US-guided interventional joint procedures in patients with rheumatic diseases--when and how we do it?

Minimally invasive interventional procedures for osteoarthritis and inflammatory arthritis: A systematic review and meta-analysis

OBJECTIVE

to summarize the evidence on the efficacy of minimally invasive interventional procedures such as radiofrequency ablation (RFA) and transcatheter arterial embolization (TAE) in patients with osteoarthritis or inflammatory arthritis.

METHODS

a literature search was conducted in PubMed and Web of Science databases. Both randomized controlled trials (RCTs) and non-randomized studies of interventions (NRSI) were included. The results were organized according to the treated anatomical site: knee, hip, foot and ankle, shoulder, hand and wrist, sacroiliac joints. Data about treatment efficacy were extracted. The main outcome was change in pain intensity using the 0-10 visual analog scale (VAS) from baseline to 1 month. Additional timepoints at 3, 6 and 12 months were assessed. Change in functional status was evaluated. Pooled estimates were calculated as the mean difference (MD) and 95 % confidence interval relative to baseline. The meta-analyses of RCTs and NRSI were conducted separately.

RESULTS

of the 4599 retrieved articles, 164 were included in the review and, considering all the established timepoints, 111 (38 RCTs and 73 NRSI) were selected for the meta-analysis. Only one article described patients with inflammatory arthritis. In the meta-analysis of RCTs, one month after the procedure, MD in VAS was -3.98 (-4.41 to -3.55; k = 21) for knee RFA, and -3.18 (-3.96 to -2.39; k = 8) for sacroiliac joints RFA. In the meta-analysis of NRSI, MD in VAS was -4.12 (-4.63 to -3.61; k = 23) for knee RFA, -3.84 (-4.77 to -2.92; k = 7) for knee TAE, -4.34 (-4.96 to -3.71; k = 2) for hip RFA, -3.83 (-4.52 to -3.15; k = 3) for shoulder RFA and -4.93 (-5.58 to -4.28; k = 14) for sacroiliac joints RFA. Significant decrease in pain intensity was found also at 3, 6 and 12 months. Additionally, functional status improved at all the assessed timepoints.

CONCLUSION

minimally invasive interventional procedures can improve pain and functional status of patients affected by OA or chronic sacroiliac pain of degenerative origin. Further research is warranted in the field of inflammatory rheumatic diseases.

Interventional Radiology for Rheumatic Diseases

Imaging plays a key role in the management of rheumatological pathologies, also as guidance for diagnostic and therapeutic interventional procedures, as it can provide better accuracy and safety compared to palpation-guided interventions. Inflammatory and degenerative conditions nonresponsive to systemic treatment may benefit from intra-articular and periarticular administration of drugs, with therapeutic and symptomatic actions or providing a bridge for surgery. Desired effects include reduction of inflammation and pain and improvement of physical function of patients. Training and knowledge of indications, appropriate procedures, contraindications, and side effects are necessary to obtain maximum accuracy and safety in performing interventional procedures.

Case Report: Portable handheld ultrasound facilitates intra-articular injections in articular foot pathologies

Background

Intra-articular injections are commonly used to manage joint pathologies, including osteoarthritis. While conventional ultrasound (US) guidance has generally improved intra-articular injection accuracy, forefoot and midfoot joint interventions are still often performed without imaging guidance. This pilot study aims to evaluate the efficacy of office-based, portable ultrasound (P-US) guided intra-articular injections for forefoot and midfoot joint pain caused by various degenerative pathologies.

Methods

A retrospective analysis was conducted on a series of consecutive patients who underwent P-US guided intra-articular injections following a chief complaint of forefoot or midfoot joint pain. Patients reported their pain levels using the Visual Analog Scale (VAS) pre-injection and at 3 months follow-up. The procedure was performed by an experienced foot and ankle surgeon using a linear array transducer for guidance, and a 25-gauge needle was used to inject a combination of 2 cc 1% lidocaine and 12 cc of Kenalog (40 mg/ml). Complications and pain scores were analyzed using a paired t-test and p < 0.05 was considered significant.

Results

We included 16 patients, 31% male and 69% female with a mean age (±SD) of 61.31 (±12.04) years. None of the patients experienced immediate complications following the intervention. The mean pre-injection VAS score was significantly reduced from 5.21 (±2.04) to a mean of 0.50 (±1.32) at 3 months follow-up (P < 0.001). Thirteen patients reported complete resolution of pain at the 3-month follow-up. No adverse events were reported throughout the duration of the study.

