COMPLICATIONS OF INTRAARTICULAR CORTICOSTEROID THERAPY

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1 COMPLICATIONS OF INTRAARTICULAR CORTICOSTEROID THERAPY KORTIKOSTEROIDŲ INJEKCIJŲ Į SĄNARIUS KOMPLIKACIJOS Egidijus Eviltis Lietuvos sveikatos mokslų universiteto Reumatologijos klinika Clinic of Rheumatology, Lithuanian University of Health Sciences SANTRAUKA Reikšminiai žodžiai: kortikosteroidai, intrasąnarinės injekcijos, komplikacijos. Santrauka. Kortikosteroidų injekcijos į sąnarius ir periartikulinius audinius yra efektyvus reumatinių ligų gydymo metodas, kurio šalutinis poveikis pakankamai neištyrinėtas. Darbo tikslas. Ištirti galimas kortikosteroidų injekcijų į sąnarius ir periartikulinius audinius komplikacijas ir jų dažnį. Tyrimo metodai ir pacientai. Tyrime dalyvavo 855 pacientai, kuriems atliktos kortikosteroidų injekcijos į sąnarius arba periartikulinius audinius. Injekcijas atliko straipsnio autorius per penkerius metus ( ) Lietuvos sveikatos mokslų universiteto Reumatologijos klinikoje ir privačiame reumatologijos kabinete. Injekcijoms naudotas triamcinolono acetonidas 0 0 mg (0,5 ml), priklausomai nuo sąnario ar periartikulinių audinių srities dydžio. Injekuojant periartikuliariai, triamcinolono acetonidas buvo maišomas su 5 ml proc. lidokaino hidrochlorido tirpalu. Injekcijos sritis buvo dezinfekuojama 5 proc. jodo ir 70 proc. spirito tirpalu. Kiekvieno paciento apsilankymo metu buvo registruojami jo dokumentiniai duomenys, diagnozė, injekcijos pobūdis ir komplikacijos. Rezultatai. Komplikacijos po intrasąnarinių ir periartikulinių kortikosteroidų injekcijų nustatytos 0,9 proc. pacientų. Dažniausia lokali komplikacija buvo sąnario skausmo laikinas paūmėjimas, nustatytas 7,5 proc. pacientų. Poodinių audinių lokali atrofija ar/ir odos depigmentacija 0,5 proc., periferinio nervo pažeidimas 0, proc., progresuojanti sąnarinio paviršiaus destrukcija pacientui (0, proc.). Reikšmingų sisteminių komplikacijų nebuvo. Poinjekcinis veido paraudimas nustatytas, proc. pacientų, laikinas mėnesinių ciklo sutrikimas ar pomenopauzinis kraujavimas 0,9 proc. (,5 proc. moterų), nualpimas 0, proc. pacientų. Išvados. Komplikacijos po kortikosteroidų injekcijų į sąnarius ir periartikulinius audinius nustatytos 0,9 proc. pacientų. Jos buvo laikinos ir kliniškai nereikšmingos. Kortikosteroidų injekcijos į sąnarius yra saugus gydymo metodas, jei tinkamai naudojamas. ABSTRACT Key words: corticosteroid, intraarticular, periarticular, injection, complication. Objective. This study was conducted to investigate possible complications of intraarticular and periarticular corticosteroid injections. Material and methods. Eighth hundred fifty five patients received injections during the 5 year ( ) study period. Injections were performed by author of this article in Clinic of Rheumatology of Lithuanian University of Health Sciences and private outpatient Rheumatologist s office. The patients were divided into two groups: those, receiving intraarticular and those, receiving periarticular injections. The corticosteroid used was triamcinolone acetonide 0 0 mg (0.5 ml), accordingly to the injected joint size. The corticosteroid was mixed with 5 ml of % lidocaine hydrochloride in case of periarticular injection. The skin at the injection site was cleaned with 5 % iodine and 70 % alcohol. For each treatment episode of the patient, diagnosis, the type of injection and complications were recorded. Results.The overall complication rate was 0.9 %. Most common local complication was postinjection flare of pain- in 7.5 % of patients, subcutaneous atrophy and/or skin depigmentation- in 0.5 %, nerve damage- in 0. %, accelerated joint destruction in patient (0. %). Systemic complications consisted of facial flushing- in. % of patients, menstrual irregularity or postmenstrual bleeding- in 0.9 % (.5 % of injected women) and syncope- in 0. % of patients. Conclusions. Complications after local intraarticular and periarticular corticosteroid injections occured in 0.9 % of injected patients and almost all of them were mild and transient. The corticosteroid therapy for joints and soft tissues is a safe form of treatment if used properly. Egidijus Eviltis Clinic of Rheumatology, Lithuanian University of Health Sciences Eiveniu g., Kaunas egidijus.eviltis@gmail.com 06 Copyright 0 MEDICINOS TEORIJA IR PRAKTIKA. ISSN 9-. All rights reserved. teorija ir praktika 0 - T. 7 (Nr. ), 06 0 p.

