The effect of local corticosteroid or ketorolac exposure on histologic and biomechanical properties of rabbit tendon and cartilage

Nonsteroidal Anti-Inflammatory Drug Injections versus Steroid Injections in the Management of Upper and Lower Extremity Orthopedic Conditions: A Systematic Review with Meta-Analysis

BACKGROUND

Although corticosteroid injections are an effective treatment for musculoskeletal pathologies, they may not be suitable for all patients. The purpose of this systematic review was to compare clinical outcomes between patients who received NSAID and corticosteroid injections for various orthopedic conditions.

METHODS

Medline, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched, and meta-analyses were performed using a random-effects model for outcomes presented in three or more studies. Other studies were qualitatively analyzed.

RESULTS

A total of 28 articles with 2113 patients were included. A meta-analysis of five studies in patients with shoulder impingement syndrome demonstrated that there was no significant difference in the pain visual analogue scale (VAS) between subacromial NSAID injections and corticosteroid injections at 1 month [weighted mean difference (WMD) -0.244; 95% CI, -1.232 to 0.745; I2, 94.5%]. For patients with knee osteoarthritis, a meta-analysis of three studies demonstrated that there was no significant difference between intraarticular NSAID injections and corticosteroid injections in pain VAS at 1 month (WMD 0.754; 95% CI, -0.413 to 1.921; I2, 90.2%) and 3 months (WMD-0.089; 95% CI, -0.345 to 0.166; I2, 0%). A review of the studies assessing pain outcomes for hip osteoarthritis, adhesive capsulitis, and plantar fasciitis showed no significant differences between the NSAID and corticosteroid groups.

CONCLUSION

NSAID injections may be safe and effective alternatives to steroid injections, especially in shoulder impingement syndrome and knee osteoarthritis.

Enthesitis in Spondyloarthritis Including Psoriatic Arthritis-To Inject or Not To Inject?: A Narrative Review

PURPOSE

Enthesitis is a key manifestation of psoriatic arthritis (PsA) and spondyloarthritis (SpA) and is considered to be the tissue where the disease initiates. Enthesitis leads to pain and substantial limitations in patients with PsA. Treatment is key in achieving remission or minimal disease activity. Whether it is safe to apply injections to entheseal tissue is unknown. This narrative review aimed to summarize the literature on the efficacy and tolerability of entheseal corticosteroid (CS) injections.

METHODS

The published literature was searched through PubMed as well as identifying relevant articles from their citations,  for articles on the anatomic location of the injection, tissue characteristics (eg, whether there is a tendon sheath), blind versus imaging-guided and entheseal versus perientheseal injections, and related studies in animals. Given that articles on SpA are limited, those on mechanical enthesopathies were also included.

FINDINGS

The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA are limited. In most articles on entheseal injection, the entheseal tissue has not actually been targeted. The decision of entheseal injection should be made on an individual basis, with consideration of the use of CS injection as the last treatment option following more conservative measures such as NSAIDs, physiotherapy, rest, and lifestyle modifications. Entheseal injection should be avoided in high-risk patients, such as those who have rupture at the enthesis. Diagnostic ultrasound is advised to ensure the presence of inflammation that can potentially benefit from corticosteroid injection, as well as the absence of rupture. In the authors' perspective, perientheseal injections should be tried before intraentheseal injections. Finally, ultrasound guidance for needle placement is strongly encouraged.

IMPLICATIONS

The literature on the efficacy and tolerability of entheseal CS injection in SpA and PsA is limited. With the lack of quality data, recommendations on entheseal corticosteroid injection remain expert opinion.

Reduction of systemic exposure and side effects by intra-articular injection of anti-inflammatory agents for osteoarthritis: what is the safer strategy?

Osteoarthritis (OA) is a chronic degenerative joint disease associated with pain, inflammation, and cartilage degradation. However, no current treatment can effectively halt the progression of the disease. Therefore, the use of NSAIDs and intra-articular corticosteroids is usually recommended as the primary treatment for OA-associated pain and inflammation. However, there is accumulating evidence that the long-term use of oral NSAIDs and intra-articular corticosteroids can lead to a myriad of negative side effects. Although numerous efforts have been made to develop intra-articular formulations for NSAIDs, the systemic exposure of intra-articular injection of NSAIDs and its potential side effects have not been explicitly investigated. To ascertain the evident and potential side effects of intra-articular injection of anti-inflammatory agents, we have summarised in this review the systemic exposure, local side effects, and systemic side effects of intra-articular injections of anti-inflammatory agents, including NSAIDs and corticosteroids. For developing a safer treatment to fulfil the unmet long-term use needs of patients, a new therapy, which combines the locally active drug and a sustained-release formulation, has been proposed in this review.

Comparison of the effect of ketorolac versus triamcinolone acetonide injections for the treatment of de Quervain's tenosynovitis: a double-blind randomized controlled trial

Background

De Quervain’s disease is tenosynovitis of the first dorsal compartment causing severely painful radial-side wrist pain and impaired function. Steroids are effective in treating this condition due to their anti-inflammatory properties. However, this drug causes problems such as hypopigmentation, and is contradicted in diabetes mellitus patients. Non-steroidal anti-inflammatory drug (NSAID) which are efficacious in shoulder pathology and not contraindicated in diabetics and can be used to avoid the local effects of steroids could be beneficial for some patients. The present study was a randomized controlled trial to examine the differences in pain scores and functional response to local injections of a corticosteroid and the NSAID ketorolac.

