Soft Tissue Atrophy Related to Corticosteroid Injection: Review of the Literature and Implications for Hand Surgeons

Cutaneous Atrophy Following Corticosteroid Injections for Tendonitis: Report of Two Cases

Unlabelled

Cutaneous atrophy resulting from corticosteroid injections for musculoskeletal indications is an underrecognized adverse effect among orthopedists and dermatologists. We present two cases of cutaneous atrophy following corticosteroid injections for wrist tendonitis. Patients presenting with cutaneous atrophy following orthopedic corticosteroid injections may be misdiagnosed with linear morphea, atrophoderma, or vascular disorders and receive unnecessary workups and delays in appropriate management. Dermatologists play an essential role in the evaluation of these patients.

The Mechanisms and Safety of Corticosteroid Injections in Orthopaedic Surgery

» Corticosteroid injections (CSIs), including intra-articular, perineural, and those involving tendon sheaths or bursae, offer potential relief from osteoarthritic and inflammatory musculoskeletal pain, including gout attacks, as well as tarsal tunnel syndrome, plantar fasciitis, and interdigital neuromas.» CSI for musculoskeletal pain is commonly used as a nonoperative management option for both diagnostic and therapeutic purposes, offering pain relief, typically lasting from days to months.» CSIs are often performed prior to surgery as part of the nonoperative management of many conditions, with multiple CSIs within the year of surgery increasing postoperative infection risk in some major joints.» Despite the potential benefits of CSI, there are risks, including a potential increase in the risk of surgical site infection secondary to bacterial contamination and the immunomodulating effect of corticosteroids when given in the perioperative period.» To date, a multitude of studies across orthopaedic subspecialties has reported on perioperative infection risk associated with CSIs. However, heterogeneity in study design and patient populations has made standardized recommendations challenging. It is, therefore, difficult to elucidate, with a high level of evidence, the most appropriate perioperative timeline for CSI administration for which infection risk is nonsignificant.

Refractory lipoatrophy treated with autologous whole blood injection: A case report

BACKGROUND

Intramuscular corticosteroid injection may cause adverse effects such as dermal and/or subcutaneous atrophy, alopecia, hypopigmentation, and hyperpigmentation. Although cutaneous atrophy can spontaneously resolve, several treatment options have been suggested for this condition.

CASE SUMMARY

In this paper, we report a case of corticosteroid injection induced lipoatrophy treated with autologous whole blood (AWB) injection, as the condition had been unresponsive to fractional laser therapy. A 29-year-old female patient visited the dermatology clinic complaining of skin depression on her right buttock area, which had appeared six months earlier. There had been only subtle improvement at the margins after fractional CO2 laser treatment; therefore, after obtaining informed consent from the patient, AWB treatment was initiated. One month after the first AWB injection, the size and depth of the lesion had noticeably improved, and a slight improvement was also observed in discoloration.

CONCLUSION

Close observation is the initial treatment of choice for steroid induced skin atrophy; however, for patients in need of immediate cosmetic improvement, AWB injection may be a safe and cost-effective alternative.

Histological evaluation of medial collateral ligament bursa injection, a new conservative treatment, in a rabbit model of medial meniscus horizontal tear

BACKGROUND

The ultrasound-guided medial collateral ligament bursa injection technique is safe, reproducible, and effective in treating symptomatic degenerative medial meniscal tears. However, the mechanisms of action and optimal drug combinations remain unclear. This study aimed to evaluate and compare the histological changes caused by injections of corticosteroids and hyaluronic acid into the medial collateral ligament bursa in a rabbit model of medial meniscus horizontal tears. Furthermore, we compared neovascularization and neurogenesis between different treatments.

METHODS

The medial meniscus horizontal tear rabbit model was created. Medial collateral ligament bursa injection with triamcinolone acetonide, purified sodium hyaluronate, saline, or needle alone was performed after model creation. The area of the medial collateral ligament bursa was measured. Immunostaining validation (cluster of differentiation31, smooth muscle alpha-actin, calcitonin gene-related peptide, and 4',6-diamidino-2-phenylindole) of the medial collateral ligament bursa injections was performed 2 and 4 weeks after injection.

RESULTS

The group injected with triamcinolone acetonide had a smaller area of the medial collateral ligament bursa than did the other groups. The groups injected with triamcinolone acetonide and purified sodium hyaluronate had lower neovascularization levels than did the other groups. The calcitonin gene-related peptide count was lower in the group injected with triamcinolone acetonide than in the other groups. Corticosteroid and hyaluronic acid injections into the medial collateral ligament bursa suppressed neovascularization and calcitonin gene-related peptide expression, while steroid injections caused adipose tissue and synovial tissue atrophy.

CONCLUSIONS

The present study revealed that ultrasound-guided triamcinolone or hyaluronic injections into the medial collateral ligament bursa inhibited neovascularization within it and concomitantly reduced calcitonin gene-related peptide release from neurogenesis. Hence, medial collateral ligament bursa injection should be considered a new treatment option for symptomatic horizontal meniscal tears.

