Intra-articular Corticosteroid Injections Research Articles

Osteoarthritis: From complications to cure

Background: Osteoarthritis (OA) is a degenerative disorder that affects the cartilage of bones and characterized by severe pain in joint, joint lock and instability. Factors associated with its risks are obesity, past trauma, advancing age, female sex and genetics. Women and older people are more susceptible to the risk of OA. There are different types of OA on basis of joint affects as hip, knee, hand etc. Innate immunity plays an important role in pathogenesis of OA. Activation of innate immunity as a result of small fragments e.g., of protein results in secretion of cytokines (IL1-β and TNF-α, IL-8, IL-17 etc.) and enzymes (MMP and ADAMTS) which cause degradation of bone and imparts inflammatory effect. Aging also plays an important role in OA as chondrocytes show reduced autophagy with aging, so risks of OA increases. Different drugs have been in use for the treatment of OA which provide anti-inflammatory, analgesic effects and help in improving bone integrity. Acetaminophen is usually prescribed as first line drug. Oral NASIDs and opioids provide an alternative when it does not prove effective. But these are associated with the high risks of gastrointestinal (GI) tract, cardiovascular (CV) and renal system, and liver toxicity. Topical NASIDs can also be used as alternative to oral NASIDs for their safety. Another option is topical capsaicin which can be used as an adjunctive treatment with only local adverse effects such burning, itching etc. Intra-articular injections of hyaluronic acid and corticosteroids are also used. Both are considered almost safe with local adverse effects. Non-pharmacological treatments for OA includes education, exercise, therapies, surgery and regenerative therapies. In this study, we have briefly enlightened the pathogenesis of osteoarthritis. Moreover, pharmacological as well as nonpharmacological treatment for OA is also explained.

Is there a short-term benefit from an intra-articular steroid injection in female patients with adhesive capsulitis of the shoulder treated with physiotherapy?

The purpose of this retrospective study was to investigate the possible short-term benefit of a single intra-articular corticosteroid injection in those patients treated with physiotherapy when compared to a group of patients undergoing physiotherapy only (PT only). A retrospective chart review was conducted to identify eligible patients treated over a 4-year period. All female patients between 40 years and 60 years with a confirmed clinical diagnosis of idiopathic adhesive capsulitis who completed a prescribed physiotherapy program were considered eligible. Sixty-three patients fulfilled the inclusion criteria, but 22 were excluded because of missing data in the medical record. The remaining 41 patients comprise the study cohort; an experienced musculoskeletal physiotherapist assessed these patients both at initial presentation and at 12 weeks. Twenty patients with a mean age of 55.1 years underwent PT only and 21 patients with a mean age of 52.4 years received a single intra-articular dose of 40 mg methylprednisolone followed by physiotherapy. Outcome measures included the visual analogue scale (VAS) and measurement of range of motion. At final assessment (12 weeks), significant between-group differences were identified for the 'PT only' group for flexion ( p = 0.01) and abduction ( p = 0.008). When comparing the mean change from the initial assessment, a significant between-group difference was observed for abduction ( p = 0.03). The results of this study suggest that the intra-articular injection of a single dose of cortisone has no significant short-term benefit in female patients with idiopathic adhesive capsulitis managed with physiotherapy.

Injectable Corticosteroids: Take Precautions and Use Caution.

Corticosteroids are routinely injected into soft tissues, tendon sheaths, bursae, and joints. These anti-inflammatory agents have different potency and solubility, and solubility is inversely correlated with the duration of action. Corticosteroids carry a low risk of complications but commonly cause systemic and local adverse effects. The use of intra-articular corticosteroid injections in the treatment of inflammatory arthritis and osteoarthritis is well established. Evidence also supports the use of injectable corticosteroids in the treatment of inflammatory tenosynovitis and bursitis associated with rheumatic diseases, trigger finger and de Quervain disease, and carpal tunnel syndrome. The role of corticosteroid injections in the management of rotator cuff disease remains unclear. Strong scientific evidence indicates that corticosteroid injections for lateral epicondylosis worsen the long-term outcomes of patients. This review article discusses the considerations related to the use of corticosteroid injections in the management of nonspinal musculoskeletal conditions.

