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Background: A corticosteroid flare reaction is a well-described phenomenon that causes significant pain and dysfunction. The paucity of literature impedes decision making regarding which corticosteroid to use for shoulder injection. The purpose of this study was to compare methylprednisolone acetate (MPA) and triamcinolone acetonide (TA) injections in the glenohumeral joint and/or subacromial space in terms of efficacy and the incidence of steroid flare reactions., Methods: In this prospective, interrupted time series, parallel study, patients received injections in the glenohumeral joint and/or subacromial space. MPA and TA were used during 2 discrete 3-month periods. The injections consisted of 2 mL of lidocaine, 2 mL of bupivacaine, and 80 mg of either MPA or TA. Visual analog scale (VAS) pain scores were recorded immediately before injection; 1-7 days after injection; and 3, 6, and 12 months after injection. The primary outcome was the incidence of a steroid flare reaction, defined as a post-injection increase in the VAS score by ≥2 points. The secondary outcome was injection failure, defined as a post-injection VAS score greater than the baseline score or the need for another intervention. We used linear mixed models with a patient-level random intercept to identify the mean VAS score change for TA injections in the first week after injection., Results: MPA or TA shoulder injections were administered in 421 patients; of these patients, 15 received bilateral-joint injections whereas 406 received a single-joint injection, for a total of 436 injections (209 MPA and 227 TA injections). Pain scores in the first week after injection were available for 193 MPA and 199 TA injections. Significantly more patients in the MPA cohort reported flare reactions compared with the TA cohort (22.8% vs. 4.0%, P < .001) during the first week after injection. In the first week after injection, the mean VAS score of patients receiving TA injections was 1.05 (95% confidence interval, 0.47-1.63) lower than that of patients receiving MPA injections when adjusted for age, sex, race, pain type, surgeon type, and injection site. At 3 months, surveys for 169 MPA and 172 TA injections were completed, with no significant difference in the rate of injection failure for MPA vs. TA (42.6% vs. 36.1%, P = .224). Treatment failure rates were significantly higher for MPA than for TA at 6 months (78.44% vs. 62.5%, P < .001) but not at 12 months (81.18% vs. 81.42%, P = .531.) CONCLUSION: TA injections resulted in a >5-fold reduction in steroid flare reactions, with statistically superior 6-month efficacy rates, compared with MPA injections. This study supports TA as a more viable corticosteroid option for shoulder injection., (Copyright © 2023 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: The chondrotoxic effects of methylprednisolone acetate (MP) and triamcinolone acetonide (TA) have been well described. However, the mechanical effects of these commonly used steroids on native cartilage are largely unknown., Purpose: To investigate the in vitro effects of a single 1-hour MP or TA exposure on the viability, mechanics, and biochemical content of native articular cartilage explants., Study Design: Controlled laboratory study., Methods: Articular cartilage explants (n = 6 per group) were harvested from the femoral condyles of bovine stifles. Explants were exposed to chondrogenic medium containing a clinical dose of MP or TA for 1 hour, followed by fresh medium wash and exchange. Explants in the control group underwent the same treatment with chondrogenic medium alone. At 24 hours after treatment, samples were assessed for viability (live/dead), mechanical properties (creep indentation and Instron tensile testing), biochemical (collagen and glycosaminoglycan) content, and pyridinoline crosslinking via mass spectrometry., Results: Mean cell viability was significantly decreased in native explants exposed to MP (35.5%) compared with the control (49.8%; P < .001) and TA (45.7%; P = .01) specimens. Significant decreases were seen in the mechanical properties of steroid-treated native explants when compared with controls, with decreases in aggregate modulus (646.3 vs 312.8 kPa [MP] and 257.0 kPa [TA]; P < .001), shear modulus (370.1 vs 191.2 kPa [MP] and 157.4 kPa [TA]; P < .001), and ultimate tensile strength (9.650 vs 5.648 MPa [MP; P = .021] and 6.065 MPa [TA; P = .0403]). No significant differences in collagen and glycosaminoglycan content were found in the steroid-treated groups. Pyridinoline crosslinking was significantly decreased in explants exposed to TA compared with controls ( P = .027)., Conclusion: Exposure of MP to articular cartilage explants was chondrotoxic, and exposure of articular cartilage explants to MP or TA resulted in significant decreases in mechanical properties of articular cartilage explants compared with controls. Clinicians should be judicious regarding use of intra-articular steroids, particularly in patients with intact healthy articular cartilage.

Background: To our knowledge, the comparative effectiveness of commonly used conservative treatments for carpal tunnel syndrome has not been evaluated previously in primary care. We aimed to compare the clinical and cost-effectiveness of night splints with a corticosteroid injection with regards to reducing symptoms and improving hand function in patients with mild or moderate carpal tunnel syndrome., Methods: We did this randomised, open-label, pragmatic trial in adults (≥18 years) with mild or moderate carpal tunnel syndrome recruited from 25 primary and community musculoskeletal clinics and services. Patients with a new episode of idiopathic mild or moderate carpal tunnel syndrome of at least 6 weeks' duration were eligible. We randomly assigned (1:1) patients (permutated blocks of two and four by site) with an online web or third party telephone service to receive either a single injection of 20 mg methylprednisolone acetate (from 40 mg/mL) or a night-resting splint to be worn for 6 weeks. Patients and clinicians could not be masked to the intervention. The primary outcome was the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. We used intention-to-treat analysis, with multiple imputation for missing data, which was concealed to treatment group allocation. The trial is registered with the European Clinical Trials Database, number 2013-001435-48, and ClinicalTrial.gov, number NCT02038452., Findings: Between April 17, 2014, and Dec 31, 2016, 234 participants were randomly assigned (118 to the night splint group and 116 to the corticosteroid injection group), of whom 212 (91%) completed the BCTQ at 6 weeks. The BCTQ score was significantly better at 6 weeks in the corticosteroid injection group (mean 2·02 [SD 0·81]) than the night splint group (2·29 [0·75]; adjusted mean difference -0·32; 95% CI -0·48 to -0·16; p=0·0001). No adverse events were reported., Interpretation: A single corticosteroid injection shows superior clinical effectiveness at 6 weeks compared with night-resting splints, making it the treatment of choice for rapid symptom response in mild or moderate carpal tunnel syndrome presenting in primary care., Funding: Arthritis Research UK., (Copyright © 2018 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

This study introduced a developed approach for dendritic β-cyclodextrin (β-CD) in order to obtain high sorption capacity. Synthetic strategy exploits the reactivity between acrylic acid and allyl glycidyl ether for high-yielding assembly via grafting on to the magnetic nanoparticles that are modified using 3-mercaptopropyltrimethoxysilane for various building branches and host-guest molecules of β-CD. The methodology has been applied for the preparation of a series of β-CD conjugated magnetic nanoparticles with dendrimers as a nano-sorbent for the extraction of methylprednisolone acetate. This study allowed us to probe (i) the effects of the dendric-cyclodextrin architecture on the affinity of sorption capacity, (ii) the drug influence between the cyclodextrin core and the polyester dendrimer, and (iii) the result of sorbent formation for using the anti-inflammatory drug as a target guest into the ring of β-CD on biological extraction. It was found that the adsorption behavior could be fitted by the Langmuir adsorption isotherm model. The adsorption capacity of MPA is found to be 12.4 mg g -1 and indicated the homogeneous sites onto polymer grafted magnetite nano-sorbent surface. Our results confirm the high capability of this type of dendrimer-β-CD for drug extraction in biological fluids and pharmaceutical samples. This nano-sorbent assists the magnetic solid phase extraction technique represented in the high extraction yield (up to 97%) for methylprednisolone acetate in biological human fluids and pharmaceutical samples. Moreover, the achieved polymeric nano-sorbent of the reaction combination was facilitated by a magnetic field and reusability was performed without any notable loss in the sorbent activity., (Copyright © 2018 Elsevier B.V. All rights reserved.)

OBJECTIVE To compare the effects of 3 equimolar concentrations of methylprednisolone acetate (MPA), triamcinolone acetonide (TA), and isoflupredone acetate (IPA) on equine articular tissue cocultures in an inflammatory environment. SAMPLE Synovial and osteochondral explants from the femoropatellar joints of 6 equine cadavers (age, 2 to 11 years) without evidence of musculoskeletal disease. PROCEDURES From each cadaver, synovial and osteochondral explants were harvested from 1 femoropatellar joint to create cocultures. Cocultures were incubated for 96 hours with (positive control) or without (negative control) interleukin (IL)-1β (10 ng/mL) or with IL-1β and MPA, TA, or IPA at a concentration of 10 -4 , 10 -7 , or 10 -10 M. Culture medium samples were collected from each coculture after 48 and 96 hours of incubation. Concentrations of prostaglandin E 2 , matrix metalloproteinase-13, lactate dehydrogenase, and glycosaminoglycan were determined and compared among treatments at each time. RESULTS In general, low concentrations (10 -7 and 10 -10 M) of MPA, TA, and IPA mitigated the inflammatory and catabolic (as determined by prostaglandin E 2 and matrix metalloproteinase-13 quantification, respectively) effects of IL-1β in cocultures to a greater extent than the high (10 -4 M) concentration. Mean culture medium lactate dehydrogenase concentration for the 10 -4 M IPA treatment was significantly greater than that for the positive control at both times, which was suggestive of cytotoxicosis. Mean culture medium glycosaminoglycan concentration did not differ significantly. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated that the in vitro effects of IPA and MPA were similar to those of TA at clinically relevant concentrations (10 -7 and 10 -10 M).

Objective: The aim of this study is to compare clinical results of ultrasound-guided corticosteroid injection, intra-sheath versus extra-sheath of the finger flexor tendon., Methods: A total of 166 patients with trigger finger were evaluated in a triple blind randomized clinical trial study. All the patients were injected with 1ml of 40mg/ml methyl prednisolone acetate, under the guidance of ultrasound. Half the patients were injected extra sheath, while the other half were injected intra sheath at the level of first annular pulley., Results: The two groups were comparable in baseline characteristics (age, gender, dominant hand, involved hand and finger, and the symptoms duration). No significant difference was observed in the two groups with regards to Quinnell grading. In the final visit, 94% of patients from each group were symptom free., Conclusion: Results of corticosteroid injection intra-sheath or extra-sheath of the finger flexor tendon under ultrasound guidance in patients with trigger finger are comparably alike. Extra-sheath injection at the level of A1 pulley is as effective as an Intra-sheath administration.

Strongyloides stercoralis hyperinfection causes high mortality rates in humans, and, while hyperinfection can be induced by immunosuppressive glucocorticoids, the pathogenesis remains unknown. Since immunocompetent mice are resistant to infection with S. stercoralis , we hypothesized that NSG mice, which have a reduced innate immune response and lack adaptive immunity, would be susceptible to the infection and develop hyperinfection. Interestingly, despite the presence of large numbers of adult and first-stage larvae in S. stercoralis -infected NSG mice, no hyperinfection was observed even when the mice were treated with a monoclonal antibody to eliminate residual granulocyte activity. NSG mice were then infected with third-stage larvae and treated for 6 wk with methylprednisolone acetate (MPA), a synthetic glucocorticoid. MPA treatment of infected mice resulted in 50% mortality and caused a significant >10-fold increase in the number of parasitic female worms compared with infected untreated mice. In addition, autoinfective third-stage larvae, which initiate hyperinfection, were found in high numbers in MPA-treated, but not untreated, mice. Remarkably, treatment with Δ7-dafachronic acid, an agonist of the parasite nuclear receptor Ss -DAF-12, significantly reduced the worm burden in MPA-treated mice undergoing hyperinfection with S. stercoralis Overall, this study provides a useful mouse model for S. stercoralis autoinfection and suggests a therapeutic strategy for treating lethal hyperinfection., Competing Interests: The authors declare no conflict of interest.

Background and Objectives: Osteoarthritis (OA) of the knee affects the aging population and has an associated influence on the health care system. Rigorous studies evaluating radiofrequency ablation for OA-related knee pain are lacking. This study compared long-term clinical safety and effectiveness of cooled radiofrequency ablation (CRFA) with intra-articular steroid (IAS) injection in managing OA-related knee pain., Methods: This is a prospective, multicenter, randomized trial with 151 subjects with chronic (≥6 months) knee pain that was unresponsive to conservative modalities. Knee pain (Numeric Rating Scale [NRS]), Oxford Knee Score, overall treatment effect (Global Perceived Effect), analgesic drug use, and adverse events were compared between CRFA and IAS cohorts at 1, 3, and 6 months after intervention., Results: There were no differences in demographics between study groups. At 6 months, the CRFA group had more favorable outcomes in NRS: pain reduction 50% or greater: 74.1% versus 16.2%, P < 0.0001 (25.9% and 83.8% of these study cohorts, respectively, were nonresponders). Mean NRS score reduction was 4.9 ± 2.4 versus 1.3 ± 2.2, P < 0.0001; mean Oxford Knee Score was 35.7 ± 8.8 vs 22.4 ± 8.5, P < 0.0001; mean improved Global Perceived Effect was 91.4% vs 23.9%, P < 0.0001; and mean change in nonopioid medication use was CRFA > IAS (P = 0.02). There were no procedure-related serious adverse events., Conclusions: This study demonstrates that CRFA is an effective long-term therapeutic option for managing pain and improving physical function and quality of life for patients with painful knee OA when compared with IAS injection., Clinical Trial Registration: ClinicalTrials.gov (NCT02343003).

Introduction: Plantar fasciitis is a common cause of heel pain. Considering different interventions which are applied for patients with plantar fasciitis, dry needling is proposed as a new modality of treatment recently. The aim of this study is to evaluate the effectiveness of dry needling versus steroid injection for plantar fasciitis., Methods: Sixty-six patients were recruited to this single-blind clinical trial study. Participants were randomly allocated to receive 1 ml (40 mg) of Depo-Medrol (methylprednisolone acetate) or dry needling. They were followed up for 12 months and monitored for total perception of pain using the visual analogue scale (VAS), with data obtained in baseline and at three weeks, six weeks, three months, six months and one year after treatment., Results: Mean VAS score before treatment was 6.96 ± 0.87 for the steroid group and 6.41 ± 0.83 for the dry-needling group (P value = 0.54). Steroid injection reduced VAS scores rapidly until three weeks after treatment compared with dry needling (0.32 ± 0.71 and 3.47 ± 1.32, respectively; P value < 0.001). However, patients who were underwent dry needling reported lower VAS scores at the end of follow-up compared with the steroid group (0.69 ± 0.93 and 2.09 ± 1.58, respectively; P value = 0.004). Over the long term, 82.3% and 17.6% of changes in pain were contributed to time since treatment and treatment method, respectively (P values < 0.001)., Conclusions: Steroid injection can palliate plantar heel pain rapidly but dry needling can provide more satisfactory results for patients with plantar fasciitis in the long term.

Background: Epidural injections (EIs) are the most commonly performed minimally invasive intervention in managing chronic low back pain (CLBP). There is inconsistency in data to accurately predict the degree of hypothalamic-piuitary-adrenal (HPA) axis suppression in patients receiving exogenous steroid therapy, especially in the form of epidural steroid injections (ESIs)., Objective: We aim to quantify the degree and duration of HPA axis suppression after a single ESI of 80 mg methyl prednisolone acetate in patients with CLBP., Study Design: A single open-label prospective study., Setting: An operating room of a tertiary care hospital., Methods: Patients with CLBP and unilateral radicular pain were included in this study. An ESI of 80 mg of methylprednisolone acetate was administered in each patient. Blood samples for cortisol and adrenocorticotropic hormone (ACTH) were collected before the ESI and on days 7, 14, and 28 after the ESI. The patients' pain levels were graded on the numeric rating scale (NRS) at baseline and on days 7, 14, 28, and 60 after the ESI in the pain clinic., Results: A total of 30 patients were enrolled in this study. The median with interquartile range (IQR) serum cortisol level at baseline and on days 7, 14, and 28 after intervention were found to be 329.55 (208.49 - 399.48) nmol/L, 72.99 (52.95 - 119.82) nmol/L, 194.45 (73.88 - 292.52) nmol/L, and 302.56 (257.68 - 357.43) nmol/L, respectively. A significant discrease in the serum cortisol levels was observed on days 7 (P < 0.001) and 14 (P < 0.001). Twenty-six (87%), 13 (43%), and 2 (7%) patients had serum cortisol levels below normal (<170 nmol/L) on days 7, 14, and 28, respectively. HPA axis suppression was observed in all of the patients for a median (IQR) period of 14 days (range: 11-17 days)., Limitations: This study was an unblinded observational study. The effect of a single ESI was studied and the sample collection of day 21 serum cortisol and ACTH were passed over., Conclusions: HPA axis function was suppressed after the ESI until day 14 and returned to the normal range by postoperative week 4., Key Words: Epidural injections, steroids, HPA, suppression, cortisol, ACTH.

Background: Arthroscopic rotator cuff (RC) repair incorporates suture anchors to secure torn RC tendons to the greater tuberosity (GT) bone. RC repair strength depends on the anchor-bone interface and on the quality of the GT. We evaluated the effect of single and multiple corticosteroid injections on the pullout strength of suture anchors., Methods: Fifty rats were divided into those receiving saline solution injection (control group), a single methylprednisolone acetate (MTA) injection (MTA1 group), or 3 once-weekly MTA injections (MTA3 group). Rats were killed humanely at 1 or 4 weeks after the last injection. A mini-suture anchor was inserted into the humeral head through the GT. Specimens were tested biomechanically., Results: At 1 week after the last injection, the mean maximal pullout strength was significantly reduced in the MTA1 group (63.5%) and MTA3 group (56%) compared with the control group (P < .05 for both). Mean stiffness decreased significantly in both treatment groups compared with controls (P < .05). At 4 weeks after the last injection, there was a significant increase in the mean maximal pullout strength after single and triple MTA injections compared with values recorded at the 1-week time point (P < .05). At 4 weeks, the mean maximal pullout strength after a single MTA injection was 92.8% of the pullout strength measured in the control group., Conclusions: We showed a significant detrimental effect of corticosteroid exposure on the pullout strength of a suture anchor at 1 week. However, this effect was transient and resolved within a relatively short period. These findings indicate that a waiting period is required between subacromial corticosteroid injection and RC repair surgery that involves the use of suture anchors., (Copyright © 2017 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Pemphigus foliaceus is a severe, autoimmune blistering skin disease, which is described in humans and some animal species. In small ruminants pemphigus foliaceus has rarely been described and, to the best of the authors' knowledge, little information is available about successful treatment in sheep., Aim: This case report describes a Berrichon du Cher ram with the presumed diagnosis of pemphigus foliaceus., Methods: The ram was treated with methylprednisolone acetate 40 mg at a dosage of 2.5 mg/kg in one subcuticular injection at four week intervals over a one year period, with regular observation of clinical parameters. Four months after treatment was initiated the haematological parameters showed lymphopenia and leukopenia; some enzyme activities were substantially increased., Results: The ram's dermatological condition improved to the point of complete healing of the affected skin. The ram was discharged in good condition. No adverse effects, except an elevation of some enzymes associated with liver function, were observed. At postmortem examination moderate fatty liver syndrome was the only abnormality found., Conclusions and Clinical Importance: This case report demonstrated that long term therapy with methylprednisolone acetate in a sheep with pemphigus foliaceus did not have a negative effect on clinical parameters. Nevertheless, due to the extended statutory withdrawal period resulting from the regular administration of glucocorticoids, such a therapeutic option must be critically assessed in food producing animals., (© 2017 ESVD and ACVD.)

