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Background/Objectives: Cervical facet joint syndrome (CFJS) is a frequent cause of neck pain and motor disability. Among the available therapies for CFJS, ultrasound (US)-guided injections are becoming more and more widespread, but the evidence about their accuracy and effectiveness is still debated in the scientific literature. The aim of this systematic review is to assess efficacy, accuracy and feasibility of US-guided cervical facet injections for the related chronic neck pain treatment. Methods: This review was conducted following the preferred reporting items for systematic reviews and meta-analysis 2020 (PRISMA) statement guidelines. The scientific articles were identified through the PubMed, Google Scholar and Cochrane Library databases. Qualitative assessment of the selected studies was carried out using the modified Oxford quality scoring system. Nine studies with a total of 958 patients were included in this review. The risk of bias was assessed using the Cochrane Collaboration tool. The protocol was registered at PROSPERO 2024 (n°CRD42024512214). Results: The results of this review suggest that the US-guided cervical facet injection for CFJS treatment is an effective technique in terms of accuracy (using the lateral technique it ranges from 92% to 98%), and efficiency (it grants pain relief with a decrease in the procedure time and fewer needle passes in comparison with the X-ray-guided technique, which also involves radiation exposure). Conclusions: US-guided injections are a safe and effective method to treat this musculoskeletal disease, granting a high functional recovery and long-lasting pain relief, net of the used drugs. However, these procedures are strictly operator-dependent and require important training to acquire good expertise.

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Introduction: Osteoarthritis (OA) and calcium pyrophosphate deposition (CPPD) often co-exist, this resulting in a clinical condition characterized by amplified inflammation and more severe and faster cartilage degeneration compared to OA alone. Our study aims to explore the efficacy of a therapeutic approach that addresses both conditions, using a combination of a high molecular weight hyaluronic acid (HMWHA) and collagen tripeptide (CTP). Additionally, safety profile and baseline characteristic predictive value were evaluated. Methods: We conducted a retrospective study on patients diagnosed with symptomatic knee OA (KOA) and CPPD treated by ultrasound (US) guided intraarticular injections of HMWHA-CT in the outpatient clinics of the Interdisciplinary Pain Medicine Unit at Santa Maria Maddalena Hospital, Occhiobello, Italy and in the Rheumatology Unit of the Emergency County Hospital Craiova, Romania (ECH Craiova). All the patients underwent clinical and US evaluation at baseline, 1, 3, and 6 months. From clinical point of view, Numeric Rating Scale (NRS) pain and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) were recorded. US data included detection of synovitis, cartilage damage, osteophytes, and CPPD deposits. Clinical efficacy was defined with NRS and WOMAC variations in respect to baseline and using the minimal clinically important difference values: an improvement of 2 point for NRS pain and 10 for the total score for WOMAC. Results: Twenty-nine patients (34 knees) were injected and evaluated. Overall pain levels, as measured by NRS, demonstrated a consistent decrease in patients across all follow-up intervals, with the most substantial improvement at the 6-month compared to baseline measurements. A significative proportion of patients achieved the minimum clinically detectable improvement, specifically 79% for NRS and 83% for WOMAC (19 and 20 patients, respectively). Conclusion: Our data showed a significant efficacy of ultrasound guided HMWHA-CT, in patients with KOA and CPPD, thus making it reasonable to consider that the combination of HMWHA and CTP can provide a strong anti-inflammatory effect.

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BACKGROUND: Neck pain and headaches can arise from the lateral atlanto-axial joint (LAA joint). This pain can be diagnosed with intra-articular injections of local anesthetic. A widely used technique for access to the lateral atlanto-axial joint uses a posterior approach, but this approach can be hazardous because of the proximity of the vertebral artery, the dural sac, and the C2 spinal nerve and dorsal root ganglion. OBJECTIVE: The objective was to describe and test a new technique for accessing the LAA joint that avoids structures that lie behind the joint. INTERVENTIONS: The new technique was described, and tested for tolerance in 10 patients with unilateral suboccipital pain, and tenderness over the LAA joint, along with evidence of LAA joint arthropathy on SPECT CT. The technique requires inserting a needle along a trajectory tangential to the dorsal surface of the C2 lamina. It involves obtaining a declined view of the C2 lamina and C2 pedicle. CONCLUSIONS: In all cases, the C2 pedicle was easily identified and allowed the needle to pass asymptomatically underneath the neurovascular structures behind the joint. The tactile response of the lamina of C2 provided important feedback regarding needle depth caudal to the LAA joint.

