Intra-articular Steroid Injection Research Articles

Meta-analysis in periprosthetic joint infection: a global bibliometric analysis

BackgroundPeriprosthetic joint infection (PJI) is the most serious complication of joint replacement surgery. Further comorbidities include bedsore, deep vein thrombosis, reinfection, or even death. An increasing number of researchers are focusing on this challenging complication. The aim of the present study was to estimate global PJI research based on bibliometrics from meta-analysis studies.MethodsA database search was performed in PubMed, Scopus, and Web of Science. Relevant studies were assessed using the bibliometric analysis.ResultsA total of 117 articles were included. The most relevant literature on PJI was found on Scopus. China made the highest contributions to global research, followed by the USA and the UK. The institution with the most contributions was the University of Bristol. The journal with the highest number of publications was The Journal of Arthroplasty, whereas the Journal of Clinical Medicine had the shortest acceptance time. Furthermore, the top three frequently used databases were Embase, MEDLINE, and Cochrane. The most frequent number of authors in meta-analysis studies was four. Most studies focused on the periprosthetic hip and knee. The alpha-defensin diagnostic test, preventive measures on antibiotics use, and risk factors of intra-articular steroid injections were the most popular topic in recent years.ConclusionBased on the results of the present study, we found that there was no single database that covered all relevant articles; the optimal method for bibliometric analysis is a combination of databases. The most popular research topics on PJI focused on alpha-defensin, antibiotic use, risk factors of intra-articular steroid injections, and the location of prosthetic hip and knee infection.

Effectiveness of radial extracorporeal shock-wave therapy versus ultrasound-guided low-dose intra-articular steroid injection in improving shoulder pain, function, and range of motion in diabetic patients with shoulder adhesive capsulitis

This was a 2-parallel-group, active-control, assessor-blinded, randomized trial. We randomized 103 diabetic patients with shoulder AC to receive either 4 sessions of rESWT, 1 week apart (rESWT group, n = 52), or a single ultrasound-guided low-dose intra-articular steroid injection of 20 mg of triamcinolone acetonide (steroid group, n = 51). The primary outcome measure was functional improvement evaluated by the Quick Disabilities of the Arm, Shoulder and Hand (qDASH) score. Secondary outcome measures were pain evaluated by the visual analogscale score and shoulder range of motion (ROM). An assessor who was blinded to treatment assignment assessed both groups at baseline and at 4, 8, and 12 weeks thereafter. By 12 weeks, both groups demonstrated a significant reduction in the qDASH score and pain severity, as well as improvement in ROM. However, significantly improved function (qDASH score, 40.4 ± 12.9 vs. 50.5 ± 13.3; P < .001) and shoulder pain reduction (visual analog scale score, 1.6 ± 1.2 vs. 2.8 ± 1.7; P < .001) were found in the rESWT group vs. the steroid group. Similar improvement in shoulder ROM was observed in both groups. At short-term follow-up, rESWT was superior to a low-dose intra-articular steroid injection in improving function and pain in diabetic patients with shoulder AC. Therefore, rESWT might be considered a safe alternative to steroid injections in diabetic patients with shoulder AC.

CT fluoroscopy-guided transforaminal and intra-articular facet steroid injections for the treatment of cervical radiculopathy: injectate distribution patterns and association with clinical outcome.

To investigate injectate dispersal patterns and their association with therapeutic efficacy during a transforaminal (TFSI) or an intra-articular facet steroid injection (IFSI) to treat cervical radiculopathy. This retrospective study examined the post-intervention cervical spine CT of 56 patients randomized to receive one CT fluoroscopy-guided IFSI (29 patients; 10 (34.5%) males; mean age 45.0years; SD 8.8years; range 26-61years) or TFSI (27 patients; 13 (48.2%) males; mean age 51.1years; SD 11.2years; range 29-72years) (December 2010 to August 2013). The presence of contrast within the intra-articular facet, juxta-articular facet, retrodural, epidural, and foraminal and extraforaminal spaces during IFSI, and within the extraforaminal, foraminal, and epidural spaces during TFSI was assessed. Descriptive data are presented as frequencies. The association between injectate dispersal patterns and therapeutic efficacy, 4-week post-intervention, was assessed with ANCOVA models. During IFSI, the injectate predominantly spread to the retrodural (62%; 18/29) or juxta-articular (21%; 6/29) space. During TFSI, the injectate predominantly spread to the extraforaminal/foraminal spaces (41%; 11/27) or to the extraforaminal/foraminal/epidural spaces (33%; 9/27). Injectate presence in the juxta-articular (p = .007) or extraforaminal (p < .001) space was a predictor of therapeutic efficacy but not in the foraminal (p = .54), epidural (p = .89), or retrodural (p = .75) space. TFSI and IFSI led to preferential extraforaminal and retrodural injectate spread, respectively. Targeting the extraforaminal or juxta-articular facet space improved the clinical efficacy of steroid injections when treating cervical radiculopathy. • During intra-articular facet injection, the injectate spreads from the facet joint to the retrodural space and rarely reaches the epidural and/or foraminal spaces. • Epidural spread of the injectate during an anterolateral transforaminal steroid injection is the least effective for pain relief in patients with cervical radiculopathy. • Injection techniques targeting the extraforaminal or juxta-articular facet space are safer than transforaminal injections and effectively relieve pain in patients with cervical radiculopathy.

