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1.
Clin Exp Dent Res ; 6(6): 642-649, 2020 12.
Article in English | MEDLINE | ID: mdl-33280278

ABSTRACT

OBJECTIVE(S): It is well appreciated that traditional analgesic delivery routes used to treat pain associated with temporomandibular disorder (TMD) often have harmful unintended side effects as a consequence of systemic distribution. Further, localized delivery of analgesic medication via intra-articular injections involves a different set of issues limiting their clinical viability. As an option, transdermal analgesic delivery provides for prolonged pain relief and flexibility in dose administration, while limiting systemic exposure and minimizing adverse events. Incorporation of a novel electroporation technique may further increase transdermal drug penetration into synovial tissue/fluid and enhance pain reduction. The present feasibility study compares the effectiveness of an electroporation-enhanced transdermal application of diclofenac sodium to a conventional intra-articular injection of triamcinolone acetonide suspension (corticosteroids) to treat patients with TMD associated pain. METHODS: Pre- and post-treatment maximal incisal mouth opening (MIO), pain visual analog scale (VAS) and surface electromyography (EMG) of 22 patients treated with electroporation-enhanced diclofenac and 37 patients treated with corticosteroids injections were collected and analyzed. RESULTS: In general, patients treated with electroporation exhibited better results in terms of pain improvement (corrected p-value = .01) compared to the standard treatment, but both methods were similarly effective for improvement of MIO (corrected p-value = .71) and improvement of all EMG indices (corrected p-values ≥ .05). CONCLUSION: The enhancing effect of electroporation in transdermal delivery of diclofenac sodium was demonstrated by decreased pain, increase MIO and EMG improvement to normal values. Its analgesic and inflammatory results are comparable with standard treatment offered by corticosteroids.


Subject(s)
Anti-Inflammatory Agents, Non-Steroidal/administration & dosage , Arthralgia/drug therapy , Diclofenac/administration & dosage , Electrochemotherapy/methods , Temporomandibular Joint Disorders/drug therapy , Adult , Aged , Arthralgia/diagnosis , Arthralgia/immunology , Electrochemotherapy/statistics & numerical data , Feasibility Studies , Female , Glucocorticoids/administration & dosage , Humans , Injections, Intra-Articular/adverse effects , Injections, Intra-Articular/statistics & numerical data , Male , Middle Aged , Pain Measurement/statistics & numerical data , Pilot Projects , Prospective Studies , Temporomandibular Joint Disorders/complications , Temporomandibular Joint Disorders/immunology , Treatment Outcome , Triamcinolone Acetonide/administration & dosage
2.
Pain Physician ; 23(5): 439-450, 2020 09.
Article in English | MEDLINE | ID: mdl-32967386

ABSTRACT

BACKGROUND: Sacroiliac joint is one of the proven causes of low back and lower extremity pain. Prevalence estimates of sacroiliac joint pain range from 10% to 25% in patients with persistent axial low back pain without disc herniation, discogenic pain, or radiculitis based on multiple diagnostic studies and systematic reviews. Over the years, utilization patterns of sacroiliac joint injections have been increasing in comparison to other interventional techniques. Further, the development of new current procedural terminology (CPT) codes and coverage policies for sacroiliac joint nerve blocks, sacroiliac joint radiofrequency neurotomy, and evolving evidence for sacroiliac joint fusion will further increase the utilization patterns. STUDY DESIGN: Analysis of growth patterns of sacroiliac joint injections from 2000 to 2018 with comparative analysis of 2000 to 2009 and 2009 to 2018. OBJECTIVES: To assess utilization patterns of sacroiliac joint injections from 2000 to 2018. METHODS: The Centers for Medicare and Medicaid Services (CMS) Physician/Supplier Procedure Summary (PSPS) Master dataset was utilized in this analysis. RESULTS: The results of the evaluation from 2009 to 2018 showed an increase of 11.3% and an annual increase of 1.2% per 100,000 Medicare population. However, from 2000 to 2009, an increase of 299.8% from 2000 to 2009 with an annual increase of 16.6% per 100,000 Medicare population. LIMITATIONS: The limitations of this study included a lack of data on the new sacroiliac joint nerve block and radiofrequency neurotomy codes. Further, this data did not include utilization patterns of sacroiliac joint fusions. In addition, Medicare Advantage patients were not included, which constitute approximately 30% of overall Medicare population. Further, there is also a possibility that state claims data may include claims from other states. As with all claims-based data analyses, this study is retrospective and thus potentially limited by bias. Finally, patients who are self or commercially insured are not part of the dataset. CONCLUSIONS: This study shows increases in utilization patterns of sacroiliac joint injections; however, at a significantly lower rate with an annual increase of 16.6% prior to 2009 and only 1.2% from 2009 to 2018 per 100,000 Medicare beneficiaries.


Subject(s)
Injections, Intra-Articular/statistics & numerical data , Low Back Pain/therapy , Pain Management/methods , Chronic Pain/therapy , Female , Humans , Male , Medicare , Retrospective Studies , Sacroiliac Joint , United States
3.
Acta Orthop ; 91(6): 743-749, 2020 12.
Article in English | MEDLINE | ID: mdl-32698659

