Intra-articular Injection In Patients Research Articles

Intra-articular injections of botulinum toxin a for refractory joint pain: a systematic review and meta-analysis

Objective: To assess the benefit of intra-articular injection of Botulinum toxin A (BoNT-A) for chronic refractory joint pain regardless of joint or pathology. Data sources: The search was performed on Ovid MEDLINE(R) In-Process and Other Non-Indexed Citations, Ovid MEDLINE(R), Ovid EMBASE, Web of Science, and Scopus inception through Week 12, 2016. Trial selection: Clinical randomized controlled trials that evaluated BoNT-A intra-articular injection in patients with refractory joint pain were included. Data extraction: Two independent reviewers conducted data extraction. Results: A total of 6 out of 284 records were included. The analysis indicated that a statistically significant decreased pain score was found in BoNT-A therapy group than control group with WMD=1.10 (95% CI: 0.35 to 1.85; P<0.001; I2=95%); WMD=0.7 (95% CI: 0.09 to 1.32; P=0.02; I2=0%) at week 4, and 8 after injection, respectively. WOMAC score was also significant decreased in BoNT-A therapy group than control group with WMD=4.71 (95% CI: 2.76 to 6.67; P<0.001; I2=0%); WMD=3.67 (95% CI: 1.08 to 6.26; P=0.006; I2=27%) at week 4 and12 after injection, respectively. There was no difference in adverse event between BoNT-A therapy group and control group with OR=1.25 (95% CI: 0.88 to 1.78; P=0.47; I2=0%). Conclusion: As compared with conventional therapy, BoNT-A intra-articular injection have beneficial effects with improved pain score and WOMAC score in adult patients with refractory joint pain.

Intra-articular injection in patients with juvenile idiopathic arthritis: factors associated with a good response

IntroductionIntra-articular injection of corticosteroids (IIC) for treatment of patients with juvenile idiopathic arthritis (JIA) is increasingly used in Pediatric Rheumatology. ObjectivesTo describe the clinical course of patients undergoing IIC in our Pediatric Rheumatology Unit. MethodsRetrospective study of patients with JIA undergoing IIC from January 2008 to December 2012, with a minimum follow-up of six months after the injection. Good response to IIC was set as the presence of inactivity on the infiltrated joint by at least six months. ResultsEighty-eight patients underwent a total of 165 IICs. Of these, 75% were girls and 35.2% had persistent oligoarticular JIA. The mean age at diagnosis was 6.8 years, and when IIC was carried out, 12.2 years. Regarding patients, younger age at diagnosis (p=0.037) and the occurrence of uveitis in the course of the disease (p=0.015) were associated with good response to IIC. From 165 IICs, 63% had a good response and joints remained inactive for a median of 18.1 months. The type of joint injection (p=0.001), lesser values stated in the overall visual analog scale by the physician (p=0.015) and by parents/patient (p=0.01) have been associated with a good response to IIC. Nine adverse events (5.4%) were observed. ConclusionIn our study, more than half of the joints showed a good response to IIC. Younger patients at diagnosis and uveitis during the course of the disease had good response to IIC. Knees, wrists and elbows were the joints that best responded to IIC. IIC proved to be a safe procedure.

Proper site of corticosteroid injection for the treatment of idiopathic frozen shoulder: Results from a randomized trial

ObjectiveThe objective is to determine whether corticosteroid injection into the subacromial space was not inferior to intra-articular injection in patients with idiopathic frozen shoulder (FS), and whether combined injections had an additive effect. MethodsPatients with idiopathic FS (n=126) were randomly assigned to receive ultrasound-guided intra-articular (IA group), subacromial (SA group), or combined IA and subacromial injections (IA+SA group). All groups received a total dose of 40mg triamcinolone acetonide. The outcome measures included the visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeon (ASES) shoulder score, subjective shoulder value (SSV), and passive range of motion before and at 3, 6, and 12 weeks after treatment. ResultsThere was significant effect of time on all measurements such that all measures improved in all groups (P<0.001) during the 12 weeks after treatment. Group-by-time interactions were significant for ASES (P=0.006), VAS (P<0.001), SSV (P=0.03), and internal rotation (P=0.014). Between-group comparisons revealed a significant improvement in the IA (P<0.001) and IA+SA (P<0.001) groups as compared to the SA group. The IA+SA group demonstrated significant improvement in internal rotation as compared to the IA group (P=0.046). ConclusionThe efficacy of corticosteroid injection into the SA space in idiopathic FS was inferior to IA injection up to 12 weeks; however, combination injections had an additive effect on increasing the internal rotation angle. These results indicate that although the glenohumeral joint is a major site in the pathogenesis of idiopathic FS, the SA space may be a contributing site.