New Technologies in the Treatment of Base of Thumb Osteoarthritis

Symptomatic osteoarthritis (OA) of the first carpometacarpal (CMC) joint is prevalent and debilitating, commonly affecting the elderly and postmenopausal population. This review highlights the latest advancements in the treatment of thumb CMC OA, which historically includes a range of nonsurgical and surgical options without a consensus benchmark. We will focus on innovative and emerging technologies. Nonsurgical treatments typically comprise custom braces and corticosteroid injections. In addition, this review explores advanced approaches such as 3D printed braces, which have improved patient satisfaction, and novel intra-articular injectables such as autologous fat, optimized by ultrasonography to enhance treatment precision and outcomes. Although standard surgical treatments include trapeziectomy, with or without ligament reconstruction and tendon interposition, more recent implant arthroplasty designs show promising long-term survival. Newer interventions include patient-specific instrumentation for metacarpal osteotomies, selective joint denervation, and innovative suspensionplasty devices, all marked by their increased precision and personalized care. However, it is important to note that these novel technologies are not yet established as superior to standard treatments of thumb CMC OA.

De Quervain Tendinopathy: Anatomical Prognostic Indicators of Corticosteroid Injection Success

BACKGROUND

Anatomical variations of the first extensor compartment can affect de Quervain tendinopathy outcomes. Our study aimed to identify the anatomical prognostic indicators of symptom recurrence following a corticosteroid (CS) injection and to assess the efficacy of CS injections.

METHODS

Fifty consecutive patients received a single CS injection for de Quervain tendinopathy. Ultrasound imaging was used to assess anatomical factors of the first extensor tendon compartment of the wrist. The primary outcome was recurrence after six weeks and six months and the identification of the anatomical prognostic indicators of the recurrence. The Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Visual Analogue Scale (VAS) for pain were evaluated as secondary outcomes.

RESULTS

Fifteen patients (30%) experienced symptom recurrence within six weeks. The intracompartmental septum and the number of tendon slips were associated with higher recurrence rates (adjusted odds ratio for the septum: 18.39, p = 0.045; adjusted odds ratio for each additional tendon slip: 24.68, p < 0.01). The mean DASH score improved from 74.1 ± 5 to 19.3 ± 25.3, and the mean VAS for pain from 8.5 ± 0.8 to 2 ± 2.7 (p < 0.01 for both scores). Five patients experienced minor adverse events with spontaneous improvement.

CONCLUSIONS

CS injections are a viable treatment for de Quervain tendinopathy. Anatomical variations can predict treatment success. Counseling patients based on these factors can help guide treatment decisions, including surgical options.

Predictors and Variation in Steroid Injection Use for Carpal Tunnel Syndrome from a Multicenter Quality Collaborative

BACKGROUND

Steroid injections are commonly used as first-line treatment for carpal tunnel syndrome (CTS); however, research has shown that their benefit is generally short term, and many patients go on to receive carpal tunnel release (CTR). The purpose of this study was to determine the variation in steroid injection use by hand surgeons.

METHODS

The authors analyzed data from a nine-center hand surgery quality collaborative. Data from 1586 patients (2381 hands) were included if they underwent elective CTR at one of the sites. Mixed effects logistic regression models were used to examine the association of receipt of steroid injection and association of receipt of more than one steroid injection among patient-level covariates.

RESULTS

Steroid injection use significantly varied by practice, ranging from 12% to 53% of patients. The odds of receiving a steroid injection were 1.4 times higher for women ( P < 0.01), 1.6 times higher for patients with chronic pain syndrome ( P < 0.01), 0.5 times lower for patients with moderate electromyography (EMG) classification, and 0.4 times lower for patients with severe EMG classification (both P < 0.01). Patients with high scores on the Six-Item CTS Scale ( P = 0.02) and patients with moderate ( P = 0.04) or severe EMG ( P = 0.05) classification had lower odds of receiving multiple steroid injections. Complete symptomatic improvement after steroid injection was significantly reported by patients with a high Six-Item CTS Scale score ( P = 0.03) and patients with severe EMG classification ( P = 0.02).

CONCLUSIONS

The authors found wide patient-level and practice-level variation in the use of steroid injections before CTR. These findings underscore the need for improved data and standard practice guidelines regarding which patients benefit from steroid injection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications

Corticosteroid injections can be associated with a range of potential side effects, which may be classified as local or systemic and further stratified as immediate or delayed in onset. Radiologists performing image-guided musculoskeletal injections should recognize the potential side effects of corticosteroid medication when counseling patients before injection and consider such side effects in planning individual injections. This Review summarizes the available evidence regarding the local and systemic side effects of corticosteroid injections performed for musculoskeletal indications. Local side effects include postinjection flare, skin hypopigmentation and atrophy, infection, tendon rupture, accelerated progression of osteoarthritis, and osseous injury. Systemic side effects include adrenal suppression or insufficiency, facial flushing, hypertension, hyperglycemia, and osteoporosis. Additional targeted counseling is warranted regarding side effects that are specific to certain patient populations (i.e., premenopausal women, patients with diabetes, athletes, and pediatric patients). Corticosteroid injections are contraindicated in the presence of superficial or deep infection, fracture, or a prosthetic joint. Guidelines on the frequency, duration, and maximal lifetime use of corticosteroid injections are currently lacking. Further research is needed regarding the long-term complications of continuous corticosteroid use, particularly with regard to osseous effects.

