title: The clinical effectiveness of intra-articular corticosteroids for arthritis of the lower limb in juvenile idiopathic arthritis: a systematic review.
abstract: BACKGROUND
  Juvenile Idiopathic Arthritis (JIA) commonly affects joints of the lower limb including the knee, ankle, subtalar and other foot joints. Intra-articular corticosteroid injections (IACIs) are considered to be effective for short-term relief of synovitis, however, there appears to be a significant lack of published evidence from comparative effectiveness studies. The aim of this study was to identify and critically appraise the evidence for the efficacy of lower limb IACIs in children/adolescents with JIA.
  
  
  METHODS
  Studies were identified in databases Medline, Embase, CINAHL, AMED, PEDro, the Cochrane Library and TRIP, with no date restrictions. The primary search terms 'juvenile idiopathic arthritis', 'lower limb', 'knee'; 'ankle', 'foot' and 'intra-articular steroid injections' and related synonyms were used to develop a comprehensive pragmatic literature search strategy. Included studies were quantitative longitudinal design such as randomised controlled trials, pseudo-randomised and non-randomised experimental studies, cohort studies, and case-control studies. All outcomes measures were subject to analysis. Quality assessment was conducted using the Cochrane Collaboration criteria with additional criteria for sample population representativeness, quality of statistical analysis and compliant intervention use and presence of co-interventions. Qualitative data synthesis was conducted for the outcome domains. Meta-analyses were not possible as multiple randomised controlled trials for outcome measures were not available. Levels of evidence were assigned to each outcome measure.
  
  
  RESULTS
  The inclusion criteria were met by twenty-one studies. One study had high quality for internal validity and nine studies had high quality for external validity. No studies had high quality for both internal and external validity. Four outcome domains were identified. There was weak evidence for IACIs decreasing clinical signs and symptoms in the lower leg, improving joint range of motion, decreasing leg length discrepancy, and for imaging techniques detecting the effects of IACIs.
  
  
  CONCLUSIONS
  There is some weak evidence for the efficacy of IACIs improving certain outcome measures. However, there is also some inconclusive evidence due to a lack of quality studies. More high quality evidence is necessary to definitely determine the efficacy of IACIs for JIA in the lower leg.
authors: School of Science & Health, University of Western Sydney, Penrith, NSW, Australia.
authors: Heidi
authors: H
authors: Jennings
authors: School of Science & Health, University of Western Sydney, Penrith, NSW, Australia.
authors: Kym
authors: K
authors: Hennessy
authors: School of Science & Health, University of Western Sydney, Penrith, NSW, Australia ; Institute for Applied Health Research/School of Health and Life Sciences, Glasgow Caledonian University, Glasgow G4 0BA, UK.
authors: Gordon J
authors: GJ
authors: Hendry
mesh_terms: D000293:Adolescent; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D001171:Arthritis, Juvenile / Q000175:diagnosis / Q000503:physiopathology / Q000628:therapy; D002648:Child; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage*; D006801:Humans; D007270:Injections, Intra-Articular / Q000379:methods; D035002:Lower Extremity / Q000473:pathology / Q000503:physiopathology; D008297:Male; D017063:Outcome Assessment, Health Care; D016059:Range of Motion, Articular; D016896:Treatment Outcome
chemical_list: D000305:Adrenal Cortex Hormones; D005938:Glucocorticoids
keywords: Ankle; Foot; Intra-articular injection; Juvenile idiopathic arthritis; Knee; Lower limb; Steroid injection; Systematic review