Contexte Un objectif important de la prise en charge de l'arthrite juvénile oligoarticulaire serait d'altérer le cours de la maladie à l'aide d'une thérapie hâtive. Nous avons étudié l'effet des injections intra-articulaires de corticostéroïdes hâtives sur les chances d'atteindre un décompte d'articulation active de zéro et une maladie inactive. Méthode Les données démographiques, cliniques et thérapeutiques des patients avec oligoarthrite juvénile enrôlés dans une étude prospective longitudinale pancanadienne ont été collectées pendant 2 ans. Une injection hâtive était définie comme étant reçue dans les 3 premiers mois suivant le diagnostic. Les équations d'estimation généralisées ont été utilisées pour l'analyse statistique. Résultats Trois cent dix patients ont été inclus. Cent onze (35.8%) ont reçu une injection hâtive. Ces derniers avaient une maladie plus active lors de l'entrée dans l'étude. Les patients exposés à une injection hâtive avaient une chance similaire d'obtenir un décompte d'articulation active de zéro, OR 1.52 (IC95% 0.68-3.37), p=0.306 mais étaient significativement moins à risque d'avoir une maladie inactive, OR 0.35 (IC95% 0.14-0.88), p=0.026. Interprétation Dans cette cohorte de 310 patients avec oligoarthrite juvénile, les injections hâtives de corticostéroïdes n'ont pas mené à une probabilité plus élevée d'atteindre un décompte d'articulation active de zéro ou une maladie inactive. Des problématiques méthodologiques intrinsèques à l'utilisation de données observationnelles pour fins d'estimation d'effets thérapeutiques auraient pu biaiser les résultats. Nous ne pouvons affirmer avec certitude que les injections hâtives n'améliorent pas le décours de la maladie. Des études prospectives adressant les limitations soulevées seront requises pour clarifier la question. / Background One of the goals in oligoarticular juvenile idiopathic arthritis would be to alter the disease course with early therapy. We examined the association between early intra-articular corticosteroid injections and the achievement of an active joint count of zero and inactive disease during the first two years after study enrollment. Methods We included oligoarticular juvenile idiopathic arthritis patients enrolled into a prospective longitudinal cohort across Canada. Demographic, clinical and treatment-related information were collected. Early intra-articular corticosteroid injections was defined as having received the first injection within 3 months of diagnosis. Generalized estimating equations were used for data analysis. Results A total of 310 patients were included, of whom 111 (35.8%) received an early injection. Participants who received an early injection had more severe disease at baseline. Patients exposed to early injections had a similar chance to achieve an active joint count of zero, OR 1.52 (95%CI 0.68-3.37), p=0.306 but were significantly less likely to achieve inactive disease, OR 0.35 (95%CI 0.14-0.88), p=0.026. Interpretation In this cohort of 310 oligoarticular juvenile idiopathic arthritis patients, early intra-articular corticosteroid injections did not result in an increased risk of achieving an active joint count of zero or inactive disease. Methodological issues encountered when estimating treatment effect using observational data might have biased the estimates obtained. Firm conclusion on the inefficacy of early injections in improving outcomes in this population cannot be drawn from this study. Prospective studies addressing the limitations raised will be needed to clarify if early injections can alter the disease course.

