Use Of Intra-articular Corticosteroids Research Articles

A Comparison of the Treatment Outcomes With and Without the Use of Intra-articular Corticosteroids for Frozen Shoulder Manipulation.

Background Manipulation under anesthesia is known to be an effective treatment method for a frozen shoulder. However, this process is painful and causes difficulty in early physiotherapy. Intra-articular corticosteroids may relieve pain after manipulation. This study compared patients who underwent manipulation under anesthesia with those who only underwent physiotherapy and those who received intra-articular corticosteroid administration and physiotherapy. Methodology A total of 33 patients presenting with frozen shoulders were included in this study. Those who underwent manipulation after anesthesia were determined as group 1 (16 patients) and those who received intra-articular corticosteroids in addition to manipulation under anesthesia were determined as group 2 (17 patients). Pain was evaluated using the Visual Analog Scale (VAS) scores. Functional outcomes were assessed using the University of California-Los Angeles (UCLA) scores and shoulder range of motion (ROM). Results VAS and UCLA scores of both groups were similar at 12 weeks and six months. ROM improved significantly after manipulation in both group 1 and group 2 (p < 0.05). There was no significant difference between the ROM in the two groups after manipulation and physiotherapy. Only the external rotation ROM value was better in group 2 (p = 0.032) Conclusions Physiotherapy after manipulation is a successful treatment method for frozen shoulder patients. It reduces pain in the early period compared to patients who are not administered intra-articular corticosteroids. However, it has no functional superiority.

Debate: Intra-articular steroid injections for osteoarthritis – harmful or helpful?

Intra-articular corticosteroids injections are a widely used treatment for pain from symptomatic osteoarthritis. Systematic reviews show that the treatment effect is modest compared with intra-articular saline (often considered as placebo) and lasts for 2-4 weeks on average. Potentially as a consequence of limited therapeutic duration, repeated injections are often given up to 4 injections annually. In this context of repeat injections, recent evidence has emerged that intra-articular corticosteroids might be associated with more MRI-assessed quantitative cartilage thickness loss than saline injections. Guidelines vary in the recommendation for use of intra-articular corticosteroids. Given the frequency with which intra-articular corticosteroids injections are used, the size and scale of the population with osteoarthritis, it is critical to fully understand the benefits and drawbacks of intra-articular corticosteroids injections. That is the focus of this debate article.

Infiltration therapy in the context of cartilage surgery.

Guideline-based surgical cartilage therapy for focal cartilage damage offers highly effective possibilities to sustainably reduce patients' complaints and to prevent or at least delay the development of early osteoarthritis. In the knee joint, it has the potential to reduce almost a quarter of the arthroses requiring joint replacement caused by cartilage damage. Biologically effective injection therapies could further improve these results. Based on the currently available literature and preclinical studies, intra- and postoperative injectables may have a positive effect of platelet-rich plasma/fibrin (PRP/PRF) and hyaluronic acid (HA) on cartilage regeneration and, in the case of HA injections, also on the clinical outcome can be assumed. The role of a combination therapy with use of intra-articular corticosteroids is lacking in the absence of adequate study data and cannot be defined yet. With regard to adipose tissue-based cell therapy, the current scientific data do not yet justify any recommendation for its use. Further studies also regarding application intervals, timing and differences in different joints are required.

Intra-articular corticosteroids for knee and hip OA: a systematic review of serious adverse joint outcomes

