Transcript Steroid Injection
Injection (Therapy) in Sports Medicine Nadhaporn Saengpetch
Division of Sports Medicine Department of Orthopaedics
Steroid Injection
Corticosteroid Injection
• Lack of good quality research data to support the wide space use • Reduce tendon strength (not universal) • Tennis elbow: effective in short term (2-6 wks) (Hey EM
BMJ
1999;319:964-8) • Report some higher recurrence rate than “wait and see” (Smidt N
Lancet
2002;359:657-662)
• 123 male Sprague-Dawley rats • Control, tendon injury, steroid injection and tendon injury with steroid injection • Single corticosteroid dose has significant short-term (transient) effects on the biomechanic properties of both injured and uninjured RCT (Mikolzyk DK
J Bone Joint Surg Am
2009;91:1172-80)
ISP Tendon
• Single strands rat tail collagen fascicle • 1 mL methylprednisolone acetate 40 mg + 9% saline 0.5 mL VS 1 mL methylprednisolone acetate 40 mg + 9% saline 2 mL • Tensile strength markedly reduced after 3 and 7-day incubation in both high and low concentration (Haraldsson BT
Am J Sports Med
2006;34(12):1992-7)
Ultimate stress in High/Low Conc.
High(40) vs Low(10) Dose
Improve pain 6 wks Improve sleep disturbance 6 wks Improve functional impairment 6 wks
• Subacromial corticosteroid injection • To analyse type III to type I collagen expression ratio (Wei AS
J Bone Joint Surg Am
2006;88(6):1331-8)
Gene Expression on Collagen Type I/III
Supraspinatus Tendinopathy
• 2 studies show a small benefit at 4 weeks • Small numbers of subject (Buchbinder R
Cochrane Database Syst Rev.
2003;1:CD004016)
Shoulder Pain
• No absolute distinction between acute and chronic pain • May reflect by ineffectiveness of initial intervention
Causes of Shoulder Pain
Pathology of Shoulder Pain
• Osteoarthritis • Rotator cuff tear • Primary adhesive capsulitis • Tendinitis (SSP, Biceps) • Bursitis (SA-SD) • Impingement syndrome • Overlapping diagnosis or shoulder pain is the secondary cause of diseases
Chronic Shoulder Pain Non-surgical Treatment Algorithm (Andrews JR
Arthroscopy
2005;21(3):333-47)
Intra-articular Steroid Injection
• Better relief than oral NSAIDs • No enough evidence to refuse or support the benefit of steroid (Cochrane 2002) • Good for polymyalgia rheumatica • Adverse effects : dermal atrophy, bacterial arthritis, hemarthrosis and thrombophleblitis
Bicipital Tendinitis
• Local and steroid (1%Xylocaine and Triamcinolone 10 mg) • Bony landmark: bicipital groove • Target tissue: biceps sheath
How to prove the
RIGHT
location?
External rotate to show the better groove exposure Palpate the groove , then point the tip more superficial to the tendon
Rotator Cuff Tendinitis
• Partial cuff torn: pain and loss of the power • Tendinitis may be the presenting symptom • Stiff shoulder with loss of AER and concomittant with impingement signs • Should we prove the tendon integrity? If yes….how?
ultrasound, CT scan and MRI
• 58 pts • 5 mL of 2% xylocaine VS or 4 mL of 2% xylocaine and 1 mL (6 mg) of betamethasone • no more effective in improving the quality of life, range of motion, or impingement sign than xylocaine alone (Alvarez CM
Am J Sports Med
2005;33(2): 225-62)
WORCI
• AIR, AER, AFE • Neer impingement tests • WORCI, ASES, DASH
Effects of Steroid on Cuffs
• Collagen fascicles • Biomechanic strength • Can mimic a rotator cuff tear (Borick JM
Arthroscopy
2008;24(7): 846-9)
• Methylprednisolone 0.6mg/kg subacromial injection • Type I and III Collagen expression 60 Sprague Dawley rats Control Tendon injury Steroid Tendon Injury + Steroid
Subacromial Methylprednisolone • A single dose corticosteroid does not alter the acute phase response of an injured rotator cuff tendon in the rat • same steroid dose in uninjured tendons initiates a short-term response equivalent to that of structural injury (Wei AS
J Bone Joint Surg Am
2006;88(6): 1331-6)
Hyaluronic Acid Injection
What is hyaluronic acid?
• A polysaccharide secreted into the joint space by type B synoviocytes or fibroblasts • Viscoelasticity for lubrication and chondroprotective effects • Anti-inflammatory properties, stimulate synovial fibroblasts to produce endogenous HA and decrease pain
What is hyaluronic acid?
