Evidence review for the clinical and cost-effectiveness of intra-articular injections for the management of osteoarthritis

Intra-articular injections are sometimes used to relieve pain for people with osteoarthritis. These include injections with corticosteroids, hyaluronan and stem cells. Corticosteroid injections are undertaken to deliver this high dose anti-inflammatory agent within the joint to reduce inflammation of the joint lining (synovium), however, they may not work for everyone in the short term and in some people, repeated injections may be required to sustain symptom control. Hyaluronan injections have been developed to replicate the natural lubricant within the joint with reported benefits, however, its mechanism of action for osteoarthritis is contentious and it can be associated with increased pain in the short term. Stem cells are cells that are capable of developing into different types of tissue. These can be injected into an osteoarthritic joint and this type of therapy has been developed to stimulate regeneration of the tissues, such as cartilage, which consequently can improve symptoms and function and may reduce the need for future joint replacement.

Ultrasound-guided versus blind subacromial bursa corticosteroid injection for paraplegic spinal cord injury patients with rotator cuff tendinopathy: a randomized, single-blind clinical trial.

INTRODUCTION: Shoulder pain is one of the common musculoskeletal complaints of the patients with spinal cord injury. Corticosteroid injection to the subacromial bursa is one of the confirmed therapies which can be guided by anatomic landmarks or ultrasound. This study is aimed to compare these two methods to find the one with the highest therapeutic impact. MATERIALS AND METHODS: In this study, 30 patients with paraplegic SCI suffering from shoulder pain were enrolled. They were divided into 2 groups based on 4-block randomization sampling. The first group received subacromial corticosteroid injection through anatomic landmarks; while in the second group, the injection was guided by ultrasound. VAS criterion was employed for investigation of pain severity; while the constant score was used to study the shoulder pain and function. BREF questionnaire was also applied to examine the quality of life. FINDINGS: The mean scores of VAS and Constant in both groups showed a significant improvement two months after intervention when compared with their condition before the intervention. This improvement was significantly higher in the ultrasound group. The physical, physiological and environmental health scores of BREF questionnaire as well as their total score showed a significant improvement in both groups two months after intervention. But this improvement was not significantly different between the two groups in terms of any of the items. DISCUSSION: Hence, although ultrasound-guided injection is more costly and requires higher skills in comparison with blind injection, it is significantly more effective in controlling the pain and improving the shoulder function.

Needle knife therapy plus sodium hyaluronate injection for knee osteoarthritis: A protocol for a systematic review and meta-analysis.

BACKGROUND: Knee osteoarthritis (KOA) is a worldwide disease and more and more people are suffered from it. With the increasing number of patients, it brings a huge burden on social economy and security system. There are varieties of methods to cure KOA, such as Traditional Chinese Medicine and surgery. Needle knife therapy plus Sodium hyaluronate Injection is one of the prevalent treatments for KOA. Therefore, we perform a systematic review and meta-analysis to evaluate the evidence for the treatment of needle knife therapy plus sodium hyaluronate Injection. METHODS: Randomized controlled trials will be used to compare the effect of needle knife therapy plus sodium hyaluronate injection with needle knife alone for KOA patients. Six studies will be included in this meta-analysis, and the relative risk and weight mean difference with 95% CI for the Lysholm knee score, visual analogue scale, and effective rate will be evaluated by using RevMan 5.3 software. Besides, the bias assessment of the included studies will be evaluated using the Cochrane risk of bias tool, and the Grading of Recommendations, Assessment Development, and Evaluation system will be applied to assess the overall quality of the evidence. RESULTS: From the study we will assess the effectiveness, safety of needle knife therapy plus sodium hyaluronate injection on joint pain relief and functional improvement in patients with KOA. CONCLUSION: The study will provide a new evidence to confirm the effect of needle knife therapy plus sodium hyaluronate injection on KOA, which can further guide the selection of therapy. PROSPERO REGISTRATION NUMBER: CRD42020169602.

Joint injection practice variations in pediatric rheumatology - a global survey and call for action.

