Intra-articular Infiltration Research Articles

Postoperative analgesia for arthroscopic shoulder surgery: a prospective randomized controlled study of intraarticular, subacromial injection, interscalenic brachial plexus block and intraarticular plus subacromial injection efficacy

The aim of the present study was to compare the new combination of intraarticular + subacromial injection, with intraarticular, subacromial injection and interscalenic brachial plexus block as postoperative analgesia in shoulder arthroscopy. One hundred and twenty patients scheduled for shoulder arthroscopy were enrolled and randomly assigned to one of five groups: intraarticular, subacromial, interscalenic brachial plexus block (IBPB), intraarticular + subacromial (intraarticular + subacromial) injection or a control group. All patients received standardized general anaesthesia and all the injections were given with the same dose and volume of local anaesthetic. The number of boluses (fentanyl 1 microg kg(-1) delivered by a patient-controlled analgesia pump applied at the end of the surgery and the visual analogue pain score (VAPS) at 0, 2, 4, 6, 12, 18 and 24 h after the intervention were recorded. A patient satisfaction score was also assessed at 24 h. Mean bolus consumption, compared with control group, was significantly less in all groups (P < 0.01). Intraarticular + subacromial group utilized fewer boluses compared with subacromial group and significantly lower boluses than intraarticular group (P < 0.01), but IBPB group utilized significantly fewer boluses than intraarticular + subacromial group. Patients in IBPB, intraarticular + subacromial and subacromial groups showed VAPSs that were significantly better than that of the control group at all time points (P < 0.01). The VAPS in intraarticular + subacromial group was statistically comparable with those in IBPB and subacromial groups at each time interval. IBPB and intraarticular + subacromial groups showed comparable patient satisfaction scores. These results confirm the analgesic efficacy of IBPB for shoulder surgery. Nonetheless, the combination of intraarticular and subacromial infiltration, studied for the first time, appears to be a clinically valid alternative with no clinical meaningful adverse effects.

Does intraarticular steroid infiltration increase the rate of infection in subsequent total knee replacements?

Steroid injection into the arthritic joint is a well-known treatment. Its efficacy is well documented. An increase in the incidence of infection secondary to steroid injection has been reported in recent literature. Based on the current literature we carried out a retrospective study to evaluate the incidence of infection in primary total knee arthroplasty as a result of previous steroid infiltration into the knee joint. In our study, 440 patients underwent total knee replacement between 1997 and 2005. Only 90 patients had intraarticular steroid injection prior to surgery, of which 45 patients had injection within 1 year prior to surgery. A matched cohort of 180 patients who had total knee replacement without steroid injection was used as control group to compare the infection rate. All patients had at least 1 year follow up. Two cases of superficial infection were noted in the study group and five cases of superficial infection in the control group. No cases of deep infection were noted in either group. Statistical analysis showed no significant difference in incidence of infection in either group ( P value 1.0). This study showed no increase in the incidence of infection in patients with total knee arthroplasty with prior steroid injection.

Similar clinical outcome after unicompartmental knee arthroplasty using a conventional or accelerated care program

Background and purpose Over the last 5 years, there has been increasing interest in reducing length of hospitalization (LOS) through accelerated programs. We examined the clinical outcome of patients undergoing a unicompartmental knee replacement (UKR) in an accelerated care program (A group) compared to a conventional care program (C group).Methods 40 patients randomized into 2 groups were included (A group: 17 patients; C group: 23 patients). Nausea, micturition problems, lower limb dysfunction, pain (VAS), opiate consumption, Knee Society score (KSS), day of discharge, rehospitalization within 3 months, contact with a general physician or nurse, and level of satisfaction were registered. Patients in the A group attended an information meeting. An intraarticular infiltration with Marcaine and adrenaline was used peroperatively. Patients in the C group had an epidural pump for 2 or 3 days. Patients in the A program were treated with NSAID and paracetamol postoperatively. Opiates were used in both groups in the case of breakthrough pain. The patients were considered ready for discharge when they were able to climb stairs to the second floor within 5 min.Results The median length of stay was 1 (1–3) day in the A group and 6 (4–7) days in the C group. The median pain score (VAS) at day 0 was 1 (0–3) in the A group and 5 (0–8) in the C group (p < 0.001). 11/23 of the patients in the C group had weakness of the lower limbs on day 1 due to the epidural; all patients in the A group were exercising on the day of the operation. Micturition problems necessitating intermediate catherization were more frequent in patients in the C program (19/23) than in patients in the A programme (3/17) (p = 0.001). There were no statistically significant differences between the two groups concerning nausea, average pain on days 1 and 2, use of opioids (during the first week postoperatively), KSS, contact with primary sector, level of satisfaction, or level of confidence.Interpretation We achieved a reduction in LOS of 5 days without affecting the clinical outcome.