Comparison of Clinical Outcomes between Idiopathic Frozen Shoulder and Diabetic Frozen Shoulder After a Single Ultrasound-Guided Intra-Articular Corticosteroid Injection.

There is no consensus on the use of intra-articular corticosteroid injections in diabetic frozen shoulder (FS). Thus, we aimed to compare clinical outcomes after intra-articular corticosteroid injections in patients with diabetic FS and idiopathic FS. Data collected from 142 FS patients who received glenohumeral joint intra-articular corticosteroid injections were retrospectively reviewed. Thirty-two patients were diagnosed with diabetic FS and 110 patients with idiopathic FS. Data including visual analog scale (VAS) for pain, American Shoulder and Elbow Surgeons (ASES) score, subjective shoulder value (SSV), and passive range of motion (ROM) were compared before the injection and at 3, 6, and 12 weeks after the injection. There were significant improvements in all outcomes (p < 0.001 for all parameters) through 12 weeks in both groups. There were no significant differences in all outcomes, except for ASES scores, between both groups at 3 weeks. However, there were significant differences in VAS score, SSVs, ASES scores, and passive ROMs, except for angle of abduction, between the two groups at 6 weeks and 12 weeks after injection. A single intra-articular steroid injection can be used as a conservative treatment for diabetic FS, but less effective than for idiopathic FS.

SAT-249 Polyarticular Osteoarthritis: A Disabling Manifestation of Acromegaly

BackgroundAcromegaly is a slow-onset rare endocrinopathy that is characterized by chronic overproduction of growth hormone (GH) and insulin-like growth factor-1 (IGF-1). Excess GH and IGF-1 levels lead to insulin resistance, which is implicated in most of the complications associated with acromegaly. We present a case of acromegaly, wherein the patient presented with worsening polyarthralgia and decreasing mobility. As the patient was undergoing workup for rapidly progressing osteoarthritis, the internist became suspicious of patient’s changing physical appearance.CaseA 53-year-old man with medical history of diabetes mellitus and hypertension was referred to endocrine clinic on account of high IGF-1 levels, 909 ng/ml (normal: 37-245 ng/ml). He was seeking medical attention because of rapidly progressing polyarthralgia and stiffness for the last two years. His symptoms were intensifying despite use of non-steroidal anti-inflammatory drugs and intra-articular steroid injections. Imaging revealed severe degenerative changes and narrowing of joint space in bilateral hip, knee and glenohumeral joints. Internist observed that the patient was exhibiting stigmata of acromegaly such as enlargement of hands and feet, prognathism and dental space widening. Patient reported headaches, blurry vision, sleep apnea, dysphagia and right ear exostosis. Colonoscopy revealed hyperplastic polyps.Repeat IGF- 1 levels were 910 ng/ml (Normal: 37-245 ng/ml). Oral glucose tolerance test showed failure of suppression of GH. Serial GH levels were 4.50, 5.08, 6.74, 5.81 and 5.21 ng/ml (Normal: 0.01- 0.97 ng/ml).Tests for other endocrinopathies revealed the following results: serum prolactin 4 ng/ml (Normal <18 ng/ml), serum cortisol 7.9 ug/dl (Normal: 6-27 ug/dl), 24 hour urine cortisol 23mcg/24 hours (Normal: 3.5-45 mcg/24 hours), serum TSH 2.25 uIU/ml (Normal: 0.34- 3 uIU/ml), serum T4 level 0.7 ng/dl (Normal: 0.6-1.6 ng/dl) and serum T3 level 144.9ng/dl (Normal: 87-178 ng/dl). Serum total and free testosterone levels were 111 ng/dl (Normal: 240-950 ng/dl) and 3.89 ng/dl (Normal: 4.06-15.6 ng/dl) respectively and were suggestive of hypogonadism.MRI Brain showed 12x10x8mm pituitary adenoma. He was referred for transsphenoidal surgery for resection of pituitary adenoma.ConclusionPolyarticular osteoarthritis is an early manifestation of acromegaly. Systemic diseases associated with acromegaly are the primary reason for which most patients seek medical attention. It is important to look for coexisting endocrinopathies whenever the diagnosis of acromegaly is established, since mass effect of pituitary adenoma can wreak havoc on the endocrine system of the body. High index of suspicion, early diagnosis and prompt treatment are the key to reverse some but not all comorbid conditions associated with acromegaly.

