The influence of ultrasound guidance in the rate of success of acromioclavicular joint injection: an experimental study on human cadavers

Ultrasound-guided injection and aspiration of small joints: techniques, pearls, and pitfalls

Ultrasound (US)-guided musculoskeletal intervention of small joints or joints other than the shoulder, elbow, hip, knee, and ankle can be technically challenging. Small joints produce a narrower landing zone for the needle and a smaller target that may be made even more inaccessible by bulky osteophytes. Sonographic (US) guidance offers important advantages including near-field visualization of the joint and soft tissues, ease of access, portability, ability to compare with the contralateral side, and lack of ionization radiation. This review article focuses on the performance of US-guided injections and aspirations involving small joints (joint capacity < 2 mL and/or typically evaluated or injected with a compact linear transducer). For each joint (temporomandibular, acromioclavicular, sternoclavicular, distal radioulnar, symphysis pubis, and joints of the digits of the hands and feet), a brief overview of the relevant anatomy, indications, procedural description, pearls and pitfalls will be highlighted. This article demonstrates the various approaches to diagnostic or therapeutic injection and aspiration of small joints with the aid of US images, cines and graphic illustrations, emphasizing joint positioning, anatomic landmarks, and needle trajectory for a safe and efficacious procedure. A brief review of available literature for each joint will also be provided.

The advantages of utilizing different ultrasound imaging techniques on joints of human cadavers in the teaching of anatomy - A scoping review

BACKGROUND

A common approach to define sonoanatomy is a reciprocal exchange of macroscopic and microscopic information in ultrasound imaging. High-resolution ultrasound has been long established and is crucial as an inexpensive and adaptable tool, not just in clinical settings but also while teaching anatomy. Early application of ultrasonography provides medical students with a couple of benefits: they acquire an improved understanding of anatomy and learn how to use it.

METHODS

A comprehensive literature review has been carried out, with relevant studies discovered in the following databases: MEDLINE, EMBASE, CENTRAL, BIOSIS Previews and Web of Science Core Collection. Gray literature was also considered in two different ways: (1) Regarding grey literature databases: National Gray Literature Collection. (2) For PhD theses and dissertations, the databases EThOS and Open Access Theses and Dissertations were screened for relevant studies by combining the keywords used in the search string. The reference lists of all relevant papers were scanned. Search process was performed on January 3rd, 2023. The search string was developed with the aid of and finally checked by a professional librarian. Only ultrasound studies on human cadavers were included, not animals or phantoms. If the studied subject was a joint, the article was included. Only B-Mode ultrasound was included, whereas Elastosonography, Doppler sonography and quantitative approaches including among others sound speed, backscatter attenuation were excluded. Intravascular, intraosseous, intraarticular, and three-dimensional or four-dimensional ultrasonography were also eliminated from the analysis. All appropriate information comprising articles, PhD theses, dissertations and chapters in textbooks were considered. There were solely English and German studies covered. There was no additional restriction on the publishing year. The included studies' general characteristics and ultrasound techniques were taken from them and examined. Using VOS viewer, a keyword analysis was also carried out.

RESULTS

142 of the 8899 results that were returned by the search satisfied the requirements. With a quarter of the included studies, the knee joint was the most extensively studied joint, followed by the elbow joint (10.6%) and the shoulder joint (9.2%). The methodological analysis includes 125 studies. Both the sample size and the ultrasonographer's qualifications were diverse. The probe position and the ultrasound method were precisely documented so that a reader could duplicate them in about three-quarters of the included studies (72.8%).

CONCLUSION

The current study, in our perspective, is the first scoping review to screen ultrasound studies on human cadaver joints. A heterogeneous field was shown by the methodological investigation. We suggest using a uniform method for conducting and presenting ultrasound examinations in future studies.

Ultrasound-guided sternoclavicular joint injection: technique and case series

Sternoclavicular joint pathology can be an uncommon cause of pain and discomfort around the neck and shoulder region. Typically, patients localize their pain deep to the joint and experience referred pain to the ipsilateral neck and shoulder; however, it often presents as a diffuse nonspecific pain. Given the paucity of this pathology and atypical presentation, the use of injections can be helpful to confirm the diagnosis of sternoclavicular arthropathy. Currently, most injections are done via computed tomography. Although this method is accurate, it exposes patients to radiation and burdens the patient with the requirement of multiple appointments. This case series outlines the use of ultrasound-guided sternoclavicular joint injections conducted in the clinic. The patients in this series underwent an ultrasound-guided injection in the affected sternoclavicular joint, which confirmed the diagnosis, and they were subsequently treated with resection arthroplasty. The use of ultrasound-guided injections of the sternoclavicular joint is a safe and accurate alternative diagnostic method, which saves the patient from harmful radiation and additional appointments. Limitations and efficacy may vary depending on skill and comfort level of the operator.

