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Lornoxicam injection is inferior to betamethasone in the treatment of subacromial impingement syndrome

A prospective randomized study of functional outcomes

Unterlegenheit der Lornoxicaminjektion gegenüber Betamethason in der Therapie des subakromialen Impingementsyndroms

Prospektive randomisierte Studie zu funktionellen Ergebnissen

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Abstract

Background

Subacromial impingement syndrome (SIS) is one of the most frequent shoulder pathologies. Initial treatment is conservative. Subacromial injection of drugs achieves a high concentration at the pathologic site with less drug use and fewer systemic side effects. Glucocorticoids are most frequently injected. One concern with steroid use is the wide array of potential systemic and local complications. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also peripherally acting and can be used locally. Although intraarticular (IA) use of NSAIDs is common in orthopedic practice, it is mostly restricted to the knee joint. Reports of local NSAID for joint pathologies are relatively rare. This study compared the efficacy of single-dose subacromial injections of betamethasone and lornoxicam for treatment of SIS.

Methods

Subacromial injections of either 7.0 mg betamethasone or 8 mg lornoxicam were received by 70 patients with mean age 53 (46–68) years. Treatment outcome was assessed with Constant–Murley and UCLA questionnaires before injection and at 2‑, 4‑, and 6‑week follow-ups.

Results

The change in outcome scores compared to pretreatment was higher in the steroid group at all follow-ups (p < 0.001). Patients in the steroid group showed a significant improvement at all follow-ups compared to pretreatment (p <0.001) and previous follow-ups (p <0.05) at all times. Patients in the lornoxicam group showed a significant functional improvement in week 2 (p <0.001), which was not evident in the following weeks (p >0.05). Although functional recovery halted after week 2, outcome scores remained significantly higher than the pretreatment values at all weeks (p <0.001).

Conclusion

Although a single subacromial lornoxicam injection provides rapid functional recovery, which partially extends into the intermediate term, its results are inferior to betamethasone and it may be an alternative only in patients where corticosteroids are contraindicated.

Zusammenfassung

Hintergrund

Das subakromiale Impingementsyndrom (SIS) ist eine der häufigsten Erkrankungen der Schulter. Initial wird es konservativ behandelt. Mit der subakromialen Injektion von Medikamenten lässt sich bei geringerem Medikamenteneinsatz und weniger systemischen Nebenwirkungen eine hohe Konzentration am Ort der Erkrankung erzielen. Glukokortikoide werden am häufigsten injiziert. Bei Verwendung von Steroiden ist das große Spektrum potenzieller systemischer und lokaler Komplikationen zu bedenken. Nichtsteroidale Antirheumatika (NSAR) wirken auch peripher und können lokal eingesetzt werden. Die intraartikuläre Injektion von NSAR ist in der orthopädischen Praxis zwar üblich, aber zumeist auf das Kniegelenk beschränkt. Berichte über lokale NSAR bei Gelenkerkrankungen sind relativ selten. In der vorliegenden Studie wurde die Wirksamkeit von subakromialen Injektionen einer Einzeldosis Betamethason und Lornoxicam zur Therapie des SIS verglichen.

Methoden

Eine subakromiale Injektion entweder von 7,0 mg Betamethason oder 8 mg Lornoxicam erhielten 70 Patienten mit einem Durchschnittsalter von 53 (46–68) Jahren. Das Therapieergebnis wurde mit den Fragebögen nach Constant-Murley und UCLA (University of California, Los Angeles) vor der Injektion und bei Nachuntersuchungen nach 2, 4, und 6 Wochen ermittelt.

Ergebnisse

Die Veränderung der Therapiewerte im Vergleich zum Zustand vor der Therapie war in der Steroidgruppe bei allen Nachuntersuchungen größer (p <0,001). Bei den Patienten in der Steroidgruppe bestand eine signifikante Verbesserung in allen Nachuntersuchungen gegenüber dem Zustand vor Therapie (p <0,001) und vorherigen Nachuntersuchungen (p <0,05) zu allen Zeitpunkten. Die Patienten in der Lornoxicamgruppe zeigten eine signifikante funktionelle Verbesserung in Woche 2 (p <0,001), die sich in den folgenden Wochen nicht belegen ließ (p >0,05). Bei ihnen kam die funktionelle Besserung nach Woche 2 zwar zu einem Stillstand, aber die Therapiewerte blieben signifikant höher als die Werte vor Therapie in sämtlichen Wochen (p <0,001).

Schlussfolgerung

Obwohl eine einzelne subakromiale Lornoxicaminjektion zu einer schnellen funktionellen Besserung führt, die sich teilweise bis in den mittelfristigen Bereich erstreckt, sind die Ergebnisse dieser Therapie der Gabe von Betamethason unterlegen und stellen möglicherweise eine Alternative nur für Patienten dar, bei denen Kortikosteroide kontraindiziert sind.

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Correspondence to C. Ermutlu.

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Conflict of interest

M. Aksakal, C. Ermutlu, G. Özkaya, and Y. Özkan declare that they have no competing interests.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Additional information

Authors’ contribution C. Ermutlu designed the study and drafted the manuscript. M. Aksakal performed the interventions, collected data, and participated in drafting the manuscript. G. Özkaya participated in design of the study and performed the statistical analysis. Y. Özkan conceived the study, participated in its design and coordination, and helped to draft the manuscript. All authors read and approved the final manuscript.

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Aksakal, M., Ermutlu, C., Özkaya, G. et al. Lornoxicam injection is inferior to betamethasone in the treatment of subacromial impingement syndrome. Orthopäde 46, 179–185 (2017). https://doi.org/10.1007/s00132-016-3302-5

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