Background Ultrasound-guided percutaneous irrigation of calcific tendinopathy (US-PICT) with intrabursal steroid injection is an elective treatment for painful rotator cuff calcific tendinopathy. Purpose To compare the efficacy of post-US-PICT intrabursal 40 mg injection of triamcinolone acetonide (TA) versus methylprednisolone acetate (MA). Material and Methods Forty patients (22 women; mean age 48.7 ± 7.2 years) with painful shoulder calcific tendinopathy, treated with TA or MA injected intrabursally after US-PICT, were included in this randomized controlled trial. At baseline and after 1, 7, 15, 30, 45, and 180 days, patients underwent US and clinical examination, using Constant (CS) and VAS (VS) scores. Complications and analgesic use were also recorded. Results Compared to baseline, at the 45-day follow-up, TA and MA group showed a similar improvement (Δ) in CS (42 ± 10 versus 36 ± 9 points) and VS (-4.4 ± 1.3 versus -3.6 ± 1.3 points). At the 180-day follow-up, the improvement was higher in TA versus MA (ΔCS: 53 ± 7 versus 44 ± 7 points; ΔVS: -4.9 ± 1.1 versus -3.9 ± 1 points). Multivariate analysis showed a mean CS higher ( P = 0.02) in TA versus MA group, while VS was similar. TA had a 5 × higher ( P = 0.007) chance of reaching complete remission (CS = 100 points) than MA group. A progressive decrease in analgesic use, concomitant to a significant and similar reduction of bursitis and calcifications, was observed in both groups. No major complications occurred. Conclusion Two-needle US-PICT with intrabursal steroid injection is safe and effective. The chance of reaching better scores and, even more important for a clinical perspective, of functional recovery, is higher in patients treated with TA than MA.

Background: Injection therapies are often considered alongside exercise for chronic midportion Achilles tendinopathy (AT), although evidence of their efficacy is sparse., Purpose: To determine whether eccentric training in combination with high-volume injection (HVI) or platelet-rich plasma (PRP) injections improves outcomes in AT., Study Design: Randomized controlled trial; Level of evidence, 1., Methods: A total of 60 men (age, 18-59 years) with chronic (>3 months) AT were included and followed for 6 months (n = 57). All participants performed eccentric training combined with either (1) one HVI (steroid, saline, and local anesthetic), (2) four PRP injections each 14 days apart, or (3) placebo (a few drops of saline under the skin). Randomization was stratified for age, function, and symptom severity (Victorian Institute of Sports Assessment-Achilles [VISA-A]). Outcomes included function and symptoms (VISA-A), self-reported tendon pain during activity (visual analog pain scale [VAS]), tendon thickness and intratendinous vascularity (ultrasonographic imaging and Doppler signal), and muscle function (heel-rise test). Outcomes were assessed at baseline and at 6, 12, and 24 weeks of follow-up., Results: VISA-A scores improved in all groups at all time points ( P < .05), with greater improvement in the HVI group (mean ± SEM, 6 weeks = 27 ± 3 points; 12 weeks = 29 ± 4 points) versus PRP (6 weeks = 14 ± 4; 12 weeks = 15 ± 3) and placebo (6 weeks = 10 ± 3; 12 weeks = 11 ± 3) at 6 and 12 weeks ( P < .01) and in the HVI (22 ± 5) and PRP (20 ± 5) groups versus placebo (9 ± 3) at 24 weeks ( P < .01). VAS scores improved in all groups at all time points ( P < .05), with greater decrease in HVI (6 weeks = 49 ± 4 mm; 12 weeks = 45 ± 6 mm; 24 weeks = 34 ± 6 mm) and PRP (6 weeks = 37 ± 7 mm; 12 weeks = 41 ± 7 mm; 24 weeks = 37 ± 6 mm) versus placebo (6 weeks = 23 ± 6 mm; 12 weeks = 30 ± 5 mm; 24 weeks = 18 ± 6 mm) at all time points ( P < .05) and in HVI versus PRP at 6 weeks ( P < .05). Tendon thickness showed a significant decrease only in HVI and PRP groups during the intervention, and this was greater in the HVI versus PRP and placebo groups at 6 and 12 weeks ( P < .05) and in the HVI and PRP groups versus the placebo group at 24 weeks ( P < .05). Muscle function improved in the entire cohort with no difference between the groups., Conclusion: Treatment with HVI or PRP in combination with eccentric training in chronic AT seems more effective in reducing pain, improving activity level, and reducing tendon thickness and intratendinous vascularity than eccentric training alone. HVI may be more effective in improving outcomes of chronic AT than PRP in the short term. Registration: NCT02417987 ( ClinicalTrials.gov identifier).

Greater trochanteric pain syndrome (GTPS) is a common clinical entity for which the most effective treatment is local corticosteroid injection (LCI). There are no studies on the effect of LCI among patients with GTPS on the hypothalamic-pituitary-adrenal axis. The present study recruited nonselected patients diagnosed with GTPS. After consenting, participants received low dose (1 μg) of adrenocorticotropin hormone (ACTH) stimulation test at 09:00. Immediately following the test, participants received a LCI of 80 mg of methylprednisolone acetate at the greater trochanteric region. The ACTH stimulation test was repeated 1, 2, 4, and 6 weeks following the LCI. Cortisol samples were obtained at just prior to (basal) and 30 min (post-stimulation) following every ACTH stimulation test. Serum cortisol levels of <500 μmol/l obtained 30 min following the ACTH stimulation test were considered evidence of secondary adrenal insufficiency. The study enrolled 22 patients, 21 of whom completed participation. There were 19 female participants (~90%), and mean age of all the participants was 55.2 ± 8.6 years. Four participants showed evidence of secondary adrenal insufficiency, which was observed only at weeks 1 and 2 following the LCI. Mean serum cortisol level among these four participants 30 min following the ACTH stimulation test was 354 μmol/l, with a range of 268-430 μmol/l. LCI of 80 mg of methylprednisolone acetate in the greater trochanteric area among patients with GTPS was associated with transient secondary adrenal insufficiency in ~20% of the patients, mainly 1 week following the injection.

Objective and Design: To determine the ability of methylprednisolone acetate (MPA) to influence interleukin 1β (IL1β)-induced gene expression in ovine knee joint tissues., Material or Subjects: Ovine articular cartilage, synovium, and infrapatellar fat pad (IPFP) explants., Treatment: Explants were treated with 10 -3  M or 10 -4  M MPA., Methods: Explant treatment groups: (1) control (DMEM); (2) inflammation (IL1β); (3) IL1β + 10 -3  M MPA; or (4) IL1β + 10 -4  M MPA. Cell viability was assessed pre- and post-treatment. Expression of mRNA levels for inflammatory, degradative, anabolic, innate immunity, and adipose-related molecules was quantified via qPCR, and analyzed via the comparative C T method., Results: Except for IL8 in a subset of cartilage locations, matrix metalloproteinases (MMPs) were the only genes consistently affected by MPA. MPA mitigated IL1β-induced MMP3 expression levels in all regions of the articular cartilage, and in the synovium and IPFP, while MMP1 mRNA expression levels were significantly decreased with MPA after IL1β in the tibial plateau and synovium, but paradoxical increases in the IPFP. MMP13 mRNA expression levels exhibited significant decreases with MPA after IL1β in the femoral condyles, tibial plateau, synovium, and IPFP., Conclusions: MPA treatment suppressed IL1β-induced mRNA levels for MMPs in articular cartilage, synovium, and IPFP and was found to be tissue-, location-, and gene-specific.

Intra-articular (IA) corticosteroid injections are a common approach in the management of osteoarthritis (OA) of the knee. The effectiveness of injections and particular injection products is often discussed and debated in clinical arenas. The following therapeutic review examines the evidence for intra-articular methylprednisolone acetate (MPA) injections in the management of OA knee. A review of research evidence, published guidelines and clinical literature was undertaken following an electronic database and relevant literature search. The review found that there is limited evidence which indicates that a single dose intra-articular MPA injection can provide short to medium term benefits for pain, with less evidence for beneficial effects on function or stiffness. There is heterogeneity across studies and until recently, most studies had only short to medium term follow-up periods, thus limiting the evidence available on longer term benefit. There was also evidence indicating equivalent overall efficacy of MPA to that of other corticosteroid products. Most guideline recommendations concerning IA injections for OA knee have drawn on evidence from pooled data for several corticosteroid products. The review also found there was limited reporting of the incidence of adverse events in most studies. Overall, MPA shows efficacy for symptom relief in OA knee. At an individual management level, evidence for a limited duration of effect needs consideration in injections decisions. Furthermore, consensus across clinical guidelines suggests that the management of OA knee should be individualized to a person's clinical history, degree of disability, risk factors, quality of life and personal preferences, whereby injecting involves a shared decision and forms part of a multimodal approach. Copyright © 2016 John Wiley & Sons Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Intra-articular administration of corticosteroids is a commonly used treatment for osteoarthritis as well as other inflammatory disorders of the joints. It is well known that delirium and psychosis can arise following the administration of oral corticosteroids but there are few documented cases of the development of acute hyperactive delirium with psychosis following intra-articular administration. We describe a case of an 82-year-old female patient with moderate dementia who developed a delirium with psychosis which responded well to a first-generation antipsychotic., (2017 BMJ Publishing Group Ltd.)