Intra-articular injections of triamcinolone hexacetonide in rheumatoid arthritis: short and long-term improvement predictors

ObjectivesIdentify good response predictors to intra-articular injection (IAI) with triamcinolone hexacetonide (TH). MethodsThis study was carried out in rheumatoid arthritis (RA) patients (American College of Rheumatology criteria) submitted to IAI (mono, pauci or polyarticular injection). Assessmenta “blinded” observer prospectively evaluated joints at one week (T1), four weeks (T4), twelve weeks (T12) and 24 weeks (T24) after IAI. Outcome measurements included Visual Analogue Scale (0-10cm) at rest, in movement and for swollen joints. Clinical, demographic and variables related to injection at baseline were analyzed according to IAI response. ResultsWe studied 289 patients with RA (635 joints) with a mean age of 48.7 years (±10.68), 48.5% of them Caucasians, VAS for global pain=6.52 (±1.73). Under univariate analysis, the variables relating the best responses following IAI (improvement > 70%) were: “elbow and metacarpophalangeal (MCP) IAI, and functional class II”. Under multivariate analysis, “males” and “non-whites” were the predictors with the best response to IAI at T4, while “elbow and MCP IAI”, “polyarticular injection”, “use of methotrexate” and “higher total dose of TH” obtained the best response at T24. ConclusionSeveral predictors of good response to IAI in patients with RA were identified. The best-response predictors for TH IAI of long term were “inject elbow and MCP IAI” and “perform polyarticular injection”.

PRP and articular cartilage: a clinical update.

The convincing background of the recent studies, investigating the different potentials of platelet-rich plasma, offers the clinician an appealing alternative for the treatment of cartilage lesions and osteoarthritis. Recent evidences in literature have shown that PRP may be helpful both as an adjuvant for surgical treatment of cartilage defects and as a therapeutic tool by intra-articular injection in patients affected by osteoarthritis. In this review, the authors introduce the trophic and anti-inflammatory properties of PRP and the different products of the available platelet concentrates. Then, in a complex scenario made of a great number of clinical variables, they resume the current literature on the PRP applications in cartilage surgery as well as the use of intra-articular PRP injections for the conservative treatment of cartilage degenerative lesions and osteoarthritis in humans, available as both case series and comparative studies. The result of this review confirms the fascinating biological role of PRP, although many aspects yet remain to be clarified and the use of PRP in a clinical setting has to be considered still exploratory.

Infiltrações intra‐articulares de triancinolona hexacetonida na artrite reumatóide: preditores de melhora a curto e longo prazo

ObjectivesIdentify good response predictors to intra‐articular injection (IAI) with triamcinolone hexacetonide (TH). MethodsThis study was carried out in rheumatoid arthritis (RA) patients (American College of Rheumatology criteria) submitted to IAI (mono, pauci or polyarticular injection). AssessmentA “blinded” observer prospectively evaluated joints at one week (T1), four weeks (T4), twelve weeks (T12) and 24 weeks (T24) after IAI. Outcome measurements included Visual Analogue Scale (0‐10cm) at rest, in movement and for swollen joints. Clinical, demographic and variables related to injection at baseline were analyzed according to IAI response. ResultsWe studied 289 patients with RA (635 joints) with a mean age of 48.7 years (±10.68), 48.5% of them Caucasians, VAS for global pain=6.52 (±1.73). Under univariate analysis, the variables relating the best responses following IAI (improvement > 70%) were: “elbow and metacarpophalangeal (MCP) IAI, and functional class II”. Under multivariate analysis, “males” and “non‐whites” were the predictors with the best response to IAI at T4, while “elbow and MCP IAI”, “polyarticular injection”, “use of methotrexate” and “higher total dose of TH” obtained the best response at T24. ConclusionSeveral predictors of good response to IAI in patients with RA were identified. The best‐response predictors for TH IAI of long term were “apply elbow and MCP IAI” and “apply polyarticular injection”.