Ultra Low‐Dose Naloxone and Tramadol/Acetaminophen in Elderly Patients Undergoing Joint Replacement Surgery: A Pilot Study

A pilot study was conducted to assess whether both the rationale and feasibility exist for future randomized clinical trials to evaluate the combined use of naloxone infusion and tramadol/acetaminophen as opioid-sparing drugs in elderly patients undergoing lower extremity joint replacement surgery. Ten patients 70 years of age or older undergoing either total knee (n=7) or total hip (n=3) arthroplasty were treated prospectively. Each patient received two tablets of tramadol/acetaminophen (Tramacet; Janssen-Ortho Inc, Canada) preoperatively and every 6 h postoperatively, as well as a naloxone infusion started preoperatively at 0.25 microg/kg/h and continued up to 48 h postoperatively. In addition, standard intraoperative care was provided with 0.2 mg of intrathecal morphine, 1.4 mL of 0.75% bupivacaine, and an intra-articular infiltration of 100 mL of 0.3% ropivacaine and 30 mg of ketorolac, as well as standard postoperative morphine via patient-controlled analgesia orders and celecoxib 200 mg twice daily for five days. Compared with seven historical controls, also 70 years of age or older, who had undergone either a total knee (n=4) or total hip (n=3) arthroplasty, postoperative opioid use was reduced by 80%. Except for transient nausea and vomiting in 40% and 20% of patients, respectively, the 10 patients on tramadol/acetaminophen and naloxone tolerated the new regimen without difficulty. Consequently, a randomized, double-blinded clinical trial comparing standard therapy versus standard therapy plus these two drugs seems warranted. In such a trial, it would require approximately 20 subjects per treatment arm to detect a 80% decrease in morphine use.

Chronicité de l’infection VIH et pathologies émergentes chez les séropositifs

This work describes a technique of platelet-rich plasma (PRP) infiltration for the treatment of severe hip osteoarthritis (OA). Although the results achieved with intra-articular infiltrations of PRP are promising, they may be insufficient in the long-term for severe hip OA. The technique consists of a combined intra-articular and intraosseous infiltration of PRP to reach all joint tissues, especially the subchondral bone, and hence facilitate a greater distribution of PRP. Diagnosis is based on clinical and radiographic findings, and patients with grade III OA according to the Tönnis scale, as well as patients who have not responded to conventional treatment, are considered candidates for this technique. After an ultrasound-guided intra-articular PRP infiltration is performed, 2 intraosseous infiltrations are conducted with a fluoroscope; the first injection is applied into the acetabulum and the second into the femoral head. However, this technique presents more difficulty than the conventional administration, so it is necessary to consider several aspects described in this work.

Continuous Interscalene Analgesia for Rotator Cuff Repair: A Retrospective Comparison of Effectiveness and Cost in 205 Patients from a Multi-Provider Private Practice Setting

Several barriers exist to the routine use of continuous interscalene block (CISB) for postoperative analgesia following rotator cuff repair There is a perception that the technique is feasible only for single operators exposed to a high volume case load. The aim of this retrospective review was to compare the three commonly employed analgesic techniques following rotator cuff repair in a multi-provider setting. The techniques studied were CISB, combined single injection interscalene block with postoperative intermittent intra-articular local anaesthetic infiltration (SSISB/IA) and intermittent intra-articular only local anaesthetic infiltration (IA). The clinical records of 205 consecutive patients having open rotator cuff repair over an 18-month period in two private care facilities were reviewed. The primary outcome endpoint was total opioid/tramadol consumption during the period of an overnight hospital stay. The median total opioid and tramadol consumption (in intravenous mg equivalents of morphine) from admission to the post anaesthesia care unit until discharge from hospital was 5 mg in the CISB group and 10 mg for the SSISB/IA and IA groups (P < 0.0001). The proportion of subjects requiring more than one antiemetic for the same period was 1.9% in the CISB group, 16.4% for the SSISB/IA group and 36.1% for the IA group (P < 0.0001). Costs related to the analgesic technique were similar in each group. CISB following rotator cuff repair in a multi-provider setting was associated with reduced total opioid/tramadol and antiemetic consumption, and occurred without a significant increase in the monetary cost.