Increased Use of Intra-Articular Steroid Injection to Treat Osteoarthritis is Associated With Chronic Opioid Dependence After Later Total Knee Arthroplasty But Not Total Hip Arthroplasty

BackgroundIntra-articular (IA) injections of corticosteroid (CO) and hyaluronic acid (HA) are commonly used for osteoarthritis. The efficacy of these interventions is controversial. Furthermore, research regarding the potential association of IA injection with later postoperative pain trajectories is lacking. MethodsWe performed analysis on Truven Health MarketScan database (2012-2016) in total hip arthroplasty (THA) and total knee arthroplasty (TKA). Trends over time were assessed. Multivariable logistic regression analyses were executed to evaluate the impact of IA injections on postoperative chronic opioid use. ResultsPreoperative CO and HA injections decreased throughout the study period in both THA and TKA. Preoperative CO and HA injections, regardless of frequency, had no significant impact on the odds of THA patients becoming chronic opioid users postoperatively. TKA patients who had 1 CO injection in the year before surgery experienced lower odds of postoperative chronic opioid use (odds ratio [OR], 0.89; 95% confidence interval [95% CI], 0.82-0.97), whereas patients who had 2 or more CO injections experienced significantly greater odds (OR, 1.14; 95% CI, 1.04-1.24). TKA patients who received 2 or more HA injections before surgery had significantly lower odds of chronic opioid use (OR, 0.90; 95% CI, 0.81-0.99). ConclusionThe utilization of IA injections in patients with hip and knee osteoarthritis appears to be decreasing over time. TKA patients who received 2 or more preoperative CO injections experienced greater odds of chronic opioid utilization, whereas TKA patients with 2 or more HA injections in the year before surgery had decreased odds of chronic opioid use.

Osteoarthritis treatment via intra-articular delivery of indoleamine 2,3-dioxygenase galectin-3 fusion protein

