Importance of placement of intra-articular steroid injections

Open pilot study of ultrasound-guided intra-articular injection of hylan G-F 20 (Synvisc) in the treatment of symptomatic hip osteoarthritis

Patients suffering from hip osteoarthritis (OA) are frequently symptomatic, and the disease can result in significant limitation of patients' activity and high social costs. Hip OA is generally managed with systemic treatments such as nonsteroidal anti-inflammatory drugs (NSAIDs) and/or symptomatic slow acting drugs. Viscosupplementation with hyaluronan (HA) or its derivatives, which aims to restore the physiological and rheological features of the synovial fluid to improve symptoms, is now a routinely prescribed treatment for OA of the knee. However, few data exist in the literature regarding the use of viscosupplementation in the treatment of hip OA. The objective of this prospective, open, uncontrolled pilot study was to investigate the safety and effectiveness of intra-articular injection, under ultrasound control, of hylan G-F 20 for the treatment of OA of the hip. Twelve patients (> or =40 years old) with symptomatic hip OA were treated with one injection of 2 ml of hylan G-F 20 under ultrasound guidance. During the study, patients were evaluated for safety and efficacy using the Lequesne index, a visual analogue scale (VAS) measure of hip OA pain and analysis of NSAID consumption. Patients treated with hylan G-F 20 in this study showed clinically significant reductions in Lequesne and VAS scores and in the consumption of NSAIDs up to 3 months after the injection. In the 12 patients treated (total of 14 injections), no systemic adverse events were observed. Three patients reported mild, local pain post-injection. This study demonstrates the potential of ultrasound-guided intra-articular injections of a viscosupplement into the hip joint and gives positive preliminary information about the safety and efficacy of hylan G-F 20 for the treatment of symptomatic hip OA.

Reliability of common knee injection sites with low-volume injections

This study's purpose was to evaluate the reliability of knee injection sites with low-volume (2-3 cc) injection typical of viscosupplementation. This was a prospective study of 131 knees randomly assigned to 3 injection groups before to knee arthroscopy: SM-superomedial, superolateral, and lateral joint line (LJL). Needles were inserted to the hub, and aspiration was attempted before injection with 3 cc diluted methylene blue (MB). Injections then were graded at the time of arthroscopy as good, fair, or poor, depending on the intra-articular staining of MB. We conclude that a lateral joint line injection site may not be reliable for routine injections of low volumes into knees, because it results in good intra- articular delivery less than half of the time, with a high incidence of soft-tissue infiltration.

A simple, accurate method to confirm placement of intra-articular knee injection

BACKGROUND

Intra-articular knee injections are routinely performed in clinical practice without documenting intra-articular placement.

HYPOTHESIS

A small amount of air to an intra-articular knee injection produces an audible "squishing" sound with range of motion.

STUDY DESIGN

Prospective nonrandomized clinical trial.

METHODS

The study group (20 knees from 20 patients) received an intra-articular injection with a mixture of local anesthetic, corticosteroid, contrast dye, and 1 to 2 cc of air. The control group (10 knees from 5 patients) received extra-articular injections of a mixture of local anesthetic, contrast dye, and 2 cc of air. All knees were examined immediately after injection for a squishing sound with range of motion. Postinjection arthrographic radiographs were taken to verify the actual placement.

RESULT

All study group knees and no control group knees had intra-articular contrast by radiograph. Clearly audible squishing sounds were heard in 17 of 20 study knees (sensitivity of 85%). Squishing sounds were audible in none of the control knees (specificity of 100%).

CONCLUSION

Adding 1 to 2 cc of air to knee injections provides a no-cost, reliable, sensitive, and specific method of confirming accurate placement.

CLINICAL RELEVANCE

This simple method is easily reproduced, can confirm accurate placement, and can eliminate extra-articular injection as the reason for clinical response failure.

Update on identification of pathogenic crystals in joint fluid

Crystal identification in joint fluid has been an essential part of diagnosis of joint disease. Recent advances have included progress in crystal identification on stained slides, attention to aspiration techniques, and arthrocenteses of asymptomatic joints. Challenges remain to increase use and optimize techniques.

Intra-articular treatments in osteoarthritis: from the symptomatic to the structure modifying

The symptomatic and structural efficacy of intra-articular (IA) injections is reviewed. IA corticosteroid injections are rapidly effective, but their symptomatic benefit is short lived. Hyaluronan has delayed onset of efficacy but its benefit for pain may be longer lasting. Lavage and debridement are probably not as efficacious as once thought in osteoarthritis.

CT-guided suprascapular nerve blocks: a pilot study

OBJECTIVE

The objective of this study was to describe the suprascapular nerve block using CT guidance and to evaluate the short- and medium-term efficacy in a range of shoulder pathologies.

DESIGN AND PATIENTS

CT-guided infiltration around the suprascapular nerve was performed with bupivacaine and Celestone Chronodose on 40 consecutive patients presenting with chronic shoulder pathologies unresponsive to conventional treatment. Patients were interviewed using the Shoulder Pain and Disability Index (SPADI) before the procedure, 30 min after the procedure and at 3 days, 3 weeks and 6 weeks afterwards.