Purpose: Intra-articular corticosteroids (IACS) are proven to provide short-term pain relief and functional improvement in individuals with knee and hip osteoarthritis (OA). However, the potential for serious adverse joint outcomes resulting from long-term use of IACS has been cause for concern. We conducted a systematic review of all RCT data comparing IACS to intra-articular saline to explore the incidence of accelerated OA progression, subchondral insufficiency fracture, complication of osteonecrosis, and/or rapid destruction of joint tissue among individuals with knee and hip OA. Methods: Medline, PubMed Central, Google Scholar, and the Cochrane Databases were systematically searched from inception to November, 2019. Reference lists of relevant reviews were searched by hand, and we sought additional data within supplements of conference proceedings that had been published up until November, 2019. Randomized controlled trials comparing IACS to intra-articular saline in participants with knee or hip OA were included. Two reviewers screened potentially relevant references and independently assessed study quality using the Cochrane Risk of Bias tool. Relevant data were independently extracted from included studies by the same two reviewers. Outcomes of interest included incidence of any one of four target serious adverse joint outcomes: accelerated OA progression, subchondral insufficiency fracture, complication of osteonecrosis, and/or rapid destruction of joint tissue. Analysis of dichotomous outcomes using the Mantel-Haenszel method was planned a priori, and effect estimates were to be reported as risk ratios (RR) with 95% confidence intervals. Results: Our search returned 516 potentially relevant references. Of these, 28 references were deemed to be potentially eligible for inclusion. Twenty two RCTs met our inclusion criteria, but 12 of them did not report safety outcomes. Ten RCTs incorporating a total of 538 patient-years of follow-up reported on safety in sufficient detail to confirm absence or incidence of the target serious adverse joint outcomes. Seven RCTs (N= 728) involved participants with knee OA, and 3 RCTs focused on hip OA (N= 162). Follow-up of the included RCTs ranged from 5 weeks to 2 years, with the most common (40% of RCTs) study duration being 6 months. 60% of RCTs involved a single IACS injection; two trials involved 8 injections total over 12 week intervals, while two other RCTs involved 3 and 5 total injections over intervals of 2 weeks and 1 week, respectively. Study quality was overall assessed to be of Low to Very Low Quality. None of the included RCTs involving participants with knee or hip OA documented incidence of accelerated OA progression, subchondral insufficiency fracture, complication of osteonecrosis, or rapid destruction of joint tissue over the course of the study follow-up. Due to a complete absence of events, statistical comparison of IACS with placebo was not possible. Conclusions: The results of our study suggest that the use of IACS is unlikely to lead to serious adverse joint outcomes in a controlled clinical setting. These findings are limited by the short follow-up and low number of total IACS injections, and may not be generalizable to patients with repeated injections over longer time periods. High-quality, long-term observational data are needed to confirm the safety of long-term use of IACS in knee or hip OA.

Are bisphosphonates a more effective treatment than intra-articular steroids in horses with distal hock osteoarthritis?

PICO question&#x0D; In horses that are lame due to osteoarthritis of the distal tarsal joints (bone spavin), is intra-articular medication with corticosteroids compared to systemic bisphosphonate treatment more effective in long-term lameness reduction?&#x0D; &#x0D; Clinical bottom line&#x0D; Category of research question &#x0D; Treatment&#x0D; The number and type of study designs reviewed&#x0D; Three papers were critically reviewed. Two were randomised controlled trials, and one was a retrospective study.&#x0D; Strength of evidence &#x0D; Weak&#x0D; Outcomes reported&#x0D; There is insufficient evidence to support the use of systemic bisphosphonates over intra-articular corticosteroids to treat distal hock osteoarthritis in horses.&#x0D; Conclusion&#x0D; Horses with distal hock osteoarthritis should not be treated with systemic bisphosphonates until further blinded randomised controlled trials are completed. Additionally, supportive evidence for the use of intra-articular corticosteroids as a treatment for degenerative hock osteoarthritis is limited to a retrospective study where modest, short-term improvements are reported: 58% of horses improved after an average of 56 days (Labens et al., 2007). Evidence does not support significant improvement in long-term outcomes: 50% of horses improved after 4 months (Watts et al., 2016) and only 38% of horses improved after a mean follow-up period of 787 days (Labens et al., 2007).&#x0D; &#x0D; How to apply this evidence in practice&#x0D; The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources.&#x0D; Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.&#x0D; &#x0D;