Purpose: Inflammation caused by acute injury or post-traumatic OA directly impacts joint dysfunction and OA pain-related behaviors. Therefore, controlling inflammation can be pivotal in improving OA symptomology. Current treatments to improve OA symptomology, including intra-articular injections of steroids and other anti-inflammatory drugs, fail to provide long term pain relief due to rapid joint clearance. As such, strategies to anchor anti-inflammatory therapeutics to joint tissues can improve bioavailability and enhance joint residence time. Here, we developed an indoleamine 2,3-dioxygenase (IDO) galectin-3 (Gal3) fusion protein, termed IDO-Gal3. IDO can polarize immune cells via catalysis of tryptophan into kynurenines, ultimately reprogramming the local environment into an anti-inflammatory state. Gal3, a carbohydrate binding protein, can bind to lubricin at the surface of articular cartilage, and therefore serves to extend IDO’s joint residence time and anti-inflammatory effects. Methods: Gal3 joint retention was assessed using 16 male Lewis rats. All rats underwent medial meniscus transection (MMT) surgery on the right hind limb. After 8 weeks, 50 μl of Nano-Glo Luciferase (NL) or Nano-Glo Luciferase Galectin-3 fusion (NL-Gal3) was injected into both knees. NL and NL-Gal3 joint retention was quantified via IVIS on 1, 2, 4, 8, 12, 16, 20, 24, and 28 days post-injection. Joint tissue distribution was assessed after euthanasia on day 28. IDO-Gal3’s effects on pain-related behaviors and intra-articular inflammation was assessed using an additional 16 male Lewis rats. Rats underwent baseline von Frey and gait behavioral testing. Three component ground reaction force data, spatiotemporal characteristics of footprint patterns, and foot strike toe off events were simultaneously collected using the Gait Analysis Instrumentation and Technology Optimized for Rodents (GAITOR) suite. All rats received MMT surgery to their right hind limb. One rat was lost one week after surgery reducing the n to 15. Von Frey testing was conducted weekly after surgery and gait data was collected on weeks 3, 5, and 7 post-surgery. At 8 weeks post-surgery, rats received a 30 μl saline (n=7) or IDO-Gal3 (n=8) injection to their operated limb. Gait and von Frey data were collected weekly until euthanasia at 12 weeks. Immediately following euthanasia, magnetic capture of IL-6, MCP-1, and CTX-II was performed on operated and contralateral limbs. Briefly, magnetic capture uses superparamagnetic beads to capture biomarkers in the joint and assay ex vivo. After magnetic capture, operated and contralateral knees were sectioned for histology and stained with toluidine blue or hematoxylin and eosin. A 2-way ANOVA was used to compare intra-articular biomarkers levels in operated and contralateral knees of IDO-Gal3 and saline injected knees. Results: NL-Gal3 was retained in the joint out to 28 days, whereas NL alone cleared with 7 days. NL and NL-Gal3 cleared from operated and contralateral limbs at similar rates (Figure 1A). 50% paw withdrawal threshold in the operated limb decreased after MMT surgery, indicating heightened sensitivity to touch. After intra-articular IDO-Gal3 injection, the 50% paw withdrawal threshold reached our maximum testing range, suggesting decreased limb sensitivity. After saline injection, rats also showed decreased limb sensitivity, but to a lesser extent than IDO-Gal3 (Figure 1B). At 4 weeks after injection and 12 weeks post-surgery intra-articular levels of IL-6 were significantly lower in IDO-Gal3 treated knees compared to other controls (p=0.02) (Figure 1C). Conclusions: The half-life of NL in the joint was less than a day after injection. Gal3 functionalization increased NL joint retention to at least 4 weeks, and promoted NL accumulation in cartilage and menisci. High Gal3-NL cartilage accumulation is likely due to Gal3 binding lubricin at the articular cartilage surface. Moreover, these data demonstrate disease does not alter joint retention for these treatments. IDO fused to Gal3 was evaluated for its effects on pain-related behaviors and intra-articular inflammation. After saline injection, von Frey data showed most rats returned to the “normal” sensitivity range for Lewis rats (25-35 g of force), while after IDO-Gal3 injection, most rats returned to and stayed at baseline sensitivity level within a week of injection. Here, IDO quickly decreases limb sensitivity and maintains pain reversal for at least 4 weeks post-injection. Decreased limb sensitivity could be caused by immune modulation of molecular markers associated with OA. Intra-articular levels of IL-6 in the operated limb were significantly reduced in IDO-Gal3 treated rats. Intra-articular levels of CTX-II and MCP-1 were both suppressed in operated limbs for IDO-Gal3 treated rats. Thus, IDO’s immunosuppressive effects may improve OA symptomology and prognosis.

Clinical and Radiological Assessment of Fluoroscopy Guided Injection of Atlantoaxial Joint in Rheumatoid Arthritis Patients

Abstract Background: Rheumatoid spondylitis is a feature of long-lasting Rheumatoid Arthritis (RA), it presented by neck pain, headache and sleep disturbance. Atlantoaxial Joint (AAJ) is the commonest joint which affected among the cervical spine in patients with RA. When it is involved, it can be associated with dangerous complications. Aim of Study: This study aimed to evaluate the efficacy of intra-articular steroid injection of inflamed AAJ in RA patients, on neck pain, headache and sleep quality as well as the pre and post injection MRI assessment. Patients and Methods: Sixty rheumatoid arthritis patients with inflamed AAJ were recruited to the study. Group 1 (AAJ injected group, n=30), received intraarticular atlantoaxial steroid injection, guided by fluoroscopy and Group 2 (control group, n=30), received systemic steroids. Both groups were assessed with: Visual Analogue Scale (VAS) for nocturnal neck pain, Headache and Pittsburgh Sleep Quality Index (PSQI) for sleep disturbances. Contrast enhanced MRI before and after intervention were done for all patients. Results: The injected AAJ group had significant improve-ment of nocturnal neck pain, headache and sleep disturbance during the three months’ interval follow-up, in comparison to the control group. The injected AAJ group had a statistically significant improvement in the MRI synovial enhancement, inflammatory pannus, fibrosis and bone marrow edema in comparison to control group. Conclusion: Intra-articular steroid injection of atlantoaxial joint is considered as an efficient therapeutic option in acute inflamed atlantoaxial joint of RA patients regarding clinical and radiological findings.

