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Onks C, Weaver L, Latorre J, Silvis M, Berg A, Phillips S, Loeffert J, French C, Armstrong A. The most effective corticosteroid dose in the treatment of glenohumeral osteoarthritis: Feasibility pilot and protocol for double blinded randomized controlled trial. OSTEOARTHRITIS AND CARTILAGE OPEN 2024; 6:100484. [PMID: 38800822 PMCID: PMC11126843 DOI: 10.1016/j.ocarto.2024.100484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 05/06/2024] [Indexed: 05/29/2024] Open
Abstract
Objective Osteoarthritis affects over 5.4 million people in the United States. A common treatment is to perform intra-articular corticosteroid injections. However, the ideal steroid dose is unknown. This study aimed to pilot a corticosteroid injection protocol for primary glenohumeral OA. Methods We conducted a double blinded randomized feasibility pilot study. Patients with primary osteoarthritis of the glenohumeral joint were recruited and randomized to receive 20 mg, 40 mg, or 80 mg of triamcinolone. The primary outcome was the feasibility of the protocol and change in the Shoulder Pain and Disability Index (SPADI) 6 months following injection. Results 300 patients were screened for participation with 78 meeting inclusion criteria. 19 subjects completed the study. The most common reason for not participating was concern they would receive a smaller dose than previous injections. There was a 26% dropout rate, with 2 patients undergoing a total shoulder arthroplasty. There was no clinically significant difference (p = 0.090) between the groups at 6-months for the SPADI although all treatment groups showed a reduction of SPADI from baseline at 6 months. There was one adverse event in the 20 mg group, with a patient experiencing facial flushing after the injection. Conclusion We were successful in developing a feasible protocol. In the future excluding those who have received previous injections would be helpful for a higher enrollment rate. This patient concern highlights the need to complete clinical trials to guide medical decisions surrounding corticosteroid administration. NCT03586687.
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Affiliation(s)
- Cayce Onks
- Penn State Health Department of Family Medicine, Penn State Hershey Medical Center, 500 University Drive, H154, Hershey, PA 17033-0850, United States
| | - Lynn Weaver
- University Health Services, University of Massachusetts, Amherst, United States
| | - Johan Latorre
- University of Alabama at Birmingham Department of Physical Medicine and Rehabilitation, United States
| | - Matthew Silvis
- Penn State Health Department of Family Medicine, Penn State Hershey Medical Center, 500 University Drive, H154, Hershey, PA 17033-0850, United States
| | - Arthur Berg
- Penn State College of Medicine Department of Public Health Sciences, United States
| | - Shawn Phillips
- Penn State Health Department of Family Medicine, Penn State Hershey Medical Center, 500 University Drive, H154, Hershey, PA 17033-0850, United States
| | - Jayson Loeffert
- Penn State Health Department of Family Medicine, Penn State Hershey Medical Center, 500 University Drive, H154, Hershey, PA 17033-0850, United States
| | - Cristy French
- Penn State Health Department of Radiology, United States
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Porter A, Newcomb E, DiStefano S, Poplawski J, Kim J, Axe M, Lucas Lu X. Triamcinolone acetonide has minimal effect on short- and long-term metabolic activities of cartilage. J Orthop Res 2024. [PMID: 38860529 DOI: 10.1002/jor.25913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 05/17/2024] [Accepted: 05/25/2024] [Indexed: 06/12/2024]
Abstract
Intra-articular corticosteroid injections, such as triamcinolone acetonide (TA), are commonly used by clinicians to manage joint synovial inflammation. However, due to conflicting evidence in literature, there is a fear among clinicians that the injections may be harmful to otherwise healthy cartilage in young patients. The purpose of this study was to evaluate the effects of TA on young, healthy chondrocytes. Articular cartilage samples were harvested from bovine knee joints (1-2 months old). In both healthy and inflammatory (interleukin-1β) challenged cartilage, samples were treated with TA at doses ranging from 1 nM to 200 μM. Following a short- (2 days) or long-term (10-14 days) treatment, chondrocyte viability, proliferation, and extracellular matrix (ECM) synthesis and degradation were evaluated with a click chemistry-based technique. Chondrocyte viability, proliferation, and anabolic activity were all minimally affected by short-term and long-term TA treatment. After both acute and sustained inflammatory challenges, TA reduced the catabolic activities in cartilage, reducing nascent glycosaminoglycan loss and maintaining cartilage mechanical properties. Overall, at physiologically relevant doses, TA had minimal negative impact on chondrocytes when maintained within their native ECM. Clinical significance: The findings provide new insight for current clinical practices concerning the use of TA in intra-articular injections, especially in young patients, and established a foundation for future investigations into the impact of corticosteroids on joint homeostasis.