Suppurative tenosynovitis with chronic carpal tunnel syndrome due to corticosteroid injections: A case report

INTRODUCTION

Steroid hormone blocking is a common treatment for tenosynovitis. However, local steroid hormone blocking requires careful attention to the local inflammatory response, as infection can cause severe local soft tissue inflammation and damage.

PRESENTATION OF CASE

A 46-year-old female patient received local steroid hormone blocking treatment for tenosynovitis of the right thumb at another hospital 3 months earlier. Five days later, the patient gradually experienced redness, swelling, and pain in her right hand. By day 7, the symptoms worsened with increased swelling, wrist pain, and finger numbness. After the carpal tunnel incision, the patient's symptoms improved upon admission to the local hospital's emergency department. However, 2 weeks post-operation, she experienced recurring numbness, pain, discomfort, and local sinus exudation in her right hand, which worsened over 2 months, prompting the patient to seek outpatient treatment at our hospital.

DISCUSSION

An increase in local content within the wrist joint content is a major cause of carpal tunnel syndrome. Repeated stimulation of the inflamed tissues often leads to the development of granulomatous hyperplasia. Hyperplastic granulomas often produce local compression. If located in the peripheral nerve duct, it may cause nerve entrapment and lead to peripheral nerve injury. Surgery is often required to excise the hyperplastic tissue and release the entrapped nerve.

CONCLUSION

Prompt and thorough debridement is necessary for addressing local soft tissue infections caused by suppurative tenosynovitis. Failure to do so may result in recurrent local granuloma hyperplasia and the development of local compression diseases, especially in wrist median nerve compression cases.

Tips and tricks in ultrasound-guided musculoskeletal interventional procedures

Ultrasound visualization affords proceduralists versatile and accurate guidance for a variety of percutaneous, minimally invasive procedures in the musculoskeletal system including joint (intra-articular) injections or aspirations, intra-bursal injections, peritendinous, and perineural injections. A variety of percutaneous procedures are traditionally performed blindly, but may be more easily or more accurately performed with the real-time assistance of ultrasound guidance. Other procedures are only possible utilizing image-guidance, due to the required precision of the injection because of delicate local anatomy or depth of the injection; ultrasound is a safe, portable, and widespread modality that can be used to assist the proceduralist in localizing the needle tip in such cases, to ensure safe and accurate delivery of the medication, most frequently a solution of steroid and anesthetic. This review aims to provide a foundational approach to ultrasound-guided procedures in the musculoskeletal system, offering tips and tricks that can be employed in many different procedures including intra-articular, juxta-articular, and perineural injections for a multitude of clinical scenarios. Technical considerations regarding ultrasound transducer selection, sonographic technique, as well as common indications, contraindications, and complications of these procedures, are presented. Additionally, a variety of pharmacologic considerations for proceduralists contemplating ultrasound-guided injections are discussed.

The Effect of Corticosteroid Injections on Postoperative Infections in Trigger Finger Release

BACKGROUND

Corticosteroid injections have proven benefit in the treatment of symptomatic trigger finger; however, the immune system and tissue repair modulating properties of corticosteroids justify further consideration in surgical candidates. The aim of this study was to assess the relationship between corticosteroid injections and postoperative infection in trigger finger release.

METHODS

A single-center retrospective review was conducted of patients seen from 2010 to 2019 to identify those who underwent trigger finger release with subsequent antibiotic prescription for chart-documented wound infection. A demographic matched cohort of 100 patients was identified for comparison. Preoperative corticosteroid injection history including timing, frequency, and dose was collected for all patients. Patient demographics, comorbidities, and presence of postoperative infection were collected from patient medical records. Superficial infection was defined as those requiring antibiotics for resolution without return to the operating room; deep infection was defined as infections that required irrigation and debridement.

RESULTS

Of 3234 patients who underwent trigger finger release, 58 (1.8%) were identified with postoperative infections, 6 (0.2%) of which were deep infections. History of corticosteroid injection was significantly more common in patients with postoperative infection. Compared with an age-matched, gender-matched, and body mass index-matched cohort, patients with postoperative infection had significantly increased rate of diabetes mellitus at 34.5% to 19% (P = .04).

CONCLUSIONS

While corticosteroid injection in the preoperative period is associated with a higher rate of postoperative infection, the time before surgery and the corticosteroid dose do not appear to have an effect.

