Ultrasound-guided percutaneous injection to treat de Quervain's disease using three different techniques: a randomized controlled trial

Efficacy of Ultrasound-Guided Hydrodissection for Treating De Quervain's Tenosynovitis

Objective

This study evaluated the effectiveness of ultrasound-guided hydrodissection treatment for De Quervain's stenosing tenosynovitis, characterized by the narrowing of the first extensor compartment of the wrist. Notably, approximately 2% of cases involve a fibrous septum that divides the compartment.

Subjects and Methods

Ninety-five patients diagnosed with De Quervain's disease using ultrasound underwent hydrodissection treatment. When a septum was present, the needle was redirected into each sub-compartment to distribute the therapeutic solution evenly and facilitate the breaking of the septum.

Results

Ninety patients reported significant improvements in pain and functionality within 2 months of the initial treatment, with a marked decrease in the mean visual analog scale score from 7.65 ± 1.31 to 1.65 ± 2.32. A second infiltration, administered 2 months later, further alleviated pain and enhanced hand functionality. However, 5 patients with septum required surgical intervention after nonconclusive results from the infiltrative treatment.

Conclusions

This study confirms that ultrasound-guided hydrodissection is an effective treatment for approximately 95% of patients with De Quervain's disease, achieving substantial pain relief and improved joint mobility after the first treatment. These findings support the continued use of ultrasound guidance to enhance the precision and efficacy of treatment in complex cases.

A Practical Guide to Injection Therapy in Hand Tendinopathies: A Systematic Review of Randomized Controlled Trials

Hand tendinopathies represent a pathological condition associated with significant disability. However, due to this high heterogeneity of the treatments and their efficacy, there is still a lack of consensus on the infiltrative therapy of the hand. This systematic review aimed to investigate the efficacy of injection techniques in the treatment of pain related to the main hand tendinopathies. We searched online medical databases (PubMed, Pedro, Cochrane Library, Scopus, and WoS). Only RCTs published in the last 10 years (up to 5 August 2024), written in English, and related to infiltrative treatment in wrist and hand tendinopathies were evaluated. The risk of bias in RCTs was assessed with Version 2 of the Cochrane Risk of Bias tool for randomized trials (RoB 2). Out of 641 articles identified, 23 were included in the final synthesis: 14 RCTs on trigger finger, and 9 RCTs on de Quervain's tenosynovitis. The present systematic review showed that infiltrative therapy of trigger finger and de Quervain's tenosynovitis constitutes a fundamental element in the treatment of these pathological conditions, in terms of pain reduction and improvement in the functionality of the hand.

A Study of High-Resolution Ultrasound and Magnetic Resonance Imaging Findings in Shoulder Joint Pain at a Tertiary Care Hospital in Central India

Objective This study aims to investigate the diagnostic efficacy of high-resolution ultrasound (USG) and magnetic resonance imaging (MRI) in patients with shoulder joint pain at a tertiary care hospital in Central India. Methods This cross-sectional study was conducted at Acharya Vinoba Bhave Rural Hospital from 2021 to 2024. The study population consisted of patients with shoulder pain, without fractures, who were evaluated using USG and MRI. Participants with infective arthritis, rheumatoid arthritis, previous shoulder surgery, or contraindications for MRI were excluded. Data were recorded and analyzed using Microsoft Excel (Microsoft Corporation, Redmond, Washington) and R 4.2.0 software (The R Foundation, Vienna, Austria). Sensitivity, specificity, and receiver operating characteristic (ROC) curves were used to compare the diagnostic performance of USG and MRI. Results A total of 80 patients were included, with 49 (61%) males and 31 (39%) females. The MRI findings showed supraspinatus partial tears in 44 (55%) cases, complete tears in 10 (12.5%), and various other shoulder pathologies. USG detected supraspinatus partial tears in 16 (19.5%) and complete tears in seven (8.8%). Kappa statistics indicated moderate to high agreement between USG and MRI for several pathologies, with near-perfect agreement for complete tears. Conclusion High-resolution USG is a valuable tool for the initial assessment of shoulder joint pain, providing reliable diagnostic information with high agreement levels with MRI for complete tears and certain shoulder conditions. MRI remains indispensable for comprehensive evaluation, particularly for partial tears and complex pathologies.

Ultrasound versus palpation-guided corticosteroid injection for de Quervain disease: A randomized controlled trial

INTRODUCTION

Corticosteroid injection effectively treats de Quervain disease, and due to the high prevalence of the intracompartmental septum in the first extensor compartment, ultrasound guidance improves injection accuracy.

OBJECTIVE

To compare the effectiveness, adverse events, and the recurrence rate between ultrasound-guided and palpation-guided injection in patients with de Quervain disease.

DESIGN

Prospective, single-blind, randomized controlled trial.