O presente estudo destinou-se a avaliar se os resultados clínicos iniciais da viscossuplementação poderiam ser melhorados com a adição de corticosteróide. As injeções intra-articulares são usadas há muitos anos no tratamento da osteoartrite dos joelhos, principalmente com suspensões cristalinas de corticosteróides. A viscossuplementação é uma intervenção relativamente nova, atualmente recomendada no tratamento da osteoartrite. Trata-se da injeção de ácido hialurônico exógeno em articulações diartrodiais, visando, além de restaurar as propriedades reológicas do líquido sinovial, efeitos modificadores da doença osteoartrite. Revisões sistemáticas mostram que a melhora clínica ocorre em duas a cinco semanas após a viscossuplementação. Comparando-se a viscossuplementação com a injeção intraarticular com corticosteróides, dados recentes sugerem maior eficiência no alívio da dor nas quatro primeiras semanas após a infiltração com corticosteróides, similaridade dos procedimentos ao redor da quarta semana e melhores resultados com a viscossuplementação após a oitava semana. Este inicio de ação mais tardio, associado a relatos de sinovite reacional após a viscossuplementação podem desencorajar médicos e pacientes ao uso desta modalidade de tratamento. No presente estudo foram avaliados 104 pacientes em tratamento para osteoartrite do joelho no grupo de doenças osteometabólicas do Instituto de Ortopedia do Hospital das Clínicas da FMUSP. Os pacientes foram randomizados em dois grupos. Um dos grupos foi denominado VS e recebeu uma única injeção intra-articular de 6ml de Hylan GF-20 (Synvisc One®-Genzyme) no joelho estudado. O segundo grupo foi denominado VS+T e recebeu uma injeção intra-articular de 6ml de Hylan GF-20 (Synvisc One®-Genzyme) mais 1ml (20mg) de Hexacetonido de Triancinolona (Triancil®-Apsen). Foram aplicados a escala visual analógica de dor (EVA) e os questionários de WOMAC e Lequesne uma semana antes da injeção e após uma, quatro, 12 e 24 semanas. Os dois grupos com 52 pacientes cada eram homogêneos. Na primeira semana, o WOMAC e a EVA apresentaram melhores resultados no Grupo VS+T (p < 0,01) em relação ao Grupo VS. Na quarta semana não houve diferença entre os grupos. Ambos apresentaram resultados similares nas semanas 12 e 24. Concluiu-se que a adição de hexacetonido de triancinolona melhorou os resultados clínicos da viscossuplementação no curto prazo, sem interferir nos resultados a longo prazo ou na incidência de efeitos adversos / The present study aims to assess if the initial results of viscosupplementation can be improved by the addition of corticosteroid. Intraarticular injections have been used for many years to treat arthritis and other painful articular disorders, mainly using long-lasting crystalline corticosteroid suspensions. Viscosupplementation is a relatively new intervention that is now widely used and recommended for the treatment of knee osteoarthritis. It is comprised of the injection of exogenous hyaluronic acid in diarthrodial joints, in order to restore the rheological properties of synovial fluid and also to promote osteoarthritis disease-modifying effects. Several placebo-controlled studies reported that clinical improvement began only within two to five weeks after viscosupplementation. When comparing viscosupplementation versus intraarticular injection of corticosteroid, recent data suggest that from baseline to week four, intraarticular steroid were more effective for pain relief. By the fourth week, however, both provided similar relief, but beyond the eighth week, hyaluronic acid provided greater pain reduction. The mechanism of action of hyaluronic acid, with delayed onset of pain/functional improvement, combined with reports of reactional sinovitis may discourage physicians and patients regarding this treatment modality. The present study evaluated 104 patients receiving usual care for knee osteoarthritis at the University of São Paulo Medical Center. Patients were randomized to receive either a single intra-articular injection of 6ml of Hylan GF-20 (Synvisc One®-Genzyme) (Group VS) or a single intra-articular injection of 6ml of Hylan GF-20 (Synvisc One®-Genzyme) plus 1ml (20mg) of Triamcinolone Hexacetonide (Triancil®-Apsen) (Group VS+T). VAS, WOMAC and Lequesne questionnaires were applied one week prior the injection, and after one, four, 12 and 24 weeks. The two groups with 52 patients each were homogeneous. At week one, WOMAC and VAS showed better results for Group VS+T compared to Group VS (p < 0,05). At week four the scores did not show statistically significant differences. The groups showed similar results at weeks 12 and 24. In conclusion, the addition of triamcinolone improved first-week symptom and functional scores of viscosupplementation, but not beyond. It did not seem to alter the likelihood of adverse effects