Background: Simple bone cysts, also known as a unicameral bone cysts or solitary bone cysts, are the most common type of benign bone lesion in growing children. Cysts may lead to repeated pathological fracture (fracture that occurs in an area of bone weakened by a disease process). Occasionally, these fractures may result in symptomatic malunion. The main goals of treatment are to decrease the risk of pathological fracture, enhance cyst healing and resolve pain. Despite the numerous treatment methods that have been used for simple bone cysts in long bones of children, there is no consensus on the best procedure. This is an update of a Cochrane review first published in 2014., Objectives: To assess the effects (benefits and harms) of interventions for treating simple bone cysts in the long bones of children, including adolescents.We intended the following main comparisons: invasive (e.g. injections, curettage, surgical fixation) versus non-invasive interventions (e.g. observation, plaster cast, restricted activity); different categories of invasive interventions (i.e. injections, curettage, drilling holes and decompression, surgical fixation and continued decompression); different variations of each category of invasive intervention (e.g. different injection substances: autologous bone marrow versus steroid)., Search Methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, the China National Knowledge Infrastructure Platform, trial registers, conference proceedings and reference lists. Date of last search: April 2016., Selection Criteria: Randomised and quasi-randomised controlled trials evaluating methods for treating simple bone cysts in the long bones of children., Data Collection and Analysis: Two review authors independently screened search results and performed study selection. We resolved differences in opinion between review authors by discussion and by consulting a third review author. Two review authors independently assessed risk of bias and data extraction. We summarised data using risk ratios (RRs) or mean differences (MDs), as appropriate, and 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the overall quality of the evidence., Main Results: In this update in 2017, we did not identify any new randomised controlled trials (RCT) for inclusion. We identified one ongoing trial that we are likely to include in a future update. Accordingly, our results are unchanged. The only included trial is a multicentre RCT conducted at 24 locations in North America and India that compared bone marrow injection with steroid (methylprednisolone acetate) injection for treating simple bone cysts. Up to three injections were planned for participants in each group. The trial involved 90 children (mean age 9.5 years) and presented results for 77 children at two-year follow-up. Although the trial had secure allocation concealment, it was at high risk of performance bias and from major imbalances in baseline characteristics. Reflecting these study limitations, we downgraded the quality of evidence by two levels to 'low' for most outcomes, meaning that we are unsure about the estimates of effect. For outcomes where there was serious imprecision, we downgraded the quality of evidence by a further level to 'very low'.The trial provided very low quality evidence that fewer children in the bone marrow injection group had radiographically assessed healing of bone cysts at two years than in the steroid injection group (9/39 versus 16/38; RR 0.55 favouring steroid injection, 95% CI 0.28 to 1.09). However, the result was uncertain and may be compatible with no difference or small benefit favouring bone marrow injection. Based on an illustrative success rate of 421 children with healed bone cysts per 1000 children treated with steroid injections, this equates to 189 fewer (95% CI 303 fewer to 38 more) children with healed bone cysts per 1000 children treated with bone marrow injections. There was low quality evidence of a lack of difference between the two interventions at two years in functional outcome, based on the Activity Scale for Kids function score (0 to 100; higher scores equate to better outcome: MD -0.90; 95% CI -4.26 to 2.46) or in pain assessed using the Oucher pain score. There was very low quality evidence of a lack of differences between the two interventions for adverse events: subsequent pathological fracture (9/39 versus 11/38; RR 0.80, 95% CI 0.37 to 1.70) or superficial infection (two cases in the bone marrow group). Recurrence of bone cyst, unacceptable malunion, return to normal activities, and participant satisfaction were not reported., Authors' Conclusions: The available evidence is insufficient to determine the relative effects of bone marrow versus steroid injections, although the bone marrow injections are more invasive. Noteably, the rate of radiographically assessed healing of the bone cyst at two years was well under 50% for both interventions. Overall, there is a lack of evidence to determine the best method for treating simple bone cysts in the long bones of children. Further RCTs of sufficient size and quality are needed to guide clinical practice.

Proliferative and necrotising otitis externa (PNOE) is a very rare disease affecting the ear canals and concave pinnae of kittens. This report describes a 5-month-old cat with PNOE. Histopathological examination confirmed the diagnosis. Treatment was initiated with local injection of methylprednisolone acetate into the lesions. The cat was subsequently treated with clobetasol propionate cream, a potent topical glucocorticoid ointment. The cat showed marked improvement. While topical treatment with tacrolimus, an immunosuppressive agent, is reported to be an effective therapy, to the best of our knowledge, this is the first report to treat PNOE with local corticosteroid therapy.

Purpose: Triamcinolone hexacetonide (TH), triamcinolone acetonide (TA), and methylprednisolone acetate (MPA) are commonly used intra-articular steroid preparations. Studies suggest that intra-articular TH is more efficacious than MPA and TA in chronic inflammatory arthritis. However, it is unclear which of the latter two preparations has better efficacy. Thus, we compared intra-articular knee injections of MPA and TA in patients with chronic inflammatory arthritis., Methods: This double-blind, randomized controlled trial included patients with rheumatoid arthritis or spondyloarthritis with an acutely swollen knee joint (≥1 week, <24 weeks). They were randomly assigned (1:1) to intra-articular knee injection with MPA or TA (80 mg, 2 mL of each). Evaluations were performed at 4, 12, and 24 weeks. Primary outcome was time to relapse (Kaplan-Meier) over 24 weeks, with relapse defined as return to baseline pain or swelling ≥1 week. Secondary outcomes were change in pain and swelling (using a numerical rating scale), range of movement, and occurrence of adverse effects. Primary analysis was intention to treat, with last observation carried forward., Findings: One hundred patients (89 with rheumatoid arthritis) were randomly assigned in equal numbers to the MPA and TA groups. Nine patients relapsed in each group over 24 weeks. The mean time to relapse was not significantly different between the MPA and TA groups (20.8 [95% CI, 18.8-22.7] weeks and 20.9 [95% CI, 19.0-22.8] weeks, respectively; P = 0.9; hazard ratio = 1.0 [95% CI, 0.4-2.5]). In both groups, there was a significant decline in pain and swelling scores at all visits (P < 0.001); however, there were no significant intergroup differences. At 24 weeks, mean change in pain in the MPA (-4.4 [3.1]) and TA groups (-3.9 [2.8]) was not significantly different (P = 0.46). No infection, hematoma or hypopigmentation occurred in any patient. In addition, no significant intergroup differences were found in joint swelling, range of movement, modified (28 joint) Disease Activity Score using 3 variables, or Health Assessment Questionnaire over 24 weeks., Implications: No significant differences were found in efficacy between intra-articular knee injections with MPA and TA in these patients with chronic inflammatory arthritis. However, results need to be extrapolated cautiously because of the small sample size. Three-quarters of the patients remained relapse free at 24 weeks. Clinical Trials Registry of India (www.ctri.nic.in) identifier: CTRI/2015/09/006187., (Copyright © 2017 Elsevier HS Journals, Inc. All rights reserved.)

Background: Frozen shoulder is not an uncommon disorder, and steroid injection into the glenohumeral (GH) joint is one of the most well-known approaches for the frozen shoulder. However, their results have been varied with beneficial effects or no additional advantage. With the understanding about the pathological changes taking place in frozen shoulder and the biomechanics involved, we wanted to evaluate the short- and long-term efficacy of steroid injection by a novel three-site (NTS) injection technique and compare it with the single-site injection (SSI)., Material and Methods: This was a prospective study with 85 patients including all stages and randomized into two groups. SSI group received steroid injection through posterior approach. NTS group received the same dose of steroid in diluted doses at three sites (posterior capsule, subacromial and subcoracoid). Second sitting was repeated after 3 weeks. Both groups had received the same physiotherapy. The patients were evaluated by CONSTANT score at initial, 3 week, 6 week and 6 month., Results: NTS group patients had significant pain relief and early improvement in activities of daily living ( p < 0.005). Both groups had improvement in shoulder movements but with NTS group, early near-normal scores were attained and sustained after 6 months. About 43% in SSI group could not attain near-normal levels and had relapses., Conclusion: The three-site approach to steroid instillation in frozen shoulder is a safe method and provides early recovery and better improvement in shoulder function with less relapses.

Objective: Osteoarthritis (OA) is a disease with a significant inflammatory component. The aim of this analysis was to determine the relationship between synovial fluid (SF) white blood cell (WBC) count and 2 parameters: disease severity and the reduction in knee pain after intraarticular (IA) steroid injection., Methods: Subjects with painful knee OA were recruited for participation in an open-label study of IA steroid therapy. Information was obtained about knee pain using the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire, and a proportion of subjects underwent magnetic resonance imaging (MRI). Prior to injection with 80 mg methylprednisolone acetate, the index knee joint was aspirated and the fluid obtained was forwarded for assessment of SF WBC count., Results: Information on SF WBC count was available for 55 subjects. An increase in WBC count category (≤100, 101-250, and 251-1,000 cells/mm 3 ) was associated with an increase in synovial tissue volume (P = 0.028) and with other MRI-based measures of disease severity. Also, with each increase in SF WBC count category, there was a greater reduction in KOOS score after steroid injection (for WBC count of ≤100 cells/mm 3 [referent], mean ± SD 12.5 ± 15.2; for WBC count of 101-250 cells/mm 3 , mean ± SD 21.3 ± 20.6 [β coefficient 0.279, P = 0.049]; for WBC count of 251-1,000 cells/mm 3 , mean ± SD 29.3 ± 15.2 [β coefficient 0.320, P = 0.024])., Conclusion: Although all participants in the analysis had SF WBC counts within the "normal" range, total SF WBC count appears to be a biomarker for synovitis on MRI and may also predict response to antiinflammatory treatment., (© 2016, American College of Rheumatology.)

