Intra-articular Methylprednisolone Research Articles

Posttraumatic Osteoarthritis Development and Progression in an Ovine Model of Partial Anterior Cruciate Ligament Transection and Effect of Repeated Intra-articular Methylprednisolone Acetate Injections on Early Disease

Background: Partial anterior cruciate ligament (p-ACL) ruptures are a common injury of athletes. However, few preclinical models have investigated the natural history and treatment of p-ACL injuries. Purpose: To (1) demonstrate whether a controlled p-ACL injury model (anteromedial band transection) develops progressive gross morphological and histological posttraumatic osteoarthritis (PTOA)–like changes at 20 and 40 weeks after the injury and (2) investigate the efficacy of repeated (0, 5, 10, and 15 weeks) intra-articular injections of methylprednisolone acetate (MPA; 80 mg/mL) in the mitigation of potential PTOA-like changes after p-ACL transection. Study Design: Controlled laboratory study. Methods: Twenty-one 3- to 5-year-old female Suffolk-cross sheep were allocated to 4 groups: (1) nonoperative controls (n = 5), (2) 20 weeks after p-ACL transection (n = 5), (3) 40 weeks after p-ACL transection (n = 6), and (4) 20 weeks after p-ACL transection + MPA (n = 5). Gross morphological grading and histological analyses were conducted. mRNA expression levels for inflammatory, degradative, and structural molecules were assessed. Results: p-ACL transection led to significantly more combined gross damage (P = .008) and significant aggregate histological damage (P = .009) at 40 weeks after p-ACL transection than the nonoperative controls, and damage was progressive over time. Macroscopically, MPA appeared to slightly mitigate gross damage at 20 weeks after p-ACL transection in some animals. However, microscopic analysis revealed that repeated MPA injections after p-ACL transection led to significant loss in proteoglycan content compared with the nonoperative controls and 20 weeks after p-ACL transection (P = .008 and P = .008, respectively). Conclusion: p-ACL transection led to significant gross and histological damage by 40 weeks, which was progressive over time. Multiple repeated MPA injections were not appropriate to mitigate injury-related damage in a p-ACL transection ovine model as significant proteoglycan loss was observed in MPA-treated knees. Clinical Relevance: A p-ACL injury leads to slow and progressive PTOA-like joint damage, and multiple repeated injections of glucocorticoids may be detrimental to the knee joint in the long term.

Intra-articular injection of methylprednisolone for reducing pain in knee osteoarthritis: A systematic review and meta-analysis.

Background:To evaluate the efficacy and safety of intra-articular methylprednisolone for reducing pain in patients with knee osteoarthritis.Methods:We conduct electronic searches of Medline (1966-2017.11), PubMed (1966-2017.11), Embase (1980-2017.11), ScienceDirect (1985-2017.11), and the Cochrane Library (1900-2017.11) for randomized clinical trials comparing the use of methylprednisolone to treat knee osteoarthritis. The primary outcomes are Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain scores and WOMAC function scores. Each outcome was combined and calculated using the statistical software STATA 12.0. Fixed/random effect model was adopted based on the heterogeneity tested by I2 statistic.Results:A total of 739 patients were analyzed across 4 randomized controlled trials (RCTs). The present meta-analysis revealed that there were significant differences between groups regarding the WOMAC pain scores at 4 weeks (WMD = −1.384, 95% CI: −1.975 to −0.793, P = .000), 12 weeks (WMD = −1.587, 95% CI: −2.489 to −0.685, P = .001), and 24 weeks (WMD = −1.563, 95% CI: −2.245 to −0.881, P = .000). Significant differences were identified in terms of physical function at 4 weeks (WMD = −7.925, 95% CI: −13.359 to −2.491, P = .004), 12 weeks (WMD = −7.314, 95% CI: −13.308 to −1.320, P = .117), and 24 weeks (WMD = −6.484, 95% CI: −11.256 to −1.711, P = .008).Conclusion:Intra-articular methylprednisolone injection was associated with an improved pain relief and physical function in patients with knee osteoarthritis. Additionally, no severe adverse effects were observed. Due to the limited quality of the evidence currently available, higher quality RCTs were required.

