Effects of joint lavage and steroid injection in patients with osteoarthritis of the knee: Results of a multicenter, randomized, controlled trial

Abstract

Objective. To evaluate the efficacy of joint lavage and intraarticular steroid injection, alone and in combination, in the treatment of patients with symptomatic knee osteoarthritis (OA).Methods. Ninety-eight patients with painful tibiofemoral OA were enrolled in a prospective, randomized, controlled, 2 ؋ 2 factorial-design trial of 6 months' duration. The 4 treatment groups consisted of 1) intraarticular placebo (1.5 ml of 0.9% normal saline), 2) intraarticular corticosteroids (3.75 mg of cortivazol in 1.5 ml), 3) joint lavage and intraarticular placebo, and 4) joint lavage and intraarticular corticosteroid. Outcome measures evaluated at baseline, week 1, week 4, week 12, and week 24 included severity of pain (100-mm visual analog scale [VAS]), global status (100-mm VAS), and Lequesne's functional index.Results. No interaction between steroid injection and joint lavage was demonstrated. Patients who had undergone joint lavage had significantly improved pain VAS scores at week 24 (P ‫؍‬ 0.020). In contrast, corticosteroid injection had no long-term effect (P ‫؍‬ 0.313); corticosteroid injection was associated with a decrease in pain only at week 1 (P ‫؍‬ 0.003) and week 4 (P ‫؍‬ 0.020). After week 4, Lequesne's functional index was not significantly improved regardless of the assigned treatment.Conclusion. Compared with placebo, both treatments significantly relieved pain but did not improve functional impairment. The effects of the 2 treatments were additive. Cortivazol provided short-term relief of pain (up to week 4). The effects of joint lavage persisted up to week 24.Osteoarthritis (OA) of the knee is one of the most common forms of arthritis and a major cause of pain and disability, particularly among the elderly (1). Intraarticular corticosteroid therapy is widely used in the treatment of OA, particularly for the knee. A recent survey of rheumatologists in the US suggested that Ͼ95% prescribe corticosteroids "at least sometimes," and 53% "frequently" (2). Such therapy is recommended in the American College of Rheumatology (ACR) guidelines for the medical management of knee OA (3), and its clinical benefit has been evaluated in several controlled studies (4-6). However, a recent systematic review of studies of intraarticular (IA) corticosteroid use in patients with knee OA (7) showed that these studies were flawed by numerous methodologic deficiencies. Two recent double-blind, placebo-controlled studies showed significantly greater decreases in pain with corticosteroid treatment than with placebo only at week 1 in 1 study and at week 3 in the other (8,9). Some authors concluded that the evidence for efficacy of IA corticosteroids in knee OA is relatively weak (10,11).The results of several studies have suggested that joint lavage, either alone or combined with arthroscopy,

Tidal irrigation as treatment for knee osteoarthritis: A sham-controlled, randomized, double-blinded evaluation

“…A multicenter study of small-and large-volume arthroscopic irrigation, supported by the American College of Rheumatology but thus far reported only in abstracts, suggests that larger irrigation volumes may be more effective, particularly in patients with evidence of calcium pyrophosphate deposition disease (28). While Ravaud et al showed comparable and additive effectiveness of intraarticular corticosteroid injection and unblinded saline irrigation, they utilized two 14-gauge ports and filled, manipulated/ mobilized, and then drained the knee with unidirectional flow (16). The single, previous sham-controlled study of needle irrigation of the knee utilized 2 ports and did not show superiority to intraarticular injection of a small volume of saline (29).…”

“…This belief has been given further credence by controlled studies that have compared, as treatments for knee OA, needle irrigation with conservative medical management (14), needle irrigation with arthroscopic irrigation (15), and blinded intraarticular corticosteroid injection with placebo injection, with or without needle irrigation (16). These studies have demonstrated that 1) needle irrigation is superior to medical management (14), 2) needle irrigation is comparable with arthroscopic debridement with irrigation, except in patients with meniscal tears (15), and 3) needle irrigation is as effective as an intraarticular corticosteroid injection but has greater durability of effect, and some additive effect of irrigation and intraarticular corticosteroid injection has been observed (16). However, an adequately designed and powered placebo-controlled trial of knee irrigation has not been previously reported.…”

Longitudinal characterization of synovial fluid biomarkers in the canine meniscectomy model of osteoarthritis

“…We cannot rule out the possibility that repeated lavage had an influence on metabolic processes in the knees operated on. Lavage with large volumes (1-3 L) has been shown in some cases to have a beneficial effect on joint pain (91). However, wc used only small volumes ( 5 ml) for diagnostic purposes.…”

The effect of ultrasonography guided intra-articular corticosteroid injections in advanced knee osteoarthritis

“…They compared 20 mg IA triamcinolone hexacetonide with placebo and reported significant difference of VAS for pain only at the first week. Ravaud et al [14] reported a 4-week duration of the effect of IA cortivazol when compared to joint lavage. VAS for pain, and subdivisions of both NHP and WOMAC scores for pain decreased significantly in our study.…”