Intra-articular Steroid Injection Research Articles

Femoroacetabular impingement in young adults: assessment and management

Femoroacetabular impingement is a cause of hip pain in young adults as a result of premature dynamic contact between the femur and acetabulum that occurs within the physiological range of hip motion. Diagnosis is made by patient history, clinical examination and radiographic findings. Cross-sectional imaging with computed tomography and magnetic resonance arthrography may be necessary in selected patients. Femoroacetabular impingement can be treated non-operatively with physiotherapist-led conservative care including analgesia and intra-articular steroid injections. Arthroscopic hip surgery aiming to restore pain-free functional range of movement and repair damaged labrum can help in selected patients with no pre-existing osteoarthritis. This review outlines the clinical assessment, investigations and management of femoroacetabular impingement in young adults.

Intra articular steroid injection versus shoulder arthroscopy in the patients with adhesive capsulitis

Introduction: Shoulder stiffness has been variously described as frozen shoulder, adhesive capsulitis and scapulohumeral periarthritis. It is commonly found disorder especially in patients with diabetes mellitus. Our aim is to compare the symptomatic and functional outcome of intra articular steroid injection as an out-patient procedure with shoulder arthroscopy for adhesive capsulitis of shoulder. Materials and Methods: The study was conducted by a single surgeon at a tertiary care hospital between October 2017 and May 2019. Total of twenty patients diagnosed with adhesive capsulitis were taken into the study. These patients were divided equally into two groups namely Intra articular injection group (IA) and Shoulder arthroscopy group (SA). The patients were followed by after two, six, twelve and sixteen weeks. They were assessed according to visual analogue scale (VAS) and Quick DASH (Disability of Arm, Shoulder and Hip). The results were analysed using SPSS software (Illinois, Chicago). P value ≤ 0.01 was considered to be statistically significant.Results: The VAS, and Quick DASH were found to be better and statistically significant in SA group as compared to IA group.Discussion: Arthroscopic capsular release when combined with biceps tenotomy, sub acromial decompression, manipulation under anaesthesia and peri articular steroid injection improves the functional outcomes of patients as compared with intra articular injection alone.Conclusion: Shoulder arthroscopy along with steroid injection provides better functional and clinical outcomes as compared with intra articular steroid injection alone.

P38 Never say never: new onset uveitis in adolescence

Abstract Background To highlight the importance of considering new onset uveitis in adolescent patients with longstanding juvenile idiopathic arthritis (JIA). Methods We performed a retrospective review of electronic medical records. Results A 16 year-old girl was diagnosed in 2004, aged 15 months with extended oligoarticular JIA (ANA positive, >1/640 homogeneous). Her initial treatment included intra-articular steroid injections and approximately eighteen months later methotrexate, which she remained on for four years. During this time she received occasional intra-articular steroid injections. Etanercept was added in 2009 due to persistent active disease and she continued on this treatment regime for the next five years. Methotrexate was discontinued in 2013 due to intolerance. Etanercept was discontinued in 2014 due to disease remission but was restarted after three months when her arthritis flared. In 2018 biologic treatment was changed due to poor disease control. Etanercept was switched to adalimumab, initially alternate weeks but increasing to weekly together with multiple joint injections. Six months later, her disease control remained poor and drug levels and antibodies were measured. She had a strongly positive anti-drug antibody level>200 AU/ml and her adalimumab level was <0.4mgs/L (normal range 5-10). At this time our patient now aged 16 presented with a four-week history of intermittent reduced vision in her right eye. Ophthalmology review found bilateral anterior uveitis. This patient had regular eye screening from her JIA diagnosis until her 11th birthday, showing no previous evidence of uveitis. Following diagnosis of uveitis she was commenced on steroid eye drops and IV methylprednisolone to treat both her uveitis and arthritis. Infliximab, (6mg/kg) was commenced then increased (10mg/kg) for ongoing uveitis and methotrexate was restarted. Despite this treatment she has persistent low grade right uveitis. Her left eye has settled and she has no lens opacities or raised intraocular pressures. She continues with joint discomfort secondary to her hypermobility but her arthritis is currently quiescent. Conclusion Type of arthritis and age at onset historically dictated the risk of developing uveitis. However uveitis can present in any age group and in patients with any type of JIA. In our case uveitis developed for the first time almost 15years after diagnosis. With disease modifying treatments now widely used early in the management of JIA, uveitis may be masked and therefore present late or atypically. It is rare for uveitis to present so long after diagnosis, however this case highlights that rheumatology teams should be aware that it can still develop. Therefore we should never say never! Conflicts of Interest The authors declare no conflicts of interest.

