Intralesional corticosteroid therapy for non-healing persistent radiation-induced oropharyngeal mucositis.

PURPOSE: Oropharyngeal mucositis is a common complication of anticancer therapy. This study aimed to determine the effectiveness and safety of intralesional corticosteroid therapy (ICT) in the management of persistent mucositis. METHODS: A retrospective chart review of patients who underwent ICT in the oral cavity to manage oral mucositis managed with basic oral care and preventive modalities and persisting at least 6 weeks after head and neck radiation or chemoradiation therapy completion between November 2017 and September 2023 was performed. Bio-demographic data, cancer and anticancer therapy characteristics, medical history, and mucositis-related variables were extracted from electronic medical records. RESULTS: Among the 34 participants, 22 (64.7%) were male. Twenty (58.8%) participants received radiotherapy; the rest received chemoradiation therapy. Before the ICT, the median mucositis lesion surface area was 225 mm2 (range 9-2025 mm2), and 22 (64.7%) patients had grade III mucositis. Post-intervention, the median size was reduced to 0 mm2 (range 0-1600 mm2). Clinically effective response (≥ 75% size and symptom reduction) was observed in 28 (82.4%) participants over a median of 26 days (7-60 days). Within this cohort, complete healing of the lesion was seen in 18 (64.3%) subjects. Overall, 25 (73.5%) participants experienced a downgradation in the mucositis stage. Local complications from injections were found in two (5.7%) participants. A correlation was found between clinically effective relief and absence of trismus (p = .03) and smaller pre-procedure surface area (p = .009). CONCLUSION: The ICT represents a viable option in managing non-healing, persistent radiation, and chemoradiation-induced oral mucositis. The modality was well tolerated and had no systemic complications.

Juvenile idiopathic arthritis management: insights into the utilization of intra-articular corticosteroid injections.

BACKGROUND: Juvenile idiopathic arthritis (JIA) is a common chronic rheumatic disease in children, requiring careful management to reduce both short- and long-term morbidity. In this study, our objective was to assess the clinical features of patients diagnosed with JIA who received intra-articular corticosteroid injections (IACI). METHODS: In this retrospective study, we evaluated the clinical and laboratory characteristics of 225 JIA patients monitored from January 2012 to October 2023 at a tertiary care center. We focused on patients who underwent intra-articular corticosteroid injections (IACI) as part of their treatment. Triamcinolone hexacetonide (TH) was used due to its demonstrated safety and efficacy. RESULTS: Our analysis revealed that IACI, particularly utilizing TH, was a widely employed and effective adjunct therapy, contributing to rapid symptom relief and local disease control. Patients receiving IACI exhibited earlier symptom onset, younger age at diagnosis, longer follow-up durations, and higher cumulative treatment burden (p < 0.001, p < 0.001, p < 0.01, p < 0.001 respectively). Despite inconclusive acute-phase reactants, a higher frequency of ANA positivity and elevated initial lymphocyte counts were associated with increased IACI use (p < 0.001, p < 0.001 respectively). Importantly, on a joint basis, a high percentage of arthritis remission following IACI underscores its efficacy and favorable safety profile. CONCLUSIONS: Notably, the high percentage of arthritis remission achieved with intra-articular corticosteroid injections (IACI) on a joint-specific basis highlights its efficacy and favorable safety profile. A lymphocyte count exceeding 5000/mm3 at the time of diagnosis may serve as an early indicator for considering intra-articular steroid administration. These findings emphasize the need for nuanced and individualized treatment strategies in JIA management to optimize outcomes for affected children.

Iatrogenic Cushing Syndrome and Adrenal Suppression Presenting as Perimenopause.

Secondary adrenal insufficiency is a life-threatening condition that may arise in the setting of iatrogenic Cushing syndrome. Intra-articular corticosteroid injections (IACs) are a standard treatment for osteoarthritis, and they carry a high risk of secondary central adrenal suppression (SAI). We present the case of a 43-year-old woman who was referred to reproductive endocrinology for evaluation of abnormal uterine bleeding with a provisional diagnosis of perimenopause. She reported new-onset type 2 diabetes mellitus, abdominal striae, hot flashes, and irregular menses. Laboratory evaluation revealed iatrogenic Cushing syndrome and SAI attributable to prolonged use of therapeutic IACs for osteoarthritis. Treatment included hydrocortisone replacement and discontinuation of IACs followed by hydrocortisone taper over the following 16 months that resulted in the return of endogenous ovarian and adrenal function. This case demonstrates the many hazards of prolonged IAC use, including suppression of ovarian and adrenal function and iatrogenic SAI.

