Steroid Injections Increased Cartilage Loss in Knee Arthritis
May 16, 2017
Quarterly corticosteroid injections for knee osteoarthritis increased cartilage loss over the course of 2 years without providing any clinical benefit, according to a randomized controlled trial published in the May 16 issue of JAMA.
“Although the cartilage loss was not associated with worsening of symptom outcomes, rates of cartilage loss have been associated with higher rates of arthroplasty, raising the possibility of potential for longer-term adverse consequences on the health of the joint,” write Timothy E. McAlindon, MD, MPH, from Tufts Medical Center in Boston, Massachusetts, and colleagues.
The researchers compared outcomes between two groups of 70 patients, average age 58 years, with symptomatic knee osteoarthritis with synovitis, identified through ultrasonography. From February 2013 to January 2015, patients in one group received 40 mg triamcinolone in intra-articular injections, and those in the other group received placebo saline injections every 12 weeks for 2 years.
Patients underwent magnetic resonance imaging at the beginning and end of the study to provide data on cartilage volume and soft-tissue structures. Among the 119 patients who completed the study, those receiving triamcinolone lost about twice as much cartilage as those in the placebo group. Specifically, the intervention group lost an average 0.21 mm in index compartment cartilage thickness compared with 0.10 mm in the control group (for a mean difference of −0.11 mm: 95% confidence interval, −0.20 to −0.03 mm).
The researchers note that their findings differ from a smaller trial that used radiography to evaluate cartilage loss. “Radiography does not image cartilage directly and is insensitive to change, so it may not have detected the small changes in cartilage loss measured on the [magnetic resonance images] in this study.” they write.
Patients rated pain scores on a Likert scale of 0 (no pain) to 20 (extreme pain). The intervention group reported a 1.2-point reduction in pain, which was 0.64 points less than the 1.9-point reduction pain reported in the control group (95% confidence interval, −1.6 to 0.29). Neither change reached the predefined value for minimal clinically important improvement of 3.94 points.
However, pain scores were only measured at each 3-month appointment, and not in the 4-week period after injection, when benefit tends to be greatest. “Thus, any transient benefit on pain ending within the 3-month period between each injection could have been missed by these methods,” the authors explain.
Neither group showed structural or clinical progression of other osteoarthritis characteristics. “In fact, superficial fibrillation worsened more frequently in the saline group, although this may have been due to chance since secondary and semiquantitative structural measures showed no difference between groups,” the authors write. “The effects that were detected on cartilage loss were statistically significant and consistent across different measurements.”
Adverse events between the two groups was similar, with five occurring in the triamcinolone group and three in the saline group. The patients receiving saline also experienced a small increase in hemoglobin A1C levels.
Despite previous study findings suggesting a potential therapeutic effect of saline injections, the authors note the strong placebo effect known to occur with intra-articular injection and the lack of sham injections in previous trials.
“Also, the rate of cartilage loss in this study was commensurate with that observed in prior natural history studies, so it is likely that the difference in cartilage loss rates between groups was due to an adverse effect of intra-articular corticosteroids on cartilage rather than a benefit from intra-articular saline,” the authors write.
The research was funded by the National Institutes of Health. The authors have disclosed no relevant financial relationships.
Un calzado adaptado a las condiciones biomecánicas y antropométricas reduce notablemente el riesgo de lesiones.
El Grado en Podología de la Universidad Católica San Antonio de Murcia (UCAM) ha celebrado la Jornada de Actualización en Podología Deportiva y Biomecánica en la que se ha destacado la figura del podólogo a la hora de prevenir lesiones y su rol dentro del protocolo de recuperación en los deportistas.
El Dr. Juan José Rodríguez Juan, profesor de Fisioterapia Deportiva en la Universidad Católica, ha señalado que “incorporar la figura del podólogo en el cuerpo médico permite conocer de manera pormenorizada parámetros como la biomecánica del pie, el calzado deportivo y su interacción con las superficies de juego”.
Y es que, entre otras cuestiones, los ponentes han destacado que con un buen asesoramiento de este tipo se podrían mejorar los métodos de recuperación y control de lesiones más frecuentes en el pie del deportista como los esguinces de tobillo, fascitis plantar y la tendinopatía aquílea.
En el caso de un jugador de fútbol, tener un calzado adaptado a sus condiciones biomecánicas y antropométricas reduciría notablemente el riesgo de otras lesiones como la fractura del quinto metatarsiano, relacionada con la pisada del deportista.
Common NSAIDs, including ibuprofen and naproxen, can increase risk of myocardial infarction (MI) within just one week of use, according to a new study published in the BMJ.
Previous studies have suggested that both traditional and selective COX-2 NSAIDs increase the risk of acute MI but the timing of the risk, the effect of dose and treatment duration, and the comparative risks between NSAIDs is still poorly understood.
This systematic review and meta-analysis of available evidence found that taking any dose of NSAIDs for one week, one month, or more than a month was associated with increased risk of MI. Likelihood of MI within one week of treatment initiation was increased by 24 per cent with celecoxib, 48 per cent with ibuprofen, 50 per cent with diclofenac, 53 per cent with naproxen, and 58 per cent with rofecoxib. Greater risk was seen with higher doses of NSAIDs.
