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Joint manifestations in scleroderma (Scl) and polymyositis (PM) are dominated by inflammatory arthralgia. Arthritis is less common and preferentially affects the hands, wrists, knees, and ankles. Involvement of the hip has been rarely reported in the literature. We report a case of coxitis diagnosed in a patient suffering from scleroderma-polymyositis overlap syndrome successfully treated by ultrasound-guided infiltration of triamcinolone hexacetonide.

Background: Osteoarthritis (OA) is a painful, chronic disease with widespread burden on patients, communities, social and health care systems. Intraarticular (IA) Hyaluronic acid (HA) and corticosteroids are established treatments for OA knee. However, concerns exist regarding effect, duration, safety, effectiveness across population and heterogeneity. Aim of the study is to compare the efficacy and safety of IA HA with THA in the treatment of primary osteoarthritis knee.Methods: A descriptive cross-sectional study was done among 30 patients. One group (n=15) received IA THA 20mg/2mL on day 0 and other group (n=15) received IA HA 20mg/2 mL on day 0, 7 and 14 under aseptic precautions. The efficacy assessment using VAS for overall pain, joint line tenderness and 15m walking time in seconds were recorded. Side effects if any were noted.Results: Comparing both treatments IA THA provided superior short-term pain relief. But HA showed sustained benefit up to six months.Conclusions: OA being a chronic disease process, we need a drug which has a long-lasting effect. Additive effect of HA and THA can be considered for better efficacy.

BACKGROUND: The purpose of this work was to study the role of intraarticular (i. a.) glucocorticoid injections on the outcome of patients with polyarticular active rheumatoid arthritis (RA). Patients with active RA and at least 2 tender and swollen joints were included in a single-centre, prospective intervention study as part of the outcome benchmarking quality project “obra” of the Association of Acute Care Hospitals for Rheumatology in Germany. PATIENTS AND METHODS: In two defined time periods of the years 2004 and 2005, 77 and 75 consecutive in-patients of our hospital were included and disease activity, pain and function were measured at the time of admission (T1), release (T2) and 3 months after release (T3). For this DAS28-CRP (T1, T 2), RADAI (T1 - 3), pain on a numeric scale (T1 - 3) and the function questionnaire Hannover = FFbH (T1, T 3) were used. Between the two periods of measurement, we expanded the indication for i. a. injections of glucocorticoids: whereas in 2004 only 4 patients (5 %) received an i. a. injection, in 2005 23 (30.7 %) of the patients had injections with triamcinolone hexacetonide in all together 45 active joints. RESULTS: In both groups of patients the mean disease activity and the mean pain score improved at time point T 2 and - together with the function - also at T 3. While the results at T 2 were comparable in both measurement periods, in 2005 there was a significantly higher rate of improvement of the RADAI above the defined end point of > 1 (p 3.6, was reached in a higher proportion in 2005 in comparison to 2004, although this parameter just did not reach significance (p = 0.06). CONCLUSIONS: The results point towards a reduced disease activity and possibly as well reduced pain after 3 months in a population of RA patients in whom the rate of i. a. injections with glucocorticoids was increased. This supports the view of i. a. injections being an important additive treatment option in the treatment of RA.

This chapter illustrates both the non-pharmacologic and pharmacologic therapeutic approaches for managing patients with juvenile idiopathic arthritis (JIA).

Objetivos: Identificar fatores preditivos de resposta à infiltração intra-articular (IIA) com triancinolona hexacetonida (TH). Métodos: Este estudo foi realizado em pacientes de artrite reumatóide (AR) (segundo critérios do American College of Rheumatology) submetidos à IIA (infiltração mono, pauci ou poliarticular). Avaliação: Um observador “cego” avaliou prospectivamente as articulações uma semana (T1), quatro semanas (T4), 12 semanas (T12) e 24 semanas (T24) após IIA. As medidas de desfecho foram Escala Visual Analógica (0-10 cm) em repouso, em movimento e para articulações edemaciadas. As variáveis clínicas e demográficas e aquelas relacionadas à infiltração no início do estudo foram analisadas de acordo com a resposta à IIA. Resultados: Foram estudados 289 pacientes com AR (635 articulações) com média de idade de 48,7 (± 10,68) anos; 48,5% eram caucasianos, EVA para dor global = 6,52 (± 1,73). Na análise univariada, as variáveis relativas às melhores respostas em seguida à IIA (melhora >70%) foram: “IIA no cotovelo e metacarpofalangeanas (MCF)” e “classe funcional II”. Na análise multivariada, “homens” e “não brancos” foram os preditores com melhor resposta à IIA na T4, enquanto “IIA no cotovelo e MCF”, “infiltração poliarticular”, “uso de metotrexato” e “dose total maior de TH” obtiveram a melhor resposta na T24. Conclusão: Foram identificados diversos fatores preditivos de boa resposta à IIA em pacientes com AR. Os preditores de melhor resposta para IIA de TH em longo prazo foram “aplicar IIA no cotovelo e MCF” e “aplicar infiltração poliarticular”. Objectives: Identify good response predictors to intra-articular injection (IAI) with triamcinolone hexacetonide (TH). Methods: This study was carried out in rheumatoid arthritis (RA) patients (American College of Rheumatology criteria) submitted to IAI (mono, pauci or polyarticular injection). Assessment: a “blinded” observer prospectively evaluated joints at one week (T1), four weeks (T4), twelve weeks (T12) and 24 weeks (T24) after IAI. Outcome measurements included Visual Analogue Scale (0-10 cm) at rest, in movement and for swollen joints. Clinical, demographic and variables related to injection at baseline were analyzed according to IAI response. Results: We studied 289 patients with RA (635 joints) with a mean age of 48.7 years (±10.68), 48.5% of them Caucasians, VAS for global pain = 6.52 (±1.73). Under univariate analysis, the variables relating the best responses following IAI (improvement > 70%) were: “elbow and metacarpophalangeal (MCP) IAI, and functional class II”. Under multivariate analysis, “males” and “non-whites” were the predictors with the best response to IAI at T4, while “elbow and MCP IAI”, “polyarticular injection”, “use of methotrexate” and “higher total dose of TH” obtained the best response at T24. Conclusion: Several predictors of good response to IAI in patients with RA were identified. The best-response predictors for TH IAI of long term were “inject elbow and MCP IAI” and “perform polyarticular injection”.