The Role of Corticosteroid Injections in the Treatment of Sacroiliitis: A Narrative Review.

OBJECTIVES: Axial spondyloarthritis (axSpA) is a chronic rheumatic, musculoskeletal, inflammatory disease with a propensity to present as sacroiliitis, which manifests as low back, buttock, or thigh pain. Effective primary management of axSpA requires a comprehensive approach specific to each patient and disease severity. Non-pharmacological measures form the cornerstone of treatment. With refractory disease, management also consists of local periarticular and intraarticular injections. The use of sacroiliac joint (SIJ) corticosteroid injections for the treatment of axSpA and localised inflammation, however, is a continuously burgeoning management option. This narrative review aims to present consolidated findings and summarise previously unreferenced or recently available evidence regarding corticosteroid injections to the SIJ for treating sacroiliitis and axSpA. METHODS: A comprehensive literary review with the following electronic databases was searched: MEDLINE via PubMed, Web of Science, Cochrane Library, and EMBASE. RESULTS: The initial search yielded a total of 126 references. After duplicates were removed and the remainder analysed for inclusion criteria, 7 studies were included. To stratify each study, injection methodology and characteristics were defined. DISCUSSION: The use of SIJ corticosteroid injections can be an appropriate and effective treatment option for refractory axSpA. The studies presented in this review reported a general trend towards a reduction in pain severity after SIJ corticosteroid injections. Because of the complexity and heterogeneity of the anatomy of the SIJ, image guidance is recommended when performing SIJ injections. Image-guided injections seem to produce better outcomes when compared to anatomic landmark-guided injections.

Rapid Osteoarthritis and Femoral Head Collapse: A Case Series.

Introduction: Rapidly progressive hip osteoarthritis (OA) leading to femoral head collapse (FHC) following intra-articular (IA) corticosteroid injections is a perplexing variant of OA. We explored eight cases of chronic joint pain treated with IA corticosteroid injections. Subsequently, they experienced swift deterioration of the femoral head integrity within as little as 10 weeks. These cases underscore the need for a comprehensive assessment of risk factors versus benefits in this patient population. Case Report: The study reveals a complex interplay between comorbidities, treatments, and outcomes. Patients exhibited various health factors, including obesity, smoking history, cancer treatment, and deficiencies in Vitamin D levels, which have been found to increase the risk of FHC. Furthermore, the study explores the chondrotoxicity of corticosteroids and local anesthetics used in IA injections. In vitro studies show complete loss of chondrocyte viability after a single dose of corticosteroids, potentially leading to cartilage degradation. In addition, local anesthetics may induce cellular demise and structural alterations in the articular cartilage. These factors highlight various influences affecting treatment outcomes in patients with OA. Conclusion: In conclusion, this case series highlights the rare adverse outcome of rapidly progressive hip OA and FHC following IA corticosteroid injections and possible risk factors. While a definitive etiology remains unclear, the study provides valuable conclusions to aid in future treatment decision-making.

[Clinical observation of sinus tarsi syndrome after lateral ankle sprain].

