The Steroid and Anesthetic Trick or Treat

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I’ve discussed more times than I can count that the high-dose corticosteroids used every day by physicians in joints, tendons, and spinal injections are like a Halloween trick. This morning we’ll go over a survey that shows just how widespread these injections are these days. Let’s dig in.

The Survey

A survey was taken of more than three thousand sports medicine physicians. Of the almost seven hundred that responded, this is the percentage that injected mega-dose steroids into various parts of the body:

  • 89% into hip joints
  • 91% into hip tendons
  • 91% into knee joints
  • 89% into knee tendons
  • 91% into shoulder joints
  • 91% into shoulder tendons

What percentage used less toxic anesthetics like Ropivacaine? On average, about 1 in 10.

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The Problem

The mega-dose steroids used by physicians every day are nasty, it’s that simple. Why do I call a milligram a mega-dose? Because that’s 100,000 to 1,000,000 more than the dose the body uses (nanogram). Here’s what steroids do:

  • Hammer stem cells (1)
  • Hurt cartilage (2,3)
  • Increase the risk of causing an infection if you have surgery (4,5,7)
  • Increase the risk of the failure of a joint replacement (6)

They do other bad things as well but let’s keep the list short.

In the meantime, you’ve heard me relay that if you decrease the dose by about 100,000 times, you still get the anti-inflammatory effect but none of these side effects. This is why we at Regenexx use nano-dose steroids. However, based on the data above, about 9 in 10 physicians use the side effect laden mega-dose steroids.

More Problems

Several scientists, including our research lab, have studied how different local anesthetics commonly used by doctors also hurt everything from cartilage to stem cells (8-11). One of the anesthetics that doesn’t hurt cells is called Ropivacaine. Hence, it would be a good thing if sports medicine physicians were beginning to get the memo. However, based on the survey above, 9 in 10 don’t use this less toxic anesthetic.

The upshot? This data is a Halloween trick for patients and not a treat! Hopefully, you’re kinder to the trick or treaters tonight than most physicians are to patients!

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References:

(1) Wyles CC, Houdek MT, Wyles SP, Wagner ER, Behfar A, Sierra RJ. Differential cytotoxicity of corticosteroids on human mesenchymal stem cells. Clin Orthop Relat Res. 2015 Mar;473(3):1155-64. doi: 10.1007/s11999-014-3925-y. Epub 2014 Sep 4. PMID: 25187334; PMCID: PMC4317436.

(2) Dragoo JL, Danial CM, Braun HJ, Pouliot MA, Kim HJ. The chondrotoxicity of single-dose corticosteroids. Knee Surg Sports Traumatol Arthrosc. 2012 Sep;20(9):1809-14. doi: 10.1007/s00167-011-1820-6. Epub 2011 Dec 21. PMID: 22186921.

(3) McAlindon TE, LaValley MP, Harvey WF, et al. Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial. JAMA.2017;317(19):1967–1975. doi: 10.1001/jama.2017.5283

(4) Wijn SRW, Rovers MM, van Tienen TG, Hannink G. Intra-articular corticosteroid injections increase the risk of requiring knee arthroplasty. Bone Joint J. 2020 May;102-B(5):586-592. doi: 10.1302/0301-620X.

(5) Richardson SS, Schairer WW, Sculco TP, Sculco PK. Comparison of Infection Risk with Corticosteroid or Hyaluronic Acid Injection Prior to Total Knee Arthroplasty. J Bone Joint Surg Am. 2019 Jan 16;101(2):112-118. doi: 10.2106/JBJS.18.00454.

(6) Ravi B, Escott BG, Wasserstein D, Croxford R, Hollands S, Paterson JM, Kreder HJ, Hawker GA. Intraarticular hip injection and early revision surgery following total hip arthroplasty: a retrospective cohort study. Arthritis Rheumatol. 2015 Jan;67(1):162-8. doi: 10.1002/art.38886.

(7) 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. 2021 Mar 31:S0749-8063(21)00289-9. doi: 10.1016/j.arthro.2021.02.047. Epub ahead of print. PMID: 33812029.
(8) Nie H, Kubrova E, Wu T, Denbeigh JM, Hunt C, Dietz AB, Smith J, Qu W, van Wijnen AJ. Effect of Lidocaine on Viability and Gene Expression of Human Adipose-derived Mesenchymal Stem Cells: An in vitro Study. PM R. 2019 Nov;11(11):1218-1227. doi: 10.1002/pmrj.12141. Epub 2019 May 30. PMID: 30784215; PMCID: PMC6699924.

(9) Gray A, Marrero-Berrios I, Weinberg J, Manchikalapati D, SchianodiCola J, Schloss RS, Yarmush J. The effect of local anesthetic on pro-inflammatory macrophage modulation by mesenchymal stromal cells. Int Immunopharmacol. 2016 Apr;33:48-54. doi: 10.1016/j.intimp.2016.01.019. Epub 2016 Feb 6. PMID: 26854576; PMCID: PMC4779686.

(10) Kubrova E, Su M, Galeano-Garces C, Galvan ML, Jerez S, Dietz AB, Smith J, Qu W, van Wijnen AJ. Differences in Cytotoxicity of Lidocaine, Ropivacaine, and Bupivacaine on the Viability and Metabolic Activity of Human Adipose-Derived Mesenchymal Stem Cells. Am J Phys Med Rehabil. 2021 Jan 1;100(1):82-91. doi: 10.1097/PHM.0000000000001529. PMID: 32657816.

(11) Gray A, Marrero-Berrios I, Ghodbane M, Maguire T, Weinberg J, Manchikalapati D, SchianodiCola J, Schloss RS, Yarmush J. Effect of Local Anesthetics on Human Mesenchymal Stromal Cell Secretion. Nano Life. 2015 Jun 1;5(2):1550001-1550014. doi: 10.1142/S1793984415500014. PMID: 26539251; PMCID: PMC4630030.

(11) Cushman DM, Teramoto M, Asay A, Clements ND, McCormick ZL. Corticosteroid and Local Anesthetic Use Trends for Large Joint and Bursa Injections: Results of a Survey of Sports Medicine Physicians. PM R. 2021 Sep;13(9):962-968. doi: 10.1002/pmrj.12499. Epub 2020 Nov 23. PMID: 32969178.

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Chris Centeno, MD is a specialist in regenerative medicine and the new field of Interventional Orthopedics. Centeno pioneered orthopedic stem cell procedures in 2005 and is responsible for a large amount of the published research on stem cell use for orthopedic applications. View Profile

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