ABSTRACT

Background and purpose - Platelet-rich plasma (PRP) is broadly used in the treatment of knee osteoarthritis, but clinical outcomes are highly variable. We evaluated the effectiveness of intra-articular injections with Autologous Conditioned Plasma (ACP), a commercially available form of platelet-rich plasma, in a tertiary referral center. Second, we aimed to identify which patient factors are associated with clinical outcome. Patients and methods - 140 patients (158 knees) with knee osteoarthritis (Kellgren and Lawrence grade 0-4) were treated with 3 intra-articular injections of ACP. The Knee Injury and Osteoarthritis Outcome Score (KOOS), pain (Numeric Rating Scale; NRS), and general health (EuroQol 5 Dimensions; EQ5D) were assessed at baseline and 3, 6, and 12 months' follow-up. The effect of sex, age, BMI, Kellgren and Lawrence grade, history of knee trauma, and baseline KOOS on clinical outcome at 6 and 12 months was determined using linear regression. Results - Mean KOOS increased from 37 at baseline to 44 at 3 months, 45 at 6 months, and 43 at 12 months' follow-up. Mean NRS-pain decreased from 6.2 at baseline to 5.3 at 3 months, 5.2 at 6 months, and 5.3 at 12 months. EQ5D did not change significantly. There were no predictors of clinical outcome. Interpretation - ACP does not lead to a clinically relevant improvement (exceeding the minimal clinically important difference) in patients suffering from knee osteoarthritis. None of the investigated factors predicts clinical outcome.


Subject(s)
Arthralgia , Injections, Intra-Articular , Osteoarthritis, Knee , Platelet-Rich Plasma , Age Factors , Arthralgia/diagnosis , Arthralgia/etiology , Body Mass Index , Female , Follow-Up Studies , Humans , Injections, Intra-Articular/methods , Injections, Intra-Articular/statistics & numerical data , Male , Medical History Taking/statistics & numerical data , Middle Aged , Netherlands/epidemiology , Osteoarthritis, Knee/epidemiology , Osteoarthritis, Knee/physiopathology , Osteoarthritis, Knee/therapy , Prognosis , Risk Assessment/methods , Sex Factors , Treatment Outcome
4.
Phys Sportsmed ; 48(2): 208-214, 2020 05.
Article in English | MEDLINE | ID: mdl-31560251

ABSTRACT

Objectives: To determine the current rates of use of available image guidance modalities for large joint and bursal injections, in addition to their relationships to physician demographics.Methods: An electronic survey was sent to 3,400 members of the American Medical Society for Sports Medicine (AMSSM), examining types of guidance used for each large joint and bursal injection.Results: A total of 674 sports medicine physicians responded to the survey. Intra-articular hip and glenohumeral joint injections were more commonly performed with ultrasound guidance, while palpation-guidance was more common with all other injections. Physicians who specialized in Physical Medicine & Rehabilitation (PM&R) were more likely to use ultrasound for trochanteric bursa (p = 0.007, OR = 4.16 [1.46-11.8]), while internal medicine-, pediatrics-, and family medicine-trained physicians were more likely to use palpation guidance for at least one joint (p < 0.05). Physicians with fewer years of experience were more likely to use ultrasound for glenohumeral joint injections (p ≤ 0.002 for all age groups with less than 20 years of experience, ORs ranging from 6.3 to 9.2).Conclusion: Palpation-guidance is the most common technique used for large joint and bursal injections, other than for glenohumeral and hip joint injections. PM&R-trained physicians and those with less experience tend to use ultrasound more frequently.


Subject(s)
Injections, Intra-Articular/methods , Injections, Intra-Articular/statistics & numerical data , Palpation/statistics & numerical data , Practice Patterns, Physicians'/statistics & numerical data , Ultrasonography/statistics & numerical data , Bursa, Synovial , Clinical Competence , Family Practice/statistics & numerical data , Hip Joint , Humans , Internal Medicine/statistics & numerical data , Pediatrics/statistics & numerical data , Physical and Rehabilitation Medicine/statistics & numerical data , Shoulder Joint , Surveys and Questionnaires
5.
BMC Musculoskelet Disord ; 20(1): 407, 2019 Sep 04.
Article in English | MEDLINE | ID: mdl-31484517

ABSTRACT

BACKGROUND: Osteoarthritis (OA) is the most common joint disorder among elderly individuals. Nonsurgical treatment plays an important role in treating knee OA. The aim of the present study was to investigate the trends and research status about nonsurgical treatment of knee OA. METHODS: Publications about the nonsurgical treatment of knee OA from 1994 to 2018 were searched from the Web of Science (WoS) database. The data were analyzed by using bibliometric methodology. The software VOSviewer was used for bibliographic coupling, coauthorship, cocitation, co-occurrence analysis and to investigate the publication trends in nonsurgical treatment of knee OA. RESULTS: In total, 8512 articles were included. The number of publications increased annually worldwide. The United States has made the largest contribution to this field, with the most publications, citations and the highest H-index. The most contributive institutions were Harvard University, the University of California system and Assistance Publique Hopitaux Paris (APHP). The journal Osteoarthritis and Cartilage published the most relative articles. Studies could be classified into five clusters: articular cartilage study, biomechanics study, physiotherapy study, oral pharmacologic study and intra-articular injection study. Articular cartilage and physiotherapy were predicted as the next hot topics in this field. CONCLUSIONS: There will be an increasing number of publications on the nonsurgical treatment of knee OA based on current global trends. The United States made the largest contribution to this field. More focus will be placed on cartilage-related and physiotherapy research, which may be the next popular topics in the nonsurgical treatment of knee OA.


