by a more recent randomized, double-blinded study comparing triamcinolone hexacetonide and methylprednisolone acetate injections in knee osteoarthritis that found both therapies equally effective at improving pain for up to 24 weeks at all time points (P= 0.523).[17] Therefore, the best steroid is yet to be determined.

The desire for longer-lasting intra-articular steroid levels with slower and decreased systemic elusion has led to new formulations of steroids. Bodick et al[18] conducted a phase-2, double-blind, randomized clinical trial on an extended-release formulation of triamcinolone acetonide (FX006) compared with a conventional immediate-release formulation. The results showed that a 40-mg dose of FX006 provided improved pain relief compared with a 40-mg dose of immediate-release triamcinolone at 2 through 12 weeks with significant superiority at each time point between 5 and 10 weeks after injection (P < 0.05).[18] Adverse events were similar between all groups and mild in nature. The sustained local effects of this medication with a safe profile show promise for future use.