The use of an intra-articular methylprednisolone acetate (MPA) injection has been shown to have benefits for symptoms of knee osteoarthritis (OA). However, considerations beyond drug efficacy can influence the appropriateness, clinical effectiveness and potential harm of an injection. A review of research evidence and published literature on clinical and procedural factors influencing the effectiveness and safety of a knee injection has been undertaken. Factors include dose, frequency, contraindications, precautions, drug interactions, side-effects, and procedural and patient-related considerations. An evaluation of evidence indicated that a 40 mg dose provides clinical benefit. No strong predictors of response were evident, with the exception of pain severity. Additional benefit for outcomes from higher doses, local anaesthetic, ultrasound guidance or particular anatomical approaches is yet to be demonstrated. Evidence for dose- and duration-related detrimental effects suggests judicious use and frequency. The evaluation showed that there are a number of contraindications and precautions arising from the drug pharmacology, concurrent medications, comorbidities and adverse events which need consideration and monitoring. There was limited safety evidence concerning anticoagulation. The review found that specialist guidance and limited evidence suggests that injection safety concerning warfarin may be enhanced by ensuring that the international normalized ratio level is within therapeutic range. However, the risk-benefit evaluation concerning non vitamin K antagonist oral anticoagulants remains challenging. Although there is published guidance, a lack of clinical studies, safety evidence and reversibility advocates caution. Overall, the review indicates that injection decisions and procedures need an individualized approach and supporting evidence is limited in many areas. Evaluation and discussion of benefits and risks, peri-procedural and post-injection management, and tailoring to the context and individuals' preferences are important in optimizing the benefits and safety of a knee injection., (Copyright © 2016 John Wiley & Sons, Ltd.)

Background: Patients diagnosed with idiopathic mild to moderate carpal tunnel syndrome (CTS) are usually managed in primary care and commonly treated with night splints and/or corticosteroid injection. The comparative effectiveness of these interventions has not been reliably established nor investigated in the medium and long term. The primary objective of this trial is to investigate whether corticosteroid injection is effective in reducing symptoms and improving hand function in mild to moderate CTS over 6 weeks when compared with night splints. Secondary objectives are to determine specified comparative clinical outcomes and cost effectiveness of corticosteroid injection over 6 and 24 months., Method/design: A multicentre, randomised, parallel group, clinical pragmatic trial will recruit 240 adults aged ≥18 years with mild to moderate CTS from GP Practices and Primary-Secondary Care Musculoskeletal Interface Clinics. Diagnosis will be by standardised clinical assessment. Participants will be randomised on an equal basis to receive either one injection of 20 mg Depo-Medrone or a night splint to be worn for 6 weeks. The primary outcome is the overall score of the Boston Carpal Tunnel Questionnaire (BCTQ) at 6 weeks. Secondary outcomes are the BCTQ symptom severity and function status subscales, symptom intensity, interrupted sleep, adherence to splinting, perceived benefit and satisfaction with treatment, work absence and reduction in work performance, EQ-5D-5L, referral to surgery and health utilisation costs. Participants will be assessed at baseline and followed up at 6 weeks, 6, 12 and 24 months. The primary analysis will use an intention to treat (ITT) approach and multiple imputation for missing data. The sample size was calculated to detect a 15 % greater improvement in the BTCQ overall score in the injection group compared to night-splinting at approximately 90 % power, 5 % two-tailed significance and allows for 15 % loss to follow-up., Discussion: The trial makes an important contribution to the evidence base available to support effective conservative management of CTS in primary care. No previous trials have directly compared these treatments for CTS in primary care populations, reported on clinical effectiveness at more than 6 months nor compared cost effectiveness of the interventions., Trial Registration: Trial registration: EudraCT 2013-001435-48 (registered 05/06/2013), ClinicalTrials.gov NCT02038452 (registered 16/1/2014), and Current Controlled Trials ISRCTN09392969 (retrospectively registered 01/05/2014).

OBJECTIVE To determine clinical effects of CT-guided lumbosacral facet joint, transforaminal epidural, and translaminar epidural injections of methylprednisolone acetate in healthy dogs. ANIMALS 15 healthy Beagles. PROCEDURES Dogs were randomly assigned to 3 groups (5 dogs/group) and received a single CT-guided lumbosacral facet joint, transforaminal epidural, or translaminar epidural injection of methylprednisolone acetate (0.1 mg/kg). Contrast medium was injected prior to injection of methylprednisolone to verify needle placement. Neurologic examinations were performed 1, 3, 7, and 10 days after the injection. In dogs with neurologic abnormalities, a final neurologic examination was performed 24 days after the procedure. RESULTS Methylprednisolone injections were successfully performed in 14 of the 15 dogs. In 1 dog, vascular puncture occurred, and the methylprednisolone injection was not performed. No major or minor complications were identified during or immediately after the procedure, other than mild transient hyperthermia. During follow-up neurologic examinations, no motor, sensory, or postural deficits were identified, other than mild alterations in the patellar, withdrawal, cranial tibial, and perineal reflexes in some dogs. Overall, altered reflexes were observed in 11 of the 14 dogs, during 27 of 65 neurologic examinations. CONCLUSIONS AND CLINICAL RELEVANCE Results suggested that CT-guided lumbosacral facet joint, transforaminal epidural, and translaminar epidural injections of methylprednisolone acetate were associated with few complications in healthy dogs. However, the number of dogs evaluated was small, and additional studies are needed to assess clinical efficacy and safety of these procedures.

Nonarteritic ischemic optic neuropathy is characterized by sudden, painless, unilateral vision loss. A case of an acute NAION patient who was treated with subtenon methyl prednisolone acetate was presented. The patient, a 65-year-old male, presented vision loss for two days. The total ophthalmologic examination, fundus photography, and automated perimetry were applied to the patient before and after 1, 3, and 6 months from injection. The visual acuity increased from 0,1 to 0,3 in the first month and to 0,7 at the last visit, the visual field defect being mostly improved. This case showed that 40 mg of subtenon methyl prednisolone acetate injection was an effective and safe treatment method for acute NAION. However, a large randomized controlled trial is needed to assess the efficacy of subtenon methyl prednisolone acetate as a treatment for NAION.

This study aimed to determine the factors associated with response to intra-articular steroid injection (IASI) in patients with knee joint osteoarthritis. One hundred seventy-four female patients, age ranging from 30 to 80 years, diagnosed to have osteoarthritis of the knee joint, were given IASI. Response to IASI was assessed by using WOMAC and VAS at 2 weeks, 4 weeks and 3 months. At 3 months, the subjects were categorized as responders, partial responders and non-responders to treatment by IASI. Various factors were narrowed down to see their effect on response, namely age, BMI, smoking habits, comorbidities, presence of clinical effusion, radiographic score, local knee tenderness, range of movement and socioeconomic status. One hundred twenty-four patients completed the study. 16.1 % showed 50 % or more improvement in WOMAC score at 3 months post IASI therapy, whereas 38.7 % of OA patients had more than 50 % improvement in VAS score. Out of all factors, range of movement, local knee tenderness and radiographic score of the affected joint are the three parameters which can predict the improvement in WOMAC score after 3 months of IASI therapy (P = 0.013, P = 0.045 and P = 0.000, respectively). Age of the patient can predict improvement in VAS at 3 months post IASI (P = 0.027). We conclude that age, range of movement, local knee tenderness and radiographic score of the affected joint can predict response to IASI after 3 months of IASI therapy.

The present study deals with preparation and optimization of a novel chitosan hydrogel-based matrix by suspension cross-linking method for controlled release of Depo-Medrol. The controlled release of Depo-Medrol for effective Rheumatoid arthritis disease has become an imperative field in the drug delivery system. In this context, it was intended to optimize loading circumstances by experimental design and also study the release kinetics of Depo-Medrol entrapped in the chitosan matrix in order to obtain maximal efficiency for drug loading. The optimum concentrations of chitosan (2.5 g), glutaraldehyde (3.05 μL) and Depo-Medrol (0.1 mg) were set up to achieve the highest value of drug loaded and the most sustained release from the chitosan matrix. In vitro monitoring of drug release kinetic using high-performance liquid chromatography showed that 73% of the Depo-Medrol was released within 120 min, whereas remained drug was released during the next 67 h. High correlation between first-order and Higuchi's kinetic models indicates a controlled diffusion of Depo-Medrol through the surrounding media. Moreover, recovery capacity >82% and entrapment efficiency of 58-88% were achieved under optimal conditions. Therefore, the new synthesized Depo Medrol-chitosan is an applicable appliance for arthritis therapy by slow release mechanism. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Introduction: We sought to document the efficacy of interlaminar epidural steroid injections (ESIs) for the relief of low back pain in a rural population., Methods: We conducted a prospective observational cohort study with brief follow-up telephone interviews at 1, 3 and 6 months after interlaminar ESI., Results: A total of 47 ESIs were administered to the 24 participants. In an intention-to-treat analysis, pain relief was achieved in 78.7%, 55.3% and 27.7% of participants at 1, 3 and 6 months., Conclusion: Interlaminar ESIs, without fluoroscopic guidance, were effective for up to 3 months of symptom relief.

Objectives: The aim of the present study was to compare the clinical results and the quality of life in patients with symptomatic knee osteoarthritis randomised to either a new HA (HYADD 4) or corticosteroid (CS). A separate rationale was to evaluate the safety profile of HYADD 4., Methods: All the patients presenting for unilateral symptomatic primary knee osteoarthritis were prospectively randomly assigned to receive 2 injections of either HYADD 4 or CS, and were evaluated before the injections and at 6, 12, 26 and 52 weeks. Primary end point was WOMAC score at 26 weeks; secondary end points were WOMAC score, VAS for pain, and SF-36 score at any time point., Results: There were 53 females and 22 males in the HYADD 4 group (mean age 71.5±10.6 years), and 50 females and 25 males in the CS group (mean age 68.6±9.9 years). The observed sided effects were mild and their incidence was similar in the two groups. Patients in the HYADD 4 group reported significantly better WOMAC scores at 26 weeks. The patients improved in all considered outcomes after the injections, with a peak of therapeutic effect between 6 and 12 weeks. Patients in the HYADD 4 group obtained significantly better scores than the CS group up to 26 weeks. At the 1-year follow-up no statistically significant differences between treatments were detected., Conclusions: HYADD 4 did not have significantly higher side effects when compared to CS injections and provided better short-term (but not long-term) control of symptoms in patients with mild to moderate knee osteoarthritis. Patients with less pain and dysfunction at baseline may be the best candidates for HYADD 4 injections.