OBJECTIVE: To study the incidence rate of sinus tarsi syndrome after lateral ankle sprain and observe the clinical efficacy of sinus tarsal corticosteroid injections. METHODS: From January 2021 to Janury 2022, 391 patients with lateral ankle sprain and 88 patients with sinus tarsi syndrome using corticosteroid injections (compound betamethasone 1 ml+ lidocaine hydrochloride 4 ml) were retrospectively analyzed. There were 22 males and 66 females, aged from 29 to 60 years old with an average of (41.00±7.52) years old, duration of the disease from 1 to 12 months with an average of (5.6±4.2) months. The visual analogue scale(VAS) and American Orthopedic Foot and Ankle Society(AOFAS) scores were collected before, 1 month, 3 months, 6 months, and 12 months after treatment. RESULTS: All 88 patients completed a 12-month follow-up. The incidence rate of sinus tarsi syndrome after lateral ankle sprain was 22.5%. One month after treatment, VAS was 1.20±0.89, AOFAS score was 88.70±7.04. Three months after treatment, VAS was 1.60±1.35, AOFAS score was 85.20±10.95. Six months after treatment, VAS 2.35±1.39, AOFAS 80.30±9.75. Twelve months after treatment, VAS was 2.80±1.51, AOFAS score was 79.1±9.94. Significant differences were found before and after treatment at all four time points of follow-up(P<0.05). CONCLUSION: The results of this study showed that the incidence rate of sinus tarsi syndrome after lateral ankle sprain was 22.5%. Corticosteroid injections were effective in the short term with a 65% recurrence rate of symptoms within 1 year. For patients with no significant long-term effect of conservative treatment, clinicians may explore alternative approaches, including options like ankle arthroscopy.

Corticosteroid injection versus immobilisation for the treatment of De Quervain's tenosynovitis: A systematic review and meta-analysis.

OBJECTIVE: De Quervain's tenosynovitis causes pain and impairment of thumb function. Conservative treatments comprise corticosteroid injection and immobilization, and it is unclear which offers greater efficacy. Previous reviews were limited by the small number of included studies; thus an updated review and meta-analysis is warranted. METHODS: A systematic review of the PubMed, Embase, and Web of Science databases was conducted. Randomized control trials comparing corticosteroid injection to immobilization were included. Two authors screened articles, extracted data, and assessed the risk of bias of included studies. Meta-analyses using the random-effects model were conducted, calculating pooled relative risks and mean differences with 95% confidence intervals. RESULTS: 16 studies comprising 1206 patients were included. Corticosteroid injection showed greater treatment success than immobilization (relative risk: 1.61; 95% confidence interval: 1.21-2.15). Combining treatments demonstrated greater efficacy than immobilization (relative risk: 2.15; 95% confidence interval: 1.77-2.62) or injection alone (relative risk: 1.23; 95% confidence interval: 1.12-1.34). Pain and disability scores were lower with injection than immobilization and with combined treatment than with either alone. CONCLUSION: Corticosteroid injection is more effective than immobilization for De Quervain's tenosynovitis, and combining the two treatments provides additional benefit. We recommend corticosteroid injection in first line treatment and immobilization as adjuvant therapy. Further research is required regarding optimal corticosteroid and local anesthetic formulations.

The effects of exercise and intra-articular injections versus exercise alone for the treatment of knee osteoarthritis: A scoping review of the evidence.

Objective: Current treatment for knee Osteoarthritis (OA) includes exercise and intra-articular injections with corticosteroid (CS), hyaluronic acid (HA), etc., which address OA-related pain and functional limitation. While these interventions can be given together, little is known about the efficacy of a multi-modal approach. The purpose of this scoping review is to examine studies that compare combining exercise and intra-articular knee injections to exercise alone for the management of knee OA. Methods: A search was performed using PubMed, CINAHL, and Clinicaltrials.gov with MeSH terms "knee osteoarthritis" AND "exercise" AND "injections". Abstracts were screened to meet inclusion criteria of both intervention groups including exercise and one group receiving an injection for treatment of knee OA. Full text articles were screened to meet inclusion criteria and rated using the Pedro Scale. Results: 11 studies that met inclusion criteria. The included studies utilized CS, hyaluronic acid (HA), and Bone Marrow Concentrate (BMC), botulinum toxin A, or a combination of dextrose and lidocaine injections. Most studies included supervised exercise interventions with all studies including strengthening of the quadriceps. CS and exercise compared to exercise alone showed similar improvements in pain. The HA injection studies yielded mixed results with two studies finding HA and exercise was not superior than exercise alone while two other studies found that HA and exercise were superior. Conclusion: There was a paucity of literature investigating multimodal approaches. Most of the included studies did not find superior effects of adding a knee injection to exercise compared to exercise alone for knee OA.