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Background: This systematic review aims to comprehensively summarise and present the available evidence for the treatment of primary acromioclavicular joint (ACJ) osteoarthritis (OA). Methods: Five databases were searched for studies investigating the management of ACJ OA. Included were studies with participants with clinical/radiological signs of primary ACJ OA, an intervention and included a functional outcome measure. Results: Forty-eight studies were included. Treatments consisted of physiotherapy (n = 1 study), medical only (n = 11) and operative management (n = 36). Operative studies included five comparative trials - physiotherapy versus surgery (n = 1) and open versus arthroscopic resection (n = 4). A total of 1902 shoulders were treated for ACJ OA, mean age (51 years), 58% male and mean follow-up (28.5 months). Treatment with injection showed a mean improvement of 50% in pain levels at follow-up (mean = 7.5 months). The commonest surgical procedure was arthroscopic excision of the distal clavicle and operative studies averaged 6 months of conservative management and a mean functional outcome of 87.8%. Conclusion: Studies varied in indication, intervention and quality but it did not provide evidence that both non-operative and operative interventions are effective. There was no significant difference between open or arthroscopic distal clavicle excision (DCE). Participants having between 0.5 and 2 cm of clavicle excised had good outcomes and those requiring concomitant shoulder procedures had similarly good outcomes.

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BACKGROUND: Periprosthetic joint infection is a devastating complication of total knee arthroplasty and is often treated with 2-stage revision. We retrospectively assessed whether replacing the patellar component with articulating stage-one spacers was associated with improved outcomes compared to spacers without patellar component replacement. METHODS: A total of 139 patients from a single academic institution were identified who underwent an articulating stage-one revision total knee arthroplasty and had at least 1-year follow-up. Of the 139 patients, 91 underwent patellar component removal without replacement, while 48 had a patellar component replaced at stage-one revision. Patellar fracture and reinfection at any point after stage-one were recorded. Knee range of motion (ROM), patellar thickness, lateral tilt, and lateral displacement were measured at 6-weeks post stage-one. Chi-square, Fisher's exact, and t-tests were utilized for comparisons. There were no significant demographic differences between groups. RESULTS: Patellar component replacement at stage-one revision was associated with fewer patellar fractures (2.1 versus 12.1%, P = .046), less lateral patellar displacement (1.7 versus 16.0 mm, P < .01), and improved pre to postoperative knee ROM 6 weeks after stage-one (+5.9 versus -11.4°, P = .03). There was no difference in reinfections after stage-2 revision for the replaced or unreplaced patellar groups (15.4 versus 15%, P = 1.000). While the mean time between stage-one and stage-2 was not different (5.2 versus 4.5 months, P = .50), at one-year follow-up, significantly more patients in the patellar component replacement group were satisfied and refused stage-2 revision (45.8 versus 3.3%, P < .001). CONCLUSIONS: Replacing the patellar component at stage-one revision is associated with a decreased rate of patellar fracture and lateral patellar subluxation, improved ROM, and possible increased patient satisfaction, as reflected by nearly half of these patients electing to keep their spacer. There was no difference in reinfection rates between the cohorts.