2 INTRODUCTION The precise pharmacological effects of corticosteroids when they are injected directly into joints or periarticular soft tissue are not very clear [,, ]. Corticosteroid injections are thought to work by localy suppressing inflammation in inflammatory systemic diseases such as rheumatoid arthritis, psoriatic arthritis, suppressing inflammatory flares in degenerative joint disease, breaking up the inflammatory damage- repair- damage cycle.in adition, localy injected corticosteroids possibly have a direct chondroprotective effect on cartilage metabolism or other effects, not related to their anti-inflammatory activity [, 5, 6, 7, 8, 9, 0, ]. In periarticular pathology pain not always might be due to inflammation (tendinitis) or structural disruption of the tendon fibers (tendinosis), but also to the stimulation of nociceptors by chemicals released from the damaged tendon. Corticosteroids also might affect the release of these chemicals []. Intraarticular and periarticular corticosteroid therapies are widely used already more than fifty years and it has been shown to be effective [, ]. Despite of this, surprisingly, almost every aspect of injection therapy is not standardized. There are few facts and mass of opinions, many of them dogmatic and contradictory [, 5]. There are few definitive studies of its application in joint and soft tissue lesions [, 6] and few studies comparing injection therapy with other treatments [7, 8]. Furthermore, there are very few reports that documents complications directly attributable to the corticosteroid injections. Possibly, this situation forms some negative predisposition of family doctors and patients as well to the injection therapy. Therefore, the study was conducted to investigate possible complications, associated with intraarticular and periarticular corticosteroid injections. This paper reviews the overall complication rate in a large number of individuals undergoing such therapy. PATIENTS AND METHODS This study includes all patients who received intraarticular and periarticular corticosteroid injections performed by author of this article in the Department of Rheumatology of Lithuanian University of Health Sciences and private Rheumatologist s office in five year period ( ). Before injection the skin of the injection site of the patients was cleaned with 5 % iodine and 70 % alcohol swab and allowed to dry for minute. The corticosteroid used was triamcinolone acetonide 0 0 mg (0.5 ml), considering the joint size. The corticosteroid was mixed with 5 ml of % lidocaine hydrochloride in case of periarticular injection. The accuracy of intraarticular needle placement was confirmed by synovial fluid aspiration before injection and the squishing test in case of knee joint injection. These tests have sensitivity of 85 % and a specificity of 00 % [0]. Imaging methods have not been used for localizing needle placement. The patients were divided into two groups: those, receiving intraarticular injections and those, receiving periarticular injections. Each treatment episode, details of the patient, diagnosis, the type of injection and complications were recorded. Patients were reevaluated every twelve weeks during the study period and within 8 hours if any complication developed. RESULTS Eighth hundred fifty five patients (9 women and 6 men) received total of injections. The median age of patients was 6 years (range from 8 to 87 years old). Intraarticular injections received 7 and periarticular 508 of patients. The incidences of complications are summarized in table. Complications after local intraarticular and periarticular corticosteroid injections occured in 0.9 %, the most common complication was postinjection flare of pain, revealed in 7.5 % of patients. Case distribution of complications is presented in table and table. Four cases of subcutaneous atrophy or/and skin depigmentation observed after injecting lateral or medial epicondylitis. Table. The overall complication rate of corticosteroid injection therapy Complication % Postinjection flare of pain Subcutaneous atrophy or/and skin depigmentation Steroid arthropathy / postmenopausal bleeding Syncope 0. Overall complication rate Total number of patients teorija ir praktika 0 - T. 7 (Nr. ) 07

3 All of them improved after eight months. Peripheral nerve damage developed in patients (0. %), accelerated joint destruction- in patient (0. %). This patient was injected intraarticularly twice within the period of weeks, because of rheumatoid shoulder. occurred in patients within 8 hours after the injection and disappeared after next hours. developed 7 women and woman had postmenopausal bleeding. Of the three cases of syncope one happened at the moment of injection and two occurred a few minutes afterwards and resolved without any complications. All of these syncope cases occurred while injecting interphalangeal joints of the hand. Afterwards, the correlations were performed between the incidence rate of complications of the injections and patients gender, age, diagnosis and injected joint site. There were no significant correlations between gender, age, diagnosis, injected joint site and the overall incidence rate or particular complication of intraarticular and periarticular injections. Table. Case distribution and complications of corticosteroid intraarticular injections Diagnosis, injected joint (n=7) Complication Rheumatoid arthritis, knee 6 Post injection flare of pain Osteoarthritis, knee Post injection flare of pain Psoriatic arthritis, knee Reactive arthritis, knee 8 Ankylosing spondylitis, knee Post injection flare of pain Rheumatoid arthritis, ankle Post injection flare of pain Osteoarthritis, ankle Post injection flare of pain Psoriatic arthritis, ankle Post injection flare of pain Reactive arthritis, ankle Post injection flare of pain Rheumatoid arthritis, shoulder 8 Steroid arthropathy Rheumatoid arthritis, elbow Post injection flare of pain Rheumatoid arthritis,wrist 0 Post injection flare of pain Rheumatoid arthritis MCP, interphalangeal Syncope Rheumatoid arthritis, temporomandibular Chronic capsulitis of the shoulder Psoriatic arthritis, acromioclavicular 6 Psoriatic arthritis, sternoclavicular 7 Post injection flare of pain Psoriatic arthritis, MTP Psoriatic arthritis, MCP and Syncope interphalangeal Reactive arthritis, MTP 08 teorija ir praktika 0 - T. 7 (Nr. )