BACKGROUND: Intraarticular injections (IAI) were first reported in adult rheumatology in the 1950s and subsequently gained acceptance as a safe and efficacious treatment in Juvenile idiopathic arthritis (JIA). IAIs are now widely performed and recommended as the initial or only treatment of oligoarticular JIA and ancillary treatment of actively inflamed joints in other varieties of JIA. However, the performance of the procedure is currently not guided by standardized recommendations, and several practice variations are observed. METHODS: This worldwide survey of pediatric rheumatologists (with 48.5% response from Pediatric Rheumatology International Trials Organization [PRINTO and Pediatric Rheumatology Collaborative Study Group [PRCSG] members) captures the differences in pre-procedural, procedural and post-procedural protocols and practices observed across the globe and asks the necessity of developing consensus in this area of Pediatric Rheumatology. RESULTS: This worldwide survey of Pediatric Rheumatologists had a response rate of just under 50% and the views of about 42% who routinely performed the procedure. It captured the differences in IAI protocols and practices observed across the globe. Significant variations in practice were noted in use of Local anesthesia, choice, and dose of therapeutic agent for the intraarticular injection and use of ultrasound to guide injections. While some practice variations may be explained by institutional protocols in different parts of the world, the clinical implications of these are largely unknown and beg the need for further studies. CONCLUSIONS: Given these practice variations, the authors recommend further studies to explore the cost and clinical implications and subsequently work towards developing consensus plans to ensure uniformity in this widely used procedure in Pediatric Rheumatology.

The Learning Curve Associated with the Administration of Intra-Articular Liposomal Bupivacaine for Total Knee Arthroplasty: A Pilot Study.

INTRODUCTION: Liposomal bupivacaine is a long-acting, local, injectable anesthetic that is used to potentially mitigate post-operative pain after total knee arthroplasty (TKA). In addition, it may reduce opioid use in the post-operative period and shorten lengths-of-stay (LOS). There have been mixed results in the literature with regards to its efficacy, which raises questions regarding the injection technique used. Therefore, we evaluated the learning curve associated with injection techniques prior to, and after, formal teaching. Specifically, we compared differences in: 1) opioid use; 2) LOS; 3) pain intensity; and 4) discharge disposition in patients who did not receive liposomal bupivacaine (no infiltration cohort), received liposomal bupivacaine with less optimal technique (subpar infiltration), and received liposomal bupivacaine with appropriate technique (optimal infiltration) during their primary TKA. MATERIALS AND METHODS: A 1:1:1 ratio of 54 consecutive cases of patients who had no liposomal bupivacaine infiltration, those who had subpar infiltration, and those who had optimal infiltration were included. To evaluate opioid use, the dosages were obtained and converted to their respective morphine milliequivalents (mEq). The total mEq usage was obtained for the day of surgery through post-operative day (POD) 3. LOS was recorded in days. Pain scores were calculated using the visual analogue scale (VAS), obtained from the first post-operative physical therapy note. Discharge status was recorded as discharged to home or rehabilitation. We used an ANOVA test for continuous and X2-square test for categorical variables. RESULTS: When compared to patients who had no infiltration, patients who had subpar infiltration had significantly lower opioid use on day 0, while patients who had optimal infiltration had lower opioid use on post-operative day (POD) 0 and 3. When comparing techniques, opioid use was lower on day 3 for patients who had optimal, as compared to subpar technique. However, LOS and VAS were not significantly different among the three groups. The rehab discharge rate was lower for patients who had optimal as compared to subpar technique. CONCLUSION: There is a learning curve associated with liposomal bupivacaine use, and incorporating an appropriate technique can markedly affect post-operative outcomes. This should be taken into account when evaluating the potential benefits of this peri-articular injection. It appears that liposomal bupivacaine may decrease opioid use and pain scores when optimal infiltration techniques are used.

Clinical study evaluating the accuracy of injecting the distal tarsal joints in the horse.