Complications Associated with Intra-Articular and Extra-Articular Corticosteroid Injections

Side effects of corticosteroids can occur in association with both intra-articular and extra-articular injections. Less-severe reactions include skin reactions and flare responses. Although rare, worrisome complications such as infections, tendon ruptures, and osteonecrosis can occur. It is important to note the effect of corticosteroids on blood glucose levels, particularly for patients with diabetes. Corticosteroid injections have visual side effects with a known relation to central serous chorioretinopathy.

Capsule-Preserving Hydrodilatation With Corticosteroid Versus Corticosteroid Injection Alone in Refractory Adhesive Capsulitis of Shoulder: A Randomized Controlled Trial

To determine whether capsule-preserved hydrodilatation with corticosteroid (CPHC) improves pain and function in patients with refractory adhesive capsulitis (AC) better than intra-articular corticosteroid injection (IACI) alone.

Comparison of high- and low-dose intra-articular triamcinolone acetonide injection for treatment of primary shoulder stiffness: a prospective randomized trial

Intra-articular corticosteroid injection has a proven effect for shoulder stiffness, yet the optimal dose is still controversial. The purpose of the study was to compare the outcomes of intra-articular triamcinolone acetonide injection at 2 different doses in patients with shoulder stiffness. Intra-articular injection of 40 mg (group I, n = 76) or 20 mg (group II, n = 71) of triamcinolone acetonide was performed in patients with shoulder stiffness. The outcome measures including range of motion (ROM), American Shoulder and Elbow Surgeons score, visual analog scale for pain score, and Simple Shoulder Test score were evaluated at 3 weeks, 6 weeks, 12 weeks, 6 months, 12 months, and the last follow-up. Among the patients with controlled diabetes, the levels of blood glucose, fructosamine, and HbA1c were measured to evaluate systemic serologic changes induced by injection. There were significant improvements in ROM and functional scores in both groups at the last follow-up. However, there was no significant difference between the groups in any of the parameters at each time point. None of the diabetic patients in either group had a significant increase in blood glucose, fructosamine, and HbA1c levels compared with levels before injection. However, those in group I showed significantly higher blood glucose levels at 6 weeks after injection compared with those in group II (P = .01). Intra-articular injection of triamcinolone is an effective method for improving ROM and clinical function in patients with shoulder stiffness. However, there was no significant difference in regard to different doses. In diabetic patients, a lower dose is recommended as short-term glucose levels may increase with a high dose of corticosteroid.

Comparative study of ultrasound guided supra-scapular nerve block versus intra-articular steroid injection in frozen shoulder

<p class="abstract"><strong>Background:</strong> Frozen shoulder is one of the most common musculoskeletal problems seen in orthopaedics. Many treatment modes are available however, it is difficult to treat and data on the comparative efficacy of various interventions are limited. Intra-articular corticosteroid injection (IASI) is a commonly used to treat frozen shoulder pain. Supra-scapular nerve block (SSNB) is also effective method to treat pain in chronic diseases that affect the shoulder. The present study was done to compare efficacy of ultrasound guided SSNB and IASI in management of painful frozen shoulder.</p><p class="abstract"><strong>Methods:</strong> 60 patients with painful frozen shoulder were divided in two groups, Group A received ultra-sound guided SSNB with 6 ml 0.5% Bupivacaine; Group B received IASI using 40 mg Triamcinolone. Outcome measures were shoulder ranges mainly lateral rotation and abduction, shoulder pain and disability index and visual analogue scale (VAS). Patients were followed-up on 2<sup>nd</sup> day, at 1<sup>st</sup>, 3<sup>rd</sup> and 6<sup>th</sup> week.<strong></strong></p><p class="abstract"><strong>Results:</strong> All baseline parameters improved significantly in both groups; however, on comparison Group A showed significant improvement in passive lateral rotation on 2<sup>nd</sup> day and 1<sup>st</sup> week follow up (P =0.038 and 0.040 respectively). VAS score showed significance at all follow-up in Group A, whereas, in Group B significance was seen after 1 week. On inter group comparison Group A shows significance on 2<sup>nd</sup> day (P =0.050), 1<sup>st</sup> week (P =0.042) and 3<sup>rd</sup> week (P =0.036).</p><strong>Conclusions:</strong>Both SSNB and IASI have efficacy in management of frozen shoulder. But supra-scapular nerve block is better than intra-articular injection and should be considered prior to steroid as it has early onset pain relief, early improvement in ranges, potentially lesser contraindications and side effects.<p> </p>

