JAMA Article just published - knee steroid injections dont work

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Timeoutofmind

Timeoutofmind

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Its attached

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Seems weird they only measured the pain scores every three months! Wouldnt expect that much improvement three months out v three weeks out...
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Timeoutofmind said:
Its attached

Discuss

Seems weird they only measured the pain scores every three months! Wouldnt expect that much improvement three months out v three weeks out...
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Was the OA mild, moderate or severe for these patients?
 
DrCommonSense said:
Was the OA mild, moderate or severe for these patients?
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445 assessed and only 119 completed

Who only injects 1 cc? Who doesn't inject local? I am certain if the result was the other way Jama wouldn't publish it.
 
Timeoutofmind said:
Its attached

Discuss

Seems weird they only measured the pain scores every three months! Wouldnt expect that much improvement three months out v three weeks out...
Click to expand...

Interesting how this study directly CONTRADICTS this study from 12 years earlier:

Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled tr... - PubMed - NCBI

Seems like these studies can say anything.

Incidentally, there was a new Ortho study that said shoulder labrum tear surgery doesn't work as well.
 
geauxg8rs said:
445 assessed and only 119 completed

Who only injects 1 cc? Who doesn't inject local? I am certain if the result was the other way Jama wouldn't publish it.
Click to expand...

Yeah but I also assume mild OA has far better benefit than severe OA.

To not compare is insane as well.

Same for visco.
 
"The active medication was 1 mL of triamcinolone (purchased from Bristol-Myers Squibb), 40 mg/mL, for injection. The Key Points Question What are the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on progression of cartilage loss and knee pain in patients with osteoarthritis? Findings In a randomized clinical trial of 140 patients with symptomatic knee osteoarthritis, the use of intra-articular triamcinolone compared with intra-articular saline resulted in greater cartilage volume loss. There was no significant difference on knee pain severity between treatment groups. Meaning Among patients with symptomatic knee osteoarthritis, intra-articular triamcinolone, compared with intra-articular saline, increased cartilage volume loss and had no effect on knee pain over 2 years. Research Original Investigation Comparison of Intra-articular Triamcinolone vs Saline for Knee Osteoarthritis 1968 JAMA May 16, 2017 Volume 317, Number 19 (Reprinted) jama.com Copyright 2017 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/pdfaccess.ashx?url=/data/journals/jama/936236/ on 05/16/2017 Copyright 2017 American Medical Association. All rights reserved. comparator was 1 mL of 0.9% sodium chloride for injection (Hosperia Inc). Neither was mixed with local anesthetic. Both were administered every 12 weeks for 2 years. Synovial fluid (≤10 mL) was aspirated prior to the injection."


- why 1ml? It's not enough volume to permeate the joint space and provide adequate pain relief. Since these are not done under image-guidance, I have doubts they were actually injected into the joint.
- why no anesthestics? Who does joint injection anesthestics?
- why in the world you inject Q3months for 8 times for 2 years? I've never heard of the practice of intra-articular joint injection of any joint, q3month for 8x? I would inject up to three times of corticosteroid at maximum. If no persistent relief or shortened duration, you would move onto other techniques, HA, Genicular, or PRP, etc.

Is this protocol common in Rheumatology field? If so, these guys need to stay away injection of anything into joint space, and just do aspiration only. Obviously they don't know how to do an injection to provide pain relief and minimum side effect.
 
Experience has taught me that if you are not using ultrasound, you aerial unlikely intra-articular.


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IN2B8R said:
Make that "you are unlikely intra-articular"


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I think that is definitely an overstatement, I believe I have seen studies that in well trained hands injection accuracy without U/S or fluro is around 80%.........
 
lonelobo said:
I think that is definitely an overstatement, I believe I have seen studies that in well trained hands injection accuracy without U/S or fluro is around 80%.........
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about my experience, too. about 20% of missed rate when I started doing under fluoro and verify with contrast spread pattern.
 
drpainfree said:
about my experience, too. about 20% of missed rate when I started doing under fluoro and verify with contrast spread pattern.
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I do US
When u guys r doing fluoro what is ur technique? Suprapatellar still? Advance the needle in AP view from lateral to medial? Or do u actually enter the articulating space itself? Have any pics?
 
inferomedial approach and if not substantially overweight, you can guarantee entry into the joint 99% of the time
 
Timeoutofmind said:
I do US
When u guys r doing fluoro what is ur technique? Suprapatellar still? Advance the needle in AP view from lateral to medial? Or do u actually enter the articulating space itself? Have any pics?
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What are the advantages (apart from less radiation) of US over fluoro and vice versa?

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Timeoutofmind said:
I do US
When u guys r doing fluoro what is ur technique? Suprapatellar still? Advance the needle in AP view from lateral to medial? Or do u actually enter the articulating space itself? Have any pics?
Click to expand...

