Would a steroid injection be beneficial for an 82-year-old patient with knee pain and chondrocalcinosis suggestive of Calcium Pyrophosphate Dihydrate (CPPD) arthropathy, and is a referral to sports medicine or orthopedics for joint fluid aspiration necessary?

From the Guidelines

I would proceed with the steroid injection for this 82-year-old patient with knee pain and X-ray findings of chondrocalcinosis suggestive of calcium pyrophosphate deposition disease (CPPD). According to the EULAR recommendations for the management of knee osteoarthritis 1, intra-articular injection of long-acting steroid is indicated for acute exacerbation of knee pain, especially if accompanied by effusion. Although the study primarily focuses on osteoarthritis, the principle of using steroid injections for acute flares can be applied to CPPD, which often presents with similar symptoms.

The patient's symptoms, including crepitus, small effusion, and swelling, are consistent with an acute flare of CPPD, and the lack of response to Meloxicam suggests the need for alternative management. Intra-articular corticosteroid injections can provide significant symptom relief for acute CPPD flares. For this patient, I would recommend a steroid injection, such as methylprednisolone 40-80mg or triamcinolone 20-40mg mixed with lidocaine, to help alleviate the acute symptoms.

In addition to the steroid injection, I would recommend referral to rheumatology rather than sports medicine or orthopedics, as CPPD is primarily a rheumatologic condition requiring specialized management 1. Joint aspiration can be both diagnostic and therapeutic, confirming the presence of calcium pyrophosphate crystals and providing immediate relief by removing inflammatory fluid.

Consider prescribing colchicine 0.6mg once or twice daily for acute flares if there are no contraindications, and continue with the planned physical therapy once the acute symptoms subside. Long-term management should focus on pain control, maintaining joint function, and preventing future flares through activity modification and appropriate use of NSAIDs when needed, as suggested by the EULAR recommendations 1.

From the FDA Drug Label

A single local injection of triamcinolone acetonide is frequently sufficient, but several injections may be needed for adequate relief of symptoms. Initial dose: 2. 5 mg to 5 mg for smaller joints and from 5 mg to 15 mg for larger joints, depending on the specific disease entity being treated.

The patient's X-ray showed chondrocalcinosis suggestive of CPPD arthropathy, and steroid injection can still be helpful for symptoms in acute flares.

• Steroid injection may be beneficial for the patient's symptoms.
• The decision to proceed with steroid injection should be made with caution, considering the patient's specific condition and medical history.
• Joint fluid aspiration may be considered to aid in the relief of pain and to prevent undue dilution of the steroid, especially if an excessive amount of synovial fluid is present in the joint.
• A sports med or ortho referral may be helpful for further evaluation and guidance on the best course of treatment, including joint fluid aspiration and steroid injection 2.

From the Research

Treatment Options for CPPD Arthropathy

• The patient's X-ray showing chondrocalcinosis suggestive of CPPD arthropathy indicates a condition that can cause acute and chronic arthritis, especially in the elderly population 3, 4, 5.
• Treatment options for CPPD arthropathy are largely based on expert opinion and evidence derived from the treatment of gout, as there is a lack of high-quality evidence supporting specific treatment modalities 3, 4, 5.
• Commonly used treatments for CPPD arthropathy include non-steroidal anti-inflammatory drugs (NSAIDs), colchicine, and corticosteroids, which are often extrapolated from use in gout 3, 5.

Steroid Injection for CPPD Arthropathy

• Steroid injections can be efficacious in CPPD arthropathy, with intra-articular glucocorticoids appearing to be effective in reducing pain intensity 3.
• However, the use of locally injected glucocorticoids can have systemic effects, including Cushing syndrome, loss of bone density, infection, and hyperglycemia, and caution should be exercised when using these injections, especially in higher risk patients 6, 7.

Referral for Joint Fluid Aspiration

• Joint fluid aspiration may be considered to confirm the diagnosis of CPPD arthropathy and to rule out other conditions, such as septic arthritis or gout 4.
• Referral to a sports medicine or orthopedic specialist may be beneficial for further evaluation and management of the patient's condition, including joint fluid aspiration and other treatment options 4, 5.