Efficacy of ultrasonography-guided intra-articular steroid injection of the shoulder and excercising in patients with adhesive capsulitis: Glenohumeral versus subacromial approaches

Aim of the workTo evaluate the efficacy of intra-articular steroid injection of the shoulder joint with exercises in the management of patients with adhesive capsulitis and to compare glenohumeral (GH) versus subacromial subdeltoid (SASD) ultrasound-guided approaches. Patients and methodsForty patients with adhesive capsulitis were randomly divided into 2 groups according to injection approach. Patients received ultrasound-guided intra-articular injection methylprednisolone acetate (40 mg) and 1 ml 2% lidocaine followed by exercise for 12 weeks. Visual analog scale (VAS) for pain, the shoulder pain and disability index (SPADI) and active range of motion (ROM) were assessed before and 12 weeks post-injection. ResultsThe mean age of the patients was 47.3 ± 8.7 years with 12 females and 8 males in each group. After injection, there was a significant improvement of pain (VAS) and SPADI in both groups (p < 0.001). Before injection, SASD bursitis was present in 18 (45%), GH joint effusion in 14 (35%), rotator cuff tendinopathy in 6 (15%), bursitis with effusion in 1 (2.5%) and with supraspinatus tendon calcification in another (2.5%). Both groups significantly equally improved regarding to ROM compared to before injection. Post-injection, the SPADI significantly improved in the SASD group compared to GH; with remarkable improvement in the joint extension, internal and external rotation (p < 0.001). ConclusionIntrarticular steroid injection of the shoulder joint followed by exercises in patients with adhesive capsulitis decreases pain, improves function and ROM with a more favorable response by the GH approach. Ultrasound-guided injection is an accurate, easy and cost-effective approach.

The Effect of Preoperative Intra-Articular Methylprednisolone on Pain After TKA: A Randomized Double-Blinded Placebo Controlled Trial in Patients With High-Pain Knee Osteoarthritis and Sensitization

Peripherally driven inflammatory pain and nociceptive changes before TKA has been suggested to be a cause for increased acute postoperative pain. However, preoperative intra-articular MP in patients with high pain osteoarthritis and sensitization did not reduce acute post-TKA pain or sensitization despite a preoperative reduction of intra-articular inflammatory markers.

Therapeutic Review of Methylprednisolone Acetate Intra-Articular Injection in the Management of Osteoarthritis of the Knee - Part 2: Clinical and Procedural Considerations.

The use of an intra-articular methylprednisolone acetate (MPA) injection has been shown to have benefits for symptoms of knee osteoarthritis (OA). However, considerations beyond drug efficacy can influence the appropriateness, clinical effectiveness and potential harm of an injection. A review of research evidence and published literature on clinical and procedural factors influencing the effectiveness and safety of a knee injection has been undertaken. Factors include dose, frequency, contraindications, precautions, drug interactions, side-effects, and procedural and patient-related considerations. An evaluation of evidence indicated that a 40 mg dose provides clinical benefit. No strong predictors of response were evident, with the exception of pain severity. Additional benefit for outcomes from higher doses, local anaesthetic, ultrasound guidance or particular anatomical approaches is yet to be demonstrated. Evidence for dose- and duration-related detrimental effects suggests judicious use and frequency. The evaluation showed that there are a number of contraindications and precautions arising from the drug pharmacology, concurrent medications, comorbidities and adverse events which need consideration and monitoring. There was limited safety evidence concerning anticoagulation. The review found that specialist guidance and limited evidence suggests that injection safety concerning warfarin may be enhanced by ensuring that the international normalized ratio level is within therapeutic range. However, the risk-benefit evaluation concerning non vitamin K antagonist oral anticoagulants remains challenging. Although there is published guidance, a lack of clinical studies, safety evidence and reversibility advocates caution. Overall, the review indicates that injection decisions and procedures need an individualized approach and supporting evidence is limited in many areas. Evaluation and discussion of benefits and risks, peri-procedural and post-injection management, and tailoring to the context and individuals' preferences are important in optimizing the benefits and safety of a knee injection.

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

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

The impact of intra-articular methylprednisolone acetate injection on fructosamine levels in diabetic patients with osteoarthritis of the knee, a case-control study.

