AIM: To assess whether an increased volume of local anaesthetic injection given with intra-articular steroids improves symptom relief in osteoarthritis of the hip.
MATERIALS AND METHODS: One hundred and ten patients with hip osteoarthritis were randomized into two groups (A and B). All patients were given 40 mg triamcinolone and 2 ml bupivicaine, and patients from group B were also given 6 ml of sterile water for injection. Change in WOMAC (Western Ontario and McMaster University Osteoarthritis Index Version 3.1) scores from baseline to 3 months were calculated and assessed for clinical and statistical significance. The patients were assessed for pain at 2 weekly intervals using the Oxford pain chart.
RESULTS: Patients from group B showed some reduction in stiffness (7%) and improved function (3%) compared with group A, and there were more clinical responders in these two categories. However, there was no significant statistical or clinical difference in WOMAC scores between the two groups at 3 months. There was also no statistical difference in pain symptoms between the two groups during the study period, measured at 2 weekly intervals. One hundred and two patients reached the study endpoint; eight patients who had bilateral hip injections were subsequently included in the analysis, and these patients did not alter the findings significantly.
CONCLUSIONS: Published total injection volumes used for treating osteoarthritis of the hip with intra-articular steroids vary from 3 to 12 ml. The present study has shown that there is no detriment to using a larger volume of injectate, and recommends that practitioners use total volumes between 3 and 9 ml.
OBJECTIVE: Intra-articular injection is being used widely for both diagnostic and therapeutic purposes in the hip. However, its efficacy is not always predictable in patients with hip osteoarthritis (OA). The purpose of this study was to determine whether the degree of radiographic severity of OA was predictive of the response to intra-articular injection of local anesthetic with corticosteroid and to determine the relationship between immediate pain relief resulting from the anesthetic and delayed pain relief resulting from corticosteroid administration.
MATERIALS AND METHODS: This retrospective study included 217 patients (220 injections) with diagnosis of hip OA who underwent a fluoroscopically guided therapeutic hip injection of local anesthetic and corticosteroid. Hip radiographs were scored using the Kellgren-Lawrence scale. Immediate and delayed pain relief was documented using a visual analog scale. Logistic regression analysis was performed to investigate whether age, gender or radiographic severity of OA were independent predictors of pain relief. Degree of agreement between immediate and delayed response was assessed with the kappa coefficient.
RESULTS: Immediate pain relief was reported in 68.2% of hips and delayed relief in 71.4% of hips. A high level of agreement was observed between immediate and delayed pain relief (kappa = 0.80, p < 0.001). 94% of patients reporting immediate relief also reported relief 2 weeks later. Univariate and multivariate analysis revealed that neither gender nor age was related to immediate or delayed pain relief. Only severity of OA (based on radiographic analysis) was observed to be predictive of pain relief.
CONCLUSION: Pain relief following intra-articular hip injection correlated with radiographic severity of OA. This intervention may be of therapeutic and prognostic value in patients awaiting hip arthroplasty.
BACKGROUND: Intra-articular injection is effective for osteoarthritis, but the best single injection strategy is not known, nor are there established predictors of response. The objectives of this study were to assess and predict response to a single ultrasound-guided injection in moderate to severe hip osteoarthritis.
METHODS: 77 hip osteoarthritis patients entered a prospective, randomised controlled trial, randomised to one of four groups: standard care (no injection); normal saline; non-animal stabilised hyaluronic acid (durolane) or methylprednisolone acetate (depomedrone).
MAIN OUTCOME MEASURES: Numerical rating scale (NRS 0-10) 'worst pain', Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain/function. Potential predictors of response (including radiographic severity, ultrasound synovitis and baseline symptom severity) were examined using univariate logistic regression analysis and Fisher's exact test.
RESULTS: NRS pain, WOMAC pain and function improved significantly for the steroid arm alone. Effect sizes at week 1 were striking: NRS pain 1.5, WOMAC pain 1.9 and WOMAC function 1.3. Outcome Measures in Rheumatoid Arthritis Clinical Trials-Osteoarthritis Research Society responder criteria identified 22 responders (intention-to-treat): steroid 14 (74%; number needed to treat, two); saline, four (21%); durolane, two (11%); and no injection, two (10%; χ(2) test between groups, p<0.001). Corticosteroid arm response was maintained over 8 weeks (summary measures analysis of variance, p<0.002 for NRS pain). Synovitis was a significant predictor of response at weeks 4 and 8 (p<0.05, Fisher's exact test; week 4 OR 16.7, 95% CI 1.4 to 204).