Subject(s)
Bibliometrics , Biomedical Research/statistics & numerical data , Osteoarthritis, Knee/therapy , Administration, Oral , Anti-Inflammatory Agents/administration & dosage , Biomechanical Phenomena , Biomedical Research/trends , Cartilage, Articular/pathology , Humans , Injections, Intra-Articular/statistics & numerical data , Knee Joint/physiopathology , Osteoarthritis, Knee/pathology , Osteoarthritis, Knee/physiopathology , Physical Therapy Modalities/statistics & numerical data
6.
Musculoskeletal Care ; 17(3): 257-268, 2019 09.
Article in English | MEDLINE | ID: mdl-31373430

ABSTRACT

OBJECTIVE: The aim of the study was to determine the effectiveness of the lateral approach to subacromial injection, compared with the posterior approach, for the treatment of subacromial impingement syndrome. METHOD: A pragmatic randomized controlled trial was carried out in an outpatient community musculoskeletal service. The sample comprised 80 adults, aged 18 years or over, with subacromial impingement syndrome. The intervention group received a single subacromial injection, using a 21-gauge green needle, of 40 mg/ml triamcinolone acetonide (Kenalog) and 4 ml 1% lignocaine using a lateral approach. The control group received identical treatment, with the exception that the injection was given using a posterior approach. The outcome measures were pain measured using 0-10 numerical pain scale and shoulder pain and disability index (SPADI) scores at 8 and 12 weeks' follow-up. RESULT: A moderate but statistically and clinically significant difference in improvement in daytime pain (mean change in score) occurred in favour of the lateral group (mean = 4.0) compared with the posterior group (mean = 2.0) between weeks 0 and 8 (1.4 points [95% confidence interval 0.3, 2.6; p = 0.018]). However, there were no statistically significant differences between the groups in night-time pain, shoulder function and SPADI scores. There was a statistically and clinically significant difference (p = 0.001) within the groups for all clinical outcomes between weeks 0 and 8, and between weeks 0 and 12. CONCLUSION: There were no significant differences in the treatments; however, both forms of treatment were associated with a significant improvement in shoulder pain, function and disability.


Subject(s)
Anti-Inflammatory Agents/administration & dosage , Cortisone/administration & dosage , Injections, Intra-Articular/statistics & numerical data , Shoulder Impingement Syndrome/drug therapy , Adolescent , Adult , Aged , Female , Humans , Injections, Intra-Articular/methods , Male , Middle Aged , Patient Reported Outcome Measures , Young Adult
7.
Am J Sports Med ; 47(11): 2577-2583, 2019 09.
Article in English | MEDLINE | ID: mdl-31373830

ABSTRACT

BACKGROUND: Intra-articular injection of adipose-derived stem cells (ASCs) has shown promise for improving symptoms and cartilage quality in the treatment of osteoarthritis (OA). However, while most preclinical studies have been performed with plastic-adherent ASCs, most clinical trials are being conducted with the stromal vascular fraction (SVF), prepared from adipose tissue without prior culture. PURPOSE: To directly compare clinical outcomes of intra-articular injection with ASCs or SVF in patients with knee OA. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The authors retrospectively compared 6-month outcomes in 42 patients (59 knees) receiving intra-articular injection with 12.75 million ASCs and 38 patients (69 knees) receiving a 5-mL preparation of SVF. All patients had Kellgren-Lawrence grade 2, 3, or 4 knee OA and had failed standard medical therapy. The visual analog scale (VAS) pain score and Knee injury and Osteoarthritis Outcome Score (KOOS) at baseline and 1, 3, and 6 months after injection were considered as outcomes. Outcome Measures in Rheumatology-Osteoarthritis Research Society International (OMERACT-OARSI) criteria were also used to assess positive response. A repeated measures analysis of variance was used for comparison between the treatment groups. RESULTS: No major complications occurred in either group. The SVF group had a higher frequency of knee effusion (SVF 8%, ASC 2%) and minor complications related to the fat harvest site (SVF 34%, ASC 5%). Both groups reported improvements in pain VAS and KOOS domains. Specifically, in the ASC group, symptoms improved earlier (by 3 months; P < .05) and pain VAS decreased to a greater degree (55%; P < .05) compared with the SVF group (44%). The proportion of OMERACT-OARSI responders in the ASC group was slightly higher (ASCs, 61%; SVF, 55%; P = .25). CONCLUSION: It was observed that both ASCs and SVF resulted in clinical improvement in patients with knee OA, but that ASCs outperform SVF in the early reduction of symptoms and pain with less comorbidity.


Subject(s)
Adipose Tissue/transplantation , Injections, Intra-Articular/methods , Knee/surgery , Osteoarthritis, Knee/therapy , Stem Cell Transplantation/classification , Aged , Aged, 80 and over , Cells, Cultured , Cohort Studies , Female , Humans , Injections, Intra-Articular/statistics & numerical data , Male , Middle Aged , Retrospective Studies , Treatment Outcome
8.
Ann Phys Rehabil Med ; 62(5): 336-341, 2019 Sep.
Article in English | MEDLINE | ID: mdl-30639581

ABSTRACT

BACKGROUND: Epicondylar tendinopathy ("tennis elbow") is a serious issue in manual labourers. Symptoms can persist over months or even more than 1 year, even when treated with trinitrine patches, acupuncture, sclerosis of neovessels, shock-wave therapy, autologous blood injections, platelet-rich plasma or hyaluronic acid. Botulinum toxin (BoNT-A) injections showed promising short-term results, but the long-term beneficial effects are not yet known. OBJECTIVE: We aimed to assess the long-term effect, side effects and recurrence rate after BoNT-A injections on chronic lateral epicondylar tendinopathy during 1 year. METHODS: This open study followed a 3-month randomized controlled trial. We included 50 patients followed at day 0 (V0), 90 (V1), 180-270 (V2) and 365 (V3). The main judgment criterion was the number of BoNT-A injections required to achieve pain relief with no further request for treatment by the patient. RESULTS: After one BoNT-A injection, 22/50 (44%) patients did not ask for further treatment during follow-up because of complete pain relief, and 20/50 (40%) asked for a second BoNT-A injection. For 20 patients with a second injection, 18 (90%) did not ask for further treatment during follow-up. Only 1 patient had a recurrence of pain after an initial pain relief of greater than 75%. Quality of life, and painful and maximal gripping force improved significantly at V1, V2 and V3 as compared with V0, and repercussions on daily and professional activities decreased significantly (P<0.05). CONCLUSIONS: One or 2 BoNT-A injections has favourable results for chronic epicondylar tendinopathy.