Fructosamine is a glycated protein that reflects blood glucose control over the last 2-3weeks. There are no studies that address the impact of intra-articular injection (IAI) of methylprednisolone acetate (MPA) on fructosamine levels among patients with type-2 diabetes and osteoarthritis of the knee (OAK). Non-selected patients attending the rheumatology or orthopedic clinic with type-2 diabetes and painful OAK, who failed non-steroidal anti-inflammatory drugs (NSAIDS) and physical therapy, were asked to participate in our study. After consent blood tests were drown for fructosamine, hemoglobin A1c (HbA1c) level, complete blood count, lipid profile, serum albumin, serum protein, c-reactive protein, and erythrocyte sedimentation rate. Demographic and different clinical parameters were also documented. Immediately after that, patients had IAI of 80mg of MPA at the knee joint (group 1). Two to three weeks later, the same blood tests were repeated (except for HbA1c). Age- and sex-matched group of patients with type-2 diabetes and painful OAK attending the same clinics, but who were managed by NSAIDS were asked to participate as a control group (group 2) and had the same evaluation at enrollment and 2-3weeks later, after consent. Eighteen patients from either group completed the study. Mean fructosamine level in group 1 patients was 263.7 ± 31.8mg% prior to the IAI vs. 274.6 ± 39.3mg% (p = 0.035), 2-3weeks later, while mean fructosamine level in the control group (group 2) at enrollments was 274.2 ± 31.2mg% vs. 269 ± 30.2mg%, p = 0.509, 2-3weeks later. There was no significant change in any other parameter tested at enrollment in either group, compared to those obtained 2-3weeks afterwards. Body mass index was on the edge of significance as a predictor for a significant change in fructosamine level in group 1 patients. IAI of 80mg of MPA in patients with type-2 diabetes and OAK had resulted in a significant, though mild increase in fructosamine levels 2-3weeks later.

A comparative study on the efficacy of Intra articular Methylprednisolone with oral Etoricoxib in the pain management of Psoriatic arthritis

Background: Psoriatic arthritis is the major complication of psoriasis and the most common medication used for pain management is NSAID’s, followed by intra-articular steroids. Aim: To compare the efficacy of intra articular Methylprednisolone with oral Etoricoxib in the pain management of Psoriatic arthritis. Materials and Methods: A prospective comparative study was conducted in the pain clinic of department of Anaesthesiology for a period of one year. A total of 120 patients with psoriatic arthritis were included for the study. The patients were divided into 2 groups of 60 in each group. Group A patients received oral etoricoxib 120 mg OD for 6 weeks and the Group B patients received only one dose of intra-articular methyl prednisolone in the dosage of 20 mg (1 ml). All the patients were followed for a period of 6 weeks with 2 follow-up visits. The outcome measures adopted were visual analogue pain scale and psoriatic arthritis quality of life score. Results: The baseline score of both visual analogue pain score and PsAQAL was found to be high and the score decreases during the 1st (1st week) and 2nd (6th week) follow-up (P

Intra-articular methylprednisolone acetate injection at the knee joint and the hypothalamic–pituitary–adrenal axis: a randomized controlled study

The objective of this study was to evaluate the effect of intra-articular corticosteroid injection (IACI) of methylprednisolone acetate (MPA) on the hypothalamic-pituitary-adrenal (HPA) axis in patients with osteoarthritis of the knee. Patients with symptomatic osteoarthritis of the knee who failed to respond to nonsteroidal anti-inflammatory medications and physical therapy were randomized between group 1 and group 2. Group 1 patients had an IACI of 80mg of MPA at the knee joint and group 2 patients had an intra-articular injection (IAI) of 6ml (60mg) of sodium hyaluronate (control group). Immediately prior to the IAI and on weeks 1, 2, 3, 4, and 8 following IAI, patients from both groups underwent a low-dose (1μg) adrenocorticotropin hormone (ACTH) stimulation test. Demographic, clinical, laboratory, and radiologic variables were documented in all patients. Both criteria of <7μg/dl increase in the serum cortisol level and absolute levels of <18μg/dl 30min following the ACTH stimulation test were used to define secondary adrenal insufficiency (SAI). Twenty patients were randomized in each group. In group 1, 25% of patients had SAI vs. none in group 2 (p = 0.0471). The earliest SAI was observed at week 2, and latest SAI was observed at week 4. SAI was observed at one time point, two consecutive time points, or two separate time points in the same patient. There was no correlation between SAI and any of the demographic, clinical, or laboratory variables. An IACI of 80mg MPA at the knee joint induced a transient SAI in 25% of the patients, an effect that was observed between week 2 and week 4 following the IACI.

