Intra-articular Joint Injections in Juvenile Idiopathic Arthritis: State of the Art

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This narrative review of the literature summarises the different aspects of IAC procedures in the treatment of JIA.Infiltration TechniqueAlthough the infiltration technique has not been completely established, it is governed by the same recommendations that apply in adults, and these are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. The literature contains a great many single-centre studies which describe their experience in performing IAC,<a class="elsevierStyleCrossRefs" href="#bib0200">5–9</a> although there are no guides or recommendations about how to do so. IAC is a situation in which children feel stress and nervousness, so that it is positive to create a relaxed atmosphere before performing the procedure.<a class="elsevierStyleCrossRef" href="#bib0190">3</a> IAC should be performed with exquisite asepsis and in as short a time as possible. It is important to use sterile gloves and clean the puncture area with a topical antiseptic. It is recommended that as much liquid as is possible be extracted from the joint before infiltrating the corticoid. The needle should be cleaned in physiological serum to prevent subcutaneous atrophy.<a class="elsevierStyleCrossRef" href="#bib0225">10</a> As is the case in adults, it is also recommendable to rest the unsupported joint for from 24 to 48h to prevent arthritis secondary to the introduced corticoid, even though this is very rare.<a class="elsevierStyleCrossRef" href="#bib0225">10</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>AnaesthesiaIt is recommendable to use a local anaesthetic in all IAC<a class="elsevierStyleCrossRef" href="#bib0230">11</a> procedures, with lidocaine that is either in an ointment (Emla®) or subcutaneous, chlorethyl in a spray or iontophoresis with lidocaine, depending on what is available. There is more evidence for the use of local anaesthetics or conscious sedation than is the case for other aspects of IAC.<a class="elsevierStyleCrossRefs" href="#bib0230">11–16</a> Uziel et al. compared the efficacy of a previous application of Emla® in reducing the pain reported by children with JIA during knee IAC.<a class="elsevierStyleCrossRef" href="#bib0235">12</a> This double-blind randomised clinical trial showed no significant differences between the patients who used Emla® and those who did not, although Emla® is in very widespread use as a local anaesthetic.<a class="elsevierStyleCrossRef" href="#bib0230">11</a> It is recommended that it be applied 60min prior to the procedure using an occlusive dressing, giving rise to anaesthesia in the top 3–5mm of the skin.<a class="elsevierStyleCrossRef" href="#bib0230">11</a> Nevertheless, in clinical practice it is sometimes hard to comply with the minimum time during which Emla® ointment should be applied. Lidocaine iontophoresis produces anaesthesia in somewhat more than the top 8mm of the skin following a 20min<a class="elsevierStyleCrossRef" href="#bib0225">10</a> application. However, this technique is not available in the majority of hospitals. It is probable that restriction of the effect of Emla® to the superficial level of the skin is the reason for the lack of differences in pain during IAC found by Uziel et al. in their clinical trial.<a class="elsevierStyleCrossRef" href="#bib0235">12</a>The use of local anaesthetics is widely accepted in paediatric rheumatology,<a class="elsevierStyleCrossRef" href="#bib0240">13</a> and a combination of a topical local anaesthetic with subcutaneous lidocaine may be beneficial in certain patients.<a class="elsevierStyleCrossRef" href="#bib0245">14</a> Weiss et al. undertook an observational study comparing the use of a local anaesthetic (Emla® or lidocaine iontophoresis) with subcutaneous lidocoaine.<a class="elsevierStyleCrossRef" href="#bib0245">14</a> They compared pain at 3 moments in the procedure: prior to the application of the local anaesthetic, after its application and just before the infiltration, and lastly after the IAC. They found no differences in reported pain between patients who had received subcutaneous lidocaine as well as a local anaesthetic and those who had only receive a local anaesthetic. The exception to this was post-IAC pain in girls, which was less when the methods of local anaesthesia were combined.<a class="elsevierStyleCrossRef" href="#bib0245">14</a>Respecting general anaesthesia or conscious sedation, although some authors propose that this should be obligatory in all procedures,<a class="elsevierStyleCrossRef" href="#bib0250">15</a> it is accepted more widely in specific situations.<a class="elsevierStyleCrossRef" href="#bib0240">13</a> The situations in which it is recommended that some type of conscious sedation (nitrous oxide, propofol, midazolam or fentanil<a class="elsevierStyleCrossRef" href="#bib0230">11</a>) be used are: patients under the age of 6 years old, when there is a need to infiltrate 3 or more joints, or in complicated or small locations (the coxofemoral joint or subastragalus, for example).<a class="elsevierStyleCrossRef" href="#bib0240">13</a> On the other hand, when parents and children were asked about their preference in the use of sedation, their opinions differed significantly.<a class="elsevierStyleCrossRef" href="#bib0255">16</a> While the younger children preferred sedation, the parents preferred to avoid the risks this involves. Nevertheless, when the children are older or have had the disease for longer, a higher proportion of them prefer to avoid sedation.<a class="elsevierStyleCrossRef" href="#bib0255">16</a>Ultrasound Scan GuidanceUltrasound scan is an ideal imaging technique for evaluating the paediatric population, and it makes it possible to guide the needle during IAC.<a class="elsevierStyleCrossRefs" href="#bib0210">7–9</a> Ultrasound scan guidance in IAC has been proven to be more precise and effective in adults.<a class="elsevierStyleCrossRef" href="#bib0260">17</a> However, in the paediatric population there is no enough scientific evidence to recommend the use of ultrasound scan guidance in all IAC procedures.