BACKGROUND: Osteoarthritis (OA) of the centrodistal (CD) and tarsometatarsal (TMT) joints is a common cause of lameness in horses. Intra-articular diagnostic anaesthesia and/or therapeutic injection are relied upon to help diagnose and treat many horses with OA of these joints. OBJECTIVES: The objective of this study was to determine the accuracy of arthrocentesis of the CD and TMT joints using a sample population of equine surgeons and surgery residents. STUDY DESIGN: Randomised experimental study. METHODS: Six operators each injected four CD and four TMT joints in 12 sedated horses. The operators were randomly assigned to inject either the left CD and right TMT or the right CD and left TMT on four randomly assigned horses. The joints were injected with a 4 ml solution of contrast medium (2 ml), sterile saline (1.5 ml) and amikacin (0.5 ml). A minimum of two radiographs of each joint was obtained to evaluate the presence of contrast medium within the target joint. RESULTS: The TMT joint was successfully injected in 23/24 joints (96% accuracy). The CD joint was successfully injected in 10/24 joints (42% accuracy). Communication between the TMT and CD joints was visible in 26% of successful TMT injections. Communication between the CD and TMT joints was visible in 20% of successful CD injections. MAIN LIMITATIONS: Despite specific requests to do so, we were unable to standardise the injection technique across all operators. CONCLUSIONS: The accuracy of injecting the TMT and CD joints of sedated horses was 96 and 42%, respectively. The CD joint was frequently missed with contrast medium being placed in the periarticular tissues. These data support the clinical impression of the difficulty of injecting the CD joint and suggests that practitioners should utilise ancillary methods, such as radiographs, to ensure proper needle placement.

Inflammatory response to the administration of mesenchymal stem cells in an equine experimental model: effect of autologous, and single and repeat doses of pooled allogeneic cells in healthy joints.

BACKGROUND: Mesenchymal stem cells (MSCs) transplantation has become a promising therapeutic choice for musculoskeletal injuries. Joint-related disorders are highly prevalent in horses. Therefore, these animals are considered as suitable models for testing MSC-based therapies for these diseases. The aim of this study was to investigate the clinical and inflammatory responses to intra-articular single and repeat dose administration of autologous or of pooled allogeneic MSCs in healthy equine healthy joints. Six horses were intra-articularly injected with a single autologous dose of bone marrow derived MSCs (BM-MSCs) and two separate doses of allogeneic BM-MSCs pooled from several donors. All contralateral joints were injected with Lactated Ringer's Solution (LRS) as the control vehicle. Signs of synovitis and lameness were evaluated at days 0, 1, 2, 3, 5 and 10 after injection. Total protein (TP), white blood cell count (WBC) and neutrophil count (NC) in synovial fluid were also measured at the same time-points. RESULTS: A mild synovial effusion without associated lameness was observed after all BM-MSCs injections. The second allogeneic injection caused the lowest signs of synovitis. Local temperature slightly increased after all BM-MSCs treatments compared to the controls. TP, WBC and NC in synovial fluids also increased during days 1 to 5 after all BM-MSCs injections. Both, clinical and synovial parameters were progressively normalized and by day 10 post-inoculation appeared indistinguishable from controls. CONCLUSIONS: Intra-articular administration of an allogeneic pool of BM-MSCs represents a safe therapeutic strategy to enhance MSCs availability. Importantly, the absence of hypersensitivity response to the second allogeneic BM-MSCs injection validates the use of repeat dose treatments to potentiate the therapeutic benefit of these cells. These results notably contribute to the development of stem cell based therapies for equine and human joint diseases.

Evidence and recommendations for use of intra-articular injections for knee osteoarthritis.

Pharmacological treatments are widely recommended in international guidelines for management of osteoarthritis (OA). However, the use of intra-articular (IA) therapies of diverse active drugs remains controversial. We critically reviewed studies of the efficacy and safety of IA injections of corticosteroids (CS), hyaluronic acid (HA), platelet-rich plasma (PRP), and botulinum toxin A (BTA) and evidence-based international recommendations for their use in treating knee OA. The process of article selection was unsystematic. Articles were selected on the basis of authors' expertise, self-knowledge, and reflective practice. Only studies assessing knee OA were included. IA CS and HA injections were conditionally to fully recommended for treating knee OA. No recommendations have been formulated for IA PRP or BTA. The evidence remains inconsistent and controversial for the use of IA therapies for knee OA. The characteristics of and selection criteria for the OA population that would likely benefit from these therapies need to be identified. Accurately phenotyping and selecting patients is mandatory in future randomized controlled trials. Therefore, efficacy and safety meta-analyses should be performed, as should qualitative and sensitivity analyses of published trial results.

[Indications and contraindications for radiosynoviorthesis]. / Indikationen und Kontraindikationen zur Radiosynoviorthese.