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Affiliation(s)
- Annie Porter
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware, USA
| | - Emily Newcomb
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware, USA
| | - Steven DiStefano
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware, USA
| | - Jacob Poplawski
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware, USA
| | - Jonathan Kim
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware, USA
| | - Michael Axe
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware, USA
| | - Xin Lucas Lu
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware, USA
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Bensa A, Albanese J, Boffa A, Previtali D, Filardo G. Intra-articular corticosteroid injections provide a clinically relevant benefit compared to placebo only at short-term follow-up in patients with knee osteoarthritis: A systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2024; 32:311-322. [PMID: 38294103 DOI: 10.1002/ksa.12057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 02/01/2024]
Abstract
PURPOSE To quantify the clinical relevance of intra-articular corticosteroid effects compared to placebo for the injective treatment of knee osteoarthritis (OA). METHODS The PubMed, Cochrane Library and Web of Science databases were searched on May 3, 2023. This study was conducted in accordance with the PRISMA guidelines. The inclusion criteria were randomized controlled trials (RCTs), published in English, with no time limitation regarding publication date, comparing intra-articular corticosteroids and placebo injections for knee OA. The effects were quantified at short- (≤6 weeks), mid- (>6 weeks and ≤3 months), and long-term (≥6 months) follow-ups. The minimal clinically important difference (MCID) for the outcomes (visual analogue scale for pain - VAS: 1.4, Western Ontario and McMaster University Osteoarthritis Index - WOMAC: 9) was used to interpret the clinical improvement provided by intra-articular corticosteroid injections compared to placebo. The quality of each article was assessed using the Cochrane RoB 2 tool and the GRADE guidelines. RESULTS Among the 1030 articles retrieved, 11 RCTs (842 patients) were included. A comparison of the two groups revealed statistically significant differences in the improvement of VAS and WOMAC scores in terms of the mean difference (MD); this difference was in favour of corticosteroids at short-term (p < 0.001, MD = -1.6 and p < 0.001, MD = -9.9, respectively) and mid-term follow-ups (p = 0.001, mean MD = -1.3 and p = 0.005, MD = -4.9, respectively). No difference was observed at the long-term follow-up. The MDs between the improvements in the two groups reached the MCID values for the VAS and WOMAC only at the short-term follow-up. The RoB 2 tool and the GRADE evaluations showed the presence of risk of bias and limited quality of evidence. CONCLUSION This systematic review and meta-analysis demonstrated that intra-articular corticosteroid injections offer clinically perceivable pain relief and functional improvement higher than the placebo effect only at short-term follow-up in patients affected by knee OA, with benefits losing clinical relevance already after 6 weeks. These results, together with the low number and the limited quality of the RCTs comparing this treatment with placebo, question the indication for the use of corticosteroid injections in clinical practice for the treatment of knee OA. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Alessandro Bensa
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
| | - Jacopo Albanese
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
| | - Angelo Boffa
- Clinica Ortopedica e Traumatologica 2, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Davide Previtali
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
| | - Giuseppe Filardo
- Service of Orthopaedics and Traumatology, Department of Surgery, EOC, Lugano, Switzerland
- Applied and Translational Research (ATR) Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
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Lavigne A, Nguyen D, Chartrand-Oberoi O, Noyon B, Spiliotopoulos S, Kfoury C, Vanasse L, Chamieh R, Bouhadana H, Boudier-Revéret M, Denis I, Mares C. Incidence and Risk Factors of Systemic Adverse Effects and Complications of Ultrasound- and Fluoroscopy-Guided Glucocorticoid Injections: A Retrospective Cohort Study. Am J Phys Med Rehabil 2024; 103:31-37. [PMID: 37256660 DOI: 10.1097/phm.0000000000002300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVES The aims of the study are to assess the incidence of systemic adverse effects and complications of ultrasound-guided and fluoroscopy-guided glucocorticoid injections and to identify associated risk factors. DESIGN This retrospective cohort study compared participants who received a glucocorticoid injection at the outpatient clinic and participants who had an appointment but did not receive a glucocorticoid injection. Participants were called to verify whether they had experienced any of the predetermined systemic adverse effects and complications. Multiple binary logistic regression was used to identify systemic adverse effect and complication risk factors. RESULTS There were 1010 participants in the glucocorticoid injection group and 328 in the nonglucocorticoid injection group. There was no statistically significant difference in the occurrence of systemic infection and decompensated heart failure between the two groups. More participants in the glucocorticoid injection group developed abnormal uterine bleeding and erectile dysfunction, but the differences did not reach statistical significance. Female participants were 1.9 times more likely to develop systemic adverse effects ( P < 0.001). Younger age ( P < 0.001), diabetes ( P = 0.012), and higher glucocorticoid injection doses ( P = 0.024) were also associated with an increased risk of developing systemic adverse effects. CONCLUSIONS Identified risk factors for developing glucocorticoid injection systemic adverse effects were younger age, female sex, diabetes, tobacco use, and high glucocorticoid injection doses.