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BACKGROUND: It is essential to distinguish between symptomatic- and asymptomatic radiographic acromioclavicular (AC) osteoarthritis (OA) because AC-targeted physical examinations are dubious. This study aimed to determine the diagnostic value of a preoperative AC injection in discriminating between symptomatic- and asymptomatic radiographic AC OA based on patient arthroscopic distal clavicle resection (aDCR) outcomes. METHODS: Forty-eight patients who underwent aDCR for AC OA were included. Their satisfaction was objectified using a 5-point Likert scale and patient willingness to repeat the surgery. The Oxford Shoulder Score (OSS), the Subjective Shoulder Value (SSV), and the Numerical Rating Scale (NRS) were used to assess postoperative shoulder function and pain. Patients were subdivided into groups based on their good or minimal reaction to an AC injection (good reaction: ≥7 consecutive days of pain reduction, Minimal reaction: <7 consecutive days of pain reduction). RESULTS: Twenty-seven patients had a good reaction and 21 patients had a minimal reaction to the AC injection (median follow-up, 45.0 months; range, 31.0-52.8 months). No significant differences were found in level of satisfaction (P=0.234) or willingness to repeat the surgery (P=0.861). No significant differences were found in OSS (P=0.612), SSV (P=0.641), NRS at rest (P=0.684) or during activity (P=0.422). CONCLUSIONS: This study found no significant differences between patients with a good reaction or a minimal reaction to an AC injection after aDCR surgery. The outcomes of this study seem to suggest that a distinction between symptomatic and asymptomatic radiographic AC OA is unnecessary, as all patients were equally satisfied with the outcome. Level of evidence: IV.

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OBJECTIVE: The immunosuppressive effects of corticosteroid (CS) injections have come under more scrutiny during the coronavirus disease 2019 (COVID-19) pandemic. The aim of the study was to explore any relationship between joint/epidural CS injection and SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) polymerase chain reaction (PCR) positivity. METHODS: A retrospective chart review was conducted on patients 18 years or over who received at least one joint or epidural CS injection by physiatrists in a tertiary care center between January 1, 2020, and December 31, 2021. This cohort of patients was then compared to a control group who did not receive any CS injection during this time period. RESULTS: A total of 766 patients were identified in the CS injection group and 1546 patients in the control group. Overall, 12.27% of patients turned SARS-CoV-2 PCR positive in the CS injection group, which was similar to 11.90% in the control group (p = 0.797). But 3-month SARS-CoV-2 PCR positivity rate showed a statistically significant higher rate among the CS injection group (3.30% in the CS injection group vs. 2.10% in the control group; p = 0.027). In multivariate regression analysis, after adjusting both groups for Charlson Comorbidity Index (CCI), there was statistically significant higher SARS-CoV-2 PCR positivity rate in the CS injection group (p = 0.024). However, after adjusting both groups for age and total number of comorbidities, there was no difference between the groups in regard to SARS-CoV-2 PCR positivity rate (p = 0.081). In the subgroup analysis of only COVID-19 vaccinated patients, there was an increased 3-month SARS-CoV-2 PCR positivity rate among patients with severe comorbidities in the CS injection group (p = 0.036). CONCLUSION: The study was not conclusive on the effect of joint or epidural CS injection on SARS-CoV-2 PCR positivity rate, although adjusted analysis suggests higher 3-month SARS-CoV-2 PCR positivity rate after CS injection in patients with severe comorbidities with significant disease burden when compared to controls.

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Ultrasound visualization affords proceduralists versatile and accurate guidance for a variety of percutaneous, minimally invasive procedures in the musculoskeletal system including joint (intra-articular) injections or aspirations, intra-bursal injections, peritendinous, and perineural injections. A variety of percutaneous procedures are traditionally performed blindly, but may be more easily or more accurately performed with the real-time assistance of ultrasound guidance. Other procedures are only possible utilizing image-guidance, due to the required precision of the injection because of delicate local anatomy or depth of the injection; ultrasound is a safe, portable, and widespread modality that can be used to assist the proceduralist in localizing the needle tip in such cases, to ensure safe and accurate delivery of the medication, most frequently a solution of steroid and anesthetic. This review aims to provide a foundational approach to ultrasound-guided procedures in the musculoskeletal system, offering tips and tricks that can be employed in many different procedures including intra-articular, juxta-articular, and perineural injections for a multitude of clinical scenarios. Technical considerations regarding ultrasound transducer selection, sonographic technique, as well as common indications, contraindications, and complications of these procedures, are presented. Additionally, a variety of pharmacologic considerations for proceduralists contemplating ultrasound-guided injections are discussed.