Conclusion

This pilot study suggests P-US-guided intra-articular injections offer a safe and effective method for managing forefoot and midfoot joint pain caused by various arthritic pathologies. Further research is warranted to establish the long-term efficacy and comparative effectiveness of P-US-guided injections in larger patient cohorts as compared to non-image guided injections.

Optimizing the anti-inflammatory strategies in (osteo)arthritis: local or systemic?

Arthritis is affecting millions of people globally, involvement and distribution depending on the type of arthritis. The most common arthritic conditions are osteoarthritis (OA) and rheumatoid arthritis (RA). Despite the pathogeneses being fundamentally different, both joint diseases share the same need for local treatment of synovitis. No current treatment can stop the progression of OA. Local articulate treatment including glucocorticoid (GC) injections, radiosynoviorthesis (RSO) and surgical synovectomy are the only options to relieve pain and temporally improve movability before surgical intervention. For RA, despite effective systemic treatments, similarly need for local articulate treatment is still present, especially early in the disease, but also in case of recurrent episodes of disease flare. Current evidence supports local GC injection as first line treatment for persistent synovitis in a single or a few joints. RSO provides an evident and effective alternative for GC refractory synovitis, especially in early RA. Surgical synovectomy is an invasive alternative, but with less documented efficacy. Whether one unsuccessful intraarticular GC injection is enough to change of mode of action for local treatment is still unclear and needs to be further investigated. In conclusion persistent single joint synovitis in OA and RA is well treated with local treatment. Intra-articular GC injection is considered as first line of treatment, but RSO provides an additional treatment alternative with less side effects and better evidence of efficacy than surgical synovectomy.

The EANM guideline for radiosynoviorthesis

PURPOSE

Radiosynoviorthesis (RSO) using the intraarticular application of beta-particle emitting radiocolloids has for decades been used for the local treatment of inflammatory joint diseases. The injected radiopharmaceuticals are phagocytized by the superficial macrophages of the synovial membrane, resulting in sclerosis and fibrosis of the formerly inflamed tissue, finally leading to reduced joint effusion and alleviation of joint pain.

METHODS

The European Association of Nuclear Medicine (EANM) has written and approved these guidelines in tight collaboration with an international team of clinical experts, including rheumatologists. Besides clinical and procedural aspects, different national legislative issues, dosimetric considerations, possible complications, and side effects are addressed.

CONCLUSION

These guidelines will assist nuclear medicine physicians in performing radiosynoviorthesis. Since there are differences regarding the radiopharmaceuticals approved for RSO and the official indications between several European countries, this guideline can only give a framework that must be adopted individually.

Safety and tolerability of ultrasound-guided synovial needle biopsy in Japanese arthritis patients

OBJECTIVES

We sought to clarify the safety and tolerability of ultrasound (US)-guided synovial needle biopsy in hand and knee joints in Japanese arthritis patients.

METHODS

A total of nine consecutive arthritis patients were recruited and scheduled for US-guided synovial needle biopsies. Patients completed a safety questionnaire and patient-reported outcomes (PRO) data of joint pain, stiffness, and swelling pre- and postbiopsy. We also recorded patients' characteristics and willingness to undergo a second biopsy by the same technique. All synovial needle biopsy samples were assessed with pathological and microbial examination to verify whether clinical evaluation was possible.

RESULTS

Five and 4 patients underwent US-guided biopsy from hand and knee joints, respectively. PRO data showed no significant differences in pain, swelling, or stiffness levels before and after biopsy, with a mean 11.8 samples collected per procedure. No significant complications, including joint infection, bleeding, or vasovagal signs, were reported. Histologically adequate synovial tissue was identified in 83 (78%) samples. We were able to submit the biopsy samples to pathological and bacterial analysis to exclude septic arthritis.

CONCLUSION

We demonstrated that a minimally invasive US-guided needle biopsy is a safe and well-tolerated procedure and the synovial tissue collected was of adequate quality for pathological analysis.