CONCLUSIONS: Ultrasound-guided corticosteroid injections are highly efficacious; furthermore synovitis on ultrasound is a biomarker of response to injection.
OBJETIVOS: Los pacientes con osteoartritis de rodilla (OA) a menudo sufren dolor que no está totalmente controlado por analgésicos ya menudo requieren terapias intraarticulares. El objetivo de este estudio fue comparar los beneficios de las inyecciones intraarticulares de corticosteroides (ICS) y el riego de las mareas (TI) en pacientes con OA de la rodilla.
MÉTODOS: Se realizó un doble centro, simple ciego, aleatorizado, de grupos paralelos comparando TI y CSI. Los pacientes con artrosis de rodilla fueron asignados al azar a cualquiera de riego utilizando un artroscopio 3,2 mm bajo anestesia local o una inyección intra-articular de 40 mg de acetato de triamcinolona y lidocaína al 1%. Los pacientes fueron seguidos durante 6 meses. La medida de resultado primaria fue la puntuación de dolor Western Ontario y McMaster total de Universidades Índice de OA (escala analógica visual, VAS).
RESULTADOS: Ciento cincuenta pacientes fueron reclutados de los cuales 71 recibieron TI y el 79 de CSI. En ambos grupos de tratamiento, más del 80% de los pacientes reportaron una mejoría a las 2 y 4 semanas. Después de este tiempo, el beneficio de CSI disminuyó mientras que la de TI se mantuvo: a las 26 semanas el alivio del dolor proporcionado por TI fue significativamente mayor que la de CSI. A las 26 semanas, el 29% del grupo CSI informó una mejoría frente al 64% del grupo de TI (P <0,001). Los pacientes con un derrame de rodilla respondieron mejor a ambos tratamientos, sin embargo, esto fue más evidente para la CSI. Los pacientes con OA radiográfica menos grave también obtienen la mayor mejora de ambos tratamientos.
CONCLUSIÓN: Ambos procedimientos conducen al alivio del dolor significativo a corto plazo de al menos 4 semanas, sin embargo, TI muestra una significativa mayor duración de la prestación. Los pacientes con derrames y el cambio radiográfico más suave obtuvieron la mejor respuesta al tratamiento.
OBJETIVO: Determinar la eficacia de la inyección de corticosteroides con guía fluoroscópica para la osteoartritis de cadera (OA) en un ensayo aleatorizado, doble ciego, controlado con placebo.
MÉTODOS: Cincuenta y dos pacientes con OA sintomática de cadera fueron asignados al azar para recibir placebo (10 mg bipuvicaine, 2 ml de solución salina) (n = 21) o tratamiento con corticosteroides (10 mg bipuvicaine, 40 mg de triamcinolona hexacetónido) (n = 31). Los pacientes fueron seguidos durante 1, 2, 3 y 6 meses. La medida de resultado primario fue la respuesta de la mejoría del dolor, que se define como una disminución del 20% en el Western Ontario y McMaster Universidades OA Index (WOMAC) puntuación de dolor (en 5 100 mm escalas analógicas visuales [EAV]) (WOMAC20) desde el inicio hasta 2 meses después de la inyección. Los resultados secundarios fueron una disminución del 50% en la puntuación de dolor WOMAC (WOMAC50), los cambios en otras puntuaciones de la subescala WOMAC, evaluación del paciente mundial de la salud (en una EVA de 100 mm), y Short Form 36 (SF-36) índices de calidad de vida . Los análisis se basan en el principio de intención de tratar.
