Ross Hauser, MD, Danielle Matias, PA-C, Demi Foster, APRN

Most people who contact us already have a good understanding that frequent or long-term cortisone use has its challenges and risks. Research has demonstrated that using cortisone injections just prior to meniscus surgery can significantly increase risks for surgical site infection and meniscus surgery failure.

In March 2021, research led by Rush University Medical Center and published in the journal Arthroscopy (1) found that patients who received knee injections within one month prior to knee arthroscopic surgery developed postoperative infections at twice the rate of those who did not receive an injection.

This of course relates to an injection increases the risk of surgical infection. But what about the overall impact of corticosteroids on the meniscus?

A November 2022 paper, also from Rush University Medical Center (2) and published in the journal Knee Surgery, Sports Traumatology, Arthroscopy offers a different perspective: “(while) consensus guidelines recommend administering a corticosteroid injection for patients with a symptomatic degenerative meniscus lesion prior to arthroscopic partial meniscectomy, (the study cited above) found that corticosteroid injection administered within one month prior to meniscectomy is associated with an increased risk of postoperative infection.”

Not all infections are the same: The authors continued: “However, infections may range in severity from superficial infections to serious infections requiring surgical interventions. Serious infections requiring surgical intervention are rare after a meniscectomy, occurring in 0.1% (1 in 1000) of arthroscopic partial meniscectomies. . . Patients were five times more likely to return to the operating room for infection after arthroscopic partial meniscectomy if they had a corticosteroid injection the month before or had multiple corticosteroid injections in the year before surgery. The risk of infection was no longer significant if there was at least a 2-month interval between preoperative corticosteroid injection and arthroscopic partial meniscectomy.”

Corticosteroid short-term success and long-term problems in meniscus injuries.

It is well understood by most medical professionals and their patients that prolonged and long-term corticosteroid injections for knee pain can break down cartilage including the meniscus. In 2017, doctors from Tufts Medical Center in Boston asked, “What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on the progression of cartilage loss and knee pain in patients with osteoarthritis?”

Writing in the Journal of the American Medical Association, (JAMA) (3) they published their answer:

“Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.”

In February 2020, a review study with the title “Medical Reversals in Family Practice: A Review,” (4) published in the journal Current Therapeutic Research, Clinical and Experimental offered these points:

Cortisone can thin out the meniscus.

In August of 2020 in the journal Scientific Reports (5) doctors expressed concerns about damaging the meniscus tissue with cortisone injections. It should be noted that this research’s main findings were that it was okay to get one cortisone injection. For many people, one injection would be considered safe. Here are the learning points of that research:

• “In conclusion, a single intra-articular corticosteroid injection for the treatment of osteoarthritis-related knee pain was shown to be safe with no negative impact on structural changes, but there was a transient meniscal thickness reduction, a phenomenon for which the clinical relevance is at present unknown.”

Cortisone during the surgery

Doctors at The Ohio State University Wexner Medical Center offered a May 2022 report (6) that evaluated the risk of post-operative infection after intra-articular steroid injection at the time of knee arthroscopy in 2416 patients who were given intra-articular steroid at the time of knee arthroscopy. The authors noted: “Knee infection following arthroscopic surgery is rare. Intra-operative steroid injection during arthroscopic knee surgery is associated with a 4.3-fold increased risk of a subsequent knee infection. While the overall risk remains low, the use of intra-operative steroids is expected to result in one additional knee infection for every 448 arthroscopic procedures performed.”

References

1 Forsythe B, Forlenza EM, Agarwalla A, Cohn MR, Lavoie-Gagne O, Lu Y, Mascarenhas R. Corticosteroid Injections One Month Before Arthroscopic Meniscectomy Increase the Risk of Surgical Site Infection. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021 Mar 31. [Google Scholar]
2 Forsythe B, Berlinberg EJ, Forlenza EM, Oeding JF, Patel HH, Mascarenhas R. Corticosteroid injections 2 months before arthroscopic meniscectomy increases the rate of postoperative infections requiring surgical irrigation and debridement. Knee Surgery, Sports Traumatology, Arthroscopy. 2022 May 27:1-9. [Google Scholar]
3 McAlindon TE, LaValley MP, Harvey WF, Price LL, Driban JB, Zhang M, Ward RJ. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee OsteoarthritisA Randomized Clinical Trial. JAMA. 2017;317(19):1967-1975. [Google Scholar]
4 Haslam A, Livingston C, Prasad V. Medical reversals in family practice: a review. Current Therapeutic Research. 2020 Feb 22:100579. [Google Scholar]
5 Pelletier JP, Raynauld JP, Abram F, Dorais M, Paiement P, Martel-Pelletier J. Intra-articular corticosteroid knee injection induces a reduction in meniscal thickness with no treatment effect on cartilage volume: a case–control study. Scientific reports. 2020 Aug 14;10(1):1-0.  [Google Scholar]
6 Kohls M, Magnussen R, Fitzpatrick S, Kaeding C, Flanigan D, Duerr R. Intra-articular steroid injection at the time of knee arthroscopy increases risk of post-operative infection. Knee Surgery, Sports Traumatology, Arthroscopy. 2022 May;30(5):1846-53. [Google Scholar]