<a class="elsevierStyleCrossRefs" href="#bib0210">7–9,18–22</a> There are many description of its use in different hospitals, but they do not compare the efficacy of procedures carried out with or without ultrasound scan guidance.<a class="elsevierStyleCrossRefs" href="#bib0275">20–22</a> In small or complicated joints such as the hip, due to its depth and the proximity to the vascular-nerve bundle, it is recommended that ultrasound scan guidance be used by an expert.<a class="elsevierStyleCrossRef" href="#bib0265">18</a> The exception to this recommendation is at the level of the temporomandibular joint (TMJ).<a class="elsevierStyleCrossRef" href="#bib0270">19</a> Resnick et al. compared the improvement in pain management and mouth opening between patients who had received IAC of the TMJ with and without ultrasound scan guidance. They found that the only difference between both groups was the time taken by the procedure, which lasted for 49min longer in the group with ultrasound scan guidance.<a class="elsevierStyleCrossRef" href="#bib0270">19</a>IndicationsAll patients with JIA are treatable using IAC or peritendinous AC as a single or complementary procedure.<a class="elsevierStyleCrossRef" href="#bib0185">2</a> The oligo-articular form may enter remission after one or several infiltrations. A recent systematic review found that IAC have a beneficial effect.<a class="elsevierStyleCrossRef" href="#bib0275">20</a>The use of systemic treatment with methotrexate in oligo-articular JIA is controversial, and it is not commenced in a routine way, especially in patients with monoarthritis.<a class="elsevierStyleCrossRef" href="#bib0290">23</a> Recently the open, longitudinal and multicentre study by Ravelli et al. has shown that adding methotrexate to the treatment of patients with oligo-articular JIA after IAC of 2 or more joints may slightly increase the effect of infiltrations.<a class="elsevierStyleCrossRef" href="#bib0295">24</a> Nevertheless, the question of whether or not children with oligo-articular JIA benefit from starting treatment with methotrexate has yet to be answered.<a class="elsevierStyleCrossRef" href="#bib0295">24</a>Dysmetria is one of the most common complications that we may find in patients with JIA, especially those with the oligo-articular form and asymmetric synovitis. The hyperaemia that produces the inflammation leads to greater growth of the affected limb and this in turn causes a biomechanical problem that may give rise to complications in adult age. IAC prevent or reduces the severity of joint discrepancy.<a class="elsevierStyleCrossRef" href="#bib0300">25</a> A classic study of 1999 which compared patients with JIA monitored in a hospital where IAC was performed as part of knee synovitis treatment with patients in another hospital where IAC was not used, showed that joint discrepancy was significantly greater in the second group of patients.<a class="elsevierStyleCrossRef" href="#bib0300">25</a>Infiltration of Multiple JointsAlthough there is no limit to the number of joints that may require infiltration, a systemic effect is inevitable when many joints are infiltrated.<a class="elsevierStyleCrossRef" href="#bib0225">10</a> The efficacy of multiple infiltrations (3 or more joints per procedure) has been evaluated in descriptive single-centre studies.<a class="elsevierStyleCrossRefs" href="#bib0305">26,27</a> In 2013, Papadopoulou et al. published a retrospective observational study in which joint remission following multiple IAC was observed in one third of the patients included, with an average follow-up of 11 months, as opposed to the two thirds of patients who had a new joint relapse following the IAC in an average time of 6 months.<a class="elsevierStyleCrossRef" href="#bib0310">27</a> These results are not very favourable regarding the routine performance of multiple IAC.<a class="elsevierStyleCrossRef" href="#bib0310">27</a> On the other hand, the efficacy of multiple infiltrations has not been compared with the use of short cycles of systemic corticoids, and it could be asked whether both strategies have a similar level of efficacy, thereby preventing an invasive procedure such as multiple infiltrations.These multiple procedures require general anaesthesia or at least conscious sedation, and they require a longer session duration, so they are not recommended as routine practice. In the authors’ opinion the maximum recommendable number of IAC per session is 3 joints.Temporomandibular JointsTMJ are often affected by JIA and they must be examined in all patients, regardless of subcategory. IAC of the TMJ is a relative frequent procedure that improve pain and mouth opening.<a class="elsevierStyleCrossRefs" href="#bib0270">19,28–30</a> The improvement is greater in those patients with a shorter time of evolution of their arthritis.<a class="elsevierStyleCrossRef" href="#bib0320">29</a> In patients with morphological alterations and a longer time of evolution, hardly any functional improvement occurs and pain relief is temporary.<a class="elsevierStyleCrossRef" href="#bib0325">30</a> The most common adverse effect of IAC in this location is subcutaneous atrophy, as this is a superficial joint. It is recommended as a complementary treatment, and, as was pointed out above, although ultrasound guidance does not increase its efficacy, it does mean that a longer time is necessary for the procedure.<a class="elsevierStyleCrossRef" href="#bib0270">19</a>Type of CorticoidThe type of corticoid to be administered depends on the size of the joint: <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the recommended dose and corticoid for each joint. It is here that the scientific evidence is the most solid, and where recommendations are the most widely accepted. IAC has longer-lasting efficacy when triamcinolone hexacetonide is used rather than more soluble corticoids such as betametasone.<a class="elsevierStyleCrossRef" href="#bib0330">31</a> The former also undergoes less systemic diffusion and it causes less alteration of cortisol and glucose levels.