Ankle intra-articular steroid effective in juvenile arthritis

Image-guided steroid injection produces durable clinical improvement in inflamed ankles of children with juvenile idiopathic arthritis and may help prevent irreversible deformity, Dr Kevin Baskin (Children’s Hospital of Philadelphia, PA) reported at the 2006 Society of Interventional Radiology annual scientific meeting

“The take-home message is to get into the joint and treat acute disease before there are chronic sequelae. Treat every time they have an acute flare until the disease burns out in adulthood, as it does for many. There is a good chance patients can be spared permanent loss of mobility, gait disturbances, pain, and disfigurement,” Baskin told rheumawire. Fluoroscopy guides steroid injection into difficult jointBaskin and colleagues at the Children’s Hospital of Philadelphia conducted a pilot study of fluoroscopically guided intra-articular ankle steroid injections in 38 children with symptoms of ankle arthritis that suggested involvement of the subtalar joint, such as decreased inversion or eversion. “Rheumatologists are used to injecting into more accessible joints and report that such steroid treatments are frequently successful,” Baskin said. “Complex joints such as the subtalar or temporomandibular are hard to access, which is how we interventional radiologists got involved. The subtalar joint is triple-faceted and extremely complex and difficult to treat with traditional methods. We found a 91% clinical improvement that lasted a mean of 1.3 years after corticosteroid was injected directly into the inflamed joint using fluoroscopy for precise needle placement.”The patients had a mean age of 4.4 years (range 1.2-13.6 years) and median elapsed time from diagnosis to intra-articular steroid treatment of 0.1 year (range 0.0-7.6 years).Patients were sedated for the injections, which were done as outpatient procedures. The researchers injected 1 mL or less of triamcinolone hexacetonide or acetonide into the mid subtalar joint using a lateral oblique approach. Clinical improvement was evaluated by change in foot inversion and eversion at follow-up office visits. Fifty-five subtalar injections were done in the 38 children.Treatment was followed by clinical improvement (physician’s subjective judgment of improved ankle mobility, plus reduction in pain) or complete resolution of symptoms and return to normal mobility in 50 of 55 injections (91%). Baskin told rheumawire that 44% of patients had complete resolution of arthritis in the treated joint, with no residual swelling, pain, or loss of mobility, and all the other patients had substantial improvement.As might be expected, treatment was most effective in those treated earliest in the disease course, with greatest improvement seen with treatment given within one year of disease onset (p=0.04 for <1 year vs >1 year between diagnosis and treatment). “If we treat early in the acute phase, there is significant or total resolution of acute symptoms before the patient develops chronic sequelae, destruction of cartilage, thickening of the joint capsule, or changes in underlying bone,” Baskin said. “Once chronic changes occur, they seem to be irreversible.”Adverse effects included asymptomatic hypopigmentation or subcutaneous atrophy in 20 patients (53%). These problems correlated directly with volume of injected steroid per patient weight (mean 0.06 mL/kg vs 0.04 mL/kg, p=0.005 for those with vs without hypopigmentation or atrophy). The investigators think that reducing the volume of steroid injected will likely prevent this problem.”It’s important for interventional radiologists and rheumatologists to pool their expertise to fight this disease together, to improve the quality of life for affected children and the long-term chances that those who outgrow this disease may live as active, mobile, pain-free adults,” Baskin said.(Source:[1] Cahill AM, Beukelman T, Kaye RD, et al. Intra-articular corticosteroid injection for subtalar arthritis in children with juvenile idiopathic arthritis. 2006 Society of Interventional Radiology annual scientific meeting; April 3, 2006; Toronto, ON. Abstract 150.Rheumawire: Joint and Bone: April 2006.)