SETTING

Rehabilitation department of a private teaching hospital.

PARTICIPANTS

We enrolled 49 patients, ≥20 years of age, clinically diagnosed with de Quervain disease based on their medical history and physical examination.

INTERVENTIONS

Patients were randomized into two groups: ultrasound-guided and palpation-guided injection. Both groups received a mixture of 10 mg triamcinolone acetonide (10 mg/1 mL) and 0.3 mL 1% lidocaine.

MAIN OUTCOME MEASURES

The primary outcome measure was the Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score at 1 week. The secondary outcome measures were visual analog scale for pain (pain VAS) score, patient satisfaction, and adverse events or complications from the interventions at 1 week, 3 months, and 6 months.

RESULTS

Both groups showed improvement over time in QuickDASH scores and pain VAS (p < .001); however, no statistically significant differences were noted between the groups for either QuickDASH scores (p = .22) or pain VAS (p = .30). In addition, no statistically significant differences were found between the groups in terms of patient satisfaction (p = .76) and adverse events (p = .47, .33, .58) at the 1-week, 3-month, and 6-month follow-ups.

CONCLUSIONS

Both ultrasound-guided and palpation-guided injections effectively treated de Quervain disease. During a 6-month follow-up, there were no statistically significant differences between the groups in pain relief, upper limb function, or patient satisfaction. However, the palpation-guided group showed a tendency for more recurrence and skin side effects.

Management of de Quervain Tenosynovitis: A Systematic Review and Network Meta-Analysis

Importance

There is a plethora of treatment options for patients with de Quervain tenosynovitis (DQT), but there are limited data on their effectiveness and no definitive management guidelines.

Objective

To assess and compare the effectiveness associated with available treatment options for DQT to guide musculoskeletal practitioners and inform guidelines.

Data Sources

Medline, Embase, PubMed, Cochrane Central, Scopus, OpenGrey.eu, and WorldCat.org were searched for published studies, and the World Health Organization International Clinical Trials Registry Platform, ClinicalTrials.gov, The European Union Clinical Trials Register, and the ISRCTN registry were searched for unpublished and ongoing studies from inception to August 2022.

Study Selection

All randomized clinical trials assessing the effectiveness of any intervention for the management of DQT.

Data Extraction and Synthesis

This study was prospectively registered on PROSPERO and conducted and reported per Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension Statement for Reporting of Systematic Reviews Incorporating Network Meta-analyses of Health Care Interventions (PRISMA-NMA) and PRISMA in Exercise, Rehabilitation, Sport Medicine and Sports Science (PERSIST) guidance. The Cochrane Risk of Bias tool and the Grading of Recommendations, Assessment, Development, and Evaluations tool were used for risk of bias and certainty of evidence assessment for each outcome.

Main Outcomes and Measures

Pairwise and network meta-analyses were performed for patient-reported pain using a visual analogue scale (VAS) and for function using the quick disabilities of the arm, shoulder, and hand (Q-DASH) scale. Mean differences (MD) with their 95% CIs were calculated for the pairwise meta-analyses.

Results

A total of 30 studies with 1663 patients (mean [SD] age, 46 [7] years; 80% female) were included, of which 19 studies were included in quantitative analyses. From the pairwise meta-analyses, based on evidence of moderate certainty, adding thumb spica immobilization for 3 to 4 weeks to a corticosteroid injection (CSI) was associated with statistically but not clinically significant functional benefits in the short-term (MD, 10.5 [95% CI, 6.8-14.1] points) and mid-term (MD, 9.4 [95% CI, 7.0-11.9] points). In the network meta-analysis, interventions that included ultrasonography-guided CSI ranked at the top for pain. CSI with thumb spica immobilization had the highest probability of being the most effective intervention for short- and mid-term function.

Conclusions and Relevance

This network meta-analysis found that adding a short period of thumb spica immobilization to CSI was associated with statistically but not clinically significant short- and mid-term benefits. These findings suggest that administration of CSI followed by 3 to 4 weeks immobilization should be considered as a first-line treatment for patients with DQT.

Unblinding de Quervain: A systematic review of ultrasound-guided injection of corticosteroids for treatment of stenosing tenosynovitis of the 1st extensor compartment

A systematic review was conducted on studies reporting steroid injections with ultrasound for de Quervain. From 10 studies included and 379 wrists, 73.9% reported complete resolution of symptoms, 18.2% with partial and 7.9% without resolution. When compared to the landmark-guided technique, ultrasound guidance showed significantly higher rates of symptom resolution (P = 0.0132) and lower pain scores (P < 0.0001). Twenty-nine patients out of 163 who initially showed complete resolution of symptoms reported subsequent recurrence. We conclude that steroid injections guided by ultrasound present high rates of symptomatic relief through precise needle insertion, especially in cases of anatomic variability with subcompartments.