<a class="elsevierStyleCrossRef" href="#bib0335">32</a> Respecting triamcinolone, hexacetonide has been shown to be more powerful than acetonide in longitudinal studies as well as in retrospective ones.<a class="elsevierStyleCrossRefs" href="#bib0335">32–35</a> On the other hand, in spite of the fact that hexacetonide has been proven to have twice the anti-inflammatory effect than acetonide, the use of a double dose of triamcinolone acetonide does not give a greater benefit than the usual dose of triamcinolone hexacetonide.<a class="elsevierStyleCrossRef" href="#bib0340">33</a> The study by Zulian et al. included patients with JIA and symmetrical synovitis (the majority in the knees); one joint was infiltrated with the standard dose of hexacetonide and the other one received an infiltration of the double dose of acetonide. A higher proportion of the joints infiltrated with hexacetonide went into remission, and they did so for a longer time.<a class="elsevierStyleCrossRef" href="#bib0340">33</a> Adverse effects, chiefly subcutaneous atrophy and hypopigmentation, are more frequent with depot corticoids, so that these are not recommended for small or superficial joints, where it is more suitable to use soluble corticoids (betamethasone or methylprednisolone).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>ConclusionsIAC are very common procedures in the treatment of JIA, especially in the oligo-articular subcategory, together with systemic treatment or alone. It is highly recommendable to use local anaesthesia before or during the procedure, and to evaluate using conscious sedation in specific situations. Although ultrasound guidance is not recommended as a routine, it may be useful in expert hands to prevent complications in the procedure. In general, large joints benefit more from the administration of triamcinolone hexacetonide, while more soluble corticoids (betamethasone or methylprednisolone)are preferable for small or superficial joints.Conflict of InterestsThe authors have no conflict of interests to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres1156708" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1084033" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1156709" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1084034" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Infiltration Technique" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Anaesthesia" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Ultrasound Scan Guidance" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Indications" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Infiltration of Multiple Joints" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Temporomandibular Joints" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Type of Corticoid" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Conclusions" ] 13 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflict of Interests" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-03-13" "fechaAceptado" => "2018-07-19" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1084033" "palabras" => array:3 [ 0 => "Juvenile idiopathic arthritis" 1 => "Intra-articular joint injections" 2 => "Ultrasound guidance" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1084034" "palabras" => array:3 [ 0 => "Artritis idiopática juvenil" 1 => "Infiltraciones intraarticulares" 2 => "Guía ecográfica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveIntra-articular corticosteroid injections (IACI) are a fundamental part in the treatment of juvenile idiopathic arthritis. The current situation of IACI is reviewed in a population of children. MethodsWe conducted a narrative review of the literature related to IACI in children, with respect to the injection technique, use of local and general anaesthesia, ultrasound guidance of the procedure, indications, special joints and type of optimal corticosteroid. ResultsIACI are indicated in any subcategory of juvenile idiopathic arthritis, especially in oligoarticular juvenile idiopathic arthritis. The use of local anaesthetic is highly recommended, and in patients younger than 6 years or requiring multiple joint injections, conscious sedation can also be an option. Ultrasound guidance of injections is recommended in expert hands, but not in a generalised way. Triamcinolone hexacetonide is the corticosteroid of choice in large joints, whereas a more soluble corticosteroid is a better alternative in small or superficial joints (betamethasone or methylprednisolone) to avoid subcutaneous atrophy or hypopigmentation, the most frequent adverse effect of IACI. ConclusionsIACI are performed heterogeneously and scientific evidence is limited in many cases." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoLas infiltraciones intraarticulares con corticoides (IAC) son parte fundamental en el tratamiento de la artritis idiopática juvenil. Se realiza una revisión sobre la situación actual de las IAC en población infantil. MétodosRevisión narrativa de la literatura de las IAC en población infantil, relacionada con la técnica de infiltración, el uso de anestesia local y general, la guía ecográfica, las indicaciones, las articulaciones especiales y el tipo de corticoide. ResultadosLas IAC están indicadas en cualquier subcategoría de artritis idiopática juvenil y especialmente en la forma oligoarticular. El uso de anestésico local es recomendable, y en pacientes menores de 6 años o que requieran infiltración múltiple, también la sedación consciente. La infiltración guiada por ecografía es recomendable en manos expertas, pero no de forma generalizada. El hexacetónido de triamcinolona es el corticoide de elección en articulaciones grandes, mientras corticoides más solubles (betametasona o metilprednisolona) serían la alternativa ideal en articulaciones pequeñas o superficiales para evitar la atrofia subcutánea o la hipopigmentación, los efectos adversos más frecuentes. ConclusionesLas IAC se realizan de forma heterogénea y la evidencia científica es limitada." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Nieto-González JC, Monteagudo I. Estado actual del tratamiento con infiltraciones intraarticulares en la artritis idiopática juvenil. Reumatol Clin. 2019;15:69–72." ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infiltrate one or two joints per procedure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reinfiltrate after at least 2–4 weeks, if necessary \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not infiltrate the same joint more than 3–4 times per year \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Painstaking asepsis during the procedure \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use a local topical or subcutaneous anaesthetic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use general anaesthesia or conscious sedation when necessary \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rest the joint for 24–48h after the procedure \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1975056.png" ] ] ] ] "descripcion" => array:1 [ "en" => "General Recommendations for the Administration of Intra-articular Infiltrations in the Paediatric Population." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of corticoid \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dose \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Large joints (shoulder, hip or knee) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Triamcinolone hexacetonide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1mg/kg (maximum 40mg)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medium-size joints (elbow, carpus and ankle) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Triamcinolone hexacetonide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.75mg/kg (maximum 30mg)<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Small joints (metacarpus and finger joints) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Methylprednisolone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5–10mg<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Special joints (subastragalus or tendon sheaths) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Methylprednisolone \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20–40mg<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1975057.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "The dose will depend on the age and size of each patient." ] ] ] "descripcion" => array:1 [ "en" => "Type of Corticoid and Recommended Dose for Each Joint." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:35 [ 0 => array:3 [ "identificador" => "bib0180" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "International League of Associations for Rheumatology classification of juvenile idiopathic arthritis: second revision, Edmonton, 2001" "autores" => array:1 [ 0 => array:3 [ "colaboracion" => "International League of Associations for Rheumatology" "etal" => true "autores" => array:6 [ 0 => "R.E. 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Intra-articular Joint Injections in Juvenile Idiopathic Arthritis: State of the Art

Estado actual del tratamiento con infiltraciones intraarticulares en la artritis idiopática juvenil

Juan Carlos Nieto-González

Corresponding author

juancarlos.nietog@gmail.com

Corresponding author.

, Indalecio Monteagudo

Servicio de Reumatología, Hospital General Universitario Gregorio Marañón, Madrid, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Juvenile idiopathic arthritis &#40;JIA&#41; encompasses all arthritis of unknown origin in individuals under the age of 16 years old which lasts for longer than 6 weeks&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">1</span></a> In all of the sub-categories of JIA local treatment with the intra-articular infiltration of corticoids &#40;IAC&#41; is a part of normal therapeutic management&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a> Oligoarticular JIA is the type that affects 4 or fewer joints during the first 6 months of evolution of the disease&#44; and it may sometimes be treated exclusively with IAC&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a> Although IAC is performed very frequently in the treatment of JIA&#44; opinions vary widely regarding the use of general or local anaesthetics&#44; the infiltration technique&#44; ultrasound guiding of the procedure or the corticoid that should be used&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">3&#44;4</span></a> The differing ages of the patients and the different locations mean that it would be complicated to standardise the IAC procedure in children&#46; This narrative review of the literature summarises the different aspects of IAC procedures in the treatment of JIA&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Infiltration Technique</span><p id="par0010" class="elsevierStylePara elsevierViewall">Although the infiltration technique has not been completely established&#44; it is governed by the same recommendations that apply in adults&#44; and these are summarised in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; The literature contains a great many single-centre studies which describe their experience in performing IAC&#44;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">5&#8211;9</span></a> although there are no guides or recommendations about how to do so&#46; IAC is a situation in which children feel stress and nervousness&#44; so that it is positive to create a relaxed atmosphere before performing the procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">3</span></a> IAC should be performed with exquisite asepsis and in as short a time as possible&#46; It is important to use sterile gloves and clean the puncture area with a topical antiseptic&#46; It is recommended that as much liquid as is possible be extracted from the joint before infiltrating the corticoid&#46; The needle should be cleaned in physiological serum to prevent subcutaneous atrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a> As is the case in adults&#44; it is also recommendable to rest the unsupported joint for