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.

Clinical applications of ultrasonography in the shoulder for the Orthopedic Surgeon: A systematic review

BACKGROUND

Ultrasound imaging offers a non-invasive method to visualize the anatomy and function of the musculoskeletal system. Despite its benefits and widespread adoption in medicine, ultrasonography is still not well utilized by orthopaedic surgeons. The purpose of this systematic review was to provide a better understanding of the diagnostic accuracy and clinical utility of ultrasound of the shoulder for orthopaedic surgeons.

METHODS

We searched Medline, Embase, Web of Science, and Scopus databases. Our search terms included orthopedic, orthopedic surgery, ultrasonography, and shoulder. Inclusion criteria consisted of studies that used bedside ultrasound for the diagnosis and therapy of patients with common clinical entities of the shoulder presenting to orthopedic clinics, to demonstrate the utility for orthopedic surgeons. We reported sensitivity, specificity, positive predictive value, negative predictive value. Studies were excluded if they used non-diagnostic ultrasound modalities (e.g. shock wave therapy, shear wave elastography, Doppler flowmetry, speckle tracking shear strain, vibro-acoustography).

RESULTS

Our search strategy yielded 771 of potentially relevant publications, 41 studies were retrieved for full text screening, and 24 were included in this systematic review. We found that ultrasound used in orthopedic clinics has good sensitivity and high specificity for the assessment of partial and full rotator cuff tears of the shoulder, including post-operative cuff repairs. There was some evidence that it may also be useful for the diagnosis of subacromial-subdeltoid bursitis, AC joint arthropathy, and labral tears; however further investigations are still required. Ultrasound improves that accuracy of injections into spaces of the shoulder (subacromial bursa, acromioclavicular joint, glenohumeral joints, and the long head of biceps tendon sheath) compared to landmark guided injections, that can be helpful for diagnostic purposes, but do not improve long term clinical outcomes.

DISCUSSION

We reviewed the literature for orthopaedic surgeons and show that ultrasound of the shoulder can be a useful diagnostic tool for orthopedic surgeons in outpatient clinics. We found no difference in sensitivity or specificity when ultrasound was performed at bedside by orthopedic surgeons or by radiologists for patients referred to orthopedic clinic.

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 I, shoulder

BACKGROUND

Image-guided interventional procedures around the shoulder are commonly performed in clinical practice, although evidence regarding their effectiveness is scarce. We report the results of a Delphi method review of evidence on literature published on image-guided interventional procedures around the shoulder with a list of clinical indications.

METHODS

Forty-five experts in image-guided musculoskeletal procedures from the ESSR participated in a consensus study using the Delphic method. Peer-reviewed papers regarding interventional procedures around the shoulder up to September 2018 were scored according to the Oxford Centre for Evidence-based Medicine levels of evidence. Statements on clinical indications were constructed. Consensus was considered as strong if more than 95% of experts agreed and as broad if more than 80% agreed.

RESULTS

A total of 20 statements were drafted, and 5 reached the highest level of evidence. There were 10 statements about tendon procedures, 6 about intra-articular procedures, and 4 about intrabursal injections. Strong consensus was obtained in 16 of them (80%), while 4 received broad consensus (20%).

CONCLUSIONS

Literature evidence on image-guided interventional procedures around the shoulder is limited. A strong consensus has been reached for 80% of statements. The ESSR recommends further research to potentially influence treatment options, patient outcomes, and social impact.

KEY POINTS

• Expert consensus produced a list of 20 evidence-based statements on clinical indications of image-guided interventional procedures around the shoulder. • The highest level of evidence was reached for five statements. • Strong consensus was obtained for 16 statements (80%), while 4 received broad consensus (20%).

Do we really need to order magnetic resonance imaging? Shoulder surgeon ultrasound practice patterns and beliefs

Background

Despite significant benefits, many orthopedic surgeons are hesitant to incorporate diagnostic ultrasound into their practice. This may be because of a lack of comfort, knowledge, and/or training. The purpose of this study was to analyze practice patterns regarding the use of shoulder ultrasound by orthopedic surgeons to diagnose rotator cuff tears.