Intra-articular corticosteroids and the risk of knee osteoarthritis progression: results from the Osteoarthritis Initiative

A recent randomized clinical trial reported that repeated intra-articular corticosteroids (IACs) were associated with a greater cartilage loss. This study aimed to examine the relation of IACs to knee radiographic osteoarthritis (ROA) progression in a real-world setting. A cohort that initiated IACs and a comparison cohort without IACs from participants with mild to moderate knee ROA in the Osteoarthritis Initiative (OAI) were assembled (from 0-month to 48-month). Two measures of knee ROA progression were assessed during the follow-up period: (1) an increase in Kellgren and Lawrence (KL) grade by ≥1 grade or having a knee replacement (i.e., KL grade worsening); and (2) a decrease in joint space width (JSW) by ≥0.7mm or having a knee replacement (i.e., JSW worsening). The associations of IACs initiation using a propensity-score matched cohort study and continuous IACs using marginal structural models with the risk of knee ROA progression were examined. Among 684 propensity-score matched participants at baseline (148 IACs initiators, 536 comparators), 65 knees (21.7/100 person-years) in the IACs initiation cohort and 90 knees (7.1/100 person-years) in the comparison cohort experienced KL worsening. The hazard ratios (HRs) of KL worsening from IACs initiation and continuous IACs were 3.02 (95% confidence interval [CI], 2.19-4.16) and 4.67 (95% CI, 2.92-7.47), respectively. The corresponding HRs of JSW worsening were 2.93 (95% CI, 2.13-4.02) and 3.26 (95% CI, 1.78-5.96), respectively. All HRs for continuous use of IACs were further away from the null. IACs, especially continuous IACs, may be associated with an increased risk of knee ROA progression.

Intra-articular Corticosteroids for Knee Pain-What Have We Learned from the Equine Athlete and Current Best Practice.

The use of intra-articular corticosteroids for traumatic arthritis and osteoarthritis (OA) is common in the horse. The beneficial and deleterious effects of the principal corticosteroids used betamethasone esters (Celestone [Soluspan], methylprednisolone acetate [Depo Medrol], and triamcinolone acetonide [TA] [Vetalog or Kenalog]) have been defined for the horse. While TA has both disease-modifying as well as symptom-modifying effects, methyl prednisolone acetate has deleterious effects on the articular cartilage. Studies in traumatically injured joints show the same rationale (suppression of deleterious mediators associated with inflammation) and positive results from the use of TA in both equine and human patients. Studies in the experimental equine OA model allow for more in-depth knowledge of disease-modifying effects. Recent insights allow us to understand posttraumatic OA as an early consequence of joint injury that may require a more aggressive and proactive treatment approach than commonly applied to date.

Expression of inflammatory and structural matrix genes in synovial fluid following intra-articular administration of isoflupredone acetate to exercised horses.

Intra-articular use of corticosteroids is commonplace in performance horses. Isoflupredone acetate (IPA) is one of four Food and Drug Administration approved corticosteroids for intra-articular use in horses. The lack of published reports describing the efficacy and duration of effects of this drug warrant further study. To assess the effects of intra-articular administration of IPA on the expression of selected anti- and pro-inflammatory and structural matrix genes following intra-articular administration to exercised Thoroughbred horses and to correlate these effects with drug concentrations. Block design in vivo experiment. Twelve exercised horses received either a single intra-articular administration of 8 mg of IPA or 0.9% saline solution. Synovial fluid samples were collected prior to and up to 42 days post drug administration from the treated joints. Microarray and qRT-PCR analysis were used to assess changes in expression levels of various inflammatory and structural genes post drug administration. On microarray analysis, 855, 23,358 and 26,411 genes had a measurable fold change (increase or decrease in expression levels) when comparing baseline samples to 24 h, baseline samples to day 7 and 24 h samples to day 7, respectively. Of the genes selected for further study by qRT-PCR analysis, expression of ANXA-1 (lipocortin) was significantly increased and IL23A and MMP1 and MMP9 significantly decreased following IPA administration. Expression levels of collagen genes were not significantly different from baseline. Limitations include the use of a noninflammatory model as results may differ in the presence of an acute inflammatory insult and the inability to measure protein concentrations of inflammatory mediators due to limited synovial fluid sample volume. Expression relative to baseline, for both inflammatory and matrix genes for up to 42 days post IPA administration, suggests a prolonged effect relative to detection time in both plasma and synovial fluid.