Intra-articular hylastan versus steroid for knee osteoarthritis

To assess the efficacy and safety of one and two intra-articular (IA) injections of the new viscosupplement, hylastan, compared with a single IA corticosteroid injection for pain due to knee osteoarthritis (OA). Hylastan is a high-molecular-weight hyaluronan derivative prepared from bacterial fermented sodium hyaluronate that was developed to remain in the joint for longer than most other viscosupplements. This 6-month, double-blind, randomized, parallel group, multicenter trial enrolled patients aged ≥40 years who met American College of Rheumatology criteria for knee OA and had continued pain despite conservative treatment. Patients were randomized 1:1:1 to one of three arms: 2 × 4 mL hylastan (n = 129; arthrocentesis then IA hylastan Day 0, same treatment Week 2); 1 × 4 mL hylastan (n = 130; arthrocentesis then IA hylastan Day 0, arthrocentesis only Week 2); steroid (n = 132; arthrocentesis then IA methylprednisolone acetate 40 mg Day 0, arthrocentesis only Week 2). Participants and evaluators were blinded to treatment. The primary clinical outcome measure was change from baseline in WOMAC A pain score over all postbaseline visits to Week 26. Statistically significant pain reduction was observed in all three arms, with similar mean (95 % CI) changes in WOMAC A: 2 × 4 mL hylastan -0.9 (-1.0, -0.7); 1 × 4 mL hylastan -0.8 (-0.9, -0.7); steroid -0.9 (-1.0, -0.8); all P < 0.0001 versus baseline. Changes in secondary outcomes (OMERACT-OARSI and WOMAC A responder rates, patient/clinical observer global assessments, and WOMAC A1 walking pain) were similar in all three arms. Target knee adverse events were comparable for all treatments. Both IA hylastan injection regimens were effective in relieving pain with an acceptable safety profile. IA hylastan did not show a difference versus IA corticosteroid; therefore, the hypothesis of superior pain relief was not met. Further research is needed to compare the efficacy and safety of hylastan with other viscosupplements.

Intra-articular corticoid injection induces circulating glucocorticoid bioactivity and systemic immune activation in juvenile idiopathic arthritis

Objective: To study the systemic effects of intra-articular (IA) glucocorticoid (GC) injections in juvenile idiopathic arthritis (JIA).Methods: The study group comprised 21 JIA patients being treated with IA methylprednisolone [MP (n = 15) or MP plus triamcinolone hexacetonide (THA) (n = 6)] prescribed on clinical indications. The systemic effect of MP was assessed by measuring circulating glucocorticoid bioactivity (GBA) with a recombinant cell transactivation assay 7 and 24 h after the IA injections, and after 2 months. The systemic immunological responses were studied with a novel assay for testing patient serum-induced changes in the secretion of interferon (IFN)-γ and interleukin (IL)-5 from target cells.Results: Administration of IA GC induced serum GBA (p = 0.001) and suppressed circulating cortisol levels (p = 0.002) 7 h after the injection. Serum withdrawn 24 h after the IA injection induced less IL-5 secretion from mitogen-activated target cells when compared with pre-treatment sera (p = 0.036). This decrease in target cell T helper (Th)2 response (IL-5) was MP dose related (r = −0.550, p = 0.018). High IL-5 secretion from target cells prior to the IA injections was associated with good clinical outcome at 2 months, seen as a low number of active (p = 0.044) and restricted joints (p = 0.049).Conclusion: IA GC injections have systemic effects that are reflected in the serum as an immediate elevation of GBA, a decrease of endogenous cortisol as well as a suppressive effect of patient serum on target cell IL-5 secretion. These systemic effects may play a role in the attenuation of disease activity.

Efficacy and safety of combining intra-articular methylprednisolone and anti-TNF agent to achieve prolonged remission in patients with recurrent inflammatory monoarthritis

Objective To control local inflammation, the role of intra-articular corticosteroid is well established; similarly, with time there are more reports on the experience of intra-articular anti-TNF agent for localized joint inflammation. The aim of this study was to assess the safety, local tolerability and clinical response after combining intra-articular administration of corticosteroids and anti-TNF agents for recurrent inflammatory monoarthritis. Methods Patients with recurrent monoarthritis of the knee were recruited from our inflammatory arthritis clinics. These patients required intra-articular corticosteroids every 8–12 weeks, with good short-term results. Five such consecutive patients were invited to partake in this study. Patients were maintained on their baseline immunosuppressive therapy. After aspiration of knee joint, the involved joint was injected with 80 mg of methylprednisolone mixed with 5 ml of lignocaine 1%; this was followed by the injection of an anti-TNF agent. Results In majority of our patients (three out of five), combining anti-TNF agent and methylprednisolone led to prolonged anti-inflammatory response, and these patients remain in remission to date (mean follow-up of 12 months). These responders were noted to be naive to anti-TNF therapy. Conversely, the remaining two patients were found to be on baseline systemic anti-TNF therapy, and both of them failed to respond either partly or completely. Conclusion Combining intra-articular corticosteroid and anti-TNF agent has proved to be safe in our cohort of patients. We conclude that in particular subset of patients who suffer from recurrent inflammatory monoarthritis or oligoarthritis, combination therapy of intra-articular corticosteroids and anti-TNF agents appears attractive and promising.