Methods

Sixty-four patients with radial styloid tenosynovitis were randomized using a computer-generated random number table into two groups receiving either a ketorolac injection or a triamcinolone injection. We evaluated post-injection pain intensity using a verbal numerical rating scale (VNRS), functional outcomes using the Thai Disabilities of the Arm, Shoulder and Hand (DASH) scale, and evaluated grip and pinch strengths, recorded at baseline and 6 weeks after the injection.

Results

Thirty-one participants in the ketorolac group and 29 participants in the triamcinolone group completed the study and were included in the analysis. There were no significant differences in the assessments at baseline. At the 6-week conclusion of the study, patients in the triamcinolone group had a statistically lower average pain score than in the ketorolac group (0.7 ± 2.0 vs 5.3 ± 3.2, P < 0.001), higher DASH functional score (4.4 ± 6.5 vs 34.1 ± 20.2, P < 0.001), higher right grip strength (60.8 ± 16.8 vs 49.2 ± 18.6, P < 0.015), and higher left grip strength (59.8 ± 18.1 vs 50.3 ± 18.0, P < 0.04). However, there was no difference in pinch strength.

Conclusions

Our study found that ketorolac injections resulted in inferior pain reduction, functional score and grip improvement than triamcinolone injection in patients with radial styloid tenosynovitis. Future studies are required to examine the effects of ketorolac in larger group and with longer follow-up periods to further elucidate the findings of this study.

Trial registration

The study was registered at Clinicaltrials.in.th (TCTR20200909006).

Nonsteroidal Anti-inflammatory and Corticosteroid Injections for Shoulder Impingement Syndrome: A Systematic Review and Meta-analysis

CONTEXT

To determine optimal treatment strategies for shoulder impingement syndrome (SIS).

OBJECTIVE

To compare subacromial nonsteroidal anti-inflammatory injections (SNIs) and subacromial corticosteroid injections (SCIs) on pain relief and functional improvement in individuals with SIS. Second, to perform a cost analysis of the 2 injections.

DATA SOURCES

MEDLINE, SPORTDiscus, CINAHL, Embase, Web of Science, and SCOPUS databases were searched for randomized controlled trials using several keywords.

STUDY SELECTION

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized, and 10 studies comparing changes in pain or function in humans with SIS receiving SNIs or SCIs were included. Quality and risk of bias were assessed using the Consolidated Standards of Reporting Trials (CONSORT) 2010 scale and the Cochrane Collaboration tool.

STUDY DESIGN

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

Level 1.

DATA EXTRACTION

Baseline and follow-up scores of the visual analog, Constant-Murley, and University of California Los Angeles shoulder scales were extracted to calculate effect sizes (ESs), represented as Cohen d. Metaregression and publication bias analyses were performed. Procedural and medication costs were extracted from Medicare guidelines.

RESULTS

A total of 7 high and 3 good quality studies were included, with a mean score of 21.1. Only 1 study had a high risk of bias. The meta-analyses produced pooled ESs of 0.05 (P = 0.83), 0.12 (P = 0.71), and 0.07 (P = 0.79) for each scale, respectively, with CIs crossing 0. Procedural costs were equal between groups, whereas ketorolac was the least costly medication ($0.47). There was no significant difference in side effects between the 2 injections.

CONCLUSION

SNIs are as effective as SCIs for short-term pain relief and improving function in patients with subacromial impingement syndrome. In addition, they are less expensive and cause no major difference in complications, providing a viable, cost-effective alternative for injection therapy in patients with SIS.

Do Nonsteroidal Anti-Inflammatory Drugs Have a Deleterious Effect on Cartilage Repair? A Systematic Review

OBJECTIVES

The purpose of this study was to systematically review the available evidence regarding any plausible deleterious effects of nonsteroidal anti-inflammatory drugs (NSAIDs) on chondrocytes, chondrocyte differentiation, and allograft or autograft incorporation after cartilage repair procedures.

DESIGN

Three databases (PubMed, Science Direct, and Cochrane Library) were screened for eligible studies: investigating the effects of NSAIDs on chondrocytes, chondrogenic differentiation, or allograft/autograft incorporation. This evaluation included studies of any level of evidence, written in English, reporting clinical or preclinical results, published in peer review journals and dealing with our topic. All articles evaluating the effects of NSAIDs on either osteoarthritic (OA) chondrocyte samples or OA chondrocyte models were excluded. Moreover, articles about bone healing in which allograft or autograft incorporation was not investigated were also excluded. Methodologic quality assessment was performed for in vivo animal studies according to ARRIVE guidelines, and risk of bias of each included study was identified using the ROBINS-I tool.

RESULTS

Eighteen studies were included in the review: 4 in vitro studies, 13 animal studies, and 1 human study. According to these studies NSAIDs have no detrimental effect on healthy mature chondrocytes; however, these drugs influence chondrocyte differentiation and graft incorporation and therefore may interfere with chondrogenesis and incorporation after transplantation of chondrocytes or osteochondral grafts.

CONCLUSION

The use of NSAIDs, systemic or local, after cartilage repair procedures should be avoided unless a substantial clinical benefit would otherwise be withheld from the patient. More human studies are needed to analyze the effect of NSAIDs on cartilage repair.