Clinical Considerations of First Extensor Wrist Compartment (FEWC) Variants and De Quervain's Disease: A Review Study

The first extensor wrist compartment (FEWC) displays significant variants. This review highlights all possible variants that may be associated with the occurrence and pathophysiology of de Quervain's tenosynovitis. A thorough search of PubMed and MEDLINE databases, following the PRISMA guidelines, was conducted from 2002 to 2022 to evaluate all FEWC variants, including the following: 1) the presence of an inter-tendinous septum, 2) the number of tendinous slips of the abductor pollicis longus (APL) and the extensor pollicis brevis (EPB) muscles, 3) their distal insertions and 4) the presence of a bony ridge within the FEWC. A total of 3878 wrists (1277 cadaveric and 1296 de Quervain patients) were included. Of the 1234 cadavers, a total of 701 (56.8%) were males and 533 (43.2%) were females. Regarding the 883 patients, 178 (20.2%) of them were males and 705 (79.8%) were females. An inter-tendinous septum was identified in 42.9% (47% of the patients' wrists compared to 39.3% of the cadaveric wrists, p<0.0001). Cadaveric wrists presented two or more slips for the APL in a significantly higher percentage (92.5%, p < 0.0001) compared to de Quervain patients' wrists (74.5%). Regarding the EPB muscle, de Quervain patients' wrists had a single slip in 93% (p=0.0007) and two or more slips in 3.6%, compared to cadaveric wrists (a single slip in 87%, and two or more slips in 11%, p< 0.0001). A bony ridge over the radial styloid process was recorded in 58.9% of the cadaveric wrists compared to 17.8% of the patients' wrists (p < 0.0001). Remarkable diversity concerning the structures within the FEWC was reported. The presence of an inter-tendinous septum dividing the FEWC and a single EPB muscle slip is more likely to be found in patients with de Quervain's disease.

Tendon injections - upper extremity

Imaging-guided tendon procedures aim to reduce pain and increase function by controlling inflammation and stimulating healing. Ultrasound is the preferable guiding modality due to its high resolution and real-time demonstration of the tendinous anatomy and needle positioning. The technique includes appropriate patient positioning, which varies depending on the targeted tendon, as well as sterile and proper draping. For most procedures, we prefer the "in-plane" approach, which demonstrates the entire needle as it advances through different tissue layers. Upper limb injections commonly use corticosteroids and anesthetics with different reported short- and long-term results depending on the tendon treated; better results are obtained in the treatment of tenosynovitis (sliding tendons such as trigger finger and De Quervain's tenosynovitis). Shoulder and elbow tendinopathies (anchor tendons) may also benefit from injections containing irritants or healing stimulants such as dextrose (prolotherapy) and platelet-rich plasma or by the stimulation of healing via tendon perforations (fenestration). The hyaluronic acid injection has also been used in the treatment of both tenosynovitis and tendinopathies. For tendons passing through osteofibrous tunnels, an additional release may be performed, and the techniques are discussed in this review. Therefore, this article provides practicing musculoskeletal radiologists and trainees with a comprehensive review of tendon injection musculoskeletal image-guided procedures.

De Quervain's tenosynovitis: a non-randomized two-armed study comparing ultrasound-guided steroid injection with surgical release

PURPOSE

Ultrasonography is currently used for both diagnostic and therapeutic purposes in de Quervain's tenosynovitis. There is a dearth of information on how effective an ultrasound-guided (USG) steroid injection is when compared to surgical release of the first extensor compartment. Hence, we performed a non-randomized two-armed comparison study to test our hypothesis that USG guided steroid injection is equally effective as surgery.

METHOD

62 consecutive patients participated in the study with 32 of them selecting the option of USG guided injection (Set A), and the rest undergoing surgical release (Set B). We reviewed them after 3 and 6 weeks and 6 months for functional outcome using DASH, PRWE and VAS scores, recurrence, or any complications. They were further followed if they were symptomatic.

RESULTS

The DASH/PRWE/VAS scores improved at the end of 6 months from 81.7/79.3/6.8 to 1.0/1.7/1.0, respectively for patients undergoing USG guided steroid injection. Similarly, for the patient undergoing surgery, the scores improved from 82.2/81.5/6.7 to 1.7/3.4/1.0, respectively. This was statistically significant in both the groups (p < 0.05) and was comparable to each other. Two patients in Set A came back with recurrence at eight and 10 months and two reported occasional pain on heavy work. Three patients had tenderness and two had numbness in Set B at the scar site.

CONCLUSION

We observed that USG guided steroid injections are comparable to surgical release in terms of pain relief, functional outcome, complications.