Capsule-Preserving Hydrodilatation With Corticosteroid Versus Corticosteroid Injection Alone in Refractory Adhesive Capsulitis of Shoulder: A Randomized Controlled Trial

ObjectiveTo determine whether capsule-preserved hydrodilatation with corticosteroid improves pain and function in patients with refractory adhesive capsulitis (AC) better than intra-articular corticosteroid injection (IACI) alone. DesignProspective randomized controlled study. SettingUniversity-affiliated tertiary care hospital. ParticipantsSubjects with primary AC (N=64) with shoulder pain level of visual analog scale (VAS) score ≥5, even after the initial administration of IACI alone. InterventionsParticipants randomly received ultrasound-guided IACI alone with 1mL of 40mg/mL triamcinolone acetonide and 3mL of 1% lidocaine (n=32) or ultrasound-guided capsule-preserved hydrodilatation with corticosteroid with a mixture of 1mL of 40mg/mL triamcinolone acetonide, 6mL of 1% lidocaine, and normative saline (n=32). Main Outcome MeasuresThe primary outcome measure was the Shoulder Pain and Disability Index score. Secondary outcomes were the VAS of shoulder pain level and angles of shoulder passive range of motion, including flexion, abduction, extension, external rotation, and internal rotation at pretreatment and weeks 3, 6, and 12 of posttreatment. ResultsThere were no significant differences between the 2 groups in terms of demographic characteristics (age, sex, duration of symptoms, shoulder affected, and body mass index) at baseline. Repeated-measures analysis of variance showed significant effect of time in all outcome measurements in both groups. However, group-by-time interactions were not significantly different for any of the outcomes between groups. ConclusionsThis study shows that compared with pretreatment, all outcome measures improved significantly in both groups by time; however, there was no significant difference between the 2 groups. Therefore, we recommend IACI alone over capsule-preserved hydrodilatation with corticosteroid when considering the corticosteroid injection as a secondary option after the initial IACI fails to improve symptoms for patients with refractory AC.

Clinical efficacy of hydrodistention with joint manipulation under interscalene block compared with intra-articular corticosteroid injection for frozen shoulder: a prospective randomized controlled study

Hydrodistention is known to be an effective method of treatment for frozen shoulder. However, hydrodistention is accompanied by severe pain during the procedure. An interscalene block may relieve the severe pain associated with the procedure of hydrodistention. This study compared the clinical efficacy of hydrodistention with joint manipulation under an interscalene block with that of intra-articular corticosteroid injection. This prospective randomized controlled study included 121 patients presenting with frozen shoulder. Patients were randomized into 2 groups; those in group A (60 patients) were treated by hydrodistention with joint manipulation under an interscalene block, and those in group B (61 patients) were managed with intra-articular corticosteroid injection. Pain intensity and patient satisfaction were assessed by the visual analog scale. Functional outcomes were assessed by the Constant score and the range of shoulder motion. Group A demonstrated better patient satisfaction and earlier restoration of range of motion than group B at 6 weeks (P ≤ .001). At 12 weeks, the pain score was lower and the Constant score was better in group A than in group B. However, at 12 months after treatment, pain score (P = .717), patient satisfaction (P = .832), range of motion (P > .05), and Constant score (P = .480) were similar in the 2 groups. Hydrodistention combined with joint manipulation under an interscalene block provided earlier pain relief and restoration of shoulder range of motion and function compared with single intra-articular corticosteroid injection in patients with primary frozen shoulder.

