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Rheumatology Advance Access published online on September 27, 2008
Rheumatology, doi:10.1093/rheumatology/ken355
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© The Author 2008. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

Accuracy of intra-articular injections in peripheral joints performed blindly in patients with rheumatoid arthritis

R. V. Lopes1, R. N. V. Furtado1, L. Parmigiani1, A. Rosenfeld2, A. R. C. Fernandes2 and J. Natour1

1Division of Rheumatology and 2Department of Radiology, Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil.

Correspondence to: J. Natour, Disciplina de Reumatologia, Universidade Federal de São Paulo, Rua Botucatu, 740, 04023-900 - São Paulo, Brazil. E-mail: jnatour{at}unifesp.br


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Discussion
 Conclusions
 References
 
Objectives. To assess the accuracy of blind IA injections (IAIs) in patients with RA and determine their effectiveness.

Methods. A controlled prospective study including 96 RA patients undergoing blind IAIs in peripheral joints was carried out. Clinical evaluation was performed at baseline (T0), 1 (T1) and 4 (T4) weeks after IAI using the following instruments: visual analogue scale (VAS) for pain at rest and movement, VAS for oedema (range 0–10 cm) and morning stiffness. Following IAI, radiographic exam was performed in all joints for further analysis by two ‘blinded’ radiologists. The {kappa}-statistic, chi-square and analysis of variance tests were performed to determine potential differences between time-points of evaluation. Significance level was set as P < 0.05.

Results. A total of 232 injections were performed. Accuracy observed for the shoulder, elbow, wrist, MCP joints, knee and ankle were 82, 100, 97, 97, 100 and 77%, respectively. A statistically significant improvement was observed for all variables at both T1 and T4 when compared with T0.

Conclusions. Blind IAI proved safe and accurate when performed by a trained professional. Significant improvement was seen in the VAS for pain at rest and during movement, VAS for oedema and morning stiffness.

KEY WORDS: Rheumatoid arthritis, Intra-articular injection, Arthritis, Corticosteroid, Injections, Accuracy


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Discussion
 Conclusions
 References
 
IA injections (IAIs) have been used for the treatment of synovitis since 1951 [1]. It has since then become a common procedure in the rheumatologist practice and is described in the treatment guidelines for RA, OA and other musculoskeletal diseases [2]. Despite its extensive use, only a few controlled prospective studies have assessed IAI accuracy and effectiveness [3–5]. Most injections are performed blindly [3–5] and most studies evaluating blind IAI have found low accuracy for the procedure [3–5]. Moreover, how the different joints are accessed by, and respond to, IAI is another issue not yet established.

The primary objective of the present study was to determine the accuracy of blind IAI performed by a rheumatologist in patients with RA. The secondary objective was to investigate the effectiveness of IAI.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Discussion
 Conclusions
 References
 
The present controlled prospective study with a ‘blinded’ examiner was carried out to determine the accuracy of blind IAI performed by a trained rheumatologist using triamcinolone hexacetonide (TH). Written informed consent was obtained from all subjects and the ethics committee of the Universidade Federal de São Paulo/São Paulo Hospital approved the study.

Patients
A total of 232 joints in 96 patients with RA were included in the study. Patients were seen at the Rheumatology Outpatient Clinics of the Universidade Federal de São Paulo (UNIFESP), Sao Paulo, Brazil, and had persistent synovitis with IAI indication in the shoulder, elbow, wrist, MCP joints, knee and/or ankle. The following inclusion criteria were employed: RA according to the criteria of the ACR [6]; age between 18 and 65 yrs; functional Class II–III according to the ACR [7]; synovitis in the joint to be studied at least 1 month prior to the injection; stable use of DMARDs in the previous 3 months; and visual analogue scale for pain in the joint to be injected (VAS 0–10 cm) score between 4 and 9 cm. The exclusion criteria were: uncontrolled hypertension or diabetes mellitus; pregnancy; severe coagulation disorder; having undergone any prior surgical procedure on the joint to be studied; IAI in any other joint in the previous month; IAI in the joint to be studied in the previous 3 months; suspicion of active systemic or IA infection; and allergy to the contrast agent.