Materials and methods

We conducted a survey of the members of the American Shoulder and Elbow Surgeons (ASES) regarding their use of ultrasound. A systematic review of the literature on the use of ultrasound in the shoulder by orthopedic surgeons was also performed.

Results

Of the members of ASES responding to the survey, 55% are using ultrasound for diagnostic purposes in the shoulder. The leading reason for not using ultrasound as the sole imaging modality prior to performing rotator cuff repair was lack of confidence in the ability to determine the reparability of the tear (83%). Our systematic review showed that for an orthopedic surgeon diagnosing a full-thickness rotator cuff tear, the mean sensitivity was 92% and mean specificity was 89%.

Conclusions

Many ASES surgeons are not using ultrasound in the shoulder despite its many potential benefits over magnetic resonance imaging. This is because of a lack of confidence in the ability to quantify fatty infiltration, muscle atrophy, and the level of retraction medial to the acromion. Our systematic review showed that orthopedic surgeons can be accurate in the diagnosis of full-thickness rotator cuff tears. Future research should focus on defining parameters of shoulder ultrasound associated with rotator cuff tendon reparability. Educating surgeons on ultrasound technique, cost, and evidence may be a promising strategy to enhance the value in musculoskeletal care delivery.

Ultrasound-guided interventions for painful shoulder: from anatomy to evidence

Shoulder pain is a common musculoskeletal disorder of variable etiology, ranging from rotator cuff pathology to peripheral nerve entrapment. Advances in ultrasound (US) technology have allowed static and dynamic evaluation of shoulder problems and most importantly, offer real-time, radiation-free guidance for interventions. The present review aims to describe shoulder anatomy in detail using information from cadaveric models and to illustrate US-guided techniques using clearly labeled figures and videos. The review will also present evidence of specific US-guided therapies for shoulder pain by summarizing landmark studies, systematic reviews, and meta-analyses. The following shoulder structures will be covered: 1) the biceps long head tendon, 2) the acromioclavicular joint, 3) the subacromial-subdeltoid bursa, 4) the glenohumeral joint, 5) the suprascapular nerve, and 6) the axillary nerve.

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.

A concise evidence-based physical examination for diagnosis of acromioclavicular joint pathology: a systematic review

OBJECTIVES

The clinical examination of the shoulder joint is an undervalued diagnostic tool for evaluating acromioclavicular (AC) joint pathology. Applying evidence-based clinical tests enables providers to make an accurate diagnosis and minimize costly imaging procedures and potential delays in care. The purpose of this study was to create a decision tree analysis enabling simple and accurate diagnosis of AC joint pathology.

METHODS

A systematic review of the Medline, Ovid and Cochrane Review databases was performed to identify level one and two diagnostic studies evaluating clinical tests for AC joint pathology. Individual test characteristics were combined in series and in parallel to improve sensitivities and specificities. A secondary analysis utilized subjective pre-test probabilities to create a clinical decision tree algorithm with post-test probabilities.

RESULTS

The optimal special test combination to screen and confirm AC joint pathology combined Paxinos sign and O'Brien's Test, with a specificity of 95.8% when performed in series; whereas, Paxinos sign and Hawkins-Kennedy Test demonstrated a sensitivity of 93.7% when performed in parallel. Paxinos sign and O'Brien's Test demonstrated the greatest positive likelihood ratio (2.71); whereas, Paxinos sign and Hawkins-Kennedy Test reported the lowest negative likelihood ratio (0.35).

CONCLUSION

No combination of special tests performed in series or in parallel creates more than a small impact on post-test probabilities to screen or confirm AC joint pathology. Paxinos sign and O'Brien's Test is the only special test combination that has a small and sometimes important impact when used both in series and in parallel. Physical examination testing is not beneficial for diagnosis of AC joint pathology when pretest probability is unequivocal. In these instances, it is of benefit to proceed with procedural tests to evaluate AC joint pathology. Ultrasound-guided corticosteroid injections are diagnostic and therapeutic. An ultrasound-guided AC joint corticosteroid injection may be an appropriate new standard for treatment and surgical decision-making.

LEVEL OF EVIDENCE

II - Systematic Review.

