Background/Purpose:

Corticosteroid joint injections are a routine procedure in pediatric rheumatology. The dearth of existing literature on current practices led the authors to conduct an online survey targeting pediatric rheumatologists in Europe and North America.

Methods: An electronic survey with 22 questions related to pre-procedural sedation, choice of anesthetic agent, dose and type of therapeutic agent, number of joints injected, use of ultrasound, and post procedure complications was designed with a web based survey engine – Survey Monkey. The survey was distributed via email to physicians registered in the PRINTO and CARRA/PRCSG networks.

Results: 187/213 respondents (Table 1) performed joint injections as a routine clinical practice, of which 110 (57.6%) had received formal training in the procedure. 51.1% procedures were performed as an outpatient, either in a procedure room, day care or minor operation room. 152/180 respondents (85.5%) injected multiple joints in one sitting. Less than half physicians (45%) resort to ultrasound guidance, most often for the hip joint. Ignoring availability, triamcinolone hexacetonide (TH) was the most preferred agent by 79.6% of respondents. Other agents were Triamcinolone acetonide, Methylprednisolone acetate, hydrocortisone acetate and betamethasone acetate, in order of frequency. Only 51.5% physicians said that TH was consistently available in their country. There was some consensus about the dose of steroid (TH equivalent) as 1 mg/kg for large joints (62.9%), but wide variation in the dose for smaller joints. 65.9% physicians resorted to local anesthesia, including EMLA cream, subcutaneous Lidocaine, Lidocaine spray, ethyl chloride spray or a combination. Intravenous sedation was used by more than half physicians (51.2%), oral sedation by 15.7%, long anesthesia by 2.4% and other methods by 30.7%

Most respondents experienced some procedural complications in their clinical experience, commonest being subcutaneous atrophy(Table 2). Most physicians recommended home ambulation for 24-48 hours after procedure, however some variations such as complete bed rest, splinting, immobilization, and rest for longer than 48 hours were observed. 48.2% respondents follow significantly different practices in 0-5 year age group, for either choice of anesthesia, setting of procedure, use of ultrasound guidance or number of joints injected.

Conclusion: Practices related to pediatric joint injection procedures are not uniform and methods to develop standardization of this extremely common procedure is the need of the hour.

Table 1:

*UK – United Kingdom

**USA – United states of America

Table 2:

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/joint-injection-practices-in-pediatric-rheumatology-preliminary-data-from-an-ongoing-web-based-survey/