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Intra-articular steroid injection frequency

Discussion in 'General Issues and Discussion Forum' started by Peter, Mar 15, 2011.

  1. Peter

    Peter Well-Known Member


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    Hi all,

    I limit extra-articular steroid injections to 2, but wonder what the concensus is for articular procedures?

    Texts very from up to 2 per annum, to whatever is required as long as its justified. Any thoughts?
     
  2. Lab Guy

    Lab Guy Well-Known Member

    my favorite injection is using dex phosphate with marcaine with epi, 1cc of each. It helps break up the pain cycle and reduce inflammation. I have found it to be quite long lasting and only use stronger steroids that are crystal based such as Kenalog if the dex phosphate has no effect which is rare.

    Even using 4mg of Dex phosphate I rarely need to give more than 3 injections as I am also treating the underlying problem why the inflammation is present in the first place.

    Steven
     
  3. Peter

    Peter Well-Known Member

    I'm restricted to a PGD for Triamcinolone (Kenalog), and methylprednisolone acetate (depo-medrone)
     
  4. and maybe these...
     

    Attached Files:

  5. Peter

    Peter Well-Known Member

    Thanks Mike, you are a star for posting stuff! I coincidentally received a research paper written by U Fredberg just last night, weird.

    oh, and thanks for not mentioning the cricket!
     
  6. kayron

    kayron Member

    Have you heard of Ostenil?? It which is Hyaluronic Acid, accoriding to the liteture (and the sales rep) it requires three weekly injections. This is only really for OA.
     
  7. Peter

    Peter Well-Known Member

    yes I have heard of it. But I don't use it
     
  8. drsarbes

    drsarbes Well-Known Member

    Hi:

    Well it is a two edged sword. INTRA articular cortisone for an arthritic weight bearing joint will allow the degenerative process to proceed more quickly.

    If I have a patient with synovitis and good ROM and no crepitation, I will not hesitate to give them an intra articular injection (I also do two max per year). This is usually an ankle joint.

    If they have obvious advanced arthritis with joint narrowing, asymmetry, pain, decreased ROM, crepitus, I "may" give them one injection - period. If these patients do not respond to NSAIs, etc... then they are a surgical candidate.

    Steve
     
  9. Mart

    Mart Well-Known Member

    Hi Steve

    Hope you are well.

    Just to put a cat amongst the pigeons;

    You say that you would use corticosteroid injection once but then proceed to surgery because corticosteroids will accelerate degenerative joint disease

    Has that been proven? Those with inflammatory osteo-arthritis may have accelerated degeneration in presence of inflammatory mediators because of aggressive bone and cartilage erosion. If synovial process is down regulated by corticosteroid perhaps the natural progression will be slowed. I am unaware that the cartilaginous surface within joint is likely to regenerate irrespective of presence of steroid unlike anticipated potential for tendon or ligament. Am I wrong here?

    Also the gold standard for surgical management of painful hallux limitus and some other foot joints remains arthrodesis; even if it were true that corticosteroid injection might accellerate degenerative joint disease since eventually painless ankylosis or frank fusion may occur why would acceleration to that point nonsurgically be important?

    Cheers


    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  10. drsarbes

    drsarbes Well-Known Member

    Hey Martin:
    All is well, thank you for asking.
    And you?

    "Has that been proven?" - of course. I did limit my remarks to weight bearing joints.

    When the natural limitation of motion due to pain is bypassed certainly, just from a common sense approach, this will increase the mechanical destruction of the cartilagenous surface with ROM. I would place the mechanical destruction of a joint as the primary cause of DJD erosion. Repeated intra articular injections for weight bearing joints has been contraindicated for many years.

    "Also the gold standard for surgical management of painful hallux limitus and some other foot joints remains arthrodesis"..........well, I have never felt a Fusion of a 1st MTPJ should be considered a "gold standard" - quite the contrary. Once the joint is eliminated what is left? A joint replacement is a much better, more functional, quicker healing option.

    BTW: I think of you each time I remove a bursae from Kager's. Need any more photos?

    Steve
     
  11. Mart

    Mart Well-Known Member


    Thanks for reply Steve; I am still keeping the wolf from the doors so no complaints.

    No disagreement regarding for first comment regarding possible increased destructive joint stress with elimination of pain. However you did not address the issue of destructive damage from inflammatory mediators; perhaps this is not answerable with current evidence. Also I would think that frequency of steroid might be issue for degenerative effects on plantar plates or other joint stabilising ligaments within diffusible range of joint capsule.