BACKGROUND: Radiosynoviorthesis (RSO) provides a simple method for the treatment of patients with chronic synovitis and has only few side effects. OBJECTIVES: Evidence-based indications and contraindications for performing RSO based on the current literature are presented. MATERIAL AND METHODS: Published information on the indications and contraindications for performing RSO in chronic synovitis were analyzed and summarized. RESULTS: According to the guideline recommendations of the German Society of Rheumatology indications for RSO are given in patients with rheumatoid arthritis, seronegative spondyloarthropathy, crystal arthropathy, villonodular synovitis and hemophilia with recurrent joint bleeding. Osteoarthritis with documented reactive synovitis is also regarded as an indication in the guidelines of the nuclear medicine societies. The European League Against Rheumatism (EULAR) and the German Society of Rheumatology (DGRh) have given no recommendations for using RSO in osteoarthritis. Given the correct indications RSO shows high success rates. CONCLUSION: The effects of RSO with the named secondary side effects last on average for 5 years. Crucial for the success of RSO are the correct indications, the correct timing and combination with other therapeutic procedures, such as surgical synovectomy.

[Intra-articular injections]. / Les injections intra-articulaires.

It is not unusual for a specialist or general practitioner to be presented with a pathology which necessitates the use of an intra-articular injection of corticosteroids, hyaluronic acid or a local anaesthetic. It would seem to be interesting to update and to precise the techniques and methods of intraarticular injections which have appeared in recent international publications, when we know that 30 % of the injections given into the knee and so called "dry" are incorrect and, therefore, inefficient. The indication of an articular injection depends, firstly, on the diagnosis which should be done with great care; after which should be an objective analysis complete with secondary effects linked to both the injection and the product used. The conditions of asepsis, the choice of needles and quantities of the injection and even the ways of the injections should be reviewed in detail. The last studies clearly question the secondary effects of the cartilage degradations of the cortisone given as an intra-articular injection and shows its efficiency on the pain and inflammatory phenomonen in osteoarthritis. Studies on hyaluronic acid are often contradictory going from a modest result to an important pain relief but it is necessary to be aware that the objective criteria are difficult to interpret. The use of local anaesthetics in intra-articular is limited by the few indications in view of the major risk of aggravating the pre-existing lesions by the disappearing signs of pain.

[Intra-articular injection of cortisone]. / Intraartikuläre Injektion mit Kortison.

Intra-articular injections with glucocorticoids are standard procedures according to therapy guidelines in many rheumatic conditions. There is increasing evidence from clinical trials on the treatment of rheumatoid arthritis that more patients will attain the target of remission using a combination of systemic medication and intra-articular injections with glucocorticoids compared to systemic medication alone. Intra-articular injections with glucocorticoids play an important role in the therapeutic management of pediatric rheumatic diseases. In many countries competency in performing intra-articular injections is among the important skills necessary for certification as a specialist in rheumatology.

[Injection treatment with hyaluronic acid]. / Injektionsbehandlung mit Hyaluronsäure.

This article presents the spectrum of indications for the use of hyaluronic acid (HA) based on the recommendations of the European League Against Rheumatism (EULAR), the American College of Rheumatology (ACR), the Osteoarthritis Research Society International (OARSI), the International Institute for Health and Clinical Excellence (NICE) and the European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO) taking the reality of patient care in Europe into account.

Determination of a safe INR for joint injections in patients taking warfarin.

INTRODUCTION: With an increase in life expectancy in 'developed' countries, the number of elderly patients receiving joint injections for arthritis is increasing. There are legitimate concerns about an increased risk of thromboembolism if anticoagulation is stopped or reversed for such an injection. Despite being a common dilemma, the literature on this issue is scarce. METHODS: We undertook 2,084 joint injections of the knee and shoulder in 1,714 patients between August 2008 and December 2013. Within this cohort, we noted 41 patients who were taking warfarin and followed them immediately after joint injection in the clinic or radiology department, looking carefully for complications. Then, we sought clinical follow-up, correspondence, and imaging evidence for 4 weeks, looking for complications from these joint injections. We recorded International Normalised Ratio (INR) values before injection. RESULTS: No complications were associated with the procedure after any joint injection. The radiologists who undertook ultrasound-guided injections to shoulders re-scanned the joints looking for haemarthroses: they found none. A similar outcome was noted clinically after injections in the outpatient setting. CONCLUSION: With a mean INR of 2.77 (range, 1.7-5.5) and a maximum INR within this group of 5.5, joint injections to the shoulder and knee can be undertaken safely in primary or secondary care settings despite the patient taking warfarin.

