Depigmentation ? a rare side effect to intra-articular glucocorticoid treatment

Fluoroscopic-guided procedures of the lower extremity

This article reviews the literature and the authors' experiences regarding the performance of lower extremity fluoroscopically guided procedures from the hip to the toes. An overview of injections and aspirations, their indications, risks, and complications are provided, focusing on anesthetics, corticosteroids, and contrast agents. A variety of approaches to each joint and the associated pearls and pitfalls of each approach will be discussed.

Consensus statements for pharmacological management, monitoring of therapies, and comorbidity management of psoriatic arthritis in the United Arab Emirates

OBJECTIVE

Psoriatic arthritis (PsA), a chronic inflammatory disease characterized by heterogeneous clinical manifestations, substantially impacts the quality of life of affected individuals. This article aims at developing consensus recommendations for the management of PsA and associated comorbidities and screening and monitoring requirements of PsA therapies in the United Arab Emirates (UAE) population.

METHODS

An extensive review of present international and regional guidelines and publications on the pharmacological management, monitoring of therapies in the context of PsA was performed. Key findings from guidelines and literature were reviewed by a panel of experts from the UAE at several meetings to align with current clinical practices. Consensus statements were formulated based on collective agreement of the experts and members of Emirates Society for Rheumatology.

RESULTS

The consensus recommendations were developed to aid practitioners in clinical decision-making with respect to dosage recommendations for pharmacological therapies for PsA, including conventional drugs, non-biologic, and biologic therapies. Consensus recommendations for therapeutic options for the treatment of PsA domains, including peripheral arthritis, axial disease, enthesitis, dactylitis, psoriasis, and nail disease, were developed. The panel emphasized the importance of monitoring PsA therapies and arrived at a consensus on monitoring requirements for PsA therapies. The expert panel proposed recommendations for the management of common comorbidities associated with PsA.

CONCLUSION

These consensus recommendations can guide physicians and healthcare professionals in the UAE in making proper treatment decisions, as well as efficiently managing comorbidities and monitoring therapies in patients with PsA.

Acupoint injection in improving pain and joint function of knee osteoarthritis patients: A protocol for systematic review and meta-analysis

BACKGROUND

Knee osteoarthritis is a common chronic progressive disease, which seriously affects the quality of life of the middle-aged and elderly, and even leads to disability. More and more evidence shows that acupoint injection is beneficial to the clinical treatment of knee osteoarthritis, but there are differences in the efficacy of different acupoints and injection drugs, and there is no systematic review to assess this therapy at present. The purpose of this study is to systematically evaluate the efficacy and safety of acupoint injection in improving pain and joint function in patients with knee osteoathrosis.

METHODS

According to the retrieval strategy, we will search from CNKI, Wanfang, VIP, Chinese Biomedical Science, PubMed, Embase, Web of Science and the Cochrane Library for randomized controlled trials of acupoint injection in the treatment of knee osteoarthritis from the establishment of the database to February 2021. The study will be screened according to the inclusion and exclusion criteria, and the Cochrane risk bias assessment tool will be used to evaluate the quality of the study. Revman 5.4 software is used for meta-analysis.

RESULTS

This study will evaluate the efficacy of acupoint injection in the treatment of knee osteoarthritis by evaluating the total effective rate, the degree of pain relief, joint function score, adverse reactions, and so on.

CONCLUSION

This study will provide reliable evidence-based basis for the clinical application of acupoint injection in the treatment of knee osteoarthritis.

ETHICS AND DISSEMINATION

Private information from individuals will not be published. This systematic review also does not involve endangering participant rights. Ethical approval will not be required. The results may be published in a peer-reviewed journal or disseminated at relevant conferences.OSF Registration number-doi: 10.17605/OSF.IO/M5FTK.

Pearls and pitfalls of fluoroscopic-guided foot and ankle injections: what the radiologist needs to know

OBJECTIVE

This article provides a comprehensive, joint-by-joint review of fluoroscopic-guided foot and ankle injections and emphasizes pre-procedural planning, relevant anatomy, appropriate technique, troubleshooting the difficult procedure, and the importance of communicating unexpected findings with the referring clinician. The interrogation of pain generators including variant ossicles, fractures, and post-surgical/traumatic findings is also described.

CONCLUSIONS

Even the most challenging foot and ankle injections may be successfully completed with a solid anatomical understanding and thoughtful approach.

Naviculocuneiform and Second and Third Tarsometatarsal Articulations: Underappreciated Normal Anatomy and How It May Affect Fluoroscopy-Guided Injections

OBJECTIVE

Because the second and third tarsometatarsal (TMT) and naviculocuneiform joints normally communicate, the least arthritic or technically most straightforward joint was injected when a fluoroscopically guided therapeutic injection was ordered for one or both joints. We hypothesized that pain relief would be equivalent regardless of the joint injected and would result in less radiation and a lower steroid dose compared with patients who had both articulations injected.