O presente estudo destinou-se a avaliar se os resultados clínicos iniciais da viscossuplementação poderiam ser melhorados com a adição de corticosteróide. As injeções intra-articulares são usadas há muitos anos no tratamento da osteoartrite dos joelhos, principalmente com suspensões cristalinas de corticosteróides. A viscossuplementação é uma intervenção relativamente nova, atualmente recomendada no tratamento da osteoartrite. Trata-se da injeção de ácido hialurônico exógeno em articulações diartrodiais, visando, além de restaurar as propriedades reológicas do líquido sinovial, efeitos modificadores da doença osteoartrite. Revisões sistemáticas mostram que a melhora clínica ocorre em duas a cinco semanas após a viscossuplementação. Comparando-se a viscossuplementação com a injeção intraarticular com corticosteróides, dados recentes sugerem maior eficiência no alívio da dor nas quatro primeiras semanas após a infiltração com corticosteróides, similaridade dos procedimentos ao redor da quarta semana e melhores resultados com a viscossuplementação após a oitava semana. Este inicio de ação mais tardio, associado a relatos de sinovite reacional após a viscossuplementação podem desencorajar médicos e pacientes ao uso desta modalidade de tratamento. No presente estudo foram avaliados 104 pacientes em tratamento para osteoartrite do joelho no grupo de doenças osteometabólicas do Instituto de Ortopedia do Hospital das Clínicas da FMUSP. Os pacientes foram randomizados em dois grupos. Um dos grupos foi denominado VS e recebeu uma única injeção intra-articular de 6ml de Hylan GF-20 (Synvisc One®-Genzyme) no joelho estudado. O segundo grupo foi denominado VS+T e recebeu uma injeção intra-articular de 6ml de Hylan GF-20 (Synvisc One®-Genzyme) mais 1ml (20mg) de Hexacetonido de Triancinolona (Triancil®-Apsen). Foram aplicados a escala visual analógica de dor (EVA) e os questionários de WOMAC e Lequesne uma semana antes da injeção e após uma, quatro, 12 e 24 semanas. Os dois grupos com 52 pacientes cada eram homogêneos. Na primeira semana, o WOMAC e a EVA apresentaram melhores resultados no Grupo VS+T (p < 0,01) em relação ao Grupo VS. Na quarta semana não houve diferença entre os grupos. Ambos apresentaram resultados similares nas semanas 12 e 24. Concluiu-se que a adição de hexacetonido de triancinolona melhorou os resultados clínicos da viscossuplementação no curto prazo, sem interferir nos resultados a longo prazo ou na incidência de efeitos adversos / The present study aims to assess if the initial results of viscosupplementation can be improved by the addition of corticosteroid. Intraarticular injections have been used for many years to treat arthritis and other painful articular disorders, mainly using long-lasting crystalline corticosteroid suspensions. Viscosupplementation is a relatively new intervention that is now widely used and recommended for the treatment of knee osteoarthritis. It is comprised of the injection of exogenous hyaluronic acid in diarthrodial joints, in order to restore the rheological properties of synovial fluid and also to promote osteoarthritis disease-modifying effects. Several placebo-controlled studies reported that clinical improvement began only within two to five weeks after viscosupplementation. When comparing viscosupplementation versus intraarticular injection of corticosteroid, recent data suggest that from baseline to week four, intraarticular steroid were more effective for pain relief. By the fourth week, however, both provided similar relief, but beyond the eighth week, hyaluronic acid provided greater pain reduction. The mechanism of action of hyaluronic acid, with delayed onset of pain/functional improvement, combined with reports of reactional sinovitis may discourage physicians and patients regarding this treatment modality. The present study evaluated 104 patients receiving usual care for knee osteoarthritis at the University of São Paulo Medical Center. Patients were randomized to receive either a single intra-articular injection of 6ml of Hylan GF-20 (Synvisc One®-Genzyme) (Group VS) or a single intra-articular injection of 6ml of Hylan GF-20 (Synvisc One®-Genzyme) plus 1ml (20mg) of Triamcinolone Hexacetonide (Triancil®-Apsen) (Group VS+T). VAS, WOMAC and Lequesne questionnaires were applied one week prior the injection, and after one, four, 12 and 24 weeks. The two groups with 52 patients each were homogeneous. At week one, WOMAC and VAS showed better results for Group VS+T compared to Group VS (p < 0,05). At week four the scores did not show statistically significant differences. The groups showed similar results at weeks 12 and 24. In conclusion, the addition of triamcinolone improved first-week symptom and functional scores of viscosupplementation, but not beyond. It did not seem to alter the likelihood of adverse effects

Cette étude a été subventionnée par le Fonds de recherche du Québec - Santé (FRQ-S, grant # 21230 – 2) / Les infiltrations foraminales cervicales sont associées à un risque de complications neurologiques majeures. Cette étude compare l’efficacité des infiltrations facettaires, plus sécuritaires, à celle des infiltrations foraminales dans le traitement de la cervico-brachialgie secondaire à une spondylose et/ou à une hernie discale, à 4 semaines post traitement. Cinquante-six sujets ont été randomisés pour recevoir une infiltration foraminale (15 hommes, 13 femmes ; âge moyen 52 ans) ou facettaire (8 hommes, 20 femmes ; âge moyen 44 ans). L’issue principale était l’intensité de la douleur mesurée sur une échelle visuelle analogique (0 – 100). Les issues secondaires étaient le Neck Disability Index et le Medication Quantitative Scale. Suivant les analyses en intention-de-traiter et en intention-du-protocole, pour un score de douleur initial moyen, une réduction significative de l’intensité de la douleur a été observée avec les infiltrations facettaires [45.3% (95%CI: 21.4; 69.2) et 37.0% (95%CI: 9.2; 64.7)] contrairement aux infiltrations foraminales [9.8% (95%CI: +11.5; 31.2) et 17.8% (95%CI: +6.6; 42.2)]. Les infiltrations facettaires ont procuré une amélioration cliniquement (mais non statistiquement) significative du Neck Disability Index [24.3% (95%CI: +2.9; 51.5) et 20.7% (95%CI: +6.2; 47.6),], contrairement aux infiltrations foraminales [9.6% (95%CI: +15.2; 34.4) et 12.8% (95%CI: +11.2; 36.7)]. Les infiltrations facettaires étaient au moins aussi efficaces que les infiltrations foraminales pour un score initial de douleur ≤ 60, alors que l’analyse de non infériorité n’était pas concluante pour un score initial ≥ 80, de même que pour le Neck Disability Index. Les infiltrations n’ont pas été associées à une réduction du score de Medication Quantitative Scale. Les infiltrations facettaires sont efficaces dans le traitement de la névralgie cervico-brachiale et représentent une alternative valable et plus sécuritaire aux infiltrations foraminales. / Transforaminal corticosteroid injections can be performed in the management of cervical radiculopathy but carry the risk of catastrophic complications. This study compares the efficacy of transforaminal and facet corticosteroid injections at 4 weeks post treatment. We randomly assigned 56 subjects to receive CT-guided transforaminal (15 men, 13 women; mean age 52 years; range 28 – 72 years) or facet (8 men, 20 women; mean 44 years; range 26 – 60 years) injections. The primary outcome was pain severity rated on a visual analog scale (0-100). Secondary outcome measures were the Neck Disability Index and the Medication Quantitative Scale. In the intention-to-treat and as-treated analyses, for a mean baseline score, facet injections demonstrated a significant pain score reduction of 45.3% (95%CI: 21.4; 69.2) and 37.0% (95%CI: 9.2; 64.7), while transforaminal injections showed nonsignificant pain score reduction of 9.8% (95%CI: +11.5; 31.2) and 17.8% (95%CI: +6.6; 42.2). While facet injections demonstrated an improvement in Neck Disability Index score of [24.3% (95%CI: +2.9; 51.5); 20.7% (95%CI: +6.2; 47.6),] as opposed to transforaminal injections [9.6% (95%CI: +15.2; 34.4); 12.8% (95%CI: +11.2; 36.7)], the results did not reach statistical significance. Noninferiority of facet to transforaminal injections was demonstrated for baseline pain score ≤ 60, while noninferiority analysis was inconclusive for baseline pain score ≥ 80 and for the Neck Disability Index score. Neither intervention showed a significant medication intake score reduction over time. Facet injections are effective for the treatment of cervical radiculopathy and represent a valid and safer alternative to transforaminal injections.