Hawley Samuel, Prats-Uribe Albert, Matharu Gulraj S, Delmestri Antonella, Prieto-Alhambra Daniel, Judge Andrew, Whitehouse Michael R
Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Learning & Research Building Level 1, Bristol, BS10 5NB, UK.
Centre for Statistics in Medicine, Nuffield, Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, OX3 7LD, UK.
BMC Med. 2025 Apr 7;23(1):195. doi: 10.1186/s12916-025-04000-6.
Intra-articular corticosteroid injection (IACI) is an established treatment option for uncontrolled pain in osteoarthritis. There is a lack of longer-term follow-up in most studies of the effects of IACI, meaning there is scarcity of data on the impact of IACI on the subsequent need for joint replacement. Our aim was to assess the effect of IACI for knee osteoarthritis on the subsequent incidence of knee replacement surgery and on associated post-operative outcomes.
We conducted a cohort study of knee osteoarthritis patients registered in the Clinical Practice Research Datalink (CPRD) GOLD database with an incident diagnosis between 2005 and 2019. Exposure was single or repeated IACI use, analysed separately. The primary outcome was knee replacement during 1-year and 5-year follow-ups. Secondary outcomes included post-operative patient-reported outcome measures and adverse events. Primary analyses used general practitioner practice preference for IACI as an instrumental variable given this methodology can account for strong and unmeasured confounding. Secondary analyses used propensity score matching, accounting for measured covariates only.
During 1-year follow-up, 1628/33,357 (4.9%) knee osteoarthritis patients underwent knee replacement, for which single IACI was associated with lower risk, which persisted to 5-year follow-up (incidence rate ratio: 0.52 [0.36, 0.77]). Conversely, in secondary propensity score analyses no association was found between IACI use and knee replacement rate at 1-year follow-up, and an estimated increased rate of knee replacement at 5-year follow-up. Use of IACI pre-joint replacement was not associated with any adverse post-operative outcomes, for example, 1-year complication rates (per 100 person-years) following knee replacement were 4.6 (3.8, 5.8), 4.0 (2.7, 6.0) and 5.0 (3.1, 8.1) among patients with no, single and repeat pre-joint replacement IACI use, respectively.
Findings from our main analysis suggest that short-term pain reduction following IACI for knee osteoarthritis may translate to lower rates of knee replacement over 5 years follow-up, although contradictory associations were observed in secondary analyses which likely reflected residual confounding by indication. Reassuringly, IACI use before knee replacement was not associated with post-operative adverse outcomes.
关节内注射皮质类固醇（IACI）是治疗骨关节炎未控制疼痛的既定治疗选择。大多数关于IACI效果的研究缺乏长期随访，这意味着关于IACI对后续关节置换需求影响的数据很少。我们的目的是评估IACI治疗膝关节骨关节炎对后续膝关节置换手术发生率及相关术后结果的影响。
我们对临床实践研究数据链（CPRD）GOLD数据库中2005年至2019年间确诊的膝关节骨关节炎患者进行了一项队列研究。暴露因素为单次或重复使用IACI，并分别进行分析。主要结局是1年和5年随访期间的膝关节置换情况。次要结局包括术后患者报告的结局指标和不良事件。主要分析使用全科医生对IACI的实践偏好作为工具变量，因为这种方法可以解释强烈且未测量的混杂因素。次要分析使用倾向评分匹配，仅考虑已测量的协变量。
在1年随访期间，33357例膝关节骨关节炎患者中有1628例（4.9%）接受了膝关节置换，单次IACI与之风险较低相关，这种关联持续到5年随访（发病率比：0.52[0.36,0.77]）。相反，在次要倾向评分分析中，1年随访时未发现IACI使用与膝关节置换率之间存在关联，而5年随访时估计膝关节置换率增加。关节置换前使用IACI与任何术后不良结局均无关联，例如，膝关节置换后1年并发症发生率（每100人年）在未使用、单次使用和重复使用关节置换前IACI的患者中分别为4.6（3.8,5.8）、4.0（2.7,6.0）和5.0（3.1,8.1）。
我们主要分析的结果表明，IACI治疗膝关节骨关节炎后短期疼痛减轻可能转化为5年随访期间较低的膝关节置换率，尽管在次要分析中观察到相互矛盾的关联，这可能反映了指征残留混杂。令人放心的是，膝关节置换前使用IACI与术后不良结局无关。