    Are you using diagnostic ultrasound exam for your joint pain exams?

    I often do; what I notice, as a generalisation, with 1st metatarso-phalangeal joint and TMT joint degenerative joint disease is frequently normal or minimally reduced joint space on radiographic exam but significant signs of osteophytosis and synovial hypertrophy with signal with power Doppler imaging noted with US. Very often the synovium can be visualised with passive range of motion to impinging into synovial tissue. This leads to speculation that pain is primarily generated within synovium and therefore that if synovial proliferation can be down regulated then impingement may be reduced. I don’t believe this has been studied but fits within the idea that inflammation, at least in early stages, may be primary factor in joint destruction and pain generation. This idea vs. primary mechanical stress remains controversial in the medical literature.

    I agree that partial or total replacement may have merit; however within my reading of literature, fusion seems to remains gold standard because small joint replacements have very mixed outcomes. Also do you replace TMT joints? I doubt it, in which case my initial argument remains plausible . . . . I think.

    If anyone is interested post a comment and I will post some dynamic exams showing the synovial impingements in 1st metatarso-phalangeal joints.

    How do these thoughts fit with you?

    Cheers

    Martin


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
    Last edited: Mar 25, 2011
  12. drsarbes

    drsarbes Well-Known Member

    Hi Martin:
    There have been numerous studies done on this; the effects of cortisone both on normal cartilage and in arthritic joints. Either way; you know what they say...too much of a good thing.

    Partial or total may have merit!!!! You're killing me Martin!!!! I have been putting Total joint implants in since 1983 (and hemi's prior to that) with....if I may say so..... excellent results. I have not fused a 1st MTPJ in decades, nor would I.

    Apparently there is more room for error in a fusion so if you have two novice surgeons doing implants and fusions, the fusions will most likely have better results ( I'm guessing here!)

    As far as your dynamic US, I think we are talking about joints at different points in the degenerative process. Here's an example.
     

    Attached Files:

  13. Mart

    Mart Well-Known Member

    Hi Steve

    I was not trying to torment you (that much) not will try not to push my point to distraction.

    I can understand that if you can get such good results replacements make good sense. Lets ignore metatarso-phalangeal joints.

    What about midfoot joints? Do you think that it is plausable to achieve stable painless TMJs by allowing natutral (possibly accellerated) degenerative joint disease to proceed to fusion whilst using serial corticosteroid injections to manage pain? I am not aware of any research to answer this; if anyone has any please post.

    BTW; why did you post a photo of a bratworst stuffed with prawn cocktail? :empathy:

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  14. drsarbes

    drsarbes Well-Known Member

    Hi MArtin:
    HAHAHAHA - that's stuffed with Cheddar!
    You and I need to get together sometime for a drink and talk feet!!!!!!

    You asked a loaded question, as I'm sure you realize the difference in anatomy and function between a MTPJ and a mid tarsal joint. In any event, I do not treat them that differently in day to day practice. I rarely make a patient suffer for months or even years with failed steroid injections and or other conservative treatment when I know I can surgically go in and make them feel better.

    Gotta run

    Cheers!!!!!!

    Steve
     
  15. Mart

    Mart Well-Known Member

    I should have guessed. Wisconsin = Cheddar. I would definitely enjoy heading south for a tour of Dells and meet up sometime.


    I guess what I am really getting to is this. I live in a city where there is no one doing metatarso-phalangeal joint replacements and fusion is the norm.

    Given current limitation in local surgical options are my patients best interests to exhaust pain control with corticosteroid injection until either they don’t work or to get fusion earlier?

    I have been doing MTP and TMT joint guided corticosteroid injections for just over one year, some repeating at approximately three months intervals; to best of my knowledge all have provided adequate pain control, most excellent when combined with foot orthoses.

    Is this approach likely to limit surgical options or outcome by adversely effecting articular or peri-articular structure?

    I am not aware that this is likely provided the drug is delivered with accuracy hence avoiding significant tendon exposure. Perhaps plantar plate is more of an issue but again not my experience and no studies to answer this properly.

    Anyone else thinking along the same lines?

    Has anyone seen a trend over time for nonsurgical fusion to occur with pain control from corticosteroid injection or is surgery inevitable regardless?

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
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