Efficacy and Safety of Sodium Hyaluronate in the Treatment of Wilkes Stage II Disease

To show whether an intra-articular (IA) infiltration of 1 mL sodium hyaluronate (SH) into the temporomandibular joint (TMJ) would significantly reduce pain and improve joint function in Wilkes stage II disease, compared with the oral administration of a combination of methocarbamol and paracetamol. Forty-one patients with Wilkes stage II disease were selected and randomly assigned to 2 groups. The experimental group received 1 IA infiltration of SH with assessments at days 14, 28, 56, and 84. The control group was given 2 tablets of a combination of methocarbamol 380 mg and paracetamol 300 mg every 6 hours for 4 weeks, with assessments at days 14 and 28. Forty-one patients were randomized into the study (SH: 20 patients, control drug: 21 patients). A statistically significant difference (P < . 05) was detected in favor of the SH group from day 56 onward for TMJ pain at rest, from day 14 onward for pain on jaw opening, and at days 28 and 56 for pain on mastication. The TMJ function was statistically significantly (P < .05) better in the test group at all follow-up visits. The global evaluation of efficacy by both, the patients and investigators, was better for the test group. No adverse reactions were detected with SH. An IA infiltration of SH showed better efficacy in reducing pain and improving joint function in Wilkes stage II disease, compared with the oral administration of methocarbamol-paracetamol tablets.

Nociceptive Nerve Fibers in the Sacroiliac Joint in Humans

A positive response to sacroiliac joint intra-articular infiltration with local anesthetics is used to confirm sacroiliac joint pain. However, current anatomical and histological knowledge concerning the anatomy of pain perception within the sacroiliac joint intra- and peri-articular structures is insufficient to explain the efficacy of this infiltration, because of the use of unspecific histochemical visualization techniques. In this study, immunohistochemistry for calcitonin gene-related peptide (CGRP) and substance P was used to trace nociceptive fibers and receptors in the anterior and interosseous sacroiliac ligaments obtained from 5 human cadavers without history of sacroiliac joint pain. Microscopic analysis of stained slides showed presence of CGRP and substance P immunoreactive fibers. Thick, wavy, formed bundles were observed in dense and loose connective tissue, whereas single, beaded nerve fibers, occasionally ramified, were observed more frequently in the dense connective tissue and next to blood vessels. Based on their morphologic features, these immunoreactive structures were classified as receptors type IV. Additionally, receptors type II were found in anterior and interosseous ligaments, which contained CGRP or substance P immunoreactive free nerve endings. We conclude that the presence of CGRP and substance P immunoreactive fibers in the normal anterior capsular ligament and interosseous ligament provides a morphological and physiological base for pain signals originating from these ligaments. Therefore, diagnostic infiltration techniques for sacroiliac joint pain should consider extra- as well as intra-articular approaches.

Douleur de l’épaule : apport de la radiologie interventionnelle

Different interventional radiology techniques used in the management of the painful shoulder will be reviewed in this article. The etiology of shoulder pain is variable, and several image guided procedures are available, from simple to more complex. US and fluoroscopy guided intra-articular and bursal infiltration techniques will be described. Percutaneous needle removal of calcific deposits and capsular distension/infiltration of adhesive capsulitis will be discussed. Cysts in the spinoglenoid or suprascapular notch may cause impingement of the suprascapular nerve and may be aspirated under US guidance. Finally, percutaneous radio-frequency treatment of symptomatic bone metastases under CT guidance may at times be performed. Musculoskeletal radiologists should be familiar with this spectrum of image guided interventional procedures.