Efficacy of Lateral View Needle Placement for Sacroiliac Joint Injections.

Introduction: Sacroiliac joint (SIJ) pathology is typically diagnosed and treated with fluoroscopy-guided intraarticular injections. Most practitioners use only an anteroposterior (AP) or oblique view. Although injection into the periarticular space may yield adequate pain relief, intraarticular needle placement is imperative to identify SIJ pathology and plan future management. This study highlights the importance of obtaining an additional lateral view during fluoroscopy to better evaluate SIJ disease. Methods: A retrospective review of 38 patients who underwent fluoroscopy guided SIJ injection was conducted, for which IRB approval was granted by the MetroWest Medical Center Institutional Review Board. Patient demographics (age, sex, BMI) and pre- and post-operative numerical rating scale (NRS) scores were collected, and initial needle location was reviewed. Patients were placed into groups according to initial needle location. Statistical analysis was conducted using a Mann-Whitney U-test with significance defined as p < 0.05. Results: The 21 females and 17 males had a mean age and BMI of 70.5 years and 27.8 kg/m2, respectively. Thirty-one patients had initial intraarticular needle placement confirmed with lateral arthrogram, and 7 patients had initial periarticular needle placement, requiring needle readjustment in lateral confirmatory view. Both groups had similar demographic characteristics. No statistically significant differences were found between the two groups' mean NRS score improvement (p=0.108). Conclusion: Using only the AP or oblique view during needle placement results in miss rates of nearly 20% while adding a lateral view can lower miss rates to near 0%. While pain relief may be adequate in either case, proper diagnosis and future management relies upon accurate needle placement.

Risk factors for failing sub-Tenon's triamcinolone acetonide for uveitic macular edema.

BACKGROUND: Sub-Tenon's triamcinolone acetonide (STA) is less effective than intravitreal corticosteroids in the treatment of uveitic macular edema (ME), but does have some relative advantages, including substantially lower cost and decreased risk of post-injection ocular hypertension. It would be useful for clinicians to know which eyes may respond well to STA and not necessarily require intravitreal therapy. The objective of this study is to identify risk factors for failing STA for the treatment of uveitic ME. MAIN BODY: A retrospective cohort study was performed. Medical records were reviewed of patients who underwent STA for the treatment of uveitic ME between January 1, 2013, and July 31, 2022, at the University of Colorado Hospital. Uveitic ME was defined by a central subfield thickness (CST) greater than 320 µm or the presence of intra-retinal cystoid spaces on optical coherence tomography (OCT), or by the presence of petaloid macular leakage on fluorescein angiography (FA). Data collected included age, race/ethnicity, sex, history of diabetes mellitus, anatomic classification of uveitis, use of corticosteroids, use of immunomodulatory therapy, presence of intra-retinal fluid on OCT, CST on OCT, and presence of petaloid macular leakage on FA. STA failure was defined as the need for additional therapy within 12 weeks of STA due to persistent or worsening uveitic ME. One hundred eighty eyes from 131 patients were included. Forty-two eyes (23.3%) were considered treatment failures. In univariate and multivariable analysis, higher baseline CST was associated with a higher likelihood of failing STA (OR 1.17 for each 30 µm increase in CST, P = 0.016). CONCLUSIONS: STA, while not as potent as intravitreal corticosteroids for the treatment of uveitic ME, was still an effective therapy, particularly for patients with lower baseline CST. Given its lower side effect profile and cost compared to intravitreal treatments, clinicians could consider STA as an initial treatment for mild uveitic ME.

Periprosthetic Joint Infection Risk After Primary Total Knee Arthroplasty: Are All Preoperative Corticosteroid Injections the Same?