The effects of intra-articular glucocorticoids and exercise on pain and synovitis assessed on static and dynamic magnetic resonance imaging in knee osteoarthritis: exploratory outcomes from a randomized controlled trial.

The aims of the present knee osteoarthritis (KOA)-study were to: (1) describe and compare the changes in magnetic resonance imaging (MRI)-measures of synovitis following an exercise program preceded by an intra-articular injection of either corticosteroid or isotonic saline and (2) investigate if any of the changes in patient reported outcome measures (PROMs) were associated with changes in MRI-measures of synovitis. We performed a randomized, double-blinded, placebo-controlled clinical trial evaluating the effects of intra-articular corticosteroid vs placebo injections given before exercise therapy in KOA-patients. PROMs were assessed using the KOOS (knee injury and osteoarthritis outcome score). Synovitis was assessed on conventional non-contrast-enhanced, conventional contrast-enhanced (CE) and dynamic contrast-enhanced (DCE) MRI. PROMs and MRIs were obtained prior to the intra-articular injection, after termination of the exercise program (week 14-primary time point) and week 26. Of 100 randomized participants (50 in each allocation group), 91 had complete MRI-data at baseline (63% female, mean age: 62 years, median Kellgren-Lawrence-grade: 3). There were no statistically significant differences between the two interventions in regards of changes in MRI-measures of synovitis at any time-point. At week 14, we found no statistical significant MRI-explanatory variables of either of the PROMs. The present study does not justify the use of intra-articular corticosteroids over intra-articular saline when combined with an exercise program for reduction of synovitis in KOA. The improvement in pain and function following the intervention with intra-articular corticosteroids/saline and exercise could not be explained by a decrease in synovitis on MRI indicating other pain causing/relieving mechanisms in KOA.

Intraarticular corticosteroid injection in adhesive capsulitis: are two doses better than a single dose? a randomized prospective study

<p class="abstract"><strong>Background:</strong> The present study aimed to compare the effectiveness of a single dose and two doses of intraarticular corticosteroids injections followed by home exercise programme in patients with adhesive capsulitis.</p><p class="abstract"><strong>Methods:</strong> The study was done over two years. Eighty four patients with adhesive capsulitis were enrolled in the study. The patients were randomly assigned to two groups: In group I 38 patients were given a single dose of intraarticular corticosteroid injection (1 mL, 40 mg methylprednisolone acetate) followed by a twelve-week home exercise programme. In group II 46 patients were given two doses of intraarticular corticosteroid injection (1 mL, 40 mg methylprednisolone acetate) at first and third week followed by home exercise programme. All the patients were assed for functional out come at six and twelve weeks using Shoulder pain and disability index (SPADI) and Constant Moore’s shoulder score (CMS).<strong></strong></p><p class="abstract"><strong>Results:</strong> Both groups showed considerable improvement from the baseline, but no significant differences were found between the two groups at twelve weeks. Mean changes in range of motion and shoulder pain and disability index–pain score were statistically no different between the two groups at the twelve weeks.</p><p><strong>Conclusions:</strong> Intraarticular corticosteroids have the additive effect of providing rapid pain relief when combined with home exercise program in adhesive capsulitis. No significant differences in outcome were found in patients treated with a single or two doses of corticosteroid injection.</p>

Total knee arthroplasty and infection: how surgeons can reduce the risks.

