Injection therapy

Steroid injection, Durolane and Biological injections

Injections are used in orthopaedics for 2 main reasons, one is to treat something and the other is to confirm a diagnosis. 

Diagnostic


Imagine you get home one night and turn on the lights, but no light comes on. The first thing you may suspect is a blown lightbulb, so you try a new one and see if the light works. If it still doesn't work then you might look at the fuse box, and if not that then the switch. 

Charles often uses injections in the same way. If you have a pain, and we think it is coming from a certain structure but we are not sure, then before doing anything drastic we can inject it to numb it and calm down inflammation (local anaesthetic and steroid) to see if that helps. 

Sometimes this can actually cure the problem too, or sometimes it can guide onward treatment. 

Treatment


For some conditions, an injection is done to solve the problem for good, or with the understanding that it won't last forever, but the objective is a medium-term relief. 

Types of injection


Steroid


Steroid injections are usually a mixture of numbing local anaesthetic what works for about 24 hours, and a synthetic steroid called Kenalog that lasts for several months - but is a bit variable. 

These are really good for Hoffa's syndrome (fat pad impingement) where they can often be a cure as they break a vicious cycle, or for iliotibial band friction syndrome, where they get you good enough to do the right rehab. 

They are not so good for arthritis, where they run the risk of damaging the joint, and only mask the problems for a few months before wearing off. 

They are cheap and are still widely used by GPs and the NHS for arthritis pain, but Charles is not keen in this as he sees quite a few cases where these have caused terrible infection needing surgery,  and then joint replacement can't be done for a long time. Be a bit wary of steroid injections for arthritis - there are much better options!

Advantages: Cheap, available on the NHS, good for the right conditions.

Disadvantages: Risk of infection, may just mask the problem (eg arthritis), the risk of flare-up, should not have a joint replacement for the next 6 months.

Durolane - Viscosupplement - Hyaluronic Acid


This is a brand of viscosupplement (there are a variety of brands). Think of it like an oil change for a worn-out joint, or artificial joint lubrication. These are more expensive injections but they are not like steroid and are a treatment for early arthritis which Charles prefers. He has had them himself and had a great result. Lots of people report a year or more of benefit when it is used in the right person at the right time. However, sometimes they seem to have little effect and can be a waste of time and money! Overall about 70-80% of people are really pleased with these. They also seem to be safer than steroid injections in terms of the risk of infection and joint replacement soon after. To get good results it is important to pick the right patients to use it on. Charles will usually give a likelihood of success based on your scans or X-rays. 


Charles does this in an ordinary 20-minute appointment and you should be fine to drive home. It can make the knee sore for the next week or so in some patients (about 1 in 10) and for this injection if this is beginning to happen then take anti-inflammatories for about 5 days to cover the flare-up. The peak effect is felt at six weeks so you do need to be patient with it. 

With any injection, there is a very small risk of making you worse by getting an infection. The risk seems to be higher with steroids. 


Advantages: Smaller risk of infection, good for arthritis, long-lasting if it works, not worried about a later joint replacement.

Disadvantages:   Not cheap (but all insurers do cover it), not available on the NHS,  risk of flare-up.


When it works (about 80%) - Its works well - here is some typical feedback: 


Charles does these at the Bournemouth Private Clinic and the cost is £449.


Dear Mr Willis-Owen, my Durolane injection last Thursday has been an incredible success. My knee is pain-free and no longer limping is beneficial to my thigh and hip. Thank you very much for recommending durolane and for your expertise in administering it.


Biological injections - Platelet Rich Plasma - Arthrex ACP

These injections rely on taking some of your blood and treating it to extract all of the powerful natural factors that make us heal up when we get injured or sick. By injecting a concentrated dose of this into a joint with early arthritis we can supercharge your bodies ability to control inflammation and calm the joint down. These injections are safe as it is made from your own blood. They can provide longer-term improvement of symptoms in early arthritis. 

Charles does this in an ordinary 20-minute appointment and you should be fine to drive home. It can make the knee sore for the next week or so in some patients (about 1 in 10) and for this injection, you should try to avoid anti-inflammatories for about 6 weeks to allow it to work. The peak effect is felt at six weeks so you do need to be patient with it. 

With any injection, there is a very small risk of making you worse by getting an infection. The risk seems to be higher with steroids. 


There are scientific studies which show these are superior to steroid injections and to the visco-supplement injections meaning this is often the best option: 


Platelet Rich Plasma Versus Hyaluronic Acid in the Treatment of Knee Osteoarthritis: a Meta-Analysis.pdf


Comparison between intra-articular infiltrations of placebo, steroids, hyaluronic and PRP for knee osteoarthritis_ a Bayesian network meta-analysis.pdf


Advantages: Natural, uses your own healing potential, promising results

Disadvantages: Expensive, no guarantee they will work in a specific case

When it works (about 80%) - Its works well - here is some typical feedback: 


Charles does these at the Bournemouth Private Clinic and the cost is £600.


Dear Charles, Unbelievably, it’s now 6 weeks since you gave me the knee injections and my overall feeling is that of a pretty dramatic improvement, especially with regard to pain.  With the way I feel at the moment I would definitely not be coming to see you thinking that I might need knee replacement surgery, as I did in mid-September.


Read the N-STRIDE APS brochure from the manufacturer

What is it like having an injection? 


This usually happens in the usual consultation time of 20 minutes and you can walk out and drive home as usual. Charles will talk you through it, clean your skin very thoroughly, clean his hands very thoroughly, get the injection ready with a tiny little needle, carefully place the injection to the exact right spot and put a plaster on. 
The needle is smaller than a blood test needle and should be less painful than that. Nearly everyone is a bit nervous before but says afterwards that it was much better than they had expected! 

What are the risks? 


Either type of injection has a very very small risk of infection, it is more with steroid into the joint, which is why Charles usually won't put steroid in the joint itself (as opposed to the fat pad or ITB). 
There is a chance of a flare-up - being more sore for the next few days before feeling the benefit.
There is a chance it does not help.
There can be rare problems such as permanent skin whitening, or permanent change in the contour of the fat under the skin leaving a little dimple. These are rare with steroid and very very rare with Durolane. 

What can I do afterwards? 


There are no rules! Do what you feel able and go purely by feel.


"Charles, the [Durolane] injection you gave me has been excellent for about 15 months now and I have been much walking better, it is beginning to wear off now and I'm really keen for another one to avoid the need for an operation" RH