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PURPOSE OF REVIEW: The purpose of this review is to evaluate the role of SPECT/CT in identifying facet joint arthropathy and the outcomes of interventions with SPECT/CT as an adjunct. RECENT FINDINGS: A positive finding of facet arthropathy on SPECT/CT is associated with a higher likelihood of a unilateral procedure and a significantly more effective intervention compared with those performed on patients with facet arthropathy diagnosed only by clinical and/or radiologic examination. Surgical treatment of SPECT/CT-positive findings appears to have a good effect; however, due to limitations in the available studies, no strong conclusion can be drawn. SPECT/CT has a good correlation identifying pain generators in chronic neck and back pain. SPECT/CT-targeted facet interventions demonstrate a higher success rate, but SPECT/CT is not recommended as a first-line diagnostic tool prior to diagnostic facet interventions. More robust studies are needed to confirm the higher success of surgical treatment for SPECT/CT-positive facet arthropathy.

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Accessing a joint with a needle (arthrocentesis) to extract synovial fluid is a skill intrinsic to the rheumatologist's praxis. Joint aspirations are essential for diagnosing or excluding septic joints, are the gold standard for diagnosing acute crystal arthritis, and can provide valuable information about the nature of other forms of arthritis. In appropriate settings, injecting medications into joints can provide rapid, temporary, or even prolonged relief of pain and swelling and can provide a window of relief until other treatment modalities (anti-inflammatories, immunomodulators, and physical therapy) can enforce durable responses. Soft tissue aspirations (e.g., of bursae) and soft tissue injections (of bursae, tendons, trigger points, and areas of nerve compression) can provide similar relief, earning the practitioner the gratitude of the patient. Here, we provide a primary on joint and soft tissue aspiration and injection, including indications for and against procedures, preparing for procedures, and approaches to specific musculoskeletal structures.

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The aim of the present study is to systematically review the current literature about diagnosis and treatment of acute inflammatory sacroiliitis in pregnant or post-partum women. A systematic search was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data about clinical presentation, diagnosis methods and treatment strategies were retrieved from included studies and reported in a table. After screening, five studies on 34 women were included; they were all affected by acute inflammatory sacroiliitis. Clinical examination and magnetic resonance imaging were used to confirm diagnosis. In four studies, patients were treated with ultrasound-guided sacroiliac injections of steroids and local anesthetics, while one study used only manual mobilization. Clinical scores improved in all patients. Ultrasound-guided injections proved to be a safe and effective strategy for inflammatory sacroiliitis treatment during pregnancy or post-partum.

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OBJECTIVE: To perform a scoping review to identify the available evidence regarding intra-articular injections in the inferior joint space (IJS) of the temporomandibular joint (TMJ). METHODS: An electronic search of the PubMed, Web of Science and Scopus databases was performed using the following terms: "Arthrocentesis", "injection", "joint injection", "technique", "Temporomandibular joint", "Temporomandibular joint disorder". Full-text articles were obtained from the records after applying the inclusion/exclusion criteria. Only articles with full-text access were included. RESULTS: Thirteen articles were included for analysis-one technical note, three cadavers studies, one animal study, two case reports, five randomised clinical trials and one retrospective study; studies were classified as 'patients-based studies' and 'non-patients-based studies'. Most 'patients-based studies' show moderate or high risk of bias. Techniques were categorised as 'anatomical technique' and 'image-guided technique'. Most 'patients-based studies' show favourable outcomes such as pain reduction, increase in maximum mouth opening, improvement in quality of life and improvement in TMJ dysfunction indexes for the treatment of arthrogenic TMDs. Comparisons between superior and IJS injections are scarce. On the other hand, 'non-patients-based' studies show that image-guided or ultrasound-checked injection techniques achieved a higher effectiveness for needle location than anatomical (or blind) techniques. CONCLUSION: The amount of available evidence is scarce, heterogeneous in design, and most 'patients-based studies' show moderate or high risk of bias, which demands the generation of new research to obtain definitive conclusions. The tendency observed suggests that intra-articular injections for the IJS of the TMJ are able to relieve TMJ pain, increase mouth opening and improve TMJ dysfunction, and image-guided injection techniques seem to be more effective than anatomical techniques to locate the needle in the IJS.