Background The aim of this article is to describe the technique used to perform ultrasound guided steroid joint injections in children in a group of joints that can be injected using ultrasound as the only image guidance modality. Findings The technique is described and didactic figures are provided to illustrate key technical concepts. Conclusion It is very important to be familiar with the sonographic appearance of the pediatric joints and the developing bone when performing ultrasound-guided joint injections in children.

Objective. – To determine whether an intraarticular glucocorticoid injection followed, when possible, by weight-bearing elimination using two crutches reduces the need for total hip arthroplasty (THA) in patients with rapidly destructive hip osteoarthritis (RDHOA). Methods. – A longitudinal retrospective study was conducted in patients admitted for RDHOA, defined as loss of more than 50% of the joint space at the narrowest point between two evaluations 1 year apart. A glucocorticoid injection was performed under fluoroscopic guidance. Patients stayed in bed for the next 24 h then used crutches for 4–6 weeks. Follow-up was at least 6 months. The efficacy criterion was absence of THA. Results. – Twenty-eight patients (22 women) were enrolled between 1993 and 2000. Mean age was 62 years, mean body mass index was 26 kg/m 2 , mean Lequesne index was 11, and mean joint space width was 1.3 mm. Narrowing was superolateral in 19 of the 28 patients. Cortivazol was injected in seven patients, betamethasone in four, and triamcinolone hexacetonide in 17. Weight-bearing elimination for at least 4 weeks was achieved in 15 patients. THA was performed in 27 patients, including 20 who underwent the procedure within the year after the glucocorticoid injection. Conclusion. – Intraarticular glucocorticoid injection with or without elimination of weight-bearing does not reduce the need for THA in patients with RDHOA.

A recent trial demonstrated that patients with knee osteoarthritis treated with a sodium hyaluronate and corticosteroid combination (Cingal) experienced greater pain reductions compared with those treated with sodium hyaluronate alone (Monovisc) or saline up to 3 weeks postinjection. In this study, injections were administered by 1 of 3 approaches; however, there is currently no consensus on which, if any, of these techniques produce a more favorable outcome. To provide additional insight on this topic, the results of the previous trial were reanalyzed to determine whether (1) the effect of Cingal was significant within each injection technique and (2) pain reductions were similar between injection techniques across all treatment groups. Greater pain reductions with Cingal up to 3 weeks were only significant in the anteromedial subgroup. Across all therapies, both the anteromedial and anterolateral techniques demonstrated significantly greater pain reductions than the lateral midpatellar approach at 18 and 26 weeks.

OBJECTIVE: This is an extended follow-up of a randomized controlled trial to evaluate if the addition of triamcinolone to viscosupplementation could alter one-year pain and function of viscosupplementation alone. This is a Level I Therapeutic study (See Guidelines for Authors for a complete description of levels of evidence). METHODS: In a previously reported study we prospectively enrolled 104 patients with knee osteoarthritis and randomized them to receive either a single intra-articular injection (6 mL) of hylan GF-20 (Group viscosupplementation [Group VS]), or a single intra-articular injection of hylan GF-20 (6 mL) and 1 mL (20 mg) of triamcinolone hexacetonide (Group VS + T). Visual Analogue Scale, WOMACTM, and Lequesne questionnaires were completed at baseline, at weeks 1, 4, 12, 24. At the one-year follow-up point, all patients were recruited and reassessed. RESULTS: At one year, the effects of treatment observed in the previous periods were present, with no differences between groups; only the Group receiving hylan + triamcinolone hexacetonide still showed a difference from baseline in the Visual Analogue Scale questionnaire. CONCLUSIONS: The addition of triamcinolone hexacetonide improves first-week symptoms and functional scores of viscosupplementation and does not alter its adverse effects. There might be benefits for the one-year pain results. RESUMO OBJETIVO: Este é o seguimento prolongado de um ensaio clínico randomizado para avaliar se a adição de triancinolona à viscosuplementação poderia alterar a dor e o efeito da viscosuplementação usada isoladamente, um ano após a aplicação terapêutica. Este é um estudo terapêutico Nível I. MÉTODOS: Em um estudo relatado anteriormente, 104 pacientes foram prospectivamente incluídos. Os pacientes apresentavam osteoartrite do joelho e foram randomizados para receber uma única injeção intra-articular (6 mL) de hylan GF-20 (grupo viscosupplemenção) ou a mesma aplicação acrescida de 1 ml (20 mg) de hexacetonida de triancinolona. Foram preenchidos os questionários Escala Visual Analógica, WOMACTM e Lequesne no início do estudo e nas semanas 1, 4, 12, 24 pós-tratamento. Ao fim de um ano de acompanhamento todos os pacientes foram recrutados e reavaliados. RESULTADOS: Em um ano, os efeitos do tratamento observado nos períodos anteriores estavam presentes, sem diferenças entre os grupos; apenas o grupo que recebeu hylan + triancinolona hexacetonida ainda mostrou uma diferença em relação linha de base no questionário Escala Visual Analógica. CONCLUSÕES: A adição de hexacetonida de triancinolona melhora os sintomas e escores funcionais observados com viscosuplementação simples na primeira semana pós-tratamento e não altera os seus efeitos adversos. Pode haver benefícios para a dor após um ano.