Intervention
The injection technique was specific to each joint as previously reported [2, 8, 9]. Radiographic images were taken before and after IAI of a non-ionic contrast agent. The following TH doses (20 mg/ml) were used for the IAI procedures: 80 mg for the shoulder and knee; 60 mg for the elbow and ankle; 30 mg for the wrist; and 10 mg for the MCP joints. Synovial effusions were emptied before injection. When a patient had more than one joint to be injected, a minimum of 50 mg and maximum dose of 160 mg of TH were stipulated. Patients were instructed to rest the joint, remaining in bed or seated for 48 h following the injection and were instructed not to change the DMARDs that were in use.

Evaluation
Clinical assessments were carried out at baseline (T0), 1 (T1) and 4 (T4) weeks following injection by a ‘blinded’ rheumatologist. At all evaluation times, the following instruments were applied: VAS for pain during movement and at rest; VAS for joint oedema according to the physician; morning stiffness (time in minutes) and local side-effects. The assessment of the accuracy of the blind IAI was performed at the end of the study by two ‘blinded’ radiologists who interpreted the images and classified them according to the IA or extra-articular (EA) localization of the contrast agent.

Statistical analysis
The {kappa}-statistic was used to study the agreement between the two radiologists regarding the classification of the procedures as IA or EA. The chi-squared test was performed to determine statistical differences between joints regarding IAI accuracy. ANOVA was performed to compare repeated measures over time. Significance level was set as P < 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Discussion
 Conclusions
 References
 
Characteristics of the population are shown in Table 1. About 61.8% of the patients were women; 69% had positive RF; 41.5% were classified as functional Class II and 58.5% were classified as functional Class III. Mean age was 47 yrs (±10.9); disease duration was 9.5 yrs (±6.7); and arthritis duration was 2.39 yrs (±2.47).


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  		TABLE 1. Baseline characteristics of RA patients undergoing blind IAIs according to radiographic classification as IA or EA

 
Seventy-two patients underwent more than one injection (on average, 2.4 injections per patient). According to radiological evaluation, patients were classified as IA or EA for data analysis. The results demonstrated strong agreement between the radiologists ({kappa} = 0.84). When there was disagreement regarding the image, the injection was considered EA.

Among the 232 joints studied, 34 were shoulders, 31 were elbows, 37 were wrists, 39 were MCP joints, 37 were knees and 54 were ankles. Table 2 displays the accuracy of IAIs according to the articular sites. Among the 212 injections considered IA, SF reflux occurred in 123 joints (54%). Among the 20 injections considered EA, reflux occurred in eight (40%) (Table 1). Among the ankle injections, 12 injections were considered EA for the talocrural joint and four were considered IA for the talocalcaneal joint.


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  		TABLE 2. Accuracy of blind IAI according to joint and local variables

 
As demonstrated in Table 2, in the IA group, there was a statistically significant improvement over time for the VAS scores for pain at rest and during movement, VAS for oedema and morning stiffness when comparing T1 with T0 (P < 0.001, P < 0.001 and P < 0.001, respectively) and comparing T4 with T0 (P < 0.001, P < 0.001 and P < 0.001, respectively). Hypotrophy and/or hypochromia of the skin occurred in 4.7% of the patients in the IA group (10 out of 212) and 10% of the patients in the EA group (2 out of 12).


   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
Conclusions
 References
 
The present study evaluated the accuracy and effectiveness of IAI in one or more peripheral joints in RA patients receiving stable doses of DMARDs. Good accuracy for blind IAI in the peripheral joints was demonstrated in this scenario. In clinical practice, most IAI are performed blindly in peripheral joints [3–5]. How the different joints are accessed by and respond to IAI is still not determined. Most of the studies evaluating IAI generally assess a single joint and use a small sample [4, 5].

Most previous studies on blind IAI have demonstrated low accuracy for the procedure [3–5]. Only one study found blind IAI to have very good accuracy in agreement with our results; however, unlike the present study, only the knee was assessed [10]. The knee is a medium-size joint of easy access to blind injection and requires less training when approached from a superior–lateral direction to the patella and that may help explaining the high accuracy observed in both studies.

The EA group in our sample was rather small, thereby hampering the statistical analysis. No comparison of the clinical variables was performed between the IA and EA groups and we cannot determine whether there was a difference in effectiveness between groups, as observed in a previous study [6].

The accuracy of blind IAI in the shoulder was among the lowest in the present study, corroborating previous reports [3, 5]. Nonetheless, the accuracy of blind IAI for the shoulder in the present study was greater than that described in the literature [4, 5]. This is likely due to the fact that the patients in the present study had the same disease and interventions were performed by a physician who was very well trained (10 yrs) in blind IAI.