Diagnostic Injections About the Shoulder

Injections about the shoulder serve diagnostic as well as therapeutic purposes. Diagnosis of shoulder conditions, such as rotator cuff tears, acromioclavicular joint pathology, subacromial impingement or anterolateral pain syndrome, glenohumeral joint pathology, suprascapular nerve entrapment, and biceps tendon pathologies, is often complicated by concomitant conditions with overlapping symptoms and by inconclusive physical examination and imaging results. Injections of anesthetic agents can often help clinicians locate the source of pain. However, technique and accuracy of needle placement can vary by route. Accuracy is often improved with the use of ultrasonography guidance, although studies differ on the benefits of guided versus unguided injection.

Diagnosis and Management of Distal Clavicle Osteolysis

Distal clavicle osteolysis is an uncommon condition that most commonly affects weight lifters and other athletes who perform repetitive overhead activity. Although this condition most commonly presents in young active men, it is becoming increasing more common in women with the rise in popularity of body building and extreme athletics. Distal clavicle osteolysis can be debilitating, especially in those with rigorous training regimens, preventing exercise because of pain with activities such as bench presses and chest flies. Aside from a careful history and physical examination, radiographic evaluation is essential in distinguishing isolated distal clavicle osteolysis from acromioclavicular joint pathology, despite a potentially similar presentation of the 2 conditions. Nonoperative therapy that includes activity modification, nonsteroidal anti-inflammatory drugs, and cortisone injections is the first-line management for this condition. Patients whose conditions are refractory to nonoperative modalities may benefit from distal clavicle resection via either open or arthroscopic techniques. Arthroscopic techniques typically are favored because of improved cosmesis and the added benefit of the ability to assess the glenohumeral joint during surgery to rule out concomitant pathology. There are varying operative techniques even within arthroscopic management, with pros and cons of a direct and an indirect surgical approach. Patients often do well after such procedures and are able to return to their preinjury level of participation in a relatively short period. [Orthopedics. 2017; 40(2):119-124.].

Musculoskeletal interventional procedures: With or without imaging guidance?

Aspiration and injection of joints and soft tissues is an indispensable skill used in everyday practice by the clinical rheumatologist. Most rheumatologists recognise that performing these procedures using anatomical landmarks is not always successful, particularly in the case of small or infrequently injected joints, bursae or tendon sheaths. Musculoskeletal ultrasound confirms the local pathological-anatomical diagnosis and is the most applicable and feasible imaging method that can be applied in clinical practice in guiding musculoskeletal interventional procedures. From 1993, there has been substantial examination of the accuracy of landmark- and imaging-guided procedures. We have searched the literature and ascertained whether imaging techniques improve the accuracy of musculoskeletal procedures and whether the accuracy of needle placement can be translated into improved clinical outcome (efficacy).

Ultrasound-guided procedures in rheumatology. What is the evidence?

Ultrasound (US) is a cost-effective, noninvasive, and accessible imaging modality that clinicians use at the point of care to assess disease activity and therapeutic efficacy in different rheumatic conditions. It can play a relevant role in invasive procedures performed by the rheumatologist, potentially ensuring a higher degree of accuracy. However, US-guided injections are still underused, and the conventional blind injection the most commonly adopted approach. In this article, we analyze the current evidence supporting the use of US-guided procedures, emphasizing comparative studies between conventional and US-guided procedures and their benefits in the daily rheumatological practice.

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.

Evolving Role of Ultrasound in Therapeutic Injections of the Upper Extremity

Ultrasound machines are creating more refined pictures and becoming more user-friendly and readily accessible. As a result, ultrasound is being increasingly used for therapeutic purposes. One example involves the use of ultrasound guidance in musculoskeletal interventional procedures, such as joint injections, tendon sheath injections, and peripheral nerve blocks. Technical considerations and therapeutic results have been described for multiple locations about the upper extremities, with varying levels of success. The implementation of ultrasound-guided injections in the orthopedist's clinic has therapeutic, financial, and provider role implications. Given these potential benefits, orthopedic providers, both in practice and residency, would benefit from increased exposure and education in ultrasound use. Ultrasound provides the benefit of real-time, dynamic imaging without the radiation exposure of fluoroscopy, and ultrasound-guided injections can be performed in the office, as opposed to the operating room, which is frequently required when using fluoroscopy. A basic knowledge of the principles and terms used in ultrasound is required. With these simple principles, a practitioner can review techniques for specific areas of the musculoskeletal system and begin using ultrasound to guide injections. Many locations for diagnostic and/or therapeutic injections in the upper extremities have improved accuracy and benefit with the use of ultrasound vs blind techniques, although a few have not been shown to have a significant difference in the literature. The educational and professional implications can be significant, but these potential benefits need to be carefully weighed against costs by each orthopedic practice.