TMJ arthritis occurs in up to 80% of children with JIA and it has been described in all JIA subtypes. TMJ arthritis can develop anytime during the course of JIA, even when patients are asymptomatic or on biologic therapy. As it can also occur in the absence of clinically evident arthritis outside the TMJ, a precocious evaluation by maxillofacial surgery is suggested.

In a prospective, randomised study 35 patients suffering from lumbar vertebral disc herniation were given an intrathecal and peridural injection of 0.5 ml (= 10 mg) Triamcinolone hexacetonide. The postoperative course of the disorder was compared with that of 35 patients operated on the same manner, however, without medication. It was established that the intraoperative administration of Triamcinolonhexacetonid had no statistically significant influence on the results of the operations.

To assess if the initial results of viscosupplementation are improved by the addition of corticosteroid.We evaluated 104 patients receiving usual care for knee osteoarthritis at the Universidade de São Paulo Medical Center. Patients were randomized to receive either a single intra-articular injection of 6 mL of Hylan GF-20 (Group 1) or a single intra-articular injection of 6 mL of Hylan GF-20 plus 1 mL (20 mg) of Triamcinolone Hexacetonide (Group 2). VAS, WOMAC and Lequesne questionnaires were applied at weeks zero (prior the injection), and after one, four, and 12 weeks.The baseline measurements of the two groups with 52 patients each were not statistically different. At week one, WOMAC and VAS showed significantly better results for Group 2 compared to Group 1 (p 0,05). At week four the scores did not show a statistically significant differences. The groups showed similar results at week 12.The addition of Triamcinolone Hexacetonide improves the short term symptom/functional scores of viscosupplementation.Avaliar se há melhora dos resultados iniciais da viscossuplementação com a adição de corticosteroide.Foram avaliados 104 pacientes em tratamento para osteoartrite do joelho no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. Os pacientes foram distribuídos aleatoriamente para receber uma única injeção intra-articular de 6 mL de Hylan GF-20 (Grupo 1) ou uma injeção intra-articular de 6 mL de Hylan GF-20, mais 1 mL (20 mg) de hexacetonido de triancinolona (Grupo 2). Foram aplicados a escala visual analógica de dor (VAS) e os questionários de WOMAC e Lequesne antes da infiltração e após uma, quatro e 12 semanas.As medidas basais dos dois grupos com 52 pacientes cada não apresentaram diferença estatística. Após uma semana, o WOMAC e a VAS mostraram resultados significativamente melhores para o Grupo 2 em relação ao Grupo 1 (p 0,05). Com quatro semanas os resultados não apresentaram diferenças estatisticamente significativas entre os grupos. Os grupos apresentaram resultados semelhantes na 12ª. semana.A adição de hexacetonido de triancinolona melhora os resultados de curto prazo da viscossuplementação.

Objective. To determine which intraarticular steroids are used by rheumatologists and whether this use and associated practice vary with time and place of training. Method. American College of Rheumatology members were mailed questionnaires that focused on steroid use in the adult knee. Results. The steroids favored by the respondents were methylprednisolone acetate (MPA), preferred most by those trained in the eastern U.S.; triamcinolone hexacetonide (TH), preferred by those trained in the Midwest and Southwest; and triamcinolone acetonide (TA), preferred by those trained in the West. Only TH was chosen primarily because of efficacy. Regardless of concentration, respondents used 1 ml of steroid. Most (especially those recently trained) combined steroid with local anesthetic. Post-injection instructions varied: 29% did not restrict weight-bearing; 8% recommended limited weight-bearing for 1 week or more. Conclusion. MPA, TH, and TA were favored. Associated techniques varied, based in part on where and when training took place. Research is needed to provide a more rational basis for clinical practice.

The objective of the study was to evaluate the effect of intra-articular (IA) triamcinolone hexacetonide (TAH) and triamcinolone acetonide (TA) on blood glucose levels in patients with controlled diabetes with symptomatic osteoarthritis of the knee (OAK).Patients with controlled diabetes with symptomatic OAK who failed nonsteroidal anti-inflammatory medication and physical therapy and use modern versions of self-monitoring blood glucose devices were offered an IA injection of either 20 mg of TAH or 40 mg of TA. If agreed, patients were asked to document blood glucose levels before and 2 hr after meals for 1 week before and daily for 5 days then every other day for 1 week following the injection. The type of IA preparation was given on an alternating pattern. A sex- and aged-matched group of patients with controlled diabetes with symptomatic OAK of the knee was offered an IA hyaluronic acid (HA) injection. Significantly increased blood glucose level following the IA injection was defined as higher by at least 2 SDs than the mean comparable level before the injection.Thirty patients completed the study: 12 patients in the TAH, 12 patients in the TA group, and 6 in the HA group. All the patients who received triamcinolone preparations had significantly increased blood glucose levels with median initial levels of 227.5 and 201 mg% seen at a median of 8.5 and 13 hr following the IA injection and median peak levels of 288 and 239.5 mg% seen after a median of 24.5 and 32.5 hr following the IA injection of TA and TAH, respectively. Levels returned to normal after ∼2.5 to ∼4 days. There was no significant increase in the HA group except in 1 measurement only with marginal level in 2 patients.Intra-articular injection of either TAH or TA is associated with significantly increased blood glucose levels in patients with controlled diabetes with OAK. This increase is quite solely due to the injected steroids.