Blind IAI in the ankle achieved the least accuracy in the present study. Another study assessing blind IAI in ankles found even lower accuracy [3]. The fact that 4 of the 12 injections considered EA for the talocrural joint were considered IA for the talocalcaneal joint was surprising. This probably occurred due to a possible communication between the two joints stemming from the extensive synovial proliferation that occurs in synovial joints of the mid-foot and hind foot in patients with RA [11].

Hypotrophy and/or hypochromia of the skin occurred in 4.7% of the patients in the IA group and 10% of the patients in the EA group. The percentage of hypotrophy in the EA group was higher than that reported in most of the related literature, except for two studies, which found 11.8 and 9.56% of hypotrophy [12, 13].

The TH doses used were higher than those described in other studies [2, 4, 13, 14]. In our clinic's experience, we have found that larger joints respond to larger doses, as also described by Furtado et al. [13]. Moreover, we have not observed any significant increase in side-effects.

The present study demonstrates that a trained rheumatologist can successfully perform blind IAI in most peripheral joints of patients with RA. For such, however, optimization in the training of this procedure is a necessary part of the education of rheumatologists.


   Conclusions
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusions
References
 
Blind IAIs in peripheral joints achieve good accuracy when performed by a trained professional. The accuracy of blind IAI in peripheral joints varied significantly depending on the joint studied. IAI in the elbow, wrist, MCP joints and knee achieved significantly better accuracy than in the shoulder and ankle. IAIs are associated with a satisfactory clinical response in RA.

Disclosure statement: The authors have declared no conflicts of interest.

Formula


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Discussion
 Conclusions
 References
 

  1. Hollander JL, Brown EM Jr, Jessar RA, Browan CY. Hydrocortisone and cortisone injected into arthritic joints: comparative effects of the use of hydrocortisone as a local antiarthritic agent. J Am Med Assoc (1951) 147:1629–35.[Abstract/Free Full Text]
  2. Bird HA. Intra-articular and intralesional therapy. In: In: Rheumatology—Hochberg MK, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH, eds. (2004) 3rd. London, UK: Elsevier Science. 393–8.
  3. Jones A, Regan M, Ledingham J, Patrtrick M, Manhire A, Doherty M. Importance of placement of intra-articular steroid injections. Br Med J (1993) 307:1329–30.[Free Full Text]
  4. Eustace JA, Brophy DP, Gibney RP, Bresnihan B, FitzGerald O. Comparison of the accuracy of steroid placement with clinical outcome in patients with shoulder symptoms. Ann Rheum Dis (1997) 56:59–63.[Abstract/Free Full Text]
  5. Sethi MP, Kingston S, Elattrache N. Accuracy of anterior intra-articular injection of the glenohumeral joint. Arthoscopy (2005) 21:77–80.
  6. Arnett FC, Edworthy SM, Block DA, et al. The American Rheumatism Association 1987 revised criteria for the classification of rheumatoid arthritis. Arthritis Rheum (1988) 31:315–24.[Web of Science][Medline]
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  8. Anderson BC. Guide to arthrocentesis and soft tissue injection (2005) Philadelphia: Elsevier Saunders.
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  10. Jackson DW, Evans NA, Thomas BM. Accuracy of needle placement into the intraarticular space of the knee. J Bone Joint Surg Am (2002) 84A:1522–7.[Abstract/Free Full Text]
  11. Theodorou DJ, Theodorou AJ, Resnick D. Rheumatoid arthritis: imaging of rheumatoid arthritis. In. In: Rheumatology—Hochberg MK, Silman AJ, Smolen JS, Weinblatt ME, Weisman MH, eds. (2004) 3rd. London: Elsevier Science. 801–10.
  12. Jalava S, Saario R. Treatment of finger joints with local steroids. A double-blind study. Scand J Rheumatology (1983) 12:12–4.[CrossRef]
  13. Furtado RN, Oliveira LM, Natour J. Polyarticular corticosteroid injection versus systemic administration in treatment of rheumatoid arthritis patients: a randomized controlled study. J Rheumatol (2005) 32:1691–8.[Abstract/Free Full Text]
  14. Eberhard BA, Sison MC, Gottlieb BS, Ilowite NT. Comparison of the intraarticular effectiveness of triancinolone hexacetonide and triancinolone acetonide in treatment of juvenile rheumatoid arthritis. J Rheumatol (2004) 31:2507–12.[Abstract/Free Full Text]
Submitted 5 February 2008; revised version accepted 30 July 2008.
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