Efficacy of intraarticular infliximab in patients with chronic or recurrent gonarthritis: A clinical randomized trial

To evaluate the efficacy and safety of intraarticular infliximab compared with intraarticular methylprednisolone in patients with gonarthritis. In 23 patients with recurrent gonarthritis despite previous intraarticular corticosteroid therapy, a total of 41 intraarticular injections (20 infliximab and 21 methylprednisolone) were performed in 28 knees. Initial therapy was randomly assigned, and crossover therapy was eligible within 3 months. The clinical effect was assessed during 6 months of followup. The primary outcome was event-free survival, defined as the time after treatment until local retreatment was performed and/or nonimprovement of the knee joint score. Adverse effects were recorded during followup. All patients treated with intraarticular infliximab had an insufficient response. In contrast, 8 of the 21 intraarticular methylprednisolone injections were effective (P = 0.004). Between groups, no differences in the patients' age, disease duration, number of disease-modifying antirheumatic drugs, or previous intraarticular methylprednisolone were observed. Reported adverse effects were not related to therapy. Treatment with intraarticular infliximab injection was not effective in patients with a chronically inflamed knee joint. Intraarticular injection with methylprednisolone was superior despite previous intraarticular corticosteroid therapy. Further investigation is needed to provide these patients with a better alternative.

A Randomized, Prospective, Double-Blind Study to Investigate the Effectiveness of Adding DepoMedrol to a Local Anesthetic Injection in Postmeniscectomy Patients With Osteoarthritis of the Knee

Background Patients with osteoarthritis of the knee are at risk for poorer outcomes after arthroscopic meniscectomy. Intra-articular corticosteroid injections have been shown to be efficacious both in patients with osteoarthritis and postarthroscopy patients. Hypothesis A postoperative, intra-articular methylprednisolone and lidocaine injection in patients with chondromalacia undergoing meniscectomy will improve patient-rated pain and function compared with control patients. Study Design Randomized, controlled trial; Level of evidence, 1. Methods A total of 58 patients (59 knees) were randomized in a double-blinded fashion to receive either saline plus lidocaine (saline) or methylprednisolone plus lidocaine (steroid) after arthroscopic meniscectomy in which chondromalacia (modified Outerbridge grade 2 or higher) was confirmed. Preoperatively and at follow-up—6 weeks and 6, 9, and 12 months—patients underwent an examination and completed a subjective functioning survey. Scores were calculated using several validated scoring systems including the Lysholm, International Knee Documentation Committee (IKDC), and Short Form–12 (SF-12). Results No statistically significant differences were observed between the saline (n = 30) and steroid (n = 29) groups in their demographics and preoperative scores. At 6 weeks, the steroid group had higher scores than the saline group on multiple scales, including the IKDC. No differences in outcome scores existed at later time points. At 12 months, 86% of the steroid and 69% of the saline group were completely or mostly satisfied with the procedure (P = .01). In the saline group, 4 patients required reinjection and 2 underwent joint replacements within 12 months, while the steroid group had 3 reinjections and 2 meniscus transplants. Conclusion The addition of a postoperative corticosteroid injection resulted in improved pain and function at an early time point; however, it provided no lasting difference compared with only local anesthetic injection.