Knee joints (n=30) from 22 adult rheumatoid arthritis (RA) patients who were previously randomized and subjected to a six-month double-blind controlled trial of yttrium-90 vs. triamcinolone hexacetonide with a six-year follow-up. In contrast to most previous studies, there was no co-administration of a steroid agent at the time the radiopharmaceutical was injected. One month after treatment the triamcinolone group had less pain (p

Shoulder MR arthrography has an important role in the assessment of rotator cuff lesions, labral tears, glenohumeral ligaments, rotator interval lesions, and postoperative shoulder status. Injection in direct MR arthrography can be performed with palpation, fluoroscopy, ultrasonography (US), or MRI. Recently, the posterior approach is the preferred method due to the presence of fewer stabilizers, absence of important articular structures and less extravasation, has been advocated. Our aim was to assess the efficacy of US-guided MR arthrography via a posterior approach on the glenohumeral joint. Thirty MR arthrographies were performed on 29 patients. Ultrasonography (Xario, Toshiba) examinations were conducted by a wide-band 5-12 Mhz linear array transducer set to muscle-skeleton. Diluted contrast medium (1 ml gadolinium chelate and 100 ml saline, approximately 15 ml) was delivered into the glenohumeral joint space from between the humeral head and posterior labrum with a 20-gauge spinal needle. MRI examination was conducted by a 1.5 T scanner. Fat-saturated T1-weighted spin echo was applied on coronal, axial, and sagittal planes within the first 30 min after contrast material injection. One (3.3%) arthrography was not successful due to technical reasons associated with obesity. Contrast extravasation around the infraspinatus and teres minor muscles was depicted in twelve examinations. One (3.3%) patient developed vasovagal collapse. Ultrasonography-guided posterior approach is an easy, reliable, fast, and comfortable method in experienced hands. It may be an alternative for fluoroscopy-guided shoulder MR arthrography.

The aim of this study was to evaluate whether intravitreal triamcinolone hexacetonide (TH) is a safe, longer lasting alternative to intravitreal triamcinolone acetonide (TA) in the rabbit eye.Three groups, each comprising of 15 Dutch-belted rabbits, received a unilateral injection of 0.1 mL of drug and 0.1 mL of physiologic salt solution in the fellow eye. Group I received TA, group II received commercially available TH, and group III received reformulated iso-osmolar triamcinolone hexacetonide (rTH). Simultaneous bilateral dark-adapted electroretinography was performed following the injection. Retinal morphology was assessed by using histopathology in each group enucleated 12 weeks after injection. High-performance liquid chromatography of vitreous isolated from the enucleated eyes was used to determine drug concentrations.A significant reduction in saturated a-wave and maximal scotopic b-wave was observed in the group II eyes relative to the fellow control eyes at both 2 and 12 weeks postinjection (P0.001 for each comparison) but not in the other groups. Histopathology showed no differences between drug-injected eyes and fellow control eyes in groups I and III, but in group II there was severe degeneration of all retina layers. In group I, the drug half-life was 17.7 +/- 1.7 days, group II 44 +/- 13 days, and group III 12.8 +/- 2.3 days.The half-life of commercially available TH in the vitreous is double that of TA, but the former is toxic to the retina in this rabbit model. Reformulated iso-osmolar TH showed no evidence of deleterious effects to retina function or structure but had a similar half-life to TA.

Background Hip involvement is a common but little studied feature of spondyloarthritis (SpA). Objectives The aim of the present paper is to study the prevalence, clinical and radiological features of hip involvement, and the association with criteria for severity, in a cohort of patients with SpA. Methods Study design: retrospective single center observational study between 2010 and 2013. Patients: definite SpA (Amor9s criteria). Data collection: prevalence of hip involvement, and if present, the date of appearance, the localization and nature of the pain, treatments performed (intra-articular injections, surgery) and outcomes of total joint replacement (TJR). Analysis: descriptive analysis. Results 152 consecutive SpA patients were assessed: 42/152 patients (27%) suffered from SpA-associated hip involvement; median age 32.38±13.5 (range 14–74) years, median symptom duration 8.24±6.3 years, 33 (78.6%) were men. None patient with hip involvement had been treated by anti TNF at data collection. Hip involvement appeared during the first 3 years of disease duration in 78%. The median Lequesne score of the hip was 17.3±3.59 [11-22]. The BASDAI was at 5.47±1.93 and the BASRI was at 6.5±3 [2-6]. Prevalence varied according to SpA predominant manifestation: more frequent in axial patients (32 patients, 76.6%), than in peripheral disease. The features of hip involvement were pseudoarthrosic in 61.9% (26 patients), destructrive or pseudorhumatoid in 10 patients (23.8%), contrictive in 5 cases (11.9%) and synostosant in 1 patient (2.4%). Hip involvement was bilateral in 50% (21/42). 23 patients (54.8%) received intra articular corticoid injections (of which, 4.8% were triamcinolone hexacetonide, and acide osmique in the other cases). 16 patients (38.1%) have one synoviorthesis, 6 (14.3%) have two and one patient had underwent three synoviorthesis. In all, 6 patients (6% of the whole group and 14.3% of patients with hip involvement) had a TJR. TJR was unilateral in 5 patients and bilateral in one case. The median delay between first hip symptoms and TJR was 47 months (range 0–29 years). After a median follow-up of TJR of 101 months (range 2– 27 years), TJR was considered as having a immediate good function in 100% and only 16% (1/6) patients had TJR complications with a second TJR of the hip. Conclusions Hip involvement is a frequent manifestation in SpA (X %), often bilateral, and associated with non-Caucasian origin. One third of the patients needed total joint replacement. Physicians should be wary of hip pain in SpA patients and implement rapid diagnostic procedures in such cases. References Burki V1, Gossec L, Payet J, Durnez A, Elhai M, Fabreguet I and al. Prevalence and characteristics of hip involvement in spondyloarthritis: a single-centre observational study of 275 patients. Clin Exp Rheumatol. 2012;30:481-6. Disclosure of Interest None declared