BACKGROUND: Previous evidence has demonstrated an increased risk of periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) in patients receiving corticosteroid injection (CSI) within 3 months of surgery. The study aimed to determine if PJI risk after TKA varied among different corticosteroid agents. METHODS: A total of 85,073 patients undergoing primary TKA from 2009 to 2019 were identified from a large national database. Of these, 1,092 (1.3%) received an ipsilateral, intra-articular CSI within 90 days of TKA. These patients were compared to those not receiving CSI using multivariate logistic regressions following 1:4 propensity score matching, with PJI development as the primary outcome. RESULTS: Patients given an injection of any corticosteroid within 90 days of TKA had significantly higher PJI rates compared to controls (1.6 versus 0.41%; P < .001). This finding was driven by patients receiving methylprednisolone acetate (n = 543) or betamethasone (n = 153), with prevalence rates of 1.7 and 2.6%, respectively (P = .003 and P = .01, respectively). No significant increase in the rate of PJI was observed for patients receiving triamcinolone (1.2%; P = .08; n = 342) or dexamethasone (0.0%; P = 1; n = 54) within 90 days preceding TKA. PJI risk for all agents, administered more than 90 days preoperatively normalized to control levels (0.51 versus 0.34%). CONCLUSIONS: These results suggest that PJI risk varies with CSI type. In this large database study, only patients given methylprednisolone acetate or betamethasone injections within 90 days of surgery had significantly higher PJI rates compared to controls.

Pre-operative corticosteroid injection within 1 month of total shoulder arthroplasty is associated with increased risk of periprosthetic joint infection.

INTRODUCTION: Corticosteroid injections (CSI) may increase the risk of peri-prosthetic infections (PJI) following total shoulder arthroplasty (TSA). Our study specifically assessed the risk of PJI in patients who received CSI: (1) less than 4 weeks prior to TSA; (2) 4-8 weeks prior to TSA; and (3) 8-12 weeks prior to TSA. MATERIALS AND METHODS: A national all-payer database was queried to identify patients who underwent TSA with a shoulder osteoarthritis diagnosis from October 1, 2015 to October 31, 2020 (n = 25,422). There were four cohorts: CSI within 4 weeks of TSA (n = 214), CSI 4-8 weeks prior to TSA (n = 473), CSI 8-12 weeks prior to TSA (n = 604), and a control cohort that did not receive CSI (n = 15,486). Bivariate chi-square analyses of outcomes were performed in addition to multivariate regression. RESULTS: A significant increase in PJI risk at 1 year (Odds Ratio [OR] = 2.29, 95% Confidence Interval [CI] = 1.19-3.99, p = 0.007) and 2 years (OR = 2.03, CI = 1.09-3.46, p = 0.016) in patients who received CSI within 1 month of TSA was noted. PJI risk was not significantly increased at any time point for patients who received a CSI greater than 4 weeks prior to TSA (all p ≥ 0.396). CONCLUSION: PJI risk is increased at both 1 and 2 years post-operatively in patients who received a CSI within 4 weeks of TSA. Therefore, TSA should be deferred at least 4 weeks after a patient receives a CSI to mitigate PJI risk. LEVEL OF EVIDENCE: Level III.

Are foot and ankle corticosteroid injections safe during the COVID-19 pandemic? A single center prospective observational study.

BACKGROUND: Intra-articular corticosteroid injections (ICSI) are commonly used in orthopedic practice. Due to concerns about their immunosuppressive effects, we conducted a prospective observational audit, to monitor for COVID-19 infection amongst a group of foot and ankle patients who received an ICSI during the pandemic. PATIENTS AND METHODS: Included were 68 patients (25 males - 43 females, mean age 59.1 years, SD 15.0, range 19 - 90 years) who received a fluoroscopy-guided ICSI within a two-month period during the pandemic. The American Society of Anaesthesiologists (ASA) grade was I in 35 % of patients, II in 58 % and III in 7 %. 16 % of patients had black, Asian or minority ethnic (BAME) background. The dose of methylprednisolone injected was 20 mg for 28 % of the patients, 40 mg for 29 % and 80 mg for 43 %. RESULTS: All patients were available for follow up at one and four weeks post-injection. None reported COVID-19 infection symptoms within this period. The only complication was a flare-up of joint pain. CONCLUSION: Our study showed that the risk of COVID-19 infection to patients receiving foot or ankle ICSI is low. The limitations of this work must be considered, but our findings support the judicious use of corticosteroid injections during the current crisis.

Does preoperative corticosteroid injection increase the risk of periprosthetic joint infection after reverse shoulder arthroplasty?