4 Table. Case distribution and complications of corticosteroid periarticular injections Diagnosis (n = 508) Complication Subacromial impingement 0 Post injection flare of pain Bicipital tendinitis 6 Post injection flare of pain Lateral epicondylitis 9 Subcutaneous atrophy and/or skin depigmentation Post injection flare of pain 7 Medial epicondylitis 77 Subcutaneous atrophy and/or skin depigmentation Olecranon bursitis Post injection flare of pain De Quervain s tenosynovitis Post injection flare of pain Trigger digit Post injection flare of pain Carpal tunnel syndrome 6 Post injection flare of pain 6 Trochanteric bursitis 69 Post injection flare of pain Meralgia paraestetica Suprapatellar bursitis 7 Post injection flare of pain Pes anserine bursitis Achilles tendinitis Peroneal tendinitis Post injection flare of pain Calcaneal spur 8 Post injection flare of pain 0 DISCUSSION Therefore, investigating 855 patients after intraarticular and periarticular injections we detected complications in 9 (0,9 %) of patients.almost all of the complications were mild and transient, resolving without aditional treatment or while using nonsteroidal antiinflamatory drugs. Post injection flare of pain observed in 7.5 %. The quoted figures from not numerous another investigations are from.8 to0,0 % [9,, 5]. It is well known to be caused by rapid intracellular ingestion of the microcrystalline steroid ester but must always be distinguished from infectious arthritis [, ]. We did not perform synovial fluid culture in case of post injection flare of pain routinely, in exeption of one case, when infectious arthritis was suspected clinically. Fortunately, postinjection flare of pain did little harm other than to reduce the patient s confidence in this method. This condition was easy manageable using nonsteroidal or simple analgesics. Another complication was subcutaneous atrophy and/ or skin depigmentation. Four women developed this condition after injecting lateral and medial epicondylitis. Medial and lateral epicondyles are near the surface and some of the injected material may leak back along the needle track and cause atrophy of subcutaneous tissue and overlaying skin, but it seems to do little harm. To avoid this complication it is needed not to allow injected material to reflux back - pressure around the needle with cotton wool when withdrawing can help []. Of course, appropriate dosage and volume must be used and corticosteroid should be diluted in case of periarticular injection. For epicondylitis we used 0 mg of triamcinolone acetonide diluted with ml % of lidocaine hydrocloride. Peripheral nerve damage is a very rare complication. It developed in cases (0. %) as severe pain and electric shock because of needling a nerve in humeroscalpular and trochanteric areas and resolved in a few hours to the few days period without transient paresis symptoms. One patient developed accelerated joint destruction after two injections of 0 mg of triamcinolone acetonide into the rheumatoid shoulder. The injections were made in weeks interval period. This patient complained of exacerbated shoulder pain, swelling of the joint was observed hours after second injection. Polarized light microscopy and microbiological culture of the synovial fluid of the joint were negative. Alizarin Red staining for calcium hydroxyapatite crystals was not performed, therefore the possibility of crystal arthropathy in this case cannot be proven or denied. On the conventional roentgenogram of the shoulder new (not observed on previous roentgenogram) bone erosions were found. Possibly this case more may reflect the disease itself (rheumatoid arthritis) rather than complication of the treatment. No evidence supports the joint destruction development by corticosteroid injections []. According to published material, repeat injections into the teorija ir praktika 0 - T. 7 (Nr. ) 09