• A long-chain biopolymer with repeated sequences of N-acetyl-glucosamine and glucuronic acid • Avian / bacterial origin • Hylan: cross-link molecules modified from HAs (to increase viscosity and clearance from the joint)
Intra-articular Hyaluronans Injection • Safety profile, no adverse effect • Enhance endogenous hyaluronan synthesis, enhance biosynthesis and degradation of cartilage, inhibit inflammation, inhibit secondary pain mediators and direct coat nociceptors • Hyalgan (Sodium Hyaluronate) clarified its true usefulness (Andrews JR
Arthroscopy
2005;21(3):333-47)
How to choose the ‘right one’ for each patients • Who is fit to have the IA-HA injection?
• The cost-effectiveness for the equivocal type of patients • How last long does it work in the joint?
• The rheological properties and molecular weight of the hyaluronan preparations??
• Which joints that I should inject it?
Who is proper to have IA-HA?
• Old age < 65 yrs.
• Early arthritis (Albach grade 1,2) without mechanical symptoms (Wang CT
J Bone Joint Surg Am
2004;86A-3:538-45 Toh EM
Knee
2002;9(4):321-30) • Inactive with household ambulation • Good expectation (Turajane T
J Med Assoc Thai
2007;90(9):1845-52)
Cost-effectiveness: Police General hospital • 183 pts.(208 knees) from 2001-2004 • A minimum of 2-year period follow up • drugs cost, hospitalization, resources • Non-response = proceed for TKA • Success group: 47,044.18 THB (12,240.41 THB)
63.26%
• Failure group: 144,884 THB (9,324 THB) (Turajane T
J Med Assoc Thai
2007;90(9):1839-44)
How does it last long?
• 1 day intra-articular sustaining • Variable onset of their efficacy • Hyalgan 26 wks, Hylan G-F20 52 wks (labeled) (Raman R
The Knee
(2008), doi:10.1016/j.knee.2008.02.012) • Inconclusive and controversial for the therapeutic efficacy (Adams ME
Drug Safety
2000;23(2):115-30 Wobig M
Clin Ther
1999;21:1549-62, Allard S
Clin Ther
2000;22:792-5) • Need a well designed prospective RCT to resolve the uncertainty about magnitude of efficacy of various products
• Hylan G-F 20 (Synvisc) (MW 6 x 10 6 Da.) vs Orthovisc (MW 1.55 x 10 6 Da.) • HMW HA produce an analgesic effect • The higher MW, the better the effect on the cartilage production • WOMAC physical function, stiffness scores and pain scores (patient & physician)
• Improvement in physical function begin at the end of the 1 st month lasted until 6 months.
• No difference for stiffness scores, pain scores (Kotevoglu N
Rheumatol Int
2006;26:325-30)
Efficacy and safety of AI-HA or Hylan: RCT • 3 preparations in Switzerland (SVISCOT-1) a cross linked HMW hylan a non-cross-linked MMW HA of avian origin a non-cross-linked low LMW HA of bacterial origin • 3 shots/cycle, N=660 pts • WOMAC pain score at 6 months • Local adverse events (flare/effusion), costs • No difference in efficacy between hylan and HAs • Hylan had more local adverse events and higher cost ($1,459>$1,238>$1,017) (J üni P
Arthritis Rheumatism
2007;56(11):3610-19)
Crosslink vs non-crosslink • Efficacy up to 1 yr in favor of cross-link HA (Torrence GW
Osteoarthritis Cartilage
2002;10(7):518-27 Raynauld JP
Osteoarthritis Cartilage
2002;10(7):506-17)
Other support evidence
• Higher viscosity and longer half-life increase long-term efficacy for duration and intensity of pain relief • Mechanism of pain relieve: directly inhibit nociceptors or binding substance P (Moreland LW
Arthritis Res Ther
2003;5:285-9) • But mechanism to relief pain in OA knee remains under investigation
Shoulder
Adhesive capsulitis
• Compared with intra-articular steroid injection • Should separate 1° frozen shoulder from post-traumatic • Hyaluronan show exponentially increasing osmotic pressure with increasing concentration (Laurent TC
Ann Rheum Dis
1995;54:429) • HAs may restore a normal capsular hydrataction. • Absorb and desorb water molecules capacity of HA can inhibit in some way the fibrotic process (Rovetta G
Tissue Reactions
1998;4:125-30)
Glenohumeral OA
Rheumatoid Arthritis both shoulder
OA shoulder
• The same idea for symptomatic OA knee • Outcome measures: VAS score, UCLA score, SST • Improved ADL and ability to sleep • Significantly improve mobility • Adverse events: local pain, swelling, flare • Main problem: correct space of injection
• Shoulder OA, impingement, bursitis, tendinopathy and frozen shoulder • N=660, Hyalgan (3&5 shots and saline) • VAS score, shoulder motion • Presence of shoulder OA may be underappreciated in the setting of rotator cuff pathology • Shoulder OA demonstrated significantly better VAS after treatment than others.