Accuracy of in vivo palpation-guided acromioclavicular joint injection assessed with contrast material and fluoroscopic evaluations

OBJECTIVE

The purpose of this study was to evaluate the accuracy of in vivo acromioclavicular (AC) joint injections without fluoroscopic guidance and assess whether patient demographics affected the accuracy of injections.

MATERIALS AND METHODS

A consecutive cohort of patients who presented with painful acromioclavicular joints was prospectively evaluated. All patients had clinical and radiographic evidence of AC arthritis, had failed conservative measures, and thus had received intraarticular corticosteroid injections. All injections were performed by experienced fellowship-trained musculoskeletal radiologists and by blinded digital palpation technique. Accuracy of injections was assessed with biplanar fluoroscopic views.

RESULTS

Forty-one AC injections in 22 males and 16 females with a mean age of 51 years (range 18 to 78) were identified. Twenty-three injections were in the right shoulder and 18 in the left. Only 15 injections were confirmed to be in the intraarticular AC joint, yielding an accuracy of 36.5%. There were no significant differences in the mean age (54 vs. 52 years; p = 0.58), male-to-female ratio (p = 0.73), and side of the injection between the accurate and inaccurate injections, respectively.

CONCLUSION

Based on the findings of the present study, the authors encourage the use of image guidance for corticosteroid treatment of the AC joint.

LEVEL OF EVIDENCE

Level IV Therapeutic Case Series.

American Medical Society for Sports Medicine 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 on the evidence, the official AMSSM position relevant to each subject is made.

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.

Successful injection of the acromioclavicular joint with use of ultrasound: anatomy, technique, and follow-up

BACKGROUND

Injection into the acromioclavicular (AC) joint is often inaccurate (approximately 50%) even in experienced hands. In light of new anatomic observations, we evaluate accuracy of an innovative ultrasound-guided method and follow the clinical course of successful therapeutic injections.

METHOD

Relevant anatomy was investigated in 200 three-dimensional computed tomography scans, 100 magnetic resonance images, and 14 cadavers. Baseline measurements of joint depth and width were performed ultrasonically in 100 normal volunteers; 50 symptomatic patients were injected. Uniquely in a clinical ultrasound study, injection success was documented by arthrography. Outcomes after concomitant steroid instillation were observed for 6 months by visual analog scale (VAS) scores and pain provocation test results.

RESULTS

Anatomic studies showed that the widest area for joint penetration was anterior superior. Injection success rate was 96%, overwhelmingly on the first needle pass. Shallow joint depth allowed access with a standard 3-cm needle. Joint width diminished with age but did not reduce injection success. Cadaveric joints admitted 1.2 ± 0.5 mL, but fluid ingress was initially blocked by soft tissues in one third of both cadaveric and clinical cases. Diligent follow-up after steroid injection showed sustained pain relief in the majority with isolated AC disease but significantly less in those with concomitant shoulder disorders.

CONCLUSION

This high level of clinical injection success, irrefutably substantiated with arthrography, has not been previously demonstrated. The anterior superior aspect of the joint is the preferred place for entry. Initial intra-articular blockage to fluid inflow is common but can be surmounted. Encouraging 6-month results of steroid instillation in isolated AC disease do not apply to patients with coexisting shoulder pathologic processes.

Intra-articular versus periarticular acromioclavicular joint injection: a multicenter, prospective, randomized, controlled trial

PURPOSE

The purpose of this randomized study was to compare the clinical efficacy of intra-articular versus periarticular acromioclavicular joint injections.

METHODS

In this multicenter, prospective, randomized, controlled trial, 101 patients (106 shoulders) with symptomatic acromioclavicular joints were treated with an injection and were randomly assigned to either the intra-articular group or the periarticular group. To ensure accurate needle placement either intra-articularly or in a periarticular manner, the needle was placed under ultrasound guidance. Baseline values including the Constant-Murley score, pain assessment with a visual analog scale for pain under local pressure and pain at night, and the crossover arm test were investigated in 7 different centers immediately before treatment. Follow-up examinations were scheduled after 1 hour, 1 week, and 3 weeks.