The effects of intra-articular glucocorticoids and exercise on pain and synovitis assessed on static and dynamic magnetic resonance imaging in knee osteoarthritis: exploratory outcomes from a randomized controlled trial.

The aims of the present knee osteoarthritis (KOA)-study were to: (1) describe and compare the changes in magnetic resonance imaging (MRI)-measures of synovitis following an exercise program preceded by an intra-articular injection of either corticosteroid or isotonic saline and (2) investigate if any of the changes in patient reported outcome measures (PROMs) were associated with changes in MRI-measures of synovitis. We performed a randomized, double-blinded, placebo-controlled clinical trial evaluating the effects of intra-articular corticosteroid vs placebo injections given before exercise therapy in KOA-patients. PROMs were assessed using the KOOS (knee injury and osteoarthritis outcome score). Synovitis was assessed on conventional non-contrast-enhanced, conventional contrast-enhanced (CE) and dynamic contrast-enhanced (DCE) MRI. PROMs and MRIs were obtained prior to the intra-articular injection, after termination of the exercise program (week 14-primary time point) and week 26. Of 100 randomized participants (50 in each allocation group), 91 had complete MRI-data at baseline (63% female, mean age: 62 years, median Kellgren-Lawrence-grade: 3). There were no statistically significant differences between the two interventions in regards of changes in MRI-measures of synovitis at any time-point. At week 14, we found no statistical significant MRI-explanatory variables of either of the PROMs. The present study does not justify the use of intra-articular corticosteroids over intra-articular saline when combined with an exercise program for reduction of synovitis in KOA. The improvement in pain and function following the intervention with intra-articular corticosteroids/saline and exercise could not be explained by a decrease in synovitis on MRI indicating other pain causing/relieving mechanisms in KOA.

Osteoarthritis in horses - Part 2: a review of the intra-articular use of corticosteroids as a method of treatment

The problem considered in this review is related to the frequent use of corticosteroids (COs) (i.e. steroids) in the practice of equine medicine and surgery as a therapeutic strategy in the treatment of degenerative joint disease, commonly known as osteoarthritis (OA). This disease is one of the most common among the equine musculoskeletal diseases, and is clinically characterized by pain, lameness, joint effusion at the initial stage, which usually reduces with the progression of the disease, and reduced physical performance. Although steroids are considered excellent drugs in the control of clinical signs resulting from osteoarthritis, they also influence cellular activity through activation of various signaling mechanisms. However, they can cause adverse effects when administered intra-articularly, since they are immunosuppressive drugs of many cell types. They are also incriminated as suppressors of the chondrocyte matrix synthetic activities, which may contribute to 'arthropathy by corticosteroids', which can also be associated with cumulative injury resulting from improper use (dose and frequency of application) of already damaged joints. The objective of this article is to review information about the advantages and disadvantages of intra-articular COs for treatment of the disease in horses. In addition, some important information of other species is also presented.

Osteoarthritis in horses - Part 1: relationship between clinical and radiographic examination for the diagnosis

Locomotor disorders are very common in the equine clinic, which may be partly due to the different types of activities horses develop. (OA), commonly known as degenerative joint disease, presents an considerable role in the series of disorders of the musculoskeletal system and may be associated with other problems such as navicular syndrome, periostitis or osteochondrosis. This affection causes progressive deterioration of articular cartilage, accompanied by bone and soft-tissue periarticular changes. In fact, it results from a complex interaction between biochemical and biomechanical factors. The objective of this article is to review information about clinical and radiographic findings of OA, the biochemical and biomechanical changes manifested in the disease and the importance of the synovial fluid. Additionally, some information on other species is also presented. This review refers to Part 1 of a study whose sequence is entitled Osteoarthritis in horses - Part 2: a review of the intra-articular use of corticosteroids as a method of treatment.