RESULTS

Within 30 min of the block overall pain scores decreased from a mean (+/-SEM) pain score of 7.0 (+/-0.4) to 3.5 (+/-0.5) ( n=39, P<0.001). At 3 days after the procedure, the mean overall improvement of the pain and disability scores were 20.4% (+/-4.9, P<0.001) and 16.8% (+/-4.8, P=0.004) respectively. Sustained pain relief and reduced disability were achieved in 10 of 35 (29%) patients at 3 weeks and longer. Patients suffering from soft tissue pathologies were the most likely patients to benefit from the injection. No serious side effects were noted.

CONCLUSIONS

In some patients with chronic soft tissue pathologies who do not respond to conventional treatment, a CT-guided suprascapular nerve block can provide safe short- and medium-term relief from pain and disability.

Nicolau's syndrome after local glucocorticoid injection

We report three cases of Nicolau's syndrome induced by intraarticular glucocorticoid injections. Nicolau's syndrome is defined as livedo-like dermatitis secondary to acute arterial thrombosis occurring immediately after intravascular injection of an insoluble drug substance. The cases described by Nicolau occurred in association with injections of oily bismuth suspensions. In 1970s and 1980s, cases occurred with delayed-action penicillin suspensions injected intramuscularly. Typically, the injection is followed immediately by excruciating pain in the buttock, sometimes with syncope. Cyanotic patches and a livedoid pattern develop. Rapid resolution of the pain and slower clearing of the skin changes occur in most patients. We report three typical cases with both severe pain and skin changes. In addition, two other patients had incomplete variants without skin abnormalities. Each of these five patients had received an injection in or about a joint of a glucocorticoid in a crystalline suspension. The pathophysiology of this syndrome probably involves acute vascular spasm related to penetration of microcrystals into a blood vessel.

A randomised study of two training programmes for general practitioners in the techniques of shoulder injection

OBJECTIVES

To evaluate the impact of two different modes of shoulder injection training on the level of confidence and number of injections performed by general practitioners (GPs)

METHODS

Demographic details, and information on referrals for shoulder problems, shoulder joint injection activity, and confidence in the six months before training were obtained for 40 GP principals at baseline. Standardised training in the techniques of shoulder joint injection using rubber mannequins was given to all GPs. Twenty of these GPs were randomly allocated to receive additional training on patients in hospital joint injection clinics. Six months after both forms of training the shoulder injection and referral activities of all GPs were reassessed.

RESULTS

Both training groups had comparable demographic characteristics and baseline clinical activity. GPs who had additional training with patients reported a marked increase in their level of confidence in performing shoulder injections and the number performed. The number of shoulder referrals did not differ between the groups

CONCLUSION

Training on patients in addition to conventional training on mannequins increased GPs' shoulder injection activity and their level of confidence. Hospital injection clinics may provide a suitable setting in which to train GPs interested in developing their shoulder joint injection skills.

Intra-articular hyaluronan therapy

Viscosupplementation, in which hyaluronan derivatives are injected into the intra-articular space of osteoarthritic joints, is now widely used to treat knee osteoarthritis (OA). No viscosupplements have been approved for osteoarthritic joints other than the knee. To date, no clinical trials using viscosupplements to treat ankle or foot OA have been published. However, the mechanisms thought to be responsible for viscosupplementation's therapeutic effects would likely apply in any synovial joint. A goal of this article is to stimulate interest in research to assess the potential role of viscosupplementation in treating foot and ankle OA.

Intraarticular corticosteroids, supervised physiotherapy, or a combination of the two in the treatment of adhesive capsulitis of the shoulder: a placebo-controlled trial

OBJECTIVE

To compare the efficacy of a single intraarticular corticosteroid injection, a supervised physiotherapy program, a combination of the two, and placebo in the treatment of adhesive capsulitis of the shoulder.

METHODS

Ninety-three subjects with adhesive capsulitis of <1 year's duration were randomized to 1 of 4 treatment groups: group 1, corticosteroid injection (triamcinolone hexacetonide 40 mg) performed under fluoroscopic guidance followed by 12 sessions of supervised physiotherapy; group 2, corticosteroid injection alone; group 3, saline injection followed by supervised physiotherapy; or group 4, saline injection alone (placebo group). All subjects were taught a simple home exercise program. Subjects were reassessed after 6 weeks, 3 months, 6 months, and 1 year. The primary outcome measure was improvement in the Shoulder Pain and Disability Index (SPADI) score.

RESULTS

At 6 weeks, the total SPADI scores had improved significantly more in groups 1 and 2 compared with groups 3 and 4 (P = 0.0004). The total range of active and passive motion increased in all groups, with group 1 having significantly greater improvement than the other 3 groups. At 3 months, groups 1 and 2 still showed significantly greater improvement in SPADI scores than group 4. There was no difference between groups 3 and 4 at any of the followup assessments except for greater improvement in the range of shoulder flexion in group 3 at 3 months. At 12 months, all groups had improved to a similar degree with respect to all outcome measures.

CONCLUSION

A single intraarticular injection of corticosteroid administered under fluoroscopy combined with a simple home exercise program is effective in improving shoulder pain and disability in patients with adhesive capsulitis. Adding supervised physiotherapy provides faster improvement in shoulder range of motion. When used alone, supervised physiotherapy is of limited efficacy in the management of adhesive capsulitis.