A randomized controlled trial of early intervention with intraarticular corticosteroids followed by sulfasalazine versus conservative treatment in early oligoarthritis

To determine the outcome after 52 weeks of early intervention with intraarticular corticosteroid injections followed by sulfasalazine versus conservative therapy in patients with recent-onset oligoarthritis in a randomized controlled trial. Patients with <or=4 joints with clinical synovitis (disease duration <or=12 months) were randomized to early intervention (EI) with intraarticular methylprednisolone into all synovitic joints or to conservative treatment (CT) with nonsteroidal antiinflammatory drugs alone. Sulfasalazine was administered in both groups for persistent disease or disease that evolved into a polyarthritis. Primary outcome was complete response (CR) defined as the absence of synovitis at 52 weeks. Secondary outcomes included CR at weeks 4 and 12, function (Health Assessment Questionnaire), pain (0-100-mm visual analog scale), and work status. Fifty-nine patients (34 men, 25 women; mean age 32.9 years; median early morning stiffness 30 minutes) were randomized. At baseline, two-thirds reported that they were work impaired. At 52 weeks, 81% of patients in the EI group achieved CR compared with 57% in the CT group (chi(2) = 3.833, 1 df, P = 0.05). In addition, 45% of patients in the EI group received sulfasalazine as opposed to 14% in the CT group (chi(2) = 5.156, 1 df, P = 0.019). There were no differences in physical disability or work impairment between the treatment groups. Oligoarthritis has a significant impact on function and work ability. Patients treated with EI using intraarticular corticosteroids followed by sulfasalazine therapy if resistant demonstrated reduced synovitis 12 months after treatment compared with those initially treated with more conservative therapy.

Evaluation of the pituitary–adrenal axis function following single intraarticular injection of methylprednisolone

To determine the effects of a single session of intraarticular methylprednisolone (IA-MP) injections on the function of the pituitary-adrenal axis. Twenty-five patients with rheumatic diseases were treated with a single IA-MP injection. The dose varied between 20 and 160 mg. The basal cortisol level and the response to 1 microg adrenocorticotropic hormone (ACTH) stimulation were determined before treatment, at 1 day, and at 1 week after IA-MP injections. Further tests were carried out for up to 6 weeks in patients with blunted cortisol response. Results were compared with those obtained in a group of 22 healthy subjects. Before treatment, all patients had normal basal and peak cortisol responses to ACTH (>396 nmoles/liter at 30 minutes). Reduced fasting cortisol levels (<147 nmoles/liter) were detected in 12 of 25 patients (48%) after 1 day, in 1 of 25 patients (4%) after 1 week, and in 1 of 25 patients (4%) 2 weeks after IA-MP injections. Blunted peak cortisol response (<396 nmoles/liter at 30 minutes) was observed in 1 of 25 patients (4%) after 1 day, in 3 of 25 patients (12%) after 1 week, and in 1 of 25 patients (4%) 2 weeks after IA-MP injections. Decreased fasting levels and peak cortisol responses to ACTH stimulation were more common in patients with inflammatory diseases and in those injected with 80-160 mg MP. Single-session IA-MP injection(s) are associated with systemic absorption of MP, causing impaired adrenocortical reserve. Recovery is expected in most patients after 1-2 weeks. Only a few patients exhibited suppression for up to 2 weeks. The magnitude of this suppression depends on the dose injected, and is more common in patients with inflammatory joint diseases. Caution is required if repeated large doses of IA-MP are considered in these patients.

The effect of intra-articular methylprednisolone acetate and exercise on equine carpal subchondral and cancellous bone microhardness.

Dorsal carpal osteochondral injury is a major cause of lameness in horses undergoing high intensity training. Intra-articular corticosteroid treatment is used commonly to manage exercise-associated articular pain, but its use remains highly controversial in the equine athlete. This project, therefore, aimed to compare the mechanical properties of intra-articular MPA and diluent-treated middle carpal subchondral and cancellous bone in horses undergoing a short-term treadmill exercise programme. It was hypothesised that subchondral and cancellous bone mechanical properties are influenced by intra-articular administration of methylprednisolone acetate (MPA). Eight 2-year-old female horses had MPA or diluent administered into contralateral middle carpal joints at 14 day intervals, for a total of 4 treatments per horse. Horses underwent a standard treadmill exercise protocol until euthanasia (Day 70). Standard sites were located on the dorsal aspect of third, radial and intermediate carpal bones. Osteochondral samples from each test site were divided into subchondral bone and cancellous bone portions. These were dried, resin-embedded and gold-coated. Microhardness measurements were obtained at each test site. No significant effect of intra-articular treatment was detected. At each site, cancellous bone trabecular struts had an 18-19% higher microhardness value than the overlying subchondral bone. These findings indicate that intra-articular administration of MPA at this dose has no effect on subchondral or cancellous bone adaptation to short-term exercise and, therefore, on the propensity of carpal bones to injury. Further investigation into the calcified cartilage layer, effect of different corticosteroid preparations and diffusion of medication are required.