Do lateral patellar approach with c arm lateral. Will try to post a pic later , Good results
 
DrCommonSense said:
Interesting how this study directly CONTRADICTS this study from 12 years earlier:

Safety and efficacy of long-term intraarticular steroid injections in osteoarthritis of the knee: a randomized, double-blind, placebo-controlled tr... - PubMed - NCBI

Seems like these studies can say anything.

Incidentally, there was a new Ortho study that said shoulder labrum tear surgery doesn't work as well.
Click to expand...

I believe the current study (Tufts -McAlindon) is the first to look directly at the cartilage (via MRI). The prior study (HND -Pelletier) used x-ray only, which obviously can not visualize the cartilage and uses joint space width as an indirect measure of cartilage thickness. By x-ray they showed no improvement or worsening of JSW. This could come down to resolution of the imaging modalities and MRI is a welcome addition to the story.
That said, I do question some of the Tufts groups interpretations...
I believe it is possible that the thinning of cartilage they observe may be a byproduct of reduced hydration of the cartilage and not technically a result of degradation. Triamcinolone has been shown to deposit in human cartilage matrix over time (measured ex vivo using MALDI), and coupled with the quarterly chronic administration protocol used, they may be observing the byproduct of an altered electrostatic environment in the cartilage matrix leading to a reduced ability to retain water molecules and ultimately a reduced volume cartilage phenotype.
If this interpretation is correct, it is still not a good thing for corticosteroid use, at least not for sustained chronic administration.
I'd predict they should be able to address this hypothesis by looking for cartilage degradation markers in the predose synovial fluid samples they obtained every three months, which would be elevated if this is truly inducing a catabolic effect.
It's also unfortunate that they didn't monitor pain and function more frequently than every three months. However, they acknowledge this as a limitation of the study and wasn't part of the question they were trying to address.
 
Timeoutofmind said:
Yeah would appreciate the pics please!
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you have the knee flexed or in neutral position? If you have the knee flexed to open the joint space, how do you position your c-arm? I don't think I can get the c-arm on lateral view to get a flexed knee in center view, unless I swing the c-arm with II on my side.
 
Pain was not measured in the 4 week post injection period, during which benefits are known to occur. Thus any transient benefit on pain ending during the three month period between each injection might have been missed by this method.

Participants were allowed to continue their usual medications during the trial, which might have attenuated any between-group differences in symptom outcomes (gee, ya think?)

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Can't believe they allowed this to be published in JAMA . Pathetic
 
painfree23 said:
Can't believe they allowed this to be published in JAMA . Pathetic
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JAMA will publish anything that makes procedural medicine look bad while simultaneously publish anything big pharma likes.

JAMA has been publishing tons of articles in the past about how PT is just as good as back surgery for at least 10 years now.

I remember when I was in anesthesia residency whereby I thought there wouldn't be any back surgeries by the time I got out because of these MANY articles that confirmed back surgery "doesn't work".
 
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Shoot the doctor who injects corticosteroids into a knee. These agents are known to be chondrotoxic regardless of whether they relieve pain.
 
GH253 said:
Shoot the doctor who injects corticosteroids into a knee. These agents are known to be chondrotoxic regardless of whether they relieve pain.
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That's a bit extreme I'd say. The chondrotoxity was assessed in irrelevant in vitro chondrocyte monolayer cultures. So many questions about looking at it that way I can't begin. In vivo pre clinical and clinical studies are less clear. Some steroids showed ill effects, but key is that triamcinolone (current std of care) was not in that category. Take a close look at the article from Stanford last year. I'm not an advocate for corticosteroids or the interpretation of this study, but they do have a clear benefit. Albeit only in pain and function. The orthopedic surgeons will be pleased. We still need better.
 
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Says exactly what I'm suggesting, genius. The literature does not support the claim that corticosteroids are chondrotoxic

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DrCommonSense said:
JAMA will publish anything that makes procedural medicine look bad while simultaneously publish anything big pharma likes.

JAMA has been publishing tons of articles in the past about how PT is just as good as back surgery for at least 10 years now.

I remember when I was in anesthesia residency whereby I thought there wouldn't be any back surgeries by the time I got out because of these MANY articles that confirmed back surgery "doesn't work".
Click to expand...

FAlthough you should keep current with the standard of care and the next wave, as a practitioner I'd say follow what works for your patients. Not just what you think is working, but actually ask them. In the end what were all doing is still experimental medicine regardless of how long they have been delivering iA steroids/HA.
 
oaresearch said:
FAlthough you should keep current with the standard of care and the next wave, as a practitioner I'd say follow what works for your patients. Not just what you think is working, but actually ask them. In the end what were all doing is still experimental medicine regardless of how long they have been delivering iA steroids/HA.
Click to expand...

Almost everything in medicine is "experimental" outside of antibiotics and vaccinations and a few rare cancer treatments that never touch the big boys.
 
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