Local Ketorolac Injection vs Popliteal Sciatic Nerve Blockade as an Adjuvant to a Spinal Block in Hindfoot Arthrodesis

BACKGROUND

Popliteal nerve blocks reduce pain and markedly improve postoperative outcomes during foot and ankle surgery; however, several potential complications may arise from nerve block procedures. The purpose of this study was to investigate local infiltration analgesia with ketorolac as a convenient alternative for pain relief.

METHODS

A total of 80 patients scheduled for hindfoot arthrodesis were randomly allocated to one of 2 anesthetic groups: a spinal block augmented with either a popliteal nerve block (n = 40) or local ketorolac and Marcaine infiltration (n = 40). Clinical assessment included postoperative visual analog scale (VAS) pain scores at 4, 8, 12, 24, and 48 hours, total morphine consumption, time to incision (time in operating room to incision), operative time, length of hospital stay, and complications.

RESULTS

Despite similar morphine consumption between groups (P = .28), VAS scores were significantly lower at 24 hours (1.6 ± 2.2 cm vs 2.7 ± 3.0 cm, P = .01) and 48 hours (0.2 ± 0.7 cm vs 1.0 ± 1.5 cm, P < .01) after surgery using local ketorolac injection. Although time from entry into the operating room to incision was also reduced after local ketorolac injection (19.0 ± 5.3 minutes vs 31.4 ± 14.6 minutes, P < .001), the length of operative time (P = .38), hospital stay (P = .43), and number of complications (P = .24) were similar between groups.

CONCLUSION

Ketorolac local injection provided effective pain control in hindfoot arthrodesis and markedly reduced VAS pain scores up to 48 hours after surgery compared with popliteal nerve block. In addition, ketorolac local injection also reduced time in the operating room compared with popliteal nerve blockade.

LEVEL OF EVIDENCE

Level 1, randomized controlled trial.

Ketorolac plus Lidocaine vs Lidocaine for pain relief following core needle soft tissue biopsy: A CONSORT-compliant double-blind randomized controlled study

BACKGROUNDS

The main objective of this study was to compare the pain control efficacy of local administration of Lidocaine with or without the nonsteroidal anti-inflammatory drug, Ketorolac, and local conventional Lidocaine injection in core needle biopsy of the musculoskeletal tumor.

METHODS

The current study was a randomized, double-blind controlled clinical trial that included 128 patients with suspected musculoskeletal tumors. Patients were randomly assigned to either the Ketorolac plus Lidocaine (n = 64) or Lidocaine group (n = 64). The Ketorolac - Lidocaine combination syringe contained 30 mg Ketorolac and 2% Lidocaine - adrenaline dosage, and the Lidocaine syringe contained 2% Lidocaine - adrenaline dosage. The level of pain after core needle biopsy was evaluated for each patient at 1, 6, 12, 24, 48, and >48 hours by a Visual Analog Scale (VAS). The mean VAS changes over time were compared between the Ketorolac plus Lidocaine and Lidocaine groups using a linear mixed model.

RESULTS

baseline information including mean age of patients in Lidocaine group (51.5 ± 19.4 years) and in Lidocaine - Ketorolac combination group (50.1 ± 18 years), diagnosis (malignant, benign, metastatic, infection), tumor location (upper and lower extremities, back), VAS score 1-hour post-operation (mild and moderate pain) were noted. The VAS score ratings were significantly lower in Lidocaine - Ketorolac combination group when compared to the Lidocaine group during the 1 to 24 hours post-operation time period.

CONCLUSION

Patients receiving Lidocaine - Ketorolac combination dosage had significantly lower VAS scores, and these results confirm that local injection of Lidocaine - Ketorolac combination had a superior pain-controlling effect during the first 24 hours after the biopsy procedure in comparison to Lidocaine injection alone, as measured by VAS score scale.

Local and Intra-articular Administration of Nonsteroidal Anti-inflammatory Drugs for Pain Management in Orthopedic Surgery

BACKGROUND

Although growing evidence demonstrates the benefits of locally administered nonsteroidal anti-inflammatory drugs (NSAIDs) for postoperative pain management, there is ongoing debate regarding NSAID use in orthopedic surgery.

AREAS OF UNCERTAINTY

Current data largely support a local site of NSAID action and suggest that effective pain control can be achieved with delivery of NSAIDs intra-articularly (IA) and/or locally at the site of injury, where they can block peripheral production of inflammatory mediators and may desensitize nociceptors. Improvements in postoperative pain control with locally administered NSAIDs have been widely reported in the total joint arthroplasty literature and may offer benefits in patient's undergoing arthroscopic procedures and those with osteoarthritis as well. The purpose of this review is to examine the available evidence in the literature regarding the efficacy and safety profile of the use of local and IA NSAIDs in orthopedic surgery.

DATA SOURCES

Narrative literature review using keywords, expert opinion, either during or from live conference.

THERAPEUTIC ADVANCES

Local and IA administration of NSAIDs for pain management in orthopedic surgery.

CONCLUSION

There is convincing evidence that NSAIDs administered locally in and around the joint reduce postoperative pain scores and opioid consumption in patients undergoing total joint arthroplasty, yet further research is required regarding the risks of potential chondrotoxicity and the inhibition of bone and soft-tissue healing with locally administered NSAIDs.

Effect of Intra-articular Ketorolac Versus Corticosteroid Injection for Knee Osteoarthritis: A Retrospective Comparative Study

BACKGROUND

Intra-articular corticosteroid injections have been widely used and are considered a mainstay in the nonoperative treatment of symptomatic knee osteoarthritis (OA). However, their increased use can have negative implications, including chondral toxicity and a high risk of infections. As a result, nonsteroidal anti-inflammatory drugs have been considered as an alternative.