RESULTADOS: La media de la puntuación de dolor WOMAC cayó 49,2% (disminución de 310,1 mm a 157,4 mm) a 2 meses después de la inyección en pacientes que reciben corticosteroides, en comparación con una disminución del 2,5% (de 314,3 mm a 306,5 mm) en el grupo placebo (P < 0,0001). La proporción de respondedores WOMAC20 a los 2 meses de seguimiento fue significativamente mayor en el grupo con corticosteroides (67,7%) en comparación con el grupo placebo (23,8%) (P = 0,004); Se observaron proporciones similares de respondedores WOMAC50 entre los grupos (61,3% en el grupo de corticosteroides en comparación con 14,3% en el grupo placebo; P = 0,001). Diferencias de respuesta se mantienen a los 3 meses de seguimiento (58,1% respondieron en el grupo de corticosteroides en comparación con 9.5% respondieron en el grupo placebo; p = 0,004). Se observaron diferencias significativas en la rigidez WOMAC y puntuaciones de función física (p <0,0001), las puntuaciones de los pacientes de salud global (P = 0,005), y el SF-36 las puntuaciones del componente físico (p = 0,04), con los pacientes en el grupo de corticosteroides mostrando mayores mejoras . No hubo diferencias en la frecuencia de eventos adversos entre los grupos.
Conclusión: Este ensayo controlado con placebo confirma que la inyección de corticosteroides puede ser un tratamiento eficaz del dolor en la OA de la cadera, con beneficios duración de hasta 3 meses en muchos casos. Los estudios futuros deben abordar las cuestiones relacionadas con los beneficios de la inyección de esteroides repetidas y los efectos de este tratamiento sobre modificación de la enfermedad.
OBJECTIVES: To assess symptomatic change after intra-articular corticosteroid (IAST) injection at 2 doses in hip osteoarthritis (OA), and to examine dose response and predictors of response.
METHODS: Patients with hip OA (90 women and 30 men and median age 64 yrs) referred for IAST fluoroscopic injection were included in this longitudinal, clinical trial. WOMAC scores, body mass index (BMI), conventional radiographic grade (Kellgren and Lawrence scoring) and ultrasound measures (including capsular thickness and osteophyte assessments) were recorded at baseline. In the first phase of the study, 75 patients were injected with 40 mg methylprednisolone; another 45 patients were injected with 80 mg in the second phase. Change in WOMAC scores from baseline to weeks 6 and 12 were calculated for each dose and then dose comparisons were made. Clinical responders (>15% reduction in baseline pain score) were identified in order to establish predictors of response.
RESULTS: For the 40 mg dose, there was a statistically significant improvement in pain (P < 0.001) and stiffness (P < 0.001) but not disability at week 6, and only the improvement in stiffness at week 12 was maintained (P = 0.041). For the 80 mg dose, there was significant improvement in pain (P < 0.001), stiffness (P < 0.001) and disability (P < 0.001) at week 6, which was maintained for all domains at week 12 (P = 0.002; P = 0.001; P < 0.001). When the doses were compared, the 80 mg dose demonstrated a significant improvement compared with the 40 mg group for stiffness at week 12 (P = 0.026) and disability at both weeks 6 and 12 (P = 0.026; P = 0.004). Imaging findings did not relate to severity of symptoms or response to IAST.
CONCLUSIONS: In these two hip OA cohorts, both the 40 mg and 80 mg IAST doses had a beneficial effect at week 6, while the 80 mg dose maintained this improvement at week 12. Comparison of the two dose groups provided some evidence of a dose response. Randomized controlled trials of IAST for hip OA are now required.
OBJECTIVE: Hyaluronic acid (HA) and corticosteroids are both widely used for intra-articular treatment of knee osteoarthritis (OA). We examined the effect of both drugs in intra-articular treatment for hip OA.
METHODS: One hundred and one patients with hip OA were included in a prospective double blind study, using a randomized controlled trial with a three-armed parallel-group design. Three ultrasound-guided, intra-articular injections were given at 14 days interval. The primary outcome measure was 'pain on walking', registered on a visual analogue scale (VAS). Evaluation was performed at baseline and after 14, 28 and 90 days. The study adhered to the Consolidated Standards of Reporting Trials. All analyses were based on intention-to-treat analyses, and used 'mixed-procedures' with the baseline-observation as covariate.