Conservative vs. surgical approach for degenerative meniscal injuries: a systematic review of clinical evidence.

Analyzing the available evidence by comparing the role of arthroscopic surgery and conservative treatment in the management of degenerative meniscopathy. A literature search was carried out on the PubMed, EMBASE, Scopus, and PEDro databases in May 2019 to identify all the randomized controlled trials (RCTs) comparing arthroscopic surgery to conservative management of painful but stable degenerated menisci. The quality of the RCTs was assessed using the Cochrane Risk of Bias Assessment. A total of 10 studies, including 1525 patients and dealing with conservative treatment vs. arthroscopic surgery were included in this review. In eight studies the effectiveness of exercise therapy was compared to surgery; in one study the effectiveness of intra-articular steroid injection was compared to surgery; in one study the effectiveness of placebo surgery was compared to partial meniscectomy. In all studies, no significant inter-group difference in terms of knee pain and knee function were observed at any follow-up evaluation. Degenerative meniscal tears, without symptoms of locking and catching, can be successfully managed by a proper regimen of physical therapy as a first line treatment. Surgical approach might be considered in case of poor response after conservative treatment.

Low back pain and radiographic severity as predictors in hip osteoarthritis patients receiving steroid injection therapy.

We investigated the effects of lower back pain (LBP) on measures of pain, disability, and function in highly symptomatic hip OA patients receiving intra-articular steroid injection (IASI) therapy. We also investigated the effect of radiographic severity of hip OA for comparison to LBP. 97 consenting subjects with symptomatic hip OA presenting for IASI were evaluated at baseline, assessed over an 8-week period, and followed at least 1 year later for new arthroplasty. At baseline and 8 weeks follow-up patient demographics, presence/absence of back pain, physical function tests, a single anteroposterior pelvis x-ray, and subjective scores of pain, stiffness and function (VAS and WOMAC) were collected. We also followed which subjects proceeded to obtain total hip arthroplasty in the examined hip. Cohorts with LBP reported significantly worse scores for all of VAS pain and WOMAC questionnaires but showed no difference in ROM and were not more likely to proceed to arthroplasty. Cohorts with severe radiographic OA had significantly worsened scores for stiffness (χ2 = 6.74, p = 0.009), decreased ROM (p < 0.01), and were more likely to proceed to arthroplasty (χ2 = 9.79, p = 0.044). Back pain has a substantial effect on clinical parameters relevant to assessment of severity of hip OA, especially self-reported pain and function. This finding highlights LBP as a significant confounding factor in hip OA patient assessments and will inform future studies to determine the most effective treatment strategies for hip OA patients.

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.

To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee.

To develop an evidence-based guideline for the comprehensive management of osteoarthritis (OA) as a collaboration between the American College of Rheumatology (ACR) and the Arthritis Foundation, updating the 2012 ACR recommendations for the management of hand, hip, and knee OA. We identified clinically relevant population, intervention, comparator, outcomes questions and critical outcomes in OA. A Literature Review Team performed a systematic literature review to summarize evidence supporting the benefits and harms of available educational, behavioral, psychosocial, physical, mind-body, and pharmacologic therapies for OA. Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of the evidence. A Voting Panel, including rheumatologists, an internist, physical and occupational therapists, and patients, achieved consensus on the recommendations. Based on the available evidence, either strong or conditional recommendations were made for or against the approaches evaluated. Strong recommendations were made for exercise, weight loss in patients with knee and/or hip OA who are overweight or obese, self-efficacy and self-management programs, tai chi, cane use, hand orthoses for first carpometacarpal (CMC) joint OA, tibiofemoral bracing for tibiofemoral knee OA, topical nonsteroidal antiinflammatory drugs (NSAIDs) for knee OA, oral NSAIDs, and intraarticular glucocorticoid injections for knee OA. Conditional recommendations were made for balance exercises, yoga, cognitive behavioral therapy, kinesiotaping for first CMC OA, orthoses for hand joints other than the first CMC joint, patellofemoral bracing for patellofemoral knee OA, acupuncture, thermal modalities, radiofrequency ablation for knee OA, topical NSAIDs, intraarticular steroid injections and chondroitin sulfate for hand OA, topical capsaicin for knee OA, acetaminophen, duloxetine, and tramadol. This guideline provides direction for clinicians and patients making treatment decisions for the management of OA. Clinicians and patients should engage in shared decision-making that accounts for patients' values, preferences, and comorbidities. These recommendations should not be used to limit or deny access to therapies.