Existing Evidence on Ultrasound-Guided Injections in Sports Medicine

Office-based ultrasonography has become increasingly available in many settings, and its use to guide joint and soft tissue injections has increased. Numerous studies have been conducted to evaluate the use of ultrasound-guided injections over traditional landmark-guided injections, with a rapid growth in the literature over the past few years. A comprehensive review of the literature was conducted to demonstrate increased accuracy of ultrasound-guided injections regardless of anatomic location. In the upper extremity, ultrasound-guided injections have been shown to provide superior benefit to landmark-guided injections at the glenohumeral joint, the subacromial space, the biceps tendon sheath, and the joints of the hand and wrist. Ultrasound-guided injections of the acromioclavicular and the elbow joints have not been shown to be more efficacious. In the lower extremity, ultrasound-guided injections at the knee, ankle, and foot have superior efficacy to landmark-guided injections. Conclusive evidence is not available regarding improved efficacy of ultrasound-guided injections of the hip, although landmark-guided injection is performed less commonly at the hip joint. Ultrasound-guided injections are overall more accurate than landmark-guided injections. While current studies indicate that ultrasound guidance improves efficacy and cost-effectiveness of many injections, these studies are limited and more research is needed.

Musculoskeletal ultrasonography for psoriatic arthritis and psoriasis patients: a systematic literature review

Objective

To systematically review the role of musculoskeletal US in patients suffering from PsA or psoriasis (Pso) in terms of prevalence, diagnosis, prognosis, monitoring and treatment.

Methods

A systematic literature review was conducted through medical databases (MEDLINE via PubMed, Embase) and the grey literature up to September 2015 to inform a new study of the Musculoskeletal Ultrasound Study Group of the Italian Society for Rheumatology. All articles reporting data on musculoskeletal US in PsA or Pso were included and extracted according to the underlying clinical question.

Results

A total of 86 publications were included. The prevalence of US abnormalities showed a wide range for each examined feature (e.g. 37-95% for entheses thickness of the lower limbs). The performance of US for diagnosis of disease or elementary lesions was variable across studies, but no study evaluated the overall performance of US in addition to clinical findings for diagnosing PsA. Considering US in defining PsA and Pso prognosis, several works focused on US of entheses of lower limbs in Pso, while for the monitoring of PsA activity five different scoring systems were identified. Last, the results of the role of US in guiding intra-articular interventions were controversial for the clinical outcomes, but in favour of US for accuracy.

Conclusion

despite the recognized importance of US in the management of PsA and Pso, this review clearly demonstrated the need of pivotal research in order to optimize the use of US in the diagnosis and monitoring of psoriatic disease.

Success Rate and Utility of Ultrasound-guided Synovial Biopsies in Clinical Practice

OBJECTIVE

The utility of synovial biopsy in increasing our understanding of the pathogenesis of inflammatory arthropathies, as well as in evaluating treatments, is well established. Ultrasound (US) allows synovial assessment and therefore assists in biopsying synovial tissue in a safe and well-tolerated manner. This study's objectives were to (1) determine the rate of success in retrieving synovial tissue using US guidance, (2) describe the indications for US-guided synovial biopsies in the clinical setting, (3) determine how frequently the synovial biopsy can lead to a clear diagnosis, and (4) assess the quality of the synovial tissue obtained using this technique.

METHODS

Synovial biopsies of small and large joints were performed under US guidance between February 2007 and December 2014 using a semiautomatic core biopsy needle. The biopsy procedure was considered successful if synovial tissue was found at histological examination.

RESULTS

Seventy-four patients with undifferentiated arthritis underwent 76 synovial biopsies. The success rate in retrieving synovial tissue was 81.6% (62/76). One patient taking acetyl salicylic acid at 75 mg at the time of the biopsy presented with hemarthrosis 48 h after the procedure, which resolved following simple arthrocentesis. A definitive diagnosis was achieved in 16% of the patients where synovial tissue was sampled successfully.

CONCLUSION

US-guided synovial biopsies in clinical practice can be performed safely on patients with undifferentiated arthritis and with heterogeneous presentations. The rate of success in acquiring synovial tissue is high. The procedure usually retrieves quality tissue and leads to a definite diagnosis in a significant minority of patients.

Sonography Is Superior to Serum-Based Biomarkers for Measuring Disease Status in Experimental Rheumatoid Arthritis

OBJECTIVES

Progress in developing novel rational treatments for rheumatoid arthritis (RA) critically depends on preclinical work in experimental animals. However, there is lack of insight into the most appropriate mode of noninvasive measurement of disease status in experimental RA. This study compared sonography with serum biomarkers in a rabbit model of RA.

METHODS

Six-month-old male New Zealand White rabbits were randomized into 2 groups: antigen-induced arthritis group (n = 25), which was subjected to ovalbumin immunization and intra-articular injection; and control group (n = 5). Pathologic changes in the knee joints were evaluated by sonography, and serum C-reactive protein, tumor necrosis factor TNF-α, and interleukin 1 were measured by enzyme-linked immunosorbent assay. Synovial pathologic scores were obtained by ultrasound-guided biopsy.