Subject(s)
Botulinum Toxins, Type A/administration & dosage , Injections, Intra-Articular/statistics & numerical data , Neurotoxins/administration & dosage , Pain Management/statistics & numerical data , Tennis Elbow/drug therapy , Adult , Chronic Disease , Female , Follow-Up Studies , Humans , Male , Middle Aged , Pain Management/methods , Recurrence , Time Factors , Treatment Outcome
9.
J Arthroplasty ; 34(2): 303-308, 2019 02.
Article in English | MEDLINE | ID: mdl-30477967

ABSTRACT

BACKGROUND: Total knee arthroplasty (TKA) for the majority of patients with severe knee osteoarthritis provides relief of symptoms and improved function. However, there remains a subset of dissatisfied patients despite an unremarkable workup. A corticosteroid injection (CSI) is a commonly used nonsurgical treatment for painful knee osteoarthritis but its efficacy in a replaced knee remains unknown. METHODS: A retrospective chart review identified primary TKA patients who subsequently received a CSI into a replaced knee from 2015 to 2016 by a single surgeon. Patients receiving a CSI underwent clinical examination, laboratory analysis to rule out infection, and radiographic evaluation before CSI. Patient variables were recorded and a patient satisfaction survey assessed the efficacy of the injection. The survey response rate was 70.1%. RESULTS: Of the 129 responders, 82.9% remembered the injection. The average time from index arthroplasty to injection was median 5.3 months (interquartile range, 2.1-23.4) and 30.8% of patients received more than 1 injection (range, 1-5). Overall, 76.6% reported decreased pain, 57.9% reported increased motion, and 65.4% reported long-term decreased swelling. Improvement lasted greater than 1 month for 56.1% of patients, and overall 84.1% reported improvement (slight to great) in the knee following CSI. No patient developed a periprosthetic joint infection (PJI) within 1 year of injection. CONCLUSION: This study suggests that certain patients following TKA may benefit from a CSI. However, this should only be performed once clinical, radiographic, and laboratory examination has ruled out conditions unlikely to improve long term from a CSI.


Subject(s)
Adrenal Cortex Hormones/administration & dosage , Arthroplasty, Replacement, Knee/adverse effects , Pain, Postoperative/drug therapy , Aged , Female , Humans , Injections, Intra-Articular/methods , Injections, Intra-Articular/statistics & numerical data , Knee Joint/surgery , Male , Middle Aged , Osteoarthritis, Knee/surgery , Pain/surgery , Patient Satisfaction/statistics & numerical data , Retrospective Studies , Surveys and Questionnaires
10.
Arthroscopy ; 35(1): 45-50, 2019 01.
Article in English | MEDLINE | ID: mdl-30473453

ABSTRACT

PURPOSE: To identify any dose-dependent association between the use of subacromial corticosteroid injections within a year before rotator cuff repair (RCR) and subsequent need for revision rotator cuff surgery. METHODS: Two large administrative databases were queried for patients undergoing arthroscopic RCR. A minimum of 1 year of preoperative database exposure and 2 years of postoperative database follow-up were required for inclusion. Patients were stratified into groups that received 0 (control), 1, 2, or 3 or more ipsilateral corticosteroid shoulder injections within the year prior to RCR. The outcome of interest was ipsilateral revision arthroscopic or open RCR or arthroscopic debridement for a diagnosis of rotator cuff tear within 2 years of the index surgery. Revision rates were compared between groups using a multivariate logistic regression analysis controlling for demographic and comorbidity confounders. RESULTS: A total of 110,567 patients from the Medicare database and 12,892 patients from the private insurance database were included. There was no association between a single injection within the year prior to RCR and revision surgery in either cohort. The use of 2 or more injections was associated with a significant increase in the risk of requiring revision surgery in both the Medicare (odds ratio [OR], 2.76-3.26; P < .0001) and private insurance (OR, 2.53-2.87; P < .0001) populations. CONCLUSIONS: A single shoulder injection within a year prior to arthroscopic RCR was not associated with any increased risk of revision surgery; however, the administration of 2 or more injections was associated with a substantially increased risk of subsequent revision rotator cuff surgery (OR, 2.53-3.26). Although causality cannot be established on the basis of this database review, caution is recommended when considering more than 1 shoulder corticosteroid injection in patients with potentially repairable rotator cuff tears. LEVEL OF EVIDENCE: Level III, retrospective cohort study.


Subject(s)
Glucocorticoids/administration & dosage , Injections, Intra-Articular/statistics & numerical data , Reoperation/statistics & numerical data , Rotator Cuff Injuries/surgery , Aged , Aged, 80 and over , Case-Control Studies , Databases, Factual , Female , Humans , Male , Retrospective Studies , Shoulder Joint , United States
11.
J Hand Surg Eur Vol ; 43(10): 1106-1110, 2018 Dec.
Article in English | MEDLINE | ID: mdl-30335596

ABSTRACT

Truven MarketScan® Databases were used to identify patients with thumb carpometacarpal arthritis who underwent surgical treatment. Pre-operative corticosteroid or hyaluronic acid injections were identified, as were post-operative complications. Multivariable regressions assessed the relationship between injections and complications. Of 16,268 patients, 4462 had steroid injections and 252 received hyaluronic acid injections. Twenty-one per cent (3381 patients) had post-operative complications. Diabetes and smoking increased the odds of complications in all models. Odds of any complication, most notably infectious complications, were increased 20% by corticosteroids (OR 1.2; 95% CI: 1.1 to 1.3). More than three injections increased the odds of a complication by 70% (OR 1.7; 95% CI: 1.3 to 2.1). Hyaluronic acid increased the odds of wound-healing complications by 110% (OR 2.1; 95% CI: 1.3 to 3.4). Corticosteroid and hyaluronic acid injections for thumb carpometacarpal arthritis increase the odds of post-operative complications. Level of evidence: IV.