PURPOSE

To determine the pain relief and safety of ketorolac versus a corticosteroid to supplement an intra-articular sodium hyaluronate injection for the treatment of symptomatic knee OA.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 84 patients with unilateral symptomatic knee OA receiving 5 weekly injections were enrolled in this retrospective study. Group A (n = 42) received 3 weekly intra-articular corticosteroid injections (0.5% lidocaine, 25 mg of triamcinolone acetonide, and 25 mg of sodium hyaluronate, followed by 2 weekly injections of 0.5% lidocaine and 25 mg of sodium hyaluronate), while group B (n = 42) received 5 weekly ketorolac injections (0.5% lidocaine, 10 mg of ketorolac, and 25 mg of sodium hyaluronate). The following parameters were used to evaluate pain relief and safety: visual analog scale (VAS) for pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and side effects before the injection and at 1, 2, and 5 weeks after treatment commencement as well as 3 months after the last injection.

RESULTS

Patients from both groups had a significant improvement in VAS and WOMAC scores from the first injection to final follow-up at 3 months. In the first week, the VAS score was lower in group A (P = .041), but no significant between-group differences were found for either the VAS or the WOMAC score at the other time points. Of the 42 patients in group A, 34 (81.0%) and 25 (59.5%) achieved successful outcomes at 5 weeks after treatment commencement and 3 months after the last injection, respectively. In group B, 32 (76.2%) and 24 (57.1%) patients achieved successful outcomes at 5 weeks after treatment commencement and 3 months after the last injection, respectively. At final follow-up, no significant difference was found in the successful treatment rate between the groups (P = .825).

CONCLUSION

The current study demonstrated that intra-articular ketorolac and corticosteroid injections produce the same pain relief and functional improvement.

Nonbiologic Injections in Sports Medicine

Nonbiologic medications (local anesthetics, corticosteroids, and nonsteroidal anti-inflammatory drugs) are commonly administered to athletes for analgesia after injury. However, the risks of nonbiologic injections often are overlooked simply because of their long-term market availability. A thorough understanding of the mechanism of action, the reported benefits, and the potential risks of nonbiologic medications is crucial prior to their use, especially in the treatment of young athletes. Sports medicine physicians and surgeons must be aware of the systemic and local effects of these medications to ensure an appropriate drug choice that minimizes side effects and avoids recently reported toxicity to myocytes, tenocytes, and chondrocytes.

The effects of intra-articular injection of ibuprofen on knee joint cartilage and synovium in rats

Objective

The aim of this animal study was to investigate the short and long-term local histomorphologic effects and the utility of intra-articular application of ibuprofen.

Methods

Forty-six Wistar Albino rats were used in the study. The rats were randomized into 5 groups of 8 and a sham group of 6. The 40 rats in the study groups were anaesthetised with 60 mg/kg of ketamine, then 0.25 ml ibuprofen (25 mg) was injected to the right knee joint of each rat (ibuprofen group) and 0.25 ml 0.9% saline to the left knee joint as the control group. To the 6 rats in the sham group, only puncture was applied to both knee joints. The rats in each of the 5 study groups were sacrificed on days 1, 2, 7, 14 and 21 respectively. The histomorphologic changes were graded on a 6-point scale regarding inflammation of the synovia, cartilage tissue, and subchondral bone. Inflammation scores were compared using the Mann Whitney U-test and comparisons of the sacrifice day and drug used were evaluated with the Kruskal Wallis test. The p values below 0.05 were considered as significant.

Results

Statistically significant difference was found between the ibuprofen injected knees (10/40) and the saline injected (0/40) and sham knees (0/12) in respect of hematoma positivity (p = 0.002). Significantly higher inflammation scores were found in ibuprofen injected knees on the 1st, 2nd, 7th and 14th days compared to controls and sham (p < 0.05). Inflammation scores were similar in ibuprofen injected knees with and without hematoma (p > 0.05). Inflammation of the ibuprofen injected group was most severe on day one and the severity of inflammation reduced gradually throughout the 3 weeks.

Conclusion

Our results show that intra-articular injection of ibuprofen can cause intra-articular hematoma. It also leads to transient inflammation of the synovia that is more severe in the early period, which gradually recovers.

Ultrasound-guided intra-articular injection of hyaluronic acid and ketorolac for osteoarthritis of the carpometacarpal joint of the thumb: A retrospective comparative study