BACKGROUND: Corticosteroid injections (CSIs) are used for the symptomatic management of osteoarthritis. However, their use may contaminate the joint space and pose an increased risk of periprosthetic joint infection (PJI) following reverse shoulder arthroplasty (RSA). Therefore, the purpose of this study was to assess whether there is any association between the timing of CSI and the incidence of PJI at 90 days, 1 year, and 2 years postoperatively. Specifically, we assessed the risk of PJI in patients who received CSI <1 month, 1-2 months, 2-3 months, and >3 months prior to RSA, as well as associated risk factors for PJI with CSI. METHODS: We queried a national, all-payer database to identify patients who underwent RSA from October 1, 2015, to October 31, 2020 (1.5 million patients). Patients who received an osteoarthritis diagnosis prior to RSA were selected, whereas those with bilateral RSA or >1 injection on the same side were excluded. This resulted in 5 cohorts: cohort receiving CSI within 4 weeks of RSA (n = 5607), cohort receiving CSI 1-2 months prior to RSA (n = 3024), cohort receiving CSI 2-3 months prior to RSA (n = 1572), cohort receiving CSI >3 months prior to RSA (n = 16,302), and control cohort with no injection prior to RSA (n = 21,938). Bivariate χ2 analyses of outcomes were conducted, in addition to multivariate regressions performed to adjust for comorbidities, as well as to assess associated risk factors. RESULTS: The adjusted analyses demonstrated a significantly increased risk of PJI at 90 days in patients who received CSI within 1 month of RSA (P < .001). Additionally, the PJI risk was increased at 1 year postoperatively in patients who received CSI within 1 month of RSA (P = .015). However, no significant increase in the PJI risk was noted at any time point for patients who received CSI >1 month before RSA (all P ≥ .088). Furthermore, alcohol abuse, chronic kidney disease, and depression were identified as risk factors that increased the risk of PJI. CONCLUSION: Intra-articular shoulder CSIs <4 weeks prior to RSA are associated with increased risks of PJI at 90 days and 1 year postoperatively as compared with patients who did not receive CSIs. RSA should be deferred ≥4 weeks after a patient receives a CSI.

The role of corticosteroid injections in treating plantar fasciitis: A systematic review and meta-analysis.

BACKGROUND: Plantar fasciitis is a recurrent cause of heel pain and is often treated by corticosteroid infections (CSI). The current study reviewed and analysed the role of CSI with platelet rich plasma (PRP), and CSI with extracorporeal shock wave therapy (EWST) for plantar fasciitis treatment. METHODS: PubMed, Medline, Web of Science, Embase, Cochrane, and Google Scholar databases were searched for relevant studies. Preferred Reporting in Systematic Review & Meta-Analysis (PRISMA) guidelines were used to search relevant studies published from infinity to April 2021. The risk of bias was performed using Cochrane Collaboration's tool. GRADE assessment was used for quality of evidence. Data analysis was performed with the use of R software and P < 0.05 was considered statistically significant. CSI was compared with PRP and EWST. RESULTS: Eighteen studies comprising 1180 patients were included in this meta-analysis. When compared to PRP, CSI with lignocaine/lidocaine had significantly higher mean difference on visual analogue scale (VAS) pain scores at 3 months (0.62 [0.13; 1.12], P = 0.01) and 6 months (MD = 1.49 [0.22; 2.76], P = 0.02). At 6 months, VAS scores were higher in the CSI group than the ESWT group (MD = 0.8 [0.38; 1.22], P = 0.1). At 6 months, a significant reduction in the American Orthopaedic Foot and Ankle Score (AOFAS) was observed in the CSI group compared to PRP (MD = - 11.53 [- 16.62; - 6.43], P < 0.0001). CONCLUSION: Patients suffering from plantar fasciitis, PRP achieved better VAS scores compared to CSI at 3 and 6-month follow-up. In addition, ESWT had better VAS score outcomes at 6 months compared to CSI. Regarding AOFAS score, PRP was more efficacious than CSI at 6 months of follow-up. Only through the development of high-quality, large-scale longitudinal studies, will the findings and conclusions of this meta-analysis be strengthened and influence our clinical practice in the treatment of plantar fasciitis. LEVEL OF CLINICAL EVIDENCE: II.