Intra-articular corticosteroid injections in juvenile idiopathic arthritis

Therapeutic intervention with intra-articular steroid injections in juvenile idiopathic arthritis (JIA) has evolved from experience with adults with inflammatory joint disease, with the earliest report being published in 1951. The technique has subsequently been introduced into paediatric rheumatology practice, although much of the evidence supporting its use remains anecdotal or based on open, non-controlled studies. This review examines the body of evidence relating to many aspects of treating children with JIA with intra-articular steroids, and is approached from both a medical and a physiotherapy perspective. Where appropriate, important areas for future research are identified and discussed.

Injection therapies for soft-tissue disorders

Local injection therapies are used in the management of a variety of musculoskeletal pain syndromes and include the local infiltration of substances such as corticosteroid and/or anaesthetic, dry needling and neural blockade. Although commonly used, the rationale for their use in many conditions is arguable and evidence of efficacy is often lacking. In this chapter, a number of common injection therapies for soft-tissue-mediated pain are described. The reasoning for their use, potential mechanisms of action and unwanted effects are discussed. The literature relating to their documented effects is critically reviewed. Practical suggestions for their utilization in the management of soft-tissue conditions are given and proposals are made for future research in this important area.

An open-label study of a second course of hylan G-F 20 for the treatment of pain associated with knee osteoarthritis

OBJECTIVE

To evaluate the efficacy and tolerability of a second course of hylan G-F 20 for the treatment of osteoarthritic knee pain in patients who experienced a clinical benefit with an initial course of therapy.

RESEARCH DESIGN AND METHODS

In this prospective, open-label study, men or women (>/=40 years of age) with knee osteoarthritis (OA) received three weekly injections of hylan G-F 20. Consecutive patients who requested a second course of hylan G-F 20 therapy due to OA knee pain subsequent to pain relief with a first course of therapy were enrolled between October 26, 2000 and January 18, 2001.

MAIN OUTCOME MEASURES

Pain while walking on a flat surface (Western Ontario and McMaster's Universities Osteoarthritis Index, WOMAC, question A1), WOMAC domain C (physical functioning), full WOMAC, and patient and investigator overall visual analog scales (VAS). Efficacy variables were measured at baseline and at weeks 1, 2, 4, 8, 12 and 26. An analgesic washout was required before all efficacy evaluations.

RESULTS

Patients receiving at least one injection of hylan G-F 20 (n = 71) were predominantly Caucasian (84.5%) and female (64.8%), with a mean age of 65.5 years and mean weight of 200.1 pounds. The mean time between the first and second courses of hylan G-F 20 was 19.6 months (median 17.6 months). With hylan G-F 20, pain while walking on a flat surface was significantly lower (p < 0.001) than baseline at all time points up to week 26 (mean +/- SEM: -1.40 +/- 0.10 at week 26). Actual scores decreased from 2.4 +/- 0.10 at baseline to 0.97 +/- 0.11 at week 26. Scores for the WOMAC domain C, full WOMAC and patient and investigator overall VAS also significantly improved (p < 0.001) at all time points. A second course of hylan G-F 20 was generally well-tolerated, based on the low incidence of local adverse events (AEs) - only one patient (1.4%) experienced a severe event, the types of AEs, and the fact that no patients discontinued the study due to these AEs. The types of related AEs observed were not qualitatively different from those listed in the current product information and published literature.

CONCLUSION

A second course of hylan G-F 20 therapy is an appropriate therapy for the treatment of OA knee pain in patients who had a previous favorable clinical response. For continued relief of osteoarthritis knee pain, this study supports repeat use of hylan G-F 20 in these patients.

The tolerability of viscosupplementation: low incidence and clinical management of local adverse events

Hylan G-F 20 (Synvisc, Genzyme Biosurgery, Ridgefield, NJ) is a visco supplement indicated for the treatment of pain due to osteoarthritis (OA) of the knee. Overall, the therapy is well tolerated with a low incidence of local and systemic adverse events (AEs). In our large clinical practice, our overall rate of local pain and swelling with treatment is consistent with that of previous reports and the product labeling. Local AEs that do occur with therapy are mostly mild to moderate in nature, transient, and resolve spontaneously or with symptomatic treatment. Local AEs thought to be related to the treatment are clinically manageable and do not result in long-term sequelae, such that their occurrence should not preclude patients from the benefit of OA pain relief with therapy, including continued pain relief with repeat treatment. Based on previous published reports of hylan G-F 20 and our extensive clinical experience, relief of OA knee pain with hylan G-F 20 far outweighs the low risk of local AEs for patients who do not respond to other therapies indicated for the treatment of OA knee pain.

Accuracy of needle placement into the intra-articular space of the knee

BACKGROUND

To achieve their potential therapeutic benefit, hyaluronic acid derivatives should be injected directly into the knee joint space and not into the anterior fat pad or the subsynovial tissues. In the absence of a knee effusion, reproducible needle placement into the intra-articular space presents a challenge to the clinician.

METHODS

The accuracy of needle placement was assessed in a prospective series of 240 consecutive injections in patients without clinical knee effusion. The injections were performed by one orthopaedic surgeon using a 2.0-in (5.1-cm) 21-gauge needle through three commonly employed knee joint portals: anteromedial, anterolateral, and lateral midpatellar. Accuracy rates for needle placement were confirmed with fluoroscopic imaging to document the dispersion pattern of injected contrast material.