The objective of this study was to improve the therapeutic efficacy of methylprednisolone acetate (MPA) in the treatment of rheumatoid arthritis (RA) by incorporating the drug into the hydroxyapatite (HAp) nanoparticles. The nanoparticles were synthesized using a chemical precipitation technique and their size and morphology were evaluated by dynamic light scattering and scanning electron microscopy (SEM). The solid-state behavior of the nanoparticles was also characterized by operating X-ray powder diffraction (XRPD), differential scanning calorimetry (DSC) and Fourier-transform infrared spectroscopy (FTIR). The Brunauer-Emmett-Teller and Barrett-Joyner-Halenda N2 adsorption/desorption analyses were also performed to determine the surface area, Vm (the volume of the N2 adsorbed on the one gram of the HAp when the monolayer is complete) and the pore size of the samples. Furthermore, the therapeutic efficacy of the prepared nanoformulation on the adjuvant induced arthritic rats was assessed. HAp mesoporous nanoparticles with a particle size of 70.45nm, pore size of 2.71nm and drug loading of 44.53% were obtained. The specific surface area of HAp as well as the Vm values were decreased after the drug loading process. The nanoformulation revealed the slower drug release profile compared to the pure drug. The MTT assay indicated that the MPA-loaded nanoparticles had a lower cytotoxic effect on NIH-3T3 and CAOV-4 cell lines compared to the pure drug. Interestingly, the in vivo study confirmed that the drug-loaded nanoparticles could considerably decrease the paw volume and normalize the hematological abnormalities in the arthritic rats., (Copyright © 2016 Elsevier B.V. All rights reserved.)

Background: Evidence on the effect of platelet-rich plasma (PRP) in treating osteoarthritis (OA) is insufficient. Therefore, the present study compares the effects of a one-time injection of PRP and corticosteroid (CS)., Methods: In the present randomized double blind clinical trial, the participants who suffered from knee osteoarthritis (Grades II/III), were randomly divided into two groups: intra articular injection of PRP and CS. Knee injury and osteoarthritis outcome score (KOOS), the 20-Meter-Walk Test (20MW), active and passive ranges of motions (ROM), flexion contracture, and pain intensity based on Visual Analog Scale (VAS) were assessed before, 2-months, and 6-months after interventions., Results: Forty-one participants (48 knees) were involved in the research (66.7% women; average age of 61.1±7.0 years old). Compared to the group treated with corticosteroid, pain relief (df: 6, 35; F=11.0; P=0.007), symptom free (df:6, 35; F=23.0; P<0.001), activities of daily living (ADL) (df:6, 35; F=10.7; P=0.005) and quality of life (df:6, 35; F=5.2; P=0.02) in the RPR group were significantly higher, but sporting ability was not different between the two groups (df: 6, 35; F=0.6; P=0.55). PRP was significantly more helpful for relieving patients' pain (VAS) compared to corticosteroids (df: 6, 35; F=32.0; P=0.001). It is also notable that using PRP was more helpful in improving the 20MW test than corticosteroid treatment (df: 6, 35; F=7.4; P=0.04) but none of the treatments had any impact on active flexion ROM، passive flexion ROM and flexion contracture (P>0.05)., Conclusions: Our study demonstrated that one shot of PRP injection, decreased joint pain more and longer-term, alleviated the symptoms, and enhanced the activity of daily living and quality of life in short-term duration in comparison with CS.

Fructosamine is a glycated protein that reflects blood glucose control over the last 2-3 weeks. There are no studies that address the impact of intra-articular injection (IAI) of methylprednisolone acetate (MPA) on fructosamine levels among patients with type-2 diabetes and osteoarthritis of the knee (OAK). Non-selected patients attending the rheumatology or orthopedic clinic with type-2 diabetes and painful OAK, who failed non-steroidal anti-inflammatory drugs (NSAIDS) and physical therapy, were asked to participate in our study. After consent blood tests were drown for fructosamine, hemoglobin A1c (HbA1c) level, complete blood count, lipid profile, serum albumin, serum protein, c-reactive protein, and erythrocyte sedimentation rate. Demographic and different clinical parameters were also documented. Immediately after that, patients had IAI of 80 mg of MPA at the knee joint (group 1). Two to three weeks later, the same blood tests were repeated (except for HbA1c). Age- and sex-matched group of patients with type-2 diabetes and painful OAK attending the same clinics, but who were managed by NSAIDS were asked to participate as a control group (group 2) and had the same evaluation at enrollment and 2-3 weeks later, after consent. Eighteen patients from either group completed the study. Mean fructosamine level in group 1 patients was 263.7 ± 31.8 mg% prior to the IAI vs. 274.6 ± 39.3 mg% (p = 0.035), 2-3 weeks later, while mean fructosamine level in the control group (group 2) at enrollments was 274.2 ± 31.2 mg% vs. 269 ± 30.2 mg%, p = 0.509, 2-3 weeks later. There was no significant change in any other parameter tested at enrollment in either group, compared to those obtained 2-3 weeks afterwards. Body mass index was on the edge of significance as a predictor for a significant change in fructosamine level in group 1 patients. IAI of 80 mg of MPA in patients with type-2 diabetes and OAK had resulted in a significant, though mild increase in fructosamine levels 2-3 weeks later.

Study Design: A prospective, randomized, placebo-controlled, double-blind trial., Objective: The aim of this study was to investigate whether the local administration of depomedrol decreases the severity of dysphagia after anterior cervical discectomy and fusion (ACDF) surgery using bone morphogenetic protein (BMP)., Summary of Background Data: Although recombinant human BMP-2 is effective in promoting arthrodesis, many physicians avoid using it in anterior cervical spine fusions due to concern for increased incidence of dysphagia, significant pre-vertebral swelling, and airway compromise. Pilot studies have shown that the local application of depomedrol may decrease the incidence of postoperative dysphagia. We performed a prospective, randomized trial to evaluate the efficacy of local depomedrol application in reducing the severity of postoperative dysphagia following anterior cervical fusions using low-dose rhBMP-2. We hypothesized that locally administered depomedrol reduces dysphagia following such surgeries., Methods: Fifty patients between 18 and 70 years of age, undergoing 1, 2, and 3-level ACDFs, were randomized to 1 of 2 groups: BMP-2 with depomedrol or BMP-2 with saline. Patients were followed for 4 weeks postoperatively by the study administrator. Dysphagia was measured at 5 time intervals (postoperative days 1, 4, 7, 14, and 28) using a 4-point Modified Dysphagia Scoring System. Additional data regarding overall length of hospital stay and the administration of dysphagia-directed treatments were also recorded., Results: Twenty-seven patients were randomized to the treatment (depomedrol) group and 23 were randomized to the control (saline) group. The 2 groups were nearly identical in terms of their demographic and operative characteristics. Patients receiving depomedrol experienced decreased dysphagia incidence and magnitude at all time intervals, with differences reaching statistical significance on postoperative days 4, 7, 14, and 28 (P < 0.05)., Conclusion: This study provides Level 1 evidence that locally administered depomedrol on a collagen sponge significantly decreases postoperative dysphagia incidence and magnitude following anterior cervical spine fusion using low-dose rhBMP-2., Level of Evidence: 1.

Objective: To compare the short-term efficacy of conventional blind injection (CBI) versus ultrasound-guided injection (USGI) of corticosteroids (CS) injection in tenosynovitis in patients with chronic arthritis and to investigate if the USGI is a less painful procedure and if there are differences in the changes of US findings during the post injection follow-up., Methods: Patients presenting tenosynovitis requiring CS injection were involved. After clinical and US evaluation, patients were randomized to receive CBI or USGI. Efficacy of procedure was assessed by the improvement in both Health Assessment Questionnaire (HAQ) and pain visual analogue scale (VAS), including procedure-VAS global-VAS and local-VAS, after 1 and 4 weeks post-procedure. Power Doppler (PD) and greyscale (GS) US findings were also object of the follow-up. CBI or USGI under an aseptic technique were performed according the local guidelines using 20mg of methylprednisolone acetate., Results: A total of 114 patients were randomized to receive CBI (54 patients) or USGI (60 patients) procedure. No significant difference was observed in terms of gender, age and pain duration among CBI and USGI groups at baseline. USGI proved to be significantly less painful than CBI (P=0.0001). AUC analysis showed that during the follow up visits, the USGI procedure had significantly better response in HAQ, local-VAS and global-VAS (P=0.0001, P=0.012 and P=0.0001 respectively) compared to CBI. During the follow up period, a significant greater reduction in the PD scores was found in the USGI group compared to the CBI group (P=0.0002), whereas no statistical differences were found in the GS findings between the groups (P=0.5627)., Conclusion: Our study demonstrates superiority of USGI over CBI for CS injections in painful tenosynovitis, having better short-term outcomes measured by functional, clinical and US scores. These data support the use of USGI for tenosynovits in typical inpatient and/or outpatient in rheumatological practices., (Copyright © 2015 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.)