Intra-articular corticosteroid for knee osteoarthritis.

Intra-articular corticosteroid for knee osteoarthritis.

Use of MRI prior to corticosteroid injections of wrist joints in children with JIA

Purpose The use of intra-articular corticosteroids in children with juvenile idiopathic arthritis (JIA) is an accepted therapeutic option as their use has been found to be safe and proven to facilitate rapid resolution of signs and symptoms of inflammation. An increasing number of studies have described improved sensitivity of magnetic resonance imaging (MRI) compared with conventional radiography in detection of early synovitis, tendinopathy, bone edema, and bone erosions. The purpose of this study was to document joints within the wrist and carpus with active synovitis in children with JIA using MRI and to explore how MRI localization of affected joints prior to intra-articular corticosteroid injection affects outcomes.

On the main stages of the history of intra-articular therapy

In this review the main stages in the history of intra-articular therapy of the rheumatic diseases are summarized. The first approach to such a local treatment has been likely performed in 1792 by the French physician Jean Gay, who injected in a swelling knee the "eau du Goulard" (Goulard's water), namely a mixture based on lead compounds. In the XIX century iodine derivatives have been mainly applied as an intra-articular treatment. In the XX century, before the wide use of intra-articular corticosteroids, chiefly due to the Joseph Lee Hollander's experiences, a variety of drugs has been employed, including cytostatics and sclerosing substances. A further important stage has been synoviorthesis, by using specific radionuclides, that would actually represent an anti-synovial treatment. In the last years a spread use of intra-articular hyaluronic acid, particularly in osteoarthritis, has been recorded, with the aim to warrant articular viscosupplementation. Future of intra-articular treatment should be represented by the biological drugs, i.e., anti-TNF, but it is still untimely to define the exact role of such a local treatment of arthritis.

Errata

Equine Veterinary JournalVolume 43, Issue 1 p. 122-122 Free Access Errata This article corrects the following: The use of intra-articular corticosteroids in the horse: What is known on a scientific basis? C. W. McILWRAITH, Volume 42Issue 6Equine Veterinary Journal pages: 563-571 First Published online: June 7, 2010 First published: 10 December 2010 https://doi.org/10.1111/j.2042-3306.2010.00345_1.xAboutSectionsPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat The Review Article by C.W. McIlwraith (2010) ‘The use of intra-articular corticosteroids in the horse: What is known on a scientific basis?’ published in the September issue of EVJ contains an error. On page 568, the 3rd sentence of the final paragraph in the left column should read: Synovial fluid concentrations were highest one day after injection (7.5 µg/ml) decreasing to a steady state concentration by Day 4 (10 ng/ml) and became undetectable by Day 15. We apologise for this error and any inconvenience it may have caused. Reference McIlwraith, C.W. (2010) The use of intra-articular corticosteroids in the horse: What is known on a scientific basis? Equine vet. J. 42, 563- 571. Wiley Online LibraryCASPubMedWeb of Science®Google Scholar Volume43, Issue1January 2011Pages 122-122 ReferencesRelatedInformation

The use of intra‐articular corticosteroids in the horse: What is known on a scientific basis?

Intra-articular use of corticosteroids has become a recent focus (or re-focus) of attention in the Thoroughbred racing industry. This manuscript reviews the clinical use and scientific basis of intra-articular corticosteroid administration including catastrophic injury, articular cartilage degradation and the development of osteoarthritis (OA), as well as the timing of injection relative to racing.

