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

Adverse Effects and Complications

Intra-articular corticosteroid injections in the knee are considered to be a relatively safe procedure. In a Cochrane review, steroid injections into the knee cause as many adverse effects as placebo (13% and 15%, respectively).[37] Contraindications (Table 2) include having an allergy to the medication being injected and the presence of an active joint infection. An intra-articular knee injection should be performed with increased caution in those with coagulopathies or infections about the knee or arthroplasty of the knee. Local adverse effects (Table 3) include skin pigmentation changes at the injection site, fat or skin atrophy, and residual injection site pain.[4] Direct injury to the cartilage with a needle, especially using the medial or lateral mid patella injection site, can also occur.

Intra-articular corticosteroid injections can cause similar systemic effects (Table 3) as steroids given orally or intravenously, but they are typically less severe. Possible systemic effects include facial flushing, hypothalamic-pituitary-adrenal axis suppression, and increased liver glucose synthesis resulting in higher blood glucose levels.[4] The increased glucose level is typically the most concerning to patients with diabetis, and they should be made aware that their blood glucose level may be elevated after a steroid injection. Other possible adverse effects include steroid-induced myopathy and osteonecrosis. To our knowledge, there have been no reports in the literature of these effects related to an intra-articular steroid injection into the knee.

The most feared complication related to corticosteroid injections in the knee is septic arthritis. The incidence has been reported to range from 1 in 3,000 to 1 in 50,000.[4] Xu et al[43] performed a retrospective, matched, case-control study of 50 deep knee infections after intra-articular injections compared with 250 controls. Significant risk factors for knee septic arthritis related to an intra-articular injection were found to be patient body mass index greater than 25 kg/m2 (odds ratio, 2.3; 95% confidence interval, 1.1 to 4.7), general practitioner administered injection versus orthopaedic surgeon or rheumatologist (odds ratio, 5.23; 95% confidence interval, 2.00 to 13.67), and patients with rheumatoid arthritis (odds ratio, 2.61; 95% confidence interval, 1.20 to 5.68). Corticosteroid injections were a significant risk factor compared with hyaluronic acid injections (odds ratio, 3.21; 95% confidence ratio, 1.63 to 6.31).[43]

Many patients receiving corticosteroid injections for management of knee osteoarthritis often ultimately progress to total knee arthroplasty (TKA). A number of recent studies have been published on the risk of infection related to steroid injections before TKA. In 2016, Amin et al[44] retrospectively studied 1,628 patients spanning a 7-year period who either received or did not receive an intra-articular injection before undergoing TKA and found no correlation with patients who developed infected total knee arthroplasties and receipt of a corticosteroid injection before surgery (relative risk of a steroid injection compared with controls 0.9389; P = 0.9146).

However, the timing of the injection may affect the risk of periprosthetic joint infection in TKA. Cancienne et al[45] performed a large database study and found no significant difference in TKA infection in patients who received a knee injection more than 3 months before surgery. However, patients who underwent TKA within 3 months of receiving a knee injection had a significantly increased incidence of infection at 3 months (2.6%; odds ratio, 2.0; confidence interval, 1.6 to 2.5; P < 0.0001) and 6 months (3.41%; odds ratio, 1.5; confidence interval, 1.2 to 1.8; P < 0.0001) after TKA.[45] Therefore, patients may benefit by waiting at least 3 months after a knee injection to undergo TKA.