P17 What is the experience of pain pre- and post intra-articular steroid injections in children and young people with juvenile idiopathic arthritis?

Abstract Background A rheumatology service evaluation was carried out in 2016 whereby we sought to understand whether children and young people (CYP) are receiving appropriate pain relief post-administration of steroid intra-articular injections (IAI’s) and whether extended time waiting for IAI’s increases CYP experience of pain. The British Society for Rheumatology BSPAR section Standard of Care for children and young people with JIA recommends 4 weeks or less waiting time for steroid IAI under general anaesthetic (GA) and 10 days or less for steroid IAI under entonox. Methods Data collection was obtained by patient questionnaire over a 4-month period. Parents/carers and CYP were asked to complete a questionnaire pre-steroid IAI (by a member of staff on the day of the IAI) and the same questionnaire post-steroid IAI (by telephone by the author within 2 weeks of the date of the IAI). Twenty parents/carers or CYP completed the questionnaires. Sixteen of the CYP were female and 4 were male. Median age was 3 years. Eighty percent had a diagnosis of oligoarticular juvenile idiopathic arthritis (JIA). Seventy-five percent had IAI’s under GA and 25% with Entonox. Fifty-four percent had knee(s) injected and 23.5% had ankle(s) injected. Results Sixty percent of CYP waited for 4 weeks or less for steroid IAI under GA. Twenty percent of CYP waited for less than 10 days for steroid IAI under entonox. The range of pain scores for CYP pre IAI was 0-10 and the median was 5. Post IAI the range of pain scores was 0-8 and the median was 3. A positive correlation was found between those waiting longer for IAI’s and higher pain scores. P17 Table 1: CYP experience of pain Pre IAI Post IAI Pain in joints injected or due to be injected 95% 55% CYP taking pain medication 85% 55% Type of pain medication: Diclofenac 10% 10% Ibuprofen 25% 10% Naproxen 5% 5% Naproxen & codeine 5% 0% Naproxen & oramorph 0% 5% Paracetamol 10% 10% Paracetamol & ibuprofen 30% 15% None 15% 40% Refusing 0% 5% General activity affected 90% 60% Pain medication required 80% 50% Pain medication effective 80% (100% of CYP requiring medication) 50% (100% of CYP requiring medication) Conclusion In our small cohort, fifty percent of CYP required no pain medication post-IAI, and fifty percent of CYP who did require pain medication post-IAI perceived the pain medication they were receiving was adequate (Table 1). A positive correlation was found between CYP waiting longer for IAI’s and CYP experiencing higher pain scores therefore, accepting our modest sample size, this service evaluation supports ensuring timely access to IAI and the avoidance of longer waiting times. Conflicts of Interest The authors declare no conflicts of interest.

What Are the Costs of Hip Osteoarthritis in the Year Prior to a Total Hip Arthroplasty?

BackgroundThe majority of the cost analysis literature on total hip arthroplasties (THAs) has been focused around the perioperative and postoperative period, with preoperative costs being overlooked. MethodsThe Humana Administrative Claims database was used to identify Medicare Advantage (MA) and Commercial beneficiaries undergoing elective primary THAs. Preoperative healthcare resource utilization in the year prior to a THA was grouped into the following categories: office visits, X-rays, magnetic resonance imagings, computed tomography scans, intra-articular steroid and hyaluronic acid injections, physical therapy, and pain medications. Total 1-year costs and per-patient average reimbursements for each category have been reported. ResultsTotal 1-year preoperative costs amounted to $21,022,883 (average = $512/patient) and $4,481,401 (average = $764/patient) for MA and Commercial beneficiaries, respectively. The largest proportion of total 1-year costs was accounted for by office visits (35% in Commercial; 41% in MA) followed by pain medications (28% in Commercial; 35% in MA). Conservative treatments (steroid injections, hyaluronic acid injections, physical therapy, and pain medications) alone accounted for 40%-44% of the total 1-year costs prior to a THA. A high healthcare utilization within the last 3 months prior to surgery was noted for opioids and steroid injections. ConclusionOn average, $500-$800/patient is spent on hip osteoarthritis-related care in the year prior to a THA. Despite their potential risks, opioids and steroid injections are often utilized in the last 3 months prior to surgery.

