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Treatment of hip osteoarthritis with glucocorticoids
  1. Jian Zhou1,2,
  2. Biao Liu3,
  3. Chenxi Li4,
  4. Yingquan Luo5,
  5. Tang Liu1,
  6. Wanchun Wang1
  1. 1 Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, China
  2. 2 Department of Sports Medicine Research Center, Central South University, Changsha, China
  3. 3 Department of Orthopedics, Hukou County Hospital of traditional Chinese Medicine, Jiujiang, China
  4. 4 Department of Clinical Medicine, School of Medicine, Shandong University, Jinan, China
  5. 5 Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha, China
  1. Correspondence to Prof Yingquan Luo, Department of Geriatrics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; luoyingquan{at}csu.edu.cn and Prof Tang Liu and Professor Wanchun Wang, Department of Orthopedics, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China; liutang1204{at}csu.edu.cn, wanchun.wang{at}csu.edu.cn

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Osteoarthritis (OA), also known as degenerative joint disease, hypertrophic arthritis, senile arthritis and articular cartilage osteoarthritis, is a common clinical disease. The common symptoms of OA include pain in affected joints, aggravation after exercise, remission after rest and a feeling of stiffness without activity for a long time.1 OA can occur in any joint, but mainly in the hip joint, knee joint, hand joint and spine facet joint. Recently, it was with great interest that we read the report entitled ‘Intramuscular glucocorticoid injection versus placebo injection in hip osteoarthritis: a 12 week blinded randomised controlled trial’ by Dorleijn and colleagues published online in 7 March 2018 in Annals of the Rheumatic Diseases.2 Dorleijn et al concluded that an intramuscular glucocorticoid injection showed effectiveness in patients with hip OA on one of the three primary outcomes at 2 weeks postinjection and all primary outcomes showed effectiveness from 4 to 6 weeks. Certainly, the study of Dorleijn et al will be important for clinicians, but there are still several questions that we would like to communicate with the authors.

First, there are several OA scoring systems, such as the American College of Rheumatology classification criteria3 and the Kellgren and Lawrence (K-L) system,4 but the K-L system is the most widely used method for knee, hip and hand joints (table 1). Dorleijn et al claimed that patients with K-L ≧2 were included if they had symptomatic disease for ≧6 months. However, the clinical manifestations of patients with scores 2, 3 and 4 are different from each other.5 Therefore, how does the author determine the amount of glucocorticoid used in patients with different scores? Moreover, is it really appropriate to compare the efficacy of intramuscular glucocorticoid injection in patients with different K-L scores?

Table 1

Kellgren-Lawrence (K-L) system of osteoarthritis

Second, currently, medications for OA include6 (1) oral: non-steroidal anti-inflammatory drugs, cyclooxygenase-2 inhibitors, cartilage protectors (such as paracetamol, diclofenac sodium, celecoxib, glucosamine sulfate, etc) and other simple analgesics (tramadol, codeine, etc); (2) external use: mainly non-steroidal anti-inflammatory drugs such as valistarin, indomethacin and so on; (3) intra-articular (IA) injections: mainly glucocorticoids and transparent acid salt. The method of intra-articular injection is easy to grasp and the curative effect is affirmative.7 It has been widely used in clinical practice in recent years. Dorleijn et al claimed that injection into the hip joint is challenging because the joint cannot be palpated and is adjacent to important neurovascular structures, so they decided to take intramuscular (IM) glucocorticoid injection. Compared with IA injection, IM glucocorticoid injection may extend the side effects of glucocorticoids to the whole body.8 9 Additionally, since the authors found that IA injection of glucocorticoids is difficult, why did the author not choose puncture injection of glucocorticoids into the joint cavity under the guidance of B-ultrasound10?

Last but not least, our previous use of topical hormonal closure therapy was generally effective only locally, but the authors’ results were actually valid for closed ipsilateral hip joints. Considering the different treatment conclusions of both parties, we conducted a short-term follow-up study. From 15 March 2018 to 15 April 2018, 16 patients (table 2) with rotor bursitis and ipsilateral hip OA (K-L ≧2) provided informed consent. Eight of them were randomised to the glucocorticoid injection and others to the placebo injection. Patients in glucocorticoid injection group received 40 mg triamcinolone acetate (1 mL) while patients in placebo injection group received 1 mL normal saline (placebo) with an IM injection. The severity of hip pain at 2 weeks postinjection was measured on an 11-point numerical rating scale (NRS: 0–10, 0=no pain) at rest and during walking. The corresponding statistical method is the same as Dorleijn et al. However, at a 2-week follow-up, the glucocorticoid injection did not show a significant association with hip pain reduction at rest or walking compared with the placebo injection (figure 1). In view of the total number of patients in our study was in a small sample size and the mean follow-up was short, so a larger number of samples, further high-quality prospective comparative studies and long-term effects are needed to be further examined.

Table 2

General information in two groups (mean±SD)

Figure 1

Pain score in rest and walking during the follow-up of glucocorticoid and placebo group. NRS, numerical rating scale.

We utterly respect the great contributions of the authors. We would be very interested in the authors’ response regarding the above issues in the meantime.

References

Footnotes

  • Contributors All authors were involved in the study conception, manuscript drafting and revising, and final approval of the submitted version.

  • Funding This work was supported by the Fundamental Research Funds for the Central Universities of Central South University (grant no. 2018zzts930), the Central South University Sports Medicine Scholarship and the National Natural Science Foundation of China (grant nos. 81000821 and 81672176).

  • Competing interests None declared.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; internally peer reviewed.