(Blaine T
J Bone joint Surg Am
2008;90:970-9)
Hip
OA hip
• No difference between steroid-HAs placebo (saline) at the endpoint result • Some clinical improvement for pain and walking ability (Qvistgaard E
Osteoarthritis Cartilage
2006;14:163-70)
U/S guide
Ankle
OA ankle
• Exposure of subchondral bone at a weight bearing site at which bone will be abraded and further damage • HAs: viscosupplement and biosupplement • 4 Meta-analyses: effect equivalent or greater than NSAIDs Listrat V
Osteoarthritis Cartilage
1997;3:153-30 Lo GH
JAMA
2003;209:3115-21 Arrich J
CMAJ
2005;172:1039-43 Wang CT
J Bone Joint Surg Am
2004;86:538-45
OA ankle
Possible saline effects • Break scar apart • Slightly lubricate • Dilute the lytic enzymes and proinflammatory cytokines
A double-blind RCT
• Hyalgan 1 mL vs phospate-buffered saline 1 mL • N=17, 6 mo, ankle OA score pain and disability assessment, WOMAC, pts’ global assessment • Only significantly difference within-subject differences (p<0.0001) (Salk RS
J Bone Joint Surg Am
2006;88(2):295-302)
Injection Techniques
Injection Techniques
(Courtney P
Best Practice Res
2005;19:345-69)
Injection Techniques
My practice: shoulder
Shoulder: anterior approach
My practice: knee
Knee: medial approach
Knee: superolateral approach
EHL Ankle: anterior approach Tibialis anterior
Complications
• Acute psuedoseptic arthritis: a case report (Ostenil), onset = ?
(Roos J
Joint Bone Spine
2004;71:352-4) • Mostly reported with Hylan • None of cases occurred after the first injection, suggesting a role of sensitization to HA • Ostenil : LMW and contains no component of animal sources (Kurosaka N
J Rheumatol
1999;26:2186-90)
Complications
• Septic Knee Arthritis: 2 case reports (Albert C
Joint Bone Spine
2006;73:205-7) •
S. aureus
and
N. Mucosa
• Giving HA injection in a brief intervals is not recommended, pathogen inoculation • Previous glucocorticoid injections promotes the occurrence of infection • The rare pathogen often associates with an underlying immunodeficiency.
(Lechowski L
Ann Med Interne (Paris)
1995;146:592-3 Vigouroux C
Presse Med
1992;21:1434-5)
Extended clinical usage
IA-HA after knee arthroscopy • A temporary synovial fluid substitute containing HA • Purpose: to remove the products of cartilage wear, inflammatory cells and molecules from the joint • Counter the onset of painful inflammatory phases • Have a negative effect on the metabolism and structure of the joint cartilage
Intra-operative IA-HA injection for knee arthroscopic debridement • High dose of HMW HA (Orthovisc) single shot 6 mL/90 mg • standard recommendation 2 mL/amp x 3 shots weekly • N=23, ICRS Grade II or III lesion • WOMAC and SF-36 • POW 1, 3, 12, 24 (Li X
J Orthop Surg Res
2008;43:1-8)
Transected ACL from hind limbs of Wistar rats 1.0 mg of HA 800 kDa from rooster comb
cartilage synovium saline saline Difference in joint width HA sham HA sham
(Yen-Hsuan Jean
J Orthop Res
2006;6:1052-60)
Management of Tendinopathy
normal Mild tendinosis Severe tendinosis
Tendinopathy
• A generic description of the clinical conditions • Pain and pathologic changes in and around the tendons arising from overuse
Tendinopathy
• Show either absent or minimal inflammation • Hypercellularity • A loss of the tight bundled collagen appearance • Increase in proteoglycan content • Neovascularization • “Failed healing response”
Tendinosis
• The histologic description • A degenerative pathologic condition with a lack of inflammatory change
Tendinitis
• An inflammatory process • It may play a role in the initiation, but not the propagation and progression of the disease process
Enthesis
• Tendon insertion or osteotendinous junction • Recognized as a site of pathologic changes in many common athletic injuries • Tendo achilles, patellar, rotator cuff, forearm extensor and thigh adductor
Achilles Tendinitis
• 3 distinct regions • Toe, linear and partial failure before it failed (Rees JD
Rheumatology
2006;45:508-521)
Eccentric exercise of TA
New Trends
Autogenous Red Cells Injection
• Poor quality studies elbow (Edward SG
J Hand Surg (Am)
2003:28:272-8) (Suresh SP
Br J Sports Med
2006;40:935-9) Patellar tendinopathy (James SL
Br J Sports Med
2007:41:518-21) • Medial epicondylopathy : may improve without any intervention • Required better study design
Sclerosant Injection
• Ultrasound-guided • Decrease pain and neovascularization • TA, tennis elbow and shoulder impingement (Ohberg L
Knee Surg Sports Traumatol Arthrosc
2003;11:339-343) (Zeisig E
Knee Surg Sports Traumatol Arthrosc
2006;13:1218-24) (Alfredson H
Knee Surg Sports Traumatol Arthrosc
2006;14:1321-6) • Nitric oxide (vasodilator), has an opposite effect of sclerosant injection