Evaluating the Outcome of Two Different Regimes in Adhesive Capsulitis: A Prospective Clinical Study

Objective: Adhesive capsulitis or frozen shoulder is a painful condition affecting up to 5% of the general population. We conducted this study with the aim of evaluating the results of physiotherapy plus intra-articular methylprednisolone injection versus physiotherapy alone in idiopathic frozen shoulder. Methods: This prospective clinical study was conducted in a tertiary care center between August 2016 and August 2018. Patients who were diagnosed with idiopathic frozen shoulder were included in the study, and each patient was randomly allocated to one of two groups: physiotherapy alone (group A) and physiotherapy plus intra-articular steroid injection (group B). Results: A total of 52 cases diagnosed with idiopathic frozen shoulder were included and treated with the two modalities. There was a significant improvement in group B compared to group A at 6 weeks and 3 months in the range of flexion, abduction, and external rotation. The Shoulder Pain and Disability Index showed improvement in both pain and disability score in group B ­compared to group A, and improvement was significant at 6 weeks and 3 months. Conclusion: The results demonstrate the advantages of physiotherapy plus intra-articular steroid injection in idiopathic frozen shoulder. The predictability of results with physiotherapy plus intra-articular steroid injection in selected patients is excellent, and it is a better modality of treatment compared to physiotherapy alone.

A prospective comparative study of functional outcome following arthroscopic debridement and hydrocortisone injection vs arthroscopic debridement and hyaluronicacid injection for the treatment of early primary osteoarthritis knee

Objective: Early knee osteoarthritis in all cases, lead to degenerative medial meniscus lesions which are visible in MRI as chondral defects. As a result, it is difficult to distinguish between unstable meniscus and early osteoarthritis which leads to symptomatic knee pain. Hence, we decided to study improvement athroscopic meniscectomy and injecting Hyaluronic acid or Hydrocortisone in cases of degenerative ruptures of the medial meniscus with changes of early stage medial compartment knee osteoarthritis. Materials and Methods: 60 consecutive cases of early OA Knee of non traumatic origin were studied. They were given treatment of arthroscopic lavage and randomly administered hydrocortisone or hyaluronic acid. The WOMAC score was obtained and compared from immediate post-op period to upto 6 months. Result: In our study on patient undergoing arthroscopic debridement of osteoarthritis knee with Inj. Hydrocortisone improvement in WOMAC score was from 50.97% to 43.81%, totally an improvement of WOMAC score 7.2% while those undergoing arthroscopic debridement of osteoarthritis knee with Inj. Hyaluronic acid improvement in WOMAC score was from 51.25% to 37.1%, totally an improvement in WOMAC score of around 15%. Conclusion: Joint lavage by arthroscopy in combination with either intra-articular steroid injection or intra-articular hyaluronic acid injection provides significant improvement in osteoarthritis knee patient. Data suggests that, those patient who underwent arthroscopic debridement and injection of hydrocortisone had symptomatic improvement at early follow up more than those of the hyaluronic acid, while arthroscopic debridement of osteoarthritis knee and injection of hyaluronic acid performed better at longer follow up. Keywords: WOMAC score, Hyaluronan, Osteoarthritis.

Radiofrequency Ablation for Management of Shoulder Pain.

The treatment options for the management of shoulder pain are broad but evolving process. Modalities for controlling shoulder pain have commonly focused on pharmacotherapy, physical therapy, rehabilitation, and invasive procedures (surgical procedures, surgical, intra-articular steroid injections, many times, being sub-optimal). The use of radiofrequency ablation (RFA) for managing shoulder pain is on the rise. Our review investigated the evidence for the use of RFA in the management of shoulder pain. In our investigation, a review of the literature was conducted using Medline, PubMed, and Cochrane Database of Systematic Reviews from 1966 to 2018. Our study included RCTs, open non-randomized control studies, prospective studies, retrospective studies, case series, and case reports. We limited our search to patients with chronic shoulder pathologies. Our initial search identified 96 articles for initial review. This was narrowed down to 31 articles, which met our inclusion criteria, with only 18 articles remaining after our exclusion criteria was applied. This systematic review suggests that shoulder RFA may provide a safe and significant benefit in the management of chronic shoulder pain. There were a few high-quality RCTs included in our study, which supports the findings of several case reports and case series.