Comparative study of the effect of suprascapular nerve block under ultrasound guidance and blind shoulder infiltration (Using lignocaine and methylprednisolone acetate) in chronic shoulder pain

Introduction: Shoulder joint is very important joint for day to day activities and pain in shoulder results in leads to increased functional disability with poor quality-of life. Chronic shoulder pain common complaints encountered by treating physicians all over world. The incidence of chronic shoulder pain is approximately 15-30% with variations among different population and age groups. The treatment modalities available for alleviating chronic shoulder pain varies from simple anti-inflammatory drugs to interventional procedures like intra-articular steroid injections, supra-scapular nerve block (SSNB).AIM: To compare the pain relief and return of function in shoulder joint using suprascapular nerve block under ultrasound guidance (lignocaine and methylprednisolone acetate) versus shoulder infiltration (lignocaine and methylprednisolone acetate) in chronic shoulder pain.Study Design: Prospective, randomised study, data was collected from patients with chronic shoulder pain in the age group of 18-60 years coming to orthopedic outpatient department at Yenepoya Medical College Hospita with chronic shoulder pain.Materials and Methods: Suprascapular nerve block group: 2ml of 40mg methyl prednisolone +2ml of lignocaine given, supervision of anesthetist under ultrasound guidance. Intra articular steroid group: 2ml of 40mg methyl prednisolone acetate +2ml 2% lignocaine hydrochloride given through posterior approach to shoulder. Eligible participants was randomly assigned to receive the same combination of medications either by supra scapular nerve block under ultrasound guidance or blind shoulder infiltration and compare the effect of lignocaine and corticosteroid in suprascapular nerve block and shoulder infiltration in chronic shoulder pain by assessing DASH score, Constant-Murley score, SPADI score and VAS pain score on day 7 and day 28 of the procedure.Results: There were no significant differences between the groups in terms of pain, demographic variables, Range of movement and disability scores when compared to baseline. (p >0.05). However suprascapular nerve block showed slight better improvement in pain, range of movement and disability score at initial (i.e. at 1week) and at 4 week follow up when compared with that of intra-articular steroid infiltration but scores were not statistically significant. Parameters obtained in both groups were significant at final assessments when compared to the baseline scores.Conclusion: Suprascapular nerve block can be considered as a safe, effective, well tolerated treatment and alternative line of treatment in patient suffering from chronic shoulder pain.

Definition, Diagnosis, Treatment, and Prognosis of Frozen Shoulder: A Consensus Survey of Shoulder Specialists.

BackgroundThe objective of this study was to identify a consensus on definition, diagnosis, treatment, and prognosis of frozen shoulder (FS) among shoulder specialists.MethodsA questionnaire composed of 18 questions about FS—definition, classification, utilization of diagnostic modalities, the propriety of treatment at each stage, and prognosis—was sent to 95 shoulder specialists in Korea. Most questions (15 questions) required an answer on a 5-point analog scale (1, strongly disagree; 5, strongly agree); three questions about the propriety of treatment were binary.ResultsWe received 71 responses (74.7%). Of the 71 respondents, 84.5% agreed with the proposed definition of FS, and 88.8% agreed that FS should be divided into primary and secondary types according to the proposed definition. Only 43.7% of the respondents agreed that FS in patients with systemic disease should be classified as secondary FS. For the diagnosis of FS, 71.9% agreed that plain radiography should be used and 64.8% agreed ultrasonography should be used. There was a high consensus on proper treatment of FS: 97.2% agreed on education, 94.4%, on the use of nonsteroidal anti-inflammatory drugs; 76.1%, on intra-articular steroid injections; and 97.2%, on stretching exercise. Among all respondents, 22.5% answered that more than 10% of the patients with FS do not respond to conservative treatment.ConclusionsThe survey revealed a general consensus among shoulder specialists on the definition and treatment of FS. However, classification of FS was found controversial.