Comparison of peri- and intraarticular analgesia with femoral nerve block after total knee arthroplasty: A randomized clinical trial

Background Postoperative pain after total knee arthroplasty (TKA) can be difficult to manage and may delay recovery. Recent studies have suggested that periarticular infiltration with local anesthetics may improve outcome.Methods 80 patients undergoing TKA under spinal anesthesia were randomized to receive continuous femoral nerve block (group F) or peri- and intraarticular infiltration and injection (group I). Group I received a solution of 300 mg ropivacaine, 30 mg ketorolac, and 0.5 mg epinephrine by infiltration of the knee at the end of surgery, and 2 postoperative injections of these substances through an intraarticular catheter.Results More patients in group I than in group F could walk < 3 m on the first postoperative day (29/39 vs. 7/37, p < 0.001). Group I also had significantly lower pain scores during activity and lower consumption of opioids on the first postoperative day. No differences between groups were seen regarding side effects or length of stay.Interpretation Peri- and intraarticular application of analgesics by infiltration and bolus injections can improve early analgesia and mobilization for patients undergoing TKA. Further studies of optimal drugs, dosage, and duration of this treatment are warranted.

Reduced hospital stay and narcotic consumption, and improved mobilization with local and intraarticular infiltration after hip arthroplasty: A randomized clinical trial of an intraarticular technique versus epidural infusion in 80 patients

Background Epidural analgesia gives excellent pain relief but is associated with substantial side effects. We compared wound infiltration combined with intraarticular injection of local anesthetics for pain relief after total hip arthroplasty (THA) with the well-established practice of epidural infusion.Methods 80 patients undergoing elective THA under spinal block were randomly assigned to receive either (1) continuous epidural infusion (group E) or (2) infiltration around the hip joint with a mixture of 100 mL ropivacaine 2 mg/mL, 1 mL ketorolac 30 mg/mL, and 1 mL epinephrine 0.5 mg/mL at the conclusion of surgery combined with one postoperative intraarticular injection of the same substances through an intraarticular catheter (group A).Results Narcotic consumption was significantly reduced in group A compared to group E (p = 0.004). Pain levels at rest and during mobilization were similar in both groups but significantly reduced in group A after cessation of treatment. Length of stay was reduced by 2 days (36%) in group A compared to group E (p < 0.001).Interpretation Wound infiltration combined with 1 intraarticular injection can be recommended for patients undergoing THA. Further studies of dosage (high/low) and duration of intraarticular treatment are warranted.

Local Anesthesia for Arthroscopy of the Knee in Day-surgery Patients

In this study we assess the effectiveness of local anesthesia in knee arthroscopies carried out in outpatients and the use of subsequent postoperative analgesia. From January to December 2003, within the framework of our Outpatient Program, 56 patients with different knee conditions underwent arthroscopy with local anesthesia and postoperative intraarticular infiltration with bupivacaine. The effectiveness of local anesthesia and postoperative analgesia were assessed by determining pain intensity using a visual analogical scale and by quantifying the use of postoperative analgesia after arthroscopy. Fifty of the 56 patients, had no pain during surgery, with the remaining 6 requiring supplementary analgesia. All patients were discharged from hospital during the 6 hours following surgery and no complications were seen. Local intraarticular anesthesia is ideal for knee arthroscopy since it allows this surgical procedure to be performed as part of an outpatient program, it decreases the need for pain-killers and shows high rates of patient satisfaction. It allows early recovery, rehabilitation, and hospital discharge. En este artículo valoramos la eficacia de la anestesia local para la cirugía artroscópica de la rodilla en pacientes ambulatorios y la analgesia postoperatoria. De enero a diciembre de 2003 y dentro del programa de cirugía ambulatoria fueron intervenidos 56 pacientes de diferentes patologías de la rodilla mediante cirugía artroscópica y bajo anestesia local, e infiltración intraarticular postoperatoria con bupivacaína. Se ha valorado la eficacia de la anestesia local y la analgesia postoperatoria determinando la intensidad del dolor mediante la escala visual analógica y el consumo de analgésicos tras la cirugía artroscópica. De los 56 pacientes, 50 no tuvieron dolor durante la cirugía, en los otros 6 fue necesario suplementar la analgesia. Todos los pacientes fueron dados de alta hospitalaria en las primeras 6 horas tras la cirugía y no se detectó ninguna complicación. La anestesia local intraarticular es un método ideal para la artroscopia de la rodilla dentro del programa de cirugía ambulatoria, permitiendo la realización de esta técnica quirúrgica disminuyendo el consumo de analgésicos por proporcionar una adecuada analgesia y una alta satisfacción. Permite una recuperación, un alta hospitalaria y una rehabilitación precoces.