RESULTS: There were no significant interactions with respect to Treatment x Time for any of the analyzed outcome measures. There was a significant treatment effect for 'pain on walking' (P=0.044) due to a significant improvement following corticosteroid compared to saline with an effect-size of 0.6 (95% confidence interval: 0.1-1.1, P=0.021). By contrast, HA compared to saline had an effect size of 0.4 (-0.1 to 0.9; P=0.13). The peak-effect was obtained after 2 weeks. There was no difference between the treatment groups at endpoint. No significant side effects of the injections were observed.
CONCLUSIONS: Patients treated with corticosteroids experienced significant improvement during the 3 months of intervention, with an effect size indicating a moderate clinical effect. Although a similar significant result following treatment with HA could not be shown, the effect size indicated a small clinical improvement. A higher number of patients in future HA studies would serve to clarify this point.
El objetivo de este estudio fue comparar la eficacia de la triamcinolona hexacetonida (THA) y metilprednisolona (MPA), dado por vía intra-articular en dosis equipotente a los pacientes con artrosis sintomática de rodilla con derrame, en un estudio aleatorio doble ciego ensayo comparativo. Consecutivos que se refiere el hospital los pacientes que cumplieron con el American College of Rheumatology criterios para la OA de la rodilla (clínica y radiológica) fueron asignados al azar para recibir ya sea 20 mg de THA (1 ml) o AMP 40 mg (1 ml). Todos los pacientes tenían líquido sinovial aspirado de su articulación de la rodilla en el momento de la inyección. Las evaluaciones se realizaron a 0, 3 y 8 semanas por un segundo operador, con lo que el paciente y el cegamiento del evaluador. Los resultados medidos en cada visita fueron los siguientes: dolor de rodilla en las últimas 48 horas (expresada en un 100 mm escala analógica visual, VAS), el tiempo de la escalera de ascenso (SCT) y el índice de Lequesne índice (LEQ). Los cambios en la EVA, la SCT y la LEQ se compararon entre los grupos mediante un Student t para datos apareados. Cincuenta y siete pacientes fueron estudiados (44 mujeres, 13 varones) con una edad media de 62,5 años. Los esteroides le dio alivio significativo del dolor (VAS) en la semana 3 (p <0,01) pero sólo AMP mostraron un efecto en las puntuaciones VAS y LEQ en la semana 8 respecto a la basal (p <0,05). THA fue más eficaz que El MPA, a la reducción del dolor en la semana 3 (p <0,01), diferencia que se perdió en la semana 8 (p = 0,17). No hubo diferencia significativa entre los dos fármacos en parámetros funcionales (SCT, LEQ) en 3 o 8 semanas. Tanto la ATC y la MPA ofrecen menos beneficio temporal sintomático en la OA de rodilla. THA es más eficaz que AMP en la semana 3, pero su efecto se pierde en la semana 8. AMP todavía tiene un efecto en la semana 8.
To assess whether an increased volume of local anaesthetic injection given with intra-articular steroids improves symptom relief in osteoarthritis of the hip.
MATERIALS AND METHODS:
One hundred and ten patients with hip osteoarthritis were randomized into two groups (A and B). All patients were given 40 mg triamcinolone and 2 ml bupivicaine, and patients from group B were also given 6 ml of sterile water for injection. Change in WOMAC (Western Ontario and McMaster University Osteoarthritis Index Version 3.1) scores from baseline to 3 months were calculated and assessed for clinical and statistical significance. The patients were assessed for pain at 2 weekly intervals using the Oxford pain chart.
RESULTS:
Patients from group B showed some reduction in stiffness (7%) and improved function (3%) compared with group A, and there were more clinical responders in these two categories. However, there was no significant statistical or clinical difference in WOMAC scores between the two groups at 3 months. There was also no statistical difference in pain symptoms between the two groups during the study period, measured at 2 weekly intervals. One hundred and two patients reached the study endpoint; eight patients who had bilateral hip injections were subsequently included in the analysis, and these patients did not alter the findings significantly.
CONCLUSIONS:
Published total injection volumes used for treating osteoarthritis of the hip with intra-articular steroids vary from 3 to 12 ml. The present study has shown that there is no detriment to using a larger volume of injectate, and recommends that practitioners use total volumes between 3 and 9 ml.