from 24 to 48<span class="elsevierStyleHsp" style=""></span>h to prevent arthritis secondary to the introduced corticoid&#44; even though this is very rare&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Anaesthesia</span><p id="par0015" class="elsevierStylePara elsevierViewall">It is recommendable to use a local anaesthetic in all IAC<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">11</span></a> procedures&#44; with lidocaine that is either in an ointment &#40;Emla<span class="elsevierStyleSup">&#174;</span>&#41; or subcutaneous&#44; chlorethyl in a spray or iontophoresis with lidocaine&#44; depending on what is available&#46; There is more evidence for the use of local anaesthetics or conscious sedation than is the case for other aspects of IAC&#46;<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">11&#8211;16</span></a> Uziel et al&#46; compared the efficacy of a previous application of Emla<span class="elsevierStyleSup">&#174;</span> in reducing the pain reported by children with JIA during knee IAC&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">12</span></a> This double-blind randomised clinical trial showed no significant differences between the patients who used Emla<span class="elsevierStyleSup">&#174;</span> and those who did not&#44; although Emla<span class="elsevierStyleSup">&#174;</span> is in very widespread use as a local anaesthetic&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">11</span></a> It is recommended that it be applied 60<span class="elsevierStyleHsp" style=""></span>min prior to the procedure using an occlusive dressing&#44; giving rise to anaesthesia in the top 3&#8211;5<span class="elsevierStyleHsp" style=""></span>mm of the skin&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">11</span></a> Nevertheless&#44; in clinical practice it is sometimes hard to comply with the minimum time during which Emla<span class="elsevierStyleSup">&#174;</span> ointment should be applied&#46; Lidocaine iontophoresis produces anaesthesia in somewhat more than the top 8<span class="elsevierStyleHsp" style=""></span>mm of the skin following a 20<span class="elsevierStyleHsp" style=""></span>min<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a> application&#46; However&#44; this technique is not available in the majority of hospitals&#46; It is probable that restriction of the effect of Emla<span class="elsevierStyleSup">&#174;</span> to the superficial level of the skin is the reason for the lack of differences in pain during IAC found by Uziel et al&#46; in their clinical trial&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The use of local anaesthetics is widely accepted in paediatric rheumatology&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a> and a combination of a topical local anaesthetic with subcutaneous lidocaine may be beneficial in certain patients&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a> Weiss et al&#46; undertook an observational study comparing the use of a local anaesthetic &#40;Emla<span class="elsevierStyleSup">&#174;</span> or lidocaine iontophoresis&#41; with subcutaneous lidocoaine&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a> They compared pain at 3 moments in the procedure&#58; prior to the application of the local anaesthetic&#44; after its application and just before the infiltration&#44; and lastly after the IAC&#46; They found no differences in reported pain between patients who had received subcutaneous lidocaine as well as a local anaesthetic and those who had only receive a local anaesthetic&#46; The exception to this was post-IAC pain in girls&#44; which was less when the methods of local anaesthesia were combined&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">14</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Respecting general anaesthesia or conscious sedation&#44; although some authors propose that this should be obligatory in all procedures&#44;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">15</span></a> it is accepted more widely in specific situations&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a> The situations in which it is recommended that some type of conscious sedation &#40;nitrous oxide&#44; propofol&#44; midazolam or fentanil<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">11</span></a>&#41; be used are&#58; patients under the age of 6 years old&#44; when there is a need to infiltrate 3 or more joints&#44; or in complicated or small locations &#40;the coxofemoral joint or subastragalus&#44; for example&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">13</span></a> On the other hand&#44; when parents and children were asked about their preference in the use of sedation&#44; their opinions differed significantly&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">16</span></a> While the younger children preferred sedation&#44; the parents preferred to avoid the risks this involves&#46; Nevertheless&#44; when the children are older or have had the disease for longer&#44; a higher proportion of them prefer to avoid sedation&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">16</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Ultrasound Scan Guidance</span><p id="par0030" class="elsevierStylePara elsevierViewall">Ultrasound scan is an ideal imaging technique for evaluating the paediatric population&#44; and it makes it possible to guide the needle during IAC&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">7&#8211;9</span></a> Ultrasound scan guidance in IAC has been proven to be more precise and effective in adults&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">17</span></a> However&#44; in the paediatric population there is no enough scientific evidence to recommend the use of ultrasound scan guidance in all IAC procedures&#46;<a class="elsevierStyleCrossRefs" href="#bib0210"><span class="elsevierStyleSup">7&#8211;9&#44;18&#8211;22</span></a> There are many description of its use in different hospitals&#44; but they do not compare the efficacy of procedures carried out with or without ultrasound scan