Subject(s)
Carpometacarpal Joints/surgery , Glucocorticoids/adverse effects , Hyaluronic Acid/adverse effects , Osteoarthritis/surgery , Postoperative Complications , Thumb/surgery , Diabetes Complications , Humans , Injections, Intra-Articular/adverse effects , Injections, Intra-Articular/statistics & numerical data , Osteoarthritis/drug therapy , Preoperative Care , Smoking/adverse effects , Viscosupplements/adverse effects
12.
J Hand Surg Am ; 43(8): 738-744, 2018 08.
Article in English | MEDLINE | ID: mdl-30077229

ABSTRACT

PURPOSE: This study examined how corticosteroid dose, injection site location, and patient demographics affect blood glucose level after corticosteroid injection in diabetic patients. METHODS: We prospectively enrolled 70 patients with diabetes mellitus requiring upper- and/or lower-extremity corticosteroid injections. Patients measured fasting and postprandial blood glucose for 14 days after the injection. Blood glucose from days 1 through 7 was compared with the average of days 10 through 14, acting as control. Changes in blood glucose were compared by corticosteroid dose, injection location, patient demographics, and insulin use. RESULTS: Patients who underwent shoulder, wrist, or hand injections and patients who received multiple injections had no significant elevations in fasting or postprandial blood glucose, whereas those with knee injections had a significant increase in fasting blood glucose on postinjection days 1 and 2. Preinjection hemoglobin A1C had a significant effect on postinjection blood glucose whereas corticosteroid dose, body mass index, insulin use, and the number of injections had no significant effect on the elevation of blood glucose. There were no cases of diabetic ketoacidosis in any subjects. CONCLUSIONS: Patients receiving corticosteroid injections in the upper extremity did not experience significant increases in blood glucose whereas those undergoing knee corticosteroid injections demonstrated elevated blood glucose levels. Because poorer glucose control was associated with greater elevations in blood glucose after injection, patients with higher hemoglobin A1C should be counseled to monitor postinjection glucose more closely. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic II.


Subject(s)
Blood Glucose/analysis , Diabetes Mellitus/blood , Glucocorticoids/administration & dosage , Injections, Intra-Articular/statistics & numerical data , Knee Joint , Upper Extremity , Aged , Body Mass Index , Diabetes Mellitus/drug therapy , Dose-Response Relationship, Drug , Female , Glycated Hemoglobin/analysis , Humans , Hypoglycemic Agents/therapeutic use , Insulin/therapeutic use , Male , Middle Aged , Prospective Studies , Triamcinolone/administration & dosage
13.
Plast Reconstr Surg ; 141(5): 1183-1191, 2018 05.
Article in English | MEDLINE | ID: mdl-29351183

ABSTRACT

BACKGROUND: Following publication of high-level evidence demonstrating that it is not an effective treatment for lateral epicondylitis, a reduction in the corticosteroid injection rate would be expected. The authors aimed to clarify current clinical practice pattern for lateral epicondylitis and identify factors that influence the introduction of evidence into clinical practice. METHODS: In this administrative claims analysis, the authors used 2009 to 2015 Truven MarketScan data to extract claims for corticosteroid injection, physical therapy, platelet-rich plasma injection, and surgery for lateral epicondylitis. The authors performed multivariable analysis using a generalized estimating equation model to identify the variables that potentially affect the odds of receiving a given treatment. RESULTS: Among 711,726 claims, the authors found that the odds of receiving a corticosteroid injection increased slightly after publication of contradictory evidence (OR, 1.7; 95 percent CI, 1.04 to 1.11 in 2015). Being male (OR, 1.21; 95 percent CI, 1.19 to 1.23), older (OR, 1.16; 95 percent CI, 1.13 to 1.19), and having managed care insurance (OR, 1.15; 95 percent CI, 1.13 to 1.18) significantly contributed to increased odds of receiving corticosteroid injections. Patients seen at facilities in the South (OR, 1.33; 95 percent CI, 1.30 to 1.36 compared with the Northeast) and by plastic/orthopedic surgeons (OR, 2.48; 95 percent CI, 2.43 to 2.52) also had increased odds of receiving corticosteroid injection. CONCLUSIONS: Corticosteroid injection use did not decrease after publication of impactful articles, regardless of provider specialty or other patient-related factors. This finding emphasizes that there are various barriers for even high-level evidence to overcome the inertia of current practice.


Subject(s)
Evidence-Based Practice/methods , Glucocorticoids/therapeutic use , Injections, Intra-Articular/statistics & numerical data , Publishing , Tennis Elbow/therapy , Administrative Claims, Healthcare/statistics & numerical data , Adult , Elbow/surgery , Evidence-Based Practice/statistics & numerical data , Female , Humans , Journal Impact Factor , Male , Middle Aged , Physical Therapy Modalities/statistics & numerical data , Platelet-Rich Plasma , Retrospective Studies , Treatment Outcome , United States
14.
Rev. bras. reumatol ; 57(6): 557-565, Nov.-Dec. 2017. tab, graf
Article in English | LILACS | ID: biblio-899477

