Intra-articular triamcinolone hexacetonide injections in hands osteoarthritis – A double-blinded randomized controlled trial with a one year follow-up

Paschoal, Natalia de Oliva Spolidoro; Natour, Jamil; Machado, Flavia Soares; Oliveira, Hilda Alcântara Veiga de; Fernandes, Artur da Rocha Correa; Furtado, Rita Nely Vilar

doi:10.1016/j.clinsp.2022.100036

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Original articles • Clinics 77 • 2022 • https://doi.org/10.1016/j.clinsp.2022.100036 copy

Intra-articular triamcinolone hexacetonide injections in hands osteoarthritis – A double-blinded randomized controlled trial with a one year follow-up

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

to evaluate the effectiveness of triamcinolone Hexacetonide (TH) Intra-Articular Injection (IAI) in hand Interphalangeal Joints (IP) of Osteoarthritis (OA) patients to improve pain and joint swelling; improve function, goniometry, and grasping force, and assess IAI influence on radiographic evolution over 1-year.

Methods:

A randomized, double-blind study. 60 patients who underwent IAI at the most symptomatic IP joint were randomly assigned to receive TH+Lidocaine (LD) (TH/LD group) or just LD (LD group). Patients were assessed blindly for 1-year, at baseline and 1, 4, 8, 12, and 48 weeks. The following variables were assessed: articular pain and swelling, AUSCAN and COCHIN functional questionnaires, grip and pinch strength, goniometry, perception of improvement, acetaminophen consumption, and simple radiography. Repeated-measures ANOVA test was used to analyze the intervention response.

Results:

Sixty patients completed the follow-up. There were nine missed assessments. 97% were women; mean age of 61-years (SD = 8.2), and approximately 5-years of disease (SD = 3.6). Half of the patients present radiographic classification Kellgren and Lawrence (KL) grades I and II, and the other half grades III and IV. The two groups evolved similarly at 48-weeks. TH/LD group had a better evaluation in joint swelling and acetaminophen consumption (p = 0.04 and p < 0.001, respectively) at 48-weeks. Radiographically there was no statistical difference between groups (KL, p = 0.564; erosive OA, p = 0.999; worsening, p = 0.573).

Conclusion:

The IAI IP hands OA is effective for the improvement of joint swelling and decrease of analgesic consumption and does not influence the radiographic evolution of the injected joint.

Keywords:
Osteoarthritis; Intra-articular injection; Corticosteroid; Hands

Highlights

Hands osteoarthritis treatment.
Intra-articular corticosteroid injection.

	TH/LD Group (n = 30)	LD Group (n = 30)	p
Age – years
Mean (SD)	60.7 (9.1)	60.7 (7.3)	0.553^a a Mann-Whitney statistical test.
Disease time onset ‒ years
Mean (SD)	4.7 (4.2)	5.2 (3.0)	0.151^a a Mann-Whitney statistical test.
Gender
Female/Male, n (%)	30 (100%)/0	28 (93.3%)/2 (6.7%)	0.15^b b Chi-Square statistical test.
Skin color
White/ no white, n (%)	17 (56.7%)/13 (43.3%)	25 (83.3%)/5 (16.7%)	0.034^b b Chi-Square statistical test.
Kelgreen Lawrence (injected joint)			0.180^b b Chi-Square statistical test.
I	8 (27%)	6 (20%)
II	9 (30%)	7 (23%)
III	7 (23%)	9 (30%)
IV	6 (20%)	8 (27%)
X-Ray erosion			0.297^b b Chi-Square statistical test.
No erosion	19 (63.3%)	15 (50%)
Erosion	11 (36.7%)	15 (50%)
Drugs			0.423^b b Chi-Square statistical test.
No drugs	23 (76.7%)	18 (60%)
Hydroxychloroquine	1 (3.3%)	2 (6.7%)
Glucosamine sulfate	5 (16.7%)	5 (16.7%)
Glucosamine sulfate + chondroitin sulfate	0	3 (10%)
Methotrexate	1 (3.3%)	1 (3.3%)
Interphalangeal joint studied
DIP, n (%)	14 (46.7%)	15 (50%)	0.796^b b Chi-Square statistical test.
PIP, n (%)	16 (53.3%)	15 (50%)	0.423^b b Chi-Square statistical test.

Time (weeks)	TH/LD Group (n = 30)	LD Group (n = 30)	p
VASr – Mean (SD)			0.599^a a ANOVA for repeated measures;
T0	6.1 (1.7)	6.1 (1.6)
T1	2.6 (2.9)	1.7 (2.7)
T4	1.3 (2.1)	1.6 (2.6)
T8	1.4 (2.6)	1.6 (2.6)
T12	0.8 (1.7)	0.9 (2.2)
T48	0.3 (1.3)	0.5 (1.5)
p intragroup	<0,001	<0,001
VASm – Mean (SD)			0.063^a a ANOVA for repeated measures;
T0	6.5 (1.8)	6.6 (1.4)
T1	3.9 (3.1)	4.1 (2.9)
T4	2.8 (2.9)	3.0 (3.0)
T8	1.8 (2.6)	4.0 (3.3)
T12	2.2 (2.9)	4.0 (3.2)
T48	2.6 (3.3)	3.0 (3.0)
p intragroup	< 0,001	< 0,001
VASs – Mean (SD)			0.040^a a ANOVA for repeated measures;
T0	3.0 (1.5)	3.0 (1.7)
T1	2.0 (1.5)	2.1 (1.4)
T4	1.4 (1.4)	2.0 (1.2)
T8	0.7 (0.8)	1.8 (1.3)
T12	1.1 (1.2)	2.0 (1.3)
T48	p intragroup	0.8 (0.9) < 0,001	1.2 (1.1) < 0.001
VAS 48h after injection ‒ Mean (SD)	3.56 (3.2)	3.8 (3.4)	0.825^b b Test t de Student
Joint Flexion (º) – Mean (SD)			0.659^b b Test t de Student
T0	71.6 (20.4)	61.1 (19.8)
T1	73.4 (22.8)	66.6 (20.6)
T4	75.6 (22.3)	68.7 (19.1)
T8	79.3 (21.1)	66.2 (19.4)
T12	72.6 (25.1)	63.6 (22.6)
T48	66.7 (26.5)	62.2 (23.4)
p intragrupo	0.012	0.012

Time (weeks)	TH/LD Group (n = 30)	LD Group (n = 30)	p
Grip strength (Kgf) – Mean (SD)			0.976
T0	14.8 (6.7)	13.7 (7.6)
T1	14.1 (6.6)	13.7 (7.8)
T4	15.1 (6.6)	14.6 (7.8)
T8	15.5 (7.3)	15.4 (7.4)
T12	16.2 (6.2)	15.2 (7.7)
T48	17.0 (7.0)	16.7 (6.7)
p intragroup	0.093	0.093
Key pinch strength (kgf) – Mean (SD)			0.679
T0	6.1 (1.8)	5.9 (2.4)
T1	5.9 (1.8)	6.3 (1.9)
T4	6.4 (1.6)	6.3 (2.1)
T8	6.4 (2.0)	6.5 (1.6)
T12	6.5 (1.9)	6.2 (1.7)
T48	6,7 (1.9)	6.6 (1.8)
p intragroup	0.066	0.066
Tip pinch strength (kgf) – Mean (SD)			0.641
T0	2.8 (1.2)	2.6 (1.3)
T1	2.8 (1.2)	3.0 (1.4)
T4	3.3 (1.1)	3.0 (1.4)
T8	3.3 (1.3)	3.3 (1.6)
T12	3.4 (1.2)	3.4 (1.7)
T48	3.5 (1.5)	3.7 (1.6)
p intragroup	<0.001	<0.001
Tripod pinch strength (kgf) – Mean (SD)			0.232
T0	4.1 (1.8)	3.8 (2.0)
T1	4.1 (1.6)	4.1 (2.0)
T4	4.5 (1.6)	4.2 (1.9)
T8	4.8 (1.8)	4.5 (2.0)
T12	4.8 (1.9)	4.5 (2.0)
T48	4.5 (1.8)	5.0 (2.0)
p intragroup	<0.001	<0.001

Time (weeks)	TH/LD Group (n = 30)	LD Group (n = 30)	p
COCHIN – Mean (SD)			0.709
T0	19.3 (17.3)	23.1 (16.3)
T1	17.8 (19.5)	22.1 (16.7)
T4	14.3 (16.4)	19.9 (16.7)
T8	15.9 (18.1)	20.5 (16.2)
T12	14.3 (15.2)	21.8 (16.7)
T48	14.3 (14.7)	16.2 (13.6)
p intragroup	0.07	0.07
AUSCAN-global – Mean (SD)			0.626
T0	25.9 (15.1)	29.1 (13.4)
T1	22.7 (13.8)	27.5 (15.2)
T4	20.0 (13.9)	25.5 (14.0)
T8	20.3 (14.6)	26.0 (14.0)
T12	18.8 (14.1)	25.7 (14.4)
T48	18.9 (11.4)	20.9 (14.1)
p intragroup	<0.001	<0.001
AUSCAN-pain – Mean (SD)			0.593
T0	8.8 (4.7)	9.2 (4.3)
T1	7.0 (4.6)	8.3 (5.1)
T4	5.9 (4.9)	7.8 (5.4)
T8	6.0 (4.9)	8.3 (4.5)
T12	5.3 (4.7)	7.0 (4.8)
T48	5.4 (4.0)	6.3 (3.9)
p intragroup	<0.001	<0.001
AUSCAN-stiffness – Mean (SD)			0.698
T0	1.7 (1.4)	2.0 (1.5)
T1	1.1 (1.3)	1.5 (1.5)
T4	1.2 (1.3)	1.8 (1.5)
T8	1.6 (1.4)	1.9 (1.2)
T12	1.2 (1.4)	2.0 (1.4)
T48	1.4 (1.3)	1.8 (1.5)
p intragroup	0.088	0.088
AUSCAN-function – Mean (SD)			0.886
T0	15.4(10.4)	17.9 (8.9)
T1	14.6 (9.5)	17.8 (9.7)
T4	12.9 (8.9)	15.9 (8.8)
T8	12.7 (9.5)	15.8 (9.8)
T12	12.3 (9.8)	16.7 (9.8)
T48	12.1 (8.2)	14.0 (9.1)
p intragroup	0.005	0.005

Tempos (semanas)	TH/LD Group (n = 30)	LD Group (n = 30)	p intergroup
Acetaminophen daily consuption – Mean (unit-750 mg) (SD)			<0.001^a a ANOVA for repeated measures
T0	0.65 (1.12)	0.17 (0.45)
T1	0.89 (1.21)	0.31 (0.58)
T4	0.71 (1.15)	0.26 (0.49)
T8	0.81 (1.19)	0.30 (0.58)
T12	0.74 (1.25)	0.33 (0.60)
T48	0.14 (0.43)	0.38 (0.76)
p intragrupo	0.019	0.488
Improvement scale, n (%)			0.236^b b ANOVA for repeated measures for categorical variables

	TH/LD Group			LD Group
	Worse	Unchanged	Improve	Worse	Unchanged	Improve
T1	2 (6.9%)	1 (3.4%)	27 (90%)	0	1 (3.3%)	29 (96.7%)
T4	0	1 (3.3%)	29 (96.7%)	0	4 (13.3%)	26 (86.7%)
T8	1 (3.3%)	1 (3.3%)	28 (93.3%)	1 (3.3%)	3 (10%)	26 (86.7%)
T12	2 (6.7%)	1 (3.3%)	27 (90%)	1 (3.3%)	5 (16.7%)	24 (80%)
T48	1 (3.3%)	5 (16.7%)	24 (80%)	5 (16.7%)	2 (6.7%)	23 (76.6%)
p intragroup	0.329			0.329

Radiographic assessment in the 48-weeks follow-up									p
KL Classification	TH/LD Group (n = 30)				LD Group (n = 30)				0.564^a a ANOVA for repeated measures
KL Classification	1	2	3	4	1	2	3	4
T0	8 (27%)	9 (30%)	7 (23%)	6 (20%)	6 (20%)	7 (23%)	9 (30%)	8 (27%)
T48	5 (17%)	7 (23%)	12 (40%)	6 (20%)	3 (10%)	7 (23%)	12 (40%)	8 (27%)
p intragroup	< 0.001				< 0.001

Erosion					p
OA classification (erosion)	TH/LD Group (n = 30)		LD Group (n = 30)		0.999^a a ANOVA for repeated measures
OA classification (erosion)	No erosion	Erosion	No erosion	Erosion
T0	19 (63%)	11 (37%)	15 (50%)	15 (50%)
T48	18 (60%)	12 (40%)	14 (47%)	16 (53%)
p intragroup	0.157		0.157

Radiographic evolution –worse/ unchanged at 48-weeks			p
	TH/LD Group (n = 30)	LD Group (n = 30)	0.573^c c Qui-Square test.
Unchanged	20 (67%)	22 (73%)
Worse	10 (33%)	8 (27%)

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[1] *Corresponding author. E-mail address:rvfurtado@hotmail.com (R.N.V. Furtado).