Bee’s Knees – Bad Knews

And here, I’ve been worried about a Cushing’s recurrence instead of knee pain relief.

 

Joint Injections: Are They Worth the Risk?

Adverse outcomes hastening joint replacement have raised concerns

  • by Nancy Walsh, Senior Staff Writer, MedPage Today

Intra-articular injections of corticosteroids for relief of the pain of hip or knee osteoarthritis (OA) may have adverse long-term consequences, researchers suggested.

These injections are commonly performed and have been “conditionally” recommended by the American College of Rheumatology and “should be considered,” according to the Osteoarthritis Research Society International. The American Academy of Orthopedic Surgeons, however, has advised clinicians to be on the lookout for emerging evidence for or against the use of intra-articular injections in the knee, explained Ali Guermazi, MD, PhD, of Boston University School of Medicine, and colleagues.

However, a review of the outcomes following 459 injection procedures performed during 2018 in a single center now has identified four potential adverse events that should raise concerns, particularly for certain patients:

  • Accelerated OA progression, reported in 6% of patients
  • Subchondral insufficiency fractures, seen in 0.9%
  • Complications of osteonecrosis, in 0.7%
  • Rapid joint destruction including bone loss, also in 0.7% of patients

These findings were published in Radiology.

The Background

Cochrane meta-analysis evaluated 27 trials that included more than 1,767 patients found moderate improvements in pain and slight benefits for physical function following intra-articular corticosteroid injections for knee OA. However, the review noted that the quality of evidence was low, concluding that the results were inconclusive.

“Whether there are clinically important benefits of intra-articular corticosteroids after 1 to 6 weeks remains unclear in view of the overall quality of the evidence, considerable heterogeneity between trials, and evidence of small-study effects,” the Cochrane reviewers wrote.

In an editorial accompanying the Boston University report, Richard Kijowski, MD, of the University of Wisconsin in Madison, wrote, “The use of intra-articular corticosteroid injection to treat OA remains commonplace in clinical practice despite the lack of strong evidence supporting its efficacy.”

In vitro and animal research has revealed that corticosteroids actually can have negative effects on cartilage. “The action by which corticosteroids are chondrotoxic is complex, but it seems to affect cartilage proteins (especially aggrecan, type II collagen, and proteoglycan) by mediating protein production and breakdown,” Guermazi and colleagues explained.

Moreover, the local anesthetics often combined with the steroids also have been linked with chondrolysis.

And a recent retrospective study of 70 patients with hip OA found that 44% of patients who were given injections of triamcinolone with ropivacaine had radiographic progression and 17% experienced collapse of the articular surface.

“Thus, there is a growing body of evidence to suggest that intra-articular corticosteroid injection can accelerate the progression of joint degeneration,” Kijowski observed.

The Events

The injection protocol used at Boston University involved 40 mg triamcinolone, 2 mL of 1% lidocaine, and 2 mL of 0.25% bupivacaine.

Accelerated OA progression, characterized by rapid loss of radiographic joint space, was first observed in trials of nerve growth inhibitors, wherein some patients required joint replacement earlier than had been expected. Some experts have suggested that a loss of joint space exceeding 2 mm within a year can be considered accelerated progression, which can be accompanied by effusions, synovitis, and local soft tissue changes.

This accelerated OA progression was seen in 26 patients, following hip injections in 21 patients and knee injections in five.

Subchondral insufficiency fractures were the second type of adverse outcome observed, and were seen in four patients undergoing intra-articular hip injections. This event was previously thought to occur in elderly patients with osteopenia, but has now been reported in younger, active patients who present with acute pain but no apparent trauma.

The affected area often is weight-bearing and may involve loss of cartilage and meniscal tearing. Radiographic findings can be normal or subtle, while on magnetic resonance imaging (MRI) subchondral hypointensity may be detected. If the condition is identified early, before articular collapse has occurred, healing can occur, but once the articular surface has collapsed, the joint must be replaced.

Early identification of subchondral insufficiency fractures also is crucial before intra-articular injections, because the steroid may interfere with resolution of the fracture. Moreover, if an injection is performed and results in pain alleviation, the patient may increase weight-bearing and worsen the insufficiency fracture, hastening collapse.

The third type of event the researchers identified involved complications of osteonecrosis, which typically present with insidious onset of pain or can be asymptomatic. MRI is required for the diagnosis, and can help predict collapse by the extent of osteonecrosis and bone marrow edema. Once collapse has occurred, the only option is joint replacement.

The fourth adverse outcome, rapid joint destruction including bone loss (also referred to as rapidly progressive OA type 2), occurred in two patients with hip injections and one following a knee injection. Some previous authors likened this event to accelerated osteonecrosis, and others have hypothesized that the joint destruction results from undiagnosed subchondral insufficiency fractures.

The Advice

There are currently no recommendations regarding imaging before performing an intra-articular corticosteroid injection, and in some cases, findings may be subtle. “However, given the relative ease of performance and the low cost of radiography, there should be a low threshold to obtain radiographs before performing an intra-articular corticosteroid injection, as the intervention may affect the disease course (i.e., it may result in accelerated progression),” Guermazi and colleagues wrote.