ABSTRACT

Abstract Objectives: Describe Brazilian rheumatologists's competence in interventional rheumatology; assess the association between this ability and demographic and training variables. Methods: A cross-sectional study with 500 Brazilian rheumatologists. Participants were assessed by self-administered questionnaire consisting of demographics, training, practice in office and knowledge in interventional rheumatology data. Results: 463 participants had their data analyzed. The mean age was 40.2 years (±11.2). 70% had performed periarticular injections and 78% had performed intra-articular injections. The sample was divided into three groups: non-interventionist, little interventionist and very interventionist. The non-interventionist group showed (p < 0.001-0.04) higher mean age, lower proportion of university bond, lower training history, higher proportion of graduates in the Southeast country, and higher proportion of graduates in the 1980s to 1989. The very interventionist group showed higher (p < 0.001-0.018) proportion of adult rheumatologists, higher proportion of university bond, longer training time with greater practice of complex procedures, and higher proportion of graduates, trained and with private practice in the South country. Variables most associated with the very interventionist subgroup are performing axial intra-articular injections (OR: 7.4, p < 0.001), synovial biopsy (OR: 5.75, p = 0.043), image-guided IAI (OR: 4.16, p < 0.001), viscosupplementation (OR = 3.41, p < 0.001), joint lavage (OR = 3.22, p = 0.019), salivary gland biopsy (OR = 2.16, p = 0.034) and over 6-month training (OR: 2.16, p = 0.008). Conclusions: Performing more complex invasive procedures and over 6-month training in interventional rheumatology were variables associated with enhanced interventional profile.


Resumo Objetivos: Descrever a competência dos reumatologistas brasileiros na reumatologia intervencionista (RI); avaliar a associação entre essa capacidade e variáveis demográficas e de treinamento. Métodos: Fez-se um estudo transversal com 500 reumatologistas brasileiros. Os participantes foram avaliados por questionário autoadministrado, constituído por dados demográficos, treinamento, prática em consultório e conhecimento em dados de RI. Resultados: Analisaram-se os dados de 463 participantes. A média foi de 40,2 anos (± 11,2). Desses, 70% fizeram injeções periarticulares (IPA) e 78% intra-articulares (IIA). A amostra foi dividida em três grupos: não intervencionista, pouco intervencionista e muito intervencionista. O grupo não intervencionista apresentou (p < 0,001 - 0,04) maior média de idade, menor proporção de vínculo universitário, menor história de treinamento, maior proporção de graduados na Região Sudeste do país e maior proporção de graduados nas décadas de 1980 a 1989. O grupo muito intervencionista apresentou (p < 0,001 - 0,018) maior proporção de reumatologias que atendem pacientes adultos, maior proporção de vínculo universitário, maior tempo de treinamento de prática de procedimentos complexos, maior proporção de graduados no sul do país, treinados e com consultório particular nessa região. As variáveis mais frequentemente associadas ao subgrupo muito intervencionista foram realização de IIA axial (OR: 7,4, p < 0,001), biópsia sinovial (OR: 5,75, p = 0,043), IIA guiada por imagem (OR: 4,16, p < 0,001), viscossuplementação (OR = 3,41, p < 0,001), lavagem articular (OR = 3,22, p = 0,019), biópsia da glândula salivar (OR = 2,16, p = 0,034) e mais de seis meses de treinamento (OR: 2,16; p = 0,008). Conclusões: Fazer procedimentos invasivos mais complexos e ter mais de seis meses de treinamento em RI foram as variáveis associadas a um maior perfil intervencionista.


Subject(s)
Humans , Male , Female , Adult , Rheumatology/standards , Practice Patterns, Physicians'/statistics & numerical data , Clinical Competence , Injections, Intra-Articular/statistics & numerical data , Rheumatology/education , Brazil , Cross-Sectional Studies , Surveys and Questionnaires , Rheumatologists/statistics & numerical data , Middle Aged
15.
Hand (N Y) ; 12(5): 461-466, 2017 09.
Article in English | MEDLINE | ID: mdl-28832210

ABSTRACT

BACKGROUND: Trapeziometacarpal (TMC) arthrosis has a variety of treatment options, including nonoperative (eg, education, splint, injection) and operative management. Symptoms and limitations vary greatly among patients. The purpose of this study was to determine an association of symptoms and limitations, quantified using the Disabilities of the Arm, Shoulder, and Hand (QuickDASH) score, with treatment choice in patients newly diagnosed with TMC arthrosis. We also addressed the association of the QuickDASH score with radiographic severity and sought factors associated with higher QuickDASH scores. METHODS: As part of the routine new patient intake paperwork, all new patients completed a QuickDASH form. We included 81 new patients with newly diagnosed TMC arthrosis visiting the office of 1 of 5 orthopedic hand surgeons between March 1, 2015, and November 30, 2015. Eight patients were excluded because of incomplete QuickDASH forms. RESULTS: Based on QuickDASH tertiles, patients with a low QuickDASH score were more likely to choose education alone than patients with intermediate and high QuickDASH scores; no patients in the lowest QuickDASH tertile chose injection or surgery. Patients who chose education alone also had a lower mean QuickDASH score than patients who chose splint or surgery. Radiographic severity and other patient-related factors were not associated with greater symptoms and limitations. CONCLUSIONS: More adaptive patients (lower QuickDASH) are less likely to choose injection or surgery, irrespective of disease severity. The psychosocial factors known to correlate with greater symptoms and limitations might lead patients to feel they have fewer options or to choose more interventional options than they would if they were more at ease. In other words, inadequate attention to psychosocial factors may increase the risk of misdiagnosis of patient preferences.