Autologous fat transplantation for multiple scattered steroid atrophy and hypopigmentation: A case report

INTRODUCTION AND IMPORTANCE

The common complications of triamcinolone acetonide injection are subcutaneous atrophy and hypopigmentation. Several therapies have been reported, including autologous fat grafting, saline injection, and various filler injections. However, severe cases of both subcutaneous atrophy and hypopigmentation occurring together are rare. In this case report, we present a successful autologous fat transplantation treatment to address multiple severe subcutaneous atrophy and hypopigmentation caused by triamcinolone acetonide injection.

CASE PRESENTATION

A 27-year-old woman presented with multiple hyperplastic scars and bulges after undergoing correcting liposuction sequela of thighs by autologous fat transplantation and received only one triamcinolone acetonide injection (the specifics of the drug, dosage and injection site were not known). Unfortunately， the injected areas showed severe subcutaneous atrophy and hypopigmentation, and there was no improvement observed for two years. To address this, we performed only one autologous fat transplantation procedure which significantly improved the atrophy and hypopigmentation. The patient was highly satisfied with the results.

CLINICAL DISCUSSION

Most cases of subcutaneous atrophy and hypopigmentation caused by triamcinolone acetonide injection resolve spontaneously within a year, but severe cases may require more aggressive treatments. Autologous fat transplantation has been shown to be a highly effective method for treating large areas or severe atrophy, with additional benefits such as scar softening and skin quality enhancement.

CONCLUSION

Autologous fat transplantation may be a promising approach for severe subcutaneous atrophic areas and hypopigmentation caused by triamcinolone acetonide injection. Further research is needed to confirm and expand upon our findings.

Intra-flexor retinaculum steroid injection in elderly patients with carpal tunnel syndrome: A randomized clinical trial

Introduction

The efficacy of ultrasonography-guided intra-flexor retinaculum corticosteroid injection is compared to within-carpal tunnel steroid injection, for the treatment of elderly patients with carpal tunnel syndrome (CTS).

Material & methods

In this prospective, double-blind, randomized trial, the elderly patients with CTS are allocated 1:1 into the two treatment groups. Subjects and assessors remained blinded to group allocation throughout the trial. All patients received 40 ​mg triamcinolone (1 ​mL) plus 1 ​mL of 2% lidocaine, either fenestrated in the flexor retinaculum (group 1) or injected within the carpal tunnel between the flexor retinaculum and median nerve (group 2). Patients were instructed to use a wrist splint for two weeks post-treatment. Symptom severity, grip, electrodiagnostic indices, and ultrasonographic features were measured at baseline and 6-weeks thereafter. The primary outcomes were median nerve distal motor and sensory latencies, and those secondary outcomes were Boston Carpal Tunnel Questionnaire (BCTQ) scores, visual analog scale (VAS) pain scores, and the median nerve inlet cross-sectional area (CSA).

Results

Of 92 individuals screened, 50 eligible participants were randomized, all of whom completed the study and were included in the analysis. Patients receiving the intra-flexor retinaculum injection demonstrated significantly greater improvements in their total BCTQ score (p ​= ​0.023), VAS score (p ​= ​0.026), and inlet CSA (p ​= ​0.004), while the electrodiagnostic indices and the grip scale did not differ between groups.

Conclusion

The intra-flexor retinaculum corticosteroid injection can provide better functional recovery and symptom reduction for elderly patients with CTS, compared to the within-carpal tunnel corticosteroid injection.

US for Traumatic Nerve Injury, Entrapment Neuropathy, and Imaging-guided Perineural Injection

US is commonly performed to help diagnose traumatic peripheral nerve injury and entrapment neuropathy, particularly with superficial nerves, where higher spatial resolution provides an advantage over MRI. Other advantages of US include dynamic evaluation, easy contralateral comparison, fewer implant contraindications, less artifact from ferromagnetic debris, and facile needle guidance for perineural injections. The authors review peripheral nerve US for traumatic peripheral nerve injury with an emphasis on injury grading and entrapment neuropathy and describe best-practice techniques for US-guided perineural injections while highlighting specific techniques and indications. Online supplemental material is available for this article. ^©RSNA, 2022.

Is a Steroid Injection in Both Compartments More Effective than an Injection in the Extensor Pollicis Brevis Subcompartment Alone in Patients with de Quervain Disease? A Randomized, Controlled Trial

BACKGROUND

Ultrasonography (US)-guided steroid injections can improve the accuracy of injection in patients with de Quervain disease, especially in those with an intracompartmental septum. Although the main lesion of de Quervain disease in patients with a septum is a stenosing tenosynovitis of the extensor pollicis brevis (EPB), no report we know of has compared injection into the EPB subcompartment with an injection into both the abductor pollicis longus (APL) and EPB subcompartments. In this randomized trial, we compared the results of US-guided steroid injections targeting both subcompartments and the EPB subcompartment alone in patients with de Quervain disease.

QUESTIONS/PURPOSES

(1) Do patients who receive a steroid injection in the EPB subcompartment alone have lower pain scores at 6 weeks and at 3 months after US-guided injection compared with patients who receive an injection in both subcompartments? (2) Do patients who receive a steroid injection in the EPB subcompartment alone experience fewer steroid injection-related complications than patients who receive an injection in both subcompartments?

