The response rate was 48.5% (358/737). 310/358 respondents (87%) routinely performed IAI in their clinical practice. The remaining 48 responses were excluded from the analysis.
Section A: Pre-procedure, procedure and post-procedure practices
Setting of Joint injection: 85% respondents said they performed the procedure in an outpatient procedure room, day care or minor Operation Theatre (OT). A minority (n=10, 3.32%) chose the major OT as a choice of setting for IAI. Approximately 8% used a combination of settings depending on age group and number of joints injected, one of which was Intensive Care Unit (ICU). Although cost implications of varying the setting of IAI are not well studied, it may be assumed that the setting will influence the cost of the procedure to the individual and the health care system.
Number of joints injected: Most respondents in this survey (80%) reported that they were comfortable injecting several joints in one sitting if required. The median number of joints injected per sitting was 4 (IQR: 4)
Ultrasound guidance: 52.16% respondents used Ultrasound to guide IAI either routinely (n=22) or selectively (n=135). Ultrasound guidance was reportedly useful for the hip, ankle, wrist, shoulder and small joints in declining order of importance. Although Ultrasound guided IAIs have proven targeted efficacy and safety for a broad spectrum of joints and tendons in Pediatric Rheumatology5,6, 47.84% of our respondents did not use Ultrasound. The precision offered by radiologically guided IAI certainly plays a role in improved clinical response in JIA, along with systemic therapy, time of initiation of treatment, severity of the disease and other factors.
Therapeutic agent: Ignoring availability, the molecule of choice for joint injections was TH. However, more than 50% respondents reported that TH was either not available (41.9%) or sporadically available (9.51%) in their country. Other choices included Triamcinolone acetonide (TA), methylprednisolone, hydrocortisone and betamethasone. Comments regarding availability of TH were: “advocacy to bring it back would be great”, “Would like to use Aristospan (TH) but Kenalog (TA) is all we have available currently”, and “Prefer TH but not available currently in US so use TA”, indicating that availability of TH is perceived as a significant barrier in IAIs.
Small prospective trials and retrospective chart reviews have studied the efficacy of TA and TH in IAI and concluded that TH offers an advantage to TA, due to long duration of action7,8.
In a study by Eberhard et al from New York, 794 IAIs were examined of which 422 were injected with TH and 372 with TA. In this study, TH proved more effective than TA with respect to the time to relapse for first injection (p < 0.001)9.
Dose of steroid in TH equivalent: The most used dose of steroid (TH equivalent) for large and small joint injections was 1 mg/kg and 0.5 mg/kg respectively (n=180:64% and n=155:55% respectively). While these are the recommended doses, several dose variations were observed in this response, ranging from 0.5mg/kg (n=24) to 2 mg/kg (n=28) with a minority using 1.5 mg/kg (n=12) for large joints (knees, shoulders and hips) and 0.25 mg/kg (n=42), 1 mg/kg (n=35) and 2 mg/kg (n=1) for small joints
Use of local anesthesia and sedation: 68% of respondents used pre-procedure local anesthesia (LA): either Emla (Lidocaine-Prilocaine) cream, subcutaneous lidocaine, or a combination. Emla cream was the most popular (39.06%) topical agent of choice.
Additionally, short anesthesia (49%) and oral sedation (19%) were offered by most respondents. A minority (2.13%) selected long anesthesia and amongst those who selected “Other” (30.85%) included no anesthesia, a mix of sedation and short anesthetic or differing choice as per age group.
Malleson et al explored anesthesia practices in pediatric joint injections in a Childhood Arthritis & Rheumatology Research Alliance (CARRA) survey in 2010 and reported a lack of standard of care with respect to anesthetic practices in Pediatric Rheumatology10. In their study, 100% of respondents used some LA contrary to our results where more than 30% denied use of LA.
Complications and prevention:
IAI is a safe procedure without major systemic side effects. The incidence of reported complications ranges from 2.6% to 8.3%6,11. Some known minor complications of IAI include infections, skin atrophy, hypopigmentation, articular calcifications and avascular necrosis.12,13 Similar complications were reported by the respondents in our survey (Table 1).
Techniques to prevent post-injection steroid leakage and subcutaneous atrophy included: reinjecting lidocaine (14.18%), quick withdrawal of needle (34.75%), combination of the above two (10.64%). 17% respondents reported no specific preventive measures. Amongst those who selected “other”, application of pressure, injecting normal saline, physiological serum, bupivacaine, air, limiting the volume injected, Z-track method and pressure application after needle withdrawal were reported.
Post-procedure monitoring: Most respondents monitored the patient in the hospital until the effect of anesthesia subsided (77%). We are not aware of any pediatric studies that explore the benefit of a longer period of rest. In the adult literature, the period of post procedure rest ranges between 24-72 hours14 and is reportedly controversial15.
Section B: Age-related practices
47% respondents followed significantly different practices for the <5year age group. Of these, the commonest age-dependent practice (72%) was choice of anesthesia. The CARRA survey10 on anesthetic practices reported more use of LA in children > 8 years of age and general anesthesia in the younger age group.
Section C: Physician demographics
60% respondents in this survey were formally trained in IAIs, and 49% had more than 15 years of clinical practice. Variations in practices based on geographical location of the respondents and years of training was analysed with chi-square and Fishers exact tests. In the USA 47% respondents used pre-procedure LA, as compared to 75% in the UK, and this difference was significant (Chi-square=4.540, p=0.033). None of the other practices varied significantly by geographical location. There was no significant difference in practices based on years of clinical experience. 67% of physicians who had received formal training followed different practices for the 0-5-year age group (Use of ultrasound, choice of setting, choice of anesthesia, number of joints and post procedure monitoring) whereas none of those without formal training did. This difference was statistically significant with Fishers exact test (p<0.0001).
Limitations of the study: Surveys have an inherent limitation of differences in understanding and interpreting questions. Most questions in the survey were self-explanatory, however language differences may have resulted in difficulties in understanding the questions. Although 48% is considered as an excellent response rate, there remain 42% Pediatric Rheumatologists that likely use IAIs in their practice who could not be reached through this survey.