Intra-articular Steroid Research Articles

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.

Comparison of intra articular autologous platelet-rich plasma with steroids in osteoarthritis knee: Experience from a North Indian tertiary care center

Background: Intra-articular (IA) platelet-rich plasma (PRP) is a promising treatment option for knee osteoarthritis (OA). It accelerates the process of healing, ligament repair, cartilage regeneration, and bone formation when given in supraphysiological doses. The aim of this study was to compare the efficacy of IA PRP versus IA methylprednisolone acetate (MPA) in patients with knee OA. Methods: Open labeled prospective observational study was conducted on 60 patients with Kellgren-Lawrence Grade 2 and 3 OA knee, who fulfilled the ACR classification criteria for knee OA. Thirty patients were given IA PRP (6 ml) and 30 received IA methyl prednisolone (80 mg) at baseline line, which was repeated at 12 weeks. The primary endpoint was an improvement in Western Ontario and McMaster Universities Index (WOMAC) and 100 mm Visual Analog Scale (VAS) pain at 24 weeks postinjections. Results: The mean change in VAS pain and total WOMAC score from baseline to 24 weeks was 32.9 ± 12.1, 31.8 ± 14.7 for PRP group, and 12.9 ± 5.9, 7.5 ± 5.5 for MPA group, which was statistically significant (P Conclusions: Treatment with IA PRP showed sustained improvements in WOMAC and VAS scores compared to IA steroids. PRP is an effective treatment for functional status and pain in moderate knee osteoarthritis.

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.

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.

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 &amp; codeine 5% 0% Naproxen &amp; oramorph 0% 5% Paracetamol 10% 10% Paracetamol &amp; 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.

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, &gt;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&gt;200 AU/ml and her adalimumab level was &lt;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.

P47 Successful treatment of two cases of refractory JIA uveitis with intravenous tocilizumab and subcutaneous methotrexate

Abstract Background There is a need for additional treatment options in refractory JIA uveitis which has responded inadequately to MTX and anti TNFα. There has been interest in the use of tocilizumab, the APTITUDE trial using SC tocilizumab in JIA uveitis and the STOP-Uveitis study comparing 2 dosing regimens of iv tocilizumab in adults. Anecdotal evidence reports JIA uveitis patients who were stable on IV tocilizumab flaring when switched to sc administration. We describe the successful use of IV tocilizumab and concurrent sc MTX in two cases. Methods Retrospective review of patient paper and electronic medical records. Results Case 1.: A five-year-old female presented with severe anterior uveitis in her right eye. She was diagnosed with idiopathic uveitis and treated with topical steroid, oral then SC MTX infliximab, mycophenolate and adalimumab, all with inadequate control of her uveitis. At the age of 12, on adalimumab, she developed arthritis and her diagnosis was changed to JIA uveitis. 7 years after initial diagnosis she was commenced on IV tocilizumab 8mgs/kg 4-weekly with improved control of her uveitis although initially still requiring some topical steroid. She required intra-articular steroids for active arthritis and agreed to restart SC MTX. On tocilizumab and MTX combined, her arthritis settled and her topical eye drops were weaned for the first time since diagnosis. From age 5 until 14 she was continually on topical steroids, consequently developing raised intraocular pressure and a dense cataract. With improved disease control she had cataract surgery aged 14. She has maintained good disease control for the last five years on the combination of IV tocilizumab and SC MTX and has not required any further steroids. Case 2: A 3 year old female with oligoarticular JIA had severe bilateral uveitis at presentation. Initial treatment was with oral prednisolone, topical steroid and SC MTX. 6 months after diagnosis her uveitis remained active and she was commenced on infliximab with additional IV methylprednisolone. Venous access was challenging, required a portacath to facilitate treatment. By the age of 6 she had developed a cataract requiring surgery and still had incomplete control of her uveitis. Infliximab was increased to 10mgs/kg 4 weekly with little further benefit and at the age of 7 she was changed to adalimumab. On this she developed macular oedema requiring pulse IV methylprednisolone. 5 years after diagnosis she was commenced on IV tocilizimab initially 4 weekly, increasing after three months to 2 weekly. Her methylprednisolone was weaned and she has subsequently maintained good disease control on IV tocilizumab 10mgs/kg 2 weekly with SC methotrexate. Conclusion We describe two cases of refractory JIA and uveitis in whom IV tocilizumab with SC methotrexate has provided good disease control. Further studies are required to determine the optimal dosing regimen. Conflicts of Interest The authors declare no conflicts of interest.

P.227Secondary clinical outcomes of spinal surgery and satisfaction in patients with spinal muscular atrophy (SMA) II and non-ambulant III

Scoliosis is a highly prevalent feature of SMA and surgery is frequently required. Studies in small cohorts have reported a positive impact of spinal surgery on respiratory function, while limited data are available on motor function, weight gain, post-surgical skeletal pain and satisfaction. We retrospectively reviewed the notes of 33 patients (26 SMA II, 7 non-ambulant SMA III) who successfully underwent spinal fusion (25), magnetic (4) or traditional (4) growth rods followed by final growth spinal fusion (3) at Great Ormond Street Hospital-London. Median age at surgery was 10.9 years (4.28–16.72), median pre-operative Cobb angle 70 degrees (35–89), median follow up before and after surgery 3.9 (0.9–12.3) and 3.7 (0.4–10.5) years respectively. Mean annual rate of Forced Vital Capacity % decline improved after surgery in SMA II: -2.8 versus -7.4 (p<0.001). Similar trajectories were observed in SMA III. At first post-surgery assessment a median decline of 4.5 points (0-14) was observed on the Hammersmith Functional Motor Scale while the Revised Upper Limb Module's scores showed a less progressive deterioration. A temporary negative deviation from previous weight curve was observed in 17 patients requiring food supplements (5); one/4 type II with significant weight loss (>5% of total weight) needed gastrostomy. Hip pain was the most common skeletal pain documented (13/33) requiring painkillers (8), intra-articular steroids (1) or surgery (1). Ten patients/parents participated in a phone interview developed by the neuromuscular team on satisfaction. Nine/10 reported major improvements in posture, physical appearance, self-image and all rated the surgical procedure as very successful. However, 7/10 did not report significant improvements in quality of life due to reduced mobility and increased unmet care needs. This ongoing study expands the knowledge on outcomes after spinal surgery in SMA and highlights the importance of a careful post-operative multidisciplinary approach.

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.