Effects of hyaluronic acid injections on pain and functioning in patients affected by tendinopathies: A narrative review

BACKGROUND

Tendinopathies are overuse tendon injuries showing load-dependant pain, stiffness, weakness of movement in the affected area, and impairment in the movements. The scientific interest on the role of Hyaluronic Acid (HA) for the management of tendinopathies has been increased due to its anti-inflammatory and lubricative properties.

OBJECTIVE

To collect evidence regarding the effectiveness and safety of HA injections in reducing pain in patients affected by tendinopathies.

METHODS

A scientific literature search was conducted using the PubMed, Medline and PEDro electronic databases. The databases were searched since their inception until July 2021. The search was limited to English language articles. Different combinations of the terms and MeSH terms "tendinopathy", "tendinosis", "tendinitis", "hyaluronic acid", "hyaluronate", "infiltration", "hyaluronic injections", "viscosupplementation" connected with various boolean operators were used for other electronic databases.

RESULTS

One hundred and one records were identified from the selected databases plus three additional papers identified by the authors through other sources. After removing duplicated papers and title/abstract screening, 19 studies were included in our review (eight papers on shoulder, three on elbow, four on hand, one on knee, and three on ankle).

CONCLUSION

The results showed that none of the studies report severe adverse effects and most of them support the use of HA injections in tendinopathies, with a special attention to pain reduction and functional assessment. Further studies are warranted to better investigate effects and methods of administration of HA in tendinopathies.

Is a Steroid Injection in Both Compartments More Effective than an Injection in the Extensor Pollicis Brevis Subcompartment Alone in Patients with de Quervain Disease? A Randomized, Controlled Trial

BACKGROUND

Ultrasonography (US)-guided steroid injections can improve the accuracy of injection in patients with de Quervain disease, especially in those with an intracompartmental septum. Although the main lesion of de Quervain disease in patients with a septum is a stenosing tenosynovitis of the extensor pollicis brevis (EPB), no report we know of has compared injection into the EPB subcompartment with an injection into both the abductor pollicis longus (APL) and EPB subcompartments. In this randomized trial, we compared the results of US-guided steroid injections targeting both subcompartments and the EPB subcompartment alone in patients with de Quervain disease.

QUESTIONS/PURPOSES

(1) Do patients who receive a steroid injection in the EPB subcompartment alone have lower pain scores at 6 weeks and at 3 months after US-guided injection compared with patients who receive an injection in both subcompartments? (2) Do patients who receive a steroid injection in the EPB subcompartment alone experience fewer steroid injection-related complications than patients who receive an injection in both subcompartments?

METHODS

A randomized controlled study was performed at a single center between August 2018 and March 2021. Patients with a diagnosis of de Quervain disease and with a complete intracompartmental septum between the APL and the EPB tendons were included. In total, 112 patients had a diagnosis of de Quervain disease during the study period. Definite, complete subcompartmentalization was seen in 50 patients. Patients were randomly assigned to US-guided injections targeting both subcompartments (n = 25) or the EPB subcompartment alone (n = 25). There were no between-group differences in age, gender, affected wrist, or disease duration, and all patients had US evidence of tendinosis of the EPB, with or without tendinosis of the APL. Although 33% of patients (16 of 48) showed tendinosis of the APL, no patient showed tendinosis of the APL alone. In all patients, a dorsal-to-palmar side injection of 0.5 mL of 2% lidocaine and 0.5 mL of triamcinolone acetonide (40 mg/mL) was administered by two experienced hand surgeons. In the both-subcompartments group, US-guided injections were performed in each of the APL and EPB subcompartments. In the EPB subcompartment group, US-guided injections were administered in the EPB subcompartment only. All patients underwent the same protocol after the procedure. Four percent (n = 2, 1 in each group) of patients were excluded after randomization because their pain level was not registered. Pre- and postinjection clinical outcome assessments were completed by orthopaedic surgery residents not involved in patient management. Patients were regularly examined at baseline, 6 weeks, and 3 months to evaluate the intensity of pain. We assessed pain by the VAS score, where 0 indicated no pain and 100 the most pain. At baseline, the VAS score was 67 ± 14 in the both-subcompartment group and 67 ± 16 in the EPB subcompartment group (mean difference 0.17 [95% CI -8.45 to 8.82]; p = 0.97). Complications related to the steroid injection, including numbness, tendon rupture, and skin hypopigmentation, were also recorded at final follow-up examinations. To determine statistical power, the VAS score for pain at 6 weeks after the injection was used as the primary outcome variable. The minimum clinically important difference for the VAS score was deemed to be 20 mm, and we estimated an SD of 23. A sample size calculation indicated that a sample of 21 patients per group would provide 80% power to detect an effect of this size between the groups at the p = 0.05 level using a t-test.