RESULTS

All patients completed the study. Overall, a highly significant clinical improvement in all tested variables and in both groups was observed over time (P < .0001) beginning with 1 hour after treatment and lasting for the entire follow-up period of 3 weeks. The difference between the 2 groups was not significant except regarding the crossover arm test (P < .016).

CONCLUSIONS

With both injection techniques, a highly significant clinical advantage for the patient can be achieved. The difference between the 2 treatments was not significant except for more pain reduction according to the crossover arm test after intra-articular injection at 3 weeks' follow-up.

LEVEL OF EVIDENCE

Level II, multicenter, randomized, prospective, controlled trial.

Degenerative joint disease of the acromioclavicular joint: a review

Osteoarthritis of the acromioclavicular (AC) joint is a common condition causing anterior or superior shoulder pain, especially with overhead and cross-body activities. This most commonly occurs in middle-aged individuals because of degeneration to the fibrocartilaginous disk that cushions the articulations. Diagnosis relies on history, physical examination, imaging, and diagnostic local anesthetic injection. Diagnosis can be challenging given the lack of specificity with positive physical examination findings and the variable nature of AC joint pain. Of note, symptomatic AC osteoarthritis must be differentiated from instability and subtle instability, which may have similar symptoms. Although plain radiographs can reveal degeneration, diagnosis cannot be based on this alone because similar radiographic findings can be seen in asymptomatic individuals. Nonoperative therapy can provide symptomatic relief, whereas patients with persistent symptoms can be considered for resection arthroplasty by open or arthroscopic technique. Both techniques have proven to provide predictable pain relief; however, each has its own unique set of potential complications that may be minimized with an improved understanding of the anatomical and biomechanical characteristics of the joint along with meticulous surgical technique.

Autologous bone marrow concentrate: review and application of a novel intra-articular orthobiologic for cartilage disease

Younger adults, aged < 65 years, increasingly present to their physicians with advanced cartilage disease or post-traumatic osteoarthritis. A number of treatments exist for lessening patient pain and improving patient function. However, many patients are becoming aware of the potential of regenerative therapies and are now seeking solutions to the impaired biology underlying their conditions rather than addressing only their symptoms. Patients do not want to merely lessen their symptoms temporarily with a surgical procedure that replaces damaged tissue, but instead seek correction and repair of the underlying biology to regenerate damaged tissue and alleviate their symptoms altogether. Current therapies for patients with cartilage disease or osteoarthritis range from non-surgical intra-articular injections with biologics, such as hyaluronic acid (HA), to total joint arthroplasty for advanced stages of disease. Total joint arthroplasty is a successful procedure for patients aged > 65 years; however, the limited long-term durability of implanted prostheses decreases the preference of using such methods in more active patients aged < 65 years. The potential of cell-based orthobiologic injection therapies (pertaining to therapeutic injectables that aim to restore the biologic environment and/or structural components of diseased or damaged musculoskeletal tissue) is of tremendous interest for younger, more active patients, and is even more appealing in that such therapy can be delivered at point-of-care in the clinic during an office visit. Notably, the exponential rate of progress in biotechnology has allowed for immediate application of myriad novel therapies prior to clear evidence of benefit from randomized clinical trials. Orthobiologic intra-articular injection therapies include HA and platelet-rich plasma (PRP). We report on current, available findings for a third-generation intra-articular orthobiologic injectable therapy for cartilage disease, bone marrow concentrate (BMC). Bone marrow concentrate contains mesenchymal stem cells (MSCs), hematopoetic stem cells, platelets (containing growth factors), and cytokines. The anti-inflammatory and immunomodulatory properties of bone marrow stem cells (BMSCs) can facilitate regeneration of tissue. Additionally, BMSCs enhance the quality of cartilage repair by increasing aggrecan content and tissue firmness. Following bone marrow aspiration (BMA), BMC is easily prepared using centrifugation, and is available for a same-day procedure with minimal manipulation of cells, thus complying with US Food and Drug Association (FDA) restrictions. To date, there are no published randomized controlled trials on the efficacy of use of autologous BMC intra-articular injections performed as a same-day in-office procedure for treating patients with cartilage disease; however, several publications have reported the ease of use of this method, its strong safety profile, and the fundamental science suggesting great therapeutic potential.