METHODS

A randomized controlled study was performed at a single center between August 2018 and March 2021. Patients with a diagnosis of de Quervain disease and with a complete intracompartmental septum between the APL and the EPB tendons were included. In total, 112 patients had a diagnosis of de Quervain disease during the study period. Definite, complete subcompartmentalization was seen in 50 patients. Patients were randomly assigned to US-guided injections targeting both subcompartments (n = 25) or the EPB subcompartment alone (n = 25). There were no between-group differences in age, gender, affected wrist, or disease duration, and all patients had US evidence of tendinosis of the EPB, with or without tendinosis of the APL. Although 33% of patients (16 of 48) showed tendinosis of the APL, no patient showed tendinosis of the APL alone. In all patients, a dorsal-to-palmar side injection of 0.5 mL of 2% lidocaine and 0.5 mL of triamcinolone acetonide (40 mg/mL) was administered by two experienced hand surgeons. In the both-subcompartments group, US-guided injections were performed in each of the APL and EPB subcompartments. In the EPB subcompartment group, US-guided injections were administered in the EPB subcompartment only. All patients underwent the same protocol after the procedure. Four percent (n = 2, 1 in each group) of patients were excluded after randomization because their pain level was not registered. Pre- and postinjection clinical outcome assessments were completed by orthopaedic surgery residents not involved in patient management. Patients were regularly examined at baseline, 6 weeks, and 3 months to evaluate the intensity of pain. We assessed pain by the VAS score, where 0 indicated no pain and 100 the most pain. At baseline, the VAS score was 67 ± 14 in the both-subcompartment group and 67 ± 16 in the EPB subcompartment group (mean difference 0.17 [95% CI -8.45 to 8.82]; p = 0.97). Complications related to the steroid injection, including numbness, tendon rupture, and skin hypopigmentation, were also recorded at final follow-up examinations. To determine statistical power, the VAS score for pain at 6 weeks after the injection was used as the primary outcome variable. The minimum clinically important difference for the VAS score was deemed to be 20 mm, and we estimated an SD of 23. A sample size calculation indicated that a sample of 21 patients per group would provide 80% power to detect an effect of this size between the groups at the p = 0.05 level using a t-test.

RESULTS

There were no differences in the VAS scores between the both-subcompartment group and the EPB group at 6 weeks (10 ± 6 versus 10 ± 7, mean difference -0.08 [95% CI -4.08 to 3.91]; p = 0.97). The same was true at 12 weeks (12 ± 13 versus 11 ± 15, mean difference 0.38 [95% CI -7.74 to 8.49]; p = 0.09). No adverse events related to treatment (such as tendon rupture, infections, and numbness) occurred in either group. However, skin hypopigmentation occurred at the final follow-up examination in both groups. The proportion of patients experiencing skin hypopigmentation in the EPB subcompartment group was lower than in the both-subcompartment group (33% [8 of 24] versus 67% [16 of 24]; odds ratio 0.25 [95% CI 0.08 to 0.83]; p = 0.02).

CONCLUSION

Our data suggest that a US-guided steroid injection targeting the EPB subcompartment alone is as effective in terms of pain reduction as targeting both subcompartments in patients with de Quervain disease who have complete septation. Furthermore, an injection targeting the EPB subcompartment alone can reduce the dose of steroids used, perhaps thereby decreasing complications related to steroid injections. We recommend using only single-compartment injections in this context, even among patients with an intracompartmental septum.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Is there an association between lumbosacral epidural lipomatosis and lumbosacral epidural steroid injections? A comprehensive narrative literature review

Background

Exogenous systemic steroid exposure is a well-established risk factor for spinal epidural lipomatosis (SEL), however the association between lumbosacral epidural steroid injections (LESIs) and lumbosacral epidural lipomatosis (LEL) is generally regarded as poorly understood. Our objective was to investigate the rationale and the evidence implicating LESI(s) as a potential cause of LEL as well as the evidence related to use of LESI(s) as a potential pain relieving treatment option for radicular pain in the setting of LEL.

Methods

PubMed, Embase, Google Scholar, OVID were searched from inception until April 2021. Three investigators identified literature that provided original descriptive patient clinical data attributing the development/progression of LEL to LESI(s) or described the use of LESI(s) as a pain relieving modality for radicular pain in the setting of LEL.

Results

Fourteen publications were included for review. Overall, the current level of evidence is of low-quality. There are significant methodological gaps on this subject matter and many studies do not account for confounding variables independently associated with LEL.

Conclusions

This review has identified substantial limitations in the literature regarding that which is truly known regarding LESI(s) and LEL, as well as conservative management overall. To provide a well-rounded perspective, we synthesized literature as it pertains to: 1) current knowledge regarding SEL, notable associations and potential implications for corticosteroid exposure; 2) corticosteroid exposure and lipoatrophy; 3) current management recommendations for SEL and 4) areas for future focus. Although LESI(s) have been associated with LEL in the literature, presently due to a lack of rigorous, high-quality studies, the presence or absence of an independent causal relationship between LESI(s) and LEL cannot be stated with confidence.