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Objective: This systematic review and meta-analysis compared the patient-reported outcomes of intra-articular facet joint injections of normal saline and selected active substances to identify a more effective agent for treating subacute and chronic low back pain (LBP). Methods: The PubMed, Embase, Scopus, Web of Science, and CENTRAL databases were searched for randomized controlled trials and observational studies published in English. A research quality assessment was performed using ROB2 and ROBINS-I. A meta-analysis was conducted using a random-effects model, and the mean differences (MD) with 95% confidence intervals (CI) in efficacy outcomes, including pain, numbness, disability, and quality of life, were assessed. Results: Of the 2467 potential studies, 3 were included (247 patients). The active substances and normal saline had similar therapeutic effects on pain within 1 h, after 1-1.5 months, and after 3-6 months, with MD and 95% CI of 2.43 and -11.61 to 16.50, -0.63 and -7.97 to 6.72, and 1.90 and -16.03 to 19.83, respectively, as well as on the quality of life after 1 and 6 months. Conclusions: The short- and long-term clinical effects of intra-articular facet joint injections of normal saline are comparable to those of other active substances in patients with LBP.

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PURPOSE:  Facet joint injection (FJI) is a minimally invasive procedure used to relieve pain and inflammation in the facet joints of the spine. In light of the growing presence of social media, it is essential to comprehend its effects on the healthcare industry. Little is known about how FJI is discussed on Instagram. The purpose of this study was to investigate the characteristics and production sources of FJI-related posts on Instagram. METHODS AND MATERIALS: This study provides a descriptive analysis of Instagram posts with the keywords #facetjointinjection, #facetjointinjections, #facetinjection, #facetinjections, #facetblock, and #facetblocks on March 1, 2023. The results were categorized by source into four groups; posts created by healthcare professionals (surgeon/non-surgeon), medical organizations, patients, or not otherwise specified. The content was categorized by type (educational and patient/physician experience) and user influence (number of followers and posts). RESULTS: The search resulted in 2718 posts. Most post uploaders were mainly physicians (43.1%, n = 275). The distribution of remaining Instagram users with FJIs posts was as follows: 27.1% (n=173) patients, 16.3% (n=104) medical organizations, and 13.4% (n=86) not otherwise specified. Among the posts, 1136 (41.7 %) were from accounts created by patients, 1015 (37.3%) by physicians, 441 (16.2%) by medical organizations, and 126 (4.6%) were unspecified. The analysis showed a significant difference in the distribution of posts among patients and physicians, as well as patients and other unspecified groups (p<0.05). The reported side effects were as follows: pain around the injection site (36%), swelling (17%), weight gain (15%), and anxiety (32%). CONCLUSIONS: This study demonstrates that physicians are widely present on social media. However, when searching for posts about facet joint interventions, posts written by patients are more likely to be seen by the public. The results of this article emphasize the impact physicians have on online platforms and the need to raise FJI awareness on Instagram. Due to a lack of information and their anxiety about the unknown, patients have voiced hesitation about undergoing FJIs. To address this issue, it is the responsibility of physicians to enhance the accessibility of accurate information for patients in order to alleviate their anxiety. Additionally, reputable pain medicine societies and qualified specialists should upload credible posts on facet joint interventions that include accurate information, high-quality images and videos, and proper scientific commentary, with the aim of enhancing the quality of online health information.