Subject(s)
Arthritis/diagnostic imaging , Arthritis/therapy , Carpometacarpal Joints/diagnostic imaging , Disability Evaluation , Patient Preference/statistics & numerical data , Conservative Treatment/statistics & numerical data , Female , Humans , Injections, Intra-Articular/statistics & numerical data , Male , Metacarpal Bones/diagnostic imaging , Middle Aged , Orthopedic Procedures/statistics & numerical data , Patient Education as Topic/statistics & numerical data , Severity of Illness Index , Splints/statistics & numerical data , Trapezoid Bone/diagnostic imaging
16.
Pain Physician ; 20(5): E721-E726, 2017 07.
Article in English | MEDLINE | ID: mdl-28727716

ABSTRACT

BACKGROUND: Higher body mass index (BMI) is associated with difficulty in obtaining imaging studies. While there is a small body of literature regarding the relationship between fluoroscopy time and BMI during injections for pain management, this has not been studied for intraarticular (IA) hip injections. Further, in academic training centers, trainee involvement may affect this relationship. OBJECTIVE: To determine the relationship between BMI and fluoroscopy time during IA hip injections, both with and without involvement of a trainee. STUDY DESIGN: Multicenter retrospective cohort study. SETTING: Three academic, outpatient musculoskeletal and pain medicine centers. METHODS: Patients who underwent fluoroscopically guided IA hip injections with encounter data regarding fluoroscopy time during the procedure and BMI were included. Mean and standard deviation fluoroscopy time were recorded. Comparisons were made between BMI categories of normal (18.5 - 24.9 kg/m2), overweight (25.0 - 29.9 kg/m2), and obese (greater than or equal to30.0 kg/m2). Statistical significance was set at P = 0.01 due to multiple comparisons. RESULTS: A total of 559 IA hip injections are represented in this cohort. Patients had a mean age of 58 (standard deviation [SD] 14) years and 63% were women. There was no significant difference in fluoroscopy time when comparing BMI categories (P = 0.02). However, when trainees were not involved in the injection, fluoroscopy times were significantly shorter with decreasing BMI category, with normal weight patients requiring the shortest fluoroscopy times (P = 0.01). LIMITATIONS: This study evaluated total fluoroscopy time, not radiation dose exposure per injection, which provides more direct and precise information with regard to provider and patient radiation exposure and overall safety. Future study of the impact of BMI on radiation dose during fluoroscopically guided IA hip injections is needed. CONCLUSIONS: Fluoroscopy times during IA hip injections increase with higher BMI categories in a statistically significant manner when performed by experienced clinicians but this relationship is not observed when injections are performed with a trainee in a teaching institution. This finding appears to be related to longer fluoroscopy time required to complete an IA hip injection in patients with lower BMI when a trainee is involved. KEY WORDS: Hip, injections, obesity, overweight, body mass index, fluoroscopy, radiation, pain.


Subject(s)
Body Mass Index , Fluoroscopy/methods , Hip , Injections, Intra-Articular/methods , Obesity , Adult , Female , Fluoroscopy/statistics & numerical data , Hip/diagnostic imaging , Humans , Injections, Intra-Articular/statistics & numerical data , Male , Middle Aged , Retrospective Studies , Time Factors
17.
J Arthroplasty ; 32(11): 3298-3303.e6, 2017 11.
Article in English | MEDLINE | ID: mdl-28648710

ABSTRACT

BACKGROUND: This study investigated preoperative interventions and their costs in the 2-year period before a patient undergoing a unicompartmental knee arthroplasty (UKA). METHODS: A retrospective cohort analysis of patients undergoing UKA between 2009 and 2011 was conducted using the PearlDiver Patient Record Database to track inpatient and outpatient billing records. RESULTS: One thousand eight hundred forty-one patients from Medicare and 4704 patients from United Healthcare underwent UKA between 2009 and 2011. In the 2 years before UKA, the per patient average charge was $3919.96 for Medicare patients and $5219.14 for United Healthcare patients, with 21.7% of Medicare-associated charges and 28.2% of United Healthcare-associated charges occurring within 3 months of surgery. In the 2-year period before surgery, 65.5% of Medicare patients and 53.6% of United Healthcare patients received an intra-articular injection, with 29.1% (Medicare) and 46.0% (United Healthcare) of these injections occurring within 3 months of surgery. In addition, 15.1% of Medicare patients and 20.7% of United Healthcare patients underwent an arthroscopy, with between 32.4% and 43.8% of these occurring in the final 6 months before UKA. CONCLUSION: Preoperative interventions (ie, imaging, procedures, physical therapy, and injections) occur at a high frequency in close proximity to UKA resulting in substantial costs. The development of algorithms to guide management of these patients is critical in reducing costs before UKA.


Subject(s)
Arthroplasty, Replacement, Knee/economics , Arthroscopy/economics , Osteoarthritis, Knee/economics , Osteoarthritis, Knee/therapy , Preoperative Care/economics , Aged , Arthroscopy/statistics & numerical data , Databases, Factual , Fees and Charges/statistics & numerical data , Humans , Injections, Intra-Articular/economics , Injections, Intra-Articular/statistics & numerical data , Knee Joint/surgery , Magnetic Resonance Imaging/statistics & numerical data , Medicare/economics , Middle Aged , Office Visits/economics , Osteoarthritis, Knee/diagnostic imaging , Physical Therapy Modalities/economics , Retrospective Studies , United States
18.
Rev Bras Reumatol Engl Ed ; 57(6): 557-565, 2017.
Article in English, Portuguese | MEDLINE | ID: mdl-28641954