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Affiliation(s)
- Alexandre Lavigne
- From the Physical Medicine and Rehabilitation, Centre hospitalier de l'Université de Montréal, Montréal, Canada (AL, DN, MB-R, ID, CM); Faculty of Medicine, Université de Montréal, Montréal, Canada (OC-O, BN, SS, CK, LV, RC); and Faculty of Medicine, Université de Sherbrooke, Montréal, Canada (HB)
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Parker EB, Hering KA, Chiodo CP, Smith JT, Bluman EM, Martin EA. Intraarticular Injections in the Foot and Ankle: Medication Selection Patterns and Perceived Risk Of Chondrotoxicity. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114231216990. [PMID: 38145274 PMCID: PMC10748709 DOI: 10.1177/24730114231216990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2023] Open
Abstract
Background Intraarticular corticosteroid injections (ICIs) are widely used to treat foot and ankle conditions. Although laboratory studies indicate certain corticosteroids and local anesthetics used in ICIs are associated with chondrotoxic effects, and selected agents such as ropivacaine and triamcinolone may have less of these features, clinical evidence is lacking. We aimed to identify the patterns of drug selection, perceptions of injectate chondrotoxicity, and rationale for medication choice among surgeons in the American Orthopaedic Foot & Ankle Society (AOFAS). Methods An e-survey including demographics, practice patterns, and rationale was disseminated to 2011 AOFAS members. Frequencies and percentages were calculated for demographic data, anesthetic and steroid choice, rationale for injectate choice, and perception of chondrotoxicity. Bivariate analysis was used to identify practice patterns significantly associated with perceptions of injectate risk and rationale. Results In total, 387 surveys were completed. Lidocaine and triamcinolone were the most common anesthetic and corticosteroid used (51.2% and 39.3%, respectively). Less than half of respondents felt corticosteroids or local anesthetics bear risk of chondrotoxicity. Respondents agreeing that corticosteroids are chondrotoxic were more likely to use triamcinolone (P = .037). Respondents agreeing local anesthetics risk chondrotoxicity were less likely to use lidocaine (P = .023). Respondents choosing a local anesthetic based on literature were more likely to use ropivacaine (P < .001). Conclusion Corticosteroid and local anesthetic use in ICIs varied greatly. Rationale for ICI formulation was also variable, as the clinical implications are largely unknown. Those who recognized potential chondrotoxicity and who chose based on literature were more likely to choose ropivacaine and triamcinolone, as reflected in the basic science literature. Further clinical studies are needed to establish guidelines that shape foot and ankle ICI practices based on scientific evidence and reduce the variation identified by this study. Level of Evidence Level IV, cross-sectional survey study.
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Affiliation(s)
- Emily B. Parker
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Kalei A. Hering
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher P. Chiodo
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Jeremy T. Smith
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Eric M. Bluman
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth A. Martin
- Department of Orthopedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Patel RP, McGill K, Motamedi D, Morgan T. Ultrasound-guided interventions of the upper extremity joints. Skeletal Radiol 2023; 52:897-909. [PMID: 35962837 PMCID: PMC10027633 DOI: 10.1007/s00256-022-04148-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/03/2022] [Accepted: 08/04/2022] [Indexed: 02/02/2023]
Abstract
Ultrasound guidance is valuable for performing precise joint interventions. Joint interventions may be requested for therapeutic and diagnostic pain injections, joint aspiration in the setting of suspected infection, or contrast injection for arthrography. In practice, interventions of the shoulder girdle, elbow, and hand/wrist joints may be performed without any imaging guidance. However, imaging guidance results in more accurate interventions and better patient outcomes than those performed by palpation alone. When compared to other modalities used for imaging guidance, ultrasound has many potential advantages. Radiologists should be prepared to perform ultrasound-guided upper extremity joint interventions utilizing recommended techniques to optimize clinical practice and patient outcomes. KEY POINTS: 1. Ultrasound-guided injections of the glenohumeral, acromioclavicular, sternoclavicular, elbow, and hand/wrist joints have higher accuracy than injections performed without imaging guidance. 2. Ultrasound-guided aspirations of upper extremity joints have advantages to fluoroscopic-guided aspirations because of the potential to identify effusions, soft tissue abscess, or bursitis. 3. Ultrasound-guided contrast injection prior to MR arthrography is as accurate as fluoroscopic-guided injection for upper extremity joints.