A systematic review of treatment of frozen shoulder by hydrodistension with or without steroid or intraarticular steroid injection

Background: Hydrodistension is a popular mode of treatment for frozen shoulder. Hydrodistension of the shoulder joint capsule is either performed with or without use of a steroid. A simple intraarticular corticosteroid injection into the shoulder joint is also used in treatment of frozen shoulder. This article reviews randomized controlled studies that have shown and compared evidence on efficacy of these two treatment methods. Methods: A systematic review of the literature was done using online database EMBASE, Pubmed, Cochrane database, Medline, and CINAHL. Only randomized studies that compared hydrodistension with or without steroid to intraarticular steroid injection alone were included. Results: Of the five studies identified, three showed no difference between steroid injections alone when compared to distension with steroids. One showed better results with distension with steroid and with intraarticular steroid alone when compared with distension alone. One showed better results with distension with steroids than with intraarticular steroid alone at short-term follow-up of 3 mo. Conclusions: Our systematic review demonstrated that patients treated by any of the three modalities improved with no significant difference among them over a period of 6 to 12 mo. However, at 3 mo distension with steroids and steroid injection alone were superior to distension alone.

Anatomic Considerations for Injection of the Lateral Atlanto-Axial Joint.

We aimed to define the potential complications of intra-articular steroid injections into the lateral C1-2 articulations and safety margins to the relevant structures. A total of 488 contrast-enhanced computed tomography angiogram (CTA) "arch to vertex" studies were retrospectively reviewed for theoretical intersection of the vertebral artery or thecal sac and distance of the named structures from the anticipated/theoretical trajectory of injection into the lateral C1-C2 joint. Patients were 60.4±15.8 years old and 55.5% male. In total, seven vertebral arteries and 11 thecal sac theoretical intersections were found. In cases without a direct intersection, the distance from the trajectory (range) was 0.71±0.18 (0.22-1.44) cm to the vertebral artery and 0.6±0.22 (0.14-1.8) cm to the thecal sac. Although injection of steroid into the lateral C1-C2 articulation for pain management has historically been reported to carry risk of severe complications due to close proximity and location variability of surrounding structures, our study quantifies the potential risk of such injections. Further, our analysis suggests that preprocedural imaging should be considered.

Cooled radiofrequency ablation of the genicular nerves for chronic pain due to osteoarthritis of the knee: a cost-effectiveness analysis based on trial data

BackgroundFor patients with painful knee osteoarthritis, long-term symptomatic relief may improve quality of life. Cooled radiofrequency ablation (CRFA) has demonstrated significant improvements in pain, physical function and health-related quality of life compared with conservative therapy with intra-articular steroid (IAS) injections. This study aimed to establish the cost-effectiveness of CRFA compared with IAS for managing moderate to severe osteoarthritis-related knee pain, from the US Medicare system perspective.MethodsWe conducted a cost-effectiveness analysis utilizing efficacy data (Oxford Knee Scores) from a randomized, crossover trial on CRFA (NCT02343003), which compared CRFA with IAS out to 6 and 12 months, and with IAS patients who subsequently crossed over to receive CRFA after 6 months. Outcomes included health benefits (quality-adjusted life-years [QALYs]), costs and cost-effectiveness (expressed as cost per QALY gained). QALYs were estimated by mapping Oxford Knee Scores to the EQ-5D generic utility measure using a validated algorithm. Secondary analyses explored differences in the settings of care and procedures used in-trial versus real-world clinical practice.ResultsCRFA resulted in an incremental QALY gain of 0.091 at an incremental cost of $1711, equating to a cost of US$18,773 per QALY gained over a 6-month time horizon versus IAS. Over a 12-month time horizon, the incremental QALY gain was 0.229 at the same incremental cost, equating to a cost of US$7462 per QALY gained versus IAS. Real-world cost assumptions resulted in modest increases in the cost per QALY gained to a maximum of US$21,166 and US$8296 at 6 and 12 months, respectively. Sensitivity analyses demonstrated that findings were robust to variations in efficacy and cost parameters.ConclusionsCRFA is a highly cost-effective treatment option for patients with osteoarthritis-related knee pain, compared with the US$100,000/QALY threshold typically used in the US.

Clinical Diagnosis of Sacroiliac Joint Pain

There is a need to establish a standardized clinical examination, based on best available evidence, that identifies those patients with persistent back and buttock pain whose symptoms arise from the sacroiliac joint. This clinical examination is the first step in the selection of patients for controlled and guided diagnostic intra-articular block (the reference standard). This in turn is the prerequisite for selection of patients for minimally invasive therapies such as intra-articular steroid injection or for surgical fusion. The use of pain location and results from pain provocation tests is described within the context of a clinical reasoning algorithm. A cluster of at least 2, preferably 3 provocation tests in the absence of any clear diagnosis of a pain source other than the sacroiliac joint, has a sensitivity of 91% and specificity of 89%. The clinical examination described is reliable, requires no special equipment, and is available from trained clinicians in most developed countries.

