A randomised controlled trial of intra-articular corticosteroid injection of the carpometacarpal joint of the thumb in osteoarthritis

OBJECTIVE: To investigate the efficacy of corticosteroid injections into the carpometacarpal joint of the thumb (CMCJ) in patients with osteoarthritis. DESIGN: A double blind, randomised controlled trial using 40 hospital referred patients with CMCJ osteoarthritis who received intra-articular injections of 5 mg triamcinolone hexacetonide (0.25 ml) or sterile 0.9% saline (0.25 ml). Injections were given under imaging control. MAIN OUTCOME MEASURES: The primary outcome was improvement in a pain visual analogue score (VAS) of 20% at 24 weeks. In addition patients were assessed at 4, 12, and 24 weeks for joint stiffness, joint tenderness, and physician and patient global assessments. Hand radiographs were evaluated for the degree of CMC joint space narrowing and marginal osteophytes according to the OARSI atlas. RESULTS: Baseline clinical variables were not significantly different between the two treatment groups. There was no improvement in the VAS of pain at 24 weeks. At each assessment point there was no significant difference between the steroid and placebo groups in median values for joint stiffness, joint tenderness, or patient and physician global assessments. Non-parametric analysis of each group individually revealed statistically significant improvements in patient and physician global assessments at weeks 4, 12, and 24 in the placebo group and at weeks 4 and 12 in the steroid group. CONCLUSIONS: No clinical benefit was gained from intra-articular steroid injection to the CMCJ in moderate to severe osteoarthritis compared with placebo injection.     

Intraarticular corticosteroid injection into rheumatoid arthritis knees improves extensor muscles strength

Summary Eleven arthritic knee joints in seven patients with rheumatoid arthritis were studied before and after intraarticular injection of a corticosteroid preparation. Extensor muscle torque and quantitative electromyography increased on days 7 and 14 after treatment, indicating that muscle function had been inhibited by synovitis. Clinical signs of synovitis, such as pain, range of motion and knee circumference, also improved. Synovial fluid withdrawal alone improved extensor muscle torque. Joints with instability and/or radiological cartilage involvement also improved.     

Clinical effectiveness and dose response of image-guided intra-articular corticosteroid injection for hip osteoarthritis

OBJECTIVES: To assess symptomatic change after intra-articular corticosteroid (IAST) injection at 2 doses in hip osteoarthritis (OA), and to examine dose response and predictors of response. METHODS: Patients with hip OA (90 women and 30 men and median age 64 yrs) referred for IAST fluoroscopic injection were included in this longitudinal, clinical trial. WOMAC scores, body mass index (BMI), conventional radiographic grade (Kellgren and Lawrence scoring) and ultrasound measures (including capsular thickness and osteophyte assessments) were recorded at baseline. In the first phase of the study, 75 patients were injected with 40 mg methylprednisolone; another 45 patients were injected with 80 mg in the second phase. Change in WOMAC scores from baseline to weeks 6 and 12 were calculated for each dose and then dose comparisons were made. Clinical responders (>15% reduction in baseline pain score) were identified in order to establish predictors of response. RESULTS: For the 40 mg dose, there was a statistically significant improvement in pain (P < 0.001) and stiffness (P < 0.001) but not disability at week 6, and only the improvement in stiffness at week 12 was maintained (P = 0.041). For the 80 mg dose, there was significant improvement in pain (P < 0.001), stiffness (P < 0.001) and disability (P < 0.001) at week 6, which was maintained for all domains at week 12 (P = 0.002; P = 0.001; P < 0.001). When the doses were compared, the 80 mg dose demonstrated a significant improvement compared with the 40 mg group for stiffness at week 12 (P = 0.026) and disability at both weeks 6 and 12 (P = 0.026; P = 0.004). Imaging findings did not relate to severity of symptoms or response to IAST. CONCLUSIONS: In these two hip OA cohorts, both the 40 mg and 80 mg IAST doses had a beneficial effect at week 6, while the 80 mg dose maintained this improvement at week 12. Comparison of the two dose groups provided some evidence of a dose response. Randomized controlled trials of IAST for hip OA are now required.     