Intra-articular hyaluronic acid (HA) is widely used to treat symptomatic osteoarthritis (OA) in the carpometacarpal joint (CMCJ) of the thumb. However, although apparently effective and relatively safe, intra-articular HA injections act relatively slowly. Therefore, a nonsteroidal anti-inflammatory drug could be added for more prompt pain relief. The aim of this study was to compare the efficacy and safety of ultrasound (US)-guided intra-articular injection of HA and ketorolac with that of HA alone in patients with OA of the CMCJ of the thumb.Seventy-four patients identified by chart review to have a diagnosis of OA of the CMCJ of the thumb received either a US-guided intra-articular injection of 0.5 mL of sodium hyaluronate and 0.5 mL of ketorolac (n = 38) or 0.5 mL of sodium hyaluronate and 0.5 mL of saline (n = 36). Disabilities of the arm, shoulder, and hand (DASH) and verbal numeric scale (VNS) pain scores were recorded before and 1, 3, and 6 months after injection. Univariable analyses (using the chi-squared test) and multiple logistic regression analysis were performed to evaluate the relationship between potential predictors of the outcome (treatment allocation, patient age and sex, duration of pain, and Eaton-Littler classification) and therapeutic effects.The DASH and VNS scores were improved at 1, 3, and 6 months postinjection in both groups. The onset of pain relief was significantly more rapid (at 1 month) after the injection containing HA and ketorolac than after the injection containing HA alone. In 55.3% of cases, pain and function were improved postinjection compared with baseline and remained so for up to 6 months. The success rate was not significantly different between the assessments at 1, 3, and 6 months, and the univariable analyses did not identify any statistically significant potential predictors of the outcome. Multiple logistic regression analysis did not identify any independent predictors of a successful outcome at midterm follow-up.The onset of analgesic action was more rapid after an injection containing HA and ketorolac than after 1 containing HA alone in patients with OA of the CMCJ of the thumb. There were no serious complications.

Achilles Tendinopathy and Associated Disorders

Degenerative disorders of the Achilles tendon are common, affecting up to 18% of the adult population. A thorough evaluation including a focused history, physical examination, and diagnostic studies helps in choosing the appropriate treatment. Initial treatment is usually nonoperative, consisting of activity modification, bracing, and physical therapy. Patents who fail nonoperative management may be treated operatively with a wide range of procedures from endoscopic surgery to open debridement and tendon transfer. Understanding a patient’s expectations and educating patients about potential treatments and their outcomes enables informed collaborative decision making. This article will review the evaluation and management Achilles tendinopathy and associated disorders.

Short-term Changes After Corticosteroid Injections Into the Normal Tendons of Rabbits: A Controlled Randomized Study

BACKGROUND

Corticosteroid injections in or around tendons for the treatment of athletic injuries are a common practice among orthopaedic surgeons and are apparently efficacious in the short term, although controversies persist related to local complications.

PURPOSE

This study evaluated short-term (48 hours) biomechanical, biochemical, and histological alterations after a single injection of betamethasone into the normal tendons of rabbits.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 72 New Zealand White rabbits were randomly divided into 2 groups: the test group-in which 36 animals underwent 1 intratendinous injection of betamethasone (1.4 mg / 0.2 mL) in the right calcaneal tendon; the control group-in which the right calcaneal tendon of 36 animals was injected with saline (placebo control group) and the left calcaneal tendon was left untreated for normal standards (normal control). Forty-eight hours later, animals were euthanized and tendons were harvested. Metalloproteinase (MMP1 and MMP2) and interleukin (IL1 and IL6) expression levels, biomechanical resistance (load × elongation parameters), and histomorphometry (hematoxylin and eosin and picrosirius red stains for collagen fibers, tenocytes, and inflammatory cells) were analyzed in the tendons.

RESULTS

The test group had a significant reduction in MMP2 expression as compared with the control groups ( P = .027). Regarding the other parameters, there were no additional significant differences between the groups.

CONCLUSION

A single injection of corticosteroid into normal calcaneal tendons did not trigger acute local morphological, structural, or biomechanical injuries at 48 hours, but it did promote a significant decrease in MMP2 levels. Additional studies are needed with increased duration of follow-up, various doses, and multiple injections and in tendinopathic models.

CLINICAL RELEVANCE

Some previous studies demonstrated early structural changes in tendons after a single corticosteroid injection, which was not corroborated by the present study. Metalloproteinase decrease is usually associated with a reduction in collagen degradation, which would be protective for the healing process. More studies are necessary to confirm the possible beneficial effect of these results in the long term and for tendinopathies.

In Vitro Chondrotoxicity of Nonsteroidal Anti-inflammatory Drugs and Opioid Medications

BACKGROUND

A variety of medications are administered to the intra-articular space for the relief of joint pain. While amide-type local anesthetics have been extensively studied, there is minimal information regarding the potential chondrotoxicity of nonsteroidal anti-inflammatory drugs (NSAIDs) and opioid medications.

PURPOSE

To investigate the in vitro chondrotoxicity of single-dose equivalent concentrations of ketorolac, morphine, meperidine, and fentanyl on human chondrocytes.

STUDY DESIGN

Controlled laboratory study.

METHODS

Human cartilage was arthroscopically harvested from the intercondylar notch and expanded in vitro. Gene expression of cultured chondrocytes before treatment was performed with quantitative polymerase chain reaction for type I collagen, type II collagen, aggrecan, and SOX9. Chondrocytes were then exposed to 0.01%, 0.02%, and 0.04% morphine sulfate; 0.3% and 0.6% ketorolac tromethamine; 0.5%, 1.0%, and 1.5% meperidine hydrochloride; 0.0005% and 0.001% fentanyl citrate; and saline. A custom bioreactor was used to constantly deliver medications, with the dosage of each medication and the duration of exposure based on standard dose equivalents, medication half-lives, and differences in the surface area between the 6-well plates and the native joint surface. After treatment, a live/dead assay was used to assess chondrocyte viability and if minimal cell death was detected. A subset of samples after treatment was maintained to analyze for possible delayed cell death.

RESULTS

All tested concentrations of ketorolac and meperidine caused significantly increased cell death versus the saline control, demonstrating a dose-response relationship. The morphine and fentanyl groups did not show increased chondrotoxicity compared with the saline group, even after 2 weeks of additional culture.