SAT0598 RHEUMATIC IMMUNE RELATED ADVERSE EVENTS ASSOCIATED WITH CANCER IMMUNOTHERAPY: A NATIONWIDE MULTI-CENTER CANADIAN COHORT FROM THE CANADIAN RESEARCH GROUP OF RHEUMATOLOGY IN IMMUNO-ONCOLOGY (CANRIO)

Background: Immune checkpoint inhibitors (ICI) have revolutionized cancer therapy by harnessing the immune system to fight cancer. As the indications for ICI continue to expand, their success in advanced stage malignancies is tempered by the development of autoimmune toxicities, referred to as immune-related adverse events (irAE). Rheumatic irAE (Rh-irAE), particularly arthralgias and arthritis are common and optimal management remains unknown. Objectives: The Canadian Research Group of Rheumatology in Immuno-Oncology (CanRIO) is an emerging network of Canadian rheumatologists with an interest in Rh-irAE secondary to ICI. We describe the clinical presentation and management of Rh-irAE associated with ICI in patients seen at 9 CanRIO sites. Methods: Patients presenting with rheumatic symptoms associated with ICI therapy between 2013 and January 2019 at participating CanRIO sites were identified. Cases were stratified based on the presence or absence of pre-existing autoimmune disease (PAD). Standardized data were extracted by chart review. The data were pooled and analyzed descriptively. Results: 118 patients without PAD who developed 140 Rh-irAE were identified, 59% were male with a mean age of 62 years. Common indications for ICI were melanoma (n=57, 48.3%), lung (n=30, 25.4%), and genitourinary cancer (n=19, 16.1%). ICI included nivolumab (n=30, 25.6%), pembrolizumab (n=38, 32.5%), ipilimumab (n=1, 0.9%), durvalumab (n=3, 2.6%), atezolizumab (n=4, 3.4%) or combination therapy (n=29, 24.8%). Common Rh-irAE included symmetric polyarthritis (n=45, 32%), arthralgias/myalgias or acute flare of osteoarthritis (n=20, 14.3%), polymyalgia rheumatica-like presentation (n=17, 12%), tenosynovitis/enthesitis (n=17, 12%), sicca syndrome (n=11, 7.9%) and myositis (n=9, 6.4%). 20 patients with PAD were identified, 70% of whom were in remission prior to starting ICI. 50% (n=10) had flares, 15% (n=3) developed a new Rh-IrAE and 20% (n=4) developed O-irAE. 53% experienced at least one other non-rheumatic irAE (O-irAE) (n=63). Mean time from first ICI exposure to onset of Rh-irAE was 6.8 months. In 65% ICI was held or discontinued (n=77). Despite this, 68.6% (n=81) had favorable tumor response, while 12% (n=14) had tumor progression. There were no deaths related to Rh-irAE. The majority of patients without PAD had partial or complete response to mono or combination therapy with oral prednisone (n=77; maximum dose 60 mg/d), nonsteroidal anti-inflammatories (NSAID; n=52), intra-articular corticosteroids (n=29), hydroxychloroquine (n=26), methotrexate (n=17), or tumor necrosis factor alpha inhibitors (n=9). Conclusion: This is the largest multi-centered cohort of Rh-irAE described to date. Seronegative inflammatory polyarthritis was the most common Rh-IrAE although a broad range of conditions were identified. The most common first-line treatment was systemic corticosteroids followed by NSAID and intra-articular steroid injections. Prednisone was effective, however higher doses were required. Disease-modifying antirheumatic drugs (DMARD) and biologic therapy were well tolerated and effective, with hydroxychloroquine being the most commonly used DMARD. Despite moderate to high doses of immunosuppression, the majority of patients had favorable tumor responses. Disclosure of Interests: Daniel Ennis: None declared, Shahin Jamal Consultant for: Consultant for Abbvie, Amgen, BMS, Eli Lilly, Pfizer, Janssen, Merck, UCB, Marie Hudson Grant/research support from: Unrestricted research funds from Bristol-Myers Squibb, Carrie Ye: None declared, Alexandra Saltman: None declared, Meghan Himmel: None declared, Janet Pope Consultant for: Eli Lilly and Company, Sabrina Hoa: None declared, Annalise Tisseverasinghe: None declared, Aurore Fifi-Mah Grant/research support from: Roche, Abbvie, Janssen, BMS, Speakers bureau: Roche, Abbvie, Janssen, BMS, Pfizer, Nancy Maltez: None declared, Janet Roberts: None declared