超声引导下局部注射皮质类固醇混合制剂治疗老年性膝骨关节炎的止痛疗效

目的本文探讨了超声引导下局部注射皮质类固醇混合制剂治疗老年性膝骨关节炎的止痛疗效。方法入选2015年5月至2015年12月期间在武警总医院超声科行超声引导下局部注射皮质类固醇混合制剂治疗的膝骨关节炎患者31例(35个膝骨关节)。皮质类固醇混合制剂采用曲安奈德、2%利多卡因和注射用水以2:1:1的容积比例配制。比较术前、术后4周和术后6个月患者的疼痛视觉模拟量表(VAS)评分结果。术后6个月对患者进行疗效满意度调查。结果超声引导下注射皮质类固醇混合制剂治疗膝骨关节炎的一次成功率为100%。与术前(5.2±1.5)相比,术后4周(0.5±0.7)和术后6个月(1.0±1.2)的VAS评分均显著降低,差异均具有统计学意义(P0.05),而术后4周和术后6个月相比,差异无统计学意义(P0.05)。术后6个月疼痛消失或明显缓解者为33例,占94.2%,患者满意度达到为91.4%。结论应用超声精准定位和实时引导,局部注射皮质类固醇混合制剂治疗老年性膝骨关节炎具有良好的消炎止痛效果,值得推荐。     

Intraarticular minocycline injection in experimental synovitis

Summary Minocycline, a semi-synthetic tetracycline, was injected into one hind joint of twenty-two rabbits with zymosan-induced arthritis, while the contralateral joint served as a control. A local inflammatory reaction was observed a few days after the zymosan injection. Most clinical parameters such as knee diameter, systemic temperature, sedimentation rate and blood cell count did not change throughout the experiment both in control and minocycline treated rabbits. However, the zymosan platelet counts rose from 3.4×10⁵/µL to 5×10⁵/µL, as well as the level of serum fibrinogen (from 99mg% to 370 mg%). Microscopically, a perivascular infiltrate consisting of lymphocytes and polymorphonuclear cells was seen. Lymphoid follicles as well as plasma cells epitheloid and giant cells were also observed. A mild tendency to fibrosis and lesser inflammatory reaction in the minocycline treated knees was noted. Our data suggest that intraarticular minocycline treatment did not alleviate the course of the rheumatoid-like inflammatory reaction of the knee joint.     

Diagnostic potential of magnetic resonance imaging (MRI) of the first carpometacarpal joint in hand osteoarthritis

Aim of this workTo assess the magnetic resonance imaging (MRI) findings compared to plain X-ray in patients with primary nodal osteoarthritis (OA) of first the carpometacarpal (CMC) joint of the thumb.Patients and methodsThis study included 35 Egyptian patients with primary nodal hand OA (HOA) and 15 healthy subjects of matched age. Each subject had plain X-rays graded by Kellgren and Lawrence (K–L) score for HOA. MRI testing of both hands done by using T1/T2 weighted axial and coronal images.ResultsThe mean age was 57.2 ± 8.3 years (45–72 years) and they were 24 females and 11 males. Disease duration of patients ranged (8 months to 10 years, 2.04 ± 1.06 years). In all HOA patients there were signs of knee OA involvement; synovial thickening in 51.4% of patients, knee effusion in 8.6%, limited knee ROM in 28.6% and night pain in 60%. There was a superiority of the MRI in detecting synovitis (71.4%), flexor tenosynovitis (71.4%), collateral ligament (60%), bone marrow lesion (85.7%) and cysts (57.1%) compared to the X-ray which could not detect them. MRI significantly detected osteophytes (88.6%), joint space narrowing (91.4%), erosions (85.7%) and malalignment (57.1%) compared to X-ray (51.4%, 62.9%, 34.3% and 14.3% respectively) (p < 0.001, p = 0.004, p < 0.001 and p < 0.001).ConclusionMRI is superior in detecting HOA changes compared to conventional radiography. As OA is recognized to involve the whole joint, modern imaging techniques such as MRI could be a valuable tool for better evaluation of HOA.     