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Ultrasound (US)-guided procedures have increasingly gained their role in the daily practice of rheumatology, owing to the growing evidence supporting their utility. The utilization of US guidance in procedures may enhance their accuracy, efficacy, and safety. This article presents a comprehensive review of the current evidence and practical knowledge pertaining to US-guided procedures in rheumatology, encompassing joint aspirations, injections, and other applications such as tendon sheath injections. We provide a detailed description of the US-guided procedure process and compare the in-plane and out-of-plane view methods, along with practical techniques based on existing evidence or our own expertise. For each joint, we summarize how to perform procedures with figures to facilitate a better understanding. Additionally, we introduce other applications of US-guided procedures for tendons, enthesis, bursae, and nerves as well as emerging therapies such as US-guided fascia hydrorelease. By utilizing these US techniques, rheumatologists can achieve the ability to manage a wider range of musculoskeletal conditions.

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OBJECTIVES: Ultrasound-guided injections are used to treat common shoulder pathologies and have been shown to be more accurate and effective than traditional landmark-guided procedures. Currently, there exists no inexpensive shoulder model that accurately simulates the anatomical structures of the shoulder while also facilitating glenohumeral joint (GHJ) injection. Our model is an alternative to the traditional bedside training and provides a low-risk training environment. METHODS: We created this model from easily accessible materials. Polyvinyl chloride pipe was used to create the skeletal infrastructure pectoral girdle. A detergent pod was used to represent the GHJ space. Steaks were used to simulate the infraspinatus and deltoid muscles, with meat glue as a fascial layer between the two simulated muscles. Total cost of materials for the model was $19.71. RESULTS: Our model successfully replicates known anatomical features of the GHJ. Additionally, the model facilitates injection into a GHJ space, representing a GHJ injection. Our model was replicated to train medical student practitioners during five different educational sessions. The model was validated through comparison to standardized educational ultrasound training videos. It was further validated by ultrasound experts. CONCLUSIONS: The shoulder model we created is effective in simulating GHJ injections under ultrasound guidance. It simulates realistic muscle and bony landmarks both for ultrasound imaging and injection feel. Importantly, it is inexpensive and easy to replicate allowing more access to medical practitioners and students to be educated on the procedure.

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Pregnant women experience a wide range of musculoskeletal pain disorders, which include general ailments occurring during pregnancy, exacerbation of pre-existing conditions, or pregnancy-specific pain/inflammatory conditions. There are significant concerns and knowledge gaps surrounding the safety, dosage, and potential long-term effects of several drugs used during pregnancy. Our article reviews the use of focal steroid injections during pregnancy. A mixture of case studies, meta-analyses, and randomised controlled trials have shown at least there is no adverse side effect to the mother or baby from maternal use of non-systemic injection during pregnancy and a significant improvement in symptoms of pain or paraesthesia can be achieved in patients that do not respond to more conservative measures. As with all patients, the use of steroid injection should be judged on a case-by-case basis to ensure that it is the most appropriate treatment choice. However, being pregnant should not be considered a contraindication to a single dose of non-systemic steroid administration, as these women can achieve significant symptomatic relief that reduces reliance on systemic medication and can significantly improve their quality of life.