Intraarticular corticosteroid injections in the management of osteoarthritis knee

Objective:- The aim of the study was to assess therapeutic efficacy, adverse events and patient satisfaction of intraarticular (IA) corticosteroid injections for knee osteoarthritis (OA).
 Methods:- Thirty-two (96) patients with OA of the knee participated in the present study. The inclusion criteria included (1) Resting visual analog scale pain >50 mm (2) Radiographic evidence for osteoarthritis (as per Kellgren-Lawrence scale) plus; age ≥50yrs, morning stiffness ≤ 30 min and crepitus on motion. Baseline Western Ontario and MacMaster University Osteoarthritis Index (WOMAC) and visual analogue score (VAS) were documented. Patients received intra-articular injections of triamcinolone acetonide 40 mg in the affected knee. The patients were reviewed at 1 weeks, 4 weeks and 8 weeks post-injection with final analysis at 3 months. Use of over the counter analgesia in the form of acetaminophen was allowed for concomitant analgesia.
 Results:- Ninety-six patients (male =45, female=51) with mean age of 50±5 years (range 45-55); duration of symptoms 5.7 ± 0.5 years and mean body mass index (BMI) 29.4kg/m2 were available at final follow-up. The VAS scores at baseline were:- at rest=71 and after 30 meter walk=80 and improved to 35 and 40, respectively. Improvement in pain and disability based on the WOMAC scores were significant. The overall efficacy “Knee Society Score” was judged as excellent in 56.25%, satisfactory in 21.87%, fair in 18.75%, and poor in 3.12%. The beneficial effects stayed till 4-6 weeks.
 Conclusion:- Intra-articular steroid injections for knee OA is safe and effective. The symptomatic relief is prompt, particularly in presence of inflammation (Effusion/synovitis). Proper patient selection and aseptic precautions yield satisfactory results. The need for concomitant analgesia is reduced.

Effectiveness of Intra-articular Steroid Injection in Treatment of Idiopathic Frozen Shoulder Followed by Physiotherapy and Home Exercise Program.

Introduction: Idiopathic frozen shoulder (IFS) is a common chronic and disabling condition of shoulder pain characterized by progressive loss of active and passive range of motion (ROM) with unclear pathogenesis. The ideal treatment protocol is still controversial but commonly used treatment includes single agent or combination of oral non-steroid anti- inflammatory drugs (NSAIDS), oral steroids, intra-articular steroid injection and physiotherapy.
 Objective: The objective of this study was to evaluate the effectiveness of intra-articular methylprednisolone injection for pain and ROM in patients suffering from idiopathic frozen shoulder who did not respond to oral NSAIDS with or without oral steroid.
 Methodology: A total of 70 patients suffering from IFS were enrolled in this cross sectional study from May 2017–October 2018 from outpatient department of orthopaedic and physiotherapy of Koshi Zonal Hospital. All the patients underwent treatment protocol that comprised of Intra-articular steroid injection followed by five days of oral NSAIDS along with five days regime of physical therapy at the physiotherapy centre, followed by home exercise program. Each patient was followed up at every two weeks interval from intra-articular injection till 6th week. Each patient was evaluated for range of motion (ROM), Numerical Pain Rating Scale (NPRS) and Shoulder Pain and Disability Index (SPADI) before the treatment protocol and at every follow up visit. Data was analyzed using Microsoft Excel Program.
 Results: All patients enrolled for the study had satisfactory response. The mean age of the patient was 51.8 years (range 40-65 years). The mean age of the 26 male patients was 54 years (range 45-65), whereas the mean age of 44 female patients was 50.5 years (range 45-60). Mean duration of illness was 26.5 weeks (range 18-32 weeks), SPADI before medication was 83.14, at 2nd week was 50.92, at 4th week was 38.63 and at 6th week was 27.22.
 Conclusion: Combination of intra-articular methylprednisolone injection, physiotherapy and home exercise program is effective in IFS for rapid improvement in pain and ROM.

