US-guided injection of the upper and lower extremity joints

Ultrasound-guided injection of the long head of the biceps tendon sheath with concomitant subacromial bursa injection through the same needlestick

Sonography and specific shoulder positions allow for injections into both the long head of the biceps tendon sheath (LHBTS) and the subacromial space (SS) with one needlestick. We validated this technique using cadavers. An experienced proceduralist injected latex solution into 12 unembalmed cadaveric shoulders, aiming for the LHBTS and SS, using an ultrasound-guided injection technique that employs a single-needle entry point. An experienced surgeon dissected each specimen and graded latex location as: (1) completely accurate (in both the SS and LHBTS); (2) partially accurate (in either the SS or LHBTS); (3) accurate with overflow (in both locations, but also elsewhere); (4) partially accurate with overflow (in either location, but also somewhere else); or (5) completely inaccurate (no latex in either location). All 12 ultrasound-guided injections using the technique accurately placed latex into both LHBTS and SS (100% accuracy). Latex was also found in adjacent regions after two (17%) injections: one within the shoulder joint and one within the deltoid musculature. This newly described technique allows highly accurate access to the LHBTS and SS with single-needle entry. This technique could become a favored alternative to subjecting patients to two needlesticks and preparing separate injections to address often concomitant pathologies.

Sonographic finding of medial ankle subcutaneous edema and its association with posterior tibial tenosynovitis

Background:

To evaluate if the sonographic finding of medial ankle subcutaneous (subQ) edema is associated with posterior tibial tenosynovitis (PTTS).

Methods:

Sonographic images of the medial ankle soft tissues from 40 patients with PTTS and 37 patients with a normal posterior tibial tendon (PTT) were randomized and independently evaluated by two musculoskeletal radiologists for the presence or absence of subQ edema. Both radiologists were blinded to the images and status of the PTT and the patient's history. Statistical analyses included the Chi-square test and Cohen's Kappa statistics for inter-observer agreement.

Results:

A statistically significant association was seen for the presence of medial ankle subQ edema and PTTS among both radiologists’ findings. Of the 40 patients with PTTS, 33 (82.5%) were found positive by the first radiologist for medial ankle subQ edema, while no subQ edema was found in 28 of the 37 (75.7%) patients with a normal PTT (P < 0.001). Similarly, the second radiologist found that 33 of the 40 (82.5%) with PTTS were positive for subQ edema, while no subQ edema was found in 24 of the 37 (64.9%) patients with a normal PTT (P < 0.001). There was also substantial inter-observer agreement between the 2 radiologists (κ-value = 0.79; 95% confidence intervals: 0.65, 0.93).

Conclusion:

A statistically significant association was present for the association of the sonographic finding of medial ankle subQ edema and the presence of PTTS. Further studies could evaluate if the sonographic finding of medial ankle subQ edema is an early predictor of PTT dysfunction.

Ultrasound-Guided Musculoskeletal Injections

Musculoskeletal injections serve a variety of diagnostic and therapeutic purposes, with ultrasonography (US) guidance having many advantages: no ionizing radiation, real-time guidance, high spatial resolution, excellent soft tissue contrast, and the ability to identify and avoid critical structures. Sonography can be cost effective and afford flexibility in resource-constrained settings. This article describes US-guided musculoskeletal injections relevant to many radiology practices and provides experience-based suggestions. Structures covered include multiple joints (shoulder, hip), bursae (iliopsoas, subacromial-subdeltoid, greater trochanteric), peripheral nerves (sciatic, radial), and tendon sheaths (posterior tibial, peroneal, flexor hallucis longus, Achilles, long head of the biceps). Trigger point and similar targeted steroid injections, as well as calcific tendinopathy barbotage, are also described.

Functional outcomes and physical performance of knee osteoarthritis patients after ultrasound-guided genicular nerve radiofrequency ablation

OBJECTIVE

To elucidate the effectiveness of ultrasound-guided genicular nerve radiofrequency ablation in alleviating pain as well as its effects on functional outcomes, quality of life and physical performance in knee osteoarthritis patients.

DESIGN

Prospective observational study.

SETTING

Patients were recruited within one community hospital.

SUBJECTS

Patients with knee osteoarthritis.

METHODS

The subjects underwent ultrasound-guided radiofrequency ablation of genicular nerves after showing a positive response to a diagnostic block. Outcome assessments were performed at baseline and at 2 and 12 weeks posttreatments using the 36-item Short Form Health Survey (SF-36), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and a physical performance evaluation including balance tests, quadriceps muscle strength test, two-minute walking test and knee joint proprioception test.