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Introduction As the use of facet joint injections (FJI) increases, practitioners performing FJI may be at increased risk of legal liability. Malpractice claim analysis is performed by several specialties as it provides valuable insight into patient values and methods to mitigate the risk of malpractice litigation pertaining to a specific procedure or treatment. Malpractice analysis regarding FJI may provide clinicians with a better understanding of the reasons that lead to malpractice due to FJI, thereby allowing practitioners to improve the quality of care delivered to patients whilst mitigating the incidence of malpractice. The aim of our study was to analyze the reasons for malpractice litigation due to FJI by querying Westlaw and VerdictSearch, two well-established legal databases widely used in medicolegal research. Methods We queried the Westlaw Edge and VerdictSearch legal databases utilizing the terms "facet injection" and "spine". Our database queries yielded 1026 results on Westlaw Edge and 545 results on VerdictSearch. Cases were reviewed and categorized by two independent reviewers based on the grievance(s) levied by the plaintiff. Discrepancies between reviewers were resolved by a third reviewer. Inclusion criteria for case relevance were defined as a basis of litigation resting on malpractice claims filed between the years 2000-2022 directly pertaining to FJI. Additional data collected included the date of the case hearing, verdict ruling, location of filed claim, payment or settlement amount, and sustained injuries. Results Of all 1571 cases reviewed, 1568 cases were excluded due to a basis of litigation unrelated to FJI. Of the three cases pertaining to FJI, the first case involved an alleged procedural error on the part of the anesthesiologist, whereby the anesthesiologist misplaced the needle during FJI, resulting in quadriplegia due to a cervical spine infarction. The plaintiff also contended that the pre-procedural timeout was improperly conducted as the practitioner utilized iohexol as the injected contrast material despite the patient's well-documented allergy to iohexol. The jury deemed both the practitioner and hospital negligent, and a plaintiff verdict was issued. The second case was filed under a basis of litigation alleging delayed diagnosis and treatment on the part of an emergency medicine physician. The court acquitted the physician, and a defense verdict was issued. The third case was filed under a basis of litigation of alleged deviation from the standard of care on the part of the anesthesiologist, whereby the anesthesiologist performing the FJI did not use fluoroscopy. The court affirmed fluoroscopy is not dictated as the standard of care for FJI and issued a defendant verdict. Conclusion This study provides insight into the risk of medical malpractice suits brought on by facet joint injection. Our findings suggest that despite the high prevalence of facet joint injections performed annually, there is limited legal liability associated with the procedure. Nevertheless, there are certain reasons a malpractice claim may be filed due to facet injection, including gross procedural error resulting in patient paralysis, delay in treatment or diagnosis, and deviation from the established standard of care. As such, treatment decisions regarding facet joint injection should not be influenced by medicolegal concerns and remain predicated on patient care needs and standard of care.

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OBJECTIVES: The objectives were to explore the response to intraarticular triamcinolone acetonide (TA) injection in children with non-systemic juvenile idiopathic arthritis (JIA) and factors associated with time to arthritis flare. METHODS: This was a retrospective cohort study of children with non-systemic JIA who received intraarticular TA injections at a tertiary care hospital in Bangkok, Thailand. Response to intraarticular TA injection was defined as absence of arthritis at 6 months after procedure. Time from joint injection to arthritis flare was recorded. Kaplan-Meier survival analysis with logarithmic rank test and multivariable Cox proportional hazards regression analysis were used for outcome analyses. RESULTS: Intraarticular TA injection was performed in 177 joints among 45 children with non-systemic JIA, most common in the knees (57 joints, 32.2%). Response to intraarticular TA injection at 6 months was observed in 118 joints (66.7%). Ninety-seven joints (54.8%) had arthritis flare following injection. The median time to arthritis flare was 12.65 months (95%CI 8.20-17.10 months). The significant risk factor associated with arthritis flare was the JIA subtypes other than persistent oligoarthritis (HR 2.62, 95%CI 1.085-6.325, p = 0.032); the significant protective factor was concomitant sulfasalazine use (HR 0.326, 95%CI 0.109-0.971, p = 0.044). Adverse effects included pigmentary changes (3, 1.7%) and skin atrophy (2, 1.1%). CONCLUSION: Intraarticular TA injection in children with non-systemic JIA had favorable response in two thirds of injected joints at 6 months. The JIA subtypes other than persistent oligoarthritis was a predictor of arthritis flare following intraarticular TA injection. Key Points • Intraarticular TA injection in children with non-systemic JIA had a favorable response in two-thirds of injected joints at 6 months. • The median time from intraarticular TA injection to arthritis flare was 12.65 months. • The risk factor predicting arthritis flare was the JIA subtypes other than persistent oligoarthritis (extended oligoarthritis, polyarthritis, ERA, and undifferentiated JIA), while the concomitant use of sulfasalazine was a protective factor. • Local adverse reactions from intraarticular TA injection were less than 2% of injected joints.

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Intra-articular viscoelastic supplements are commonly administered by musculoskeletal radiologists for the treatment of symptomatic osteoarthritis (OA). This article provides an overview of the putative mechanism of action of the agents, a brief review of the evidence base underlying the practice, a commentary on some of the major society guidelines regarding the treatment, and a description of the adverse events that are associated with intra-articular hyaluronic acid administration.

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