CONCLUSION

In vitro exposure of chondrocytes to single-dose equivalent concentrations of either ketorolac or meperidine demonstrated significant chondrotoxicity, while exposure to morphine or fentanyl did not lead to increased cell death.

Systemic corticosteroids improve tendon healing when given after the early inflammatory phase

Inflammation initiates tendon healing and then normally resolves more or less completely. Unresolved inflammation might disturb the remodeling process. We hypothesized that suppression of inflammation during the early remodeling phase by systemic dexamethasone treatment can improve healing. 36 rats underwent Achilles tendon transection and were randomized to dexamethasone or saline on days 0-4 after surgery (early inflammatory phase), and euthanasia day 7. Another 54 rats received injections days 5-9 (early remodeling phase) and were euthanized day 12 for mechanical, histological and flow cytometric evaluation. Dexamethasone treatment days 0-4 reduced the cross-sectional area, peak force and stiffness by day 7 to less than half (p < 0.001 for all), while material properties (peak stress and elastic modulus) were not significantly affected. In contrast, dexamethasone treatment days 5-9 increased peak force by 39% (p = 0.002) and stiffness by 58% (p < 0.001). The cross-sectional area was reduced by 42% (p < 0.001). Peak stress and elastic modulus were more than doubled (p < 0.001 for both). Semi-quantitative histology at day 12 showed that late dexamethasone treatment improved collagen alignment, and flow cytometry revealed reduced numbers of CD8a+ cytotoxic T cells in the tendon callus. These results suggest that downregulation of lingering inflammation during the early remodeling phase can improve healing.

Therapeutic use of hormones on tendinopathies: a narrative review

BACKGROUND

Hormones can modify tendon homeostasis, some of them leading to tendon damage, while others are essentials for healing. This narrative review summarizes the current knowledge on the topic, focusing on the hormones normally secreted by endocrine glands.

METHODS

A search in PubMed, Web of Knowledge and EMBASE, using the terms tendinopathy or tendon, combined with estrogens, testosterone, thyroid and parathyroid hormones, glucocorticoids and growth hormone, independently, was performed. Relevant articles focusing on the correlation between hormones and tendons, and their therapeutic use in tendinopathies, were selected.

RESULTS

Tendon abnormalities observed in subjects with hyperparathyroidism, hypercortisolism and acromegaly are described. At present, experimental studies and preliminary observations in humans suggest that parathyroid and growth hormones, locally administered, are promising therapeutic tools in specific tendon disorders. Local injections of glucocorticoids are useful in several tendinopathies, exploiting their anti-inflammatory and anti-proliferative properties, but carry the risk of further tendon degeneration and ruptures, due to the detrimental direct effect of glucocorticoids on the tendon structure.

CONCLUSION

Because tendons injuries are frequent, often with long lasting sequels, it is important to improve our understanding concerning the therapeutic potential of hormones on healing.

LEVEL OF EVIDENCE

IV.

Ultrasound guided intra-articular ketorolac versus corticosteroid injection in osteoarthritis of the hip: a retrospective comparative study

OBJECTIVE

Intra-articular steroid injection has been widely used in the management of symptomatic osteoarthritis; however, its frequent use is avoided since there is an increase in the incidence of articular infection and several mechanical side effects such as cartilage breakdown and loss of elasticity of the articular cartilage. For these reasons, nonsteroidal anti-inflammatory drugs instead of corticosteroids can be considered for intra-articular injection. On this basis, we investigated the effects and safety of ultrasound-guided intra-articular ketorolac versus corticosteroid injection for patients with osteoarthritis of the hip.

MATERIALS AND METHODS

This retrospective study included 98 patients with diagnoses of hip osteoarthritis who underwent ultrasound-guided intra-articular ketorolac or corticosteroid injection. Fifty patients who received ultrasound-guided intra-articular corticosteroid injection were administered a mixture of 0.5% lidocaine and triamcinolone. Forty-eight patients who received ultrasound-guided intra-articular ketorolac injection were administered 0.5% lidocaine and ketorolac. Outcome measurement was assessed using the Harris hip score and verbal numeric pain scale, which were evaluated before the injections and at 1, 3 and 6 months following the injection. Univariate analysis (using the x (2) test) and multiple logistic regression analysis were performed to evaluate the relationship between the possible outcome predictors (injected medications, patients' age, gender, pain duration and Kellgren-Lawrence classification) and the therapeutic effects.

RESULTS

The Harris hip score and verbal numeric pain scale were improved at 1, 3 and 6 months after the injection in both groups. No statistical differences in the Harris hip score and verbal numeric pain scale were observed between the groups. The success rate was also not significantly different among the time periods of 1, 3 and 6 months. Multiple logistic regression and univariate analysis showed that injected medications patients' age, gender, pain duration and Kellgren-Lawrence classification were not independent predictors of successful outcome at midterm follow-up.

CONCLUSION

The treatment of osteoarthritis of the hip with intra-articular ketorolac injection is as effective as that with intra-articular corticosteroid injection. Intra-articular ketorolac injection can be considered useful for patients with contraindications to using corticosteroids.