Intraarticular corticosteroid injections of the temporomandibular joint in juvenile idiopathic arthritis

OBJECTIVE: To describe the clinical and radiographic outcomes in a series of patients with juvenile idiopathic arthritis (JIA) who underwent one or more intraarticular corticosteroid (IAS) injections of the temporomandibular joint (TMJ) performed without imaging guidance. METHODS: Retrospective chart review was performed for all patients with JIA diagnosed and treated at our institution between January 1, 2000, and January 1, 2006, who underwent one or more IAS injections of their TMJ. IAS injections were performed by the same oral and maxillofacial surgeon without imaging guidance, using either triamcinolone acetonide or triamcinolone hexacetonide. The primary outcomes assessed were maximal incisal opening (MIO) measurements, patient-reported symptoms, physical examination findings, and imaging results. RESULTS: Twenty-five patients were identified. Twenty-one (84%) had radiographic evidence of TMJ disease when TMJ disease was first suspected by their physician. The 25 patients underwent 74 IAS injections on 47 separate occasions. When baseline MIO measurements were compared to the last MIO measurements of the study period, there was a mean increase in MIO of 6.9 mm (p = 0.002; 95% CI 3, 10.7). There was a mean increase in MIO of 3.8 mm following each IAS injection (p = 0.003; 95% CI 1.4, 6.2). Patients who underwent multiple IAS injections had a mean increase in MIO after first injection of 6.6 mm (p < 0.001; 95% CI 4.1, 9.1); however, the mean increase in MIO after subsequent injections was 0.4 mm (p = 0.8; 95% CI -3.5, 4.4). One patient developed subcutaneous atrophy at the injection site. Two patients developed small, asymptomatic intraarticular calcifications. No additional adverse events were reported. CONCLUSIONS: In this patient population, there was an overall increase in MIO measurements following initial IAS injection and during the study period. Patients tended to have minimal response to subsequent injections. IAS injections performed without imaging guidance by an experienced oral and maxillofacial surgeon were well tolerated with only rare adverse events. The presence of radiographic changes when the physician first suspected TMJ disease in 84% of patients emphasizes the need for better screening and early intervention for synovitis in this joint.     

Association of matrilin-3 polymorphisms with spinal disc degeneration and osteoarthritis of the first carpometacarpal joint of the hand

BACKGROUND: Seven polymorphisms in the matrilin-3(MATN3) gene were previously tested for genetic association with hand osteoarthritis in an Icelandic cohort. One of the variants, involving a conserved amino acid substitution (T303M; SNP5), was related to idiopathic hand osteoarthritis. OBJECTIVES: To investigate SNP5 and two other promising polymorphisms (rs2242190; SNP3, rs8176070; SNP6) for association with radiographic and symptomatic hand osteoarthritis phenotypes, as well as other heritable phenotypes. METHODS: Polymorphisms were examined in two distinct cohorts of subjects: a population based sample from the Rotterdam study (n = 809), and affected siblings from the genetics, osteoarthrosis and progression (GARP) study (n = 382). RESULTS: The originally described association of T303M with the hand osteoarthritis phenotype was not observed in the populations studied. In the Rotterdam sample, however, carrying the T allele of T303M conferred an odds ratio of 2.9 (95% confidence interval (CI), 1.2 to 7.3; p = 0.02) for spinal disc degeneration. In the GARP study, carriers of the A allele of SNP6 had an odds ratio of 2.0 (95% CI, 1.3 to 3.1, p = 0.004) for osteoarthritis of the first carpometacarpal joint (CMC1) as compared with the Rotterdam sample as a control group. Subsequent haplotype analysis showed that a common haplotype, containing the risk allele of SNP6, conferred a significant risk in sibling pairs with CMC1 osteoarthritis (odds ratio = 1.7 (95% CI, 1.1 to 2.7, p = 0.02)). CONCLUSIONS: These associations suggest that the MATN3 region also determines susceptibility to spinal disc degeneration and CMC1 osteoarthritis.     

Intra-articular corticosteroid treatment in osteoarthritis.

Intra-articular corticosteroids remain widely used for symptomatic treatment of peripheral joint osteoarthritis (OA). Several studies in knee OA have indicated a significant benefit compared with placebo, although the effect appears to last for only 1 to 3 weeks. Two placebo-controlled studies have confirmed these findings. A further uncontrolled study has examined the effect of intra-articular corticosteroid at the hip. Attention is increasingly focused on a possible disease-modifying role for steroids in OA. Although a beneficial effect can be demonstrated in some animal models, caution should be exercised when extrapolating to human cartilage. Osteoarthritis is increasingly viewed as a phasic condition in which organ damage occurs intermittently. An ability to detect these phases of increased disease activity, perhaps with new imaging or biochemical techniques, could lead to a more rational approach to the use of intra-articular steroids in OA.     