“Given that the onset of risk of acute myocardial infarction occurred in the first week and appeared greatest in the first month of treatment with higher doses, prescribers should consider weighing the risks and benefits of NSAIDs before instituting treatment, particularly for higher doses,” the authors concluded.
An international panel of experts has strongly recommended against the use of arthroscopy in nearly all patients with degenerative knee disease.
Most guidelines continue to support the use of arthroscopy in key subgroups. However, a randomised controlled trial published in the BMJ in June 2016 found that, among patients with degenerative medial meniscus tear, outcomes with knee arthroscopy were no better than those seen with exercise therapy.
The findings prompting a panel to be convened to review all current relevant research on the issue. The resulting Rapid Recommendation has concluded that arthroscopy does not, on average, result in lasting improvement in pain or function.
Given that there is evidence of harm and no evidence of important lasting benefit in any subgroup, “the panel believes that the burden of proof rests with those who suggest benefit for any other particular subgroup before arthroscopic surgery is routinely performed in any sub-group of patients”.
The new clinical practice guideline was developed under the BMJ Rapid Recommendation project, which aims to have synopses and decision-support tools available to clinicians within 90 days of identification of potentially practice-changing evidence.
La tendinitis puede producirse por un mal uso, pero también por sobrecarga.
La epicondilitis o ‘codo de tenista’ es una de las lesiones más frecuentes tras esta práctica deportiva, sin embargo, ahora existe una técnica basada en infiltraciones ecodirigidas con la que el especialista puede encontrar el lugar donde se produce la mayor inflamación y así depositar de manera más precisa el tratamiento más adecuado.
“La infiltración ecodirigida, es decir, guiada mediante ecógrafo, permite encontrar el sitio preciso de inserción del tendón, donde la inflamación es mayor, para depositar ahí la sustancia empleada en la infiltración, que puede ser un tratamiento antiinflamatorio de depósito o un tratamiento biológico, con plasma rico en factores de crecimiento”, ha explicado el traumatólogo del Hospital Vithas Nuestra Señora de América, Agustín Garabito.
El codo de tenista se produce por una inflamación de la inserción en el epicóndilo de la musculatura extensora y supinadora del antebrazo y, según ha añadido el experto, “no es una lesión exclusiva de los tenistas, pero sí es cierto que los deportes de raqueta pueden producir esta tendinitis por la acción repetida en la musculatura extensora del codo, que se inserta en el epicóndilo y se sobrecarga”.
El dolor de larga duración en la cara lateral del codo es el principal síntoma de esta patología, que se agudiza con determinados movimientos de la mano en los que interviene la musculatura extensora e incluso se puede producir en reposo.
La prevención de este tipo de lesiones “pasa por un buen entrenamiento, con un calentamiento previo, estiramientos posteriores y postura correcta, ya que la tendinitis puede producirse por un mal uso, pero también por sobrecarga”, ha concluido Garabito.
Age alone should not be a contraindication to lumbar microdiskectomy, as long as the individual is fit for surgery. That is the conclusion of the authors of a new study which compared outcomes among 5,195 patients younger than 65 years of age and 381 patients 65 years of age or older, from the Norwegian Registry for Spine Surgery (NORspine).
The study found that elderly patients actually experienced more improvement in low back pain following the surgery. Compared with younger patients however, older patients experienced more perioperative complications (4.2 per cent versus 2.3 per cent) and more complications occurring within three months of hospital discharge (12.4 per cent versus 5.4 per cent). The most common complications among elderly paricipants were urinary tract infections, micturition problems, and unintentional durotomies. Younger patients had shorter hospital stays than patients aged 65 years of age or older (2.7 versus 1.8 days).
Writing in JAMA Surgery , the authors said: “Although the patients 65 years of age or older had more minor complications and longer hospital stays, they experienced improvements in their conditions after a lumbar microdiskectomy that were similar to those of the patients younger than 65 years of age.”
New research presented at the 2017 Pediatric Academic Societies Meeting in San Francisco suggests infants prescribed antacids in the first year of life suffer more bone fractures later in childhood.
While proton pump inhibitors (PPIs) and H2-receptor antagonists have been linked with increased bone fractures in adults, there has been a lack of research into whether they might have the same effect in children. Analysis of records of 874,447 healthy children born between 2001 to 2013 who received care found approximately 10 per cent were prescribed antacids in the first year of life.
Children who used PPIs had a 22 per cent increased likelihood of fracture, while children who used both PPIs and H2-blockers had a 31 per cent increased likelihood of fracture. Use of H2-blockers was not associated with an immediate increase in fractures, but there was an increased likelihood of fracture with time. In addition, the number of bone fractures increased with treatment duration. The younger the child starting antacids, the higher the risk. Children who started antacids after age 2 did not have increased fractures compared to children who were not prescribed antacids in the first five years of life.