Intraarticular Infiltration Therapy with Cortisone

Intraarticular infiltration therapy with cortisone (synonym: infiltration of joints with cortisone) is a therapeutic procedure in radiology and orthopedics, which can be used especially for the treatment of synovialitis (inflammation of the inner synovium) in both rheumatic and degenerative origin. The application of cortisone, which is a steroid hormone with anti-inflammatory and immunosuppressive effects, can rapidly reduce an existing effusion in the mucosa and reduce swelling.

Indications (areas of application)

  • Rheumatoid arthritis – rheumatoid arthritis represents the classic clinical picture that can be effectively treated by intra-articular (injected into the joint) cortisone injection. However, an inflammatory reaction caused by bacteria must be safely excluded before therapy.
  • Collagenosis with joint involvement – a common autoimmune disease included in the group of collagenoses is systemic lupus erythematosus (SLE). In 90% of cases, there is joint involvement, which can be treated symptomatically by intra-articular cortisone injection.
  • Hydrops articulorum intermittens – in this clinical picture, recurrent effusions can be found in young women primarily at the knee joint, although they can be significantly symptomatically alleviated by intra-articular injection of cortisone. However, the recurrence (recurrence) can not be influenced by this.
  • Acute activated osteoarthritis – acute inflammatory change in a joint can further aggravate pre-existing osteoarthritis, significantly reducing joint function. Targeted intervention with intra-articular cortisone should be considered as goal-directed.
  • Juvenile chronic oligoarticular arthritis (usually one or a maximum of 2 to 4 (= oligoarticular) large joints are affected) – this form of arthritis occurs in childhood and adolescence and progresses processively. A rapid effective therapy including intra-articular infiltration therapy with cortisone can contain the joint inflammation, so that the structural damage to cartilage and the capsular ligamentous apparatus of the joint can be prevented.
  • Gout – in the context of gout there is acute exudative crystal arthritis, which can be treated by infiltration therapy. The injection can be treated especially the swelling that occurs. Also, the pain can be effectively relieved in combination with non-steroidal anti-inflammatory drugs (NSAID / painkillers; synonyms: non-steroidal anti-inflammatory drug (NSAP) or NSAID).
  • Chondrocalcinosis (synonym: pseudogout) – gout-like disease of the joints caused by deposition of calcium pyrophosphate in the cartilage and other tissues; leads, among other things, to joint degeneration (often of the knee joint); symptomatology resembles an acute gout attack; intra-articular injection of cortisone is an important treatment component.

Contraindications

Relative contraindications

  • Degenerative joint disease without inflammatory reaction.
  • Multiple recurrent joint effusions

Absolute contraindications

  • Bacterial inflammation of the joint
  • Bacterial infection in the neighborhood of the inflamed joint
  • Severe general infection
  • Coagulation disorder
  • Allergic reaction to cortisone

Before therapy

Precise verification of the suitability of the therapeutic measure for the disease is absolutely necessary. In the presence of bacterial infections of joints, the joint may be further damaged by the injection of cortisone. Strict attention must be paid when corticosteroid is injected:

  • The dose and galenics of the corticosteroid must be adapted to the joint (no depot injection! Avoid application in subcutaneous and adipose tissue).
  • The minimum time interval between injections must be observed.
  • Observance of asepsis
  • Immediate intervention at the slightest suspicion of infection!

The procedure

The basic principle of intra-articular infiltration therapy is based on the application of the anti-inflammatory and immunosuppressive steroid hormone cortisone. However, depending on the cortisone preparation, sometimes significant differences in effect can be observed.In particular, the strength and duration of action vary depending on the preparation used. The reasons for this include the size, shape and chemical esterification of the crystals used. The optimal substance is a cortisone preparation that remains in the joint for a long time and is absorbed from the joint only to a small extent. Triamcinolone hexacetonide currently comes closest to this optimal preparation. Other preparations are currently being researched. The advantages of intraarticular infiltration therapy with cortisone include the minimal systemic effects of cortisone. Furthermore, not only can the swelling and pain be reduced by the therapy, but the restriction of movement can also be minimized. Not only can the use of injections postpone surgery, but if necessary, the sufficiency of the therapy may eliminate the need for surgical intervention.

After therapy

After therapy, follow-up visits are absolutely necessary to verify the success of therapy. In addition to permanent pain, massive joint damage can also occur, which can severely limit the function of the joint.

Possible complications

  • Joint empyema (accumulation of pus in the joint; in 95% of cases, the large joints are affected; most common pathogens: Staphylococcus aureus (40-80%), Staphylococcus epidermidis, and streptococci) and abscess formation
  • Joint damage: intraarticular corticosteroid injection (administration of glucocorticoids into the joint cavity) is likely to cause joint damage. This is suggested by the following radiologic findings:
    • Rapid narrowing of the joint space (rapid progressive osteoarthrits, RPOA type 1) occurred in 6% of all participants.
    • In about one percent were so-called SIF (subchondral insufficiency fractures) detectable); it is assumed that this is the result of a relative overload in structurally or density reduced bone
    • Other patients showed osteonecrosis (ON) or joint destruction with demonstrable bone loss (RPOA type 2).

    Here, the authors discuss the following issue: they state that they do not know whether the observed damage was already proceeding at the time of injection or whether it was a consequence or complication of corticosteroid treatment. It is possible that the injections may have prevented pre-existing damage from healing?! Note: This is an observational study with a small number of cases.

  • Bone necrosis – the injection may cause bone death. However, this is a very rare complication.
  • Cartilage damage – depending on the preparation and the concentration used, permanent cartilage damage may occur.
  • Crystal synovitis – regardless of the preparation used, the injection can cause an inflammatory reaction, which usually occurs after a few hours and usually recedes within two hours.
  • Necrotizing fasciitis (lat. Fasciitis necroticans) – foudroyant proceeding life-threatening infection of the skin, subcutis (subcutis) and fascia with progressive gangrene; it is often patients with diabetes mellitus or other diseases that lead to circulatory disorders or reduced immune defenses.
  • Systemic effect of cortisone – usually the systemic effect of cortisone is mild, yet systemic reactions are common.