Intra-articular corticosteroid injections are associated with a dose-dependent risk of total knee arthroplasty at 5 years.

PURPOSE: Intra-articular corticosteroid injections (CSI) are used commonly for the non-operative management of patients with knee pain. Recent literature has raised concern for chondrotoxicity of CSI. The purpose of the present study is to evaluate for any dose-dependent association between CSI in non-osteoarthritic knees and subsequent total knee arthroplasty (TKA). METHODS: The Pearl Diver database identified patients with a diagnosis of knee pain without concomitant osteoarthritis who were administered CSI over a 2-year period. Patients were compared to matched and unmatched cohorts. The primary endpoint was the incidence of TKA at 5 years. Multivariable regression analysis was used to assess CSI quantity as an independent risk factor. RESULTS: 49,443 of 986,162 (5.0%) Patients diagnosed with knee pain without concomitant knee osteoarthritis who received at least one CSI were identified. At 5 years, there was a higher incidence of TKA in the matched injection cohort relative to the non-injection matched cohort (0.26 vs 0.13%; p < 0.001) and unmatched cohort (0.26 vs. 0.10%, p < 0.001). The quantity of CSI corresponded with an increased probability of TKA at 5 years; one injection: 0.22% (OR 1.23, 95% CI [0.87-1.74], p = 0.236); two injections: 0.39% (OR 1.98 CI [1.06-3.67], p = 0.03, three or more injections: 0.49% (OR 3.22 CI [1.60-6.48], p = 0.001). The average time to TKA after one CSI was 3.03 ± 2.29 years. This time was nearly halved with three CSI (1.78 ± 0.80 years, p < 0.001). CONCLUSIONS: Intra-articular corticosteroid injections in patients without knee osteoarthritis at the time of injection are associated with a dose-dependent risk of TKA at 5 years. CSI may not be as benign of a treatment modality as previously thought.

When Is It Safe to Operate After Therapeutic Carpal Tunnel Injections?

BACKGROUND: Recent studies suggest increased complications when surgery closely follows corticosteroid injection. The purpose of this study was to understand the occurrence of surgical site infection (SSI), wound complications, and reoperation rates after carpal tunnel release (CTR) when corticosteroid injections were given within 180 days preoperatively. METHODS: Data were collected from the Truven MarketScan database from 2009 to 2018. Cohorts were created based on preoperative timing of injection (<30, 30-60, 61-90, 91-180 days) and number of injections (0, 1, 2, 3+). Logistic regression was performed to assess the contribution of preoperative injections on 90-day surgical site complications and 1-year reoperation while controlling for demographics and comorbidities. RESULTS: Overall, 223 899 patients underwent CTR. Of these, 17 391 (7.76%) had a preoperative injection in the 180 days preceding surgery. Univariate analysis demonstrated a relationship between timing of injections and noninfectious wound complications (P = .006) and rate of 1-year reoperation (P = .045). Univariate analysis demonstrated a relationship between number of injections and 1-year reoperation (P < .001). On multivariate analysis, those receiving injections within 30 days preoperatively had increased rates of SSI (P = .034) and noninfectious wound complications (P = .006) compared with those with no injection or at other time points. Patients with 2 (P = .002) or 3 or more injections (P < .001) in the 180-day preoperative period had increased odds of 1-year reoperation. CONCLUSION: Our study suggests increased risk of SSI, wound complications, and 1-year reoperation when corticosteroid injections are administered in the 30-day preoperative period. In addition, multiple steroid injections may increase the risk of 1-year reoperation.

Pay attention to the evidence: in the longer term, intraarticular corticosteroid injections offer only harm for knee osteoarthritis.

