Do Cortisone Injections Delay Knee Replacement Surgery?
No, cortisone injections should not be used to delay knee replacement surgery in patients with moderate-to-severe osteoarthritis who are already indicated for total joint arthroplasty (TJA). In fact, the most recent evidence suggests they may accelerate the need for surgery and increase associated risks.
Primary Recommendation for Surgical Candidates
For patients with radiographically moderate-to-severe knee osteoarthritis who have completed trials of appropriate nonoperative therapy and are indicated for knee replacement through shared decision-making, proceed to surgery without delaying for a trial of corticosteroid injections. 1
Key Supporting Evidence:
The 2023 American College of Rheumatology and American Association of Hip and Knee Surgeons conditionally recommend proceeding to TJA without delay over delaying surgical treatment for a trial of intra-articular glucocorticoid injections (evidence quality: very low) 1
Delaying surgery for corticosteroid injections may cause increased pain due to disease severity, with limited clinical benefit in this population 1
Harmful Effects of Delaying Surgery with Injections
Increased Risk of Requiring Arthroplasty:
Patients receiving corticosteroid injections have a 57% increased risk (HR 1.57,95% CI 1.37-1.81) of requiring knee arthroplasty compared to those who do not receive injections 2
Each injection increases the absolute risk of arthroplasty by 9.4% at 9 years follow-up 2
There is a dose-dependent relationship: patients receiving three or more injections have a 3.22-fold increased risk of TKA at 5 years compared to those receiving one injection (OR 3.22,95% CI 1.60-6.48) 3
Time to arthroplasty is nearly halved with multiple injections: 3.03 years after one injection versus 1.78 years after three injections 3
Infection Risk:
Performing surgery within 3 months of intra-articular injection increases the risk of periprosthetic joint infection 1, 4
The incidence of serious infectious complications following knee joint injections may be as high as 1 in 3,000, and potentially far higher in high-risk patients 5
When Corticosteroid Injections Are Appropriate
Early-Stage Disease (Not Surgical Candidates):
Corticosteroid injections provide effective but short-lived pain relief (1-4 weeks, occasionally up to 12 weeks) in patients with knee osteoarthritis, particularly when accompanied by effusion 1, 4
They are indicated for acute flares of knee pain, especially with effusion, in patients who are not yet surgical candidates 1
Evidence level 1B supports their efficacy for short-term symptom relief, though benefits diminish by 12-24 weeks 1
Specific Exceptions for Surgical Candidates:
Patients with acute flares of OA or inflammatory arthropathy (gout, calcium pyrophosphate deposition disease) who need immediate pain relief while awaiting surgery for personal reasons (work/family obligations) 1
Critical caveat: Diabetic patients have increased risk of hyperglycemia with intra-articular glucocorticoids and should monitor glucose levels for 1-3 days post-injection 4
Clinical Algorithm for Decision-Making
Step 1: Assess Disease Severity
Moderate-to-severe radiographic OA (Kellgren-Lawrence grade) with refractory pain and disability despite trials of ≥1 appropriate nonoperative therapy → Proceed to surgery without delay 1
Mild-to-moderate OA without surgical indication → Consider corticosteroid injection for symptom management 1
Step 2: If Patient Requires Delay for Personal/Medical Reasons
Acceptable to use corticosteroid injection for temporary pain relief while awaiting surgery 1
Must wait at least 3 months between injection and surgery to minimize infection risk 1, 4
Avoid repeated injections, as each additional injection increases TKA risk and shortens time to surgery 2, 3
Step 3: Monitor for Complications
Rule out infection with clinical examination, laboratory analysis, and radiographic evaluation before any injection 6
Avoid overuse of injected joint for 24 hours following injection 4
Common Pitfalls to Avoid
Do not use repeated corticosteroid injections as a strategy to postpone inevitable surgery - this increases surgical risk and accelerates disease progression 2, 3
Do not inject within 3 months of planned surgery - significantly increases periprosthetic joint infection risk 1, 4
Do not assume accurate intra-articular placement - up to 20% of injections miss the joint space, reducing efficacy 5
Do not use injections as a substitute for surgical evaluation in patients with severe disease - joint replacement should be considered when radiographic evidence shows severe OA with refractory pain and disability 1