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Table 2 Description of included studies

From: The clinical effectiveness of intra-articular corticosteroids for arthritis of the lower limb in juvenile idiopathic arthritis: a systematic review

Author, year Study type Participant description No. entered/ completed study Follow-up period Intervention (including post-injection procedure) Outcome measures
Balogh et al, [30] RCT Fulfilment of EULAR/WHO Oslo Criteria for JCA. 23/23 (23 knees) 1, 3, 7 and 42 days TH in 11/23 Knee Joint Circumference (cm); Knee Joint Flexion (degrees).
BM in 12/23
(Dose not recorded)
Pauciarticular form of disease. Post-injection: Not specified.
Co-interventions: Not specified
Al-wahadneh, [31] OBS Failure to respond to NSAIDs with/without slow acting anti-inflammatories. 24/24 (30 knee joints) 3, 6, 9, 12 and 24 months. MA 1 mg/kg/joint mixed with 1 cc 1% lidocaine without adrenaline. Sustained Clinical Response: ‘Active Inflammation’ (joint effusion and heat and tenderness/pain with/without correction of deformity)
Co-interventions: 10/24: MTX (10 mg/kg/wk), 24/24: Naproxen (10-20 mg/kg/day), 24/24: NSAIDs, 11/24: Prednisolone (0.25 mg/kg/day) Post-injection: Immobilisation 24 hrs post injection before commencing physiotherapy.
Allen et al., [32] OBS <16 yrs of age at onset of chronic arthritis 29/40 pauciarticular onset JRA 40/40 (53 knees) 4 patients lost to follow-up. 3, 6, 12 and 24 months. 20-40 mg TH with 1% xylocaine without epinephrine infiltration. Sustained Clinical Response: ‘Active
4/40 seronegative enthesopathy-arthropathy syndrome Post-injection: Not specified Inflammation’(Joint effusion and heat and tenderness, with or without complete correction of deformity)
6/40 psoriatic arthritis
Co-interventions: 100%- acetylsalicylic acid for at least 3 months; 30%- 1 NSAID; 22.5%- 2 NSAIDs; 20%- ≥ 3 NSAIDs; 3 patients previously on oral prednisone; 1 patient on hydroxychloroquine; 4 patients prior corticosteroid injection (other than TH); all patients maintained on the same NSAIDs post-injection.
Beukelman et al., [26] OBS Definitive JIA diagnosis based on criteria. 38/38 (55 STJ injections) 1-30 weeks (median = 6 weeks) TH in 13/38TA in 24/38 Sustained Clinical Response: STJ Eversion/Inversion and pain and gait abnormalities
Decreased foot inversion or eversion on physical examination (Medication and dose not recorded in 1/39 injection)
Co-interventions: 14/38: MTX, 3/38: TNF-alpha inhibitor, 3/38: TNF-alpha inhibitor and MTX. TA used when TH was commercially unavailable.
Post-injection: Non-weight bearing 24 hrs post-injection. Normal activity resumed afterwards.
Cahill et al., [25] OBS Clinical signs of STJ inflammation 38/38; 24/38 2-3 months 0.5-1 ml, 20 mg/ml TH Increased STJ
Referral for image-guided IACI. single STJ; 4/38 bilateral STJ; 3/38 subsequent contra-lateral STJ; 7/38 at least one repeated STJ. (active disease) 6 months (without active disease) Post-injection: Not specified. inversion and eversion: Normal ROM, without pain and limping
Co-interventions: Not specified.
Earley et al., [33] OBS Pauci-articular onset JCA. 23/23 (86 knees) 3, 6 and 12 months TH 20 mg for children weighing <20 kg (63 knees) OR for children >20 mg 40 mg (20 knees) Sustained Clinical Response: Soft tissue swelling and joint effusion and degree of flexion contracture and degree of valgus deformity.
Painful swollen knee with poor function.
Not respondent to at least 3 months of conventional treatment.
Post-injection: Not specified.
Co-interventions: All patients were on at least one NSAID and physiotherapy and splinting, 3/23 on gold, 1/23 on prednisolone
Eberhard et al., [34] OBS JRA diagnosis based on ACR criteria. 85/85 (51/99 received TH and 48/99 received TA; 14 patients received both) 2 weeks then every 3 months for a minimum for 15 months. TH: 40 mg (knee), 30 mg (ankle). Sustained Clinical Response: Non-bony swelling and (if no swelling) limitation ROM pain on motion or joint tenderness.
Co-interventions: TH group: 33/51 NSAIDs; 16/51 MTX; 9/51 sulfasalzine; 3/51 prednisone + etanercept; 14/51 no medication.
TA: 80 mg (knee), 60 mg (ankles)
Post injection: Minimal activity for 24 hrs post-injection.
TA group: 33/51 NSAIDs; 12/51 MTX; 2/51 sulfasalazine; 4/51 etanercept; 2/51 prednisone; 2/51 leflunomide; 15/51 no medication.