Total joint arthroplasty (TJA) is one of the most common orthopaedic procedures. Nevertheless, several complications can lead to implant failure.Peri-prosthetic joint infections (PJI) certainly represent a significant challenge in TJA, constituting a major cause of prosthetic revision. The surgeon may have an important role in reducing the PJI rate by limiting the impact of significant risk factors associated to either the patient, the operative environment or the post-operative care.In the pre-operative period, several preventive measures may be adopted to manage reversible medical comorbidities. Other recognised pre-operative risk factors are urinary tract infections, intra-articular corticosteroid injections and nasal colonisation with Staphylococcus (S.) aureus, particularly the methicillin-resistant strain (MRSA).In the intra-operative setting, protective measures for PJI include antibiotic prophylaxis, surgical-site antisepsis and use of pre-admission chlorhexidine washing and pulsed lavage during surgery. In this setting, the use of plastic adhesive drapes and sterile stockinette, as well as using personal protection systems, do not clearly reduce the risk of infection. On the contrary, using sterile theatre light handles and splash basins as well as an increased traffic in the operating room are all associated with an increased risk for PJI.In the post-operative period, other infections causing transient bacteraemia, blood transfusion and poor wound care are considered as risk factors for PJI.Cite this article: Ratto N, Arrigoni C, Rosso F, Bruzzone M, Dettoni F, Bonasia DE, Rossi R. Total knee arthroplasty and infection: how surgeons can reduce the risks. EFORT Open Rev 2016;1: 339-344 DOI: 10.1302/2058-5241.1.000032.

Outcomes of Intra-articular Corticosteroid Injections for Adolescents with Hip Pain

Outcomes of Intra-articular Corticosteroid Injections for Adolescents with Hip Pain

Efficacy and safety of point-of-care ultrasound-guided intra-articular corticosteroid joint injections in patients with haemophilic arthropathy.

Intra-articular corticosteroid injections are standard of care for managing joint pain secondary to osteoarthritis or rheumatoid arthritis but are rarely used in haemophilic arthropathy. We have introduced and evaluated the efficacy and safety of ultrasound-guided corticosteroid injections for pain relief in patients with haemophilic arthropathy. Ultrasound-guided intra-articular injections performed on haemophilia patients at UCSD between March 2012 and January 2016 were analysed. Needle placement and injection (40 mg triamcinolone; 3-5 mL lidocaine) were performed with musculoskeletal ultrasound and Power Doppler. Analysis included patient demographics, joint-specific parameters such as tissue hypervascularity and effusions, pain relief, and procedure-associated complications. Forty-five injections (14 ankles, 13 elbows, 18 knees) were administered in 25 patients. Advanced arthropathy with hypervascularity and/or effusions was present in 91% and 61% of joints, respectively. Ninety-one per cent of injections resulted in pain relief which was significant in 84% (>30% reduction). Median pain score was reduced from 7 of 10 to 1 of 10 (P < 0.001), usually within 24 h. Median duration of pain relief was 8 weeks (range 1-16 weeks). Haemophilia B patients experienced longer periods of relief, and high Pettersson scores were associated with shorter duration of relief. There were no procedure-associated complications. Repeat ultrasound of eight joints within 4 weeks of injection demonstrated nearly complete resolution of hypervascularity. Point-of-care ultrasound enabled intra-articular corticosteroid injections that provided highly effective, safe, and relatively long-lasting pain relief in haemophilic arthropathy. This approach should be used to improve pain management in haemophilic arthropathy.

Intra-articular steroid injection for osteoarthritis of the hip prior to total hip arthroplasty : is it safe? a systematic review.

Using a systematic review, we investigated whether there is an increased risk of post-operative infection in patients who have received an intra-articular corticosteroid injection to the hip for osteoarthritis prior to total hip arthroplasty (THA). Studies dealing with an intra-articular corticosteroid injection to the hip and infection following subsequent THA were identified from databases for the period between 1990 to 2013. Retrieved articles were independently assessed for their methodological quality. A total of nine studies met the inclusion criteria. Two recommended against a steroid injection prior to THA and seven found no risk with an injection. No prospective controlled trials were identified. Most studies were retrospective. Lack of information about the methodology was a consistent flaw. The literature in this area is scarce and the evidence is weak. Most studies were retrospective, and confounding factors were poorly defined or not addressed. There is thus currently insufficient evidence to conclude that an intra-articular corticosteroid injection administered prior to THA increases the rate of infection. High quality, multicentre randomised trials are needed to address this issue. Cite this article: Bone Joint J 2016;98-B:1027-35.

