Transcoracoacromial Ligament Glenohumeral Injection Technique: Accuracy of 116 Injections in Idiopathic Adhesive Capsulitis

High accuracy of intra-articular needle position during anterior landmark guided glenohumeral injections

OBJECTIVES

Image-guided ultrasound or fluoroscopic glenohumeral injections have high accuracy rates but require training, equipment, cost, and radiation exposure (fluoroscopy). In contrast, landmark-guided glenohumeral injections do not require additional subspecialist referrals or equipment. An optimal technique would be safe and accurate and have few barriers to implementation. The purpose of this study was to define the accuracy of glenohumeral needle placement via an anterior landmark-guided approach as assessed by direct arthroscopic visualization.

METHODS

A consecutive series of adult patients undergoing shoulder arthroscopy in the beach chair position were included in this study. Demographic and procedural data were collected. The time required to perform the injection, the precise location of the needle tip, and factors that affected the accuracy of the injection were also assessed.

RESULTS

A standardized anterior landmark-guided glenohumeral joint injection was performed in the operating room prior to surgery, and the location of the needle tip was documented by arthroscopic visualization with a low complication profile and few barriers to implementation. A total of 81 patients were enrolled. Successful intra-articular glenohumeral needle placement by sports medicine and shoulder/elbow fellowship-trained orthopedic surgeons was confirmed in 93.8% (76/81) of patients. The average time to complete the procedure was 24.8 ​s. There were no patient-related variables associated with nonintra-articular injections in the cohort.

CONCLUSIONS

This study demonstrated that the technique of anterior landmark-guided glenohumeral injection has an accuracy of 93.8% and requires less than 30 ​s to perform. This method is safe, yields similar accuracy to image-guided procedures, has improved cost and time efficiency, and requires less radiation exposure. No patient-related factors were associated with inaccurate needle placement. Anterior landmark-guided glenohumeral injections may be utilized with confidence by providers in the clinical setting.

LEVEL OF EVIDENCE

Level 5. IRB: Approved under Stanford IRB-56323.

Is the Anterior Injection Approach Without Ultrasound Guidance Superior to the Posterior Approach for Adhesive Capsulitis of the Shoulder? A Sequential, Prospective Trial

BACKGROUND

Shoulder injections for conditions such as adhesive capsulitis are commonly performed and can be administered through image-based or landmark-based injection approaches. Ultrasound-guided injections are widely used and accurate because ultrasound allows real-time visualization of the needle and injected contrast. Landmark-based injections would be advantageous, if they were accurate, because they would save the time and expense associated with ultrasound. However, few prospective studies have compared well-described landmark-based shoulder injection techniques without ultrasound.

QUESTION/PURPOSE

Using anatomic landmarks, and without using ultrasound, is the accuracy of glenohumeral injection for adhesive capsulitis greater via the posterior approach or via a new anterior approach?

METHODS

Between 2018 and 2020, we treated 108 patients potentially eligible for adhesive capsulitis treatment. These patients had clinical symptoms of aggravating shoulder pain with a duration of less than 4 months and passively impaired, painful glenohumeral ROM. Due to the exclusion of patients with other shoulder conditions (full-thickness rotator cuff ruptures and posttraumatic stiffness), 95 patients received an injection in this sequential, prospective, comparative study. Between 2018 and 2019, 41 patients (17 males and 24 females; mean age 52 ± 5 years; mean BMI 24 ± 3 kg/m2) were injected through the posterior approach, with the acromion as the anatomical landmark, during the first part of the study period. After that, between 2019 and 2020, 54 patients (20 males and 34 females; mean age 54 ± 4 years; mean BMI 23 ± 3 kg/m2) received an injection through a new anterior approach, with the acromioclavicular joint as the anatomic landmark, during the second part of the study period. Injections via both approaches were administered by two experienced shoulder specialists (both with more than 10 years of experience). Both specialists had experience with the posterior approach before this study, and neither had previous training with the new anterior approach. Injections contained a corticosteroid, local anaesthetic, and contrast medium. Radiographs were taken within 20 minutes after the injection, and a radiologist blinded to the technique determined accuracy. Accurate injections were defined as having contrast fluid limited to the glenohumeral joint, while inaccurate injections displayed leakage of contrast fluid into the soft tissue or subacromial space. All of the enrolled patients were analyzed.

RESULTS

In the group with the posterior approach, the accuracy was 78% (32 of 41) in contrast to 94% (51 of 54, odds ratio 0.21 [95% CI 0.05 to 0.83]; p = 0.03) in patients with the new anterior approach.

CONCLUSION

The new anterior approach without the use of ultrasound was more accurate than the posterior approach. In fact, it was nearly as accurate as previously published ultrasound-guided approaches. We recommend using the new anterior approach for intraarticular glenohumeral injections instead of ultrasound-guided injections because it will save time and costs associated with ultrasound. Still, the clinical effects (anxiety, pain, functional outcome, and adverse events) of the new anterior approach should be compared with ultrasound-guided injections in a randomized study.

LEVEL OF EVIDENCE

Level II, therapeutic study.