RESULTS

Thirteen out of 38 patients were eligible for genicular nerve radiofrequency ablation. There were significant improvements from baseline to posttreatment in the numeric rating scale score, physical health domain score of SF-36, and pain and stiffness domain scores of the WOMAC. Regarding physical performance, the step test result significantly improved over the 12 weeks of follow-up. On the other hand, no significant deteriorations in the single leg stance test, isokinetic quadriceps muscle strength test, knee joint proprioception test or two-minute walking test results were observed after radiofrequency ablation of genicular nerves.

CONCLUSIONS

Radiofrequency ablation of genicular nerves may significantly alleviate pain and improve functional outcomes in knee osteoarthritis patients. More importantly, static balance control and quadriceps muscle strength were preserved and there was a change of proprioception in the good direction.

A comparison of ultrasound-guided rotator interval and posterior glenohumeral injection techniques for MR shoulder arthrography

PURPOSE

The aim of this prospective, randomized study was to compare the performance of a rotator interval approach with the posterior glenohumeral approach for ultrasound-guided contrast injection prior to MR shoulder arthrography.

METHOD

This study was approved by the institutional review board. One hundred and twenty consecutive patients referred for MR shoulder arthrography were randomized into four groups: rotator interval approach in-plane (n = 30); rotator interval approach out-of-plane (n = 30); posterior approach in-plane (n = 30); and posterior approach out-of plane (n = 30). Outcome measures included procedure time, number of injection attempts, patient-reported pain score (0-10), and radiologist-reported technical difficulty (0-10). MR arthrograms were assessed for adequacy of joint distension, diagnostic utility, and extra-capsular contrast leakage.

RESULTS

All 120 patients had a successful ultrasound-guided injection with adequate joint distension and diagnostic utility for MR arthrography. In-plane needle guidance was less technically demanding, quicker, required fewer injection attempts, and had a lower frequency of contrast leakage than out-of-plane needle guidance. The posterior glenohumeral approach was less technically demanding though had a higher frequency of contrast leakage and caused more patient discomfort than the rotator interval approach.

CONCLUSION

For ultrasound-guided shoulder joint injection, an in-plane approach is preferable. The posterior glenohumeral approach is less technically demanding though causes more patients discomfort than the rotator interval approach possibly due to the longer needle path.

Image guidance used for large joint and bursa injections; a survey study

Objectives: To determine the current rates of use of available image guidance modalities for large joint and bursal injections, in addition to their relationships to physician demographics.Methods: An electronic survey was sent to 3,400 members of the American Medical Society for Sports Medicine (AMSSM), examining types of guidance used for each large joint and bursal injection.Results: A total of 674 sports medicine physicians responded to the survey. Intra-articular hip and glenohumeral joint injections were more commonly performed with ultrasound guidance, while palpation-guidance was more common with all other injections. Physicians who specialized in Physical Medicine & Rehabilitation (PM&R) were more likely to use ultrasound for trochanteric bursa (p = 0.007, OR = 4.16 [1.46-11.8]), while internal medicine-, pediatrics-, and family medicine-trained physicians were more likely to use palpation guidance for at least one joint (p < 0.05). Physicians with fewer years of experience were more likely to use ultrasound for glenohumeral joint injections (p ≤ 0.002 for all age groups with less than 20 years of experience, ORs ranging from 6.3 to 9.2).Conclusion: Palpation-guidance is the most common technique used for large joint and bursal injections, other than for glenohumeral and hip joint injections. PM&R-trained physicians and those with less experience tend to use ultrasound more frequently.

Sonographic and radiographic findings of posterior tibial tendon dysfunction: a practical step forward

The purpose of this article is to describe the sonographic and radiographic findings in the diagnosis and treatment of posterior tibial tendon dysfunction. Ultrasound and radiographs play a crucial role in the diagnosis of posterior tibial tendon dysfunction and in imaging the postoperative changes related to posterior tibial tendon dysfunction. Early detection and diagnosis of posterior tibial tendon dysfunction is important in helping to prevent further progression of disease, obviating the need for more invasive and complex procedures.

Optimisation of platelet concentrates therapy: Composition, localisation, and duration of action

Platelet concentrates (PC) generally refers to a group of products that are prepared from autologous blood intended to enhance healing activities. PC therapy is now very popular in treating musculoskeletal injuries; however, inconsistent clinical results urge the need to understand the working mechanism of PC. It is generally believed that the platelet-derived bioactive factors are the active constituents, and their bioavailability in the vicinity of the lesion sites determines the treatment efficacies. Therefore, the composition, localisation, and duration of the action of PC would be key determinants. In this review, we discuss how different preparations and delivery methods of PC would affect the treatment outcomes with respect to clinical evidence about PC therapy for osteoarthritis, tendinopathies, rotator cuff tears, anterior cruciate ligament injuries, and bone fractures. This review can be used as a quick guide for the use of PC therapy and provide insights for the further optimisation of the therapy in the near future.