Delineating injectable triamcinolone-induced cutaneous atrophy and therapeutic options in 24 patients—A retrospective study

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The effectiveness of dextrose prolotherapy in plantar fasciitis: A systemic review and meta-analysis

BACKGROUND

Dextrose prolotherapy (DPT) is considered to be a type of regenerative therapy and is widely used in various musculoskeletal disorders. Plantar fasciitis is a common cause of heel pain that affects the quality of life of many people. We aimed to evaluate the effectiveness and safety of DPT for plantar fasciitis.

METHODS

PubMed, Embase, and the Cochrane Library were searched from their respective inception dates to June 2021. Only randomized controlled trials comparing DPT and other interventions for plantar fasciitis were included in this review. Standardized mean differences (SMDs) with 95% confidence intervals were calculated for comparison. The outcome measurements included visual analog score, numeric rating scale, Foot Function index, Revised Foot Function index, American Orthopedic Foot and Ankle Score, and plantar fascia thickness. Post-treatment duration was classified as short-term (1-2 months), medium-term (3 months), or long-term (6 months).

RESULTS

Six studies with 388 adult patients diagnosed with plantar fasciitis were included for the meta-analysis. In terms of pain scores improvement, DPT was superior to placebo or exercise in the short-term (SMD: -1.163, 95%CI: -2.17 to -0.156) and the medium-term (SMD: -1.394, 95%CI: -2.702 to -0.085). DPT was inferior to corticosteroid injection in the short-term (SMD: 0.781, 95%CI: 0.41 to 1.152). For functional improvement, DPT was superior to placebo or exercise in the short-term (SMD: -1.51, 95%CI: -2.96 to -0.059), but inferior to corticosteroid injection (SMD: 0.526, 95%CI: 0.161 to 0.89) and extracorporeal shock wave therapy in the short-term (SMD: 0.484, 95%CI: 0.145 to 0.822). Randomized controlled trials showed a better pain improvement in the long-term for patients treated with DPT compared to corticosteroid (P = .002) and exercise control (P < .05). No significant differences were found between patients treated with DPT and patients treated with platelet-rich plasma.

CONCLUSION

Dextrose prolotherapy was a safe and effective treatment option for plantar fasciitis that may have long-term benefits for patients. The effects were comparable to extracorporeal shock wave therapy or platelet-rich plasma injection. Further studies with standardized protocols and long-term follow-up are needed to address potential biases.

Comparison of Different Dosages and Volumes of Triamcinolone in the Treatment of Stenosing Tenosynovitis: A Prospective, Blinded, Randomized Trial

Background

Stenosing tenosynovitis is a condition due to a size mismatch between the flexor tendons and the first annular pulley. Corticosteroid injection is the mainstay treatment. The purpose of this study is to compare different dosages and volumes of triamcinolone in the treatment of primary stenosing tenosynovitis.

Methods

Patients with primary Quinnell grades 1 or 2 stenosing tenosynovitis were recruited in this prospective, blinded, randomized trial. Patients were randomized into 1 of 2 groups. Group A received 0.25 mL of triamcinolone 40 mg/mL, mixed with 0.25 mL of 1% lidocaine with epinephrine (10 mg of triamcinolone, 0.5 mL in total volume). Group B received 0.5 mL of triamcinolone 40 mg/mL, mixed with 0.5 mL of 1% lidocaine with epinephrine (20 mg of triamcinolone, 1 mL in total volume). Patients were assessed by a blinded hand therapist at 2 and 4 weeks, and by a blinded hand surgeon at 6 weeks. The primary outcome was complete symptom resolution at 6 weeks. Both per-protocol and intention-to-treat analyses were performed.

Results

One hundred ninety-one patients were recruited from 2009 to 2018. Eighty-two and 77 patients had complete data in group A and B, respectively. There was no difference in success rates in complete symptom resolution at 6 weeks between group A (59.8%) and group B (62.3%). The mean visual analogue pain scores on injection were 4.31 ± 2.11 for group A and 4.30 ± 2.09 for group B.

Conclusions

Triamcinolone 10 mg was as effective as 20 mg in the resolution of symptoms of Quinnell grade 1 or 2 stenosing tenosynovitis at 6 weeks.

Corticosteroid injection for coccydynia: a review of 241 patients

Aims

We aimed to establish the short- and long-term efficacy of corticosteroid injection for coccydynia, and to determine if betamethasone or triamcinolone has the best effect.

Methods

During 2009 to 2016, we treated 277 patients with chronic coccydynia with either one 6 mg betamethasone or one 20 mg triamcinolone cortisone injection. A susequent injection was given to 62 (26%) of the patients. All were reviewed three to four months after injection, and 241 replied to a questionnaire a mean of 36 months (12 to 88) after the last injection. No pain at the early review was considered early success. When the patient had not been subsequently operated on, and indicated on the questionnaire that they were either well or much better, it was considered a long-term success.