guidance&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">20&#8211;22</span></a> In small or complicated joints such as the hip&#44; due to its depth and the proximity to the vascular-nerve bundle&#44; it is recommended that ultrasound scan guidance be used by an expert&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">18</span></a> The exception to this recommendation is at the level of the temporomandibular joint &#40;TMJ&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">19</span></a> Resnick et al&#46; compared the improvement in pain management and mouth opening between patients who had received IAC of the TMJ with and without ultrasound scan guidance&#46; They found that the only difference between both groups was the time taken by the procedure&#44; which lasted for 49<span class="elsevierStyleHsp" style=""></span>min longer in the group with ultrasound scan guidance&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Indications</span><p id="par0035" class="elsevierStylePara elsevierViewall">All patients with JIA are treatable using IAC or peritendinous AC as a single or complementary procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">2</span></a> The oligo-articular form may enter remission after one or several infiltrations&#46; A recent systematic review found that IAC have a beneficial effect&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">20</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The use of systemic treatment with methotrexate in oligo-articular JIA is controversial&#44; and it is not commenced in a routine way&#44; especially in patients with monoarthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">23</span></a> Recently the open&#44; longitudinal and multicentre study by Ravelli et al&#46; has shown that adding methotrexate to the treatment of patients with oligo-articular JIA after IAC of 2 or more joints may slightly increase the effect of infiltrations&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a> Nevertheless&#44; the question of whether or not children with oligo-articular JIA benefit from starting treatment with methotrexate has yet to be answered&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">24</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Dysmetria is one of the most common complications that we may find in patients with JIA&#44; especially those with the oligo-articular form and asymmetric synovitis&#46; The hyperaemia that produces the inflammation leads to greater growth of the affected limb and this in turn causes a biomechanical problem that may give rise to complications in adult age&#46; IAC prevent or reduces the severity of joint discrepancy&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">25</span></a> A classic study of 1999 which compared patients with JIA monitored in a hospital where IAC was performed as part of knee synovitis treatment with patients in another hospital where IAC was not used&#44; showed that joint discrepancy was significantly greater in the second group of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Infiltration of Multiple Joints</span><p id="par0050" class="elsevierStylePara elsevierViewall">Although there is no limit to the number of joints that may require infiltration&#44; a systemic effect is inevitable when many joints are infiltrated&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">10</span></a> The efficacy of multiple infiltrations &#40;3 or more joints per procedure&#41; has been evaluated in descriptive single-centre studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">26&#44;27</span></a> In 2013&#44; Papadopoulou et al&#46; published a retrospective observational study in which joint remission following multiple IAC was observed in one third of the patients included&#44; with an average follow-up of 11 months&#44; as opposed to the two thirds of patients who had a new joint relapse following the IAC in an average time of 6 months&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">27</span></a> These results are not very favourable regarding the routine performance of multiple IAC&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">27</span></a> On the other hand&#44; the efficacy of multiple infiltrations has not been compared with the use of short cycles of systemic corticoids&#44; and it could be asked whether both strategies have a similar level of efficacy&#44; thereby preventing an invasive procedure such as multiple infiltrations&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">These multiple procedures require general anaesthesia or at least conscious sedation&#44; and they require a longer session duration&#44; so they are not recommended as routine practice&#46; In the authors&#8217; opinion the maximum recommendable number of IAC per session is 3 joints&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Temporomandibular Joints</span><p id="par0060" class="elsevierStylePara elsevierViewall">TMJ are often affected by JIA and they must be examined in all patients&#44; regardless of subcategory&#46; IAC of the TMJ is a relative frequent procedure that improve pain and mouth opening&#46;<a class="elsevierStyleCrossRefs" href="#bib0270"><span class="elsevierStyleSup">19&#44;28&#8211;30</span></a> The improvement is greater in those patients with a shorter time of evolution of their arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">29</span></a> In patients with morphological alterations and a longer time of evolution&#44; hardly any functional improvement occurs and pain relief is temporary&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">30</span></a> The most common adverse effect of IAC in this location is subcutaneous atrophy&#44; as this is a superficial joint&#46; It is recommended as a complementary treatment&#44; and&#44; as was pointed out above&#44; although ultrasound guidance does not increase its efficacy&#44; it does mean that a longer time is necessary for the procedure&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">19</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Type