Safely Managing Acute Osteoarthritis in the Emergency Department: An Evidence-Based Review

BackgroundJoint pain caused by acute osteoarthritis (OA) is a common finding in the emergency department. Patients with OA often have debilitating pain that limits their function and ability to complete their activities of daily living. In addition, OA has been associated with a high percentage of arthritis-related hospital admissions and an increased risk of all-cause mortality. Safely managing OA symptoms in these patients can present many challenges to the emergency provider. ObjectivesWe review the risks and benefits of available treatment options for acute OA-related pain in the emergency department. In addition, evidence-based recommendations will be made for safely managing pain and disability associated with OA in patients with comorbidities, including cardiovascular disease, renal insufficiency, and risk factors for gastrointestinal bleeding. DiscussionCommonly used treatments for OA include acetaminophen, oral nonsteroidal anti-inflammatory drugs, and opioids, each with varying degrees of efficacy and risk depending on the patient's underlying comorbidities. Effective alternative therapies, such as topical preparations, intra-articular corticosteroid injections, bracing, and rehabilitation are likely underused in this setting. ConclusionsEmergency providers should be aware of the risks and benefits of all treatment options available for acute OA pain, including oral medications, topical preparations, corticosteroid injections, bracing, and physical therapy.

Clinical outcomes of non-operative treatment for patients presenting SLAP lesions in diagnostic provocative tests and MR arthrography.

In the present prospective study, the functional outcomes of non-operative treatment were evaluated in patients aged between 30 and 45years presenting SLAP lesion in diagnostic provocative tests and magnetic resonance (MR) arthrography. Forty-six patients with a symptomatic SLAP lesion who participated in recreational level of sports were prospectively enroled. SLAP lesion was diagnosed using combinations of several clinical tests and MR arthrography findings. All patients were treated with intra-articular corticosteroid injections, followed by rotator cuff and periscapular muscle-strengthening exercises. Patients with persistent discomfort after second injection underwent arthroscopic SLAP repair. Functional outcomes were evaluated using ASES and Constant scores, and pain and satisfaction for visual analogue scale (VAS). Pain had significantly improved from 5.2±2.2 to 1.0±1.1 (p<0.001) in all patients after the first corticosteroid injection. SLAP symptoms relapsed in 12 patients at an average of 2.4months after the first injection. Symptoms were relieved in 5 of 12 patients after the second injection and strengthening exercises. The remaining seven patients underwent arthroscopic SLAP repair. Thirty-nine patients (85%) who were treated non-operatively showed improved VAS, Constant, and ASES scores at final follow-up (p<0.001). Non-operative treatment with an appropriate regimen provided satisfactory clinical outcomes in middle-aged patients with symptomatic SLAP lesions and should be considered before recommending operative treatment. Non-operative management using combined intra-articular corticosteroid injection with rotator cuff and periscapular strengthening exercises could be applied as primary treatment for patients with symptomatic SLAP lesion who participate in recreational level of sports. IV.

Immediate Administration of Intraarticular Triamcinolone Acetonide After Joint Injury Modulates Molecular Outcomes Associated With Early Synovitis.