MATERIALS AND METHODS

Seventy-eight patients were divided into four joint groups: naviculocuneiform requested and injected (n = 15), nonrequested naviculocuneiform or second and third TMT injected (n = 25), both injected (n = 23), and TMT requested and injected (n = 15). Variables recorded included patient age and sex, fluoroscopy time, steroid dose, pre- and postprocedural pain, osteoarthrosis (OA) grade, and confidence of intraarticular injection. Statistical analysis compared mean pain level change before and after injection, mean fluoroscopy time, and mean steroid dose between groups. The mean OA grade of the nonrequested joint was compared with that of the requested joint in patients whose injected and requested joints did not match (group 2).

RESULTS

Pre- and postinjection pain reduction (p = 0.630) and postinjection pain (p = 0.935) were not significantly different. Mean steroid dose (p < 0.001) and fluoroscopy time (p = 0.0001) were significantly increased for the both joint injection group. Within the nonrequested naviculocuneiform or second and third TMT injection group, there was a significant difference in OA grade between injected (least arthritic) and requested joints (p = 0.001).

CONCLUSION

When faced with challenging naviculocuneiform or second and third TMT joint injections, choosing the technically most straightforward joint may result in less radiation and steroid dose without compromising quality of care or pain reduction.

Therapeutic Review of Methylprednisolone Acetate Intra-Articular Injection in the Management of Osteoarthritis of the Knee - Part 2: Clinical and Procedural Considerations

The use of an intra-articular methylprednisolone acetate (MPA) injection has been shown to have benefits for symptoms of knee osteoarthritis (OA). However, considerations beyond drug efficacy can influence the appropriateness, clinical effectiveness and potential harm of an injection. A review of research evidence and published literature on clinical and procedural factors influencing the effectiveness and safety of a knee injection has been undertaken. Factors include dose, frequency, contraindications, precautions, drug interactions, side-effects, and procedural and patient-related considerations. An evaluation of evidence indicated that a 40 mg dose provides clinical benefit. No strong predictors of response were evident, with the exception of pain severity. Additional benefit for outcomes from higher doses, local anaesthetic, ultrasound guidance or particular anatomical approaches is yet to be demonstrated. Evidence for dose- and duration-related detrimental effects suggests judicious use and frequency. The evaluation showed that there are a number of contraindications and precautions arising from the drug pharmacology, concurrent medications, comorbidities and adverse events which need consideration and monitoring. There was limited safety evidence concerning anticoagulation. The review found that specialist guidance and limited evidence suggests that injection safety concerning warfarin may be enhanced by ensuring that the international normalized ratio level is within therapeutic range. However, the risk-benefit evaluation concerning non vitamin K antagonist oral anticoagulants remains challenging. Although there is published guidance, a lack of clinical studies, safety evidence and reversibility advocates caution. Overall, the review indicates that injection decisions and procedures need an individualized approach and supporting evidence is limited in many areas. Evaluation and discussion of benefits and risks, peri-procedural and post-injection management, and tailoring to the context and individuals' preferences are important in optimizing the benefits and safety of a knee injection.

Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma

Steroid injection is frequently used in the treatment of interdigital neuroma and has a high rate of success. We report the case of a patient who develops skin depigmentation at the injection site and linear streaks of depigmentation over the foot, the ankle and half way up to the knee after a steroid injection for interdigital neuroma. Minor disadvantages such as subcutaneous fat atrophy and depigmentation of the skin at the injection site are well known problems following steroid injection. Depigmentation of the skin with a lymphatic distribution in the foot after steroid injection for interdigital neuroma however, has not yet been reported before. This complication is a serious aesthetic problem and clinicians should be aware of this complication when treating patients with steroid injections for interdigital neuroma.

Intra-articular corticosteroid injections to manage trapeziometacarpal osteoarthritis-a systematic review

BACKGROUND

Osteoarthritis of the trapeziometacarpal joint (TMJ) is a common condition causing significant disability. The aim of this study is to ascertain whether an intra-articular corticosteroid injection leads to pain relief and increased function and what is the duration and magnitude of this effect.

METHODS

A systematic review with a critical appraisal of identified studies that met the inclusion criteria was performed. Two authors performed the literature review by independently searching the Cochrane, PubMed and Google Scholar databases.

RESULTS

A total of 118 relevant articles were found, but only nine studies met the inclusion criteria which included 4 double-blinded randomised control trials (RCTs) and 5 prospective case series. There is some evidence in the literature to support the efficacy of steroid injections into the TMJ. Most studies do suggest a good short-term benefit. However, one identifies no benefit over placebo but two studies found a benefit lasting at least 6 months.

CONCLUSIONS

This study demonstrates that there are potentially significant although short-term benefits to be gained from steroid injections into the TMJ. They can lead to pain relief and improved function, certainly in the first 1 to 3 months post-injection. Steroid injections are a low-risk procedure and are helpful in delaying or avoiding the need for surgery.