A46: Analysis of Factors Associated With Good Response to Intra‐articular Injections in Patients With Juvenile Idiopathic Arthritis

Background/Purpose:The intra‐articular steroids injections (IASI) for treatment of juvenile idiopathic arthritis (JIA) patients are being increasingly used in pediatric rheumatology. Most on knowledge about IASI comes from studies on adults and animal models and there are few reports on children. The aims of this study were to describe and to assess the factors associated with good response to IASI in JIA patients.Methods:A retrospective study of JIA patients who were administered IASI with a minimum follow‐up of six months was performed between January 2008 and December 2012. The response to IASI regarding the patients was classified as a good response (complete—all joints remained inactive for at least six months or partial—part of the joints remained inactive for at least six months) or poor response (all joints remained active or reactivated in less than six months). The response to IASI regarding the joints was classified as a good response (the joints remained inactive for at least six months) or poor response (the joints remained active or reactivated in less than six months).Results:A total of 165 IASI were administered to 88 patients. Of the 88 JIA patients, 66 were female, 35.2% were persistent oligoarticular, 19.3% extended oligoarticular, 38.6% polyarticular, 4.5% systemic, 1.1% enthesitis related arthritis and 1.1% psoriatic. Patients were grouped according to disease course in oligoarticular—37.5%, polyarticular—58% and systemic—4.5%. The mean time to diagnosis was 10.5 ± 16 months, the mean age at diagnosis was 6.8 ± 4 years and the mean follow‐up time was 7.0 ± 4 years. Sixty‐two patients (70.4%) showed good response to IASI, 44.3 % complete and 26.1% partial. There were no associations between the responses to the IASI and gender (p = 0.42), JIA subtype (p = 0.07), disease course (p = 0.08), antinuclear antibodies (p = 0.12), rheumatoid factor (p = 0.27), time to diagnosis (p = 0.73) and mean follow‐up time (p = 0.08). There was an association between good response to IASI and presence of uveitis (p = 0.01) and earlier age of diagnosis (p = 0.03). From the 165 joints injected, there were 100 knees, 30 ankles, 15 wrists, 9 elbows, 6 hips, 3 shoulders and 2 hand's proximal interphalangeal. A hundred and four joints (63%) showed good response to IASI, with mean duration of 18.1 ± 13 months. There were no associations between the responses to the IASI and the severity of joint effusion (p = 0.49), use of DMARDs (p = 0.31) or oral steroids (p = 0.55), time of follow‐up until the IASI (p = 0.25), age at IASI (p = 0.53), CHAQ (p = 0.53), C reactive protein (p = 0.22), erythrocyte sedimentation rate (p = 0.41) and number of active (p = 0.09) and limited (p = 0.77) joints at the time of IASI. There was an association between good response to IASI and the injected joint (p = 0.001)—knees, wrists and elbows, the use of ultrasonography to guide the IASI (p = 0.02) and the parents (p = 0.01) and physician (p = 0.01) visual analogue scale. Local adverse events occurred in nine (0.05%) IASI (five atrophy and four hypochromia).Conclusion:This study showed that IASI are effective, safe and have a good sustained response. More prospective studies are needed to better define the profile of JIA patients who may benefit from IASI.

Efetividade da infiltração intra-articular guiada por imagem: comparação entre fluoroscopia e ultrassom

ObjectiveCompare the effectiveness of ultrasound and fluoroscopy to guide intra-articular injections (IAI) in selected cases. Material and methodsA prospective study in our outpatient clinics at the Rheumatology Division at Universidade Federal de São Paulo (UNIFESP), Brazil, was conducted to compare the short-term (4 weeks) effectiveness of ultrasound and fluoroscopy-guided IAI in patients with rheumatic diseases. Inclusion criteria were: adults with refractory synovitis undergo- ing IAI with glucocorticoid. All patients had IAI performed with triamcinolone hexaceton- ide (20mg/ml) with varying doses according to the joint injected. ResultsA total of 71 rheumatic patients were evaluated (52 women, 44 whites). Mean age was 51.9 ± 13 years and 47 of them (66.2%) were on regular DMARD use. Analysis of the whole sample (71 patients) and hip sub-analysis (23 patients) showed that significant im- provement was observed for both groups in terms of pain (P < 0.001). Global analysis also demonstrated better outcomes for patients in the FCG in terms of joint flexion (P < 0.001) and percentage change in joint flexion as compared to the USG. Likert scale score analyses demonstrated better results for the patients in the USG as compared to the FCG at the end of the study (P < 0.05). No statistically significant difference between groups was observed for any other study variable. Discussion and conclusionImaging-guided IAI improves regional pain in patients with vari- ous types of synovitis in the short term. For the vast majority of variables, no significant difference in terms of effectiveness was observed between fluoroscopy and ultrasound- guided IAI.

