RESEARCH - Ankle intra-articular steroid effective in juvenile arthritis

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Ankle intra-articular steroid effective in juvenile arthritis

Rheumawire

April 4, 2006

Janis

Toronto, ON - Image-guided steroid injection produces durable clinical

improvement in inflamed ankles of children with juvenile idiopathic

arthritis and may help prevent irreversible deformity, Dr Baskin

(Children's Hospital of Philadelphia, PA) reported at the 2006 Society of

Interventional Radiology annual scientific meeting [1].

" The take-home message is to get into the joint and treat acute disease

before there are chronic sequelae. Treat every time they have an acute flare

until the disease burns out in adulthood, as it does for many. There is a

good chance patients can be spared permanent loss of mobility, gait

disturbances, pain, and disfigurement, " Baskin told rheumawire.

Fluoroscopy guides steroid injection into difficult joint

Baskin and colleagues at the Children's Hospital of Philadelphia conducted a

pilot study of fluoroscopically guided intra-articular ankle steroid

injections in 38 children with symptoms of ankle arthritis that suggested

involvement of the subtalar joint, such as decreased inversion or eversion.

" Rheumatologists are used to injecting into more accessible joints and

report that such steroid treatments are frequently successful, " Baskin said.

" Complex joints such as the subtalar or temporomandibular are hard to

access, which is how we interventional radiologists got involved. The

subtalar joint is triple-faceted and extremely complex and difficult to

treat with traditional methods. We found a 91% clinical improvement that

lasted a mean of 1.3 years after corticosteroid was injected directly into

the inflamed joint using fluoroscopy for precise needle placement. "

The patients had a mean age of 4.4 years (range 1.2-13.6 years) and median

elapsed time from diagnosis to intra-articular steroid treatment of 0.1 year

(range 0.0-7.6 years).

Patients were sedated for the injections, which were done as outpatient

procedures. The researchers injected 1 mL or less of triamcinolone

hexacetonide or acetonide into the mid subtalar joint using a lateral

oblique approach. Clinical improvement was evaluated by change in foot

inversion and eversion at follow-up office visits. Fifty-five subtalar

injections were done in the 38 children.

Treatment was followed by clinical improvement (physician's subjective

judgment of improved ankle mobility, plus reduction in pain) or complete

resolution of symptoms and return to normal mobility in 50 of 55 injections

(91%). Baskin told rheumawire that 44% of patients had complete resolution

of arthritis in the treated joint, with no residual swelling, pain, or loss

of mobility, and all the other patients had substantial improvement.

As might be expected, treatment was most effective in those treated earliest

in the disease course, with greatest improvement seen with treatment given

within one year of disease onset (p=0.04 for <1 year vs >1 year between

diagnosis and treatment). " If we treat early in the acute phase, there is

significant or total resolution of acute symptoms before the patient

develops chronic sequelae, destruction of cartilage, thickening of the joint

capsule, or changes in underlying bone, " Baskin said. " Once chronic changes

occur, they seem to be irreversible. "

Adverse effects included asymptomatic hypopigmentation or subcutaneous

atrophy in 20 patients (53%). These problems correlated directly with volume

of injected steroid per patient weight (mean 0.06 mL/kg vs 0.04 mL/kg,

p=0.005 for those with vs without hypopigmentation or atrophy). The

investigators think that reducing the volume of steroid injected will likely

prevent this problem.

" It's important for interventional radiologists and rheumatologists to pool

their expertise to fight this disease together, to improve the quality of

life for affected children and the long-term chances that those who outgrow

this disease may live as active, mobile, pain-free adults, " Baskin said.

Source

1. Cahill AM, Beukelman T, Kaye RD, et al. Intra-articular

corticosteroid injection for subtalar arthritis in children with juvenile

idiopathic arthritis. 2006 Society of Interventional Radiology annual

scientific meeting; April 3, 2006; Toronto, ON. Abstract 150.

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