The long-term efficacy of corticosteroid injection into the acromioclavicular joint using a dynamic fluoroscopic method

Purpose: Accuracy and efficacy of an intra-articular infiltration of corticosteroid and local anesthetic in the symptomatic acromioclavicular joint were studied in 44 patients. Methods: Accuracy of the infiltration was studied using a blind technique with a dynamic fluoroscopic control. Results: Accuracy of the blind infiltration technique was only 50% and the dynamic fluoroscopic technique remains our preferred technique in the clinical setting. On average patients reported a 65% decrease in the intensity of the pain following the injection. At an average follow-up of forty-two months, 59% had undergone surgery, 14% of patients reported more than three months of symptoms relief. Conclusions: Despite the poor long-term results of injecting the acromioclavicular joint, it remains a valuable technique. It has a low cost, minor risks of complications and has high diagnostic value. All but one patients reporting short-term pain relief. Level of Evidence: Level III, case control study.

Knee Osteoarthritis: Condroprotector Action and Symptomatic Effect of Ozone on Pain, Function, Quality of Life, Minimal Joint Space and Knee Arthroplasty Delay

Objectives: To evaluate the effect of Ozone on pain, function, quality of life, minimal joint space and knee arthroplasty delay in a case series of patients with knee osteoarthritis (OA). Methods: Prospective quasi-experimental before-after study on 52 out of 120 patients with knee osteoarthritis (OA) Kellgren-Lawrence (K-L) grade 2 or more, who attended Santa Cristina's University Hospital, from January 2012 to June 2016. The Ozone protocol consisted of four sessions (1 session/week) of an intra-articular infiltration of a medical mixture of oxygen-ozone (95% - 5%) at a 20 µg/mL concentration. Pain and quality of life (QoL) were measured by visual analogical scale (VAS) and western ontario and Mc master universities index for osteoarthritis (WOMAC), and minimal internal/external joint space width were measured by plain posterior-anterior weight-bearing knee radiographies at the beginning / end of treatment. Results: Mean age 70.36 years. Women 80.8% (n = 42), men 19.2% (n = 10). The severity of OA according to Kellgren-Lawrence scale was 3° (n = 36; 69.2%). Pain measured by VAS significantly decreased (P < 0.0001) from 8.1 to 2.5. The WOMAC-pain, WOMAC-stiffness and WOMAC-function subscales decreased significantly (P < 0.0001) from 16.5 to 4.9 points, 3.2 to 2 and 48 to 17.6, respectively. With respect to minimal joint space, the internal compartment measured 4.17 mm and increased significantly to 4.44 mm (P = 0.0003); while the external compartment was 6.02 mm and improved significantly to 6.26 mm (P = 0.0032) after the treatment protocol. After a mean of 10 months follow-up to a maximum of 28 months, none of knee OA patients underwent knee arthroplasty replacement. Conclusions: Ozone treatment is capable of producing pain relief, recovery of function and radiological improvement on minimal joint space in knee OA patients. Based on the results of our study, it is assumed that Ozone could slow/revert OA progression, due to the increase in the minimal internal and external joint space width. Ozone treatment delays the need for total knee arthroplasty.

Intraarticular Bupivacaine-Clonidine-Morphine Versus Femoral-Sciatic Nerve Block in Pediatric Patients Undergoing Anterior Cruciate Ligament Reconstruction

We hypothesized that combined femoral-sciatic nerve block (FSNB) offers better analgesia with fewer side effects than intraarticular infiltration (IA) in children undergoing anterior cruciate ligament (ACL) reconstruction. Thirty-six children undergoing ACL reconstruction were randomized to FSNB or IA. FSNB patients had FSNB with bupivacaine (0.125%)-clonidine (2 microg/kg), whereas IA patients received bupivacaine (0.25%)-clonidine (1 microg/kg)-morphine (5 mg). Postoperatively, analgesia was provided with patient-controlled analgesia and rescue morphine. Patient demographics were similar. FSNB patients required less intraoperative fentanyl (50 +/- 40 microg versus 80 +/- 50 microg; P = 0.04). Visual analog scale score for FSNB was smaller than IA in the recovery room (1.8 +/- 3 versus 5.4 +/- 3; P = 0.0002) and during the first 24 h (1.6 +/- 1 versus 2.9 +/- 2; P = 0.01)). FSNB morphine use in the first 18 h was less (7 +/- 13 mg versus 21 +/- 21 mg; P = 0.03). Fewer FSNB patients vomited (11% versus 50%; P = 0.03). IA patients required morphine patient-controlled analgesia sooner. After ACL reconstruction in children, FSNB with bupivacaine-clonidine provides better analgesia with fewer side effects than IA with bupivacaine-clonidine-morphine.