Intra-articular glucocorticoid injection therapy is frequently used to relieve symptoms of arthritis, but there is considerable variation in injection routines among physicians. One issue of debate concerns the importance of synovial fluid aspiration during the injection procedure. In the present randomised controlled study of patients with rheumatoid arthritis (RA), a significantly reduced risk for arthritis relapse was observed when arthrocentesis was included in the intra-articular injection procedure of the knee. Furthermore, there is no consensus about the post-injection regimes. Previous studies have shown beneficial effects of post-injection rest of the knee, but also injection routines for other joints often include such recommendations. The present randomised controlled trial showed that 48-hour rest in elastic orthosis after intra-articular injection in the wrist did not improve the outcome. Thus, the effect of post-injection rest varies between different joints. The improved treatment result of post-injection rest of the knee is supposed to be caused by retarded steroid resorption from the joint. In order examine the metabolic effects in cartilage, bone and the hypothalamic-piuitary-adrenal (HPA)-axis, resting and mobile RA patients were studied after intra-articular knee injections. Serum levels of the injected glucocorticoid, triamcinolone hexacetonide (THA), were analysed, as well as cartilage oligomeric matrix protein (COMP) as a marker of cartilage turnover, osteocalcin for bone formation and deoxypyridinoline for bone resorption. The HPA-axis was assessed using serum levels of cortisol and adrenocorticotropine hormone. The result showed a short term and reversible suppression of the HPA-axis and bone formation, whereas bone resorption was unaffected. No differences between mobile and resting patients were observed. In both groups reduction of COMP levels were seen, but these were significantly more pronounced in resting patients, suggesting a cartilage-protective effect. The THA levels increased similarly in both groups, indicating that rest did not affect glucocorticoid resorption. Consequently, another explanation for the beneficial effects of postinjection rest of knee synovitis should be considered. In the present material the incidence of infectious complications of intra-articular treatment was less than 1/12,000 injections. The findings in this thesis can be applied in the clinical practice and should be considered when new guidelines for intra-articular glucocorticoid therapy are created.

After one intra-articular injection of 20 mg triamcinolone hexacetonide in the knee, the length of the contralateral lower leg was found to be reduced in 2 boys with juvenile rheumatoid arthritis.

Background Despite being a very prevalent joint condition, there is a lack of studies on the effectiveness of the intra-articular injection (IAI) of corticosteroids in interphalangeal joints (IPs) with osteoarthritis (OA). Objectives Assess the medium-term effectiveness of IPs IAI with triamcinolone hexacetonide (TH) of OA hands patients. Methods A randomized, controlled, double-blind trial was carried out involving 60 OA hands patients (proximal or distal IPs), allocated to two groups. The TH/LD group (n=30) received IAI in the most symptomatic IP with 0.1ml of 2% lidocaine and TH at a dose of 4mg(0.2ml) and 6mg(0.3ml) in the distal and proximal IPs, respectively. The LD group (n=30) received IAI with only 0.1ml of 2% lidocaine. The patients were evaluated by blinded raters at baseline (T0) and one, four, eight and 12 weeks (T1, T4, T8 and T12) after the procedure. Outcome measures:Visual Analogic Scale(VAS: 0 to 10cm) for pain in the IP at rest (VASr) and during movement (VASm), VAS for swelling (VASs), goniometry( 0 ), grip strength(kgf), pinch strength(kgf) and hand function (COCHIN questionnaire and AUSCAN index). Ultrasound evaluation: Quantitative measure (in mm) of synovial hypertrophy in palmar and dorsal joint recesses of IP injected. The level of significance in the statistical analysis was set to 5% (p Results Females accounted for 96.67%of the sample (58 patients). Mean age was 60.7 ± 8.2 years. Mean disease duration was 5.0 ± 3.6 years. Twenty-nine proximal (48.3%) and 31 distal (51.7%) IPs received IAI, with no significant differences between groups. Significant intra-group improvements (p Conclusions Proximal and distal IPs IAI with TH was effective in reducing swelling and joint movement pain in OA hands patients. References DIEPPE, P. – Osteoarthritis. In: KLIPPEL, J. H.; STONE, J.H.; CROFFORD, L.J.; WHITE, P.H..- Primer on the rheumatic diseases. 13th ed. Atlanta GA, Arthritis Foundation., 2008.p. 224-240. HOCHBERG, M.C., et al. American CollegeofRheumatology2012 Recommendations for the Use of Nonpharmacology and Pharmacologic Therapies in Osteoarthritis of the Hand, Hip and Knee Arthritis Care & Research. 2012(64)4: 465-474. Disclosure of Interest None Declared