RESULTS

Of eighty injections performed through an anterolateral portal, fifty-seven were confirmed to have been placed in the intra-articular space on the first attempt (an accuracy rate of 71%). Sixty of eighty injections performed through an anteromedial approach were intra-articular on the first attempt (75% accuracy rate), as were seventy-four of eighty injections performed through a lateral midpatellar portal (93% accuracy rate).

CONCLUSIONS

Using real-time fluoroscopic imaging with contrast material, we demonstrated the difficulty of accurately placing a needle into the intra-articular space of the knee when an effusion is not present. This study revealed that a lateral midpatellar injection (an injection into the patellofemoral joint) was intra-articular 93% of the time and was more accurate than injections performed by the same orthopaedic surgeon using either of the other two portals. This study highlights the need for clinicians to refine injection techniques for delivering intra-articular therapeutic substances that are intended to coat the articular surfaces of the knee joint.

Increased frequency of acute local reaction to intra-articular hylan GF-20 (synvisc) in patients receiving more than one course of treatment

BACKGROUND

Intra-articular knee injections with hylan GF-20 (Synvisc) have been shown to provide temporary relief of osteoarthritic symptoms. Several studies have suggested that repeated courses of treatment with this product may be administered without an increase in the likelihood of an adverse reaction. The present study was performed to test the hypothesis that the likelihood of a painful reaction to hylan GF-20 does not increase in patients who receive more than one course of treatment.

METHODS

The records of all patients who had received more than one course of treatment with hylan GF-20 were compared with a group of patients who had received only one course of treatment during the same fifteen-month period at a single center. The single-course group was prospectively enrolled and followed, as part of an ongoing randomized trial. The two groups were compared with respect to several demographic and clinical parameters as well as with respect to the frequency of painful acute local reactions following injections of hylan GF-20.

RESULTS

Local reactions to hylan GF-20 occurred significantly more often in patients who had received more than one course of treatment than they did in patients who had received only a single course of treatment; the reactions occurred in four (21%) of nineteen patients in the former group and in one (2%) of the forty-two patients in the latter (p = 0.029). All of the reactions were severe enough to cause the patient to seek unscheduled care. Following corticosteroid injection, the reactions abated without apparent sequelae. With the numbers available, no significant differences were detected between the multiple-course and single-course groups in terms of age, gender, body-mass index, or severity or bilaterality of the disease.

CONCLUSIONS

The present study suggests that it may be reasonable to counsel patients who have been treated with a course of hylan GF-20 and who desire an additional course that the likelihood of a painful acute local reaction to the medication appears to be increased. Additional study of the frequency of acute local reactions following repeated courses of hylan GF-20 and investigation of the mechanisms of those reactions are warranted.

The efficacy and safety of intraarticular corticosteroid therapy for coxitis in juvenile rheumatoid arthritis

OBJECTIVE

To study the efficacy and safety of intraarticular triamcinolone hexacetonide (IATH) for the treatment of coxitis in patients with juvenile rheumatoid arthritis (JRA).

METHODS

Fifty consecutive patients with JRA and coxitis were studied prospectively. Forty-eight children received IATH in 67 arthritic hips. The remaining 2 children exhibited 3 cases of femoral head necrosis (FHN) at the initial assessment and were only followed up; both were receiving long-term systemic steroids. After a minimum of 2 years, the study was concluded with a final evaluation that included magnetic resonance imaging.

RESULTS

In 39 of 67 hip joints (58%), remission of the coxitis for a period of 2 years was obtained through a single administration of IATH, while another 12 hip joints showed remission of coxitis after repeated TH injections (total remission rate 76%). We observed 2 patients with FHN following IATH. Both of these children were receiving long-term systemic steroids. During the period between onset of JRA and screening assessment for this study, the children exhibited 2.4 cases of FHN per 100 patient-years, while 1.5 cases of FHN per 100 patient-years were observed between IATH treatment and final followup. All 5 observed cases of FHN occurred among the 20 children who received long-term systemic steroids, while no necrosis occurred in the 30 children who did not receive systemic corticosteroids (P = 0.009 by Fisher's exact test).

CONCLUSION

IATH for juvenile rheumatoid coxitis was an effective treatment that did not increase the rate of FHN. Systemic steroids, however (or their covariable, severity of JRA), may increase the risk of FHN in JRA.

Synvisc perisynovitis

Synvisc (hylan G-F 20) is a high molecular weight hyaluronan which is manufactured from chicken combs. It is currently one of the options used in the treatment of severe osteoarthritis of the knee joint. Synvisc is directly injected into the diseased joint, where it provides elasticity and viscosity. Published experience suggests than Synvisc is a safe and well-tolerated material with occasional mild local reactions but no long-term adverse sequelae. This article describes a case of Synvisc-related granulomatous inflammation in the perisynovial adipose tissue. To our knowledge, this is the first histological account of tissue reaction to Synvisc.

Injections in the treatment of osteoarthritis

Injections, especially of corticosteroids but also of hyaluronan, are widely used in the treatment of osteoarthritis. The various joints - knee, hip, hand - affected by OA are accessible to these local treatments. This chapter concentrates on the evidence for efficacy of these treatments and attempts to delimit their respective indications and optimal doses. The side-effects of corticosteroid injections are reviewed, and the potential interest in post-injection rest is discussed. Finally, the potential structure-modifying effect of hyaluronan is investigated.