Background: Abdominal wall pain (AWP) is an important cause of chronic abdominal pain. History and physical examination are critical to the diagnosis of AWP. Trigger point injection (TPI) using either a steroid or a local anesthetic or a combination of both is often used to treat AWP., Aim: To determine the efficacy of ultrasound-guided TPI and to determine the predictors of a successful response., Methods: Patients who received ultrasound-guided TPI between July 2010 and June 2011 were surveyed. The primary outcome was determined using the Treatment Efficacy Questionnaire (TEQ). Electronic medical records were reviewed to determine patient, pain and TPI characteristics. Linear regression was used to determine the predictors of a successful response on the TEQ., Results: Right upper quadrant was the most common site of AWP, and the median pain duration was 12 months. Pain was rated as >8 (1-10 scale) by 57 % and 30 % described it as an ache. Narcotic use was reported in 38 %, and 73 % had a history of at least one abdominal surgery. Forty-four of the 120 (37 %) patients met the criteria for responder on the TEQ. Compared to before treatment, 36 % reported being "significantly better" and 22 % "slightly better." Multiple linear regression analysis showed that higher somatization negatively predicted response. None of the other historical, examination or TPI characteristics were associated with response to the TPI., Conclusion: TPI can provide significant, long-term symptom relief in a third of patients with chronic abdominal pain attributed to AWP. Somatization was inversely related to the treatment success.

Background: This study compared the effectiveness of joint mobilization combined with stretching exercises (JM&Str) vs steroid injection (SI) in the treatment of plantar fasciitis (PF)., Methods: A total of 43 patients (mean age, 45.5 ± 8.5 years; range, 30-60 years; 23 females) with PF were randomly assigned to receive either JM&Str (n = 22) or SIs (n = 21). JM&Str was applied 3 times per week for 3 weeks for a total of 9 visits. The SI group received 1 injection at baseline. The patients' functional scores were assessed using the Foot and Ankle Ability Measure (FAAM), and pain was evaluated using the Visual Analog Scale (VAS). Outcomes of interest were captured at baseline and at 3-week, 6-week, 12-week, and 1-year follow-ups. The primary aim was examined using a mixed-model analysis of variance (ANOVA). Pairwise comparisons were performed to examine differences between the baseline and follow-up periods using Bonferroni equality at an alpha level of 0.05., Results: Age, sex, body mass index, and dorsiflexion range of motion did not significantly impact pain relief or functional outcome (P > .05) at the 3-, 6- or 12-week follow-ups compared to baseline. Planned pairwise comparisons demonstrated significant improvements in pain relief and functional outcomes in both groups (P < .05) at the 3-, 6-, and 12-week follow-ups compared to baseline. However, at the 12-week and 1-year follow-ups, pain and functional outcomes were significantly improved in only the JM&Str group (P = .002). The overall group-by-time interaction was statistically significant for both FAAM (P = .001; F = 7.0) and VAS (P = .001; F = 8.3) scores. Between-group differences favored the SI group at the 3-week (P = .001, P = .001), 6-week (P = .002, P = .001), and 12-week (P = .008, P = .001) follow-ups for pain relief and functional outcomes. However, no significant differences (P = .62, P = .57) were detected in the measured outcomes at the 1-year follow-up., Conclusion: Our study demonstrated that while both groups achieved significant improvements at the 3-, 6-, and 12-week follow-ups, the SI group exhibited better outcomes at all 3 time points. The noted improvements continued in only the JM&Str group for a period of time ranging from 12 weeks to 1 year., Level of Evidence: Level II, comparative study., (© The Author(s) 2015.)

The hypothesis tested in this experiment was that Trichostrongylus colubriformis infection would reduce growth rates of grazing meat-breed lambs; however production loss would be reduced by suppression of the host immune response. The experiment had a 3×2 factorial design using 6-7 month old meat-breed lambs which remained uninfected or infected (IFY) with 2000 or 4000 T. colubriformis L3/week for 12 weeks and were immunosuppressed (SUPY) using methylprednisolone acetate once weekly or remained non-immunosuppressed (SUPN). Immunosuppression increased worm egg counts (WEC) of infected lambs (SUPY 2421 eggs per gram (epg), SUPN 1154 epg on day 84, p<0.05) and T. colubriformis burdens (p<0.05-0.10) and reduced circulating eosinophils (p<0.05 on days 11, 42, 56 and 84) and intestinal total antibody titres (p<0.02). There was a significant (p<0.05) interaction between the main effects of infection and immunosuppression with infection having a larger negative effect on the liveweight of non-immunosuppressed lambs. The immunological response of the host to T. colubriformis infection accounted for 75% of the overall cost of infection (3.1kg) with the majority of this cost occurring during the first 35 days of infection. In contrast, most of the cost associated with the direct effect of infection occurred after day 35. These results confirm in grazing meat-breed lambs that the host's immunological response to T. colubriformis infection is the major component of production loss., (Copyright © 2015 Elsevier B.V. All rights reserved.)

Background: The effect of corticosteroids on tendons is poorly understood, and current data are insufficient and conflicting., Purpose: To evaluate the effects of corticosteroid injections on intact and injured rotator cuffs (RCs) through biomechanical and radiographic analyses in a rat model., Study Design: Controlled laboratory study., Methods: A total of 70 rats were assigned to 7 groups. Uninjured rats (no tear) received either a single saline injection, a single methylprednisolone acetate (MTA) injection, or triple MTA injections. Injured rats (unilateral supraspinatus injury) received either a single saline injection, triple saline injections, a single MTA injection, or triple MTA injections (injections were subacromial; repeat injections were administered weekly). Rats were sacrificed 1 week after final injection. Shoulders were harvested and grossly inspected, and the supraspinatus tendon was evaluated biomechanically. Bone density at the tendon insertion site on the greater tuberosity was assessed by micro-computed tomography., Results: Intact RCs exposed to triple MTA injections had significantly decreased maximal load and stiffness compared with the control group (14.43 vs 21.25 N and 8.21 vs 16.6 N/mm, respectively; P < .05). Injured RCs exposed to steroid treatment had significantly lower maximal load (single saline: 10.91 N, single steroid: 8.43 N [P < .05]; triple control: 15.77 N, triple steroid: 11.65 N [P < .05]) compared with the control at 3 weeks. Greater tuberosity volume density and connectivity density were significantly lower in undamaged rats after triple MTA injection (P < .05)., Conclusion: The study results clearly showed that repeated doses of corticosteroids significantly weaken rat RC and negatively affect bone quality in addition to possibly causing deterioration of the osteotendinous junction. However, data retrieved from animals must be scrupulously analyzed before extrapolation to humans. As such, the potential benefits and harms of subacromial corticosteroid treatment must be considered before administration., Clinical Relevance: The potential benefit and detrimental effects of corticosteroid injection should be thoroughly considered before it is administered subacromially in patients with RC injuries., (© 2015 The Author(s).)

The aim of the present study was to formulate methylprednisolone acetate -Eudragit(®) RS100 nanofibers and nanobeads by the electrospinning method. The physicochemical characteristics of the prepared electrospuns were assessed as well. The particle size and morphology were evaluated using scanning electron microscopy. The crystallinity of the drug in the nanofibers and nanobeads obtained was also studied by X-ray crystallography and differential scanning calorimetry (DSC) thermograms. In addition, FT-IR spectroscopy was applied to investigate any possible chemical interaction between the drug and carrier during the preparation process. The drug release kinetics were considered, to predict the release mechanism. Increasing the concentration of the injected solution resulted in the production of more nanofibers and less nanobeads, with the particle size ranging from 100 to 500 nm. The drug crystallinity was decreased during the electrospinning process; however, no interaction between drug and polymer was observed. The electrospuns showed faster drug release pattern compared to the pure drug. The release data were best fitted to the Weibull model, in which the corresponding shape factor values of the model were less than 0.75 indicating the diffusion mechanism of drug release. In conclusion, electrospinning could be considered as a simple and cost effective method for fabricating the drug: polymer nanofibers and nanobeads.

Purpose: The primary objective of this pilot study was to compare pain and function scores from patients before and after an ozone injection in combination with steroids and bupivacaine to treat herniated discs. A secondary objective was to correct some of the methodological weaknesses of some previously published ozone studies., Methods: Fifty patients were enrolled; 1-3 mL of 2 wt% ozone in 98 wt% oxygen was delivered into the nucleus pulposus, and 7-9 mL into the adjacent paravertebral tissues. The oxygen/ozone treatment was followed by a periganglionic injection of corticosteroid and bupivacaine. All patients were evaluated 1 month after the treatment to quantify improvement in pain and function, and to monitor for potential adverse events., Results: Forty-four patients had intradiscal injections and were included in the analysis. After 1 treatment, 75.0% showed significant improvement in pain based on the visual analog scale (improvement >1.8), 72.7% showed significant improvement in function based on the Oswestry disability index (improvement >15%), and 79.5% showed improvement based on the modified MacNab criteria. There were no adverse events associated with the treatment., Conclusions: Patients showed significant improvement in pain and function after receiving ozone injections in combination with steroids and bupivacaine for the treatment of herniated discs. Because of the lack of a control group and short follow-up times, conclusions about the safety and efficacy of ozone injections for the treatment of herniated discs are not warranted. However, the results provide sufficient evidence that the risk and expense of an additional randomized controlled study is merited., (Copyright © 2015 Canadian Association of Radiologists. Published by Elsevier Inc. All rights reserved.)