The role of viscosupplementation

The treatment of early osteoarthritis in middle-aged athletes with intra-articular (IA) viscosupplementation using hyaluronic acid (HA) has been used since the late 1980s. Administration of IA HA has demonstrated anti-inflammatory, anabolic, and analgesic effects. Treatment of acute injuries such as anterior cruciate ligament reconstruction and full thickness chondral lesions have benefited with the addition of IA HA. Use of IA HA has also been shown to delay total knee arthroplasty. Although IA HA has shown significant benefits in the middle-aged athletes, it is not a ubiquitous treatment option. Success with corticosteroid injections can be used as a clinical marker for subsequent success with HA injections.

Percutaneous steroidal treatment in relapses of chronic tendinopathies: a pilot study

Relapses are frequently observed in subjects with chronic tendinopathies. Corticosteroid injections are usually performed with positive results, but are uncomfortable for the patient and not free from side effects. The aim of this pilot study is to evaluate the short-term efficacy and tolerability of an occlusive Betamethasone Valerate medicated Plaster (BMVP). Fifteen subjects with relapses of chronic tendinopathies (clinical and ultrasound diagnosis) were enrolled, and treated according to RICE (Rest - Ice - Compression - Elevation) protocol. An BMVP plaster was also applied on the affected tendon. Clinical examination, at baseline and after 7, 14, 21 and 28 days, included pain (VAS at rest and during activities) and functional evaluation. Local side effects on the area and drop-outs were also recorded. Pain, both at rest and during activities, significantly decreased at 28 days (from 3.7 ± 2.7 to 1.1 ± 1.7 p < 0.01, and from 7.3 ± 1.7 to 3.3 ± 1.4 p < 0.0000, respectively). Moreover, the patients reported a significant improvement in the functional limitation. Five subjects dropped out of the study. No side effects were reported. The release of the steroid in pharmacologically-active concentrations over 12 - 24 hours and the good penetration of the drug in subcutaneous tissues explain the positive results. BMVP application may be considered a reliable first therapeutic approach in relapses of chronic tendinopathies.

Adverse events from diagnostic and therapeutic joint injections: a literature review

This review article classifies the various adverse reactions arising from intra-articular injections by severity, diagnostic category, and whether they are due to corticosteroid, local anesthetic or viscosupplementation injections. Life-threatening and serious adverse events from intra-articular injections are rare and range from local complications to systemic afflictions. Measures to reduce the likelihood of an adverse event occurring are outlined and patients with significant features in their clinical histories, predisposing them to adverse events, are highlighted.

Local effects of intra-articular corticosteroids

Intra-articular corticosteroid injection (IACI) is a very popular procedure. In this review, we wanted to review all that had been published about local effects of IACIs. English literature search was made through PubMed using the terms intra-articular and local effect. Effects on subjective, functional, structural, cellular, humoral, molecular, and imaging aspects were included. Also, all local adverse effects were documented. The main beneficial effect of IACI is pain relief. The duration of this effect is variable and depends on underlying disease, type of disease, amount of structural damage, type of IACI, dose of IACI, presence of joint effusion, level of inflammatory mediators, emptiness of joint effusion, availability of imaging, and others. At large, inflammatory problems had higher rate of favorable response in terms of pain and function. IACI at the knee joint in juvenile idiopathic arthritis patients resulted in remission for >6 months in >80% of the patients with a mean duration of approximately 1.2 years, while in the osteoarthritic knee there was a pain relief for 3 weeks only and in rheumatoid arthritis (RA) knee for 8 weeks. There was no joint space loss at the knee joint following multiple IACI in osteoarthritis and also no increase in cartilage or bone erosions in RA following a single IACI. IACI guide imaging is important in achieving better results in particular joints. Joint infection rate is very low. Other adverse effects included intra-articular and periarticular calcifications, cutaneous atrophy, cutaneous depigmentation, avascular necrosis, rapid destruction of the femoral head, acute synovitis, Charcot's arthropathy, tendinopathy, Nicolau's syndrome, and joint dislocation. IACI is associated with a wide range of local effects. Subjective and functional favorable response is prominent mainly in juvenile idiopathic arthritis patients. Adverse effects are either rare or insignificant.

Injectable corticosteroid and local anesthetic preparations: a review for radiologists

Corticosteroids and local anesthetics are some of the most commonly administered medications in radiology departments. These medications have marked variability in their formulations, which may increase their adverse event profile for specific procedures. In particular, certain corticosteroid preparations are associated with adverse central nervous system (CNS) sequelae. This is most likely due to distal embolization by particulate formulations. Nonparticulate steroid formulations are not associated with such events. Local anesthetics have severe CNS and cardiac adverse effects if injected intravascularly and have recently been associated with intraarticular chondrolysis if used in large doses. This review discusses these medications with particular emphasis on their established and postulated adverse effects. The administering radiologist should be aware of these potential effects and how best to reduce their occurrence.