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Affiliation(s)
- Rina P Patel
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA, 94143, USA.
| | - Kevin McGill
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Daria Motamedi
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA, 94143, USA
| | - Tara Morgan
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA, 94143, USA
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Assi R, Quintiens J, Monteagudo S, Lories RJ. Innovation in Targeted Intra-articular Therapies for Osteoarthritis. Drugs 2023; 83:649-663. [PMID: 37067759 DOI: 10.1007/s40265-023-01863-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/18/2023]
Abstract
Osteoarthritis is the most common chronic joint disease characterized by progressive damage to the joints, leading to pain and loss of function. There is currently no cure or disease-modifying therapy for osteoarthritis. Hence, the increasing disease prevalence linked with ageing and obesity represents a substantial socio-economic burden. Intra-articular therapy by injection of drugs into affected joints can optimize local drug bioavailability, while reducing risks of systemic toxicity, a concern in an ageing patient population. In this review, we investigate the current landscape of intra-articular drug therapies for osteoarthritis, including established approaches and those in clinical development. We performed a literature review using PubMed, complemented with a search for clinical trials using the ClinicalTrials.gov repository. Additionally, conference abstracts and presentations were identified and systematic snowballing was applied. Identified drugs were divided into several groups by main mechanism of action, and include drugs that reduce inflammation (anti-inflammatory), drugs aiming to prevent or reverse structural damage (structure modifying), drugs that aim to reduce the pain, and other drugs with a specific target. Most studies have been performed for osteoarthritis of the knee, a joint that is easily accessible for intra-articular treatments. Optimal therapy would provide symptomatic relief, while preventing further damage to the joint. The field of intra-articular drug therapies for osteoarthritis is rapidly evolving with clear challenges identified: definition of relevant outcome measures, optimization of clinical trial set-ups, and dealing with placebo responses. While many uncertainties persist, it appears that the innovation in drug development and improved clinical trial set-up may finally deliver successful therapies for this important disease.
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Affiliation(s)
- Reem Assi
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, Laboratory of Tissue Homeostasis and Disease, KU Leuven, Leuven, Belgium
| | - Jolien Quintiens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, Laboratory of Tissue Homeostasis and Disease, KU Leuven, Leuven, Belgium
- Division of Rheumatology, University Hospitals Leuven, 3000, Leuven, Belgium
| | - Silvia Monteagudo
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, Laboratory of Tissue Homeostasis and Disease, KU Leuven, Leuven, Belgium
| | - Rik J Lories
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Center, Laboratory of Tissue Homeostasis and Disease, KU Leuven, Leuven, Belgium.
- Division of Rheumatology, University Hospitals Leuven, 3000, Leuven, Belgium.
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Cushman DM, Kobayashi JK, Wheelwright JC, English J, Monson N, Teramoto M, Dunn R, Lash M, Zarate M. Prospective Evaluation of Pain Flares and Time Until Pain Relief Following Musculoskeletal Corticosteroid Injections. Sports Health 2023; 15:227-233. [PMID: 35331061 PMCID: PMC9950997 DOI: 10.1177/19417381221076470] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Corticosteroid injections are used ubiquitously within musculoskeletal medicine. One of the most common side effects is a postinjection pain flare, though little is known regarding this phenomenon. HYPOTHESIS Some risk factors are related to postinjection pain flare following an ultrasound-guided corticosteroid injection. STUDY DESIGN Prospective clinical research study. LEVEL OF EVIDENCE Level 2. METHODS Patients undergoing ultrasound-guided corticosteroid injections in an academic orthopaedic and sports medicine clinic were approached to participate. Patients completed a survey immediately following their injection and again 2 weeks later, asking them about their pain and side effects. A postinjection pain flare was defined as an increase in pain, as defined by the patient. RESULTS A total of 140 patients completed the entirety of the study, with 29 (20.7%) patients reporting a flare of pain. There was a significant effect of younger age on the development of a pain flare after the injection, estimated as 5.5% decreased odds of developing a flare per year of age (P < 0.01). Gender, injection location, body mass index (BMI), preinjection pain, and corticosteroid type had no contributing effect. When patients obtained relief following the corticosteroid injection, 60.4% had improved pain within 3 days, whereas over 93.7% obtained relief within a week. CONCLUSION Pain flares seem to affect approximately 1 in 5 patients. With increasing age, the likelihood of postinjection pain flare becomes less likely. Sex, injection location, BMI, preinjection pain, and corticosteroid type do not seem to significantly relate to an increase in pain following injection. CLINICAL RELEVANCE Corticosteroid injections are common procedures in the orthopaedic and sports medicine settings. Younger patients can be counseled on the higher likelihood of a pain flare following a corticosteroid injection.