OBJECTIVE--To assess the efficacy of a single intra-articular injection of triamcinolone hexacetonide (THA) in knee osteoarthritis (OA) and examine factors which may relate to treatment efficacy. METHODS--Eighty four patients with clinical and radiographic evidence of knee OA were recruited and randomly allocated to receive either THA (20 mg in 1 ml) or placebo (0.9% normal saline, 1 ml). Follow up assessments evaluated the following outcome variables: patient opinion of overall change in the treated knee, visual analogue pain score (VAS), distance walked in one minute (WD), and Health Assessment Questionnaire modified for lower limb function (HAQ). RESULTS--Seventy eight percent of THA and 49% of placebo treated patients reported overall improvement at week 1 (p < 0.05). At week 6, improvement was reported in 57% and 55% of patient groups, respectively. VAS improved in both groups at week 1 (THA, p < 0.001; placebo, p < 0.05) and week 6 (both p < 0.01). Improvement in VAS was significantly greater among THA treated patients at week 1 only (p < 0.01). Subgroup analysis of THA treated patients revealed greater improvement in VAS among patients with clinical evidence of an effusion (p < 0.05), and those who had synovial fluid successfully aspirated at the time of injection (p < 0.01). WD improved in THA treated patients at week 1 (p < 0.001), and in both groups at week 6 (THA, p < 0.001; placebo, p < 0.01). Improvements in HAQ were seen in THA patients only at weeks 1 and 6 (p < 0.05). Regression analysis did not identify any additional clinical, radiographic, or synovial fluid characteristics which influenced the response. CONCLUSIONS--THA provided short term pain relief in knee OA. Increased benefit was associated with both clinical evidence of joint effusion and successful aspiration of synovial fluid at the time of injection.

Methods A retrospective chart review was conducted of all JIA patients who received IACI from 6/05 to 3/10, and had at least six months of follow-up. Data collected included demographic information, JIA subtype, date of injection and arthritis flare, type of joint injected and concomitant medications. Any joint that did not flare by the study end date in 9/10 was censored. Time to flare of arthritis was calculated based on the Kaplan-Meier product limit estimator. Two-sided log-rank test was conducted to compare the time to flare within each characteristic group: joints, diagnosis, medications. All analysis in this study was performed using SAS 9.2 (SAS Institute Inc, Cary, NC).

Methods: Fourty two patients with clinical and radiographic evidence of knee OA were studied. It was a randomized control trial. Two groups were made each having 21 cases which were randomly selected the study was conducted in department of orthopedics NIMS Medical college and hospital for the duration of one year between june 2011 to july 2012 the groups were allocated to receive either THA (20 mg in 1 ml)or placebo (0.9% normal saline, 1 ml). Follow up assessments evaluated the following outcome variables: patient opinion of overall change in the treated knee, visual analogue pain score (VAS),distance walked in one minute (WD), and Health Assessment Questionnaire modified for lower limb function (HAQ).

Since the introduction of intra-articular steroid therapy 40 yr ago there have been many changes in the treatment of rheumatoid patients. Previous studies suggest differing times of response for the same agents. This study reports the response, measured by a five-point pain chart, of 300 patients with painful rheumatoid knees. Sixty received hydrocortisone succinate (HC), 150 received triamcinolone acetonide (TA), and 120 triamcinolone hexacetonide (TH). Results demonstrated little effect with HC, but good responses with TA and TH. More patients were rendered painfree for a longer time with TH; 18% at 12 weeks, as against 9% with TA (chi 2 test P < 0.005). At 12 weeks 59% showed continued improvement with TH as against 44% with TA (chi 2 test P < 0.05). TH is the preferred preparation for injection of the rheumatoid knee.

In rheumatoid arthritis (RA) erosive joint changes are the dominating cause of chronic disability. In a cohort of patients with RA followed from early stages of the disease, we have observed a much larger prevalence of destructions in hips than in knee joints. The latter were frequently injected with triamcinolone hexacetonide in contrast to the former. In order to elucidate a possible role of local glucocorticoids we studied the antigen-induced arthritis model of Dumonde and Glynn in rabbits which, untreated, caused advanced joint destruction in 3/5 animals, whereas 0/14 animals receiving 3 injections of triamcinolone hexacetonide developed no such changes. The treatment was effective when started up to 2 weeks after induction of the arthritis. It is suggested that locally administered glucocorticoids may prevent or delay large joint destruction in RA.

The authors report an open study of 30 cases of intradiscal injection of triamcinolone hexacetonide in the treatment of sciatica. The patients were monitored at months 1 and 3. The results were judged to be good in 36.6% of the cases, moderate in 36.6% and poor in 26.7% of the cases. Two adverse effects were reported: 1 case of reversible urinary retention and 1 case of deficiency of the dorsiflexor muscles of the foot. The good results reported in previous series were only found in this study when the indications were restricted to certain favourable prognostic factors: duration of sciatica less than 6 months and CAT-scan appearance of discal hernia. This technique has the advantage of being simple, economical and nonallergic. On the basis of the encouraging results of the initial series, this technique should be considered as an interesting therapeutic alternative in sciatica. Larger series and double-blind studies, however, are necessary to confirm the initial results.