Guidance by ultrasound of intra-articular injections in the knee and hip joints

OBJECTIVE

To develop and assess a stable method for ascertaining the placement of intraarticular injections for osteoarthritis (OA) in the hip and knee.

METHODS

Injections into the hip or knee joint with e.g. hyaluronan or cortisone were performed under the guidance of ultrasound. For this purpose an Acuson Sequoia apparatus and a 8-15 MHz transducer were used. After perforation of the capsule with a 21 G needle, 0.5-1 ml of atmospheric air and 1 ml lidocain 1% was injected with simultaneous recording of the ultrasound signals. This procedure was undertaken before the injection of the medication through the in situ needle.

RESULTS

In the hip joint the injected air could readily ascertain the placement of the injection with a sharp echoic contrast forming on the ultrasound picture respecting the joint cavity. In the knee joint the procedure gave the best results in joints which have a small amount of fluid in either the suprapatellar bursa or in a pouch regularly observed over the lateral joint margin. However, also in some so-called 'dry' knee joints the air could be traced in the bursa by ultrasound.

CONCLUSION

By the injection of air, it is possible to test the placement of intraarticular injections in both hip and knee joints. This procedure will give a supplementary documentation of the injection as compared to a mere ultrasonographic demonstration of the position of the needle in the joint. The method is proposed as a tool for both learning purposes and quality assurance in daily therapy.

Sonographically guided procedures in rheumatology

OBJECTIVE

To provide some representative examples of sonographically guided arthrocentesis and intralesional injection therapy.

METHODS

Sonographic evaluation was performed with high-frequency linear (13 MHz) and mechanical sector (20 MHz) transducers. The images were obtained in representative patients with rheumatoid arthritis and posttraumatic subacromial bursitis.

RESULTS

Sonographically guided intralesional injection is a rapid and reliable procedure, especially in patients with arthritis, tenosynovitis, and bursitis. After target localization, needle placement can be performed under continuous sonographic monitoring. Sonographic guidance is particularly useful when fluid collections are small (less than 5 mm) and deep or when the inflammatory process is adjacent to anatomic structures that could be seriously damaged by the injection.

CONCLUSIONS

Over the last few years, the rapid technologic advancements in ultrasonography have dramatically increased the potential applications of sonographically guided procedures. The simplicity and reliability of the technique might warrant rheumatologists to undergo sonographic training.

What practical skills do rheumatologists of the future need?

In this chapter, we consider future practical skills required for rheumatologists. While difficult to predict against a background of rapid technological advance and successive changes to health-care provision world wide, a number of questions are examined. The first question is what core skills are essential in the curriculum? This has been addressed in at least one joint European effort by UEMS. Great diversity in both clinical practice and training was found across Europe; clearly, the difference across continents may prove even more significant. Second, the role of arthroscopy is considered, the evidence for its therapeutic benefit in clinical rheumatology practice being inconclusive. Issues concerning diagnostic methods including electrophysiology and ultrasound (US) are also discussed in this chapter. There is evidence to support the use of electrophysiology in routine diagnosis for specific diseases. US has become popular as technology improves. It is cheap but highly operator dependent, and the feasibility of rheumatologists using US in the clinic remains to be proved. In conclusion, health care is changing rapidly, and training must adapt, and is adapting, to meet its challenges. A number of opportunities will present to the rheumatologist of the future, but the feasibility of these in routine clinical practice remains to be seen.

Effect of triamcinolone acetonide injections on hemiplegic shoulder pain : A randomized clinical trial

Background and Purpose-Hemiplegic shoulder pain is not uncommon after stroke. Its origin is still unknown, and although many different methods of treatment are applied, none have yet been proved to be effective. We sought to study the efficacy of 3 injections of intra-articular triamcinolone acetonide on pain and arm function in stroke patients with hemiplegic shoulder pain.

METHODS

-In a multicenter, randomized, placebo-controlled clinical trial, patients with hemiplegic shoulder pain received either 3 intra-articular injections of 40 mg triamcinolone acetonide or 1 mL physiological saline solution (placebo). Primary outcomes were pain measured according to 3 visual analogue scales (score range, 0 to 10), and arm function was measured by means of the Action Research Arm test and the Fugl-Meyer assessment scale; secondary outcomes were passive external rotation of the shoulder and general functioning measured according to Barthel Index and the Rehabilitation Activities Profile.

RESULTS

-In the triamcinolone group (n=18), the median decrease in pain, 3 weeks after the last injection, was 2.3 (interquartile range, 0.3 to 4.3) versus 0.2 (interquartile range, -0.5 to 2.2) in the placebo group. This result was not statistically significant. The change in the other outcome measures did not differ significantly between the 2 treatment groups. Twenty-five patients reported side effects.

CONCLUSIONS

-In the 37 participants included in this study, triamcinolone injections seemed to decrease hemiplegic shoulder pain and to accelerate recovery, but this effect was not statistically significant. Therefore, on the basis of the results of this study, these injections cannot be recommended for the treatment of patients with hemiplegic shoulder pain.