Intra-articular tibiofemoral injection of a nonsteroidal anti-inflammatory drug has no detrimental effects on joint mechanics in a rat model

Administration of intra-articular medications, including corticosteroids and analgesics, is common clinical practice for knee pathology and dysfunction. Non-steroidal anti-inflammatory drugs (NSAIDs) are another category of medication commonly prescribed for their analgesic and anti-inflammatory properties. Recent studies demonstrated the efficacy of injectable NSAIDs in the treatment of intra-articular pathology and postoperative analgesia. However, little data exist regarding the safety of intra-articular injection, despite the increase in its application. Therefore, we investigated the effects of intra-articular NSAID injection on articular cartilage, the anterior cruciate ligament (ACL), and joint function in the rat. Sixty-four Sprague-Dawley rats were divided into either saline (SAL) or ketorolac (NSAID) tibiofemoral single injection treatment groups. Animals were euthanized at 2, 7, 28, and 84 days post-injection for histological and mechanical analyses. Additionally, a subset of animals underwent longitudinal ambulatory evaluation to determine joint functional properties. We hypothesized that intra-articular ketorolac injection would result in no detrimental mechanical, histological, or functional changes. No differences were reported between the NSAID and SAL groups in any of the parameters measured at any time point, demonstrating the potential safety of intra-articular NSAID administration. Therefore, NSAID injection could be further considered for clinical application in humans.

The risks and benefits of glucocorticoid treatment for tendinopathy: a systematic review of the effects of local glucocorticoid on tendon

OBJECTIVE

Our primary objective was to summarise the known effects of locally administered glucocorticoid on tendon tissue and tendon cells.

METHODS

We conducted a systematic review of the scientific literature using the PRISMA and Cochrane guidelines of the Medline database using specific search criteria. The search yielded 50 articles, which consisted of 13 human studies, 36 animal studies and one combined human/animal study.

RESULTS

Histologically, there was a loss of collagen organisation (6 studies) and an increase in collagen necrosis (3 studies). The proliferation (8 studies) and viability (9 studies) of fibroblasts was reduced. Collagen synthesis was decreased in 17 studies. An increased inflammatory cell infiltrate was shown in 4 studies. Increased cellular toxicity was demonstrated by 3 studies. The mechanical properties of tendon were investigated by 18 studies. Descriptively, 6 of these studies showed a decrease in mechanical properties, 3 showed an increase, while the remaining 9 showed no significant change. A meta-analysis of the mechanical data revealed a significant deterioration in mechanical properties, with an overall effect size of -0.67 (95% CI = 0.01 to -1.33) (data from 9 studies).

CONCLUSIONS

Overall it is clear that the local administration of glucocorticoid has significant negative effects on tendon cells in vitro, including reduced cell viability, cell proliferation and collagen synthesis. There is increased collagen disorganisation and necrosis as shown by in vivo studies. The mechanical properties of tendon are also significantly reduced. This review supports the emerging clinical evidence that shows significant long-term harms to tendon tissue and cells associated with glucocorticoid injections.

The effect of ketorolac tromethamine, methylprednisolone, and platelet-rich plasma on human chondrocyte and tenocyte viability

PURPOSE

The purpose of this study was to evaluate the effect on cell viability of the isolated and combined use of allogeneic platelet-rich plasma (PRP) and ketorolac tromethamine on human chondrocytes and tenocytes in a highly controlled in vitro environment.

METHODS

PRP was produced from 8 subjects. Human chondrocytes (Lonza, Hopkinton, MA) and tenocytes isolated from samples of the long head of the biceps tendons were treated in culture with PRP, ketorolac tromethamine, and methylprednisolone, both alone and in combination. Control samples were treated in media containing 2% or 10% fetal bovine serum (FBS). Cells were exposed for 1 hour. Luminescence assays were obtained to examine cell viability after 24 hours and long-term effects on cell viability after 120 hours. Radioactive thymidine assay was used to measure proliferation after 120 hours.

RESULTS

For chondrocytes, cell viability (120 hours) increased significantly with the treatment of PRP alone (43,949 ± 28,104 cells; P < .001) and with the combination of ketorolac tromethamine and PRP (43,276 ± 31,208; P < .001), compared with the 2% FBS group (7,397 ± 470). Cell viability decreased significantly after exposure to methylprednisolone (1,323 ± 776; P < .001) and its combination with PRP (4,381 ± 5,116; p < .001). For tenocytes, cell viability (120 hours) was significantly higher with the treatment of PRP (61,287 ± 23,273; P < .001) and the combined treatment of ketorolac tromethamine and PRP (52,025 ± 17,307; P < .001), compared with the 2% FBS group (23,042 ± 2,973). Cell viability decreased significantly after exposure to methylprednisolone (3,934 ± 1,791; P = .001) and its combination with PRP (5,201 ± 2,834; P = .003), compared with 2% FBS.

CONCLUSIONS

Tendon and cartilage cells showed increased cell viability after an exposure to allogeneic PRP and ketorolac tromethamine. Exposure to methylprednisolone alone decreased cell viability, and addition of PRP could partially reverse this negative effect.

CLINICAL RELEVANCE

Intra-articular injections of pain-modifying or anti-inflammatory drugs are routinely given in orthopaedic practice. Among the many agents available for intra-articular injection, corticosteroids and local anesthetics are the most common in clinical practice. Potential detrimental side effects of intra-articular injections of corticosteroids and local anesthetics have prompted investigation into alternative treatment options such as combinations of PRP and ketorolac tromethamine. In vitro evaluation of their effect on cell viability might build a basis for further translational research and clinical application.