Intraarticular glucocorticoid, morphine and bupivacaine reduces pain and convalescence after arthroscopic ankle surgery: A randomized study of 36 patients

In a double-blind randomized study, 36 patients undergoing arthroscopic removal of bony spurs and synovitis causing impingement of the ankle were allocated to intraarticular saline or bupivacaine 15 mg + morphine 5 mg + intraarticular methylprednisolone 40 mg. Combined methylprednisolone, bupivacaine and morphine reduced pain, joint swelling, time of immobilization, duration of sick leave and return to sports after the arthroscopic procedure. In the treatment group, 1 patient had transitory purulent arthritis requiring antibiotics and arthroscopic synovectomy occurred.

Intra-articular glucocorticoid, bupivacaine and morphine reduces pain, inflammatory response and convalescence after arthroscopic meniscectomy

Convalescence after arthroscopic meniscectomy is dependent on pain and the inflammatory response. The aim of the study was therefore to investigate the effect of intra-articular bupivacaine+morphine+methylprednisolone versus bupivacaine+morphine or saline on post-meniscectomy pain, mobilisation and convalescence. In a double-blind randomized study 60 patients undergoing arthroscopic meniscectomy were allocated to intra-articular saline, intra-articular bupivacaine 150 mg+morphine 4 mg or the same dose of bupivacaine+morphine+intra-articular methylprednisolone 40 mg. All patients were instructed to resume normal activities immediately after operation. Pain during movement and walking, leg muscle force and joint effusion, use of crutches and duration of sick leave were assessed. Combined bupivacaine and morphine significantly reduced pain, time of immobilisation and duration of convalescence. Addition of methylprednisolone further reduced pain, use of additional analgesics, joint swelling and convalescence, improved muscle function and prevented the inflammatory response (acute phase protein) ( P<0.05). A multimodal analgesic and anti-inflammatory treatment may enhance post-arthroscopic convalescence, which depends on the trauma induced inflammatory response and pain.

Acute synovitis and intra-articular methylprednisolone acetate in ponies

Objective: To determine how acute synovitis, with and without intra-articular methylprednisolone acetate (MPA), affect synthesis of proteoglycan, total protein, and collagen in articular cartilage and total protein synthesis in synovial membrane.Design: Synovitis was induced in 10 ponies by the injection of 0.5 ng lipopolysaccharide (LPS) into the left radiocarpal and midcarpal joints every 2 days for a total of four treatments. Synovitis was documented by clinical examination and synovial fluid analyses. Two days before euthanasia, MPA (0.1 mg/kg) was injected with the last dose of LPS into both the left and right radiocarpal and midcarpal joints of five of these ponies. Proteoglycan synthesis in articular cartilage explants from these joints was measured by incorporation of sodium [35S]sulfate. The size of the proteoglycan monomers and their aggregation with hyaluronan was assessed by size-exclusion chromatography. Protein synthesis in articular cartilage was measured by incorporation of [3H]proline and collagen synthesis by conversion of [3H]proline into [3H]hydroxyproline. Protein synthesis was measured in synovial membrane explants by incorporation of [35S]methionine.Results: Ponies developed carpal effusion and mild lameness accompanied by increased total nucleated cell count and total solids in synovial fluid in response to the LPS injections. Moderate to severe synovial membrane proliferation and inflammation were observed histopathologically in joints injected with LPS but no consistent light-microscopical changes were observed in the articular cartilage from these joints. Intra-articular MPA alone was associated with decreased proteoglycan synthesis and increased protein and collagen synthesis in the cartilage explants. Total protein synthesis by synovial membrane was also increased by MPA alone. In contrast, no differences in protein or proteoglycan synthesis were observed in explants from the joints with synovitis, with or without intra-articular MPA. Treatment with MPA, LPS, and LPS/MPA did not alter proteoglycan aggregate size, but LPS-induced synovitis resulted in an increase in the second largest population of monomers. MPA increased the synthesis of small proteoglycan monomers.Conclusion: Based on the methods used, acute synovitis prevented changes induced by intra-articular MPA alone. Results suggested that the effect of intra-articular MPA on joint metabolism was different between inflamed and normal joints. Experimental studies must consider the effect of inflammation, as well as the potential to introducein vitroculture artifacts when investigating the effect of intra-articular corticosteroids on chondrocyte function.