RESULTS

There were no differences in the VAS scores between the both-subcompartment group and the EPB group at 6 weeks (10 ± 6 versus 10 ± 7, mean difference -0.08 [95% CI -4.08 to 3.91]; p = 0.97). The same was true at 12 weeks (12 ± 13 versus 11 ± 15, mean difference 0.38 [95% CI -7.74 to 8.49]; p = 0.09). No adverse events related to treatment (such as tendon rupture, infections, and numbness) occurred in either group. However, skin hypopigmentation occurred at the final follow-up examination in both groups. The proportion of patients experiencing skin hypopigmentation in the EPB subcompartment group was lower than in the both-subcompartment group (33% [8 of 24] versus 67% [16 of 24]; odds ratio 0.25 [95% CI 0.08 to 0.83]; p = 0.02).

CONCLUSION

Our data suggest that a US-guided steroid injection targeting the EPB subcompartment alone is as effective in terms of pain reduction as targeting both subcompartments in patients with de Quervain disease who have complete septation. Furthermore, an injection targeting the EPB subcompartment alone can reduce the dose of steroids used, perhaps thereby decreasing complications related to steroid injections. We recommend using only single-compartment injections in this context, even among patients with an intracompartmental septum.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Utility of Ultrasonography and Significance of Surgical Anatomy in the Management of de Quervain Disease: A Systematic Review and Meta-Analysis

BACKGROUND

The role of ultrasound in plastic surgery practice has grown significantly over the past decade, with notable applications for conditions of the upper extremity. Its utility for the management of de Quervain disease, however, remains to be established, and the prevalence of first dorsal compartment anatomical variations needs to be adequately assessed.

METHODS

A systematic review was performed to evaluate the role of ultrasound in the diagnosis, anatomical characterization, and clinical management of de Quervain disease. A meta-analysis was conducted to establish the prevalence of first dorsal compartment anatomical variations in the de Quervain disease and general population, along with the diagnostic accuracy of ultrasound for their detection. Outcomes were documented and compared to alternative treatment options.

RESULTS

Extensor retinaculum thickening, tendon sheath swelling, peritendinous edema, and tendon enlargement were the most common sonographic features of de Quervain disease. The prevalence of an intercompartmental septum in the de Quervain disease surgical population was shown to be significantly greater than in the general cadaveric population (67 percent versus 35 percent, respectively). Although the efficacy of energy-based therapeutic ultrasound remains elusive, ultrasound-guided corticosteroid injections were shown to be more accurate than manual injections (90 to 100 percent versus 40 to 100 percent), and to confer significantly better treatment outcomes (73 to 100 percent versus 59 to 83 percent success rates, respectively).

CONCLUSIONS

Ultrasound use is essential to achieve the best evidence-based outcomes in the management of de Quervain disease. The varied prevalence of first dorsal compartment anatomical variations and high accuracy of ultrasound for their detection carry significant prognostic implications.

Ultrasound-guided musculoskeletal interventional procedures around the elbow, hand and wrist excluding carpal tunnel procedures

Ultrasound is a fast, reliable and radiation-free method for the assessment of a wide range of pathological conditions, as well as for the guidance of percutaneous interventional procedures around the elbow, hand and wrist. Intraarticular and periarticular interventional procedures can be easily performed under continuous ultrasound monitoring to ensure correct needle positioning and medication delivery to a specific target. The most common ultrasound-guided procedures performed around the elbow, wrist, and hand are described in this review, excluding carpal tunnel procedures. Specifically, elbow steroid injections are performed in patients with inflammatory disorders, while hyaluronic acid can be administered in case of osteoarthritis. Septic olecranon bursitis requires percutaneous drainage for diagnosis and appropriate treatment. Dry needling and injection of regenerative medications, such as blood derivatives, are among the treatment options for lateral epicondylosis. Steroid injections are performed to give symptom relief in patients with ulnar neuropathy at the elbow. Hand and wrist steroid injections are performed in case of osteoarthritis, subsequently followed by hyaluronic acid injections, and in inflammatory disorders. Wrist ganglia can be safely aspirated and injected with steroids under ultrasound guidance. De Quervain’s tenosynovitis and trigger finger are chronic tenosynovitides of the wrist and digits, respectively, which can be treated with steroid injections, subsequently followed by hyaluronic acid injections. In conclusion, proper knowledge of the musculoskeletal disorders around the elbow, hand and wrist, as well as US-guided treatment options and operator training, are prerequisites to achieve good outcomes.

Conservative Management of de Quervain Stenosing Tenosynovitis: Review and Presentation of Treatment Algorithm

BACKGROUND

Nonsurgical management of de Quervain disease relies mainly on the use of oral nonsteroidal antiinflammatory drug administration, splint therapy, and corticosteroid injections. Although the latter is most effective, with documented success rates of 61 to 83 percent, there exists no clear consensus pertaining to conservative treatment protocols conferring the best outcomes. This article reports on all present conservative treatment modalities in use for the management of de Quervain disease and highlights specific treatment- and patient-related factors associated with the best outcomes.