Results

At the three- to four-month review, 22 (9%) reported that they had no pain. The long-term success of one injection was 15% and rose to 29% after a second injection. Logistic regression tests showed that both early success (odds ratio (OR) 5.5, 95% confidence interval (CI) 2.1 to 14.4; p = 0.001) and late success (OR 3.7, 95% CI 1.7 to 8.3; p = 0.001) was greater with triamcinolone than with betamethasone. Late success was greater for patients with symptoms for less than 12 months (OR 3.0, 95% CI 1.4 to 6.7; p = 0.006). We saw no complications of the injections.

Conclusion

We conclude that the effect of corticosteroid injection for coccygodynia is moderate, possibly because we used modest doses of the drugs. Even so, they seem worthwhile as they are easily and quickly performed, and complications are rare. If the choice is between injections of betamethasone or triamcinolone, the latter should be selected.

Cite this article: Bone Joint Open 2020;1-11:709–714.

Incidence and Outcome of Uveitic Glaucoma in Eyes With Intermediate, Posterior, or Panuveitis Followed up to 10 Years After Randomization to Fluocinolone Acetonide Implant or Systemic Therapy

PURPOSE

To evaluate long-term risk and outcomes of glaucoma in eyes with intermediate, posterior, and panuveitis managed with systemic or fluocinolone acetonide (0.59 mg, "implant") therapy.

DESIGN

Prospective Follow-up of the Multicenter Uveitis Steroid Treatment (MUST) Clinical Trial Cohort.

METHODS

Patients with intermediate, posterior, or panuveitis randomized to implant or systemic therapy (corticosteroid plus immunosuppression in >90%) were followed prospectively for glaucoma incidence and outcome.

RESULTS

Among 405 uveitic at-risk eyes of 232 patients (median follow-up = 6.9 years), 40% (79/196) of eyes assigned and treated with implant and 8% (17/209) of eyes assigned and treated with systemic therapy (censoring eyes receiving an implant on implantation) developed glaucoma (hazard ratio [HR] = 5.9, 95% confidence interval [CI] 3.2, 10.8; P < .001). Adjustment for intraocular pressure (IOP) elevation during follow-up only partially mitigated the association of implant treatment with glaucoma incidence: HR = 3.1 (95% CI 1.6, 6.0); P = .001. Among 112 eyes of 83 patients developing glaucoma, the 5-year cumulative incidence following diagnosis of sustained (2 or more consecutive visits) worsening of mean deviation by ≥6 dB was 20% (95% CI 12%, 33%); 5-year cumulative incidence of sustained worsening of cup-to-disc ratio by ≥0.2 was 26% (95% CI 17%, 39%).

CONCLUSIONS

The implant has substantially higher risk of glaucoma than systemic therapy, a difference not entirely explained by posttreatment IOP elevation. Management of IOP elevation was effective in preventing worsening of glaucoma for the large majority of cases, but even under expert clinical management, some glaucoma worsened. Uveitis cases should be monitored carefully for IOP elevation and glaucoma indefinitely.

Addition of corticosteroids to local anaesthetics for chronic non-cancer pain injections: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Despite common use, the benefit of adding steroids to local anaesthetics (SLA) for chronic non-cancer pain (CNCP) injections is uncertain. We performed a systematic review and meta-analysis of English-language RCTs to assess the benefit and safety of adding steroids to local anaesthetics (LA) for CNCP.

METHODS

We searched MEDLINE, EMBASE, and CENTRAL databases from inception to May 2019. Trial selection and data extraction were performed in duplicate. Outcomes were guided by the Initiative in Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT) statement with pain improvement as the primary outcome and pooled using random effects model and reported as relative risks (RR) or mean differences (MD) with 95% confidence intervals (CIs).

RESULTS

Among 5097 abstracts, 73 trials were eligible. Although SLA increased the rate of success (42 trials, 3592 patients; RR=1.14; 95% CI, 1.03-1.25; number needed to treat [NNT], 13), the effect size decreased by nearly 50% (NNT, 22) with the removal of two intrathecal injection studies. The differences in pain scores with SLA were not clinically meaningful (54 trials, 4416 patients, MD=0.44 units; 95% CI, 0.24-0.65). No differences were observed in other outcomes or adverse events. No subgroup effects were detected based on clinical categories. Meta-regression showed no significant association with steroid dose or length of follow-up and pain relief.

CONCLUSIONS

Addition of cortico steroids to local anaesthetic has only small benefits and a potential for harm. Injection of local anaesthetic alone could be therapeutic, beyond being diagnostic. A shared decision based on patient preferences should be considered. If used, one must avoid high doses and series of steroid injections.

CLINICAL TRIAL REGISTRATION

PROSPERO #: CRD42015020614.

Prospective randomized comparison of ultrasonography-guided and blind corticosteroid injection for de Quervain's disease

BACKGROUND

Ultrasonography (US)-guided corticosteroid injection (CI) has been attempted to improve injection accuracy in de Quervain's disease (dQD), but its role in improving clinical outcomes and decreasing skin hypopigmentation or atrophy was not established well.

