Kyle P. Maloney, n/a
Medical Student
University of Queensland-Ochsner Clinical School
New Orleans, Louisiana, United States
Taylor Colon, DO
Attending Physician
Ochsner Medical Center
New Orleans, Louisiana, United States
81-year-old female with medical history significant for mitral valve prolapse, hypothyroidism, and headaches presented to the outpatient PM&R clinic 03/01/2023 for management of chronic bilateral knee pain and swelling. The patient historically managed with short-acting steroids, viscosupplementation, and deep genicular radiofrequency ablation. Physical exam showed no abnormalities outside of tenderness to palpation over bilateral joint lines. X-rays from 09/16/2019 revealed bilateral tricompartmental osteoarthritis, Kellgren-Lawrence System Grade 2.
Management began with bilateral knee triamcinolone acetonide (Kenalog) 40 mg/mL injections, followed by bilateral knee hyaluronate sodium 88 mg (Monovisc) beginning on 5/15/2023. Further management included aspiration before delivery of intra-articular injections and/or procedures. On average, aspiration effusion before and after Zilretta injection was 21.9cc/33.5cc and 1cc/2.5cc in the left/right knees, respectively - a 95.4%/92.5% decrease in aspiration volume following Zilretta injection.
Discussions:
Corticosteroids exert part of their effects via a genomic mechanism, that works via glucocorticoid receptors that translocate into the nucleus upon binding corticosteroids.1 In the nucleus, this glucocorticoid-glucocorticoid receptor substrate inhibits the expression of leukocytes, cytokines, chemokines, other inflammatory proteins, lessens vascular permeability, inhibits vasodilation, and decreases leukocyte emigration.1,2 Corticosteroids reduce aspirations through this mechanism. Specifically, long-acting corticosteroids/Zilretta have an enhanced effect on aspirate volume, confirmed by the precipitous decrease in aspirate following Zilretta injection. The role of long-acting steroids in inflammation has been extensively studied; its anti-inflammatory properties reduce pain and improve function, with long-acting steroids requiring fewer injections to achieve the same result as short-acting steroids.3 However, its role in chronic effusion management also needs to be considered; given this patient's history, more research must be completed to confirm the notion that long-acting steroids can effectively reduce chronic effusions.
Conclusions:
