INTRAARTICULAR CORTICOSTEROID INJECTION

This strength of recommendation was downgraded to moderate for several reasons including heterogeneity in study design and corticosteroid dosing as well as a lack of reporting of adverse events (e.g., infection, rapidly progressive osteoarthritis of the hip).

Four high quality studies (Qvistgaard et al, Lambert et al, Atchia et al Paskins et al) compared intraarticular corticosteroid with placebo and showed improvement in pain and function scores in the short-term with intraarticular corticosteroids. Paskins (2022) found superior Western Ontario McMaster Arthritis Index (WOMAC) Total Scores, and 5-Level EuroQuol 5 Dimension self-report survey (EQ5D-5L) Scores at two and four month follow ups. Similarly, Atchia (2011) reported superior WOMAC function with corticosteroid injection at one, four, and eight week follow ups. Lambert (2007) reported superior WOMAC Stiffness, WOMAC Function Scores, and 36-Item Short Form Survey (SF-36) Scores (Social Functioning, Physical Functioning, and PCS) at one and two months as well. Pain outcomes (WOMAC Pain, SF-36 Bodily Pain, Visual Analogue Score / Numerical Rating Score for Pain) were superior for corticosteroid groups at short term follow ups up to eight weeks (Atchia 2011, Qvistgaard 2006, Lambert 2007, Paskins 2022).

Benefits/Harms of Implementation
While intraarticular corticosteroids can improve pain and function in the short-term for patients with symptomatic osteoarthritis of the hip there are risks with their use. The most common risks are infection as well as rapidly progressive osteoarthritis after an intraarticular corticosteroid injection, which should be considered.

Outcome Importance
Intra-articular corticosteroids injections of the hip may not only improve pain and function of the hip, but also may improve patient activity levels, patient satisfaction, and quality of life.

Cost Effectiveness/Resource Utilization
There is limited comparative data on the cost-effectiveness of intraarticular corticosteroid injections of the hip compared to other nonoperative treatments of osteoarthritis of the hip. Intraarticular corticosteroid injections of the hip are often performed with image guidance, such as ultrasound or fluoroscopy, which increase cost and resource utilization.

Acceptability
This recommendation should be readily implemented as it does not influence a major change in clinical practice. Intraarticular injections of the hip are commonly performed. It provides further evidence to support and guide this clinical practice.

Feasibility
Intraarticular corticosteroid injections of the hip are feasible for most, however they are often performed with image-guidance, such as fluoroscopy or ultrasound. Thus, patients who do not have access to clinicians with those imaging technologies may not have access to intraarticular corticosteroid injections in the hip.

Future Research
Future research is warranted to better understand the adverse events with intraarticular corticosteroid use, particularly infection and rapidly progressive osteoarthritis of the hip. Further studies are also needed with consistent dosing of corticosteroids as well as delivery methods.