A practical guide for performing arthrography under fluoroscopic or ultrasound guidance

Abstract

We propose a practical approach for performing arthrography with fluoroscopic or ultrasound guidance. Different approaches to the principal joints of the upper limb (shoulder, elbow, wrist and fingers), lower limb (hip, knee, ankle and foot) as well as the facet joints of the spine are discussed and illustrated with numerous drawings. Whenever possible, we emphasise the concept of targeting articular recesses, which offers many advantages over traditional techniques aiming at the joint space.

Teaching Points

• Arthrography remains a foremost technique in musculoskeletal radiology

• Most joints can be successfully accessed by targeting the articular recess

• Targeting the recess offers several advantages over traditional approaches

• Ultrasound-guidance is now favoured over fluoroscopy and targeting the recess is equally applicable

Ultrasound-guided interventional procedures for chronic pain management

Ultrasonography has multiple advantages over traditional radiologic imaging modalities when used for interventional procedures. It allows improved visualization of the anatomy while avoiding ionizing radiation and risks associated with contrast use. It has proved superiority at accuracy of delivery and procedural effectiveness over blind procedures when used in association with interventional pain procedures. Although limited in its ability to see through bony structures, ultrasound has utility in visualizing soft tissues and vascular structures in anatomic regions of interest resulting in increased use for posterior neuraxial, periaxial, peripheral nerve and joint-related structures. Current evidence for use in these settings is presented here. In some cases, optimal utility may be improved by combining ultrasonography with other imaging modalities.

Ultrasound-guided corticosteroid injection of the subtalar joint for treatment of juvenile idiopathic arthritis

BACKGROUND

The subtalar joint is commonly affected in children with juvenile idiopathic arthritis and is challenging to treat percutaneously.

OBJECTIVE

To describe the technique for treating the subtalar joint with US-guided corticosteroid injections in children and young adults with juvenile idiopathic arthritis and to evaluate the safety of the treatment.

MATERIALS AND METHODS

We retrospectively analyzed 122 patients (age 15 months-29 years) with juvenile idiopathic arthritis who were referred by a pediatric rheumatologist for corticosteroid injection therapy for symptoms related to the hindfoot or ankle. In these patients the diseased subtalar joint was targeted for therapy, often in conjunction with adjacent affected joints or tendon sheaths of the ankle. We used a protocol based on age, weight and joint for triamcinolone hexacetonide or triamcinolone acetonide dose prescription. We describe the technique for successful treatment of the subtalar joint.

RESULTS

A total of 241 subtalar joint corticosteroid injections were performed under US guidance, including 68 repeat injections for recurrent symptoms in 26 of the 122 children and young adults. The average time interval between repeat injections was 24.8 months (range 2.2-130.7 months, median 14.2 months). Subcutaneous tissue atrophy and skin hypopigmentation were the primary complications observed. These complications occurred in 3.9% of the injections.

CONCLUSION

With appropriate training and practice, the subtalar joint can be reliably and safely targeted with US-guided corticosteroid injection to treat symptoms related to juvenile idiopathic arthritis.

Palpation versus ultrasound-guided corticosteroid injections and short-term effect in the distal radioulnar joint disorder: a randomized, prospective single-blinded study

The aim of this study was to conduct a randomized, prospective single-blinded clinical study on the mid-term benefits and accuracy rate of the ultrasound (US)-guided versus palpation-guided intra-articular (IA) injections for the treatment of distal radioulnar joint (DRUJ) disorder. Subjects with DRUJ disorder (n = 60) were randomly assigned to undergo US-guided or palpation-guided IA injection. Primary outcomes were measured with Disability of the Arm, Shoulder, and Hand questionnaire (DASH) and secondary outcomes included Verbal Numeric Pain Scale (VNS), Modified Mayo Wrist Score (MMWS), range of motion (ROM), and accuracy rate between two groups; 1.25 mL of mixed material (0.5 ml Omnipaque + 1 % lidocaine 0.25 ml + triamcinolone 20 mg 0.5 ml) was injected into the intra-articular space of the DRUJ. Treatment effects were assessed by using VNS, DASH, MMWS, and passive ROM of the DRUJ (supination, pronation from neutral) before the injections and at 1, 3, and 6 months after the injections. After the US-guided and palpation-guided IA injection into DRUJ, a radiographic image was taken to determine whether the injected material had reached the IA space or infiltrated into the soft tissue. US-guided IA injections showed significantly higher accuracy (100 %) than palpation-guided IA injections (75.8 %) in DRUJ. VNS, DASH, MMWS, and ROM were improved at 1, 3, and 6 months in both groups. There was no significant difference in clinical outcomes between the group receiving US-guided injections and the group receiving palpation-guided injections. US-guided IA injection showed significantly higher accuracy than palpation-guided IA injection in the DRUJ, and corticosteroid IA injections were effective in improving of the pain of patients with DRUJ disorder during 6 months of follow-up.