Evaluation of results of physical therapy v/s intra articular steroid injection in periarthritis of shoulder: a comparative prospective study

<p class="abstract"><strong>Background:</strong> Frozen shoulder or adhesive capsulitis is a condition where the patient experience stiffness and pain in joint of the shoulder. It is an enigma as till now its etiology is unknown. It affects both the genders of the middle and elderly age. A retrospective, comparative study was to evaluate the effects of physical therapy versus intra-articular steroid injection in periarthritis of shoulder.</p><p class="abstract"><strong>Methods:</strong> 30 patients each with frozen shoulder who were treated either using physical therapy (Group 1) and intra-articular steroid injection (Group 2). The data was collected at baseline and at different follow-up periods and analyzed.<strong></strong></p><p class="abstract"><strong>Results:</strong> There were 3 lost to follow-up in physiotherapy group and 4 in intra-articular injection group. Slight male preponderance (51.9% vs. 48.1%) was seen in physiotherapy group. Left side more affected in both the groups. Literacy (p=0.064), socioeconomic status (p=0.22), occupation (p=0.866), comorbidities (p=0.974), abnormal x-ray (p=0.34) were all comparable between the two groups. Mean duration of shoulder pain and restriction of shoulder motion were also comparable (p>0.05). Side effects– 46.2% were higher in intra-articular injection group. Response to treatment, disability score and SPADI index showed significant reduction in both the groups, but significantly more reduction in intra-articular injection was seen in comparison to the physiotherapy group.</p><p class="abstract"><strong>Conclusions:</strong> The overall treatment outcome in intra-articular injection group is much better in comparison to the physiotherapy group, but with higher side effects. Intra-articular injection of steroid will prove to be a boon after effective management of side effects.</p>

Intra-articular injection of steroids in the early postoperative period does not have an adverse effect on the clinical outcomes and the re-tear rate after arthroscopic rotator cuff repair.

The purpose of this study was to compare clinical outcomes and structural integrity following arthroscopic rotator cuff repair, either with intra-articular injection of corticosteroids in the early postoperative period using ultrasound guidance or without it. This study included 318 patients who underwent arthroscopic repair for either a partial-thickness or small-to-medium-sized full-thickness rotator cuff tear from 2012 to 2015. Patients were divided into two groups based on the administration of an intra-articular corticosteroids injection at 3 months after the surgery: group A (with corticosteroid injection, n = 56) and group B (without corticosteroid injection, n = 262). Functional outcomes were evaluated using the visual analog scale (VAS) pain score, subjective shoulder value (SSV), American Shoulder and Elbow Surgeons (ASES) score, University of California Los Angeles (UCLA) shoulder score, and active range of motion (ROM). Postoperative magnetic resonance arthrography (MRA) was performed 6months postoperatively to assess structural integrity. At the 2-year follow-up, both groups showed no significant differences in VAS pain score (group A/B, 1.1 ± 0.9/1.1 ± 1.1), functional scores including SSV (88.5 ± 10.8/88.3 ± 10.0), ASES (90.8 ± 6.6/90.4 ± 6.9), and UCLA scores (30.2 ± 5.6/30.7 ± 5.2), and active ROM including forward flexion (151° ± 8°/153° ± 7°), external rotation (54° ± 5°/55° ± 7°), and internal rotation (10 ± 1/10 ± 2). Follow-up MRA imaging collected 6months after surgery showed no significant difference in the re-tear rate (n.s.) between group A and B (n = 10/56, 17.9% and 45/262, 17.2%, respectively). Intra-articular corticosteroids injection in the early postoperative period after arthroscopic rotator cuff repair provided satisfactory pain relief and ROM improvement without increasing the re-tear rate or deteriorating clinical outcomes at the 2-year follow-up. III.

Management of adhesive capsulitis by combination of hydrodilatation, intra-articular steroid injection and manipulation under anaesthesia

Adhesive capsulitis is characterized by gradually progressive pain and stiffness of the shoulder. Different treatment modalities are available for the management of primary adhesive capsulitis. The aim of this study was to assess the efficacy of using a combination of Hydrodilatation, Intra-articular steroid injection and Manipulation under anaesthesia. The study group comprised of 20 patients with primary adhesive capsulitis with a mean age of 56.15 years. There was significant improvement in pain, range of motion and function in six months follow-up period. No complications were reported in our study.

Management of hip and knee osteoarthritis in general practice: a systematic review