Intra-articular hyaluronan therapy

The hyaluronan in normal synovial fluid plays an important role in joint homeostasis. It contributes to joint lubrication, buffers load transmission across articular surfaces, provides a renewed source of hyaluronan to joint tissues, and imparts antinociceptive and anti-inflammatory properties to synovial fluid. In osteoarthritis, the molecular weight and concentration of hyaluronan in synovial fluid are diminished. This has led to the proposition that removal of pathologic osteoarthritic synovial fluid and replacement with hyaluronan-based products that restore the molecular weight and concentration of hyaluronan toward normal levels can have beneficial therapeutic effects. This form of treatment for osteoarthritis has been termed viscosupplementation. Within the musculoskeletal community there are diverse opinions, ranging from skepticism to acceptance, about viscosupplementation as a mainstream symptom-modifying osteoarthritis therapy. This review focuses on recent basic and clinical studies dealing with mechanism of action, symptomatic efficacy, safety, and disease modification, and places these studies in context with earlier studies.

A risk-benefit assessment of injections of hyaluronan and its derivatives in the treatment of osteoarthritis of the knee

Hyaluronan is critical for the homeostasis of the joint as an organ, in part, because it provides the rheological properties (viscosity and elasticity) of the synovial fluid. These properties depend upon both the concentration and the molecular weight of the hyaluronan in the synovial fluid. In osteoarthritis, the hyaluronan is both smaller in size and lower in concentration. Thus, it is rational and physiologically meaningful to treat osteoarthritis with viscosupplementation, i.e. injection of material designed to increase the rheological properties of the synovial fluid. It is important, though, to assess the risks and benefits of such a physiological treatment. There are various products on the market for viscosupplementation. These include hyaluronan preparations of relatively low molecular weight (Hyalgan and ARTZ), a hyaluronan preparation of intermediate molecular weight, but still lower molecular weight than that of the hyaluronan in normal healthy synovial fluid (Orthovisc), and a cross-linked hyaluronan (a hylan) of high molecular weight (Synvisc). The evidence from in vitro and in vivo models of osteoarthritis and from clinical trials to date suggests that efficacy, as would be expected by mechanistic reasoning, depends strongly upon molecular weight. The available evidence indicates that these products differ little in the incidence and severity of adverse events (about 2 to 4%, almost always local swelling, and with no adverse sequelae). All are very well tolerated in comparison to nonsteroidal anti-inflammatory drug therapy, although direct comparisons are few. The only potentially serious adverse event is joint infection, which is rare and directly dependent upon the number of injections, among other factors. No infection has been related to contamination of any of the products. In summary, treatment with low molecular weight preparations of hyaluronan seems to be effective. However, viscosupplementation with hyaluronan preparations may have slightly higher risk and less benefit than viscosupplementation with hylans, because the relatively lower molecular weight hyaluronan preparations require more injections which may incur higher costs and theoretically an increased chance of infection. Viscosupplementation with hylans is clearly effective, and the available evidence suggests that the benefits almost certainly outweigh the risks.

Importance of synovial fluid aspiration when injecting intra-articular corticosteroids

OBJECTIVE

The aim of this prospective study was to find if a complete synovial fluid aspiration before injecting intra-articular corticosteroids influences the treatment result.

METHODS

The study was performed in 147 patients with rheumatoid arthritis (RA). One hundred and ninety one knees with synovitis were randomised to arthrocentesis (n=95) or no arthrocentesis (n = 96) before 20 mg triamcinolone hexacetonide was injected. The duration of effect was followed up for a period of six months. All patients were instructed to contact the rheumatology department if signs and symptoms from the treated knee recurred. If arthritis could be confirmed by a clinical examination a relapse was noted.

RESULTS

There was a significant reduction of relapse in the arthrocentesis group (p = 0.001).

CONCLUSION

The study shows that aspiration of synovial fluid can reduce the risk for arthritis relapse when treating RA patients with intra-articular corticosteroids. It is concluded that arthrocentesis shall be included in the intra-articular corticosteroid injection procedure.

A risk-benefit assessment of intra-articular corticosteroids in rheumatic disorders

The appeal of intra-articular corticosteroid therapy has increased with the growing emphasis on early disease control in rheumatoid disease. The impact on the patient's pain and stiffness is impressive and prompt. This may encourage patient compliance with longer term therapies given to slow the course of the disease. The release of corticosteroid into the circulation also provides some generalised improvement. This can prove helpful during the management of flares of inflammatory disease. There is less evidence to support the use of intra-articular corticosteroids in other inflammatory arthritides, but experience suggests that the benefits are similar. In osteoarthritis the benefits are less certain, but intra-articular therapy may prove important in patients who cannot undergo salvage operative procedures because of intercurrent illness. The benefits of intra-articular corticosteroids may be enhanced by rest after the injection, or by the additional administration of agents such as radio-colloids, rifampicin (rifampin), or osmic acid. Most controlled trial data have been published on knee injections, but other joints can be useful targets for local therapy. The risks are mainly related to the discomfort of the procedure, localised pain post-injection and flushing, but most feared is septic arthritis which probably occurs in about 1 in 10000 injections. Careful aseptic technique is the best protection. Tissue atrophy at the injection site, abnormal uterine bleeding, hypertension and hyperglycaemia rarely cause problems. Osteonecrosis might be as much a problem with uncontrolled painful arthritis as with a joint rendered less symptomatic by corticosteroid injections. Intra-articular corticosteroids form an important part of the management of inflammatory joint disease and might be considered where an inflammatory element occurs in osteoarthritis. They may be used at any stage in the arthritic process, but should be seen as an adjunct to other forms of symptom relief. In patients needing multiple joint injections, systemic therapy should be reviewed to see if better disease control could reduce the need for invasive therapy.

