Discussion
JIA, active joints, knee arthritis, oligoarticular JIA, capsular calcification, synovitis, arthritis, pain, avascular necrosis, atrophy, ankle arthritis, rheumatoid
KNEE ARTHRITIS, SYNOVITIS, OSTEOARTHRITIS, DISEASE, HYPOPIGMENTATION, ARTHRITIS, OSTEOARTHRITIS KNEE, AVASCULAR NECROSIS, ATROPHY, BLIND, ANKLE ARTHRITIS, DISEASES, COMPLICATIONS
Persistent knee arthritis in JIA was always considered a difficult situation. In many patients, escalating systemic treatment failed to control arthritis. Local therapy was considered a practical alternative, as it can control arthritis without change in systemic treatment plans [It was known that GNB is effective in alleviating pain for 2 weeks on average and for function for 1 week only in osteoarthritis knee [In another systemic review for lower limb intra-articular in JIA, the authors found that the evidence about the role of intra-articular steroid injection is weak. This effect is more apparent in persistent oligoarticular JIA. Furthermore, the improvement was noticed in only few outcome measures. They could not reach a clear conclusion about the duration of improvement. One major obstacle they noticed is the lack of randomized clinical trials in the previous studies. They confirmed that US-guided injection is superior to blind injection with respect to accuracy and post-injection complications [In another comprehensive review, Gotte noticed that more than half of the injected knees with persistent arthritis in oligoarticular JIA could achieve complete resolution of arthritis after steroid injections. The question about the duration of improvement was answered partially in this study. They recorded a mean duration of improvement of between 28 and 74 weeks. The quality, blinding, and level of evidence of the included studies were questionable. They found that good responders had higher ESR and shorter disease duration whereas the effect of sex and age at onset was controversial. Furthermore, the knee showed the longest improvement among different injected joints in some studies, and in other studies, the upper limb joints achieved a longer improvement. Regarding the complications of steroid injections, they found capsular calcification, avascular necrosis (especially for weight-bearing joints), subcutaneous atrophy with or without hypopigmentation, steroid-induced synovitis, and systemic absorption. These side effects depend on the dose, the type of injected steroid, and the frequency of the injection [Iversen et al. reported that patients with JIA and ankle arthritis with disturbed gait dynamics failed to return to normal gait after intra-articular steroid injection for 3 months. This was attributed to pain. This shortcoming of steroid injections highlights the necessity of treating pain in active joints in JIA especially in weight-bearing joints to restore normal gait [Habib et al. reviewed the effect of intra-articular steroid injection in different diseases. They remarked that the duration of improvement depends on the type of arthritis. The duration of improvement was only 3 weeks in osteoarthritis, whereas this improvement extended to 8 weeks in adult rheumatoid and 6 months in JIA. In the listed studies in their review, the systemic treatment changes were not registered. Another essential finding is that they recorded that a single steroid injection has no effect on cartilage size [The elimination half-life of lidocaine is nearly 2 h [