Background: Seroma formation, the most prevalent postoperative complication after mastectomy, is an inflammatory process that is potentially preventable via local steroid administration. This study investigated the effect of local steroid administration on seroma formation., Methods: This was a double-blind randomized placebo-controlled intervention study of a single dose of 80 mg methylprednisolone versus saline on seroma formation after mastectomy. Patients were further classified according to the surgical axillary procedure: mastectomy with sentinel lymph node biopsy (M + SLNB) or mastectomy with level I-II axillary lymph node dissection (M + ALND). Treatments were administered into the wound cavity via the drain orifice following removal of the drain on the first day after surgery. The primary endpoint was seroma formation; secondary endpoints included the frequency of side-effects and complications., Results: A total of 212 women scheduled for mastectomy for primary breast cancer were included. After M + SLNB, 32 (46 per cent) of 69 women developed a seroma in the methylprednisolone group, compared with 52 (78 per cent) of 67 in the saline group (P < 0.001). The mean cumulative seroma volume in the intention-to-treat population for the first 10 and 30 days was significantly lower in the methylprednisolone group (24 ml versus 127 ml in the saline group, and 177 versus 328 ml respectively) (P < 0.001). After M + ALND, similar proportions of patients developed a seroma in the methylprednisolone (35 of 37, 95 per cent) and saline (34 of 36, 94 per cent) groups, and methylprednisolone administration had no significant effect on seroma formation. No differences in infection rate were observed., Conclusion: Methylprednisolone administered into the wound cavity on the first day after M + SLNB exerted a highly significant preventive effect against seroma formation during the next 30 days. This effect was not seen in the M + ALND group. Future studies may clarify whether higher or repeated methylprednisolone doses increase the efficacy., (© 2015 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Objective: Intraarticular (IA) corticosteroid injections are broadly used in knee osteoarthritis (OA); however, the best corticosteroid agent is not well defined. The aim of the present study was to compare the efficacy of triamcinolone hexacetonide (TH) and methylprednisolone acetate (MA) injections in knee OA., Methods: Patients with symptomatic knee OA and Kellgren-Lawrence grade II or III were randomized to receive 40 mg of IA TH or MA. Evaluations were performed at 4, 12, and 24 weeks. The primary outcome was a change in the patient's assessment of pain by visual analog scale from baseline to Week 4. Secondary outcomes included a global assessment of the disease by patients and physicians, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequesne index (LI), and Outcome Measures in Rheumatology Clinical Trials and Osteoarthritis Research Society International (OMERACT-OARSI) criteria of response. Generalized estimating equations were used in statistical analysis., Results: The intention-to-treat population included 100 patients; 50 in each study arm. A significant improvement in pain was observed at Week 4 for both groups (p < 0.0001), with no difference between them (p = 0.352). This improvement was sustained up to Week 24. A significant improvement from the baseline was observed for both the patient's and the physician's global assessments, WOMAC questionnaire, and LI, with no differences between the groups. Improvements in the secondary outcomes were sustained during the study. The OMERACT-OARSI criteria of response was achieved by 74% and 72% of patients in the TH and the MA groups, respectively., Conclusion: Both IA therapies are equally effective, and improvement in pain and function can be sustained for up to 24 weeks. Controlled-trials.com identifier: ISRCTN15077843.

Introduction: We conducted a randomized, double-blind, placebo-controlled trial to evaluate the effect of ultrasound-guided corticosteroid injection in patients with ulnar neuropathy at the elbow (UNE)., Methods: Fifty-five patients were randomized between an ultrasound-guided injection of 1 ml containing 40 mg methylprednisolone acetate and 10 mg lidocaine hydrochloride or a placebo injection. The primary outcome was the subjective change of symptoms after 3 months. The secondary outcomes were change in electrodiagnostic studies and ultrasonography findings., Results: A success rate of 30% was found in the corticosteroid injection group versus 28% in the placebo injection group. Only the nerve cross-sectional area changed significantly in the intervention group, from a mean of 11.9 mm(2) to 10.9 mm(2) ., Conclusions: We could not demonstrate a positive effect of ultrasound-guided corticosteroid injection in UNE compared with placebo. Favorable outcomes may be attributed to the natural course of UNE or the effect of patient education., (© 2014 Wiley Periodicals, Inc.)

Background: High-dose intravenous glucocorticoid (ivGC) pulse therapy, which is commonly used for Graves' orbitopathy (GO), has been associated with acute liver damage (ALD), resulting in a fatal outcome in a few cases. No certain risk factors for ALD have been established. Consequently, a large retrospective cohort study was performed., Methods: The relationship between ALD and several potential risk factors was assessed in 1076 consecutive patients with GO given ivGC. ALD was defined as an increase of alanine aminotransferase ≥300 IU/L., Results: Fourteen cases of ALD were recorded, resulting in a morbidity of 1.3%. Thirteen patients recovered and one died, resulting in a mortality of 0.09%. There was a significant, positive correlation of ALD with age and methylprednisolone acetate (MPA) cumulative dose, and ALD was more common (relative risk [RR]=2.8; p=0.05) in patients aged ≥53 years (9/420; 2.14%) than in those aged <53 years (5/656; 0.76%). In patients aged ≥53 years, there was a significant positive correlation of ALD with MPA cumulative dose, and with MPA dose per infusion. Thus, the frequency of ALD in this age group was greater (RR=3.48; p=0.04) in patients with a MPA dose per infusion ≥0.7 g (5/111, 4.5% vs. 4/308, 1.29%). Regardless of age, no cases of ALD were observed for MPA doses per infusion <0.57 g., Conclusions: Age and MPA dose are significant risk factors for ALD, with the following practical implications. First, the total MPA cumulative dose should not exceed 8.5 g (the average dose in patients without ALD). Second, in patients aged ≥53 years, selection and observation should be quite strict. However, being aged ≥53 years should not be seen as an absolute contraindication to ivGC, especially in patients with severe GO, considering that the risk of ALD, although statistically significant, was relatively low. Third, the MPA dose should not exceed 0.57 g per infusion, a measure to be applied regardless of age.

Importance: Osteoarthritis (OA) of the knee is the most frequent form of arthritis and a cause of pain and disability. Combined nonpharmacologic and pharmacologic treatments are recommended as the optimal treatment approach, but no evidence supports the recommendation., Objective: To assess the clinical benefits of an intra-articular corticosteroid injection given before exercise therapy in patients with OA of the knee., Design, Setting, and Participants: We performed a randomized, blinded, placebo-controlled clinical trial evaluating the benefit of intra-articular corticosteroid injection vs placebo injection given before exercise therapy at an OA outpatient clinic from October 1, 2012, through April 2, 2014. The participants had radiographic confirmation of clinical OA of the knee, clinical signs of localized inflammation in the knee, and knee pain during walking (score >4 on a scale of 0 to 10)., Interventions: Participants were randomly allocated (1:1) to an intra-articular 1-mL injection of the knee with methylprednisolone acetate (Depo-Medrol), 40 mg/mL, dissolved in 4 mL of lidocaine hydrochloride (10 mg/mL) (corticosteroid group) or a 1-mL isotonic saline injection mixed with 4 mL of lidocaine hydrochloride (10 mg/mL) (placebo group). Two weeks after the injections, all participants started a 12-week supervised exercise program., Main Outcomes and Measures: The primary outcome was change in the Pain subscale of the Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire (range, 0-100; higher scores indicate greater improvement) at week 14. Secondary outcomes included the remaining KOOS subscales and objective measures of physical function and inflammation. Outcomes were measured at baseline, week 2 (exercise start), week 14 (exercise stop), and week 26 (follow-up)., Results: One hundred patients were randomized to the corticosteroid group (n = 50) or the placebo group (n = 50); 45 and 44 patients, respectively, completed the trial. The mean (SE) changes in the KOOS Pain subscale score at week 14 were 13.6 (1.8) and 14.8 (1.8) points in the corticosteroid and placebo groups, respectively, corresponding to a statistically insignificant mean difference of 1.2 points (95% CI, -3.8 to 6.2; P = .64). We found no statistically significant group differences in any of the secondary outcomes at any time point., Conclusions and Relevance: No additional benefit results from adding an intra-articular injection of 40 mg of corticosteroid before exercise in patients with painful OA of the knee. Further research is needed to establish optimal and potentially synergistic combinations of conservative treatments., Trial Registration: clinicaltrialsregister.eu Identifier: 2012-002607-18; clinicaltrials.gov Identifier: NCT01945749.

Purpose: To compare the six-month outcome of three different ultrasound-guided treatments for de Quervain's disease (DQD)., Methods: We prospectively treated 75 consecutive patients (51 females, 24 males, mean age ± standard deviation = 45.3 ± 9.8 years) with DQD. Patients' features (hand dominance, intraretinaculum septum, accessory tendons) were recorded. Visual analogue scale (VAS), reduced disability (quickDASH) score, and retinaculum thickness were evaluated at baseline and after one (excluding retinaculum thickness), three, and six months. Patients were randomized into three groups of 25 patients each treated under ultrasound guidance: Group A (1 ml methylprednisolone acetate; mean baseline thickness = 1.6 mm; mean baseline VAS = 6; mean baseline quickDASH = 55); Group B (1 ml methylprednisolone acetate +15-day delayed 2 ml saline 0.9 %; 1.4; 6; 56); Group C (1 ml methylprednisolone acetate +15-day delayed 2 ml low molecular weight hyaluronic acid; 1.7; 6; 55)., Results: After one month results were: Group A mean VAS = 2; mean quickDASH = 23; Group B 2; 22; Group C 2; 21. After three months results were: Group A retinaculum thickness = 0.7 mm; 3; 27); Group B 0.8 mm; 1; 25; Group C 0.5 mm; 1; 23. After six months results were: Group A 1.5 mm; 3; 51; Group B 1 mm; 2; 51; Group C 0.7 mm; 1; 26 (P < 0.001 for all vs. baseline). Patients' age, sex, hand dominance, presence of subcompartment dividing septum, and supernumerary tendons had no influence on outcome (P  ≥  0.177)., Conclusion: Addition of hyaluronic acid to ultrasound-guided injections of steroids to treat DQD seems to improve the outcome and to reduce the recurrence rate., Key Points: • Ultrasound guidance allows for safe injection procedures to treat de Quervains' disease • Steroid injections allow prompt recovery in de Quervain's disease with short-term recurrence • Addition of hyaluronic acid allows recurrence rate reduction compared to simple steroid injections.