of Corticoid</span><p id="par0065" class="elsevierStylePara elsevierViewall">The type of corticoid to be administered depends on the size of the joint&#58; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the recommended dose and corticoid for each joint&#46; It is here that the scientific evidence is the most solid&#44; and where recommendations are the most widely accepted&#46; IAC has longer-lasting efficacy when triamcinolone hexacetonide is used rather than more soluble corticoids such as betametasone&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">31</span></a> The former also undergoes less systemic diffusion and it causes less alteration of cortisol and glucose levels&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">32</span></a> Respecting triamcinolone&#44; hexacetonide has been shown to be more powerful than acetonide in longitudinal studies as well as in retrospective ones&#46;<a class="elsevierStyleCrossRefs" href="#bib0335"><span class="elsevierStyleSup">32&#8211;35</span></a> On the other hand&#44; in spite of the fact that hexacetonide has been proven to have twice the anti-inflammatory effect than acetonide&#44; the use of a double dose of triamcinolone acetonide does not give a greater benefit than the usual dose of triamcinolone hexacetonide&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">33</span></a> The study by Zulian et al&#46; included patients with JIA and symmetrical synovitis &#40;the majority in the knees&#41;&#59; one joint was infiltrated with the standard dose of hexacetonide and the other one received an infiltration of the double dose of acetonide&#46; A higher proportion of the joints infiltrated with hexacetonide went into remission&#44; and they did so for a longer time&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">33</span></a> Adverse effects&#44; chiefly subcutaneous atrophy and hypopigmentation&#44; are more frequent with depot corticoids&#44; so that these are not recommended for small or superficial joints&#44; where it is more suitable to use soluble corticoids &#40;betamethasone or methylprednisolone&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0070" class="elsevierStylePara elsevierViewall">IAC are very common procedures in the treatment of JIA&#44; especially in the oligo-articular subcategory&#44; together with systemic treatment or alone&#46; It is highly recommendable to use local anaesthesia before or during the procedure&#44; and to evaluate using conscious sedation in specific situations&#46; Although ultrasound guidance is not recommended as a routine&#44; it may be useful in expert hands to prevent complications in the procedure&#46; In general&#44; large joints benefit more from the administration of triamcinolone hexacetonide&#44; while more soluble corticoids &#40;betamethasone or methylprednisolone&#41;are preferable for small or superficial joints&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Conflict of Interests</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare&#46;</p></span></span>"
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          "titulo" => "Introduction"
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          "identificador" => "sec0010"
          "titulo" => "Infiltration Technique"
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          "titulo" => "Anaesthesia"
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          "titulo" => "Ultrasound Scan Guidance"
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          "titulo" => "Infiltration of Multiple Joints"
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          "titulo" => "Temporomandibular Joints"
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          "titulo" => "Type of Corticoid"
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          "titulo" => "Conclusions"
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          "titulo" => "References"
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    "fechaRecibido" => "2018-03-13"
    "fechaAceptado" => "2018-07-19"
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          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Juvenile idiopathic arthritis"
            1 => "Intra-articular joint injections"
            2 => "Ultrasound guidance"
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          "clase" => "keyword"
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          "palabras" => array:3 [
            0 => "Artritis idiop&#225;tica juvenil"
            1 => "Infiltraciones intraarticulares"
            2 => "Gu&#237;a ecogr&#225;fica"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Intra-articular corticosteroid injections &#40;IACI&#41; are a fundamental part in the treatment of juvenile idiopathic arthritis&#46; The current situation of IACI is reviewed in a population of children&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We conducted a narrative review of the literature related to IACI in children&#44; with respect to the injection technique&#44; use of local and general anaesthesia&#44; ultrasound guidance of the procedure&#44; indications&#44; special joints and type of optimal corticosteroid&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">IACI are indicated in any subcategory of juvenile idiopathic arthritis&#44; especially in oligoarticular juvenile idiopathic arthritis&#46; The use of local anaesthetic is highly recommended&#44; and in patients younger than 6 years or requiring multiple joint injections&#44; conscious sedation can also be an option&#46; Ultrasound guidance of injections is recommended in expert hands&#44; but not in a generalised way&#46; Triamcinolone hexacetonide is the corticosteroid of choice in large joints&#44; whereas a more soluble corticosteroid is a better alternative in small or superficial joints &#40;betamethasone or methylprednisolone&#41; to avoid subcutaneous atrophy or hypopigmentation&#44; the most frequent adverse effect of IACI&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">IACI are performed heterogeneously and scientific evidence is limited in many cases&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objective"
