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Effect of Intra-articular Triamcinolone vs Saline on Knee Cartilage Volume and Pain in Patients With Knee Osteoarthritis: A Randomized Clinical Trial

PainSci » bibliography » McAlindon et al 2017
updated
Tags: injections, knee, arthritis, harms, bad news, medicine, treatment, leg, limbs, pain problems, aging

One page on PainSci cites McAlindon 2017: The Complete Guide to Patellofemoral Pain Syndrome

PainSci notes on McAlindon 2017:

This is 2-year trial of corticosteroid injections for knee osteoarthritis in 140 patients. Steroids were compared to saline injections, and fared poorly: they had no effect on pain, and a negative effect on cartilage. In theory, corticosteroids might suppress the inflammation that could be causing cartilage to erode in the first place; in practice, in this trial, there was more cartilage loss! Ruh roh. The authors note, “It is likely that the difference in cartilage loss rates between groups was due to an adverse effect of intra-articular corticosteroids … .”

By design, pain was not measured in the weeks after injection, when steroids are well known to have at least a temporary benefit. The study was structured to detect any long-term changes in pain.

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

IMPORTANCE: Synovitis is common and is associated with progression of structural characteristics of knee osteoarthritis. Intra-articular corticosteroids could reduce cartilage damage associated with synovitis but might have adverse effects on cartilage and periarticular bone.

OBJECTIVE: To determine the effects of intra-articular injection of 40 mg of triamcinolone acetonide every 3 months on progression of cartilage loss and knee pain. DESIGN, SETTING, AND PARTICIPANTS: Two-year, randomized, placebo-controlled, double-blind trial of intra-articular triamcinolone vs saline for symptomatic knee osteoarthritis with ultrasonic features of synovitis in 140 patients. Mixed-effects regression models with a random intercept were used to analyze the longitudinal repeated outcome measures. Patients fulfilling the American College of Rheumatology criteria for symptomatic knee osteoarthritis, Kellgren-Lawrence grades 2 or 3, were enrolled at Tufts Medical Center beginning February 11, 2013; all patients completed the study by January 1, 2015.

INTERVENTIONS: Intra-articular triamcinolone (n=70) or saline (n=70) every 12 weeks for 2 years.

Main Outcomes and Measures: Annual knee magnetic resonance imaging for quantitative evaluation of cartilage volume (minimal clinically important difference not yet defined), and Western Ontario and McMaster Universities Osteoarthritis index collected every 3 months (Likert pain subscale range, 0 [no pain] to 20 [extreme pain]; minimal clinically important improvement, 3.94).

RESULTS: Among 140 randomized patients (mean age, 58 [SD, 8] years, 75 women [54%]), 119 (85%) completed the study. Intra-articular triamcinolone resulted in significantly greater cartilage volume loss than did saline for a mean change in index compartment cartilage thickness of -0.21 mm vs -0.10 mm (between-group difference, -0.11 mm; 95% CI, -0.20 to -0.03 mm); and no significant difference in pain (-1.2 vs -1.9; between-group difference, -0.6; 95% CI, -1.6 to 0.3). The saline group had 3 treatment-related adverse events compared with 5 in the triamcinolone group and had a small increase in hemoglobin A1c levels (between-group difference, -0.2%; 95% CI, -0.5% to -0.007%).

CONCLUSIONS AND RELEVANCE: Among patients with symptomatic knee osteoarthritis, 2 years of intra-articular triamcinolone, compared with intra-articular saline, resulted in significantly greater cartilage volume loss and no significant difference in knee pain. These findings do not support this treatment for patients with symptomatic knee osteoarthritis.

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