Assessment of the efficacy of joint lavage versus joint lavage plus corticoids in patients with osteoarthritis of the knee

SUMMARYPurpose: Joint lavage (JL), involves the passage of cold sterile 0.9% saline through the knee joint in order to have the fluid reach the inside of the joint capsule. This technique was evaluated as a local treatment for osteoarthritis (OA) of the knee alone (JL) and in combination with intra-articular infiltration with glucocorticoids (JLC).Patients and methods: An overall 299 knees belonging to 205 patients (22% males, 78% females) with a mean age of 67 ± 8 years and osteoarthritis of the knee of radiological grade II or III on the Kellgren scale were randomised in the ratio of 1:4 into two therapeutic groups, namely: JL (n = 62) and JLC (n = 237). All patients received joint lavage on day 0; in those of the JLC group, joint lavage was followed by infiltration of 40 mg of triamcinolone acetonide. The efficacy of both treatments was assessed by recording the corresponding values for the following variables: pain strength as measured by a visual analogy scale (VAS), effusion, crepitation, restricted motion, spontaneous pain, pain on pressure, pain on passive motion and pain on active motion; all of these were recorded at the onset of the study, and after 1 and 3 months.Results: There were no significant differences in the values of the variables at the different follow-up times. Also, pain severity was similar in both treatment groups. Thus, VAS for pain was 7.3 ± 0.3 for the JL group and 7.1 ± 0.2 for the JLC group at the onset, and decreased to 3.0 ± 0.3 in the former and 2.8 ± 0.2 in the latter after 1 month; the decrease was statistically significant in both cases. After 3 months, the JL and JLC groups had a VAS of 3.5 ± 0.3 and 3.8 ± 0.2, respectively.Conclusions: The results of this work suggest the absence of significant differences between the two treatments, such that both joint lavage alone and with infiltration with corticoids can be concluded as similarly effective for the symptomatic management of osteoarthritis of the knee.

Acute Treatment of Facet Syndrome by CT-Guided Injection of Dexamethasone-21-Palmitate???Alone and in Combination with Mepivacaine

To compare the efficacy and tolerability of dexamethasone-21-palmitate and mepivacaine alone and in combination in the acute treatment of facet syndrome. A total of 157 patients requiring acute therapy for lumbar facet syndrome were treated with computed tomography (CT)-guided intra-articular infiltration of either an anti-inflammatory corticosteroid, a local anaesthetic or a combination of the two. Patients assigned to the first treatment group (n = 60) received the corticosteroid dexamethasone-21-palmitate (Lipotalon((R))); patients in the second group (n = 36) received the local anaesthetic mepivacaine (Meaverin((R))); patients in the third group (n = 61) received a combination of the two drugs. The study duration was from November 2002 until June 2003. In all three groups, values for compression pain, stress pain and rest pain improved significantly from baseline within 1 hour of injection: in the dexamethasone monotherapy group there was a 13% reduction in compression pain, 20% reduction in stress, and 22% reduction in rest pain; in the groups that received mepivacaine only or a combination of the two drugs there was a 63% and 60%, respectively, reduction of compression pain, 81% and 83%, respectively, reduction of stress pain, and 84% and 77%, respectively, reduction of rest pain. After 72 hours, improvements in these variables were significantly greater in patients treated with dexamethasone-21-palmitate (either as monotherapy or in combination therapy) than in patients treated with mepivacaine alone. In both groups treated with dexamethasone palmitate there was a 57% and 64%, respectively, reduction of compression pain, 70% and 66%, respectively, reduction of stress pain, and 75% and 64%, respectively, reduction of rest pain. In the mepivacaine monotherapy group there was a 17% reduction in compression pain, 26% reduction in stress pain and 13% reduction in rest pain. Both physicians and patients also rated the dexamethasone-21-palmitate-containing regimens as more effective than mepivacaine alone at 72 hours. Over the entire observation period, combination therapy was, on average, superior to both monotherapy regimens. The proportion of patients using concomitant NSAID medication after 3 days was reduced by 50% in the mepivacaine group and by 76% and 100%, respectively, in the dexamethasone-21-palmitate and combination therapy groups. CT-guided infiltration treatment was well tolerated and was associated with virtually no side effects in this study. CT-guided infiltration of dexamethasone palmitate, particularly in combination with mepivacaine, represents a safe and effective method for the acute therapy of lumbar facet syndrome. The combination is superior to the local anaesthetic alone with regard to pain reduction up to 3 days after injection.

