LEIDEN, The Netherlands—Arthroscopic lavage plus intraarticular steroids was three times as effective as joint aspiration plus steroids in relieving the swelling and pain of knee inflammatory arthritis, according to a randomized controlled trial in a recent issue of Arthritis Care & Research.¹ The greatest response to lavage and steroids occurred among patients who had the least fibrotic synovial tissue.

"These data suggest that the initial anti-inflammatory effect of corticosteroid administration can be prolonged with lavage due to a more complete removal of degradation products (eg, fibrin)," conclude researchers led by Martijn van Oosterhout, MD, of Leiden University, in The Netherlands.

Arthroscopic lavage plus steroids delays recurrence 9.6 months

Seventy-eight patients with knee arthritis (not due to gout, osteoarthritis, or septic arthritis) were randomized to undergo arthroscopic lavage plus intraarticular steroids (n = 26), arthroscopic lavage plus placebo (n = 23) or joint aspiration plus steroids (n = 26). Patients had received a mean of 3.3 intraarticular injections prior to the study, a finding which points to the refractory nature of their disease. The primary endpoint was event-free survival, with events defined as recurrence or persistence of symptomatic knee swelling requiring re-treatment or as nonimprovement of the knee joint score. The researchers also analyzed synovial tissue biopsies to identify any factors that may predict response.

The median time until recurrence was 9.6 months after arthroscopic lavage plus steroids, 3 months following joint aspiration plus steroids, and 1 month after lavage plus placebo. The estimated relative risk of an arthritis recurrence during the 9 months after undergoing the procedure was 2.2 for joint aspiration plus steroids versus lavage plus steroids (P = .02) and 4.7 for aspiration plus steroids versus lavage plus steroids (P <.0001). Both steroid treatments resulted in significantly greater improvements in knee scores compared with lavage plus placebo. Patients in the lavage plus steroid group showed the greatest decrease in knee score. The lavage plus steroids procedure also was the most beneficial regardless of the number of previous injections participants had received.

Patients without fibrosis were less likely to experience a recurrence. "Our study is the first to demonstrate the absence of fibrosis in synovium to be an independent predictive factor of responsiveness to lavage with corticosteroid as local treatment for arthritis," study authors conclude. "Whether extensive synovial fibrosis is a feature of a different form of joint inflammation or reflects an advanced stage of chronic inflammation remains to be determined."

Practice-changing implications

"This is a useful study," said John Hardin, MD, chief scientific officer of the Arthritis Foundation, in Atlanta, Georgia, and professor of medicine at the Albert Einstein College of Medicine, in the Bronx, New York. "Rheumatologists will frequently inject cortisone into inflamed joints in inflammatory arthritis which produces quite a dramatic benefit that subsides in few weeks or months."

Dr. Hardin said that rheumatologists typically "draw off as much of fluid as possible, put steroids in, and hope for the best."

The new study offers "very nice data showing that if we do this, about one-third of patients will have significant benefit for the first 3 months, but after that benefit seems to disappear," Dr. Hardin said.  "If we do the wash-out and use cortisone, there is substantial improvement noted in terms of benefit."

"The ideal thing is to wash the joint out and put the steroids in, and the data look pretty strong, but the problem is that the patient has to be scheduled for an arthroscopic procedure," Dr. Hardin told CIAOMed. "It's a more cumbersome operation, but the benefit seems to be much more prolonged. This paper would lead me to be more likely to refer patients to an orthopaedic surgeon for joint lavage and steroid injection rather than just doing the injection myself. This will likely modify the approach of a lot of rheumatologists to joint injections."

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Reference

1. Van Oosterhout M, Sont JK, Bajema IM, et al. Comparison of efficacy of arthroscopic lavage plus administration of corticosteroids, arthroscopic lavage plus administration of placebo, and joint aspiration plus administration of corticosteroids in arthritis of the knee: a randomized controlled trial. Arthritis Care Res. 2006;55:964–970.