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Abstract Number: 281

Retrospective Review of Immobilization Vs. Immediate Resumption of Activity in Patients with Oligoarticular Juvenile Idiopathic Arthritis and Corticosteroid Knee Injections

Elaine Ramsay1, Heather Benham2, Jenna Tress3, Janille Diaz4 and David D. Sherry3, 1Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, 2Pediatric Rheumatology, Texas Scottish Rite Hospital for Children, Dallas, TX, 3Pediatric Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, 4Pediatric Rheumatology, The Children's Hospital of Philadelphia, Philadelphia,, PA

Meeting: 2014 ACR/ARHP Annual Meeting

Keywords: Joint procedures, juvenile idiopathic arthritis (JIA) and pediatric rheumatology

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Session Information

Title: Pediatric Rheumatology - Clinical and Therapeutic Aspects: Juvenile Idiopathic Arthritis

Session Type: Abstract Submissions (ACR)

Background/Purpose

Intraarticular corticosteroid injection (IACI) is one of the most common treatment modalities in oligoarticular Juvenile Idiopathic Arthritis (JIA). There is widespread use of IACI in the treatment of arthritis, but recommendations following the procedure vary, as there are no published studies on splinting patients post-IACI. Post-injection, Texas Scottish Rite Hospital for Children (TSRHC) splints patients for 24 hours while The Children’s Hospital of Philadelphia (CHOP) does not. The aim of this study was to compare the number of cases of recurrent arthritis and re-injection following IACI.

Methods

Data (see Table) were retrospectively collected at CHOP and TSRHC. All patients diagnosed with oligoarticular JIA according to ILAR criteria (2nd revision, 2001) between 2008-2010 were included. Chi square and T test were utilized for preliminary analysis. 

Results

131 patients at CHOP and 70 patients at TSRHC received a knee IACI. The average age was 9.1 (CHOP) v. 6.7 (TSRHC) (p=0.0002). There were more Hispanics at TSRHC (6 v. 10, p=0.055), and a higher number of ANA positive patients (54 v. 74, p=0.003). Overall mean joint disease severity scores (sum of range of motion restriction, joint swelling and tenderness) at CHOP were higher (3.4 v. 2.3, p <0.001). Mean dose of triamcinolone hexacetonide was higher at CHOP (1.4 mg/kg v 0.8 mg/kg, p<0.001). Arthritis reoccurred in 37 (28%) at CHOP v. 30 (43%) at TSRHC (p=0.041). 37 patients at CHOP received re-injection of the same knee v. 5 at TSRHC (p <0.001).

Conclusion

TSRHC patients were younger and more frequently ANA positive and Hispanic. Joint disease severity scores were higher at CHOP, and patients received a higher mean dose of triamcinolone hexacetonide IACI. The number of recurrent arthritis cases was similar between institutions and there was a trend toward more recurrent arthritis at TSRHC, but CHOP completed a larger amount of repeat injections. This may indicate that TSRHC begins systemic immunosuppression if IACI fails to clinically remit the knee. Future plans include comparison of time to recurrent arthritis to see if splinting extends remission. If it does, the practice of splinting knees following IACI may be beneficial in children with oligoarticular JIA. Examining co-variables such as age, ethnicity, ANA status, disease activity, steroid type and dose, and concomitant medications are planned. Limitations of this study include: 1) possibility that some subjects with oligoarticular JIA were missed; 2) some subjects were lost to follow-up; 3) variation in recording and practice styles. Also, the study only examined knee IACIs, splinting duration was less than reported in adults, and adherence was not monitored.

Table

 

 

CHOP n=131 (%)

Not splinted post injection

TSRHC n=70 (%)

Splinted post injection

P

Mean Age (yrs)

 

9.1

6.7

0.0002

Female

 

108(82)

58 (83)

>0.999

Race

 

 

 

0.220

 

White

110(86)

66(94)

 

 

Black

6 (5)

4 (6)

 

 

Asian

1 (1)

0

 

 

Other*

11(8.6)

0

 

Ethnicity

 

 

 

 

 

Hispanic

6 (5%, n=117)

10 (14%, n=70)

0.055

 

Not Hispanic

111 (95%, n=117)

60 (85%, n= 70)

 

Labs

 

 

 

 

 

ANA +

74 (57%, 130 tested)

54 (78%, 69 tested)

0.003

 

RF +

3 (2.3%, 131 tested)

2 (3%, 70 tested)

0.741

 

HLA B 27+

7 (5.5%, 128 tested B27)

3 (4.3%, 70 tested)

0.750

 

ESR>20

13 (25%, 52 tested)

22 (35%, 63 tested)

0.310

Iritis present

 

4 (3.1%, n=131)

2 (3%, n=70)

0.6344

Injection  dose (mg/kg)

Triamcinolone Hexacetonide

1.4 (112)

0.8 (68)

<0.001

Total joint activity (sum of ROM, swelling, tenderness) (mean)

 

3.4

2.3

<0.001

Arthritis reoccurred

 

37 (28)

30 (43)

0.041

Patients receiving re-injection

 

37 (31%, n=119)

5 (7%, n=69)

<0.001

Legend: CHOP=The Children’s Hospital of Philadelphia, TSRHC=Texas Scottish Rite Hospital for Children, NSAID=non-steroidal anti-inflammatory drug, ROM=range of motion, CHAQ=Children’s Health Assessment Questionnaire, * Includes: Native American, Hawaiian, other, not specified

 


Disclosure:

E. Ramsay,
None;

H. Benham,
None;

J. Tress,
None;

J. Diaz,
None;

D. D. Sherry,
None.

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