Eich et al., [35] OBS JCA diagnosis based on EULAR criteria. 15/15 (11 knees) Clinical and US assessment: 1 week and 1 month MRI: 1 month TH: 40 mg (knee) Pain
Post-injection: Not specified.
Failure of systemic therapy and physiotherapy. Swelling
Hyperthermia
Local growth disturbances.
Limited ROM
Popliteal cyst in affected knee.
Leg-length discrepancy
With/without complete deformity correction.
MRI: Joint effusion
Co-interventions: Not specified.
Popliteal cyst
Destruction of articular cartilage and/or bone
Destruction of menisci
Marrow oedema
Avascular necrosis
US: Joint effusion and/or pannus
Popliteal cyst
Hertzberger-ten Cate et al., [36] OBS Type 1 pauciarticular JCA. 21/21 (27 knees) 6 months TA: 20 mg in children weighing >20 kg with 1 ml lignocaine. Sustained Clinical Response: swelling and synovial fluid and no increased temperature.
Chronic arthritis in ≥1 knee.
No response ≥6 months of conventional treatment.
Flexion contracture, muscle wasting and/or growth disturbances.
Co-interventions: 81% used splints at night and 1 hr during the day, 50% received physiotherapy, 77% received NSAIDs. Post-injection: knee passively flexed and extended several times to distribute drug. No advice regarding activity levels.
Honkanen et al., [37] OBS JIA diagnosis. 79/79 (79 knees) 6-8 weeks MA: in 45/79 (Mean dose 1.5 mg/kg) Sustained Clinical Response: absence/presence of ‘symptoms’
With/without previous IACI.
Co-interventions: 100% on NSAID agents and regular physiotherapy, 17/79 on hydroxychloroquine, sodium aurothiomalate or auranofin (slow-acting antirheumatics), 5/79 on alternate day glucocorticoid therapy. TH: in 34/79 (mean dose 0.7 mg/kg)
Post-injection: Non- weight bearing for 24 hrs.
Huppertz et al., [38] OBS Children with chronic arthritis, not responding to NSAIDs. 21/21(18 knees, 2 ankles) 7, 13 weeks Knees: 1 mg/kg TH with 20 mg min dose and 60 mg maximum dose. Joint Swelling
Co-interventions: Not pre-specified. After 13 weeks, 10/21 had been treated with concomitant NSAIDs and 5/21 received chloroquine. Effusion
Ankle: “a lower dose”
Post injection: Not specified. Joint limitation
Joint tenderness/pain
Laurell et al., [24] OBS JIA diagnosis based on ILR criteria. 30/30 (40 ankle regions) 4 weeks TA 40 mg/ml Pain
Post-injection: Not specified. US: Synovial hypertrophy Synovial
Active disease.
Co-interventions: 26 patients had ongoing systemic treatment: 58% with MTX hyperaemia
23% with MTX and biologics (3 etanercept, 2 adalimumab, 1 abatacept), 19% with systemic corticosteroids Joint ROM
Lepore et al., [39] OBS JIA patients. 37/37 (87 injections of 37 knees) 7-65 months (average of 31.3 months) TH: 1 mg/kg (maximum 40 mg) Sustained Clinical Response: ‘Clinical signs of inflammation’
Failure to respond to 2 months NSAIDs.
Post-injection: Advised to keep child at home for first 24 hrs and to avoid physical exertion and carrying weights.
Relapse after full remission period.
Co-interventions: NSAID use was discontinued in all patients at time of local treatment
Marti et al., [19] OBS JIA patients who received injections and follow up as in patients. 60/60 (108 knees; 29 ankles, 5 STJ and 3 midfoot) Knee: 1-69 months, Ankle: 1-39 months, STJ: 13 months, Midfoot: 0-3months. Digits: 18-66 months TH: 40 mg (knee, shoulder and hips); 20 mg (wrist, elbow, ankle and STJ); 5 mg (finger and toes) Sustained Clinical Response: Swelling and effusion and tenderness/pain
Co-interventions: Non-steroidal anti-rheumatic drugs, MTX, Systemic corticosteroids, Salazopyrine
TA: 80 mg (knee, shoulder and hips); 40 mg (wrist, elbow, ankle and STJ); 10 mg (finger and toes).
Children with a body weight 20-40 kg received 75% of these doses. Children with body weight <20 kg received 50% of these doses.
Post-injection: Advised to keep injected joint as quiet as possible for 24 hrs post-injection.
Papadopoulou et al., [40] OBS Diagnosis JIA based on ILR criteria. 220/220 (186 knees, 168 ankles, 67 STJ, 14 MTJ and 14 IPJ) 6 months TH: 1 mg/kg (maximum 40 mg) in knee & hips; 0.75 mg/kg (maximum 30 mg) in ankles. Synovitis
MA: 20-40 mg in STJ & intertarsal joints; 5-10 mg in smaller foot joints.
Post-injection: Avoid activity or weight bearing for 24 hrs post-injection.
Previous IACIs with minimum follow-up of 6 months.    