Comparison of intra-articular steroid injection and hyaluronic acid in mono-articular synovitis knee

Introduction: Mono articular presentation of rheumatoid arthritis is infrequent and has been previously reported to involve the hip and knee joints. Rheumatoid arthritis is a common symmetrical chronic inflammatory arthritis with the prevalence of 1% worldwide. Mono- articular rheumatoid arthritis is a rare entity reported to initially affect large joints such as hips and knees, progressing to a poly articular presentation within 3 to 5 years. Synovitis is an important component of rheumatoid arthritis, so we conducted a study to include all the recurrent effusion of knee cases, and we have compared the functional outcome of intra-articular steroid injection and hyaluronic acid in the treatment of such cases. Material and Methods: 40 cases of recurrent effusion of knee joint attending the OPD or emergency services at Government Medical College and Rajindra hospital, Patiala between July 2016 to July 2019 were evaluated with the clinical examination, haematological investigations and radiological investigations. In all the cases, the joint was aspirated with a 16 G Needle and aspirated fluid was sent for pus cultural sensitivity in a microbiology Department of our hospital and was sent for CBNAAT to chest and TB hospital of our hospital. In Group 1, following the aspiration, injection of local corticosteroid (methylprednisolone acetate 80 mg) was given and in group 2, injection of hyaluronic acid was given, followed by a short course of antibiotics for 5 days and short course of non-steroidal anti-inflammatory drugs was given for 10 days and a crêpe bandage was applied for 2 days. The results were assessed by VAS for pain and KOOS (Knee Injury and Osteoarthritis Outcome Score) scores. Results: In all 40 patients, the pus cultural sensitivity was negative for any microorganism and CBNAAT was negative in all the 40 patients. By comparing the results obtained in KOOS scale it was seen that symptoms improved after six months in both steroid (P = 0.017) and HA groups (P = 0.004). Besides, daily activity improved in both steroid (P = 0.027) and HA groups (P = 0.047). On the contrary, pain did not decrease 6 months after intervention in both steroid (P = 0.096) and HA groups (P = 0.17) Conclusion: Mono articular synovitis in an otherwise seronegative patient is due to recurrent inflammatory response due to recurrent stress or any other intra articular pathology. Patients are advised rest, and a short course of steroidal anti-inflammatory drugs, which also helped to relieve the inflammation. This was markedly improved by intra-articular HA injection as shown by the recovery in intra-articular HA injection group as compared to the steroid group.

COVID-19 and its impact on pain management practices: A nation-wide survey of Indian pain physicians.

COVID-19 and its impact on pain management practices: A nation-wide survey of Indian pain physicians.

Intra-articular steroid for adhesive capsulitis: does hydrodilatation give any additional benefit? A randomized control trial.

To assess the benefit offered by capsular hydrodilatation in addition to intra-articular steroid injections in cases of adhesive capsulitis, assess outcomes in diabetic patients with capsular hydrodilatation as compared to non-diabetics and correlate duration of symptoms with outcome based on the type of intervention given. This prospective double-blinded randomized control trial included patients presenting with clinical features of adhesive capsulitis with no evidence of rotator cuff pathology and randomized them into two groups-intra-articular steroid with hydrodilatation (distension group) and only intra-articular steroid (non-distension group) with intervention being performed as per the group allotted. Primary outcome measure was Shoulder Pain and Disability Index (SPADI) scores which were taken pre-intervention, at 1.5, 3 and 6months post-intervention, which were assessed by generalized linear model statistics and Pearson correlation. Although there was statistically significant drop in SPADI in both groups over time [F(1.9, 137.6) = 112.2; p < 0.001], mean difference in SPADI between the 2 groups was not statistically significant (1.53; CI:-3.7 to 6.8; p = 0.56). There was no significant difference between both groups among diabetics [F(1,38) = 0.04; p = 0.95] and no significant difference between diabetic and non-diabetic patients who received hydrodilatation [F(1.8, 60) = 2.26; p = 0.12]. There was no significant correlation between the reduction in SPADI scores and duration of symptoms in any subset of the study population. Shoulder joint hydrodilatation offered no additional benefit compared to intra-articular steroid injections for shoulder adhesive capsulitis. Outcome for diabetics and non-diabetics were similar and there was no correlation between duration of symptoms and outcome.

Improved Pain and Function in Knee Osteoarthritis with Dexamethasone Phonophoresis: A Randomized Controlled Trial.