We describe a patient who had an immediate, intense, localized synovitis due to intraarticular triamcinolone hexacetonide injection. The reaction was secondary to rapid intracellular ingestion of the steroid microcrystals as demonstrated by compensated polarized microscopy. We report the unique nature of this patient's response, and we review previous literature regarding "steroid flare" after intraarticular injection.

EDITOR,—The article on pain in the neck, shoulder, and arm advises on the choice of steroid preparations for intra-articular and soft tissue use in the conditions mentioned.1 I disagree with the authors that the use of long acting depot preparations should be avoided. Several studies have shown that hydrocortisone acetate is the weakest and triamcinolone hexacetonide and triamcinolone acetonide are the most potent of the steroids …

A new method of treating osteo-arthritis of the hip involving an intraneural injection of a depot steroid, Triamcinolone Hexacetonide, is described. The results are superior to the more conventional method of systemic or intra-articular route of steroid administration. The rapidity of action in the relief of spasm and pain would tend to confirm similar results shown in a previous article in the Journal (1).

Unlike cleft palate, relatively few teratogens have been found to induce cleft lip in mice. The present study was designed to assess the teratologic, topographic (SEM), and histologic effects on lip morphogenesis following the administration of triamcinolone hexacetonide on the eighth day of gestation. The frequency of cleft lip in treated A/J mice was found to be more than three times greater than the spontaneous frequency in untreated controls. Comparable studies with other murine strains suggest no association between the cleft lip response and either a maternal effect or the H-2 complex. Affected A/J embryos showed a severe reduction in the size of the lateral nasal processes; affected embryos also demonstrated localized cell type-specific alterations, particularly in the epithelia and at the interface between epithelium and mesenchyme.

Seven maintenance hemodialysis patients suffering from intractable uremic pericardial effusion were treated with instillation of a non-absorbable steroid, triamcinolone hexacetonide, into the pericardial sac via a large-bore catheter. The latter was placed under direct vision by subxiphoid pericardiotomy. All patients responded to the treatment while complications of the procedure were few and minor.

Thirty-seven patients suffering from sustained gonitis with recurrent hydrops, not satisfactorily controlled by systemic treatment, participated in the study. Twenty-three patients had bilateral and fourteen patients had unilateral gonitis. Controls were obtained through the use of the contra-lateral knee joint in the twenty-three patients with bilateral gonitis. A total of 60 knees were randomized into three groups of 20 knees and received either 30 mg triamcinolone hexacetonide (TH), 60 mg methylprednisolone (MP) or 9 mg betamethasone (BM). The clinical parameters evaluated were: recurrence of hydrops, pain, local tenderness, range of joint movement and joint circumference. The period of time elapsing between the injection and the need for a new injection or other treatment was used as the criterion for the duration of effect. Relief lasting for an average of 176 days was obtained in the 20 knees treated with local injections of TH, compared to 125 days for MP and 79 days for BM. No general or local adverse effects were noted in the patients studied. The observed long duration of effect and the absence of adverse effects justify the use of TH in cases of therapy-refractory gonitis.

A comparison of intra-articular methotrexate and intra-articular triamcinolone hexacetonide was made in 42 arthritic patients with persistent bilateral knee effusions. One knee was injected with either 5 mg methotrexate (two injections of 2.5 mg a week apart) or a single injection of 20 mg triamcinolone. An objective assessment of both knees was made by quantitative thermography at 0,3,7,14 and 21 days. Joints injected with triamcinolone showed a greater fall in thermographic index (T.I) than the joints injected with methotrexate, which showed similar change to the non-injected knee joints in both groups. Four patients received larger doses of methotrexate, up to 20 mg, though the fall in T.I. was still less than the mean fall for triamcinolone injected joints. Peak venous blood levels of methotrexate were reached 1 hour after intra-articular injection, and a sphygmomanometer cuff inflated around the leg above the injected knee for periods of up to 1 hour did not appreciably delay this. Methotrexate had no immediate anti-inflammatory effect, even in psoriatic arthropathy, and did not give the relief of intra-articular steroid.

Summary— Forty-five patients with Peyronie's disease are described. No patient received treatment for one year from the time of presentation. Three had a complete resolution of their symptoms and signs during this period. The remaining patients received injections of triamcinolone hexacetonide (Lederle) into the plaques at 6-weekly intervals for 36 weeks. Thirty-three per cent had complete or marked improvement in their symptoms; those responding were younger patients with small, firm, discrete plaques in the distal penis. We recommend a non-operative approach in this group. Surgery or chemotherapy should be reserved for those older patients with harder, larger or confluent plaques.

Nineteen patients with idiopathic pruritus ani, for whom all previous treatment had failed, were studied. In the study the only treatment administered to each patient was intralesional injection of triamcinolone hexacetonide. Results obtained were good or excellent in 73.6 per cent of the cases; fair in 10.5 per cent; the treatment failed in 15.7 per cent. The most convenient dosage was found to be 5 mg, administered four times for a total dose of 20 mg. In each of three severe cases injection of 20 mg each week up to a total of 40 or 80 mg provided very satisfactory results.