METHODS

A systematic search was performed using the PubMed database using appropriate search terms; two independent reviewers evaluated retrieved articles using strict inclusion and exclusion criteria.

RESULTS

A total of 66 articles met the inclusion criteria for review, consisting of 22 articles reporting on outcomes following a single conservative treatment modality, eight articles reporting on combined treatment approaches, 13 articles directly comparing different conservative treatment regimens, and 23 case reports.

CONCLUSIONS

A multimodal approach using splint therapy and corticosteroid injections appears to be more beneficial than either used in isolation. Although there exists some evidence showing that multipoint injection techniques and multiple injections before surgical referral may provide benefit over a single point injection technique and a single injection before surgery, corticosteroid use is not benign and should thus be performed with caution. Ultrasound was proven valuable in the visualization of an intercompartmental septum, and ultrasound-guided injections were shown to both be more accurate and confer better outcomes. Several prior and concurrent medical conditions may affect conservative treatment outcome. A Level I to II evidence-based treatment protocol is recommended for the optimal nonsurgical management of de Quervain disease.

Prospective randomized comparison of ultrasonography-guided and blind corticosteroid injection for de Quervain's disease

BACKGROUND

Ultrasonography (US)-guided corticosteroid injection (CI) has been attempted to improve injection accuracy in de Quervain's disease (dQD), but its role in improving clinical outcomes and decreasing skin hypopigmentation or atrophy was not established well.

HYPOTHESIS

We hypothesized that the US-guided CI is superior to blind CI in symptom improvement and development of skin hypopigmentation or atrophy.

PATIENTS AND METHODS

Forty-four patients (48 wrists) with dQD received ultrasonography-guided CI (24 wrists/22 patients, group A) or blind CI (24 wrists/22 patients, group B) between December 2016 and February 2018. The visual analogue scale for pain and the Patient-rated Wrist Evaluation (PRWE) were used for evaluation. Skin hypopigmentation or atrophy was evaluated using the modified Vancouver scar scale (mVSS) RESULTS: At 4 weeks post-injection, pain and PRWE scores improved for 22 wrists in group A and 21 wrists in group B. At 3 months post-injection, 10.0% (2/20) and 26.3% (5/19) of wrists in group A and B, respectively, had symptom recurrence after initial improvement. Improvement and aggravation rates were not significantly different between the groups. The incidence of skin hypopigmentation or atrophy was 69.6% (16/23 wrists) and 70.0% (14/20 wrists) in group A, and 59.1% (13/22 wrists) and 78.9% (15/19 wrists) in group B at 4 weeks and 3 months post-injection, respectively. The mean mVSS scores at the injection site in group A and B were 2.0 (0-4.0) and 1.8 (0-5.0) at 4 weeks post-injection and 2.4 (0-7.0) and 2.9 (0-6.0) at 3 months post-injection, respectively. The incidence and severity of skin hypopigmentation or atrophy were not significantly different between the groups at both time points.

DISCUSSION

Pain and clinical outcomes significantly improved after CI in dQD. Pain, clinical outcomes, and the incidence and severity of skin hypopigmentation or atrophy were not significantly different between ultrasonography-guided and blind CI.

LEVEL OF EVIDENCE

I, Therapeutic.

Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-Part II, elbow and wrist

BACKGROUND

Although image-guided interventional procedures of the elbow and wrist are routinely performed, there is poor evidence in the literature concerning such treatments. Our aim was to perform a Delphi-based consensus on published evidence on image-guided interventional procedures around the elbow and wrist and provide clinical indications on this topic.

METHODS

A board of 45 experts in image-guided interventional musculoskeletal procedures from the European Society of Musculoskeletal Radiology were involved in this Delphi-based consensus study. All panelists reviewed and scored published papers on image-guided interventional procedures around the elbow and wrist updated to September 2018 according to the Oxford Centre for Evidence-based Medicine levels of evidence. Consensus on statements drafted by the panelists about clinical indications was considered as "strong" when more than 95% of panelists agreed and as "broad" if more than 80% agreed.

RESULTS

Eighteen statements were drafted, 12 about tendon procedures and 6 about intra-articular procedures. Only statement #15 reached the highest level of evidence (ultrasound-guided steroid wrist injections result in greater pain reduction and greater likelihood of attaining clinically important improvement). Seventeen statements received strong consensus (94%), while one received broad consensus (6%).

CONCLUSIONS

There is still poor evidence in published papers on image-guided interventional procedures around the elbow and wrist. A strong consensus has been achieved in 17/18 (94%) statements provided by the panel on clinical indications. Large prospective randomized trials are needed to better define the role of these procedures in clinical practice.

