Introductions

To apply knowledge of anatomy in needle placement of injections of the shoulder, knee and foot

To understand the pharmacology of injectates

To understand the current evidence base supporting the use of joint injections, and where evidence is lacking

To apply knowledge of the evidence in practical decision making regarding injections

To understand the indications for, and procedure of hydro dilation in adhesive capsulitis

Learning outcomes for day

1. What is it – define?2. Who gets it (M:F, age?) / what are the risk

factors3. How common is it?4. Typical clinical presentation5. What investigations are relevant and what

would they demonstrate?6. What is the management?

Frozen shoulder/ Adhesive Capsulitis

Arthritis Research UK Primary Care CentreWinner of the Queen’s Anniversary Prize For Higher and Further Education 2009

Evidence for Intra-articular Injections for RA, OA &

various Soft Tissue DiseasesDr Zoe Paskins

Clinical Lecturer and Honorary Consultant Rheumatologist

Q - What is evidence based medicine?

‘The conscientious, explicit and judicious use of current best evidence in making decisions

about the care of individual patients’. Sackett et al, BMJ 1996

Hollander Arthritis and Allied Conditions 1972

“…since…1951 we have administered intrasynovial injections of steroids over 250,000 times into more than 8,000 patients who had inflamed joints, bursae or tendon sheaths. The generally favourable response in symptomatology… has been confirmed in more than 100 reports in the literature.”

Treatment of rheumatoid joint inflammation with intrasynovial triamciniolone hexacetonide

McCarty et al J Rheumatol 1995;22:1631-5

Historical review 140 patients with RA 956 injections with Triamcinolone hexacetonide Joint immobilisation post injection

- eg crutch-walking for 4 weeks Mean follow up 7 years “Sustained clinical remission” in 75% of injected

joints Side effects: No infections; 2 tendon ruptures

Polyarticular corticosteroid injection versus systemic administration in treatment of RA patient

Furtado, Oliveira and Natour J Rheumatol 2005;32:1691-8

75 patients with RA Randomised to multiple concomitant IA

triamcinolone injections or equivalent IM dose (minimum 160mg)

Outcome- ACR improvement criteria at baseline 1,4,12,24

weeks- Any adverse effects

Furtado et al 2005IM group (%) IA group (%)

ACR 20 at 1 wk 10 21 *

ACR 20 at 4 wks

15 25 **

ACR 20 at 12 wks

12 16

ACR 50 at 1 wk 2 10 **

ACR 50 at 4 wks

7 15 *

ACR 50 at 12 wks

4 8Fewer side effects in IA group

Importance of synovial fluid aspiration when injecting intra-articular corticosteroids

Weitoft and Uddenfeldt Ann Rheum Dis 2000;59:233-235

147 patients (191 knees) with RA Patients randomised to arthrocentesis or no

arthrocentesis All were injected with triamcinolone Outcome: relapse of inflammation in the

injected joint

Weitoft and Uddenfeldt 2000

Efficacy of IACS in adult RA and JIA- 5 RCTs included IACS knee in adult RA- Concluded that effect on range of movement

(up to 12 weeks), pain, knee swelling (up to 6 weeks), morning stiffness.

- No harm identified - Effects appear to be dose dependant

Cochrane review Wallen and Gillies 2006

Retrospective case review of 220 patients Multiple (>3) IACS associated with

‘sustained joint remission in a substantial proportion of patients’

66% flared 33% remission post IAC

Papadopoulou et al, 2013 Arthritis Care Res

JIA

OA RCT evidence

Joint Duration of improvement

Pain Function

Knee 2-3* -

Hip 8-12/52** 8

CMC 6/12*** (not RCT) 6/12

AC joint -

1st MTP -

OA: RCT evidence

*Bellamy et al, Cochrane 2005Atchia, Robinson, Qvistagard, ** Kullenberg 2004, Lambert 2007***Bahadir, 2009

OA: predictors of response of IACS

Effusion Synovitis Pain BMI Gender Illness beliefs Radiographic severity Age USGI

OA knee: predictors of response of IACS

Effusion Absence of Synovitis Pain BMI Gender Illness beliefs Radiographic severity Age USGI

Maricar, 2013

OA hip: predictors of response of IACS

Effusion Synovitis Pain Lower BMI Gender Illness beliefs Radiographic severity Age USGI

Atchia, 2011Robinson, 2007Desmukh, 2011

Why might the evidence not align with our clinical impressions?

N = Small Different injectates, different doses Different controls Population of severe disease?

Limitations of Studies of IACS

Plantar fasciitis- USGI reduces pain at 4/52 (McMillan 2012)- Recommended in NICE CKS after conservative

treatment Achilles tendonitis

- 1: 40 rupture. Do not inject Tennis Elbow

- In patients with symptoms for >6/52, CSI resulted in higher rate of recurrence at 12/12 (Coombes 2013)

Soft Tissue

Is the effectiveness of ultrasound guided joint injections supported

by evidence?

Does accuracy improve efficacy?- YES (Jones, 1993)

Does ultrasound improve accuracy?- YES*

Does ultrasound improve efficacy?- Yes, in some joints

- shoulders in RA, 6/52 pain and function (Naredo 2003)

Are USGI clinically effective? Are USGI cost effective?*although knee accuracy 87% unblinded

The evidence

Evidence based medicine uses the best available evidence

Systematic review/ RCTs do support the clinical effectiveness of IACS in RA, OA knee and hip

Caution with soft tissue injections for tennis elbow and achilles tendonitis.. poorer clinical outcomes

Summary

Questions?

Acknowledgements

(Plus any other acknowledgements you may have)