To test whether intraarticular corticosteroid injection mitigates injury-induced synovitis and collagen degradation after anterior cruciate ligament transection (ACLT) and to characterize the synovial response using a functional genomics approach in a preclinical model of posttraumatic osteoarthritis. Yorkshire pigs underwent unilateral ACLT without subsequent corticosteroid injection (the ACLT group; n = 6) or ACLT with immediate injection of 20 mg triamcinolone acetonide (the steroid group; n = 6). A control group of pigs (the intact group; n = 6) did not undergo surgery. Total synovial membrane cellularity and synovial fluid concentration of C1,2C neoepitope-bearing collagen fragments 14 days after injury were primary end points and were compared between the ACLT, steroid, and intact groups. Cells were differentiated by histologic phenotype and counted, while RNA sequencing was used to quantify transcriptome-wide gene expression and monocyte, macrophage, and lymphocyte markers. In the intact group, total cellularity was 13% (95% confidence interval [95% CI] 9-16) and the C1,2C concentration was 0.24 μg/ml (95% CI 0.08-0.39). In the ACLT group, significant increases were observed in total cellularity (to 21% [95% CI 16-27]) and C1,2C concentration (to 0.49 μg/ml [95% CI 0.39-0.59]). Compared to values in the ACLT group, total cellularity in the steroid group was nonsignificantly decreased to 17% (95% CI 15-18) (P = 0.26) and C1,2C concentration in the steroid group was significantly decreased to 0.29 μg/ml (95% CI 0.23-0.35) (P = 0.04). A total of 255 protein-coding transcripts were differentially expressed between the ACLT group and the intact group. These genes mainly enriched pathways related to cellular immune response, proteolysis, and angiogenesis. Mononuclear leukocytes were the dominant cell type in cell-dense areas. MARCO, SOCS3, CCR1, IL4R, and MMP2 expression was significantly associated with C1,2C levels. Early intraarticular immunosuppression mitigated injury-induced increases in collagen fragments, an outcome better predicted by specific marker expression than by histologic measures of synovitis.

Therapeutic Review of Methylprednisolone Acetate Intra-Articular Injection in the Management of Osteoarthritis of the Knee - Part 1: Clinical Effectiveness.

Intra-articular (IA) corticosteroid injections are a common approach in the management of osteoarthritis (OA) of the knee. The effectiveness of injections and particular injection products is often discussed and debated in clinical arenas. The following therapeutic review examines the evidence for intra-articular methylprednisolone acetate (MPA) injections in the management of OA knee. A review of research evidence, published guidelines and clinical literature was undertaken following an electronic database and relevant literature search. The review found that there is limited evidence which indicates that a single dose intra-articular MPA injection can provide short to medium term benefits for pain, with less evidence for beneficial effects on function or stiffness. There is heterogeneity across studies and until recently, most studies had only short to medium term follow-up periods, thus limiting the evidence available on longer term benefit. There was also evidence indicating equivalent overall efficacy of MPA to that of other corticosteroid products. Most guideline recommendations concerning IA injections for OA knee have drawn on evidence from pooled data for several corticosteroid products. The review also found there was limited reporting of the incidence of adverse events in most studies. Overall, MPA shows efficacy for symptom relief in OA knee. At an individual management level, evidence for a limited duration of effect needs consideration in injections decisions. Furthermore, consensus across clinical guidelines suggests that the management of OA knee should be individualized to a person's clinical history, degree of disability, risk factors, quality of life and personal preferences, whereby injecting involves a shared decision and forms part of a multimodal approach. Copyright © 2016 John Wiley & Sons Ltd.

Ultrasound in juvenile idiopathic arthritis.

BackgroundIn the recent years, musculoskeletal ultrasound (MSUS) has been regarded as especially promising in the assessment of juvenile idiopathic arthritis (JIA), as a reliable method to precisely document and monitor the synovial inflammation process.Main contentMSUS is particularly suited for examination of joints in children due to several advantages over other imaging modalities. Some challenges should be considered for correct interpretation of MSUS findings in children, due to the peculiar features of the growing skeleton. MSUS in JIA is considered particularly useful for its ability to detect subclinical synovitis, to improve the classification of patients in JIA subtypes, for the definition of remission, as guidance to intraarticular corticosteroid injections and for capturing early articular damage. Current evidence and applications of MSUS in JIA are documented by several authors. Recent advances and insights into further investigations on MSUS in healthy children and in JIA patients are presented and discussed in the present review.ConclusionsMSUS shows great promise in the assessment and management of children with JIA. Nonetheless, anatomical knowledge of sonographic changes over time, underlying immunopathophysiology, standardization and validation of MSUS in healthy children and in patients with JIA are still under investigation. Further research and educational efforts are required for expanding this imaging modality to more clinicians in their daily practice.