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Affiliation(s)
- Daniel M. Cushman
- Daniel M. Cushman, MD,
University of Utah, 590 Wakara Way, Salt Lake City, UT 84108 (
)
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Cushman DM, Knox J, Kobayashi JK, Zarate M, Wheelwright JC, Monson N, English J, Teramoto M. Does Anesthetic Relief Correspond to Future Pain Relief?: A Prospective Trial Examining Future Pain Relief for Ultrasound-Guided Corticosteroid-Anesthetic Injections. Am J Phys Med Rehabil 2022; 101:1020-1025. [PMID: 35019871 PMCID: PMC10448910 DOI: 10.1097/phm.0000000000001959] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The aim of the study was to prospectively evaluate the association between immediate pain relief from injections of local anesthetic with corticosteroid and subsequent pain relief up to 3 mos. The secondary aim was to examine the time until subjective pain relief after these injections. DESIGN This was a single-center, prospective study of patients undergoing ultrasound-guided corticosteroid injections for musculoskeletal pain. Subjects completed follow-up surveys at 2 wks, 1 mo, and 3 mos postinjections. χ 2 tests and sensitivity analysis were used to examine the primary outcome, at least 50% relief from the injection. Regression modeling examined the effects of demographic and injection-related variables on outcome measures. RESULTS A total of 132 patients were enrolled (55% female, mean age 52 yrs). Response rates were 87.1% at 2 wks and 77.2% at 3 mos. The positive likelihood ratios from 50% initial pain relief ranged from 1.22 to 1.29 at the three time points, whereas the negative likelihood ratios ranged from 0.54 to 0.63. More than 75% of participants reported subjective pain relief by day 4 after injection. CONCLUSIONS The predictive value of immediate pain relief for subsequent longer-term pain relief from corticosteroid-anesthetic injections is not particularly high. Most patients will obtain pain relief within 4 days of a corticosteroid injection.
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Affiliation(s)
- Daniel M Cushman
- From the Department of Physical Medicine and Rehabilitation, University of Utah, Salt Lake City, Utah (DMC, MT); Department of Family and Preventive Medicine, University of Utah, Salt Lake City, Utah (JK); University of Utah School of Medicine, Salt Lake City, Utah (JKK, MZ, JCW); and Department of Orthopaedics, University of Utah, Salt Lake City, Utah (NM, JE)
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A Systematic Review of the Efficacy of Corticosteroid Injections of Tendon Sheaths, Excluding Stenosing Tenosynovitis of the Wrist and Hand. Am J Phys Med Rehabil 2021; 100:683-688. [PMID: 33017344 DOI: 10.1097/phm.0000000000001609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Corticosteroid injections into tendon sheaths are common in clinical practice for treatment of a variety of tendon disorders. Previous systematic reviews have been performed on injections for stenosing tenosynovitis (DeQuervain tenosynovitis and trigger finger), but little high-level evidence remains for other tendon sheath injections. This systematic review analyzes the available literature on improvements in pain and function after these injections. DESIGN This systematic review of MEDLINE and Embase databases, as well as article bibliographies, examined studies of adult tendon sheath injections, excluding DeQuervain and trigger finger injections. Studies with and without comparison groups were examined. Risk of bias assessment was additionally performed. RESULTS Abstracts from 1293 records were screened, and 187 full-text articles were reviewed. Seven articles met final inclusion criteria, of which five were prospective trials and none were compared with a placebo. The proximal biceps, peroneal, finger flexor, and posterior tibialis tendons were explicitly examined. All articles reported at least short-term improvements in pain, and some reported improvement in function. CONCLUSIONS Low-quality studies exist that suggest tendon sheath injections may provide at least short-term improvement in pain. Controlled studies are required to fully demonstrate efficacy.
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Tenti S, Cheleschi S, Mondanelli N, Giannotti S, Fioravanti A. New Trends in Injection-Based Therapy for Thumb-Base Osteoarthritis: Where Are We and where Are We Going? Front Pharmacol 2021; 12:637904. [PMID: 33927620 PMCID: PMC8079141 DOI: 10.3389/fphar.2021.637904] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 02/23/2021] [Indexed: 01/06/2023] Open
Abstract
Thumb-base osteoarthritis (TBOA) is a common condition, mostly affecting post-menopausal women, often inducing a significant impact on quality of life and hand functionality. Despite its high prevalence and disability, the therapeutic options in TBOA are still limited and few have been investigated. Among the pharmacological strategies for TBOA management, it would be worthwhile to mention the injection-based therapy. Unfortunately, its efficacy is still the subject of debate. Indeed, the 2018 update of the European League Against Rheumatism (EULAR) recommendations for the management of hand osteoarthritis (OA) stated that intra-articular (IA) injections of glucocorticoids should not generally be used, but may be considered in patients with painful interphalangeal joints, without any specific mention to the TBOA localization and to other widely used injections agents, such as hyaluronic acid (HA) and platelet-rich plasma (PRP). Even American College of Rheumatology (ACR) experts conditionally recommended against IA HA injections in patients with TBOA, while they conditionally encouraged IA glucocorticoids. However, the recommendations from international scientific societies don’t often reflect the clinical practice of physicians who routinely take care of TBOA patients; indeed, corticosteroid injections are a mainstay of therapy in OA, especially for patients with pain refractory to oral treatments and HA is considered as a safe and effective treatment. The discrepancy with the literature data is due to the great heterogeneity of the clinical trials published in this field: indeed, the studies differ for methodology and protocol design, outcome measures, treatment (different formulations of HA, steroids, PRP, and schedules) and times of follow-up. For these reasons, the current review will provide deep insight into the injection-based therapy for TBOA, with particular attention to the different employed agents, the variety of the schedule treatments, the most common injection techniques, and the obtained results in terms of efficacy and safety. In depth, we will discuss the available literature on corticosteroids and HA injections for TBOA and the emerging role of PRP and other injection agents for this condition. We will consider in our analysis not only randomized controlled trials (RCTs) but also recent pilot or retrospective studies trying to step forward to identify satisfactory management strategies for TBOA.