OBJECTIVE:to assess the effects of injectable triamcinolone on keloid scars length, height and thickness, and on the number of cells undergoing apoptosis.METHODS:This study consists in a prospective, controlled, randomized, single-blinded clinical trial, conducted with fifteen patients with ear keloids divided into two groups: group 1 - seven patients undergoing keloid excisions, and group 2 - eight patients undergoing keloid excisions after three sessions of infiltration with one ml of Triamcinolone hexacetonide (20mg/ml) with three week intervals between them and between the last session and surgery. The two groups were homogeneous regarding age, gender and evolution of the keloid scar. The keloid scars of patients in group 2 were measured for the length, height and thickness before triamcinolone injection and before surgery. A blinded observer performed morphological detailing and quantification of cells in hematoxylin-eosin-stained surgical specimens. An apoptotic index was created.RESULTS: The apoptotic index in group 1 was 56.82, and in group 2, 68.55, showing no significant difference as for apoptosis (p=0.0971). The reduction in keloid dimensions in Group 2 was 10.12% in length (p=0.6598), 11.94% in height (p=0.4981) and 15.62% in thickness (p=0.4027).CONCLUSION:This study concluded that the infiltration of triamcinolone in keloid scars did not increase the number of apoptosit and did not reduce keloids' size, length, height or thickness. OBJETIVO:comparar o efeito da triancinolona injetável em cicatrizes queloidianas quanto ao número de células em apoptose e avaliar o efeito da triancinolona quanto às alterações no comprimento, altura e espessura dessas cicatrizes.MÉTODOS: estudo clínico longitudinal, prospectivo, controlado, aleatorizado, unicego, com 15 pacientes portadores de queloides de orelha distribuídos em dois grupos: grupo 1, com sete pacientes submetidos apenas às exéreses dos queloides; e grupo 2, com oito pacientes submetidos às exéreses das lesões após três sessões de infiltração de 1ml de hexacetonida de triancinolona (20mg/mL), com intervalos de três semanas entre elas, assim como entre a última sessão e a operação. Os dois grupos foram homogêneos quanto à: idade (p=0,867), sexo (p=0,782) e tempo de evolução da cicatriz queloidiana (p=0,779). As cicatrizes queloidianas dos pacientes do grupo 2 foram medidas quanto ao comprimento, altura e espessura antes da injeção da triancinolona e antes do procedimento cirúrgico. Um observador mascarado realizou detalhamento morfológico e quantificação das células nas peças cirúrgicas, coradas com HE. Foi criado um índice apoptótico.RESULTADOS: os dois grupos foram homogêneos quanto à: idade (p=0,867), sexo (p=0,782) e tempo de evolução da cicatriz queloidiana (p=0,779). o índice apoptótico no grupo 1 foi 56,82 e no grupo 2, 68,55, sem diferença (p=0,0971). As reduções nas dimensões dos queloides dos grupos 2 foram 10,12% para o comprimento (p=0,6598), 11,94% para a altura (p=0,4981) e 15,62% para a espessura (p=0,4027).CONCLUSÃO: a infiltração de triancinolona nas cicatrizes queloidianas não aumentou o número de apoptoses e não houve redução das dimensões, comprimento, altura e espessura dos queloides.

ObjectivesIdentify good response predictors to intra-articular injection (IAI) with triamcinolone hexacetonide (TH).MethodsThis study was carried out in rheumatoid arthritis (RA) patients (American College of Rheumatology criteria) submitted to IAI (mono, pauci or polyarticular injection).Assessmenta “blinded” observer prospectively evaluated joints at one week (T1), four weeks (T4), twelve weeks (T12) and 24 weeks (T24) after IAI. Outcome measurements included Visual Analogue Scale (0-10cm) at rest, in movement and for swollen joints. Clinical, demographic and variables related to injection at baseline were analyzed according to IAI response.ResultsWe studied 289 patients with RA (635 joints) with a mean age of 48.7 years (±10.68), 48.5% of them Caucasians, VAS for global pain=6.52 (±1.73). Under univariate analysis, the variables relating the best responses following IAI (improvement > 70%) were: “elbow and metacarpophalangeal (MCP) IAI, and functional class II”. Under multivariate analysis, “males” and “non-whites” were the predictors with the best response to IAI at T4, while “elbow and MCP IAI”, “polyarticular injection”, “use of methotrexate” and “higher total dose of TH” obtained the best response at T24.ConclusionSeveral predictors of good response to IAI in patients with RA were identified. The best-response predictors for TH IAI of long term were “inject elbow and MCP IAI” and “perform polyarticular injection”.

The aim of this study was to determine the comparative efficacy and safety of intra-articular (i/a) triamcinolone. hexacetonide (TH) and i/a hyaluronic acid (HA) in inflammatory knee osteoarthritis. A randomized double-blind comparative trail was carried out in a rheumatology outpatient department. There were 63 patients (24 male, 39 female, mean age 70.5 years) with bilateral symptomatic knee osteoarthritis with effusion. Each was given five HA injections at weekly intervals; or 20 mg TH followed by four placebo (saline) injections. Patients were examined weekly during the treatment period and then at monthly intervals for a further 6 months. Assessment included recording of: visual analog scores (VAS) for pain; duration of stiffness; range of movement; joint effusion; local heat; synovial thickening; joint-line and periarticular tenderness. The principal outcome measure was pain on a self-selected activity assessed by Vas. The two groups were comparable at entry and no significant differences between the groups developed at any time during the treatment period. However, there was a high drop-out rate and intention to treat analysis failed to demonstrate statistically significant differences between the groups. In patients remaining in the study, significantly less pain was experienced by the HA group during the 6 month follow-up period. Other parameters showed a similar trend in favor of experienced by the HA group during the 6 month follow-up period. Other parameters showed a similar trend in favor of HA. We could not, however, demonstrate significant differences between the placebo and active treatments. HA may therefore be a useful additional therapy for symptomatic knee osteoarthritis and may have a long duration of action.