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Vol. 17. Issue 3.
Pages 179-181 (March 2021)
Vol. 17. Issue 3.
Pages 179-181 (March 2021)
Letter to the Editor
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Response to: Current Status of Treatment With Intra-Articular Infiltrations in Juvenile Idiopathic Arthritis
Respuesta a: Estado actual del tratamiento con infiltraciones intra-articulares en la artritis idiopática juvenil
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Sara Murias Lozaa,
Corresponding author
, Genaro Graña Gilb
a Sección de Reumatología Pediátrica, Hospital Universitario La Paz, Madrid, Spain
b Servicio de Reumatología, Complejo Hospitalario Universitario A Coruña, A Coruña, La Coruña, Spain
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Table 1. Results of the survey of 120 members of the SERPE with replies from 85 of them
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Dear Editor,

We read the publication by Nieto-González and Monteagudo1 in Reumatología Clínicawith interest, where a narrative review is undertaken of the literature in connection with the practice of using intra-articular infiltrations with corticoids (IAIC) in patients with juvenile idiopathic arthritis (JIA). We would like to describe the results of a survey of all of the members of the Spanish Paediatric Rheumatology Society (SERPE) in 2017, in which they were asked about their habitual practice in connection with several aspects of the said technique.

The survey consisted of 10 questions devised by the Scientific Committee of the 2017 National Congress of the said society. The questions refer to the medical speciality of the staff who perform IAIC (rheumatologist, paediatrician, rehabilitation doctor or orthopaedic surgeon); the type of JIA used in the said procedure; indication of analgesia and/or sedation during the process; drug(s) used; details of the IAIC technique (asepsis, washing in saline solution, dilution of the corticoid and others); maximum number of joints infiltrated in a single session; maximum number of IAIC in the same joint in one year; recommendations after infiltration; complications after infiltration; and differences between children according to their age. The “SurveyMonkey” platform was used, which makes it possible to create online surveys, (https://es.surveymonkey.com). This platform interprets the replies to surveys and creates basic descriptive statistics for them.

Eighty-five of the 120 members contacted replied. The survey results showed the heterogeneity of the range of professionals who perform IAIC for JIA, as other authors have reported in the past.2 The appended table shows the said results. In general, the answers to the survey reflect the absence of recognised treatment guides for this technique, showing the existence of practice that is “based on art” in the hospitals that treat young people and children with rheumatic diseases. A North American study that was also based on a survey reached similar conclusions.3

This study has several limitations, the chief one of which may be the fact that only 85 or 70% of 120 members responded to the survey. Additionally, not all of the doctors who treat rheumatic diseases in children in our country belong to the SERPE, although the majority do. On the other hand, one potentially interesting analysis was not carried out: to evaluate whether, within the heterogeneous nature of the replies, they could be found to be more homogeneous if classified according to the speciality of the respondent (rheumatologist, paediatrician, rehabilitator or orthopaedic surgeon).

There are other relevant aspects in connection with IAIC technique which we believe were included in the survey. One of these is the increasing importance of ultrasound scan imaging in paediatric rheumatology, as in recent years it has come to be included as another tool4 for use when infiltrating several locations that are considered to be “difficult” (the temporomandibular joint,5 tenosynovitis,6 the tarsal joint7). On the other hand, in all fields of paediatrics sedation-analgesic techniques are being adopted to improve the quality of care for paediatric patients; including IAIC, according to several recent publications.8–10

Although IAIC is not a technique that involves important adverse events and does not require long training to be performed in a sufficiently expert way, the authors believe it necessary to prepare guides or recommendations for the technique, for paediatric and young patients (Table 1).

Table 1.

