Help with joint injection protocols

[kayjayvet]

I am a DVM, CCRT, cVMA in Colorado Springs who is currently in the process of helping a general practice open a new rehab and surgery offshoot. Part of this means I am helping create protocols for new types of treatment options, ie. Conservative treatment of a cruciate injury, post-TPLO protocols, ect.

I am now in the process of doing the same for joint injections. I have access to bone marrow derived stem cells, platelet rich plasma, hyaluronic acid (Evervisc), and steroids (triamcinolone and depomedrol). In my research it seems like there are a lot of rehab vets out there doing all of these types of injections but there does not seem to be any protocols agreed upon across the board - ie. when it is appropriate to choose HA vs HA + a steroid (ie. it seems obvious that steroid injections would be geared primarily toward end stage joints but I would love more specifics). I know we can divide them up into categories based on price (how much the client can afford), how long the injection benefits usually last, which ones are a one and done deal vs which ones need to be given in multiples (HA?), etc. I am looking for doses and protocols. Also, because I need to teach the other GP's in our hospital, what kind of joint would you be comfortable doing HA over PRP - is it just HA if they can't afford PRP or are there other reasons you might go for HA first? And, say you have a really really crappy joint (lets pick elbows - just because they are so tough).

And of course, I am always recommending this in conjunction with rehab.

Thanks everyone - and I am interested in the perspective of non-DVM's as well - what do you see on your end?

Thanks so much ahead of time.

Dr. Kelly Hutchison

[David Lane]

Ok…. So this is a big topic. Here is my subjective perspective on injections, what I pick and why

HA – I routinely give this for all arthrotomy surgical procedures (ie: TPLOs) at the end of surgery, unless I am giving PRP instead. If the patient has bilateral disease, I inject the other knee at that same time. I don’t give it for OA palliation because the protocols require 3 injections and I find that a hard sell given the other options.

HA plus steroids – I rarely give corticosteroids on their own without HA. If I do, it is generally due to a small volume of the joint – eg: interphalangeal joints or the tarsus. In-vitro studies suggest triamcinolone is not chondrotoxic (I am unaware of in-vivo studies), so it is my first choice, hoping to get 6 weeks out of it. Methoprednisolone is definitely chondrotoxic, so I only use that in end stage OA joints where there is no cartilage to save anyway. I’m hoping to get 2-3 months effect. I prefer PRP over HA+S, and am generally only using HA+S if I am unsure how much IA pain is causing the lameness and it is a gaitway injection to try, that is cheaper than PRP, or if I have a more acute inflammatory condition that I just want to settle down, and don’t think there will be ongoing insult (eg an acute bicipital tenosynovitis with no evidence of connective tissue damage). When in doubt, I PRP instead.

PRP – my first choice for IA OA treatment. Hoping for 9 months benefit. Really seems to help short term comfort for TPLOs when given at end of surgery. If I have macroscopic tissue damage, (biceps, achilles, etc.) then I tend to not use as a solo agent, and combine with BMAC or cultured ADSC instead.

BMAC – always combine with PRP. First choice agent when macroscopic damage of connective tissue is evident. Is overkill for routine OA relative to PRP (lasts 11m vs 9m), but I will use it for refractory OA cases, a/o if maladaptive pain is suspected.

[David Lane]

And then I stumbled across this... might have to start combining PRP with HA.
https://read.qxmd.com/read/33091549/int ... 1893049c4d