Of particular concern are patients who have no apparent OA or very mild changes on radiographs who have been referred for injections because of pain. In these cases, the indication for injection should be “closely scrutinized,” as destructive or rapidly progressive joint space loss tends to develop in patients with severe pain but minimal structural change on radiographs.

“Clinicians should consider obtaining a repeat radiograph before each subsequent intra-articular injection to evaluate for progressive narrowing of the joint space and any interval changes in the articular surface that can indicate subchondral insufficiency fracture or type 1 or 2 rapidly progressive OA,” the authors advised.

“We believe that certain patient characteristics, including but not limited to acute change in pain not explained by using radiography and no or only mild OA at radiography, should lead to careful reconsideration of a planned intra-articular corticosteroid injection,” the authors concluded, adding that MRI may be helpful in these circumstances.

“Patients might be more than willing to take the small risk of an adverse joint event requiring eventual joint replacement for the possibility of at least some degree of pain relief after intra-articular corticosteroid injection,” wrote Kijowski.

“However, patients have the right to make this decision for themselves,” he stated.

From https://www.medpagetoday.com/rheumatology/arthritis/82753

Issues of Aging

Once again, I’ve changed the focus of this blog.  This time to the issues and problems that come with aging.

In January 2018, I managed to do something painful to my thumb.  I finally couldn’t take it anymore and went to the ER on February 1.  They did x-rays and sent me away with a spica splint (I thought they were calling it a thumb spike), a diagnosis of deteriorating thumb joint plus tendonitis, and a referral to an orthopedic doctor.

Here it is the end of March and I still haven’t been able to get to that new doctor.  Maybe soon?


February 6, 2018 we were still living at the Residence Inn due to water damage at our home on November 6, 2017 (more on that in another blog, someday).  My mom and I were coming back from WalMart and she fell in the parking lot.  Luckily, DH was still in our apartment and he came right down.  He couldn’t get her to stand up, so I drove the car over to her.  Although she didn’t want to go, we took her to the emergency room.

They did lots of scans there.  The first determined that she’d broken her pelvis in 2 places.  Thankfully, they don’t do surgery for a broken pelvis.  They thought that they would send her to Mount Vernon Hospital for intensive rehab.

Her white blood count was high, so they assumed infection and started 2 IV meds for that.  Her blood pressure dropped very low several times, causing her to pass out.

A chest x-ray was clear, so no infection there.  Because of the passing out episodes, they sent her for a head scan in case there had been a stroke.  Nope.

About 1 am on the 7th, a hospitalist came in to admit her.  He asked if she had abdominal pain and she said yes.  So, he started palpating various areas and found a tender spot.  He called for an abdominal scan, which showed internal bleeding.  So, the WBC wasn’t from infection but massive blood loss.

They called an ambulance and sent her to Fairfax Hospital for emergency surgery to stop the bleeding.

At Fairfax, they did a new scan with contrast – missed that she was allergic to that – and found that the bleeding was stopping all by itself.  Then, they gave her Benadryl.

She stayed there for 3 nights because Medicare required 3 midnights before going to rehab.  <Sheesh!>

From there, she went to Manor Care for rehab.  She no longer qualified for Mount Vernon.

She was doing really well…until she started having internal bleeding.  Back to Fair Oaks.  Same room.  AARRGGHH!  She was admitted for a few days to stop the bleeding and turned out to have an ulcer.  Then, edema.

Finally, she came home and is doing really well with a walker.  The pelvis is supposed to heal itself in a couple months.


 

 

 

Bee’s Knees, Continued

bees-knees

 

My left knee is still bothering me, even after doing Physical Therapy since January. <sigh>
It seems to get better, then something happens and it’s back to pain again.  When we were on a trip to New York a month ago, we walked a lot and climbed so many stairs, I had to buy a new brace.
Today is supposed to be my final PT but I don’t think I’m ready.
When this clinical trial came to my email, I just went through the whole survey for this but there was no doctor nearby:
 
Osteoarthritis Research Studies. Knee and hip arthritis studies enrolling now. No-cost medication. http://curec.lk/1VL5hu9
 
We’ll see what the next step is (so to speak!)
Someday…
no-pain

Bee’s Knees

bees-knees

 

No, I don’t think bees have knees but I do – and one of them was hurting a lot.  Mine started, I think, the day after DH’s heart attack – January 28, 2013.

Fast forward to January 2016.

I fell in the bathroom in the middle of the night and hit my left knee on the tub. I used a brace for a few days and it seemed better.

Around January 27-28, I was in Walmart and had to get a produce bag that was way over my head.  I had to stand on tiptoe…and my knee felt like something ripped.  Thankfully, I had a cart available to use as a temporary crutch.

Got home, used the brace, took Tylenol but the pain got worse.

Thursday, I drove home from choir at church.  My car is a manual so the act of using the clutch, extending my foot that way, made everything worse again.

Friday, we went to the Limp-In Clinic in Greenbriar.   That doctor was going to prescribe Cortef or NSAIDs but I couldn’t take either due to my history of Cushing’s (Cortef) and kidney cancer (NSAIDs).  He prescribed Vicodin and sent me for an x-ray.

January 31, I got very itchy, presumably from Vicodin so I stopped that and started taking Benadryl for the itchiness.

February 2, I went back to the clinic for the results of x-rays and  I mentioned the itchiness.  Since I have very limited meds available to me, he recommended an Orthopedist.  I called him when I got home and he didn’t take my insurance.  I tried another doctor who supposedly took my insurance but they didn’t.

February 7, I really needed the sleep so I took half a Vicodin.  No pain and no itching.  HOORAY!

LCL-tearFebruary 8, I saw my regular doctor.   She thinks it’s a possible “lateral collateral ligament vs meniscus tear”.  https://www.nlm.nih.gov/medlineplus/ency/article/001079.htm

I was surprised that she thought my knee was swollen but one of my therapists showed me later that it was.

She referred me to Physical Therapy (PT) and prescribed Ultram http://www.drugs.com/ultram.html.  As of this writing, I haven’t used that yet.

February 11, 8:30 am  My first appointment with PT.  Since my blood pressure was high, we mostly did assessments.  I had a main therapist and a student. They had to use 3 types of BP machine to do this.

I bent my knee and they took measurements with a caliper.  I lay on my front and they manipulated my knee to see what happened. They also concluded that it was a lateral collateral ligament.

A suggestion – to rest my foot on the walker without the brace and see if gravity helps my knee straighten out.

After this, there was more pain than before but I know this is the right thing to do.

February 13.  My leg feels a bit better.  I had the brace off last night and almost straightened my knee out.

Somewhere in this period, I learned how to manually move my knee cap (patella) around.  I saw my day 1 therapist again and he said my knee was angry.  Swollen, angry, whatever.  I just want a normal non-hurting knee!

One of the therapists had me doing a stretching exercise and my hip was out of kilter (everything is attached!) since I’ve been walking with my knee bent.  So she manipulated that back into alignment.

vastus-medFebruary 22, A new-to-me therapist had me do an exercise with a basketball under my knee, pointing my toe to the left.  I didn’t remember doing that before but she said I had.  Hmmm…

That hurt too much so we moved to a foam roll under my knee.  It was still uncomfortable but I did it, a bit too much, apparently.

Turns out this exercise hurt my “VMO”, which is short for Vastus Medialis Oblique.

“This is the most important quad muscle and arguably the most responsible muscle for knee stability. The VMO’s main function is to control knee extension…” Read more at  http://sportskneetherapy.com/the-best-vmo-exercises/

February 25,  My VMO pain still hurt.  I told my regular therapist about it and she worked on it some.  She concurred that my knee was swollen.

February 26,  I went all day with no brace at all!!  A bit of pain but manageable.

Today is February 28 and I haven’t worn the brace since the 27th. I still need assistance to get up from sitting but I can see huge improvement.

I still have 6 more PT sessions, finishing on March 16, but I’m really impressed with what they’ve done for me.  I still have twinges of pain and I don’t plan on stepping on tiptoe anytime soon but I can tell I’m on the right track.

If there are any significant changes (I sure hope not!), I’ll post an update.  When I’m done – and have approval – I intend to keep exercising, walking, climbing stairs, riding the bike.  I never, ever want to go through this kind of pain again.

I’ve learned a lot from PT – lots of new exercises, stretching, how to move manually my knee cap, all kinds of muscle names, that the lateral collateral ligament is attached to my ankle, that ice is better than heat for this kind of thing.

 

no-pain

 

 

 

 

 

Consumer Updates > FDA Strengthens Warning of Heart Attack and Stroke Risk for Non-Steroidal Anti-Inflammatory Drugs

Next time you reach into the medicine cabinet seeking relief for a headache, backache or arthritis, be aware of important safety information for non-steroidal anti-inflammatory drugs.

FDA is strengthening an existing warning in prescription drug labels and over-the-counter (OTC) Drug Facts labels to indicate that nonsteroidal anti-inflammatory drugs (NSAIDs) can increase the chance of a heart attack or stroke, either of which can lead to death. Those serious side effects can occur as early as the first few weeks of using an NSAID, and the risk might rise the longer people take NSAIDs. (Although aspirin is also an NSAID, this revised warning doesn’t apply to aspirin.)

The OTC drugs in this group are used for the temporary relief of pain and fever. The prescription drugs in this group are used to treat several kinds of arthritis and other painful conditions. Because many prescription and OTC medicines contain NSAIDs, consumers should avoid taking multiple remedies with the same active ingredient.

via Consumer Updates > FDA Strengthens Warning of Heart Attack and Stroke Risk for Non-Steroidal Anti-Inflammatory Drugs.