Background:Intraarticular corticosteroid injection is an adjunct to core treatments for relief of moderate-to-severe pain in osteoarthritis (OA) patients. This randomized controlled trial was conducted to determine the effect of dexamethasone phonophoresis (DxPh) on knee OA.Patients and Methods:Forty six female patients with knee OA were randomized into two equal groups. The study group received DxPh over the medial side of the knee, transcutaneous electrical nerve stimulation (TENS), and quadriceps strengthening exercises. Control group received ultrasound therapy and the same TENS and exercise program. Pain was assessed using the visual analog scale (VAS) and the pain subscale of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pre- and posttreatment. Functional mobility was assessed by the Timed Up and Go (TUG) test, total WOMAC, and the joint stiffness and physical function subscales of WOMAC. The minimal clinically identifiable difference was used to calculate treatment effect sizes of both modalities, which was compared to intraarticular steroid injections.Results:The VAS, TUG, and WOMAC scores improved with both modalities. Pain intensity improved by 50.6%–58.0% in the study group (VAS and pain subscale of WOMAC, respectively) compared to 17.8%–28.6% for the control group. Functional mobility showed a higher rate of improvement in the DxPh group compared to control (37.7 vs. 17.5% for TUG and 53.2 vs. 23.0 and 56.1 vs. 26.4% for the joint stiffness and physical function subscales of WOMAC, respectively). Posttreatment results revealed statistically and clinically significant improvement in pain intensity and functional mobility in the DxPh group.Conclusion:DxPh resulted in a greater improvement in pain and function in patients with knee OA than therapeutic ultrasound combined with exercise and TENS. The effect size of phonophoresis was clinically significant and higher than that reported for intraarticular steroid injection from pooled data in the literature.

Cooled Radiofrequency Ablation Treatment of the Genicular Nerves in the Treatment of Osteoarthritic Knee Pain: 18- and 24-Month Results.

ObjectiveThe primary objective of this observational, prospective, multicenter study was to evaluate the long‐term outcomes, including pain, function, and perceived effect of treatment, in subjects undergoing cooled radiofrequency ablation (CRFA) who have pain due to osteoarthritis (OA) of the knee.MethodsThis analysis included a subset of subjects previously enrolled in a prospective, multicenter randomized study comparing the safety and effectiveness of CRFA and intra‐articular steroid injection in patients with knee OA through 12 months who were contacted to participate in this extension study. Subjects were enrolled if they agreed to participate in up to 2 additional follow‐ups, at 18 and 24 months.ResultsEighty‐three subjects from the 5 participating sites underwent CRFA during the original study and were contacted for this extension study. Of the 33 subjects enrolled, 25 were evaluated at 18 months after CRFA treatment, and their mean numeric rating scale (NRS) score was 3.1 ± 2.7, with 12 subjects reporting ≥50% pain relief compared to baseline. At 24 months, 18 subjects reported a mean NRS score of 3.6 ± 2.8, with 11 demonstrating ≥50% pain relief. Functional improvement as measured by the Oxford Knee Score continued to be present, with an overall mean change from baseline of 26.0 ± 9.6 points at 18 months and 29.9 ± 10.4 points at 24 months.ConclusionIn this subset of subjects from a randomized controlled trial, CRFA provided sustained pain relief, improved function, and perceived positive effect through 24 months for subjects with OA knee pain with no safety concerns identified.

Intra-articular facet joint steroid injection-related adverse events encountered during 11,980 procedures.

To analyze the incidence and characteristics of intra-articular facet joint injection (FJI)-related adverse events requiring hospitalization and emergency room visits. From January 2007 to December 2017, a total of 11,980 FJI procedures in 6066 patients (mean age 66.8 years, range 15-97 years, M:F = 2004:4062) were performed in our department. Of these, we retrospectively reviewed 489 cases in 432 patients who were hospitalized or visited the emergency room within a month of FJI. FJI-related adverse events were classified as procedure-related complications, drug-related systemic events, or uncertain etiology events, on the basis of consensus of two spine radiologists. This is a descriptive study without statistical analysis. There were 101 FJI-related adverse event cases in 99 patients (mean age 71.8 years, range 39-97 years, M:F = 39:60). The overall incidence of FJI-related adverse events was 0.84% (101/11,980) per case and 1.63% (99/6066) per patient. The incidence of procedure-related complications and drug-related systemic adverse events was 0.07% (8/11,980) and 0.15% (18/11,980), respectively; the rate of uncertain etiology events was 0.63% (75/11,980). All eight procedure-related complication cases involved major complications. There are seven cases of infectious spondylitis and one was progression of systemic aspergillosis to the spine. One patient died of an uncontrolled infection with infective endocarditis, and two patients experienced partial recovery with neurological sequelae. The overall incidence of FJI-related adverse events is low, and procedure-related major complications are rare without dural puncture or epidural hematoma. Nevertheless, infection can occur, resulting in serious outcomes. • The incidence of FJI-related adverse events requiring hospitalization or ER visit was 0.84%. • The incidence of major procedure-related complications was 0.07%. • All major complications were associated with infection and there were no cases of epidural hematoma.