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Affiliation(s)
- Sara Tenti
- Department of Medicine, Surgery and Neuroscience, Rheumatology Unit, Clinic for the Diagnosis and Management of Hand Osteoarthritis, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Sara Cheleschi
- Department of Medicine, Surgery and Neuroscience, Rheumatology Unit, Clinic for the Diagnosis and Management of Hand Osteoarthritis, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Nicola Mondanelli
- Department of Medicine, Surgery and Neuroscience, Orthopedics and Traumatology Unit, University of Siena, Siena, Italy
| | - Stefano Giannotti
- Department of Medicine, Surgery and Neuroscience, Orthopedics and Traumatology Unit, University of Siena, Siena, Italy
| | - Antonella Fioravanti
- Department of Medicine, Surgery and Neuroscience, Rheumatology Unit, Clinic for the Diagnosis and Management of Hand Osteoarthritis, Azienda Ospedaliera Universitaria Senese, Siena, Italy
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Makovitch SA, Mills CA, Eng C. Update on Evidence-Based Diagnosis and Treatment of Acetabular Labral Tears. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2020. [DOI: 10.1007/s40141-020-00295-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Dassé R, De Monès Del Pujol E. First-line treatment of exudative vocal fold-lesions by in-office local corticosteroid injection: A literature review. Eur Ann Otorhinolaryngol Head Neck Dis 2020; 138:169-175. [PMID: 33191161 DOI: 10.1016/j.anorl.2020.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES There are emerging reports of the effectiveness of in-office awake vocal-fold corticosteroid injection in the treatment of exudative vocal-fold lesions. The aim of this study was to review this therapy and specify indications, practical modalities and outcomes. STUDY DESIGN Systematic review of the literature without meta-analysis. METHODS A systematic review by PubMed search for the period January 2000 to December 2018 was carried out. RESULTS Nine articles were included, for a total of 502 lesions: nodules (46.4%), polyps (31.7%), and Reinke's edema (21.9%). Submucosal injection of low-dose triamcinolone acetonide (0.1 to 0.3mL) was transoral, transcutaneous or transnasal via flexible endoscope with operating channel. Lesion volume was significantly reduced in more than 90% of cases, with significant vocal improvement in all studies. Relapse rates ranged between 4% and 31%, with time to relapse of 1 to 40 months. CONCLUSIONS First-line treatment of exudative glottic lesions by submucosal corticosteroid injection provides at least transient significant reduction in lesion volume and vocal improvement. It is consensually reserved to moderate-sized mainly exudative lesions without fibrosis. In-office injection provides an immediate therapeutic response in case of vocal impairment, enabling surgery under general anesthesia to be postponed.
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Affiliation(s)
- R Dassé
- Service ORL et chirurgie cervico-faciale, CHU de Bordeaux-Pellegrin, place Amélie Rabat-Léon, 33000 Bordeaux, France.