With respect to the long-term effects of intra-articular corticosteroid injections (IACIs) in knee osteoarthritis (OA), we are at the stage where it seems like the jury has returned a verdict but the judge hasn't yet accepted it. Supporters of IACIs for knee OA, when reading about potential and actual harms and complete lack of any benefit in the medium- or long- term, are now clutching at straws that we shouldn't even expect to observe any benefit in the longer term. Sadly, the same arguments that orthopaedic surgeons use to justify continuing with knee arthroscopy when there are only documented long-term harms and no documented long-term benefits, are being used by rheumatologists to justify continuing with IACIs for knee OA. The only actual reason to keep recommending both IACIs and knee arthroscopy (which sadly society guidelines still do) is the "status quo", with the self-affirming argument that the quality of the RCTs published to date is not (yet) high enough to justify a change in expert opinion. There is a very strong argument against preserving the status quo for knee OA: outcomes everywhere keep getting worse. Knee replacements seem to be on a steady growth curve upwards in all countries and knee OA prevalence itself is also increasing. Something is badly wrong with the status quo for knee OA: if we were getting good results with medical treatment then fewer people would be needing knee replacements, not more. A very easy place to start questioning the status quo is to read a systematic review showing worse results than all comparators for IACIs followed by an editorial saying "let's not give up on IACIs for knee OA just yet". But as mentioned you could just as easily start with an orthopaedic journal editorial saying "let's not give up on knee arthroscopy just yet" after a systematic review showing no benefit for this procedure either.

Corticosteroid therapy versus physiotherapy on pain, mobility and function in shoulder impingement: A short note.

Background: The global estimate of shoulder pain is 67% and is often associated with subacromial impingement syndrome. Interventions include corticosteroid injection (CSI) therapy and physiotherapy. Further information is needed to compare the effect of these interventions on pain, joint range of motion (ROM) and shoulder function. Objectives: To summarise the best evidence comparing the effect of CSI versus physiotherapy on pain, shoulder ROM and shoulder function in patients with subacromial impingement syndrome. Method: This evidence statement is based on a systematic review and meta-analysis of three randomised controlled trials (RCTs), namely, Rhon et al. (2014) (n = 136), Hay et al. (2003) (n = 207) and Van der Windt et al. (1998) (n = 109), with a total of 452 participants. A total of 14 studies were reviewed and only 3 studies met the inclusion criteria. Results: An improvement in shoulder function was found in favour of CSI at 6- to 7-week follow-up (p < 0.0001), but no evidence was found for the superiority of CSI compared to physiotherapy for pain and ROM over 4-12 weeks. In 24 and 48 weeks, no evidence was found for the superiority of CSI compared to physiotherapy for shoulder function, pain or ROM. Conclusion: No evidence was found for the superiority of CSI compared to physiotherapy for pain and ROM in the short term besides an improvement in shoulder function in favour of CSI at 6-7 weeks. There was a weak recommendation with moderate quality of evidence based on three RCTs (2B). Clinical implications: This evidence statement may inform clinical practice when determining which intervention is best suited to manage patients with shoulder pain.

Research priorities for intra-articular corticosteroid injections for osteoarthritis: A Delphi study.

Objective: To identify research priorities for intra-articular corticosteroid injections for osteoarthritis using a Delphi study. Design: In the Round 1 questionnaire, participants generated up to five potential research topics related to corticosteroid injections for osteoarthritis. These responses were collated and grouped to develop candidate research questions. Literature searches were conducted and questions with a lack of evidence were included in the next round. In Round 2, importance ratings (1-9; not important to very important) were assigned to each question. Those questions given an importance rating of 7-9 by ≥ 70% of participants were carried forward. In Round 3, participants were provided with the group ratings and the rating process was repeated to develop the final research priority list. Results: All three Delphi rounds were completed by 75 participants (82%; 34 patients, 21 healthcare professionals and 20 academics). A total of 310 research topics were generated in Round 1, from which 26 research questions were developed. None had been robustly answered by research and therefore all were included in the Round 2 questionnaire. In Round 2, 14 research questions were retained; all 14 were prioritised in Round 3 and included in the final research priority list. The questions covered long-term effects, clinical and cost-effectiveness, measurement of outcomes, comparison to other treatments, provision, safety, identifying responders, maximising benefits, patient experience, delaying the need for joint replacement, and dosage. Conclusion: Using a robust consensus technique with key stakeholders, we have developed a research priority list to guide future research into corticosteroid injections for osteoarthritis.