Effectiveness of imaging-guided intra-articular injection: a comparison study between fluoroscopy and ultrasound

ObjectiveCompare the effectiveness of ultrasound and fluoroscopy to guide intra-articular injections (IAI) in selected cases. Material and methodsA prospective study in our outpatient clinics at the Rheumatology Division at Universidade Federal de São Paulo (UNIFESP), Brazil, was conducted to compare the short-term (4 weeks) effectiveness of ultrasound and fluoroscopy-guided IAI in patients with rheumatic diseases. Inclusion criteria were: adults with refractory synovitis undergo- ing IAI with glucocorticoid. All patients had IAI performed with triamcinolone hexaceton- ide (20mg/ml) with varying doses according to the joint injected. ResultsA total of 71 rheumatic patients were evaluated (52 women, 44 whites). Mean age was 51.9 ± 13 years and 47 of them (66.2%) were on regular DMARD use. Analysis of the whole sample (71 patients) and hip sub-analysis (23 patients) showed that significant im- provement was observed for both groups in terms of pain (P < 0.001). Global analysis also demonstrated better outcomes for patients in the FCG in terms of joint flexion (P < 0.001) and percentage change in joint flexion as compared to the USG. Likert scale score analyses demonstrated better results for the patients in the USG as compared to the FCG at the end of the study (P < 0.05). No statistically significant difference between groups was observed for any other study variable. Discussion and conclusionImaging-guided IAI improves regional pain in patients with vari- ous types of synovitis in the short term. For the vast majority of variables, no significant difference in terms of effectiveness was observed between fluoroscopy and ultrasound- guided IAI.

AB0969 Accuracy of blind intra-articular injections in patients with osteoarthritis of the knee. An ultrasonography controlled study

BackgroundViscosupplementation by intra-articular injections (IAI) of hyaluronic acid in the knee is widely used for symptom relief in patients with osteoarthritis of this joint. Previous studies have demonstrated that blind...

Frequency of the bleeding risk in patients receiving warfarin submitted to arthrocentesis of the knee

To evaluate the potential bleeding risks of arthrocentesis in patients with different arthropathies and taking oral anticoagulants. Fifteen consecutive patients, 8 males and 7 females, treated with anticoagulant therapy for atrial fibrillation (9 pts), deep venous thrombosis (4 pts) and replacement of cardiac valves (3 pts) were submitted to arthrocentesis for synovial fluid effusion due to different arthropathies. In all patients INR was </= 5. Nine of them were assuming AINS for the joint pain. Two of fifteen patients have hemarthrosis, the first only lightly, the second more frankly. Both the patients were in therapy with AINS and INR was 3.8 and 5, respectively. The hemarthrosis or bleeding frequency associated with intraarticular injections in patients taking anticoagulant therapy seems not very high. Therefore the therapy with oral anticoagulants would not be an absolute contraindication to the arthrocentesis execution.

The Effects of Platelet-Rich Plasma on Cartilage: Basic Science and Clinical Application

Platelet-rich plasma (PRP) is emerging as a biological therapy for the treatment of cartilage injuries and for intra-articular application to address knee pain. Basic science studies indicate that PRP stimulates cell proliferation and the production of cartilage matrix by chondrocytes and bone marrow–derived mesenchymal stromal cells and increases the production of hyaluronic acid by synoviocytes. In preclinical animal model studies, PRP slows the progression of osteoarthritis, but there are mixed results after the use of PRP to facilitate the repair of chondral or osteochondral defects. Clinical studies indicate that PRP-bone marrow–derived stromal cell constructs aid in the repair of chondral defects. A clinical benefit from PRP was also shown for 1 year after intra-articular injection in patients suffering from knee pain. Although most studies support the clinical use of PRP for the treatment of cartilage injury and joint pain, improved classification schemes for PRP and more extensive testing and reporting on the contents of the PRP preparation being applied in the study would aid in the development of treatment protocols.

Intraarticular injection of anakinra in osteoarthritis of the knee: A multicenter, randomized, double‐blind, placebo‐controlled study

To evaluate the clinical response, safety, and tolerability of a single intraarticular injection of anakinra in patients with symptomatic osteoarthritis (OA) of the knee. Patients with OA of the knee were enrolled in a multicenter, double-blind, placebo-controlled study and randomized 2:1:2 to receive a single intraarticular injection of placebo, anakinra 50 mg, or anakinra 150 mg in their symptomatic knee. Patients were evaluated for 12 weeks postinjection. The primary end point was the change in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score from baseline to week 4. Safety assessments included the evaluation of adverse events (AEs), laboratory tests, and vital signs. Pharmacokinetic parameters were assessed in a subset of patients. Of 170 patients who enrolled, 160 (94%) completed the study. The mean improvements from baseline to week 4 in the WOMAC score were not statistically different between the placebo group and the patients who received 50 mg of anakinra (P = 0.67) or 150 mg of anakinra (P = 0.77). Anakinra was well tolerated. No withdrawals due to AEs or serious AEs, and no serious infections or deaths were reported. No clinically significant trends were noted in laboratory values or vital signs. Pharmacokinetic parameters demonstrated that the mean terminal half-life of anakinra in serum after intraarticular injection was approximately 4 hours. Anakinra was well tolerated as a single 50-mg or 150-mg intraarticular injection in patients with OA of the knee. However, anakinra was not associated with improvements in OA symptoms compared with placebo.