Larsen grades in evaluating the first carpometacarpal joint

OBJECTIVE: To illustrate different Larsen grades for CMC I. METHODS: In the Heinola Follow-up Survey of Arthritis 103 seropositive patients with rheumatoid arthritis (RA) were followed prospectively over 20 years. Hand radiographs were taken at onset and at 1, 3, 8, 15, and 20 years from entry. One female patient was selected to demonstrate Larsen grades for CMC I, as she presented all the different grades of destruction during the progression of RA. Interobserver and intraobserver errors in grading of CMC I were tested. RESULTS: Radiographs of the different grades with schematic presentation are illustrated. Interobserver and intraobserver errors were in the Weighted Kappa test 0.75 and 0.82, respectively. CONCLUSION: We emphasise the importance of following the destruction of CMC I separate from the entire carpus during the course of RA.     

Intraarticular hyaulonic acid injection for sports related chondral lesion of the knee

In many cases intraarticular injections of hyaulonic acid were effective for sports related chondral lesion, because the chondral defect is recognized as an early stage of osteoarthritis. But in some young cases whose MRI showed chondral defects the hyaulonic acid injection were not effective and further more treatment might be needed. To those cases arthroscopic microfracture method and succeeding intraarticular hyaulonic injections revealed good results.     

Sonographically guided hydrodissection and corticosteroid injection for scleroderma hand

Scleroderma is associated with intractable hand pain from vasospasm, digital ischemia, tenosynovitis, and nerve entrapment. This study investigated the effect of hydrodissection of the carpal tunnel followed by corticosteroid injection for the painful scleroderma hand. Twenty-six consecutive subjects [12 with painful scleroderma hand and 14 with rheumatoid arthritis and carpal tunnel syndrome (RA/CTS)] underwent sonographically observed carpal tunnel hydrodissection with 3 ml of 1% lidocaine administered with a 25-gauge 1-in. needle on a 3-ml RPD mechanical syringe (reciprocating procedure device). After hydrodissection, a syringe exchange was performed, and 80 mg of triamcinolone acetonide was injected. Baseline pain, procedural pain, pain at outcome, responders, therapeutic duration, and reinjection interval were determined. Hydrodissection and injection with corticosteroid significantly reduced pain scores by 67% in scleroderma (p < 0.001) and by 47% in RA/CT (p < 0.001). Scleroderma and RA/CTS were similar in outcome measures: injection pain (p = 0.47), pain scores at outcome (p = 0.13), responders (scleroderma, 83.3%; RA/CTS, 57.1%, p = 0.15), pain at 6 months (p = 0.15), and therapeutic duration (p = 0.07). Scleroderma patients responded better in time to next injection (scleroderma, 8.5 ± 3.0 months; RA/CTS, 5.2 ± 3.1 months, p = 0.03). Reduced Raynaud’s attacks and healing of digital ulcers occurred in 83% of subjects. There were no complications. Hydrodissection with lidocaine followed by injection of triamcinolone reduces pain and vasomotor changes in the scleroderma hand. The mechanism may be a combination of hydrodissection-mediated mechanical freeing of entrapped arteries, nerves, and tendinous structures and corticosteroid-induced reduction of inflammatory vasospasm.     

Persistent local cutaneous atrophy following corticosteroid injection for tendinitis.

A 21-year-old female, treated with triamcinolone for tendinitis in the oblique muscles of both forearms, developed a skin atrophy, localized around the injection points. The patient was followed over a period of more than five years during which a partial remission of the skin changes was observed. A synopsis covering local use of steroids for various diseases is given.     

Long-term follow-up of corticosteroid injection for traumatic olecranon bursitis.

Forty-seven patients with traumatic olecranon bursitis were evaluated after a mean follow-up of 31 months (range 6 to 62 months). Twenty-two patients treated with bursal aspiration had delayed recovery and no complications of therapy. Twenty-five patients treated with intrabursal injection of 20 mg of triamcinolone hexacetonide had rapid recovery, usually within one week, but suffered complications such as infection (3 cases), skin atrophy (5 cases), and chronic local pain (7 cases). Since spontaneous resolution can be expected, a conservative approach is suggested in the treatment of traumatic olecranon bursitis.