Co-interventions: 61.8% of patients received systemic medications including: MTX (56.8%),     
Biologic agents (9.5%), Systemic corticosteroids (11.4%)
Ravelli et al., [41] OBS JIA diagnosis. 94/94 (66/94- unilateral knee 28/94 bilateral knees) 6 months TH: 1 mg/kg (maximum 40 mg) with 0.5 ml lignocaine (2%). Sustained Clinical Response: Synovitis
Initial injection between Feb 1996 and June 1990.
Co-interventions: 57% on NSAIDs, 24% on NSAIDs and “2nd line drugs” (no specification of second line drugs)
Post-injection: Rest joints for 24 hrs
Remedios et al., [42] OBS Children with JIA presenting as painful swollen ankles. 11/11 (13 ankles) >64 weeks TH: 20 mg with 1 ml 0.5% bupivacaine. Sustained Clinical Response: Synovitis (clinically assessed)
Co-interventions: Not Specified    Post-injection: Not specified. MRI: Pannus
Sherry et al., [43] OBS Pauciarticular JCA from ACR criteria. 16/16 (15 knees and 6 ankles) Mean follow-up University of Washington group: 42 months (SD +/- 11). University of Washington Group: 20 mg TH within 2 months of diagnosis. Leg Length Discrepancy (cm)
<7 years at diagnosis.
Reviewed at rheumatology centres at University of Washington or North Carolina (University of North Carolina/Duke University)
  North Carolina group: 46 months (SD +/- 15) North Carolina Group: No IACI. Thigh circumference discrepancy (cm)
Co-interventions: University of Washington Group: 25% on DMARD therapy, 44% with physical therapy evaluation, 31% with splints, 0% with shoe lifts North Carolina Group: 21% on DMARD therapy, 57% with physical therapy evaluation, 43% with splints, 50% with shoe lifts    Post-injection: Not specified.
Sornay-Soares et al., [44] OBS Children meeting the 1997 Durban criteria for JIA with knee involvement. 8/8 (13 knees) 6 months, 12 months Joint lavage using 2 needles and 0.5-1.51 ml saline. Followed by one vial of TH, except in 2 knees (one patient) BM was used. Sustained Clinical Response: Pain and joint effusion
Co-interventions: 6/8 on NSAIDs, 5/8 on MTX, 1/8 on Azathioprine, 2/8 on Cyclosporine
Post-injection: Knees were taped and advised to rest for 24 hrs, keeping in extension with walking crutches. Ice packs could be used for pain relief.
Verma et al., [45] OBS Diagnosis of unresponsive oligoarticular/polyarticular JIA. 13/13 (13 knees and 3 ankles) 3 patients were lost to follow-up at 6 months due to uncontrolled arthritis. 6, 12 weeks. TA (0.5-1 ml, 20-40 mg). Mid-leg circumference (cm)
Joint swelling/effusion, limitation of ROM, tenderness, pain, warmth. 4 children were lost to follow-up at 12 months.   Post-injection: Reduced movement for 24 hrs.
12 weeks daily oral naproxen and/or weekly MTX.
Co-interventions: All patients were on NSAIDs.
Zulian et al., [46] OBS Diagnosis persistent or extended oligoarticular JIA 85/85 (115 knees and 15 ankles) 1, 3, 6, 9, 12, 18 and 24 months TH: 42 patients treated; 1 mg/kg (>40 mg) Sustained Clinical Response: Swelling and limited ROM and pain and warmth.
Patients managed at University of Padua paediatric rheumatology unit TA:43 patients treated; 1 mg/kg (>40 mg) (Availability issues of TH meant TA was used as an alternative in some cases).
Received IACIs from Jan 1996 and Dec 2000.
Unsatisfactory response to NSAIDs.
Persistent isolated joint involvement. Post-injection: Non-weight bearing for
Co-interventions: TH: 64.3% on NSAIDs, 11.4% on MTX at last 72 hrs post-injection.
   TA:51.7% on NSAIDs, 5% on MTX    
  1. OB = observational; RCT = randomised controlled trial; JIA = juvenile idiopathic arthritis; JCA = juvenile chronic arthritis; JRA = juvenile rheumatoid arthritis; WHO = World Health Organization; ACR = American College of Rheumatology; EULAR = European League Against Rheumatism; ILR = International League of Associations for Rheumatology; ROM = range of motion; MTX = methotrexate; IACI(s) = intra-articular corticosteroid injection; TH = triamcinolone hexacetonide; TA = triamcinolone acetonide; NSAID(s) = Non-steroidal Anti-Inflammatory Drug(s); MA = methylprednisolone acetonide; BM = betamethasone; IACI(s) = intra-articular corticosteroid injection(s); US = ultrasound; MRI = magnetic imaging resonance; STJ = subtalar joint; MTPJ = metatarsophalangeal joint; IPJ = interphalangeal joint; SD = standard deviation; TNF-alpha = tumour necrosis factor alpha; DMARD = Disease Modifying Anti-Rheumatic Drug.