The chondrotoxicity of single-dose corticosteroids

PURPOSE

Corticosteroids are commonly injected into the joint space. However, studies have not examined the chondrotoxicity of one-time injection doses. The purpose of this study is to evaluate the effect of dexamethasone sodium phosphate (Decadron), methylprednisolone acetate (Depo-Medrol), betamethasone sodium phosphate and betamethasone acetate (Celestone Soluspan), and triamcinolone acetonide (Kenalog) on human chondrocyte viability in vitro.

METHODS

Single-injection doses of each of the corticosteroids were separately delivered to human chondrocytes for their respective average duration of action and compared to controls using a bioreactor containing a continuous infusion pump constructed to mimic joint fluid metabolism. A 14-day time-controlled trial was also performed. A live/dead reduced biohazard viability/cytotoxicity assay was used to quantify chondrocyte viability.

RESULTS

Over their average duration of action, betamethasone sodium phosphate/acetate solution and triamcinolone acetonide caused significant decreases in chondrocyte viability compared to control media (19.8 ± 2.9% vs. 5.2 ± 2.1%, P = 0.0025 and 10.2 ± 1.3% vs. 4.8 ± 0.9%, P = 0.0049, respectively). In the 14-day trial, only betamethasone sodium phosphate/acetate solution caused a significant decrease in chondrocyte viability compared to control media (21.5% vs. 4.6%, P < 0.001).

CONCLUSIONS

A single-injection dose of betamethasone sodium phosphate and betamethasone acetate solution illustrated consistent and significant chondrotoxicity using a physiologically relevant in vitro model and should be used with caution. Given the observed chondrotoxicity of triamcinolone acetonide in a single trial, there may be some evidence that this medication is chondrotoxic. However, at 14 days, betamethasone sodium phosphate and betamethasone acetate was the only condition that caused significant cell death.

Corticosteroid injections in the treatment of foot & ankle disorders: an AOFAS survey

BACKGROUND

Evidence-based guidelines for the use of injectable corticosteroids are lacking, and the true incidence of complications is unknown.

MATERIALS AND METHODS

The 2007--2008 AOFAS membership (969 members) was electronically queried to identify corticosteroid injection practices for certain clinical entities and rates of complications. One hundred ninety-seven surveys were returned. Eleven clinical diagnoses were evaluated for number of injections per year per respondent, rate of injection, plans to change injection pattern, and use of immobilization. Thirteen possible complications were analyzed for observed frequencies and total number of complications.

RESULTS

Those in practice less than 5 years showed the lowest rate of injections at 14.1 per month, which increased to 26.1 for those in practice 6 to 10 years. An overall average of 20.6 injections per month per clinician was reported. Injections for midsubstance Achilles tendinopathy was largely avoided as demonstrated by a 98% no-inject rate. Insertional Achilles tendonitis was similar, albeit lower with an 88% no-inject rate. Non-Achilles tendonitis showed a varied response for injections. Posterior tibial tendonitis was injected 26% of the time, whereas peroneal tendonitis was injected 54% of the time. Complications including skin depigmentation were observed most frequently (5.1%), followed by atrophy (4%), flare reaction (3.5%), MTPJ dislocation (2.7%), plantar fascia rupture (1.5%), and heel pad atrophy (1.4%).

CONCLUSION

Despite many case reports of complications, our survey indicates that the incidence of complications was perceived to be low and generally related to the injection site (skin depigmentation, atrophy, flare reaction).

Efficacy and safety of hylan G-F 20 for symptomatic glenohumeral osteoarthritis: a prospective, pilot study

OBJECTIVE

To determine the safety and efficacy of 2 intra-articular, fluoroscopically guided hylan G-F 20 injections for painful glenohumeral osteoarthritis.

DESIGN

This study was a prospective open-label pilot investigation with both U.S. Food and Drug Administration and institutional review board approval.

SETTING

Private, outpatient practice within a tertiary care, university medical school.

PARTICIPANTS

Thirty-six subjects with moderate to severe glenohumeral osteoarthritis, with pain (visual analog scale [VAS] 40 mm or greater) despite following a 3-month standard, nonsurgical treatment program.

INTERVENTIONS

Two injections of 2 mL hylan G-F 20, under fluoroscopic guidance confirmed by arthrography, 2 weeks apart. No new treatments were allowed during the course of the study. Analgesics were discontinued 24 hours before visits.

MAIN OUTCOME MEASUREMENTS

Data collected were radiographs; rotator cuff integrity as determined with magnetic resonance imaging; VAS for pain at rest, at night, and with activity; and shoulder-related quality of life (Western Ontario Rotator Cuff Index [WORC]). Subjects were re-evaluated after each injection and at 6 weeks, 3 months, and 6 months. Changes from baseline for VAS and WORC were recorded in Excel and analyzed using SPSS. Intent-to-treat analysis was performed. The type and severity of adverse events were recorded.

RESULTS

Mean VAS at baseline was 63 mm (SD 14.5). Clinically (>or=20% improvement) and statistically significant improvements (P < .001) in VAS pain were seen at 6 weeks, 3 months, and 6 months. Mean improvement in WORC at 6 months was 16.5 (P < .01), with most gains in "lifestyle" and "emotion" questions. Age, gender, body mass index, and rotator cuff pathology did not correlate with response. Three subjects described heightened pain for a few days after injections. Three subjects reported greater pain at 6 months and were unsatisfied. Four experienced no effect of treatment. There were no inflammatory reactions.

CONCLUSION

Two hylan G-F 20 injections improved pain and function, and should be considered as part of a multimodal shoulder osteoarthritis treatment program.