Temporomandibular joint arthritis in juvenile idiopathic arthritis: the forgotten joint

This review explores the prevalence, clinical and radiographic signs, and treatment of temporomandibular joint arthritis in children with juvenile idiopathic arthritis. Temporomandibular joint arthritis seems to be a more frequent manifestation in patients with juvenile idiopathic arthritis than previously believed, in part due to the paucity of clinical symptoms and poor sensitivity of conventional radiographs used for diagnosis. Antinuclear antibody positivity, early onset of disease, and presence of systemic or polyarticular disease are all risk factors for temporomandibular joint arthritis but may underpredict temporomandibular joint involvement in juvenile idiopathic arthritis. Magnetic resonance imaging enhanced with gadolinium is currently the gold standard in detection of temporomandibular joint arthritis, and treatment with intra-articular corticosteroids has been shown to be effective and safe, with minimal side effects. Given the paucity of clinical symptoms in temporomandibular joint arthritis, detection of temporomandibular joint inflammation using contrast-enhanced magnetic resonance imaging is essential for instituting appropriate therapy in a timely fashion. The use of intra-articular corticosteroids holds promise for control of temporomandibular joint inflammation and prevention of associated morbidities.

Therapeutic targets in osteoarthritis: from today to tomorrow with new imaging technology

Over the last decade, there have been several interesting advances in the treatment of osteoarthritis (OA). A clearer understanding of the pathophysiology of this disease1 has facilitated the development of...

Postarthroscopy surgical site infections: review of the literature.

The use of arthroscopy for both diagnosis and operative intervention has been increasing steadily since its introduction in the 1970s. It is generally associated with fewer complications and shorter times to mobilization than are open procedures. Overall reported rates of complications are low (0.1%-0.6% of procedures). This review focuses on infectious complications of arthroscopy, which are rare (0.01%-0.48% of procedures) but result in significant morbidity for the patient when they occur. The most commonly reported causative organisms are staphylococci. Several outbreaks have been reported related to breaks in infection control or to contaminated instruments. Suggested risk factors include use of intra-articular corticosteroids, prolonged tourniquet time, patient's age >50 years, failure to prepare the surgical site again before conversion to arthrotomy, procedure complexity, and a history of previous procedures. However, most reports use variable and unclear definitions of infection, which makes it difficult to draw firm conclusions.

A risk-benefit assessment of intra-articular corticosteroids in rheumatic disorders.

The appeal of intra-articular corticosteroid therapy has increased with the growing emphasis on early disease control in rheumatoid disease. The impact on the patient's pain and stiffness is impressive and prompt. This may encourage patient compliance with longer term therapies given to slow the course of the disease. The release of corticosteroid into the circulation also provides some generalised improvement. This can prove helpful during the management of flares of inflammatory disease. There is less evidence to support the use of intra-articular corticosteroids in other inflammatory arthritides, but experience suggests that the benefits are similar. In osteoarthritis the benefits are less certain, but intra-articular therapy may prove important in patients who cannot undergo salvage operative procedures because of intercurrent illness. The benefits of intra-articular corticosteroids may be enhanced by rest after the injection, or by the additional administration of agents such as radio-colloids, rifampicin (rifampin), or osmic acid. Most controlled trial data have been published on knee injections, but other joints can be useful targets for local therapy. The risks are mainly related to the discomfort of the procedure, localised pain post-injection and flushing, but most feared is septic arthritis which probably occurs in about 1 in 10000 injections. Careful aseptic technique is the best protection. Tissue atrophy at the injection site, abnormal uterine bleeding, hypertension and hyperglycaemia rarely cause problems. Osteonecrosis might be as much a problem with uncontrolled painful arthritis as with a joint rendered less symptomatic by corticosteroid injections. Intra-articular corticosteroids form an important part of the management of inflammatory joint disease and might be considered where an inflammatory element occurs in osteoarthritis. They may be used at any stage in the arthritic process, but should be seen as an adjunct to other forms of symptom relief. In patients needing multiple joint injections, systemic therapy should be reviewed to see if better disease control could reduce the need for invasive therapy.