KEY POINTS

• The panel provided 18 evidence-based statements on clinical indications of image-guided interventional procedures around the elbow and wrist. • Only statement #15 reached the highest level of evidence: ultrasound-guided steroid wrist injections result in greater pain reduction and greater likelihood of attaining clinically important improvement. • Seventeen statements received strong consensus (94%), while broad consensus was obtained by 1 statement (6%).

Upper Limb Interventions

Ultrasound has been reported to be a quick, cheap, and effective imaging modality to guide the interventional procedures in the musculoskeletal system. The use of ultrasound results in increased accuracy of needle placement associated with a reduction of complications. In the upper limb, ultrasound-guided procedures are applied to joints and soft tissues around the shoulder, elbow, wrist, and hand. This article reviews the clinical and technical aspects of the most common procedures performed in this anatomic area.

Ultrasound-guided steroid injection for the treatment of de Quervain's disease: an anatomy-based approach

OBJECTIVE

To suggest different ultrasound-guided steroid injection (USI) techniques based on anatomical variations of the first extensor compartment (FEC), and to evaluate the usefulness of it, in patients with de Quervain's disease.

MATERIALS AND METHODS

Twenty-eight patients who underwent USI for de Quervain's disease were included. Anatomical variations were classified into complete sub-compartmentalization (n = 11), distal incomplete sub-compartmentalization (n = 5), and no sub-compartmentalization (n = 12) on ultrasound. Involved sub-compartments were recorded in patients with complete sub-compartmentalization. USIs were performed based on the anatomical variations: in both sub-compartments (n = 2) or only in the affected sub-compartment (n = 9) depending on the location of tenosynovitis involvement, in patients with complete sub-compartmentalization; in proximal FEC in patients with distal incomplete sub-compartmentalization (n = 5); in the common compartment in patients with no sub-compartmentalization (n = 12). Medical charts were retrospectively reviewed for evaluation of clinical outcome at follow-up visits.

RESULTS

Twenty-three out of 28 patients were followed up with a mean period of 31.2 days after injection (6~87 days). Mean VAS was 7.96 before injection (range: 4 to 10), which was significantly reduced to 0.65 at rest and 1.57 during activity at follow-up visits (p < 0.05). Twenty-two out of 23 patients were satisfied with the results. The mean proportion of subjective pain reduction was 82.0% (median 95%).

CONCLUSION

Ultrasound-guided steroid injections using different injection techniques based on the anatomical variations of the FEC have shown to be beneficial in the management of de Quervain's disease.

APPLICABILITY OF RANDOMIZED TRIALS IN HAND SURGERY: SURVEY STUDY

OBJECTIVE

To assess the applicability of randomized clinical trials and whether certain factors (surgeon experience/journal impact factor) influence their applicability.

METHODS

In this survey study we used the Pubmed/Medline database to select 32 consecutive randomized clinical trials published between 2013 and 2015, involving hand surgery (high/low impact). These studies were independently assessed by 20 hand surgeons (with more or less than 10 years of practice) who answered 4 questions regarding their applicability. Agreement was assessed using Cohen's kappa and comparison of proportions via chi-square statistics. P-value <5% constituted statistical significance.

RESULTS

A total of 640 evaluations were produced, generating 2560 responses. A weak correlation was observed between less and more experienced respondents (kappa <0.2; range 0.119-0.179). Applicability between the least and most experienced respondents was similar (p = 0.424 and p = 0.70). Stratification by journal impact factor showed no greater propensity of applicability (p = 0.29) for any of the groups.

CONCLUSIONS

Low agreement was found between the respondents for the applicability of the randomized studies. Surgeon experience and journal impact do not seem to influence this decision. Level of Evidence II, Prospective comparative study.

Rotator cuff calcific tendinopathy: from diagnosis to treatment

Rotator cuff calcific tendinopathy (RCCT) is a very common condition caused by the presence of calcific deposits in the rotator cuff (RC) or in the subacromial-subdeltoid (SASD) bursa when calcification spreads around the tendons. The pathogenetic mechanism of RCCT is still unclear. It seems to be related to cell-mediated disease in which metaplastic transformation of tenocytes into chondrocytes induces calcification inside the tendon of the RC. RCCT is a frequent finding in the RC that may cause significant shoulder pain and disability. It can be easily diagnosed with imaging studies as conventional radiography (CR) or ultrasound (US). Conservative management of RCCT usually involves rest, physical therapy, and oral NSAIDs administration. Imaging-guided treatments are currently considered minimally-invasive, yet effective methods to treat RCCT with about 80% success rate. Surgery remains the most invasive treatment option in chronic cases that fail to improve with other less invasive approaches. (www.actabiomedica.it)

In vivo feasibility of real-time MR-US fusion imaging lumbar facet joint injections

OBJECTIVES

Traditionally, facet joint injections (FJI) are performed under fluoroscopic or computed tomography (CT) guidance, mainly due to the deep anatomical location and the presence of bony landmarks. Fusion imaging technology, which couples the ultrasound scan with the corresponding CT or magnetic resonance (MR) image obtained from the diagnostic examination and reformatted in real time according to the ultrasound scanning plane, allows to combine the panoramic view and the elevated anatomical detail of MR or CT with the ease of use of ultrasound without patient exposure to ionizing radiation.