Glucocorticosteroids inhibit degradation in bovine cartilage explants stimulated with concomitant plasminogen and interleukin-1 alpha.

Glucocorticosteroids are beneficial in the treatment of osteoarthritis (OA) in humans, and have been shown to protect cartilage in animal models of OA. Therefore, we undertook the present study to investigate the in vitro effect of several glucocorticosteroids on cartilage degradation. Bovine articular cartilage explants labeled with [35S] Sulfate and stimulated either with IL-1 alpha alone or with concomitant plasminogen plus IL-1 alpha were used in this study as an in vitro model of cartilage degradation. Clobetasol propionate, fluocinolone-acetonide-21-acetate, prednisolone, triamcinolone and triamcinolone hexacetonide were the glucocorticosteroids investigated in a series of experiments, at concentrations ranging from 10 picomolar to 10 micromolar. Degradation in [35S] Sulfate-labeled bovine articular cartilage explants was induced with IL-1 alpha or with concomitant IL-1 alpha plus human plasminogen. The effects of several glucocorticosteroids were studied, and a comparison between efficacy in explants stimulated with IL-1 alpha alone or IL-1 alpha plus concomitant plasminogen was made. Glucocorticosteroid efficacy was expressed as percent inhibition of degradation, and their IC50S were also calculated. Glucocorticosteroids showed no protective effects on cartilage degradation in the presence of IL-1 alpha alone. When degradation was induced by IL-1 alpha in the presence of concomitant human plasminogen, all the glucocorticosteroids showed statistically significant.inhibition (p < 0.05) with calculated IC50S of 450-2500 picomolar. The inhibition of cartilage degradation by glucocorticosteroids may be due to down-regulation of urokinase plasminogen activator (u-PA) activity. It has been shown that u-PA may be the first enzyme in the cascade of activation of pro-matrix metalloproteinases by the fibrinolytic system. Inhibition of u-PA activity may be one explanation for the efficacy of glucocorticosteroids observed in animal models of OA and with intraarticular injection in patients with OA.

Methotrexate pharmacokinetics after intraarticular injection in patients with rheumatoid arthritis

Arthritis & RheumatismVolume 23, Issue 1 p. 119-122 Brief ReportsFree to Read Methotrexate pharmacokinetics after intraarticular injection in patients with rheumatoid arthritis Scott M. Wigginton, Scott M. Wigginton From the Department of Medicine, University of California, San Diego, La Jolla, California 92093.Search for more papers by this authorBarbara C. F. Chu, Barbara C. F. Chu From the Department of Medicine, University of California, San Diego, La Jolla, California 92093.Search for more papers by this authorMichael H. Weisman, Michael H. Weisman From the Department of Medicine, University of California, San Diego, La Jolla, California 92093.Search for more papers by this authorStephen B. Howell, Corresponding Author Stephen B. Howell From the Department of Medicine, University of California, San Diego, La Jolla, California 92093.Department of Medicine T006, University of California, San Diego, La Jolla, California 92093Search for more papers by this author Scott M. Wigginton, Scott M. Wigginton From the Department of Medicine, University of California, San Diego, La Jolla, California 92093.Search for more papers by this authorBarbara C. F. Chu, Barbara C. F. Chu From the Department of Medicine, University of California, San Diego, La Jolla, California 92093.Search for more papers by this authorMichael H. Weisman, Michael H. Weisman From the Department of Medicine, University of California, San Diego, La Jolla, California 92093.Search for more papers by this authorStephen B. Howell, Corresponding Author Stephen B. Howell From the Department of Medicine, University of California, San Diego, La Jolla, California 92093.Department of Medicine T006, University of California, San Diego, La Jolla, California 92093Search for more papers by this author First published: January 1980 https://doi.org/10.1002/art.1780230121Citations: 54AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Citing Literature Volume23, Issue1January 1980Pages 119-122 RelatedInformation