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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

BMJ 2022; 377 doi: https://doi.org/10.1136/bmj-2021-068446 (Published 06 April 2022) Cite this as: BMJ 2022;377:e068446

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The tear, flare, and repair model of osteoarthritis

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Re: 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

Dear Editor

Paskins et al [1] report favourable effects of ultrasound-guided intra-articular lidocaine with or without triamcinolone, in patients with moderate to severe pain from primary hip osteoarthritis. A strong placebo response cannot be excluded, but the attenuated efficacy of lidocaine alone in patients with synovitis and effusion suggests a definite therapeutic benefit of at least 4 months duration with dual injection therapy.

Ultimately however the safety of repeated intra-articular steroid administration needs careful scrutiny, given the potential local and systemic adverse effects of potent, long-acting glucocorticoids. Previous studies of parenteral glucocorticoids in large joint osteoarthritis suggest that the therapeutic efficacy may be materially unaffected by accuracy of needle placement, [2] and even remote intra-muscular delivery may be clinically effective, [3] suggesting some systemic treatment effects.

Paskins’ data also suggests that in patients without significant secondary inflammation, lidocaine alone might confer equal benefit with respect to the main outcome measure at least. Indeed, if lidocaine does possess significant short-medium term immunomodulatory activity, [4] then ultrasound guided intra-articular delivery of local anaesthesia (without steroids) might be safer and non-inferior to triamcinolone in this patient group; a placebo-controlled trial of such a strategy would be worthwhile, and might also permit evaluation of exploratory explanatory variables. For those patients whose degenerative hip disease is complicated by ultrasonic evidence of inflammation, where steroid treatment might be expected to provide superior short-term benefit, a comparative trial of intra-muscular steroids versus intra-articular delivery might show similar efficacy at substantially lower cost. [5]

1. Paskins Z, Bromley K, Lewis M, et al. 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. BMJ 2022; 377: e068446. doi: 10.1136/bmj-2021-068446. PMID: 35387783

2. Hirsch G, O'Neill TW, Kitas G, Sinha A, Klocke R. Accuracy of injection and short-term pain relief following intra-articular corticosteroid injection in knee osteoarthritis - an observational study. BMC Musculoskelet Disord. 2017; 18: 44. doi: 10.1186/s12891-017-1401-z. PMID: 28122535.

3. Dorleijn DMJ, Luijsterburg PAJ, Reijman M, et al. Intramuscular glucocorticoid injection versus placebo injection in hip osteoarthritis: a 12-week blinded randomised controlled trial. Ann Rheum Dis. 2018; 77: 875-882. doi: 10.1136/annrheumdis-2017-212628. Epub 2018 Mar 7. PMID: 29514801.

4. Karnina R, Arif SK, Hatta M, Bukhari A. Molecular mechanisms of lidocaine. Ann Med Surg (Lond). 2021; 69: 102733. doi: 10.1016/j.amsu.2021.102733. PMID: 34457261.

5. Dorleijn DM, Luijsterburg PA, Reijman M, et al. Effectiveness of intramuscular corticosteroid injection versus placebo injection in patients with hip osteoarthritis: design of a randomized double-blinded controlled trial. BMC Musculoskelet Disord. 2011; 12: 280. doi: 10.1186/1471-2474-12-280. PMID: 22151921.

Mark.Garton@Wales.nhs.uk

Competing interests: No competing interests

12 May 2022
Mark J Garton
Consultant Physician
Wrexham Maelor Hospital, North Wales