Placement of intra-articular injections verified by mini air-arthrography

OBJECTIVE

To develop and assess a simple, inexpensive method for ascertaining the placement of intra-articular injections for knee osteoarthritis

METHODS

During a one year period patients with "dry" osteoarthritis of the knee who received intra-articular therapy were tested by air-arthrography. Along with triamcinolone and lignocaine (lidocaine), 5 ml of air was injected into the joint. On subsequent lateral and anterior-posterior radiographs a correct placement was verified by a sharply defined shadow of air in the suprapatellar pouch, while extra-articular air was diffusely spread in the surrounding tissue.

RESULTS

In 51 of 56 cases the injection was correctly placed. In the remaining five cases the injection was immediately repeated and positioned within the joint. No adverse events were seen that could be ascribed to the use of air during the study, although bleeding in the quadriceps was seen one week after an extra-articular injection.

CONCLUSION

With mini-air arthrography, it is possible to test the placement of intra-articular injections in knee joints. The method is proposed as a learning tool as well as providing a means of quality assurance in studies involving intra-articular injections.

Ultrasound in inflammatory disease

US may be used effectively to diagnose and treat a wide range of musculoskeletal inflammatory conditions. It is likely that its usage will increase with regards to such conditions especially in the management of rheumatology clinic patients.

Altered leucocyte trafficking and suppressed tumour necrosis factor alpha release from peripheral blood monocytes after intra-articular glucocorticoid treatment

OBJECTIVES

A generalised transient improvement may follow intra-articular administration of glucocorticoids to patients with inflammatory arthropathy. This may represent a systemic anti-inflammatory effect of glucocorticoid released from the joint, mediated through processes such as altered leucocyte trafficking or suppressed release of pro-inflammatory cytokines. Patients, who had received intra-articular injections of glucocorticoids were therefore studied for evidence of these two systemic effects.

METHODS

Patients with rheumatoid arthritis were studied. Peripheral blood leucocyte counts, tumour necrosis factor alpha (TNF alpha) release by peripheral blood monocytes, blood cortisol concentrations, and blood methylprednisolone concentration were measured for 96 hours after intra-articular injection of methylprednisolone acetate.

RESULTS

Measurable concentrations of methylprednisolone were present in blood for up to 96 hours after injection. Significant suppression of the hypothalamic-pituitary-adrenal axis persisted throughout this time. Altered monocyte and lymphocyte trafficking, as evidenced by peripheral blood monocytopenia and lymphopenia, was apparent by four hours after injection and resolved in concordance with the elimination of methylprednisolone. Granulocytosis was observed at 24 and 48 hours. Release of TNF alpha by endotoxin stimulated peripheral blood monocytes was suppressed at four hours and thereafter. Suppression was maximal at eight hours and was largely reversed by the glucocorticoid antagonist, mifepristone.

CONCLUSIONS

After intra-articular injection of methylprednisolone, blood concentrations of glucocorticoid are sufficient to suppress monocyte TNF alpha release for at least four days and to transiently alter leucocyte trafficking. These effects help to explain the transient systemic response to intra-articular glucocorticoids. Suppression of TNF alpha is principally a direct glucocorticoid effect, rather than a consequence of other methylprednisolone induced changes to blood composition.

Effectiveness of corticosteroid injections versus physiotherapy for treatment of painful stiff shoulder in primary care: randomised trial

OBJECTIVE

To compare the effectiveness of corticosteroid injections with physiotherapy for the treatment of painful stiff shoulder.

DESIGN

Randomised trial.

SETTING

40 general practices.

SUBJECTS

109 patients consulting general practitioners for shoulder pain were enrolled in the trial.

INTERVENTIONS

Patients were randomly allocated to 6 weeks of treatment either with corticosteroid injections (53) or physiotherapy (56).

MAIN OUTCOME MEASURES

Outcome assessments were carried out 3, 7, 13, 26, and 52 weeks after randomisation; some of the assessments were done by an observer blind to treatment allocation. Primary outcome measures were the success of treatment as measured by scores on scales measuring improvement in the main complaint and pain, and improvement in scores on a scale measuring shoulder disability.

RESULTS

At 7 weeks 40 (77%) out of 52 patients treated with injections were considered to be treatment successes compared with 26 (46%) out of 56 treated with physiotherapy (difference between groups 31%, 95% confidence interval 14% to 48%). The difference in improvement favoured those treated with corticosteroids in nearly all outcome measures; these differences were statistically significant. At 26 and 52 weeks differences between the groups were comparatively small. Adverse reactions were generally mild. However, among women receiving treatment with corticosteroids adverse reactions were more troublesome: facial flushing was reported by 9 women and irregular menstrual bleeding by 6, 2 of whom were postmenopausal.

CONCLUSIONS

The beneficial effects of corticosteroid injections administered by general practitioners for treatment of painful stiff shoulder are superior to those of physiotherapy. The differences between the intervention groups were mainly the result of the comparatively faster relief of symptoms that occurred in patients treated with injections. Adverse reactions were generally mild but doctors should be aware of the potential side effects of injections of triamcinolone, particularly in women.