METHODS

Thirty eight patients (24 females; mean age ± SD: 64 ± 9 years) received MR fusion-assisted ultrasound-guided FJI of 1 ml of a mixture of local anaesthetic and corticosteroid using a ultrasound machine (Logiq E9, GE Healthcare) equipped with a GPS-enhanced fusion imaging technology which couples real-time B-mode images with those of the previous recent diagnostic MR examination. Low-dose CT needle positioning confirmation was performed in the first 28 patients. Patients' pain was recorded using a visual analogue scale (VAS), at baseline and at 2, 4 and 8 weeks.

RESULTS

All fusion imaging-guided injections were performed successfully. Out of 112, 96 FJI had optimal intra-articular needle positioning (accuracy: 85.7%). Patients VAS significantly decreases after the procedure with no differences among who received CT needle positioning control and who did not receive it. No major complications were observed.

CONCLUSIONS

Ultrasound needle guidance with MR fusion assistance allows for safe and effective injection of degenerative facet joint disease.

Clinical benefits and drawbacks of local corticosteroids injections in tendinopathies

INTRODUCTION

local glucocorticoids injections are widely administered for the treatment of tendinopathies. positive results have been observed in some tendinopathies but not in others. moreover, worsening of symptoms, and even spontaneous tendon ruptures has been reported. the characteristics of the tendinopathies, the clinical peculiarities of the patient, and the technique used to administer glucocorticoids, can influence the therapeutic response. Areas covered: After reviewing the pertinent literature on the clinical results, basic information, both on the pathogenesis of tendinopathies and the effects of glucocorticoids on tendons, is reported. The pharmacological properties of glucocorticoids are useful to counteract some pathogenetic mechanisms of tendinopathies. However, several experimental studies suggest that the direct action of glucocorticoids on tendons is detrimental. Loss of collagen organization, impaired viability of fibroblasts, depletion of stem cells pool, and reduced mechanical properties have been observed. Expert opinion: Drawbacks of local glucocorticoids injections could be predicted on an individual basis, after a careful appraisal of patient characteristics and concomitant medications, along with the specific stage of tendon disease.

Ultrasound-Guided Interventional Procedures of the Wrist and Hand: Anatomy, Indications, and Techniques

Acute and chronic wrist and hand conditions are commonly seen by neuromuscular and musculoskeletal specialists. High-frequency diagnostic ultrasonography (US) has facilitated advances in the diagnosis and interventional management of wrist and hand disorders. US provides excellent soft tissue resolution, accessibility, portability, lack of ionizing radiation, and the ability to dynamically assess disorders and precisely guide interventional procedures. This article review the relevant anatomy, indications, and interventional techniques for common disorders of the wrist and hand, including radiocarpal joint arthritis, scaphotrapeziotrapezoidal joint arthritis, trapeziometacarpal joint arthritis, phalangeal joint arthritis, first dorsal compartment tenosynovitis, ganglion cysts, and stenosing tenosynovitis.

Ultrasound-guided procedures to treat sport-related muscle injuries

Ultrasound is well known as a low-cost, radiation-free and effective imaging technique to guide percutaneous procedures. The lower limb muscles represent a good target to perform such procedures under ultrasound guidance, thus allowing for clear and precise visualization of the needle during the whole procedure. The knowledge of guidelines and technical aspects is mandatory to act in the most safe and accurate way on target tissues that can be as small as a few millimetres. This review will focus above the local treatments of traumatic lower limb muscle injuries described in literature, focusing on new and promising approaches, such as platelet-rich plasma treatment of muscle tears in athletes. For each procedure, a brief how-to-do practical guide will be provided, emphasizing precautions and tricks based on day-by-day experience that may help to improve the outcome of percutaneous ultrasound-guided procedures around the lower limb muscles.

Ultrasound-guided intervention in the ankle and foot

In this comprehensive review, we discuss the main interventions performed in the foot and ankle for Achilles tendinopathy, Morton's neuromas and Plantar fasciitis as well as techniques for intra-articular and peritendinous injections. We present the different imaging techniques and injectable agents that can be used in clinical practice, trying to help the reader decide the most appropriate way of managing the patient with a problem in the ankle and foot.