Intra‐articular rifamycin in haemophilic arthropathy

Synoviorthesis is the intra-articular injection of chemical or radioactive substances able to produce fibrosis of hypertrophied synovium, which has proved effective in the treatment of chronic haemophilic synovitis. Between September 1999 and October 2001 we treated 28 outpatients (25 with haemophilia A, three with haemophilia B). Our treatment was focused on pain and functional limitation of joints. A schedule was adopted to treat each joint using intra-articular rifamycin once a week, repeated five times. Patients were covered with factor replacement on demand. Oral analgesia was offered as required because of acute but transient painful inflammatory reaction. Their median age was 34 years (range 15-60 years). The indication for synoviorthesis was chronic synovitis characterized by recurrent haemarthroses, persistent pain and limited range of motion (ROM). Thirty-five joints were treated with a total of 169 injections, including six joints (20%) in patients with inhibitors. In five patients two joints were treated in the same session. Thirty procedures were completed: 24 (80%) were considered effective (as excellent or good), while six were considered insufficient (20%). Pain was reduced in 96% of cases and in 70% the ROM was improved. In our experience intra-articular infiltration with rifamycin appears to be effective in reducing joint pain and in improving the ROM. The procedure presents a low risk of bleeding, can be used for patients with inhibitors and multiple joints can be treated without any additional cost.

Incidence and mechanisms of infiltration of sarcomas in the shoulder.

The intraarticular infiltration of sarcomas around the shoulder was analyzed. Of 58 sarcomas located around the shoulder, which were treated between 1993 and 1998, 15 osteosarcomas, 12 chondrosarcomas, and one Ewing's sarcoma that abutted the shoulder were selected. Radiologic images of 28 tumors were analyzed and compared with pathologic examinations. In 17 of 28 sarcomas (15 in the proximal humerus and two in the scapula), joint infiltration was suspected radiologically because of the existence of a tumor mass probably inside the joint or disruption of the joint surface and protrusion of the tumor. Seven of 17 tumors with radiologically positive and zero of 11 tumors with radiologically negative findings showed histologically positive findings for tumor inside the joint. Four of 11 osteosarcomas and three of four chondrosarcomas of the proximal humerus showed histologic findings of joint infiltration. Pericapsular extension was seen in two patients, direct articular spread with a pathologic fracture was seen in two patients, direct articular spread was seen in one patient, direct articular spread with pericapsular extension was seen in one patient, and pericapsular extension with a pathologic fracture was seen in one patient. The current study showed that pericapsular or direct articular infiltration into the glenohumeral joint is a phenomenon in sarcoma around the shoulder. Exact assessment of tumor existence inside the joint can be difficult in osteosarcoma and chondrosarcoma, so abnormal radiologic findings should be regarded as proof of existence of tumor, and extraarticular wide resection should be planned.

Local and intra-articular infiltration of bupivacaine before surgery: Effect on postoperative pain after anterior cruciate ligament reconstruction

In a double-blind, randomized trial, 40 patients undergoing open anterior cruciate ligament (ACL) reconstruction using a bone-patellar tendon-bone autograft were randomly allocated to two groups: group A (n = 20) received an intra-articular instillation of 20 mL bupivacaine (0.25%) and a local infiltration of 20 mL bupivacaine (0.5%) 15 minutes before surgery. Group B (n = 20) received an injection of saline solution in the same manner. Patient-controlled on-demand analgesia (PCA) with intravenous piritramid was used for postoperative pain control. A significant decrease in pain scores on a visual analog scale (VAS scale, 0 to 10) was found in the bupivacaine group (group A) at bedrest on the day of surgery only (pain score, 5.5 v 7.3 (scale, 0 to 10), P < .05). At all other times, no significant differences were found. The overall supplemental opioid requirements were not different between the study groups (63.9 v 62.6 mg piritramid/72 hours). A long-lasting, clinically relevant, pain-reducing effect with infiltration of bupivacaine before surgery could not be shown with this study.