| | - E De Monès Del Pujol
- Service ORL et chirurgie cervico-faciale, CHU de Bordeaux-Pellegrin, place Amélie Rabat-Léon, 33000 Bordeaux, France
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Cushman DM, Teramoto M, Asay A, Clements ND, McCormick ZL. Corticosteroid and Local Anesthetic Use Trends for Large Joint and Bursa Injections: Results of a Survey of Sports Medicine Physicians. PM R 2020; 13:962-968. [PMID: 32969178 DOI: 10.1002/pmrj.12499] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 08/31/2020] [Accepted: 09/09/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Physician decision-making surrounding choices for large joint and bursa injections is poorly defined, yet influences patient safety and treatment effectiveness. OBJECTIVE To identify practice patterns and rationale related to injectate choices for large joint and bursal injections performed by physician members of the American Medical Society for Sports Medicine (AMSSM). DESIGN An electronic survey was sent to 3400 members of the AMSSM. Demographic variables were collected: primary specialty (residency), training location, practice location, years of clinical experience, current practice type, and rationale for choosing an injectate. PARTICIPANTS A total of 674 physicians responded (minimum response rate of 20%). INTERVENTION Not applicable. MAIN OUTCOME MEASURES Outcomes of interest included corticosteroid type and dose, local anesthetic type, and total injectate volume for each large joint or bursa (hip, knee, and shoulder). RESULTS Most respondents used triamcinolone (50% to 56% of physicians, depending on injection location) or methylprednisolone (25% to 29% of physicians), 21 to 40 mg (53% to 60% of physicians), diluted with lidocaine (79% to 87%) for all large joint or bursa injections. It was noted that 36.2% (244/674) of respondents reported using >40 mg for at least one injection type. Most (90.5%, 610/674) reported using an anesthetic other than ropivacaine for at least one type of joint or bursa injection. Physicians who reported lidocaine use were less likely to report that their injectate choice was based on the literature that they reviewed (odds ratio [OR] 0.41 [0.27-0.62], P < .001). Respondents predominantly used 5 to 7 mL of total injectate for all large joints or bursae (45% to 54% of respondents), except for the pes anserine bursa, where 3-4 mL was more common (51% of physicians). CONCLUSIONS It appears that triamcinolone and methylprednisolone are the most commonly used corticosteroids for sports medicine physicians; most physicians use 21 to 40 mg of corticosteroid for all injections, and lidocaine is the most-often used local anesthetic; very few use ropivacaine. Over one-third of respondents used high-dose (>40 mg triamcinolone or methylprednisolone) for at least one joint or bursa.
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Affiliation(s)
- Daniel M Cushman
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT
| | - Masaru Teramoto
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT
| | - Alexandra Asay
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT
| | - Nathan D Clements
- Department of Physical Medicine & Rehabilitation, University of Texas Health Science Center, San Antonio, TX
| | - Zachary L McCormick
- Division of Physical Medicine & Rehabilitation, University of Utah, Salt Lake City, UT
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The Magnitude and Duration of the Effect of Intra-articular Corticosteroid Injections on Pain Severity in Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Am J Phys Med Rehabil 2020; 99:617-625. [PMID: 31972612 DOI: 10.1097/phm.0000000000001384] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The aims of the study were to clarify the evidence on the magnitude and duration of treatment effect of intra-articular corticosteroid injections for knee osteoarthritis compared with placebo, to evaluate a treatment effect by steroid type, and to describe the reported adverse effects. DESIGN Cochrane Controlled Trials Register, Medline, Embase, CINAHL, Scopus, and Web of Science databases were searched. The risk of systematic bias was assessed according to the Cochrane Collaboration's domain-based evaluation framework. RESULTS The final sample included eight randomized controlled studies with follow-ups from 1 to 26 wks. The risk of systematic bias was considered low in five and high in three studies. The pooled standardized mean difference was -0.58 (95% confidence interval = -0.88 to -0.27) and number needed to treat 5.1 (95% confidence interval = 10.0 to 3.7). The heterogeneity was considerable. The pooled effect size approached the level of statistical insignificance at 4 mos. The pooled risk ratio of adverse effects was insignificant 0.95 (95% confidence interval = 0.34 to 2.55). CONCLUSIONS The intra-articular corticosteroid had a mild to moderate effect on pain severity up to 3 mos after the injection-much longer than it had previously been reported. The effect may vary substantially in different patient groups and appropriate patient selection is important. The risk of adverse effects was low.
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Cushman DM, Christiansen J, Kirk M, Clements ND, Cunningham S, Teramoto M, McCormick ZL. Image guidance used for large joint and bursa injections; a survey study. PHYSICIAN SPORTSMED 2020; 48:208-214. [PMID: 31560251 DOI: 10.1080/00913847.2019.1674122] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objectives: To determine the current rates of use of available image guidance modalities for large joint and bursal injections, in addition to their relationships to physician demographics.Methods: An electronic survey was sent to 3,400 members of the American Medical Society for Sports Medicine (AMSSM), examining types of guidance used for each large joint and bursal injection.Results: A total of 674 sports medicine physicians responded to the survey. Intra-articular hip and glenohumeral joint injections were more commonly performed with ultrasound guidance, while palpation-guidance was more common with all other injections. Physicians who specialized in Physical Medicine & Rehabilitation (PM&R) were more likely to use ultrasound for trochanteric bursa (p = 0.007, OR = 4.16 [1.46-11.8]), while internal medicine-, pediatrics-, and family medicine-trained physicians were more likely to use palpation guidance for at least one joint (p < 0.05). Physicians with fewer years of experience were more likely to use ultrasound for glenohumeral joint injections (p ≤ 0.002 for all age groups with less than 20 years of experience, ORs ranging from 6.3 to 9.2).Conclusion: Palpation-guidance is the most common technique used for large joint and bursal injections, other than for glenohumeral and hip joint injections. PM&R-trained physicians and those with less experience tend to use ultrasound more frequently.