Intra-articular therapy in osteoarthritis

Although intra-articular therapy is widely used in the treatment of osteoarthritis (OA), those controlled clinical trials which include placebo groups suggest that there is little to be gained over joint aspiration alone, or even over a simple needle prick. Glucocorticoids may however offer a small additional symptom benefit over one or two weeks. Viscosupplementation may offer a slightly longer benefit. Intra-articular radiotherapy probably confers no benefit. Serious adverse effects are rare but local effects may occur in up to 10% of patients treated with viscosupplements. Future research should always include a placebo group in clinical studies, should clarify the possible benefits of viscosupplementation and should include in vitro work to consider the biological basis for possible actions of intra-articular therapy.

Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms

OBJECTIVE

To study the effect of accuracy on the clinical outcome of local steroid injections to the shoulder.

METHODS

37 patients with shoulder symptoms of at least two months' duration received local injections of a mixture of triamcinolone and radiographic contrast material using a standardised technique. Radiographs of the joint were taken immediately afterwards. Details of the patients' symptoms (assessed by visual analogue scales) and range of movement at the joint were obtained before and two weeks after the injection. At follow up the patients were also assessed by means of a five point global rating scale of maximum and current benefit.

RESULTS

14 of the 38 procedures (37%) were judged to be accurately placed: four of the 14 attempted subacromial injections (29%) and 10 of the 24 attempted glenohumeral injections (42%). There were significant differences in relation to outcome between the accurately placed and the inaccurately placed groups.

CONCLUSIONS

Accuracy of steroid placement by injection in patients with shoulder symptoms may significantly affect the clinical outcome.

Intra-articular corticosteroids are effective in osteoarthritis but there are no clinical predictors of response

OBJECTIVES

To show whether intra-articular steroid injections are effective in osteoarthritis; to determine factors that predict response; and to determine whether injection has a beneficial effect on muscle strength.

METHODS

Double blind, placebo controlled, crossover study in 59 patients with symptomatic osteoarthritis of the knee. Outcome measure-Primary outcome measure: change in visual analogue score for pain at three weeks. Predictors of response analysed using logistic regression with a 15% decrease in pain score at three weeks defining response.

RESULTS

Intra-articular methyl prednisolone acetate produced a significant reduction in visual analogue pain score at three weeks compared to both baseline (median change -2.0 mm, interquartile range -16.25 to 4.0) and placebo (median 0.0 mm, interquartile range -9.0 to 6.25). No clinical predictors of response could be identified. Muscle strength was not significantly improved in the short term by intra-articular injection.

CONCLUSIONS

Intra-articular corticosteroids are effective for short term relief of pain in osteoarthritis but predicting responders is not possible. There may be a place for their more widespread use.

Steroid injections for shoulder disorders: a systematic review of randomized clinical trials

BACKGROUND

Patients with shoulder disorders are believed to benefit considerably from steroid injections. However, the controversy about their efficacy persists.

AIM

The study was designed to assess the efficacy of steroid injections for shoulder disorders.

METHOD

A systematic computerized literature search in Medline (Index Medicus 1/1966-10/1995) and Embase (Excerpta Medica 1/1984-10/1995) was conducted, supplemented with citation tracking of all relevant publications. Studies published before November 1995 were selected if steroid injections were randomly allocated to patients with shoulder disorders and when clinically relevant outcome measures were reported. Because the validity of study outcomes depends heavily on the strength of methodological quality, the methods were assessed systematically by two 'blinded' independent reviewers. This resulted in a method score (maximum 100 points) that was based on four categories: study population, interventions, measurement of effect, and data presentation and analysis. Confidence intervals for the differences between groups in success rates were calculated in order to summarize the efficacy of steroid injections.

RESULTS

Only three out of the 16 studies scored more than 50 points, indicating a generally poor quality of methods. Most studies reported small sample sizes. The flaws most often found were incomparability of co-interventions and poor blinding of therapist. The methods assessment was frequently hampered by incomplete information about randomization, prognostic comparability, compliance, outcome measures included, blinding of patients and blinding of outcome measurement.

CONCLUSIONS

The evidence in favour of the efficacy of steroid injections for shoulder disorders is scarce. The methods of most studies appear to be of poor quality. The few studies that appear to be credible do not provide conclusive evidence about which patients at what time in the course of shoulder disorders benefit most from steroid injections.

Current pharmacological treatment of osteoarthritis

In this overview, the currently available symptomatic treatments of osteoarthritis from the published literature are evaluated. Paracetamol attracts growing interest as a less toxic yet potent alternative to NSAIDs. These latter agents are, however, used more widely than paracetamol, although adverse reactions associated with their use are of increasing concern among both patients and physicians. New NSAIDs are still under development. While there is not much evidence of important differences between NSAIDs in overall efficacy, they do vary with regard to toxicity. The cytoprotective effect of misoprostol in at-risk patients on NSAIDs is established but the cost-effectiveness is unclear. Furthermore, percutaneous administration of NSAIDs, capsaicin, and other substances may have some merit. Opioids, such as dextropropoxyphene, are used in combination with paracetamol in patients intolerant to NSAIDs or when pain is not controlled with NSAIDs. Locally administered glucocorticoids may have a disease-modifying effect and are of symptomatic use in certain situations. The role, if any, of hyaluronan therapy remains to be established. Although this agent appears to have a good safety profile, it is expensive. Chondroprotection is an interesting field for future research, although there is no good evidence supporting its existence in clinical medicine as practised now.