Physios co-write paper showing steroid injections may provide longer lasting benefits for hip pain

Study findings 'widen patients' choices'

The research team compared the clinical effectiveness of adding a single ultrasound guided intra-articular hip injection of corticosteroid and local anaesthetic to advice and education in adults with hip osteoarthritis. Dr Paskins and her colleagues believe their findings ‘provide evidence to inform international guidelines and offer important choice to patients, who often believe their treatment options are limited’.

The study focused on 199 adults whose average age was 63 and who were being seen at two NHS community musculoskeletal centres in England. More than half (57 per cent) were women. All had hip osteoarthritis and reported having pain at moderate levels or above.

Of these, 67 were randomly assigned to receive advice and education (best current treatment or BCT), 66 to BCT plus ultrasound guided injection of the steroid triamcinolone with lidocaine, and 66 to BCT plus ultrasound guided injection of lidocaine only.

The two groups’ baseline characteristics were similar and participants in the ultrasound guided groups were masked to the injection they received.

The main (primary) outcome measure was current intensity of hip pain on a numerical rating scale of 0-10. The ratings were reported by the patients at two weeks and at two, four, and six months. Secondary outcomes included physical function and pain ‘self-efficacy’ – which refers to a person's belief in their capacity to improve their health.

Results

Over six months, participants in the BCT plus ultrasound-triamcinolone-lidocaine group reported a greater reduction in pain intensity (by an average score of 1.4 and 0.5 on the pain scale), compared to those receiving BCT alone and BCT plus ultrasound-lidocaine, respectively. Generally, greater differences were seen at earlier time points (two weeks and two months) than at later time points (four and six months), and no significant differences in pain or function were reported at the six-month point.

Participants in the BCT plus ultrasound-triamcinolone-lidocaine group were more likely to meet the criterion for low pain (a score of less than 5 on the pain scale) at two weeks and at two and four months than were those in the BCT group. Greater improvements in physical function and pain self-efficacy also persisted to four months in the BCT-ultrasound-triamcinolone-lidocaine group compared with those receiving BCT.

At six months, participants in the BCT plus ultrasound-triamcinolone-lidocaine group were more likely to be satisfied with care and treatment received than those receiving BCT (58.2 per cent v 34 per cent) and were more likely to say they were not limited in their usual activities because of hip pain (66.7 per cent v 44.6 per cent).

Ultrasound guided corticosteroid and local anaesthetic injection with advice and education led to greater pain reduction and improvement in function over six months, compared with advice and education alone [Zoe Paskins et al.]

Adverse events and limitations

Of the seven serious adverse events that were recorded, one (a bacterial infection) was could have been related to trial treatment, and the researchers say caution should be applied with patients having risk factors for, or signs of, infection.

The trial’s limitations included a lack of blinding between the BCT versus BCT plus ultrasound-triamcinolone-lidocaine groups and relying on self-reporting by patients, which may have affected accuracy.

However, the team says its strengths included the large sample size, the inclusion of two comparison arms, the length of follow-up, and the high response rates. The results remained similar when further analyses were conducted, suggesting that they are robust.

Conclusions

Dr Paskins and her colleagues conclude: ‘In patients with mild to moderate hip osteoarthritis, ultrasound guided corticosteroid and local anaesthetic injection with advice and education led to greater pain reduction and improvement in function over six months, compared with advice and education alone.'

They add: ‘These findings provide evidence to inform international guidelines and offer important choice to patients, who often believe their treatment options are limited.’

Factfile

• hip osteoarthritis is a leading cause of global disability
• in the UK, more than 100,000 total hip replacements were carried out in 2019 (at a cost of more than £500 million)
• nine hip replacements in ten (90 per cent) were performed for osteoarthritis
• guidelines in the UK recommend combining non-drug and drug treatments for hip osteoarthritis
• while some trials have shown clinical benefit eight weeks after injection in patients with hip osteoarthritis, the existing evidence, overall, has been conflicting

To view the research article, titled Clinical effectiveness of one ultrasound guided intra-articular corticosteroid and local anaesthetic injection in addition to advice and education for hip osteoarthritis (HIT trial): single blind, parallel group, three arm, randomised controlled trial, visit: https://www.bmj.com/content/377/bmj-2021-068446