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Affiliation(s)
- Daniel M Cushman
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
| | - Jacob Christiansen
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
| | - Melissa Kirk
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
| | - Nathan D Clements
- Department of Physical Medicine & Rehabilitation, University of Texas Health Science Center, San Antonio, TX, USA
| | - Shellie Cunningham
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
| | - Masaru Teramoto
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
| | - Zachary L McCormick
- University of Utah Division of Physical Medicine & Rehabilitation, Salt Lake City, UT, USA
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Knee Osteoarthritis and Meniscal Injuries in the Runner. CURRENT PHYSICAL MEDICINE AND REHABILITATION REPORTS 2019. [DOI: 10.1007/s40141-019-00235-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Cushman DM, Ofek E, Syed RH, Clements N, Gardner JE, Sams JM, Mulvey JL, McCormick ZL. Comparison of Varying Corticosteroid Type, Dose, and Volume for the Treatment of Pain in Small‐ and Intermediate‐Size Joint Injections: A Narrative Review. PM R 2019; 11:758-770. [DOI: 10.1016/j.pmrj.2018.09.040] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 09/22/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Daniel M. Cushman
- Division of Physical Medicine & RehabilitationUniversity of Utah Salt Lake City UT
| | - Erika Ofek
- Department of Sports MedicineUniversity of Hawaii Honolulu HI
| | - Raafay H. Syed
- Department of Physical Medicine & RehabilitationHarvard Medical School Boston MA
| | - Nathan Clements
- Department of Physical Medicine & RehabilitationUniversity of Texas Health San Antonio San Antonio TX
| | | | | | - Jade L. Mulvey
- University of Utah, School of Medicine Salt Lake City UT
| | - Zachary L. McCormick
- Division of Physical Medicine & RehabilitationUniversity of Utah Salt Lake City UT
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Wang JC, Chang KV, Wu WT, Han DS, Özçakar L. Ultrasound-Guided Standard vs Dual-Target Subacromial Corticosteroid Injections for Shoulder Impingement Syndrome: A Randomized Controlled Trial. Arch Phys Med Rehabil 2019; 100:2119-2128. [PMID: 31150601 DOI: 10.1016/j.apmr.2019.04.016] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/20/2019] [Accepted: 04/25/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To compare dual-target injection with standard ultrasound (US)-guided subacromial injection in patients with subacromial impingement syndrome (SIS) and possible disorders of the biceps long-head tendons. DESIGN Double-blind, randomized controlled trial. SETTING Rehabilitation outpatient clinic. PARTICIPANTS Patients with SIS (N=60). INTERVENTION (1) US-guided standard subacromial bursa; (2) dual-target (subacromial bursa plus proximal biceps long-head tendon) injection, with 40-mg triamcinolone acetonide administered to patients in each group. MAIN OUTCOME MEASURES Clinical assessments were performed at baseline. The outcomes, including results from a self-administered questionnaire, the Shoulder Pain and Disability Index (SPADI), and a self-pain report, the visual analog scale (VAS) scores for pain at rest, at night, and during overhead activities, were evaluated at baseline and at the first and third months postintervention. RESULTS No significant difference was observed in baseline evaluations between groups (n=30 in each treatment arm) prior to injections. Both groups exhibited significant SPADI and VAS-score improvements after the first month. The dual-target injection group had less rebounding pain at the 3-month follow-up. The standard injection group had more patients reporting worsening pain within 1 day postinjection. CONCLUSION US-guided dual-target corticosteroid injection showed similar short-term efficacy to standard subacromial injections, but with an extended duration of symptom relief. Therefore, dual-target corticosteroid injections may be useful for shoulder pain treatment in patients with SIS.
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Affiliation(s)
- Jia-Chi Wang
- Department of Physical Medicine and Rehabilitation, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Ke-Vin Chang
- Department of Physical Medicine and Rehabilitation, National Taiwan University, Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei, Taiwan.
| | - Wei-Ting Wu
- Department of Physical Medicine and Rehabilitation, National Taiwan University, Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Der-Sheng Han
- Department of Physical Medicine and Rehabilitation, National Taiwan University, Hospital, Bei-Hu Branch and National Taiwan University College of Medicine, Taipei, Taiwan
| | - Levent Özçakar
- Department of Physical and Rehabilitation Medicine, Hacettepe University Medical School, Ankara, Turkey
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