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          1 => array:2 [
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            "titulo" => "Methods"
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          2 => array:2 [
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      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Las infiltraciones intraarticulares con corticoides &#40;IAC&#41; son parte fundamental en el tratamiento de la artritis idiop&#225;tica juvenil&#46; Se realiza una revisi&#243;n sobre la situaci&#243;n actual de las IAC en poblaci&#243;n infantil&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n narrativa de la literatura de las IAC en poblaci&#243;n infantil&#44; relacionada con la t&#233;cnica de infiltraci&#243;n&#44; el uso de anestesia local y general&#44; la gu&#237;a ecogr&#225;fica&#44; las indicaciones&#44; las articulaciones especiales y el tipo de corticoide&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Las IAC est&#225;n indicadas en cualquier subcategor&#237;a de artritis idiop&#225;tica juvenil y especialmente en la forma oligoarticular&#46; El uso de anest&#233;sico local es recomendable&#44; y en pacientes menores de 6 a&#241;os o que requieran infiltraci&#243;n m&#250;ltiple&#44; tambi&#233;n la sedaci&#243;n consciente&#46; La infiltraci&#243;n guiada por ecograf&#237;a es recomendable en manos expertas&#44; pero no de forma generalizada&#46; El hexacet&#243;nido de triamcinolona es el corticoide de elecci&#243;n en articulaciones grandes&#44; mientras corticoides m&#225;s solubles &#40;betametasona o metilprednisolona&#41; ser&#237;an la alternativa ideal en articulaciones peque&#241;as o superficiales para evitar la atrofia subcut&#225;nea o la hipopigmentaci&#243;n&#44; los efectos adversos m&#225;s frecuentes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Las IAC se realizan de forma heterog&#233;nea y la evidencia cient&#237;fica es limitada&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Nieto-Gonz&#225;lez JC&#44; Monteagudo I&#46; Estado actual del tratamiento con infiltraciones intraarticulares en la artritis idiop&#225;tica juvenil&#46; Reumatol Clin&#46; 2019&#59;15&#58;69&#8211;72&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Infiltrate one or two joints per procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reinfiltrate after at least 2&#8211;4 weeks&#44; if necessary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Do not infiltrate the same joint more than 3&#8211;4 times per year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Painstaking asepsis during the procedure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use a local topical or subcutaneous anaesthetic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use general anaesthesia or conscious sedation when necessary&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rest the joint for 24&#8211;48<span class="elsevierStyleHsp" style=""></span>h after the procedure&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Type of corticoid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Large joints &#40;shoulder&#44; hip or knee&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Triamcinolone hexacetonide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg &#40;maximum 40<span class="elsevierStyleHsp" style=""></span>mg&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Medium-size joints &#40;elbow&#44; carpus and ankle&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Triamcinolone hexacetonide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;75<span class="elsevierStyleHsp" style=""></span>mg&#47;kg &#40;maximum 30<span class="elsevierStyleHsp" style=""></span>mg&#41;<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Small joints &#40;metacarpus and finger joints&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Methylprednisolone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5&#8211;10<span class="elsevierStyleHsp" style=""></span>mg<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Special joints &#40;subastragalus or tendon sheaths&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Methylprednisolone&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20&#8211;40<span class="elsevierStyleHsp" style=""></span>mg<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Type of Corticoid and Recommended Dose for Each Joint&#46;</p>"
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Article information

ISSN: 21735743
Original language: English

DOI:10.1016/j.reumae.2018.07.003

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Year/Month	Html	Pdf	Total

2024 November	6	13	19
2024 October	48	49	97
2024 September	71	25	96
2024 August	62	37	99
2024 July	84	29	113
2024 June	76	42	118
2024 May	78	31	109
2024 April	76	23	99
2024 March	89	34	123
2024 February	125	29	154
2024 January	65	28	93
2023 December	67	39	106
2023 November	69	58	127
2023 October	249	40	289
2023 September	167	72	239
2023 August	150	28	178
2023 July	47	34	81
2023 June	60	28	88
2023 May	67	44	111
2023 April	50	22	72
2023 March	84	36	120
2023 February	78	38	116
2023 January	80	37	117
2022 December	85	43	128
2022 November	70	45	115
2022 October	85	50	135
2022 September	59	60	119
2022 August	97	42	139
2022 July	81	55	136
2022 June	75	33	108
2022 May	78	29	107
2022 April	86	62	148
2022 March	99	70	169
2022 February	116	61	177
2022 January	78	51	129
2021 December	64	40	104
2021 November	57	61	118
2021 October	157	60	217
2021 September	60	53	113
2021 August	44	60	104
2021 July	51	28	79
2021 June	72	45	117
2021 May	104	97	201
2021 April	159	112	271
2021 March	114	40	154
2021 February	82	25	107
2021 January	77	26	103
2020 December	98	27	125
2020 November	124	42	166
2020 October	119	29	148
2020 September	151	31	182
2020 August	113	34	147
2020 July	66	19	85
2020 June	71	19	90
2020 May	58	20	78
2020 April	35	20	55
2020 March	28	6	34
2019 June	1	2	3
2019 February	1	2	3

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