HYPOTHESIS

We hypothesized that the US-guided CI is superior to blind CI in symptom improvement and development of skin hypopigmentation or atrophy.

PATIENTS AND METHODS

Forty-four patients (48 wrists) with dQD received ultrasonography-guided CI (24 wrists/22 patients, group A) or blind CI (24 wrists/22 patients, group B) between December 2016 and February 2018. The visual analogue scale for pain and the Patient-rated Wrist Evaluation (PRWE) were used for evaluation. Skin hypopigmentation or atrophy was evaluated using the modified Vancouver scar scale (mVSS) RESULTS: At 4 weeks post-injection, pain and PRWE scores improved for 22 wrists in group A and 21 wrists in group B. At 3 months post-injection, 10.0% (2/20) and 26.3% (5/19) of wrists in group A and B, respectively, had symptom recurrence after initial improvement. Improvement and aggravation rates were not significantly different between the groups. The incidence of skin hypopigmentation or atrophy was 69.6% (16/23 wrists) and 70.0% (14/20 wrists) in group A, and 59.1% (13/22 wrists) and 78.9% (15/19 wrists) in group B at 4 weeks and 3 months post-injection, respectively. The mean mVSS scores at the injection site in group A and B were 2.0 (0-4.0) and 1.8 (0-5.0) at 4 weeks post-injection and 2.4 (0-7.0) and 2.9 (0-6.0) at 3 months post-injection, respectively. The incidence and severity of skin hypopigmentation or atrophy were not significantly different between the groups at both time points.

DISCUSSION

Pain and clinical outcomes significantly improved after CI in dQD. Pain, clinical outcomes, and the incidence and severity of skin hypopigmentation or atrophy were not significantly different between ultrasonography-guided and blind CI.

LEVEL OF EVIDENCE

I, Therapeutic.

Risk of Infection in Trigger Finger Release Surgery Following Corticosteroid Injection

PURPOSE

To determine the risk for infection in trigger finger release surgery after preoperative corticosteroid injection.

METHODS

We retrospectively evaluated all patients undergoing trigger finger release by 16 surgeons over a 2-year period. Data collected included demographic information, medical comorbidities, trigger finger(s) operated on, presence of a prior corticosteroid injection, date of most recent corticosteroid injection, postoperative signs of infection, and need for surgery owing to deep infection. Superficial infection was defined per Centers for Disease Control criteria. Deep infection was defined as the need for surgery related to a surgical site infection.

RESULTS

In this cohort of 2,480 fingers in 1,857 patients undergoing trigger release surgery, 53 (2.1%) developed an infection (41 superficial [1.7%] and 12 deep [0.5%]). Before surgery, 1,137 fingers had no corticosteroid injection. These patients developed 1 deep (0.1%) and 17 superficial (1.5%) infections. In contrast, 1,343 fingers had been given a corticosteroid injection before surgery. These patients developed 11 deep (0.8%) and 24 superficial (1.8%) infections. Median time from corticosteroid injection to trigger release surgery was shorter for fingers that developed a deep infection (63 days) compared with those that developed no infection (183 days). The risk for developing a deep infection in patients who were operated on within 90 days of an injection (8 infections in 395 fingers) was increased compared with patients who were operated on greater than 90 days after an injection (3 infections in 948 fingers).

CONCLUSIONS

Preoperative corticosteroid injections are associated with a small but statistically significantly increased rate of deep infection after trigger finger release surgery. The risk for postoperative deep infection seems to be time dependent and greater when injections are performed within 90 days of surgery, especially in the 31- to 90-day postinjection period.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Reflectance confocal microscopy and histological features of depigmentation after local corticosteroid injection

BACKGROUND

Clinically, depigmentation after local corticosteroid injection is not rare. But there are less articles about its reflectance confocal microscopy (RCM) and histological features. This study aimed to define the RCM features and histopathologic findings of hypopigmentation after local corticosteroid injection and to analyze the correlations between the above two methods.

METHODS

Forty cases with hypopigmentation after local corticosteroid injection were used to analyze the clinical and RCM features. Subsequently, for 20 of 40, an excision biopsy of the same imaged areas for histopathologic examination was executed.

RESULTS

Our results showed that all 40 cases had round or ellipse hypopigmented macules with obscure boundary and 26 of 40 lesions' long diameter went along limbs. The RCM features and the histological findings revealed all patients had variable degrees of epidermal thinning, flattening rete ridges, reduced melanin, and no inflammatory cell infiltration. MART-1 analysis revealed the number of melanocytes was normal but with no or less melanin by Fontana-Masson staining.

CONCLUSIONS

Depigmentation after local corticosteroid injection was a kind of disease with intact melanocytes, whose function was impaired. RCM features offer a high consistency with histopathologic findings. It thus constitutes a promising adjuvant tool for its diagnosis and for therapeutic follow-up.