RESULTS

A total of 23 rabbits (2 rabbits died before the end of the study) in the antigen-induced arthritis group and 5 rabbits in the control group completed the study. Sonographic scores for all rabbits were graded from 0 to 3, according to grayscale sonography, synovitis, and blood flow. Synovial lesions were evident on sonography before week 4; however, serum biomarkers slowly increased until weeks 5 and 6 (P < .05). Although both sonography and serum biomarkers correlated significantly with synovitis scoring, the correlations for the sonographically derived parameters were better. The correlation indices between pathologic scores and synovial membranes thickness, blood flow, and resistive index were 0.798, 0.557, and -0.320, respectively, whereas the correlation indices between pathologic scores and tumor necrosis factor α, interleukin 1, and C-reactive protein levels were 0.451, 0.503, and 0.529.

CONCLUSIONS

Sonographic findings had better correlations with histologic scoring than serologic biomarkers of disease activity in the RA rabbit model, especially at early stages. Local pathologic assessment of disease status by sonography is possible.

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilization is by nonradiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases, and hydrodissections. This American Medical Society for Sports Medicine (AMSSM) position statement critically reviews the literature and evaluates the accuracy, efficacy, and cost-effectiveness of ultrasound-guided injections in major, intermediate, and small joints, and soft tissues, all of which are commonly performed in sports medicine. New ultrasound-guided procedures and future trends are also briefly discussed. Based upon the evidence, the official AMSSM position relevant to each subject is made.

Radiological intervention of the hand and wrist

The role of radiological guided intervention is integral in the management of patients with musculoskeletal pathologies. The key to image-guided procedures is to achieve an accurately placed intervention with minimal invasion. This review article specifically concentrates on radiological procedures of the hand and wrist using ultrasound and fluoroscopic guidance. A systematic literature review of the most recent publications relevant to image-guided intervention of the hand and wrist was conducted. During this search, it became clear that there is little consensus regarding all aspects of image-guided intervention, from the technique adopted to the dosage of injectate and the specific drugs used. The aim of this article is to formulate an evidence-based reference point which can be utilized by radiologists and to describe the most commonly employed techniques.

Sonography of the first metatarsophalangeal joint and sonographically guided intraarticular injection of corticosteroid in acute gout attack

OBJECTIVE

The aims of this study were to identify the characteristic ultrasound (US) findings of the first metatarsophalangeal joint (MTPJ1) in acute gout attack and to evaluate the efficacy and safety of US-guided intraarticular corticosteroid injection of the MTPJ1.

METHODS

We enrolled 21 patients with acute gout attack involving the MTPJ1 unilaterally. US evaluation of each affected MTPJ1 was compared with radiographic features. US-guided intraarticular corticosteroid (0.5 ml [20 mg] of triamcinolone mixed with 0.5 ml of 2% lidocaine) was injected into the affected MTPJ1s. Pain, general disability, and walking disability were assessed at baseline, 24 hours, 48 hours, and 7 days after injection with visual analog scales.

RESULTS

The characteristic US findings of MTPJ1 were erosion, joint effusion, synovial hypertrophy, tophus-like lesion, double contour, hyperechoic spots, and increased power Doppler signal in acute gout attack. US was more sensitive than conventional radiograph in detecting erosion and tophus-like lesion. The reductions of mean visual analog scale scores in pain, general disability, and walking disability were 48 mm (SD, 27), 35 mm (SD, 26) and 39 mm (SD, 26), respectively, 48 hours after US-guided intraarticular corticosteroid injection. There were no adverse events.

CONCLUSIONS

US is a sensitive tool to evaluate joint abnormality of the MTPJ1 in acute gout attack and US-guided intraarticular corticosteroid injection to this joint is effective and safe.

American Medical Society for Sports Medicine (AMSSM) position statement: interventional musculoskeletal ultrasound in sports medicine

BACKGROUND

The use of diagnostic and interventional ultrasound has significantly increased over the past decade. A majority of the increased utilisation is by non-radiologists. In sports medicine, ultrasound is often used to guide interventions such as aspirations, diagnostic or therapeutic injections, tenotomies, releases and hydrodissections.

OBJECTIVE

Critically review the literature related to the accuracy, efficacy and cost-effectiveness of ultrasound-guided injections (USGIs) in major, intermediate and small joints; and soft tissues.