5 knee joint every months seem to be safe over years [5]. In many cases injected steroid can be chondroprotective rather than destructive [5]. Evidence exists linking prolonged high- dose oral steroid usage with osteonecrosis, but almost all the reports linking injected steroids with accelerated non- specific joint destruction mainly related to joints receiving huge numbers of injections []. after injection experienced patients (, %), 8 of them were women. It came on within hours after the injection and lasted hours. Transient menstrual irregularity had 7 women at age of - years, one 55 years old woman developed post menopausal bleeding and was consulted by gynecologist to exclude other potentially serious causes of postmenopausal bleeding. The mechanism of post injection menstrual irregularity or bleeding episodes is unknown. Syncope was observed in patients (0, %) while injecting small interphalangeal joints. Patients were easily managed without any serious problems. Patients who express apprehension before having an injection should lie down for the procedure. On statistical analysis patients gender, age, diagnosis, injected joint site were not associated with overall complication rate or particular complication. We did not find any reports of another authors, analizing these correlations. We haven t had any one complication of infectious arthritis. This investigation makes no attempt to evaluate the possibility of development of local osteoporosis as a complication of corticosteroid injection therapy. Local osteoporosis is unproven complication of more than months period interval injections according to published materials. The overall complication rate was 0,9 % (9 patients) and consisted mostly of post injection flare of pain (6 patients) that was easily controlled using analgesics or nonsteroidals. Complications of significance were practically uncommon. CONCLUSIONS Complications after local intraarticular and periarticular corticosteroid injections occured in 0,9 % of injected patients and almost all of them were mild and transient. The intraarticular corticosteroid therapy for joints and soft tissues is a safe form of treatment if used properly. REFERENCES. Owen DS. Aspiration and injection of joints and soft tissues.in: KellyWN et al.textbook of Rheumatology, 5 th Edn. New York; WB Saunders 997: Cutolo M. The roles of steroid hormones in arthritis. British Journal of Rheumatology 998; 7: Saunders S, Longworth S. Injection Techniques in Ortopaedic and Sports Medicine, th Edn. Edinburg; Elsevier lim.006: 7.. Clarke A, Allard L, Braybooks B. Rehabilitation in Rheumatology The Team Approach. London; Martin Dunitz 987: Perkins P, Jones AC. Masterclass: Gout. Annals of the Rheumatic Diseases 999; 58: Gossec L, Dougados M. Intra-articular treatments in osteoarthritis: from the symptomatic to the structure modifying. Annals of the Rheumatic Diseases 00; 6: Creamer P. Intra-articular corticosteroid injections in osteoarthritis: do they work, and if so, how? Annals of the Rheumatic Disseases 997; 56: Larsson E, Harris HE, Larsson A. Corticosteroid treatment of experimental arthritis retards cartilage destruction as determined by histology and serum COMP. Rheumatology, 00; (): Raynauld JP. Clinical trials: impact of intra-articular steroid injections on the progression of knee osteoarthritis. Osteoarthritis and Cartilage 999; 7: Hills BA, Ethell MT, Hodgson DR. Release of lubricating synovial surfactant by intra-articular steroid. British Journal of Rheumatology 998; 7(6): Khan KM, Cook JL, Maffulli N, Kannus P. Where is the pain coming from in tendinopathy? It may be biochemical, not structural in origin. British Journal of Sports Medicine 000; (): Kullenberg B, Runesson R, Tuvhag R, et al. Intraarticular corticosteroid injection: pain relief in osteoarthritis of the hip? 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Annals of the Rheumatic Diseases 00; 6: Van der Windt DAWM, Bouter LM.Physiotherapy or corticosteroid injection for shoulder pain?annals of the Rheumatic Diseases 00; 6: Saunders S, Longworth S.Injection Techniques in Ortopedics and Sports Medicine, th Edn. Edinburg; Elsevier lim. 006: 7, Glattes RC, Spindler KP, Blanchard GM et al. A simple, accurate method to confirm placement of intra-articular knee injection. American Journal of Sports Medicine. 00; : Berger RG,Yount WJ.Immediate steroid flare from intra-articular triamcinolone hexacetonide injection: case report and review of the literature. Arthritis and Rheumatism. 990; (8): Pullar T. Routes of drug administration: intra-articular route. Prescribers Journal. 998; 8(): 6.. Cameron G.Steroid arthropathy: myth or reality? Journal of Orthopedic Medicine 995; 7(): Arroll B, Goodyear-Smith F. Corticosteroid injections for osteoarthritis of the knee: meta-analysis. British Medical Journal 00; 8: Raynauld J, Buckland-Wright C, Ward R et al. Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee. Arthritis and Rheumatism 00; 8: Gautas 00 m. birželio 9 d., aprobuotas 00 m. lapkričio 5 d. Submitted June 9, 00, accepted November 5, teorija ir praktika 0 - T. 7 (Nr. )

Aspiration, Intra-articular and Soft Tissue Injections. MR KEWAL SINGH, MS(orth), FRCS(Eng)

Aspiration, Intra-articular and Soft Tissue Injections MR KEWAL SINGH, MS(orth), FRCS(Eng) Indications for Aspiration Haemarthrosis Septic arthritis Symptomatic relief of a large effusion Crystal-induced