Department of Orthopaedic Surgery and Biomedical Engineering, The University of Tennessee Health Science Center-Campbell Clinic, Memphis, TN, USA.
Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN, USA.
J Shoulder Elbow Surg. 2023 Nov;32(11):2214-2221. doi: 10.1016/j.jse.2023.05.023. Epub 2023 Jun 20.
A corticosteroid flare reaction is a well-described phenomenon that causes significant pain and dysfunction. The paucity of literature impedes decision making regarding which corticosteroid to use for shoulder injection. The purpose of this study was to compare methylprednisolone acetate (MPA) and triamcinolone acetonide (TA) injections in the glenohumeral joint and/or subacromial space in terms of efficacy and the incidence of steroid flare reactions.
In this prospective, interrupted time series, parallel study, patients received injections in the glenohumeral joint and/or subacromial space. MPA and TA were used during 2 discrete 3-month periods. The injections consisted of 2 mL of lidocaine, 2 mL of bupivacaine, and 80 mg of either MPA or TA. Visual analog scale (VAS) pain scores were recorded immediately before injection; 1-7 days after injection; and 3, 6, and 12 months after injection. The primary outcome was the incidence of a steroid flare reaction, defined as a post-injection increase in the VAS score by ≥2 points. The secondary outcome was injection failure, defined as a post-injection VAS score greater than the baseline score or the need for another intervention. We used linear mixed models with a patient-level random intercept to identify the mean VAS score change for TA injections in the first week after injection.
MPA or TA shoulder injections were administered in 421 patients; of these patients, 15 received bilateral-joint injections whereas 406 received a single-joint injection, for a total of 436 injections (209 MPA and 227 TA injections). Pain scores in the first week after injection were available for 193 MPA and 199 TA injections. Significantly more patients in the MPA cohort reported flare reactions compared with the TA cohort (22.8% vs. 4.0%, P < .001) during the first week after injection. In the first week after injection, the mean VAS score of patients receiving TA injections was 1.05 (95% confidence interval, 0.47-1.63) lower than that of patients receiving MPA injections when adjusted for age, sex, race, pain type, surgeon type, and injection site. At 3 months, surveys for 169 MPA and 172 TA injections were completed, with no significant difference in the rate of injection failure for MPA vs. TA (42.6% vs. 36.1%, P = .224). Treatment failure rates were significantly higher for MPA than for TA at 6 months (78.44% vs. 62.5%, P < .001) but not at 12 months (81.18% vs. 81.42%, P = .531.) CONCLUSION: TA injections resulted in a >5-fold reduction in steroid flare reactions, with statistically superior 6-month efficacy rates, compared with MPA injections. This study supports TA as a more viable corticosteroid option for shoulder injection.
皮质类固醇激惹反应是一种众所周知的现象，会导致明显的疼痛和功能障碍。文献的缺乏阻碍了我们决定使用哪种皮质类固醇进行肩部注射。本研究的目的是比较在盂肱关节和/或肩峰下间隙中使用醋酸甲泼尼龙（MPA）和曲安奈德（TA）的疗效和类固醇激惹反应的发生率。
在这项前瞻性、间断时间序列、平行研究中，患者接受盂肱关节和/或肩峰下间隙注射。在两个不同的 3 个月期间分别使用 MPA 和 TA。注射药物包括 2 毫升利多卡因、2 毫升布比卡因和 80 毫克 MPA 或 TA。在注射前、注射后 1-7 天以及注射后 3、6 和 12 个月记录视觉模拟量表（VAS）疼痛评分。主要结局是类固醇激惹反应的发生率，定义为注射后 VAS 评分增加≥2 分。次要结局是注射失败，定义为注射后 VAS 评分高于基线评分或需要进行另一次干预。我们使用具有患者水平随机截距的线性混合模型来确定 TA 注射后第一周的平均 VAS 评分变化。
在 421 名患者中进行了 MPA 或 TA 肩部注射；其中 15 名患者接受了双侧关节注射，而 406 名患者接受了单关节注射，总共进行了 436 次注射（209 次 MPA 和 227 次 TA 注射）。193 次 MPA 和 199 次 TA 注射后第一周的疼痛评分可用。与 TA 组相比，MPA 组在注射后第一周报告激惹反应的患者明显更多（22.8%比 4.0%，P<0.001）。在注射后第一周，接受 TA 注射的患者的平均 VAS 评分比接受 MPA 注射的患者低 1.05（95%置信区间，0.47-1.63），调整年龄、性别、种族、疼痛类型、外科医生类型和注射部位后。在 3 个月时，完成了 169 次 MPA 和 172 次 TA 注射的调查，MPA 与 TA 的注射失败率无显著差异（42.6%比 36.1%，P=0.224）。6 个月时，MPA 的治疗失败率明显高于 TA（78.44%比 62.5%，P<0.001），但 12 个月时无显著差异（81.18%比 81.42%，P=0.531）。
与 MPA 注射相比，TA 注射可使类固醇激惹反应减少 5 倍以上，6 个月时的疗效具有统计学优势。这项研究支持 TA 作为肩部注射更可行的皮质类固醇选择。
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