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine.

BACKGROUND: The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilisation is by non-radiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases and hydrodissections. OBJECTIVE: Critically review the literature related to the accuracy, efficacy and cost-effectiveness of ultrasound-guided injections (USGIs) in major, intermediate and small joints; and soft tissues. DESIGN: Systematic review of the literature. RESULTS: USGIs are more accurate than landmark-guided injections (LMGIs; strength of recommendation taxonomy (SORT) Evidence Rating=A). USGIs are more efficacious than LMGIs (SORT Evidence Rating=B). USGIs are more cost-effective than LMGIs (SORT Evidence Rating=B). Ultrasound guidance is required to perform many new procedures (SORT Evidence Rating=C). CONCLUSIONS: The findings of this position statement indicate there is strong evidence that USGIs are more accurate than LMGI, moderate evidence that they are more efficacious and preliminary evidence that they are more cost-effective. Furthermore, ultrasound-guided (USG) is required to perform many new, advanced procedures and will likely enable the development of innovative USG surgical techniques in the future.

Ultrasound-guided shoulder girdle injections are more accurate and more effective than landmark-guided injections: a systematic review and meta-analysis.

OBJECTIVE: To compare the accuracy and efficacy of ultrasound (US)-guided injections versus landmark-guided injections of the subacromial space, biceps tendon sheath, acromioclavicular (AC) joint and glenohumeral (GH) joint. METHODS: PubMed, Medline and Cochrane libraries were searched up to 31 July 2013. Two independent authors selected and evaluated randomised controlled trials comparing the accuracy and/or efficacy of US versus landmark-guided injection of the shoulder girdle. A meta-analysis of accuracy, pain Visual Analog Scale (VAS), function score and reported adverse events were performed. RESULT: Four cadaveric studies (300 cadaveric shoulders) and nine live human studies (514 patients) were reviewed. Based on three studies for AC joint, the accuracy of US versus a landmark-guided injection was 93.6% vs 68.2% (p<0.0001). Based on single studies, the accuracy of US versus a landmark-guided injection was 65% vs 70% for the subacromial space (p>0.05), 86.7% vs 26.7% for the biceps tendon sheath (p<0.05), and 92.5% vs 72.5% for the GH joint (p=0.025). Based on three studies for the subacromial space, the US group had a significantly greater reduction in pain (mean difference (MD)=1.47, 95% CI 1.0 to 1.93), and improvement in function (standardised MD=0.70, 95% CI 0.39 to 1.01) at 6 weeks postinjection. Based on a single study for the biceps tendon sheath, the US group had a significantly greater reduction in pain (MD 1.9, 95% CI 1.2 to 2.6) and improvement in function (MD=10.9, 95% CI 6.57 to 15.23). CONCLUSIONS: US-guided injections showed greater accuracy for all shoulder girdle injections, with the exception of the subacromial space. There was improved efficacy for the subacromial space and biceps tendon sheath injections.

American Medical Society for Sports Medicine position statement: interventional musculoskeletal ultrasound in sports medicine.

The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilization is by nonradiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases, and hydrodissections. This American Medical Society for Sports Medicine (AMSSM) position statement critically reviews the literature and evaluates the accuracy, efficacy, and cost-effectiveness of ultrasound-guided injections in major, intermediate, and small joints, and soft tissues, all of which are commonly performed in sports medicine. New ultrasound-guided procedures and future trends are also briefly discussed. Based on the evidence, the official AMSSM position relevant to each subject is made.

[Intra-articular punctures and injections]. / Intraartikuläre Punktionen und Injektionen.

Joint punctures and injections are a widely used approach to obtain a differential diagnostic assessment for the formation of a treatment concept for recurrent joint effusions, to exclude a periprosthetic infection in painful and loosened endoprostheses before a planned revision, to assign the origin of pain symptoms to a specific joint or to provide a treatment for arthritis of any kind. In all medical fields the standardization of processes has progressed. Therefore, for joint punctures there are standards relating to the implementation and hygiene of intra-articular punctures or injections in order to prevent the occurrence of complications, such as joint infections.