DESIGN

Systematic review of the literature.

RESULTS

USGIs are more accurate than landmark-guided injections (LMGIs; strength of recommendation taxonomy (SORT) Evidence Rating=A). USGIs are more efficacious than LMGIs (SORT Evidence Rating=B). USGIs are more cost-effective than LMGIs (SORT Evidence Rating=B). Ultrasound guidance is required to perform many new procedures (SORT Evidence Rating=C).

CONCLUSIONS

The findings of this position statement indicate there is strong evidence that USGIs are more accurate than LMGI, moderate evidence that they are more efficacious and preliminary evidence that they are more cost-effective. Furthermore, ultrasound-guided (USG) is required to perform many new, advanced procedures and will likely enable the development of innovative USG surgical techniques in the future.

Total hip replacement rate in a cohort of patients affected by symptomatic hip osteoarthritis following intra-articular sodium hyaluronate (MW 1,500-2,000 kDa) ORTOBRIX study

Hip osteoarthritis is very common and costly. The European League Against Rheumatology Committee agenda asks for research to investigate treatments able to slow down the progression of hip osteoarthritis (OA), to delay joint replacement, and to determine the comparative effectiveness and cost-effectiveness of non-surgical and surgical treatment modalities as well as criteria relating to the indications for and timing of total hip replacement (THR). After publishing the results of a randomized controlled trial and a cohort study on the efficacy of Intra-articular sodium hyaluronate (MW 1,500-2,000 kDa) on symptomatic hip OA, we performed this retrospective study in patients suffering from hip OA treated with ultrasound-guided intra-articular injections of HyalOne (Hyalubrix 60 Italian brand name) involving a group of THR expert orthopedic surgeons to appraise whether or not considered eligible for THR and the frequency and timing of THR. Six orthopedists, not routinely performing hip intra-articular injections, each independently assessed whether 176 patients suffering from hip OA and treated with ultrasound-guided intra-articular injections of sodium hyaluronate (MW 1,500-2,000 kDa) were candidates for THR according to the clinical data (age, body mass index, Pain Visual Analog Scale, Lequesne Algofunctional Index, global patient assessment, global physician assessment, nonsteroidal anti-inflammatory drug intake, and hip X-ray) collected at the first intra-articular sodium hyaluronate injection visit and provided as anonymous electronic data. At 24 months, 159 out of 76 (90 %) patients did not undergo to THR. At 48 months, 82 % (N = 144) of the study population treated with intra-articular hyaluronic acid avoided THR. In the group of 93 patients considered candidates for THR (that is, in which 4, 5, or 6 orthopedic surgeons agreed that the patient was a suitable candidate for THR), only 17 had undergone THR, with survival results of 82 % at 24 months. At 48 months, this percentage reduced to 66 % in this group. In the other groups of patients (in which respectively 3, 2, 1 or no surgeons were in agreement that the patient was a candidate for THR) arthroplasty is not recorded. Sodium hyaluronate (MW 1,500-2,000 kDa) given by ultrasound-guided injection seems to delay THR in the real context of actual overall management of symptomatic hip OA patients. Although further studies are necessary to confirm these data and to identify outcome predictors, hip viscosupplementation should be considered as conservative treatment to perform before proposing patients for THR.

¹⁵³Sm-HM for arthritic knee pain. Estimated dosimetry

Osteoarthritis is the most common type of arthropathy and after cardiovascular diseases is the most disabling disease in developing countries. The dosimetry for the clinical application of 153-samarium-hydroxymacroaggregates (¹⁵³Sm-HM) for radiation synovectomy (RSV) and palliative treatment for arthritic pain, as far as we know, has not been reported. The aim of this research was to estimate the radiation dose necessary for synovial ablation and pain palliation with minimum risk to the patient. ¹⁵³Sm-HM (370 MBq) was administered intra-articularly in a patient with severe knee pain and hindered motility. Regions of interest drawn on sequential, conjugated, anterior and posterior scintigraphy images were used to obtain the respective activity. The data was entered into a knee joint histological-geometric model designed with micrometric dimensions to represent the synovial cell layers. The Monte Carlo code was used to calculate the absorbed dose in each of the 12 model-cells representing the distance from the synovial liquid to the cartilage or bone. The absorbed dose in the synovial cavity was 114 Gy which is sufficient energy for RSV. The treated patient referred little pain and higher motility with no adverse reactions. ¹⁵³Sm-HM is a potentially valid radiopharmaceutical for RSV, which effectively palliates knee pain.