Purpose: Osteoarthritis (OA) management by general practitioners (GPs) is aimed at improving quality of life, self-management and preventing further progression of the disease. Understanding GP reported clinical practice is key when trying to improve adherence to the well-established management guidelines. The aim of this study was to summarise GP reported management of hip and knee OA, including pharmacological and non-pharmacological management, referrals, diagnostic tools and assessment patterns. Methods: Databases (Embase, MEDLINE, CINHAL and Cochrane Central Register for Controlled Trial) were searched using the keywords “general practice”, “treatment” and “osteoarthritis” from inception to June 2018. Published studies that comprised GP reported management for people with hip and knee OA were identified. Risk of bias was assessed based on predetermined measures of informativeness and internal validity. Results: Out of a total of 13,930 records identified through the databases search, 14 original articles were included in this review, all of which used a prospective cross-sectional design. Results were collected from ∼19,446 GPs; response rates ranged from 17% to 90%. Of the included studies, seven studies reported respondents’ male percentage (mean (SD) 72% (18)), six reported respondents’ practice location (urban 60% (18) versus rural 40% (14)) and five reported respondents’ time since graduation (20 years (8)). Overall, studies scored high in most internal validity measures including reproducibility of results and standardising GP management definitions across cohorts. However, eight of the included studies did not adjust analyses for confounding factors such as patients and GPs’ characteristics. Informativeness rated low as seven included studies lacked data on respondents’ baseline characteristics. Pharmacological management: Twelve of the 14 studies included data on GP reported management with non-steroidal anti-inflammatory drugs (NSAIDs) with prescription rates ranging from 15% to 84%. NSAID prescription rates differed by stages of disease severity (stage 1: 43%, stage 2 and 3 >70%) and before and after treatment (19% before, 9.3% after). Paracetamol prescription rates ranged from 7% to 91%, as reported in 10 out of the 14 studies. One Australian study showed that for every 100 patients treated for hip and knee OA, 23 were prescribed paracetamol. Prescription of NSAIDs combined with paracetamol was reported in one study, while prescription of NSAIDs combined with analgesics was reported in three out of the 14 included studies. The rates ranged from 1.4% to 42.8%. Non-pharmacological management: GP reported non-pharmacological management of OA using exercise prescription and/or weight reduction advice was reported in 10 of the 14 studies. The percentages of GPs recommending general exercise ranged from 15% to 87%. Four of the 10 studies which included data on exercise prescription showed that types of recommended exercise included walking, swimming, cycling and hydrotherapy. Weight reduction advice rates ranged from 32% to 68%, as reported in nine of the 14 studies. Five of the 14 included studies reported on management using intra-articular steroid injections and rates were low ranging from 4% to 25%. There was a low percentage of GPs recommending the use of walking sticks in early-stage OA (25% as reported in two studies) and this percentage increased to 45% in the case of acute exacerbation. Referrals: Referral rates to allied health professionals (physiotherapists, exercise physiologists and/or nutritionists) ranged from 0.1% to 62.7%, as reported in seven of the 14 included studies. Referral to orthopaedic surgeons ranged from 7% to 75%, as reported in three studies. GPs also referred to other health care practitioners (6% to 18%), secondary care (13%), rheumatologists (5%) and clinical specialists (46%). Diagnostic tools and assessment patterns Five of the 14 studies reported data on GPs’ use of diagnostic tools when assessing patients with knee or hip OA. Across these studies, 35% to 85% of GPs reported requesting plain radiography (X-ray). One study reported that 28% of GPs would request additional imaging even if patients had previously undergone radiography within the past six months. Two studies reported that >50% of GPs request blood tests to investigate erythrocyte sedimentation rate and blood count. Conclusions: Pharmacological management largely concentrated on NSAIDs and paracetamol, with similar prescription rates for both. Non-pharmacological management using exercise and/or weight reduction and referral to allied health professionals varies widely but appears to be underutilised. Diagnostic imaging use appears high, given OA can be diagnosed clinically, suggesting that GPs over investigate the diagnosis. More work needs to be done to support GPs’ implementation of evidence-based management of hip and knee OA.

Arthroscopic-Assisted Suspensionplasty Using the Palmaris Longus Tendon for Osteoarthritis of the Thumb Carpometacarpal Joint

Osteoarthritis of the thumb carpometacarpal joint is common, especially in postmenopausal women. Numerous surgical techniques, including ligament reconstruction, partial or complete trapeziectomy, arthrodesis, and arthroplasty have been introduced. Suspensionplasty combined with trapeziectomy has been introduced to prevent proximal subsidence of the first metacarpal. To prevent excessive release of periarticular capsuloligamentous tissues, resection of the proximal part of the trapezium, and the cosmetically unappealing bump, arthroscopic partial trapeziectomy has been used as a less-invasive treatment option. With advanced techniques and devices, arthroscopic suspensionplasty with the autograft can be performed; thus far, there have been no series reporting on arthroscopic treatment options for this common condition. The purpose of this article is to present a technique for arthroscopic-assisted suspensionplasty using the palmaris longus tendon to reinforce the graft–bone interface, based on the concept of the tension slide technique to treat thumb carpometacarpal osteoarthritis.