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. 2025 Apr 7;23(1):195.
doi: 10.1186/s12916-025-04000-6.

Effect of intra-articular corticosteroid injections for knee osteoarthritis on the rates of subsequent knee replacement and post-operative outcomes: a national cohort study of England

Samuel Hawley  1 , Albert Prats-Uribe  2 , Gulraj S Matharu  3 , Antonella Delmestri  2 , Daniel Prieto-Alhambra  2 , Andrew Judge  3   2   4 , Michael R Whitehouse  3   4
Affiliations

Effect of intra-articular corticosteroid injections for knee osteoarthritis on the rates of subsequent knee replacement and post-operative outcomes: a national cohort study of England

Samuel Hawley et al. BMC Med. .

Abstract

Background: 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.

Methods: 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.

Results: 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.

Conclusions: 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.

Keywords: Complications; Infection; Knee replacement; Osteoarthritis; Pain; Pharmacoepidemiology; Post-operative outcomes; Real-world evidence; Steroid injection; Surgery.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: The study protocol was approved via the CPRD Research Data Governance process (number 20_067) and feedback from the Independent Scientific Advisory Committee provided on 28/05/2020. No additional ethical approval was required as this study used pseudo-anonymised routinely collected data. Consent for publication: Not applicable. Competing interests: All authors have completed the unified competing interest form (available on request from the corresponding author) and declare: SH and AD have nothing to declare. APU: Institution has received research funding from the European Medicines Agency. GM: Institution has received research funding from the NIHR (HTA and as an NIHR Clinical Lecturer) and the Academy of Medical Sciences. DPA: Institution has received research funding from the European Medicines Agency, Innovative Medicines Initiative, Amgen, Chiesi-Taylor, Lilly, Janssen, Novartis and UCB Biopharma. Received consultancy fees from AstraZeneca and UCB Biopharma. Amgen, Astellas, Janssen, Synapse Management Partners and UCB Biopharma have funded or supported training programmes organised by DPA’s department. AJ: Institution has received research funding from the NIHR, HDR UK, Versus Arthritis, Healthcare Quality Improvement Partnership, Royal College of Physicians, and Tommy’s, Health Foundation. MW: Institution has received research funding from the NIHR, NIHR Bristol Biomedical Research Centre, Healthcare Quality Improvement Partnership, and Ceramtec. Receives royalties from Taylor Francis. Institution receives payment for teaching from Heraeus.

Figures

Fig. 1
Fig. 1
Diagram of model set-up for analyses estimating the effect of IACI on subsequent rates of joint surgery
Fig. 2
Fig. 2
Estimated effect of IACI on subsequent occurrence of joint surgery analysed using instrumental variable and propensity score methods: A at 1-year follow-up and B 5-year follow-up
See this image and copyright information in PMC

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