A cadaveric study of the three different palpation-guided techniques for glenohumeral joint injections

BACKGROUND

It is not known whether an anterior, posterior or superior approach using the Neviaser portal is more accurate for glenohumeral joint injections. The aim of this study was to evaluate the accuracy of the palpation-guided technique and compare the three different approaches.

METHODS

Palpation-guided glenohumeral joint injections were performed in 48 shoulders (24 cadavers) by two operators. Each shoulder was injected by three different approaches with a different coloured latex solution. The three approaches included the anterior, posterior and superior methods. The accuracy and location of unsuccessful injections were assessed through dissection of the shoulders.

RESULTS

Posterior injections were the most successful with an accuracy rate of 89.6%, followed by anterior injections (75%) and superior injections (54.2%). Both posterior (p = 0.0001) and anterior injections (p = 0.03) were statistically significantly more accurate than superior injections. The most common failure mode was an intratendinous or intramuscular injection, which occurred most frequently with a superior approach.

CONCLUSIONS

Use of a superior approach through the Neviaser portal for the palpation-guided technique for glenohumeral joint injections showed a statistically significant inferior accuracy when compared to both the posterior and anterior approaches and is therefore not recommended. Posterior approached injections were the most accurate.

Trans-coracoacromial Ligament Glenohumeral Injection With Arthroscopic Confirmation

PURPOSE

To arthroscopically evaluate the trans-coracoacromial ligament glenohumeral (GH) injection technique by understanding intra-articular needle-tip placement and potential misplacement and complications.

METHODS

The technique relies on the palpation of 3 bony landmarks: anterolateral corner of the acromion, superolateral border of the coracoid tip, and curved depression of the distal clavicle. The skin entry site lies on the line connecting the curved depression of the distal clavicle and superolateral border of the coracoid tip, two-thirds of the way from the former and one-third of the way from the latter. The direction of the needle is perpendicular to the triangle formed by the 3 bony landmarks. The technique is used to insufflate the GH joint at the start of shoulder arthroscopy procedures with patients in the beach-chair position. Saline solution is injected, and the position of the needle tip in the GH joint is evaluated arthroscopically. An injection is considered successful if saline solution can be injected and the needle tip can be visualized intra-articularly.

RESULTS

This study enrolled 195 patients undergoing shoulder arthroscopy. Successful needle placement in the GH joint occurred in 179 patients (91.8%); placement occurred through the rotator interval in 122 of these, adjacent or through the long head of the biceps tendon in 41, through the upper subscapularis or anterior supraspinatus in 13, and through the anterior labrum in 3. Regarding the 16 failures (8.2%), the needle position did not allow saline solution to be injected because of high resistance in 3 patients whereas the needle tip was not visualized in 13. The needle tip was presumed to rest within the subscapularis muscle or tendon or the labrum in 10 failed injections.

CONCLUSIONS

The trans-coracoacromial ligament injection technique showed a high success rate (91.8%) in anesthetized patients about to undergo arthroscopy, whereas the failed injections mainly occurred because the needle was inserted into the subscapularis or labrum. This technique can be used for awake patients with different diagnoses in multiple settings.

LEVEL OF EVIDENCE

Level IV, diagnostic study.

Transcoracoacromial Ligament Glenohumeral Injection Technique Using Bony Surface Landmarks

Intra-articular glenohumeral injection is an important technique used to diagnose and treat shoulder disorders. However, it is frequently performed as an image-guided technique with the use of fluoroscopy, ultrasound, computed tomography, or magnetic resonance. The purpose of this Technical Note is to describe a transcoracoacromial ligament glenohumeral injection technique that uses anatomic surface landmarks to avoid the need for radiographic guidance. After identification of the anterolateral corner of acromion, the superior lateral border of the coracoid tip, and the curved depression of the distal clavicle, the needle entry site is determined at the trisection point between the distal and middle thirds of the line formed by the superior lateral border of the coracoid tip and the curved depression of the distal clavicle. The needle is first inserted perpendicular to the triangular plane of the 3 points and is then advanced toward the humeral head. This injection technique is highly accurate and reproducible and can be done in the outpatient clinic without the use of imaging guidance, reducing the costs and barriers of intra-articular glenohumeral injections for patients.

Editorial Commentary: Unguided Glenohumeral Injections-Do We Achieve Sufficient Accuracy?

Image-guided (fluoroscopy, ultrasound, computed tomography, magnetic resonance imaging) and unguided glenohumeral injection techniques are frequently used for different diagnostic and therapeutic purposes in clinical practice. Guided injections are highly accurate, reproducible, and more often performed in routine practice. Nevertheless, these techniques are more cost intensive and time consuming, and require special imaging devices. In case of fluoroscopic- or computed tomography-guided injections, radiation exposure of the patient is a disadvantage. In contrast, unguided glenohumeral injection techniques do not have these drawbacks, but rather are based on the precise identification of anatomic landmarks and depend on the experience of the provider. That is the reason they are supposed to be less accurate and less reproducible than guided techniques. But recent studies showed comparable accuracy; therefore, the use of unguided glenohumeral injection techniques should be considered in daily clinical practice in the hands of experienced shoulder arthroscopists.