Results of the survey of 120 members of the SERPE with replies from 85 of them

Questions
Who performs IAIC in your hospital?
Orthopaedic surgeon: 11%  We do not perform IAIC: 1.2% 
Paediatrician: 87%  Rehabilitation doctor: 11% 
Rheumatologist: 19%
  Never  Sometimes  Often  Always 
In what clinical situations do you perform IAIC?
Monoarthritis, %  2,3  1,2  35  62 
Oligoarthritis, %  18  71  11 
Polyarthritis, %  2,4  47  45 
Relapse, %  1,2  27  61  11 
What about analgesia and sedation?
Chlorethyl spray, %  60  17  13  10 
EMLA, %  27  25  25  22 
Nitrous oxide, %  17  28  46 
Benzodiazepines, %  28  42  28  2,6 
Fentanyl, %  69  20  12 
General anaesthetic, %  42  27  30  1,3 
Local anaesthesia, %  45  30  12  12 
Which drug do you use?
Triamcinolone acetonide, %  3.6  17  35  45 
Triamcinolone hexacetonide, %  31  37  22 
Betamethasone, %  75  15  10 
Hyaluronic acid, %  68  29 
Itrium, %  64  35 
What dose do you use depending on joint size?
0,5mg/kg in small joints and 1mg/kg in large joints: 50%
20mg in small joints and 40mg in large joints: 50%
In respect of the technique  Never  Sometimes  Often  Always 
Guided by ultrasound scan, %  13  50  31 
Sterile gloves WITH surgical field, %  13  72 
Sterile gloves WITHOUT surgical field, %  53  17  16  14 
Only skin sterilisation, %  89  2,5 
Dose calculated according to weight, %  23  34  19  23 
I consider the total dose, %  14  18  25 
I obtain informed consent, %  15  13  18  54% 
How many joints do you infiltrate in the same session?  Two  Three  Four  More than four 
  30%  31%  35%  4% 
Do you think that the same joint should not be infiltrated >3 times per year?  Yes: 76%    No: 24%   
In connection with joint locations
  I infiltrate for tenosynovitis  Yes: 63%  No: 33%   
  I infiltrate the tarsal joint  Yes: 61%  No: 33%   
  I infiltrate TMJ  Yes: 30%  No: 70%   
  I infiltrate for IFP, MCF  Yes: 71%  No: 29%   
  I infiltrate for dactylitis  Yes: 50%  No: 50%   
  I infiltrate the hips  Yes: 60%  No: 40%   
  I infiltrate the sacroiliac  Yes: 6%  No: 94%   
In post-filtration recommendations  Never  Sometimes  Often  Always 
I recommend normal life without excessive effort, %  28  25  23  23 
I recommend rest for 12-24hrs., %  13  73 
I recommend oral analgesia, %  14  41  24  21 
I make an appointment for them in 1-2 weeks for evaluation, %  22  20  58 
I do not evaluate again, they contact in case of no improvement, %  74  14 
Have you seen these complications?  Never  Rarely (<1/100)  Often (1/10-1/100) 
Cutaneous atrophy, %  64  27 
Septic arthritis, %  95 
Vasovagal reaction, %  55  41  3.5 
Haemorrhage due to arterial puncture, %  90  9.4 
Do you establish differences for the smallest patients (< 5 years)?  Yes  No 
I use ultrasound scan more often, %  49  51 
I use more sedation/analgesia methods, %  95 
I reduce the maximum number of IAIC, %  35  64 
I use a lower dose of steroid in large joints, %  63  37 

EMLA: Eutectic Mixture of Local Anaesthetic; IAIC: intra-articular infiltration with corticoids; IFP: proximal interphalangeal; MCF: metacarpophalangeal; SERPE: Sociedad Española de Reumatología Pediátrica; TMJ: temporomandibular joint.

References
[1]
J.C. Nieto-González, I. Monteagudo.
Intra-articular joint injections in juvenile idiopathic arthritis: state of the art.
Reumatol Clin., 15 (2019), pp. 69-72
[2]
H. Jennings, K. Hennessy, G.J. Hendry.
The clinical effectiveness of intra-articular corticosteroids for arthritis of the lower limb in juvenile idiopathic arthritis: a systematic review.
Pediatr Rheumatol Online J., 12 (2014), pp. 23
[3]
T. Beukelman, J.P. Guevara, D.A. Albert, D.D. Sherry, J.M. Burnham.
Usage of intra-articular corticosteroid injections for the treatment of juvenile idiopathic arthritis: a survey of pediatric rheumatologists in the United States and Canada.
Clin Exp Rheumatol., 26 (2008), pp. 700-703
[4]
D.A. Parra.
Technical tips to perform safe and effective ultrasound guided steroid joint injections in children.
Pediatr Rheumatol Online J., 13 (2015), pp. 2
[5]
C.M. Resnick, P.M. Vakilian, L.B. Kaban, Z.S. Peacock.
Is intra-articular steroid injection to the temporomandibular joint for juvenile idiopathic arthritis more effective and efficient when performed with image guidance?.
J Oral Maxillofac Surg, 75 (2017), pp. 694-700
[6]
S.E. Peters, R.M. Laxer, B.L. Connolly, D.A. Parra.
Ultrasound-guided steroid tendon sheath injections in juvenile idiopathic arthritis: a 10-year single-center retrospective study.
Pediatr Rheumatol Online J., 15 (2017), pp. 22
[7]
C.M. Young, D.M. Horst, J.W. Murakami, W.E. Shiels.
Ultrasound-guided corticosteroid injection of the subtalar joint for treatment of juvenile idiopathic arthritis.
Pediatr Radiol, 45 (2015), pp. 1212-1217
[8]
J.E. Weiss, K.A. Haines, E.C. Chalom, S.C. Li, G.A. Walco, T.L. Nyirenda, et al.
A randomized study of local anesthesia for pain control during intra-articular corticosteroid injection in children with arthritis.
Pediatr Rheumatol Online J., 13 (2015), pp. 36
[9]
A. Oren-Ziv, D. Hoppenstein, A. Shles, Y. Uziel.
Sedation methods for intra-articular corticosteroid injections in Juvenile Idiopathic Arthritis: a review.
Pediatr Rheumatol Online J., 13 (2015), pp. 28
[10]
R. Casado, J. Lumbreras, J. de Inocencio, A. Remesal, R. Merino, J. García-Consuegra.
Sedation for intra-articular corticosteroid injections in juvenileidiopathic arthritis: the views of patients and their parents.
Eur J Pediatr., 172 (2013), pp. 1411-1413

Please cite this article as: Murias Loza S, Graña Gil G. Respuesta a: Estado actual del tratamiento con infiltraciones intra-articulares en la artritis idiopática juvenil. Reumatol Clin. 2021;17:179–181.

Copyright © 2019. Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología
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