ABSTRACT

OBJECTIVES: Describe Brazilian rheumatologists's competence in interventional rheumatology; assess the association between this ability and demographic and training variables. METHODS: A cross-sectional study with 500 Brazilian rheumatologists. Participants were assessed by self-administered questionnaire consisting of demographics, training, practice in office and knowledge in interventional rheumatology data. RESULTS: 463 participants had their data analyzed. The mean age was 40.2 years (±11.2). 70% had performed periarticular injections and 78% had performed intra-articular injections. The sample was divided into three groups: non-interventionist, little interventionist and very interventionist. The non-interventionist group showed (p<0.001-0.04) higher mean age, lower proportion of university bond, lower training history, higher proportion of graduates in the Southeast country, and higher proportion of graduates in the 1980s to 1989. The very interventionist group showed higher (p<0.001-0.018) proportion of adult rheumatologists, higher proportion of university bond, longer training time with greater practice of complex procedures, and higher proportion of graduates, trained and with private practice in the South country. Variables most associated with the very interventionist subgroup are performing axial intra-articular injections (OR: 7.4, p<0.001), synovial biopsy (OR: 5.75, p=0.043), image-guided IAI (OR: 4.16, p<0.001), viscosupplementation (OR=3.41, p<0.001), joint lavage (OR=3.22, p=0.019), salivary gland biopsy (OR=2.16, p=0.034) and over 6-month training (OR: 2.16, p=0.008). CONCLUSIONS: Performing more complex invasive procedures and over 6-month training in interventional rheumatology were variables associated with enhanced interventional profile.


Subject(s)
Clinical Competence , Injections, Intra-Articular/statistics & numerical data , Practice Patterns, Physicians'/statistics & numerical data , Rheumatology/standards , Adult , Brazil , Cross-Sectional Studies , Female , Humans , Male , Middle Aged , Rheumatologists/statistics & numerical data , Rheumatology/education , Surveys and Questionnaires
19.
Med Ultrason ; 18(4): 457-462, 2016 Dec 05.
Article in English | MEDLINE | ID: mdl-27981278

ABSTRACT

OBJECTIVE: To identify and analyse existing data regarding knee ultrasound (US) feasibility in clinical practice. Material and methods: A systematic literature review was performed using the terms: ("knee") AND ("ultrasound" OR "ultrasonography") AND ("feasibility" OR "pilot" OR "proof of concept"). Feasibility studies regarding knee US or US aided maneuver involving knee joint, published during 2005-2015, were selected and evaluated against a complex framework constructed around mandatory key areas for feasibility studies: acceptability, demand, implementation, practicality, adaptation, integration and expansion. RESULTS: One hundred and fifty-nine publications were identified, of which 9 were included in the final analysis: 6 dealt with the development and implementation of novel US scores, while the rest focused on implementing MSUS in clinical practice, evaluating the usefulness of articular cartilage US assessment and the feasibility of sonography for intra-articular knee injections, respectively. Six studies quantified feasibility as time spent for the evaluation, with only two addressing areassuch as acceptability, implementation and practicality, although none of these systematically assessed all feasibility domains. CONCLUSION: Knee US feasibility is still poorly addressed; the time required for US assessment is the main area addressed. This information gap should be properly addressed in future works, in order to ensure the right place for this technique.


Subject(s)
Injections, Intra-Articular/statistics & numerical data , Joint Diseases/diagnostic imaging , Knee Injuries/diagnostic imaging , Knee Joint/diagnostic imaging , Translational Research, Biomedical/statistics & numerical data , Ultrasonography/statistics & numerical data , Feasibility Studies , Humans , Injections, Intra-Articular/methods , Knee Injuries/epidemiology , Prevalence
20.
J Bone Joint Surg Am ; 98(17): 1429-35, 2016 Sep 07.
Article in English | MEDLINE | ID: mdl-27605686

ABSTRACT

BACKGROUND: The prevalence of knee osteoarthritis is increasing in the aging U.S. POPULATION: The efficacy and cost-effectiveness of the use of hyaluronic acid (HA) injections for the treatment of knee osteoarthritis are debated. In this study, we assessed the utilization and costs of HA injections in the 12 months preceding total knee arthroplasty (TKA) and evaluated the usage of HA injections in end-stage knee osteoarthritis management in relation to other treatments. METHODS: MarketScan Commercial Claims and Encounters and Medicare Supplemental and Coordination of Benefits databases (Truven Health Analytics) were reviewed to identify patients who underwent TKA from 2005 to 2012. The utilization of patient-specific osteoarthritis-related health care (including medications, corticosteroid injections, HA injections, imaging, and office visits) and payment information were analyzed for the 12 months preceding TKA. RESULTS: A total of 244,059 patients met the inclusion criteria. Of those, 35,935 (14.7%) had ≥1 HA injection in the 12 months preceding TKA. HA injections were responsible for 16.4% of all knee osteoarthritis-related payments, trailing only imaging studies (18.2%), and HA injections accounted for 25.2% of treatment-specific payments, a rate that was higher than that of any other treatment. Patients receiving HA injections were significantly more likely to receive additional knee osteoarthritis-related treatments compared with patients who did not receive HA injections. CONCLUSIONS: Despite numerous studies questioning the efficacy and cost-effectiveness of HA injections for osteoarthritis of the knee, HA injections are still utilized for a substantial percentage of patients. Given the paucity of data supporting the effectiveness of HA injections and the current cost-conscious health-care climate, decreasing their use among patients with end-stage knee osteoarthritis may represent a substantial cost reduction that likely does not adversely impact the quality of care.


Subject(s)
Hyaluronic Acid/therapeutic use , Injections, Intra-Articular/statistics & numerical data , Osteoarthritis, Knee/drug therapy , Viscosupplements/therapeutic use , Aged , Arthroplasty, Replacement, Knee/economics , Cost-Benefit Analysis , Female , Health Care Costs , Humans , Hyaluronic Acid/administration & dosage , Hyaluronic Acid/economics , Injections, Intra-Articular/economics , Knee Joint/surgery , Male , Medicare , Middle Aged , Osteoarthritis, Knee/economics , United States , Viscosupplements/administration & dosage , Viscosupplements/economics
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